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appropriateness of NAAT among patients who met laboratory cri- teria for hospital-onset C. difficile infection.13 It was determined that 14.8% of NAAT sent did not meet criteria. In 65.5% of cases, documentation of symptoms was not adequate, further underscor- ing the need for improved NAAT utilization. Our findings support the feasibility of ASP-driven initiatives to reduce inappropriate test- ing and treatment of C. difficile colonization. Although decreases in HO-CDI can be obtained through
improving antibiotic use and optimizing the hygiene practices, 14–16 the impact ofASP interventions aimed at reducing inappro- priate NAAT is beginning to emerge. Kociolek et al17 imple- mented an educational intervention to improve CDI testing in pediatric patients and observed improved trends in testing rates and test positivity without altering the HO-CDI incidence den- sity. Khoury et al18 developed an EHR tool to identify patents at high risk for CDI, yielding a significant decrease in HO-CDI-IR by increasing appropriateness of testing. Others have taken a multifaceted approach to decreasing HO-CDI-IR and improv- ing patient outcomes. Mermel et al19 demonstrated reduced HO-CDI IR and lower mortality after implementing a protocol that included daily monitoring, improved environmental cleaning, and implementation of a recommended CDI treatment plan. Quan et al20 demonstrated that a computerized physician order entry (CPOE) alert could improve testing conditions, including decreasing concomitant laxative use, while also lowering HO-CDI IR. White et al21 utilized a similar clinical deci- sion support tool and demonstrated decreased inappropriate test- ing and avoidance of testing among patients with concomitant laxative use. Our approach was similar to the aforementioned studies in that we optimized education targeting appropriate C. difficile NAAT testing and implemented EHR reinforcement; however, we added preauthorization to this milieu to address inap- propriate testing, all of which led to reductions in HO-CDI-IR and SIR. Our study has several limitations. First, our analysis was a retro-
spective, single-center epidemiological analysis subject to inherent limitations. Patients may have been misclassified as asymptomatic carriers who had active CDI. However, individual cases were pro- spectively assessed in consultation with the primary treatment teams as a standard of care. Providers were encouraged to re-send NAAT if patients continued to report diarrhea after confounding factors were addressed (eg, discontinuation of laxatives). Second, while our present analysis does not address patient-level outcomes, we evaluated the need for repeat CDI testing and treatment in a 30-day follow-up of patients in a pilot study.22 We only identified a single case (2% of the intervention group) in which persistent diarrhea prompted repeat C. difficile testing which was positive and required treatment. Third, certain aspects of the intervention were somewhat unique to our center (eg, test batching), limiting generalizability. However, our daily clinical review of NAAT orders demonstrated efficiency that may be similar to the experi- ence at other centers. Daily work by a single ASP team member, with or without pharmacy trainees, required only 1–2 hours per day and was sustainable throughout the intervention period. Fourth, concurrent provider education and stewardship interven- tions existed during the study period; however, this is reflective of real-world practice and increases generalizability. Fifth, while we were not powered to compare weekday versus weekend NAAT orders, we observed similar proportions of positive tests classified as HO-CDI, irrespective of stewardship coverage. Although this suggests that the intervention maintained effectiveness during off-shifts, further improvements could potentially be realized if
Alyssa B. Christensen et al
7-day-a-week coverage were instituted. Lastly, we are unable to discern the impact attributed to the ASP preauthorization from the clinical decision support alert given the short time period between implementation. Our findings demonstrate that ASP pre- authorization coupled with individual provider education can meaningfully reduce clinical false-positiveNAATresults while also decreasing antibiotic overuse. In summary, our multifaceted, multidisciplinary, antimicrobial
stewardship-led approach to decreasing clinical false-positive C. difficile NAAT led to reductions in HO-CDI-IR. Our findings support the guideline-recommended strategy of linking established institutional testing criteria with C. difficile NAAT testing. Interventions similar to ours may be useful for ASPs seeking to reduce inappropriate CDI testing and treatment which may lead to favorable reductions in the SIR.
Financial support. No financial support for the present study was received. The project was completed as part of our normal work.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
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