Hospital Dramatically Decreased CDI With 2 Interventions

Implementing a simple admission screening question and a 2-step testing algorithm dramatically decreased incidence of Clostridioides difficile infections (CDI) at a hospital, according to a study published in American Journal of Infection Control.

The Milton S. Hershey Medical Center, an academic health center with approximately 550 beds, introduced a concerted set of interventions to reduce the number of incident CDI cases after experiencing increasing numbers of CDI cases.

“…our hospital was still documenting an average of 14 cases/month in 2017, despite attention to cleaning protocols, extending contact precautions until discharge for most CDI patients, and instituting after-action reviews,” the authors explained.

As of July 2018, the hospital implemented multiple interventions:

• A nursing protocol to identify CDI cases present on admission. All admissions older than 1 year old were screened with the question “Has the patient had 1 or more liquid or watery stools in the last 24 hours?” If the answer was “yes,” there was an order for a C difficile stool testing and contact precautions.
• A 2-step CDI testing algorithm for all samples that were positive. Patients with diarrhea with a positive polymerase chain reaction result but had a negative enzyme immunoassay may not need treatment, but still require isolation.
• A new order set for treating adults with C difficile
• Adding fidaxomicin to formulary.
• Other interventions such as stewardship of acid-suppressing drugs, probiotics for some patients on antibiotics, and vancomycin for patients on antibiotics who had CDI within the last year.

The researchers compared the 3 years prior and the 3 years after implementing the interventions. From 2009 to 2017, the number of health care–associated infection due to CDI (HAI-CDI) increased from an average of 4.5 a month to 15.5 a month. This increase was due to multiple changes: the implementation of more sensitive tests and a change in definition of HAI-CDI.

In the year after implementing the new interventions, the researchers found the number of HAI-CDI cases dropped from 161 to 63. “Importantly, the improvement was durable, with 52 cases in the most recent complete year of 2020–2021,” they wrote.

The researchers also found:

1. Mean time from stool collection to reporting the PCR result was approximately 7.5 hours
2. The enzyme immunoassay (EIA) took a mean of 68 additional means to be reported for tests that were PCR(+)
3. There were no significant differences between patients who were PCR(+)/EIA(+) and those who were PCR(+)/EIA(-) when it came to the percentage who received inpatient antibiotics in the previous 60 days (61.9% vs 63.2%), proton-pump inhibitors or histamine-2 receptor blockers in the previous 7 days (2.5% vs 5.1%), or laxatives in the previous 3 days (22.9% vs 29.6%)

Overall, 46.6% of all PCR(+)/EIA(+) cases were from stool collected on hospital day 1 or 2, which indicates that many cases were present on admission but not identified as such. The admission question accounted for 29.1% of the patients who were PCR(+)/EIA(+) on hospital day 1 or 2.

The 2-step testing algorithm also prevented an overdiagnosis that could result from testing everyone who had diarrhea in the 24 hours prior to admission. Patients who were PCR(+)/EIA(-) had similar outcomes to patients who were PCR(-), which supports the decision to isolate that patients despite many of them not needing treatment. The 2-step algorithm “reduced the number of people unnecessarily treated for CDI,” the authors noted.

While there were other interventions, none of the others were as systematically implemented as the 2 highlighted and the others did not have as much data collection because they were not expected to have as large of an impact.

“…in-depth analysis of the two major interventions demonstrated that the number of incident cases of CDI in hospitalized patients can be dramatically decreased by implementing an admission screening protocol that inquires about diarrhea and the use of a 2-step testing algorithm,” they concluded.

Reference

Katzman M, Cohrs AC, Hnatuck PE, et al. Impact of a multipronged approach to reduce the incidence of Clostridioides difficile infections in hospitalized patients. Am J Infect Control. Published online September 5, 2022. doi:10.1016/j.ajic.2022.08.027