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A Tiered Approach to Reduce Hospital Onset C. difficile
Brian Koll, MD, FACP, FIDSA
Medical Director and Chief
Infection Prevention and Control, BIMC
Professor of Medicine, AECOM
HO Clostridium difficile (CDI)CMS 10th SOW
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National SOW NYS SOW
HO CDI Rate Jul - Dec 2012
Jan - Jun 2013
Goal is 10% reduction6
HO Clostridium difficile (CDI)New York State DOH
7.67.77.87.9
88.18.28.38.48.58.6
2010 2011 2012 2013
HO CDI Rate
7
HO Clostridium difficile (CDI)10th SOW BIMC
0
2
4
6
8
10
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18
BI Petire BI Brooklyn
HO CDI Rate
Jul - Dec 2012
8
Tiered Approach
1. Hand hygiene2. Contact precautions3. Sign placement4. PPE readily available
and used5. Dedicated rectal
thermometers
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Tiered Approach
6. Patient placement7. Commodes8. Environmental
cleaning protocols9. Chlorhexidine bathing
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Tiered Approach
10. Antibiotic stewardship11. Pharmaceutical
stewardship
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Begins with Leadership
•Accountability
•Link infection prevention with organizational strategy and resources
•Link a culture of safety to outcomes
•Engage and facilitate teamwork
•Goal setting and measuring and assessing effectiveness
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Begins with Those on the Front Line
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Begins with Those on the Front LineOwnership
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Begins with Those on the Front LineOwnership
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Begins with Those on the Front LineOwnership - Nursing
University of Nebraska
1.bathing three days per weekfollowed by
2.daily bathing
followed by
3.four-month washout period returning to standard soap-and-water bathing
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Infect Control Hosp Epidemiol 2012;33:1094 - 1100
Begins with Those on the Front LineOwnership - Nursing
30% reduction in HO CDI with three days per week protocol
59% reduction with daily bathing
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Infect Control Hosp Epidemiol 2012;33:1094 - 1100
CDI Survey
Antimicrobial Resistance: Scope of the Problem and Key Contributors
Disagree Neither Agree
1. Antibiotic resistance is a problem in this institution.
5% 17% 78%
2. Patient rooms are cleaned according to hospital cleaning protocol once a C. difficile patient has been discharged.
4% 15% 81%
3. Adherence to hand hygiene protocols is excellent at this institution.
26% 20% 54%
4. Adherence to isolation and contact precautions is excellent at this institution.
34% 16% 50%
5. This institution does NOT do enough to control the development of C. difficile. 44% 30% 26%
6. This institution provides adequate staff education regarding C. difficile. 12% 36% 52%
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Antibiotic Stewardship
• Community acquired pneumonia• moxifloxacin vs ceftriaxone-based therapy
• colonization and infection with multidrug-resistant organisms higher in moxifloxacin group
• restriction policies to diminish moxifloxacin use
Goldstein RC, Lalite S, Mildvan D, Perlman DC, Jodlowski T,Ruhe J. IDSA Poster Presentation 205. Boston, October 2011.
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Antibiotic Stewardship
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10
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25
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35
40
Feb Mar
Number of
Orders
Moxifloxicin Use
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Begins with Those on the Front LineOwnership - Physicians
•San Francisco General
•Jun 2005 – Dec 2010
•historical cohort study
•development of CDI within 30 days of ceftriaxone therapy
•3,730 patients
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Clinical Infectious DiseasesSept 1, 2012 Volume 55 page 615
Begins with Those on the Front LineOwnership - Physicians
•Multivariate analysis• doxycycline associated with
protection against development of CDI
• 27% lower rate•Hazard ratios ctx + doxy
• vs ctx + azith = 0.15• vs ctx + fluoroquinolone = 0.13
• Stongest predictor of CDI• length of stay
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Clinical Infectious DiseasesSept 1, 2012 Volume 55 page 615
Antibiotic Stewardship
0
20
40
60
80
100
120
Nov Dec Jan Feb Mar
Number of Orders CTX + AZITH
CTX + DOXY
Clinical Infectious DiseasesSept 1, 2012 Volume 55 page 615 23
Proton Pump Inhibitors• elderly• underlying medical conditions• broad spectrum antibiotics• PPI
• 28 observational studies• strength of association ranged from 1.4 to 2.8x higher
• Indications• erosive gastritis• symptomatic GERD• NSAID gastric ulcer risk reduction• H. pylori eradication
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Proton Pump Inhibitors
25
0
500
1000
1500
2000
2500
3000
Dec Jan Feb Mar
Number of Units
Nexium
HO CDI
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HO Clostridium difficile (CDI)10th SOW BIMC
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2
4
6
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12
14
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BI Petire BI Brooklyn
HO CDI RateJul - Dec 2012
Jan - Jun 2013
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Value Analysis
On the CUSP Calculator
▶CDI Cases
▶Increased Length of Stay
▶Mortality
▶Median Excess Costs
▶Savings Based on Percent Reduction
– Range $329,640 - $849,756
Tiered Approach
1. Successful2. Involvement at all
levels of the organization
3. Sustainable results4. Assure continued
improvement
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The Team
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