Evaluating the Effectiveness of an Antimicrobial Stewardship Program on Reducing the Incidence Rate of Healthcare-Associated Clostridium difficile Infection: A Non-Randomized, Stepped Wedge, Single-Site, Observational Study

Abstract

BackgroundThe incidence rate of healthcare-associated Clostridium difficile infection (HA-CDI) is estimated at 1 in 100 patients. Antibiotic exposure is the most consistently reported risk factor for HA-CDI. Strategies to reduce the risk of HA-CDI have focused on reducing antibiotic utilization. Prospective audit and feedback is a commonly used antimicrobial stewardship intervention (ASi). The impact of this ASi on risk of HA-CDI is equivocal. This study examines the effectiveness of a prospective audit and feedback ASi on reducing the risk of HA-CDI.MethodsSingle-site, 339 bed community-hospital in Barrie, Ontario, Canada. Primary outcome is HA-CDI incidence rate. Daily prospective and audit ASi is the exposure variable. ASi implemented across 6 wards in a non-randomized, stepped wedge design. Criteria for ASi; any intravenous antibiotic use for ≥ 48 hrs, any oral fluoroquinolone or oral second generation cephalosporin use for ≥ 48 hrs, or any antimicrobial use for ≥ 5 days. HA-CDI cases and model covariates were aggregated by ward, year and month starting September 2008 and ending February 2016. Multi-level mixed effect negative binomial regression analysis was used to model the primary outcome, with intercept and slope coefficients for ward-level random effects estimated. Other covariates tested for inclusion in the final model were derived from previously published risk factors. Deviance residuals were used to assess the model’s goodness-of-fit.FindingsThe dataset included 486 observation periods, of which 350 were control periods and 136 were intervention periods. After accounting for all other model covariates, the estimated overall ASi incidence rate ratio (IRR) was 0.48 (95% 0.30, 0.79). The ASi effect was independent of antimicrobial utilization. The ASi did not seem to reduce the risk of Clostridium difficile infection on the surgery wards (IRR 0.87, 95% CI 0.45, 1.69) compared to the medicine wards (IRR 0.42, 95% CI 0.28, 0.63). The ward-level burden of Clostridium difficile as measured by the ward’s previous month’s total CDI cases (CDI Lag) and the ward’s current month’s community-associated CDI cases (CA-CDI) was significantly associated with an increased risk of HA-CDI, with the estimated CDI Lag IRR of 1.21 (95% 1.15, 1.28) and the estimated CA-CDI IRR of 1.10 (95% CI 1.01, 1.20). The ward-level random intercept and slope coefficients were not significant. The final model demonstrated good fit.ConclusionsIn this study, a daily prospective audit and feedback ASi resulted in a significant reduction in the risk of HA-CDI on the medicine wards, however, this effect was independent of an overall reduction in antibiotic utilization. In addition, the ward-level burden of Clostridium difficile was shown to significantly increase the risk of HA-CDI, reinforcing the importance of the environment as a source of HA-CDI.

Clostridium difficile infection in hospitalized patients with inflammatory bowel disease

“…[ 2 ] Its clinical manifestations range from asymptomatic carriage to severe forms of fulminant colitis and death. [ 3 , 4 ] There has been a dramatic worldwide increase in the incidence and severity of CDI over the past 2 decades, [ 1 ] despite the prevention programs implemented in many countries. [ 2 – 4 ]…”

Antibiotic Resistance Trends Among Ocular Pathogens in the US—Cumulative Results from the Antibiotic Resistance Monitoring in Ocular Microorganisms (ARMOR) Surveillance Study

“…Indeed, in terms of systemic infections, increased education regarding judicious antibiotic use by limiting overprescription of antibiotics, cycling between antibiotic classes, and using combination therapies has led to a decrease in antibiotic resistance in systemic infections. [19][20][21][22] The ARMOR study is the only nationwide evaluation of antibacterial susceptibility of common ocular pathogens in the US, and now includes almost 1,000 additional isolates beyond those included in the 2015 evaluation. 18 Although trends over the past 7 years show a small but significant decrease in S. aureus resistance to some antibiotic classes, and confirmed the previous finding of a decrease in resistance among CoNS to ciprofloxacin, some increases in resistance were also noted.…”

Clostridioides difficile Enteritis in Patients Following Total Colectomy—a Rare but Genuine Clinical Entity

“…The discrepancy between the prior prevalence estimate and ours (5.1%) may be driven by Tsiouris et al study period being concentrated during the CDI epidemic driven by the BI/NAP/027 strain, whereas our study included cases before and after the outbreak. Another possible explanation for the differences in prevalence could be an increasing emphasis on antibiotic stewardship during the later years of our study, which has been shown to decrease the risk of CDI [30]. Finally, C. dificile testing in postcolectomy patients was likely low during the earliest years of our study period due to decreased recognition of CDE as a clinical entity.…”