This toolkit describes an individualized approach and tailoring of selected stewardship interventions based on the results of limited case-control studies and identified issues at each facility. As you begin to identify antibiotics to target, you will also need to look at prescribing practices that will be targeted for change. You will need to plan the strategies you will use with prescribers to appropriately limit the targeted antibiotics in use. The strategy will depend on a combination of known evidence-based promising practices and what will work in your organization. To address these issues, you should consider four questions, discussed in the following sections.
2.1. What is the institutional risk assessment approach and how can it help us?
For many reasons, a targeted risk assessment offers a promising path for identifying antimicrobial stewardship interventions to reduce C. difficile. First, most ASPs have limited resources, time, and staff to have activities that affect all antimicrobial prescribing within their health care facility. Second, some traditional components of a stewardship program may have little impact on C. difficile rates. Third, while there may be less variability in practices for infection control and environmental cleaning so that bundled approaches have controlled outbreaks and prevented healthcare-associated infections, the same is unlikely to be true of antimicrobial prescribing. Finally, antibiotic type and use vary considerably at health care facilities throughout an area (formularies are large).
The institutional risk assessment approach offers a more sophisticated approach than a uniform bundle of interventions at each facility. The tools below provide a roadmap for performing an assessment and information for tallying antimicrobial use in your facility.
Resources and Tools
Ø 2B RESOURCE: A Comparison of Antibiotic Data Sources
Ø 2C RESOURCE: Possible Methods for Evaluating Antibiotic Use
2.2. How do we conduct a time-limited internal case-control study for C. difficile? What are some of the challenges?
To identify antibiotics most associated with C. difficile cases that may be targets of stewardship interventions, an internal, time-limited, focused retrospective case-control study can be performed. There is no single perfect way to perform the case-control study. The best methods may vary by facility based on number of C. difficile cases, resources, personnel, availability of medical records and antibiotic use data, time, and interest. However, in selecting your method, there are common factors to consider, including:
- Timeframe and number of cases of C. difficile.
- Choice of controls.
- Data selection and collection.
- Data analysis, including resources for calculating odds ratios and p values.
Resources and Tools
Ø 2E RESOURCE: Sample Tracking and Summary Forms for Case-Control Study (can be used to organize your case-control comparisons and summarize results and potential antibiotic targets)
2.3. What methods can we use to review the use of potential target antibiotics for intervention activities?
As shown in the Institutional Risk Assessment Roadmap in Resource 2A, multiple approaches can be taken to reviewing the use of potential target antibiotics. You will need to choose the approach that best fits your organization. For example, you can conduct a formal medication review for several weeks or longer of prescribing patterns of the targeted antibiotic. For many facilities, this timeframe is unrealistic; a review of only a few days of prescribing patterns (potentially on random days) may suffice to begin to strategize interventions.
Details to review will include but not be limited to: number of patients given prescriptions/length of therapy; most common prescribers; most common wards or patients receiving target; reason for target drug prescribing (e.g., empiric therapy, directed therapy, prophylactic regimen); most common syndromes and diagnoses treated by the target drug; and appropriateness and potential for prescribing changes (choice, length, other options).
Resources and Tools
2.4. What factors do we need to consider in choosing interventions?
The target antibiotic from the case-control study and the medication review will start to guide your intervention decisions. Other factors will also need to be considered, including stewardship staffing and skill set; ability to affect a large enough burden of prescribing, IT, and other external resources; acceptability of activities to prescribers, stewardship team, pharmacy, administration, and other key players at your facility; and previous and current stewardship activities (what has and has not worked in the past, what will complement current activities). Examples of intervention strategies from other hospitals may help you identify the interventions most likely to fit your organization.
Resources and Tools
2.5. How do we implement the intervention?
Once you determine what the interventions will be in terms of the factors described above, you need to develop strategies tailored to your organization for implementing the interventions. With leadership support, the C. difficile ASP team will need to guide, coordinate, and support the implementation efforts during the initial phases and as the ASP practices are rolled out across the hospital to intended populations and prescribers.
Because the interventions may involve changes in the way people work, you may have difficulty incorporating them into practice. Consider the following questions to determine the changes that will be needed:
- Whose help is needed to implement and sustain the interventions?
- Do we need to pilot test the new practices?
- How do we engage staff in an ASP to reduce C. difficile?
- How should we work with staff at the unit level? How can we help staff learn new practices?