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"Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)"

update in progress
Published: Infection Control and Hospital Epidemiology ; 2010 ; 31 : 431 -455

Abstract

This guideline is designed to improve the diagnosis and management of Clostridium difficile infection (CDI) in adult patients. A case of CDI is defined by the presence of symptoms (usually diarrhea) and either a stool test positive for C. difficile toxins or toxigenic C. difficile, or colonoscopic or histopathologic findings revealing pseudomembranous colitis. In addition to diagnosis and management, recommended methods of infection control and environmental management of the pathogen are presented. The recommendations are based on the best available evidence and practices, as determined by a joint Expert Panel appointed by SHEA and the Infectious Diseases Society of America (IDSA) (the SHEA-IDSA Expert Panel). The use of these guidelines can be impacted by the size of the institution and the resources, both financial and laboratory, available in the particular clinical setting. 

Full text

*Projected publication, Winter 2018

Recommendations

I. EPIDEMIOLOGY: WHAT ARE THE MINIMUM DATA THAT SHOULD BE COLLECTED FOR SURVEILLANCE PURPOSES AND HOW SHOULD THE DATA BE REPORTED?

  1. To increase comparability between clinical settings, use available standardized case definitions for surveillance of (1) healthcare facility (HCF)‐onset, HCF‐associated CDI; (2) community‐onset, HCF‐associated CDI; and (3) community‐associated CDI (Figure 1) (B‐III).
  2. At a minimum, conduct surveillance for HCF‐onset, HCF‐associated CDI in all inpatient healthcare facilities, to detect outbreaks and monitor patient safety (B‐III).
  3. Express the rate of healthcare‐associated CDI as the number of cases per 10,000 patient‐days (B‐III).
  4. If CDI rates are high compared with those at other facilities or if an outbreak is noted, stratify rates by patient location in order to target control measures (B‐III).

II. DIAGNOSIS: WHAT IS THE BEST TESTING STRATEGY TO DIAGNOSE CDI IN THE CLINICAL LABORATORY AND WHAT ARE ACCEPTABLE OPTIONS?

  1. Testing for C. difficile or its toxins should be performed only on diarrheal (unformed) stool, unless ileus due to C. difficile is suspected (B‐II).
  2. Testing of stool from asymptomatic patients is not clinically useful, including use as a test of cure. It is not recommended, except for epidemiological studies (B‐III).
  3. Stool culture is the most sensitive test and is essential for epidemiological studies (A‐II).
  4. Although stool culture is not clinically practical because of its slow turnaround time, the sensitivity and specificity of stool culture followed by identification of a toxigenic isolate (ie, toxigenic culture), as performed by an experienced laboratory, provides the standard against which other clinical test results should be compared (B‐III).
  5. Enzyme immunoassay (EIA) testing for C. difficile toxin A and B is rapid but is less sensitive than the cell cytotoxin assay, and it is thus a suboptimal alternative approach for diagnosis (B‐II).
  6. Toxin testing is most important clinically, but is hampered by its lack of sensitivity. One potential strategy to overcome this problem is a 2‐step method that uses EIA detection of glutamate dehydrogenase (GDH) as initial screening and then uses the cell cytotoxicity assay or toxigenic culture as the confirmatory test for GDH‐positive stool specimens only. Results appear to differ based on the GDH kit used; therefore, until more data are available on the sensitivity of GDH testing, this approach remains an interim recommendation (B‐II).
  7. Polymerase chain reaction (PCR) testing appears to be rapid, sensitive, and specific and may ultimately address testing concerns. More data on utility are necessary before this methodology can be recommended for routine testing (B‐II).
  8. Repeat testing during the same episode of diarrhea is of limited value and should be discouraged (B‐II).

III. INFECTION CONTROL AND PREVENTION: WHAT ARE THE MOST IMPORTANT INFECTION CONTROL MEASURES TO IMPLEMENT IN THE HOSPITAL DURING AN OUTBREAK OF CDI?

A. MEASURES FOR HEALTHCARE WORKERS, PATIENTS, AND VISITORS

  1. Healthcare workers and visitors must use gloves (A‐I) and gowns (B‐III) on entry to a room of a patient with CDI.
  2. Emphasize compliance with the practice of hand hygiene (A‐II).
  3. In a setting in which there is an outbreak or an increased CDI rate, instruct visitors and healthcare workers to wash hands with soap (or antimicrobial soap) and water after caring for or contacting patients with CDI (B‐III).
  4. Accommodate patients with CDI in a private room with contact precautions (B‐III). If single rooms are not available, cohort patients, providing a dedicated commode for each patient (C‐III).
  5. Maintain contact precautions for the duration of diarrhea (C‐III).
  6. Routine identification of asymptomatic carriers (patients or healthcare workers) for infection control purposes is not recommended (A‐III) and treatment of such identified patients is not effective (B‐I).

B. ENVIRONMENTAL CLEANING AND DISINFECTION

  1. Identification and removal of environmental sources of C. difficile, including replacement of electronic rectal thermometers with disposables, can reduce the incidence of CDI (B‐II).
  2. Use chlorine‐containing cleaning agents or other sporicidal agents to address environmental contamination in areas associated with increased rates of CDI (B‐II).
  3. Routine environmental screening for C. difficile is not recommended (C‐III).

C. ANTIMICROBIAL USE RESTRICTIONS

  1. Minimize the frequency and duration of antimicrobial therapy and the number of antimicrobial agents prescribed, to reduce CDI risk (A‐II).
  2. Implement an antimicrobial stewardship program (A‐II). Antimicrobials to be targeted should be based on the local epidemiology and the C. difficile strains present, but restricting the use of cephalosporin and clindamycin (except for surgical antibiotic prophylaxis) may be particularly useful (C‐III).

D. USE OF PROBIOTICS

  1. Administration of currently available probiotics is not recommended to prevent primary CDI, as there are limited data to support this approach and there is a potential risk of bloodstream infection (C‐III).

IV. TREATMENT: DOES THE CHOICE OF DRUG FOR CDI MATTER AND, IF SO, WHICH PATIENTS SHOULD BE TREATED AND WITH WHICH AGENT?

  1. Discontinue therapy with the inciting antimicrobial agent(s) as soon as possible, as this may influence the risk of CDI recurrence (A‐II).
  2. When severe or complicated CDI is suspected, initiate empirical treatment as soon as the diagnosis is suspected (C‐III).
  3. If the stool toxin assay result is negative, the decision to initiate, stop, or continue treatment must be individualized (C‐III).
  4. If possible, avoid use of antiperistaltic agents, as they may obscure symptoms and precipitate toxic megacolon (C‐III).
  5. Metronidazole is the drug of choice for the initial episode of mild‐to‐moderate CDI. The dosage is 500 mg orally 3 times per day for 10–14 days (A‐I).
  6. Vancomycin is the drug of choice for an initial episode of severe CDI. The dosage is 125 mg orally 4 times per day for 10–14 days. (B‐I)
  7. Vancomycin administered orally (and per rectum, if ileus is present) with or without intravenously administered metronidazole is the regimen of choice for the treatment of severe, complicated CDI. The vancomycin dosage is 500 mg orally 4 times per day and 500 mg in approximately 100 mL normal saline per rectum every 6 hours as a retention enema, and the metronidazole dosage is 500 mg intravenously every 8 hours (C‐III).
  8. Consider colectomy for severely ill patients. Monitoring the serum lactate level and the peripheral blood white blood cell count may be helpful in prompting a decision to operate, because a serum lactate level rising to 5 mmol/L and a white blood cell count rising to 50,000 cells per μL have been associated with greatly increased perioperative mortality. If surgical management is necessary, perform subtotal colectomy with preservation of the rectum. (B‐II)
  9. Treatment of the first recurrence of CDI is usually with the same regimen as for the initial episode (A‐II) but should be stratified by disease severity (mild‐to‐moderate, severe, or severe complicated), as is recommended for treatment of the initial CDI episode (C‐III).
  10. Do not use metronidazole beyond the first recurrence of CDI or for long‐term chronic therapy because of potential for cumulative neurotoxicity (B‐II).
  11. Treatment of the second or later recurrence of CDI with vancomycin therapy using a tapered and/or pulse regimen is the preferred next strategy (B‐III).
  12. No recommendations can be made regarding prevention of recurrent CDI in patients who require continued antimicrobial therapy for the underlying infection (C‐III).

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