Clostridium difficile infection objectives updated

NHS Improvement | Clostridium difficile infection objectives for NHS organisations in 2018/19, guidance on sanction implementation and notification of changes to case attribution definitions from 2019| March 2018

NHS Improvement have updated the objectives on Clostridium difficile infection (CDI). This document outlines the objectives for acute trusts and clinical commissioning groups to make continuous improvement in Clostridium difficile infection (CDI) care.

They objectives are updated every April. The updated objectives are available from NHS Improvement 

Clostridium difficile infection assessment tool and action plan guidance can be accessed from NHS England 

Background information to the CDI objectives can be read here  


Is pulsed the answer to treatment of Clostridium difficile infection?

Antibiotic treatment of Clostridium difficile infection has been plagued by high rates of recurrent diarrhoea attributed to C difficile and requiring retreatment, often repeatedly. In the latest edition of The Lancet Infectious Diseases, Benoit Guery and colleagues describe a novel dosing regimen for fidaxomicin in which the standard 200 mg, 20-dose, 10-day regimen is extended (the EXTEND study) by giving 200 mg twice daily for the first 5 days, followed by 200 mg every-other-day for an additional 20 days. The comparator regimen was standard-dose vancomycin (125 mg four times daily for 10 days), which is the same comparator dose that was used in two phase 3 licensing trials of standard-dose fidaxomicin (200 mg twice daily for 10 days). (The Lancet Infectious Diseases)


Further information can be found  at The Lancet Infectious Diseases 

Full reference: Gerding, D. N| (2017) | Is pulsed dosing the answer to treatment of Clostridium difficile infection?| The Lancet Infectious Diseases | Published online

The full article is available for Rotherham NHS staff to request here 

Assessing the burden of Clostridium difficile infections for hospitals

Nosocomial infections place a heavy burden on the healthcare system. However, quantifying the burden raises many questions, ranging from the way to accurately estimate the extra length of stay at hospital to defining and costing the preventative methods among the different care providers | Journal of Hospital Infection

B0008374 Clostridium difficile colony
Image source: David Goulding, Wellcome Trust Sanger Institute – Wellcome Images // CC BY 4.0

A total of 52 episodes were screened during the study period. The estimated mean cost of CDI was approximately €23,909 (SD = 17,458) for an extended length of hospital stay (N = 27). In the case of a reduced length of the hospital stay (N = 25), the mean cost was approximately € –14,697 (SD = 16,936), which represents net savings for the hospitals. The main cost/savings driver was the productivity losses/gains resulting from the nosocomial infection. A sensitivity analysis showed that the main factor explaining the amount of costs or savings due to nosocomial infections was the length of the hospital stay.

Conclusion: We discuss the notion of productivity gains in the case of deaths as a factor revealing the incompleteness of the payment systems. We then discuss the methodological issues associated with the statistical method used to control for temporality bias.

Full reference: Hebbinckuys, E. et al. (2017) Assessing the burden of Clostridium difficile infections for hospitals. Journal of Hospital Infection. Published online: September 07, 2017

Can improving patient hand hygiene impact Clostridium difficile infection events at an academic medical center?


  • An educational intervention study was completed to improve patient hand hygiene opportunities for patients at a large academic medical center.
  • After the intervention, it was possible to study the effects of improved patient hand hygiene on health care facility–onset Clostridium difficile infection events.
  • C difficile infection events decreased significantly (P ≤ .05) for 6 months after the intervention.
  • Patient hand hygiene may be an underused prevention measure for C difficile disease; successful implementation requires staff to engage the patient with opportunities, reminders, and encouragement to keep their hands clean


Full reference: Pokrywka, M. et al. (2017) Can improving patient hand hygiene impact Clostridium difficile infection events at an academic medical center? American Journal of Infection Control. Vol. 45 (Issue 9) pp. 959–963

Antimicrobial stewardship program and Clostridium difficile

Institutional antimicrobial stewardship programs seek to decrease the occurrence of C difficile by implementing strategies to address antibiotic usage; however, optimal structure and strategies for accomplishing this remain largely unknown | American Journal of Infection Control

A colour-enhanced scanning electron micrograph image showing a cluster of Clostridium difficile on a surface.
Image source: Annie Cavanagh – Wellcome Images // CC BY-NC-ND 4.0

Image shows a colour-enhanced scanning electron micrograph image showing a cluster of Clostridium difficile on a surface.


  • More hospitals with non-better Clostridium difficile rank used prospective audit and feedback.
  • More better C difficile rank hospitals used a preauthorization strategy.
  • More better C difficile rank hospitals restricted more high-risk antibiotics.

Full reference: Barlow, G. et al. (2017) Associations between antimicrobial stewardship program elements and Clostridium difficile infection performance. American Journal of Infection Control. Published online: 27 July 2017.

Tobacco use as a screener for Clostridium difficile infection outcomes

A retrospective cohort study to evaluate the utility of self-reported tobacco use for developing a clinical prediction rule for poor outcomes of Clostridium difficile infection | Journal of Hospital Infection


We found that patients with any history of smoking were significantly less likely than never smokers to be cured of their infection within two weeks. Disease recurrence, readmission within thirty days, death before treatment completion, and the severity of Clostridium difficile infection were not associated with smoking status.

Full reference: Barker, A.K. et al. (2017) Tobacco use as a screener for Clostridium difficile infection outcomes. Journal of Hospital Infection. Published online: 26 June 2017

Are alcohol-based dispensers fomites for C difficile?

The purpose of this study was to evaluate alcohol-based dispensers as potential fomites for Clostridium difficile | American Journal of Infection Control


A convenience sample of 120 alcohol-based dispensers was evaluated for the presence of C difficile either by culture or polymerase chain reaction for C difficile toxin. The results demonstrated that C difficile was not cultured, and C difficile toxin was not detected using polymerase chain reaction; however, gram-positive rods, Clostridium perfringens, Pantoea agglomerans, coagulase-negative Staphylococcus, Peptostreptococcus, Bacillus spp, and microaerophilic Streptococcus were present within the overflow basins of the alcohol-based dispensers.

Full reference: Hall, J.A. et al. (2017) Dipping into the Clostridium difficile pool: Are alcohol-based dispensers fomites for C difficile? American Journal of Infection Control. DOI: 10.1016/j.ajic.2017.04.284

Risk Factors for Community-Associated Clostridium difficile Infection in Children

Adams, D.J. et al. The Journal of Pediatrics | Published online: 7 April 2017


Objective: To characterize the medication and other exposures associated with pediatric community-associated Clostridium difficile infections (CA-CDIs).

Conclusions: CA-CDI is associated with medications regularly prescribed in pediatric practice, along with exposure to outpatient healthcare clinics and family members with CDI. Our findings provide additional support for the judicious use of these medications and for efforts to limit spread of CDI in ambulatory healthcare settings and households.

Read the full abstract here

Clostridium difficile: still costly, still difficult to treat, and still here

Trafford, G. Journal of Hospital Infection | Published online: 18 March 2017
Image source: David Goulding, Wellcome Trust Sanger Institute – Wellcome Images // CC BY-NC-ND 4.0

Clostridium difficile infection (CDI) remains a formidable problem in the healthcare setting and there is much left to learn regarding the biology of this troublesome pathogen. This special section in this issue of the Journal contains a range of papers covering the epidemiology, treatment, and costs of CDI. Individual cases and outbreaks come at considerable cost to institutions, with the subset of patients who fail to respond to conventional antibiotic therapy presenting an even greater morbidity risk and cost largely due to increased length of stay

Read the abstract here

Effects of control interventions on Clostridium difficile infection in England

Dingle, K.E. et al. The Lancet Infectious Diseases. Published online: 24 January 2017

A colour-enhanced scanning electron micrograph image showing a cluster of Clostridium difficile on a surface.
Image source: Annie Cavanagh – Wellcome Images // CC BY-NC-ND 4.0

A colour-enhanced scanning electron micrograph image showing a cluster of Clostridium difficile on a surface.

Background: The control of Clostridium difficile infections is an international clinical challenge. The incidence of C difficile in England declined by roughly 80% after 2006, following the implementation of national control policies; we tested two hypotheses to investigate their role in this decline. First, if C difficile infection declines in England were driven by reductions in use of particular antibiotics, then incidence of C difficile infections caused by resistant isolates should decline faster than that caused by susceptible isolates across multiple genotypes. Second, if C difficile infection declines were driven by improvements in hospital infection control, then transmitted (secondary) cases should decline regardless of susceptibility.

Interpretation: Restricting fluoroquinolone prescribing appears to explain the decline in incidence of C difficile infections, above other measures, in Oxfordshire and Leeds, England. Antimicrobial stewardship should be a central component of C difficile infection control programmes.

Read the full article here