Cost burden of Clostridioides difficile infection to the health service: A retrospective cohort study in Scotland.

BACKGROUND: Clostridioides difficile infection (CDI) is associated with high healthcare demands and related costs. AIM: To evaluate the healthcare and economic burden of CDI in hospitalized patients with community- (HOCA-CDI) or hospital-associated CDI (HOHA-CDI) in the National Health Service in Scotland. METHODS: A retrospective cohort study was conducted, examining data between August 2010 and July 2013 from four patient-level Scottish datasets, linked to death data. Data examined included prior antimicrobial prescriptions in the community, hospitalizations, length of stay and mortality. Each CDI case was matched to three hospital-based controls on the basis of age, gender, hospital and date of admission. Descriptive economic evaluations were based on bed-day costs for different types of wards. FINDINGS: Overall, 3304 CDI cases were included in the study. CDI was associated with additional median lengths of stay of 7.2 days for HOCA-CDI and 12.0 days for HOHA-CDI compared with their respective, matched controls. The 30-day mortality rate was 6.8% for HOCA-CDI and 12.4% for HOHA-CDI. Overall, recurrence within 90 days of the first CDI episode occurred in 373/2740 (13.6%) survivors. The median additional expenditure for each initial CDI case compared with matched controls was £1713. In the 6 months after the index hospitalization, the cost associated with a CDI case was £5126 higher than for controls. CONCLUSION: Using routinely collected national data, we demonstrated the substantial burden of CDI on healthcare services, including lengthy hospital stays and readmissions, which increased the costs of managing patients with CDI compared with matched controls.

Residual effect of community antimicrobial exposure on risk of hospital onset healthcare-associated Clostridioides difficile infection: a case-control study using national linked data.

BACKGROUND: Associations between antimicrobial exposure in the community and community-associated Clostridioides difficile infection (CA-CDI) are well documented but associations with healthcare-associated CDI (HA-CDI) are less clear. This study estimates the association between antimicrobial prescribing in the community and HA-CDI. METHODS: A matched case-control study was conducted by linking three national patient level datasets covering CDI cases, community prescriptions and hospitalizations. All validated cases of HA-CDI (August 2010 to July 2013) were extracted and up to three hospital-based controls were matched to each case on the basis of gender, age, hospital and date of admission. Conditional logistic regression was applied to estimate the association between antimicrobial prescribing in the community and HA-CDI. A sensitivity analysis was conducted to consider the impact of unmeasured hospital antimicrobial prescribing. RESULTS: Nine-hundred and thirty unique cases of HA-CDI with onset in hospital and no hospital discharge in the 12 weeks prior to index admission were linked with 1810 matched controls. Individuals with prior prescription of any antimicrobial in the community had an odds ratio (OR) = 1.41 (95% confidence interval (CI) 1.13-1.75) for HA-CDI compared with those without. Individuals exposed to high-risk antimicrobials (cephalosporins, clindamycin, co-amoxiclav or fluoroquinolones) had an OR = 1.86 (95% CI: 1.33-2.59). After accounting for the likely impact of unmeasured hospital prescribing, the community exposure, particulary to high-risk antimicrobials, was still associated with elevated HA-CDI risk. CONCLUSIONS: Community antimicrobial exposure is an independent risk factor for HA-CDI and should be considered as part of the risk assessment of patients developing diarrhoea in hospital.

Prioritizing research areas for antibiotic stewardship programmes in hospitals: a behavioural perspective consensus paper.

SCOPE: Antibiotic stewardship programmes (ASPs) are necessary in hospitals to improve the judicious use of antibiotics. While ASPs require complex change of key behaviours on individual, team organization and policy levels, evidence from the behavioural sciences is underutilized in antibiotic stewardship studies across the world, including high-income countries (HICs). A consensus procedure was performed to propose research priority areas for optimizing effective implementation of ASPs in hospital settings using a behavioural perspective. METHODS: A workgroup for behavioural approaches to ASPs was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). Eighteen clinical and academic specialists in antibiotic stewardship, implementation science and behaviour change from four HICs with publicly funded healthcare systems (e.g. Canada, Germany, Norway and the UK) met face-to-face to agree on broad research priority areas using a structured consensus method. Question addressed and recommendations: The consensus process assessing the ten identified research priority areas resulted in recommendations that need urgent scientific interest and funding to optimize effective implementation of ASPs for hospital inpatients in HICs with publicly funded healthcare systems. We suggest and detail behavioural science evidence-guided research efforts in the following areas: (a) comprehensively identifying barriers and facilitators to implementing ASPs and clinical recommendations intended to optimize antibiotic prescribing; (b) identifying actors ('who') and actions ('what needs to be done') of ASPs and clinical teams; (c) synthesizing available evidence to support future research and planning for ASPs; (d) specifying the activities in current ASPs with the purpose of defining a control group for comparison with new initiatives; (e) defining a balanced set of outcomes and measures to evaluate the effects of interventions focused on reducing unnecessary exposure to antibiotics; (f) conducting robust evaluations of ASPs with built-in process evaluations and fidelity assessments; (g) defining and designing ASPs; (h) establishing the evidence base for impact of ASPs on resistance; (i) investigating the role and impact of government and policy contexts on ASPs; and (j) understanding what matters to patients in ASPs in hospitals. CONCLUSIONS: Assessment, revisions and updates of our priority-setting exercise should be considered at intervals of 2 years. To propose research priority areas in low- and middle-income countries, the methodology reported here could be applied.

MRSA as a cause of lung infection including airway infection, community-acquired pneumonia and hospital-acquired pneumonia.

Staphylococcus aureus has been recognised as a cause of community-acquired pneumonia, albeit uncommon, and an important cause of healthcare-associated (HA) pneumonia, including ventilator-associated pneumonia. Resistance of S. aureus to methicillin developed shortly after its introduction into clinical practice. Since then, methicillin-resistant S. aureus (MRSA) has predominantly been a feature of hospital-acquired, or latterly HA, infections as the boundaries became more blurred between the community and hospital environments. However, more recently true community-acquired (CA)-MRSA infections have been detected and are becoming increasingly common, especially in the USA. Europe has not been immune to the development of MRSA in healthcare settings and although the prevalence of CA-MRSA is currently relatively low, there is the risk of wider spread. These new CA-MRSA strains appear to behave differently to HA-MRSA strains. Although predominantly causing skin and soft tissue infections, mainly as boils and abscesses requiring drainage, life threatening invasive infections including necrotising pneumonia can also occur. This article summarises the pathogenesis and clinical presentations of MRSA-related lung infections.

Appropriate vs. inappropriate antimicrobial therapy.

Inappropriate antimicrobial treatment (defined as use of antimicrobial agent to which a pathogen is resistant) or a delay in starting appropriate treatment are both associated with increased morbidity and mortality. Studies of ventilator-associated pneumonia, intra-abdominal infections or bacteraemia document higher mortality in patients who received inappropriate therapy. In addition, the outcome in patients switched from inappropriate to appropriate therapy is better than for patients who remained on inappropriate therapy, but the benefit is not as great as for those who were started on appropriate therapy initially. While inappropriate therapy undoubtedly has an important influence on outcomes, it needs to be considered in the context of other patient risk-factors, such as co-morbid conditions, severity score measures, and functional status. When assessing the impact of inappropriate therapy on outcomes such as length of hospital stay, it is important to be as precise as possible about the time of onset of infection. Failure to do so may lead to inaccurate estimation of the effect of inappropriate therapy. While the likelihood that resistant pathogens can increase costs throughout the healthcare system is generally recognised, an under-appreciated aspect of resistance is its consequences for patients and their carers. Initiatives are underway to gauge the impact of resistance and strategies to combat its spread.

Infection control and management of MRSA: assessing the knowledge of staff in an acute hospital setting.

Much of the recent work in tackling meticillin-resistant Staphylococcus aureus (MRSA) has focused on hygiene in hospitals, but it is unclear how much hospital staff know about the treatment and management of patients who are colonized or infected with MRSA. The aim of this study was to assess the knowledge and perceived practice of staff regarding MRSA and its management in an acute hospital setting. A further aim was to determine what staff felt was needed in terms of information or education on the risks, management and treatment of MRSA. A questionnaire survey was carried out through group administration during a study day and by face-to-face interviews. Subjects included in the questionnaire were infection and colonization, treatment, and the availability of local support and advice. There were 174 responses, divided equally between doctors and nurses. Knowledge on many aspects of MRSA and its management was deficient, although the majority of participants who felt that they required additional information about MRSA acknowledged this. The survey confirmed that assumptions should not be made about adequate knowledge and expertise of staff in relation to MRSA. Gaps in awareness of aspects of care and management were highlighted and information and educational needs identified.