Reduction of Clostridium Difficile Infection in an Academic Medical Center Blood and Marrow Transplant Population

Background/Aim: Clostridium difficile infection (CDI) is the leading cause of infectious diarrhea among hospitalized patients. Blood and Marrow Transplant patients appear to be one of the most vulnerable populations due to previous antimicrobial exposure, graft vs. host disease and prolonged hospitalizations. CDI in cancer patients is associated with higher mortality rates and prolonged hospitalization. CDI affects the course of the disease by delaying treatments such as chemotherapy. Furthermore, the estimated CDI infection-related costs are 4.8 billion dollars for acute care facilities alone.

Methods: In 2015, an increase in house-wide CDI at Robert Wood Johnson University Hospital occurred and triggered an extensive analysis of these cases with Blood and Marrow Transplant and leukemic patients totaling 30% of all CDI in the hospital in 2019. This increase occurred despite the previous implementation of Tru D ultraviolet radiation for all CDI rooms and all Blood and Marrow Transplant unit rooms. Several other initiatives including decreased use of proton pump inhibitors, decreased utilization of piperacillin-tazobactam and house-wide monitoring of hand hygiene did not significantly decrease the percentage of CDI comprised by Oncology patients.

In 2018, various other CDI prevention initiatives included: daily Chlorhexidine bathing for adults, implementation of a nursing specimen collection sheet with CDI Criteria; cleaning with OxyCide sporicidal hospital disinfectant, and ongoing hand hygiene champion training with the implementation of an electronic hand hygiene system. Although this resulted in a house-wide CDI SIR < 1 for 3 out of 4 Quarters of 2018, which was a 13% decrease from 2017, there was still no change in the rates in oncology population comprising 25% of all CDI cases.

In 2019, CDI orders were updated to increase the denial of testing if patients received laxatives within the last 48 hours and work began with nursing to start screening upon admission for diarrhea within the past 48 triggering a CDI order. Again, the 2019 house-wide CDI SIR decreased (0.903) but Blood and Marrow Transplant and leukemic patients CDI increased, making up 30% of all CDI cases. A retrospective review of all oncology CDI cases was conducted, noting that all tested PCR positive. A Blood and Marrow Transplant- specific action plan was developed which included the initiation of prophylactic oral Vancomycin on admission for all allogeneic and autologous patients.

Results:

After implementation of prophylactic oral vancomycin, there have been 9 CDI in the first 7 months of 2020 in the oncology population and only 1 CDI in the Blood and Marrow Transplant and leukemic population during this timeframe. This is an 89% decrease from the same period of 2019 for the Blood and Marrow/leukemic population. In addition, only 3.7% of the house-wide CDI is from the Blood and Marrow Transplant and leukemic population; 23% of the house-wide CDI is from the Oncology population.

As of yet, np untoward effects have been seen after this implementation. The incidence of documented bacteremia has remained constant at approximately 1.5 patients/ quarter; acute GVHD in allogeneic patients has remained constant at approximately 4 patients/ quarter.

Conclusions:

The utilization of vancomycin prophylactically upon admission for all autologous and allogeneic patients may have a significant impact on CDI rates in the oncology population. More time is needed to evaluate the effects of this at Robert Wood Johnson University Hospital but this is the first and only intervention that has helped to decrease the CDI rates in Oncology in 5 years.

Next steps include participating in a national collaborative on CDI prevention with several other similar institutions to drive actions for improvement. Goals of this collaboration include strengthening our antibiotic stewardship committee, to have a dedicated staff person to coordinate CDI prevention activities including nurse and physician champions and to increase adherence to use of hand hygiene/ gowns/ gloves for families and visitors.