A Tiered Approach for Preventing Clostridioides difficile Infection

Impact of Mandatory Infectious Disease Specialist Approval on Hospital-Onset Clostridioides difficile Infection Rates and Testing Appropriateness

BACKGROUND

Inappropriate Clostridioides difficile testing is common in the hospital setting, leading to potential overdiagnosis of infection when single-step nucleic acid amplification testing is used. The potential role of infectious diseases (ID) specialists in enforcing appropriate C. difficile testing is unclear.

METHODS

At a single 697-bed academic hospital, we performed a retrospective study from 1 March 2012 to 31 December 2019 comparing hospital-onset C. difficile infection (HO-CDI) rates during 3 consecutive time periods: baseline 1 (37 months, no decision support), baseline 2 (32 months, computer decision support), and intervention period (25 months, mandatory ID specialist approval for all C. difficile testing on hospital day 4 or later). We used a discontinuous growth model to assess the impact of the intervention on HO-CDI rates.

RESULTS

During the study period, we evaluated C. difficile infections across 331 180 admission and 1 172 015 patient-days. During the intervention period, a median of 1 HO-CDI test approval request per day (range, 0-6 alerts/day) was observed; adherence by providers with obtaining approval was 85%. The HO-CDI rate was 10.2, 10.4, and 4.3 events per 10 000 patient-days for each consecutive time period, respectively. In adjusted analysis, the HO-CDI rate did not differ significantly between the 2 baseline periods (P = .14) but did differ between the baseline 2 period and intervention period (P < .001).

CONCLUSIONS

An ID-led C. difficile testing approval process was feasible and was associated with a >50% decrease in HO-CDI rates, due to enforcement of appropriate testing.

Healthcare-associated infection prevention and control practices in Israel: results of a national survey

Background

Healthcare-associated infection (HAI) is a common and largely preventable cause of morbidity and mortality. The COVID-19 pandemic has presented unprecedented challenges to health systems. We conducted a national survey to ascertain hospital characteristics and the use of HAI prevention measures in Israel.

Methods

We e-mailed surveys to infection prevention and control (IPC) leads of acute care hospitals in Israel. The survey included questions about the use of practices to prevent catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and Clostridioides difficile infection (CDI). The survey also assessed COVID-19 impact and healthcare worker well-being.

Results

IPC leads from 15 of 24 invited hospitals (63%) completed the survey. Only one-third of respondents reported strong support for IPC from hospital leadership. Although several prevention practices were used by all hospitals (e.g., maximum sterile barrier precautions for CLABSI and real-time assessment of environmental cleaning for CDI), use of other practices was suboptimal—particularly for CAUTI and VAP. COVID-19 had a profound impact on Israeli hospitals, with all hospitals reporting opening of new units to care for COVID patients and most reporting moderate to extreme financial hardship. All hospitals reported highly successful plans to vaccinate all staff and felt confident that the vaccine is safe and effective.

Conclusion

We provide a status report of the IPC characteristics and practices Israeli hospitals are currently using to prevent HAIs during the COVID-19 era. While many globally accepted IPC practices are widely implemented, opportunities to increase the use of certain IPC practices in Israeli hospitals exist.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07721-8.

Gut microbiota in burned patients with Clostridioides difficile infection

BACKGROUND

The survival rate of patients with severe burn is positively associated with increasing the incidence of the Clostridioides difficile (C. difficile) infection (CDI). The surviving rate of severe burn patients now has an improved but the incidence of Clostridioides difficile (C. difficile) infection (CDI) has been continues increasing during recent two decades. This study assessed the molecular typing and phenotypic characterization isolates of C. difficile in burn patients with diarrhea, as well as environmental and skin infections with C. difficile spores at a referral burn hospital in Isfahan, Iran. It mainly aimed to evaluate the dominant bacterial structure in the gut microbiome of burned subjects with and without CDI.

METHODS

In general, 309 samples were collected from 189 burned patients with hospital-acquired diarrhea and 120 swabs were collected from the healthcare workers' dominant hands, different sites of patients' skin, and medical tools. In addition, C. difficile isolates were characterized considering the existence of antibiotic resistance and toxin genes. Clinical cultures with identification of organisms and antibiotic susceptibility were done. C. difficle isolates were then genotyped and compared to clinical outcomes. Finally, the clinical characteristics of the participants were gathered through their records, and the bacterial targets of the gut microbiome were detected using quantitative real-time polymerase chain reaction (PCR).

RESULTS

Based on the findings, 51 C. difficile isolates were detected from 189 severe burn patients hospitalized in the hospital. Further, PCR amplification tcdB and tcdA showed 23 isolates (12.2%) as toxigenic. Overall, 18.3% (22/120) of skin and environment samples demonstrated a positive result for C. difficile colonization. A low concentration of metronidazole and vancomycin (MIC90, 0.5, and 1.2 mg/L) inhibited all toxigenic C. difficile strains. Moreover, these isolates represented the highest rates of resistance to moxifloxacin and clindamycin (MIC90, 0.5, and 1.6 mg/L). A significantly reduced abundance of Clostridium spp., Bacteroidetes, and Bifidobacterium and an increase in the quantity of Firmicutes was observed in the gastrointestinal microbiome of burn patients (P < 0.01). Burn patients with CDI showed a significant decrease in Faecalibacterium prausnitzii (F. prausnitzii) while higher Akkermansia muciniphila (A. muciniphila) loads in comparison with healthy controls (P < 0.001 and P < 0.05). Contrarily, burned cases displayed increased levels of opportunistic pathogenic bacteria including the members of Enterococcus spp. and Escherichia coli (P < 0.05).

CONCLUSIONS

Despite appropriate infection control strategies in the burn intensive care unit, CDI remains prevalent in severe burn patients. Eventually, the overgrowth of A. muciniphila and the decreased abundance of F. prausnitzii in burn cases with CDI could be potential predictive microbiome biomarkers in burned patients.

Trends in Healthcare Facility-Onset Clostridioides difficile Infection and the Impact of Testing Schemes in an Acute Care Hospital System in New York City, 2016-2019

BACKGROUND

Healthcare facility-onset Clostridioides difficile infection is associated with adverse clinical outcomes and hospital reimbursement. A four-year review involving eleven hospitals of the NYC Health + Hospital system was undertaken.

METHODS

From 2016-2019, infection rates and standardized infection ratios (SIRs) were gathered from National Healthcare Safety Network. The C. difficile testing scheme at each facility was recorded.

RESULTS

For the eleven hospitals, declines in rates of C. difficile infection and SIRs were documented. However, this decline was driven by two hospitals that had high rates of infection in 2016; for the remaining nine hospitals, rates of infection and SIRs were at a plateau. Most hospitals used a testing scheme that fell into the nucleic acid amplification test (NAAT) category for SIR risk adjustment. Hospitals that used the algorithm glutamate dehydrogenase (GDH) and toxin A/B immunoassay (EIA) followed by NAAT for discrepant results had significantly lower rates of C. difficile infection but similar SIRs.

CONCLUSIONS

For most hospitals in this system, rates of C. difficile remained level. Within the NAAT test categories, SIRs may not correlate with infection rates. Given the controversies regarding testing and calculation of SIRs, alternatives to C. difficile infection should be sought as a hospital quality measurement.

Catheter-Associated Urinary Tract Infection, Clostridioides difficile Colitis, Central Line-Associated Bloodstream Infection, and Methicillin-Resistant Staphylococcus aureus

Hospital-acquired infections increase cost, morbidity, and mortality for patients across the United States and the world. Principal among these infections are central line-associated bloodstream infection, catheter-associated urinary tract infection, Clostridioides difficile, and methicillin-resistant Staphylococcus aureus colonization and infections. This article provides succinct summaries of the background, epidemiology, diagnosis, and treatment of these conditions. In addition, novel prevention strategies, including those related to recent national interventions, are reviewed.

Quantitative Results of a National Intervention to Prevent Central Line-Associated Bloodstream Infection: A Pre-Post Observational Study

BACKGROUND

Central line-associated bloodstream infection (CLABSI) remains prevalent in hospitals in the United States.

OBJECTIVE

To evaluate the impact of a multimodal intervention in hospitals with elevated rates of health care-associated infection.

DESIGN

Pre-post observational evaluation of a prospective, national, clustered, nonrandomized initiative of 3 cohorts of hospitals.

SETTING

Acute care, long-term acute care, and critical access hospitals, including intensive care units and medical/surgical wards.

PARTICIPANTS

Target hospitals had a cumulative attributable difference above the first tertile of performance for Clostridioides difficile infection and another health care-associated infection (such as CLABSI). Some hospitals that did not meet these criteria also participated.

INTERVENTION

A multimodal intervention consisting of recommendations and tools for prioritizing and implementing evidence-based infection prevention strategies, on-demand educational videos, webinars led by content experts, and access to content experts.

MEASUREMENTS

Rates of CLABSI and device utilization ratio pre- and postintervention.

RESULTS

Between November 2016 and May 2018, 387 hospitals in 23 states and the District of Columbia participated. Monthly preimplementation CLABSI rates ranged from 0 to 71.4 CLABSIs per 1000 catheter-days. Over the study period, the unadjusted CLABSI rate was low and decreased from 0.88 to 0.80 CLABSI per 1000 catheter-days. Between the pre- and postintervention periods, device utilization decreased from 24.05 to 22.07 central line-days per 100 patient-days. However, a decreasing trend in device utilization was also observed during the preintervention period.

LIMITATIONS

The intervention period was brief. Participation in and adherence to recommended interventions were not fully assessed. Rates of CLABSI were low. Patient characteristics could not be assessed.

CONCLUSION

In hospitals with a disproportionate burden of health care-associated infection, a multimodal intervention did not reduce rates of CLABSI.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Qualitative Assessment of a State Partner-Facilitated Health Care-Associated Infection Prevention National Collaborative

BACKGROUND

The Centers for Disease Control and Prevention (CDC) funded a 3-year national collaborative focused on facilitating relationships between health care-associated infection (HAI) prevention stakeholders within states and improving HAI prevention activities within hospitals. This program-STRIVE (States Targeting Reduction in Infections via Engagement)-targeted hospitals with elevated rates of common HAIs.

OBJECTIVE

To use qualitative methods to better understand STRIVE's effect on state partner relationships and HAI prevention efforts by hospitals.

DESIGN

Qualitative case study, by U.S. state.

SETTING

7 of 22 eligible STRIVE state partnerships.

PARTICIPANTS

Representatives from state hospital associations, state health departments, and other participating organizations (for example, Quality Innovation Networks-Quality Improvement Organizations), referred to as "state partners."

MEASUREMENTS

Phone interviews (n = 17) with each organization were conducted, recorded, and transcribed.

RESULTS

State partners reported that relationships with each other and with participating hospitals improved through STRIVE participation. The partners saw improvements in hospital-level HAI prevention activities, such as improved auditing and feedback practices and inclusion of environmental services in prevention efforts; however, some noted those improvements may not be reflected in HAI rates. Many partners outlined plans to sustain their partner relationships by working on future state-level initiatives, such as opioid abuse prevention and antimicrobial stewardship.

LIMITATION

Only 7 participating states were included; direct feedback from participating hospitals was not available.

CONCLUSION

Although there were no substantial changes in aggregate HAI rates, STRIVE achieved its goal of improving state partner relationships and coordination. This improved collaboration may lead to a more streamlined response to future HAI outbreaks and public health emergencies.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Quantitative Results of a National Intervention to Prevent Clostridioides difficile Infection: A Pre-Post Observational Study

BACKGROUND

Clostridioides difficile infection (CDI) is on the rise.

OBJECTIVE

To evaluate the effect of a tiered, evidence-based intervention to prevent CDI.

DESIGN

Pre-post observational evaluation of a prospective, 12-month, national, nonrandomized, clustered quality improvement project to reduce hospital health care-associated infection.

SETTING

Acute care, long-term acute care, and critical access hospitals working with state partner organizations (state hospital associations and state health departments) to improve health care-associated infection prevention practices.

PARTICIPANTS

Targeted hospitals had a high burden of CDI and another health care-associated infection. Other hospitals that did not meet these criteria volunteered to participate.

INTERVENTION

Multimodal intervention that consisted of 1) on-demand educational modules and webinars, 2) in-person meetings facilitated by state-level partners, 3) feedback and recommendations for implementation of evidence-based recommendations (including a CDI-specific guide on which interventions to implement), and 4) guided facilitation through infection prevention resources and site visits.

MEASUREMENTS

Pre- and postintervention CDI rates.

RESULTS

Between November 2016 and May 2018, 387 hospitals (366 of which reported CDI data) in 23 states and the District of Columbia participated in the intervention. There was a statistically significant decrease in CDI incidence over the study period, from 7.0 cases per 10 000 patient-days in the preintervention period to 5.7 cases per 10 000 patient-days in the postintervention period. However, this decrease appeared to be part of a temporal trend rather than due to the study intervention.

LIMITATIONS

Commitment to and adherence with recommended infection prevention practices before and after the intervention were not assessed. The intervention period was relatively brief, and patient-level data were not available.

CONCLUSION

Although a statistically significant decline in hospital-onset CDI was observed, this trend appears to be unrelated to the study intervention.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.