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Yogurt: A tasty tool against C. difficile

From the February ACP Hospitalist, copyright © 2014 by the American College of Physicians

By Stacey Butterfield

Where: Holy Redeemer Hospital, a 242-bed acute care facility in Meadowbrook, Pa.

The issue: Reducing hospital-acquired Clostridium difficile infections.

Background

In 2011, Holy Redeemer was working hard to prevent inpatients from acquiring C. difficile. “We tried a number of different interventions, including education, monitoring. They tried a new cleaning product,” said Jeanie Ryan, a registered dietitian and member of the hospital's infection control committee. “All of those interventions seemed to have no effect.”

A surgeon on the committee suggested prescribing probiotics to all inpatients taking antibiotics. Concerned about the cost of probiotic supplements, however, the hospital decided to start dosing patients with a simpler source of bacteria: yogurt.

How it works

Beginning around the start of 2012, dietitians at Holy Redeemer got a daily list from the pharmacy of all patients on antibiotics. They visited these patients and encouraged them to eat yogurt twice a day during their stay. “We ask the patient if they would like [yogurt at] breakfast and lunch or lunch and dinner and we add it to their meal plan,” said Anne Kathryn Bromm, also a dietitian at Holy Redeemer.

Noting a lack of evidence to support any specific brand or type of yogurt, the project stuck with the variety of yogurt already available in the hospital, just a lot more of it. “We arbitrarily served 2 cups a day,” said Ms. Ryan, which added up to more than 50,000 yogurts served in the hospital in 2012.

Results

The increase in yogurt was associated with a dramatic decrease in hospital-acquired C. difficile. The hospital had 75 cases in 2011 and only 23 in 2012. The infection rate for 2013 was on track to match 2012. “We decreased 52 cases, so we really saved money in the long run and also helped patients out,” said Ms. Ryan.

At 65 cents apiece, the yogurts did increase the hospital's food budget by about $35,000, but that cost would be substantially outweighed by the overall health care cost savings of preventing even a couple of C. difficile cases.

Since the yogurt intervention wasn't randomized (an intensive care unit pilot was initially planned, but it was decided to launch hospital-wide instead), the clinicians can't be completely sure that the drop is attributable to the yogurt, but they believe it is. “In 2011, we tried a number of different things##hellip; that did not seem to have an impact,” said Ms. Ryan. “As far as I know, there's nothing else that changed [since then].”

Challenges

The dietitians have not had much trouble convincing patients that yogurt will do them good. “Most people are very aware of probiotics and the benefit of them,” said Ms. Bromm.

Patients who aren't eating, due to not feeling well or physicians' orders, also miss out on the yogurt, and Ms. Ryan has noticed an anecdotal association between this group and the hospital's remaining infections.

“Our infection prevention nurse sends out a list every day of patients that are in isolation. I just check the C. diff patients…Usually the patient's a really poor eater or they've been NPO, so they did not get any probiotics. That's generally the cases we're seeing that are hospital-acquired C. diff,” she said.

The dietitians try to put patients who aren't consuming yogurt on probiotic supplements when possible.

Other benefits

The evidence review conducted before the intervention started found no disadvantages to yogurt consumption, and there are other benefits. “There's calories and protein and everybody that enters the hospital is at risk for malnutrition, so I think that's a good approach to introduce food before a pill,” said Ms. Bromm.

Next steps and words of wisdom

Based on the program's success, the yogurt regimen has been expanded from the hospital to 2 long-term care facilities in the same health system. “They too have seen a decrease in the number of C. diff cases acquired in the institutions,” said Ms. Ryan.

Athough dietitians are on the front lines of implementing this intervention, hospitalists may be well-placed to suggest the idea and to explain the potential cost and health benefits, the Holy Redeemer clinicians said. “It was easy for us because it came from above, rather than us having to push upwards,” said Ms. Ryan. “Sometimes when it comes to departmental budgets, people will balk and say, ‘I don't want my budget to go up.’ [But] it helps the hospital overall.”

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