Implementing AHRQ Effective Health Care Reviews

Helping Clinicians Make Better Treatment Choices

Clostridium difficile Infection: Prevention and Treatment

 

The online version of this article has been updated to incorporate recommendations from the SHEA/IDSA clinical practice guideline published on February 15, 2018.

Am Fam Physician. 2018 Feb 1;97(3):196-199.

Key Clinical Issue

How effective are interventions to prevent and treat Clostridium difficile infection?

Evidence-Based Answer

Antibiotic stewardship and handwashing campaigns reduce C. difficile infection without reported harms. (Strength of Recommendation [SOR]: B, based on inconsistent or limited-quality patient-oriented evidence.) Vancomycin has a higher initial cure rate than metronidazole, although the recurrence rate is equal between the two drugs. Fidaxomicin has a lower recurrence rate than vancomycin, although there is no difference in the initial cure rate. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) There is low strength but consistent evidence that Lactobacillus, multiorganism probiotics, and fecal microbiota transplantation are effective in reducing C. difficile infection recurrence.1 (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.)

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CLINICAL BOTTOM LINE

Summary of Key Findings and Strength of Evidence for Interventions to Prevent Clostridium difficile Infection

InterventionNumber of studiesSummary of key findingsStrength of evidence

Antibiotic stewardship

6

Appropriate prescribing practices were associated with decreased C. difficile infection.

●○○

Handwashing campaigns

1

Handwashing campaigns reduced C. difficile infection incidence (rates fell from 16.75 to 9.49 cases per 10,000 bed days).

●○○

Multicomponent prevention interventions*

4

Multicomponent interventions were sustainable over several years.

●○○


Strength of evidence scale

●●● High: High confidence that the evidence reflects the true effect. Further research is very unlikely to change the confidence in the estimate of effect.

●●○ Moderate: Moderate confidence that the evidence reflects the true effect. Further research may change the confidence in the estimate of effect and may change the estimate.

●○○ Low: Low confidence that the evidence reflects the true effect. Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate.

○○○ Insufficient: Evidence either is unavailable or does not permit a conclusion.

*—Multicomponent interventions consisted of using multiple prevention strategies to reduce C. difficile rates (e.g., the simultaneous use of education, isolation, handwashing, contact precautions, and environmental disinfection).

Adapted from the Agency for Healthcare Research and Quality, Effective Health Care Program. Diagnosis, prevention, and treatment of C. difficile: current state of the evidence. Clinician summary. Rockville, Md.: Agency for Healthcare Research and Quality; May 2017. https://ahrq-ehc-application.s3.amazonaws.com/media/pdf/c-difficile-update_clinician.pdf. Accessed November 6, 2017.

CLINICAL BOTTOM LINE

Summary of Key Findings and Strength of Evidence for Interventions to Prevent Clostridium difficile Infection

InterventionNumber of studiesSummary of key findingsStrength of evidence

Antibiotic stewardship

6

Appropriate prescribing practices were associated with decreased C. difficile infection.

●○○

Handwashing campaigns

1

Handwashing campaigns reduced C. difficile infection incidence (rates fell from 16.75 to 9.49 cases per 10,000 bed days).

●○○

Multicomponent prevention interventions*

4

Multicomponent interventions were sustainable over several years.

●○○


Strength of evidence scale

●●● High: High confidence that the evidence reflects the true effect. Further research is very unlikely to change the confidence in the estimate of effect.

●●○ Moderate: Moderate confidence that the evidence reflects the true effect. Further research may change the confidence in the estimate of effect and may change the estimate.

●○○ Low: Low confidence that the evidence reflects the true effect. Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate.

○○○ Insufficient: Evidence either is unavailable or does not permit a conclusion.

*—Multicomponent interventions consisted of using multiple prevention strategies to reduce C. difficile rates (e.g., the simultaneous use of education, isolation, handwashing, contact precautions, and environmental disinfection).

Adapted from the Agency for Healthcare Research and Quality, Effective Health Care Program. Diagnosis, prevention, and treatment of C. difficile: current state of the evidence. Clinician summary. Rockville, Md.: Agency for Healthcare Research and Quality; May 2017. https://ahrq-ehc-application.s3.amazonaws.com/media/pdf/c-difficile-update_clinician.pdf. Accessed November 6, 2017.

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CLINICAL BOTTOM LINE

Summary of Key Findings and Strength of Evidence for the Effectiveness of Fecal Microbiota Transplantation in

Address correspondence to Tyler W. Barreto, MD, at barreto@uthscsa.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Butler M, Olson A, Drekonja D, et al. Early diagnosis, prevention, and treatment of Clostridium difficile: update. Rockville, Md.: Agency for Healthcare Research and Quality; March 2016. https://ahrq-ehc-application.s3.amazonaws.com/media/pdf/c-difficile-update_research.pdf. Accessed November 6, 2017....

2. DePestel DD, Aronoff DM. Epidemiology of Clostridium difficile infection. J Pharm Pract. 2013;26(5):464–475.

3. Dubberke ER, Olsen MA. Burden of Clostridium difficile on the healthcare system. Clin Infect Dis. 2012;55(suppl 2):S88–S92.

4. McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2018 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. . https://academic.oup.com/cid/advance-article/doi/10.1093/cid/cix1085/4855916. Accessed February 19, 2018.

5. Bezlotoxumab (Zinplava) for prevention of recurrent Clostridium difficile infection. JAMA. 2017;318(7):659–660.

The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer based upon the review. AHRQ's summary is accompanied by an interpretation by an AFP author that will help guide clinicians in making treatment decisions. For the full review, clinician summary, and consumer summary, go to https://effectivehealthcare.ahrq.gov/topics/c-difficile-update/clinician/.

This series is coordinated by Kenny Lin, MD, MPH, Deputy Editor for AFP Online.

A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at http://www.aafp.org/afp/ahrq.

 

 

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