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Efficacy of a stewardship intervention focused on reducing unnecessary use of non- Clostridioides difficile antibiotics in patients with Clostridioides difficile infection. Infect Control Hosp Epidemiol 2021; 41:216-218. [PMID: 31843033 DOI: 10.1017/ice.2019.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In a tertiary-care hospital and affiliated long-term care facility, a stewardship intervention focused on patients with Clostridioides difficile infection (CDI) was associated with a significant reduction in unnecessary non-CDI antibiotic therapy. However, there was no significant reduction in total non-CDI therapy or in the frequency of CDI recurrence.
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2
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Olmedo M, Valerio M, Reigadas E, Marín M, Alcalá L, Muñoz P, Bouza E. Clinical impact of a Clostridioides ( Clostridium) difficile bedside infectious disease stewardship intervention. JAC Antimicrob Resist 2020; 2:dlaa037. [PMID: 34223003 PMCID: PMC8210181 DOI: 10.1093/jacamr/dlaa037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 01/23/2020] [Accepted: 04/06/2020] [Indexed: 11/17/2022] Open
Abstract
Objectives To evaluate the clinical impact of a bedside visit to patients with a positive Clostridioides difficile test on the antimicrobial stewardship of C. difficile infection (CDI) and non-C. difficile infections. Methods All patients ≥18 years old with positive CDI laboratory tests hospitalized between January 2017 and August 2017 received an immediate bedside intervention that consisted mainly of checking protective measures and providing recommendations on infection control and the management of CDI and other infections. Results A total of 214 patients were evaluated. The infectious disease (ID) physician was the first to establish protective measures in 25.2% of the cases. In 22/29 (75.9%) cases, physicians in charge accepted ID consultant recommendations to stop CDI treatment in asymptomatic patients. Unnecessary non-CDI antibiotics were discontinued in 19.1% of the cases. ID recommendations were not accepted by physicians in charge in only 12.6% of the cases. Conclusions A bedside rapid intervention for patients with a CDI-positive faecal sample was effective in avoiding overdiagnosis and unnecessary antibiotic treatment, optimizing anti-CDI drugs, increasing compliance with infection control measures and providing educational advice.
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Affiliation(s)
- María Olmedo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Maricela Valerio
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Elena Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Mercedes Marín
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Luis Alcalá
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Salud Carlos III, Madrid, Spain
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3
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Bundling Probiotics With Antimicrobial Stewardship Programs for the Prevention of Clostridiodes difficile Infections in Acute Care Hospitals. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2020. [DOI: 10.1097/ipc.0000000000000853] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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4
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Rohde JM, Jones K, Padron N, Olmsted RN, Chopra V, Dubberke ER. A Tiered Approach for Preventing Clostridioides difficile Infection. Ann Intern Med 2019; 171:S45-S51. [PMID: 31569223 DOI: 10.7326/m18-3444] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jeffrey M Rohde
- University of Michigan Medical School, Ann Arbor, Michigan (J.M.R., K.J.)
| | - Karen Jones
- University of Michigan Medical School, Ann Arbor, Michigan (J.M.R., K.J.)
| | - Norma Padron
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois (N.P.)
| | - Russell N Olmsted
- Integrated Clinical Services, Trinity Health, Livonia, Michigan (R.N.O.)
| | - Vineet Chopra
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (V.C.)
| | - Erik R Dubberke
- Washington University School of Medicine, St. Louis, Missouri (E.R.D.)
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5
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Abstract
Clostridioides difficile (formerly Clostridium) is a major cause of healthcare associated diarrhea, and is increasingly present in the community. Historically, C difficile infection was considered easy to diagnose and treat. Over the past two decades, however, diagnostic techniques have changed in line with a greater understanding of the physiopathology of C difficile infection and the use of new therapeutic molecules. The evolution of diagnosis showed there was an important under- and misdiagnosis of C difficile infection, emphasizing the importance of algorithms recommended by European and North American infectious diseases societies to obtain a reliable diagnosis. Previously, metronidazole was considered the reference drug to treat C difficile infection, but more recently vancomycin and other newer drugs are shown to have higher cure rates. Recurrence of infection represents a key parameter in the evaluation of new drugs, and the challenge is to target the right population with the adapted therapeutic molecule. In multiple recurrences, fecal microbiota transplantation is recommended. New approaches, including antibodies, vaccines, and new molecules are already available or in the pipeline, but more data are needed to support the inclusion of these in practice guidelines. This review aims to provide a baseline for clinicians to understand and stratify their choice in the diagnosis and treatment of C difficile infection based on the most recent data available.
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Affiliation(s)
- Benoit Guery
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, Lausanne, Switzerland
- French Group of Faecal Microbiota Transplantation
- European Study Group on Host and Microbiota Interactions
- European Study Group on Clostridium difficile
| | - Tatiana Galperine
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, Lausanne, Switzerland
- French Group of Faecal Microbiota Transplantation
| | - Frédéric Barbut
- National Reference Laboratory for Clostridium difficile, Paris, France
- INSERM, Faculté de Pharmacie de Paris, Université Paris Descartes, Paris, France
- European Study Group on Clostridium difficile
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6
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Timbrook TT, Spivak ES, Hanson KE. Current and Future Opportunities for Rapid Diagnostics in Antimicrobial Stewardship. Med Clin North Am 2018; 102:899-911. [PMID: 30126579 DOI: 10.1016/j.mcna.2018.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Rapid diagnostic testing has improved clinical care of patients with infectious syndromes when combined with antimicrobial stewardship. The authors review the current data on antimicrobial stewardship and rapid diagnostic testing in bloodstream, respiratory tract, and gastrointestinal tract infections. Evidence for the potential benefit of rapid tests in bloodstream infections seems strong, respiratory tract infections mixed, and gastrointestinal tract infections still evolving. The authors also review future directions in rapid diagnostic testing and suggest areas of focus for antimicrobial stewardship efforts.
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Affiliation(s)
- Tristan T Timbrook
- Department of Pharmacy, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA
| | - Emily S Spivak
- Department of Medicine, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA
| | - Kimberly E Hanson
- Department of Medicine, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA; Institute for Clinical and Experimental Pathology, ARUP Laboratories, 500 Chipeta Way, Salt Lake City, UT 84108, USA; Department of Pathology, University of Utah, 15 North Medical Drive East, Salt Lake City, UT 84112, USA.
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7
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Foolad F, Nagel JL, Eschenauer G, Patel TS, Nguyen CT. Disease-based antimicrobial stewardship: a review of active and passive approaches to patient management. J Antimicrob Chemother 2018; 72:3232-3244. [PMID: 29177489 DOI: 10.1093/jac/dkx266] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Although new antimicrobial stewardship programmes (ASPs) often begin by targeting the reduction of antimicrobial use, an increasing focus of ASPs is to improve the management of specific infectious diseases. Disease-based antimicrobial stewardship emphasizes improving patient outcomes by optimizing antimicrobial use and increasing compliance with performance measures. Directing efforts towards the comprehensive management of specific infections allows ASPs to promote the shift in healthcare towards improving quality, safety and patient outcome metrics for specific diseases. This review evaluates published active and passive disease-based antimicrobial stewardship interventions and their impact on antimicrobial use and associated patient outcomes for patients with pneumonia, acute bacterial skin and skin structure infections, bloodstream infections, urinary tract infections, asymptomatic bacteriuria, Clostridium difficile infection and intra-abdominal infections. Current literature suggests that disease-based antimicrobial stewardship effects on medical management and patient outcomes vary based on infectious disease syndrome, resource availability and intervention type.
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Affiliation(s)
- Farnaz Foolad
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Jerod L Nagel
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Gregory Eschenauer
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA.,College of Pharmacy, University of Michigan, 428 Church St., Ann Arbor, MI 48109, USA
| | - Twisha S Patel
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Cynthia T Nguyen
- Department of Pharmacy, University of Chicago Medicine, 5841 S. Maryland Ave. MC0010, Chicago, IL 60637, USA
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8
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Transmission of Clostridium difficile from asymptomatically colonized or infected long-term care facility residents. Infect Control Hosp Epidemiol 2018; 39:909-916. [PMID: 29848392 DOI: 10.1017/ice.2018.106] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To test the hypothesis that long-term care facility (LTCF) residents with Clostridium difficile infection (CDI) or asymptomatic carriage of toxigenic strains are an important source of transmission in the LTCF and in the hospital during acute-care admissions. DESIGN A 6-month cohort study with identification of transmission events was conducted based on tracking of patient movement combined with restriction endonuclease analysis (REA) and whole-genome sequencing (WGS). SETTING Veterans Affairs hospital and affiliated LTCF.ParticipantsThe study included 29 LTCF residents identified as asymptomatic carriers of toxigenic C. difficile based on every other week perirectal screening and 37 healthcare facility-associated CDI cases (ie, diagnosis >3 days after admission or within 4 weeks of discharge to the community), including 26 hospital-associated and 11 LTCF-associated cases. RESULTS Of the 37 CDI cases, 7 (18·9%) were linked to LTCF residents with LTCF-associated CDI or asymptomatic carriage, including 3 of 26 hospital-associated CDI cases (11·5%) and 4 of 11 LTCF-associated cases (36·4%). Of the 7 transmissions linked to LTCF residents, 5 (71·4%) were linked to asymptomatic carriers versus 2 (28·6%) to CDI cases, and all involved transmission of epidemic BI/NAP1/027 strains. No incident hospital-associated CDI cases were linked to other hospital-associated CDI cases. CONCLUSIONS Our findings suggest that LTCF residents with asymptomatic carriage of C. difficile or CDI contribute to transmission both in the LTCF and in the affiliated hospital during acute-care admissions. Greater emphasis on infection control measures and antimicrobial stewardship in LTCFs is needed, and these efforts should focus on LTCF residents during hospital admissions.
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Gateau C, Couturier J, Coia J, Barbut F. How to: diagnose infection caused by Clostridium difficile. Clin Microbiol Infect 2018; 24:463-468. [DOI: 10.1016/j.cmi.2017.12.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 11/30/2017] [Accepted: 12/07/2017] [Indexed: 01/05/2023]
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10
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Larrainzar-Coghen T, Rodríguez-Pardo D, Fernández-Hidalgo N, Puig-Asensio M, Pigrau C, Ferrer C, Rodríguez V, Bartolomé R, Campany D, Almirante B. Secular trends in the epidemiology of Clostridium difficile infection (CDI) at a tertiary care hospital in Barcelona, 2006-2015: A prospective observational study. Anaerobe 2018; 51:54-60. [PMID: 29655966 DOI: 10.1016/j.anaerobe.2018.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 03/05/2018] [Accepted: 04/02/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Describe secular trends in the epidemiology and outcome of Clostridium difficile infection (CDI) at a tertiary hospital. METHODS All consecutive primary CDI episodes in adults (January 2006-December 2015) were included. CDI was diagnosed on the presence of diarrhoea and a positive stool test for C. difficile toxin A and/or B. To define trends, a time-series analysis was performed using yearly data on demographics, clinical characteristics, management, antimicrobial treatment, and outcome of CDI. Patients were followed-up for three months after the diagnosis. RESULTS There were 724 CDI episodes. Over the period from 2006 to 2015, the incidence rose from 0.18 episodes/1000 admissions to 0.26 episodes (relative rate [RR] 1.43; 95%CI, 1.02-2.00; P = 0.035). Median Charlson comorbidity index increased from 2 (IQR 1-3) to 4 (IQR 2-4) (RR 1.65; 95%CI, 1.12-2.41; P = 0.005). Overall, 80.4% of patients received proton pump inhibitors (PPIs) prior to CDI, and the percentage of PPI discontinuations rose from 2.3% to 20.4% (RR 8.80; 95%CI 1.20-64.36; P = 0.006). Management of non-Clostridium antibiotics also changed: antibiotic withdrawals or switches increased from 4.2% to 29.2% (RR 7.00; 95%CI 1.68-29.15, P = 0.001). Regarding CDI treatment, the percentage of patients treated with metronidazole decreased (88.9% vs 52.6%) (RR 0.59 (0.48-0.73), P < 0.001), whereas the percentage receiving vancomycin increased (1.9% vs 32.6%) (RR 17.62 (2.47-125.49), P < 0.001). The percentages of cures, deaths, and first recurrences did not significantly change over the 10-year period. CONCLUSIONS Changes in CDI management were associated with a stable prognosis (percentage of cures and first recurrences), even though affected patients had a greater number of comorbidities over time.
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Affiliation(s)
- Thais Larrainzar-Coghen
- Infectious Diseases Department, Hospital Universitari Vall D'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Dolors Rodríguez-Pardo
- Infectious Diseases Department, Hospital Universitari Vall D'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Spanish Network for the Research in Infectious Diseases (REIPI RD16/0016/0003), Instituto de Salud Carlos III, Madrid, Spain.
| | - Nuria Fernández-Hidalgo
- Infectious Diseases Department, Hospital Universitari Vall D'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Spanish Network for the Research in Infectious Diseases (REIPI RD16/0016/0003), Instituto de Salud Carlos III, Madrid, Spain
| | - Mireia Puig-Asensio
- Infectious Diseases Department, Hospital Universitari Vall D'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Spanish Network for the Research in Infectious Diseases (REIPI RD16/0016/0003), Instituto de Salud Carlos III, Madrid, Spain
| | - Carles Pigrau
- Infectious Diseases Department, Hospital Universitari Vall D'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Spanish Network for the Research in Infectious Diseases (REIPI RD16/0016/0003), Instituto de Salud Carlos III, Madrid, Spain
| | - Carmen Ferrer
- Infectious Diseases Department, Hospital Universitari Vall D'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Spanish Network for the Research in Infectious Diseases (REIPI RD16/0016/0003), Instituto de Salud Carlos III, Madrid, Spain
| | - Virginia Rodríguez
- Microbiology Department, Hospital Universitari Vall D'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rosa Bartolomé
- Microbiology Department, Hospital Universitari Vall D'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Campany
- Pharmacy Department, Hospital Universitari Vall D'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Benito Almirante
- Infectious Diseases Department, Hospital Universitari Vall D'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Spanish Network for the Research in Infectious Diseases (REIPI RD16/0016/0003), Instituto de Salud Carlos III, Madrid, Spain
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11
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Baclet N, Ficheur G, Alfandari S, Ferret L, Senneville E, Chazard E, Beuscart JB. Explicit definitions of potentially inappropriate prescriptions of antibiotics in older patients: a compilation derived from a systematic review. Int J Antimicrob Agents 2017; 50:640-648. [PMID: 28803931 DOI: 10.1016/j.ijantimicag.2017.08.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/12/2017] [Accepted: 08/01/2017] [Indexed: 12/23/2022]
Abstract
Potentially inappropriate prescriptions (PIPs) of antibiotics (antibiotic-PIPs) are generally detected by applying implicit definitions based on expert opinion. Explicit definitions are less frequently used, even though this approach would enable the automated detection of antibiotic-PIPs in electronic health records. Here, explicit definitions of antibiotic-PIPs used in studies of older adults were systematically reviewed. The MEDLINE®, Scopus® and Web of ScienceTM core collection databases were searched with a combination of three terms and their synonyms: 'potentially inappropriate prescription' AND 'antibiotic treatment' AND 'older patients'. Following standardised selection of publications, explicit definitions of antibiotic-PIPs were extracted and were classified into infectious diseases domains and subdomains. A total of 600 search queries identified 4270 records, 93 of which were selected for review. A total of 160 mentions of antibiotic-PIPs were found, corresponding to 62 distinct definitions in 19 infectious diseases domains. Nearly one-half of the definitions were related to upper respiratory tract infections (n = 11 definitions; 17.7%), lower respiratory tract infections (n = 8; 12.9%) and drug-drug interactions (n = 11; 17.7%). Almost 75% of definitions (n = 46) were mentioned in a single study only. Only three definitions concerned critically important antibiotics such as third-generation cephalosporins and fluoroquinolones. This systematic review identified 62 explicit definitions of antibiotic-PIPs. Most of the definitions were not found in more than one study and they varied in the degree of precision. We advocate the implementation of an expert consensus on explicit definitions of antibiotic-PIPs that correspond to today's challenges in public health.
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Affiliation(s)
- Nicolas Baclet
- Univ. Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, F-59000 Lille, France; Lille Catholic Hospitals, Department of Infectious Diseases, F-59160 Lille, France.
| | - Grégoire Ficheur
- Univ. Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, F-59000 Lille, France
| | - Serge Alfandari
- Gustave Dron Hospital, University Department of Infectious Diseases, F-59200 Tourcoing, France
| | - Laurie Ferret
- Univ. Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, F-59000 Lille, France; Valenciennes General Hospital, Pharmacy Department, F-59300 Valenciennes, France
| | - Eric Senneville
- Gustave Dron Hospital, University Department of Infectious Diseases, F-59200 Tourcoing, France
| | - Emmanuel Chazard
- Univ. Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, F-59000 Lille, France
| | - Jean-Baptiste Beuscart
- Univ. Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, F-59000 Lille, France; CHU Lille, Department of Geriatric Medicine, F-59000 Lille, France
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12
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Patel I, Wungjiranirun M, Theethira T, Villafuerte-Galvez J, Castillo N, Akbari M, Alonso CD, Leffler DA, Kelly CP. Lack of adherence to SHEA-IDSA treatment guidelines for Clostridium difficile infection is associated with increased mortality. J Antimicrob Chemother 2017; 72:574-581. [PMID: 28115504 PMCID: PMC6074846 DOI: 10.1093/jac/dkw423] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 09/01/2016] [Accepted: 09/08/2016] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES The objective of this study was to determine our institution's compliance with 2010 Society for Healthcare Epidemiology of America and IDSA Clostridium difficile infection (CDI) treatment guidelines and their respective outcomes. METHODS We collected clinical parameters, laboratory values, antibiotic therapy and clinical outcomes from the electronic medical records for all patients hospitalized at our institution with a diagnosis of CDI from December 2012 to November 2013. We specifically evaluated whether SHEA-IDSA treatment guidelines were followed and evaluated the associations between guideline adherence and severe outcomes including mortality. RESULTS We identified 230 patients with CDI meeting inclusion criteria during the study period. Of these, 124 (54%) were appropriately treated, 46 (20%) were under-treated and 60 (26%) were over-treated. All-cause 90 day mortality was 17.4% overall; 43.5% in the under-treated group versus 12.9% in those appropriately treated (P < 0.0001) and 10.9% in those appropriately treated plus over-treated (P < 0.0001). Similarly, 90 day mortality attributed to CDI was 21.7% in those under-treated versus 8.9% in those appropriately treated (P = 0.03) and 8.2% in those either appropriately treated or over-treated (P = 0.015). Severe-complicated CDI occurred in 46 patients. In this subgroup, there was a non-significant trend towards increased mortality in under-treated patients (56.7%) compared with appropriately treated patients (37.5%, P = 0.35). Under-treatment was also associated with a higher rate of CDI-related ICU transfer (17.4% versus 4.8% in those appropriately treated, P = 0.023). CONCLUSIONS Adherence to CDI treatment guidelines is associated with improved outcomes especially in those with severe disease. Increased emphasis on provision of appropriate, guideline-based CDI treatment appears warranted.
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Affiliation(s)
- I Patel
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - M Wungjiranirun
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - T Theethira
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - J Villafuerte-Galvez
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - N Castillo
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - M Akbari
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - C D Alonso
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - D A Leffler
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - C P Kelly
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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13
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The burden of healthcare-associated Clostridium difficile infection in a non-metropolitan setting. J Hosp Infect 2016; 95:387-393. [PMID: 28131640 DOI: 10.1016/j.jhin.2016.12.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 12/09/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Healthcare-associated Clostridium difficile infection (HCA-CDI) remains a major cause of morbidity and mortality in industrialized countries. However, few data exist on the burden of HCA-CDI in multi-site non-metropolitan settings. This study examined the introduction of an antimicrobial stewardship programme (ASP) in relation to HCA-CDI rates, and the effect of HCA-CDI on length of stay (LOS) and hospital costs. METHODS A comparative before-and-after intervention study of patients aged ≥16 years with HCA-CDI from December 2010 to April 2016 across the nine hospitals of a non-metropolitan health district in New South Wales, Australia was undertaken. The intervention comprised a multi-site ASP supported by a clinical decision support system, with subsequent introduction of email feedback of HCA-CDI cases to admitting medical officers. MAIN OUTCOME MEASURES HCA-CDI rates, comparative LOS and hospital costs, prior use of antimicrobials and proton pump inhibitors, and appropriateness of CDI treatment. RESULTS HCA-CDI rates rose from 3.07 to 4.60 cases per 10,000 occupied bed-days pre-intervention, and remained stable at 4 cases per 10,000 occupied bed-days post-intervention (P=0.24). Median LOS (17 vs six days; P<0.01) and hospital costs (AU$19,222 vs $7861; P<0.01) were significantly greater for HCA-CDI cases (N=91) than for matched controls (N=172). Half of the patients with severe HCA-CDI (4/8) did not receive initial appropriate treatment (oral vancomycin). CONCLUSIONS HCA-CDI placed a significant burden on the regional and rural health service through increased LOS and hospital costs. Interventions targeting HCA-CDI could be employed to consolidate the effects of ASPs.
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14
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Welch HK, Nagel JL, Patel TS, Gandhi TN, Chen B, De Leon J, Chenoweth CE, Washer LL, Rao K, Eschenauer GA. Effect of an antimicrobial stewardship intervention on outcomes for patients with Clostridium difficile infection. Am J Infect Control 2016; 44:1539-1543. [PMID: 27592160 DOI: 10.1016/j.ajic.2016.05.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 05/25/2016] [Accepted: 05/25/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Although antimicrobial stewardship programs (ASPs) are uniquely positioned to improve treatment of Clostridium difficile infection (CDI) through targeted interventions, studies to date have not rigorously evaluated the influence of ASP involvement on clinical outcomes attributed to CDI. METHODS We performed a quasiexperimental study of adult patients with CDI before (n = 307) and after (n = 285) a real-time ASP review was initiated. In the intervention group, an ASP pharmacist was notified of positive CDI results and consulted with the care team to initiate optimal therapy, minimize concomitant antibiotic and acid-suppressive therapy, and recommend surgical/infectious diseases consultation in complicated cases. The primary outcome was a composite of attributable 30-day mortality, intensive care unit admission, colectomy/ileostomy, and recurrence. RESULTS A higher percentage of patients in the ASP intervention group had acid-suppressive therapy discontinued (30% vs 13%; P < .01). Among patients with severe CDI, more patients in the intervention group received an infectious diseases consultation (17% vs 10%; P = .04), received appropriate therapy with oral vancomycin (87% vs 59%; P <.01), and vancomycin was initiated earlier (mean, 1.1 vs 1.7 days; P <.01). Incidence of the composite outcome was not significantly different between the 2 groups (12.3% vs 14.7%; P = .40). CONCLUSIONS ASP review and intervention improved CDI process measures. A decrease in composite outcomes was not found, which may be due to low baseline rates of attributable complications in our institution.
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Affiliation(s)
- Hanna K Welch
- College of Pharmacy, University of Michigan, Ann Arbor, MI
| | - Jerod L Nagel
- Department of Pharmacy, University of Michigan Health System, Ann Arbor, MI
| | - Twisha S Patel
- Department of Pharmacy, University of Michigan Health System, Ann Arbor, MI
| | - Tejal N Gandhi
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI
| | - Benrong Chen
- Office of Performance Assessment and Clinical Effectiveness, University of Michigan Health System, Ann Arbor, MI
| | - John De Leon
- College of Pharmacy, University of Michigan, Ann Arbor, MI
| | - Carol E Chenoweth
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI
| | - Laraine L Washer
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI; Department of Infection Prevention and Epidemiology, University of Michigan Health System, Ann Arbor, MI
| | - Krishna Rao
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI; Division of Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Gregory A Eschenauer
- College of Pharmacy, University of Michigan, Ann Arbor, MI; Department of Pharmacy, University of Michigan Health System, Ann Arbor, MI.
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15
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Clostridium difficile Infections in Medical Intensive Care Units of a Medical Center in Southern Taiwan: Variable Seasonality and Disease Severity. PLoS One 2016; 11:e0160760. [PMID: 27509051 PMCID: PMC4979958 DOI: 10.1371/journal.pone.0160760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 07/25/2016] [Indexed: 01/24/2023] Open
Abstract
Critical patients are susceptible to Clostridium difficile infections (CDIs), which cause significant morbidity and mortality in the hospital. In Taiwan, the epidemiology of CDI in intensive care units (ICUs) is not well understood. This study was aimed to describe the incidence and the characteristics of CDI in the ICUs of a medical center in southern Taiwan. Adult patients with diarrhea but without colostomy/colectomy or laxative use were enrolled. Stool samples were collected with or without 5 ml alcohol and were plated on cycloserine-cefoxitin-fructose agar. C. difficile identification was confirmed by polymerase chain reaction. There were 1,551 patients admitted to ICUs, 1,488 screened, and 145 with diarrhea. A total of 75 patients were excluded due either to laxative use, a lack of stool samples, or refusal. Overall, 70 patients were included, and 14 (20%) were diagnosed with CDI, with an incidence of 8.8 cases per 10,000 patient-days. The incidence of CDI was found to be highest in March 2013 and lowest in the last quarter of 2013. The cases were categorized as the following: 5 severe, complicated, 5 severe, and 4 mild or moderate diseases. Among the 14 cases of CDI, the median patient age was 74 (range: 47-94) years, and the median time from admission to diarrhea onset was 16.5 (4-53) days. Eight cases received antimicrobial treatment (primarily metronidazole), and the time to diarrheal resolution was 11.5 days. Though 6 cases were left untreated, no patients died of CDI. The in-hospital mortality of CDI cases was 50%, similar to that of patients without CDI (46.4%; P = 1.0). We concluded that the overall incidence of CDI in our medical ICUs was low and there were variable seasonal incidences and disease severities of CDI.
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16
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Klatte JM, Selvarangan R, Jackson MA, Myers AL. Reducing Overutilization of Testing for Clostridium difficile Infection in a Pediatric Hospital System: A Quality Improvement Initiative. Hosp Pediatr 2016; 6:9-14. [PMID: 26692547 DOI: 10.1542/hpeds.2015-0116] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Study objectives included addressing overuse of Clostridium difficile laboratory testing by decreasing submission rates of nondiarrheal stool specimens and specimens from children ≤12 months of age and determining resultant patient and laboratory cost savings associated with decreased testing. METHODS A multifaceted initiative was developed, and components included multiple provider education methods, computerized order entry modifications, and automatic declination from laboratory on testing stool specimens of nondiarrheal consistency and from children ≤12 months old. A run chart, demonstrating numbers of nondiarrheal plus infant stool specimens submitted over time, was developed to analyze the initiative's impact on clinicians' test-ordering practices. A p-chart was generated to evaluate the percentage of these submitted specimens tested biweekly over a 12-month period. Cost savings for patients and the laboratory were assessed at the study period's conclusion. RESULTS Run chart analysis revealed an initial shift after the interventions, suggesting a temporary decrease in testing submission; however, no sustained differences in numbers of specimens submitted biweekly were observed over time. On the p-chart, the mean percentage of specimens tested before the intervention was 100%. After the intervention, the average percentage of specimens tested dropped to 53.8%. Resultant laboratory cost savings totaled nearly $3600, and patient savings on testing charges were ∼$32 000. CONCLUSIONS Automatic laboratory declination of nondiarrheal stools submitted for CDI testing resulted in a sustained decrease in the number of specimens tested, resulting in significant laboratory and patient cost savings. Despite multiple educational efforts, no sustained changes in physician ordering practices were observed.
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Affiliation(s)
- J Michael Klatte
- Department of Pediatrics, Baystate Medical Center and Tufts University School of Medicine, Springfield, Massachusetts; and
| | - Rangaraj Selvarangan
- Children's Mercy Hospital and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Mary Anne Jackson
- Children's Mercy Hospital and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Angela L Myers
- Children's Mercy Hospital and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
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17
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Molecular Diagnostics for Clostridium difficile. Mol Microbiol 2016. [DOI: 10.1128/9781555819071.ch16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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18
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Brumley PE, Malani AN, Kabara JJ, Pisani J, Collins CD. Effect of an antimicrobial stewardship bundle for patients with Clostridium difficile infection. J Antimicrob Chemother 2015; 71:836-40. [PMID: 26661392 DOI: 10.1093/jac/dkv404] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 10/29/2015] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES The study objective was to determine whether there was an improvement in compliance with recommended Clostridium difficile infection (CDI) treatment after introduction of an institutional CDI bundle with daily antimicrobial stewardship assessment. PATIENTS AND METHODS This was a single-centre, quasi-experimental study evaluating compliance with an antimicrobial stewardship team-implemented care bundle in patients with CDI compared with historical controls. The primary outcome, compliance with overall bundle elements, was achieved when the following measures were accomplished: (i) appropriate CDI antimicrobial therapy based on the institutional treatment algorithm; (ii) discontinuation of acid-suppressant therapy in the absence of a pre-specified indication; and (iii) discontinuation of unnecessary antimicrobials. Secondary objectives were to evaluate the extent to which antimicrobial stewardship involvement affected treatment compliance and to assess trends in CDI clinical outcomes, such as mortality and readmission. RESULTS One-hundred-and-sixty-nine patients were evaluated; 83 after implementation of the care bundle (bundle group) and 89 prior to bundle implementation (historical control group). Compliance with overall bundle endpoints was significantly higher in the bundle group versus the control group (81% versus 45%, P < 0.001). Individual bundle components that were significantly improved in the bundle group were discontinuation of non-essential acid suppressants (90% versus 18%, P < 0.001) and administration of appropriate CDI therapy (82% versus 64%, P < 0.009). No significant differences were observed in overall or CDI-related mortality or readmissions, durations of therapy or reduction of non-essential concomitant antimicrobials. CONCLUSIONS Introduction of an antimicrobial stewardship bundle for CDI significantly improved adherence to institutional treatment recommendations and overall management of patients with CDI.
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Affiliation(s)
- Paul E Brumley
- Department of Pharmacy Services, St. Joseph Mercy Health System, 5301 East Huron River Drive, Ann Arbor, MI, USA
| | - Anurag N Malani
- Department of Internal Medicine, Division of Infectious Diseases, St. Joseph Mercy Health System, 5301 East Huron River Drive, Ann Arbor, MI, USA Department of Infection Prevention and Control, St. Joseph Mercy Health System, 5301 East Huron River Drive, Ann Arbor, Michigan, USA
| | - Jared J Kabara
- Quality Institute, St. Joseph Mercy Health System, 5301 East Huron River Drive, Ann Arbor, MI, USA
| | - Jennifer Pisani
- University of Michigan College of Pharmacy, 428 Church Street, Ann Arbor, MI, USA
| | - Curtis D Collins
- Department of Pharmacy Services, St. Joseph Mercy Health System, 5301 East Huron River Drive, Ann Arbor, MI, USA
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19
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Yeung SST, Yeung JK, Lau TTY, Forrester LA, Steiner TS, Bowie WR, Bryce EA. Evaluation of a Clostridium difficile infection management policy with clinical pharmacy and medical microbiology involvement at a major Canadian teaching hospital. J Clin Pharm Ther 2015; 40:655-60. [PMID: 26547905 DOI: 10.1111/jcpt.12329] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 09/28/2015] [Indexed: 12/15/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Clostridium difficile infection (CDI) represents a spectrum of disease and is a significant concern for healthcare institutions. Our study objective was to assess whether implementation of a regional CDI management policy with Clinical Pharmacy and Medical Microbiology and Infection Control involvement would lead to an improvement in concordance in prescribing practices to an evidence-based CDI disease severity assessment and pharmacological treatment algorithm. METHODS Conducted at a tertiary care teaching hospital, this two-phase quality assurance study consisted of a baseline retrospective healthcare record review of patients with CDI prior to the implementation of a regional CDI management policy followed by a prospective evaluation post-implementation. RESULTS AND DISCUSSION One hundred and forty-one CDI episodes in the pre-implementation group were compared to 283 episodes post-implementation. Overall treatment concordance to the CDI treatment algorithm was achieved in 48 of 141 cases (34%) pre-implementation compared with 136 of 283 cases (48·1%) post-implementation (P = 0·01). The median time to treatment with vancomycin was reduced from five days to one day (P < 0·01), with median length of hospital stay decreasing from 30 days to 21 days (P = 0·01) post-implementation. There was no difference in 30-day all-cause mortality. WHAT IS NEW AND CONCLUSION A comprehensive approach with appropriate stakeholder involvement in the development of clinical pathways, education to healthcare workers and prospective audit with intervention and feedback can ensure patients diagnosed with CDI are optimally managed and prescribed the most appropriate therapy based on CDI disease severity.
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Affiliation(s)
- S S T Yeung
- BC Provincial Academic Detailing Service, Fraser Health Authority, Vancouver, BC, Canada
| | - J K Yeung
- Lower Mainland Pharmacy Services, Fraser Health Authority, Vancouver Coastal, Providence Health Care, Provincial Health Services Authority, Vancouver, BC, Canada.,Pharmaceutical Sciences, Vancouver General Hospital (VGH), Vancouver, BC, Canada.,Faculty of Pharmaceutical Sciences, University of British Columbia (UBC), Vancouver, BC, Canada
| | - T T Y Lau
- Pharmaceutical Sciences, Vancouver General Hospital (VGH), Vancouver, BC, Canada.,Faculty of Pharmaceutical Sciences, University of British Columbia (UBC), Vancouver, BC, Canada.,Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, UBC, Vancouver, BC, Canada
| | - L A Forrester
- Infection Control, Vancouver Coastal Health (VCH), Powell River, BC, Canada
| | - T S Steiner
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, UBC, Vancouver, BC, Canada.,Division of Infectious Diseases, VGH, Vancouver, BC, Canada
| | - W R Bowie
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, UBC, Vancouver, BC, Canada.,Division of Infectious Diseases, VGH, Vancouver, BC, Canada
| | - E A Bryce
- Division of Medical Microbiology and Infection Control, VCH, Vancouver, BC, Canada.,Department of Pathology & Laboratory Medicine, Faculty of Medicine, UBC, Vancouver, BC, Canada
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