Infection Control & Hospital Epidemiology
Table 1. Guideline-Based Clostridoides difficile Infection Prescribing and Outcomes Before and After Implementation of a Best Practice Alert Linked to a Treatment Order Set
Outcome
Guideline-based initial therapy, no. (%)
Reason for
noncompliance, no. (%)
Inappropriate initial agent
Inappropriate route of administration Inappropriate dose
Days to resolution of diarrhea, mean–SD
In-hospital mortality, no. (%)
Length-of-stay, median (IQR)
Treatment failure, no. (%)
30-day recurrence, no. (%)
30-day readmission, no. (%)
4.4±6.1 4 (6.1) 9.5 (5–20.75) 8 (12.1) 4 (6.1) 16 (24.2) 4.2±5.2 4 (6.2) 14 (6–28) 13 (20) 4 (6.2) 21 (32.3) Note. BPA, best practice alert; SD, standard deviation; IQR, interquartile range.
compliance. Additionally, familiarity with the 2010 IDSA and 2013 ACG guidelines likely improved over time via external mechanisms. Several limitations should be considered with our study. The retrospective design introduces several opportunities for con- founding that are difficult to identify through chart review and may have impacted prescribing. The effect of daily interactions with the stewardship team and various ID consult services over time may have influenced practice as well. Additionally, electronic charting may not have been consistent and outcomes, such as bowel movements and outpatient symptoms, may have been poorly documented. The BPA was only triggered for those not on therapy, limiting its ability to influence treatment of those empirically initiated on therapy. The impact of this was likely lim- ited as CDI turnaround time is rapid at our institution and empiric therapy is rarely used. Also, the building requirements to create a CDSS that would evaluate appropriateness of therapy after initia- tion was complex and beyond our technical ability at the time. Finally, multiple treatment guidelines exist for CDI, including the IDSA and ACG guidelines, with some discrepancies noted between them. Therefore, providers had several outside resources available to guide their decision-making process for CDI treat- ment. We attempted to alleviate this limitation by evaluating the post-BPA and order-set group using a modified severity assess- ment requiring 2 of 3 criteria for severe CDI. Although the positive response seen for the CDI BPA in our study was impressive compared to our institutional BPAs,
.842 .999 .29 .674 1 References .796
1. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridoides difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America. Clostridoides difficile 2010;31:431–455.
2. SurawiczCM, Brandt LJ, BinionDG, et
al.Guidelines for diagnosis, treatment, and prevention of Clostridoides difficile infections. Am J Gastroenterol 2013; 108:478–498.
3. Wieczorkiewicz S, Zatarski R. Adherence to and outcomes associated with a Clostridoides difficile guideline at a large teaching institution. Hosp Pharm 2015;50:42–50.
4. Brown AT, Seifert CF. Effect of treatment variation on outcomes in patients with Clostridoides difficile. Am J Med 2014;127:865–870.
5. Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vanco- mycin and metronidazole for the treatment of Clostridoides difficile– associated diarrhea, stratified by disease severity. Clin Infect Dis 2007;45: 302–307.
6. Stevens VW, Nelson RE, Schwab-Daugherty EM, et al. Comparative effec- tiveness of vancomycin and metronidazole for the prevention of recurrence and death in patients with Clostridoides difficile infection.JAMAIntern Med 2017;177:546–553.
7. Wright A, Phansalkar S, Bloomrosen M, et al. Best practices in clinical deci- sion support. The case of preventive care reminders. Appl Clin Inform 2010;1:331–345.
8. Wenisch JM, Schmid D, Kuo HW, et al. Prospective observational study comparing three different treatment regimens in patients with Clostridoides difficile infection. Antimicrob Agents Chemother 2012;56: 1974–1978.
9. Revolinski S. Implementation of a clinical decision support alert for the management of Clostridoides difficile infection. Antibiotics (Basel, Switzerland) 2015;4:667–674.
10. McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridoides difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clostridoides difficile 2018;66(7):e1–e48.
Preimplementation (N=66)
26 (39.4) 30 (45.5) 16 (24.2) 5 (7.6)
Postimplementation (N=65)
44 (67.7) 17 (26.2) 11 (16.9) 0 (0)
P Value
.014 :: : :: : :: :
469
opportunities exist to improve order-set utilization and guide- line-based prescribing. New IDSA CDI guidelines were published in early 2018 with a recommendation to treat mild-to-moderate CDI preferentially with oral vancomycin therapy.10 In 2018, our institutional BPA, linked order set and clinical pathway were updated to be in alignment with the new IDSA treatment recom- mendations. In this way, the BPA has proven to be a useful method to rapidly provide education on changes in clinical guidelines. Application of the BPA for outpatient antimicrobial stewardship and recommending discontinuation of active CDI treatment fol- lowing negative CDI laboratory results may be feasible extensions of the alert. With further advancements in CDSS, data mining fea- tures could determine a patient’s CDI severity and the correspond- ing guideline-based treatment recommendation in the future.
Supplementary material. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2019.18.
Author ORCIDs. Holly Reed, 0000-0001-8240-070X
Financial support. None reported outside of routine work at each authors’ institution.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
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