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

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.