How can Clostridioides difficile (C. difficile) infection be prevented when using clindamycin?

Preventing C. difficile Infection When Using Clindamycin

To prevent Clostridioides difficile infection (CDI) when using clindamycin, implement antibiotic stewardship by restricting clindamycin use to only necessary cases, minimizing duration of therapy, and considering alternative antibiotics when possible, as clindamycin is strongly associated with CDI risk. 1

Antibiotic Stewardship Strategies

• Minimize the frequency and duration of clindamycin therapy whenever possible, as it is one of the highest-risk antibiotics for CDI development 1
• Consider alternative antibiotics with lower CDI risk when clinically appropriate 1
• Implement an antibiotic stewardship program that specifically targets high-risk antibiotics like clindamycin, fluoroquinolones, and cephalosporins 1
• Discontinue clindamycin therapy as soon as clinically feasible to reduce CDI risk 1, 2
• When continued antibiotic therapy is necessary, consider switching from clindamycin to antibiotics less frequently implicated with CDI 3

Infection Control Measures

• Practice proper hand hygiene with soap and water before and after patient contact, as alcohol-based sanitizers do not effectively remove C. difficile spores 1
• In CDI outbreak or hyperendemic settings, preferentially use soap and water instead of alcohol-based hand hygiene products 1
• Implement contact precautions for patients with confirmed or suspected CDI 1
• Ensure thorough environmental cleaning with sporicidal agents, particularly in areas with ongoing C. difficile transmission 1
• Consider daily cleaning with sporicidal agents in settings with high CDI rates 1

Additional Preventive Strategies

• Discontinue unnecessary proton pump inhibitors (PPIs), as they have an epidemiologic association with increased CDI risk 1, 3
• For patients requiring continued PPI therapy, use the minimum effective dose 3
• Consider temporary discontinuation of PPIs during acute CDI treatment if clinically feasible 3
• Encourage patients to wash hands and shower to reduce the burden of spores on the skin 1
• Use disposable patient equipment when possible and ensure reusable equipment is thoroughly cleaned with sporicidal disinfectants 1

Clinical Considerations

• Be aware that a single dose of clindamycin can profoundly alter intestinal microbiota for extended periods (up to 28 days), creating sustained susceptibility to C. difficile colonization 4
• Monitor patients receiving clindamycin for symptoms of CDI (≥3 loose stools in 24 hours with no alternative explanation) 1
• The risk of CDI may persist for weeks after clindamycin discontinuation due to prolonged disruption of normal gut flora 4
• Restriction of clindamycin use at institutional level has been shown to effectively reduce nosocomial CDI rates 2

Common Pitfalls and Caveats

• Do not rely solely on alcohol-based hand sanitizers when caring for patients with CDI, as they do not kill C. difficile spores 1
• Avoid assuming that short courses of clindamycin are safe; even a single dose can significantly disrupt gut microbiota 4
• Do not overlook the importance of environmental cleaning, as C. difficile spores can persist in the environment for months 1
• Be aware that sub-inhibitory concentrations of clindamycin may affect toxin production in C. difficile, potentially influencing disease severity 5
• Remember that resolution of diarrhea does not necessarily indicate complete clearance of C. difficile, and patients may remain colonized and potentially infectious 4