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

Abstract

Objective: To evaluate whether incorporating mandatory prior authorization for Clostridioides difficile testing into antimicrobial stewardship pharmacist workflow could reduce testing in patients with alternative etiologies for diarrhea. Design: Single center, quasi-experimental before-and-after study. Setting: Tertiary-care, academic medical center in Ann Arbor, Michigan. Patients: Adult and pediatric patients admitted between September 11, 2019 and December 10, 2019 were included if they had an order placed for 1 of the following: (1) C. difficile enzyme immunoassay (EIA) in patients hospitalized >72 hours and received laxatives, oral contrast, or initiated tube feeds within the prior 48 hours, (2) repeat molecular multiplex gastrointestinal pathogen panel (GIPAN) testing, or (3) GIPAN testing in patients hospitalized >72 hours. Intervention: A best-practice alert prompting prior authorization by the antimicrobial stewardship program (ASP) for EIA or GIPAN testing was implemented. Approval required the provider to page the ASP pharmacist and discuss rationale for testing. The provider could not proceed with the order if ASP approval was not obtained. Results: An average of 2.5 requests per day were received over the 3-month intervention period. The weekly rate of EIA and GIPAN orders per 1,000 patient days decreased significantly from 6.05 ± 0.94 to 4.87 ± 0.78 (IRR, 0.72; 95% CI, 0.56–0.93; P = .010) and from 1.72 ± 0.37 to 0.89 ± 0.29 (IRR, 0.53; 95% CI, 0.37–0.77; P = .001), respectively. Conclusions: We identified an efficient, effective C. difficile and GIPAN diagnostic stewardship approval model.

Addressing the COVID-19 transmission in inner Brazil by a mathematical model

“…The bias generated by the under-reported data impacts our model’s parameter estimation, since the diagnosis capacity, compared to the number of cases in the population, changes over time. Recent works have demonstrated and have argued that the delay into case reports and the mitigation strategies may directly impact the estimation 27 , 28 . With more information about the available data and complex models, fitting the model parameters to the epidemic curve would be an interesting approach worthy of study.…”

Diagnostic stewardship for Clostridioides difficile testing in an acute care hospital: A quality improvement intervention

“…Various studies have used similar models to improve diagnostic stewardship of C. difficile . Two studies of antimicrobial stewardship pharmacist approval of C. difficile orders showed a significant decrease in orders 7 and a significant reduction in C. difficile HAIs after implementation. 13 In 2 studies that utilized infection prevention approval of orders, decreases occurred in testing and C. difficile HAIs.…”

“…5 However, various studies have shown that administrative or laboratory test restriction for C. difficile, rather than passive decision support more effectively improve diagnostic stewardship of C. difficile. 1,[6][7][8] Passive decision support via alerts can result in "alert fatigue," in which providers no longer engage with the alert due to overfiring. 5 Root-cause analyses performed prior to the intervention identified diagnostic stewardship as an opportunity for hospitals A and B. Unadjusted baseline C. difficile HAI rates for hospital A were 8.83 and 8.36 per 10,000 patient days in 2020 and 2021 and for hospital B these rates were 7.03 and 9.34 per 10,000 patient days in 2020 and 2021.…”

Impact of mandatory nucleic acid amplification test (NAAT) testing approval on hospital-onset Clostridioides difficile infection (HO-CDI) rates: A diagnostic stewardship intervention

“…Approximately 4%–15% of hospitalized patients and 50% of long-term care patients are asymptomatically colonized with C. difficile . 1 , 2 , 7 Without 2-step testing to detect toxin production, NAAT must be ordered properly to avoid overdiagnosis of CDI in general. Inconsistent definition and documentation of diarrhea, laxative use dismissal, leukocytosis, and perception of “increased-risk” for CDI are factors that drive inappropriate C. difficile testing.…”

“…Inconsistent definition and documentation of diarrhea, laxative use dismissal, leukocytosis, and perception of “increased-risk” for CDI are factors that drive inappropriate C. difficile testing. 7 , 8 …”