C. difficile: Infection prevention and pharmacy considerations
In the United States, Clostridium difficile is the most frequently reported nosocomial infection. Nosocomial C. difficile is estimated to quadruple the cost of hospitalization and leads to an approximate $1.5 billion increase in annual expenditures in the U.S. C. difficile will continue to be a burden for infection prevention programs and a target for antimicrobial stewardship efforts in the acute care setting and in the community.
Prevention of C. difficile
A task for all hospital infection prevention programs should be to monitor the rate of hospital-acquired C. difficile. An important role for infection preventionists is to catch when C. difficile rates start climbing in real-time, investigate the increase, and take action to drive rates down. A rise in C. difficile rates in a hospital can often be attributed to an increase in environmental burden, inadequate prevention methods by health care workers, or an increase in antibiotic use. To combat a potential increase in environmental burden, the infection control program should work with environmental services to ensure rooms previously occupied by a patient with C. difficile are being adequately terminally cleaned, appropriate cleaning products are being used, and staff members have been adequately trained to clean these high-risk rooms.
All health care workers entering a room where the patient has C. difficile should follow the necessary contact precautions, which include wearing required gloves and gowns. It is also imperative that health care workers follow proper hand hygiene. The introduction of alcohol-based hand sanitizers greatly improved hand hygiene rates, but it is well known that alcohol-based hand sanitizers do not kill C. difficile spores. Hand washing with soap and water is essential when caring for a patient with C. difficile or after leaving a potentially contaminated environment. Infection prevention programs often monitor hand hygiene rates and should continue to stress the importance of proper hand hygiene, especially when caring for patients with C. difficile as to limit its transmission to other patients.
There are a few pharmacological preventive measures that should be considered. In theory, gastric acid suppressants, such as proton pump inhibitors and histamine-2 receptor antagonists, allow more C. difficile organisms to survive passage through the stomach and reach the colon. Unfortunately, C. difficile spores are resistant to gastric acid. Whether or not the use of gastric acid-suppressing agents increase the risk for C. difficile infection remains controversial. Some investigators have reported an increased risk for C. difficile infection associated with the use of gastric acid suppressants, while others have not. Nonetheless, hospitalized patients are frequently started on gastric acid suppressants unnecessarily, so it is prudent to verify that a patient has an indication for a gastric acid suppressant before therapy is initiated. If there is no indication, discontinuing the acid suppressant may decrease the risk for C. difficile.
Use of probiotics has been protective against noninfectious antibiotic-associated diarrhea. The ability of probiotics to prevent antibiotic-associated C. difficile infection is uncertain. Routine use of probiotics for prevention of C. difficile is not recommended at this time. Some clinicians have attempted to prevent C. difficile infections in patients receiving antibiotics without diarrhea or any other symptoms of C. difficile infection by prescribing metronidazole or oral vancomycin. This practice is likely to cause more harm than good. Exposure to any antibiotic, including those used for C. difficile infection treatment, can increase the risk for C. difficile infection as they disturb microbiota, a known risk factor for development of C. difficile infection. Vancomycin use also has been associated with an increase in vancomycin resistance in other organisms.
Opportunity for outpatient pharmacists
Reducing the rates of hospital-acquired C. difficile has long been a goal of antimicrobial stewardship programs as antibiotic use is the leading risk factor in developing C. difficile infection. The majority of C. difficile infections are hospital-acquired, but community-acquired infections have been on the rise and may account for nearly one-third of new cases. A key factor in reducing the rate of C. difficile infections in the community is to use antibiotics in outpatients more judiciously. One way to do this is to utilize community and discharge pharmacists. There is a lack of information available to community pharmacists when filling antimicrobial prescriptions. Pharmacists often have no more than patient demographics, allergy information, previous medications filled by that specific pharmacy, and information on the current prescription, which is sometimes furnished by the patient or caregiver. While outpatient or discharge pharmacies located within health systems or hospitals may have access to electronic medical records (EMR), microbiology culture and sensitivity results, and provider notes explaining treatment rationales, the majority of community pharmacies do not share this luxury. Frequent calls to providers for clarification are cumbersome and disruptive to both medical and pharmacy staff, delay dispensing of medication, and are not a practical solution for gathering information to assess the appropriateness of the antimicrobial prescription. In this environment, pharmacists are relegated to simply ensuring the product dispensed meets the request set forth by the prescriber. Without additional information, pharmacists are unable to assist in valuable ways that would promote antimicrobial stewardship, including antibiotic selection, dose optimization and duration of therapy.
Increased utilization of available pharmacy services at discharge could help bridge the gap between hospital and community care. Inpatient, outpatient and discharge pharmacists can provide valuable input when selecting an appropriate antimicrobial agent, converting from an IV agent to a targeted oral equivalent, monitoring for proper duration of therapy, and reviewing relevant comorbidities that may affect therapy (eg, renal or hepatic function). Furthermore, utilization of discharge or outpatient pharmacies with access to patients’ EMR will ensure pharmacists have relevant information available when assessing antimicrobial appropriateness and that patients are leaving the facility with necessary medications in hand, thus promoting medication adherence.
Pharmacists in the community setting could benefit from improved information availability during the dispensing process. This could be accomplished by stating the indication for the antibiotic, causative pathogen (if known), renal function and other pertinent factors related to the prescription. This additional communication with pharmacy professionals may result in improved antimicrobial stewardship efforts. Electronic prescriptions also could be enhanced to include some of these key pieces of information, which are needed to assess the appropriateness of an antimicrobial prescription. These efforts can decrease the overall cost of care, antimicrobial resistance and complications from antimicrobial therapy, including C. difficile infection.
Ultimately, C. difficile is costly, and incidence is on the rise, especially in the community. Infection prevention measures inside the hospital, where the majority of C. difficile infections occur, will continue to be important in the battle against C. difficile. Infection prevention in the community is much more difficult. Since antibiotic use is a major risk factor for acquiring C. difficile infection, antimicrobial stewardship initiatives to increase the appropriateness of antibiotic use in the community should have a positive impact on the rate of community-acquired C. difficile infections. One place to focus these antimicrobial stewardship efforts is in community and discharge pharmacies. By applying the principles of infection prevention and antimicrobial stewardship, the incidence of C. difficile infection in both hospital and community settings can be reduced dramatically.
- Allen SJ, et al. Lancet. 2013;doi:10.1016/S0140-6736(13)61218-0.
- Gao XW, et al. Am J Gastroenterol. 2010;doi:10.1038/ajg.2010.11.
- Hempel S, et al. JAMA. 2012;doi:10.1001/jama.2012.3507.
- Hickson M, et al. BMJ. 2007;doi:10.1136/bmj.39231.599815.55.
- Khanna S, et al. Am J Gastroenterol. 2012;doi:10.1038/ajg.2011.398.
- Leffler DA, et al. N Engl J Med. 2015;doi:10.1056/NEJMc1506004.
- For more information:
- Kati Shihadeh, PharmD, is a clinical pharmacy specialist in infectious diseases at Denver Health Medical Center, Denver. Shihadeh can be reached at firstname.lastname@example.org.
- Brandon Ferlas, PharmD, MS, is a pharmacy manager at Centura Health in Denver.
Disclosure: Ferlas and Shihadeh report no relevant financial disclosures.