2. 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

7. HO Clostridium difficile (CDI) CMS 10th SOW Goal is 10% reduction 6

8. HO Clostridium difficile (CDI) New York State DOH 7

9. HO Clostridium difficile (CDI) 10 th SOW BIMC 8

10. Tiered Approach 1. Hand hygiene 2. Contact precautions 3. Sign placement 4. PPE readily available and used 5. Dedicated rectal thermometers 9

11. Tiered Approach 6. Patient placement 7. Commodes 8. Environmental cleaning protocols 9. Chlorhexidine bathing 10

12. Tiered Approach 10. Antibiotic stewardship 11. Pharmaceutical stewardship 11

13. 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 12

14. Begins with Those on the Front Line 13

15. Begins with Those on the Front Line Ownership 14

16. Begins with Those on the Front Line Ownership 15

17. Begins with Those on the Front Line Ownership - Nursing University of Nebraska 1. bathing three days per week followed by 2. daily bathing followed by 3. four-month washout period returning to standard soap-and-water bathing 16 Infect Control Hosp Epidemiol 2012;33:1094 - 1100

18. Begins with Those on the Front Line Ownership - Nursing 30% reduction in HO CDI with three days per week protocol 59% reduction with daily bathing 17 Infect Control Hosp Epidemiol 2012;33:1094 - 1100

19. 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% 18

20. 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. 19

21. Antibiotic Stewardship 20

22. Begins with Those on the Front Line Ownership - Physicians San Francisco General Jun 2005 – Dec 2010 historical cohort study development of CDI within 30 days of ceftriaxone therapy 3,730 patients 21 Clinical Infectious Diseases Sept 1, 2012 Volume 55 page 615

23. Begins with Those on the Front Line Ownership - 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 22 Clinical Infectious Diseases Sept 1, 2012 Volume 55 page 615

24. Antibiotic Stewardship Clinical Infectious Diseases Sept 1, 2012 Volume 55 page 615 23

25. 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 24

26. Proton Pump Inhibitors 25

27. HO CDI 26

28. HO Clostridium difficile (CDI) 10 th SOW BIMC 27

29. 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

30. Tiered Approach 1. Successful 2. Involvement at all levels of the organization 3. Sustainable results 4. Assure continued improvement 29

31. The Team 30