Prevention of Clostridium difficile Infection: A Systematic Survey of Clinical Practice Guidelines

Abstract

BACKGROUND Clostridium difficile infection (CDI) is the most common cause of hospital-acquired infectious diarrhea. OBJECTIVE To analyze the methodological quality, content, and supporting evidence among clinical practice guidelines (CPGs) on CDI prevention. DESIGN AND SETTING We searched medical databases and gray literature for CPGs on CDI prevention published January 2004-January 2015. Three reviewers independently screened articles and rated CPG quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument, composed of 23 items, rated 1-7, within 6 domains. We reported each domain score as a percentage of its maximum possible score and standardized range. We summarized recommendations, extracted their supporting articles, and rated individually the level of evidence using the Oxford Centre for Evidence-Based Medicine Levels of Evidence. RESULTS Of 2,578 articles screened, 5 guidelines met inclusion criteria. Median AGREE II scores and interquartile ranges were: clarity of presentation, 75.9% (75.9%-79.6%); scope and purpose, 74.1% (68.5%-85.2%); editorial independence, 63.9% (47.2%-66.7%); applicability, 43.1% (19.4%-55.6%); stakeholder involvement, 40.7% (38.9%-44.4%); and rigor of development, 18.1% (17.4%-35.4%). CPGs addressed several common strategies for CDI prevention, including antibiotic stewardship, hypochlorite solutions, probiotic prophylaxis, and bundle strategies. Recommendations were often not consistent with evidence, and most were based on low-level studies. CONCLUSION CPGs did not adhere well to AGREE II reporting standards. Furthermore, there was limited transparency in moving from evidence to recommendations. CDI prevention CPGs need to better adhere to AGREE-II and be transparent in moving from evidence to recommendations, and recommendations need to be consistent with available evidence. Infect Control Hosp Epidemiol 2016;37:901-908.

Microbial Preparations (Probiotics) for the Prevention of Clostridium difficile Infection in Adults and Children: An Individual Patient Data Meta-analysis of 6,851 Participants

“…Our results corroborate the findings in a previous aggregate-data meta-analysis 12 47 Recent clinical practice guidelines currently do not recommend probiotic prophylaxis, even though probiotics have the highest quality evidence among cited prophylactic therapies, including antibiotic stewardship, hypochlorite solutions, and bundle strategies 14 …”

“…12,47 Recent clinical practice guidelines currently do not recommend probiotic prophylaxis, even though probiotics have the highest quality evidence among cited prophylactic therapies, including antibiotic stewardship, hypochlorite solutions, and bundle strategies. 14 Some suggest that probiotics are most likely to be of benefit in high CDI incidence settings. 48,49 Data on disease pressure were not available; thus, we approximated the baseline CDI risk using the control group event rates of individual trials.…”

“…An updated aggregate data meta-analysis incorporating the study showed that the beneficial effect of the probiotic remained. 13 A recent review of clinical practice guidelines on CDI prevention 14 found that recommendations mainly revolved around core strategies (eg, education of healthcare staff on CDI, patient isolation, antimicrobial stewardship, and utilization of disinfectants), but none recommend probiotics for prophylaxis. [15][16][17][18][19] Guidelines cited concerns regarding insufficient evidence, 17,20 too much weight given to studies with high baseline CDI risk, 16 and safety concerns.…”

Surveillance von nosokomialen Infektionen

“…Surveillance ist integraler Bestandteil des internen Qualitätsmanagements nach dem "Plan-Do-Check-Act"-Zyklus, der den kontinuierlichen, mehrstufigen Ansatz im Qualitätsmanagement verdeutlicht [11] [20][21][22][23], beatmungsassoziierte Pneumonien [23,24], katheterassoziierte Harnwegsinfektionen [25] und Clostridioides difficile-Infektionen (CDI) [26,27]. In einem systematischen Review wurden Kohortenstudien, die den Einfluss der Surveillance auf das Auftreten von nosokomialen Infektionen untersucht haben, zusammenfassend analysiert [28].…”

Prevention of Clostridium difficile Infection and Associated Diarrhea: An Unsolved Problem

“…To reduce the total CD burden, infection prevention has been repeatedly recommended, and several clinical practice guidelines have been developed [ 16 ]. Antibiotic stewardship, compliance with CDC, WHO and the European Society of Clinical Microbiology and Infectious Diseases hand-hygiene and contact precaution recommendations, and the use of a sporicidal disinfectant or diluted sodium hypochlorite for environmental cleaning and disinfection are the most commonly recommended strategies to prevent CD infection development and diffusion [ 17 , 18 ]. Moreover, although no guidelines have included them among suggested methods to prevent CD infection and disease, probiotics have been considered by some authors a potential measure in this regard [ 19 ].…”