Case Study: Reducing C. Diff. at Alabama's Huntsville Hospital
Clostridium difficile has surpassed MRSA as the most common hospital-acquired infection in community hospitals, according to a study (pdf) by Duke University Medical Center researchers. Research has also indicated that C. diff infection can cost an average of $4,000 per patient and increase each patient's length of stay by 3.6 days on average (Jodlowski et al., 2006).
Huntsville (Ala.) Hospital had a number of poor C. diff practices that needed improvement; they included staff members taking stool cultures for a test of cures and therapy that would sometimes be cut short, resulting in readmissions and colectomies, according to Edward H. Eiland, III, PharmD, MBA, BCPS (AQ-ID), clinical practice and business supervisor in the hospital's department of pharmacy. To combat this infection more effectively, in Feb. 2010 Huntsville Hospital created a CDI Clinical Pathway, a set of evidence-based processes designed to reduce the chance of infection. The pathway was one element of an organization-wide effort to improve the hospital's C. diff practices and decrease HAIs from 3.29 percent down to 3.12 percent to rank in the top 10 percent of hospitals in infection control.
CDI Clinical Pathway
The pathway focuses on C. diff-associated diarrhea and involves six key elements: surveillance, education, antimicrobial stewardship, environmental cleaning, hand hygiene and contact isolation. These elements are implemented through the following four steps by the CDI Reduction Team, a multidisciplinary group that includes pharmacists, physicians, nurses, infection preventionists, microbiologists, environmental services staff and the antimicrobial management team.
1. Microbiology lab diagnostics. The first step in the pathway is diagnosing the patient using polymerase chain reaction. PCR is highly sensitive and can therefore detect C. diff early, which is associated with better outcomes. At Huntsville, the PCR results were timelier than previously utilized diagnostic methodology, which allowed for more prompt treatment initiation, according to Dr. Eiland. This early treatment initiation resulted in a decrease of severe cases of C. diff at the hospital over time.
However, the high sensitivity of PCR also meant that the overall incidence of C. diff at the hospital seemed to increase significantly. "It wasn't because we weren't doing the necessary steps or elements of the pathway, but because PCR is a better test and more sensitive," Dr. Eiland says. Thus, while the actual incidence of C. diff may not have increased, benchmarks against other hospitals suggested that Huntsville had higher infection rates. Huntsville is working with the Centers for Disease Control and Prevention and third party payors to ensure that the hospital is not financially penalized for its method of measuring the infection.
While PCR is effective in detecting C. diff, it should not be used as a test of cure per the most recent Infectious Diseases Society of America/Society for Healthcare Epidemiology of America C. diff guidelines, according to Dr. Eiland. A negative result following insufficient drug therapy does not provide useful clinical information, as the test is best suited to evaluating patient symptoms, he says. The hospital instituted a microbiology laboratory policy that prohibited PCR testing for 14 days after a positive result to ensure that only symptomatic patients were tested based on established guidelines.
2. Isolation procedures. The second step in the CDI Clinical Pathway is isolating the infection to prevent transference to healthcare professionals or other patients. A critical element in isolation is correct hand hygiene. The hospital educates providers to use soap and water as opposed to alcohol-based cleaners and to use certain kinds of bleach effective in killing C. diff when cleaning a room. Another tool the hospital uses to prevent transmission is a device that emits an ultraviolet light to kill C. diff spores in a room where an infected patient stayed, Dr. Eiland says.
3. Treatment recommendations. The CDI Clinical Pathway recommends treatment based on whether the case is an initial or recurrent infection and whether the case is mild or moderate, severe or severe complicated. For example, one of the recommendations for a recurrence of severe or severe complicated cases is delivering Fidaxomicin 200 mg orally twice a day for 10 days. Fidaxomicin is the first drug for C. diff approved by the FDA in the last 25 years, Dr. Eiland says. While it offers another treatment option for resistant bacteria, it is also expensive, costing approximately $2,800 for a 10-day course, according to Dr. Eiland. "We are left with the need to cost-justify why we use the new agent," he says. As the drug is so new, there is limited primary literature available for review. Thus, the hospital began an ongoing internal analysis to study its effectiveness by evaluating mortality and recurrence rates compared to alternate therapies.
4. Monitoring. The CDI Reduction Team follows several rules when monitoring C. diff patients. For instance, providers do not give infected patients antidiarrheal or antiperistaltic drugs and they monitor prothrombin time/international normalized ratio if the patient is on warfarin and metronidazole concurrently due to the potential of a severe drug-drug interaction. In addition, the hospital continues to measure CDI cases per 10,000 patient days and mortality from CDI as key metrics for internal and external benchmarking.
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