A Centers for Disease Control report on Clostridium difficile infections offers encouragement for hospitalists that prevention is possible, but also offers further evidence that more work is needed to prevent the potentially deadly infections.
The report examines three sets of data on C. diff infections. According to an analysis of the CDC’s Emerging Infections Program, 94% of the more than 10,000 infections identified were related to the receipt of healthcare. Also, 75% of the infections had their onset in patients who were not hospitalized at the time.
An analysis of National Healthcare Safety Network data of present-at-admission and hospital-onset C. diff infections found that 52% of the cases involved patients already infected at admission, although they were largely healthcare-related.
—Ketino Kobaidze, MD, PhD, assistant professor, Emory University School of Medicine, Atlanta
And an analysis of data from three state-administered CDI-prevention projects in Illinois, Massachusetts, and New York found that, cumulatively, C. diff infections were reduced by 20%, showing that prevention efforts can pay off.
The heavy involvement of healthcare settings in infections shows that more should be done, says Clifford McDonald, MD, chief of prevention and response in CDC’s Division of Healthcare Quality and Promotion in Atlanta. He took aim specifically at careful use of antibiotics, as broad-spectrum antibiotics kill off bacteria that can help keep C. diff at bay.
“Certainly in the area of antibiotic stewardship, hospitals can do a lot more,” he told The Hospitalist. “A lot of the most potent antibiotics are being prescribed in the hospital. … If they’re necessary, that’s the way it is. It’s necessary and people are put at increased risk because they had to get those antibiotics. But if they weren’t necessary, it’s all the more critical that greater judiciousness be applied to the use of those antibiotics.”
Since many of the cases had their onset outside the hospital, hospitals must emphasize quick evaluation of admitted patients, including asking them an uncomfortable question: “Have you had diarrhea recently?” Three unformed stools in the previous 24 hours, along with antibiotic use in the previous 12 weeks—particularly the previous four to eight weeks—means a C. diff infection is a distinct possibility.
“We don’t think to ask, and patients may not bring it up because they are embarrassed by it,” Dr. McDonald says. Patients suspected of having C. diff infections must be isolated right away, he adds. (Click here to listen to more of Dr. McDonald's interview.)
The success in lowering the infection rate within the three state initiatives is encouraging, Dr. McDonald says, particularly because almost the entire emphasis in those programs was infection control; only the Massachusetts program included antibiotic stewardship, and only as a minor component.
“It does appear that prevention’s possible,” he notes. “Even more can be done if more tools are brought to bear and brought to bear across settings.”
Ketino Kobaidze, MD, PhD, assistant professor at the Emory University School of Medicine in Atlanta and a member of the antimicrobial stewardship and infectious-disease-control committees at Emory’s Hospital Midtown, says that while hospitalists have long been aware of C. diff infections in community settings, she was surprised to learn that 75% of cases were found in patients not currently in the hospital.
“This information will make all hospital-based doctors be more alert when a patient comes with diarrhea—and include CDI in their differential,” she says. “We need to change our approach and make appropriate recommendations on how to screen and prevent further spread.
“What this data tells us is that we need to educate our doctors to prescribe antibiotics more carefully; ask patients about diarrhea even if they are coming in for another disease; and order diagnostic tests if [they report it].”
He also says that while it’s widely accepted that antibiotics are overprescribed, the use of antibiotics in agriculture─in the poultry and cattle industries, for example─is an area that should be explored.
“One of the things to think about is the amount of antibiotics that are used for non- healthcare reasons,” he says, “and that also is a very large contributor to the problem.”
Thomas R. Collins is a freelance medical writer in South Florida.