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The Effect of Reducing the Use of High Risk Antibiotics on the Rate of Clostridium difficile in a General Hospital.C Bradley, S Brown, A Foden, D Allison, C Aldridge, J Sloss, L Lim, D Nayar.County Durham and Darlington Foundation Trust, UK
e80 Here, we describe a development process to validate a novel CDK assessment tool. Two previously published CDK questionnaires were amalgamated, to produce a "combined" questionnaire. Content was evaluated by a panel of blinded CDI experts for accuracy and appropriateness to produce a "Lothian" questionnaire. The "combined" questionnaire was evaluated in control populations (infection control nurses (ICN), non-clinically trained individuals and a cohort of doctors). We compared the efficacy of our novel questionnaires against the previously published questionnaires.
Scientific findings The combined questionnaire was composed of 37 individual statements. 3 statements were deemed inappropriate by a majority of the expert panel and were removed to produce the Lothian questionnaire. All questionnaires studied significantly discriminated between non-clinical and clinical populations (ICN/doctors) (p<0.001). No questionnaire could statistically discriminate between ICNs and doctors. However, the "Lothian" questionnaire trended towards improved sensitivity and specificity in discrimination between these populations. A receiver operator characteristic curve showed that a Lothian questionnaire pass mark of 65.3% distinguished between the non-clinical and clinical populations with a sensitivity of 0.93 and specificity of 0.82.
Discussion We have shown that previously published CKD questionnaires will statistically discriminate between non-clinical and clinical populations despite a lack of formal validation. Furthermore we have produced a novel validated questionnaire assessment tool which tends to have greater specificity and sensitivity than those previously published. The inability of any of the questionnaires to distinguish between ICNs and doctors may reflect the small response rate amongst doctors. There may be bias towards those doctors who have greater knowledge of CDI and thus preferentially returned the questionnaires. The response rate of ICNs was higher, reducing the impact of any responder bias.
Abstracts risk factors for poor knowledge or evaluate trends over time and/or following interventions.
THE EFFECT OF REDUCING THE USE OF HIGH RISK ANTIBIOTICS ON THE RATE OF CLOSTRIDIUM DIFFICILE IN A GENERAL HOSPITAL.C BRADLEY, S BROWN, A FODEN, D ALLISON, C ALDRIDGE, J SLOSS, L LIM, D NAYAR.COUNTY DURHAM AND DARLINGTON FOUNDATION TRUST, UKCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL Caroline Bradley, Stuart Brown, Alwyn Foden, David Allison, Catherine Aldridge, John Sloss, Ling Lim, Deepa Nayar County Durham And Darlington Foundation Trust, Tyne and Wear, United Kingdom
Introduction Clostridium difficile infection (CDI) is a severe nosocomial enteric infection which is associated with healthcare provision and exposure to antibiotics. Rates of CDI increased sharply in the UK from 2002 reaching a peak in 2007. Despite the introduction of rigorous infection control procedures, the rates of CDI at County Durham and Darlington Foundation Trust (CDDFT) failed to fall. There is evidence that quinolone and cephalosporin antibiotics have a high association with CDI1,2,3. As part of an antibiotic stewardship programme a strict policy of quinolone and cephalosporin restriction was introduced at CDDFT in 2008/9. In late 2008 the CDDFT antibiotic formulary was reviewed and empiric recommendations for cephalosporins and quinolone antibiotics were substituted with narrow spectrum or aminopenicillin antibiotics in most cases. The use of cephalosporins and quinolones was restricted by the introduction of a traffic light system for antibiotics which only permitted use in exceptional cases or on Microbiological advice. Other broad spectrum antibiotics such as carbapenems were restricted for use on Microbiological advice only. An education and training programme was put in place and assurance and monitoring was achieved through an audit and feed back programme.
Conclusions Scientific findings Here, we describe the development of a robust CDK assessment tool containing previously peer-reviewed content, evaluated through testing in control populations and reviewed by a panel of experts. The questionnaire significantly discriminates between populations with assumed high and low levels of knowledge of CDI with improved sensitivity and specificity across the pass mark range compared to the other questionnaire tools. This has relevance to those aiming to assess individual levels of CDK, compare levels within populations, identify
The total consumption of all cephalosporins (cefradine, cefuroxime, ceftriaxone and ceftazidime) decreased by over 83%(standardised for activity). The use of quinolone antibiotics (mainly ciprofloxacin) decreased by 41% (standardised for activity). The use of the main broad spectrum antibiotics (co-amoxiclav, cephalosporins and quinolones) decreased by 5% and total antibiotic consumption decreased by 8% for the same activity. The numbers of post 48 hour CDI decreased from 313 in 2007/8 and 241 in 2008/9
Abstracts to 94 in 2009/10. This was close to a halving of the rate from 7.1 to 2.9 per 10,000 bed days.
Discussion Most cases of CDI occur following antibiotic use. There was no reduction in the rate of CDI at our Trust with enhanced infection control measures alone, however it fell significantly with a change in antibiotic prescribing. It is recognised that some antibiotics have a higher risk of causing CDI than others due to a complex interaction between gut lumen concentrations, effect on the normal intestinal flora and activity against Clostridium difficile. Clostridium difficile is resistant to all cephalosporins and recent epidemic strains are resistant to quinolones. Clindamycin resistance is also documented. Sensitivity studies have shown that Clostridium difficile retains sensitivity to aminopenicillins like amoxicillin.
Conclusions Following a reduction in cephalosporins and quinolone use of 81% and 41% (for the same activity) whilst co-amoxiclav use initially increased then returned to levels pre change in prescribing, the number of cases of CDI decreased from 7.1 to 2.9 per 10,000 bed days. It is possible that the antibiotic susceptibility profile of Clostridium difficile may play a causative role.
A FIVE YEAR REVIEW OF EPIDIDYMO-ORCHITIS IN EXETERCATEGORY: SCIENTIFIC FREE PAPER Thomas Dutton, Marwa Al-Saedi, John McGrath, John Aning Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, United Kingdom
Introduction Epididymo-orchitis is commonly referred for review by the on call surgical team. Anecdotally, inadequate knowledge regarding the condition has led to inconsistent patient management and often unnecessary overnight hospital stays in order to enable senior assessment prior to discharge. Reducing unnecessary inpatient bedstays and improving quality of care are now fundamental parts of Department of Health strategy - the authors believe that microbiology has a vital role in delivering better patient outcomes. This study investigated the management of patients diagnosed with epididymo-orchitis over a five year period in a district general hospital. The results were contrasted with the recently published 2010 British Association for Sexual Health and HIV Guidelines. Patients and Methods: The medical and laboratory records of 232 consecutive patients diagnosed with epididymo-orchitis by the on call surgical team between August 2004 and August 2009 were retrospectively analysed. Data
e81 assessed included patient demographics, length of stay, investigations performed (microbiological and radiological), antibiotic prescription and length of prescription on discharge.
Scientific findings Of 232 patients, 105 (45%) had a mid-stream urine sample sent for microscopy and culture and 15 (6.5%) had a urethral swab performed for Neisseria gonorrheae / Chlamydia trachomatis. MSU cultures were positive in 17/105 patients: Coliforms - 16/105, Staphylococcus aureus - 1/105. Three urethral swabs yielded a positive culture for Chlamydia. A testicular ultrasound scan was performed in 82/232 patients. Median hospital overnight stay was one night (range 0-9). All patients received antibiotics on discharge; the majority (67%) were prescribed ciprofloxacin for a mean of 12.8 days. Advice to attend genito-urinary medicine followup was documented in 9/232 medical records.
Discussion By comparison to the recently published British Association for Sexual Health and HIV Guidelines, our study has shown areas for potential improvement in the assessment and management of epdidiymo-orchitis.
Conclusions Recognition of this study’s findings led to the local publication of hospital guidelines regarding the investigation and treatment of epididymo-orchitis. By detailing a clear management protocol we hope that the quality of patient care will improve and the number of unnecessary bedstays will be reduced, however this will be the subject of a future reaudit. Following up mid-stream urine and urethral swab culture results enables appropriate antibiotic prescribing practices to be monitored and may negate the need for unnecessary radiological imaging of patients diagnosed with epididymo-orchitis.
EPIDEMIOLOGY OF CANDIDAEMIA IN A UK DISTRICT GENERAL HOSPITALCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL Catherine Jeppesen, Donald Lyon Department of Microbiology, East Surrey Hospital, Surrey and Sussex Healthcare NHS Trust, Redhill, Surrey, United Kingdom
Introduction The literature suggests that the incidence of Candida blood stream infection is rising, especially in the US where it accounts for 5-10% of bloodstream infection. An increasing proportion is reported to be due to non-albicans species,
Scientific findings The combined questionnaire was composed of 37 individual statements. 3 statements were deemed inappropriate by a majority of the expert panel and were removed to produce the Lothian questionnaire. All questionnaires studied significantly discriminated between non-clinical and clinical populations (ICN/doctors) (p<0.001). No questionnaire could statistically discriminate between ICNs and doctors. However, the "Lothian" questionnaire trended towards improved sensitivity and specificity in discrimination between these populations. A receiver operator characteristic curve showed that a Lothian questionnaire pass mark of 65.3% distinguished between the non-clinical and clinical populations with a sensitivity of 0.93 and specificity of 0.82.
Discussion We have shown that previously published CKD questionnaires will statistically discriminate between non-clinical and clinical populations despite a lack of formal validation. Furthermore we have produced a novel validated questionnaire assessment tool which tends to have greater specificity and sensitivity than those previously published. The inability of any of the questionnaires to distinguish between ICNs and doctors may reflect the small response rate amongst doctors. There may be bias towards those doctors who have greater knowledge of CDI and thus preferentially returned the questionnaires. The response rate of ICNs was higher, reducing the impact of any responder bias.
Abstracts risk factors for poor knowledge or evaluate trends over time and/or following interventions.
THE EFFECT OF REDUCING THE USE OF HIGH RISK ANTIBIOTICS ON THE RATE OF CLOSTRIDIUM DIFFICILE IN A GENERAL HOSPITAL.C BRADLEY, S BROWN, A FODEN, D ALLISON, C ALDRIDGE, J SLOSS, L LIM, D NAYAR.COUNTY DURHAM AND DARLINGTON FOUNDATION TRUST, UKCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL Caroline Bradley, Stuart Brown, Alwyn Foden, David Allison, Catherine Aldridge, John Sloss, Ling Lim, Deepa Nayar County Durham And Darlington Foundation Trust, Tyne and Wear, United Kingdom
Introduction Clostridium difficile infection (CDI) is a severe nosocomial enteric infection which is associated with healthcare provision and exposure to antibiotics. Rates of CDI increased sharply in the UK from 2002 reaching a peak in 2007. Despite the introduction of rigorous infection control procedures, the rates of CDI at County Durham and Darlington Foundation Trust (CDDFT) failed to fall. There is evidence that quinolone and cephalosporin antibiotics have a high association with CDI1,2,3. As part of an antibiotic stewardship programme a strict policy of quinolone and cephalosporin restriction was introduced at CDDFT in 2008/9. In late 2008 the CDDFT antibiotic formulary was reviewed and empiric recommendations for cephalosporins and quinolone antibiotics were substituted with narrow spectrum or aminopenicillin antibiotics in most cases. The use of cephalosporins and quinolones was restricted by the introduction of a traffic light system for antibiotics which only permitted use in exceptional cases or on Microbiological advice. Other broad spectrum antibiotics such as carbapenems were restricted for use on Microbiological advice only. An education and training programme was put in place and assurance and monitoring was achieved through an audit and feed back programme.
Conclusions Scientific findings Here, we describe the development of a robust CDK assessment tool containing previously peer-reviewed content, evaluated through testing in control populations and reviewed by a panel of experts. The questionnaire significantly discriminates between populations with assumed high and low levels of knowledge of CDI with improved sensitivity and specificity across the pass mark range compared to the other questionnaire tools. This has relevance to those aiming to assess individual levels of CDK, compare levels within populations, identify
The total consumption of all cephalosporins (cefradine, cefuroxime, ceftriaxone and ceftazidime) decreased by over 83%(standardised for activity). The use of quinolone antibiotics (mainly ciprofloxacin) decreased by 41% (standardised for activity). The use of the main broad spectrum antibiotics (co-amoxiclav, cephalosporins and quinolones) decreased by 5% and total antibiotic consumption decreased by 8% for the same activity. The numbers of post 48 hour CDI decreased from 313 in 2007/8 and 241 in 2008/9
Abstracts to 94 in 2009/10. This was close to a halving of the rate from 7.1 to 2.9 per 10,000 bed days.
Discussion Most cases of CDI occur following antibiotic use. There was no reduction in the rate of CDI at our Trust with enhanced infection control measures alone, however it fell significantly with a change in antibiotic prescribing. It is recognised that some antibiotics have a higher risk of causing CDI than others due to a complex interaction between gut lumen concentrations, effect on the normal intestinal flora and activity against Clostridium difficile. Clostridium difficile is resistant to all cephalosporins and recent epidemic strains are resistant to quinolones. Clindamycin resistance is also documented. Sensitivity studies have shown that Clostridium difficile retains sensitivity to aminopenicillins like amoxicillin.
Conclusions Following a reduction in cephalosporins and quinolone use of 81% and 41% (for the same activity) whilst co-amoxiclav use initially increased then returned to levels pre change in prescribing, the number of cases of CDI decreased from 7.1 to 2.9 per 10,000 bed days. It is possible that the antibiotic susceptibility profile of Clostridium difficile may play a causative role.
A FIVE YEAR REVIEW OF EPIDIDYMO-ORCHITIS IN EXETERCATEGORY: SCIENTIFIC FREE PAPER Thomas Dutton, Marwa Al-Saedi, John McGrath, John Aning Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, United Kingdom
Introduction Epididymo-orchitis is commonly referred for review by the on call surgical team. Anecdotally, inadequate knowledge regarding the condition has led to inconsistent patient management and often unnecessary overnight hospital stays in order to enable senior assessment prior to discharge. Reducing unnecessary inpatient bedstays and improving quality of care are now fundamental parts of Department of Health strategy - the authors believe that microbiology has a vital role in delivering better patient outcomes. This study investigated the management of patients diagnosed with epididymo-orchitis over a five year period in a district general hospital. The results were contrasted with the recently published 2010 British Association for Sexual Health and HIV Guidelines. Patients and Methods: The medical and laboratory records of 232 consecutive patients diagnosed with epididymo-orchitis by the on call surgical team between August 2004 and August 2009 were retrospectively analysed. Data
e81 assessed included patient demographics, length of stay, investigations performed (microbiological and radiological), antibiotic prescription and length of prescription on discharge.
Scientific findings Of 232 patients, 105 (45%) had a mid-stream urine sample sent for microscopy and culture and 15 (6.5%) had a urethral swab performed for Neisseria gonorrheae / Chlamydia trachomatis. MSU cultures were positive in 17/105 patients: Coliforms - 16/105, Staphylococcus aureus - 1/105. Three urethral swabs yielded a positive culture for Chlamydia. A testicular ultrasound scan was performed in 82/232 patients. Median hospital overnight stay was one night (range 0-9). All patients received antibiotics on discharge; the majority (67%) were prescribed ciprofloxacin for a mean of 12.8 days. Advice to attend genito-urinary medicine followup was documented in 9/232 medical records.
Discussion By comparison to the recently published British Association for Sexual Health and HIV Guidelines, our study has shown areas for potential improvement in the assessment and management of epdidiymo-orchitis.
Conclusions Recognition of this study’s findings led to the local publication of hospital guidelines regarding the investigation and treatment of epididymo-orchitis. By detailing a clear management protocol we hope that the quality of patient care will improve and the number of unnecessary bedstays will be reduced, however this will be the subject of a future reaudit. Following up mid-stream urine and urethral swab culture results enables appropriate antibiotic prescribing practices to be monitored and may negate the need for unnecessary radiological imaging of patients diagnosed with epididymo-orchitis.
EPIDEMIOLOGY OF CANDIDAEMIA IN A UK DISTRICT GENERAL HOSPITALCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL Catherine Jeppesen, Donald Lyon Department of Microbiology, East Surrey Hospital, Surrey and Sussex Healthcare NHS Trust, Redhill, Surrey, United Kingdom
Introduction The literature suggests that the incidence of Candida blood stream infection is rising, especially in the US where it accounts for 5-10% of bloodstream infection. An increasing proportion is reported to be due to non-albicans species,