Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities

Create nurse-driven protocols^a to facilitate immediate isolation of patients with suspected or confirmed CDI

• For suspected patients, ensure rapid evaluation by medical providers and infection prevention
• Place symptomatic patients^b on contact precautions, in a single-patient room with a dedicated toilet
  • If single-patient rooms are not available, cohort like patients
• For patients with confirmed CDI, maintain contact precautions throughout the duration of hospitalization^c
• Adhere to recommended hand hygiene practices
• Use dedicated patient-care equipment (e.g., blood pressure cuffs, stethoscopes), and use single-use disposable items (e.g., single patient digital thermometer) if possible
• Implement daily patient bathing or showering with soap and water
• When transferring patients: Notify receiving wards (intra-facility movement) or facilities (inter-facility transfer) about the patient’s CDI status so contact precautions are maintained at the patient’s new location

• Clinical staff
  • Assess for appropriateness of testing: Consider other infectious or non-infectious^d causes of diarrhea before proceeding to testing for CDI
  • Discontinue laxatives and wait for at least 48 hours before testing if still symptomatic
  • Once a patient has a positive CDI test do not repeat testing to detect cure; patients may remain positive for ≥6 weeks
• Laboratory personnel
  • Implement laboratory procedures to ensure testing of appropriate specimens (e.g., unformed stool) for C. difficile or its toxins
  • Report test results immediately to clinical care providers and infection control staff through reliable means (e.g., a laboratory alert system)

• Create daily and terminal cleaning protocols and checklists for patient-care areas and equipment
• Perform daily cleaning using a C. difficile sporicidal agent (EPA List K agent)
  • Clean and disinfect the patient-care environment (including the immediate vicinity around a CDI patient and high touch surfaces) at least once a day, including the toilets
  • Clean and disinfect all shared equipment prior to use by another patient
• Perform terminal cleaning after CDI patient transfer/discharge with a C. difficile sporicidal agent (EPA List K agent). Additional disinfection with no-touch technologies could be considered (e.g., UV light).
• Clean additional areas that are contaminated during transient visits by patients with suspected or confirmed CDI (e.g., Radiology, Emergency Departments, Physical Therapy) with a C. difficile sporicidal agent (EPA List K agent)
• Consider the need for cleaning of equipment that is commonly moved between patient rooms (e.g., housekeeping carts, wheelchairs, gurneys)

• Incorporate reduction of CDI into the facility healthcare-associated infection prevention program
  • Include a multidisciplinary workgroup, including nursing, environmental services, antibiotic stewardship to identify and implement strategies and to follow results of interventions
• Monitor facility CDI rates, and target units with highest incidence of CDI for evaluation and intervention
  • Review individual CDI episodes to assess modifiable CDI risk factors including clinical management decisions (e.g., use of high-risk antibiotics) and the use of infection control measures to identify gaps
• Educate and train healthcare personnel on prevention practices for CDI
• Routinely audit
  • Adherence to hand hygiene and contact precautions.
  • Adequacy of room cleaning using methods described in “Options for Evaluating Environments Cleaning”
• Provide CDI rates to senior leadership, clinical staff, laboratory staff, environmental services, and other stakeholders
  • Notify appropriate individuals and facility departments about changes in the incidence (or frequency), complications (including recurrences), or severity of CDI

• Implement the 7 Core Elements of Hospital Antibiotic Stewardship programs
• Assess the appropriateness of antibiotic prescribing for agents that pose the highest risk for CDI, especially fluoroquinolones and 3^rd and 4^th generation cephalosporins
  • Evaluate antibiotic treatment of common infections such as urinary tract infection, upper respiratory infections, and community-acquired pneumonia to ensure it is in accordance with facility or national guidelines and facility antibiogram
  • Consider developing facility-specific treatment recommendations for common infections that include first- and second-line antibiotics
  • Consider restriction of antibiotics with highest risk for CDI

*Supplemental strategies may be considered for use in circumstances such as an outbreak or if CDI reduction goals are not met.

• Consider participating in regional CDI prevention activities
• Cohorted patients should be managed by dedicated staff (i.e., without responsibility for care of non-CDI patients) to care for them to minimize the risk of transmission to other patients
• Consider evaluating and testing patients at high risk for CDI to detect asymptomatic carriage
  • Isolate patients that test positive, but do not treat in the absence of symptoms
    • Avoid using high-risk antibiotics
• Consider limiting the use of patient medications (e.g., proton pump inhibitors, H2-receptor blockers) that are hypothesized to increase risk for CDI