movements, how many in the last 24 hours, are they on laxatives, have they had prior C. diff testing, and if so, what was the result, any high-risk antimicrobials, and then they have to include an indication for why. There’ s only a couple indications and everything else is an urgent exception, which they have to write some information about. Generally, we see that people are including appropriate information there. We have the same policy of the lab rejecting formed stool, discouraging repeat testing, and locking people out of repeat testing. That results in a two-step process which is PCR first. If PCR is positive we do the reflex; we have a nudge in the results that describes when the C. diff result is more consistent with colonization. We are looking to optimize that because sometimes it can be confusing, what we’ re trying to tell them. So, we are actively looking at ways to improve that communication, with the overall goal of trying to reduce the amount of unnecessary treatment that we’ re providing to patients.”
The panelists then pivoted to the topic of screening for asymptomatic carriage, with most panelists indicating that their institutions do not screen.
“ I think there are two reasons why a group would want to test on admission and they have different purposes,” said Kociolek.“ I think one would be a patient who comes in with diarrhea but you’ re not super worried about it, or they have some other things going on so you’ re not focused on the diarrhea. And then you finally get around on day four to testing them when they’ ve had diarrhea the whole time and then they’ re positive. And now you’ re dinged for the hospital-onset test. And so, some hospitals will implement strategies for early identification of true C. diff infection in patients who otherwise do meet testing criteria. That’ s a group you probably want to test because you are going to identify the infection early, put them on contact precautions, which will help prevent transmission, and then also treat them, which means they’ ll get better quickly and potentially not progress to complications. Then there’ s the other where a patient comes in without diarrhea and we’ re testing them just to say they had it in case they develop it later or put them on contact precautions as a carrier and in the Compendium, we felt that the data were not strong enough to suggest that we should be testing asymptomatic patients at admission for screening and because that would lead to contact precautions which can also lead to harm and there aren’ t clear data to suggest they are actually going to prevent transmission to others in the hospital setting.”
Moving from testing to isolation, Shenoy asked the panelists,“ So, people who are doing two-step or who are screening for asymptomatic carriage, if you’ re doing two-step you’ re going to identify people who are carriers just by virtue of the testing are, is everyone isolating carriers If you identify them?”
“ We do not,” Kociolek said.“ While carriers can transmit, certainly those who transmit the most frequently are individuals with diarrhea. I’ d also point out in the pediatric population, carriage is extraordinarily frequent. We know that infants can carry C. diff without symptoms, and we just don’ t see them leading to reservoirs and huge outbreaks of C. diff. Because of the negative impact of transmission-based precautions on patients, on the non-infectious risk adverse events from that, we don’ t follow that strategy. I think there’ s probably some potential for transmission from patients who are carriers, but also in our testing method, it would require a chart review to really identify if people are true carriers. So, I think practically, it is not possible to identify from our testing algorithm truly who is a carrier versus who has an infection.”
“ We do, as I think there is some potential for transmission from patients who are carriers,” Shenoy reported.“ But also in our testing method, it would require a chart review to identify if people are true carriers, so I think practically, it is not feasible to determine who is a
I think any stewardship is good stewardship, and certainly creating a culture of mindful antibiotic use is likely going to be effective and that’ s going to bleed into all the high-risk antibiotics.”
— Larry Kociolek, MD, MSCI, FSHEA, FPIDS
carrier versus who has infection.”
Drees responded,“ In our policy, we differentiate those who are treated despite being toxin-negative, and they would have the same isolation as someone who is toxin-positive, which is they have to finish their treatment and then for at least 48 hours of no diarrhea. And for those who are not treated, it’ s really just more time-based. I think it’ s 10 days and no diarrhea.”
Perl noted,“ We’ re isolating,” while Linam replied,“ We’ re not testing for carriers but the way we do our isolation is we’ re predominately doing symptom-based isolation. So, if a child comes in, they have or they develop diarrhea, they should go on contact precautions. And then we have another layer in there that if they are tested and determined to be positive for C. diff, we put them on an additional kind of isolation called‘ contact with handwashing.’ And when they’ re on that, it causes three things happen: One, we recommend handwashing with soap and water after you remove your PPE, we clean the room with a sporicidal agent-- we use bleach for cleaning the room, and then when that patient is discharged, that isolation sign alerts EVS that in addition to using bleach, to also use a UV robot that blasts the room with UV light. The duration of isolation is 48 hours after resolution of diarrhea. Something we are looking at doing and I’ ve done it at prior institutions is if you have a child or patient who has had C. diff they’ re treated, they’ re now asymptomatic but they’ re still in the hospital; what we’ ve looked into is moving that patient to a clean room and then go back in and have them take their linens home that are their own and then you would clean the room at discharge, and try to maintain a clean new environment when you take the child off isolation.”
The final topic addressed during the townhall was the highest-yield stewardship strategies for C. diff.
“ I think any stewardship is good stewardship, and certainly creating a culture of mindful antibiotic use is likely going to be effective and that’ s going to bleed into all the high-risk antibiotics,” Kociolek said.“ The best data are for avoiding use of antibiotics to which C. diff is resistant. In the 1970s in hospitals when C. diff was identified as the cause of antibiotic-associated diarrhea, those strains were predominantly clindamycin-resistant at that time. So that’ s why this antibiotic was a risk factor. Over time, strains have evolved and the Clindamycin susceptibility rate is much better. So while avoiding this antibiotic is good, it’ s no longer the highest-risk antibiotic. C. diff is inherently resistant to third- and fourth-generation cephalosporins. And so stewardship programs focus on the use of ceftriaxone and cefepime in particular, and tend to be quite good. The fluoroquinolone resistance rate for epidemic strains is quite high; for endemic strains it’ s not quite as high. And so, fluoroquinolone prevention historically has been shown to be quite effective, maybe not as effective now for current strains, but it’ s still best practice, particularly in the outpatient setting where fluoroquinolones are prescribed much more readily than cephalosporins.
18 • www. healthcarehygienemagazine. com • jan-feb 2026