COMMENTARY

Preventing Clostridium difficile Infection: Clarifying Common Misperceptions

Erik R. Dubberke, MD, MSPH

Disclosures

March 23, 2015

In This Article

Clostridium difficile Infection: No Small Problem

The study published by the Centers for Disease Control and Prevention (CDC) in the New England Journal of Medicine[1] highlights the tremendous burden of Clostridium difficile infection (CDI) in the United States. The CDC estimates that there were 453,000 incident cases of CDI in the United States in 2011, resulting in 29,300 deaths. Between 10% and 30% of people who have an initial episode of CDI will develop at least one recurrence.[2] On the basis of the number of incident cases found in 2011, 45,300-135,900 people developed recurrent CDI.[1,2]

The cost of treating CDI in the hospital is $3427-$9960 (in 2012 dollars), and the cost of treating patients with recurrent CDI is $11,631, for a total cost of more than $1.2 billion annually in the United States.[2,3] Hospital CDI incidence comparisons are now available on the Centers for Medicare & Medicaid Hospital Compare website. CDI will probably become a measure used for value-based purchasing, and thereby increase the cost of CDI to hospitals.

The morbidity, mortality, and cost of CDI highlight the importance of CDI prevention. Unfortunately, and in comparison with other healthcare-associated infections, the quality of data to support CDI prevention recommendations are relatively poor. For example, in the Society for Healthcare Epidemiology of America compendium to prevent healthcare-associated infections, all components of the basic central line-associated bloodstream infection (CLABSI) prevention bundle (eg, hand-washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, and avoiding the femoral site) have a moderate to high level of supporting evidence.[4,5] That is, randomized controlled trials of several of the individual CLABSI bundle components demonstrate a reduction in CLABSI incidence with their use. The CLABSI bundle itself has been validated as well.[6,7]

In contrast, there are no CDI prevention recommendations with a high quality of evidence, and for most recommendations, supporting evidence is of low quality.[8] Probably as a result of the lack of high-quality data, it is not uncommon for clinicians to have misperceptions about the key areas on which to focus to optimize CDI prevention in hospitals. Therefore, this review will cover the most important areas to focus on, as well as some misperceptions, based on our current understanding of CDI prevention.

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