Infection Control & Hospital Epidemiology In a population with a low pretest probability of disease, such
as NICU patients, the authors believe that it is most appropriate to choose a diagnostic approach that includes a toxin test to increase the specificity of the result. Although some experts have recommended that toxigenic culture be included as part of CDI testing for infants,26 it is impractical for most clinical labs to perform culture and this approach is rarely used in practice. Repeat testing after an initial negative result is associated with
higher rates of false-positive results and unnecessary antibiotic therapy.27–30 Similarly, “test of cure” specimens are not useful. C. difficile toxin can persist in stool for up to a month after reso- lution of diarrhea following treatment. Continued detection of toxin after disease resolution may lead to false-positive test results, unnecessary therapy, and prolonged contact precautions.31,32 Question: What is the preferred hand hygiene agent when caring for NICU patients who test positive for C. difficile? Answer:
1. In a nonoutbreak setting, there is no consensus on the optimal approach to hand hygiene when caring for a patient with CDI. Based on a hospital’s assessment of risk, any of the following options could be considered:
∙ Standard hand hygiene using alcohol-based hand rub (ABHR) for room entry and exit
∙ Soap and water hand hygiene for room exit only, with ABHR for room entry and when needed between tasks for a single patient unless hands are visibly soiled
∙ Soap and water preferred over ABHR for room entry and exit
2. Soap and water are recommended for hand hygiene during a C. difficile outbreak or in hyperendemic settings.
3. The facility must consider sink accessibility when making recommendations for soap-and-water hand hygiene.
Barriers to hand hygiene will have the effect of decreasing
hand hygiene compliance, so hand hygiene should be made as convenient as possible. Gloves are effective at preventing con- tamination of the hands with C. difficile, but they are not a substitute for effective hand hygiene.31 Patients may be infected or colonized with >1 pathogen, and ABHR effectively interrupts transmission of most other organisms.33 It is reasonable to use ABHR before patient contact and within the patient’s area when moving from dirty to clean (eg, after a dressing change or diaper change, before starting a feeding). Although alcohol is not sporicidal, handwashing with soap
and water is not a perfect option, as handwashing may remove<1 log10 of C. difficile spores.31 The potential advantage of soap and water for C. difficile spores must be weighed against the potential disadvantage of lower hand hygiene compliance when soap and water use is recommended. Hospitals should make recommendations according to their assessment of risk, as well as the availability of infrastructure (sinks and ABHR) to support those recommendations. Question: What is the appropriate type and duration of isolation for an infant with a positive C. difficile test? Recommendations:
∙ Infants with diarrhea and a positive C. difficile test should be placed on contact precautions. Infants without diarrhea who have tested positive for C. difficile do not require contact precautions.
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∙ Contact precautions can be discontinued 48 hours after diarrhea has resolved. At that time, consideration can be given to moving the patient to a new incubator and/or a new room.
Clostridioides difficile infections are transmitted from infected patients to other patients, either directly or indirectly, through the environment. Hands of healthcare workers in conjunction with environmental contamination are recognized sources of trans- mission.34,35 Healthcare worker hand contamination increases as the rate of environmental contamination increases. Environ- mental contamination is higher in rooms of patients with C. difficile-associated diarrhea than in rooms of patients who do not have diarrhea.36 Patients with asymptomatic C. difficile colonization shed spores, but generally they shed fewer spores and cause less contamination than symptomatic patients.31 Thus, contact precautions are important to preventing transmission from patients with CDI and should be used until 48 hours after resolution of diarrhea. Although prolongation of contact pre- cautions until discharge is a strategy that can be adopted for older patients when CDI rates remain high, extending this practice to NICU patients is not recommended for the following reasons:
1. Determining true CDI rates in the NICU is difficult because testing is not recommended and positive results most likely reflect colonization.
2. Prolonging contact precautions until discharge could result in extended isolation for premature infants who are expected to remain hospitalized for long durations. Although emerging data suggest that asymptomatic carriers may also play a role in transmission, current guidelines do not recommend using contact precautions for colonized patients without diarrhea.5
Bacterial burden in stool of patients with CDI decreases with appropriate treatment, but it does not correlate with the amount of diarrhea.37 Given the risk of persistent contamination of environmental surfaces in a patient’s room (and inside and around an incubator), consideration should be given to moving the patient to a new room and/or changing the incubator or warmer after diarrhea has resolved to further decrease the risk of transmission, although no specific data addressing the effective- ness of this strategy are available. Question: What is the appropriate cleaning and disinfection strategy for C. difficile in the NICU? Answer:
∙ In endemic settings, standard daily cleaning is appropriate. ∙ Bleach or another product with an Environmental Protec- tion Agency–approved claim for C. difficile sporicidal activity should be considered for disinfecting the environ- ment during CDI outbreaks or in hyperendemic settings.
∙ For patients whose CDI has resolved but whose continued hospitalization is required, consider moving the patient to a new room once diarrhea has resolved.
∙ Incubators may be thought of similarly to the patient’s room:
° In endemic settings, standard cleaning and processing of an incubator should occur before it is used for the next patient.
° Consider moving the patient to a clean incubator when diarrhea has resolved.
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