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∙ Develop a strong communication plan with environmental services to identify rooms requiring cleaning with a sporicidal disinfectant.
Data are conflicting as to whether inactivation of spores is necessary to prevent C. difficile transmission in the endemic setting.31 The decision to use a sporicidal disinfectant (eg, bleach) for C. difficile patient rooms in a nonoutbreak setting should take into consideration workflow and communication with environ- mental services. A system will be needed to alert environmental services staff to rooms requiring sporicidal disinfection. No studies have examined incubators as potential reservoirs
for C. difficile, though incubators have been implicated in trans- mission of vancomycin-resistant Enterococcus from patient to patient in a published study.38 Question: What is the role for antimicrobial stewardship in the prevention of C. difficile infection in infants? Answer: Antimicrobial stewardship has resulted in decreases in CDI in many populations, and because of its beneficial impact on other adverse events seen in the NICU, encouraging appropriate use of antimicrobials in the NICU should be a priority. Antimicrobial stewardship efforts have been shown to significantly decrease rates of CDI in adults,39 although data for the neonatal population are lacking and would be more challenging to interpret given high colonization rates. Prolonged use of empiric antibiotics in neonates has been associated with an increased risk of necrotizing enterocolitis and death40 and invasive candidiasis.41 Therefore, although no specific recommendation can be made regarding antimicrobial stewardship as a means of prevention of CDI in the NICU, every NICU should have stewardship processes in place to ensure appropriate use of antimicrobials.
Acknowledgments. The authors thank Susan Coffin, MD, MPH at Chil- dren’s Hospital of Philadelphia (CHOP) for her extensive and thoughtful review of the manuscript. NICUAdvisoryPanel:Kenneth M. Zangwill, MD, American Academy of Pediatrics (AAP); Nancy Foster, American Hospital Association (AHA); Katrina Crist, MBA, CAE, Association for Professionals in Infection Control and Epidemiology (APIC); Beth Huizinga, MSN, RNC-NIC, National Association of Neonatal Nurses (NANN); Pablo Sanchez, MD, Infectious Diseases Society of America (IDSA); Aaron M. Milstone, MD, Pediatric Infectious Diseases Society (PIDS); Margaret VanAmringe, MHS, The Joint Commission.
Conflicts of Interest. The following disclosures have been reported to SHEA. To provide thorough transparency, SHEA requires full disclosure of all relationships, regardless of relevancy to the guideline topic. Evaluation of such relationships as potential conflicts of interest is determined by a review pro- cess. The assessment of disclosed relationships for possible COI will be based on the relative weight of the financial relationship (ie, monetary amount) and the relevance of the relationship (ie, the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recommendation of consideration). The reader of this guidance should be mindful of this when the list of disclosures is reviewed. T.S. reports research grants/contracts with NIH/NIAID BIDMC/Boston
Children’s Hospital: Ultrasensitive C. difficile Toxin Measurement for Diagnosis and Outcome Prediction; LEAP (IDSA, SHEA, PIDS): assessing and optimizing the utility of the Massachusetts statewide antibiogram; hospital bacterial genomics to elucidate the source of HAIs; effect of a revised clinical practice guideline for empiric treatment of fever and neutropenia on microbiological resistance patterns in pediatric oncology patients. K.B. reports honoraria from MedStudy, research funding from Pfizer for clinical vaccine trials, clinical funding from Kosair Charities for the University of Louisville Department of Pediatrics Fellowship Program in Pediatric Infectious Disease (>$25,000), and organizational involvement with PIDS and the PIDS Foundation. A.B. reports advisory/consultant role with CVS/Caremark, research grants/contracts with
Thomas J. Sandora et al
NIDCD Lead Investigator: Albert H. Park, MD, University of Utah School of Medicine, ‘Randomized Controlled Trial of Valganciclovir for Asymptomatic Cytomegalovirus Infected Hearing Impaired Infants’ PCORI Lead Investigator: Jane C. Burns, MD, UCSD, Kawasaki Disease Comparative Effectiveness Trial. All other authors report that they have nothing to disclose.
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