Strategies to Prevent Clostridioides difficile Infections in Acute-Care Hospitals

Publication Date: April 12, 2023

Key Points

Key Points

  • Encourage appropriate use of antimicrobials by implementing an antimicrobial stewardship program.
  • Implement diagnostic stewardship practices for appropriate use and interpretation of C. difficile testing.
  • Assess adequacy of room cleaning.
  • This pocket guide highlights practical recommendations to assist acute care hospitals in implementing and prioritizing Clostridioides difficile infection (CDI) prevention efforts.
  • It is based on a synthesis of evidence, theoretical rationale, current practices, practical considerations, author consensus, and consideration of potential harm, where applicable.
  • No guideline or expert guidance document can anticipate all clinical situations. This pocket guide is not meant to be a substitute for individual clinical judgment by qualified professionals.

Table 1. Commonly Used Clostridioides difficile Infection (CDI) Surveillance Definitions

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Case Type Definition
Healthcare facility-onset CDI (HO-CDI) CDI symptom onset ≥4 days after admission to a healthcare facility (HCF), with day of admission being day 1.a
Healthcare facility-onset, treated CDI (HT-CDI) (The proposed definition currently being evaluated.) CDI symptom onset ≥4 days after admission to an HCF, with day of admission being day 1, and ≥5 days of CDI treatment started within 2 calendar days of the positive C. difficile test; if a patient is discharged or transferred before receiving 5 days of treatment, any treatment will count.a
Community-onset, healthcare facility-associated CDI (CO-HCFA-CDI) CDI symptom onset in the community or <4 days from admission (day of admission being day 1), provided that symptom onset was <4 weeks after the last discharge from an HCF, according to National Healthcare Safety Network (NHSN) definitions.a,b
Indeterminate onset CDI CDI case patient who does not fit any of the above criteria for an exposure setting, e.g., CDI symptom onset in the community or <4 days from admission (day of admission being day 1) provided that symptom onset was >4 weeks but <12 weeks after the last discharge from an HCF.a
Community-associated CDI (CA-CDI) CDI symptom onset in the community or <4 days from admission (day of admission being day 1), provided that symptom onset was >12 weeks after the last discharge from an HCF.a
Healthcare-associated CDI (HA-CDI) Includes cases of HO-CDI, CO-HCFA-CDI, and indeterminate per CDC Emerging Infections Program definitions.
Community-onset CDI (CO-CDI) Includes both CA-CDI and indeterminate CDI (distinct from CO-HCFA-CDI) per NHSN definitions.
Unknown Exposure setting cannot be determined because of lack of available data.
Recurrent CDI A CDI episode that occurs 8 weeks (56 days) or less after the onset of a previous CDI episode, provided that CDI symptoms from the earlier episode resolved.
a When utilizing laboratory-based reporting symptoms, date and time of stool specimen collection can be used as a surrogate for symptom onset. If data on time a patient was admitted (in addition to date) and/or time stool was collected for testing are not available, CDI can be considered healthcare facility onset if stool is positive for toxigenic C. difficile or toxin after the third calendar day from hospital admission, where the first day is the day of admission (i.e., a patient admitted on Monday with stool first positive for C. difficile toxin on Thursday or later is considered to have healthcare facility-onset CDI).
b CDC Emerging Infections Program definitions include CO-HCFA-CDI cases as defined above and indeterminate onset cases as defined below (i.e., all CDI occurring <12 weeks after last discharge) in their specific CO-HCFA-CDI definition.

Table 2. CDI Prevention - Process Measuresa

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Compliance with hand hygiene guidelines. (If hand hygiene with soap and water is the preferred method of hand hygiene when caring for patients with CDI, also assess proper hand washing technique with the same formula.) (No. of observed proper hand hygiene episodes performed by healthcare personnel (HCP) ÷ total no. of observed opportunities for hand hygiene) × 100 = % compliance with hand hygiene compliance
Compliance with contact precautions (No. of observed patient care episodes in which contact precautions are appropriately implemented ÷ the no. of observed patient care episodes in which contact precautions are indicated) × 100 = % compliance with contact precautions
Compliance with environmental cleaning and disinfection One specific measure of compliance for use in all hospitals cannot be recommended. However, many hospitals use checklists, environmental rounds, fluorescent markers, and/or ATP bioluminescence to assess the cleaning and disinfection process and cleanliness of equipment and the environment (see Table 3: Essential practices).
a Ongoing measurement of recommended CDI prevention practices to permit risk assessment of CDI.

Table 2. CDI Prevention - Outcome Measuresb

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  • Calculate CDI rates.
  • See Table 1 for case definitions.
(No. of CDI cases in the population being monitored ÷ total number of patient days in the population being monitored) × 10,000 = No. of CDI cases per 10,000 patient days.
b Ongoing measurement of incidence density of CDI for longitudinal assessment of outcomes related to the processes of care.

Recommendations

...mmendation...

Table 3. Summary of Recommendations to Pr...

...ial Practices...

...dopted by all acute-care hospitals unless a...

...age appropriate use of antimicrobials...

...nostic stewardship practices for ensuring ap...

3.

...hand hygiene (L)33...

...ves (M)3305355...

...or gowns (L)3305355

for single-patient room (L)3305...

4.

...ipment (L)3305355...

...environment (L)33...

...equacy of room cleaning. (L) Work with the en...

...a laboratory-based alert system to prov...

...rveillance and analyze and report CDI data....

...ducate HCP, environmental service personn...

...ts and their families about CDI as appropria...

...mpliance with CDC or WHO hand hygiene...

...itional Approaches

...considered for use in locations and/or hos...

...he assessment of compliance with proce...

...preferred method, perform hand hygiene wi...

...ts with diarrhea on contact precautions while C....

...Prolong the duration of contact pr...

...e an EPA-approved sporicidal disinfe...

...es...