1. Multidisciplinary Partnerships to Reduce Clostridium difficile Infection: A Success Story
Laura Johnson, MD Hospital Epidemiologist, Infectious Diseases Henry Ford Health System Rachel Chambers, PharmD Pharmacy Specialist, Antimicrobial Stewardship Henry Ford Hospital

2. Objectives
The burden and severity of Clostridium difficile infection (CDI) has dramatically increased in recent years
Multidisciplinary collaboration is key to minimizing CDI in the health care setting
This presentation will provide an overview of the key players and multidisciplinary interventions necessary to successfully manage and reduce CDI

3. Clostridium difficile Infection (CDI)
Bacterial infection of colon resulting in spectrum of disease from mild diarrhea to severe colitis with sepsis, toxic megacolon, and even death.
Spores persist in healthcare environment and are transmitted by fecal-oral route.
Hands and Environment
Antibiotic exposure kills off normal protective gut flora and C. difficile can grow and produce toxins, resulting in disease.

4. Deaths per million population
Yearly Clostridium difficile–related Mortality by Listing on Death Certificates, United States, 1999–2004.
Deaths per million population
Redelings MD, et al. Emerg Infect Dis. 2007;13:

5. Increased and Severe CDI at HFH
2007/8: Patients noted to have severe CDI, some requiring colectomy
1988 to 2007: 8 colectomies
March to May 2008: 7 colectomies
Surveillance of CDI Initiated

6. Investigation of Problem
Infection Prevention started surveillance program
Deep dive into severe CDI cases
Collaboration of Infection Prevention, Pharmacy, Clinical Quality and Safety Office, and Care Providers

7. Guidelines for C. difficile Prevention and Control

8. CDC Prevention Strategies: Core
Contact Precautions for duration of diarrhea
Hand hygiene in compliance with CDC/WHO
Cleaning and disinfection of equipment and environment
Laboratory-based alert system for immediate notification of positive test results
Educate about CDI: HCP, housekeeping, administration, patients, families
Dubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92.

9. CDC Prevention Strategies: Supplemental
Extend use of Contact Precautions beyond duration of diarrhea
Presumptive isolation for symptomatic patients pending confirmation of CDI
Evaluate and optimize testing for CDI
Implement soap and water for hand hygiene before exiting room of a patient with CDI
Implement universal glove use on units with high CDI rates
Use sodium hypochlorite (bleach) – containing agents for environmental cleaning
Implement an antimicrobial stewardship program

10. Implementing CDC Guidelines Requires a “SWOT” Team
Clear guidelines to prevent and control C. difficile
The challenge
Implementation
Sustainability
C. difficile Task Force created
To identify and address our “strengths, weakness, opportunities and threats”
To reach multiple disciplines in hospital and facilitate buy-in
To change practice and culture related to prevention and control practices

11. C. difficile Task Force Infection prevention practitioners
Providers: infectious disease, medicine, surgery, intensive care, gastroenterology
Nursing (general practice, intensive care, front line and educators)
Pharmacy
Laboratory
Environmental services
Facilities/plant operations
Office of clinical quality and safety
Reporting to hospital leaders

12. Examples of Collaboration
Infection Prevention and Environmental Services
Weekly rounds (with “bug meter”)
Developed enhanced bleach cleaning protocols
Laboratory and Infection Prevention
Improved turn around time for lab result
Developed process for daily notification of results
Enhanced lab testing with better sensitivity and specificity
Infection Prevention and ICU Nursing Team
Developed protocol for RN-Initiated testing for CDI
“Caboodles” for supplies to decrease contamination of supplies in room
Eventually, protocol for “fecal transplant” for treatment of difficult cases
Transportation and Nursing
Identified need to keep chart clean during transport – cover chart in plastic bag during transportation

13. Examples of Collaboration
Inter-Nursing Collaboration
Sticker on chart in addition to door sign for improved communication
Facilities, Nursing, Infection Prevention
Identified areas with limited sinks and installed sinks on multiple floors
Installed wall caddies for easy access to PPE
Stickers on Alcohol Hand Rub canisters
Admissions Office, Nursing, Infection Prevention
Extended Precautions till discharge
Cohorting patients during room shortages
Surgeons and Infectious Disease Team
Implemented trial of probiotic yogurt in ICU
Infectious Disease Fellows and Pharmacy
Reviewed management of CDI cases daily with interventions as necessary
Enhancement of Antimicrobial Stewardship Program – A major collaboration with pharmacy colleagues…

14. The Case for Antimicrobial Stewardship
As much as 50% of antibiotic use is inappropriate
Inappropriate antibiotic use associated with poor patient outcomes, resistance development, increased health-care costs
Declining antibiotic pipeline in recent years
New Antibiotic Approvals
Modified from Spellberg B et al. Clin Infect Dis; 2008;46:155-64
By a show of hands, who in this room has a formal antimicrobial stewardship team at your practice site?
Dellitt TH et al. Clin Infect Dis 2007;44:

15. Dellitt TH et al. Clin Infect Dis 2007;44:159-77.

16. Highlights of the Stewardship Guidelines
Multidisciplinary collaboration: stewardship team, infection control, Pharmacy &Therapeutics
Support from hospital leadership and medical staff
Appropriate compensation (ideally through offices of quality/patient safety)
Administrative support to track outcomes
2 core strategies:
Prospective audit with intervention & feedback
Formulary restriction with preauthorization
Dellitt TH et al. Clin Infect Dis 2007;44:

17. Antimicrobial Stewardship Strategies
Component
IDSA/ SHEA Guideline Strength of Evidence
Implemented at
Henry Ford Hospital
Formulary restriction with audit and feedback AI 
Education
AIII, BII
Guidelines, pathways
AI, AIII
Antimicrobial cycling
CII No
Antimicrobial order form
BII
Combination therapy
Not routine
De-escalation
AII
Dose optimization
IV to PO Conversion
Dellitt TH et al. Clin Infect Dis 2007;44:

18. Henry Ford Hospital (HFH) Antimicrobial Stewardship Program (ASP)
What is it?
A comprehensive system of health-care providers, pathways, guidelines, order sets, and informatics designed to optimize antimicrobial utilization
Mission statement
To improve patient outcomes through optimization of antimicrobial therapy and support the education of health-care providers in appropriate antimicrobial use

19. 7 Strategies for a Successful Stewardship Program Cooke FJ, et al
7 Strategies for a Successful Stewardship Program Cooke FJ, et al. Clinical Governance 2004
Key Element
Local Action at HFH
Quality and safety coordination of multidisciplinary CDI task force
Pharmacy and antimicrobial subcommittee ownership for antimicrobial stewardship
Recommendations implemented by antimicrobial subcommittee of Pharmacy & Therapeutics
Integration into Pre-Existing Structures
Strong Leadership
Dedicated Individuals Responsible for Antibiotic Use
Harnessing Existing Resources to Deliver Change
Fiona Cooke, introduce 7 strategies.
Several recommendations were produced by the C. difficile task force, antimicrobial subcommittee, P&T, and hospital medical executive committee pertaining to good antimicrobial stewardship: 1. Implement restrictive criteria for antibiotics found to be implicated with inappropriate prescribing; 2. Revised C difficile management pathway; 3. Implemented an antimicrobial order form and encouraged use of stop dates/ minimization of antibiotic duration
Obtaining Local Data on Prescribing and Resistance
Communication
Education and Training

20. 7 Strategies for a Successful Stewardship Program Cooke FJ, et al
7 Strategies for a Successful Stewardship Program Cooke FJ, et al. Clinical Governance 2004
Key Element
Local Action at HFH
Integration into Pre-Existing Structures
Quality and Safety coordination
Strong multidisciplinary involvement with Chief of Infectious Disease and Gastroenterology directly involved
Support from Director of Pharmacy Services, Chief Medical Officer, Hospital Administration
Strong Leadership
Dedicated Individuals Responsible for Antibiotic Use
Harnessing Existing Resources to Deliver Change
Leadership willing to invest financial resources to improve the system
Obtaining Local Data on Prescribing and Resistance
Communication
Education and Training

21. 7 Strategies for a Successful Stewardship Program Cooke FJ, et al
7 Strategies for a Successful Stewardship Program Cooke FJ, et al. Clinical Governance 2004
Key Element
Local Action at HFH
Integration into Pre-Existing Structures
Strong Leadership
Dedicated Individuals Responsible for Antibiotic Use
Antimicrobial Subcommittee
Stewardship pharmacist
Stewardship rounds with Chief of Infectious Diseases
Infectious Diseases pharmacy residency program added
Harnessing Existing Resources to Deliver Change
Talk about implementation of multidisciplinary rounds with ID staff
Obtaining Local Data on Prescribing and Resistance
Communication
Education and Training

22. 7 Strategies for a Successful Stewardship Program Cooke FJ, et al
7 Strategies for a Successful Stewardship Program Cooke FJ, et al. Clinical Governance 2004
Key Element
Local Action at HFH
Integration into Pre-Existing Structures
Strong Leadership
Dedicated Individuals Responsible for Antibiotic Use
Placing a higher priority on the “stewardship agenda” within existing clinical pharmacy and infectious diseases practice model
Pharmacy resident project dedicated to validation of CDI management algorithm
Infectious diseases fellows performed daily review of C. difficile infected patients
Harnessing Existing Resources to Deliver Change
Obtaining Local Data on Prescribing and Resistance
Communication
Education and Training

23. 7 Strategies for a Successful Stewardship Program Cooke FJ, et al
7 Strategies for a Successful Stewardship Program Cooke FJ, et al. Clinical Governance 2004
Key Element
Local Action at HFH
Integration into Pre-Existing Structures
Strong Leadership
Dedicated Individuals Responsible for Antibiotic Use
Harnessing Existing Resources to Deliver Change
Deep dive into C. difficile cases to identify “problem” antibiotics
Stewardship program efficiency improved with implementation of Theradoc® decision support software
Another capital investment came in the form of an investment in Theradoc, a computerized decision support software system
Obtaining Local Data on Prescribing and Resistance
Communication
Education and Training

24. 7 Strategies for a Successful Stewardship Program Cooke FJ, et al
7 Strategies for a Successful Stewardship Program Cooke FJ, et al. Clinical Governance 2004
Key Element
Local Action at HFH
Integration into Pre-Existing Structures
Strong Leadership
Multidisciplinary task force members responsible for disseminating change to their department/ discipline
Presentations at grand rounds and departmental meetings
Policies and guidelines communicated in hard copy and on Intranet
National presentations and posters to describe the work (e.g. C. difficile management algorithm presented at ICAAC 2009)
Dedicated Individuals Responsible for Antibiotic Use
Harnessing Existing Resources to Deliver Change
Obtaining Local Data on Prescribing and Resistance
Communication
Education and Training

25. Antimicrobial Stewardship Website: Guidelines and Education

26. C. difficile Management Pathway
Adapted from: Drugs 2007; 67(4): and Infection Cont Hosp Epidemiol 2010; 31:

27. Compliance with institutional pathway was associated with improved outcome
Interventions in the pathway:
Specific dose/route of therapy recommended
Expanded therapy for SEVERE infection
Emphasized discontinuation of unnecessary broad spectrum antimicrobials
Treatment success was defined as clinical resolution of CDI by day 14 or end of treatment (EOT) and the absence of complications or relapse
Richardson C et al, abstract 423, IDSA 2009, Philadelphia, PA

28. 7 Strategies for a Successful Stewardship Program Cooke FJ, et al
7 Strategies for a Successful Stewardship Program Cooke FJ, et al. Clinical Governance 2004
Key Element
Local Action at HFH
Integration into Pre-Existing Structures
Priorities are set by antimicrobial subcommittee, identification of key messages for educational initiatives
Continuous improvement sought:
Larger role for ID pharmacist and stewardship pharmacist
More multidisciplinary education, ensure training is at an appropriate level for each group
Increase involvement of ID fellows, hospital epidemiology, microbiology
Strong Leadership
Dedicated Individuals Responsible for Antibiotic Use
Harnessing Existing Resources to Deliver Change
Impact of education is transient. Needs to continuously be reinforced.
Obtaining Local Data on Prescribing and Resistance
Communication
Education and Training

29. Follow Through and Accountability
Guidelines are well established and often many eager participants – but challenge is to move process forward
Consistent data/messages to hospital leadership
Problem identified as a priority to leaders
Capital and resources
Structure to support accountability
Office of Clinical Quality and Safety
Leaders and executive committees maintain accountability

30. Task Force Results

31. Summary
Implementing improvement projects with sustained results requires:
Thorough investigation of problem/issue
Communication to key leaders and front line staff
Multidisciplinary team approach
Process to hold key players accountable with support from hospital leaders