88. Reduction in Clostridium difficile infections among neurosurgical patients through the discontinuation of antimicrobial prophylaxis for the duration that an external ventricular drain remains in place
Session: Oral Abstract Session: New Considerations in C. difficile Prevention and Treatment
Thursday, October 3, 2013: 9:06 AM
Room: The Moscone Center: 300
Background:

There remains debate about the effectiveness of continuing prophylactic antibiotics for the duration that an external ventricular drain (EVD) remains in place relative to the risk for selecting antimicrobial resistance or developing Clostridium difficile infection.  In response to an increase in C. difficile among patients in our neurosurgical ICU (NICU), we modified our protocol to discontinue routine cefazolin prophylaxis for EVDs.  We evaluated in the incidence of C. difficile during the 12 months before and after protocol change at a level 1 trauma center.

Methods:

Retrospective review of the incidence of C. difficile among patients in the NICU, patients with an EVD, and patients on the neurosurgical service regardless of location.  We also compared the amount of cefazolin used in the NICU as well as proportion of patients with and EVD and positive CSF cultures before and after protocol modification. No other changes in infection control practices occurred during this time.

Results:

In the baseline period of January-December 2011, 19/352 (5.4%) of patients with an EVD developed C. difficile compared to 9/369 (2.4%) from January –December 2012 (p=0.040).  The incidence of C. difficile decreased from 19 cases (1.97 per 1000 pt-days) to 5 cases (0.51 per 1000 pt-days) in the NICU (p=0.0036) and from 20 cases (1.18 per 1000 pt-days) to 10 cases (0.55 per 1000 pt-days) among the neurosurgical service during this time (p=0.046).  The percent of patients with an EVD and subsequent positive CSF cultures was similar during the before and after protocol change period despite the discontinuation of antimicrobial prophylaxis (45/352 [12.8%] versus 38/369 [10.3%], p=0.29).  Cefazolin use decreased from 735 doses to 268 doses per 1000 pt-days in the NICU (p<0.0001) and from 568 doses to 269 doses per 1000 pt-days among the neurosurgical service (p<0.0001) resulting in a pharmaceutical cost savings of $13,000.

Conclusion:

Discontinuing antimicrobial prophylaxis for the duration of EVD placement was associated with a reduction in C. difficile without increasing the risk of a positive CSF culture, thus improving patient care while reducing costs.   A similar approach can be used to examine other areas where antimicrobial prophylaxis is used without supporting evidence.

Timothy H. Dellit, MD1, Jeannie D. Chan, PharmD, MPH2, Charlotte Fulton, RN MHA1, Ronald Pergamit, MPA1, Elizabeth Mc Namara, RN MN1, Louis Kim, MD3, Richard Ellenbogen, MD3 and John B. Lynch, MD MPH1, (1)Infection Control, Harborview Medical Center, Seattle, WA, (2)Pharmacy, Harborview Medical Center, Seattle, WA, (3)Neurosurgery, Harborview Medical Center, Seattle, WA

Disclosures:

T. H. Dellit, None

J. D. Chan, None

C. Fulton, None

R. Pergamit, None

E. Mc Namara, None

L. Kim, None

R. Ellenbogen, None

J. B. Lynch, None

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