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Reducing Clostridium difficile in the Inpatient Setting: A Systematic Review of the Adherence to and Effectiveness of C. difficile Prevention Bundles

Published online by Cambridge University Press:  27 March 2017

Anna K. Barker
Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
Caitlyn Ngam
Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
Jackson S. Musuuza
William S. Middleton Memorial Veterans Affairs Hospital, Madison, Wisconsin
Valerie M. Vaughn
Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan The Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Health System, Ann Arbor, Michigan
Nasia Safdar
William S. Middleton Memorial Veterans Affairs Hospital, Madison, Wisconsin Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Department of Infection Control, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
E-mail address:



Clostridium difficile infection (CDI) is the most common infectious cause of nosocomial diarrhea, and its prevention is an urgent public health priority. However, reduction of CDI is challenging because of its complex pathogenesis, large reservoirs of colonized patients, and the persistence of infectious spores. The literature lacks high-quality evidence for evaluating interventions, and many hospitals have implemented bundled interventions to reduce CDI with variable results. Thus, we conducted a systematic review to examine the components of CDI bundles, their implementation processes, and their impact on CDI rates.


We conducted a comprehensive literature search of multiple computerized databases from their date of inception through April 30, 2016. The protocol was registered in PROSPERO, an international prospective register of systematic reviews. Bundle effectiveness, adherence, and study quality were assessed for each study meeting our criteria for inclusion.


In the 26 studies that met the inclusion criteria for this review, implementation and adherence factors to interventions were variably and incompletely reported, making study reproducibility and replicability challenging. Despite contextual differences and the variety of bundle components utilized, all 26 studies reported an improvement in CDI rates. However, given the lack of randomized controlled trials in the literature, assessing a causal relationship between bundled interventions and CDI rates is currently impossible.


Cluster randomized trials that include a rigorous assessment of the implementation of bundled interventions are urgently needed to causally test the effect of intervention bundles on CDI rates.

Infect Control Hosp Epidemiol 2017;38:639–650

Original Articles
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved 

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Authors of equal contribution.


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