Antibiotic Stewardship: Part Three
It is time to place a spotlight on Clostridium difficile (C. diff). Clostridium difficile (C.diff.) is an infection that causes significant disruption in the nursing home setting as it is easily transmitted and difficult to treat. Overall, C. diff causes 250,000 infections per year and roughly 14,000 deaths. Furthermore, costs are greater than one billion dollars per year associated with C.diff. One main goal of a antibiotic stewardship is to help decrease C. diff occurrence. This article will describe some C. diff basics, prevention and treatment options, and ways an antibiotic stewardship may help decrease C. diff in a skilled nursing facility (SNF) environment.
Geriatrics are more susceptible to acquiring C.diff. This is thought to be due to increased antibiotic use, decreased immune function, and more likely to be on acid suppression therapy (omeprazole, pantoprazole, etc.). A study in Canada showed that geriatric residents are 10 times more likely to acquire C.diff. Signs and symptoms include watery or green diarrhea (5-15 episodes/day), abdominal pain, appetite loss, and fever. This diarrhea is particularly harmful to our residents as it further amplifies dehydration in the elderly. Studies in long term care facilities (LTCs) showed that up to 27% of those referred to the hospital were dehydrated. Combine dehydration and a C. diff infection and you have a recipe for significantly increased hospitalization and mortality risk.
Treatment options are somewhat limited and may not always work. For this reason, prevention practices are vital. An antibiotic stewardship involves a substantial prevention system that should involve consistent training of current and new employees of proper C. diff prevention practices. This includes proper hand washing (alcohol does not kill C. diff!), isolation precautions, and bleach based cleaning protocols. Treatments include the use of metronidazole, oral vancomycin, Dificid (fidaxomicin – expensive), and fecal implants. Determining which one to use depends on the complications and if recurrence has occurred.
One main function of an antibiotic stewardship is decreasing the use of broad spectrum antibiotics. Broad spectrum antibiotics are those that are effective against both many gram positive and gram negative bacteria. All antibiotics increase C. diff risk, but penicillins (Augmentin, Zosyn), fluoroquinolones (Cipro and Levaquin), clindamycin, and certain cephalosporins (cefuroxime, cefpodoxime, etc.) are more likely to lead to C.diff. C. diff occurs when the normal bacteria are removed by an antibiotic and C. diff is allowed to flourish. Strategies used in stewardship to decrease broad spectrum antibiotic use include automatic stop orders for evaluation, antibiogram utilization, education, and guideline implementation. Proper implementation of these strategies leads to more targeted antimicrobial therapy, which helps avoid broad spectrum antibiotics and therefore less C.diff.
When implementing your stewardship, I recommend placing C. diff in a spotlight of proper prevention and treatment. Thwarting this infection will lead to decreased hospitalizations and mortality for your nursing home. The elderly are much more susceptible to this infection so it is even more important that a stewardship program is properly implemented. Please do not hesitate to contact your consultant pharmacist regarding further C. diff information and trainings, and partner with Mercury Pharmacy to help prevent C. diff in all of the residents we serve.
Grant Walker, PharmD
Lavizzo-Mourey R, Johnson J, Stolley P. Risk factors for dehydration among elderly nursing home residents. J Am Geriatr Soc 1988;36:213-8.
Bourdel-Marchasson I, Proux S, Dehail P, et al. One-year incidence of hyperosmolar states and prognosis in a geriatric acute care unit. Gerontology 2004;50:171-6.