News Release

Interprofessional collaboration leads to significant and sustained reduction in hospital-onset c. difficile infections

Community hospital reduced infections by 63% after one year and 77% after three years

Peer-Reviewed Publication

Association for Professionals in Infection Control

Arlington, Va., May 12, 2022 – A new study published today in the American Journal of Infection Control (AJIC), suggests that health care facilities can significantly reduce the incidence of hospital-onset Clostridioides difficile infection (HO-CDI) by establishing interprofessional teams to implement selected, evidence-based infection-prevention interventions.

“Our project showed that interprofessional collaboration and continuous improvement can profoundly impact HO-CDI incidence, and sustain reductions over years,” said Cherith Walter, MSN, RN, Emory St. Joseph’s Hospital, and first author on the published study. “We hope our findings will help other healthcare teams struggling with this incredibly challenging healthcare-associated infection to improve patient safety and reduce associated costs.”

According to the Centers for Disease Control and Prevention, an estimated 500,000 cases of CDI occur in the United States annually[1], making it one of the most prevalent healthcare-associated infections (HAI) in the country. Due to the cost of caring for patients with HO-CDI, as well as financial penalties levied under the Centers for Medicare and Medical Services’ (CMS) hospital-acquired condition reduction program, these infections have increased the financial burden on the healthcare system.

To address the HO-CDI incidence at their 410-bed community hospital, which was consistently above the national CMS benchmark, Walter and colleagues created an interprofessional team comprising a clinical nurse specialist, a physician champion, a hospital epidemiologist, an infection preventionist, a clinical microbiologist, unit nurse champions, an antimicrobial stewardship pharmacist, and an environmental services representative. The team reviewed HO-CDI events at their facility between 2014 and 2016 to determine causative factors, and then identified appropriate, evidence-based infection prevention interventions. The selected interventions comprised diagnostic stewardship, including the development of a Diarrhea Decision Tree (DDT) testing algorithm with a nurse-driven ordering protocol; enhanced environmental cleaning; antimicrobial stewardship, including a system-wide Electronic Medical Record intervention to reduce fluoroquinolone use; and education and accountability, the latter of which focused on encouraging compliance with the DDT algorithm.

After the first year, the project leads recorded a 63% decrease in HO-CDIs as compared to the two years prior (4.72 per 10,000 patient days vs. 12 per 10,000 patient days). This number improved further to 2.8 per 10,000 days three years after implementation of the selected interventions (a 77% decrease from baseline). The team also saw a decrease in their facility’s standardized HO-CDI infection ratio (the total number of infections divided by the National Health Safety Network’s risk-adjusted predicted number of infections), from 1.11 in 2015 to 0.43 in 2020 – significantly lower than the national benchmark.

Interventions also improved CDI testing practices, increasing testing for appropriate patients within the first three days of hospital admission from 54% in 2014 to 81.1% in late 2019, to support prompt treatment of infected patients. This practice also helped identify and differentiate cases of community-acquired CDI (CA-CDI) from HO-CDI, reducing the financial impact of HO-CDIs on the facility after 2016. Finally, by empowering nurses to hold providers accountable for judicious test ordering and creating a system of ‘accountability notices’ alerting nurses and providers to DDT algorithm deviations, the team successfully increased compliance with the algorithm, from 50% in mid-2018 to 80% in mid-2020.

“These study findings are exciting, because they suggest that professional collaboration to consistently apply known, evidence-based practices can significantly reduce the incidence of HO-CDI, an intractable and costly HAI,” said Linda Dickey, RN, MPH, CIC, FAPIC, and 2022 APIC president. “They are also the first findings demonstrating the impact of education and accountability interventions in reducing HO-CDI incidence and improving compliance with standards of practice.”

 About APIC

Founded in 1972, the Association for Professionals in Infection Control and Epidemiology (APIC) is the leading association for infection preventionists and epidemiologists. With more than 15,000 members, APIC advances the science and practice of infection prevention and control. APIC carries out its mission through research, advocacy, and patient safety; education, credentialing, and certification; and fostering development of the infection prevention and control workforce of the future. Together with our members and partners, we are working toward a safer world through the prevention of infection. Join us and learn more at

About AJIC

As the official peer-reviewed journal of APIC, The American Journal of Infection Control (AJIC) is the foremost resource on infection control, epidemiology, infectious diseases, quality management, occupational health, and disease prevention. Published by Elsevier, AJIC also publishes infection control guidelines from APIC and the CDC. AJIC is included in Index Medicus and CINAHL. Visit AJIC at


“An Interprofessional Approach to Reducing Hospital-Onset Clostridioides difficile Infections,” by Cherith Walter, MSN, RN; Tanushree Soni, PhD, MPH; Melanie Alice Gavin, MPH; Julianne Kubes, MPH; and Kristen Paciullo, PharmD, was published online in AJIC on May 12, 2022. The article may be found online at:



Cherith Walter, MSN, RN, APRN, AGPCNP-BC, AGCNS-BC (corresponding author:

Emory Saint Joseph’s Hospital, Atlanta, GA, USA


Tanushree Soni, PhD, MPH, CIC

Emory Saint Joseph’s Hospital, Atlanta, GA, USA


Melanie Alice Gavin, MPH, CIC, M (ASCP)

Emory Saint Joseph’s Hospital, Atlanta, GA, USA


Julianne Kubes, MPH

Emory Healthcare, Atlanta, GA, USA


Kristen Paciullo, PharmD, BCIDP

Emory Saint Joseph’s Hospital, Atlanta, GA, USA


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[1] Guery B, Galperine T, Barbut F. Clostridioides difficile: diagnosis and treatments. BMJ. 2019 Aug 20;366:l4609.

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