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

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.

A Baker’s Dozen of Top Antimicrobial Stewardship Intervention Publications in 2019

“…Christensen and colleagues performed a quasi-experimental retrospective, single-center study evaluating ASP-led education and prior authorization on C. difficile NAATs [ 15 ]. The study had a pre-intervention period from January 2014 to September 2016 and a postintervention period from October 2016 to April 2018.…”

Incorporating preauthorization into antimicrobial stewardship pharmacist workflow reduces Clostridioides difficile and gastrointestinal panel testing

“…Our study is not novel in its outcomes; other centers have also demonstrated reductions in C. difficile testing and HO-CDI rates with diagnostic stewardship processes. [11][12][13][14] However, we developed a novel model that was similarly effective and easily integrated into existing resources and infrastructure. Existing models described in the literature were not felt to be an appropriate fit for our institution for several reasons.…”

“…First, 2 centers utilized a model whereby once or twice daily review of batched orders was performed. 13,14 Recommendations were made to the primary team to discontinue the order if testing was deemed inappropriate. This model was not considered tenable at our institution because testing was not batched; also, concerns were expressed regarding the condensed workload at the point of review.…”

Impact of an antimicrobial stewardship program in the antimicrobial-resistant and prevalence of clostridioides difficile infection and amount of antimicrobial consumed in cancer patients

“…Similar to the results of other studies in Canada, the US, and Iran the rates of CDI and MDR positive cases are decreased significantly in our patients (P = 0.004 & 0.011) respectively. (5,23,28).…”