A Comparison of Current Guidelines of Five International Societies on Clostridium difficile Infection Management

Infect Dis Ther (2016) 5:207–230 DOI 10.1007/s40121-016-0122-1 REVIEW A Comparison of Current Guidelines of Five International Societies on Clostridium difficile Infection Management Csaba Fehér . Josep Mensa Received: May 27, 2016 / Published online: July 28, 2016 Ó The Author(s) 2016. This article is published with open access at Springerlink.com ABSTRACT Clostridium increasingly Keywords: Clostridium difficile infection (CDI); CDI recurrence risk; CDI severity; Contact difficile infection (CDI) is recognized as an emerging healthcare problem of elevated importance. Prevention and treatment strategies are constantly evolving along with the apperance of new scientific evidence and novel treatment methods, which is well-reflected in the isolation precautions; International guidelines INTRODUCTION The worldwide increasing burden of Clostridium difficile infection (CDI) has converted the quest differences among consecutive international for optimal treatment strategies into one of the hottest topics in the field of nosocomial guidelines. In this article, we summarize and compare current guidelines of five international infectious diseases. The incidence of CDI have been steadily growing in the past decades [1], medical societies on CDI management, and discuss some of the controversial and currently partially due to an increasing awareness of the unresolved aspects which should be addressed by future research. disease, but mainly because of an important increase in the susceptible population during this period, such as the elderly or the immunocompromised [2], the appearance of BI/NAP1/027 [3] and other hypervirulent C. Enhanced content To view enhanced content for this article go to http://www.medengine.com/Redeem/ 75E4F0604CDDD341. Electronic supplementary material The online version of this article (doi:10.1007/s40121-016-0122-1) contains supplementary material, which is available to authorized users. C. Fehér (&)
J. Mensa Department of Infectious Diseases, Hospital Clı́nic of Barcelona, C/Villarroel 170, 08036 Barcelona, Spain e-mail: difficile strains and a growing prevalence of asymptomatic C. difficile carriage [4]. Patients with CDI have increased length of hospital stay, higher readmission rates, more elevated inpatient costs and higher mortality than patients without CDI [5–7]. Boards of experts approving clinical guidelines constantly have to cope with the lack of sound scientific evidence on important Infect Dis Ther (2016) 5:207–230 208 aspects of CDI management, such as the precise measures, definition of CDI severity [8–11], duration of surgical treatment. contact isolation measures [12], or the indications and optimal time of surgical Five of these guidelines offer guidance on the treatment of CDI: the 2010 guidelines of the intervention [13]. The consequence of this situation is the coexistence of guidelines with Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of certain differences in their recommendations America (IDSA) 2010 [26]—whose updated that may raise doubts in the minds of treating physicians at the time of clinical decision version is under progress at the publication of this article; the 2013 guidelines of the American making [14]. This insecurity, in turn, may also contribute to the low adherence to existing College of Gastroenterology (ACG) [27]; the 2014 guidelines of the European Society of guidelines observed in various studies [15–17]. Clinical Microbiology and Infectious Diseases Indeed, an elevated proportion of clinicians agree on the main points where current CDI (ESCMID) [28]; the 2015 guidelines of the World Society of Emergency Surgery (WSES) management practices could and should be improved [18]. [29]; and the most recent 2016 update of the 2011 guidelines of the Australasian Society for In the following, we present a critical Infectious Diseases (ASID) [30, 31]. This last summary and comparison of the latest international guidelines published by five document also deals with CDI treatment in children, but we will focus exclusively on the international societies on the management of CDI, and briefly discuss some of the most recommendations made for adult patients. Three of the above guidelines (IDSA/SHEA, controversial and currently unresolved questions in this field in the light of the most ACG and WSES) recommendations on include direct contact isolation up-to-date available evidence. This article is measures, ESCMID based on previously conducted studies and does not involve any new studies of human or document makes reference to separate guidelines approved by the same society on animal subjects performed by any of the authors. CDI spread control [32]. The new ASID guidelines pay only marginal attention to this pharmacological whereas the therapy, and guidance issue, but there is a position statement on infection control measures in CDI published by the same society (in collaboration with the CURRENT GUIDELINES ON CDI MANAGEMENT There are a number of guidelines recommendations on the prevention Australian Infection Control Association, AICA) in 2011 [33] which is referred to by the and and previous, 2011 treatment guidelines as the one treatment of CDI approved by national expert recommended to follow. The recommendations of these two guidelines supported by the boards in various countries [19–25]. In this article, however, we will center our attention ESCMID and the ASID will also be taken into consideration in the following analysis. on seven international guidelines published in the last 6 years, reviewing and comparing their recommendations on three fundamental aspects of CDI management: contact isolation The ASID document on CDI management [31] does not indicate recommendation strength and evidence quality, whereas the ASID/AICA guidelines on CDI prevention [33] Infect Dis Ther (2016) 5:207–230 209 use the same grading system as the IDSA/SHEA The minimum allowed chlorine concentration guidelines. On the other hand, the two of these solutions, however, is higher in the documents backed by the ESCMID [28, 32] use different grading systems. Supplementary ACG guidelines than the other documents (5000 vs. 1000 ppm). The ASID/AICA and the Table 1 compares the different criteria utilized by these documents for the strength of each ESCMID guidelines also importance of thorough individual recommendation and the quality of cleaning after discharge or transfer of a CDI evidence on which it is based. patient, and the ESCMID also recommends additional immediate cleaning to take place in CONTACT ISOLATION MEASURES cases of environmental fecal contamination. The details of the individual recommendations Human-to-human transmission of C. difficile are summarized in Table 1. was first suspected in the early 1980s [34], and today there is wide consensus on the Unresolved Issues importance of app (...truncated)