Prevention of Clostridium difficile Infection: A Systematic Survey of
Clinical Practice Guidelines
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Abstract
background. Clostridium difficile infection (CDI) is the most common cause of hospital-acquired infectious diarrhea.
objective. To analyze themethodological quality, content, and supporting evidence among clinical practice guidelines (CPGs) on CDI prevention.
design and setting. We searched medical databases and gray literature for CPGs on CDI prevention published January 2004-January
2015. Three reviewers independently screened articles and rated CPG quality using the Appraisal of Guidelines for Research and Evaluation II
(AGREE II) instrument, composed of 23 items, rated 1–7, within 6 domains. We reported each domain score as a percentage of its maximum
possible score and standardized range. We summarized recommendations, extracted their supporting articles, and rated individually the level of
evidence using the Oxford Centre for Evidence-Based Medicine Levels of Evidence.
results. Of 2,578 articles screened, 5 guidelines met inclusion criteria. Median AGREE II scores and interquartile ranges were: clarity of
presentation, 75.9% (75.9%–79.6%); scope and purpose, 74.1% (68.5%–85.2%); editorial independence, 63.9% (47.2%–66.7%); applicability,
43.1% (19.4%–55.6%); stakeholder involvement, 40.7% (38.9%–44.4%); and rigor of development, 18.1% (17.4%–35.4%). CPGs addressed
several common strategies for CDI prevention, including antibiotic stewardship, hypochlorite solutions, probiotic prophylaxis, and bundle
strategies. Recommendations were often not consistent with evidence, and most were based on low-level studies.
conclusion. CPGs did not adhere well to AGREE II reporting standards. Furthermore, there was limited transparency in moving from
evidence to recommendations. CDI prevention CPGs need to better adhere to AGREE-II and be transparent in moving from evidence to
recommendations, and recommendations need to be consistent with available evidence