A hospital effort to rapidly identify potential sepsis cases and initiate antibiotic treatment led to an unintended consequence: an increase in Clostridium difficile infections.
The administration of broad spectrum antibiotics has been previously shown to wipe out commensal bacteria in the gut and allow C. diff to multiply and set up as an enteric infection. From there, it can spread to other patients and is exceedingly difficult to remove from the hospital environment.
The order set used to rapidly intervene for suspected sepsis recommends broad-spectrum antibiotics, which can be administered without preauthorization from the hospital’s antibiotic stewardship team, explains Jashvant Poeran, MD, PhD, assistant professor of medicine at Icahn School of Medicine at Mount Sinai in New York City.
“The main message is when you implement any healthcare intervention, always think of the unintended consequences,” he says. “Because here, this sepsis protocol calls for early screening. The earlier you screen for sepsis, the more nonspecific your symptoms are going to be. You are going to have a lot of false positives, meaning you are going to label someone potentially with sepsis who doesn’t have sepsis. Based on that labeling, they may get [unnecessary] antibiotics.”
As IPs are well aware, there is a national effort to rein in antibiotic use and overuse, moving to the narrowest spectrum drug as soon as possible because bacteria are becoming too resistant to treat the resulting infections.
“You see this is with other screening [protocols] as well. It is a double-edged sword,” Poeran says. “You may overtreat and that’s exactly the case here with this sepsis protocol. You’re going to find people who will not be developing sepsis and you are treating them with unnecessary antibiotics.”
By the same token, an indistinct presentation may trigger the use of broad-spectrum antibiotics, which are more likely than narrow-band drugs to spur C. diff.
Poeran and colleagues found that antibiotic use spiked after implementation of a sepsis care bundle. Though C. diff rates were decreasing before the sepsis care bundle was implemented, the infections began to increase as more antibiotics were used in the intervention.
“On the one hand, you want to give these broad-spectrum antibiotics because you don’t necessarily know what is the nature of the bug that is causing the sepsis,” he says. “On the other hand, broad spectrum antibiotics increase the risk for C. diff.”
Interestingly, the effect diminished as the sepsis bundle became “normalized” in other units of the hospital. This suggests that as clinicians acquire more experience in implementing the bundle, they are able to better identify cases and curtail unnecessary antibiotic use.
“My team’s thinking behind this was that with any new thing you implement in a hospital, people need to get used to it,” Poeran said. “There is a whole work flow involved, and it takes time to get adjusted to this. So, what you see when it goes hospitalwide is that [it] starts to normalize. I think that is because people get better used to the new system. There are going to be a lot of false positives [at first], but then they start anticipating the false positives better and then you see it normalize a bit.”
It may be well to learn these lessons now, as sepsis bundle programs may become more common as CMS moves to link them to their pay-for-performance incentives.
- Hiensch R, Poeran J, Saunders-Hao, et al. Impact of an electronic sepsis initiative on antibiotic use and health care facility-onset Clostridium difficile infection rates. Am J Infect Control 2017;45(10):1091-1100.