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Preventing Clostridium difficile From Getting Loose

Clostridium difficile infection (CDI) due to antimicrobial therapy accounts for 20% to 30% of cases of antibiotic-associated diarrhea.1 C. diff is also one of the most common organisms that causes hospital-acquired infections: from 2000 to 2009, the rate of CDI more than doubled and although that rate has leveled, it remains high. The burden of CDI comes with an attributable mortality of 5% to 10%, an increase in hospital stay from 2.8 to 5 days, and a yearly management cost in the United States of $1 billion to $4.9 billion.1,2
For surveillance purposes, CDI can be broken down into standardized definitions to allow for monitoring for a potential outbreak and ensure patient safety that include community-associated, community-onset healthcare facility–associated CDI, and healthcare facility–onset and –associated. Several methods are available to diagnose CDI either alone or in combination, usually by detecting the presence of C. diff toxins in a patient with diarrhea.2 Because of the low sensitivity and/or specificity of rapid toxin detection tests, however, such as an enzyme immunoassay (EIA) for toxin A and B, a two-step approach can be utilized using EIA detection of glutamate dehydrogenase with confirmation of positive results by cell cytotoxicity assay, cell culture, or polymerase chain reaction (PCR).3 Alternatively, findings from a colonoscopy or histopathology that demonstrate pseudomembranous colitis with the presence of symptoms, usually diarrhea, can help diagnose CDI.2
There are several risk factors for CDI: age, duration of hospitalization, and antimicrobial exposure (the most modifiable risk factor). Antibiotics modify the normal bowel flora and allow the C. diff to flourish. During hospitalization, the risk for developing CDI is related to specific classes of antibiotics, such as fluoroquinolones, beta-lactam/beta-lactamase inhibitors, and cephalosporins; the number of different antimicrobials prescribed; and the duration of treatment.4 When appropriate, using the minimum number of antibiotics with the narrowest spectrum of activity for the shortest treatment duration may help reduce the rate of CDI. Antibiotic stewardship programs, in collaboration with infection control practices, have been shown to reduce incidence of CDI in hospitals. Different mechanisms can be utilized as part of the stewardship program, and these may include antimicrobial de-escalation based on culture and antibiotic susceptibility, formulary restrictions/prior approval for selected antimicrobials, standard guidelines for treatment and prophylaxis, and development of an antibiogram to guide empiric therapy.
The results of several studies have demonstrated the benefit of appropriate antibiotic utilization on the incidence of CDI as well.5-8 For instance, Valiquette and colleagues implemented guidelines for antibiotic use that incorporated recommendations for antibiotics and shortening antibiotic durations in a tertiary care center in Quebec. As a result, the incidence of CDI decreased by 60% between 2003-2004 and 2005-2006; total and antibiotic consumptions fell as well.6 Likewise, Muto and colleagues used a team-based approach toward appropriate antibiotic utilization, combining targeted antimicrobial restriction, education, and expanded infection control measures at the University of Pittsburgh Medical Center. The team observed a decrease in antibiotic-associated CDI of 41%, with the overall rate decreasing to 3/1000 discharges from 7.2/1000 discharges.5

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