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Clostridium difficile, a spore-forming organism, causes as many as 25% of cases of healthcare-associated diarrhoea.1–4 In many developed countries, C. difficile infection (CDI) is now the most important healthcare-associated infection (HAI), suggesting an urgent need of strategies for effective containment.5 Recent studies on the impact of antimicrobial stewardship initiatives and CDI prevention ‘bundles’ have reported variable reductions in CDI rates.6–10 For example, a recent meta-analysis found that implementing an antimicrobial stewardship programme was associated with a 50% reduction in CDI rates, particularly if it utilised restrictive over persuasive policies.11 Following declines in other types of HAI such as central line (CL)-associated bloodstream infection and catheter-associated urinary tract infection with the use of a checklist of recommended practices and bundled interventions, many healthcare institutions have adopted a similar approach to reducing CDI.12–14
This is easier said than done. The complex, incompletely understood pathogenesis of CDI, large reservoirs in the environment and in asymptomatically colonised patients, multiple pathways for spread of the organism, lack of a readily removable ‘device’ to target, uncertain relative roles of antibiotic stewardship versus infection control practices, and a relatively sparse evidence base for prevention all combine to make C. difficile containment extremely challenging in comparison to device-related HAI.
Daneman et al15 report the findings of a survey conducted in 2011 with the goal …
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