Treatment of C. Diff. — follow the guidelines
Brown AT, et al. Effect of treatment variation on outcomes in patients with Clostridium difficile. Am J Med 2014;127(9):865-870.
Formal recommendations for the treatment of C. difficile infection (CDI), based on expert opinion and available literature, were published by the IDSA in 2010.1 These authors performed a retrospective study for 6 months in 2011, evaluating the effectiveness of the IDSA Guideline-directed CDI treatment compared with alternate treatment at their tertiary care county teaching hospital. IDSA recommendations for CDI treatment are included in Table 1. Patients with CDI were identified based on ICD-9 coding at discharge and treatment for CDI infection. Demographic information was collected, and patients were classified as mild-to-moderate, severe, or severe-complicated based on the IDSA guidelines. The primary outcome of study was the occurrence of complications, including relapse within 4 weeks, surgery, toxic megacolon, and 30-day mortality. Secondary outcomes included length of stay and clinical cure.
A total of 180 adults with CDI met criteria for inclusion in the study, 93 of whom (52%) were treated in accordance with the IDSA guidelines. The two groups (guideline-directed care and alternate care) were similar with respect to race and classification of disease severity, although those who received alternate care tended to be older and were more likely male. Only 116 of the participants (64%) had received antibiotics within the previous 8 weeks. In these subjects, antibacterials were used for an average of 8 days +/- 10 days. Quinolones were received more often (32%) than other agents. In addition, proton pump therapy was administered within the previous 8 weeks to 100 patients (55%).
The NAP-1 strain was identified in 37% of the group receiving guideline-directed care, compared with 41.4% of the group receiving alternate care ( p = NS), although was more frequently identified in patients with severe/complicated infection. Patients with the NAP-1 strain had a higher rate of ICU admission and significantly higher risk of mortality.
Guideline-directed care was associated with significantly fewer complications than alternate care (17.2% vs 56.3%; p < .0001). This was due in large part to a lower rate of mortality in persons receiving guideline-directed care compared with those in the alternate therapy group (5% vs 21.8%, p = 0.0012), as well as a lower rate of recurrence (14% vs 35.6%, p = 0.0007). Clinical cures were more frequent in patients receiving guideline-directed care compared with alternate care (93.5% vs 71.3%). Multiple logistical regression analysis demonstrated that relapses were 72% less likely in patients receiving guideline-directed care compared with alternate care.
Guideline-directed care was more often used in patients with mild-to-moderate disease (81%) compared with those with severe disease (35%) or those with severe-complicated disease (19.7%). The main reasons for patients with severe disease not meeting criteria for guideline-directed care included the use of flagyl as a single agent (55%) and failure to receive a taper or pulse therapy in those with multiple recurrences (23%). The main reasons for patients with severe-complicated disease not meeting criteria for guideline-directed care were the use of flagyl as single agent (57%) and the use of oral vancomycin without parenterally administered flagyl (35%).
In conclusion, many of the patients with CDI in this study were initially treated with flagyl — regardless of their disease classification — which meant those with mild-to-moderate disease met the Guidelines (and did well), while many of those with more severe disease received inadequate therapy with flagyl or vancomycin alone, with a resulting increased risk of complications and mortality. Treatment based on the IDSA guidelines appears to improve outcomes, with a lower risk of relapse, surgery, and death, and should be broadly implemented. Teaching hospitals, in particular, have a responsibility to train and educate their house staff about the use of currently recommended therapies.
Cohen SH, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010;31(5):
Semi roll-over causes Cryptosporidiosis
Outbreak of Cryptosporidiosis among responders to a rollover of a truck carrying calves — Kansas, April 2013. MMWR Morbid Mortal Wkly Rep December 10, 2014;63(5):1185-1188.
A disastrous roll-over accident of a semi-tractor-trailer carrying baby Holsteins in a late winter snowstorm near Colby, Kansas, occurred in March 2013. There were 350 pre-weaned, less than 10-day-old Holsteins on board — many of which died in the accident, the bodies spread over the pavement. Calves that survived the accident were collected and loaded onto another truck by police, emergency personnel, and volunteers at the site. Once the wrecked truck was righted with the help of a towing company and local volunteers on horseback, the dead calves were loaded onto the wrecked truck and hauled away by a towing company to a local sale barn. The next day, the towing company employees had to remove the dead calves from the truck, loading them onto another truck that took them to a rendering plant.
Holsteins are the most common dairy cow in the United States (the black and white ones, like the California Clover Stornetta Farms ads with “Clo”), and a newborn calf weighs about 85 lbs. The emergency personnel later commented that many of the calves seemed ill with diarrhea — or what is commonly called “scours.” Baby calves are especially vulnerable to diarrheal illness, especially when transported under stressful or crowded conditions. Pre-weaned calves are the most likely to develop diarrheal illness, especially from Cryptosporidium parvum because they may not have received their full dose of colostrum from the mother. Like human babies, a newborn calf does not have a fully developed immune system and relies on passive antibodies in its mother’s milk to provide protection. A calf typically receives up to 5% of its body weight in colostrum with each feeding twice daily — a good portion of which is antibodies — much more so than in standard whole milk. Colostrum is only produced by prepartum cows — which ends at birth — so farmers save it, and administer it to calves when they are young. Not until they are at least 1-2 months old does their immune system start to provide better protection.
In total, 5 police and county sheriffs, 8 volunteers, and 2 tow truck personnel had close contact with the animals. It was a grueling night — and the tow truck personnel who loaded and unloaded the animals at the sale barn did not have access to electricity or running water. Six of these individuals developed symptomatic cryptosporidiosis, including one law enforcement officer, both tow truck employees, the driver of the wrecked truck, and 2 volunteers. Five of the 6 sought medical care; 2 of the cases were confirmed by rapid antigen testing. The incubation period ranged from 6 to 8 days, and the duration of illness ranged from 7 to 13 days.
This was the first recognized occupational-associated “outbreak” of cryptosporidiosis in law enforcement and volunteer emergency responders. Although such close contact with ill animals is not common, emergency responders and law enforcement should be educated about the benefits of good hand washing and disinfecting clothing worn at the scene of an accident and when in contact with animals.
Antibiotics prescribed from decision-fatigue?
Linder JA, et al. Time of day and the decision to prescribe antibiotics (letter). JAMA 2014;174(12):2029-2031.
Psychologists describe the erosion of self-control after repeated decisions as “decision fatigue.” Specifically, it is the erosion of judgment or the increased risk of poor choices after a long session requiring decisions. A good example of this is the car salesman’s technique — wearing down the consumer with many decisions, and eventually “decision avoidance” or bad default decisions will occur. It has been known to occur in judges after a long session in court, in which the default is to more frequently deny parole (the “safer” option).
These authors hypothesized that decision fatigue may affect physicians as they work through their day. They examined 21,867 visits for acute respiratory infection (ARI) (in adults aged 18-64 years) to 204 clinicians in 23 practices during a 5-month period in 2012. Clinicians with fewer than 40 visits for ARI were excluded. For all ARI visits, 44% were prescribed antibiotics.
Each of the physician’s clinic day was divided into hourly segments, so if they worked from 8 to noon — each hour of the day was considered ARI visit 1 through 4 to represent a visit time. Prescriptions for antibiotics for ARI were reviewed according to national guidelines and designated as “sometimes indicated” and “never indicated.” In this study, 65.5% of antibiotics prescribed were “never indicated.”
Clinicians were increasingly more likely to prescribe antibiotics for each of the consecutive hours of their day, both for antibiotics that were sometimes indicated and for antibiotics that were never indicated. Relative adjusted odds ratios for antibiotic prescriptions for the second, third, and fourth hours were 1.01, 1.14, and 1.26 (p < .001, for a linear trend).
Two-thirds of the prescriptions for acute respiratory illness in this study were not indicated — and the risk for prescribing any antibiotic, and especially an unwarranted antibiotic, increased throughout a physician’s day. I was not entirely convinced this was due to physician decision fatigue or diminished judgment — I would argue that most physicians understand that antibiotics are not the “safer” option — although it might be the easier option. You simply get tired of arguing with people and run out of time to convince them otherwise. Not prescribing an antibiotic requires time for education. How many times have you spent 10 or 15 minutes trying to explain why an antibiotic was not necessary? And even then, with patient satisfaction scores dictating some physician reimbursement, who cares about a Z-Pak or two?