Reducing Clostridium Difficile Infection Rates by Reducing the Duration of Fluoroquinolones

From the 2018 HVPAA National Conference

Steven Allen (Grand Strand Medical Center), Andrew Mangano (Grand Strand Medical Center), Hajra Awwab (Grand Strand Medical Center), Mohamed Faris (Grand Strand Medical Center)

Background

Clostridium difficile infection (CDI) rates at our community hospital were higher than acceptable. Our typical prescribed fluoroquinolone duration was greater than standard guidelines.  Fluoroquinolones incur one of the greatest risk of CDI. We focused on fluoroquinolone duration for community acquired pneumonia, acute COPD exacerbation, simple UTI, complicated UTI, and colitis.

Objectives

To implement mechanisms into our electronic medical records to reduce fluoroquinolone antibiotic use in efforts to reduce the rates of CDI

Methods

We performed chart audits for patients from our EMR who received FQs during their hospital stay for the following infections: community acquired pneumonia (CAP), acute chronic obstructive pulmonary disease exacerbation (ACOPDE), simple urinary tract infection (UTI), complicated UTI, and colitis. Our baseline data was gathered for three months, from May through June 2017.

Our first intervention in August 2017 added a duration and indication screen when ordering antibiotics, with pre-selected days for common infections.  CAP duration was levofloxacin 750 mg for five days. ACOPED duration was levofloxacin 750 mg for five days. Simple UTI was ciprofloxacin 250mg twice a day for three days or levofloxacin 750 mg for three days.  Complex UTI was defined as male patient or pyelonephritis. Bacteremia was excluded due to most patients having infectious disease consult and management. The duration of levofloxacin was 750 mg for 7 days and ciprofloxacin was 500mg BID for seven days.   Colitis was ciprofloxacin 500mg for 14 days or levofloxacin 750 mg for 14 days.

The second intervention occurred in November 2017.  An additional pop up was added that warned physicians if the patient was on previous antibiotics before ordering a similar class, thus they could adjust the duration appropriately

Results

The average total days patients were exposed to fluoroquinolones did decrease after implementation of these two steps. After baseline data was collected we performed chart review at two intervals. In October 2017, data was collected to assess the duration and indication screen effectiveness.  In January 2018 data was collected to reflect the addition of the pop-up box. The data we collected is as follows: CAP fluoroquinolone days were 9.4, 8.1, and 7.83 respectively.  Acute COPD exacerbation days were 6.84, 5.57, and 6.18. Simple UTI days were 7.1, 5.1, and 4.9. Complex UTI days were 15.1, 9.6, and 10.8. Colitis days were 9.7, 11.2, and 11.45 respectively.

With the decrease in antibiotic use, there was a concurrent decrease in CDIs.  The first six months prior to our implementation there were sixteen cases of CDI.  After these interventions the hospital had eight cases of CDI for the following six months.

Conclusion

We were able to reduce the duration of use of fluoroquinolones for community acquired pneumonia, Acute COPD exacerbation, simple UTI, and complex UTI.  This correlated with a reduction in CDI in our hospital. Colitis days did not change but fluoroquinolone duration was within standard practice prior to intervention.  The addition of a duration and indication screen plus a pop up box warning when on previous antibiotics has been effective at our hospital to reduce the number of clostridium difficile infections

Implications for the Patient

Reducing the use of fluoroquinolones in our community hospital have reduced our rate of CDI.  This in turn reduced morbidity and mortality as well as cost for the hospital and the patient.