Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities

• Create nurse-driven protocols^a to facilitate rapid isolation of patients with suspected or confirmed CDI
• For suspected patients, ensure rapid evaluation by healthcare personnel 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 for at least 48 hours after diarrhea has resolved, or longer, up to the duration of hospitalization^c
• Adhere to recommended hand hygiene practices
• Use dedicated patient-care equipment (e.g., blood pressure cuffs, stethoscopes)
• Implement daily patient bathing or showering with soap and water
• When transferring patients: Notify receiving wards or facilities about the patient’s CDI status so contact precautions are maintained at the patient’s new location

• Clinical personnel
  • Assess for appropriateness of testing: Consider other infectious or non-infectious^d causes of diarrhea before 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; tests may remain positive for ≥6 weeks
• Laboratory personnel
  • Implement laboratory procedures to ensure testing of only appropriate specimens (e.g., unformed stool) for C. difficile or its toxins
  • Report test results immediately to clinical care providers and infection control personnel 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 of CDI patient rooms 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 toilets
  • Clean and disinfect all shared equipment prior to use with another patient (e.g., wheelchairs, gurneys)
• Perform terminal cleaning after CDI patient transfer/discharge with a C. difficile sporicidal agent (EPA List K agent)
• 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)

• 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 for modifiable CDI risk factors including clinical management decisions (e.g., use of high-risk antibiotics) and gaps in infection control measures
• 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 providers, laboratory personnel, 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
• Assess the appropriateness of prescribing antibiotics that pose the highest risk for CDI, especially fluoroquinolones and 3^rd and 4^th generation cephalosporins
  • Develop facility-specific treatment recommendations for common infections that include first- and second-line antibiotics
  • Evaluate antibiotic treatment of conditions that commonly lead to high-risk antibiotic use, such as asymptomatic bacteriuria and common infections such as urinary tract infection and community-acquired pneumonia to minimize the use of high-risk antibiotics
  • Ensure that patients receive the shortest effective duration of antibiotic therapy
  • Include inpatient antibiotic duration when determining post-discharge antibiotic duration

The below interventions are listed as supplemental due to a limited evidence-base to support their use (theoretical benefit only), cost, or logistical difficulty in implementation. Supplemental interventions could be considered during an outbreak or if CDI reduction goals are not met with adherence to baseline strategies. Some interventions might have unintended consequences, and risks and benefits should be considered prior to implementation.  Supplemental interventions include:

• Dedicate healthcare personnel to the care of patients with CDI only (i.e., without responsibility to care for non-CDI patients),  to minimize the risk of transmission to others
• Restrict the use of antibiotics with the highest risk for CDI (e.g., fluoroquinolones)
• Limit the use of non-antibiotic patient medications (e.g., proton pump inhibitors, H2-receptor blockers) that are hypothesized to increase risk for CDI
• Expand the use of environmental disinfection strategies (e.g., sporicidal agents (EPA List K agent) for daily and terminal cleaning in all rooms on affected units
• Use of additional disinfection of CDI patient rooms with no-touch technologies (e.g., UV light)
• Evaluate and test patients at high risk for CDI to detect asymptomatic carriage
  • Isolate patients that test positive, but do not treat in the absence of symptoms
• Participate in regional CDI prevention activities