New guidance deems antibiotic stewardship essential for preventing C diff infections

C difficile bacteria

CDC / Jennifer Oosthuizen

New guidance from five US medical organizations says implementing antimicrobial stewardship programs (ASPs) in acute care hospitals is essential for preventing Clostridioides difficile infection (CDI).

The document, published today in Infection Control & Hospital Epidemiology, says ASPs are needed not only to ensure that patients with CDI are receiving appropriate antibiotic therapy for their infections, but that patients with other infections are receiving appropriate antibiotics as well. Previous antibiotic exposure is among the leading risk factors for C difficile, which causes more than 450,000 infections in the United States each year, is associated with as many as 30,000 deaths, and costs the healthcare system $5 billion annually.

"C. difficile is an urgent health threat, and hospitals need system-wide commitment to stop it," lead author Larry K. Kociolek, MD, vice president of system preparedness, prevention, and response at Lurie's Children's Hospital of Chicago and a member of the Society for Healthcare Epidemiology of America (SHEA), said in a press release. "Because the use of antibiotics is strongly associated with C. difficile infections, antimicrobial stewardship—an approach to making sure these drugs are prescribed and used appropriately—is a strong first-line defense."  

The most modifiable risk factor

The new guidance is a collaborative effort that includes a panel of experts affiliated with SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control, and The Joint Commission, with contributions from the Centers for Disease Control and Prevention (CDC). It updates a previous set of strategies for preventing CDI in acute care hospitals, published in 2014, that encouraged the formation of ASPs but did not recommend it as an essential practice.

CDI occurs when C difficile bacteria multiply in the gut and release toxins that inflame the colon and cause severe diarrhea. It commonly occurs after patients take antibiotics, which can wipe out both good and bad bacteria in the gut and create room for C difficile to flourish.

The guidance notes that while third/fourth-generation cephalosporins, fluoroquinolones, carbapenems, and clindamycin confer the highest risk of CDI, virtually every antibiotic has been associated with the infection. Other significant CDI risk factors include advanced age, length of hospitalization, use of gastric acid-suppressing medication, gastrointestinal surgery, and inflammatory bowel disease.

"Antibiotic exposure is the most modifiable risk factor for CDI," the experts wrote.

Research indicates that a significant amount of antibiotic use in hospitals is inappropriate. A 2021 study led by the CDC found that 56% of antibiotic use in US hospitals in 2015 was unsupported, either because patients didn't have signs or symptoms of a bacterial infection, the wrong antibiotic was prescribed, or the length of treatment was too long.

Because the use of antibiotics is strongly associated with C. difficile infections, antimicrobial stewardship—an approach to making sure these drugs are prescribed and used appropriately—is a strong first-line defense.

The data from that study were collected only a year after the CDC recommended that all US hospitals have an ASP. In 2018, roughly 85% of acute care hospitals reported having all seven of the CDC's core elements of hospital ASPs in place, up from 41% in 2014.

The experts note that two large meta-analyses suggest that ASP implementation reduces CDI incidence in hospitals by 30% to 50%.

Emphasis on diagnostic stewardship, room cleaning

Another strategy deemed essential for preventing CDI in the new guidance is implementing diagnostic stewardship to ensure that C difficile testing is being performed appropriately. The document explains that the tests used to detect C difficile should be used judiciously because they can't reliably differentiate colonization from infection, which can result in misdiagnosis and unnecessary antibiotic use.

The experts urge C difficile testing be avoided, at minimum, in patients without clinically significant diarrhea, those who have been tested in the previous 7 days, and children under 1 year of age.

The third new essential practice recommendation is assessing the adequacy of room cleaning to improve cleaning and disinfection techniques. One of the reasons CDI has become such a burden for hospitals—which account for roughly half of 450,000 annual infections—is that C difficile spores are hard to get rid of and spread easily from sick patients to the hospital environment and healthcare workers­­, who then spread them to other patients.

Other essential practice recommendations carried over from the previous guidance include use of contact precautions for infected patients, adequate cleaning and disinfection of equipment and the environment of CDI patients, implementing a lab-based alert system to provide hospital staff with notifications of newly diagnosed CDI patients, conducting CDI surveillance and analyzing and reporting CDI data, educating patients and staff about CDI, and measuring compliance with hand hygiene and contact precaution recommendations.

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