Prevention of Clostridioides difficile in hospitals: ISID position paper
Delhi: A panel of experts convened by the International Society for Infectious Diseases (ISID) reviewed the current state of C. difficile infections globally and made evidence-based recommendations for infection prevention that are broadly applicable. Recommendations are published in the International Journal of Infectious Diseases.
Clostridioides difficile infection is an increasing presence worldwide. Prevention is multipronged, reflecting a complex and evolving epidemiology. Multiple guidelines exist regarding the prevention of C. difficile infection in healthcare settings; however, existing guidelines do not address C. difficile in low- and middle-income countries (LMIC). Nevertheless, the prevalence of C. difficile in LMIC likely parallels, if not exceeds, that of high-income countries, and LMIC may experience additional challenges in C. difficile diagnosis and control.
- Screening of asymptomatic individuals for C. difficile is not recommended as it may falsely increase HAI rates and does not result in safer care.
- Repeated stool tests using PCR, either to check for positivity or as a test of cure, are not recommended.
- Testing for C. difficile should be done only in patients with compatible clinical syndromes, including liquid stools, and clinical correlation should guide the interpretation of lab results. Other alternative enteropathogens should be considered, particularly in children, as approximately 10%–20% may have a concomitant infection.
C. Difficile Surveillance
- Healthcare centers should track C. difficile rates particularly on inpatient units, expressed as the number of cases per 10,000 patient days.
- Abrupt increases in rates should incite a review of infection control practices and/or an outbreak investigation as indicated.
- Alcohol-based hand rubs are not effective in removing C. difficile spores, leading to recommendations for HH preferentially with soap and water in the setting of high C. difficile rates within an institution.
- HH is recommended following the World Health Organization's 5 Moments of Hand Hygiene, with either alcohol-based hand rub or soap and water in the absence of an outbreak of C. difficile. During outbreak situations, units and/or facilities should consider preferential soap and water HH to remove spores.
- Provider hands should be washed preferentially with soap and water after an encounter with a patient with known C. difficileinfection or diarrhea of suspected infectious etiology.
- HH should also be performed with soap and water after exposure to fecal material or when hands are visibly soiled.
Isolation and Contact Precautions
- It is recommended that patients with C. difficile infection be isolated in single rooms and/or cohorted with other C. difficile-infected patients to limit patient-to-patient cross transmission in healthcare settings.
- Infected patients should ideally have their own toilet. Furthermore, personal protective equipment (PPE), including gloves and gowns should be worn by providers to limit self-contamination with C. difficile and its spores from either the patient or the environment around the patient.
- PPE should be removed and discarded when exiting the patient room before initiating care with other patients. Hands must be washed before putting on PPE, including gloves and after taking off PPE/gloves.
- Once the patient improves to baseline, there is variability from 24 to 48 h to the duration of stay in the amount of additional time on isolation that is recommended.
- If feasible in terms of space and staff resources, continuing isolation for 48 h after the resolution of diarrhea is recommended to allow for patient hygiene and environmental cleaning to reduce bioburden and the risk of transmission to other patients.
- Patients should be encouraged to bathe and/or be assisted with bathing daily in healthcare facilities to reduce C. difficile and other potential pathogens on the skin.
- Daily cleaning of high touch surfaces is recommended with a disinfecting agent as well as terminal cleaning of rooms with a disinfecting agent when a patient is discharged.
- A sporicidal agent can be considered in the setting of an outbreak of C. difficile and/or for terminal cleaning of C. difficile patient rooms.
- Cleaning practices should be validated regularly either with direct observation, the placement of a fluorescent marker, or ATP as resources allow.
- The researchers recommend that every health care facility should have an ASP. C. difficile rates should be included as an indicator outcome along with other antimicrobial resistance pathogens contributing to healthcare-associated infections.
Low Resource Settings
- Maintaining cleanliness of the healthcare environment, frequent HH following the WHO's 5 moment recommendations, and rational antimicrobial usage are critically important regardless of the capacity to perform routine diagnosis and the isolation of cases and/or longitudinal surveillance.
"Prevention of Clostridioides difficile in hospitals: A position paper of the International Society for Infectious Diseases," is published in the International Journal of Infectious Diseases.