What are the precautions and treatment options for Clostridioides difficile (C diff) infection?

C. difficile Infection Precautions and Treatment

Patients with C. difficile infection must be placed on contact precautions for at least 48 hours after diarrhea has resolved, and should be isolated in a private room with a dedicated toilet whenever possible. 1, 2

Infection Control Precautions

Isolation and Contact Precautions

• Place patient in a private room with dedicated toilet facilities 1, 2
• If private rooms are limited, prioritize patients with stool incontinence 1
• If cohorting is necessary, only cohort with other C. difficile patients (never with patients having other multidrug-resistant organisms) 1, 2
• Continue contact precautions for at least 48 hours after diarrhea resolves 1
• Consider prolonging contact precautions until discharge if facility CDI rates remain high 1

Hand Hygiene

• In routine settings: Perform hand hygiene before and after patient contact with either soap and water or alcohol-based products 1
• In outbreak or hyperendemic settings: Use soap and water preferentially over alcohol-based products due to superior spore removal 1, 2
• Alcohol-based sanitizers do not effectively kill C. difficile spores 1

Environmental Cleaning

• Daily cleaning with a sporicidal agent (particularly in outbreak settings) 1
• Terminal room cleaning with a sporicidal agent after patient discharge 1
• Use disposable patient equipment when possible 1
• Ensure reusable equipment is thoroughly cleaned with sporicidal disinfectants 1
• Encourage patients to wash hands and shower to reduce spore burden on skin 1
• Implement measures to verify cleaning effectiveness 1

Treatment Approach

Initial Management

• Discontinue the inciting antibiotic(s) as soon as possible to reduce recurrence risk 1
• If continued antibiotic therapy is required for another infection, choose agents less associated with CDI (aminoglycosides, sulfonamides, macrolides, tetracyclines) 1

Treatment Based on Severity

1. Mild-to-moderate CDI:

   • Fidaxomicin 200mg orally twice daily for 10 days (preferred) 3, 4
   • Alternative: Oral vancomycin 125mg four times daily for 10 days 1

2. Severe CDI:

   • Oral vancomycin 125mg four times daily for 10 days 1
   • Higher doses (up to 500mg) may be used in severe or fulminant cases 1

3. Recurrent CDI:

   • Vancomycin taper and pulse regimen or fidaxomicin 4
   • Consider bezlotoxumab (monoclonal antibody against toxin B) for patients at high risk of recurrence 4, 5
   • For multiple recurrences: Consider fecal microbiota transplantation following a course of antibiotics 4, 5

Antibiotic Stewardship

• Implement an antibiotic stewardship program to reduce CDI risk 1
• Minimize frequency, duration, and number of antibiotics prescribed 1
• Target restriction of fluoroquinolones, clindamycin, and cephalosporins based on local epidemiology 1
• Discontinue unnecessary proton pump inhibitors (PPIs) as they are associated with increased CDI risk, though evidence for this intervention is limited 1

Special Considerations

• Implement precautions while awaiting test results if CDI is suspected 2
• C. difficile is not transmitted via airborne route, so negative pressure rooms are not required 2
• Asymptomatic carriers: Insufficient data to recommend screening or placing on contact precautions 1

Common Pitfalls to Avoid

• Premature discontinuation of contact precautions (maintain for at least 48 hours after diarrhea resolution)
• Using alcohol-based hand sanitizers alone in outbreak settings (soap and water is superior for spore removal)
• Using non-sporicidal cleaning agents (ineffective against C. difficile spores)
• Failing to dedicate or properly disinfect patient care equipment
• Delaying treatment initiation while awaiting test results in highly suspicious cases

By implementing these comprehensive infection control measures and appropriate treatment strategies, healthcare facilities can effectively reduce C. difficile transmission and improve patient outcomes.