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"Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)

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Published: Clinical Infectious Diseases ; 2018 ; : -

Abstract

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.

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*Every 12 to 18 months following publication, IDSA reviews its guidelines to determine whether an update is required. The guideline was published February of 2018 and is the most current version.

Recommendations

Guideline Recommendations for Clostridium difficile Infection

Epidemiology

I. How Are CDI cases best defined?

  1. To increase comparability between clinical settings, use available standardized case definitions for surveillance of (1) healthcare facility-onset (HO) CDI; (2) community-onset, healthcare facility–associated (CO-HCFA) CDI; and (3) community-associated (CA) CDI (good practice recommendation).

II. What is the minimal surveillance recommendation for institutions with limited resources?

  1. At a minimum, conduct surveillance for HO-CDI in all inpatient healthcare facilities to detect elevated rates or outbreaks of CDI within the facility (weak recommendation, low quality of evidence).

III. What is the best way to express CDI incidence and rates?  

  1. Express the rate of HO-CDI as the number of cases per 10000 patient-days. Express the CO-HCFA prevalence rate as the number of cases per 1000 patient admissions (good practice recommendation).

IV. How should CDI surveillance be approached in settings of high endemic rates or outbreaks?

  1. Stratify data by patient location to target control measures when CDI incidence is above national and/or facility reduction goals or if an outbreak is noted (weak recommendation, low quality of evidence).
 

Epidemiology (Pediatric Considerations)

V. What is the recommended CDI surveillance strategy for pediatric institutions?

  1. Use the same standardized case definitions (HO, CO-HCFA, CA) and rate expression (cases per 10000 patient-days for HO, cases per 1000 patient admissions for CO-HCFA) in pediatric patients as for adults (good practice recommendation).
  2. Conduct surveillance for HO-CDI for inpatient pediatric facilities but do not include cases <2 years of age (weak recommendation, low quality of evidence).
  3. Consider surveillance for CA-CDI to detect trends in the community (weak recommendation, low quality of evidence).
 

Diagnosis

VI. What is the preferred population for C. difficile testing, and should efforts be made to achieve this target?

  1. Patients with unexplained and new-onset ≥3 unformed stools in 24 hours are the preferred target population for testing for CDI (weak recommendation, very low quality of evidence).

VII. What is the best-performing method (i.e., in use positive and negative predictive value) for detecting patients at increased risk for clinically significant C. difficile infection in commonly submitted stool specimens?

  1. Use a stool toxin test as part of a multistep algorithm (ie, glutamate dehydrogenase [GDH] plus toxin; GDH plus toxin, arbitrated by nucleic acid amplification test [NAAT]; or NAAT plus toxin) rather than a NAAT alone for all specimens received in the clinical laboratory when there are no preagreed institutional criteria for patient stool submission (Figure 2) (weak recommendation, low quality of evidence).

VIII. What is the most sensitive method of diagnosis of CDI in stool specimens from patients likely to have CDI based on clinical symptoms?

  1. Use a NAAT alone or a multistep algorithm for testing (ie, GDH plus toxin; GDH plus toxin, arbitrated by NAAT; or NAAT plus toxin) rather than a toxin test alone when there are preagreed institutional criteria for patient stool submission (Figure 2) (weak recommendation, low quality of evidence).

IX. What is the role of repeat testing, if any? Are there any symptomatic patients in whom repeat testing should be allowed, including test of cure?

  1. Do not perform repeat testing (within 7 days) during the same episode of diarrhea and do not test stool from asymptomatic patients, except for epidemiological studies (strong recommendation, moderate quality of evidence).

X. Does detection of fecal lactoferrin or another biologic marker improve the diagnosis of CDI over and above the detection of toxigenic C. difficile? Can such a subset predict a more ill cohort?

  1. There are insufficient data to recommend use of biologic markers as an adjunct to diagnosis (no recommendation).
 

Diagnosis (Pediatric Considerations)

XI. When should a neonate or infant be tested for C. difficile?

  1. Because of the high prevalence of asymptomatic carriage of toxigenic C. difficile in infants, testing for CDI should never be routinely recommended for neonates or infants ≤12 months of age with diarrhea (strong recommendation, moderate quality of evidence).

XII. When should a toddler or older child be tested for C. difficile?

  1. Clostridium difficile testing should not be routinely performed in children with diarrhea who are 1–2 years of age unless other infectious or noninfectious causes have been excluded (weak recommendation, low quality of evidence).
  2. In children ≥2 years of age, C. difficile testing is recommended for patients with prolonged or worsening diarrhea and risk factors (e.g., underlying inflammatory bowel disease or immunocompromising conditions) or relevant exposures (e.g., contact with the healthcare system or recent antibiotics) (weak recommendation, moderate quality of evidence).
 
 

Infection Prevention and Control

Isolation Measures for Patients with CDI

XIII. Should private rooms and/or dedicated toilet facilities be used for isolated patients with CDI?

  1. Accommodate patients with CDI in a private room with a dedicated toilet to decrease transmission to other patients. If there is a limited number of private single rooms, prioritize patients with stool incontinence for placement in private rooms (strong recommendation, moderate quality of evidence).
  2. If cohorting is required, it is recommended to cohort patients infected or colonized with the same organism(s)—that is, do not cohort patients with CDI who are discordant for other multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus (strong recommendation, moderate quality of evidence).

XIV. Should gloves and gowns be worn while caring for isolated CDI patients?

  1. Healthcare personnel must use gloves (strong recommendation, high quality of evidence) and gowns (strong recommendation, moderate quality of evidence) on entry to a room of a patient with CDI and while caring for patients with CDI.

XV. When should isolation be implemented?

  1. Patients with suspected CDI should be placed on preemptive contact precautions pending the C. difficile test results if test results cannot be obtained on the same day (strong recommendation, moderate quality of evidence).

XVI. How long should isolation be continued?

  1. Continue contact precautions for at least 48 hours after diarrhea has resolved (weak recommendation, low quality of evidence).
  2. Prolong contact precautions until discharge if CDI rates remain high despite implementation of standard infection control measures against CDI (weak recommendation, low quality of evidence).

XVII. What is the recommended hand hygiene method (assuming glove use) when caring for patients in isolation for CDI?

  1. In routine or endemic settings, perform hand hygiene before and after contact of a patient with CDI and after removing gloves with either soap and water or an alcohol-based hand hygiene product (strong recommendation, moderate quality of evidence).
  2. In CDI outbreaks or hyperendemic (sustained high rates) settings, perform hand hygiene with soap and water preferentially instead of alcohol-based hand hygiene products before and after caring for a patient with CDI given the increased efficacy of spore removal with soap and water (weak recommendation, low quality of evidence).
  3. Handwashing with soap and water is preferred if there is direct contact with feces or an area where fecal contamination is likely (e.g., the perineal region) (good practice recommendation).

XVIII. Should patient bathing interventions be implemented to prevent CDI?

  1. Encourage patients to wash hands and shower to reduce the burden of spores on the skin (good practice recommendation).

XIX. Should noncritical devices or equipment be dedicated to or specially cleaned after being used on the isolated patient with CDI?

  1. Use disposable patient equipment when possible and ensure that reusable equipment is thoroughly cleaned and disinfected, preferentially with a sporicidal disinfectant that is equipment compatible (strong recommendation, moderate quality of evidence).

XX. What is the role of manual, terminal disinfection using a C. difficile sporicidal agent for patients in isolation for CDI?

  1. Terminal room cleaning with a sporicidal agent should be considered in conjunction with other measures to prevent CDI during endemic high rates or outbreaks, or if there is evidence of repeated cases of CDI in the same room (weak recommendation, low quality of evidence).

XXI. Should cleaning adequacy be evaluated?

  1. Incorporate measures of cleaning effectiveness to ensure quality of environmental cleaning (good practice recommendation).

XXII. What is the role of automated terminal disinfection using a method that is sporicidal against C. difficile?

  1. There are limited data at this time to recommend use of automated, terminal disinfection using a sporicidal method for CDI prevention (no recommendation).

XXIII. What is the role of daily sporicidal disinfection?

  1. Daily cleaning with a sporicidal agent should be considered in conjunction with other measures to prevent CDI during outbreaks or in hyperendemic (sustained high rates) settings, or if there is evidence of repeated cases of CDI in the same room (weak recommendation, low quality of evidence).

XXIV. Should asymptomatic carriers of C. difficile be identified and isolated if positive?

  1. There are insufficient data to recommend screening for asymptomatic carriage and placing asymptomatic carriers on contact precautions (no recommendation).

XXV. What is the role of antibiotic stewardship in controlling CDI rates?

  1. Minimize the frequency and duration of high-risk antibiotic therapy and the number of antibiotic agents prescribed, to reduce CDI risk (strong recommendation, moderate quality of evidence).
  2. Implement an antibiotic stewardship program (good practice recommendation).
  3. Antibiotics to be targeted should be based on the local epidemiology and the C. difficile strains present. Restriction of fluoroquinolones, clindamycin, and cephalosporins (except for surgical antibiotic prophylaxis) should be considered (strong recommendation, moderate quality of evidence).

XXVI. What is the role of proton pump inhibitor restriction in controlling CDI rates?

  1. Although there is an epidemiologic association between proton pump inhibitor (PPI) use and CDI, and unnecessary PPIs should always be discontinued, there is insufficient evidence for discontinuation of PPIs as a measure for preventing CDI (no recommendation).

XXVII. What is the role in primary prevention of CDI?

  1. There are insufficient data at this time to recommend administration of probiotics for primary prevention of CDI outside of clinical trials (no recommendation).
 

Treatment

XXVIII. What are important ancillary treatment strategies for CDI?

  1. Discontinue therapy with the inciting antibiotic agent(s) as soon as possible, as this may influence the risk of CDI recurrence (strong recommendation, moderate quality of evidence).
  2. Antibiotic therapy for CDI should be started empirically for situations where a substantial delay in laboratory confirmation is expected, or for fulminant CDI (described in section XXX) (weak recommendation, low quality of evidence).

XXIX. What are the best treatments of an initial CDI episode to ensure resolution of symptoms and sustained resolution 1 month after treatment?

  1. Either vancomycin or fidaxomicin is recommended over metronidazole for an initial episode of CDI. The dosage is vancomycin 125 mg orally 4 times per day or fidaxomicin 200 mg twice daily for 10 days (strong recommendation, high quality of evidence) (Table 1).
  2. In settings where access to vancomycin or fidaxomicin is limited, we suggest using metronidazole for an initial episode of nonsevere CDI only (weak recommendation, high quality of evidence). The suggested dosage is metronidazole 500 mg orally 3 times per day for 10 days. Avoid repeated or prolonged courses due to risk of cumulative and potentially irreversible neurotoxicity (strong recommendation, moderate quality of evidence). (See Treatment section for definition of CDI severity.)

XXX. What are the best treatments of fulminant CDI?

  1. For fulminant CDI*, vancomycin administered orally is the regimen of choice (strong recommendation, moderate quality of evidence). If ileus is present, vancomycin can also be administered per rectum (weak recommendation, low quality of evidence). 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. Intravenously administered metronidazole should be administered together with oral or rectal vancomycin, particularly if ileus is present (strong recommendation, moderate quality of evidence). The metronidazole dosage is 500 mg intravenously every 8 hours.*   (*Fulminant CDI, previously referred to as severe, complicated CDI, may be characterized by hypotension or shock, ileus, or megacolon.)
  2. If surgical management is necessary for severely ill patients, perform subtotal colectomy with preservation of the rectum (strong recommendation, moderate quality of evidence). Diverting loop ileostomy with colonic lavage followed by antegrade vancomycin flushes is an alternative approach that may lead to improved outcomes (weak recommendation, low quality of evidence).

XXXI. What are the best treatments for recurrent CDI?

  1. Treat a first recurrence of CDI with oral vancomycin as a tapered and pulsed regimen rather than a second standard 10-day course of vancomycin (weak recommendation, low quality of evidence), OR
  2. Treat a first recurrence of CDI with a 10-day course of fidaxomicin rather than a standard 10-day course of vancomycin (weak recommendation, moderate quality of evidence), OR
  3. Treat a first recurrence of CDI with a standard 10-day course of vancomycin rather than a second course of metronidazole if metronidazole was used for the primary episode (weak recommendation, low quality of evidence).
  4. Antibiotic treatment options for patients with >1 recurrence of CDI include oral vancomycin therapy using a tapered and pulsed regimen (weak recommendation, low quality of evidence), a standard course of oral vancomycin followed by rifaximin (weak recommendation, low quality of evidence), or fidaxomicin (weak recommendation, low quality of evidence).
  5. Fecal microbiota transplantation is recommended for patients with multiple recurrences of CDI who have failed appropriate antibiotic treatments (strong recommendation, moderate quality of evidence).
  6. There are insufficient data at this time to recommend extending the length of anti–C. difficile treatment beyond the recommended treatment course or restarting an anti–C. difficile agent empirically for patients who require continued antibiotic therapy directed against the underlying infection or who require retreatment with antibiotics shortly after completion of CDI treatment, respectively (no recommendation).
 

Treatment (Pediatric Considerations)

XXXII. What is the best treatment of an initial episode or first recurrence of nonsevere CDI in children?

  1. Either metronidazole or vancomycin is recommended for the treatment of children with an initial episode or first recurrence of nonsevere CDI (see Pediatric treatment section for dosing) (weak recommendation, low quality of evidence) (Table 2).

XXXIII. What is the best treatment of an initial episode of severe CDI in children?

  1. For children with an initial episode of severe CDI, oral vancomycin is recommended over metronidazole (strong recommendation, moderate quality of evidence).

XXXIV. What are the best treatments for a second or greater episode of recurrent CDI in children?

  1. For children with a second or greater episode of recurrent CDI, oral vancomycin is recommended over metronidazole (weak recommendation, low quality of evidence).

XXXV. Is there a role for fecal microbiota transplantation in children with recurrent CDI?

  1. Consider fecal microbiota transplantation for pediatric patients with multiple recurrences of CDI following standard antibiotic treatments (weak recommendation, very low quality of evidence).

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