Giulio DiDiodato

Evaluating the Effectiveness of an Antimicrobial Stewardship Program on Reducing the Incidence Rate of Healthcare-Associated Clostridium difficile Infection: A Non-Randomized, Stepped Wedge, Single-Site, Observational Study.

Background The incidence rate of healthcare-associated Clostridium difficile infection (HA-CDI) is estimated at 1 in 100 patients. Antibiotic exposure is the most consistently reported risk factor for HA-CDI. Strategies to reduce the risk of HA-CDI have focused on reducing antibiotic utilization. Prospective audit and feedback is a commonly used antimicrobial stewardship intervention (ASi). The impact of this ASi on risk of HA-CDI is equivocal. This study examines the effectiveness of a prospective audit and feedback ASi on reducing the risk of HA-CDI. Methods Single-site, 339 bed community-hospital in Barrie, Ontario, Canada. Primary outcome is HA-CDI incidence rate. Daily prospective and audit ASi is the exposure variable. ASi implemented across 6 wards in a non-randomized, stepped wedge design. Criteria for ASi; any intravenous antibiotic use for ≥ 48 hrs, any oral fluoroquinolone or oral second generation cephalosporin use for ≥ 48 hrs, or any antimicrobial use for ≥ 5 days. HA-CDI cases and model covariates were aggregated by ward, year and month starting September 2008 and ending February 2016. Multi-level mixed effect negative binomial regression analysis was used to model the primary outcome, with intercept and slope coefficients for ward-level random effects estimated. Other covariates tested for inclusion in the final model were derived from previously published risk factors. Deviance residuals were used to assess the model’s goodness-of-fit. Findings The dataset included 486 observation periods, of which 350 were control periods and 136 were intervention periods. After accounting for all other model covariates, the estimated overall ASi incidence rate ratio (IRR) was 0.48 (95% 0.30, 0.79). The ASi effect was independent of antimicrobial utilization. The ASi did not seem to reduce the risk of Clostridium difficile infection on the surgery wards (IRR 0.87, 95% CI 0.45, 1.69) compared to the medicine wards (IRR 0.42, 95% CI 0.28, 0.63). The ward-level burden of Clostridium difficile as measured by the ward’s previous month’s total CDI cases (CDI Lag) and the ward’s current month’s community-associated CDI cases (CA-CDI) was significantly associated with an increased risk of HA-CDI, with the estimated CDI Lag IRR of 1.21 (95% 1.15, 1.28) and the estimated CA-CDI IRR of 1.10 (95% CI 1.01, 1.20). The ward-level random intercept and slope coefficients were not significant. The final model demonstrated good fit. Conclusions In this study, a daily prospective audit and feedback ASi resulted in a significant reduction in the risk of HA-CDI on the medicine wards, however, this effect was independent of an overall reduction in antibiotic utilization. In addition, the ward-level burden of Clostridium difficile was shown to significantly increase the risk of HA-CDI, reinforcing the importance of the environment as a source of HA-CDI.

Evaluating the impact of an antimicrobial stewardship program on the length of stay of immune-competent adult patients admitted to a hospital ward with a diagnosis of community-acquired pneumonia: A quasi-experimental study.

BACKGROUND The purpose of this study was to demonstrate an antimicrobial stewardship intervention can reduce length of stay for patients admitted to hospital with community-acquired pneumonia (CAP). METHODS Starting April 1, 2013, consecutive adult patients with CAP admitted to an acute care community hospital in Barrie, Ontario, Canada, were eligible for enrollment until March 31, 2015. The antimicrobial stewardship intervention was a prospective audit and feedback recommendation implemented in a stepped-wedge design across 4 wards. The primary outcome was time to hospital discharge, and secondary outcomes included time to antibiotic discontinuation and a composite outcome of 30-day readmission or all-cause mortality. The intervention effect was estimated by survival (time to discharge and antibiotic discontinuation) and logistic (30-day readmission or all-cause mortality) regression analyses. RESULTS Complete data were available for 763 patients. The primary outcome was observed in 196 (82%) control patients and 402 (77%) intervention patients. Length of stay was reduced by 11% (95% confidence interval [CI], -9% to 35%). Time to antibiotic discontinuation was shortened by 29% (95% CI, 10%-52%). Odds ratio for 30-day readmission or all-cause mortality was 0.79 (95% CI, 0.49-1.29). CONCLUSIONS A prospective audit and feedback intervention did not significantly reduce length of hospital stay in CAP patients despite reducing overall antibiotic utilization.

Just clean your hands: Measuring the effect of a patient safety initiative on driving transformational change in a health care system

In 2007, the Ontario government introduced the Just Clean Your Hands program across all provincial hospitals. The goal of this patient safety initiative was to improve hand hygiene practices among health care providers through workplace culture change. A survey questionnaire was distributed to 729 nurses employed at a single large community-based hospital from April to July 2011. Of the 223 nurses who responded to the questionnaire, 153 had completed the program (exposed group). By using the other 70 nurses as a contemporaneous control group (nonexposed), this study demonstrates that the Just Clean Your Hands program contributed to improved hand hygiene practices, but we were unable to demonstrate positive changes in patient safety culture.

Can an antimicrobial stewardship program reduce length of stay of immune-competent adult patients admitted to hospital with diagnosis of community-acquired pneumonia? Study protocol for pragmatic controlled non-randomized clinical study

BackgroundPneumonia is responsible for a large proportion of hospital admissions and antibiotic utilization. Physician adherence to evidence-based pneumonia management guidelines is poor. Antimicrobial stewardship programs (ASPs) are an effective intervention to mitigate against unwarranted variation from these guidelines. Despite this benefit, ASPs have not been shown to reduce the length of stay of hospitalized patients with pneumonia. In immune-competent adult patients admitted to a hospital ward with a diagnosis of community-acquired pneumonia, does a multi-faceted ASP utilizing prospective chart audit and feedback reduce the length of stay, compared with usual care, without increasing the risk of death or readmission 30 days after discharge from hospital?Methods/DesignStarting on 1 April 2013, all consecutive immune-competent adult patients (>18 years old) admitted to a hospital ward with a positive febrile respiratory illness screening questionnaire and a diagnosis of pneumonia by the attending physician will be eligible for inclusion in this non-randomized study. All eligible patients who fulfill the ASP review criteria will undergo a prospective chart audit, followed by an ASP recommendation provided to the attending physician. The attending physician is responsible for implementing or rejecting the ASP recommendation. This is a modified stepped-wedge design with a baseline data collection period of 3 months, followed by non-random sequential introduction of the ASP intervention on each of four hospital wards in a single community-based, academic-affiliated 339-bed acute-care hospital in Barrie, ON, Canada. The primary outcome measure is hospital length of stay; secondary outcome measures include days and duration of antibiotic therapy, and inadvertent adverse outcomes of 30 day post-discharge mortality and hospital readmission rates. Differences in outcome measures will be assessed using extended Cox regression analysis. Time to ASP intervention is included as a time-dependent covariate in the final model, to account for time-dependent bias.DiscussionBy designing a pragmatic clinical trial with unique design and analytic features, we not only expect to demonstrate the effectiveness of a real-world ASP, but also provide a model for program evaluation that can be used more broadly to improve patient safety and quality of care.Trial registrationClinicalTrials.gov NCT02264756.

Antibiotic exposure and risk of community-associated Clostridium difficile infection: A self-controlled case series analysis

HIGHLIGHTSCommunity‐associated Clostridium difficile infection is inconsistently associated with antibiotic exposure.Previous case‐control studies likely overestimate this association.Self‐controlled case series studies can reduce the bias in these estimates. Background: Community‐associated Clostridium difficile infection is inconsistently associated with antibiotic exposure. This study uses a self‐controlled case series (SCCS) design to estimate antibiotic exposure effect sizes and compare them with those estimated from previous case‐control studies. Methods: We estimated the association between antibiotic exposure and community‐associated Clostridium difficile infection among 139,000 patients registered to the Barrie Family Health Team from January 1, 2011, to May 1, 2017, using an SCCS design. Poisson regression analysis was used to estimate the incidence rate ratio (IRR) between antibiotic exposure versus nonexposure periods within individuals. Antibiotic exposure was categorized as either high risk (fluoroquinolone, clindamycin, or cephalosporin) or low risk (all other antibiotic classes). Results: The final analysis included 189 cases. The pooled IRR for high‐risk antibiotics was 2.26 (95% confidence interval [CI] 1.29, 3.98) and 2.03 (95% CI 1.19, 3.47) for lower‐risk antibiotics. There was no difference between high‐risk and lower‐risk antibiotics (IRR 1.11, 95% CI 0.53, 2.36). Interpretation: The IRRs were smaller than the odds ratios reported in previous case‐control studies, suggesting a less biased estimate because SCCS designs control for time‐invariant confounders. Compared with case‐control studies, SCCS designs are underused in infection prevention and control studies.

Transition from a dedicated to a non-dedicated, ward-based pharmacist antimicrobial stewardship programme model in a non-academic hospital and its impact on length of stay of patients admitted with pneumonia: a prospective observational study

Pharmacists play an integral role in antimicrobial stewardship (AS). Some AS programmes employ dedicated pharmacists, sometimes with infectious diseases (ID) training, while others employ ward-based pharmacists. The role and impact of both are under investigation. This study compares the length of stay (LOS) of patients admitted to hospital with community-acquired pneumonia (CAP) after the implementation of an AS programme initially led by a dedicated ID-trained pharmacist, and then transitioned to a ward-based pharmacist. Starting 1 April 2013, all adult patients admitted with CAP were prospectively reviewed by the AS programme. The control period (phase 0) lasted 3 months. Thereafter, AS was implemented in each of four medicine wards at 2-month intervals in a staggered fashion. During this period (phase 1), an ID-trained pharmacist and physician performed daily prospective audit and feedback. After 24 months, ward-based pharmacists assumed this AS role (phase 2). Over the 36-month study period, 1125 patients with CAP were entered into the AS database, with 518 and 247 patients receiving an AS audit and feedback in phases 1 and 2, respectively. The acceptance rate for AS recommendations was similar for phases 1 and 2, each exceeding 82%. After accounting for secular trends, the overall reduction in LOS was 19.4% (95% CI 1.4% to 40.5%). There was no difference in LOS between phases 1 and 2. This study demonstrated that an AS audit and feedback intervention reduced the median LOS in patients with CAP by approximately 0.5 days regardless of pharmacist model. However, fewer patients were exposed to the AS intervention in phase 2, suggesting dedicated AS pharmacists may be necessary to realise the full benefits of AS.

The research activities of Ontario's large community acute care hospitals: a scoping review.

BackgroundOntario’s large community hospitals (LCHs) provide care to 65% of the province’s hospitalized patients, yet we know very little about their research activities. By searching for research publications from 2013 to 2015, we will describe the extent, type and collaborative nature of Ontario’s LCHs’ research activities.MethodsWe conducted a scoping review by searching PubMed, Embase and the Cumulative Index to Nursing and Allied Health Literature databases from January 1, 2013 until December 31, 2015 for all publication types whose author(s) was affiliated with any of the 44 LCHs. Articles were screened and abstracted by three reviewers, independently. The data were charted and results described using summary statistics, scatter plots, and bar charts.ResultsWe included 798 publications from 39 LCHs and 454 authors. The median number of publications was 7 (Interquartile range (IQR) 23). Observational study design was most commonly reported in over 50% of publications. Program evaluation was the focus in 40% of publications. Primary LCH authorship was observed for 535 publications. Over 25% and 65% of the publications were attributable to 24 authors and 9 LCHs, respectively. There was minimal collaboration both within (21.2%) and between (7.8%) LCHs. LCH size and geographic proximity to academic hospitals had minimal impact on research activity.ConclusionsOntario’s LCHs publish infrequently, collaborate infrequently, and their role in translational research activity is not well defined. A future survey questionnaire to LCH researchers identified through this review is planned to both validate and elicit their interpretations of our study findings and opinions about LCH involvement in research.

Interhospital patient transfers between Ontario's academic and large community hospitals increase the risk of Clostridium difficile infection

HighlightsInterhospital patient transfers increase the risk of Clostridium difficile.This increased risk can be estimated by using a novel C difficile infection (CDI) score.CDI score is a surrogate measure of CDI pressure from the sending facility.Antimicrobial stewardship program effects can reduce this increased risk.Antimicrobial stewardship programs have variable effects on this risk. Background: The objective of this study is to determine the impact of interhospital patient transfers on the risk of Clostridium difficile infection (CDI). Methods: The number of interhospital patient transfers and CDI cases for 11 academic and 40 large community hospitals (LCHs) were available from 2010‐2015. These data were used to compute a CDI score for each sending facility as a measure of CDI pressure on the receiving facility. This CDI score was included as a variable in a multilevel mixed‐effect Poisson regression model of CDI cases. Other covariates included year, CDI testing strategy, antimicrobial stewardship program (ASP), and criteria used for patient isolation. Hospital‐specific random effects were estimated for the baseline rate of CDI (intercept) and ASP effect (slope). Results: The CDI score ranged from 0‐103, with a mean score ± SD of 20.4 ± 21.8. Every 10‐point increase in the CDI score was associated with a 4.5% increase in the incidence of CDI in the receiving academic hospital (95% confidence interval [CI], 0.9‐8.5) and 3.6% increase in the receiving LCHs (95% CI, 0.3‐7). The random components of the model varied significantly, with a strong negative correlation of −0.85 (95% CI, −0.94 to −0.65). Conclusions: Our results suggest interhospital patient transfers increase the risk of CDI. ASPs appear to reduce this risk; however, these ASP effects demonstrate significant heterogeneity across hospitals.

Evaluating the Effectiveness of an Antimicrobial Stewardship Intervention on Reducing the Incidence Rate of Healthcare-Associated Clostridium difficile Infection.

Background. The incidence rate of healthcare-associated Clostridium difficile infection (HA-CDI) is estimated at 1 in 100 patients. Antibiotic exposure is the most consistently reported risk factor. Strategies to reduce HA-CDI have focused on reducing antibiotic utilization. Prospective audit and feedback (PAF) is a commonly used antimicrobial stewardship intervention (ASi). The impact of this ASi on HA-CDI is equivocal. This study examines the impact of a PAF ASi on the incidence of HA-CDI. Methods. Single-site, 339 bed community-hospital in Ontario, Canada. Primary outcome is HA-CDI incidence rate. Daily PAF ASi is the exposure variable. PAF ASi is implemented across wards in a non-randomized stepped wedge design starting in July 2013. Criteria for ASi; any intravenous antibiotic use for ≥48 hours, or any fluoroquinolone or cephalosporin use for ≥48 hours. HA-CDI cases and model covariates aggregated by ward and month. Pooled statistical analyses done using generalized linear models with log link function. Potential clustering by ward and serial correlation of HA-CDI accounted for in final model. Other covariates tested for inclusion in final model were derived from previously published risk factors. Final pooled model was compared with random coefficient model (RCM). Goodness-of-fit (GOF) assessed using deviance statistics. Results. N = 430 observations with ASi implemented in 64 periods. The final model included; ASi, days of antibiotic therapy (DOT), previous months CDI cases (LCDI), current months community-associated-CDI cases (CA-CDI), length of stay (LOS) and days of hospitalization due to age over 65 years (Age), and interaction terms between ASi-DOT, LOS-Age and ASi-LCDI. ASi incidence rate ratio (IRR) is 0.42 (95% CI, 0.19–0.92). ASi-DOT interaction IRR was not significant. LCDI IRR was 1.20 (95% CI, 1.07–1.35) and CA-CDI IRR was 1.26 (95% CI, 1.12–1.42). Pooled model was equivalent to RCM and provided excellent GOF. Conclusion. Daily PAF ASi resulted in a significant reduction in HA-CDI; however, this effect was not mediated by an overall reduction in antibiotic utilization. In addition, the importance of CDI environmental pressure was demonstrated through the significant impact of both CA-CDI and LCDI on subsequent HA-CDI incidence rates. Disclosures. All authors: No reported disclosures.