Clostridioides difficile-Associated Diarrhea: Infection Prevention Unknowns and Evolving Risk Reduction Strategies

Estimating the effect of active detection and isolation on Clostridioides difficile infections in a bone marrow transplant unit

OBJECTIVE

To model the effects of active detection and isolation (ADI) regarding Clostridioides difficile infection (CDI) in the bone marrow transplant (BMT) unit of our hospital.

SETTING

ADI was implemented in a 21-patient bone marrow unit.

PATIENTS

Patients were bone marrow recipients on this unit.

INTERVENTIONS

We compared active ADI, in which patients who tested positive for colonization of C. difficile before their hospital stay were placed under extra contact precautions, with cases not under ADI.

RESULTS

Within the BMT unit, ADI reduced total cases of CDI by 24.5% per year and reduced hospital-acquired cases by ∼84%. The results from our simulations also suggest that ADI can save ∼$67,600 per year in healthcare costs.

CONCLUSIONS

Institutions with active BMT units should consider implementing ADI.

Clostridioides difficile Near-Patient Testing Versus Centralized Testing: A Pragmatic Cluster Randomized Crossover Trial

BACKGROUND

Management of suspected Clostridioides difficile infection (CDI) in the hospital setting typically results in patient isolation, laboratory testing, infection control, and presumptive treatment. We investigated whether implementation of rapid near-patient testing (NPT) reduced patient isolation time, hospital length of stay (LOS), antibiotic usage, and cost.

METHODS

A 2-period pragmatic cluster randomized crossover trial was conducted. Thirty-nine wards were randomized into 2 study arms. The primary outcome measure was effect of NPT on patient isolation time using a mixed-effects generalized linear regression model. Secondary outcomes examined were hospital LOS and antibiotic therapy based on a negative binomial regression model. Natural experiment (NE), intention-to-treat (ITT), and per-protocol (PP) analyses were conducted.

RESULTS

During the entire study period, a total of 656 patients received NPT for CDI and 1667 received standard-of-care testing. For the primary outcome, a significant decrease of patient isolation time with NPT was observed (NE, 9.4 hours [P < .01]; ITT, 2.3 hours [P < .05]; PP, 6.7 hours [P < .1]). A significant reduction in hospital LOS was observed with NPT for short stay (NE, 47.4% [P < .01]; ITT, 18.4% [P < .01]; PP, 34.2% [P < .01]). Each additional hour delay for a negative result increased metronidazole use (24 defined daily doses per 1000 patients; P < .05) and non-CDI-treating antibiotics by 70.13 mg (P < .01). NPT was found to save 25.48 US dollars per patient when including test cost to the laboratory and patient isolation in the hospital.

CONCLUSIONS

This pragmatic cluster randomized crossover trial demonstrated that implementation of CDI NPT can contribute to significant reductions in isolation time, hospital LOS, antibiotic usage, and healthcare cost. Clinical Trials Registration. NCT03857464.

Volatilomes of Bacterial Infections in Humans

Sense of smell in humans has the capacity to detect certain volatiles from bacterial infections. Our olfactory senses were used in ancient medicine to diagnose diseases in patients. As humans are considered holobionts, each person's unique odor consists of volatile organic compounds (VOCs, volatilome) produced not only by the humans themselves but also by their beneficial and pathogenic micro-habitants. In the past decade it has been well documented that microorganisms (fungi and bacteria) are able to emit a broad range of olfactory active VOCs [summarized in the mVOC database (http://bioinformatics.charite.de/mvoc/)]. During microbial infection, the equilibrium between the human and its microbiome is altered, followed by a change in the volatilome. For several decades, physicians have been trying to utilize these changes in smell composition to develop fast and efficient diagnostic tools, particularly because volatiles detection is non-invasive and non-destructive, which would be a breakthrough in many therapies. Within this review, we discuss bacterial infections including gastrointestinal, respiratory or lung, and blood infections, focusing on the pathogens and their known corresponding volatile biomarkers. Furthermore, we cover the potential role of the human microbiota and their volatilome in certain diseases such as neurodegenerative diseases. We also report on discrete mVOCs that affect humans.

The learning hospital: From theory to practice in a hospital infection prevention program

The learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation of clinical best practices. We describe a model for the learning hospital within the framework of a hospital infection prevention program and argue that a critical assessment of safety practices is possible without significant grant funding. We reviewed 121 peer-reviewed manuscripts published by the VCU Hospital Infection Prevention Program over 16 years. Publications included quasi-experimental studies, observational studies, surveys, interrupted time series analyses, and editorials. We summarized the articles based on their infection prevention focus, and we provide a brief summary of the findings. We also summarized the involvement of nonfaculty learners in these manuscripts as well as the contributions of grant funding. Despite the absence of significant grant funding, infection prevention programs can critically assess safety strategies under the learning hospital framework by leveraging a diverse collaboration of motivated nonfaculty learners. This model is a valuable adjunct to traditional grant-funded efforts in infection prevention science and is part of a successful horizontal infection control program.

Clostridioides difficile nurse driven protocol: A cautionary tale

In a 12-month study, a nurse driven protocol was implemented at a tertiary academic medical center. The purpose of the nurse driven protocol was to identify community-onset Clostridioides difficile infections, expeditiously isolate patients with presumed C difficile diarrheal illness, and prevent transmission while simultaneously decreasing the incidence of hospital-onset C difficile. The overall adherence to fidelity of the protocol was poor and failed to have a significant impact on infection rates.