Encouraging Appropriate Testing and Antibiotic Stewardship to Reduce Healthcare-acquired Clostridium difficile Infections

Abstract

BACKGROUND A community hospital of 167 licensed beds was assessed with a high number of Clostridium difficile infections (CDIs). The journey started after identifying thirty-five (35) Healthcare Facility onset (HO) events of CDIs in 2015 and antimicrobial duration of therapy (DOT)/1000 days trended 55.5 - 62.8. Healthcare Facility onset (HO) according to the National Healthcare Safety Network reporting criteria is a LabID event specimen collected greater than 3 calendar days after admission to the facility. (On or after hospital day 4). Day one is day of admission. Several factors contributed to the high numbers of CDIs, including antimicrobial utilization and inappropriate testing. The purpose of this practice is to encourage appropriate testing and antibiotic stewardship to reduce HO CDIs. METHODS To reduce CDIs we implemented guidelines for appropriate testing and tailoring antibiotics for each patient according to their treatment plan. We created a diarrhea decision tree to guide appropriate testing for Clostridium difficile. We tested, when clinically indicated, to avoid identifying patients only colonized with Clostridium difficile. The Antimicrobial Stewardship team created criteria for use of commonly prescribed antibiotics such as: Zosyn, Vancomycin, Carbapenems, Fluoroquinolones and Ceftriaxone based on recommendations from the Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS). We implemented criteria guided mandatory duration of therapy for Fluoroquinolones and Ceftriaxone orders to help discourage prolonged unnecessary use. RESULTS In 2016 – 2018, the annual DOT/1000 days for Quinolones(Q) and Carbapenems(C) trended downward. There were some variations and outliers with monthly totals of DOT/1000 days that ranged from (Q) 27.6 – 72.0 and (C) 23.5 – 41.0. HO CDIs decreased to 16 in 2016 and significantly decreased to 1 in 2017. 6 HO CDIs year-to-date 2018. CONCLUSIONS Essential intervention in appropriate testing and antimicrobial stewardship promotes patient safety and reduces HO CDIs.