Clostridium difficile Screening Effective in Reducing HO-CDI Among Bone Marrow Transplant Recipients

Implementing a standardized C. difficile screening protocol was associated with a significant decrease in the rate of HO-CDI among BMT patients

Nasia Safdar, MD, PhD

According to study findings reported in Infection Control & Hospital Epidemiology, screening for Clostridium difficile (C. difficile) among patients undergoing bone marrow transplant (BMT) is safe, feasible, and well-received among healthcare practitioners.

In addition, screening for C. difficile may be associated with reductions in hospital-onset C. difficile infection (HO-CDI).

“The key takeaway for us is that screening for C. difficile is an unresolved question that needs further study,” study investigator Nasia Safdar, MD, PhD, an Associate Professor of Infectious Disease in the Department of Medicine, University of Wisconsin, said. “From our experience and paper, we found that providers would welcome participation in such a study to answer the question of whether or not screening for C. difficile reduces acquisition of C. difficile in bone marrow transplant patients.”

Infection with C. difficile infection (CDI) is a common complication associated with allogeneic hematopoietic cell transplantation and can often cause severe diarrhea among this patient population. Early identification of the infection may be helpful for reducing severity as well as decreasing the likelihood of the spread of infection among patients. Screening strategies in the hospital setting may be helpful for identification; however, some barriers exist in relation to appropriate implementation of such a screening strategy in at-risk patients.

In this study, investigators sought to determine promoters and barriers to C. difficile screening for patients undergoing BMT. Additionally, researchers assessed the efficacy of screening on reducing the incidence of HO-CDI.

A total of 5357 patients attending a 505-bed tertiary-care medical center for BMT were included in the final analysis. Also, nurses (n = 4), administrators (n = 4), and physicians (n = 3) were included in the interview portion of the study.

During the interviews, healthcare practitioners were asked about screening rates, and investigators evaluated the association between screening and the incidence of HO-CDI. Investigators used the Systems Engineering Initiative for Patient Safety conceptual framework to code responses to the interview portion. Using a time-series analysis, pre- and post-intervention HO-CDI rates were compared in BMT and general internal medicine hospital wards.

Within 48 hours of hospital admission, patients with BMT were screened for C. difficile. Patients with a stool analysis that demonstrated colonization by a C. difficile-positive polymerase chain reaction (PCR) were given contact precautions throughout their stay in the hospital.

Implementing a standardized C. difficile screening protocol was associated with a significant decrease in the rate of HO-CDI among BMT patients (P <.0001). The effect, however, was not significantly different when investigators compared BMT patients to controls (P =.93).

The investigators found that engagement of stakeholders at the personal and organizational level was associated with greater standardization and optimization of C. difficile screening protocols. According to the interviews, the technology and tools used for screening were concerning and sometimes difficult to use, despite the overall intervention being well implemented among admitted patients.

“We report the first mixed-methods study to evaluate a C. difficile screening intervention among the BMT population,” concluded the investigators.

Considering screening for C. difficile appears to have been well received by laboratory staff, frontline clinical staff, and administrators in this study, the investigators suggest the findings show promise for future studies evaluating implementation of screening strategies among participants receiving other forms of care.


  1. Barker AK, Krasity B, Musuuza J, Safdar N. Screening for Asymptomatic Clostridium difficile Among Bone Marrow Transplant Patients: A Mixed-Methods Study of Intervention Effectiveness and Feasibility [published online January 25, 2018]. Infect Control Hosp Epidemiol. doi: 10.1017/ice.2017.286.

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