By Megan Headley
Medical campuses have led a sweeping trend in pushing patients toward outpatient centers, ensuring that more care happens in the community and not in the hospital. But with this trend, more outpatient centers—particularly surgery centers—are seeing an increase not just in patients, but also Clostridium difficile (C. diff) infections. C. diff was once associated primarily with hospital settings. However, an October 2017 study in Open Forum Infectious Diseases, “Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study,” found that from 2011 to 2014, instances of community-associated C. diff infections in the U.S. grew from 35% of all C. diff infections to 41%. The study highlights gaps in outpatient centers that healthcare providers and researchers are just now beginning to address.
Tracking risk factors
The Open Forum study, with support from the Centers for Disease Control and Prevention (CDC), tracked adult patients from 10 U.S. sites during 2014–2015. These patients had tested positive for C. diff as an outpatient or within three days of being hospitalized, and had not been admitted to a healthcare facility within the past 12 weeks. Each patient in the study was matched to a person who did not have a C. diff infection as a control. All of the 452 study participants were interviewed for detailed information about their health, including medication use, recent healthcare visits, household exposures, and diet.
The data indicated that larger percentages of patients with community-associated C. diff infections had prior outpatient healthcare visits (82%) and had taken antibiotics (62%), compared to individuals who were not infected (58% and 10%, respectively). But the study’s researchers also saw a correlation between receiving care in an emergency department (ED) within the past three months and encountering C. diff infection, independent of antibiotic use.
The researchers note that more study is needed to clarify EDs’ contribution to the transmission of C. diff in the community. However, co-author Alice Y. Guh, MD, MPH, of the CDC, speculates that high patient turnover, in addition to longer duration and greater contact with healthcare providers and the environment, may help explain why EDs and other settings with similar characteristics potentially pose a higher risk for C. diff transmission.
Like other recent studies have concluded, Guh and her fellow researchers agreed that outpatient antibiotic use also poses a primary risk factor for acquiring C. diff infection in the community. The most commonly reported indications for outpatient antibiotic use in the study included ear, sinus, and upper respiratory infections, and prophylactic antibiotics prior to dental procedures.
Guh also participated in a CDC-led analysis published in the same journal examining facility-level rates of hospital-onset C. diff infection; that study tracked a similar trend. In examining inpatient antibiotic use in a large group of U.S. acute care hospitals over a seven-year period, the researchers found that for every 50 days of therapy/1,000 patient days increase in antibiotic use, there was a 4.4% increase in the hospital-onset C. diff infection rate.
“There is a lot of work that needs to be done in terms of improving outpatient prescribing practices and making sure that providers are appropriately prescribing antibiotics,” commented Guh in a news release issued on the latter report. “Healthcare-associated C. difficile infection is still a huge burden, but there is increasingly more recognition that community-associated C. difficile can occur. Outpatient antibiotic use is a risk factor, and we need to improve antibiotic stewardship not just in inpatient settings but also outpatient settings.”
Improving antibiotic stewardship across all facilities
As Guh mentions, outpatient facilities have their work cut out for them. That said, a boost in antibiotic stewardship could help control C. diff not just in outpatient settings, but throughout the healthcare industry.
“Some of the most recent literature, as well as the article published in Open Forum, indicate improved antibiotic (and other medication) stewardship may address many infection control issues, such as C. difficile rates,” says Naomi Kuznets, PhD, vice president and senior director of the Accreditation Association for Ambulatory Health Care Inc.’s (AAAHC) Institute for Quality Improvement.
It’s for this reason that The Joint Commission began implementation of a Medication Management standard, MM.09.01.01, in January 2017 that requires accredited hospitals, critical access hospitals, and nursing care centers to have an antibiotic stewardship program in place. But as Elizabeth Eaken Zhani, media relations manager for The Joint Commission, points out, “It is too early to know whether the standard has actually impacted prescribing of antibiotics.” Zhani adds, “We have been discussing with the CDC how we can measure this.”
At present, The Joint Commission is monitoring 2017 survey findings to determine if additional work is needed on the current standard, and working on a project to research the expansion of antimicrobial stewardship to the ambulatory accreditation setting.
The Joint Commission’s research aligns with the work of the Centers for Medicare and Medicaid Services (CMS) in this area. In 2016, CMS issued a proposed rule that would, among other things, promote antibiotic stewardship in hospitals and critical access centers.
“The CDC defines antibiotic stewardship activities as efforts to improve and measure antibiotic prescribing by minimizing inappropriate antibiotic prescribing and overuse, as well as ensuring the right drug, dose, and duration are selected when antibiotics are needed,” Kuznets says. The CDC’s antibiotic stewardship program includes a program checklist, insight on implementation, and case studies demonstrating successful programs.
Lest this focus on hospital settings leave outpatient centers out in the cold, the AAAHC Institute designed an Antibiotic Stewardship Toolkit to aid ambulatory health facilities in promoting appropriate antibiotic selection while reducing overuse through an overview of illnesses for which inappropriate antibiotic prescriptions are written. “Providers in ambulatory healthcare settings can use the toolkit as both a baseline assessment of policies and practices, and a resource for reviewing and expanding activities on a regular basis,” Kuznets says.
What outpatient centers can learn from small hospitals
Smaller hospitals are also taking new steps to develop antibiotic stewardship best practices. Researchers at Intermountain Healthcare and University of Utah Health in Salt Lake City have completed a study identifying strategies to help community hospitals with fewer than 200 beds develop more effective antibiotic stewardship programs.
In comparing three such programs in 15 small hospitals within Intermountain Healthcare for 15 months, researchers found the most effective program brought together infectious disease physicians and pharmacists at a central hospital with local pharmacists. These integrated programs reduced broad-spectrum antibiotic use by nearly 25% and total antibiotic use by 11%.
Each of the hospitals involved in the study was randomly assigned to one of three program types to determine which was most effective in reducing broad-spectrum antibiotic use. While having 24/7 access to infectious disease physicians via a hotline proved popular, this on its own wasn’t enough. Hospitals that were able to reduce antibiotic use applied the following strategies:
> Provided more advanced antibiotic stewardship education
> Provided a 24/7 infectious disease hotline staffed by infectious disease specialists
> Implemented a pharmacy-based initiative in which local pharmacists reviewed most antibiotic prescriptions and provided recommendations for improvement to prescribers
> Restricted certain broad-spectrum antibiotics, with only centralized infectious disease pharmacists able to approve their use
> Had infectious disease specialists review selected microbiology results and speak with local providers about recommendations for treatment
“Having an antibiotic stewardship program in place that ensures the right antibiotic is used for the right patient, at the right time, in the right dose and route, and for the right duration will help us protect the effectiveness of the antibiotics we use,” comments Eddie Stenehjem, MD, lead author and an infectious disease specialist with Intermountain Medical Center.
The bottom line, however, is that an ideal program has not yet been established and more research needs to be done to identify the right solution.
Inconsistent expectations for infection prevention
Of course, antibiotic use is not the only risk factor for the increase in community-associated C. diff infections, as noted in the Open Forum articles. The other leading risk is one that highlights a glaring shortcoming in many ambulatory care centers.
“Most freestanding clinics and EDs do not have trained infection preventionists,” points out Angela Vassallo, MPH, MS, CIC, FAPIC, vice chair of the Communications Committee within the Association for Professionals in Infection Control and Epidemiology (APIC).
Even in ambulatory care centers with on-staff infection preventionists, there tend to be major gaps in how infection control is managed, Vassallo finds. “In most outpatient settings, the title ‘infection preventionist’ is often handed to someone who has little to no training or experience in infection prevention and who has several other job responsibilities,” she says. “This makes it difficult—especially for those who have very little training—to focus on the task of preventing infections. It’s a big job that requires constant focus and agility. Infection preventionists must know their staff’s practices and their facility’s risks in order to improve them.”
At this point, improving consistency is likely to happen on a system-by-system basis. As of December 2015, per an article in Health Affairs by Harvard Medical School researchers, 32 states had collectively 400 freestanding EDs. The article focused on the regulatory situation—noting that 21 states had regulations allowing freestanding EDs, while 29 states had no regulations applying specifically to such EDs. State policies, the researchers found, varied widely on what freestanding EDs required in terms of staffing or clinical capabilities.
While the American College of Emergency Physicians has recommended core policies that freestanding EDs should adopt, the Harvard Medical School study found that “State requirements for freestanding EDs range from thorough and well-defined to vague or nonexistent. Patients may assume that freestanding EDs provide the same services as hospital-based EDs and seek care from a freestanding ED that is not capable of providing them with definitive care—which results in treatment delays that could adversely affect patient outcomes.”
While Vassallo urges that all healthcare settings—from outpatient clinics to freestanding EDs, ambulatory surgery centers, nursing homes, and doctors’ offices—invest in trained infection preventionists, she points out that the industry’s true need is education, not regulations.
“Infection prevention practices in healthcare settings are only as good as the team of trained experts who lead the charge. If there is not a trained expert in infection prevention, the staff’s practices are likely to be less than optimal,” she says. “Improving infection prevention practices in freestanding EDs takes ongoing education targeted at reducing healthcare-acquired infections.”
To that end, APIC is working on a collaborative project to improve infection prevention practices in California ambulatory surgery centers. “It is a shared model between California Department of Public Health, LA County Department of Public Health, and Health Services Advisory Group,” Vassallo explains. “Together we provide education, resources, and technical assistance to California ambulatory surgery centers.”
In addition, this year California APIC is focusing on providing more educational offerings for outpatient infection preventionists. And the California Ambulatory Surgery Association offers annual education for infection preventionists in ambulatory surgery center settings.
Ultimately, says Vassallo, “A collaborative approach provides the best opportunity to expand the breadth and reach needed to assist ambulatory surgery centers in such a large state. No one organization can do it alone.”
No single approach will be sufficient in reducing the spread of community-associated C. diff as evolving expectations around how healthcare is provided continue to push patients to local outpatient centers. Healthcare providers will need to work to close the gaps being revealed in this evolving model.
“Ambulatory surgery centers seem to be our most vulnerable healthcare facilities when it comes to infection prevention practices,” Vassallo adds. “They need more education targeted specifically to the work they do and the populations they serve. This change in mindset and focus on education will be the future of infection prevention over the next few years.”
Megan Headley is a freelance writer and owner of ClearStory Publications. She has covered healthcare safety and operations for numerous publications. Headley can be reached at firstname.lastname@example.org.