Original Research

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

Journal of Clinical Outcomes Management. 2015 September;22(9)

References

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= 0.009, OR 2.94).

Acid Suppression

In evaluating the effects of limiting the use of PPIs, patients who received an H2RA or no antacid prophylaxis were significantly less likely to have a recurrence of CDI than those who received a PPI (chi square = 6.35, df = 1, P = 0.012). The OR for recurrence with PPIs was 3.05 (95% CI 1.25 to 7.44). Of patients exposed to PPIs, those exposed in the later time period (2011 through 2013) were significantly less likely to have a recurrence than those exposed in the early time period (third quarter 2008 through 2010; chi square = 15.14, df = 1, P < 0.001). The OR was 0.23 (95% CI, 0.11 to 0.49).

As seen in Figure 2, the number of CDI events declined markedly over the first 2 years then plateaued or very slowly declined for the remainder of the study. As seen in Figure 7 , the use of PPIs continued to decline, and the use of H2RAs continued to increase from 2011 on. Initially, in 2009, 95% of CDI cases were on a PPI, but by 2010 the rate of PPI use was declining rapidly at our facility, with only 55% of the CDI patients on a PPI, and 48% on an H2RA.

Probiotics

During 2009–2011, only 15% of the CDI patients had received probiotics with an antibiotic course. Probiotic therapy as part of CDI treatment increased from 60% in 2009 to 91% in 2011. Among patients that contracted CDI in 2012–2013, only 2 patients received probiotics with their antibiotic courses.

Recurrences

In 2009, the recurrence rate was 64%, with the rate decreasing dramatically over the study period ( Figure 8 ). The time frame for inclusion of a recurrent CDI event was 0–180 days. It is likely the events occurring from 91 to 180 days later may have been new events; however, all were included as recurrent events in our study ( Figure 9 ). In reviewing acid suppression of the recurring CDI patients, 70% were on PPI, 20% on H2RA, and 10% had no acid reduction.

With regard to the effect of probiotics within this population, those who received

probiotics in the later time period were significantly less likely to have a recurrence (chi square = 8.75, df = 1, P = 0.003). The OR was 0.26 (95% CI 0.10 to 0.65). More specifically, for all episodes of CDI, patients who received probiotics with their initial CDI treatment were significantly less likely to have a recurrence (OR 0.35; 95% CI 0.14 to 0.87).

One patient with significant initial antibiotic pressure was continued on her PPI during CDI treatment and continued to have recurrences, despite probiotic use. After her fourth recurrence, her PPI was changed to an H2RA, and she had no further recurrences. She continues off PPI therapy and is CDI-free 2 years later. Another patient who remained on his PPI had 3 recurrences, until finally a probiotic was added and the recurrences abated.

Discussion

CDI is common in hospitalized patients, and its incidence has increased due to multiple factors, which include the widespread use of broad-spectrum antimicrobials and increased use of PPIs. Our observational study showed a statistically significant reduction in the number of health care–associated CDI cases during our implementation period (mid–2008 through 2010). From 2011 on, all initiatives were maintained. As the lower rates of CDI continued, physician confidence in antimicrobial stewardship recommendations increased. During this latter portion of the study period, hospitalists uniformly switched patients to H2RA for GI prophylaxis, added prophylactic probiotics to antibiotic courses as well as CDI therapy, and were more receptive to streamlining and limiting durations of antibiotic therapy. Although the study was completed in 2013, follow-up data have shown that the low CDI incidence has continued through 2014.