SHEA Issues Practical Advice for C Difficile Testing and Treatment in NICU

Clostridioides difficile (C difficile) is considered one of the most frequently occurring healthcare-associated infections, but incidences are rare in patients <1 year due to a relative resistance to C difficile toxins or other protective factors in the intestinal environment of this population.

In an evidence-based white paper published in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America (SHEA), a panel of experts have published practical advice related to C difficile in the neonatal intensive care unit (NICU).

In this document, the authors recommend against routine testing for C difficile in NICU patients and in the presence of diarrhea,. The authors also advocate for testing for more common illnesses before administering a C difficile test.

The authors indicate that this advice is based on the high prevalence of asymptomatic carriage of toxigenic C difficile in infants <12 months. According to the report, approximately 35% of neonates are colonized with C difficile and the toxigenic strains can persist for months.

“Given the high rate of colonization, interpretation of a positive C diff test in a symptomatic (diarrhea, bloody stool, abdominal distension) neonate is challenging,” Allison H. Bartlett, MD, MS, associate professor of pediatric infectious diseases at the University of Chicago Medicine Comer Children’s Hospital and a lead author on the study, told Contagion® “In fact, there isn’t even a great definition of what ‘diarrhea’ is in a neonate—especially a preterm infant.”

If diarrhea is present in a neonate, the authors indicate that the first step should be evaluating the possibility for non-infectious causes. According to the authors, it is more likely for other gastrointestinal (GI) pathogens to be the source of the diarrhea, such as food-borne infections linked to formula or breast milk or practicing poor hand hygiene when preparing formula. Viral pathogens such as norovirus have also been linked with outbreaks in the past. GI pathogens linked to symptomatic family members or health care workers can also be a source of infection, Dr. Barlett added.

If testing for other pathogens is inconclusive, and C difficile is suspected, the authors suggest using a toxin test to produce specific results. Toxigenic cultures have been recommended in the past but are impractical for use in most clinical settings. If the result of the test is negative, repeat testing is not advised due to the potential for false-positives which could lead to unnecessary antibiotics and have harmful consequences.

If an infant in the NICU tests positive for C difficile, the authors indicate that appropriate measures to prevent further spread should include the use of contact precautions if diarrhea is present. Following a 48-hour period since resolution of diarrhea, contact precautions can be discontinued, and the infant can be moved to a new incubator and/or a new room.

In addition to advising on appropriate measures for testing, the authors also discussed the importance of hand hygiene and appropriate cleaning strategies to prevent C difficile in the NICU. As indicated in the document, most sanitary regulations are determined by each specific institution, but hand hygiene practices that include soap and water or alcohol-based hand rubs should be used. Standard daily cleaning is another appropriate strategy for reducing rates of C difficile in the NICU.

Antimicrobial stewardship has played a role in decreasing C difficile infections in different populations and although there is no specific recommendation regarding the role of stewardship in preventing C difficile in the NICU, the authors write that all NICUs should have a stewardship process in place to encourage the proper use of antimicrobials.

Despite the advice from this document, there are still many areas of C difficile research that require future research. “Open research questions include why infants are less susceptible to symptomatic CDI,” Dr. Bartlett stressed, “Hypotheses include absence of toxin receptors on the intestinal lining, competitive colonization with non-toxin producing strains, immune system immaturity.”

This white paper is the first in a series of reports that will include information from the latest research regarding best practices for treatment and prevention of infections in the NICU. Future releases will address Staphylococcus aureus (Staph infections), respiratory infections, and central line-associated blood stream infections (CLABSI).