Strategy to prevent hospital-onset C diff shows mixed results

Clostridioides difficile

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A strategy designed by the Centers for Disease Control and Prevention (CDC) to prevent one of the leading causes of healthcare-associated infections in US hospitals was not associated with reduced incidence over time, researchers reported today in JAMA Network Open.

In a study conducted in hospitals in the southeastern United States, researchers from Duke University and the CDC found that although hospitals that implemented the strategy saw a reduced incidence of hospital-onset Clostridioides difficile infection (HO-CDI) compared with a control group of hospitals, incidence was already declining at those hospitals before the intervention and didn't change significantly during the intervention.

But the study also found that the COVID-19 pandemic may have affected the results by preventing full implementation of measures included in the strategy.

No association with declining incidence over time

Introduced in 2018, the CDC's Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities Framework includes 39 discrete interventions organized into five focal areas: (1) isolation and contact precautions, (2) CDI confirmation, (3) environmental cleaning, (4) infrastructure development, and (5) antimicrobial stewardship engagement.

The aim of the Framework, as it's known, was to codify evidence-based HO-CDI prevention strategies in acute care hospitals, which currently see an estimated 8.3 cases per 10,000 patient-days. CDI causes severe diarrhea and inflammation of the colon.

"Hospitals need feasible and effective HO-CDI prevention strategies, especially as CDI-related health care costs, morbidity, and mortality remain substantial: in the US, CDI was responsible for over $1 billion in health care costs and nearly 13,000 deaths in 2017 alone," the study authors wrote.

To evaluate the Framework's effectiveness, the researchers invited hospitals within the Duke Infection Control Outreach Network to participate in an implementation study if their HO-CDI incidence rate was above the network's median prior to the study. Infection preventionists from each participating hospital supported implementation by taking part in an in-person launch event and joining monthly teleconference calls. Implementation occurred from July 2019 through March 2022.

The researchers then compared HO-CDI incidence at the 20 hospitals that implemented the Framework with the incidence at 26 control hospitals within the network. In a secondary analysis, they compared trends within the 20 participating hospitals before and after Framework implementation.

Hospitals need feasible and effective HO-CDI prevention strategies, especially as CDI-related health care costs, morbidity, and mortality remain substantial: in the US, CDI was responsible for over $1 billion in health care costs and nearly 13,000 deaths in 2017 alone.

At the outset of the study, the median HO-CDI incidence rate at the intervention hospitals was 2.8 cases per 10,000 patient-days, compared with 1.1 at the control hospitals. In the first analysis, the researchers observed a steeper decline in HO-CDI incidence among intervention hospitals relative to controls (yearly incidence rate ratio [IRR], 0.79; 95% confidence interval [CI], 0.67 to 0.94), but the decline was nonsignificant over time.

In the second analysis, the researchers saw a significant decline in HO-CDI incidence at the 20 intervention hospitals in the two years before Framework implementation (yearly IRR, 0.76; 95% CI. 0.68 to 0.85) but did not observe a significant change in incidence temporally associated with study onset (IRR, 0.98; 95% CI, 0.77 to 1.24).

The impact of COVID-19

Upon further analysis, however, the researchers noticed that rates of Framework implementation fell significantly after the COVID-19 pandemic began in March 2020, as infection prevention personnel were redirected to assist with the COVID-19 response. That likely reduce the impact of the intervention, the researchers suggest.

When they accounted for differences in Framework measure adoption, they found that the degree to which hospitals implemented the Framework was associated with steeper declines in HO-CDI incidence (yearly IRR, 0.95; 95% CI, 0.90 to 0.99).

"Using the incidence rate changes from the second analysis of intervention effects before vs after the pandemic, lost intervention opportunities could have accounted for an additional 40% relative reduction in HO-CDI incidence by study close," the authors wrote.

Analysis of individual interventions showed that case reviews to identify areas for improvement, conversion to two-step testing, and stewardship interventions designed to target antibiotics with a high risk of CDI were associated with estimated trends toward lower HO-CDI incidence over time.

The authors say an intervention score based on the Framework could be "a valuable tool for bridging the current gap between HO-CDI prevention recommendations and real-world practice."

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