Reduced Clostridioides difficile infection in a pragmatic stepped-wedge initiative using admission surveillance to detect colonization

Abstract

Background: Clostridioides difficile Infection (CDI) is a persistent healthcare issue. In the US, CDI is the most common infectious cause of hospital-onset (HO) diarrhea.

Objective: Assess the impact of admission testing for toxigenic C. difficile colonization on the incidence of HO-CDI.

Design: Pragmatic stepped-wedge Infection Control initiative.

Setting: NorthShore University HealthSystem is a four-hospital system near Chicago, IL.

Patients: All patients admitted to the four hospitals during the initiative.

Interventions: From September 2017 through August 2018 we conducted a quality improvement program where admitted patients had a peri-rectal swab tested for toxigenic C. difficile. All colonized patients were placed into contact precautions.

Measurements: We tested admissions who: i) had been hospitalized within two months, ii) had a past C. difficile positive test, and/or iii) were in a long-term care facility within six months. We measured compliance with all other practices to reduce the incidence of HO-CDI.

Results: 30% of admissions were tested and 8.3% were positive. In the year prior to the initiative (Period 1) there were 63,057 admitted patients when HO-CDI incidence was 5.96 cases/10,000 patient days. During the 12-month initiative (Period 2) there were 62,760 admissions and the HO-CDI incidence was 4.23 cases/10,000 patient days (p = 0.02). There were no other practice or antibiotic use changes. Continuing admission surveillance provided a HO-CDI incidence of 2.9 cases/10,000 patient days during the final 9 months of 2018 (p<0.0001 compared to Period 1), equaling <1 case/1,000 admissions.

Limitations: This was not a randomized controlled trial, and multiple prevention practices were in place at the time of the admission surveillance initiative.

Conclusion: Admission C. difficile surveillance testing is an important tool for preventing hospital-onset C. difficile infection.

Registration: This quality improvement initiative is registered at ClinicalTrials.gov. The unique registration identifier number is NCT04014608.

Conflict of interest statement

I have read the journal's policy and the authors of this manuscript have the following competing interests: LRP has been a consultant on novel assay development for Roche Molecular Diagnostics. There are no other disclosures. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1. Participant flow diagram for the intervention portion of this report.

Fig 2. Monthly incidence of HO-CDI during 29 months of observation (S1 Table).

Fig 3

a. and b. Compliance with infection control practices designed to reduce risk of HO-CDI (3a represents Period 1 and 3b represents Period 2; S2 Table).

Fig 4. Antimicrobial agent use (in days of therapy per 1,000 patient days) between the two study periods depicted as total use ±1 S.E.; S3 Table).