Infection Control & Hospital Epidemiology (2019), 40, 269–275 doi:10.1017/ice.2018.336
Original Article
Diagnostic stewardship of C. difficile testing: a quasi-experimental antimicrobial stewardship study
Alyssa B. Christensen PharmD1,2,a, Viktorija O. Barr PharmD2, David W. Martin PharmD1,b, Morgan M. Anderson PharmD1,3,c, Amanda K. Gibson PharmD1,d, Brian M. Hoff PharmD1, Sarah H. Sutton MD4,6, Valerie Widmaier MBA, MLS(ASCP)CM5, Asra A. Salim MPH, CIC, CPH6,e, Christina Silkaitis MT(ASCP), CIC6, Chao Qi PhD5,7,
Teresa R. Zembower MD, MPH4,5,6, Michael J. Postelnick BSPharm1 and Nathaniel J. Rhodes PharmD, MSc1,3,8 1Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, 2Department of Pharmacy Practice, Rosalind Franklin University, North Chicago, Illinois, 3Department of Pharmacy Practice, Midwestern University, Downers Grove, Illinois, 4Division of Infectious Diseases, Department of Medicine, Feinberg School of Medicine, Northwestern University, Illinois, 5Department of Microbiology, Northwestern Memorial Hospital, Chicago, Illinois, 6Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, Illinois, 7Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois and 8Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, Illinois
Abstract
Objective: We evaluated whether a diagnostic stewardship initiative consisting of ASP preauthorization paired with education could reduce false-positive hospital-onset (HO) Clostridioides difficile infection (CDI). Design: Single center, quasi-experimental study. Setting: Tertiary academic medical center in Chicago, Illinois.
Patients: Adult inpatients were included in the intervention if they were admitted between October 1, 2016, and April 30, 2018, and were eligible for C. difficile preauthorization review. Patients admitted to the stem cell transplant (SCT) unit were not included in the intervention and were therefore considered a contemporaneous noninterventional control group.
Intervention: The intervention consisted of requiring prescriber attestation that diarrhea has met CDI clinical criteria, ASP preauthorization, and verbal clinician feedback. Data were compared 33 months before and 19 months after implementation. Facility-wide HO-CDI incidence rates (IR) per 10,000 patient days (PD) and standardized infection ratios (SIR) were extracted from hospital infection prevention reports.
Results: During the entire 52 month period, the mean facility-wide HO-CDI-IR was 7.8 per 10,000 PD and the SIR was 0.9 overall. The mean ± SD HO-CDI-IR (8.5 ± 2.0 vs 6.5 ± 2.3; P < .001) and SIR (0.97 ± 0.23 vs 0.78 ± 0.26; P = .015) decreased from baseline during the intervention. Segmented regression models identified significant decreases in HO-CDI-IR (Pstep = .06; Ptrend = .008) and SIR (Pstep = .1; Ptrend=.017) trends concurrent with decreases in oral vancomycin (Pstep<.001; Ptrend<.001). HO-CDI-IR within a noninterventional control unit did not change (Pstep = .125; Ptrend = .115).
Conclusions:Amultidisciplinary, multifaceted intervention leveraging clinician education and feedback reduced the HO-CDI-IR and the SIR in select populations. Institutions may consider interventions like ours to reduce false-positive C. difficile NAAT tests.
(Received 4 August 2018; accepted 27 November 2018)
Clostridioides difficile infection (CDI) is a major cause of morbidity and excess healthcare costs worldwide.1 In 2011, C. difficile was estimated to cause nearly half a million infections annually in
Author for correspondence: Nathaniel J. Rhodes, Email:
nrhode@midwestern.edu aPresent affiliation: Department of Pharmacy, Providence St. Vincent Medical Center,
Portland, Oregon. bPresent affiliation: Syneos Health/GlaxoSmithKline, Parsippany, New Jersey. cPresent affiliation: Department of Pharmacy, Advocate Aurora Health, Chicago, Illinois. dPresent affiliation: Department of Pharmacy, University of Utah Health, Salt Lake City,
Utah. ePresent affiliation: Division of Infection Prevention, VigiLanz, Chicago, Illinois. Cite this article: Christensen AB, et al. (2019). Diagnostic stewardship of C. difficile
testing: a quasi-experimental antimicrobial stewardship study. Infection Control & Hospital Epidemiology, 40: 269–275,
https://doi.org/10.1017/ice.2018.336
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved.
the United States.2,3 Although CDI is now common, false-positive C. difficile test results have been observed among patients who are colonized and asymptomatic. Screening for C. difficile in asympto- matic patients is not recommended by consensus guidelines.1 Pre- venting testing and treatment of asymptomatic patients is supported by multiple studies.4–6Most antibiotic treatments targeting C. difficile are nonselective and may exacerbate pre-existing dysbiosis among carriers.7,8 Treatmentwith commonly prescribed C. difficile–directed antibiotic agents (eg, metronidazole and oral vancomycin) has been shown to reduce gut microbial diversity,7 delaying restoration of a eubiotic state. Thus, avoiding antibiotic treatment of asymptomatic carriers is expected to benefit patients, lower CDI rates, and decrease antibiotic consumption by curtailing unnecessary prescribing.
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