1. Reducing the Risk of Clostridium difficile Infection:
Rethinking C. diff Testing at UCM
Background
Changes Made
Important cause of infectious disease death in the US
~500,000 C. difficile infections (CDI) in U.S. in 2011
Rivals MRSA for most common organism to cause HAIs in U.S.
Rates are increasing nationwide
Discharge diagnosis of CDI doubled between
50% episodes have onset in community
Outcomes
CDI increases length of stay days
Cost per episode $3,000 - $15,000
U.S. hospital costs estimated at $1-5 billion per year
Attributable mortality: 5-10% (14,000-20,000 deaths/year)
Education provided to all newly admitted patients on the importance of C. diff prevention
Patients who refused screening were placed on Contact Plus isolation for presumed C. diff
Patients screened were not placed on isolation unless result was positive
Nurse-driven protocol allowed nurses to order screen without waiting for a physician’s order
New C. diff screening test code helped identify patients easier for tracking purposes
Microbiology notified Infection Control of (+) results to isolate accordingly
Epic list shared with ASP to notify physicians of result, assess whether colonization or infection, assist with proper management of C. diff if applicable, recommend modifications in concomitant antibiotic or use of proton-pump inhibitors (PPI) when applicable, and recommend consideration of probiotics in non-immune suppressed patients
Clinical & laboratory data was collected to answer the following questions: 1.) Is it possible to clearly differentiate between colonization (asymptomatic) versus infection (symptomatic)? 2.) Should testing of patient who has been on a laxative in the 48 hours preceding testing be restricted?
Aims
To decrease the hospital-onset, hospital-acquired (HO-HA) CDI from to 7.12 HO-HA CDI / 10,000 patient days
Identify colonized, asymptomatic carriers with C. difficile
Isolate patients to prevent transmission of CDI
Prevent colonized patients from developing CDI themselves with the help of the Anti-microbial Stewardship (ASP)
Investigate alternative method of testing symptomatic patients for CDI via EIA (i.e. to determine if PCR testing method is overly sensitive)
Outcomes & Lessons Learned
From August 30, 2015 to Feb. 29, 2016, 2105 / 2481 (84.8%) of patients admitted or transferred to pilot units were screened.
50 patients (2.4%) were positive
9 screen-negative patients went on to develop C. diff. (0.4%)
376 (15.1%) patients not screened because refused versus other cause
Of the 50 patients that screened positive, ASP review resulted in 20 interventions
13 (65%) interventions recommending discontinuation of a PPI, 3 (16%) discontinuation or modification of concomitant antibiotics, 4 (21%) initiation of probiotic therapy, 1 (5%) recommending initiation of CDI treatment.
Over the first 6 months, HOHA CDI rate decreased by 60% compared to the prior 6 months:
15.5 cases/10,000 patient days  6.14 cases/10,000 patient days
Of symptomatic patients who had positive clinical specimens for C. diff by PCR, 258 were tested using C.DIFF QUIK CHEK COMPLETE® test by Alere (EIA).
26 of EIA Ag+/tox- or Ag- cases were reviewed. Of these, 20 (77%) had clinical symptoms consistent with C. diff and would have been false negatives based on the EIA. This suggests that change of testing methodology for symptomatic patients could lead to missed cases.
Project Design/Strategy
CCD units with highest CDI rates were chosen.
Screening occurred on 9West (In-patient surgical ward) & 10West (Oncology)
As part of admission process, RNs educated patient about CDI (brochure provided), screened for prior history and current symptoms, obtained perirectal swab for C. diff, or initiated isolation if patient refused swab.
Compliance monitored daily and unit notified if a patient was missed in an attempt to test during first 48 hours.
Flowchart (right) implemented to guide nursing staff with screening process
Samples from patient with clinical specimens were tested for toxin using C.DIFF QUIK CHEK COMPLETE® test by Alere (EIA).
C. diff Patient Education Brochure
Acknowledgements
Next Steps
A special thanks to our 9W /10W Nurses and physicians for volunteering to pilot this program, the EPIC Team for computer support, and Clinitka Harper for following up on patients who would otherwise have been missed.
To expand the C. diff screening on admission process to other units and eventually house-wide.
Authors: Cynthia Murillo (M (ASCP), CIC), Rachel Marrs (MSN, RN CIC), Sylvia Garcia-Houchins (RN, MBA CIC), Anabel Bedoya (MSN, RN, NE-BC), Pamela McCall (BSN, OCN, NE-BC), Natasha Pettit (PharmD, BCPS), Zhe Han (PharmD), Jennifer Pisano (MD), Lindsay Petty (MD), Colleen Nash (MD, MPH), Emily Landon (MD), Kathleen G. Beavis (MD), Allison Bartlett (MD) , Jessica Ridgway (MD, MS )