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Clostridium difficile Progress Lags Other Infection-Control Goals

Jsnuary 15, 2013, AJHP News]

Kate Traynor

WASHINGTON, DC 28 Dec 2012—When it comes to infection rates, what goes up doesn't necessarily come down, at least for Clostridium difficile.

At first glance, data unveiled in Washington, D.C., during a November 27 conference on health care-associated infections indicate that C. difficile infection rates in hospitals may be rising after what appeared to be a leveling off a year ago.

Paul Malpiedi, health scientist at the Centers for Disease Control and Prevention (CDC), said "very, very preliminary" data indicate a 28% increase during the first half of 2012 in the number of patients infected with C. difficile while hospitalized, compared with infections reported 2010–11.

Malpiedi's data came from CDC's National Healthcare Safety Network (NHSN). This Internet-based surveillance system is affected by reporting lags, and final data won't be submitted until this spring. Malpiedi said this makes it difficult to draw sound conclusions from the currently available information.

He also said that some hospitals switched to more sensitive C. difficile tests during the 2012 reporting period, possibly boosting the number of cases detected. The NHSN data on C. difficile will be adjusted for testing methods before the final figures for 2012 are released.

But data presented by Claudia Steiner, research medical officer for the Agency for Healthcare Research and Quality (AHRQ), also painted a poor picture for C. difficile infection-reduction efforts.

Steiner's preliminary figures for C. difficile infections in patients hospitalized last year—identified through the applicable International Classification of Diseases code—showed 12.9 infections per 1000 discharges, up from 11.6 per 1000 in the baseline year of 2008.

An AHRQ analysis last year found that the rate of hospital stays for patients with a primary or secondary diagnosis of C. difficile infection tripled from 1993 to 2008 and then leveled off to 109.6 hospitalizations per 100,000 population.

In all, these figures make it unlikely that the nation will meet its five-year goal for reducing hospitalizations due to C. difficile infection—one of nine areas addressed in the U.S. government's "National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination."

The action plan set a goal of a 30% reduction in laboratory-identified hospital-onset C. difficile infections by the end of this year.

During the November conference, a group of experts tasked with strategizing about C. difficile named a lack of research on endemic C. difficile infections as one of the barriers to progress. At the practice level, they said, there is a need to improve environmental and hand hygiene and to develop effective, physician-supported antimicrobial stewardship programs across the patient-care continuum.

Initiatives focused on other areas described in the action plan are on target to meet their year-end goals.

Don Wright, deputy assistant secretary for health care quality at the Department of Health and Human Services, said he is pleased with "the tremendous success that we've had in reducing infections over the last four years" since the action plan was released.

Wright said efforts to reduce central line-associated bloodstream infections (CLABSIs) have been the most successful of those specified in the action plan.

Malpiedi said the overall CLABSI rate for hospitals in 2011 represented a 41% reduction from the baseline rate and is consistent with attaining the year-end target of a 50% reduction.

Intensive care units (ICUs) reduced their CLABSI rate by 44% overall in 2011, compared with a 36% reduction in hospital wards.

"This goes to show you that progress is good everywhere, . . . but there is work to be done in the wards," Malpiedi said.

Essentially the opposite scenario is playing out for catheter-associated urinary tract infections (CAUTIs). Malpiedi said these infections fell by 15% in hospital wards during 2011 from the baseline rate but dropped by just 1% in ICUs. The combined rate of reduction was 7%, he said.

Overall, efforts to combat CAUTIs are on track to meet the goal of a 25% reduction from the baseline by the end of 2014.

The action plan calls for a 25% reduction in hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) infections. So far, Malpiedi said, preliminary data for the first half of 2012 show a 5% reduction from the 2009–10 baseline period. CDC has extended the end date for attainment of the goal to December 31, 2015, because of a change in the way data are collected for this goal.

Malpiedi emphasized that MRSA-reduction efforts need to include both outpatient and inpatient settings. He said that half of all community-onset MRSA infections occur in patients discharged from a health care facility within the past three months, and a quarter occur in patients undergoing dialysis.

He also said CDC surveillance data indicate that CLABSIs caused by S. aureus are now half as frequent as infections caused by enterococci and gram-negative organisms.

Malpiedi said there has been a downward trend in surgical-site infections (SSIs) since 2008, and the 25%-reduction goal is expected to be met. Preliminary data show a 17% overall reduction in SSIs during 2011, although the reduction rate has varied by procedure type.

"We see the highest reductions in the cardiac procedures, so, coronary bypass grafting and cardiac procedures in general," Malpiedi said. "There are . . . lower reductions in hip and knee arthroplasties, and also some slight reductions in the hysterectomies and abdominal hysterectomies."

Malpiedi said CDC will release a report by early this year that shows SSI data grouped by procedure type.

 

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