A growing body of evidence indicates that probiotics are both safe and effective for preventing CDIs [9]. Probiotics may counteract disturbances in intestinal flora, thereby reducing the risk for colonization by pathogenic bacteria. Probiotics can inhibit pathogen adhesion, colonization, and invasion of the gastrointestinal mucosa [10].
We hypothesized that preservation and/or restoration of the diversity of the fecal microbiome would prevent CDI and disease recurrence in our facility. Prior to 2009, we had strict infection prevention measures in place to prevent disease transmission, similar to many other institutions. In 2009, we implemented 3 additional interventions to reduce the rising incidence of CDI: (1) an antibiotic stewardship program, (2) lowering the intensity of acid suppression, and (3) expanding the use of probiotic therapy. The 3 interventions were initiated over the 19-month period January 2009 through July 2010. This study addresses the effects of these interventions.
Methods
Patients and Data Collection
The study was conducted at a community hospital (59 beds) that has an associated LTC facility (122 beds). We conducted a retrospective analysis of hospital and LTC data from all documented cases of CDI between January 2009 and December 2013. Study subjects included all patients with stools positive for C. difficile antigen and toxin with associated symptoms of infection (n = 123). Institutional review board approval was obtained prior to data collection.
The following information was collected: admission diagnosis, number of days from admission until confirmed CDI, residence prior to admission, duration and type of antibiotics received prior to or during symptoms of CDI, type of GI prophylaxis received within 14 days prior to and during CDI treatment, probiotic received and duration, and the type and duration of antibiotic treatment given for the CDI. The data collected was used to determine the likely origin of each C. difficile case, dates of recurrences, and the possible effects of the interventions. Antibiotic use was categorized as: (1) recent antibiotic course (antibiotics received within the preceding 4 weeks), (2) antibiotic courses greater than 10 days, and (3) multiple antibiotic courses (more than 1 antibiotic course received sequentially or concurrently).
Positive C. difficile infections were detected using a 2-step algorithm, starting in 2009. The samples were first screened with a rapid membrane enzyme immunoassay for glutamate dehydrogenase (GDH) antigen and toxin A and B in stool (C. Diff Quik Chek Complete, Techlab, Blacksburg, VA). Discrepant samples (GDH positive and toxin A and B negative) were reflexed to DNA-based PCR testing. The PCR assay was changed to the Verigene C. difficile test (Nanosphere, Northbrook, IL) in 2012. Up to 30 days after discharge from our facility, positive results were considered as acquired from our facility and positive results within 2 days of admission with symptoms of CDI were considered positive on admission and were not attributed to our facility. A primary episode of CDI was defined to be the first identified episode or event in each patient. Recurrent CDI was defined as a repeated case of CDI within 180 days of the original CDI event.