To the Editor—We read with great interest the excellent review of evidence-based recommendations for the prevention of Clostridium difficile infection (CDI) by Louh et al.Reference Louh, Greendyke and Hermann ¹ In this article, the authors reviewed 4 studies that assessed the impact of hand-hygiene campaigns to reduce CDI. Based on these papers, the authors did not recommend any hand-hygiene interventions to reduce CDI.

In their discussion section, Louh et al stated, “Although older studies have shown a significant reduction in nosocomial infections by observing good hand hygiene, further benefit from promoting hand hygiene is unlikely, as the margin for improvement diminishes. Therefore, if any institution has adequate hand-hygiene processes, incremental efforts to improve hand hygiene may not be as beneficial as other interventions.” We have 2 concerns with this statement and their conclusion. First, the authors did not define a level of “adequate hand hygiene.” Second, their conclusion that moving from high to very high levels of hand-hygiene compliance offer diminishing benefits is not supported by the literature. We have previously demonstrated that an improvement in hand-hygiene compliance from a high baseline level (>80%) to an even higher level (>95%) led to a significantly decreased healthcare-associated infection rate (P=.0066).Reference Sickbert-Bennett, DiBiase, Willis, Wolak, Weber and Rutala ² Based on our data, we believe that achieving very high levels of hand-hygiene compliance is both feasible and worthwhile to reduce healthcare-associated infections.