CDI Prevention Strategies

Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities

Introduction

Purpose:

This document provides information on the basic principles and interventions recommended for the prevention of Clostridioides (formerly known as Clostridium) difficile infection (CDI) in acute care facilities. The strategies are intended to facilitate implementation of CDI prevention efforts by state and local health departments, quality improvement organizations, hospital associations, and healthcare facilities.

Core strategies for the prevention of CDI in acute care facilities include:

1. ISOLATE AND INITIATE CONTACT PRECAUTIONS FOR SUSPECTED OR CONFIRMED CDI
  • Create nurse-driven protocolsa to facilitate rapid isolation of patients with suspected or confirmed CDI
  • For suspected patients, ensure rapid evaluation by healthcare personnel and infection prevention
  • Place symptomatic patientsb on contact precautions, in a single-patient room with a dedicated toilet
    • If single-patient rooms are not available, cohort like patients
  • For patients with confirmed CDI, maintain contact precautions for at least 48 hours after diarrhea has resolved, or longer, up to the duration of hospitalizationc
  • Adhere to recommended hand hygiene practices
  • Use dedicated patient-care equipment (e.g., blood pressure cuffs, stethoscopes)
  • Implement daily patient bathing or showering with soap and water
  • When transferring patients: Notify receiving wards or facilities about the patient’s CDI status so contact precautions are maintained at the patient’s new location

2. CONFIRM CDI IN PATIENTS
  • Clinical personnel
    • Assess for appropriateness of testing: Consider other infectious or non-infectiousd causes of diarrhea before testing for CDI
    • Discontinue laxatives and wait for at least 48 hours before testing if still symptomatic
    • Once a patient has a positive CDI test do not repeat testing to detect cure; tests may remain positive for ≥6 weeks
  • Laboratory personnel
    • Implement laboratory procedures to ensure testing of only appropriate specimens (e.g., unformed stool) for C. difficile or its toxins
    • Report test results immediately to clinical care providers and infection control personnel through reliable means (e.g., a laboratory alert system)

3. PERFORM ENVIRONMENTAL CLEANING TO PREVENT CDI
  • Create daily and terminal cleaning protocols and checklists for patient-care areas and equipment
  • Perform daily cleaning of CDI patient rooms using a C. difficile sporicidal agent (EPA List K agent)
    • Clean and disinfect the patient-care environment (including the immediate vicinity around a CDI patient and high touch surfaces) at least once a day, including toilets
    • Clean and disinfect all shared equipment prior to use with another patient (e.g., wheelchairs, gurneys)
  • Perform terminal cleaning after CDI patient transfer/discharge with a C. difficile sporicidal agent (EPA List K agent)
  • Clean additional areas that are contaminated during transient visits by patients with suspected or confirmed CDI (e.g., Radiology, Emergency Departments, Physical Therapy) with a C. difficile sporicidal agent (EPA List K agent)

4. DEVELOP INFRASTRUCTURE TO SUPPORT CDI PREVENTION
  • Incorporate reduction of CDI into the facility healthcare-associated infection prevention program
    • Include a multidisciplinary workgroup, including nursing, environmental services, antibiotic stewardship to identify and implement strategies and to follow results of interventions
  • Monitor facility CDI rates, and target units with highest incidence of CDI for evaluation and intervention
    • Review individual CDI episodes to assess for modifiable CDI risk factors including clinical management decisions (e.g., use of high-risk antibiotics) and gaps in infection control measures
  • Educate and train healthcare personnel on prevention practices for CDI
  • Routinely audit
  • Provide CDI rates to senior leadership, clinical providers, laboratory personnel, environmental services, and other stakeholders
    • Notify appropriate individuals and facility departments about changes in the incidence (or frequency), complications (including recurrences), or severity of CDI

5. ENGAGE THE FACILITY ANTIBIOTIC STEWARDSHIP PROGRAM
  • Implement the 7 Core Elements of Hospital Antibiotic Stewardship
  • Assess the appropriateness of prescribing antibiotics that pose the highest risk for CDI, especially fluoroquinolones and 3rd and 4th generation cephalosporins
    • Develop facility-specific treatment recommendations for common infections that include first- and second-line antibiotics
    • Evaluate antibiotic treatment of conditions that commonly lead to high-risk antibiotic use, such as asymptomatic bacteriuria and common infections such as urinary tract infection and community-acquired pneumonia to minimize the use of high-risk antibiotics
    • Ensure that patients receive the shortest effective duration of antibiotic therapy
    • Include inpatient antibiotic duration when determining post-discharge antibiotic duration

CONSIDER USE OF SUPPLEMENTAL INTERVENTIONS

The below interventions are listed as supplemental due to a limited evidence-base to support their use (theoretical benefit only), cost, or logistical difficulty in implementation. Supplemental interventions could be considered during an outbreak or if CDI reduction goals are not met with adherence to baseline strategies. Some interventions might have unintended consequences, and risks and benefits should be considered prior to implementation.  Supplemental interventions include:

  • Dedicate healthcare personnel to the care of patients with CDI only (i.e., without responsibility to care for non-CDI patients),  to minimize the risk of transmission to others
  • Restrict the use of antibiotics with the highest risk for CDI (e.g., fluoroquinolones)
  • Limit the use of non-antibiotic patient medications (e.g., proton pump inhibitors, H2-receptor blockers) that are hypothesized to increase risk for CDI
  • Expand the use of environmental disinfection strategies (e.g., sporicidal agents (EPA List K agent) for daily and terminal cleaning in all rooms on affected units
  • Use of additional disinfection of CDI patient rooms with no-touch technologies (e.g., UV light)
  • Evaluate and test patients at high risk for CDI to detect asymptomatic carriage
    • Isolate patients that test positive, but do not treat in the absence of symptoms
  • Participate in regional CDI prevention activities

aProtocols that can be immediately initiated by bedside nurse to allow isolation of patients with suspected or confirmed CDI
bPatients with clinically significant unexplained diarrhea
cInfection control measures should be maintained for patients with EIA-positive test result as well as for those with EIA-negative but PCR-positive test result
dNon-infectious causes of diarrhea include inflammatory bowel disease, and therapies such as eternal tube feeding, intensive cancer chemotherapy, or laxatives.

References

  1. L Clifford McDonald, Dale N Gerding, Stuart Johnson, Johan S Bakken, Karen C Carroll, Susan E Coffin, Erik R Dubberke, Kevin W Garey, Carolyn V Gould, Ciaran Kelly, Vivian Loo, Julia Shaklee Sammons, Thomas J Sandora, Mark H Wilcox; Clinical Practice Guidelines for Clostridium difficileInfection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)Externalexternal iconClinical Infectious Diseases, Volume 66, Issue 7, 19 March 2018, Pages e1–e48. https://doi.org/10.1093/cid/cix1085external icon
  2. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee,  2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
  3. Banach, D., Bearman, G., Barnden, M., Hanrahan, J., Leekha, S., Morgan, D., . . . Wiemken, T. (2018). Duration of Contact Precautions for Acute-Care SettingsExternalexternal icon. Infection Control & Hospital Epidemiology, 39(2), 127-144. doi:10.1017/ice.2017.245.
  4. Guh A, Carling P, and Environmental Evaluation Workgroup. Options for Evaluating Environmental Cleaning
  5. Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs
  6. Centers for Disease Control and Prevention. The Targeted Assessment for Prevention (TAP) Strategy