Antibiotic Antibiotic Stewardship Stewardship

Program Program By: By:

M. Hajiabdolbaghi.MD.MPHM. Hajiabdolbaghi.MD.MPHTUMSTUMS

•Antimicrobial Antimicrobial resistance results in resistance results in increased Morbidityincreased Morbidity

•Mortality Mortality •Cost of health care.Cost of health care.

A meta-analysis of 9 studies of A meta-analysis of 9 studies of VRE BSIs VRE BSIs found an attributable excess found an attributable excess mortality of mortality of 30%, 30%, compared with compared with vancomycin-vancomycin-susceptible Enterococcus BSIs susceptible Enterococcus BSIs

Increased Increased 2 times 2 times length of length of hospital hospital stay stay and an attributable and an attributable cost of $27,190 cost of $27,190 per episodeper episode

•

•Bacteremia and SSI infections Bacteremia and SSI infections due todue to

MRSA have been MRSA have been associated with associated with a a higher mortality higher mortality rate than rate than similar infections due to MSSAsimilar infections due to MSSA with the mean attributable with the mean attributable cost cost of an MRSA infection ranging of an MRSA infection ranging from from $9275 to$13,901 $9275 to$13,901 ..

• In 1998, the Institute In 1998, the Institute of Medicine estimated that of Medicine estimated that the annual the annual cost of cost of infections infections caused by caused by antimicrobial-resistant antimicrobial-resistant bacteria bacteria was $4–$5 billionwas $4–$5 billion

•Antimicrobials account for Antimicrobials account for upwards of upwards of 30% of hospital 30% of hospital pharmacy budgets pharmacy budgets up to up to 50% of antimicrobial use is 50% of antimicrobial use is inappropriateinappropriate, adding , adding considerable cost to patient considerable cost to patient carecare

• Given the emergence of MDRsGiven the emergence of MDRs•pathogens and pathogens and their impact on clinical their impact on clinical

care, care, appropriate use of appropriate use of antimicrobial agents has become a antimicrobial agents has become a focus of patient safetyfocus of patient safety and quality and quality assurance along with medication assurance along with medication errors, allergy identification, and drug-errors, allergy identification, and drug-drug interactionsdrug interactions

• Infection Control Infection Control and and Antimicrobial Antimicrobial StewardshipStewardship: Our only : Our only two strategies two strategies to to combat antimicrobial combat antimicrobial resistanceresistance

•Antimicrobial Antimicrobial stewardship stewardship includes not only includes not only limiting limiting inappropriate useinappropriate use

Primary Primary goalgoal• – – Optimize clinical outcomes Optimize clinical outcomes

while while minimizing unintended minimizing unintended consequences of antibiotic consequences of antibiotic useuse

• • ToxicityToxicity

• • Selection of pathogenic bacteria Selection of pathogenic bacteria (eg, (eg, C difficile)C difficile)

• • Emerging resistanceEmerging resistance

• • Secondary Secondary goalgoal

– – Reduce healthcare Reduce healthcare cost without cost without compromising compromising quality of carequality of care

•The ultimate goal The ultimate goal of of antimicrobial antimicrobial stewardship stewardship is to is to improve patient care improve patient care and health care and health care outcomes.outcomes.

• Core members of aCore members of a• antimicrobial stewardship teamantimicrobial stewardship team• includeinclude• An An infectious diseases infectious diseases physician physician

(usually director(usually director))• A A clinical pharmacist clinical pharmacist with with

infectious diseases training who infectious diseases training who should be compensated for their should be compensated for their time. time.

• With With the inclusion the inclusion of aof a

• A clinical microbiologistA clinical microbiologist, ,

•An information system An information system specialistspecialist

• An infection control An infection control professionalprofessional, and A hospital , and A hospital epidemiologist epidemiologist

being being optimaloptimal

•CollaborationCollaboration between the between the antimicrobial stewardship antimicrobial stewardship team team and the and the hospital hospital infection control infection control and and pharmacy and therapeutics pharmacy and therapeutics committeescommittees or their or their equivalents is equivalents is essentialessential

• The support and collaboration The support and collaboration ofof

• Hospital administrationHospital administration• Medical staff leadershipMedical staff leadership• Local providers in the Local providers in the

development and maintenance development and maintenance of antimicrobial stewardship of antimicrobial stewardship programs is essential.programs is essential.

•

• The infectious diseases The infectious diseases physician and the head of physician and the head of pharmacy, as appropriate, pharmacy, as appropriate,

should should negotiatenegotiate with hospital administrationwith hospital administration

to to obtain adequate authorityobtain adequate authority, , compensation, and compensation, and expected expected outcomes for the programoutcomes for the program

• Hospital administrative Hospital administrative support for the necessary support for the necessary infrastructure to measure infrastructure to measure antimicrobial use antimicrobial use and to and to tracktrack use on an ongoing use on an ongoing basis basis is essentialis essential

Active Antimicrobial Active Antimicrobial Stewardship StrategiesStewardship Strategies

• There are There are 2 core strategies2 core strategies, , both proactive, that provide both proactive, that provide the foundation for an the foundation for an antimicrobial stewardship antimicrobial stewardship program.program.

•These strategies are not These strategies are not mutually mutually exclusiveexclusive

A. A. Prospective audit with Prospective audit with intervention and intervention and

feedbackfeedbackProspective audit of antimicrobial Prospective audit of antimicrobial

use use with direct interaction and with direct interaction and feedback to the prescriberfeedback to the prescriber, , performed by either an performed by either an infectious infectious diseases physician or a clinical diseases physician or a clinical pharmacistpharmacist with infectious with infectious

• diseases training, can result in diseases training, can result in reduced inappropriate use of reduced inappropriate use of antimicrobialsantimicrobials

Study 1Study 1• In a large teaching hospital, house staff In a large teaching hospital, house staff

werewere• randomized to receive either no randomized to receive either no

intervention or intervention or one-on-oneone-on-one education by a education by a clinical specialist (academic detailing) on clinical specialist (academic detailing) on a patient-specific basis, emphasizing a patient-specific basis, emphasizing microbiologic data, local resistance microbiologic data, local resistance patterns, and clinical literature, when the patterns, and clinical literature, when the pharmacy received an pharmacy received an orderorder for for either either levofloxacin or ceftazidime. levofloxacin or ceftazidime.

• This resulted in This resulted in a 37% reduction in a 37% reduction in the the number of days number of days of unnecessary of unnecessary levofloxacin or ceftazidime use by levofloxacin or ceftazidime use by decreasing the duration of therapy, decreasing the duration of therapy, reducing new startsreducing new starts

• suggesting that house suggesting that house staff learned staff learned not to initiate unnecessarynot to initiate unnecessary antibiotic treatment regimens .antibiotic treatment regimens .

Study 2Study 2• At a 600-bed tertiary teaching At a 600-bed tertiary teaching

hospital, hospital, inpatients receiving inpatients receiving parenteral antimicrobials parenteral antimicrobials chosen by chosen by their their primary care physician primary care physician were were randomized to an intervention group randomized to an intervention group that received antimicrobial-related that received antimicrobial-related suggestionssuggestions from an from an infectious infectious diseases fellow diseases fellow and a and a clinical clinical pharmacistpharmacist versus no antimicrobial versus no antimicrobial suggestionssuggestions. .

• Physicians in the intervention group Physicians in the intervention group received 74 suggestions for 62 of 127 received 74 suggestions for 62 of 127 patients, including suggestions on a more patients, including suggestions on a more appropriate agent, route of administration, appropriate agent, route of administration, dosing, discontinuation of the drug, or dosing, discontinuation of the drug, or toxicity monitoring.toxicity monitoring.

• 85% of the suggestions were 85% of the suggestions were implementedimplemented, resulting , resulting in 1.6 fewer days in 1.6 fewer days of parenteral therapy and a cost savings of parenteral therapy and a cost savings of of $400 $400 per patient, with no adverse impact per patient, with no adverse impact on clinical response, compared with the on clinical response, compared with the control groupcontrol group

Study 3Study 3• Prospective audit and interventions by a Prospective audit and interventions by a

clinical pharmacist and infectious diseases clinical pharmacist and infectious diseases physician physician at a medium-sized community at a medium-sized community hospital resulted in a hospital resulted in a 22% decrease in the 22% decrease in the use of parenteraluse of parenteral

• broad-spectrum antimicrobialsbroad-spectrum antimicrobials, despite a , despite a 15% increase in patient acuity 15% increase in patient acuity over a 7-year over a 7-year period period They also demonstrated They also demonstrated a decrease in a decrease in rates of rates of C. difficile infectionC. difficile infection and nosocomial and nosocomial infection infection caused by drug-resistant caused by drug-resistant Enterobacteriaceae, compared with the Enterobacteriaceae, compared with the preintervention periodpreintervention period

In these studiesIn these studiesInterventions were Interventions were communicatedcommunicated to to

prescribers prescribers either either verbally or in writingverbally or in writing..• WrittenWritten communication was typically communication was typically

accomplished by using specialaccomplished by using special, , nonpermanent formsnonpermanent forms that were placed in that were placed in the medical record or chart but were the medical record or chart but were subsequently removed after the subsequently removed after the intervention or at the time of discharge intervention or at the time of discharge from the hospital.from the hospital.

• Each intervention provides the Each intervention provides the opportunity for provider educationopportunity for provider education..

•Effective audit with Effective audit with intervention intervention and feedback and feedback can be can be facilitated facilitated through through computer surveillance computer surveillance of of antimicrobial useantimicrobial use

• . . Formulary Formulary restriction and restriction and preauthorization preauthorization requirementsrequirements for for specific agentsspecific agents

• Most hospitals have a pharmacy Most hospitals have a pharmacy and and therapeutics committee therapeutics committee or an or an equivalent group that evaluates equivalent group that evaluates drugs for inclusion on the hospital drugs for inclusion on the hospital formulary formulary on the basis of on the basis of considerations of therapeutic considerations of therapeutic efficacy, toxicity, and cost efficacy, toxicity, and cost while while limiting redundant new agents with limiting redundant new agents with no significant additional benefitno significant additional benefit

•Longitudinal Longitudinal studies studies implementing implementing restrictive restrictive policies policies have demonstrated have demonstrated significant initial decreases significant initial decreases in the use of the targeted in the use of the targeted antimicrobials, antimicrobials, with annual with annual antimicrobial antimicrobial cost savings cost savings ranging upwards of ranging upwards of $800,000 $800,000

Study 4Study 4• Both formulary restriction and Both formulary restriction and

preauthorization requirements for use of preauthorization requirements for use of clindamycinclindamycin during during nosocomial epidemics of nosocomial epidemics of C. difficile C. difficile infection have led to infection have led to prompt prompt cessation of cessation of the outbreaksthe outbreaks, whereas , whereas preapproval restriction of broads pectrum preapproval restriction of broads pectrum antimicrobials has led to antimicrobials has led to short-term short-term increased susceptibilities among gram-increased susceptibilities among gram-negative negative pathogens, such as pathogens, such as Pseudomonas Pseudomonas aeruginosaaeruginosa, , Klebsiella pneumoniae, and Klebsiella pneumoniae, and Enterobacter cloacae, during a 6–12-month Enterobacter cloacae, during a 6–12-month period period

• Restriction of Restriction of vancomycin vancomycin and and third-generation cephalosporins third-generation cephalosporins in response to increasing rates of in response to increasing rates of VRE has demonstrated VRE has demonstrated mixed mixed resultsresults. .

• The The effectivenesseffectiveness of a of a preauthorization program preauthorization program depends on depends on who is making who is making the recommendationsthe recommendations. .

• RecommendationsRecommendations from an from an antimicrobial management team antimicrobial management team consisting of a pharmacist and consisting of a pharmacist and an an infectious diseases physician infectious diseases physician resulted in increased antimicrobial resulted in increased antimicrobial appropriatenessappropriateness, increased clinical , increased clinical cure, and a trend towards improved cure, and a trend towards improved economic outcome, compared with economic outcome, compared with recommendations made by recommendations made by infectious diseases fellowsinfectious diseases fellows

• Formulary restriction and Formulary restriction and preauthorization requirements preauthorization requirements can lead to immediate and can lead to immediate and significant significant reductions in reductions in antimicrobial use antimicrobial use and cost and and cost and may be beneficial as part of a may be beneficial as part of a multifaceted multifaceted response to a response to a nosocomial outbreak of nosocomial outbreak of infection infection

• The use The use of preauthorization of preauthorization requirementsrequirements

• as a means of as a means of controlling controlling antimicrobial resistance is antimicrobial resistance is less less clearclear, because a long-term , because a long-term beneficial impact on resistance has beneficial impact on resistance has not been established, and in some not been established, and in some circumstances, usecircumstances, use

• may simply may simply shift to an alternative shift to an alternative agent agent with resulting increased with resulting increased resistance .resistance .

• The following elements The following elements may may be considered and prioritized be considered and prioritized as supplements to the core as supplements to the core active antimicrobial active antimicrobial stewardship strategies based stewardship strategies based on local on local practice patterns practice patterns and and resources.resources.

• A. A. Education.Education. is considered to be an essential is considered to be an essential

element of element of any program any program designed to designed to influence prescribing behavior and influence prescribing behavior and can provide a foundation of can provide a foundation of knowledge that will enhance and knowledge that will enhance and increase the increase the acceptanceacceptance of of stewardship strategies stewardship strategies

Education.Education.Include Include passive activitiespassive activities, such as , such as • conference presentations,conference presentations,• Student and house staff teaching sessions,Student and house staff teaching sessions,• written guidelines written guidelines • E-mail alerts.E-mail alerts.• However, education aloneHowever, education alone, without , without

incorporationincorporation• of active intervention, is only marginally of active intervention, is only marginally

effective in changing antimicrobial effective in changing antimicrobial prescribing practices and prescribing practices and has not has not demonstrated a sustained impactdemonstrated a sustained impact

B. B. Guidelines and clinical Guidelines and clinical pathwayspathways. . MultidisciplinaryMultidisciplinary

• Development of evidence-based Development of evidence-based practice practice guidelines incorporating guidelines incorporating local microbiology and resistance local microbiology and resistance patterns patterns can improve can improve antimicrobial utilization .antimicrobial utilization .

• Guideline implementation can be Guideline implementation can be facilitated facilitated through provider through provider education and feedbackeducation and feedback

• on antimicrobial use and patient on antimicrobial use and patient outcomesoutcomes

Antimicrobial selection Antimicrobial selection is only is only 11 componentcomponent in improving the in improving the management of infectious diseases management of infectious diseases and and cannotcannot be done without be done without recommendations for recommendations for diagnosis and diagnosis and testing, admission criteria, nursing testing, admission criteria, nursing care, conversion to oral medication, care, conversion to oral medication, and dischargeand discharge

planning.planning.

D. D. Antimicrobial order Antimicrobial order forms. Antimicrobial orderforms. Antimicrobial order

• FormsForms can be an effective can be an effective component of antimicrobial component of antimicrobial stewardship and can facilitate stewardship and can facilitate implementation of practice implementation of practice guidelinesguidelines..

• The educational handbook led to The educational handbook led to a marginal improvement in a marginal improvement in compliance (from 11% to 18%), compliance (from 11% to 18%), whereas introduction of the whereas introduction of the order form order form led to significantly led to significantly improved complianceimproved compliance

• (from (from 17% to 78%)17% to 78%)

StudyStudy

• Use of Use of perioperative prophylactic perioperative prophylactic order forms order forms with with automatic automatic discontinuation at 2 days discontinuation at 2 days resulted in resulted in a decrease in the mean durationa decrease in the mean duration

• of antimicrobial prophylaxis (from of antimicrobial prophylaxis (from 4.9 to 2.4 days) and a decrease in the 4.9 to 2.4 days) and a decrease in the percentage of patients receiving percentage of patients receiving perioperativeperioperative

• prophylaxis (from 85% to 44%)prophylaxis (from 85% to 44%)

•Automatic stop orders Automatic stop orders should should not not replace clinical judgmentreplace clinical judgment, , and renewal requirements and renewal requirements must be clearly must be clearly communicated to providers communicated to providers to avoid inappropriate to avoid inappropriate treatment interruptionstreatment interruptions..

C. C. Antimicrobial cyclingAntimicrobial cycling• . There are insufficient data . There are insufficient data to routine use of to routine use of

antimicrobial cycling for preventing or reducing antimicrobial cycling for preventing or reducing antimicrobial resistance over a prolonged time antimicrobial resistance over a prolonged time

may transiently reduce resistance to the may transiently reduce resistance to the restricted agent. restricted agent.

• Unless the Unless the resistance determinant has been resistance determinant has been eliminated eliminated from the bacterial population, from the bacterial population, however, reintroduction of the original however, reintroduction of the original antimicrobial antimicrobial is again likely to select for the is again likely to select for the expression of the resistance expression of the resistance determinant in determinant in the exposed bacterial population.the exposed bacterial population.

• It should be noted that It should be noted that mathematical mathematical modeling modeling suggests that true cycling suggests that true cycling is unlikely to reduce the evolution or is unlikely to reduce the evolution or spread of antimicrobial resistance.spread of antimicrobial resistance.

• RatherRather, such modeling suggests that, such modeling suggests that• the simultaneous the simultaneous mixed use of mixed use of

different antimicrobial classesdifferent antimicrobial classes in a in a heterogeneous fashion may heterogeneous fashion may slow the slow the spread of resistancespread of resistance

EE. . Combination therapyCombination therapy• . . There are insufficient data There are insufficient data to to

recommend the routine use of recommend the routine use of combination therapy to prevent the combination therapy to prevent the emergence of resistance emergence of resistance

• Combination therapy does have a role in Combination therapy does have a role in certain clinical contexts, including use certain clinical contexts, including use for empirical therapy for critically ill for empirical therapy for critically ill patients at risk of infection with MDR patients at risk of infection with MDR pathogens, to increase the breadth of pathogens, to increase the breadth of coverage and the likelihood of adequate coverage and the likelihood of adequate initial therapyinitial therapy

. . Streamlining or de-Streamlining or de-escalation of therapy.escalation of therapy.

•Continuing excessively Continuing excessively broad therapy contributes broad therapy contributes to the selection of to the selection of antimicrobial resistant antimicrobial resistant pathogenspathogens

F. F. Streamlining or de-Streamlining or de-escalation of therapy.escalation of therapy.

• Streamlining Streamlining or de-escalation of or de-escalation of empirical antimicrobial therapy empirical antimicrobial therapy on the basis of culture resultson the basis of culture results and and elimination of redundant elimination of redundant combination therapy can more combination therapy can more effectively target the causative effectively target the causative pathogen ,resulting in pathogen ,resulting in decreased decreased antimicrobial exposure antimicrobial exposure and and substantial substantial cost savingscost savings

Dose optimizationDose optimization

• . Optimization of antimicrobial . Optimization of antimicrobial dosing based on individual patient dosing based on individual patient characteristics, causative organism, characteristics, causative organism, site of infection, and site of infection, and pharmacokinetic and pharmacokinetic and pharmacodynamic characteristics of pharmacodynamic characteristics of the drug is an important part of the drug is an important part of antimicrobial stewardshipantimicrobial stewardship

H. H. Parenteral to oral Parenteral to oral conversionconversion

• . . A systematic plan A systematic plan for parenteral to oral for parenteral to oral conversion of antimicrobials with conversion of antimicrobials with excellentexcellent

• bioavailability, when the patient’s bioavailability, when the patient’s condition allows, can decrease the length condition allows, can decrease the length of hospital stay and health care costs .of hospital stay and health care costs .

• Development of clinical criteria and Development of clinical criteria and guidelines guidelines allowing switch to use of oral allowing switch to use of oral agents can facilitate implementation at agents can facilitate implementation at the institutional levelthe institutional level

Computer Surveillance and Computer Surveillance and Decision SupportDecision Support

• A program A program presents epidemiologic presents epidemiologic informationinformation

with detailed recommendations and with detailed recommendations and warnings warnings regarding antimicrobial regarding antimicrobial regimens and courses of therapy. regimens and courses of therapy.

Electronic medical Electronic medical recordsrecords

• Can improve antimicrobial decisions Can improve antimicrobial decisions through the incorporation of data through the incorporation of data on patient-specific microbiology on patient-specific microbiology cultures and susceptibilities, cultures and susceptibilities, hepatic and renal function, hepatic and renal function, drug-drug-drug interactions, allergies, and drug interactions, allergies, and cost.cost.

• ..

• Even if a physician Even if a physician overridesoverrides the the recommendation for the recommendation for the antimicrobial andantimicrobial and

selects his or her own treatment selects his or her own treatment planplan, the computer still , the computer still automatically reviews the patient’s automatically reviews the patient’s allergies and potential drug drug allergies and potential drug drug interactions, recommending a interactions, recommending a dosage and interval based on the dosage and interval based on the patient’s renal and hepatic functionpatient’s renal and hepatic function

• HoweverHowever, implementation , implementation of of these features has these features has been slowbeen slow, and , and conformation of the technology conformation of the technology to the clinical environment to the clinical environment remains a challengeremains a challenge

• . Computer-based surveillance . Computer-based surveillance can can facilitate good stewardship facilitate good stewardship by more efficient targeting of by more efficient targeting of antimicrobial interventionsantimicrobial interventions, , tracking of antimicrobial tracking of antimicrobial resistance patternsresistance patterns, and , and identification of nosocomial identification of nosocomial infectionsinfections and and adverse drug adverse drug eventsevents

• The clinical microbiology laboratory The clinical microbiology laboratory plays a plays a critical role critical role in antimicrobial in antimicrobial stewardship by providing patient-stewardship by providing patient-specific culture and susceptibility data specific culture and susceptibility data to optimize individual antimicrobial to optimize individual antimicrobial management management and by assisting and by assisting infection control efforts in the infection control efforts in the surveillance of resistant organisms surveillance of resistant organisms and in the molecular epidemiologic and in the molecular epidemiologic investigation of outbreaksinvestigation of outbreaks

• In hospitals where In hospitals where daily review daily review of of antimicrobial use is not feasible because of antimicrobial use is not feasible because of limited resources, a scaled-down model can limited resources, a scaled-down model can still have a significant impact, as illustrated still have a significant impact, as illustrated by a small, 120-bed community hospital by a small, 120-bed community hospital that used an infectious diseases physicianthat used an infectious diseases physician

• and clinical pharmacist and clinical pharmacist 3 days per week 3 days per week to to review patients receiving multiple, review patients receiving multiple, prolonged, or high-cost courses of prolonged, or high-cost courses of antimicrobial therapy antimicrobial therapy

• Monitoring of Process and Monitoring of Process and Outcome Measurements Outcome Measurements health health care systems must care systems must invest in invest in data systems data systems to allow the to allow the evaluation of antimicrobial evaluation of antimicrobial

stewardship stewardship as a routine as a routine measure of quality measure of quality improvement improvement

•It is clear that effectiveIt is clear that effective

antimicrobial stewardship antimicrobial stewardship requires a requires a multidisciplinary multidisciplinary team team approach that approach that incorporates many of these incorporates many of these elements elements simultaneouslysimultaneously

QuestionsQuestions

• As a member of your As a member of your hospital hospital Infection control Infection control and and therapeutics committee, you are therapeutics committee, you are probing a recent outbreak of probing a recent outbreak of suspiciossuspicios

•C difficile colitisC difficile colitis. Items that . Items that should be should be included in your included in your evaluation might be:evaluation might be:

Diagnosis of CDIs Diagnosis of CDIs • Testing for Testing for C. difficile or its toxins C. difficile or its toxins

should be performed should be performed only on only on diarrheal stooldiarrheal stool. .

• Stool culture Stool culture (ie, toxigenic culture(ie, toxigenic culture), ), is the most sensitive and is the most sensitive and specific testspecific test( not clinically practical ( not clinically practical because of its time consuming)because of its time consuming)

• Enzyme immunoassay (EIAEnzyme immunoassay (EIA) ) testing for testing for C. difficile C. difficile toxin toxin ( rapid but is less sensitive than ( rapid but is less sensitive than the cell cytotoxin assay the cell cytotoxin assay

• Toxin testing Toxin testing is most important is most important clinicallyclinically

• ( lack of sensitivity). ( lack of sensitivity).

• 2-step method 2-step method that uses EIA detection that uses EIA detection of glutamate dehydrogenase (GDH) as of glutamate dehydrogenase (GDH) as initialinitial

• screening and then uses the cell screening and then uses the cell cytotoxicity assay or toxigenic culture cytotoxicity assay or toxigenic culture as the confirmatory test for as the confirmatory test for (recommendation). (recommendation).

• PCRPCR testing appears to be rapid, testing appears to be rapid, sensitive, and specificsensitive, and specific

•What are the most What are the most important important infection infection control control measures to measures to implement in the hospital implement in the hospital during an outbreak of during an outbreak of CDI CDI ??

• HCW and visitors must use HCW and visitors must use glovesgloves and and gownsgowns on entry to a room of a on entry to a room of a

patientpatient

with CDI.with CDI.

Emphasize compliance with the practice Emphasize compliance with the practice ofof hand hand

• Hygiene( Hygiene( with soap (or antimicrobial with soap (or antimicrobial soapsoap) and water) after caring for or ) and water) after caring for or contacting patients contacting patients with CDIwith CDI

• Place patients with CDI in a Place patients with CDI in a private roomprivate room with with contact contact precautions precautions . .

• If single rooms are not If single rooms are not available, available, cohortcohort patients, patients, providing a dedicated providing a dedicated commode for each patient .commode for each patient .

• Maintain Maintain contact precautions contact precautions for the duration of for the duration of diarrheadiarrhea ..

. . Routine identification of Routine identification of asymptomatic asymptomatic carriers (patients carriers (patients or healthcare workers) for infection or healthcare workers) for infection control purposes control purposes is not is not recommended recommended and treatment and treatment of such identified of such identified patients is not patients is not effective effective

• Environmental Cleaning and Environmental Cleaning and DisinfectionDisinfection

• . Identification and removal of . Identification and removal of environmental sources of environmental sources of C. difficile, C. difficile, including replacement of electronic including replacement of electronic rectal rectal thermometers thermometers with with disposablesdisposables, , can can reduce the incidence of CDIreduce the incidence of CDI

• Use Use chlorine-containing cleaning chlorine-containing cleaning agents agents or other sporicidal agents to address or other sporicidal agents to address environmental contamination in areas environmental contamination in areas associated with increased rates of CDIassociated with increased rates of CDI

• . Routine environmental screening . Routine environmental screening for for C. difficile is C. difficile is not recommended not recommended

• Antimicrobial Use RestrictionsAntimicrobial Use Restrictions• . . MinimizeMinimize the the frequency and frequency and

duration duration of antimicrobial therapy of antimicrobial therapy and the number of antimicrobial and the number of antimicrobial agents prescribed, agents prescribed, to reduce to reduce CDI CDI risk risk (cephalosporin and (cephalosporin and clindamycin…except for surgical clindamycin…except for surgical antibiotic prophylaxis)antibiotic prophylaxis)

• Implement an antimicrobial Implement an antimicrobial stewardship programstewardship program

• Discontinue therapy Discontinue therapy with the with the inciting antimicrobial agent(s) as inciting antimicrobial agent(s) as soon as possible, as this may soon as possible, as this may influence the risk of CDI influence the risk of CDI recurrencerecurrence

• . . When severe or complicated CDI When severe or complicated CDI is suspected, initiate is suspected, initiate empirical empirical treatment treatment as soon as the diagnosis as soon as the diagnosis is suspectedis suspected

• If the stool toxin assay result is If the stool toxin assay result is negative, the decision to initiate, negative, the decision to initiate, stop, or continue treatment must stop, or continue treatment must be individualizedbe individualized

• If possible, avoid use of If possible, avoid use of antiperistaltic agents, as they may antiperistaltic agents, as they may obscure symptoms and precipitate obscure symptoms and precipitate toxic megacolontoxic megacolon

• MetronidazoleMetronidazole is the drug of is the drug of choice for the initial episode of choice for the initial episode of mild-to-moderate CDI. The dosage mild-to-moderate CDI. The dosage is 500 mg orally 3 times per day is 500 mg orally 3 times per day for 10–14 days. for 10–14 days.

• VancomycinVancomycin is the drug of choice is the drug of choice for an initial episode of severe CDI. for an initial episode of severe CDI.

• The dosage is 125 mg orally 4 The dosage is 125 mg orally 4 times per day for 10–14 days.times per day for 10–14 days.