Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship
Clostridium difficile infection (C. difficile) is a serious public health problem that has recently increased in both incidence and severity. Centers for Disease Control and Prevention (CDC) surveillance data show that U.S. hospital discharges with C. difficile doubled between 2000 and 20031 and rates are highest in the northeastern United States.2 Persons over age 65 years have been most affected, but recent changes in epidemiology suggest that lower risk populations, including healthy postpartum women and community dwellers with no recent health care contact or antimicrobial exposures, may also be affected.3
Further, there are indications of recent increases in the severity of C. difficile, including increased complications and C. difficile-related mortality. In addition to advanced age, the major risk factors for C. difficile are exposure to antimicrobials and hospitalization. Studies have found major costs associated with C. difficile, such as longer inpatient lengths of stay, and a significant increase in costs both for inpatient care and at 180 days after the initial hospitalization when the C. difficile occurred.4
Taking steps to reduce C. difficile is a major health and public health imperative. Twenty-seven States and the District of Columbia now require reporting of healthcare-associated infections to the National Healthcare Safety Network (NHSN).5 Moreover, CDC's NHSN created a reporting module for C. difficile as part of its Patient Safety Component to encourage infection surveillance or laboratory-identified event reporting across hospitals nationwide.6
What is antimicrobial stewardship and how can it help us in reducing C. difficile?
Significant progress has been made in working to control C. difficile through targeted strategies such as infection prevention measures and environmental cleaning using a hypochlorite-based solution.7 However, particularly as new resistant C. difficile strains emerge, the problem persists and additional strategies are needed. Antimicrobial stewardship targeted to C. difficile reduction shows promise as a complementary strategy for addressing the problem of C. difficile, because inappropriate antibiotic use may contribute to increased rates of C. difficile.
An antimicrobial stewardship program (ASP) is a systematic approach to developing coordinated interventions to reduce overuse and inappropriate selection of antibiotics, and to achieve optimal outcomes for patients in cost-efficient ways. Through both monitoring and, when necessary, altering current antimicrobial prescribing practices, antimicrobial stewardship has been shown to improve patient care, reduce antimicrobial use, reduce antimicrobial resistance, and reduce pharmacy and overall hospital operating costs.8
How can this toolkit help us?
The aim of this toolkit is to assist hospital staff and leadership in developing an effective ASP with the potential to reduce C. difficile. It responds to the challenge facilities face as they translate guidelines into practice, in this case the implementation of an ASP. The toolkit:
- Is designed as a companion to the Antimicrobial Stewardship Program toolkit developed by the Greater New York Hospital Association (GNYHA) and the United Hospital Fund (UHF) for the New York State Department of Health, which supports the basic development and implementation of antimicrobial stewardship. The New York toolkit follows the Roadmap to Stewardship shown in Figure 1. This new toolkit assumes that your hospital already has components that make up the foundation for an ASP from which to launch the ASP targeted to C. difficile reduction.
- Is designed to help hospitals consider the organizational changes and resources needed to create and sustain an effective ASP for reducing C. difficile. The toolkit covers the full planning and implementation process from deciding to make changes to monitoring sustainability. While all the steps outlined here are important, some sections may be more relevant than others, depending on whether your hospital has an ASP framework on which to build and how you tailor your strategies and implementation to your needs, structures, and culture.
How do we use the toolkit?
This toolkit is organized by four major questions and multiple supporting questions that will guide you through the full process of developing, implementing, and sustaining an ASP for C. difficile. The four questions are:
Each question has a link to more detailed discussion of the issues to be considered and to tools and resources that will support the stewardship initiative. Links to tools and other resources are highlighted by a symbol: Ø.
How was the toolkit developed?
This toolkit was developed under a contract from the Agency for Healthcare Research and Quality (AHRQ) through its Accelerating Change and Transformation in Organizations and Networks (ACTION) initiative. Boston University School of Public Health collaborated with Montefiore Medical Center and GNYHA together with UHF to implement and evaluate ASP interventions to reduce C. difficile. The team worked with a collaborative of 10 New York hospitals that included 6 intervention sites and 4 nonintervention sites.
Despite the inability to demonstrate an association with reduced C. difficile rates in the time available, this project had many measured and unmeasured benefits. Among them, the project provided for growth and development of ASP infrastructures at each intervention site, measurable decreases in prescribing of target antibiotics at intervention facilities, and potential reduction of C. difficile with future ASP activities or with longer timeframes. The toolkit incorporates lessons learned from the experiences of the intervention hospitals, including facilitators of and barriers to building successful stewardship to reduce the use of antibiotics associated with high rates of C. difficile.