infection control & hospital epidemiology july 2018, vol. 39, no. 7 original article
Effectiveness of Probiotic for Primary Prevention of Clostridium difficile Infection: A Single-Center Before-and-After Quality Improvement Intervention at a Tertiary-Care Medical Center
William E. Trick, MD;1 Stephen J. Sokalski, DO;2 Stuart Johnson, MD;3 Kristen L. Bunnell, PharmD;4 Joseph Levato, PharmD;2 Michael J. Ray, MPH;1 Robert A. Weinstein, MD1
objective. To evaluate probiotics for the primary prevention of Clostridium difficile infection (CDI) among hospital inpatients. design. A before-and-after quality improvement intervention comparing 12-month baseline and intervention periods. setting. A 694-bed teaching hospital.
intervention. Weadministered a multispecies probiotic comprising L. acidophilus (CL1285), L. casei (LBC80R), and L. rhamnosus (CLR2) to eligible antibiotic recipients within 12 hours of initial antibiotic receipt through 5 days after final dose. We excluded (1) all patients on neonatal, pediatric and oncology wards; (2) all individuals receiving perioperative prophylactic antibiotic recipients; (3) all those restricted from oral intake; and (4) those with pancreatitis, leukopenia, or posttransplant. We defined CDI by symptoms plus C. difficile toxin detection by polymerase chain reaction. Our primary outcome was hospital-onset CDI incidence on eligible hospital units, analyzed using segmented regression.
results. The study included 251 CDI episodes among 360,016 patient days during the baseline and intervention periods, and the incidence rate was 7.0 per 10,000 patient days. The incidence rate was similar during baseline and intervention periods (6.9 vs 7.0 per 10,000 patient days; P=.95). However, compared to the first 6 months of the intervention, we detected a significant decrease in CDI during the final 6 months (incidence rate ratio, 0.6; 95% confidence interval, 0.4–0.9; P=.009). Testing intensity remained stable between the baseline and intervention periods: 19% versus 20% of stools tested were C. difficile positive by PCR, respectively. From medical record reviews, only 26% of eligible patients received a probiotic per the protocol.
conclusions. Despite poor adherence to the protocol, there was a reduction in the incidence of CDI during the intervention, which was delayed ~6 months after introducing probiotic for primary prevention.
Infect Control Hosp Epidemiol 2018;39:765–770
While many proven interventions have successfully reduced certain healthcare-associated infections (HAIs),1 Clostridium difficile infection (CDI) remains common in many institutions. Strategies to reduce the risk of CDI (eg, reduced antimicrobial use and enhanced environmental cleaning)2 have been difficult to sustain across facilities. One challenge specific to controlling CDI is that the condition results in diarrhea, facilitating environmental surface contamination.3,4 In addition, C. diffi- cile spores are resistant to alcohol-based hand gel5 and most disinfectants used for room cleaning.6 To test a control strat- egy enhanced by the use of probiotics, we collaboratedwith the Illinois Department of Public Health to identify hospitals with high CDI rates as reported to the Centers for Disease Control and Prevention (CDC) that were actively engaged in infection prevention efforts (eg, hand hygiene and environmental
disinfection).We contacted these hospitals and identified a large teaching hospital with the capacity to implement a probiotic- based quality improvement intervention. Although most CDI cases can be treated with antibiotics,
primary prevention is critical for the following reasons: (1) almost 1 in 5 treated patients experiences a recurrence, and each recurrence increases the likelihood of treatment failure; (2) infected patients serve as a reservoir for ongoing trans- mission; and (3) implementation of contact isolation precau- tions can have deleterious consequences for patients.7 Also, CDI can result in severe disease, leading to colectomy and death. Because C. difficile is spread between patients,8 primary prevention reduces the risk of exposure for other patients. Some probiotic strains hold promise to interfere with colonization and/or infection with C. difficile. The appeal of
Medical Center, Oak Lawn, Illinois; 3. Loyola University Medical Center, Maywood, Illinois; 4. College of Pharmacy, University of Illinois, Chicago, Illinois. © 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2018/3907-0001. DOI: 10.1017/ice.2018.76
Affiliations: 1. Department of Medicine, Cook County Health & Hospitals System, Chicago, Illinois; 2. Division of Infectious Diseases, Advocate Christ Received December 5, 2017; accepted March 4, 2018; electronically published April 26, 2018
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