Preventing Clostridioides difficile infection in hospitals: what is the endgame?

Clostridioides difficile infection (CDI) remains an important healthcare-associated infection and threat to patient safety since the height of the NAP1/027 epidemic in the early part of the millennium. In 2011, C. difficile caused almost half a million infections and 29 000 deaths in the USA alone, with 24% of those cases occurring in hospital settings.1 The US Centres for Disease Control identifies C. difficile as one of three pathogens that poses ‘an immediate antibiotic resistance threat that requires urgent and aggressive action’.2 Many jurisdictions now require public reporting of hospital CDI rates. In some countries, hospitals face financial penalties for elevated CDI rates. CDI rates are also top priorities on hospital quality agendas, often associated with ambitious reduction targets. Some institutions even aim for complete elimination of healthcare-associated CDI—a goal referred to as ‘getting to zero’. There is no argument that healthcare-associated CDI is a significant patient safety issue and that aggressive efforts should be taken to prevent its harmful effects. However, external pressures and a lack of appreciation for the complexity of C. difficile epidemiology are interfering with the mission to prevent healthcare-associated CDI. We expose the challenges of the current approach to CDI prevention in hospitals and highlight where prevention efforts deserve further attention. With the focus on reducing CDI rates, diagnostic test stewardship for CDI is a popular quality improvement initiative in hospitals. Typical symptoms for CDI—diarrhoea and abdominal pain—are common in hospitalised patients due to comorbidities, medication exposures (including laxatives) and initiation of enteral feeds. Coupled with the increasing use of highly sensitive C. difficile molecular tests, CDI is overdiagnosed in up to half of those under investigation.3 Algorithms thus exist to discourage testing in patients with alternative aetiologies of diarrhoea. Diagnostic C. difficile test stewardship may provide the benefit of heightening accurate case …