Incidence of Clostridium difficile infections related to the

Incidence of Clostridium difficile infections related to the administration of broadspectrum 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 A S B SA B BSA

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 p. H 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

The chance of becoming this hospitalized patient is increased by being administered these

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 Med. Mined® T 3 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 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

Va Zo nc syn om yc in Fl a Le gyl va qu in C C ef ipro tri ax Tr on im et Av e hel Su lfa Roc ox m e et ph ho in xa zo l Ty e G ga c ar am il yc C ila in Er stat i ta pe n n Az em C act lin a da m D my ox c yc in yc lin M e er re m Zy vo x Az ith Anc ry e om f C ef ycin ur ox im e Frequency of Administration Results 35 30 20 15 10 5 29 26 25 15 14 10 7 4 3 3 2 2 2 Broad-Spectrum Antibiotics 1 1 1 0

Results Most Frequent Two BSA Combinations BSA #1 Zosyn Vancomycin Levaquin Flagyl Zosyn 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 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 Trimeth. Sulfamethoxazol e Azactam Cefuroxime Clindamycin Total 6 9 14 0 2 0 0 14 1 5 1 1 1 6 1 4 1 3 1 1 2 0 0 0 0 1 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 Flagyl Zosyn 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 1 2 3 2 1 0 1 2 0 1 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: Total. Days Rec. ABX Rec. PPI 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 Rec. ABX*Rec. PPI Crosstabulation Rec. PPI No Count % of Total Rec. ABX Yes Count % of 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 Chi. Square N of Valid Cases Value df Asymp. Sig. (2 sided) 4. 222 1 0. 04 95 Exact Sig. (2 sided) Exact Sig. (1 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 • 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

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