A Hard Look at C.difficile- To What Degree Can it Be Prevented?

I have been giving some thought as of late to the vexing issue of C. difficile associated diarrhea (CDAD). To what degree can CDAD be prevented?

Unlike other hospital acquired infections,  such as  catheter associated urinary tract infections, central line associated bloodsteam infections and surgical site infections where the estimated impact of bundled interventions have been well studied (neatly summarized here), CDAD is a different beast. It is epidemiologically much more complex a matter.

Here is some background:

• A significant proportion of the population (up to 20%) is asymptomatically colonized with C.difficile and colonization is much more common than infection.
• There is no mechanism for identifying and treating / decolonizing asymptomatic carriers
• The only infection prevention strategy for asymptomatic carriers is universal gloving and gowning, hospital wide. This is likely not feasible.
• Alcohol based hand rubs, the preferred agents for hand hygiene, may be inferior to soap and water for hand hygiene

The cited interventions for preventing cross transmission of C.difficile are hand hygiene with soap and water, room cleaning with sporicidal agent, terminal enhanced cleaning with UV C light emitting technologies, contact precautions with a lab based alert system to heighten early recognition, antimicrobial stewardship and universal gown and glove.

Even with the above, many cases are not preventable as asymptomatic, colonized patients are not targeted by current infection prevention strategies and are likely a major reservoir of C.difficile.

No studies exist to confirm the expected, proportionate reduction in CDAD with the above bundled interventions (summarized here).

The prevention of CDAD continues to vex us. We are fooling ourselves if we feel that the current infection prevention practices will significant impact CDAD rates in the hospital.