Hospital-acquired Clostridium Difficile Research Articles

Clostridium difficile infection after orthopedic surgery: Incidence, associated factors, and impact on outcome

To identify the incidence, associated factors, and impact of hospital-acquired Clostridium difficile infection (CDI) among patients who have undergone orthopedic surgery. We retrospectively reviewed the charts of all adults patients who underwent orthopedic surgery from January 2016 through December 2017 at a tertiary hospital. Of 7,363 patients who underwent orthopedic surgical procedures, 52 (0.7%) developed hospital-acquired CDI. The independent factors associated with CDI were age ≥65 years (adjusted odds ratio [aOR], 3.4; P < .001), preoperative hospital stay ≥3 days (aOR, 3.7; P < .001), operating time ≥3 hours (aOR, 2.5; P < .005), and antibiotic use for infection treatment (aOR, 4.3; P < .001). After adjusting for the timing of CDI using a multistate model, the mean excess LOS attributable to CDI was 2.8 days (95% confidence interval [CI], 0.4-5.3). The impact of CDI on excess LOS was more evident among patients aged ≥65 years (4.4 days; 95% CI, 1.8-7.0) and those with any comorbidity (5.6 days; 95% CI, 3.0-8.1). The overall incidence of CDI after orthopedic surgery was 0.7%. The occurrence of CDI after orthopedic surgery contributes to increased LOS. The greatest impact of CDI on LOS occurs among elderly patients and patients with comorbidities.

Using a Systems Engineering Framework to Evaluate Proton Pump Inhibitor Prescribing in Critically Ill Patients.

Proton pump inhibitors (PPIs) are a risk factor for hospital-acquired Clostridium difficile infection (CDI). Much PPI use is inappropriate, and interventions to reduce PPI use, such as for stress ulcer prophylaxis in all critically ill patients, are essential to reduce CDI rates. This mixed-methods study in a combined medical-surgical intensive care unit at a tertiary academic medical center used a human factors engineering approach to understand barriers and facilitators to optimizing PPI prescribing in these patients. We performed chart review of patients for whom PPIs were prescribed to evaluate prescribing practices. Semistructured provider interviews were conducted to determine barriers and facilitators to reducing unnecessary PPI use. Emergent themes from provider interviews were classified according to the Systems Engineering Initiative for Patient Safety model. In our intensive care unit, 25% of PPI days were not clinically indicated. Barriers to optimizing PPI prescribing included inadequate provider education, lack of institutional guidelines for stress ulcer prophylaxis, and strong institutional culture favoring PPI use. Potential facilitators included increased pharmacy oversight, provider education, and embedded decision support in the electronic medical record. Interventions addressing barriers noted by front line providers are needed to reduce unnecessary PPI use, and future studies should assess the impact of such interventions on CDI rates.

Adoption of electronic hand hygiene monitoring systems in New York state hospitals and the associated impact on hospital-acquired C. difficile infection rates

Approximately 721,800 hospital acquired infections occur annually, generating an estimated $10 billion in provider costs. Proper hand hygiene (HH) prevents hospital acquired infections, yet compliance is low. Electronic hand hygiene monitoring systems (EHHMS) are a potential solution, tracking and signaling HH events. We explored adoption of EHHMS in New York State acute care hospitals through a survey and interviews. Trend analysis was used to evaluate the impact of EHHMS on hospital-acquired Clostridium difficile infection (HA-CDI) rates. Survey respondents represented approximately 30% (N = 56) of the total population of hospitals (N = 184) and EHHMS adoption was low (N = 2). The primary reason for nonadoption was cost (79.6%). HH compliance increased 20%-30% and HA-CDI decreased 70% for one hospital after an EHHMS, though not sustained; robust HH culture was mentioned as a necessary accompaniment. The trend analysis showed negligible impact on HA-CDI post-EHHMS for the second hospital. A critical access hospital without an EHHMS reported HH compliance of 90% attributed to strong HH culture. Proliferation of EHHMS is low in New York State acute care hospitals and its impact on HH compliance and infection rates is questionable. Putting technology aside, strong HH culture seems essential for high compliance.

Characteristics of Clostridium difficile isolates and the burden of hospital-acquired Clostridium difficile infection in a tertiary teaching hospital in Chongqing, Southwest China

BackgroundClostridium difficile infection (CDI), especially hospital-acquired Clostridium difficile infection (HA-CDI), continues to be a public health problem and has aroused great concern worldwide for years. This study aimed to elucidate the clinical and epidemiological features of HA-CDI and the characteristics of C.difficile isolates in Chongqing, Southwest China.MethodsA case-control study was performed to identify the clinical incidence and risk factors of HA-CDI. C. difficile isolates were characterised by polymerase chain reaction (PCR) ribotyping, multilocus sequence typing (MLST), toxin gene detection and antimicrobial susceptibility testing.ResultsOf the 175 suspicious patients, a total of 122 patients with antibiotic-associated diarrhea (AAD) were included in the study; among them, 38 had HA-CDI. The incidence of AAD and HA-CDI was 0.58 and 0.18 per 1000 patient admissions, respectively. Chronic renal disease and cephalosporin use were independent risk factors for HA-CDI. Fifty-five strains were assigned into 16 sequence types (STs) and 15 ribotypes (RTs). ST2/RT449 (8, 14.5%) was the predominant genotype. Of the 38 toxigenic isolates, A + B + CDT- isolates accounted for most (34, 89.5%) and 1 A + B + CDT+ isolate emerged. No isolate was resistant to vancomycin, metronidazole or tigecycline, with A-B-CDT- being more resistant than A + B + CDT-.ConclusionsDifferent genotypes of C. difficile strains were witnessed in Chongqing, which hinted at the necessary surveillance of HA-CDI. Adequate awareness of patients at high risk of HA-CDI acquisition is advocated and cautious adoption of cephalosporins should be highlighted.

Clinical impact of an antimicrobial stewardship program on high-risk pediatric patients

To evaluate the clinical impact of an antimicrobial stewardship program (ASP) on high-risk pediatric patients. Retrospective cohort study. Free-standing pediatric hospital. This study included patients who received an ASP review between March 3, 2008, and March 2, 2017, and were considered high-risk, including patients receiving care by the neonatal intensive care (NICU), hematology/oncology (H/O), or pediatric intensive care (PICU) medical teams. The ASP recommendations included stopping antibiotics; modifying antibiotic type, dose, or duration; or obtaining an infectious diseases consultation. The outcomes evaluated in all high-risk patients with ASP recommendations were (1) hospital-acquired Clostridium difficile infection, (2) mortality, and (3) 30-day readmission. Subanalyses were conducted to evaluate hospital length of stay (LOS) and tracheitis treatment failure. Multivariable generalized linear models were performed to examine the relationship between ASP recommendations and each outcome after adjusting for clinical service and indication for treatment. The ASP made 2,088 recommendations, and 50% of these recommendations were to stop antibiotics. Recommendation agreement occurred in 70% of these cases. Agreement with an ASP recommendation was not associated with higher odds of mortality or hospital readmission. Patients with a single ASP review and agreed upon recommendation had a shorter median LOS (10.2 days vs 13.2 days; P &lt; .05). The ASP recommendations were not associated with high rates of tracheitis treatment failure. ASP recommendations do not result in worse clinical outcomes among high-risk pediatric patients. Most ASP recommendations are to stop or to narrow antimicrobial therapy. Further work is needed to enhance stewardship efforts in high-risk pediatric patients.

Reducing Hospital-acquired Catheter-associated Urinary Tract Infections and Clostridium difficile Infection Rates through a Multi-disciplinary Approach

BACKGROUND Outcome data in 2017 from a 400-bed hospital in Michigan demonstrated an opportunity for improvement in the reduction of hospital-acquired catheter-associated urinary tract infections (CAUTIs) and Clostridium difficile infections (CDIs). Inappropriate urine cultures and C. difficile toxin tests were being collected, leading to an increased risk of over diagnosis involving cases of colonization as opposed to true hospital-acquired infection. Our aim was to develop a multi-disciplinary process that would lead to sustainable practice in reducing hospital-acquired CAUTIs and CDIs. METHODS Best practices were reviewed to design a daily culture monitoring process that met the needs for the hospital. Based on that process, all urine cultures and C. difficile toxin tests were reviewed by Infection Prevention, nursing leadership, and the Infection Prevention Medical Director. If the culture was not clinically indicated, the order would be cancelled. A CDI policy was created and implemented for early identification, testing, and appropriate isolation of cases. All indwelling urinary catheters were monitored daily to assess the appropriateness in order to potentially reduce the length of device utilization. Emphasis on the hospital's antimicrobial stewardship program was increased to monitor the appropriateness of antibiotic use. RESULTS Between the first three quarters of 2017 and 2018, the CAUTI rate reduction was 52% (7 cases and 3 cases, respectively) and CDI rate reduction was 64% (29 cases and 11 cases, respectively). The average Standardized Interval Ratio (SIR) for the first three quarters of 2017 and 2018 for CAUTI was 0.763 and 0.374, respectively and for CDI was 0.786 and 0.315, respectively. CONCLUSIONS Based on the results, monitoring urine cultures and C. difficile toxin test appropriateness is an achievable and sustainable practice to reducing hospital-acquired CAUTIs and CDIs. Daily multi-disciplinary collaboration is essential to the sustainability of reducing these infections.

Mo1944 – Adherence to the Testing Guidelines for Clostridium Difficile Toxin in Stool Improved the Rates of Hospital Acquired Clostridium Difficile Infection

Mo1944 – Adherence to the Testing Guidelines for Clostridium Difficile Toxin in Stool Improved the Rates of Hospital Acquired Clostridium Difficile Infection

Su1959 – Trends in Incidence, Mortality, and Costs Associated with Hospital Acquired Clostridium Difficile Infection: A 10-Year Nationwide Retrospective Study

Su1959 – Trends in Incidence, Mortality, and Costs Associated with Hospital Acquired Clostridium Difficile Infection: A 10-Year Nationwide Retrospective Study

Hospital-acquired Clostridium difficile infection: an institutional costing analysis

Healthcare-acquired Clostridium difficile infection (HA-CDI) is a common infection and a financial burden on the healthcare system. To estimate the hospital-based financial costs of HA-CDI by comparing time-fixed statistical models that attribute cost to the entire hospital stay to time-varying statistical models that adjust for the time between admission, diagnosis of HA-CDI, and discharge and that only attribute HA-CDI costs post diagnosis. A retrospective cohort study was conducted (April 2008 to March 2011) using clinical and administrative costing data of inpatients (≥15 years) who were admitted to The Ottawa Hospital with stays >72 h. Two time-fixed analyses, ordinary least square regression and generalized linear regression, were contrasted with two time-dependent approaches using Kaplan-Meier survival curve. A total of 49,888 admissions were included and 366 (0.73%) patients developed HA-CDI. Estimated total costs (Canadian dollars) from time-fixed models were as high as $74,928 per patient compared to $28,089 using a time-varying model, and these were 1.47-fold higher compared to a patient without HA-CDI (incremental cost $8,997 per patient). The overall annual institutional cost at The Ottawa Hospital associated with HA-CDI was as high as $10.07 million using time-fixed models and $1.62 million using time-varying models. When calculating costs associated with HA-CDI, accounting for the time between admission, diagnosis, and discharge can substantially reduce the estimated institutional costs associated with HA-CDI.

Association of Antibiotic and Proton Pump Inhibitor Usage in Patients with Hospital Acquired Clostridium difficile Infection: A Single Center Experience

Introduction: There is an increasing incidence of hospital-acquired clostridium difficile infection (HACDI) with a high associated morbidity and mortality. Antibiotic and proton pump inhibitor (PPI) usage have been known to increase the risk of HACDI. The objective of this study was to determine the association of antibiotic and PPI usage in patients with HACDI at our institution. Methods: This is an IRB-approved case control study of patients from August 2015-November 2016 with hospital acquired CDI defined as a positive stool toxin assay greater than 72 hours into hospitalization. Case and control groups were matched by age and sex. Results: There were a total of 394 patients (134 cases and 260 controls) with a mean age of 73 ± 10 years. 51.49% were female. Exposure to at least one antibiotic during hospitalization was significantly higher in patients with HACDI compared to control [95.1% vs. 56.5%; p = 0.002, odds ratio (OR) 3.7, 95% CI (1.5-8.9)]. Antibiotic usage one month prior to hospitalization was also significantly higher in the case group [29.9 % vs. 18.6%; p = 0.019; OR 1.84, 95 % CI (1.12-3)]. There was no statistically significant difference between PPI usage during hospitalization between the case and control populations [52.2 % vs 59.5%; p = 0.197,OR 0.75, 95% CI (0.49-1.13)]. Usage of PPI therapy one month prior to hospitalization was also not statistically different between populations [31.2 % vs 37.8%; p = 0.262, OR 0.77, 95% CI (0.49-1.20)]. Diarrhea, as presenting complaint upon admission, was significantly higher in the case group [23.1 % vs. 11.2%; p = 0.003; OR 2.4, 95% CI (1.4-4.2)]. Usage of laxative one month prior to hospitalization was higher among patient without CDI compared to those with CDI [23.5% vs. 14.2%, p = 0.034, OR=1.86 95% CI (1.04-3.3)]. Conclusion: There is a strong association between HACDI and antibiotic therapy, whether it was prescribed during hospitalization or one month prior to admission. Although there is literature suggesting an increased risk of HACDI secondary to PPI therapy, it was not borne out in our study. This may be secondary to our small sample size and/or other confounding factors. Given the increased risk of HACDI in patients on antibiotics, a concerted effort should be made to be judicious with antibiotic administration and de-escalating usage when appropriate. Further sub-set analyses should be performed to identify other risk factors for HACDI.

The Association of Inpatient Occupancy with Hospital-Acquired Clostridium difficile Infection.

Few studies have evaluated the relationship between high hospital occupancy and hospital-acquired complications. We evaluated the association between inpatient occupancy and hospital-acquired Clostridium difficile infection (CDI) using a novel measure of hospital occupancy. We analyzed administrative data from California hospitals from 2008-2012 for Medicare recipients aged 65 years with a discharge diagnosis of acute myocardial infarction, heart failure, or pneumonia. Using daily census data, we constructed patient-level measures of occupancy on admission day and average occupancy during hospitalization (range: 0-1), which were split into 4 groups. We used logistic regression with cluster standard errors to estimate the adjusted and unadjusted relationship of occupancy with hospital-acquired CDI. Across 327 hospitals, 558,344 discharges met our inclusion criteria. Higher admission day occupancy was associated with significantly lower adjusted likelihood of CDI. Compared to the 0-0.25 occupancy group, patients admitted on a day of 0.51-0.75 occupancy had 0.86 odds of CDI (95% CI 0.75-0.98). The 0.76-1.00 admission occupancy group had 0.87 odds of CDI (95% CI 0.75-1.01). With regard to average occupancy, intermediate levels of occupancy 0.26-0.50 (odds ratio [OR] = 3.04, 95% CI 2.33-3.96) and 0.51-0.75 (OR = 3.28, 95% CI 2.51-4.28) had over 3-fold increased adjusted odds of CDI relative to the low occupancy group; the high occupancy group did not have signifcantly different odds of CDI compared to the low occupancy group (OR = 0.96, 95% CI 0.70-1.31). These findings should prompt exploration of how hospitals react to occupancy changes and how those care processes translate into hospital-acquired complications in order to inform best practices.

EPOP-153 - Battling Hospital Acquired Clostridium Difficile with Innovative Infection Prevention Tools

Background: With the increase in antibiotic use in the United States, Clostridium difficile has become the most common microbial cause of healthcare associated infections. After seeing the number of Clostridium difficile cases double from 2015 to 2016, our community hospital faced a critical safety challenge for our patients. Using innovative techniques in standard prevention tools, our goal was to reduce our Clostridium difficile infection rate by 50%.

EPOP-134 - Preventing Hospital Acquired Clostridium Difficile Infections: It Takes a Team

EPOP-134 - Preventing Hospital Acquired Clostridium Difficile Infections: It Takes a Team

EI-100 - Impact of the Use of Ultraviolet Robots on the Rates of Hospital-Acquired Clostridium difficile Infection Rates

Background: Clostridium difficile (C. diff) is one of the important causes of infectious disease deaths in the United States. Healthcare facilities are implementing varying approaches to decrease high rates of hospital-acquired (HA) C. diff such as hand hygiene auditing, validation reports by fluorescent tagging of high-touch surfaces including bed rails, call buttons and bathroom items after terminal cleaning of rooms, and use of Ultraviolet (UV) robots. The impact of the use of UV robots on the rates of HA- C. diff in our tertiary level care University hospital in six units where the UV robots are used is evaluated in this study.

Reducing Clostridium difficile Colitis Rates Via Cost-Saving Diagnostic Stewardship.

We conducted a quality improvement project at a large public tertiary-care academic hospital to reduce reported hospital-acquired Clostridium difficile infection (CDI) rates. We introduced diagnostic stewardship and provider education, resulting in a 2-fold reduction in C. difficile nucleic acid amplification test (NAAT) orders and markedly lower hospital CDI rate.Infect Control Hosp Epidemiol 2018;39:734-736.

The Effect of Bundled Interventions on Prevention of Hospital Acquired Clostridium Difficile Infection: An Integrative Review

The Effect of Bundled Interventions on Prevention of Hospital Acquired Clostridium Difficile Infection: An Integrative Review

Can the Electronic Health Record Be Mined to Deepen Our Understanding of Hospital Epidemiology

The contribution of procedural areas and common areas of the hospital to hospital-acquired Clostridium difficile infection (CDI) are not well known. To

Proton Pump Inhibitors Not a Major Risk Factor for Hospital-acquired Clostridium difficile Infection in Young, African American Males

Introduction: Clostridium difficile infection (CDI) is the leading cause of healthcare-associated infections. Due to its increased morbidity and mortality, there is great need to identify associated demographics and risk factors. National epidemiology reveals a predominance of elderly, Caucasian females. Proton pump inhibitors (PPIs) have been associated with a 1.4-2.75x increased risk of CDI. The exact relationship between hospital-acquired CDI (HA-CDI) and PPIs is unclear. We performed a retrospective analysis to (1) Examine CDI epidemiology at Hahnemann University Hospital compared to national epidemiology and (2) Investigate the association between PPIs as a risk factor for HA-CDI.Figure: Demographic and PPI characteristics of the CDI cases and controls.Methods: We conducted a case-control study of HA-CDI from 08/2014 to 04/2017. Cases (n=229) were defined as confrmed diagnosis 72 hrs post-admission. Controls (n=454) were frequency matched in a 2:1 ratio based on age and length of stay. PPI was classified into 4 categories: dosage (20mg, 40mg), frequency (QD, BID), delivery (PO, IV) and duration (10 days). Student's T-test, Wilcoxon rank sum test, Chisquared test were used to compare risk factors between cases and controls. Results: HA-CDI cases had a mean age of 60 with male predominance (54%, n=123) vs. females (46%, n=106), and by race, 56% (n=120) African American and 36% (n=77) Caucasian. In our sample (cases & controls), 48% (n=328) were on a PPI with the combined majority 73% (n=239) on 40mg daily vs. 25% (n=83) on 40mg BID. PPIs were administered orally in 61% (n=200) vs. IV in 38% (n=123) of all combined patients with the majority exposed for 10+ days (59%, n=190). There were no statistically significant differences between cases and controls in PPI use, dosage, route of administration or duration. Conclusion: National CDI epidemiology reveals a predominance of elderly (51.9% age >65), Caucasian (78.6%) and female (59%) patients. In contrast, our CDI epidemiology showed a predominance of younger, African American males. PPIs are theorized to increase the risk of CDI due to increased gastric pH which may prevent protective flora from actively suppressing the germination of Clostridium difficile spores and toxin synthesis. However, given that there was no significant association detected between PPI and CDI in our sample, we must consider alternative risk factors that may uniquely predispose our distinct cohort to CDI. The relationship between PPI and CDI in unique demographic cohorts such as ours needs to be further explored in future studies.

A Nurse-Driven Protocol to Reduce Hospital-Acquired Clostridium difficile Infections

Abstract Background Clostridium difficile infection (CDI) is one of the most common healthcare-associated infections. Timely diagnosis is key to reducing associated morbidity and costs. Healthcare-onset (HO) CDI is defined as infection diagnosed 72 hours after hospitalization. Centers for Medicare and Medicaid Services has established benchmarks for HO-CDI for hospitals, which are based on several factors including type of hospital and case mix index. There is a financial penalty if we are above the benchmark. In 2016, 20% of our community-onset C. difficile (CO-CDI) cases were misclassified as HO-CDI. In order to reduce this misclassification, we established a process to assist in early diagnosis. Methods We designed and implemented a nurse-driven C. difficile screening protocol to assist in early identification of CO-CDI. Every patient admitted to Keck Hospital (KH) (401 beds) and Norris Comprehensive Cancer Center (35 beds) was screened for diarrhea within the past 24 hours. If diarrhea was present, additional questions were used to capture CO-CDI cases. A nursing order for C. difficile testing was activated for patients who met any of these criteria. Additionally, we used Bristol stool scale (BSS) to standardize stool collection. Only Bristol stool type 7 was accepted by laboratory for processing. Our study period was January 1st through April 30th, 2017 and our baseline period was January 1st through April 30th, 2016. Results Screening protocol and BSS were introduced on January 1st, 2017. During the baseline period, a total of 351 orders were placed with 31% within first 3 days of admission. During the study period, a total of 200 orders were placed with 43% within 3 days of admission. Compliance with using the screening tool was nearly 100%. Inter-rater reliability between nurses and lab for identifying the correct BSS was 100%. Baseline misclassification rate was 16%. With the introduction of this screening tool, misclassification decreased to 9%. The HO-CDI rate for the baseline period was 11.5 per 10,000 patient-days and it decreased to 6.27 per 10,000 patient-days in the study period. Conclusion We have demonstrated a reduction in HO-CDI rates by establishing a process to assist in early identification of CO-CDI. Disclosures All authors: No reported disclosures.

Obesity Not a Major Risk Factor for Hospital-Acquired Clostridium difficile Infection in Young, African American Males

Obesity Not a Major Risk Factor for Hospital-Acquired Clostridium difficile Infection in Young, African American Males