Effectiveness of Probiotic for Primary Prevention of Clostridium difficile Infection: A Single-Center Before-and-After Quality Improvement Intervention at a Tertiary-Care Medical Center.

OBJECTIVETo evaluate probiotics for the primary prevention of Clostridium difficile infection (CDI) among hospital inpatients.DESIGNA before-and-after quality improvement intervention comparing 12-month baseline and intervention periods.SETTINGA 694-bed teaching hospital.INTERVENTIONWe administered a multispecies probiotic comprising L. acidophilus (CL1285), L. casei (LBC80R), and L. rhamnosus (CLR2) to eligible antibiotic recipients within 12 hours of initial antibiotic receipt through 5 days after final dose. We excluded (1) all patients on neonatal, pediatric and oncology wards; (2) all individuals receiving perioperative prophylactic antibiotic recipients; (3) all those restricted from oral intake; and (4) those with pancreatitis, leukopenia, or posttransplant. We defined CDI by symptoms plus C. difficile toxin detection by polymerase chain reaction. Our primary outcome was hospital-onset CDI incidence on eligible hospital units, analyzed using segmented regression.RESULTSThe study included 251 CDI episodes among 360,016 patient days during the baseline and intervention periods, and the incidence rate was 7.0 per 10,000 patient days. The incidence rate was similar during baseline and intervention periods (6.9 vs 7.0 per 10,000 patient days; P=.95). However, compared to the first 6 months of the intervention, we detected a significant decrease in CDI during the final 6 months (incidence rate ratio, 0.6; 95% confidence interval, 0.4-0.9; P=.009). Testing intensity remained stable between the baseline and intervention periods: 19% versus 20% of stools tested were C. difficile positive by PCR, respectively. From medical record reviews, only 26% of eligible patients received a probiotic per the protocol.CONCLUSIONSDespite poor adherence to the protocol, there was a reduction in the incidence of CDI during the intervention, which was delayed ~6 months after introducing probiotic for primary prevention.Infect Control Hosp Epidemiol 2018;765-770.

Importance of Molecular Methods to Determine Whether a Probiotic is the Source of Lactobacillus Bacteremia.

There has been an increasing interest in the use of probiotic products for the prevention of Clostridium difficile infection (CDI). Bio-K+(®) is a commercial probiotic product comprising three strains of lactobacilli--Lactobacillus acidophilus CL1285(®), Lact. casei LBC80R(®) and Lact. rhamnosus CLR2(®)--that have been applied to prevent CDI. Generally considered as safe, lactobacilli have potential to cause bacteremia, endocarditis and other infections. The source of Lactobacillus bacteremia can be normal human flora or lactobacilli-containing probiotic. The aim of this study was to assess whether probiotic lactobacilli caused bacteremia and to show the value of molecular identification and typing techniques to determine probiotic and patient strain relatedness. We report an episode of Lactobacillus bacteremia in a 69-year-old man admitted to a hospital with severe congestive heart failure. During his hospitalization, he required long-term antibiotic therapy. Additionally, the patient received Bio-K+(®) probiotic as part of a quality improvement project to prevent CDI. Subsequently, Lactobacillus bacteremia occurred. Two independent blinded laboratory evaluations, using pulse field gel electrophoresis, 16S rRNA gene sequencing and DNA fingerprint analysis (rep-PCR), were performed to determine whether the recovered Lact. acidophilus originated from the probiotic product. Ultimately, the patient strain was identified as Lact. casei and both laboratories found no genetic relation between the patient's strain and any of the probiotic lactobacilli. This clinical case of lactobacillus bacteremia in the setting of probiotic exposure demonstrates the value of using discriminatory molecular methods to clearly determine whether there were a link between the patient's isolate and the probiotic strains.

Evaluation of International Classification of Diseases, Ninth Revision, Clinical Modification Codes for reporting methicillin-resistant Staphylococcus aureus infections at a hospital in Illinois.

BACKGROUND: States, including Illinois, have passed legislation mandating the use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for reporting healthcare-associated infections, such as methicillin-resistant Staphylococcus aureus (MRSA). OBJECTIVE: To evaluate the sensitivity of ICD-9-CM code combinations for detection of MRSA infection and to understand implications for reporting. METHODS: We reviewed discharge and microbiology databases from July through August of 2005, 2006, and 2007 for ICD-9-CM codes or microbiology results suggesting MRSA infection at a tertiary care hospital near Chicago, Illinois. Medical records were reviewed to confirm MRSA infection. Time from admission to first positive MRSA culture result was evaluated to identify hospital-onset MRSA (HO-MRSA) infections. The sensitivity of MRSA code combinations for detecting confirmed MRSA infections was calculated using all codes present in the discharge record (up to 15); the effect of reviewing only 9 diagnosis codes, the number reported to the Centers for Medicare and Medicaid Services, was also evaluated. The sensitivity of the combination of diagnosis codes for detection of HO-MRSA infections was compared with that for community-onset MRSA (CO-MRSA) infections. RESULTS: We identified 571 potential MRSA infections with the use of screening criteria; 403 (71%) were confirmed MRSA infections, of which 61 (15%) were classified as HO-MRSA. The sensitivity of MRSA code combinations was 59% for all confirmed MRSA infections when 15 diagnoses were reviewed compared with 31% if only 9 diagnoses were reviewed (P < .001). The sensitivity of code combinations was 33% for HO-MRSA infections compared with 62% for CO-MRSA infections (P < .001). CONCLUSIONS: Limiting analysis to 9 diagnosis codes resulted in low sensitivity. Furthermore, code combinations were better at revealing CO-MRSA infections than HO-MRSA infections. These limitations could compromise the validity of ICD-9-CM codes for interfacility comparisons and for reporting of healthcare-associated MRSA infections.