Antibiotic Stewardship and Infection Control in Patients at High Risk of Developing Infection by Clostridium Difficile, Vancomycin-Resistant Enterococci or Multi-Resistant Gram-Negatives (ABSOLUTE)

Throughout project, the investigators design, evaluate and disseminate infection control and antibiotic stewardship (ABS) measures aimed at reducing the incidence of Clostridium difficile infection (CDI). The measures will focus on known departments with high incidence of CDI, i.e. a) hematology/oncology, b) other departments/wards demonstrating above-average infection rates, which were identified throughout previous studies. The infection control package will include staff training, hand hygiene programs and disinfection measures. Throughout the ABS package, investigators will develop and implement ABS measures specifically designed for patients at the highest risk of developing hospital-acquired infections, i.e. those treated on hematological/oncological wards. Potentially useful ABS actions even in critically ill patients are early reduction of exposure based on microbiological results, timely cessation of anti-infective treatment, thoughtful implementation of screening measures and biomarkers, defined approaches to patients known to be allergic to penicillins, and vigorous enforcement of clinical and microbiological diagnosis of infection focus.

The IC and ABS measures aim at educating and assisting clinical personnel in realizing treatments according to official guidelines. There will not be a direct contact between study personnel and patient. There will be no direct recruitment of patients.

Study Overview

• Status: Completed
• Conditions: Clostridium Difficile Infection; Nosocomial Infection; VRE Infection; MRGN Bacteria
• Intervention / Treatment: Other: Infection Control; Other: Antibiotic Stewardship

Detailed Description

In recent years, a distinct group of healthcare-associated pathogens (HPs) has become highly prevalent among hospital inpatients worldwide. Clostridium difficile, vancomycin-resistant enterococci (VRE), and multi-resistant gram-negative bacteria (MRGN) today are an immediate threat to hospitalized patients in Western countries, given inferior outcomes and prolonged treatment associated with such infections.

There are two key clinical strategies to prevent transmission and reduce the overall incidence of infections by Clostridium difficile and other gut-derived HPs. Infection control (IC) measures act by avoiding in-hospital transmissions using various interventions, including hand hygiene, contact isolation and environmental cleaning/disinfection. Antibiotic stewardship (ABS) on the other hand aims at reducing selective pressure by ascertaining adequacy of treatment duration, dose, and selection of antibiotics.However, there is a scarcity of studies showing effectiveness of these strategies in actually reducing nosocomial infection by HPs. Single room contact isolation has deleterious implications, i.e. increased cost, decreased patient contacts and quality of life, but has not been proven effective for most HPs. Current ABS concepts are usually not aimed at the patients with the highest antibiotic consumption and the highest risk of contracting nosocomial infection by HPs, e.g. patients with neutropenia following chemotherapy.

ABSOLUTE is a comprehensive clinical study programme assessing IC/ABS measures to reduce Clostridium difficile infections (CDI) on high-incidence HP/CDI wards in a stepped-wedge cluster-randomized trial. The study will focus on known departments with high incidence of CDI, i.e. a) hematology/oncology, b) other departments/wards demonstrating above-average infection rates, which will be identified throughout previous study by the German Center for Infection Research (DZIF). This design was chosen as high-risk groups allow optimal resource utilization by expedited observation of target outcomes and because there is a translational gap towards implementing established strategies of infection control and ABS in critically ill patient groups.

Each partner site will identify eight observation wards. To allow measurement of secondary endpoints relevant to the IC/ABS bundle, especially safety, at least three of the sites should include their hematology/oncology department into the analysis. The other wards/departments will be selected based on CDI epidemiology. Incidence of CDI on candidate study wards/departments should exceed the 75 percentile based on R-Net (DZIF study) data collected during the preparation phase. The study coordinators will make the ultimate decision on the participating wards based on discussion with the local team of investigators. Besides the above-mentioned entry criteria, knowledge of current practices and approachability of the ward and the related staff may be regarded during the discussion. In total, each site will perform the analysis on at least ten wards of at least three departments.

Infection control measures for Clostridium difficile are well established and can be easily applied into hospital routine. This work package can therefore start ahead of the ABS bundle with measures aimed at reducing transmission of Clostridium difficile. The infection control bundle will include staff training, hand hygiene programs, disinfection measures, and contact isolation. Physicians will be discouraged to prescribe proton pump inhibitors (PPIs) where not explicitly needed. The bundle will be defined based on current literature. During the preparation phase of the study, investigators and other personnel from each site will receive central training courses in infection control measures targeted at reduction of effective Clostridium difficile transmission. It will be their task to train local staff (ward physicians, nurses) for compliance with the infection control bundle. For implementation, the investigator will adapt the bundle to specific local needs, discuss with the responsible department heads and ward staff, perform training and disseminate standards of care. The following indicators of process quality will be measured be the investigator in collaboration with the local hygiene staff: compliance observations (contact isolation, hand hygiene), education assessment (surveys), and PPI consumption.

Throughout the ABS work package, the investigators will develop and implement an ABS bundle specifically designed for patients at the highest risk of developing hospital-acquired infections, i.e. those treated on hematological/oncological wards. Potentially useful ABS measures even in critically ill patients are early reduction of exposure based on microbiological results, timely cessation of anti-infective treatment, thoughtful implementation of screening measures and biomarkers, defined approaches to patients known to be allergic to penicillins, and vigorous enforcement of clinical and microbiological diagnosis of infection focus. The study hypothesis is, that the consumption of glycopeptides, carbapenems, daptomycin, tigecycline, and linezolid can be significantly reduced without jeopardizing patient outcomes. Reduction of these antibiotics will save last resort antimicrobials for documented breakthrough infections, reduce colonization and blood stream infections (BSI) with VRE and extended-spectrum beta-lactamase-producing gram-negatives (ESBL), and reduce the incidence of CDI.

As a first step, the investigators will guide a consensus process to develop specific ABS guidelines for hematology/oncology wards. They will develop this guideline primarily as German S2k (consensus) guideline, but will also seek publication in an international peer-reviewed journal. For the consensus process, relevant German medical societies and groups will be invited to send delegates. External experts will be invited to participate in the process and comment on the guideline as needed. The consensus process will consist of a kick-off face-to-face meeting with discussion and distribution of work packages, monthly telephone conferences and finally, a consensus meeting. The guidelines will contain advice on specific strategies to avoid excessive or wrong usage of anti-infectives and also on quality indicators of appropriate antibiotic use.

All study sites will receive comprehensive training in the defined ABS criteria as part of a 3-day course program. In addition, sites without established ABS groups or trained ABS experts will receive standard three-week training by the ABS Initiative (www.antibiotic-stewardship.de). Afterwards, implementation of the ABS measures will start. Antibiotic stewards will develop local standards of procedure based on the provided training and guidelines. They will then train the responsible staff and disseminate guidelines as best suited for the local work environment, e.g. as pocket cards, posters, or electronically. Point-prevalence investigations will assure adherence to guidelines.

• Study Type: Observational
• Enrollment (Actual): 80000

Contacts and Locations

Study Locations

• Germany
  • NRW
    • Cologne, NRW, Germany, 50931
      • University Hospital of Cologne

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Patients admitted on wards with high incidence of CDI.

Description

Inclusion Criteria:

- patients admitted to departments with high incidence of CDI, i.e. a) hematology/oncology, b) other departments/wards demonstrating above-average infection rates (identified by previous studies)

Exclusion Criteria:

- patients admitted in opthalmology, paediatrics, psychiatry

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Prospective

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
CDI incidence	Significant reduction of the overall CDI incidence on intervention wards following implementation of the combined IC and ABS bundles in pre-post analysis stratified by center.	Baseline and every 3 months up to 144 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Effectiveness of IC bundle through incidence of CDI or BSI by VRE and MRGN	Effectiveness of the infection control bundle for preventing nosocomial infection by incidence of a) CDI, or BSI by b) VRE, and c) MRGN by pre-post analysis before implementation of the ABS bundle.	Baseline and every 3 months up to 144 weeks
PPI usage	Reduction in the consumption of PPIs, measured by Defined Daily Dose (DDD) before and after IC bundle implementation	Baseline and every 3 months up to 144 weeks
Improvement of process indicators by calculating disinfectant consumption and antibiotic consumption	Improvement of process indicators for the IC (disinfectant consumption) and ABS (antibiotic consumption) bundles by pre-post analysis before implementation of the measures	Baseline and every 3 months up to 144 weeks
Effectiveness of ABS interventions by continuously measuring RDDs	Effectiveness of ABS interventions in reducing consumption of antibiotics discouraged for empirical treatment (3rd generation cephalosporins, glycopeptides, carbapenems, daptomycin, tigecycline, and linezolid), measured by Recommended Daily Dose (RDDs) before and after ABS bundle implementation	Baseline and every 3 months up to 144 weeks
Antibiotic consumption	Time series analysis using monthly aggregations of antibiotic consumption (RDDs) and incidence of a) CDI, b) VRE, and c) MRGN on participating wards and correlation with IC and ABS intervention activities	Baseline and every 3 months up to 144 weeks
Cost-effectiveness by comparing expenditures of implementing IC/ABS measures with reduction in antibiotic consumption	Cost-effectiveness of the different bundles by reducing antibiotic consumption, abbreviating average inpatient stays, and reducing the need for intensive care treatment compared to expenditure for IC and ABS bundle implementation	Baseline and after 144 weeks (end of the study)

Collaborators and Investigators

• Sponsor: University Hospital of Cologne
• Collaborators: Charite University, Berlin, Germany; University Hospital Tuebingen; University Hospital Freiburg; University of Hamburg-Eppendorf; University Hospital Lübeck
• Investigators: Principal Investigator: Jörg Janne Vehreschild, MD, University Hospital Cologne

Publications and helpful links

General Publications

• Gastmeier P, Weitzel-Kage D, Behnke M, Eckmanns T. Surveillance of Clostridium difficile-associated diarrhoea with the German nosocomial infection surveillance system KISS (CDAD-KISS). Int J Antimicrob Agents. 2009 Mar;33 Suppl 1:S19-23. doi: 10.1016/S0924-8579(09)70011-1.
• Meyer E, Gastmeier P, Weizel-Kage D, Schwab F. Associations between nosocomial meticillin-resistant Staphylococcus aureus and nosocomial Clostridium difficile-associated diarrhoea in 89 German hospitals. J Hosp Infect. 2012 Nov;82(3):181-6. doi: 10.1016/j.jhin.2012.07.022. Epub 2012 Sep 27.
• Vonberg RP, Kuijper EJ, Wilcox MH, Barbut F, Tull P, Gastmeier P; European C difficile-Infection Control Group; European Centre for Disease Prevention and Control (ECDC), van den Broek PJ, Colville A, Coignard B, Daha T, Debast S, Duerden BI, van den Hof S, van der Kooi T, Maarleveld HJ, Nagy E, Notermans DW, O'Driscoll J, Patel B, Stone S, Wiuff C. Infection control measures to limit the spread of Clostridium difficile. Clin Microbiol Infect. 2008 May;14 Suppl 5:2-20. doi: 10.1111/j.1469-0691.2008.01992.x.
• Vehreschild MJ, Hamprecht A, Peterson L, Schubert S, Hantschel M, Peter S, Schafhausen P, Rohde H, Lilienfeld-Toal MV, Bekeredjian-Ding I, Libam J, Hellmich M, Vehreschild JJ, Cornely OA, Seifert H. A multicentre cohort study on colonization and infection with ESBL-producing Enterobacteriaceae in high-risk patients with haematological malignancies. J Antimicrob Chemother. 2014 Dec;69(12):3387-92. doi: 10.1093/jac/dku305. Epub 2014 Aug 6.
• Vehreschild MJ, Weitershagen D, Biehl LM, Tacke D, Waldschmidt D, Tox U, Wisplinghoff H, Von Bergwelt-Baildon M, Cornely OA, Vehreschild JJ. Clostridium difficile infection in patients with acute myelogenous leukemia and in patients undergoing allogeneic stem cell transplantation: epidemiology and risk factor analysis. Biol Blood Marrow Transplant. 2014 Jun;20(6):823-8. doi: 10.1016/j.bbmt.2014.02.022. Epub 2014 Mar 6.
• Borde JP, Litterst S, Ruhnke M, Feik R, Hubner J, deWith K, Kaier K, Kern WV. Implementing an intensified antibiotic stewardship programme targeting cephalosporin and fluoroquinolone use in a 200-bed community hospital in Germany. Infection. 2015 Feb;43(1):45-50. doi: 10.1007/s15010-014-0693-2. Epub 2014 Oct 25.
• Borde JP, Kaier K, Steib-Bauert M, Vach W, Geibel-Zehender A, Busch H, Bertz H, Hug M, de With K, Kern WV. Feasibility and impact of an intensified antibiotic stewardship programme targeting cephalosporin and fluoroquinolone use in a tertiary care university medical center. BMC Infect Dis. 2014 Apr 15;14:201. doi: 10.1186/1471-2334-14-201.
• Vehreschild JJ, Bohme A, Cornely OA, Kahl C, Karthaus M, Kreuzer KA, Maschmeyer G, Mousset S, Ossendorf V, Penack O, Vehreschild MJGT, Bohlius J. Prophylaxis of infectious complications with colony-stimulating factors in adult cancer patients undergoing chemotherapy-evidence-based guidelines from the Infectious Diseases Working Party AGIHO of the German Society for Haematology and Medical Oncology (DGHO). Ann Oncol. 2014 Sep;25(9):1709-1718. doi: 10.1093/annonc/mdu035. Epub 2014 Mar 14.
• Vehreschild JJ, Morgen G, Cornely OA, Hartmann P, Koch S, Kalka-Moll W, Wyen C, Vehreschild MJ, Lehmann C, Gillor D, Seifert H, Kremer G, Fatkenheuer G, Jung N. Evaluation of an infectious disease consultation programme in a German tertiary care hospital. Infection. 2013 Dec;41(6):1121-8. doi: 10.1007/s15010-013-0512-1. Epub 2013 Aug 8.

Study record dates

Study Major Dates

• Study Start (Actual): November 1, 2016
• Primary Completion (Actual): December 1, 2018
• Study Completion (Actual): July 1, 2019

Study Registration Dates

• First Submitted: June 27, 2017
• First Submitted That Met QC Criteria: August 14, 2017
• First Posted (Actual): August 15, 2017

Study Record Updates

• Last Update Posted (Actual): July 31, 2020
• Last Update Submitted That Met QC Criteria: July 30, 2020
• Last Verified: July 1, 2020

More Information

Terms related to this study

• Keywords: antimicrobial stewardship; infection control; VRE; nosocomial infection; clostridium difficile; MRGN bacteria; health-care associated pathogens
• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Bacterial Infections; Bacterial Infections and Mycoses; Gram-Positive Bacterial Infections; Iatrogenic Disease; Infections; Communicable Diseases; Clostridium Infections; Cross Infection; Anti-Infective Agents; Anti-Bacterial Agents
• Other Study ID Numbers: TTU HAARBI 8.810

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No
• IPD Plan Description: Individual participant data will not be shared after the end of the study

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No