Effects of a predictive preventive model for prevention of Clostridium difficile infection in patients in intensive care units

A Simple Prediction Model for Clostridioides difficile Infection: A Hospital-Based Administrative Database Study

BACKGROUND AND AIM

Few prediction scores for Clostridioides difficile infection (CDI), a potentially life-threatening nosocomial diarrhea, combine high accuracy with simplicity. A simple prediction score for routine clinical practice is needed.

METHODS

We conducted a retrospective cohort study of all inpatients aged ≥ 18 at a secondary care hospital in Japan. The derivation and validation cohorts consisted of patients from January 2016 to December 2020 and January 2021 to September 2022, respectively. Demographic and clinical data were retrieved using electronic medical records and an administrative database. The primary outcome was to derive and validate an accurate, simple prediction score for primary hospital-onset CDI. A derived prediction score by logistic regression analysis was calibrated and validated.

RESULTS

CDI developed in 102 of 25 517 and 25 of 6259 patients in the derived and validation cohorts (2.7 cases/10 000 patient-days). The derived model for predicting CDI, including antibiotic use, acid suppressant (proton pump inhibitors or vonoprazan) use, Charlson comorbidity index, and Barthel index, yielded c-statistics of 0.89 and 0.82 in the derivation and validation cohort. The model was well calibrated.

CONCLUSIONS

This simple prediction score enables early medical intervention and modification of treatment plans to reduce the risk of developing primary hospital-onset CDI.

Implementation strategies for hospital-based probiotic administration in a stepped-wedge cluster randomized trial design for preventing hospital-acquired Clostridioides difficile infection

BACKGROUND

Clostridioides difficile infection (CDI) is associated with considerable morbidity and mortality in hospitalized patients, especially among older adults. Probiotics have been evaluated to prevent hospital-acquired (HA) CDI in patients who are receiving systemic antibiotics, but the implementation of timely probiotic administration remains a challenge. We evaluated methods for effective probiotic implementation across a large health region as part of a study to assess the real-world effectiveness of a probiotic to prevent HA-CDI (Prevent CDI-55 +).

METHODS

We used a stepped-wedge cluster-randomized controlled trial across four acute-care adult hospitals (n = 2,490 beds) to implement the use of the probiotic Bio-K + ® (Lactobacillus acidophilus CL1285®, L. casei LBC80R® and L. rhamnosus CLR2®; Laval, Quebec, Canada) in patients 55 years and older receiving systemic antimicrobials. The multifaceted probiotic implementation strategy included electronic clinical decision support, local site champions, and both health care provider and patient educational interventions. Focus groups were conducted during study implementation to identify ongoing barriers and facilitators to probiotic implementation, guiding needed adaptations of the implementation strategy. Focus groups were thematically analyzed using the Theoretical Domains Framework and the Consolidated Framework of Implementation Research.

RESULTS

A total of 340 education sessions with over 1,800 key partners and participants occurred before and during implementation in each of the four hospitals. Site champions were identified for each included hospital, and both electronic clinical decision support and printed educational resources were available to health care providers and patients. A total of 15 individuals participated in 2 focus group and 7 interviews. Key barriers identified from the focus groups resulted in adaptation of the electronic clinical decision support and the addition of nursing education related to probiotic administration. As a result of modifying implementation strategies for identified behaviour change barriers, probiotic adherence rates were from 66.7 to 75.8% at 72 h of starting antibiotic therapy across the four participating acute care hospitals.

CONCLUSIONS

Use of a barrier-targeted multifaceted approach, including electronic clinical decision support, education, focus groups to guide the adaptation of the implementation plan, and local site champions, resulted in a high probiotic adherence rate in the Prevent CDI-55 + study.

Reducing the Healthcare-Associated Infections in a Rehabilitation Hospital under the Guidance of Lean Six Sigma and DMAIC

The reduction of healthcare-associated infections (HAIs) is one of the most important issues in the healthcare context for every type of hospital. In three operational units of the Scientific Clinical Institutes Maugeri SpA SB, a rehabilitation hospital in Cassano delle Murge (Italy), some corrective measures were introduced in 2017 to reduce the occurrence of HAIs. Lean Six Sigma was used together with the Define, Measure, Analyze, Improve, Control (DMAIC) roadmap to analyze both the impact of such measures on HAIs and the length of hospital stay (LOS) in the Rehabilitative Cardiology, Rehabilitative Neurology, Functional Recovery and Rehabilitation units in the Medical Center for Intensive Rehabilitation. The data of 2415 patients were analyzed, considering the phases both before and after the introduction of the measures. The hospital experienced a LOS reduction in both patients with and without HAIs; in particular, Cardiology had the greatest reduction for patients with infections (-7 days). The overall decrease in HAIs in the hospital was 3.44%, going from 169 to 121 cases of infections. The noteworthy decrease in LOS implies an increase in admissions and in the turnover indicator of the hospital, which has a positive impact on the hospital management as well as on costs.

Perils and pitfalls of probiotic quasi-experimental studies for primary prevention of Clostridioides difficile infection: A review of the evidence

BACKGROUND

Primary prevention of Clostridioides (Clostridium) difficile infections (CDI) is an important but challenging infection control goal for hospitals and health care facilities. Enhanced infection control protocols have reduced CDI rates, but the problem persists and administration of probiotics to patients at risk could be very useful if shown to be safe and effective. Randomized controlled trials are largely impractical for primary prevention CDI trials due to large required study sizes and quasi-experimental studies are becoming more frequent as a method to assess this problem.

OBJECTIVE

Our goal is to review the published quasi-experimental studies adding probiotics to their infection control protocols to reduce CDI and determine the strengths and limitations for this type of study design.

METHODS

The literature was searched using PubMed, Google Scholar, Medline and Cochrane Databases and gastrointestinal meeting abstracts from January 2000 to January 2020 for quasi-experimental intervention studies testing various probiotics for the primary prevention of CDI.

RESULTS

We found 28 studies with 7 different types of probiotics (10 studies implementing a hospital-wide intervention, 6 studies targeting 1-3 wards, and 12 studies on either sustainability, cost-effectiveness or subgroup analysis). Some probiotics demonstrated a significant reduction in CDI rates; all four of the probiotic types given only on specific wards and 3 of the 4 probiotics given facility-wide. However, this type of study design was influenced by numerous factors which must be carefully accounted for in the analysis.

CONCLUSIONS

Some probiotics may be an effective addition to infection control protocols to prevent C. difficile infections, but careful study design considerations are needed.

Identification of patients at risk of Clostridioides difficile infection for enrollment in vaccine clinical trials

BACKGROUND

Clostridioides difficile infection (CDI) is an important cause of diarrheal disease associated with increasing morbidity and mortality. Efforts to develop a preventive vaccine are ongoing. The goal of this study was to develop an algorithm to identify patients at high risk of CDI for enrollment in a vaccine efficacy trial.

METHODS

We conducted a 2-stage retrospective study of patients aged ≥ 50 within the US Department of Veterans Affairs Health system between January 1, 2009 and December 31, 2013. Included patients had at least 1 visit in each of the 2 years prior to the study, with no CDI in the past year. We used multivariable logistic regression with elastic net regularization to identify predictors of CDI in months 2-12 (i.e., days 31 - 365) to allow time for antibodies to develop. Performance was measured using the positive predictive value (PPV) and the area under the curve (AUC).

RESULTS

Elements of the predictive algorithm included age, baseline comorbidity score, acute renal failure, recent infections or high-risk antibiotic use, hemodialysis in the last month, race, and measures of recent healthcare utilization. The final algorithm resulted in an AUC of 0.69 and a PPV of 3.4%.

CONCLUSIONS

We developed a predictive algorithm to identify a patient population with increased risk of CDI over the next 2-12 months. Our algorithm can be used prospectively with clinical and administrative data to facilitate the feasibility of conducting efficacy studies in a timely manner in an appropriate population.

Predictors of Hospital-Acquired Clostridioides difficile Infection: A Systematic Review

BACKGROUND

Clostridioides difficile infections (CDIs) have been identified as a major health concern due to the high morbidity, mortality, and cost of treatment. The aim of this study was to review the extant literature and identify the various patient-related, medication-related, and organizational risk factors associated with developing hospital-acquired CDIs in adult patients in the United States.

METHODS

A systematic review of four (4) online databases, including Scopus, PubMed, CINAHL, and Cochrane Library, was conducted to identify empirical studies published from 2007 to 2017 pertaining to risk factors of developing hospital-acquired CDIs.

FINDINGS

Thirty-eight studies (38) were included in the review. Various patient-level and medication-related risk factors were identified including advanced patient age, comorbidities, length of hospital stay, previous hospitalizations, use of probiotic medications and proton pump inhibitors. The review also identified organizational factors such as room size, academic affiliation, and geographic location to be significantly associated with hospital-acquired CDIs.

CONCLUSION

Validation of the factors associated with high risk of developing hospital-acquired CDIs identified in this review can aid in the development of risk prediction models to identify patients who are at a higher risk of developing CDIs and developing quality improvement interventions that might improve patient outcomes by minimizing risk of infection.

[Clostridium difficile in the intensive care unit]

Clostridium difficile infections (CDI) are encountered in about 1-2% of patients in the intensive care unit (ICU) and pose a special challenge to those who provide care. Only little data regarding severity and management of CDI in ICU patients in Europe are available. Extrapolation of results from one patient population to another is often difficult. The comorbidities of those patients often limit the application of general recommendations concerning diagnosis and therapy. In addition, there are a relevant percentage of patients (10-20%) with asymptomatic C. difficile colonization. The relevance for the patient and for the risk of patient to patient infection is not yet fully understood. Based on available data, we give an overview of current challenges in the diagnosis, assessment of disease course, primary management options, and alternatives in special cases and treatment failures of CDI. We also discuss prevention of new CDI in the intensive care unit.

Primary prevention of Clostridium difficile infections with a specific probiotic combining Lactobacillus acidophilus, L. casei, and L. rhamnosus strains: assessing the evidence

Clostridium difficile infection (CDI) has become the leading healthcare-associated infection and cause of outbreaks around the world. Although various innovative treatments have been developed, preventive strategies using multi-faceted infection control programmes have not been successful in reducing CDI rates. The major risk factor for CDI is the disruption of the normally protective gastrointestinal microbiota, typically by antibiotic use. Supplementation with specific probiotics has been effective in preventing various negative outcomes, including antibiotic-associated diarrhoea and CDI. However, a consensus of which probiotic strains might prevent CDI has not been reached and meta-analyses report high degrees of heterogeneity when studies of different probiotic products are pooled together. We searched the literature for probiotics with sufficient evidence to assess clinical efficacy for the prevention of CDI and focused on one specific probiotic formulation comprised of three lactobacilli strains (Lactobacillus acidophilus CL1285, Lactobacillus casei LBC80R, Lactobacillus rhamnosus CLR2, Bio-K+) for its ability to prevent CDI in healthcare settings. A literature search on this probiotic formulation was conducted using electronic databases (PubMed, Google Scholar), abstracts from infectious disease and infection control meetings, and communications from the probiotic company. Supporting evidence was found for its mechanisms of action against CDI and that it has an excellent safety and tolerability profile. Evidence from randomized controlled trials and facility-level interventions that administer Bio-K+ show reduced incidence rates of CDI. This probiotic formulation may have a role in primary prevention of healthcare-associated CDI when administered to patients who receive antibiotics.

Clostridium difficile: More Challenging than Ever

Clostridium difficile infection is not new, but it is posing more problems than ever before, described by the Centers for Disease Control and Prevention as an urgent threat. Its pathophysiology allows C difficile to be very difficult to manage, both within the hospital environment and in a patient's body. This article reviews clinical manifestations of the infection, outlines both medical and surgical treatment options, and discusses risk factors and predictors. Implications for nurses are thoroughly described. The epidemic proportion of C difficile infection gives cause for serious concern, especially for vulnerable populations, such as adults over age 65.

Sleeping with the enemy: Clostridium difficile infection in the intensive care unit

Over the last years, there was an increase in the number and severity of Clostridium difficile infections (CDI) in all medical settings, including the intensive care unit (ICU). The current prevalence of CDI among ICU patients is estimated at 0.4–4% and has severe impact on morbidity and mortality. An estimated 10–20% of patients are colonized with C. difficile without showing signs of infection and spores can be found throughout ICUs. It is not yet possible to predict whether and when colonization will become infection. Figuratively speaking, our patients are sleeping with the enemy and we do not know when this enemy awakens.

Most patients developing CDI in the ICU show a mild to moderate disease course. Nevertheless, difficult-to-treat severe and complicated cases also occur. Treatment failure is particularly frequent in ICU patients due to comorbidities and the necessity of continued antibiotic treatment. This review will give an overview of current diagnostic, therapeutic, and prophylactic challenges and options with a special focus on the ICU patient.

First, we focus on diagnosis and prognosis of disease severity. This includes inconsistencies in the definition of disease severity as well as diagnostic problems. Proceeding from there, we discuss that while at first glance the choice of first-line treatment for CDI in the ICU is a simple matter guided by international guidelines, there are a number of specific problems and inconsistencies. We cover treatment in severe CDI, the problem of early recognition of treatment failure, and possible concepts of intensifying treatment. In conclusion, we mention methods for CDI prevention in the ICU.

Primary prevention of Clostridium difficile infections - how difficult can it be?

C. difficile infections (CDI) have been a challenging disease to treat, much less to prevent, for decades. Efforts for primary prevention have mainly focused on improving infection control practices, but CDI outbreaks continue to plague healthcare facilities. Areas covered: A literature search from 1970-December 2016 found 13 facility-level and 2 patient-level strategies that were evidence-based. The aim of this manuscript is to assess the current state of the literature on primary prevention of CDI and offer insights into which strategies may be more effective. Expert commentary: The strongest evidence for primary prevention is based on multi-faceted infection control bundles, while there is promising moderate evidence involving facility-wide use of specific probiotics. Moderate-level evidence was found for patient-level use of specific probiotics and low level evidence for vaccines. Future suggestions include use of consistent outcome metrics, measurements of implementation compliance and program sustainability.

Antibiotic resistance

Antimicrobial resistance in bacterial pathogens is a challenge that is associated with high morbidity and mortality. Multidrug resistance patterns in Gram-positive and -negative bacteria are difficult to treat and may even be untreatable with conventional antibiotics. There is currently a shortage of effective therapies, lack of successful prevention measures, and only a few new antibiotics, which require development of novel treatment options and alternative antimicrobial therapies. Biofilms are involved in multidrug resistance and can present challenges for infection control. Virulence, Staphylococcus aureus, Clostridium difficile infection, vancomycin-resistant enterococci, and control in the Emergency Department are also discussed.