Multiple Interventions are Necessary to Decrease C Difficile Infections

Background: Beginning in 11/04, there was a significant increase in the rates of hospital acquired C. difficile infections at the VA Boston HCS. 

Objective: This review presents the interdisciplinary model & interventions used to control and decrease the incidence of C. difficile infections.

Methods:  An interdisciplinary team, comprised of Administration, Nursing, Infection Prevention, Pharmacy, and Environmental Services, partnered to assess the scope of the problem,  design and implement appropriate strategies for infection rate reduction. 

Disease Management	Enhanced Infection Prevention Efforts	Environmental Management
Implemented bundled approach to management (early diagnosis, more aggressive use of oral vancomycin and discontinuation of systemic antibiotics)	Enhanced surveillance Strict hand hygiene	Enhanced cleaning & disinfection of patient units & environment
	Improved availability HH products, PPE	Use of bleach product for environmental cleaning between patients
Antibiotic stewardship including aggressive restriction of  respiratory fluoroquinolones  2005	Implementation of “Special Contact Precautions”-gowns and gloves for all room entry, handwashing on exit & empiric precautions Private rooms-no cohorting 1/2010	Ongoing review of cleaning/disinfection procedures
2/2010 Better diagnostic testing  (PCR-fewer false positives), testing loose stools only,  q7D, 18% tests positive with PCR vs 10% with EIA, 60% decrease # monthly tests, facilated removal of patients from precautions.	Multiple educational offerings (disease epidemiology & transmission, antibiotic management and overuse,  environmental cleaning and RME)
Developed progress note & order  set to facilitate bundled approach	Improved intra/inter departmental communication of patient infectious status
Isolates sent to CDC-40% isolates BI strain	Enhanced cleaning/disinfection of RME & purchase of additional patient commodes & non-re-usable equipment

Results:

Rates for Acute Care Division/1000 BDOC
	CDI	Cipro DOT	Gati  DOT	Levo  DOT	Moxi  DOT	Tot Q DOT	RFQ DOT
FY2004	2.330803	11.07666	148.872	13.15086	0.085534	173.1851	162.1084
FY2005	3.771778	19.97645	114.4705	14.26889	2.314953	151.0308	131.0543
FY2006	3.256566	49.87016	13.19654	6.364139	0.872675	70.30352	20.43336
FY2007	2.39988	45.49058	0	1.821338	1.842765	49.15469	3.664103
FY2008	2.305338	63.47629	0	2.961167	1.391152	67.82861	4.352319
FY2009	1.639903	64.8933	0	2.278826	1.639903	68.81203	3.918729
FY2010	1.051333	65.74877	0	2.284628	2.163321	70.19672	4.447949

Conclusions: Appropriate interventions have affected a 50% decrease over 4 yrs in the rate of HA C difficile, with sustained rates near the published benchmark of 1.0/1000 BDOC.  DOT for quinolone(Q) use decreased 50% from 2005-2010 with a dramatic decrease in respiratory FQ use. Rates continued to decrease despite implementation of PCR testing.