New Guidelines Recommend Practical Approaches for C Difficile in the NICU

Allison H. Bartlett, MD, MS

Special considerations must be made when diagnosing Clostridium difficile in newborns, according to a white paper, the first to be released in a series.

Authors from the Society for Healthcare Epidemiology of America gathered a panel of experts in pathogens to collaborate with the CDC's Healthcare Infection Control Practice Advisory Committee (HICPAC) in order to develop guidelines for NICU patients diagnoses with C difficile, where current guidelines are lacking.

“This white paper (and 3 others to follow) is a companion document to the new HICPAC Systematic Review Documents,” paper author Allison H. Bartlett, MD, MS, Associate Professor of Pediatric Infectious Diseases at the University of Chicago Medicine Comer Children’s Hospital, told MD Magazine®. “The review highlights the lack of evidence [available] to make specific recommendations regarding which patients in the NICU should be tested for C difficile, which test should be used, what the significance of a positive C difficile test is, and what the impact of C difficile in the NICU is. In the face of these knowledge gaps that prevent us from being able to put forth evidence-based recommendations, we wrote this white paper ‘to provide practical, expert opinion-based answers to frequently asked questions on C difficile detection and prevention in the NICU.’”

The paper also addresses frequently asked questions about C difficile detection and prevention in the NICU in a question and answer format. These responses offer suggestions about hand hygiene, contact precautions, as well as cleaning and disinfection inside the NICU.

For example, when should clinicians test a newborn for C difficile? An evidence-based response points out that tests should not be done if the only evidence of potential infection is significant diarrhea and other noninfectious causes of diarrhea have not been ruled out yet.

The paper also addressed the role of hand hygiene in preventing C difficile. In a setting without a current outbreak, the authors pointed out there are no clear-cut guidelines or consensus on best practices. Based on the healthcare center's risk assessment, hand hygiene and washing with alcohol-based hand rubs, plus soap and water use, were recommended, and the authors noted sink accessibility as a key point in their soap-and-water recommendations.

Some sample strategies for cleaning and disinfecting the NICU included standard daily cleaning and bleach use for C difficile disinfectant. A hospital may also consider developing a relationship with environmental services to detect rooms that may require sporicidal disinfectant. When a patient is cured of C difficile, but needs to remain in the hospital, clinicians can consider moving the newborns to clean incubators or rooms.

Bartlett added that "neonatologists, general pediatricians, pediatric infectious diseases specialists and pediatric gastroenterologists are not likely to be surprised by any of our recommendations to limit testing of NICU infants for C difficile and to focus on environmental cleaning and hand hygiene to prevent transmission of C difficile."

However, she added, "I suspect that many share the frustration with our current knowledge gaps in C difficile in infants and the technical limitations of current testing methods which do not allow differentiation between C difficile colonization from C difficile infection."

While the paper focuses more on testing and prevention for C difficile in the NICU, Dr. Bartlett did outline another major highlight from the paper.

"A key point in our white paper is the difficulty in interpreting C difficile testing in NICU infants given the high prevalence of colonization and the lack of consensus regarding a definition of ‘diarrhea’ in a population where having a soft yellow, seedy stool with each feeding (6-8 per day) can be completely normal. Furthermore, infants appear to be less susceptible to symptomatic C difficile infection for reasons that are not completely understood but may include: absence of toxin receptors on the intestinal lining, competitive colonization with non-toxin producing strains, and immune system immaturity."

The paper was published in Infection Control & Hospital Epidemiology as "SHEA neonatal intensive care unit (NICU) white paper series: Practical approaches to Clostridioides difficile prevention."