ASHP Best Practices Award Mortar and Pestle
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Successes of a Clostridium difficile Infection Reduction Team

Ed Eiland, Pharm.D., M.B.A., BCPS-ID, Lyn Tipton, R.N., B.S.N., CIC, Kathi Hathcock, M(ASCP)SM, CIC, Cindy Mize, R.N., B.S.N., CIC, Bill Lindgren, MT (ASCP), Joycelyn Craighead, R.N., M.P.H., Linda Bonilla, R.N., Diane Pratt, R.N., M.S.N., David Crump, Vicky McClain, John Dunkel, M.D.


Huntsville Hospital System, Huntsville, Alabama

Clostridium diffficile infection (CDI) is the most common cause of infectious diarrhea, occurring in approximately 25% of hospitalized patients with antibiotic associated diarrhea. Mortality rates secondary to CDI are up to 30% in outbreak settings and lengths of stay are extended by 3.6 days increasing the overall hospitalization cost by $4000 per episode. Treatment options for CDI are limited so it remains paramount to stratify patient drug therapy based on the recently published Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America. A multidisciplinary team, the CDI Reduction Team, was created as part of our hospital’ Antimicrobial Stewardship Program. The team’s purpose was to implement strategies referred to as the “CDI Prevention Bundle” to reduce Clostridium difficile infection in the hospital and community.

The CDI Prevention Bundle was implemented due to three concerns: 1) initiative to decrease nosocomial infection rates from 3.29% to 3.12%; 2) inappropriate stool culture testing, and 3) inappropriate discontinuation of therapy prior to or at discharge leading to readmissions and colectomies. The bundle consists of surveillance, education, antimicrobial stewardship, environmental cleaning, hand hygiene, and contact isolation.

Metrics associated with CDI are reviewed monthly looking for improvement opportunities.  In 2005, comprehensive and consistent infection control initiatives including hand hygiene, contact isolation, and the use of soap and water cleaners rather than alcohol based cleaners were implemented.  Compliance with these measures is tracked by secret shoppers.  In August 2009, polymerase chain reaction (PCR) diagnostic technology was adopted to assess for NAP1strain. PCR technology is fast and highly specific and sensitive, yet more expensive per test compared to the antigen assay. However, repeat testing is less likely with PCR than with the antigen test, therefore cost is comparable. PCR more accurately and promptly identifies CDI allowing for more timely and accurate initiation of antimicrobial therapy. In April 2010, the CDI Clinical Pathway was approved and is used to guide diagnostics, isolation procedures, treatment recommendations, and monitoring parameters. CDI has been reduced to 4.1 cases per 10,000 patient days, an all time low since 2004, and the mortality rate has been cut in half from 2009 to fiscal year 2010.

The recently published Clostridium difficile guidelines have helped to justify, support, and guide the continued efforts of the CDI Reduction Team. Additionally, the acceptance and resultant success of the CDI Clinical Pathway has resulted in a positive impact on clinical outcomes and mortality for patients diagnosed with infectious diarrhea in our hospital.


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Kuijper EJ, Coignard B, Tull P. Emergence of Clostridium difficle-associated disease in North America and Europe. Clin Microbiol Infect.2006; 12(Suppl 6):2-18.

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Jodlowski TZ, Oehler R, Kam LW et al. Emerging therapies in the treatment of Clostridium difficile-associated disease. Ann Pharmacothe.r 2006; 40:2164-9.

Bartlett JG. Clinical practice. Antibiotic-associated diarrhea. N Engl J Med. 2002; 346:334-49.

Aichinger E, Schleck CD, Harmsen WS et al. Nonutility of repeat laboratory testing for detection of Clostridium difficile by use of PCR or enzyme immunoassay. J Clin Microbiol. 2008; 46:3795-7.

View a pdf of the poster from the Midyear Meeting (816 KB).