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Volume 27, Number 7—July 2021
Synopsis

Risks and Preventive Strategies for Clostridioides difficile Transmission to Household or Community Contacts during Transition in Healthcare Settings

Ramin AsgaryComments to Author , Jessica A. Snead, Nabeel A. Wahid, Vicky Ro, Marina Halim, and Judy C. Stribling
Author affiliations: George Washington University, Washington, DC, USA (R. Asgary); Weill Cornell Medical College of Cornell University, New York, New York, USA (R. Asgary, N.A. Wahid, J.C. Stribling); New York Presbyterian Hospital of Cornell University, New York (J.A. Snead, N.A. Wahid, M. Halim); Columbia University Vagelos College of Physicians and Surgeons, New York (V. Ro)

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Table 4

Summary of current CDI prevention and treatment guidelines for in-patient settings*

Society/reference Scope Prevention recommendations Treatment recommendations
Infectious Disease Society of America and Society for Healthcare Epidemiology of America 2017 Update (4) Primarily targeted toward pediatric and adult inpatient facilities Isolate patients in private rooms with single toilets. In resource limited settings, prioritize incontinent patients in private rooms; cohort patients with same organism(s) when necessary. Healthcare workers should use gloves and gowns. Hand hygiene: use soap and water or alcohol-based hand hygiene; prefer handwashing in hyperendemic areas. Initiate isolation preemptively; continue isolation for at least 48 h after diarrhea resolves or until discharge. Encourage patient had washing and showering. Use disposable equipment when possible and disinfect with sporicidal disinfectant. Daily cleaning with sporicidal agent should be considered. Insufficient data for isolating asymptomatic carriers. Minimize frequency and duration of antimicrobial drugs; initiate antimicrobial rug stewardship programs. Discontinue inciting antimicrobial drugs; start treatment empirically when laboratory delay or fulminant CDI. Initial episode: oral vancomycin or fidaxomicin; Metronidazole second line. Fulminant CDI: prefer oral vancomycin (rectally if ileus). Recurrent CDI: oral vancomycin with taper OR 10-d course of fidaxomicin OR 10-d course of vancomycin if metronidazole was used for previous episode. Fecal transplantation recommended in patients with multiple recurrences who failed appropriate antimicrobial drugs. Above guidelines for adults
American College of Gastroenterology 2013 (13) Primarily targeted toward adults in acute care facilities Antimicrobial drug stewardship reduces risk for CDI. Isolate CDI patients in private or in a room with another CDI patient for at least 48 h after diarrhea stops. Encourage hand hygiene and barrier protection (gloves and gowns). Preferentially use single-use equipment; other equipment should be cleaned thoroughly with Environmental Protection Agency‒registered C. difficile‒-sporicidal label claim or 5,000 ppm chlorine-containing agents. Stop inciting antimicrobial drugs if possible. Mild-to-moderate CDI: metronidazole for 10 d. Severe: CDI: oral vancomycin for 10 d. Severe and complicated CDI: oral vancomycin plus intravenous metronidazole. Surgical consultation should be obtained for all patients with complicated CDI. If no response to metronidazole for 5–7 d, change to vancomycin. Rectal vancomycin if oral antimicrobial drugs cannot reach a segment of the colon. CT abdomen pelvis recommended in patients with complicated C. difficile . Recurrent CDI: first recurrence, same regimen used previously; second recurrence, pulsed vancomycin; third recurrence, fecal microbiota transplant should be considered
European Society of Clinical Microbiology and Infectious Diseases (14,15)
 Primarily targeted toward adults in acute care facilities in endemic and outbreak settings
 No specific recommendations regarding most effective technique for handwashing. Prefer handwashing over alcohol-based hand rub in outbreak settings, but not in endemic settings. Use gloves, gowns/disposable aprons to decrease transmission. Use daily sporicidal disinfection of rooms. No-touch disinfection systems may be effective in reducing transmission. Restrict antimicrobial drug agents/classes and decrease duration to decrease rates of CDI. Provide education to healthcare workers on prevention strategies.
 Nonsevere CDI in nonepidemic situations: can consider stopping inducing antimicrobial drugs and observing clinical response for 48 h before starting therapy; first-line treatments: oral metronidazole for 10 d, oral vancomycin for 10 d, oral fidaxomicin for 10 d. Severe CDI: prefer vancomycin over metronidazole; fidaxomicin noninferior to vancomycin. Total abdominal colectomy in following cases: perforation of colon or systemic inflammation and deterioration of clinical condition despite maximal antimicrobial drugs. First recurrence and multiple recurrences (nonsevere): prefer oral vancomycin or oral fidaxomicin. When oral treatment is unavailable, intravenous metronidazole is recommended.
World Society of Emergency Surgery 2019 (16) Primarily targeted toward adults in acute care facilities Use proper antimicrobial drug stewardship. Place C. difficile carriers (in addition to those actively effected) on contact precautions. Hand hygiene with soap and water. Stop unnecessary antimicrobial drugs and proton-pump inhibitors. Do not start empiric treatment for CDI unless there is strong clinical suspicion. Oral metronidazole limited to treatment for initial episode of mild-moderate CDI; use oral vancomycin if refractory to metronidazole. Severe CDI: use vancomycin or fidaxomicin. First recurrence: use vancomycin or fidaxomicin. Multiple recurrences: oral vancomycin using a tapered or pulsed regimen. Consider fecal microbiota transplantation if multiple recurrences with failure of appropriate antimicrobial drug treatments. Use vancomycin enema if oral antimicrobial drugs cannot reach colon. Indications for surgery (patients with severe CDI who progress to systemic toxicity should undergo early surgical consultation; Fulminant colitis: consider resection of entire colon). Consider prophylactic probiotics in inpatients receiving antimicrobial drugs during high-risk period before disease develops. Probiotics might be effective in the prevention of recurrent CDI in conjunction with standard antimicrobial drugs. Can consider monoclonal antibodies (bezlotoxumab) to prevent recurrences of CDI in patients with 027 epidemic strain in immunocompromised patients and in patients with severe CDI. Intravenous immunoglobulin should only be used as adjuvant therapy in patients with multiple recurrent or fulminant CDI.

*CDI, Clostridioides difficile infection.

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