In this guidelines side-by-side comparison, we compare the latest clinical practice guidelines from the American College of Gastroenterology (ACG) and the Society for Healthcare Epidemiology of America (SHEA) on Clostridioides Difficile Infection (CDI), also referred to as C. diff.
Clostridioides difficile is a bacteria that causes diarrhea and inflammation of the colon. The bacteria can occur in adult and pediatric patients, but most frequently affects people over the age of 65. Being hospitalized or in a nursing home also increases the risk of CDI. Once exposed to clostridioides difficile, the chance of having a recurrent infection increases, and with each subsequent infection that risk escalates.
Antibiotic use is a modifiable risk factor for the development of CDI. The antibiotics most often associated with this health risk are third and fourth generation cephalosporins, fluoroquinolones, carbapenems, and clindamycin.
CDI represents a significant healthcare burden. Primary prevention is essential to reducing this burden.
Guidelines for Comparison
| ACG Clinical Guideline: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections | Strategies to Prevent Clostridioides difficile Infections in Acute-care Hospitals: 2022 Update | |
|---|---|---|
| Authoring Organization | American College of Gastroenterology (ACG) | Society for Healthcare Epidemiology of America (SHEA) |
| Publication Date | June 2021 | April 2023 |
| Graded Recommendations | Yes | Yes |
| Uses GRADE | Yes | Yes |
| Links | Summary Full Text | Summary Full Text |
Key Takeaways
Here are some of the key takeaways between the recent ACG and SHEA guidelines for the prevention of CDI.
General:
- SHEA’s article provides recommendations for essential practices to prevent CDI in acute care hospitals, as well as, additional approaches that may be considered in other locations and/or other patient populations.
- ACG’s article makes recommendations for prevention, diagnosis, and treatment of CDI, including prevention of CDI recurrence and treatment of CDI in patients with irritable bowel disease (IBD). They do not give any graded recommendations on infection control and prevention, instead deferring this to SHEA and the Infectious Diseases Society of America (IDSA). The ACG’s guideline is meant to complement existing guidelines from SHEA/IDSA on this topic by expanding on areas of interest.
Antimicrobial Stewardship:
- SHEA encourages appropriate use of antimicrobials by implementing antimicrobial stewardship programs.
- ACG did not address this.
Diagnosis of CDI:
- Both societies agree that appropriate testing for C. difficile is important, but the ACG expands on this to include testing to distinguish between colonization versus active infection.
Transmission Prevention:
- SHEA makes recommendations for contact precautions, cleaning, and disinfection practices to prevent the spread of CDI.
- The ACG does not address this.
Probiotics:
- The ACG recommends against the use of probiotics for primary and secondary prevention of CDI.
- SHEA lists the use of probiotics for primary prevention as an unresolved issue that needs further study to make a recommendation.
Prevention of CDI Recurrence:
- The ACG recommends treatment with fecal microbiota transplantation (FMT) for patients who have a recurrence of CDI to prevent further recurrence.
- This was beyond the scope of the SHEA guideline.
Antibiotic Prophylaxis:
- The ACG suggests that vancomycin prophylaxis or bezlotoxumab may be considered for certain patient populations to prevent CDI and/or CDI recurrence.
- SHEA lists antibiotic prophylaxis as an unresolved issue when it comes to primary prevention of CDI and does not address this as a form of secondary prevention.
Gastric Acid Suppressants:
- The ACG suggests against stopping gastric acid suppressants to prevent CDI in patients who have an appropriate indication for treatment with such medications.
- SHEA lists stopping gastric acid suppressants as an unresolved issue.
Comparison of Recommendations
| Topic | ACG | SHEA |
|---|---|---|
| Antimicrobial Stewardship | Not addressed | Encourage appropriate use of antimicrobials through implementation of an antimicrobial stewardship program. Ensure appropriate use of antimicrobials for CDI treatment: HCP should work with their antimicrobial stewardship program to ensure that patients with CDI are receiving appropriate severity-based treatment based on current guidance. Ensure the appropriate use of non–CDI-treatment antimicrobials. |
| Diagnostic Stewardship | CDI testing algorithms should include both a highly sensitive and a highly specific testing modality to help distinguish colonization from active infection. | Implement diagnostic stewardship practices for ensuring appropriate use and interpretation of C. difficile testing. |
| Contact Precautions | No recommendations made, defers to IDSA/SHEA for recommendations. | Use contact precautions for infected patients, single-patient room preferred. Measure compliance with the CDC or WHO hand hygiene and contact precautions recommendations. Additional considerations: Intensify the assessment of compliance with process measures. Additional considerations: As the preferred method, perform hand hygiene with soap and water following care of or interacting with the healthcare environment of a patient with CDI. Additional considerations: Place patients with diarrhea on contact precautions while C. difficile testing is pending. Additional considerations: Prolong the duration of contact precautions after the patient becomes asymptomatic until hospital discharge. |
| Cleaning/Disinfecting | No recommendations made, defers to IDSA/SHEA for recommendations. | Adequately clean and disinfect equipment and the environment of patients with CDI. Assess the adequacy of room cleaning. Additional considerations: Use an EPA-approved sporicidal disinfectant, such as diluted (1:10) sodium hypochlorite, for environmental cleaning and disinfection. Implement a system to coordinate with environmental services if it is determined that sodium hypochlorite is needed for environmental disinfection. |
| Automated Alert Systems | Not addressed | Implement a laboratory-based alert system to provide immediate notification to infection preventionists and clinical personnel about newly diagnosed patients with CDI. |
| Surveillance | Not addressed | Conduct CDI surveillance and analyze and report CDI data. |
| Education | Not addressed | Educate HCP, environmental service personnel, and hospital administration about CDI, including risk factors, routes of transmission, local CDI epidemiology, patient outcomes, and treatment and prevention measures. Educate patients and their families about CDI as appropriate. |
| Probiotics | We recommend against probiotics for the prevention of CDI in patients being treated with antibiotics (primary prevention). We recommend against probiotics for the prevention of CDI recurrence (secondary prevention). | Use of probiotics as primary prophylaxis remains an unresolved issue. |
| Prevention of Recurrence | We recommend patients experiencing their second or further recurrence of CDI be treated with FMT to prevent further recurrences. We recommend FMT be delivered through colonoscopy or capsules for treatment of rCDI; we suggest delivery by enema if other methods are unavailable. We suggest repeat FMT for patients experiencing a recurrence of CDI within 8 weeks of an initial FMT. | Not addressed |
| Other Prevention Strategies | For patients with rCDI who are not candidates for FMT, who relapsed after FMT, or who require ongoing or frequent courses of antibiotics, long-term suppressive oral vancomycin may be used to prevent further recurrences. Oral vancomycin prophylaxis (OVP) may be considered during subsequent systemic antibiotic use in patients with a history of CDI who are at high risk of recurrence to prevent further recurrence. We suggest bezlotoxumab (BEZ) be considered for prevention of CDI recurrence in patients who are at high risk of recurrence. We suggest against discontinuation of antisecretory therapy in patients with CDI, provided there is an appropriate indication for their use. | Restriction of gastric acid suppressants remains an unresolved issue. |
That wraps up our comparison side-by-side of the ACG and SHEA guidelines on clostridioides difficile infection prevention. Sign up for alerts to stay informed on the latest published guidelines and guideline updates.
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