Original Research

A Multipronged Approach to Decrease the Risk of Clostridium difficile Infection at a Community Hospital and Long-Term Care Facility

Journal of Clinical Outcomes Management. 2015 September;22(9)

References

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Reduction of Antibiotic Pressure

In June 2009, our institution implemented a pharmacist-based antimicrobial stewardship program. Program initiatives included streamlining antibiotic therapy and focusing antimicrobial coverage, with proper dosing and appropriate duration of therapy ( Figure 1 ). Acceptance by physicians of antimicrobial stewardship interventions rose from 79% in 2010 to 95% by 2012 and has remained consistently high, with many of the changes contributing to reducing antibiotic pressure.

Other actions taken to improve antimicrobial prescribing as part of the stewardship program included medication usage evaluations (MUEs) for levofloxacin and carbapenems, implementing an automatic dosing/duration protocol for levofloxacin, and carbapenem restriction to prevent inappropriate use. Nursing and pharmacy staffs were educated on vancomycin appropriateness, benefits of MRSA screening for de-escalation, procalcitonin, and treatment of sepsis. Emergency department staff was educated on (1) empiric antimicrobial treatment recommendations for urinary and skin and soft tissue infections based on outpatient antibiogram data, (2) renal adjustment of antimicrobials, (3) fluoroquinolones: resistance formation, higher CDI risk and higher dosing recommendations, (4) GI prophylaxis recommendations, and (5) probiotics.

Reduction in the Intensity of Acid Suppression for GI Prophylaxis

PPIs were substituted with histamine-2 receptor antagonists (H2RA) whenever acid suppression for GI prophylaxis was warranted. If GI symptoms persisted, sucralfate was added. In May 2010, all eligible LTC patients were converted from PPIs to H2RA.

Expanding the Use of Probiotics

We expanded the use of probiotics as an adjunctive treatment for CDI with metronidazole ± vancomycin oral therapies. Probiotics were included concurrently with any broad-spectrum antibiotic administration, longer antibiotic courses (≥ 7 days), and/or multiple courses of antibiotics. The combination of Saccromyces boulardii plus Lactobacillus acidophilus and L. bulgaricus was given with twice daily dosing until the end of 2011. In January 2012, our facility switched over to daily administration of a probiotic with the active ingredients of Lactobacillus acidophilus and Lactobacillus casei , 50 billion colony-forming units. Probiotics were given during the antibiotic course plus for 1 additional week after course completion. Probiotics were not administered to selected groups of patients: (1) immunocompromised patients, (2) patients who were NPO, or (3) patients excluded by their physicians.

There was no change or enhanced targeting of infection prevention or environmental hygiene strategies during the study period.

Data Analysis and Statistical Methods

All data were collected on data collection sheets and transcribed into Microsoft Office Excel 2007 Service Pack 3. No data were excluded from analysis. Continuous variables, eg, number of cases of CDI, are reported as mean ± standard deviation. Categorical variables, eg, number of recurrent CDI cases, are reported as the count and percentage. Comparison of populations was done with the Wilcoxon rank sum test. Segments of the interrupted time series were assessed using linear regression. Associations were tested using χ2. Statistical tests were deemed significant when the α probability was < 0.05. No adjustments were made for multiplicity. Data descriptive statistics (including frequency histograms for visual examination of distributions) and statistical analyses were performed using Stata 11.1 (StataCorp, College Station, TX).

Results

CDIs

The results show a significant reduction in the number of health care facility–associated C. difficile