Hostname: page-component-586b7cd67f-gb8f7 Total loading time: 0 Render date: 2024-11-30T21:29:51.420Z Has data issue: false hasContentIssue false
  • English
  • Français

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

Published online by Cambridge University Press:  26 April 2018

William E. Trick ,
Stephen J. Sokalski ,
Stuart Johnson ,
Kristen L. Bunnell ,
Joseph Levato ,
Michael J. Ray  and
Robert A. Weinstein
William E. Trick*
Affiliation:
Department of Medicine, Cook County Health & Hospitals System, Chicago, Illinois
Stephen J. Sokalski
Affiliation:
Division of Infectious Diseases, Advocate Christ Medical Center, Oak Lawn, Illinois
Stuart Johnson
Affiliation:
Loyola University Medical Center, Maywood, Illinois
Kristen L. Bunnell
Affiliation:
College of Pharmacy, University of Illinois, Chicago, Illinois
Joseph Levato
Affiliation:
Division of Infectious Diseases, Advocate Christ Medical Center, Oak Lawn, Illinois
Michael J. Ray
Affiliation:
Department of Medicine, Cook County Health & Hospitals System, Chicago, Illinois
Robert A. Weinstein
Affiliation:
Department of Medicine, Cook County Health & Hospitals System, Chicago, Illinois
*
Address correspondence to William E. Trick, MD, Collaborative Research Unit, 1900 W Polk Street, Ste 1600, Chicago, IL 60612 ([email protected]).
Get access Rights & Permissions [Opens in a new window]

Abstract

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

We administered 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;765–770

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 39 , Issue 7 , July 2018 , pp. 765 - 770
Copyright
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1. Pronovost, P, Needham, D, Berenholtz, S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New Engl J Med 2006;355:2725–2732.CrossRefGoogle ScholarPubMed
2. Gerding, DN, Muto, CA, Owens, RC. Measures to control and prevent Clostridium difficile infection. Clin Infect Dis 2008;46:S43–S49.CrossRefGoogle ScholarPubMed
3. Trick, WE, Temple, RS, Chen, D, Wright, MO, Solomon, SL, Peterson, LR. Patient colonization and environmental contamination by vancomycin-resistant enterococci in a rehabilitation facility. Arch Phys Med Rehab 2002;83:899–902.CrossRefGoogle Scholar
4. Sethi, AK, Al-Nassir, WN, Nerandzic, MM, Donskey, CJ. Skin and environmental contamination with vancomycin-resistant enterococci in patients receiving oral metronidazole or oral vancomycin treatment for Clostridium difficile–associated disease. Infect Control Hosp Epidemiol 2009;30:13–17.CrossRefGoogle ScholarPubMed
5. McDonald, LC, Owings, M, Jernigan, DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996–2003. Emerg Infect Dis 2006;12:409–415.CrossRefGoogle ScholarPubMed
6. Dubberke, ER, Gerding, DN, Classen, D, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(Suppl 1):S81–S92.CrossRefGoogle ScholarPubMed
7. Stelfox, HT, Bates, DW, Redelmeier, DA. Safety of patients isolated for infection control. JAMA 2003;290:1899–1905.CrossRefGoogle ScholarPubMed
8. Johnson, S, Clabots, CR, Linn, FV, Olson, MM, Peterson, LR, Gerding, DN. Nosocomial Clostridium difficile colonisation and disease. Lancet 1990;336:97–100.CrossRefGoogle ScholarPubMed
9. Goldenberg, JZ, Ma, SS, Saxton, JD, et al. Probiotics for the prevention of Clostridium difficile–associated diarrhea in adults and children. Cochrane Libr 2013.CrossRefGoogle Scholar
10. Lau, CS, Chamberlain, RS. Probiotics are effective at preventing Clostridium difficile–associated diarrhea: a systematic review and meta-analysis. Int J Gen Med 2016;9:27–37.Google ScholarPubMed
11. Johnson, S, Maziade, PJ, McFarland, LV, et al. Is primary prevention of Clostridium difficile infection possible with specific probiotics? Int J Infect Dis 2012;16:786–792.CrossRefGoogle ScholarPubMed
12. Beausoleil, M, Fortier, N, Guenette, S, et al. Effect of a fermented milk combining Lactobacillus acidophilus CL1285 and Lactobacillus casei in the prevention of antibiotic-associated diarrhea: a randomized, double-blind, placebo-controlled trial. Canad J Gastroenterol 2007;21:732–736.CrossRefGoogle ScholarPubMed
13. Sampalis, J, Psaradellis, E, Rampakakis, E. Efficacy of BioK+ CL1285 in the reduction of antibiotic-associated diarrhea–a placebo-controlled double-blind randomized, multi-center study. Arch Med Sci 2010;6:56–64.Google Scholar
14. Gao, XW, Mubasher, M, Fang, CY, Reifer, C, Miller, LE. Dose-response efficacy of a proprietary probiotic formula of Lactobacillus acidophilus CL1285 and Lactobacillus casei LBC80R for antibiotic-associated diarrhea and Clostridium difficile-associated diarrhea prophylaxis in adult patients. Am J Gastroenterol 2010;105:1636–1641.CrossRefGoogle ScholarPubMed
15. Maziade, P-J, Andriessen, J, Pereira, P, Currie, B, Goldstein, E. Impact of adding prophylactic probiotics to a bundle of standard preventative measures for Clostridium difficile infections: enhanced and sustained decrease in the incidence and severity of infection at a community hospital. Curr Med Res Opin 2013;29:1341–1347.CrossRefGoogle Scholar
16. Goldstein, EJ, Citron, DM, Claros, MC, Tyrrell, KL. Bacterial counts from five over-the-counter probiotics: are you getting what you paid for? Anaerobe 2014;25:1–4.CrossRefGoogle ScholarPubMed
17. McDonald, LC, Coignard, B, Dubberke, E, Song, X, Horan, T, Kutty, PK. Recommendations for surveillance of Clostridium difficile–associated disease. Infect Control Hosp Epidemiol 2007;28:140–145.CrossRefGoogle ScholarPubMed
18. Longtin, Y, Paquet-Bolduc, B, Gilca, R, et al. Effect of detecting and isolating Clostridium difficile carriers at hospital admission on the incidence of c difficile infections: a quasi-experimental controlled study. JAMA Intern Med 2016;176:796–804.CrossRefGoogle ScholarPubMed
19. Song, X, Srinivasan, A, Plaut, D, Perl, TM. Effect of nosocomial vancomycin-resistant enterococcal bacteremia on mortality, length of stay, and costs. Infect Control Hosp Epidemiol 2003;24:251–256.CrossRefGoogle ScholarPubMed
20. Averill, RF, McCullough, EC, Goldfield, N, Hughes, JS, Bonazelli, J, Bentley, L. 3M APR DRG classification system: methodology overview. Agency for Healthcare Research and Quality website. https://www.hcup-us.ahrq.gov/db/nation/nis/grp031_aprdrg_meth_ovrview.pdf. Published 2013. Accessed July 6, 2017.Google Scholar
21. Hernan, MA, Robins, JM. Per-protocol analyses of pragmatic trials. New Engl J Med 2017;377:1391–1398.CrossRefGoogle ScholarPubMed
22. Weber, DJ, Rutala, WA, Miller, MB, Huslage, K, Sickbert-Bennett, E. Role of hospital surfaces in the transmission of emerging health care-associated pathogens: norovirus, Clostridium difficile, and Acinetobacter species. Am J Infect Control 2010;38:S25–S33.CrossRefGoogle ScholarPubMed
23. Samore, MH, Venkataraman, L, DeGirolami, PC, Arbeit, RD, Karchmer, AW. Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea. Am J Med 1996;100:32–40.CrossRefGoogle ScholarPubMed
24. Halpin, AL, McDonald, LC. The dawning of microbiome remediation for addressing antibiotic resistance. Clin Infect Dis 2016;62:1487–1488.CrossRefGoogle ScholarPubMed
25. Freedberg, DE, Salmasian, H, Cohen, B, Abrams, JA, Larson, EL. Receipt of antibiotics in hospitalized patients and risk for Clostridium difficile infection in subsequent patients who occupy the same bed. JAMA Intern Med 2016;176:1801–1808.CrossRefGoogle ScholarPubMed
26. Aroutcheva, A, Auclair, J, Frappier, M, et al. Importance of molecular methods to determine whether a probiotic is the source of lactobacillus bacteremia. Probiot Antimicrob Prot 2016;8:31–40.CrossRefGoogle ScholarPubMed
27. McFarland, LV, Huang, Y, Wang, L, Malfertheiner, P. Systematic review and meta-analysis: multi-strain probiotics as adjunct therapy for Helicobacter pylori eradication and prevention of adverse events. United Eur Gastroen J 2015;4:546–561.CrossRefGoogle ScholarPubMed
28. Johnston, BC, Ma, SS, Goldenberg, JZ, et al. Probiotics for the prevention of Clostridium difficile–associated diarrhea: a systematic review and meta-analysis. Ann Intern Med 2012;157:878–888.CrossRefGoogle ScholarPubMed