At North Shore Medical Center in Massachusetts, antibiotics stewardship was the most effective intervention in reducing C. diff infections.
Resource-challenged community hospitals with high levels of Clostridium difficile (C. diff) infections among patients should focus on four contributing factors of the potentially deadly illness, recent research shows.
C. diff is the most common hospital-acquired infection at U.S. hospitals, the Centers for Disease Control and Prevention reported in 2015. Patients infected with C. diff shed millions of clostridial spores with every bowel movement, and the spores have been shown to survive for as long as five months on hospital surfaces.
In the hospital setting, there are multiple contributing factors that can drive C. diff infections. The lead author of the recent research, which was published in The Joint Commission Journal on Quality and Patient Safety, told HealthLeaders the main drivers of C. diff infections are likely to vary from hospital to hospital.
"There are many contributing factors, and they may carry different weights at different hospitals," said Barbara Lambl, MD, MPH, an infectious disease specialist and the hospital epidemiologist at North Shore Medical Center in Salem, Massachusetts. The medical center, which is an affiliate of Boston-based Partners HealthCare, features two community hospitals.
Starting in November 2013, North Shore Medical Center launched a systematic, four-pronged effort to reduce C. diff infections, according to the journal article:
1. Environmental services: Housekeeping efforts included cleaning of high-touch surfaces as well as terminal cleaning with bleach and ultraviolet disinfection.
2. Infection prevention: Several measures were introduced to increase staff hand washing with soap and water after caring for C. diff patients, including colorful signs posted on hand sanitizers outside patient rooms and anonymous observers to monitor hygiene compliance. When staff members raised concern that there were not enough sinks for hand washing, nine sinks were installed on five nursing units in two hospitals.
3. Antibiotic stewardship: In 2014, the medical center launched an effort to reduce use of clindamycin and fluoroquinolones. Studies have shown that clindamycin increases C. diff infection rates 20-fold, and fluoroquinolones increase risk 6-fold. A key component of the antibiotic stewardship initiative was an electronic decision support tool that encouraged clinicians to use alternative agents as substitutes for clindamycin and fluoroquinolones.
4. Emergency department processes: The ED staff developed an algorithm to identify and isolate patients with diarrhea or a recent C. diff infection. Inpatient nursing units were notified of patients who had been placed in isolation. Infection prevention practices in the ED were increased such as "SWAT teams" that properly cleaned and disinfected emergency room bays.
Interventions by the numbers
North Shore Medical Center's C. diff reduction efforts generated significant results over a four-year period:
- Hospital-acquired C. diff infections fell 55.5%, from 12.2 cases per 10,000 patient-days to 5.4 cases
- Antibiotics stewardship had the biggest impact, accounting for a 20.6% reduction in hospital-acquired C. diff infections
- Use of high-risk antibiotics fell 88.1%
- Infection prevention measures were the second-most effective intervention, accounting for a 13.0% reduction in hospital-acquired C. diff
Appropriate use of antibiotics
To craft the electronic decision support tool for antibiotics stewardship, North Shore Medical Center drew upon three of David Bates' "ten commandments," Lambl told HealthLeaders. "The decision support was speedy. It was timely. And it offered alternative antibiotics."
Staff pharmacists played a crucial role in securing physician compliance with antibiotics stewardship, she said.
"Getting the support of our pharmacist leaders and pharmacists was probably the most important factor in allaying clinician discomfort or unease about switching antibiotics. They would speak with the doctors and reassure anxious clinicians. Without the pharmacists, the whole thing might have failed. Electronic decision support can only get you so far. Having face-to-face interactions is critical."
Improving C. diff diagnostics to target only actively infected patients was also essential, Lambl said. "There's a difference between being colonized with a germ and being sick with the germ. People can be colonized with viruses and bacteria but not get sick. Whereas, other people who have the same germ will get very sick. That's the way it is with C. diff."
Testing needs to be able to distinguish between colonization and active infection, she said. "We believe that people who are just colonized are not transmitting infection to other patients. They certainly do not transmit at the same rate as people who are shedding millions and millions of spores with each diarrheal bowel movement."
Christopher Cheney is the senior clinical care editor at HealthLeaders.
C. diff is the most common hospital-acquired infection at U.S. hospitals, according to the Centers for Disease Control and Prevention.
The drivers of C. diff infections are multidimensional, and the primary drivers of infections are likely to vary from hospital to hospital.
Electronic decision support for antibiotics stewardship should be speedy, timely, and geared to offer alternative antibiotics.