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Lessons Learned from Implementing Clostridium difficile-Focused Antibiotic Stewardship Interventions

Published online by Cambridge University Press:  10 May 2016

B. Ostrowsky ,
R. Ruiz ,
S. Brown ,
P. Chung ,
E. Koppelman ,
C. van Deusen Lukas ,
Y. Guo ,
H. Jalon ,
Z. Sumer  and
C. Araujo
...Show all authors
B. Ostrowsky
Affiliation:
Montefiore Medical Center, Bronx, New York Albert Einstein College of Medicine, Bronx, New York
R. Ruiz
Affiliation:
Greater New York Hospital Association, New York, New York
S. Brown
Affiliation:
Montefiore Medical Center, Bronx, New York
P. Chung
Affiliation:
Montefiore Medical Center, Bronx, New York Albert Einstein College of Medicine, Bronx, New York
E. Koppelman
Affiliation:
Boston University School of Public Health, Boston, Massachusetts
C. van Deusen Lukas
Affiliation:
Boston University School of Public Health, Boston, Massachusetts
Y. Guo
Affiliation:
Montefiore Medical Center, Bronx, New York Albert Einstein College of Medicine, Bronx, New York
H. Jalon
Affiliation:
United Hospital Fund, New York, New York
Z. Sumer
Affiliation:
Greater New York Hospital Association, New York, New York
C. Araujo
Affiliation:
Greater New York Hospital Association, New York, New York
I. Sirtalan
Affiliation:
Greater New York Hospital Association, New York, New York
C. Brown
Affiliation:
Montefiore Medical Center, Bronx, New York Albert Einstein College of Medicine, Bronx, New York
P. Riska
Affiliation:
Montefiore Medical Center, Bronx, New York Albert Einstein College of Medicine, Bronx, New York
B. Currie
Affiliation:
Montefiore Medical Center, Bronx, New York Albert Einstein College of Medicine, Bronx, New York
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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 < .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.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 35 , Issue S3: Preventing Healthcare–Associated Infections: Results and Lessons Learned from AHRQ's HAI Program , October 2014 , pp. S86 - S95
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2014

References

1. O'Grady, NP, Alexander, M, Dellinger, EP, et al. Guidelines for the Prevention of Intravascular Catheter-Related Infections. Atlanta: Centers for Disease Control and Prevention, 2011. http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf.Google Scholar
2. Malpiedi, PJ, Peterson, KD, Soe, MM, et al. 2011 National and State Healthcare-Associated Infection Standardized Infection Ratio Report. Atlanta: Centers for Disease Control and Prevention, 2011. http://www.cdc.gov/hai/national-annual-sir/index.html.Google Scholar
3. McDonald, LC, Owings, M, Jernigan, DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003. Emerg Infect Dis 2006;12:409–415.CrossRefGoogle ScholarPubMed
4. Elixhauser, A, Jhung, MA. Clostridium difficile-associated Diseases in U.S. Hospitals, 1993-2005. Healthcare Cost and Utilization Project statistical brief 50. Rockville, MD: Agency for Healthcare Research and Quality, 2008. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb50.jsp.Google Scholar
5. Lessa, FC, Gould, CV, McDonald, LC. Current status of Clostridium difficile infection epidemiology. Clin Infect Dis 2012;55(S2): S65–S70.CrossRefGoogle ScholarPubMed
6. Redelings, MD, Sorvillo, F, Mascola, L. Increase in Clostridium difficile–related mortality rates, United States, 1999-2004. Emerg Infect Dis 2007;13:1417–1419.CrossRefGoogle ScholarPubMed
7. Chitnis, AS, Holzbauer, SM, Belflower, RM, et al. Epidemiology of community-associated Clostridium difficile infection, 2009 through 2011. JAMA Intern Med 2013;173:1359–1367.CrossRefGoogle ScholarPubMed
8. Cohen, SH, Gerding, DN, Johnson, S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010;31:431–455.CrossRefGoogle Scholar
9. Dellit, T, Owen, R, McGowan, J, Gerding, D, Weinstein, J, Burke, J. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159–177.CrossRefGoogle Scholar
10. Moody, J, Cosgrove, S, Olmstead, R, et al. Antimicrobial stewardship: a collaborative partnership between infection preventionists and healthcare epidemiologists. Infect Control Hosp Epidemiol 2012;33(4):328–330.CrossRefGoogle ScholarPubMed
11. Koll, B, Ruiz, R, Calfee, B, et al. Prevention of hospital-onset Clostridium difficile infection in the New York metropolitan region using a collaborative intervention model. J Healthc Qual 2014;36:35–45.CrossRefGoogle ScholarPubMed
12. Agency for Healthcare Research and Quality (AHRQ). Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship: The Evaluation and Research on Antimicrobial Stewardship's Effect on Clostridium difficile (ERASE C. difficile) Project. Rockville, MD: AHRQ, 2012. http://www.ahrq.gov/qual/cdifftoolkit/cdiffllqu.htm.Google Scholar
13. Chung, P, Guo, Y, Ostrowsky, B. Does choice of control group affect the association of antibiotics with Clostridium difficile–associated diarrhea? In: SHEA 2011 Annual Scientific Meeting; April 1-4, 2011; Dallas, TX. http://shea.confex.com/shea/2011/webprogram/Paper4443.html.Google Scholar
14. McDonald, L, Coignard, B, Dubberke, E, Song, X, Horan, T, Kutty, P. Ad hoc Clostridium difficile surveillance working group recommendations for surveillance C. difficile–associated disease. Infect Control Hosp Epidemiol 2007;28:140–145.CrossRefGoogle Scholar
15. Gase, K, Haley, V, Xiong, K, Van Antwerpen, C, Stricof, R. Comparison of two Clostridium difficile surveillance methods: National Healthcare Safety Network's laboratory-identified event reporting module versus clinical surveillance. Inject Control Hosp Epidemiol 2013;34(3):284–290.CrossRefGoogle Scholar
16. Centers for Disease Control and Prevention (CDC), National Healthcare Safety Network. MDRO-CDAD Module. Atlanta: CDC, 2008. http://www.cdc.gov/nhsn/PDFs/MDRO_CDADprotocolv41Dec08final.pdf.Google Scholar
17. World Health Organization (WHO). Anatomical Therapeutic Chemical Classification System with Defined Daily Doses (ATC/DDD). Geneva: WHO, 2014. http://www.who.int/classifications/atcddd/en/.Google Scholar
18. Polk, RE, Fox, C, Mahoney, A, Letcavage, J, MacDougall, C. Measurement of adult antibacterial drug use in 130 U.S. hospitals: comparison of defined daily dose and days of therapy. Clin Infect Dis 2007;44(5):664–670.CrossRefGoogle ScholarPubMed
19. StataCorp. Stata Statistical Software: Release 11.2. College Station, TX: StataCorp, 2009.Google Scholar
20. Centers for Medicare and Medicaid Services (CMS). Healthcare Cost Report Information System. Baltimore, MD: CMS, 2009. http://www.resdac.org/cms-data/files/hcris.Google Scholar
21. New York State Department of Health. Hospital Profiles Report. Albany, NY: New York State Department of Health, 2013. http://www.health.ny.gov/facilities/hospital/.Google Scholar
22. Brown, C, Guo, Y, Chung, P, Brown, S, Ostrowsky, B. Feasibility and acceptability of an audit and feedback method of antibiotic stewardship: a pilot study. In: Annual Infectious Diseases Society of America meeting; October 2011; Boston, MA. Poster 31615.Google Scholar
23. VanDeusen Lukas, C, Koppelman, E, Ostrowsky, B, et al. Developing the Capacity to Implement Antimicrobial Stewardship: Opportunities for the Future. Rockville, MD: Agency for Healthcare Research and Quality, 2013. Publication 14-0003.Google Scholar
24. New York State Department of Health. Public Health Law Section 2819: Hospital-Acquired Infection Reporting. Albany, NY: New York State Department of Health, 2009. http://www.health.ny.gov/regulations/public_health_law/section/2819/.Google Scholar
25. New York State Department of Health. Hospital-Acquired Infection (HAI) Rates in New York State Hospitals. Albany, NY: New York State Department of Health, 2013. http://www.health.ny.gov/statistics/facilities/hospital/hospital_acquired _infections/.Google Scholar
26. US Department of Health and Human Services and Centers for Medicare and Medicaid Services. Adoption of NHSN C. diff into FY 2017 Hospital-Acquired Condition Reduction Program. Federal Register, August 19, 2013:50717.Google Scholar
27. US Department of Health and Human Services and Centers for Medicare and Medicaid Services. CMS Intent to Propose Inclusion of NHSN C. diff into FY 2017 Value-Based Purchasing Program in FY 2015 Inpatient Prospective Payment System Proposed Rule. Federal Register, August 19, 2013:50717.Google Scholar