What are the recommendations for Clostridioides difficile (Cdiff) prophylaxis?

Clostridioides difficile Prophylaxis

Pharmacologic prophylaxis with antibiotics (such as vancomycin or fidaxomicin) is NOT recommended for preventing primary C. difficile infection, as there is insufficient evidence to support this practice. 1

Primary Prevention Strategy: Antibiotic Stewardship

The cornerstone of CDI prevention is aggressive antibiotic stewardship rather than prophylactic antimicrobials:

High-Risk Antibiotics to Restrict

• Minimize or avoid fluoroquinolones, clindamycin, and cephalosporins (except for surgical prophylaxis), as these are the highest-risk agents for triggering CDI 1, 2
• Reduce the frequency, duration, and number of concurrent antibiotics prescribed, as CDI risk increases dramatically with multiple agents (adjusted hazard ratios: 2.5 for 2 antibiotics, 3.3 for 3-4 antibiotics, and 9.6 for ≥5 antibiotics) 3
• Discontinue inciting antibiotics as soon as clinically feasible when CDI develops 1

Institutional Measures

• Implement a formal antibiotic stewardship program targeting high-risk antibiotics based on local epidemiology 1, 2

Probiotics: Not Recommended

Do not use probiotics for primary CDI prevention outside of clinical trials, as current evidence is insufficient to support this practice 1

Proton Pump Inhibitor Management

While PPIs have an epidemiologic association with increased CDI risk (odds ratios 1.69-2.34):

• Discontinue unnecessary PPIs as part of good stewardship practice 1, 3
• However, there is insufficient evidence to discontinue PPIs solely as a CDI prevention measure if a legitimate indication exists 1
• For patients requiring continued PPI therapy, use the minimum effective dose 3

Important caveat: The number needed to harm varies dramatically by population—from 899-3,925 in the general population to only 28-50 in hospitalized patients on antibiotics, making PPI discontinuation most impactful in high-risk hospitalized patients 3

Infection Control Measures (Not Prophylaxis, But Essential Prevention)

These environmental and hygiene measures prevent transmission but are not pharmacologic prophylaxis:

Hand Hygiene

• Use soap and water preferentially over alcohol-based hand rubs, as alcohol does not kill C. difficile spores 1, 2, 4, 5
• In outbreak/hyperendemic settings, mandate soap and water exclusively 1, 2
• Soap and water reduces spore counts by approximately 0.89 log10 CFU/cm² more than water alone, while alcohol-based products show minimal additional benefit 5

Contact Precautions

• Implement contact precautions with gloves and gowns for all patients with suspected or confirmed CDI 1
• Continue precautions for at least 48 hours after diarrhea resolution, or until discharge in high-rate settings 1

Environmental Cleaning

• Use sporicidal agents (bleach-based solutions) for terminal room cleaning in outbreak/hyperendemic settings or when repeated cases occur in the same room 1, 2, 6
• Standard hospital germicides are NOT sporicidal and will not prevent transmission 6

Patient Placement

• Place patients in private rooms with dedicated toilets when possible, prioritizing those with stool incontinence 1

Common Pitfalls

• Do not rely on alcohol-based hand sanitizers when caring for patients at risk for or with CDI—they provide false reassurance while allowing spore transmission 2, 4, 5
• Do not screen asymptomatic carriers for placement on contact precautions, as there is insufficient evidence for this practice 1
• Do not use parenteral vancomycin for CDI prophylaxis or treatment—it is not effective for intestinal infections 7
• Residual C. difficile spores transfer readily (approximately 30% via handshake) even after alcohol-based hand rub use 5