Healthcare facility-onset, healthcare facility-associated Clostridioides difficile infection in Veterans with spinal cord injury and disorder

The Journal of Spinal Cord Medicine, 2020 · DOI: 10.1080/10790268.2019.1672953 · Published: January 1, 2020

Spinal Cord Injury Immunology Healthcare

Simple Explanation

This study investigated Clostridioides difficile infection (CDI) in Veterans with spinal cord injuries and disorders (SCI/D). It found that CDI rates decreased between 2002 and 2010, but remain high. Antibiotic and proton-pump inhibitor (PPI) use were independently associated with increased CDI risk. The research also revealed a synergistic risk when both antibiotics and PPIs were used together. Older age, geographic location (Northeast region), and invasive respiratory procedures were also identified as independent risk factors. Longer SCI duration and care at specialized SCI centers were protective. The findings suggest that targeted interventions to reduce antibiotic and PPI use could significantly decrease CDI in this high-risk population. The study highlights the need for antimicrobial stewardship and pharmacy interventions to improve medication use in Veterans with SCI/D.

Study Duration

9 Years

Participants

12,511 Veterans with SCI/D

Evidence Level

Retrospective, longitudinal cohort study

Key Findings

1
Antibiotic and PPI/H2 blocker use were independently associated with HO-HCFA CDI.
2
The risk of HO-HCFA CDI was synergistic when both antibiotics and PPI/H2 blockers were used.
3
Longer duration of SCI and care at a SCI center were associated with a decreased risk of CDI.

Research Summary

This retrospective cohort study examined the incidence and risk factors for healthcare facility-onset, healthcare facility-associated (HO-HCFA) Clostridioides difficile infection (CDI) in Veterans with spinal cord injury and disorder (SCI/D) from 2001 to 2010. The study identified 1,409 cases of HO-HCFA CDI across 94 Veterans Affairs acute care facilities. The study found that while CDI rates decreased from 2002 to 2010, they remained high. Multivariable regression analyses revealed that antibiotic and proton-pump inhibitor (PPI)/H2 blocker use were independently associated with increased HO-HCFA CDI risk. A synergistic effect was observed when both medication types were used concurrently. The authors concluded that targeted antimicrobial stewardship and pharmacy interventions aimed at reducing antibiotic and PPI/H2 blocker use could substantially decrease HO-HCFA CDI in this high-risk population. The study also identified older age, Northeast region, and invasive respiratory procedures as independent risk factors, while longer SCI duration and care at an SCI center were protective.

Practical Implications

Antimicrobial Stewardship Programs

Enhance and expand antimicrobial stewardship programs specifically targeting the SCI/D population to reduce unnecessary antibiotic use.

Judicious Use of PPIs/H2 Blockers

Promote interventions focused on improving the appropriate and judicious use of PPIs and H2 blockers, especially in conjunction with antibiotics, among patients with SCI/D.

Targeted Interventions

Develop and implement targeted infection control interventions in the Northeast region and for older patients with SCI/D to address the higher risk of CDI in these subgroups.

Study Limitations

1
The study focused on a laboratory-based definition of CDI, which may have included colonized patients.
2
Data on laboratory tests performed outside the VA was not included, potentially underestimating CDI rates.
3
The definition of CDI severity was not validated, potentially overestimating the percentage of severe complicated cases.

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