Primary prevention
Using antimicrobial agents appropriately and discontinuing them as soon as possible helps reduce changes in bowel flora, thereby making the acquisition of Clostridioides difficile less likely.
Probiotics
The use of probiotics might be helpful in primary prevention. Current evidence suggests that the use of certain probiotic strains or combinations of probiotic strains may prevent C difficile infection in patients on antibiotic treatment, and the American Gastroenterology Association (AGA) guidelines recommend their use in this situation. However, the quality of evidence is low and the reporting of potential harms was not always consistent.[57]
Guidelines from the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) and the American College of Gastroenterology (ACG) do not recommend probiotics for the primary prevention of C difficile infection outside of clinical trials due to insufficient data.[2][58] The reason for the difference between recommendations between the AGA and the ACG is because the AGA accounted for strain specificity in their analysis of the evidence.[59]
A Cochrane review of 31 randomized controlled trials (8672 patients) found that there was moderate-quality evidence that probiotics were both safe and effective for preventing C difficile-associated diarrhea when used with antibiotics in patients who are not immunocompromised or severely debilitated.[60] [
]
[Evidence B]
Administering probiotics close to the first dose of antibiotics has been found to reduce the risk of C difficile infection by more than 50% in hospitalized adults.[61]
In one systematic review and meta-analysis, Lactobacillus casei ranked as the best intervention out of 9 probiotic interventions for the prevention of C difficile-associated disease.[62]
Infection prevention and control
Infection control advice and hand washing with soap and water will help prevent patient-to-patient spread. The World Health Organization provides guidelines on correct hand-washing technique. A structured washing technique was found to be more effective than an unstructured technique against C difficile.[63] WHO: guidelines on hand hygiene Opens in new window Patients should receive care with contact precautions for at least 48 hours after resolution of diarrhea.[64]
Environmental cleaning in hospitals is imperative to prevent the introduction or spread of pathogens.[65][66] Decontamination methods include the use of hydrogen peroxide, chlorine-releasing agents, and ultraviolet light. Hydrogen peroxide significantly reduced the frequency of C difficile contamination compared with hypochlorite, and reduced the incidence of hospital-acquired C difficile infection compared to other cleaning methods. UV decontamination significantly reduced the frequency of hospital-acquired C difficile infection compared with hypochlorite.[67]
It is not clear whether bathing critically ill patients with chlorhexidine reduces hospital‐acquired infections, mortality, or length of stay in the intensive care unit due to the very low‐certainty evidence available.[68]
Antimicrobial stewardship programs
Antimicrobial stewardship should be a central component of C difficile infection control programs.[28] Benefits of stewardship programs include reduced adverse effects and improved patient outcomes.
Recommendations include:[2]
Minimizing the frequency and duration of high-risk antibiotics, as well as the number of antibiotics prescribed, to reduce the risk of C difficile infection
Implementing an antibiotic stewardship program
Considering restriction of fluoroquinolones, clindamycin, and cephalosporins (except for surgical prophylaxis).
One meta-analysis found that stewardship programs have been shown to significantly reduce the incidence of C difficile infections by 32% in hospital inpatients, and were more effective when implemented with infection-control measures.[29]
Discontinuing proton-pump inhibitors
There is insufficient evidence to recommend discontinuing proton-pump inhibitors to prevent C difficile infection; however, they should be discontinued if they are not necessary.[2]
Vaccines
Vaccines are not available but several are in development.[69]
Secondary prevention
Use caution with antibiotics that are known to cause (or are suspected to cause) Clostridioides difficile infection (e.g., ampicillin, cephalosporins, clindamycin, carbapenems, and fluoroquinolones), particularly in specific patient groups (e.g., elderly people, hospitalized patients, and immunosuppressed patients). Strict hand washing should be observed.
Oral vancomycin prophylaxis may reduce the risk of recurrent infections in high-risk patients taking systemic antibiotics.[158] However, secondary prophylaxis strategies (e.g., probiotics, prophylactic doses of vancomycin or fidaxomicin) in patients who require antibiotic therapy for another indication after C difficile treatment have not been studied in randomized controlled trials. Probiotics are not recommended for prevention of recurrence.[58]
Bezlotoxumab, a human monoclonal antibody that binds to C difficile toxin B, may be considered for the prevention of recurrence in patients who are at high risk of recurrence. See the Emerging section for more information.
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