Hostname: page-component-cd9895bd7-jkksz Total loading time: 0 Render date: 2024-12-23T03:59:15.888Z Has data issue: false hasContentIssue false
  • English
  • Français

Diagnostic stewardship of C. difficile testing: a quasi-experimental antimicrobial stewardship study

Published online by Cambridge University Press:  21 February 2019

Alyssa B. Christensen ,
Viktorija O. Barr ,
David W. Martin ,
Morgan M. Anderson ,
Amanda K. Gibson ,
Brian M. Hoff ,
Sarah H. Sutton ,
Valerie Widmaier ,
Asra A. Salim  and
Christina Silkaitis
...Show all authors
Alyssa B. Christensen
Affiliation:
Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois Department of Pharmacy Practice, Rosalind Franklin University, North Chicago, Illinois
Viktorija O. Barr
Affiliation:
Department of Pharmacy Practice, Rosalind Franklin University, North Chicago, Illinois
David W. Martin
Affiliation:
Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois
Morgan M. Anderson
Affiliation:
Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois Department of Pharmacy Practice, Midwestern University, Downers Grove, Illinois
Amanda K. Gibson
Affiliation:
Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois
Brian M. Hoff
Affiliation:
Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois
Sarah H. Sutton
Affiliation:
Division of Infectious Diseases, Department of Medicine, Feinberg School of Medicine, Northwestern University, Illinois Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, Illinois
Valerie Widmaier
Affiliation:
Department of Microbiology, Northwestern Memorial Hospital, Chicago, Illinois
Asra A. Salim
Affiliation:
Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, Illinois
Christina Silkaitis
Affiliation:
Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, Illinois
Chao Qi
Affiliation:
Department of Microbiology, Northwestern Memorial Hospital, Chicago, Illinois Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Teresa R. Zembower
Affiliation:
Division of Infectious Diseases, Department of Medicine, Feinberg School of Medicine, Northwestern University, Illinois Department of Microbiology, Northwestern Memorial Hospital, Chicago, Illinois Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, Illinois
Michael J. Postelnick
Affiliation:
Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois
Nathaniel J. Rhodes*
Affiliation:
Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois Department of Pharmacy Practice, Midwestern University, Downers Grove, Illinois Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, Illinois
*
Author for correspondence: Nathaniel J. Rhodes, Email: [email protected]
Get access Rights & Permissions [Opens in a new window]

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:

A multidisciplinary, 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.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 40 , Issue 3 , March 2019 , pp. 269 - 275
Copyright
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved. 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

a

Present affiliation: Department of Pharmacy, Providence St. Vincent Medical Center, Portland, Oregon.

b

Present affiliation: Syneos Health/GlaxoSmithKline, Parsippany, New Jersey.

c

Present affiliation: Department of Pharmacy, Advocate Aurora Health, Chicago, Illinois.

d

Present affiliation: Department of Pharmacy, University of Utah Health, Salt Lake City, Utah.

e

Present affiliation: Division of Infection Prevention, VigiLanz, Chicago, Illinois.

References

McDonald, LC, Gerding, DN, Johnson, S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clostridium Difficile 2018;66:987–994.Google Scholar
Lessa, FC, Mu, Y, Bamberg, WM, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med 2015;372:825–834.CrossRefGoogle ScholarPubMed
Healthcare-Associated Infections—Community Interface (HAIC). Annual report for the emerging infections program for Clostridium difficile infection, 2015. Centers for Disease Control and Prevention website. https://www.cdc.gov/hai/eip/clostridium-difficile.html. Published 2015. Accessed December 5, 2018.Google Scholar
Gerding, DN, Olson, MM, Peterson, LR, et al. Clostridium difficile-associated diarrhea and colitis in adults. A prospective case-controlled epidemiologic study. Arch Intern Med 1986;146:95–100.CrossRefGoogle ScholarPubMed
Samore, MH, DeGirolami, PC, Tlucko, A, Lichtenberg, DA, Melvin, ZA, Karchmer, AW. Clostridium difficile colonization and diarrhea at a tertiary care hospital. Clin Infect Dis 1994;18:181–187.CrossRefGoogle Scholar
Loo, VG, Bourgault, AM, Poirier, L, et al. Host and pathogen factors for Clostridium difficile infection and colonization. N Engl J Med 2011;365:1693–1703.CrossRefGoogle ScholarPubMed
Lamendella, R, Wright, JR, Hackman, J, et al. Antibiotic treatments for Clostridium difficile infection are associated with distinct bacterial and fungal community structures. mSphere 2018;3:e00572–17.CrossRefGoogle ScholarPubMed
Cannon, K, Byrne, B, Happe, J, et al. Enteric microbiome profiles during a randomized Phase 2 clinical trial of surotomycin versus vancomycin for the treatment of Clostridium difficile infection. J Antimicrob Chemother 2017;72:3453–3461.CrossRefGoogle ScholarPubMed
Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases. Division of Healthcare Quality Promotion. U.S. Deparment of Health and Human Services. National Healthcare Safety Network (NHSN). The NHSN standardized infection ratio (SIR): a guide to the SIR. Atlanta, GA: 2017. Available at: https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/nhsn-sir-guide.pdf.Google Scholar
Dubberke, ER, Han, Z, Bobo, L, et al. Impact of clinical symptoms on interpretation of diagnostic assays for Clostridium difficile infections. J Clin Microbiol 2011;49:2887–2893.CrossRefGoogle ScholarPubMed
R Development Core Team. R: a language and environment for statistical computing. 3rd ed. Vienna, Austria: R Foundation for Statistical Computing. http://www.R-project.org/. Published 2016. Accessed December 5, 2018.Google Scholar
Bernal, JL, Cummins, S, Gasparrini, A. Interrupted time series regression for the evaluation of public health interventions: a tutorial. Int J Epidemiol 2017;46:348–355.Google ScholarPubMed
Kelly, SG, Yarrington, M, Zembower, TR, et al. Inappropriate Clostridium difficile testing and consequent overtreatment and inaccurate publicly reported metrics. Infect Control Hosp Epidemiol 2016;37:1395–1400.CrossRefGoogle ScholarPubMed
Price, J, Cheek, E, Lippett, S, et al. Impact of an intervention to control Clostridium difficile infection on hospital- and community-onset disease; an interrupted time series analysis. Clin Microbiol Infect 2010;16:1297–1302.CrossRefGoogle ScholarPubMed
Lewis, PO, Lundberg, TS, Tharp, JL, Runnels, CW. Implementation of global strategies to prevent hospital-onset Clostridium difficile. infection: targeting proton pump inhibitors and probiotics. Ann Pharmacother 2017;51:848–854.CrossRefGoogle ScholarPubMed
Barker, AK, Alagoz, O, Safdar, N. Interventions to reduce the incidence of hospital-onset Clostridium difficile infection: an agent-based modeling approach to evaluate clinical effectiveness in adult acute care hospitals. Clin Infect Dis 2018;66:1192–1203.CrossRefGoogle ScholarPubMed
Kociolek, LK, Bovee, M, Carter, D, et al. Impact of a healthcare provider educational intervention on frequency of Clostridium difficile polymerase chain reaction testing in children: a segmented regression analysis. J Pediatric Infect Dis Soc 2017;6:142–148.Google ScholarPubMed
Khoury, JA, Sistrunk, WW, Hixson, F, et al. Sustained reduction in rates of hospital-onset Clostridium difficile infection using an automated electronic health record protocol. Am J Infect Control 2018;46:542–548.CrossRefGoogle ScholarPubMed
Mermel, LA, Jefferson, J, Blanchard, K, et al. Reducing Clostridium difficile incidence, colectomies, and mortality in the hospital setting: a successful multidisciplinary approach. Jt Comm J Qual Patient Saf 2013;39:298–305.CrossRefGoogle ScholarPubMed
Quan, KA, Yim, J, Merrill, D, et al. Reductions in Clostridium difficile infection (CDI) rates using real-time automated clinical criteria verification to enforce appropriate testing. Infect Control Hosp Epidemiol 2018;39:625–627.CrossRefGoogle ScholarPubMed
White, DR, Hamilton, KW, Pegues, DA, Hanish, A, Umscheid, CA. The impact of a computerized clinical decision support tool on inappropriate Clostridium difficile testing. Infect Control Hosp Epidemiol 2017;38:1204–1208.CrossRefGoogle ScholarPubMed
Christensen, AB, Gibson, AK, Martin, DW, Rhodes, NJ, et al. Reduction of inappropriate hospital-onset Clostridium difficile testing through preauthorization of PCR Clostridium difficile lab orders. ASM Microbe 2017. Platform presentation. New Orleans, LA.Google Scholar