Erik R. Dubberke, MD, MSPH; Jeffrey M. Rohde, MD; Sanjay Saint, MD, MPH; Karen Jones, RN, MPH; Ashley Snyder, MPH; Andrew J. Rolle, MPH; Vineet Chopra, MD, MSc
Disclaimer: The findings and conclusions in this report are those of the authors and do not represent the official position of the CDC, the American Hospital Association, or the Department of Veterans Affairs.
Acknowledgment: The authors thank the Health Research & Educational Trust (HRET) Health Care-Associated Infection team, as well as the National Program Team and all members of the CDC STRIVE collaborative. The authors also thank Rachel Ehrlinger, BA; Jason Engle, BS; Karen E. Fowler, MPH; and Jason Mann, MSA, for assistance with manuscript preparation and David Ratz, MS, for assistance with statistical analysis.
Disclosures: Dr. Dubberke reports grants from the CDC during the conduct of the study; grants from Pfizer, Merck, and Rebiotix outside the submitted work; and personal fees from Pfizer, Merck, Valneva, Rebiotix, Achaogen, Biofire, Abbott, and Synthetic Biologics outside the submitted work. Dr. Rohde reports a CDC contract with the HRET, which subcontracted with the Society of Hospital Medicine, and personal fees from the Society of Hospital Medicine during the conduct of the study. Dr. Saint, Ms. Snyder, and Dr. Chopra report a CDC contract with the HRET, which subcontracted with the University of Michigan to support faculty/staff effort for this contract, during the conduct of the study. Dr. Saint also reports personal fees from Doximity and Jvion during the conduct of the study. Ms. Jones reports a CDC contract with an HRET subcontract during the conduct of the study. Mr. Rolle reports a CDC contract to the HRET during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-3545.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement: Study protocol: Not applicable. Statistical code: Available from David Ratz (e-mail, email@example.com). Data set: Not available.
Corresponding Author: Erik R. Dubberke, MD, MSPH, Washington University School of Medicine, 4523 Clayton Avenue, Box 8051, St. Louis, MO 63110; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Dubberke: Washington University School of Medicine, 4523 Clayton Avenue, Box 8051, St. Louis, MO 63110.
Dr. Rohde: University of Michigan, Department of Internal Medicine, 1500 East Medical Center Drive UH South, Unit 4, F4309, Ann Arbor, MI 48109-5226.
Dr. Saint and Ms. Snyder: University of Michigan, Department of Internal Medicine, 2800 Plymouth Road, NCRC Building 16, Room 430W, Ann Arbor, MI 48109-2800.
Ms. Jones: University of Michigan Geriatrics, 300 North Ingalls Building, Room 914, Ann Arbor, MI 48109-2007.
Mr. Rolle: American Hospital Association, 155 North Wacker Drive, Suite 400, Chicago, IL 60606.
Dr. Chopra: University of Michigan, Department of Internal Medicine, 2800 Plymouth Road, NCRC Building 16, Room 432W, Ann Arbor, MI 48109-2800.
Author Contributions: Conception and design: J.M. Rohde, S. Saint, A.J. Rolle, V. Chopra.
Analysis and interpretation of the data: E.R. Dubberke, J.M. Rohde, A. Snyder, V. Chopra.
Drafting of the article: E.R. Dubberke, J.M. Rohde, K. Jones, V. Chopra.
Critical revision of the article for important intellectual content: E.R. Dubberke, J.M. Rohde, S. Saint, K. Jones, A.J. Rolle, V. Chopra.
Final approval of the article: E.R. Dubberke, J.M. Rohde, S. Saint, K. Jones, A. Snyder, A.J. Rolle, V. Chopra.
Statistical expertise: A. Snyder.
Obtaining of funding: S. Saint, V. Chopra.
Administrative, technical, or logistic support: K. Jones, A.J. Rolle.
Collection and assembly of data: A.J. Rolle.
Clostridioides difficile infection (CDI) is on the rise.
To evaluate the effect of a tiered, evidence-based intervention to prevent CDI.
Pre–post observational evaluation of a prospective, 12-month, national, nonrandomized, clustered quality improvement project to reduce hospital health care–associated infection.
Acute care, long-term acute care, and critical access hospitals working with state partner organizations (state hospital associations and state health departments) to improve health care–associated infection prevention practices.
Targeted hospitals had a high burden of CDI and another health care–associated infection. Other hospitals that did not meet these criteria volunteered to participate.
Multimodal intervention that consisted of 1) on-demand educational modules and webinars, 2) in-person meetings facilitated by state-level partners, 3) feedback and recommendations for implementation of evidence-based recommendations (including a CDI-specific guide on which interventions to implement), and 4) guided facilitation through infection prevention resources and site visits.
Pre- and postintervention CDI rates.
Between November 2016 and May 2018, 387 hospitals (366 of which reported CDI data) in 23 states and the District of Columbia participated in the intervention. There was a statistically significant decrease in CDI incidence over the study period, from 7.0 cases per 10 000 patient-days in the preintervention period to 5.7 cases per 10 000 patient-days in the postintervention period. However, this decrease appeared to be part of a temporal trend rather than due to the study intervention.
Commitment to and adherence with recommended infection prevention practices before and after the intervention were not assessed. The intervention period was relatively brief, and patient-level data were not available.
Although a statistically significant decline in hospital-onset CDI was observed, this trend appears to be unrelated to the study intervention.
Centers for Disease Control and Prevention.
STRIVE project timeline.
Outcome data were hospital-onset Clostridioides difficile infections as reported by participating hospitals to the CDC National Healthcare Safety Network. CDC = Centers for Disease Control and Prevention; ICAR = Infection Control Assessment and Response; PCA = Practice Change Assessment; SHA = state hospital association; STRIVE = States Targeting Reduction in Infections via Engagement; TAP = Targeted Assessment for Prevention.
Study flow diagram.
CAD = cumulative attributable difference; CDC = Centers for Disease Control and Prevention; CDI = Clostridioides difficile infection; HAI = health care–associated infection; NHSN = National Healthcare Safety Network.
* “States” includes the District of Columbia.
† “Withdrew” defined as hospital and state jointly decided the hospital would stop participating in the program.
‡ 336 of the 366 hospitals self-reported that they focused on CDI prevention during the program.
Table 1. Characteristics of Hospitals That Submitted Clostridioides difficile Infection Data*
Table 2. Pre- and Postintervention CDI Data, by Hospital Type
Appendix Table 1. CDI Rates for All 366 Hospitals
Hospital-onset CDI incidence per 10 000 patient-days before and after the intervention.
Rates are shown by month for the 12-month preintervention (baseline) and 12-month postintervention periods. The solid line represents the monthly CDI rate; dashed lines represent the 95% CIs. B = baseline month; CDI = Clostridioides difficile infection; M = intervention month.
Appendix Table 2. CDI Rates for the 336 Hospitals That Indicated That CDI Prevention Was a Specific Area of Focus
Hospital-onset CDIs per 10 000 patient-days among the 336 participating hospitals that indicated that CDI prevention was a specific area of focus during the project period.
Changes in CDI incidence from the pre- to the postintervention periods.
In this Sankey bar chart, the connecting segments show how hospitals changed from the pre- to the postintervention periods. The slopes of the connecting segments should be interpreted cautiously because some segments connecting to the same rate category are increasing or decreasing visually but indicate no change in rates in these hospitals. Only segments that connect to a different category indicate changes in rates from the pre- to the postintervention period. Data are from 365 hospitals. CDI = Clostridioides difficile infection.
Appendix Table 3. Comparison of CDI Rates Between the Pre- and Postintervention Periods
Dubberke ER, Rohde JM, Saint S, et al. Quantitative Results of a National Intervention to Prevent Clostridioides difficile Infection: A Pre–Post Observational Study. Ann Intern Med. 2019;171:S52–S58. doi: https://doi.org/10.7326/M18-3545
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Published: Ann Intern Med. 2019;171(7_Supplement):S52-S58.
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