23/08/25
Impact of enhanced infection control and antimicrobial stewardship on infections by Clostridioides difficile, vancomycin-resistant enterococci, and third-generation cephalosporin-resistant Enterobacterales: A stepped-wedge cluster intervention study
Classen, A. Y., Dietz, T., Durán Graeff, L., Eisenbeis, S., Gastmeier, P., Göpel, S., Hoffmann, A., Hölzl, F., Käding, N., Kern, W. V., Kramme, E., Belmar Campos, C., Maurer, F. P., Seifert, H., Meißner, A., Rohde, A. M., Rohde, H., Rupp, J., Tacconelli, E.
Objectives: Infection prevention and control (IPC) and antimicrobial stewardship (AMS) measures are critical to reduce transmission and infection by Clostridioides difficile (CDI) and other enteric pathogens. This study evaluated the impact of enhanced IPC and AMS on CDI and bloodstream infections (BSI) by vancomycin-resistant enterococci (VRE), and third-generation cephalosporin-resistant Enterobacterales (3GCREB).
Methods: The study was conducted in five German university hospitals from January 2016 to July 2019. IPC and AMS interventions were sequentially enhanced in three departments with high-incidence CDI at baseline using a stepped-wedge cluster intervention approach. Main outcome measures were incidence densities of CDI and BSI caused by VRE and 3GCREB. An interrupted time series analysis (ITSA) was performed to assess the intervention effects during a normalized study period.
Results: Across 15 departments, over 384,000 patient-days were included. Incidence density of target infections was low (CDI 0.77, VRE BSI 0.07, 3GCREB BSI 0.09 per 1,000 patient days). Pooled ITSA results showed a significant reduction in CDI incidence density following enhancement of AMS measures (AMS period reg. slopes diff. -.089, F(p) = 5.400 (0.037)). Regarding the incidence density of VRE/3GCREB BSI no relevant changes could be observed (regression slopes diff. -0.19, F(p) = 0.667 (0.429). A subgroup analysis focusing on haematological and oncological departments showed that AMS influenced prescription behaviour according to implemented AMS strategies, but not clinical outcomes.
Conclusions: Combined with IPC enhanced short-term AMS measures led to a significant reduction in the incidence of CDI, while incidence of BSI by VRE and 3GCREB remained unchanged in sites with well-established baseline IPC and AMS programs and low incidence of hospital-associated infections.
Keywords: Clostridioides difficile; VRE; antimicrobial stewardship; haematology-oncology; infection prevention and control; multi-resistant Gram-negative bacteria.