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Fig. 5. Relationship between facility-wide HO-CDI incidence rate and oral vancomycin consumption. Note. AD, antimicrobial days; CDI, Clostridioides difficile infection; days present (DP); HO, hospital-onset; patient days (PD).
Fig. 6. Percent change in NAAT classified HO- CDI from baseline according to ASP coverage. The proportional change in positive NAAT consid- ered to be HO-CDI were calculated as a percent change from baseline and stratified according to weekday or weekend day of ordering. ASP pre- authorization was in effect only during weekdays during the study. Control units were comprised of stem-cell transplant and were excluded from the intervention. Note. CDI, Clostridioides difficile infection; NAAT, nucleic acid amplification test.
significant time-dependent decrease in the monthly facility-wide SIR trend (Pstep = .10; Ptrend = .017) with a mean rate change of −2.9%(95% CI, −0.52%to−5.4%) permonth postimplementation. Reductions in NAAT and HO-CDI-IR per 10,000 patient days and SIR were accompanied by decreases in oral vancomycin consumption, as summarized in Fig. 4. Segmented regression analysis identified significant time-dependent decreases in oral vancomycin consumption (Pstep < .001; Ptrend < .001) with a mean rate change of −3.1% (95% CI, −2.6% to −3.7%) per month post- implementation. Vancomycin consumption was significantly (P = .002) positively correlated with HO-CDI-IR at the facility- wide level (Fig. 5). Time-series models of HO-CDI-IR parameter- ized with step-change only versus both step and slope changes produced inferior data fits by likelihood ratio testing (P = .008), whereas time-series models of HO-CDI-IR parameterized with education (starting at month 25) plus preauthorization interven- tion (starting at month 34) did not improve model fitness versus parameterization with preauthorization intervention alone accord- ing to likelihood ratio testing (P = .34). Alternative time-series models of SIR were also considered but did not improve model fitness by likelihood ratio testing (data not shown). The stratification of HO-CDI NAAT orders by whether the order was placed during a weekday or on the weekend is shown
in Fig. 6. There was no significant difference in the proportion of test positivity on weekdays versus weekends within the interven- tional units after implementation of the stewardship initiative (−29% vs −39% change from baseline; P = .27). Likewise, control units demonstrated similar proportions of test positivity on week- days versus weekends after implementation of the stewardship ini- tiative (−14% vs −18% change from baseline; P = .99).
Discussion
We observed reductions in HO-CDI NAAT, HO-CDI incident rates, CDI SIR, and oral vancomycin consumption within our center after implementation of a clinical review and preauthoriza- tion protocol led by ASP to decrease inappropriate testing. Noninterventional control unit (ie, SCT) NAAT positivity and HO-CDI-IRwere similar before and after protocol implementation, strengthening the association between the intervention and the out- come. Practice guidelines call for institutional guidance and proto- cols to improve appropriate detection and treatment of CDI.1 The high sensitivity of NAAT testing makes it difficult to differentiate carriers of the toxigenic C. difficile strain from CDI based on test results alone, yet NHSN classifies HO-CDI-IR solely based on lab- oratory event reporting. Our center previously examined the
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