title: Prevention of endemic healthcare-associated Clostridium difficile infection: reviewing the evidence.
abstract: OBJECTIVE
  Clostridium difficile is the most common infectious cause of healthcare-associated diarrhea. Because of the increasing incidence and severity of endemic C. difficile infection (CDI), interventions to prevent healthcare-associated CDI are essential. We undertook a systematic review of interventions to reduce healthcare-associated CDI.
  
  
  METHODS
  We searched multiple computerized databases, and manually searched for relevant articles to determine which interventions are useful in preventing CDI. Studies were required to be controlled in design and to report the incidence of endemic CDI as an outcome. Data on the patient population, intervention, study design, and outcomes were abstracted and reviewed using established criteria.
  
  
  RESULTS
  Few randomized controlled trials exist in the area of CDI prevention. The interventions with the greatest evidence for the prevention of CDI include antimicrobial stewardship, glove use, and disposable thermometers. Environmental decontamination also may decrease CDI rates, although the level of evidence is not as strong as for the other proven interventions. Treatment of asymptomatic carriage of C. difficile is not recommended. There is insufficient evidence to make a recommendation for or against the use of probiotics. In cases of known or suspected CDI, hand hygiene with soap and water is preferred over use of waterless alcohol hand rub. Many nonrandomized trials included in our analysis used multiple interventions concurrently, making the independent role of each preventive strategy difficult to determine. We chose to include only studies that focused on endemic CDI because studies of outbreaks have used multiple strategies, making it difficult to measure the relative efficacy of each strategy. Environmental disinfection and probiotics need to be studied further to evaluate their roles in the prevention of CDI. Although there have been no studies assessing the utility of isolation and cohorting for the prevention of endemic CDI specifically, it is a widely used intervention for containment of this and other similar multidrug-resistant pathogens.
  
  
  CONCLUSIONS
  Antimicrobial stewardship, glove use, hand hygiene, and disposable thermometers should be routinely used for the prevention of CDI. Environmental disinfection and probiotics should be studied further for their role in reducing CDI.
authors.affiliation: Section of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53792, USA.
authors.forename: J
authors.initials: J
authors.lastname: Hsu
authors.forename: C
authors.initials: C
authors.lastname: Abad
authors.forename: M
authors.initials: M
authors.lastname: Dinh
authors.forename: Nasia
authors.initials: N
authors.lastname: Safdar
mesh_terms: D016360:Clostridioides difficile; D003428:Cross Infection / Q000517:prevention & control*; D004203:Disinfection; D004761:Enterocolitis, Pseudomembranous / Q000517:prevention & control*; D017575:Gloves, Protective; D006235:Hand Disinfection; D006801:Humans