Q: What illness:
- Affects half a million U.S. patients per year?
- Kills approximately 29,000 patients within 30 days of their initial diagnosis?
- Reoccurs in one of every five patients who were previously diagnosed?
A: Clostridium difficile (C. difficile).
C. difficile is a bacterial infection, and the most common cause of potentially deadly, antibiotic-associated diarrhea. New strains of the infection and recent antibiotic stewardship programs (ASPs) are making C. difficile a hot topic in the healthcare community today. But, what causes it and how can you prevent it? Let’s find out…
Are Antibiotics to Blame?
Patients who take antibiotics are seven to 10 times more likely to get C. difficile, both while on the drugs and during the month after. More than half of hospitalized patients will take an antibiotic during their hospital stay, with up to 50 percent being prescribed incorrectly. In one study, researchers found that for every 10 percent increase in ward-level antibiotic use, there was a 34 percent increase in C. difficile infections. Patients without symptoms can still shed the bacteria, which is particularly unsettling, as their spores can be passed on to other people.
New Strain Proves More Severe
Over the past decade, we have seen more aggressive and severe C. difficile infections with a higher mortality rate. These changes are largely related to the emergence of a new epidemic C. difficile strain (NAP1/207) that produces more toxins and is more resistant to a commonly used class of antibiotics known as fluoroquinolones.
The Cost Burden is Significant
A recent 2015 Premier study of patients with C. difficile treated at 477 U.S. acute care hospitals found that they had longer a length of stay (4.7 days), greater risk for readmission (77 percent chance) and total additional cost of $7,286 per case. In total, C. difficile is estimated to add nearly $5 billion in excess healthcare costs for acute care facilities alone.
C. Difficile Impacts Reimbursement
New 2020 national reduction targets have been established for C. difficile in the National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination. Since 2013, all hospitals participating in Medicare’s Hospital Inpatient Quality Reporting Program have been reporting C. difficile infection data to CDC’s NHSN. Starting in Oct. 2016 (FY 2017), CMS will be adding a C. difficile infection measure to its Value-Based Purchasing and HAC Reduction programs. The C. difficile measure that CMS is using is NHSN’s C. difficile lab testing data measure that is a proxy for infection burden and allows comparison across settings. The National Quality Forum recently endorsed the NHSN’s Antimicrobial Use measure, which will be essential for tracking and setting national benchmarks.
C. difficile infections occur across the continuum of care and in the community. CDC research found that two thirds of the nearly half a million U.S. cases a year are related to a recent inpatient stay in a healthcare facility. Patients with C. difficile in the community have noted a recent outpatient visit to a doctor or dentist. With a focus on population health, it will be important to prevent infection at all points of care delivery.
Improving Antibiotic Use is Critical
ASPs, dedicated to improving appropriate antibiotic use, are critical in healthcare settings. In March 2015, the White House released a comprehensive National Action Plan for Combating Antibiotic-Resistant Bacteria, which identified critical actions that need to be taken in order to combat the rise of antibiotic-resistant bacteria. This includes monitoring of antimicrobial use and healthcare adoption of ASPs. These programs reduce the risk of C. difficile, improve antibiotic resistance and even help clinicians improve the quality of care through increased infection cure rates and reduced treatment failures. The CDC recommends that all acute care hospitals implement ASPs and has published resources to support program efforts. Some of these initiatives appear to be working, as the CDC reported an eight percent decrease from 2011 to 2014 in hospital-onset cases of C. difficile in their most recent 2016 Healthcare Associated Infection Progress Report. In the United Kingdom, a national ASP was able to reduce hospitals C. difficile rates by more than 60 percent over a three-year period.
How to Prevent C. Difficile
The CDC has identified six key steps to prevent the transmission of C. difficile:
C. difficile produces spores that allow it to survive in the environment and are not inactivated by many disinfectants commonly used in hospitals. These spores can survive for up to five months in the environment. Patients both with and without C. difficile symptoms can shed spores and contaminate the environment, so knowledge and implementation of proper guidelines are key.
Treatment Options On the Horizon
C. difficile produces toxins that damage the lining of the colon and cause inflammation, severe diarrhea and sepsis, which can be fatal. Although caused by antibiotic use, a few antibiotics are still the preferred treatment for severe or recurrent C. difficile infections, such as Vancomycin. Because no antibiotic has been completely successful yet, recurrence rates remain so high that for one in five patients the infection comes back. There are a few promising drugs on the horizon, including ebselen, which is thought to potentially inactivate the C. difficile toxin. Patients not responding to initial treatments have seen success with a fecal transplant, which transfers a volunteer’s healthy colon bacteria to the patient. However, fecal transplants are difficult to regulate and are hard to make a standardized treatment.
Leadership: Setting the Tone for Prevention
Ultimately, senior leadership sets the tone in an organization. This includes both monitoring the problem and providing resources necessary to implement effective prevention measures. ASPs should be at the top of the list. Leaders that make C. difficile prevention an organizational goal have achieved the greatest success.