Primary prevention of Clostridium difficile infections – how difficult can it be?

Abstract

C. difficile infections (CDI) have been a challenging disease to treat, much less to prevent, for decades. Efforts for primary prevention have mainly focused on improving infection control practices, but CDI outbreaks continue to plague healthcare facilities. Areas covered: A literature search from 1970-December 2016 found 13 facility-level and 2 patient-level strategies that were evidence-based. The aim of this manuscript is to assess the current state of the literature on primary prevention of CDI and offer insights into which strategies may be more effective. Expert commentary: The strongest evidence for primary prevention is based on multi-faceted infection control bundles, while there is promising moderate evidence involving facility-wide use of specific probiotics. Moderate-level evidence was found for patient-level use of specific probiotics and low level evidence for vaccines. Future suggestions include use of consistent outcome metrics, measurements of implementation compliance and program sustainability.

Prevention of Clostridium difficile Infection in Critically Ill Adults

“…Second, the horizontal transmission of C. difficile spores from patients infected with CDI, asymptomatic carriers, and environmental surfaces must be interrupted to avoid an episode of nosocomial CDI in a subsequent susceptible host . To address these two mechanisms, specific strategies to prevent CDI are implemented at one of two levels: patient level (reducing susceptibility) or facility level (interrupting horizontal transmission) . Because many health systems incorporate both facility‐ and patient‐level components, the attributable impact of individual elements is uncertain and creates difficulty in determining which items should be a target for emphasis or accountability .…”

“…Because many health systems incorporate both facility‐ and patient‐level components, the attributable impact of individual elements is uncertain and creates difficulty in determining which items should be a target for emphasis or accountability . Bundles of CDI prevention strategies, often termed “standard prevention measures,” vary widely but typically have a common foundation of disrupting horizontal transmission of CDI and C. difficile spores by emphasizing timely detection of disease, hand hygiene, and environmental disinfection (e.g., terminal cleaning with effective agents) . The discussion that follows introduces specific strategies for prevention at the patient and facility level that are pertinent to clinical pharmacists: prevention of transmission, diagnostic stewardship, antimicrobial stewardship, CDI prophylaxis, deprescribing of acid suppression, routine use of probiotics, and other ancillary strategies.…”

“…14 To address these two mechanisms, specific strategies to prevent CDI are implemented at one of two levels: patient level (reducing susceptibility) or facility level (interrupting horizontal transmission). 9 Because many health systems incorporate both facility-and patient-level components, the attributable impact of individual elements is uncertain and creates difficulty in determining which items should be a target for emphasis or accountability. 15 Bundles of CDI prevention strategies, often termed "standard prevention measures," vary widely but typically have a common foundation of disrupting horizontal transmission of CDI and C. difficile spores by emphasizing timely detection of disease, hand hygiene, and environmental disinfection (e.g., terminal cleaning with effective agents).…”

“…Total prevalence of CDI in the ICU was estimated to be ~2% (11% among diarrheal patients), and the requirement of ICU services involves more severe or complicated courses of CDI . Indeed, C. difficile also remains a common colonizer in critically ill patients (10–20%), and spores are ubiquitous in ICUs, making this opportunistic pathogen difficult to control at a patient, facility, and community level …”

“…8 Indeed, C. difficile also remains a common colonizer in critically ill patients (10-20%), and spores are ubiquitous in ICUs, making this opportunistic pathogen difficult to control at a patient, facility, and community level. 9 Numerous clinical investigations have assessed optimal ways to treat active CDI. 10 Recently updated guidelines from the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) summarize best practices for CDI diagnosis and management.…”