A Tiered Approach to Reduce Hospital Onset C. difficile

1. 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

6. HO Clostridium difficile (CDI)CMS 10th SOW Goal is 10% reduction

7. HO Clostridium difficile (CDI)New York State DOH

8. HO Clostridium difficile (CDI)10th SOW BIMC

9. Tiered Approach Hand hygiene Contact precautions Sign placement PPE readily available and used Dedicated rectal thermometers

10. Tiered Approach Patient placement Commodes Environmental cleaning protocols Chlorhexidine bathing

11. Tiered Approach Antibiotic stewardship Pharmaceutical stewardship

12. 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

13. Begins with Those on the Front Line

14. Begins with Those on the Front LineOwnership

15. Begins with Those on the Front LineOwnership

16. Begins with Those on the Front LineOwnership - Nursing University of Nebraska bathing three days per week followed by daily bathing followed by four-month washout period returning to standard soap-and-water bathing Infect Control Hosp Epidemiol 2012;33:1094 - 1100

17. Begins with Those on the Front LineOwnership - Nursing 30% reduction in HO CDI with three days per week protocol 59% reduction with daily bathing Infect Control Hosp Epidemiol 2012;33:1094 - 1100

18. CDI Survey

19. Antibiotic Stewardship • Community acquired pneumonia • moxifloxacinvsceftriaxone-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.

20. Antibiotic Stewardship

21. 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 Clinical Infectious Diseases Sept 1, 2012  Volume 55   page 615

22. 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 Clinical Infectious Diseases Sept 1, 2012  Volume 55   page 615

23. Antibiotic Stewardship Clinical Infectious Diseases Sept 1, 2012  Volume 55   page 615

24. 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

25. Proton Pump Inhibitors

26. HO CDI

27. HO Clostridium difficile (CDI)10th SOW BIMC

28. 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

29. Tiered Approach Successful Involvement at all levels of the organization Sustainable results Assure continued improvement

30. The Team