Screening for Asymptomatic Clostridium difficile Among Bone Marrow Transplant Patients: A Mixed-Methods Study of Intervention Effectiveness and Feasibility

Abstract

OBJECTIVE To identify facilitators and barriers to implementation of a Clostridium difficile screening intervention among bone marrow transplant (BMT) patients and to evaluate the clinical effectiveness of the intervention on the rate of hospital-onset C. difficile infection (HO-CDI). DESIGN Before-and-after trial SETTING A 505-bed tertiary-care medical center PARTICIPANTS All 5,357 patients admitted to the BMT and general medicine wards from January 2014 to February 2017 were included in the study. Interview participants included 3 physicians, 4 nurses, and 4 administrators. INTERVENTION All BMT patients were screened within 48 hours of admission. Colonized patients, as defined by a C. difficile-positive polymerase chain reaction (PCR) stool result, were placed under contact precautions for the duration of their hospital stay. METHODS Interview responses were coded according to the Systems Engineering Initiative for Patient Safety conceptual framework. We compared pre- and postintervention HO-CDI rates on BMT and general internal medicine units using time-series analysis. RESULTS Stakeholder engagement, at both the person and organizational level, facilitates standardization and optimization of intervention protocols. While the screening intervention was generally well received, tools and technology were sources of concern. The mean incidence of HO-CDI decreased on the BMT service postintervention (P<.0001). However, the effect of the change in the trend postintervention was not significantly different on BMT compared to the control wards (P=.93). CONCLUSIONS We report the first mixed-methods study to evaluate a C. difficile screening intervention among the BMT population. The positive nature by which the intervention was received by front-line clinical staff, laboratory staff, and administrators is promising for future implementation studies. Infect Control Hosp Epidemiol 2018;39:177-185.

A physician-scientist preceptorship in clinical and translational research enhances training and mentorship

“…Based on the survey results, at least 11 peer-reviewed manuscripts based on preceptorship projects, which are distinct from the trainees’ doctoral thesis projects, were produced by the 38 students that participated in the clerkship. Some of these preceptorship-based manuscripts have already been published [39–46], while others remain under peer-review. An additional 11 abstracts were submitted and accepted for presentation at either local or national meetings, and four students identified that the data generated from their project was used in the submission of a grant application.…”

Effect of a Standard vs Enhanced Implementation Strategy to Improve Antibiotic Prescribing in Nursing Homes

“…A mixed deductive and inductive thematic analysis guided by the Systems Engineering Initiative for Patient Safety framework will be used to analyze interview data. The Systems Engineering Initiative for Patient Safety framework is a human factors engineering framework that has been used extensively in a variety of health care settings to characterize work systems and document changes to the work system following implementation of quality improvement interventions . Interview transcripts will be coded independently with tests for reliability.…”

“…The Systems Engineering Initiative for Patient Safety framework is a human factors engineering framework that has been used extensively in a variety of health care settings to characterize work systems and document changes to the work system following implementation of quality improvement interventions. [32][33][34][35] Interview transcripts will be coded independently with tests for reliability. Analyses will focus on identifying the changes (or lack thereof) that occurred in study NH work systems as a result of implementing the Wisconsin UTI Toolkit in an effort to identify key barriers and facilitators to adoption.…”

Bring it on: Top five antimicrobial stewardship challenges in transplant infectious diseases and practical strategies to address them

“…79 Screening transplant patients at admission for C. difficile colonization facilitates early implementation of infection prevention measures and may result in decreased horizontal transmission. 78,80 In one study of patients admitted to an inpatient hematological unit, colonization with C. difficile conferred an 11.6 times higher odds of progression to CDI compared to those without colonization. 81 Identification of these asymptomatic carriers is an opportunity for targeted risk-reduction measures, such as antimicrobial review, to reduce the risk not only for symptomatic infection but for vertical transmission as well.…”

“…It is unclear how to optimally use asymptomatic screening for AMS efforts without unintentionally causing inappropriate treatment from misinterpretation of tests. 80,82 Oral vancomycin prophylaxis is an attractive option to prevent CDI. Retrospective reviews suggest that primary prophylaxis in allogenic HSCT recipients is associated with significantly lower rates of CDI 83,84 and that secondary prophylaxis is effective in reducing CDI recurrence in kidney transplant patients.…”