1. Improvement of management and reduction in mortality following implementation of audit recommendations in Clostridium difficile diarrhoea at James Cook University Hospital
Dr Brett Doleman and Dr Richard Bellamy
Introduction
Results
Implementations
Clostridium difficile diarrhoea has an incidence of 18,005 cases annually in England and a 30 day mortality of 32.5% in one north of England NHS Trust1.
Risk factors include recent broad-spectrum antibiotics(clindamycin2, cephalosporins2 and fluroquinolones3), cytotoxics, proton pump inhibitors4, increasing age1, significant co-morbidity and surgery. Prevention involves limiting antibiotics5, soap hand-washing and probiotics6.
Management involves cessation of antibiotics, patient isolation, barrier nursing and metronidazole in mild-moderate disease or vancomycin for severe cases7. Complications like toxic megacolon may require surgery.
Audit results were presented to infectious diseases consultants at their weekly meeting and at the South Tees NHS Trust meeting. In addition, results were incorporated into new staff induction lectures which included junior medical staff.
The Trust C. difficile management algorithm was redesigned to make it more visually attractive. This was then displayed on every ward within the hospital.
A multidisciplinary team ward round was instigated to review all patients with a positive toxin test. This weekly ward round comprised an infectious diseases consultant, infection control nurses and a pharmacist. The role of the ward round was to ensure that various aspects of patient management were optimised.
Following the audit implementations, standards two and four improved to 100% from 86% and 84% respectively. In addition, standard one improved from 23% to 87% (Figure 1).
Despite this, no improvement was achieved in standard three, where compliance decreased from 46% to 39%.
However, in-patient mortality from C. difficile diarrhoea fell from 25% (April 2009-January 2011) to 15% (February 2011-July 2012) following the audit implementations (Figure 2). .
Aims and Standards
The aim of this audit was to assess compliance in the following standards based on Department of Health best practise8. 100% was the target compliance. Exclusions were end-of-life care and missing documentation for all standards and no antibiotics for standard four.
1) The disease severity should be documented
2) Antibiotics prescribed according to actual severity
3) All patients should have a daily Bristol Stool Chart completed to monitor disease progress
4) Predisposing antibiotics stopped if appropriate
Limitations
Only 26 of the 47 cases identified were available for the re-audit data collection. This may have introduced selection bias and confounded the audit findings.
Factors such as reduced ribotype 027 prevalence and increased staff awareness may have confounded the mortality figures.
Conclusion
This re-audit has demonstrated improved management and reduced mortality from C. difficile diarrhoea following the above implementations.
Methods
Audit approval was obtained from the Clinical Audit Department at James Cook University Hospital.
The Infection Control Doctor provided the details of all 38 in-patient cases between September-December Following audit implementations, 23 in-patient cases were reviewed between July-December 2011 to identify any improvements.
A pro-forma was created to collect data from case notes retrospectively. Mortality figures were provided by the Infection Control Doctor from official hospital figures.
References
1McGowern MP et al. Thirty-day mortality of Clostridium difficile infection in a UK NHS Foundation Trust between 2002 and Journal of Hospital Infection. 2011; 77(1):
2Thomas C et al. Antibiotics and hospital acquired C. difficile diarrhoea: a systematic review. Journal of Antimicrobial Chemotherapy. 2003; 51(6):
3Pepin J et al. Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec. Clinical Infectious Diseases. 2005; 41(9):
4Dial S et al. Use of gastric acid suppressive agents and the risk of community-acquired Clostridium difficile associated disease. Journal of the American Medical Association. 2005; 294:
5Valiquette L et al. Impact of a reduction in the use of high- risk antibiotics on the course of an epidemic of C. difficile associated disease caused by the hypervirulent NAP1/027 strain. Clinical Infectious Diseases. 2007; 45(2):
6Hickson M et al. Use of probiotic Lactobacillus preparation to prevent diarrhoea associated with antibiotics: randomised double blind placebo controlled trial. British Medical Journal. 2007; 335: 80.
7Zar FA et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clinical Infectious Diseases. 2007; 45:
8Clostridium difficile infection: How to deal with the problem Department of Health.