Transcript Incidence of Clostridium difficile infections related to the

Incidence of Clostridium difficile infections
related to the administration of broad-spectrum
antibiotics and proton pump inhibitors
By: Jacob A. Foret, Dr. Amanda Eymard DNS, RN, CNE,
Mrs. Jeanne Hamner, RN, MSN
Nicholls State University
Thibodaux, LA
Clostridium difficile
.25 μm
Let’s Talk About C. difficile.
• What is Clostridium difficile?
• Gram positive bacteria
• Infection rates in hospitals
• 337,000 infected annually
• 14,000 deaths annually
• How is it spread?
• Fecal to oral route from bacterial spores
• Patients are placed on contact precautions
Let’s Talk About C. difficile.
• Where can C. difficile normally live?
• Digestive tract of any human or on surfaces inactivated
for two weeks.
• What kills on C. difficile surfaces or people’s hands?
• Surfaces – bleach
• People’s hands– only soap and water
• Alcohol gels do not kill C. difficile
• What does that mean for you?
• Anyone can potentially have a colonization without
symptoms.
Let’s Talk About C. difficile.
• What are complications to an infection?
• DEATH, subtotal colectomy, electrolyte depletion,
or metabolic acidosis
• How does death occur?
• Severe dehydration from uncontrollable diarrhea
• Financial Impact
• 1 billion dollars annually absorbed by health care
agencies
Known Contributors
Broad-spectrum antibiotics and proton pump inhibitors are known
contributors to a patient contacting C. difficile in the hospital
because of the mechanism of action of the medications.
Broad-Spectrum Antibiotics
• Intended Purpose
• Destroy harmful bacteria that cause disease in
humans
• Actual Effects
• Destroy harmful bacteria and also the natural flora
• Relation to C. difficile
• The natural flora helps protect against C. difficile by
keeping a healthy, natural balance.
Broad-Spectrum Antibiotics
Proton-Pump Inhibitors
• What are proton-pump inhibitors?
• A class of medications that inhibits the production
of hydrochloric acid of the stomach through
blocking proton pumps.
• How does this relate to C. difficile?
• Raising the pH of gastric contents can lower the
body’s primary GI defense mechanism against C.
difficile.
Let’s Talk About You and Me
• How does this affect you and me?
• How many of you have ever been prescribed a
broad-spectrum antibiotic for a cold or upper
respiratory infection?
• How many of you have taken a drug to lower the
amount of acid in your stomach?
• Or, how many of you know someone that fits into
the two criteria above?
• Criteria met?
• Have a higher potential to contract C. difficile
Why Do Research?
• Purpose
• Determine if a single BSA or PPI or a combination
of BSAs and a PPIs occur more frequently in
patients with a positive C. difficile lab culture during
hospital admission
• Goal
• Raise awareness in healthcare systems that
medication administration plays a vital role in
patients contracting C. difficile infections
• Share results with local healthcare organizations
regarding correlation between BSAs and PPIs and the
incidence of C. difficile infections
Methodology
• Design
• Retrospective chart review of patient data relevant
to the diagnosis of C. difficile that was retrieved
from two hospitals
• Sample
•
•
•
•
Convenience sampling was utilized
Inclusion Criteria
Infection Control Nurse and MedMined®
T3 Power Analysis
Methodology
• Data
• Demographics and medications administered
during hospital stay
• Data Analysis
• Descriptive statistics, ANOVA, Chi-square, and
linear regression were utilized in the program of
SPSS (v.19)
• Multiple cross tabulations were also conducted to
illustrate combination therapy
Descriptive Statistics
• The average age of patients was 64.52 with a standard
deviation of 17.78
• 65.1% of patients were female and 34.9% were male
• The average number of days a BSA was administered
was 11.24 with a standard deviation of 11.16
• The average number of days a PPI was administered
was 10.47 days with a standard deviation of 11.13
Results
35
Frequency of
Administration
30
29
26
25
20
15
10
5
15
14
10
7
4
3
3
2
2
2
2
2
2
1
1
0
Broad-Spectrum Antibiotics
1
1
1
1
Results
Most Frequent Two BSA
Combinations
BSA #1
Zosyn
Vancomycin
Levaquin
Levaquin
Flagyl
Flagyl
Flagyl
Zosyn
Zosyn
Zosyn
Zosyn
Vancomycin
Vancomycin
Vancomycin
Vancomycin
BSA #2
Vancomycin
Cipro
Flagyl
Zosyn
Cipro
Zosyn
Vancomycin
Garamycin
Cipro
Cilastatin
Rocephin
Garamycin
Ceftriaxone
Azactam
Clindamycin
# of Cases
15
5
4
4
4
3
3
2
2
2
2
2
2
2
2
Vancomycin and
Piperacillin/tazobactam
(Zosyn) in combination
occurred in 15 out of 80
cases in which more than
one BSA was administered
to a patient.
Results
Frequency of Administration
60
50
47
57 patients were
administered a PPI.
Pantoprozole (Protonix)
was the most frequent PPI
administered in
singularity with 47 cases.
40
30
20
10
8
2
0
Protonix
Prilosec
Zantac
Proton Pump Inhibitors
Total ABX*PPI Crosstabulation
PPI
Protonix Prilosec Zantac
Levaquin
Flagyl
Zosyn
Doxycycline
Rocephin
Tygacil
Merrem
Vancomycin
Garamycin
Cipro
Ancef
Cilastatin
Ertapenem
Ceftriaxone
Avelox
TrimethSulfamethoxazol
e
Azactam
Cefuroxime
Clindamycin
Total
Total
6
9
14
0
2
0
0
14
1
5
1
1
1
6
1
4
1
3
1
1
1
1
2
0
0
0
0
0
0
2
0
0
0
0
0
0
0
1
0
0
0
0
0
0
1
10
10
17
1
3
1
1
17
1
5
1
1
1
6
4
2
0
0
2
1
1
1
66
0
0
0
16
1
0
0
3
2
1
1
85
A cross-tabulation was
performed that
measured how many
occurrences a PPI was
administered in
combination with a
BSA.
Results
Zosyn
Vancomyci
n
Levaquin
Levaquin
Flagyl
Flagyl
Flagyl
Zosyn
Zosyn
Zosyn
Zosyn
Vancomyci
n
Vancomyci
n
Vancomyci
n
Vancomyci
n
Crosstabulation ABX*PPI
Protonix Prilosec
Vancomycin
15
7
1
Zantac
0
Cipro
Flagyl
Zosyn
Cipro
Zosyn
Vancomycin
Garamycin
Cipro
Cilastatin
Rocephin
5
4
4
4
3
3
2
2
2
2
1
2
1
2
3
2
1
0
1
2
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Garamycin
2
1
0
0
Ceftriaxone
2
2
0
0
Azactam
2
1
Clindamycin
2
1
1
0
0
A cross-tabulation
was performed that
measured how many
occurrences two
BSAs were
administered in
combination with a
PPI.
Results
Descriptive Statistics for Each Group
Dependent Variable: TotalDays
RecABX RecPPI
No
Yes
Total
No
Yes
Total
No
Yes
Total
No
Yes
Total
Mean
Std.
Deviation
N
5.18
6.71
5.87
8.29
16.69
13.89
6.89
14.2
11.24
3.206
5.567
4.418
6.109
13.906
12.485
5.203
13.057
11.161
17
14
31
21
42
63
38
56
94
Patients who received
no BSAs and PPIs
stayed an average of
5.18 days and patients
who received both
stayed an average of
16.69.
Results
RecABX*RecPPI Crosstabulation
RecPPI
No
Count
% of Total
RecABX
Yes
Count
% of Total
Total
Count
% of Total
Total
No
Yes
17
14
31
17.9%
14.7%
32.6%
21
43
64
22.1%
45.3%
67.4%
38
57
95
40.0%
60.0%
100.0%
Chi-Square Tests
Pearson ChiSquare
N of Valid
Cases
Value
df
Asymp.
Sig. (2sided)
4.222
1
0.04
95
Exact
Exact
Sig. (2- Sig. (1sided) sided)
Chi-square analysis was
conducted on patients who
received either a BSA or
PPI. 45.3% of the patients
in the study received both a
PPI and BSA. Pearson
regression was conducted
showing a p = 0.04.
Limitations
• BSA administration in the study was not uniform, but
more patients received BSAs and PPIs in combination
than patients with single BSA administration.
• The study included data from patients who were
admitted for the primary diagnosis of C. difficile. Home
medication lists were not performed on some of these
patients resulting in no BSA or PPI data.
• Retrospective chart review was performed by a single
researcher.
Conclusions
• Conclusions
• Piperacillin/tazobactam (Zosyn) was administered more
frequently than any other BSA, in combination with
other BSAs, and in combination with PPIs.
• Pantoprazole (Protonix) accounted for the majority of
PPI usage in the hospital.
• The administration of BSAs and PPIs together correlate
with a patient having a positive C. difficile lab result in
the hospital.
• Future Studies
• The study should be expanded to additional facilities to
include a broader sample of prescribers. A control group
should be utilized to support BSAs and PPIs in
combination have the potential to cause C. difficile.
What Does It Really Mean?
• Home Implications
• Prescribers need to possibly be more conservative
with prescribing BSAs and PPIs, especially in
combination.
• Contributors to a patient contracting C. difficile have
been identified but are still currently being prescribed
to patient.
• Implications for practice
Acknowledgements
Acknowledgements cont.
Questions???