Incidence of Clostridium difficile Infection After Sepsis Protocol Antibiotics

• Published in: The western journal of emergency medicine Vol. 20; no. 6; pp. 977 - 981
• Main Authors: LaFave, Jordan, Levy, David, Gekle, Robert, Bramante, Robert
• Format: Journal Article
• Language: English
• Published: United States University of California Digital Library - eScholarship 24.10.2019; Department of Emergency Medicine, University of California, Irvine School of Medicine; eScholarship Publishing, University of California
• Subjects: Anti-Bacterial Agents - therapeutic use; Antibiotics; Clinical Protocols; Clostridium Infections - diagnosis; Clostridium Infections - drug therapy; Emergency Service, Hospital; Humans; Incidence; Retrospective Studies; Sepsis; Sepsis - drug therapy; Sepsis - physiopathology
• ISSN: 1936-900X; 1936-9018; 1936-9018
• DOI: 10.5811/westjem.2019.10.42070

The management of sepsis includes the prompt administration of intravenous antibiotics. There is concern that sepsis treatment protocols may be inaccurate in identifying true sepsis and exposing patients to potentially harmful antibiotics, sometimes unnecessarily. This study was designed to investigate those concerns by focusing on in-hospital Clostridium difficile infection (CDI), which is a known complication of exposure to antibiotics. Our emergency department (ED) recently implemented a protocol to help combat sepsis and increase compliance with the 2017 Sepsis CMS Core Measures (SEP-1) guidelines. In this single-center, retrospective cohort analysis we queried the electronic health record to gather data on nosocomial CDI and antibiotics prescribed over a five-year period to analyze the effect of the introduction of a sepsis protocol order set. The primary goal of this study was to measure the hospital-wide CDI rate for three years prior to implementation of the sepsis bundle, and then compare this to the hospital-wide CDI rate two years post-implementation. As a secondary outcome, we compared the number of antibiotics prescribed in the ED 12 months prior to administration of the sepsis protocol vs 12 months post-initiation. Over the course of five years, the hospital averaged 9.4 nosocomial CDIs per 10,000 patient hours. Prior to implementation of the sepsis bundle, the average CDI rate was 11.6 (±1.11, 95%) and after implementation the average rate dropped to 6.2 (±1.27, 95%, p<0.01). The mean number of antibiotics ordered per patient visit was 0.33 (±0.015, 95%) prior to bundle activation, and, following sepsis bundle activation, the rate was 0.38 (±0.019, 95%, p<0.01). This accounted for 38% of all ED patient visits receiving antibiotics, a 5% increase after the sepsis bundle was introduced. In this study, we found that CDI infections declined after implementation of a sepsis bundle. There was, however an increase in the number of patients being exposed to antibiotics after this hospital policy change. There are more risks than just CDI with antibiotic exposure, and these were not measured in this study. Subsequent studies should focus on the ongoing effects of timed, protocolized care and the associated risks.