Hospital-onset Clostridium Difficile Infection Cases Research Articles

Predicting hospital-onset Clostridium difficile using patient mobility data: A network approach.

To examine the relationship between unit-wide Clostridium difficile infection (CDI) susceptibility and inpatient mobility and to create contagion centrality as a new predictive measure of CDI. Retrospective cohort study. A mobility network was constructed using 2 years of patient electronic health record data for a 739-bed hospital (n = 72,636 admissions). Network centrality measures were calculated for each hospital unit (node) providing clinical context for each in terms of patient transfers between units (ie, edges). Daily unit-wide CDI susceptibility scores were calculated using logistic regression and were compared to network centrality measures to determine the relationship between unit CDI susceptibility and patient mobility. Closeness centrality was a statistically significant measure associated with unit susceptibility (P < .05), highlighting the importance of incoming patient mobility in CDI prevention at the unit level. Contagion centrality (CC) was calculated using inpatient transfer rates, unit-wide susceptibility of CDI, and current hospital CDI infections. The contagion centrality measure was statistically significant (P < .05) with our outcome of hospital-onset CDI cases, and it captured the additional opportunities for transmission associated with inpatient transfers. We have used this analysis to create easily interpretable clinical tools showing this relationship as well as the risk of hospital-onset CDI in real time, and these tools can be implemented in hospital EHR systems. Quantifying and visualizing the combination of inpatient transfers, unit-wide risk, and current infections help identify hospital units at risk of developing a CDI outbreak and, thus, provide clinicians and infection prevention staff with advanced warning and specific location data to inform prevention efforts.

Collect that Stool! The Impact of Delay in Specimen Collection to NHSN Lab ID C. difficile Events

BACKGROUND Despite multiple rapid laboratory tests available for Clostridium difficile infection (CDI), delays in specimen collection may contribute to delays in diagnosis and treatment. Additionally, specimen collection delays may contribute to falsely increased National Health and Safety Network (NHSN) laboratory-identified (Lab ID) hospital onset (HO) CDI rates. Time from order to specimen collection and the impact of collection delays on HO CDI rates is unknown. METHODS Two community hospitals (450 and 472 licensed beds) conducted a retrospective review of electronic data from March-October 2018, including date of order for C. difficile toxin assay and date of specimen collection. Time to collection was compared for hospital of admission, level of care (intensive care unit [ICU] versus other) and shift of order (day versus night) using Mann-Whitney U (SPSS) and Chi-square analysis (Epi Info). The impact of delay on HO CDI cases was assessed. RESULTS 1516 stool specimens were collected. On average, there were 7.7?hours between order and collection (maximum delay = 7.9 days). Hospital A, ICU level of care, and night shift were correlated with significantly shorter time to specimen collection (p = 0.01, 0.02. 0.02, respectively). 330 specimens (22%) were collected on a subsequent calendar day, although this was only significantly impacted by level of care (p = 0.04). Of the 31 cases determined to be HO-CDI per NHSN Lab ID definition, 4 (13%) would have been CO had they been collected on the day ordered. Conclusions In this sample, delay in specimen collection for C. difficile testing was common, with many tests delayed to the next day. This may have a considerable impact on HO CDI rates, impacting reimbursement and hospital reputation. Future research is needed to remedy these delays. Until that time, use of order date and time should be considered for inclusion into NHSN Lab ID event definitions.

Clostridium difficile multidisciplinary team root cause analysis: impact on clinical care and circumvention of financial penalties posed by clinical commissioning groups, but at what cost?

In Hampshire Hospitals NHS Foundation Trust, in addition to an on-the-spot investigation into hospital-onset Clostridium difficile infection (CDI) by the infection prevention team, a multidisciplinary team root cause analysis (MDT-RCA) forum has been developed. The MDT-RCA aims to deliver a more thorough investigation into individual cases and the recommendation of cases to the clinical commissioning groups (CCG) appeals panel against potential financial penalties (£10,000 per breached case). We mainly aimed to investigate the financial impact of MDT-RCAs to the Trust. Over two years, 84 cases of hospital-onset CDI cases were reviewed by the MDT-RCA forum. Among this cohort, no additional learning outcomes were identified by the MDT-RCAs over those that were found by on-the-spot investigations. In total, 543 staff members attended the MDT-RCAs at a potential cost to the Trust of £23,795.74-£51,670.10. The Trust appealed against financial penalties for 27 cases and 14 were successful, i.e. £140,000 would have been avoided had targets been breached by 14 cases. However, targets were only breached by two cases, meaning only £20,000 in fines was avoided. Deducting this from the total costs of the MDT-RCA meant the Trust lost £3,795.74-£31,670.10. Over the two years reviewed, the MDT-RCA proved to be costly to the Trust, with no additional learning or quality improvement measures identified.

Investigation of a cluster of Clostridium difficile infections in a pediatric oncology setting

We investigated an increase in Clostridium difficile infection (CDI) among pediatric oncology patients. CDI cases were defined as first C difficile positive stool tests between December 1, 2010, and September 6, 2012, in pediatric oncology patients receiving inpatient or outpatient care at a single hospital. A case-control study was performed to identify CDI risk factors, infection prevention and antimicrobial prescribing practices were assessed, and environmental sampling was conducted. Available isolates were strain-typed by pulsed-field gel electrophoresis. An increase in hospital-onset CDI cases was observed from June-August 2012. Independent risk factors for CDI included hospitalization in the bone marrow transplant ward and exposure to computerized tomography scanning or cefepime in the prior 12weeks. Cefepime use increased beginning in late 2011, reflecting a practice change for patients with neutropenic fever. There were 13 distinct strain types among 22 available isolates. Hospital-onset CDI rates decreased to near-baseline levels with enhanced infection prevention measures, including environmental cleaning and prolonged contact isolation. C difficile strain diversity associated with a cluster of CDI among pediatric oncology patients suggests a need for greater understanding of modes and sources of transmission and strategies to reduce patient susceptibility to CDI. Further research is needed on the risk of CDI with cefepime and its use as primary empirical treatment for neutropenic fever.

Lessons Learned from Implementing Clostridium difficile-Focused Antibiotic Stewardship Interventions

Objective.To determine whether controlling the prescription of targeted antibiotics would translate to a measurable reduction in hospital-onset Clostridium difficile infection (CDI) rates.Design.A multicenter before-and-after intervention comparative study.Setting/Participants.Ten medical centers in the greater New York region. Intervention group comprised of 6 facilities with early antimicrobial stewardship programs (ASPs). The 4 facilities without ASPs made up the nonintervention group.Interventions/Methods.Intervention facilities identified target antibiotics using case-control studies and implemented ASP-based strategies to control their use. Pre- and postintervention hospital-onset CDI rates and antibiotic consumption were compared for a 20-month period from June 2010 to January 2012. Antibiotic usage was compared using defined daily dose, days of therapy, and number of courses prescribed. Comparisons used bivariate and regression techniques.Results.Intervention facilities identified piperacillin/tazobactam, fluoroquinolones, or cefepime (odds ratio, 2.0-9.8 in CDI case patients compared with those without CDI) as intervention targets and selected several interventions (all included a component of audit and feedback). Varying degrees of success were observed in reducing antibiotic consumption over time. Total target antibiotic use significantly decreased (P &lt; .05) when measured by days of therapy and number of courses but not by defined daily dose. Intravenous moxifloxacin and oral ciprofloxacin use showed significant reduction when measured by defined daily dose and days of therapy (P ≤ .01). Number of courses with all forms of these antibiotics was reduced (P ≤ .005). Intervention hospitals reported fewer hospital-onset CDI cases (2.8 rate point difference) compared with nonintervention hospitals; however, we were unable to show statistically significant decreases in aggregate hospital-onset CDI either between intervention and nonintervention groups or within the intervention group over time.Conclusions.Although decreases in target antibiotic consumption did not translate into reductions of hospital-onset CDI in this study, many valuable lessons (including implementation strategies and antibiotic consumption measures) were learned. The findings can inform potential policy decisions regarding incorporating control of CDI and ASP as healthcare quality measures.

Lessons learned from implementing Clostridium difficile-focused antibiotic stewardship interventions.

To determine whether controlling the prescription of targeted antibiotics would translate to a measurable reduction in hospital-onset Clostridium difficile infection (CDI) rates. A multicenter before-and-after intervention comparative study. Ten medical centers in the greater New York region. Intervention group comprised of 6 facilities with early antimicrobial stewardship programs (ASPs). The 4 facilities without ASPs made up the nonintervention group. Intervention facilities identified target antibiotics using case-control studies and implemented ASP-based strategies to control their use. Pre- and postintervention hospital-onset CDI rates and antibiotic consumption were compared for a 20-month period from June 2010 to January 2012. Antibiotic usage was compared using defined daily dose, days of therapy, and number of courses prescribed. Comparisons used bivariate and regression techniques. Intervention facilities identified piperacillin/tazobactam, fluoroquinolones, or cefepime (odds ratio, 2.0-9.8 in CDI case patients compared with those without CDI) as intervention targets and selected several interventions (all included a component of audit and feedback). Varying degrees of success were observed in reducing antibiotic consumption over time. Total target antibiotic use significantly decreased (P < .05) when measured by days of therapy and number of courses but not by defined daily dose. Intravenous moxifloxacin and oral ciprofloxacin use showed significant reduction when measured by defined daily dose and days of therapy (P ≤ .01). Number of courses with all forms of these antibiotics was reduced (P < .005). Intervention hospitals reported fewer hospital-onset CDI cases (2.8 rate point difference) compared with nonintervention hospitals; however, we were unable to show statistically significant decreases in aggregate hospital-onset CDI either between intervention and nonintervention groups or within the intervention group over time. Although decreases in target antibiotic consumption did not translate into reductions of hospital-onset CDI in this study, many valuable lessons (including implementation strategies and antibiotic consumption measures) were learned. The findings can inform potential policy decisions regarding incorporating control of CDI and ASP as healthcare quality measures.

Validation of a Clinical Prediction Scale for Hospital-onset Clostridium difficile Infection

The aim of this study was to validate a clinical prediction scale for hospital-onset Clostridium difficile infection (CDI). The study included a consecutive cohort of patients admitted to the adult medical service over a period of 17 months (June 2011 to October 2012). The clinical prediction scale comprised of new-onset loose stools (5 points), length of hospital stay >7days (4 points), aged 65 years or older (3 points), resides in long-term care facility (2 points), broad spectrum antibiotics use (1 point), and hypoalbuminemia (1 point). The hospital-onset CDI cases were defined as any new-onset diarrhea after 48 hours of hospital admission that tested positive on polymerase chain reaction assay for C. difficile toxin gene in the absence of history of CDI in the prior 8 weeks. The predictive performance of the scale was assessed using area under the receiver operating curve. A total of 10,357 patients were admitted to the medical service, of which, 7026 stayed in hospital beyond 48 hours. Mean (SD) age was 68.5 (18.2) years and 41.9% patients were male. A total of 1030 patients were tested for C. difficile toxin gene using polymerase chain reaction assay, of which, 159 patients were positive and 62 of them were unique hospital-onset CDI cases. The scale had area under the receiver operating curve of 0.94 [95% confidence interval (CI), 0.92-0.95]. At the cutoff score of 9, scale was 98.3% (95% CI, 90.2-99.9) sensitive and 85.2% (95% CI, 84.3-86.0) specific. Our study results support excellent predictive performance of a clinical prediction scale for hospital-onset CDI. This simple scale can be used in risk stratification leading to prompt tailoring of modifiable risk factors, empirical treatment, and use of probiotics.

Attributable Burden of Hospital-OnsetClostridium difficileInfection: A Propensity Score Matching Study

To determine the attributable in-hospital mortality, length of stay (LOS), and cost of hospital-onset Clostridium difficile infection (HO-CDI). Propensity score matching. Six Pennsylvania hospitals (2 academic centers, 1 community teaching facility, and 3 community nonteaching facilities) contributing data to a clinical research database. Adult inpatients between 2007 and 2008. We defined HO-CDI in adult inpatients as a positive C. difficile toxin assay result from a specimen collected more than 48 hours after admission and more than 8 weeks following any previous positive result. We developed an HO-CDI propensity model and matched cases with noncases by propensity score at a 1∶3 ratio. We further restricted matching within the same hospital, within the same principal disease group, and within a similar length of lead time from admission to onset of HO-CDI. Among 77,257 discharges, 282 HO-CDI cases were identified. The propensity score-matched rate was 90%. Compared with matched noncases, HO-CDI patients had higher mortality (11.8% vs. 7.3%; P < .05), longer LOS (median [interquartile range (IQR)], 12 [9-21] vs. 11 [8-17] days; P < .01), and higher cost (median [IQR], $20,804 [$11,059-$38,429] vs. $16,634 [$9,413-$30,319]; P < .01). The attributable effect of HO-CDI was 4.5% (95% confidence interval [CI], 0.2%-8.7%; P < .05) for mortality, 2.3 days (95% CI, 0.9-3.8; P < .01) for LOS, and $6,117 (95% CI, $1,659-$10,574; P < .01) for cost. Patients with HO-CDI incur additional attributable mortality, LOS, and cost burden compared with patients with similar primary clinical condition, exposure risk, lead time of hospitalization, and baseline characteristics.

Complete Restriction of Fluoroquinolone Use to Control an Outbreak ofClostridium difficileInfection at a Community Hospital

To review the effect of interventions, including a complete restriction in the use of fluoroquinolones (FQs), used to control an outbreak of hospital-onset Clostridium difficile infection (HO-CDI) caused primarily by the epidemic North American pulsed-field gel electrophoresis type 1 strain. Retrospective cohort and case-control study of all episodes of HO-CDI both before and after 2 interventions. Community hospital; January 1, 2005, through March 31, 2007. Interventions. Complete, 5-month, facility-wide restriction of fluoroquinolone use, during which a change in the environmental-services contractor occurred. During a 27-month period, 319 episodes of HO-CDI occurred. The hospital-wide mean defined daily doses of antimicrobials decreased 22% after restricting FQ use, primarily because of a 66% decrease in the use of FQs. The interventions were also associated with a significant change in the HO-CDI incidence trends and with an absolute decrease of 22% in HO-CDI cases caused by the epidemic strain (from 66% before the intervention period to 44% during and after the intervention period; P=.02). Univariate analysis revealed that case patients with HO-CDI due to the epidemic strain were more likely than control patients, who did not have diarrhea, to receive a FQ, whereas case patients with HO-CDI due to a nonepidemic strain were not. However, FQ use was not significantly associated with HO-CDI in multivariable analysis. An outbreak of epidemic-strain HO-CDI was controlled at a community hospital after an overall decrease in antimicrobial use, primarily because of a restriction of FQ use and a change in environmental-services contractors. The restriction of FQ use may be useful as an adjunct control measure in a healthcare facilities during outbreaks of epidemic-strain HO-CDI.