Healthcare-Associated Infections _ ______________________________________________________________
SHEA/IDSA GUIDELINES FOR INFECTION CONTROL MEASURES FOR CLOSTRIDIOIDES DIFFICILE Restriction of Antibiotic Use • Minimize the frequency and duration of antibiotic therapy and the number of antibiotic agents prescribed (level II, A). • Implement an antibiotic stewardship program (level II, A). Antibiotic to be targeted should be based on the local epidemiology and the C. difficile strains present, but restricting the use of fluoroquinolones, cephalosporin and clindamycin (except for surgical antibiotic prophylaxis) may be particularly useful (level III, C). Measures for Healthcare Workers, Patients, and Visitors • Healthcare personnel and visitors must use gloves (level I, A) and gowns (level III, B) on entering the room of a patient with C. difficile infection. • Emphasize compliance with appropriate hand hygiene (level II, A). • Instruct visitors and healthcare personnel to wash hands with soap (or antimicrobial soap) and water before and after caring for or contacting patients with C. difficile infection (level III, B). • Use a private room with contact precautions for patients with C. difficile infection (level III, B); cohort patients if single
rooms are not available, and provide a dedicated commode for each patient (level III, C). • Maintain contact precautions until 48 hours after diarrhea has resolved (level III, C). Environmental Cleaning and Disinfection
• Identify and remove environmental sources of C. difficile , to reduce the incidence of infection (level II, B). • Use chlorine-containing cleaning agents or other sporicidal agents to address environmental contamination in areas associated with increased rates of C. difficile infection (level II, B). Source: [35] Table 16
II, B) [35]. The SHEA/IDSA guidelines note that polymerase chain reaction testing appears to be rapid, sensitive, and spe- cific, but more data on its usefulness are needed before it can be recommended for routine use (level II, B) [35]. Treatment The most important step in treating C. difficile- associated diarrhea is to discontinue the inciting antibiotic as soon as possible [35]. This approach alone will lead to resolution of diarrhea in approximately 15% to 25% of patients with mild infection [270; 282]. Antibiotic treatment of the diarrhea should not begin until the culture or toxin assay results are known, as approximately 30% of hospitalized patients with antibiotic-associated diarrhea will have C. difficile infection [35]. However, if severe or complicated C. difficile infection is suspected, empirical treatment should be started as soon as the diagnosis is suspected (level III, C) [35]. The SHEA/ IDSA guidelines recommend fidaxomicin rather than a stan- dard course of vancomycin for an initial episode of C. difficile gastrointestinal infection, whether mild or moderately severe. Implementation of this recommendation depends upon avail- able resources. This recommendation places a high value on the beneficial effects and safety of fidaxomicin. Vancomycin remains an acceptable alternative [274]. Metronidazole has demonstrated decreasing efficacy and is no longer recom- mended. For an initial episode of C. difficile , a dosage of fidax- omicin 200 mg orally twice daily for 10 days is recommended. Vancomycin 125 mg orally four times per day for 10 days is the recommended alternative regimen [274]. Table 17 outlines the guideline recommendations for treatment according to severity of illness [274].
According to the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America
(SHEA), patients with at least three unexplained and new-onset unformed stools in 24 hours are the preferred target population for testing for Clostridioides difficile infection (CDI). (https://www.idsociety.org/practice-guideline/ clostridium-difficile. Last accessed January 26, 2025.) Strength of Recommendation/Level of Evidence : Weak recommendation, very low quality of evidence Diagnostic stool testing should be done only on unformed stool (level II, B), and testing for asymptomatic patients is not useful (level III, B) [35]. Repeat testing during the same episode of diarrhea is discouraged, as it does not provide clinically useful information (level II, B) [35]. Several diagnostic tests are available to detect C. difficile , and they vary in terms of sensitivity, specificity, and turnaround times. Stool culture is the most sensitive test, but it is not clini- cally practical because of the slow turnaround time [35]. The sensitivity of cell cytotoxicity assay has been reported to range from 67% to 100%, whereas enzyme immunoassay testing for toxins A and B has a sensitivity ranging from 63% to 94% and a specificity of 75% to 100% [35]. Enzyme immunoassay testing is rapid and less expensive than other tests but it is a suboptimal choice compared with cell cytotoxicity assay (level
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