Prevention of Clostridium difficile Infection in Critically Ill Adults

Abstract

The incidence and severity of Clostridium difficile infection (CDI) remain high across intensive care units in the United States despite national efforts to decrease this escalating health care burden. Most published literature and guidelines address treatment rather than prevention, yet this approach may be too downstream to limit morbidity and mortality from the disease and its complications. Mechanisms to prevent CDI successfully include reducing modifiable risk factors and minimizing horizontal transmission of C. difficile spores between patients and the health care environment. Because CDI prevention is characterized by a bundled approach, it is difficult to quantify the individual impact of any one element; however, a number of patient‐ and facility‐level strategies can be considered for CDI prevention. Robust hygiene strategies, diagnostic and antimicrobial stewardship, and particular prophylaxis maneuvers such as continuation of oral vancomycin or fidaxomicin in the setting of systemic antibiotics have all demonstrated benefit. The preventive roles of deprescribing acid suppressants, routine use of probiotics, or early fecal microbiota transplantation remain unclear. The focus of this review is to summarize the evidence related to primary and secondary CDI prevention in critically ill adults and provide a concise implementation pathway for clinicians and policymakers.

Analysis of the impact of secondary prophylaxis on Clostridioides difficile recurrence in critically ill adults

“…This study emphasizes the challenging and common clinical question that arises when patients with a recent or persistent history of CDI require subsequent antibiotics, as there is little data to guide clinical practice regarding the provision of secondary prophylaxis, and many unanswered questions remain. 4,14 To our knowledge, based on an extensive literature search and a review of information from clinicaltrials. gov, ours is the first known study to evaluate the role of secondary CDI prophylaxis in a critically ill patient population, and there are no ongoing trials evaluating CDI secondary prophylaxis specifically in the ICU setting.…”

Prevention Strategies to Improve Outcomes in Critically Ill Adults

“…A metaanalysis 6 indicated that the benefit of acid suppressants for stress ulcer prophylaxis is limited to prevention of gastrointestinal bleeding, but mortality is not changed. Moreover, two other studies 7,8 suggested that acid suppressants may be associated with multidrug-resistant pneumonia and Clostridium difficile infection, respectively. The latter 8 provides actionable interventions to reduce C. difficile infection that include minimizing acid suppressant therapy.…”

“…Moreover, two other studies suggested that acid suppressants may be associated with multidrug‐resistant pneumonia and Clostridium difficile infection, respectively. The latter provides actionable interventions to reduce C. difficile infection that include minimizing acid suppressant therapy. At the very least, the sentiment expressed in these three articles leads to questions surrounding which outcome is important to prevent (gastrointestinal bleeding vs mortality) relative to the risk of increasing complications that may lead to worse outcomes.…”

Epidemiology and Prevention of Healthcare-Associated Infections in Geriatric Patients: A Narrative Review

“…Robust hygiene strategies (in particular a strong hand hygiene program), diagnostic and antimicrobial stewardship, and particular prophylaxis maneuvers such as continuation of oral vancomycin or fidaxomicin alongside systemic antibiotics have all demonstrated benefit. It is of fundamental importance to isolate infected patients as soon as possible after the onset of their first symptoms [85][86][87]. Many randomized controlled trial studies assessed probiotics as an adjunct to standard antibiotic treatment for the prevention of C. difficile infection.…”