Curbing C. difficile in Australian hospitals: lessons from HM17

Clostridioides difficile infection (CDI) remains one of the most stubborn healthcare-associated infections in Australian acute care. At the Hospital Medicine 2017 meeting in Las Vegas, antimicrobial stewardship, diagnostic testing, and ward-level prevention bundles dominated conversations about how hospitalists can bend the curve. New data there reinforced a familiar lesson: when hospitalists lead, CDI rates fall.

Australia's experience mirrors the global picture, with local quirks. The Antimicrobial Use and Resistance in Australia (AURA) surveillance system tracks CDI year on year, and recent reports show community-onset, healthcare-associated cases climbing in eastern states. Hospitals in Sydney, Melbourne, and Brisbane have linked outbreaks to fluoroquinolone and cephalosporin prescribing, while rural facilities face delayed laboratory turnaround and limited infectious-diseases cover. These realities make the bedside clinician unusually central, because the prescriber, reviewer, and documenter of antibiotics are usually the same person.

HM17 was built to support exactly that work. Education tracks spanned antibiotic selection, handoff communication, and quality improvement, and the meeting brought together hospitalists, pharmacists, microbiologists, and infection-prevention teams. The sections ahead walk through the strongest evidence from that gathering and what it means for clinicians in Australian wards, whether in a Melbourne tertiary centre, a Toowoomba regional hospital, or a Perth day-stay unit.

The practical message is consistent: hospitalists can drive measurable CDI reductions when stewardship, sensible testing, and a tight prevention bundle line up behind a single improvement plan owned by the bedside team.

The scale of the problem in Australian hospitals

C. difficile places a real and growing load on the Australian acute-care system. The Australian Commission on Safety and Quality in Health Care has classified CDI as a priority organism for surveillance, and NSQHS reports document thousands of cases each year, with disproportionate impact on adults over 65 and on patients recently exposed to broad-spectrum antibiotics. Hot Australian summers and crowded winter periods amplify transmission in aged-care wings and sub-acute units, where hospitalists frequently consult.

The toll is more than a dashboard number. AURA's annual updates consistently highlight CDI as a leading cause of infectious diarrhoea in hospitalised patients, with excess length of stay estimated at three to seven days per case. That means longer ward stays, higher readmission rates, and recurrent courses of vancomycin or fidaxomicin for the same patient returning months later. The economic burden — recurrent testing, isolation rooms, contact precautions, and bed-days lost — weighs on hospitals under activity-based funding pressures.

These figures explain why antibiotic choice is the single most powerful lever hospitalists pull each day. The next section looks at how HM17 framed that lever.

Antimicrobial stewardship: where hospitalists lead

Antimicrobial stewardship was the centrepiece of every credible CDI reduction program at HM17. Multiple plenaries argued that consistent gains come when hospitalists, not just specialist infectious-diseases teams, make daily prescribing decisions within an agreed framework. Australian stewardship programs, formalised through the National Antimicrobial Stewardship Initiative and embedded in NSQHS standards, already give local teams a structure. The HM17 evidence reminded delegates that participation only translates to fewer infections when prescribers engage in real time.

The hospitalist advantage is proximity. Every morning round is a stewardship moment: reviewing the indication, narrowing the spectrum on day three, and converting IV to oral therapy where appropriate. Data presented at HM17 from large US networks suggested hospitals where hospitalists carried formal stewardship responsibilities saw CDI reductions of 20 to 35 per cent within eighteen months. Australian pilots in Melbourne and Brisbane produced similar directional results, though smaller cohorts limit direct comparison.

Practical moves include documenting a clear indication and review date on every antibiotic order, switching from ceftriaxone to amoxicillin for sensitive community-acquired pneumonia, and using the electronic medical record to flag a CDI history before prescribing fluoroquinolones. Speakers also stressed de-escalation — stepping down once cultures return — as a habit that compounds across thousands of encounters.

Diagnostic stewardship and the testing paradox

If prescribing is one lever, testing is the other, and it is where many Australian hospitals still struggle. HM17 dwelt on the testing paradox: the more sensitive the assay, the more likely clinicians detect colonisation rather than true infection, and the more likely they treat patients who do not need treatment. PCR testing for the toxin B gene is fast and highly sensitive, but cannot reliably distinguish asymptomatic carriers from active disease. Australian laboratories have moved overwhelmingly to molecular methods, inflating reported rates when clinical context is ignored.

The takeaway was to pair every positive test with a clinical algorithm. That means reviewing the patient for new-onset unformed stools, abdominal pain, or leucocytosis; checking recent laxatives; and avoiding repeat testing within seven days. Multistep algorithms combining a sensitive screen with a toxin-specific confirmatory test preserve sensitivity while reducing false positives, and Sydney and Adelaide laboratories are piloting these approaches.

Hospitalists play a pivotal role by ordering fewer unnecessary tests. Standing-order protocols, where nurses could send stool for C. difficile testing without a doctor's note, drove inappropriate testing rates up; explicit hospitalist-led criteria-based protocols brought them back in line. The Australian context is supportive: Therapeutic Goods Administration-approved diagnostics are widely accessible, and state health departments in Victoria and Queensland publish testing criteria ready for adoption.

Bundled prevention on the ward

Stewardship and testing reduce the risk that C. difficile establishes itself; prevention bundles reduce the risk that it spreads. The strongest evidence at HM17 supported contact precautions for symptomatic patients, single-room isolation or cohorting where private rooms are limited, daily sporicidal cleaning, soap-and-water hand hygiene, and antimicrobial review at every transition of care. NSQHS standards already require most elements, and state guidelines add specific cleaning protocols.

A bedside focus was the hand-hygiene moment for hospitalists. Compliance among senior medical staff remains lower than among nurses in Australian ward audits, and CDI control is one of the few areas where the gap shows in outcome data. Hospitalists who model soap-and-water washing, enter isolation rooms deliberately, and ask about CDI history at handoff lift the safety culture. The handoff strategies from HM17 emphasising explicit CDI history at transition have direct relevance to outbreak-prone wards.

Environmental services matter too. Australian outbreaks have been traced to reusable equipment that escapes terminal cleaning. HM17 reinforced daily sporicidal cleaning for rooms housing known CDI cases, alongside terminal cleaning at discharge, and supported fluorescent marker audits to confirm cleaning thoroughness — trialled in Melbourne hospitals with measurable reductions.

Building a hospitalist-led program

Bringing all of this together requires structure. The most successful Australian programs at HM17 started with a clear governance line: a hospitalist lead, a senior pharmacist, an infection-prevention nurse, and a microbiology liaison, meeting fortnightly to review a small dashboard — CDI cases per 10,000 bed-days, fluoroquinolone and cephalosporin days of therapy, and the proportion of tests meeting clinical criteria. Some sites tied this to existing meetings, which matters in busy regional services.

The Hospital Medicine 2017 platform hosts resources that support this kind of structured work — slide decks, sample order sets, and improvement toolkits adaptable to Australian conditions. Hospitalists can fold those resources into local induction, share dashboard definitions with executive sponsors, and publish internal results so good practice spreads across networks.

Funding alignment helps. Activity-based funding rewards shorter, uncomplicated admissions, so reducing CDI is both a clinical and a financial good. Linking stewardship to Choosing Wisely initiatives, state antimicrobial resistance strategies, and accreditation cycles gives hospitalists a stronger mandate. Clinical leadership, reliable measurement, and executive backing separate hospitals that have moved the CDI needle from those that have not. Clinicians at the bedside own the prescribing, the testing, the handwash, and the handoff.

Three things are worth carrying forward from the HM17 conversation into Australian practice. First, antibiotic selection and review remain the most controllable daily decision driving CDI risk in Australian wards. Second, sensible testing, anchored in clear clinical criteria rather than reflex orders, is the second lever, and one that hospitalists can pull by changing their own ordering habits. Third, the bedside clinician's ownership of stewardship, testing, handwash, and handoff is what separates hospitals that have reduced CDI from those that have not. Each lever alone produces modest gains; combined, they produced the 20 to 35 per cent reductions reported at HM17, and they map directly onto Australian NSQHS standards, state infection control guidelines, and local Choosing Wisely priorities already embedded in everyday practice.