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Ø 2H RESOURCE: Specific Intervention Examples From ERASE C. difficile Project

Tools and Resources

Purpose: Overview of implemented antimicrobial stewardship by ERASE C. difficile participants. Describes examples of antimicrobial stewardship interventions implemented by six participating facilities in ERASE C. difficile Project, including details of activities, timeframes, locations, and stewardship staffing or activities.

Source: Adapted from ERASE C. difficile Project by H. Jalon, United Hospital Fund, and B. Ostrowsky, Montefiore Medical Center.

Facility DescriptionInterventionsStart DateLocationNotes/Comments
481-bed teaching hospitalSpecific programming of antibiotic stewardship computer software to identify patients with longer antibiotic lengths (>14 days)Approximately 1 yearHospitalwide
  • Overall issue with staffing (no infectious disease fellows).
  • For IV to oral, computer prompt done at 3-day mark for fluoroquinolones.
  • Antibiotic policy change catalyzed by patient experience; very new official policy, but education started September 2011.
  • Had intended to target piperacillin/tazobactam, including de-escalation; more opportunities with ciprofloxacin.
  • Ciprofloxacin policy verbalized in September-November 2011 and officially implemented in December 2011.
Clinical computer prompts IV to oral switch (asks for indication)July 2011Hospitalwide
Antibiotic change policy away from ciprofloxacin for urinary tract infectionsSeptember-November 2011ER(ED), then hospitalwide
December 2011-January 2012
863-bed teaching hospitalPiperacillin/tazobactam restrictionAugust 2010Hospitalwide
  • Overall limited resources (pharmacist part time); activities sporadic some months.
  • Piperacillin/tazobactam restriction (mainly by infectious disease fellows) saved money; push toward cefepime/ceftriaxone; main outcome number of courses.
  • Background—auditing, de-escalation, days of therapy/defined daily dose.
Audit and feedbackOngoing
(predates ERASE C. difficile Project)		Hospitalwide
709-bed teaching hospital, with two sites (each similar size): Activities at Site 1Piperacillin/tazobactam restriction (many years old)Ongoing
(predates ERASE C. difficile Project)		Hospitalwide
  • ASP and infection control activities ongoing prior to ERASE C. difficile Project; resulted in significant decrease in C. difficile rates.
  • Overall staffing problems (PharmD for both hospital sites, used pharmacy residents).
  • Audit/feedback (pharmacy residents with PharmD—both campuses): educational component in ICU to reduce cefepime use, infectious disease guidance, days of therapy/defined daily dose (infectious disease attending with ICU, primarily at one site). Reemphasized beginning July 2011.
Audit and feedback (de-escalation; emphasis on cefepime)Ongoing
July-September 2011		Hospitalwide
Ongoing
October 2011-present
709-bed teaching hospital, with two sites (each similar size): Activities at Site 2Piperacillin/tazobactam restriction (many years old)Ongoing
(predates ERASE C. difficile Project)		Hospitalwide
Audit and feedback (de-escalation; emphasis on cefepime)Ongoing
July-September 2011		Hospitalwide
Ongoing
October 2011-present
Algorithms/education targeting efepime use specifically in ICUJanuary 2011MICU (7EM Medical)
1,038-bed teaching hospital, with two sites: Activities at Site 1, approximately 700 bedsAzithromycin restrictionApril-May 2011Hospitalwide
  • More interventions overall done at one of the two sites.
  • Azithromycin first restricted, then unrestricted to move patients away from moxifloxacin; formal medication utilization review for fluoroquinolones (ciprofloxacin and moxifloxacin).
  • Followup �medication utilization review showed increase in azithromycin and decrease in moxifloxacin (by 25%) at both campuses.
  • Piperacillin/tazobactam audit mainly on medicine services (teaching and nonteaching services).
  • Education in conjunction with interventions (series of educational programs to different clinical �services showing C. difficile rates, data, and teaching about de-escalation).
  • More sensible antibiotic choices, especially for sepsis.
Piperacillin/tazobactam audit and feedback
Educational component		Pilot (with infectious disease fellow):
February-April 2011

Increased activity (restructuring with clinical pharmacists):
May-October 2011		Medicine (Teaching and PA)
Klau and NW
Sepsis antibiotic protocolsMay 2011ER(ED); reflected in hospitalwide prescribing
1,038-bed teaching hospital, with two sites: Activities at Site 2, approximately 300-400 bedsAzithromycin restrictionApril-May 2011Hospitalwide
Piperacillin/tazobactam audit and feedback
Educational component		Pilot (with infectious disease fellow):
February-April 2011

Increased activity (restructuring with clinical pharmacists):
May-October 2011		Medicine (Teaching and PA)
Instructions: Use as a reference.
Return to Question 2
Current as of September 2012
Internet Citation: Ø 2H RESOURCE: Specific Intervention Examples From ERASE C. difficile Project: Tools and Resources. September 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/cdifftoolkit/cdiffl2tools2h.html