Clostridium difficile infection (CDI) is one of the most common causes of infectious healthcare-associated diarrhea in hospitals, with as many as 25% of cases caused by the organism. The increasing incidence and severity of CDI has led to greater efforts to prevent healthcare-associated CDI. The infection has been associated with increased length of hospital stay and inflicts a significant financial burden on healthcare institutions, with an estimated cost of $1.1 billion per year in the United States.

“There have been several recent studies analyzing the prevalence of C difficile,” says Jennifer L. Hsu, MD. “One recent investigation showed about 13.1 patients per 1,000 in U.S. hospitals acquired CDI, and about 73% of those were healthcare-associated. In addition, studies have found acquisition rates of CDI in 1% to 13% of patients hospitalized for less than 1 week. This figure increases to 50% for patients hospitalized for more than 4 weeks.”

Key Recommendations

Researchers from the University of Wisconsin School of Medicine and Public Health conducted a systematic review of interventions to reduce healthcare-associated CDI. Searching multiple computerized databases and relevant articles, the study team sought to identify interventions that were deemed effective in preventing CDI. Although more research is needed on many established and novel prevention measures, the review revealed that antimicrobial stewardship, glove use, and disposable thermometers can be recommended for the prevention of CDI (Table).

“Traditional hand hygiene with soap and water has clearly been shown to reduce the rates of CDI,” says Dr. Hsu, who was the lead author of the review. “Two studies examined the effects of alcohol-based hand rub products on the rates CDI. One found a slight decrease in rates, while the other found no change. The concern is that alcohol-based hand rubs are not active against the spores of C difficile. As such, use of traditional hand hygiene with soap and water is recommended.”

“It’s critical for hospitals to establish methods to monitor hand hygiene. While this can be challenging for institutions, it’s a practice that is required to reduce the burden of healthcare-acquired infections.”

There is also sufficient evidence suggesting that CDI can spread from the hands, equipment, or clothing of healthcare workers. A prospective, non-randomized study that assessed the use of vinyl gloves found a decrease in healthcare-associated CDI rates from 7.7 per 1,000 patient discharges before glove use to 1.5 per 1,000 after implementation of glove use. “There also was a decrease in CDI rates with the use of disposable rectal thermometers,” says Dr. Hsu. “On the basis of the studies we reviewed, single-use disposable thermometers are recommended for preventing the transmission of CDI.”

The review notes that the oldest measure to prevent healthcare-associated infections is hand hygiene. However, despite broad acknowledgement that hand washing is the cornerstone of healthcare-associated infection control programs, achieving over 50% compliance has been difficult. “It’s critical for hospitals to establish methods to monitor hand hygiene,” says Dr. Hsu. “While this can be challenging for institutions, it’s a practice that is required to reduce the burden of healthcare-acquired infections. Hospitals should observe compliance among staff directly and regularly. They should also monitor their use of barrier precautions on a regular basis.”

Treatment of Asymptomatic Patients

Patients who are asymptomatic carriers of C difficile may contribute to horizontal spread within an institution. Studies examining asymptomatic carriage of CDI have not found that treating these individuals leads to interrupted healthcare transmission. “Two studies looked at prevention of CDI by treating asymptomatic carriers in the hospital with metronidazole or vancomycin,” says Dr. Hsu. “Metronidazole was not effective at eliminating carriage. Vancomycin initially cleared C difficile from the stools, but the rate of recolonization was high at the 2-month follow-up. Our review does not provide sufficient evidence about the treatment of asymptomatic carriers. This is in agreement with current guidelines, which do not support treatment of asymptomatic carriage of C difficile.”

Research Areas of Interest

According to Dr. Hsu, there are two particular areas of active research with regard to the management of CDI. One is environmental disinfection and the use of hydrogen peroxide vapor as a possible means of environmental disinfection. “Thus far, the evidence speaks to needing bleach products for successful decontamination of surfaces because it is the only sporicidal agent,” she says. “However, there is active research into using hydrogen peroxide vapor. Although this strategy appears to be promising, we don’t have enough data at this point to recommend it universally.”

The other area of active research surrounds the use of probiotics. “It is biologically plausible that when you disrupt the normal gastrointestinal flora with antimicrobials, you risk predisposing patients to CDI,” says Dr. Hsu. “Probiotics such as Lactobacillus may help reestablish that normal gastrointestinal flora. However, there is currently insufficient evidence to recommend routine use of probiotics to prevent CDI. Larger trials with longer follow-up are needed to better assess the efficacy of probiotics for the prevention of CDI. The hope is that investigators conduct more research into environmental disinfection strategies and the use of probiotics so that we can find more ways to further reduce the burden of CDI in hospitals.”



Hsu J, Abad C, Dinh M, Safdar N. Prevention of Endemic Healthcare-Associated Clostridium difficile Infection: Reviewing the Evidence. Am J Gastroenterol. 2010 Jul 6. [Epub ahead of print].

Jarvis WR, Schlosser J, Jarvis AA, et al. National point prevalence of Clostridium difficile in US health care facility inpatients, 2008. Am J Infect Control. 2009;37:263-270.

McDonald LC, Coignard B,  Dubberke E, et al. Recommendations for surveillance of Clostridium difficile-associated disease. Infect Control Hosp Epidemiol. 2007;28:140-145.

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