ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Clostridioides difficile infection: Prevention and control

Clostridioides difficile infection: Prevention and control
Authors:
L Clifford McDonald, MD
Preeta K Kutty, MD, MPH
Section Editors:
Stephen B Calderwood, MD
Sheldon L Kaplan, MD
Deputy Editor:
Milana Bogorodskaya, MD
Literature review current through: Jan 2024.
This topic last updated: Jan 12, 2023.

INTRODUCTION — Clostridioides difficile is the causative organism of antibiotic-associated colitis. It is the most common infectious cause of health care-associated diarrhea and a significant cause of morbidity and mortality among hospitalized patients [1]. Most cases of C. difficile infection (CDI) in the United States are associated with inpatient or outpatient contact with a health care setting [2-4].

Development of CDI usually requires two events: disruption of the fecal microbiota (typically via exposure to antibiotics) and ingestion of spores via the fecal-oral route. C. difficile may be shed into the environment by individuals who are infected or colonized. High colonization rates may occur among hospitalized adults, nursing home residents, and healthy infants [5-7].

C. difficile spores can be transmitted between patients via environmental surfaces and contaminated hands of health care personnel [8]. Thus, efforts to prevent CDI must focus on two goals: reducing patient susceptibility to CDI and preventing organism transmission [9]. Prevention of C. difficile transmission is especially challenging because the organism forms spores that can persist on environmental surfaces for months and are resistant to commonly used cleaning agents and alcohol-based hand gels [10].

Issues related to prevention of CDI in health care and community settings are discussed here. Issues related to prevention of CDI in individual patients are discussed separately. (See "Clostridioides difficile infection in adults: Treatment and prevention".)

The pathophysiology, epidemiology, clinical manifestations, diagnosis, and treatment of CDI are discussed separately. (See related topics.)

INPATIENT CARE SETTINGS — Infection control and antibiotic stewardship are critical for reducing the incidence of CDI in health care settings [11-13]. Appropriate testing is an important step to prevent unnecessary antibiotic prescribing [9,14,15]. There have been reports of severe CDI in some settings and waves of the COVID-19 pandemic, highlighting the importance of both antibiotic stewardship and avoiding delays in diagnosis during a pandemic [16].

Infection control — Guidance for prevention of CDI in acute-care hospital settings was published in 2018 by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America [9]; the recommendations are summarized briefly here.

Surveillance — Standardized case definitions for C. difficile surveillance are as follows [9]:

●Health care facility onset (HO) – CDI case established based on laboratory test collected >3 days after admission to the facility (ie, on or after day 4). The rate of HO-CDI should be expressed as the number of cases per 10,000 patient-days.

●Community onset, health care facility associated (CO-HCFA) – CDI case occurring within 28 days after discharge from a health care facility. The CO-HCFA prevalence rate should be expressed as the number of cases per 1000 patient admissions.

●Community associated (CA) – CDI case occurring in the absence of health care facility admission or CDI case occurring ≥28 days following discharge.

At a minimum, inpatient health care facilities should conduct surveillance (among patients ≥2 years of age) for HO-CDI to detect elevated rates or outbreaks. When CDI incidence is above goals or in outbreak settings, data should be stratified by patient location to target control measures.

In the United States, reporting of facility-wide CDI events using the National Healthcare Safety Network (NHSN) [17] is required in acute-care hospitals, long-term acute-care facilities, and inpatient rehabilitation facilities [18-20].

The United States Centers for Disease Control and Prevention developed a strategy known as the Targeted Assessment for Prevention (TAP), which includes a CDI assessment tool that can help identify and address specific gaps in infection prevention in a unit or facility [21]. In addition, the strategies to prevent CDI in acute care facilities have been created to facilitate CDI-prevention efforts [14].

Prevention strategies

Early detection and isolation — Early detection of CDI with rapid implementation of contact precautions is essential for preventing transmission; it requires vigilant screening for new-onset diarrhea in patients at risk and rapid, accurate testing. (See "Clostridioides difficile infection in adults: Clinical manifestations and diagnosis", section on 'Diagnosis' and "Clostridioides difficile infection in children: Clinical features and diagnosis", section on 'Approach to diagnosis'.)

Issues related to transmission of CDI are discussed further separately. (See "Clostridioides difficile infection in adults: Epidemiology, microbiology, and pathophysiology".)

Contact precautions — Patients with suspected or proven CDI should be placed on contact precautions, including assignment to a private room with dedicated toileting facilities. If the number of such rooms is limited, patients with stool incontinence should be prioritized [9]. Gloves and gowns should be donned upon room entry and removed prior to exiting the room [9].

If cohorting is required, patients infected or colonized with the same organism(s) should be cohorted (ie, patients with CDI who are discordant for other multidrug-resistant organisms should not be cohorted together). In cohort rooms, gowns and gloves should be removed, and hand hygiene should be performed between patients [9,22,23].

General principles regarding contact precautions and attire of health care personnel are discussed further elsewhere. (See "Infection prevention: Precautions for preventing transmission of infection", section on 'Contact precautions' and "Infection prevention: Precautions for preventing transmission of infection", section on 'Attire for health care personnel'.)

The optimal approach for discontinuation of contact precautions for CDI is uncertain. We are in agreement with guidelines regarding the duration of contact precautions for acute care settings that were published in 2018 by the Society for Healthcare Epidemiology of America and Infectious Disease Society of America [9,24]. These guidelines favor continuation of contact precautions for at least 48 hours after resolution of diarrhea. Continuation of contact precautions beyond resolution of diarrhea is reasonable since persistent stool shedding of C. difficile spores is common [9,25]. In acute care settings with elevated CDI rates despite appropriate infection prevention and control measures, continuation of contact precautions until discharge is reasonable.

Hand hygiene — Prior to contact with a patient with CDI, health care personnel should perform hand hygiene then don gloves. Following contact with a patient with CDI, health care personnel should remove gloves then perform hand hygiene.

In routine settings, hand hygiene may be performed with soap and water or an alcohol-based hand rub (ABHR) [9]. In outbreak settings, hand hygiene should be performed preferentially with soap and water before and after caring for patients with suspected or proven CDI; use of ABHR is not adequate because ABHR does not eradicate C. difficile spores [9,26-30]. In addition, hand hygiene with soap and water is preferred if there is direct content with feces or an area where fecal contamination is likely (eg, the perineal region).

Hand washing with soap and water involves vigorous mechanical scrubbing and rinsing, so it is more effective than ABHR for physical removal of bacterial spores. However, hand washing with soap and water is less effective than ABHR for inactivation of vegetative (ie, non-spore-forming) bacteria [31]. (See "Infection prevention: Precautions for preventing transmission of infection", section on 'Hand hygiene'.)

Patients with CDI should wash hands with soap and water after using the bathroom, before eating or food preparation, and when hands are visibly soiled.

Environmental cleaning and disinfection — Careful attention to environmental cleaning of clinical areas where patients with CDI are treated is critical; this includes daily cleaning and cleaning following discharge.

C. difficile spores can survive on dry surfaces for up to several months, and routine disinfection with standard quaternary ammonium-based chemicals does not eliminate C. difficile spores [5,6,32-38]. Disinfection of clinical areas where patients with CDI are treated requires use of a sporicidal agent (such as bleach or an alternative agent with a C. difficile sporicidal label claim; in the United States, a list of these is available on the Environmental Protection Agency website). Some sporicidal agents can cause caustic damage to equipment surfaces and cause skin irritation for patients and health care personnel; these issues should be considered in the agent selection [38-40]. (See "Infection prevention: General principles", section on 'Health care environment: Cleaning and disinfection'.)

However, interventions that focus only on improving cleaning may not be sufficient to control health care-associated CDI. In one randomized trial including 16 hospitals in Ohio, an environmental disinfection intervention improved the thoroughness and effectiveness of cleaning but did not reduce the incidence of health care-associated CDI [41].

When possible, disposable medical equipment should be used, since multiuse equipment (such as blood pressure cuffs, stethoscopes, and thermometers) can serve as fomites for C. difficile transmission [9,42-44]. If use of disposable equipment is not possible, equipment should be dedicated to a single patient with CDI. Equipment that must be shared between patients should be cleaned and disinfected with a sporicidal agent between uses [9]. (See "Infection prevention: General principles", section on 'Medical equipment: Disinfection and sterilization'.)

The impact of ultraviolet (UV) light for disinfection on the incidence of CDI is uncertain. One report that evaluated the impact UV irradiation following 542 patient discharges noted a reduction in CDI incidence by 25 percent compared with a preintervention baseline period [45]. In contrast, in another study that included 21,395 patients (in the intention-to-treat analysis) admitted to rooms from which a patient on contact precautions was discharged, no substantial decrease in CDI was observed in patients who subsequently occupied the same room, despite the addition of UV light to bleach disinfection (versus bleach alone) for room cleaning [46]. However, a secondary analysis of these data noted a broader effect, with declines in facility-wide incidence of both C. difficile and vancomycin-resistant enterococci infection or colonization, which were associated with enhanced terminal disinfection involving UV light [47].

Patient bathing — Patients should be encouraged to wash hands and shower to reduce the burden of spores on the skin [9].

Based on available data, the role for routine chlorhexidine (CHG) bathing for prevention of CDI is uncertain [48,49]. In one study including administration of more than 68,000 CHG baths, the incidence of CDI decreased with bathing daily (relative risk [RR] 0.41, 95% CI 0.29-0.59) or three times weekly (RR 0.71, 95% CI 0.57-0.89) [48]. However, another trial including 9340 adults in intensive care units noted that daily CHG bathing demonstrated no impact on CDI incidence [49].

Asymptomatic carriers — Asymptomatic carriers appear to play a role in C. difficile transmission. Data suggest that many new CDI cases are not molecularly linked to symptomatic CDI cases [50-52]. In one study including 1200 cases of CDI, patients with symptomatic infection served as the likely source for no more than 35 percent of new cases, suggesting an important role for asymptomatic carriers [50].

There is no clear role for routine implementation of precautions for asymptomatic carriers although benefits have been observed in some studies [9]. Use of precautions may be beneficial in selected circumstances; further study is needed [14,53,54]. Benefit associated with use of precautions for asymptomatic carriers has been observed in some studies. In one study including more than 360 asymptomatic carriers identified and placed on precautions, the incidence of health care-associated CDI decreased from 6.9 to 3.0 per 10,000 patient-days over a two-year period [55]. Similar studies in oncology and bone marrow transplant units have also observed decreases in the incidence of health care-associated CDI [56,57].

Antibiotic stewardship — Antibiotic stewardship to reduce the unnecessary use of antibiotics plays an important role in controlling CDI rates [9]. Administration of antibiotics disrupts the intestinal microbiota and has been linked to C. difficile colonization [58], increasing the likelihood of a colonized patient contaminating their immediate environment [59]. Antibiotic use also increases risk for developing infection by 7- to 10-fold during and up to one month after treatment and by approximately threefold for two months thereafter [3,54]. In addition, antibiotic use has been shown to be a risk factor for recurrent CDI [60]. (See "Clostridioides difficile infection in adults: Epidemiology, microbiology, and pathophysiology", section on 'Antibiotic use' and "Clostridioides difficile infection in children: Microbiology, pathogenesis, and epidemiology", section on 'Antibiotic exposure'.)

Antibiotic stewardship programs can significantly aid in the reduction of CDI incidence [61]. Targeted restriction of a particular antibiotic agent or class of agents can facilitate control of hospital outbreaks and reduce CDI rates in the community and in health care settings [62-67]. (See "Antimicrobial stewardship in hospital settings", section on 'Reducing the incidence of C. difficile infection'.)

Antibiotics frequently associated with increased CDI risk include clindamycin, fluoroquinolones, cephalosporins, carbapenems, and penicillins (table 1):

●Clindamycin restriction has been followed by rapid reductions in CDI cases in several outbreaks [65,68]. Similar findings have been observed in outbreaks caused by the highly clindamycin-resistant J strain [64]. In one study, for example, a policy requiring infectious disease physician approval for clindamycin use led to reduction in CDI cases (from 11.5 to 3.3 cases per month) [68].

●Fluoroquinolone use has been associated with outbreaks caused by the highly fluoroquinolone-resistant PCR ribotype 027 strain [69-71]. Restriction of all fluoroquinolones may be required for effective control in such circumstances [67,72,73]. In one study, elimination of fluoroquinolone use was associated with a reduction in CDI cases and in the proportion of cases due to the 027 strain [74]. In another study, reduction in fluoroquinolone use across England was primarily responsible for reduction in CDI incidence [67]. (See "Clostridioides difficile infection in adults: Epidemiology, microbiology, and pathophysiology", section on 'PCR ribotype 027 strain'.)

●Restriction of third- and fourth-generation cephalosporins has been successful in reducing CDI rates [62,63,75-77]. Other studies have noted associations between formulary restrictions and reduced CDI rates by limiting antibiotics to penicillin, trimethoprim-sulfamethoxazole, and aminoglycosides in the setting of an outbreak [63].

●With increased use and reliance on carbapenems to address resistance caused by extended-spectrum beta-lactamases, there may be an increasing role for this class in driving facility CDI rates [78].

Even reducing the duration of broad-spectrum antibiotics might have a role in decreasing CDI rates. In a retrospective cohort study of 808 patients with Enterobacteriaceae bloodstream infections, receipt of empiric antipseudomonal beta-lactam therapy for <48 hours was independently associated with a lower 90-day risk of CDI compared with continued antipseudomonal beta-lactam use beyond 48 hours [79]. Further study is needed to determine if systematic early de-escalation of antibiotics can result in decreased incidence of CDI.

OUTPATIENT CARE SETTINGS — Patients may present to an outpatient setting if they acquired the infection in the community, after discharge from a health care setting where they received antibiotics, or as a follow-up from a hospital admission related to CDI or exposure to an outpatient setting [2,80].

In general, outpatient care settings should follow the same prevention strategy guidelines as inpatient care setting, such as developing an IPC program, providing education and training to all health care personnel on the basic principles and practices for preventing the spread of CDI, performance of hand hygiene by both the patient and health care personnel, and contact precautions for all health care personnel who enter the examination room or are in contact with the infected patient [81,82]. (See 'Contact precautions' above and 'Hand hygiene' above.)

Whenever possible, disposable medical equipment should be used (eg, stethoscopes, blood pressure cuffs, thermometers), especially when evaluating a patient with diarrhea. When possible, a patient with diarrhea should be placed in a private room. Meticulous cleaning should be performed with an EPA-registered sporicidal disinfectant (List K) for environmental disinfection.

While preventing transmission in outpatient as well as inpatient settings is important, antibiotic stewardship is imperative for reducing unnecessary antibiotic use that increases patient susceptibility to C. difficile infection [83-85].

COMMUNITY SETTINGS — Outpatient antibiotic use is a risk factor for developing CDI [4]. In addition, emergency departments may serve as an environmental reservoir [4].

Households — C. difficile can spread among household contacts; however, it is rare for otherwise healthy individuals to develop CDI in the absence of antibiotic use.

Patients with CDI should wash hands with soap and water after using the bathroom, before eating or food preparation, and when hands are visibly soiled. If possible, patients with diarrhea should avoid using the same toilet as other family members. In addition, bathroom and kitchen areas (including toilet seats, toilet bowl, flush handle, sink faucet handles, and countertops) may be cleaned with a mixture of bleach and water (1 part bleach to every 10 parts water) to help prevent spread of infection. More information can be found on the CDC website.

Childcare settings — Children with diarrhea due to CDI should be excluded from childcare settings for the duration of diarrhea [86]. Diaper changing surfaces in childcare settings where children with CDI have been cared for may be sanitized with a disinfectant with sporicidal activity (eg, hypochlorite) [86].

Neonates and infants frequently are colonized with toxigenic C. difficile. They rarely develop symptomatic disease but can serve as a reservoir of infection for others. (See "Clostridioides difficile infection in children: Microbiology, pathogenesis, and epidemiology", section on 'Neonates and infants'.)

Antibiotic stewardship — Antibiotic stewardship plays an important role in controlling CDI rates [9]. (See 'Antibiotic stewardship' above and "Antimicrobial stewardship in outpatient settings".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Clostridioides difficile infection".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: C. difficile infection (The Basics)")

●Beyond the Basics topics (see "Patient education: Antibiotic-associated diarrhea caused by Clostridioides difficile (Beyond the Basics)")

SUMMARY

●Overview – Clostridioides difficile is the causative organism of antibiotic-associated colitis. It is the most common infectious cause of health care-associated diarrhea and a significant cause of morbidity and mortality among hospitalized patients. (See 'Introduction' above.)

●Hand hygiene – Hand hygiene is an important factor in reducing the spread of CDI. Gloves should be donned by health care personnel prior to caring for individuals with suspected or proven CDI. All health care personnel, patients, caretakers, and household members should perform hand hygiene by washing hands with soap and water following care of individuals with suspected or proven CDI; use of alcohol-based hand rub (ABHR) is not adequate because ABHR does not eradicate C. difficile spores. Hand washing with soap and water involves vigorous mechanical scrubbing and rinsing, so it is more effective than ABHR for physical removal of bacterial spores. (See 'Hand hygiene' above and 'Households' above and 'Childcare settings' above.)

●Prevention strategies for health care settings – Prevention and control of C. difficile infection (CDI) in health care settings require early detection and isolation with contact precautions, careful attention to hand hygiene, and effective environmental cleaning. (See 'Infection control' above.)

•Contact precautions – Patients with suspected or proven CDI should be placed on contact precautions, including assignment to a single room with dedicated toileting facilities or cohorting with other patients who have CDI. Gloves and gowns should be donned upon room entry and removed prior to exiting the room. (See 'Contact precautions' above.)

•Environmental cleaning and disinfection – Careful attention to environmental cleaning of clinical areas where patients with CDI are treated is critical. C. difficile spores can survive on dry surfaces for up to several months, and routine disinfection with standard quaternary ammonium-based chemicals does not eliminate C. difficile spores. Disinfection of clinical areas where patients with CDI are treated requires use of a sporicidal agent (such as bleach or an alternative agent with a C. difficile sporicidal label). (See 'Environmental cleaning and disinfection' above.)

•Use of medical equipment – When possible, disposable medical equipment should be used, since multiuse equipment (such as blood pressure cuffs, stethoscopes, and thermometers) can serve as fomites for C. difficile transmission. If use of disposable equipment is not possible, equipment should be dedicated to a single patient with CDI. Equipment that must be shared between patients should be cleaned and disinfected with a sporicidal agent between uses. (See 'Environmental cleaning and disinfection' above.)

•Antibiotic stewardship – Administration of antibiotics disrupts the intestinal microbiota and has been linked to C. difficile colonization and disease. Targeted restriction of a particular antibiotic agent or class of agents can facilitate control of hospital outbreaks and reduce CDI rates in the community and in health care settings. Antibiotics frequently associated with increased CDI risk include clindamycin, fluoroquinolones, cephalosporins, and penicillins (table 1). (See 'Antibiotic stewardship' above.)

●Prevention strategies for community settings – C. difficile can spread among household contacts, although it is rare for otherwise healthy individuals to develop CDI in the absence of antibiotic use. Patients and household members should be counseled to wash their hands frequently, especially after the use of the bathroom, before preparation of or contact with food, and when hands are visibly soiled. Children with diarrhea due to CDI should be excluded from childcare settings for the duration of diarrhea. (See 'Community settings' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Jay McDonald, MD, and Carolyn Gould, MD, who contributed to an earlier version of this topic.

  1. Guh AY, Mu Y, Winston LG, et al. Trends in U.S. Burden of Clostridioides difficile Infection and Outcomes. N Engl J Med 2020; 382:1320.
  2. Jury LA, Sitzlar B, Kundrapu S, et al. Outpatient healthcare settings and transmission of Clostridium difficile. PLoS One 2013; 8:e70175.
  3. Centers for Disease Control and Prevention (CDC). Vital signs: preventing Clostridium difficile infections. MMWR Morb Mortal Wkly Rep 2012; 61:157.
  4. Guh AY, Adkins SH, Li Q, et al. Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study. Open Forum Infect Dis 2017; 4:ofx171.
  5. McFarland LV, Mulligan ME, Kwok RY, Stamm WE. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989; 320:204.
  6. Larson HE, Barclay FE, Honour P, Hill ID. Epidemiology of Clostridium difficile in infants. J Infect Dis 1982; 146:727.
  7. Riggs MM, Sethi AK, Zabarsky TF, et al. Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 2007; 45:992.
  8. Loo VG, Bourgault AM, Poirier L, et al. Host and pathogen factors for Clostridium difficile infection and colonization. N Engl J Med 2011; 365:1693.
  9. McDonald LC, Gerding DN, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018; 66:e1.
  10. Gerding DN, Muto CA, Owens RC Jr. Measures to control and prevent Clostridium difficile infection. Clin Infect Dis 2008; 46 Suppl 1:S43.
  11. Dubberke ER, Carling P, Carrico R, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 Update. Infect Control Hosp Epidemiol 2014; 35:628.
  12. Brown KA, Jones M, Daneman N, et al. Importation, Antibiotics, and Clostridium difficile Infection in Veteran Long-Term Care: A Multilevel Case-Control Study. Ann Intern Med 2016; 164:787.
  13. Tschudin-Sutter S, Kuijper EJ, Durovic A, et al. Guidance document for prevention of Clostridium difficile infection in acute healthcare settings. Clin Microbiol Infect 2018; 24:1051.
  14. United States Centers for Disease Control and Prevention. Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities. https://www.cdc.gov/cdiff/clinicians/cdi-prevention-strategies.html (Accessed on October 18, 2022).
  15. Aslam A, Eagan J, Kaplan J, et al. Know When to Test: Optimizing Diagnostic Practices for Clostridium difficile Infection (CDI) Among Patients at a Tertiary-Care Cancer Center. Open Forum Infect Dis 2017; :S397.
  16. Vendrik KEW, Baktash A, Goeman JJ, et al. Comparison of trends in Clostridioides difficile infections in hospitalised patients during the first and second waves of the COVID-19 pandemic: A retrospective sentinel surveillance study. Lancet Reg Health Eur 2022; 19:100424.
  17. Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN), MDRO & CDI. https://www.cdc.gov/nhsn/psc/cdiff/index.html (Accessed on November 08, 2022).
  18. Centers for Medicare & Medicaid Services. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and FY 2012 rates; hospitals’ FTE resident caps for. US Department of Health and Human Services, Baltimore, MD 2011.
  19. Centers for Disease Control and Prevention. Operational Guidance for Long Term Care Hospitals* to Report Facility-Wide Inpatient (FacWideIN) Clostridium difficile Infection (CDI) Laboratory-Identified (LabID) Event Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Long Term Care Hospital Quality Reporting Requirements. https://www.cdc.gov/nhsn/pdfs/cms/ltac/ltch-cdi-op-guidance.pdf (Accessed on October 18, 2022).
  20. Centers for Disease Control and Prevention. Operational Guidance for Inpatient Rehabilitation Facilities to Report Clostridium difficile Infection (CDI) Laboratory-Identified (LabID) Event Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Quality Reporting Program Requirements. https://www.cdc.gov/nhsn/pdfs/cms/irfs/irf-cdi-op-guidance.pdf (Accessed on October 18, 2022).
  21. Centers for Disease Control and Prevention. The Targeted Assessment for Prevention (TAP) Strategy. https://www.cdc.gov/hai/prevent/tap.html (Accessed on October 18, 2022).
  22. Johnson S, Gerding DN, Olson MM, et al. Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. Am J Med 1990; 88:137.
  23. Landelle C, Verachten M, Legrand P, et al. Contamination of healthcare workers' hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol 2014; 35:10.
  24. Banach DB, Bearman G, Barnden M, et al. Duration of Contact Precautions for Acute-Care Settings. Infect Control Hosp Epidemiol 2018; 39:127.
  25. Bobulsky GS, Al-Nassir WN, Riggs MM, et al. Clostridium difficile skin contamination in patients with C. difficile-associated disease. Clin Infect Dis 2008; 46:447.
  26. Bettin K, Clabots C, Mathie P, et al. Effectiveness of liquid soap vs. chlorhexidine gluconate for the removal of Clostridium difficile from bare hands and gloved hands. Infect Control Hosp Epidemiol 1994; 15:697.
  27. Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee, HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 2002; 51:1.
  28. Jabbar U, Leischner J, Kasper D, et al. Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands. Infect Control Hosp Epidemiol 2010; 31:565.
  29. Oughton MT, Loo VG, Dendukuri N, et al. Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile. Infect Control Hosp Epidemiol 2009; 30:939.
  30. Kundrapu S, Sunkesula V, Jury I, et al. A randomized trial of soap and water hand wash versus alcohol hand rub for removal of Clostridium difficile spores from hands of patients. Infect Control Hosp Epidemiol 2014; 35:204.
  31. Edmonds SL, Zapka C, Kasper D, et al. Effectiveness of hand hygiene for removal of Clostridium difficile spores from hands. Infect Control Hosp Epidemiol 2013; 34:302.
  32. Dubberke ER, Reske KA, Noble-Wang J, et al. Prevalence of Clostridium difficile environmental contamination and strain variability in multiple health care facilities. Am J Infect Control 2007; 35:315.
  33. Samore MH, Venkataraman L, DeGirolami PC, et al. Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea. Am J Med 1996; 100:32.
  34. Kim KH, Fekety R, Batts DH, et al. Isolation of Clostridium difficile from the environment and contacts of patients with antibiotic-associated colitis. J Infect Dis 1981; 143:42.
  35. Savage AM, Alford RH. Nosocomial spread of Clostridium difficile. Infect Control 1983; 4:31.
  36. Brooks SE, Veal RO, Kramer M, et al. Reduction in the incidence of Clostridium difficile-associated diarrhea in an acute care hospital and a skilled nursing facility following replacement of electronic thermometers with single-use disposables. Infect Control Hosp Epidemiol 1992; 13:98.
  37. Kaatz GW, Gitlin SD, Schaberg DR, et al. Acquisition of Clostridium difficile from the hospital environment. Am J Epidemiol 1988; 127:1289.
  38. Mayfield JL, Leet T, Miller J, Mundy LM. Environmental control to reduce transmission of Clostridium difficile. Clin Infect Dis 2000; 31:995.
  39. Wilcox MH, Fawley WN, Wigglesworth N, et al. Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection. J Hosp Infect 2003; 54:109.
  40. Simor AE, Bradley SF, Strausbaugh LJ, et al. Clostridium difficile in long-term-care facilities for the elderly. Infect Control Hosp Epidemiol 2002; 23:696.
  41. Ray AJ, Deshpande A, Fertelli D, et al. A Multicenter Randomized Trial to Determine the Effect of an Environmental Disinfection Intervention on the Incidence of Healthcare-Associated Clostridium difficile Infection. Infect Control Hosp Epidemiol 2017; 38:777.
  42. Vajravelu RK, Guerrero DM, Jury LA, Donskey CJ. Evaluation of stethoscopes as vectors of Clostridium difficile and methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 2012; 33:96.
  43. Manian FA, Meyer L, Jenne J. Clostridium difficile contamination of blood pressure cuffs: a call for a closer look at gloving practices in the era of universal precautions. Infect Control Hosp Epidemiol 1996; 17:180.
  44. Jernigan JA, Siegman-Igra Y, Guerrant RC, Farr BM. A randomized crossover study of disposable thermometers for prevention of Clostridium difficile and other nosocomial infections. Infect Control Hosp Epidemiol 1998; 19:494.
  45. Pegues DA, Han J, Gilmar C, et al. Impact of Ultraviolet Germicidal Irradiation for No-Touch Terminal Room Disinfection on Clostridium difficile Infection Incidence Among Hematology-Oncology Patients. Infect Control Hosp Epidemiol 2017; 38:39.
  46. Anderson DJ, Chen LF, Weber DJ, et al. Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study. Lancet 2017; 389:805.
  47. Anderson DJ, Moehring RW, Weber DJ, et al. Effectiveness of targeted enhanced terminal room disinfection on hospital-wide acquisition and infection with multidrug-resistant organisms and Clostridium difficile: a secondary analysis of a multicentre cluster randomised controlled trial with crossover design (BETR Disinfection). Lancet Infect Dis 2018; 18:845.
  48. Rupp ME, Cavalieri RJ, Lyden E, et al. Effect of hospital-wide chlorhexidine patient bathing on healthcare-associated infections. Infect Control Hosp Epidemiol 2012; 33:1094.
  49. Noto MJ, Domenico HJ, Byrne DW, et al. Chlorhexidine bathing and health care-associated infections: a randomized clinical trial. JAMA 2015; 313:369.
  50. Eyre DW, Cule ML, Wilson DJ, et al. Diverse sources of C. difficile infection identified on whole-genome sequencing. N Engl J Med 2013; 369:1195.
  51. Curry SR, Muto CA, Schlackman JL, et al. Use of multilocus variable number of tandem repeats analysis genotyping to determine the role of asymptomatic carriers in Clostridium difficile transmission. Clin Infect Dis 2013; 57:1094.
  52. Lim SC, Knight DR, Riley TV. Clostridium difficile and One Health. Clin Microbiol Infect 2020; 26:857.
  53. Linsenmeyer K, O'Brien W, Brecher SM, et al. Clostridium difficile Screening for Colonization During an Outbreak Setting. Clin Infect Dis 2018; 67:1912.
  54. Hensgens MP, Goorhuis A, Dekkers OM, Kuijper EJ. Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. J Antimicrob Chemother 2012; 67:742.
  55. Longtin Y, Paquet-Bolduc B, Gilca R, et al. Effect of Detecting and Isolating Clostridium difficile Carriers at Hospital Admission on the Incidence of C difficile Infections: A Quasi-Experimental Controlled Study. JAMA Intern Med 2016; 176:796.
  56. Cho J, Seville MT, Khanna S, et al. Screening for Clostridium difficile colonization on admission to a hematopoietic stem cell transplant unit may reduce hospital-acquired C difficile infection. Am J Infect Control 2018; 46:459.
  57. Barker AK, Krasity B, Musuuza J, Safdar N. Screening for Asymptomatic Clostridium difficile Among Bone Marrow Transplant Patients: A Mixed-Methods Study of Intervention Effectiveness and Feasibility. Infect Control Hosp Epidemiol 2018; 39:177.
  58. Privitera G, Scarpellini P, Ortisi G, et al. Prospective study of Clostridium difficile intestinal colonization and disease following single-dose antibiotic prophylaxis in surgery. Antimicrob Agents Chemother 1991; 35:208.
  59. Freedberg DE, Salmasian H, Cohen B, et al. Receipt of Antibiotics in Hospitalized Patients and Risk for Clostridium difficile Infection in Subsequent Patients Who Occupy the Same Bed. JAMA Intern Med 2016; 176:1801.
  60. Deshpande A, Pasupuleti V, Thota P, et al. Risk factors for recurrent Clostridium difficile infection: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2015; 36:452.
  61. Baur D, Gladstone BP, Burkert F, et al. Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis. Lancet Infect Dis 2017; 17:990.
  62. Carling P, Fung T, Killion A, et al. Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infect Control Hosp Epidemiol 2003; 24:699.
  63. McNulty C, Logan M, Donald IP, et al. Successful control of Clostridium difficile infection in an elderly care unit through use of a restrictive antibiotic policy. J Antimicrob Chemother 1997; 40:707.
  64. Johnson S, Samore MH, Farrow KA, et al. Epidemics of diarrhea caused by a clindamycin-resistant strain of Clostridium difficile in four hospitals. N Engl J Med 1999; 341:1645.
  65. Pear SM, Williamson TH, Bettin KM, et al. Decrease in nosocomial Clostridium difficile-associated diarrhea by restricting clindamycin use. Ann Intern Med 1994; 120:272.
  66. Lawes T, Lopez-Lozano JM, Nebot CA, et al. Effect of a national 4C antibiotic stewardship intervention on the clinical and molecular epidemiology of Clostridium difficile infections in a region of Scotland: a non-linear time-series analysis. Lancet Infect Dis 2017; 17:194.
  67. Dingle KE, Didelot X, Quan TP, et al. Effects of control interventions on Clostridium difficile infection in England: an observational study. Lancet Infect Dis 2017; 17:411.
  68. Climo MW, Israel DS, Wong ES, et al. Hospital-wide restriction of clindamycin: effect on the incidence of Clostridium difficile-associated diarrhea and cost. Ann Intern Med 1998; 128:989.
  69. Biller P, Shank B, Lind L, et al. Moxifloxacin therapy as a risk factor for Clostridium difficile-associated disease during an outbreak: attempts to control a new epidemic strain. Infect Control Hosp Epidemiol 2007; 28:198.
  70. McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med 2005; 353:2433.
  71. Labbé AC, Poirier L, Maccannell D, et al. Clostridium difficile infections in a Canadian tertiary care hospital before and during a regional epidemic associated with the BI/NAP1/027 strain. Antimicrob Agents Chemother 2008; 52:3180.
  72. Ashiru-Oredope D, Sharland M, Charani E, et al. Improving the quality of antibiotic prescribing in the NHS by developing a new Antimicrobial Stewardship Programme: Start Smart--Then Focus. J Antimicrob Chemother 2012; 67 Suppl 1:i51.
  73. Wilcox MH, Shetty N, Fawley WN, et al. Changing epidemiology of Clostridium difficile infection following the introduction of a national ribotyping-based surveillance scheme in England. Clin Infect Dis 2012; 55:1056.
  74. Kallen AJ, Thompson A, Ristaino P, et al. Complete restriction of fluoroquinolone use to control an outbreak of Clostridium difficile infection at a community hospital. Infect Control Hosp Epidemiol 2009; 30:264.
  75. Settle CD, Wilcox MH, Fawley WN, et al. Prospective study of the risk of Clostridium difficile diarrhoea in elderly patients following treatment with cefotaxime or piperacillin-tazobactam. Aliment Pharmacol Ther 1998; 12:1217.
  76. Khan R, Cheesbrough J. Impact of changes in antibiotic policy on Clostridium difficile-associated diarrhoea (CDAD) over a five-year period in a district general hospital. J Hosp Infect 2003; 54:104.
  77. Nelson DE, Auerbach SB, Baltch AL, et al. Epidemic Clostridium difficile-associated diarrhea: role of second- and third-generation cephalosporins. Infect Control Hosp Epidemiol 1994; 15:88.
  78. Slimings C, Riley TV. Antibiotics and healthcare facility-associated Clostridioides difficile infection: systematic review and meta-analysis 2020 update. J Antimicrob Chemother 2021; 76:1676.
  79. Seddon MM, Bookstaver PB, Justo JA, et al. Role of Early De-escalation of Antimicrobial Therapy on Risk of Clostridioides difficile Infection Following Enterobacteriaceae Bloodstream Infections. Clin Infect Dis 2019; 69:414.
  80. Simecka JW, Fulda KG, Pulse M, et al. Primary care clinics can be a source of exposure to virulent Clostridium (now Clostridioides) difficile: An environmental screening study of hospitals and clinics in Dallas-Fort Worth region. PLoS One 2019; 14:e0220646.
  81. D'Agata EMC, Apata IW, Booth S, et al. Suggestions for the prevention of Clostridioides difficile spread within outpatient hemodialysis facilities. Kidney Int 2021; 99:1045.
  82. Centers for Disease Control and Prevention. Guide to infection prevention for outpatient settings: Minimum expectations for safe care. https://www.cdc.gov/infectioncontrol/pdf/outpatient/guide.pdf (Accessed on November 08, 2022).
  83. American Dental Association. Antibiotic Prophylaxis Prior to Dental Procedures. https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/antibiotic-prophylaxis (Accessed on November 08, 2022).
  84. Centers for Disease Control and Prevention. Oral Health: Antibiotic Stewardship. https://www.cdc.gov/oralhealth/infectioncontrol/faqs/antibiotic-stewardship.html (Accessed on November 08, 2022).
  85. Centers for Disease Control and Prevention. Antibiotic Prescribing and Use: Core Elements of Outpatient Antibiotic Stewardship. https://www.cdc.gov/antibiotic-use/core-elements/outpatient.html (Accessed on November 08, 2022).
  86. American Academy of Pediatrics. Red Book: 2018 Report of the Committee on Infectious Diseases, 31st ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Itasca, IL 2018.
Topic 2687 Version 47.0

References

1 : Trends in U.S. Burden of Clostridioides difficile Infection and Outcomes.

2 : Outpatient healthcare settings and transmission of Clostridium difficile.

3 : Vital signs: preventing Clostridium difficile infections.

4 : Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study.

5 : Nosocomial acquisition of Clostridium difficile infection.

6 : Epidemiology of Clostridium difficile in infants.

7 : Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents.

8 : Host and pathogen factors for Clostridium difficile infection and colonization.

9 : Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).

10 : Measures to control and prevent Clostridium difficile infection.

11 : Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 Update.

12 : Importation, Antibiotics, and Clostridium difficile Infection in Veteran Long-Term Care: A Multilevel Case-Control Study.

13 : Guidance document for prevention of Clostridium difficile infection in acute healthcare settings.

14 : Guidance document for prevention of Clostridium difficile infection in acute healthcare settings.

15 : Know When to Test: Optimizing Diagnostic Practices for Clostridium difficile Infection (CDI) Among Patients at a Tertiary-Care Cancer Center

16 : Comparison of trends in Clostridioides difficile infections in hospitalised patients during the first and second waves of the COVID-19 pandemic: A retrospective sentinel surveillance study.

17 : Comparison of trends in Clostridioides difficile infections in hospitalised patients during the first and second waves of the COVID-19 pandemic: A retrospective sentinel surveillance study.

18 : Comparison of trends in Clostridioides difficile infections in hospitalised patients during the first and second waves of the COVID-19 pandemic: A retrospective sentinel surveillance study.

19 : Comparison of trends in Clostridioides difficile infections in hospitalised patients during the first and second waves of the COVID-19 pandemic: A retrospective sentinel surveillance study.

20 : Comparison of trends in Clostridioides difficile infections in hospitalised patients during the first and second waves of the COVID-19 pandemic: A retrospective sentinel surveillance study.

21 : Comparison of trends in Clostridioides difficile infections in hospitalised patients during the first and second waves of the COVID-19 pandemic: A retrospective sentinel surveillance study.

22 : Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission.

23 : Contamination of healthcare workers' hands with Clostridium difficile spores after caring for patients with C. difficile infection.

24 : Duration of Contact Precautions for Acute-Care Settings.

25 : Clostridium difficile skin contamination in patients with C. difficile-associated disease.

26 : Effectiveness of liquid soap vs. chlorhexidine gluconate for the removal of Clostridium difficile from bare hands and gloved hands.

27 : Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America.

28 : Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands.

29 : Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile.

30 : A randomized trial of soap and water hand wash versus alcohol hand rub for removal of Clostridium difficile spores from hands of patients.

31 : Effectiveness of hand hygiene for removal of Clostridium difficile spores from hands.

32 : Prevalence of Clostridium difficile environmental contamination and strain variability in multiple health care facilities.

33 : Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea.

34 : Isolation of Clostridium difficile from the environment and contacts of patients with antibiotic-associated colitis.

35 : Nosocomial spread of Clostridium difficile.

36 : Reduction in the incidence of Clostridium difficile-associated diarrhea in an acute care hospital and a skilled nursing facility following replacement of electronic thermometers with single-use disposables.

37 : Acquisition of Clostridium difficile from the hospital environment.

38 : Environmental control to reduce transmission of Clostridium difficile.

39 : Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection.

40 : Clostridium difficile in long-term-care facilities for the elderly.

41 : A Multicenter Randomized Trial to Determine the Effect of an Environmental Disinfection Intervention on the Incidence of Healthcare-Associated Clostridium difficile Infection.

42 : Evaluation of stethoscopes as vectors of Clostridium difficile and methicillin-resistant Staphylococcus aureus.

43 : Clostridium difficile contamination of blood pressure cuffs: a call for a closer look at gloving practices in the era of universal precautions.

44 : A randomized crossover study of disposable thermometers for prevention of Clostridium difficile and other nosocomial infections.

45 : Impact of Ultraviolet Germicidal Irradiation for No-Touch Terminal Room Disinfection on Clostridium difficile Infection Incidence Among Hematology-Oncology Patients.

46 : Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study.

47 : Effectiveness of targeted enhanced terminal room disinfection on hospital-wide acquisition and infection with multidrug-resistant organisms and Clostridium difficile: a secondary analysis of a multicentre cluster randomised controlled trial with crossover design (BETR Disinfection).

48 : Effect of hospital-wide chlorhexidine patient bathing on healthcare-associated infections.

49 : Chlorhexidine bathing and health care-associated infections: a randomized clinical trial.

50 : Diverse sources of C. difficile infection identified on whole-genome sequencing.

51 : Use of multilocus variable number of tandem repeats analysis genotyping to determine the role of asymptomatic carriers in Clostridium difficile transmission.

52 : Clostridium difficile and One Health.

53 : Clostridium difficile Screening for Colonization During an Outbreak Setting.

54 : Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics.

55 : Effect of Detecting and Isolating Clostridium difficile Carriers at Hospital Admission on the Incidence of C difficile Infections: A Quasi-Experimental Controlled Study.

56 : Screening for Clostridium difficile colonization on admission to a hematopoietic stem cell transplant unit may reduce hospital-acquired C difficile infection.

57 : Screening for Asymptomatic Clostridium difficile Among Bone Marrow Transplant Patients: A Mixed-Methods Study of Intervention Effectiveness and Feasibility.

58 : Prospective study of Clostridium difficile intestinal colonization and disease following single-dose antibiotic prophylaxis in surgery.

59 : Receipt of Antibiotics in Hospitalized Patients and Risk for Clostridium difficile Infection in Subsequent Patients Who Occupy the Same Bed.

60 : Risk factors for recurrent Clostridium difficile infection: a systematic review and meta-analysis.

61 : Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis.

62 : Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years.

63 : Successful control of Clostridium difficile infection in an elderly care unit through use of a restrictive antibiotic policy.

64 : Epidemics of diarrhea caused by a clindamycin-resistant strain of Clostridium difficile in four hospitals.

65 : Decrease in nosocomial Clostridium difficile-associated diarrhea by restricting clindamycin use.

66 : Effect of a national 4C antibiotic stewardship intervention on the clinical and molecular epidemiology of Clostridium difficile infections in a region of Scotland: a non-linear time-series analysis.

67 : Effects of control interventions on Clostridium difficile infection in England: an observational study.

68 : Hospital-wide restriction of clindamycin: effect on the incidence of Clostridium difficile-associated diarrhea and cost.

69 : Moxifloxacin therapy as a risk factor for Clostridium difficile-associated disease during an outbreak: attempts to control a new epidemic strain.

70 : An epidemic, toxin gene-variant strain of Clostridium difficile.

71 : Clostridium difficile infections in a Canadian tertiary care hospital before and during a regional epidemic associated with the BI/NAP1/027 strain.

72 : Improving the quality of antibiotic prescribing in the NHS by developing a new Antimicrobial Stewardship Programme: Start Smart--Then Focus.

73 : Changing epidemiology of Clostridium difficile infection following the introduction of a national ribotyping-based surveillance scheme in England.

74 : Complete restriction of fluoroquinolone use to control an outbreak of Clostridium difficile infection at a community hospital.

75 : Prospective study of the risk of Clostridium difficile diarrhoea in elderly patients following treatment with cefotaxime or piperacillin-tazobactam.

76 : Impact of changes in antibiotic policy on Clostridium difficile-associated diarrhoea (CDAD) over a five-year period in a district general hospital.

77 : Epidemic Clostridium difficile-associated diarrhea: role of second- and third-generation cephalosporins.

78 : Antibiotics and healthcare facility-associated Clostridioides difficile infection: systematic review and meta-analysis 2020 update.

79 : Role of Early De-escalation of Antimicrobial Therapy on Risk of Clostridioides difficile Infection Following Enterobacteriaceae Bloodstream Infections.

80 : Primary care clinics can be a source of exposure to virulent Clostridium (now Clostridioides) difficile: An environmental screening study of hospitals and clinics in Dallas-Fort Worth region.

81 : Suggestions for the prevention of Clostridioides difficile spread within outpatient hemodialysis facilities.

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟