C. difficile action plan at Denver Health Medical Center

Issue: August 2017

ByAmelia Nelson, PharmD

Clostridium difficile infection, or CDI, is frequently a preventable health care-acquired infection that is associated with high morbidity, mortality and cost. It is estimated to affect more than 500,000 patients annually in the United States, and one in five patients will have a recurrent infection. The CDC have deemed C. difficile an urgent threat requiring increased monitoring and prevention efforts, including antimicrobial stewardship.

Denver Health Medical Center is a level I trauma center and safety-net teaching hospital. The rate of CDI at Denver Health fluctuates. To keep the CDI rate consistently low, an action plan was developed by the infection prevention committee and includes the environmental services department (EVS) and antimicrobial stewardship program. The action plan includes the following interventions, which have been implemented in a stepwise fashion over the past 18 months: environmental cleaning, probiotics, prospective audit and review of CDI cases, and fecal transplant.

Environmental cleaning

C. difficile spores are easily spread from person to person, especially in health care settings. Because C. difficile spores can withstand standard decontamination measures, comprehensive environmental service programs are warranted to reduce risk of transmission. At Denver Health, the infection prevention committee works closely with EVS. Several environmental cleaning interventions were included in the action plan. The standard cleaning product was changed to Perisept (Triple S), a sporicidal disinfectant with efficacy against C. difficile spores. In 2016, Denver Health purchased two additional UV light-emitting machines to disinfect rooms previously occupied by patients with CDI. The proportion of previously infected inpatient rooms cleaned by UV light disinfection per month increased from 43% to 84%. Additionally, by having more UV light machines, EVS is now able to disinfect emergency department rooms previously occupied by patients with CDI in addition to inpatient rooms. The EVS manager and infection preventionists use adenosine triphosphate (ATP) monitoring on surfaces of patient rooms to determine the level of matter that remains on surfaces after cleaning. The goal of this action plan item is to increase the number of rooms that have ATP monitoring performed and the number of rooms that pass the ATP test.

Probiotic for CDI prevention

One of the main risk factors for CDI is the use of systemic, broad-spectrum antibiotics. The CDC estimates that patients are seven to 10 times more likely to develop CDI during and in the 3 months following antibiotic therapy. Introduction of systemic, broad-spectrum antibiotics alters normal gut flora allowing for C. difficile to flourish without competition of other microbes. Co-administration of probiotics restores normal flora and may reduce the risk for CDI. A meta-analysis by Johnston and colleagues reviewed 20 randomized control trials evaluating probiotic use for prevention of CDI. This meta-analysis showed probiotics reduced CDI by 66% (RR = 0.34; 95% CI, 0.24-0.49). A multiphase prospective cohort study by Maziade and colleagues demonstrated the efficacy of Bio-K+ probiotic (Bio-K+ International Inc.) in addition to standard prevention methods. The Bio-K+ addition significantly reduced CDI compared with standard preventive methods alone (1.5% vs 5.8%; P < .001). After a review of the literature, the antimicrobial stewardship team at Denver Health instituted a probiotic protocol with Bio-K+ for patients who are at high risk for developing CDI. Bio-K+ probiotic contains three strains of Lactobacillus — L. acidophilus CL1285, L. casei LBC8OR and L. rhamnosus CLR2. Adults who are admitted to the hospital and receive at least 24 hours of broad-spectrum antibiotics will be considered for daily Bio-K+ for the duration of and 5 days after completing the antibiotic course. Providers are encouraged to order Bio-K+ via an electronic best practice alert at the time they sign the order for a high-risk antibiotic. Certain immunocompromised patients are excluded from the protocol. This intervention went live in March. The effectiveness of this intervention will be evaluated over the next year.

Prospective review of CDI cases

In August 2016, a prospective review of CDI cases with real-time provider feedback intervention was initiated. The infectious diseases pharmacist runs a report twice weekly that captures all patients who tested positive for CDI over the previous week. Patients are reviewed to ensure that they are receiving optimal treatment for their CDI. The patient is also reviewed to ensure that any offending antibiotics or unnecessary gastric acid suppressants are discontinued. When opportunities to optimize patient care arise, the ID pharmacist relays those recommendations to the provider.

Fecal microbiota transplantation at Denver Health

Due to the increasing incidence of recurrent CDI across the U.S., Denver Health has developed a fecal microbiota transplant (FMT) program, which was implemented in 2017. FMT is the introduction of donated human fecal samples to the gastrointestinal tract of a patient through colonoscopy, endoscopy, nasogastric tube, enema or fecal capsules. FMT is becoming a widely accepted and safe treatment option for patients with recurrent CDI, and has a reported CDI cure rate of up to 90%. Historically, Denver Health has been limited in our ability to perform FMT due to practical challenges of identifying and screening appropriate donors, as well as processing approved specimens. To overcome these challenges, Denver Health signed a contract with OpenBiome, a nonprofit organization that provides frozen, prescreened fecal microbiota preparations to more than 500 hospitals across the U.S. and Europe. Adult patients with a second recurrence of CDI who are not immunocompromised, pregnant, or receiving antibiotics for an infection other than CDI, will be eligible for FMT at Denver Health.

Conclusion

CDI continues to affect thousands of patients annually. Hospitals should consider a multifaceted approach to driving down CDI rates. Denver Health has a comprehensive action plan, and the effectiveness of these interventions will be assessed over the coming year.

References:
CDC. Clostridium difficile Infection (CDI) Prevention Primer. https://www.cdc.gov/hai/pdfs/toolkits/cdi-primer-2-2016.pdf. Accessed July 25, 2017.
Drekonja D, et al. Ann Intern Med. 2015;doi:10.7326/M14-2693.
Johnston BC, et al. Ann Intern Med. 2012;157:878-888.
Lee CH, et al. JAMA. 2016;doi:10.1001/jama.2015.18098.
Leffler DA, Lamont JT. N Engl J Med. 2015;doi:10.1056/NEJMra1403772.
Lessa FC, et al. N Engl J Med. 2015;doi:10.1056/NEJMoa1408913.
Maziade PJ, et al. Clin Infect Dis. 2015;doi:10.1093/cid/civ178.
OpenBiome. The Problem: Safe access to FMT. http://www.openbiome.org/safe-access. Accessed on July 25, 2017.
Van Nood E, et al. N Engl J Med. 2015;doi:10.1056/NEJMoa1205037.
Youngster I, et al. Clin Infect Dis. 2014;doi:10.1093/cid/ciu135.
Youngster I, et al. JAMA. 2014;doi:10.1001/jama.2014.13875.

For more information:
Amelia Nelson, PharmD, is a PGY1 pharmacy resident at Denver Health Medical Center.
Katherine Shihadeh, PharmD, is a clinical pharmacy specialist in infectious diseases at Denver Health Medical Center. Shihadeh can be reached at katherine.shihadeh@dhha.org.

Disclosures: Nelson and Shihadeh report no relevant financial disclosures.