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Strategies to Prevent C. difficile in Acute Care Facilities

Introduction

Purpose:

This document provides information on the basic principles and interventions recommended for the prevention of C. 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 identification and isolation of patients with suspected or confirmed CDI

  • Place symptomatic patientsb on contact precautions, in a single-patient room with a dedicated toilet. For patients with confirmed CDI, maintain contact precautions throughout the duration of hospitalization.c
  • Adhere to recommended hand hygiene practices
  • Use dedicated patient-care equipment (e.g., bedpans, blood pressure cuffs, stethoscopes), and use single-use disposable items (e.g., single patient digital thermometer) if possible
  • Implement daily patient bathing or showering with soap and water
  • When transferring patients: Notify receiving wards (intra-facility movement) or facilities (inter-facility transfer) about the patient’s CDI status so contact precautions are maintained at the patient’s new location
    • Healthcare personnel involved in the transport of a CDI patient should consider wearing gloves

2. CONFIRM CDI IN PATIENTS

  • Clinical staff
    • Assess for appropriateness of testing: Consider other infectious or non-infectiousd causes of diarrhea before proceeding to 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; patients may remain positive for ≥6 weeks
  • Laboratory personnel
    • Implement laboratory procedures to ensure testing of appropriate specimens (e.g., unformed stool) for C. difficile or its toxins
    • Report test results immediately to clinical care providers and infection control staff 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 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 the toilets
    • Clean and disinfect all shared equipment prior to use by another patient
  • Perform terminal cleaning after CDI patient transfer/discharge with a difficile sporicidal agent (EPA List K agent). Additional disinfection with no-touch technologies could be considered (e.g., UV light)
  • 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)
  • Consider the need for cleaning of equipment that is commonly moved between patient rooms (e.g., housekeeping carts, wheelchairs, gurneys)

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 modifiable CDI risk factors including clinical management decisions (e.g., use of high-risk antibiotics) and the use of infection control measures to identify gaps
  • Educate and train healthcare personnel on prevention practices for CDI
  • Routinely audit
  • Provide CDI rates to senior leadership, clinical staff, laboratory staff, 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. DEVELOP A FACILITY-SPECIFIC ANTIBIOTIC STEWARDSHIP PROGRAM

  • Implement the 7 Core Elements of Hospital Antibiotic Stewardship programs
  • Assess the appropriateness of antibiotic prescribing for agents that pose the highest risk for CDI, especially fluoroquinolones and 3rd and 4th generation cephalosporins
    • Evaluate antibiotic treatment of common infections such as urinary tract infection, upper respiratory infections, and community-acquired pneumonia to ensure it is in accordance with facility or national guidelines and facility antibiogram
    • Consider developing facility-specific treatment recommendations for common infections that include first- and second-line antibiotics
    • Consider restriction of antibiotics with highest risk for CDI

CONSIDER USE OF SUPPLEMENTAL STRATEGIES TO REDUCE CDI RATES*

*Supplemental strategies may be considered for use in circumstances such as an outbreak or if CDI reduction goals are not met.

  • Consider participating in regional CDI prevention activities
  • Consider cohorting of confirmed CDI patients
    • Cohorted patients should be managed by dedicated staff when possible to minimize the risk of transmission to other patients
  • Consider evaluating and testing patients at high risk for CDI to detect asymptomatic carriage
    • Isolate patients that test positive, but do not treat in the absence of symptoms
      • Avoid using high-risk antibiotics
  • Consider limiting the use of patient medications (e.g., proton pump inhibitors, H2-receptor blockers) that are hypothesized to increase risk for CDI

aProtocols that can be immediately initiated by bedside nursing staff to allow rapid identification and 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 difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA), Clinical Infectious Diseases, Volume 66, Issue 7, 19 March 2018, Pages e1–e48, https://doi.org/10.1093/cid/cix1085
  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 https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html
  3. Banach, D., Bearman, G., Barnden, M., Hanrahan, J., Leekha, S., Morgan, D., . . . Wiemken, T. (2018). Duration of Contact Precautions for Acute-Care Settings. Infection Control & Hospital Epidemiology, 39(2), 127-144. doi:10.1017/ice.2017.245 https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/duration-of-contact-precautions-for-acutecare-settings/94E38FDCE6E1823BD613ABE4E8CB5E56
  4. Guh A, Carling P, and Environmental Evaluation Workgroup. Options for evaluating environmental cleaning https://www.cdc.gov/hai/toolkits/evaluating-environmental-cleaning.html
  5. Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs https://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html
  6. Centers for Disease Control and Prevention. The Targeted Assessment for Prevention (TAP) Strategy https://www.cdc.gov/hai/prevent/tap.html
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