What strategies can be implemented in a hospital setting to reduce the incidence of Clostridioides difficile (C. diff) infections among elderly patients and those with underlying chronic conditions?

Hospital Strategies to Reduce C. difficile Infections in Elderly and High-Risk Patients

Implement an antibiotic stewardship program with restriction of fluoroquinolones, clindamycin, and cephalosporins, combined with daily sporicidal disinfection of high-touch surfaces using chlorine-based products—these are the most effective evidence-based interventions for reducing CDI in hospital settings. 1

Core Prevention Strategies (Highest Priority)

1. Antibiotic Stewardship (Most Critical)

• Minimize the frequency, duration, and number of antibiotic agents prescribed to reduce CDI risk, as this represents one of the most useful control measures 1
• Target fluoroquinolones, clindamycin, and cephalosporins (except for surgical prophylaxis) based on local epidemiology, as these antibiotics carry the highest CDI risk 1
• Implement either formulary restriction strategies or prospective audit and feedback mechanisms 1
• Studies demonstrate that antibiotic restriction can reduce CDI rates by 45-85% when properly implemented 1

2. Environmental Disinfection (Equally Critical)

• Perform daily to twice-daily disinfection of high-touch surfaces (including bed rails) using chlorine-based products, which achieves 45-85% reduction in CDI rates 1, 2
• Conduct terminal room cleaning with sporicidal agents (chlorine-based products with 5000 ppm available chlorine or equivalent) after patient discharge 1
• Agent-based modeling shows daily sporicidal cleaning reduces HO-CDI by 68.9%, making it the single most effective intervention 3
• A multi-site study demonstrated that optimized daily hospital-wide sporicidal disinfectant cleaning achieved a sustained 50% decrease in HO-CDI when cleaning thoroughness reached 93.6% 4

Important caveat: Sporicidal disinfection is most effective during outbreaks or hyperendemic settings; in endemic low-rate settings, the benefit may be less pronounced 1

3. Contact Precautions and Isolation

• Place patients with CDI in private rooms with dedicated toilets, prioritizing those with stool incontinence 1
• Use personal protective equipment (gloves and gowns/disposable aprons) for all patient contact 1
• Continue contact precautions for at least 48 hours after diarrhea resolution, or until discharge if CDI rates remain high despite standard measures 1
• Ensure disposable patient equipment when possible, with thorough sporicidal disinfection of reusable equipment 1

4. Hand Hygiene Protocols

• In routine endemic settings, perform hand hygiene with either soap and water or alcohol-based products before and after patient contact 1
• During outbreaks or hyperendemic settings, preferentially use soap and water instead of alcohol-based products due to superior spore removal 1
• Encourage patients to wash hands and shower to reduce spore burden on skin 1

Critical pitfall: Intensified hand hygiene practices alone without other interventions have NOT been shown to reduce CDI rates 1, 2

Supplemental Strategies

5. Surveillance and Monitoring

• Perform active CDI surveillance with timely feedback of infection rates at both hospital and ward levels 1
• Incorporate measures of cleaning effectiveness (fluorescent markers, ATP bioluminescence) with real-time feedback to environmental services staff 1
• A dedicated environmental services team focused on thorough cleaning is more effective than automated technologies alone 1

6. Advanced Environmental Technologies (Adjunctive)

• Consider UV light or hydrogen peroxide vapor (HPV) no-touch disinfection as supplements to, not replacements for, daily cleaning 1
• UV light technology shows statistically significant CDI reduction (RR = 0.64; 95% CI 0.49–0.84) 1
• HPV implementation reduced CDI rates from 1.0 to 0.4 cases per 1000 patient-days 1

Important limitation: Current evidence for automated disinfection technologies has significant methodological limitations including before-after designs and concurrent interventions 1

7. Healthcare Worker Education

• Educate all healthcare workers on CDI prevention strategies to enhance knowledge and skills 1
• Focus training on proper isolation precautions, environmental cleaning protocols, and antibiotic stewardship principles 1

8. Diagnostic Stewardship

• Test only patients with clinically significant diarrhea (≥3 loose stools in 24 hours) with no alternative explanation 1
• Implement expert review of C. difficile orders before testing, which can reduce inappropriate testing by 83.6% and HO-CDI by 41.7% 5
• Avoid testing formed stools or patients on laxatives 1

Strategies NOT Currently Recommended

What to Avoid

• Do NOT routinely screen asymptomatic patients for C. difficile colonization, as current guidelines find insufficient evidence despite promising single-center data 1
• Do NOT screen healthcare workers for C. difficile colonization as a routine control measure 1
• Do NOT rely on chlorhexidine bathing to reduce CDI rates, as it has proven ineffective 1, 2
• Insufficient evidence exists to recommend discontinuing proton pump inhibitors specifically for CDI prevention, though unnecessary PPIs should always be stopped 1

Special Considerations for Elderly and High-Risk Patients

Probiotic Prophylaxis (Conditional Recommendation)

• Consider Saccharomyces boulardii I-745 at 1 g/day or two-strain combination of L. acidophilus CL1285 and L. casei LBC80R for elderly hospitalized patients receiving antibiotics 6
• Number needed to treat is approximately 6-9 patients to prevent one case of antibiotic-associated diarrhea 6

Critical contraindication: Do NOT use probiotics in immunocompromised patients due to risk of bacteremia or fungemia 6

Optimal Bundle Approach

The most effective strategy combines: Daily sporicidal cleaning + antibiotic stewardship + contact precautions + surveillance, which modeling studies suggest can reduce HO-CDI by 82.3% and asymptomatic colonization by 90.6% 3

When implementing bundled interventions, prioritize the components with strongest evidence (antibiotic stewardship and environmental disinfection) before adding supplemental measures 1, 2