National European guidelines for the prevention of Clostridium difficile infection: a systematic qualitative review

Clostridium difficile is the most frequent infectious cause of nosocomial diarrhoea and a major topic in infection prevention.

To overview current national European guidelines for C. difficile infection (CDI) prevention and review the recommendations in respect of their evidence base and conformity to each other and the European Centre for Disease Control and Prevention (ECDC) guidance.

In 34 European countries, the ECDC healthcare-associated infection (HCAI) surveillance National Contact Points and other HCAI experts (NCPs) were invited to complete an online questionnaire and to supply their guidelines. Guidelines not available in English, French or German were translated into English. For the qualitative analysis, a matrix with key measures based on the 2008 ECDC guidance was established. The review process was conducted independently by two reviewers.

All 34 NCPs responded to the questionnaire and supplied 15 guidelines in total. Six of 34 (18%) countries reported having used the ECDC guidance as a basis for the development or revision of their national guideline. There was wide variation in the scope and detailing. Only six of the documents and the ECDC guidance supplied a rating for the strength of recommendations. The rating systems varied in how the categories were defined. Furthermore, the stated strength for similar measures varied across different guidelines.

The ECDC guidance has not yet had a strong influence on the development or revision of national CDI prevention guidelines. One possible explanation for the variations is the necessity to adapt recommendations to national conditions. The use of internationally recognized instruments for the development of guidelines could help to improve their quality. Recommendations about monitoring or auditing the implementation would make them more useful.