Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship
Antimicrobial stewardship for reducing C. difficile offers a potentially promising path for facilities invested in and committed to the effort. Developing and implementing a successful ASP will involve structural, process, and cultural changes in your organization. To effect the changes needed in clinical practice, organizations require multiple adjustments in roles, responsibilities, workflow, decisionmaking, and communication.
Failure to assess your organization's readiness for the change at multiple levels can lead to unanticipated implementation challenges. Bringing about organizational change of any type is difficult. You will not want to move ahead until you are confident of your organization's readiness. Even then, it will be important to balance the need to proceed thoughtfully with the need to move quickly enough to show progress and maintain momentum.
1.1. Do we have the appropriate ASP foundation on which to build?
This toolkit assumes that your hospital already has an ASP or the foundation for an ASP from which to launch the ASP targeted to promote appropriate antibiotic use and potential C. difficile reduction. Implementing and maintaining an effective ASP requires a dedicated multidisciplinary team and ongoing communication and collaboration as well as ongoing monitoring of systems. Further, ongoing monitoring may necessitate course corrections.
Team membership will vary among organizations, but the core team should include an infectious disease physician, PharmD, clinical microbiologist, infection control representative, hospital epidemiologist, information technology (IT) representative, and senior administrator. Ideally, the team should be supported by an in-house lab and IT resources.
Before going further, you should review your facility's current ASP or, if necessary, take steps to develop a basic ASP from which to target C. difficile reduction. To develop an ASP, you can use the GNYHA ASP toolkit. Also remember that antimicrobial stewardship is intended to complement other antibiotic prescribing practices and efforts to promote C. difficile prevention in your organization. You may also want to review the other prevention measures you have in place.
- Is there an active ASP in place? Who are its members and how does it operate?
- What other C. difficile prevention measures do you have in place?
Resources and Tools
Ø 1A RESOURCE: SHEA/IDSA/PIDS Policy Statement. Policy Statement on Antimicrobial Stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS)
Ø 1B RESOURCE: GNYHA/UHFAntimicrobial Stewardship Toolkit
Ø 1D RESOURCE: Examples of State and Local Stewardship Programs
Ø 1E TOOL: Assessment of Current ASP Elements
1.2. What do we need to do before we begin to use our ASP to target C. difficile?
Even if you have a strong stewardship foundation in place, you will need to assess your facility's stage of readiness for targeting an ASP to C. difficile reduction. Developing an ASP to work toward reducing C. difficile will require a coordinated systems approach with readiness to change on many levels.
To stimulate your thinking in making the case for ASP for C. difficile reduction and considering your path forward, consider the following reasons to move forward with further developing ASPs. These were cited by facilities with newly established ASPs.
Reasons To Develop ASPs for C. difficile Reduction
- Desire to decrease C. difficile.
- Desire to optimize antibiotic use, including decreased use of specific/targeted antibiotics and shortened length of antibiotic courses.
- Desire to strengthen interdisciplinary cooperation and relationships.
- Desire to increase back-end strategies and streamline audit and feedback.
- Desire to find best practices for stewardship.
- Desire to advocate for more resources to conduct stewardship activities.
- Desire to further develop existing program or refine current program.
- Desire to understand the differential effect or impact of stewardship versus infection control and environmental cleaning.
You will need to begin this process by addressing six questions about both readiness and support from various components of your organization. You will need to cycle back to the last five questions throughout your change process. Reviewing these questions will reinforce communication with colleagues and stakeholders and strengthen answers about the clinical case, business case, and resources needed as you gather data and experience.
- Do multiple disciplines understand why a structured ASP is needed? Is there an urgency to change?
- Do senior leaders and other key stakeholders support and provide guidance to planning and implementing an ASP?
- Do key stakeholders in multiple disciplines understand why a structured ASP is needed?
- Is there a clinical and business case for creating an ASP for reducing C. difficile? Do leadership and prescribers understand and support it?
- What kinds of resources are needed to develop an effective ASP?
- What barriers might we face and how might we deal with them?
Resources and Tools
Ø 1G TOOL: Assessing Leadership Support
Ø 1H TOOL: Stakeholder Analysis
Ø 1K TOOL: Developing Business Case
Ø 1L TOOL: Assessing Resource Needs
Ø 1M TOOL: Potential Barriers to Implementing an ASP