Stewardship / Resistance Scan for Nov 22, 2017

C diff and stewardship
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Clinical decision support
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EMR protocol and C diff rates

Hospital stewardship tied to some Clostridium difficile reductions

Implementing an antimicrobial stewardship program was associated with lower use of antimicrobials deemed high risk and some reduction in Clostridium difficile infection (CDI), according to a single-center study yesterday in the Journal of Antimicrobial Chemotherapy.

UK investigators sought to evaluate the effect of an antimicrobial stewardship intervention targeting high-risk antimicrobials (HRAs) that was implemented in October 2008 and to compare their findings with those from similar previously published studies. They analyzed data on all medical and surgical patients at Ninewells Hospital—a large teaching hospital in Dundee, Scotland—from October 2006 to September 2010.

Six months after the program was implemented, medical wards saw a 33% HRA reduction, while surgery patients were prescribed 32% fewer HRAs. After a year, CDIs dropped 24% among medical patients (reduction of 7 cases per 1,000 admissions), but there was no change in disease rate among surgery patients. The authors noted that HRA use was also reduced significantly in six comparable studies, but only two reported reductions in CDI rates.

The researchers conclude, "Despite large reductions in HRA prescribing and reductions in CDI, demonstrating real-world impact of stewardship interventions remains challenging."
Nov 21 J Antimicrob Chemother study

 

Study shows clinical decision support may help cut antibiotic use

California investigators demonstrated that clinical decision support (CDS) integrated in an electronic health record can discourage inappropriate antibiotic prescribing, but provider education is unlikely to have a sustained effect on antibiotic prescribing, according to their study published yesterday in the American Journal of Managed Care.

The researchers used a stepped-wedge cluster randomized design to evaluate antibiotic use for acute sinusitis (sinus infection) at 127 Kaiser Permanente South California clinics from September 2014 through April 2015.

Their analysis of 21,949 visits (10,491 before and 11,458 after CDS intervention) showed a 22% reduction in antibiotic use after CDS implementation, but the absolute drop in use—from 85.9% to 83.9%—was small. They also found that the effect varied by a statistically significant amount by clinic. Education of healthcare providers, the investigators found, led to a 49% reduction in antibiotic use initially, but the difference did not persist.

The authors conclude, "Provider education and CDS improved antibiotic stewardship and changed diagnosis patterns. The benefits of education were brief, and CDS effectiveness varied by medical center."
Nov 21 Am J Manag Care study

 

EMR protocol tied to lower incidence of C diff infections

Researchers who conducted a single-center study in St. Louis reported yesterday in the American Journal of Infection Control that implementation of an automated electronic health record (EMR) protocol for targeted testing of high-risk patients for C difficile led to reduced rates of hospital-onset CDI by improving the timing and appropriateness of testing.

The scientists included patients in the study who had two or more of the following CDI risk factors: (1) admission to a medical institution in the preceding 90 days, (2) administration of antibiotics in the preceding 90 days, or (3) a history of CDI. The protocol involves identifying in the EMR high-risk patients who have diarrhea in the first 3 days of admission and promptly testing them for C difficile. After day 3, if diarrhea develops, providers ask a series of questions to help identify the appropriate patients for C difficile diagnostic testing.

The researchers found that the standardized infection ratio for C difficile dropped from 1.276 before the protocol to 0.645 afterward, a 49% statistically significant decrease. They note thathospital leadership commitment and buy-in from nurses and physicians was essential for the success of the intervention.
Nov 21 Am J Infect Control study

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