Gut Check: <i>Clostridium difficile</i> Testing and Treatment in the Molecular Testing Era

Buckel, Whitney R.; Avdic, Edina; Carroll, Karen C.; Gunaseelan, Vidhya; Hadhazy, Eric; Cosgrove, Sara E.

doi:10.1017/ice.2014.19

Cited by 49 publications

(33 citation statements)

References 10 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Rather than adopting less sensitive tests for CDI, the CML director should work with clinical partners to implement policies to limit more sensitive testing (e.g., NAAT) to those truly at risk (e.g., antibiotic exposure, frequent liquid stools, etc.). Up to half of hospitalized patients tested for CDI do not have significant diarrhea, and over 40% in some studies received laxatives (17). Testing patients with low pretest probability of CDI thus increases the likelihood that a positive test represents C. difficile colonization rather than disease (18,19).…”

Section: Unintended Consequences For Cmlsmentioning

confidence: 99%

Rising Stakes for Health Care-Associated Infection Prevention: Implications for the Clinical Microbiology Laboratory

Diekema

2017

J Clin Microbiol

View full text Add to dashboard Cite

Health care-associated infection (HAI) rates are subject to public reporting and are linked to hospital reimbursement from the Centers for Medicare and Medicaid Services (CMS). The increasing pressure to lower HAI rates comes at a time when advances in the clinical microbiology laboratory (CML) provide more-precise and -sensitive tests, altering HAI detection in ways that may increase reported HAI rates. I review how changing CML practices can impact HAI rates and how the financial implications of HAI metrics may produce pressure to change diagnostic testing practices. Finally, I provide suggestions for how to respond to this rapidly changing environment.KEYWORDS clinical microbiology, infection prevention, nosocomial, pay for performance, health care-associated infections C onsider the following three scenarios related to the role of the clinical microbiology laboratory (CML) in health care-associated infection (HAI) surveillance and prevention. In scenario 1, during an investigation of rising rates of central-line-associated bloodstream infection (CLABSI), the infection prevention program (IPP) notes that some CLABSIs were due to organisms that grew in only one of several blood cultures and which, prior to the institution of matrix-assisted laser desorption-ionization time of flight (MALDI-TOF) mass spectrometry for organism identification, would have been classified as contaminants. An example included a CLABSI attributed to an unusual species of Actinomyces that previously would have been categorized as a "diphtheroid." Your hospital leadership requests that you either revert to former identification methods or change your reporting in a way that prevents these events from being classified as CLABSIs.In scenario 2, since you changed to a nucleic acid amplification test (NAAT) for Clostridium difficile detection, your positivity rate has increased by over 100%. The rate of hospital-onset C. difficile infection (HO-CDI) has increased similarly. During an investigation of the increase in CDI, you find that many samples positive by NAAT are toxin negative by enzyme immunoassay (EIA) and that many patients with a low pretest probability of disease are being tested. However, after an initiative to improve testing practices, your HO-CDI lab identification (LabID) event rate remains high (standardized infection ratio [SIR], Ͼ1). Concerned about how this rate will impact the value-based purchasing (VBP) and health care-associated condition (HAC) scores, your hospital leadership asks you to consider a change back to EIA for CDI diagnosis.In scenario 3, even after a campaign to reduce your hospital's rate of catheterassociated urinary tract infection (CAUTI) through a reduction in catheter use and improvement in catheter placement and care, the CAUTI rate remains unacceptably high. Your hospital epidemiologist sets up a meeting with you to discuss how to reduce the number of urine cultures ordered or performed by the laboratory as another way to reduce both the CAUTI rate and unnecessary antibiotic use. She is...

show abstract

Section: Unintended Consequences For Cmlsmentioning

confidence: 99%

Rising Stakes for Health Care-Associated Infection Prevention: Implications for the Clinical Microbiology Laboratory

Diekema

2017

J Clin Microbiol

View full text Add to dashboard Cite

show abstract

“…In routine practice, providers often test for C. difficile despite the absence of diarrhea. In North American studies, diarrhea has been reported to be absent in up to 39.0% of patients tested for C. difficile and up to 66.5% of patients diagnosed with CDI (13)(14)(15)(16)(17). Laxative therapy was also documented in up to 50% of patients undergoing testing or diagnosed with CDI in some studies (13,14,16).…”

mentioning

confidence: 99%

“…In North American studies, diarrhea has been reported to be absent in up to 39.0% of patients tested for C. difficile and up to 66.5% of patients diagnosed with CDI (13)(14)(15)(16)(17). Laxative therapy was also documented in up to 50% of patients undergoing testing or diagnosed with CDI in some studies (13,14,16). Furthermore, in some studies, 100% of patients with positive C. difficile results were treated for CDI whether diarrhea was present or not (16,18).…”

mentioning

confidence: 99%

“…Laxative therapy was also documented in up to 50% of patients undergoing testing or diagnosed with CDI in some studies (13,14,16). Furthermore, in some studies, 100% of patients with positive C. difficile results were treated for CDI whether diarrhea was present or not (16,18). Combined with the fact that most cases of nosocomial diarrhea have a noninfectious etiology (19), current testing practices lead to inappropriate C. difficile diagnosis and overtreatment.…”

mentioning

confidence: 99%

“…Combined with the fact that most cases of nosocomial diarrhea have a noninfectious etiology (19), current testing practices lead to inappropriate C. difficile diagnosis and overtreatment. Given that provider education is often insufficient to improve ordering practice (16), novel interventions are needed to improve appropriate C. difficile testing.…”

mentioning

confidence: 99%

See 2 more Smart Citations

Real-Time Electronic Tracking of Diarrheal Episodes and Laxative Therapy Enables Verification of Clostridium difficile Clinical Testing Criteria and Reduction of Clostridium difficile Infection Rates

et al. 2017

View full text Add to dashboard Cite

Health care-onset health care facility-associated Clostridium difficile infection (HO-CDI) is overdiagnosed for several reasons, including the high prevalence of C. difficile colonization and the inability of hospitals to limit testing to patients with clinically significant diarrhea. We conducted a quasiexperimental study from 22 June 2015 to 30 June 2016 on consecutive inpatients with C. difficile test orders at an academic hospital. Real-time electronic patient data tracking was used by the laboratory to enforce testing criteria (defined as the presence of diarrhea [Ն3 unformed stools in 24 h] and absence of laxative intake in the prior 48 h). Outcome measures included C. difficile test utilization, HO-CDI incidence, oral vancomycin utilization, and clinical complications. During the intervention, 7.1% (164) and 9.1% (211) of 2,321 C. difficile test orders were canceled due to absence of diarrhea and receipt of laxative therapy, respectively. C. difficile test utilization decreased upon implementation from an average of 208.8 tests to 143.0 tests per 10,000 patient-days (P Ͻ 0.001). HO-CDI incidence rate decreased from an average of 13.0 cases to 9.7 cases per 10,000 patient-days (P ϭ 0.008). Oral vancomycin days of therapy decreased from an average of 13.8 days to 9.4 days per 1,000 patient-days (P ϭ 0.009). Clinical complication rates were not significantly different in patients with 375 canceled orders compared with 869 episodes with diarrhea but negative C. difficile results. Realtime electronic clinical data tracking is an effective tool for verification of C. difficile clinical testing criteria and safe reduction of inflated HO-CDI rates.KEYWORDS Clostridium difficile, data tracking, evidence-based medicine, verification C lostridium difficile is the most common identifiable cause of antibiotic-associated diarrhea (1). Clostridium difficile infection (CDI) is estimated to be the most expensive health care-associated infection, costing the U.S. health system $5.4 billion annually (2). A major challenge with accurate diagnosis of CDI is the high prevalence of C. difficile colonization. Studies indicate that 4.4% to 21% of hospitalized patients are asymptomatically colonized with toxigenic C. difficile (3-10, 30). In the absence of disease-specific

show abstract

Diagnosis ofClostridium difficileInfection

Dubberke

2015

JAMA Intern Med

View full text Add to dashboard Cite

Gut Check: Clostridium difficile Testing and Treatment in the Molecular Testing Era

Cited by 49 publications

References 10 publications

Rising Stakes for Health Care-Associated Infection Prevention: Implications for the Clinical Microbiology Laboratory

Rising Stakes for Health Care-Associated Infection Prevention: Implications for the Clinical Microbiology Laboratory

Real-Time Electronic Tracking of Diarrheal Episodes and Laxative Therapy Enables Verification of Clostridium difficile Clinical Testing Criteria and Reduction of Clostridium difficile Infection Rates

Diagnosis ofClostridium difficileInfection

Contact Info

Product

Resources

About