CDC calls for better stewardship to combat C. difficile mortality

Although infection rates for most hospital-acquired infections are on the decline, rates for Clostridium difficile-associated diarrhea continue to climb and now account for about 14,000 deaths annually in the United States, according to the Centers for Disease Control and Prevention (CDC). CDC is calling on hospitals to exercise better antibiotic stewardship to help stem the tide.

"Nearly 50% of antibiotics are inappropriately prescribed," said Jan E. Patterson, MD, MS, president of the board of trustees for the Society for Health Epidemiology of America (SHEA). "The increased prevalence of C. difficile throughout healthcare settings demonstrates the need for better control and use of antibiotics, not only to preserve the efficacy of these life-saving drugs, but to prevent adverse events like C. difficile infection."

SHEA's support for antibiotic stewardship is a far cry from attitudes common in past decades. It wasn't until SHEA and the Infectious Diseases Society of America (IDSA) published joint infection control guidelines in 2007 that the infectious disease and infection control community officially recognized antibiotic use can affect infectious disease rates, patterns, and outcomes.

The American Society of Health-System Pharmacists (ASHP) has endorsed the joint SHEA/IDSA infection control guidelines. ASHP is also updating its own best practices compendium to address C. difficile control, said Shekhar Mehta, PharmD, MS, ASHP director, clinical guidelines and quality improvement.

Resistance is half of the problem with C. difficile infection. Morbidity and mortality are rising, too.

A new report from CDC's Vital Signs, Morbidity and Mortality Weekly Report, published March 9, 2012, found that the number of hospitalized patients with a C. difficile discharge diagnosis more than doubled from 139,000 in 2000 to 336,600 in 2009. The number of hospital patients with a primary C. difficile diagnosis more than tripled, from 33,000 to 111,000. Deaths related to C. difficile increased by 400% between 2000 and 2007, from 3,000 to 14,000, with more than 90% in patients ≥ 65 years.

Cost is also an issue. CDC noted that a single case of hospital-onset C. difficile added between $5,042 and $7,179 in care costs. That translates into an annual bill of somewhere between $897 million and $1.3 billion in excess healthcare costs.

"Antibiotic stewardship is a very important area for pharmacy to be involved," Shekhar said. "The emphasis on stewardship and more appropriate prescribing practices for prevention is growing."

That growing emphasis translates into increased demand for clinical pharmacists with infectious diseases training. SHEA and IDSA have launched antibiotic stewardship and infection control training programs for pharmacists across the country, Polk said.

"Hospitals are looking for pharmacists trained in antibiotic stewardship," he said. "The supply can't keep up with the demand. Infectious disease physicians and departments are desperate to hire pharmacists who have the knowledge and the expertise."

CDC also is urging more effective infection control measures, including better hand hygiene and cleansing of hard surfaces with bleach or another disinfectant that can kill C. difficile spores. But the problem is larger than infection control practices in any single institution.

Most C. difficile infections are associated with healthcare settings. About a quarter of infections initially appear in hospital patients, the other three-quarters in nursing home patients or those recently treated in outpatient settings.

"There is a greater appreciation for the morbidity and mortality that comes with C. difficile than ever before," Polk said. "There is broader recognition that we need to improve the quality of antibiotic prescribing. That has helped to solidify the relationship between infectious disease physicians and pharmacists."