The Use of a Computerized Provider Order Entry Alert to Decrease Rates of Clostridium difficile Testing in Young Pediatric Patients

Abstract

BACKGROUND Infants and young children are frequently colonized with C. difficile but rarely have symptomatic disease. However, C. difficile testing remains prevalent in this age group. OBJECTIVE To design a computerized provider order entry (CPOE) alert to decrease testing for C. difficile in young children and infants. DESIGN An interventional age-targeted before-after trial with comparison group SETTING Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, Tennessee. PATIENTS All children seen in the inpatient or emergency room settings from July 2012 through July 2013 (pre-CPOE alert) and September 2013 through September 2014 (post-CPOE alert) INTERVENTION In August of 2013, we implemented a CPOE alert advising against testing in infants and young children based on the American Academy of Pediatrics recommendations with an optional override. We further offered healthcare providers educational seminars regarding recommended C. difficile testing. RESULTS The average monthly testing rate significantly decreased after the CPOE alert for children 0-11 months old (11.5 pre-alert vs 0 post-alert per 10,000 patient days; P<.001) and 12-35 months old (61.6 pre-alert vs 30.1 post-alert per 10,000 patients days; P<.001), but not for those children ≥36 months old (50.9 pre-alert vs 46.4 post-alert per 10,000 patient days; P=.3) who were not targeted with a CPOE alert. There were no complications in those children who testing positive for C. difficile. CONCLUSIONS The average monthly testing rate for C. difficile for children <35 months old decreased without complication after the use of a CPOE alert in those who tested positive for C. difficile. Infect Control Hosp Epidemiol 2017;38:542-546.

Reduced Clostridium difficile Tests and Laboratory-Identified Events With a Computerized Clinical Decision Support Tool and Financial Incentive

“… 5 Of 2 studies of CCDS for C. difficile testing that targeted laxative use (an issue not addressed in our CCDS tool), only 1 demonstrated reduced rates of total tests and C. difficile events. 9 , 10 Nicholson et al 11 observed reduced C. difficile testing rates with CCDS-based guidance in pediatric patients, but CDI rates were not compared.…”

“…Similarly, other studies using CCDS for C. difficile testing have not been associated with poor outcomes. 10 , 11 Nevertheless, these studies have not systematically addressed the potential for diagnostic stewardship to cause patient harm. Future diagnostic stewardship studies for C. difficile NAAT or other testing methodologies should ideally include outcome measures targeted to patients with prevented tests to determine clinical relevance and patient safety.…”

Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection and Other Conditions in Children

“…Human clinical studies appear to be in line with the rabbit model observations, with questionable evidence supporting the ability of C difficile to act as a diarrheal pathogen in infants (27). Consequently, many pediatric infectious diseases and gastroenterology experts, adult CDI experts, and the American Academy of Pediatrics have all suggested that CDI should not be considered in children younger than 1 year and that caution should be exercised when diagnosing CDI in children 1 to 2 years of age (4,28–30). They have also emphasized the common occurrence of coinfections with other pathogenic bacteria in young pediatric patients with diarrhea who also test positive for C difficile .…”

Healthcare provider diagnostic testing practices for identification of Clostridioides (Clostridium) difficile in children: an Emerging Infections Network survey

“…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 unnecessary antibiotic therapy for C. difficile carriage, leading to reduced healthcare costs. 7,9 However, reducing unnecessary testing in older children may be more challenging.…”