A Multipronged Approach to Decrease the Risk of Clostridium difficile Infection at a Community Hospital and Long-Term Care Facility

From Sharp HealthCare, San Diego, CA.

Abstract

• Objective: To examine the relationship between the rate of Clostridium difficile infections (CDI) and implementation of 3 interventions aimed at preserving the fecal microbiome: (1) reduction of antimicrobial pressure; (2) reduction in intensity of gastrointestinal prophylaxis with proton-pump inhibitors (PPIs); and (3) expansion of probiotic therapy.
• Methods: We conducted a retrospective analysis of all inpatients with CDI between January 2009 and December 2013 receiving care at our community hospital and associated long-term care (LTC) facility. We used interrupted time series analysis to assess CDI rates during the implementation phase (2008–2010) and the postimplementation phase (2011–2013).
• Results: A reduction in the rate of health care facility–associated CDIs was seen. The mean number of cases per 10,000 patient days fell from 11.9 to 3.6 in acute care and 6.1 to 1.1 in LTC. Recurrence rates decreased from 64% in 2009 to 16% by 2014. The likelihood of CDI recurring was 3 times higher in those exposed to PPI and 0.35 times less likely in those who received probiotics with their initial CDI therapy.
• Conclusion: The risk of CDI incidence and recurrence was significantly reduced in our inpatients, with recurrent CDI associated with PPI use, multiple antibiotic courses, and lack of probiotics. We attribute our success to the combined effect of intensified antibiotic stewardship, reduced PPI use, and expanded probiotic use.

Clostridium difficile is classified as an urgent public health threat by the Centers for Disease Control and Prevention [1]. A recent study by the CDC found that it caused more than 400,000 infections in the United States in 2011, leading to over 29,000 deaths [2]. The costs of treating CDI are substantial and recurrences are common. While rates for many health care–associated infections are declining, C. difficile infection (CDI) rates remain at historically high levels [1] with the elderly at greatest risk for infection and mortality from the illness [3].

CDIs can be prevented. A principal recommendation for preventing CDIs is improving antibiotic use. Antibiotic use increases the risk for developing CDI by disrupting the colonic microbiome. Hospitalized and long-term care (LTC) patients are frequently prescribed antibiotics, but studies indicate that much of this use is inappropriate [4]. Antimicrobial stewardship has been shown to be effective in reducing CDI rates. Other infection prevention measures commonly employed to decrease the risk of hospital-onset CDI include monitoring of hand hygiene compliance using soap and water, terminal cleaning with bleach products of rooms occupied by patients with CDI, and daily cleaning of highly touched areas. At our institution, patients identified with CDI are placed on contact precautions until they have been adequately treated and have had resolution of diarrhea for 48 hours.

In addition to preventing CDI transmission through antimicrobial stewardship, attention is being paid to the possibility that restricting PPI use may help in preventing CDI. The increasing utilization of proton-pump inhibitors (PPIs) in recent years has coincided with the trend of increasing CDI rates. Although C. difficile spores are acid-resistant, vegetative forms are easily affected by acidity. Several studies have shown the association of acid suppression and greater susceptibility of acquiring CDI or recurrences [5–7]. Elevated gastric pH by PPIs facilitates the growth of potentially pathogenic upper and lower gastrointestinal (GI) tract flora, including the conversion of C. difficile from spore to vegetative form in the upper GI tract [5,8].

A growing body of evidence indicates that probiotics are both safe and effective for preventing CDIs [9]. Probiotics may counteract disturbances in intestinal flora, thereby reducing the risk for colonization by pathogenic bacteria. Probiotics can inhibit pathogen adhesion, colonization, and invasion of the gastrointestinal mucosa [10].

We hypothesized that preservation and/or restoration of the diversity of the fecal microbiome would prevent CDI and disease recurrence in our facility. Prior to 2009, we had strict infection prevention measures in place to prevent disease transmission, similar to many other institutions. In 2009, we implemented 3 additional interventions to reduce the rising incidence of CDI: (1) an antibiotic stewardship program, (2) lowering the intensity of acid suppression, and (3) expanding the use of probiotic therapy. The 3 interventions were initiated over the 19-month period January 2009 through July 2010. This study addresses the effects of these interventions.