A Tiered Approach to Reduce Hospital Onset C. difficile

Brian Koll, MD, FACP, FIDSA

Medical Director and Chief

Infection Prevention and Control, BIMC

Professor of Medicine, AECOM

HO Clostridium difficile (CDI)CMS 10th SOW

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National SOW NYS SOW

HO CDI Rate Jul - Dec 2012

Jan - Jun 2013

Goal is 10% reduction6

HO Clostridium difficile (CDI)New York State DOH

7.67.77.87.9

88.18.28.38.48.58.6

2010 2011 2012 2013

HO CDI Rate

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HO Clostridium difficile (CDI)10th SOW BIMC

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BI Petire BI Brooklyn

HO CDI Rate

Jul - Dec 2012

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Tiered Approach

1. Hand hygiene2. Contact precautions3. Sign placement4. PPE readily available

and used5. Dedicated rectal

thermometers

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Tiered Approach

6. Patient placement7. Commodes8. Environmental

cleaning protocols9. Chlorhexidine bathing

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Tiered Approach

10. Antibiotic stewardship11. Pharmaceutical

stewardship

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Begins with Leadership

•Accountability

•Link infection prevention with organizational strategy and resources

•Link a culture of safety to outcomes

•Engage and facilitate teamwork

•Goal setting and measuring and assessing effectiveness

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Begins with Those on the Front Line

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Begins with Those on the Front LineOwnership

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Begins with Those on the Front LineOwnership

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Begins with Those on the Front LineOwnership - Nursing

University of Nebraska

1.bathing three days per weekfollowed by

2.daily bathing

followed by

3.four-month washout period returning to standard soap-and-water bathing

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Infect Control Hosp Epidemiol 2012;33:1094 - 1100

Begins with Those on the Front LineOwnership - Nursing

30% reduction in HO CDI with three days per week protocol

59% reduction with daily bathing

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Infect Control Hosp Epidemiol 2012;33:1094 - 1100

CDI Survey

Antimicrobial Resistance: Scope of the Problem and Key Contributors

Disagree Neither Agree

1.            Antibiotic resistance is a problem in this institution.

5% 17% 78%

2.            Patient rooms are cleaned according to hospital cleaning protocol once a C. difficile patient has been discharged.

4% 15% 81%

3.            Adherence to hand hygiene protocols is excellent at this institution.

26% 20% 54%

4.            Adherence to isolation and contact precautions is excellent at this institution.

34% 16% 50%

5.            This institution does NOT do enough to control the development of C. difficile. 44% 30% 26%

6.            This institution provides adequate staff education regarding C. difficile. 12% 36% 52%

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Antibiotic Stewardship

• Community acquired pneumonia• moxifloxacin vs ceftriaxone-based therapy

• colonization and infection with multidrug-resistant organisms higher in moxifloxacin group

• restriction policies to diminish moxifloxacin use

Goldstein RC, Lalite S, Mildvan D, Perlman DC, Jodlowski T,Ruhe J. IDSA Poster Presentation 205. Boston, October 2011.

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Antibiotic Stewardship

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Feb Mar

Number of

Orders

Moxifloxicin Use

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Begins with Those on the Front LineOwnership - Physicians

•San Francisco General

•Jun 2005 – Dec 2010

•historical cohort study

•development of CDI within 30 days of ceftriaxone therapy

•3,730 patients

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Clinical Infectious DiseasesSept 1, 2012  Volume 55   page 615

Begins with Those on the Front LineOwnership - Physicians

•Multivariate analysis• doxycycline associated with

protection against development of CDI

• 27% lower rate•Hazard ratios ctx + doxy

• vs ctx + azith = 0.15• vs ctx + fluoroquinolone = 0.13

• Stongest predictor of CDI• length of stay

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Clinical Infectious DiseasesSept 1, 2012  Volume 55   page 615

Antibiotic Stewardship

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40

60

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120

Nov Dec Jan Feb Mar

Number of Orders CTX + AZITH

CTX + DOXY

Clinical Infectious DiseasesSept 1, 2012  Volume 55   page 615 23

Proton Pump Inhibitors• elderly• underlying medical conditions• broad spectrum antibiotics• PPI

• 28 observational studies• strength of association ranged from 1.4 to 2.8x higher

• Indications• erosive gastritis• symptomatic GERD• NSAID gastric ulcer risk reduction• H. pylori eradication

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Proton Pump Inhibitors

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3000

Dec Jan Feb Mar

Number of Units

Nexium

HO CDI

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HO Clostridium difficile (CDI)10th SOW BIMC

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BI Petire BI Brooklyn

HO CDI RateJul - Dec 2012

Jan - Jun 2013

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Value Analysis

On the CUSP Calculator

▶CDI Cases

▶Increased Length of Stay

▶Mortality

▶Median Excess Costs

▶Savings Based on Percent Reduction

– Range $329,640 - $849,756

Tiered Approach

1. Successful2. Involvement at all

levels of the organization

3. Sustainable results4. Assure continued

improvement

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The Team

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