Increase In Clostridium Difficile Infection Research Articles

Mandatory Pre-Authorization or “Hard Stop Order” to Decrease Inappropriate Testing for Clostridium difficile Infection. A Testing Stewardship at 2 Hospitals.

BACKGROUND Despite implementation of the Clostridium difficile Infection (CDI) algorithm in 2016, inappropriate testing remains an issue. To further reduce this problem, Mandatory Pre-Authorization (MPrA) or Hard Stop Order (HSO) was implemented in March 2017. MPrA/HSO requires the ordering physician to apply the criteria set in the algorithm and obtain approval from an Infectious Disease (ID) physician. The test is stopped if the criteria are not met and without approval. The objective of this review is to examine the effectiveness of the MPrA/HSO in our hospitals. METHODS An order set was built in the electronic medical record (EMR) identifying the ordering physician and ID attending approving the test. Educational sessions, posters and pocket size algorithm were provided. Orders without ID approval were referred back to the ordering physician or escalated to the Chief of Service or to the Director of Infection Prevention. Exclusion for the MPrA/HSO were Emergency Room patients suspected with CDI. National Healthcare Safety Network (NHSN) data from February 2016 to March 2018 were retrospectively analyzed. RESULTS Comparison of Pre and Post implementation data showed a decline of 68% in CDI testing for Hospital A and 61% for Hospital B. The Hospital-Onset CDI dipped to 74% in Hospital A and 61% in Hospital B and inappropriate testing decreased by 75% and 100% respectively. >97% met testing criteria and ID approval. Pre and Post MPrA/HSO Standard Infection Ratio (SIR) were statistically significant. CONCLUSIONS Testing stewardship accomplished a reduction of CDI testing without a corresponding increase in CDI, and without evidence of missed cases. Our goal of reducing inappropriate testing is achieved, thereby improving patient outcome as unnecessary isolation and exposure to antibiotics are avoided. Administrative support, interdisciplinary teamwork and integration of the MPrA/HSO in the EMR are essential in the success of this initiative.

One size doesn't fit all: different antibiotics are associated with decreases in surgical site infections in pancreaticoduodenectomy versus distal pancreatectomy

Background: The utility of prophylactic antibiotics before skin incision to decrease surgical site infection is well-documented. However, there is limited data comparing the use of different classes of antibiotics to mitigate this risk in pancreatic surgery. Multiple different antibiotic regimens are utilized nationwide, and there remains a gap in knowledge as to the risks and benefits of various antibiotic choices. It is hypothesized that certain antibiotics may be associated with lower rates of surgical site infection in pancreatic procedures. Methods: Demographic, comorbidity, perioperative, intraoperative, and outcomes data were captured from the 2016 ACS National Surgical Quality Improvement Program (NSQIP) targeted pancreatectomy database. Pre-operative antibiotics were classified into first generation cephalosporin (1stCE), second or third generation cephalosporin (2-3CE), and broad-spectrum antibiotics (br-ABX). Br-ABX include anti-pseudomonals, ticarcillin-clavulanate, piperacilin/tazobactam, fourth generation cephalosporins, aminoglycosides, and fluoroquinolones. Univariate and multivariate analysis was performed to compare various outcomes between the different groups. Subset analysis was performed by surgery type (pancreaticoduodenectomy vs. distal pancreatectomy) and approach (open vs. minimally invasive (MIS)). Distal pancreatectomy with enteric reconstruction were excluded. The primary end-point was surgical site infection. Results: Of the 5,803 pancreatectomies performed throughout the U.S. in 2016, 38% received a first generation cephalosporin (1CE), 26% a second or third generation cephalosporin (2-3CE), and 36% a broad spectrum antibiotic (br-ABX). After controlling for patient demographics, comorbidities, perioperative variables including blood administration, gland characteristics, receipt of neoadjuvant therapy, stent and drain use; br-ABX, and not 2-3CE, was associated with a decrease in superficial surgical site infection (SSI) (OR = 0.67, p = 0.014) and organ space SSI (OR = 0.81, p = 0.05) compared to 1CE. The decreases in SSI occurred after open and not MIS pancreatectomy (p < 0.006). Subset analysis identified that the br-ABX-associated decrease in superficial and organ space SSIs were only associated with open pancreaticoduodenectomy (superficial: p = 0.003; organ space: p = 0.025), and not open distal pancreatectomy. Interestingly, an increase in organ space SSI was observed with br-ABX for MIS distal pancreatectomy (OR = 3.15, p = 0.002). For all pancreatectomies, there was a two-fold increase in clostridium difficile infection with 2-3CE (OR = 2.08, p=0.014), and a two-fold decrease in urinary tract infections (UTI) with Br-abx (OR = 0.52, p = 0.012), compared to 1CE. There were no differences in deep incisional SSI, wound dehiscence, sepsis, and length of stay or readmission rates across all groups of antibiotics. Conclusion: Broad-spectrum antibiotics are associated with decreased SSIs after open pancreaticoduodenectomy, but increased SSIs after MIS distal pancreatectomy. There was no difference in SSI for MIS pancreaticoduodenectomy or open distal pancreatectomy regardless of antibiotic regimen. Thus, since 2-3CE were associated increased clostridium difficile infection, Br-ABX may be appropriate for open pancreaticoduodenectomy, and 1CE for MIS pancreatectomy and all distal pancreatectomy in order to decrease SSIs. Prospective trials are warranted.

Опыт проведения трансплантации фекальной микробиоты у пациентки с клостридиальной инфекцией

In recent decades, against the background of widespread and, often, unfounded antibiotic therapy, an increase in Clostridium difficile infection (CDI) due to hypervirulent strains has been observed. According to international CDI treatment protocols, metronidazole and vancomycin are starting therapy for patients with newly diagnosed infections, even though the likelihood of a relapse is about 65%. In addition, the increased interest in CDI is associated with the need to develop and use alternative strategies aimed at preventing and increasing the effectiveness of treatment. In this regard, we first transplanted fecal microflora for this group of patients in Russia. This alternative method of treatment removes the spores of C. difficile, replenishes the normal intestinal flora, reduces the level of vegetative forms of C. difficile in the intestines, and supports the patient’s own immune response.

Fluoroquinolone Prophylaxis Is Highly Effective for the Prevention of Central Line-Associated Bloodstream Infections in Autologous Stem Cell Transplant Patients.

Patients undergoing stem cell transplant (SCT) for the treatment of hematologic malignancy are at increased risk for central line-associated bloodstream infections (CLABSIs). The use of prophylactic antibiotics to prevent CLABSIs in the setting of autologous SCT is of unclear benefit. We aimed to evaluate the impact of levofloxacin prophylaxis on reducing CLABSIs in this high-risk population. Patients undergoing autologous SCT at a tertiary care hospital received levofloxacin prophylaxis from January 13, 2016 to January 12, 2017. Levofloxacin was administered from autologous SCT (day 0) until day 13, absolute neutrophil count > 500/mm3, or neutropenic fever, whichever occurred first. Clinical outcomes were compared with a baseline group who underwent autologous SCT but did not receive antibacterial prophylaxis during the previous year. The primary endpoint was incidence of CLABSIs assessed using Cox proportional hazards regression. A total of 324 patients underwent autologous SCT during the entire study period, with 150 receiving levofloxacin prophylaxis during the intervention period. The rate of CLABSIs was reduced from 18.4% during the baseline period to 6.0% during the intervention period. On multivariable analysis levofloxacin prophylaxis significantly reduced CLABSI incidence (hazard ratio, .33; 95% confidence interval [CI], .16 to .69; P = .003). There was also a reduction in the risk of neutropenic fever (odds ratio [OR], .23; 95% CI, .14 to .39; P < .001) and a trend toward a reduction in intensive care unit transfer for sepsis (OR, .33; 95% CI, .09 to 1.24; P = .10) in patients receiving levofloxacin prophylaxis. Notably, there was no increase in Clostridium difficile infection in the levofloxacin group (OR, .66; 95% CI, .29 to 1.49; P = .32). Levofloxacin prophylaxis was effective in reducing CLABSIs and neutropenic fever in patients undergoing autologous SCT. Further studies are needed to identify specific patient groups who will benefit most from antibiotic prophylaxis.

Reprint of: Overview and changing epidemiology of Clostridium difficile infection

There has been an increase in Clostridium difficile infection (CDI) incidence, severity, and mortality during the last decade. Although the elderly receiving antibiotic therapy are the most common group at risk for infection, CDI occurs in all age groups, and recent data indicate that CDI is emerging in groups that have been traditionally considered at low risk for infection. Additionally, approximately one-third of all CDI cases are now considered to be community associated in the U.S. New information is emerging on risk factors for an initial episode of CDI as well as recurrent disease. Increases in the burden of disease and severe outcomes related to CDI has been associated with the emergence of a new epidemic strain, restriction enzyme analysis BI, North American Pulsed-Field Type 1, and PCR Ribotype 027 (BI/NAP1/027) as well as other emerging strains. This article explores the changing epidemiology of CDI based on the latest available data as well as the recent developments in diagnosis and infection control.

Role of Antimicrobial Stewardship Programs in Decreasing Hospital-Associated Clostridium difficile Infections

To provide a review of literature that discusses some of the most successful antimicrobial stewardship interventions reported across institutions worldwide in response to increased Clostridium difficile infection (CDI) rates. Although many different types of antimicrobial reduction practices have been proven effective, differences in resources across varying sizes of institutions may make some interventions more attainable than other. Regardless of available resources, an initial assessment of the correlation of positive laboratory tests to clinical disease is necessary to quantify the true burden of hospital-onset CDIs (HO-CDI). Infection prevention programs, in conjunction with antimicrobial reduction interventions, and the appropriate identification of patients to undergo laboratory testing, are key components of a HO-CDI reduction program. Clostridium difficile is an important cause of serious healthcare-associated infections (HAIs), causing adverse consequences for patients including, but not limited to, increased length of hospital stay, healthcare costs, and mortality. Since the early 2000s, there has been a notable increase in CDI. Antimicrobial stewardship programs (ASPs) have responded to this public health threat with a number of different strategies including antimicrobial use reduction, education, appropriate testing, and multiple other interventions. Along with providing a literature review on ASP interventions to address the CDI threat, we describe our experience in successfully reducing HO-CDI at Northwestern Memorial Hospital with the use of multiple interventions.

National age group trends in Clostridium difficile infection incidence and health outcomes in United States Community Hospitals.

BackgroundPrior studies have demonstrated an increase in Clostridium difficile infection (CDI) incidence in the United States (U.S.) in recent years, but trends among different age groups have not been evaluated. This study describes national CDI incidence by age group over a 10-year period and mortality and hospital length of stay (LOS) among patients with CDI.MethodsThis was a retrospective analysis of the U.S. National Hospital Discharge Surveys from 2001 to 2010. Eligible patients with an ICD-9-CM discharge diagnosis code for CDI (008.45) were stratified by age: <18 years (pediatrics), 18–64 years (adults), and ≥65 years (elderly adults). Data weights were used to derive national estimates. CDI incidence was calculated as CDI discharges/1000 total discharges. Mortality and LOS were compared between age groups using chi-square or Wilcoxon rank sum tests.ResultsThese data represent 2.3 million hospital discharges for CDI over the study period. CDI incidence was highest among elderly adults (11.6 CDI discharges/1000 total discharges), followed by adults (3.5 CDI discharges/1000 total discharges) and pediatrics (1.2 CDI discharges/1000 total discharges). The elderly also had higher rates of mortality (8.8%) compared to adults (3.1%) and pediatrics (1.4%) (p < 0.0001). In addition, median hospital LOS was highest in the elderly (8 days) compared to adults (7 days) and pediatrics (6 days) (p < 0.0001).ConclusionsCDI incidence among patients hospitalized in U.S. hospitals differed based on age group between 2001 and 2010. CDI incidence, mortality, and hospital LOS were highest in the elderly adult population.

Epidemiological and economic burden of Clostridium difficile in the United States: estimates from a modeling approach.

BackgroundDespite a large increase in Clostridium difficile infection (CDI) severity, morbidity and mortality in the US since the early 2000s, CDI burden estimates have had limited generalizability and comparability due to widely varying clinical settings, populations, or study designs.MethodsA decision-analytic model incorporating key input parameters important in CDI epidemiology was developed to estimate the annual number of initial and recurrent CDI cases, attributable and all-cause deaths, economic burden in the general population, and specific number of high-risk patients in different healthcare settings and the community in the US. Economic burden was calculated adopting a societal perspective using a bottom-up approach that identified healthcare resources consumed in the management of CDI.ResultsAnnually, a total of 606,058 (439,237 initial and 166,821 recurrent) episodes of CDI were predicted in 2014: 34.3 % arose from community exposure. Over 44,500 CDI-attributable deaths in 2014 were estimated to occur. High-risk susceptible individuals representing 5 % of the total hospital population accounted for 23 % of hospitalized CDI patients. The economic cost of CDI was $5.4 billion ($4.7 billion (86.7 %) in healthcare settings; $725 million (13.3 %) in the community), mostly due to hospitalization.ConclusionsA modeling framework provides more comprehensive and detailed national-level estimates of CDI cases, recurrences, deaths and cost in different patient groups than currently available from separate individual studies. As new treatments for CDI are developed, this model can provide reliable estimates to better focus healthcare resources to those specific age-groups, risk-groups, and care settings in the US where they are most needed. (Trial Identifier ClinicaTrials.gov: NCT01241552)Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-016-1610-3) contains supplementary material, which is available to authorized users.

Toxic megacolon associated with Clostridium difficile infection: A case study

Hyper virulent bacterial strain and irrational antibiotics use are among main causes of incidence increase in Clostridium difficile infection. The most difficult complication of clostridia infection is toxic megacolon with the incidence of 0.4 - 3 % of cases. The study shows a female 56-year-old patient hospitalized at Infectious Disease Clinic in Kragujevac, on the fourth day of the disease, with stomach ache, nausea, vomiting and diarrhea. The patient was previously hospitalized at Pulmonary Clinic for twenty-two days where she had been treated for pneumonia with combined antibiotic therapy. Laboratory analyses showed increased levels of leucocytes (WBC 50.4h109A), nitrates (urea: 15.4 mmol/l, creatinine: 328 mmol/L) and C-reactive proteins (CRP: 221.2 mg/L), while albumin levels were decreased (16 g/L). Stool was positive on Clostridium difficile. Computerized tomography (CT) was used to visualize diffuse thickening of colon s wall, especially ascendant, with peritoneum density increase and the presence of free liquid. Despite eradication antibiotic (amp. Vankomycin 125mg/6h per os, amp. Orvagyl 500mg/8h iv), substitution and symptomatic therapy, as well as multidisciplinary approach, the patient passed away on the third day of hospitalization. Recognizing risk factors for clostridia infection onset, monitoring clinical course of the disease, adequate medicament therapy, and early surgical intervention due to complications can lead to lower morbidity and mortality infection rates.

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.

Uncovering the role of antibiotics in the transmission of multidrug-resistant organisms.

Uncovering the role of antibiotics in the transmission of multidrug-resistant organisms.

Overview and changing epidemiology of Clostridium difficile infection

There has been an increase in Clostridium difficile infection (CDI) incidence, severity, and mortality during the last decade. Although the elderly receiving antibiotic therapy are the most common group at risk for infection, CDI occurs in all age groups, and recent data indicate that CDI is emerging in groups that have been traditionally considered at low risk for infection. Additionally, approximately one-third of all CDI cases are now considered to be community associated in the U.S. New information is emerging on risk factors for an initial episode of CDI as well as recurrent disease. Increases in the burden of disease and severe outcomes related to CDI has been associated with the emergence of a new epidemic strain, restriction enzyme analysis BI, North American Pulsed-Field Type 1, and PCR Ribotype 027 (BI/NAP1/027) as well as other emerging strains. This article explores the changing epidemiology of CDI based on the latest available data as well as the recent developments in diagnosis and infection control.

Health Care Burden of Clostridium difficile Infection in Hospitalized Children with Inflammatory Bowel Disease

Children with inflammatory bowel disease (IBD), similar to adults, are at increased risk of acquiring a Clostridium difficile infection (CDI). Our objective was to characterize the health care burden associated with CDI in hospitalized pediatric patients with IBD. We extracted and analyzed cases with a discharge diagnosis of IBD or CDI from the U.S. Healthcare Cost and Utilization Project Kids' Inpatient Database. In our primary analysis, we evaluated pediatric cases with a principal diagnosis of IBD or CDI. For the year 2009, we identified 12,610 weighted cases with IBD of which 3.5% had CDI. In children with IBD, CDI was independently associated with lengthier hospital stays (8.0 versus 6.0 days; adjusted regression coefficient, 2.1 days; 95% confidence interval [CI], 1.4-2.8), higher charges ($45,126 versus $34,703; adjusted regression coefficient, $11,506; 95% CI, 6192-16,820), and greater need for parenteral nutrition (15.9% versus 12.1%; adjusted odds ratio, 1.5; 95% CI, 1.1-2.0) and blood transfusion (17.7% versus 9.8%; adjusted odds ratio, 1.8; 95% CI, 1.4-2.4). There were no deaths. We made similar observations in a subanalysis of cases with principal or secondary diagnoses of IBD or CDI. The incidence of CDI in patients with IBD increased between 2000 and 2009 from 21.7 to 28.0 cases per 1000 IBD cases per year (P < 0.001). There was a significant increase in CDI complicating ulcerative colitis (28.1 versus 42.2, P < 0.001) but not for Crohn's disease (18.3 versus 20.3). CDI represents a significant health care burden in hospitalized children with IBD.

Aggressive Attack on C. difficile Results in Significant Decrease in Hospital Infection Rate - The INTEGRIS Baptist Medical Center Experience

Purpose: In recent years there has been a dramatic increase in frequency of Clostridium difficile infection (CDI), with CDC estimates of 500,000 cases in the U.S. annually, with approximately 15,000 deaths. INTEGRIS Baptist Medical Center, a tertiary care facility in Oklahoma City admitting approximately 26,000 patients per year, experienced a similar increase in CDI. Methods: A “war on C. diff” committee was formed, consisting of GE's, ID specialists, an internist and the nursing head of infection control. We initiated a multi-faceted attack on CDI, including improved prevention, early detection and aggressive treatment measures. National SHEA infection control guidelines were reviewed and fully implemented. In addition to standard isolation procedures, we elicited suggestions from physicians and nurses to best ensure compliance, such as: trash can near door to avoid traversing room after de-gowning; uncluttered sink area; appropriate size gloves; easily accessible stethoscopes. We held multiple discussions with physician groups and nursing leaders about our goals. Periodic “snapshots” of physician and nursing staff compliance with isolation procedures was undertaken. We initiated a campaign to limit proton pump inhibitor use outside of critical care units. We encouraged nursing staff to send stool for CDT if CDI was suspected, without waiting for physician order, so as to cut the “lead time” between earliest symptom of CDI and initiation of isolation and treatment. We initiated a C. diff prevention trial on the general medical service. Consenting patients who required in-hospital antibiotics were randomized, in 2:1 fashion, to receive concurrent probiotics vs. placebo. Daily reports on CDT positive specimens are reviewed for patient characteristics and hospital location. Review of CDT positive cases revealed a disproportionately high rate of CDI in our transplant population. Consequently, we plan to initiate a C. diff prevention trial assessing both efficacy and safety of probiotics in the transplant population. Stools were tested for CDT using enzyme immunoassay; methodology remained the same throughout the study intervals. Results: In the 12 months prior to our interventions, the incidence of CDT positive hospitalized patients was 11.3 per 1000 admissions (national average reported as 13 per 1000). After a 3 month implementation period, the ensuing 12 month CDT positive incidence fell to 6.9 per 1000 patients, a decrease in CDI incidence of 40%. The rate of CDT (+) patients also decreased on the Transplant unit from 6.8% during months 1-6 post implantation, to 3.6% in months 7-12. Conclusion: A “war on C. diff” can have a significant positive impact on a hospital's rate of CDI.

Proton pump inhibitors increase significantly the risk of Clostridium difficile infection in a low‐endemicity, non‐outbreak hospital setting

Proton pump inhibitors (PPI) have been linked to higher risk of Clostridium difficile infection (CDI). The relevance of this association in hospitals with low disease activity, where an outbreak strain is nondominant, has been assessed in relatively few studies. To assess the association of PPI and CDI in a setting of low disease activity. A retrospective cohort study was conducted at two hospitals. Patients admitted for > or = 7 days receiving antibiotics were included. Demographics, exposure to PPI, antibiotics and other drugs in relation to diagnosis of CDI were assessed by univariate and multivariate analyses. Of 14 719 patients, 149 (1%) first episode CDI were documented; PPI co-exposure increased CDI [1.44 cases/100 patients vs. 0.74 cases/100 non-exposed (OR: 1.96, 95% CI: 1.42-2.72)]. By logistic regression, PPI days (adjusted OR: 1.01 per day, 95% CI: 1.00-1.02), histamine-2 blockers, antidepressants, antibiotic days, exposure to medications, age, admission service and length of admission were significant predictors. A statistically significant increase in CDI was observed in antibiotic recipients who received PPI, but the absolute risk increase is modest. In settings of with low rates of CDI, the benefit of PPI therapy outweighs the risk of developing CDI. These data support programmes to decrease inappropriate use of PPI in hospitalized patients.

Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their Clostridium difficile infection (CDI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Increasing rates of CDIC. difficile now rivals methicillin-resistant Staphylococcus aureus (MRSA) as the most common organism to cause healthcare-associated infections in the United States.a. In the United States, the proportion of hospital discharges in which the patient received the International Classification of Diseases, Ninth Revision discharge diagnosis code for CDI more than doubled between 2000 and 2003, and CDI rates continued to increase in 2004 and 2005 (L. C. McDonald, MD, personal communication, July 2007). These increases have been seen in pediatric and adult populations, but elderly individuals have been disproportionately affected. CDI incidence has also increased in Canada and Europe.b. There have been numerous reports of an increase in CDI severity.c. Most reports of increases in the incidence and severity of CDI have been associated with the BI/NAP1/027 strain of C. difficile. This strain produces more toxins A and B in vitro than do many other strains of C. difficile, produces a third toxin (binary toxin), and is highly resistant to fluoroquinolones.