Infection Control & Hospital Epidemiology
asymptomatic carriage is exceedingly uncommon, certain diag- nostic stewardship practices, particularly IDSA/SHEA-endorsed age-based restrictions of testing, were reported by only half of respondents, irrespective of whether or not toxin or NAAT test- ing was being used in their institution. In addition, roughly one-third of respondents reported the use of a multiplex PCR to diagnose CDI, and nearly three-quarters reported that results were provided even if they were not requested by the clinician. Thus, these data suggest that asymptomatic carriage is likely commonly detected, particularly in patients in whom toxin test- ing is not performed. Because antibiotics are not generally indicated for asympto-
matic carriage, misdiagnosis of carriage as CDI leads to unneces- sary antibiotic exposure. The antibiotic stewardship implications of judicious use of C. difficile testing are highlighted in this survey by responses regarding management of NICU patients tested for C. difficile. Despite strong evidence that C. difficile does not cause infection in neonates5 and American Academy of Pediatrics6 (AAP) guidelines discouraging testing in this age group, roughly half of respondents who reported testing NICU patients for C. difficile provide treatment for CDI. The AAP-endorsed age-based restrictions of C. difficile testing were adopted by the updated IDSA/SHEA guideline.4 Age-based testing restrictions, the uptake of which may be improved with electronic order entry messaging,7,8 may improve testing decisions and reduce unneces- sary antibiotic therapy for C. difficile carriage, leading to reduced healthcare costs.7,9 However, reducing unnecessary testing in older children may be more challenging. Although the vast majority of respondents report that C. difficile testing is restricted for formed stools submitted to the laboratory, this does not prevent testing in children with clinically insignificant diarrhea (ie, 2 or fewer unformed stools in 24 hours) or diarrhea in patients who are unlikely to have CDI. In these cases, pediatric healthcare provider education7 and/or leveraging the electronic health record9 to mon- itor frequency of diarrhea and recent laxative use may be effective. Notably, although this definition of clinically significant diarrhea has not been validated in children, this definition is recommended in the AAP CDI clinical care guidelines.4 In addition to the antibiotic stewardship implications of CDI
misdiagnosis, there are also other consequences. For example, misattribution of diarrheal symptoms to C. difficile may delay identification of the true diarrheal etiology, potentially leading to worse outcomes. We have observed diarrheal symptoms caused by conditions such as typhlitis, ulcerative colitis, and toxic shock syndrome initially mistakenly attributed to CDI because of positive tcdB PCR in these patients. Furthermore, CDI misdiagnosis leads to overestimation of hospital CDI rates, impairing accurate institu- tional CDI surveillance and limiting reliable interfacility compar- isons of CDI rates. Healthcare-associated infection rates are an important hospital quality metric, and implementation and mon- itoring the impact of CDI prevention initiatives require accurate surveillance. The impact of overestimation of CDI rates may be even higher in populations at high risk for C. difficile carriage, such as hospitalized children10 and children with cancer.11 Furthermore, with the potential for hospital nonreimbursement for healthcare- associated infections such as CDI, hospitals have a financial incen- tive for accurately measuring and avoiding overestimation of CDI rates.12 These consequences highlight the importance of develop- ing diagnostic testing methods that reliably distinguish carriage and CDI, which has been a difficult task.2 Until that happens, diag- nostic stewardship will remain an important strategy for optimiz- ing utilization of C. difficile diagnostic testing.
279 Our study has some limitations. Although our 57% physician
response rate was relatively high, and respondents are similar to nonrespondents regarding all practice variables examined, a response bias may still exist. Testing practices may have differed between respondents and non-respondents. Physicians elect to join the EIN, and this convenience samplemay not be generalizable to all pediatric infectious diseases physicians. In addition, although respondents reported the prevalence of policies, hospital and pro- vider compliance with these strategies could not be determined. In summary, these data suggest that there are pervasive oppor-
tunities to improve CDI diagnostic stewardship practices in chil- dren and to develop institutional policies to align with recently updated IDSA/SHEA guidance, particularly in hospitals using NAATs alone for CDI diagnosis in children. However, even with implementation of these IDSA/SHEA-endorsed practices, provider education remains an essential component of diagnostic steward- ship to assist providers in appropriately selecting patients for C. difficile testing. Future work should identify cost-effective, scalable, and sustainable strategies for CDI diagnostic stewardship.
Author ORCIDs. Larry K. Kociolek, 0000-0002-8756-3417
Acknowledgments. We thank Dr David Kuhar and Ronda Sinkowitz- Cochran for their input on the survey and comments that improved the manuscript.
Financial support. This publication was funded by the Centers for Disease Control and Prevention (Cooperative Agreement No. 1 U50 CK000477). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services. L.K.K. is supported by the National Institute of Allergy and Infectious Diseases at the National Institutes of Health (grant no. K23 AI123525).
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
Supplementary material. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2018.347.
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