Higher Antibiotic Use & C. diff Rates Found After Sepsis Program Implementation

A new study conducted by researchers from New York’s Icahn School of Medicine at Mount Sinai found that efforts to diagnose and treat sepsis in hospitals may be leading to unintended consequences, including the overuse of antibiotics and more cases of Clostridium difficile infections.

Sepsis is a complication that can occur as a body’s extreme response to infection, progressing rapidly and leading to tissue damage, organ failure, and even death. A 2014 study published in The Journal of the American Medical Association found that sepsis is the leading cause of death in hospitals in the United States, contributing to 1 in every 2 to 3 hospital deaths. Pneumonia, urinary tract infections, skin infections, and gut infections are most often linked to sepsis, particularly when left untreated. The pathogens that most commonly cause sepsis include Staphylococcus aureus, Escherichia coli, and certain Streptococcus strains. Adults 65 and older, children under the age of 1, and people with chronic conditions or weakened immune systems are at greatest risk of developing sepsis from an infection.

In a recent study published in the American Journal of Infection Control, investigators studied the impact of an electronic sepsis screening initiative on antibiotic use and C. difficile infection rates. The study was conducted in four wards from June 1, 2011, to June 30, 2014, and looked at a total of 127,346 patient days. The wards in the study were participants in a sepsis performance improvement program that included the use of a sepsis screening tool integrated into the electronic health record system and an electronic sepsis treatment bundle that facilitates antibiotic administration to patients suspected to have sepsis. Patients included in the analysis were 18 years or older and had been prescribed selected broad-spectrum antibiotics. The investigators aimed to study patterns in antibiotic prescribing before, during, and after implementation of the sepsis program, and to identify changes in the incidence of hospital-onset C. difficile infections. In 2011, it was estimated that half a million such infections in the United States, resulting in about 29,000 deaths.

The investigators found that there was an increase in antibiotic use with the implementation of the sepsis program, with the highest rate of antibiotic use of 50.4 days of therapy per 1,000 patient days occurring directly after the implementation of the program. In addition, while rates of hospital-onset C. difficile had been declining prior to the sepsis care program, with -1.4 such infections per 10,000 patient days per month, the rate rose to 10.8 infections per 10,000 patient days per month following the program’s implementation. The researchers suggested that the increase in antibiotic administration could be related to a rise in sepsis cases, but possibly due to changes in documentation and diagnosis patterns, as the program may have identified patients with sepsis earlier leading to increased doses of antibiotics.

“Integrated sepsis care streamlines how treatment is delivered. Yet as our research indicates, providers face the tough task of addressing how to deliver timely sepsis care, while mitigating potential unintended consequences such as an increase in healthcare facility-onset Clostridium difficile infection that may be linked to increased use of broad-spectrum antibiotics,” said the study’s lead researcher Jashvant Poeran, MD, PhD, in a press release. “Hospitals’ antibiotic stewardship teams can use these observations to align protocol with processes that ensure appropriate antibiotic administration.”

Despite its unintended consequences, the study authors point out that the sepsis program has demonstrated positive improvements overall in sepsis-related outcomes, and that they could not confirm causality between the program and the antibiotic use and C. difficile rates observed during the study period.