Nosocomial Diarrhea: Evaluation and Treatment of Causes Other Than Clostridium difficile

Polage, Christopher R.; Solnick, Jay V.; Cohen, Stuart H.

doi:10.1093/cid/cis551

Cited by 152 publications

(105 citation statements)

References 52 publications

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“…Valenstein et al reported the findings of a College of American Pathologist Q-Probe, which demonstrated that when interventions are not in place, almost 40% of stool cultures may be submitted after the third day of hospitalization, with a yield of only 0.6% (10). It is also well known that diarrhea that develops after hospitalization is more likely to be associated with Clostridium difficile, medications, enteral feedings, or the underlying illness (11,12). Exceptions to the "3-day rule," however, have been described.…”

Section: Discussionmentioning

confidence: 99%

Implementation of a Clinical Decision Support Tool for Stool Cultures and Parasitological Studies in Hospitalized Patients

et al. 2017

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There is substantial evidence that stool culture and parasitological examinations are of minimal to no value after 3 days of hospitalization. We implemented and studied the impact of a clinical decision support tool (CDST) to decrease the number of unnecessary stool cultures (STCUL), ova/parasite (O&P) examinations, and Giardia/Cryptosporidium enzyme immunoassay screens (GC-EIA) performed for patients hospitalized Ͼ3 days. We studied the frequency of stool studies ordered before or on day 3 and after day 3 of hospitalization (i.e., categorical orders/total number of orders) before and after this intervention and denoted the numbers and types of microorganisms detected within those time frames. This intervention, which corresponded to a custom-programmed hard-stop alert tool in the Epic hospital information system, allowed providers to override the intervention by calling the laboratory, if testing was deemed medically necessary. Comparative statistics were employed to determine significance, and cost savings were estimated based on our internal costs. Before the intervention, 129/670 (19.25%) O&P examinations, 47/204 (23.04%) GC-EIA, and 249/1,229 (20.26%) STCUL were ordered after 3 days of hospitalization. After the intervention, 46/521 (8.83%) O&P examinations, 27/157 (17.20%) GC-EIA, and 106/1,028 (10.31%) STCUL were ordered after 3 days of hospitalization. The proportions of reductions in the number of tests performed after 3 days and the associated P values were 54.1% for O&P examinations (P Ͻ 0.0001), 22.58% for GC-EIA (P ϭ 0.2807), and 49.1% for STCUL (P Ͻ 0.0001). This was estimated to have resulted in $8,108.84 of cost savings. The electronic CDST resulted in a substantial reduction in the number of evaluations of stool cultures and the number of parasitological examinations for patients hospitalized for more than 3 days and in a cost savings while retaining the ability of the clinician to obtain these tests if clinically indicated.KEYWORDS O&P examinations, stewardship, stool culture, utilization T he current migration from volume-based reimbursement to value-based health care delivery encourages health care leaders to reexamine practices to optimize cost-effective care delivery (1, 2). There is a substantial literature that demonstrates that clinical laboratory tests are often overused by health care providers (3, 4). Unnecessary testing not only results in inflated health care costs but may also result in patient harm secondary to iatrogenic anemia and false-positive test results that require retesting and other follow-up procedures.Microbiologists have been among the earliest advocates for the appropriate use of laboratory studies (5). The value of cultures for bacterial enteric pathogens and parasitological examinations of the stool for patients who develop diarrhea after 3 days of hospitalization has been examined by many researchers over decades (6)(7)(8)(9). It has been shown that there is no to very low detection of community-acquired pathogens (e.g., Salmonella, Giardia, et cetera), i...

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Section: Discussionmentioning

confidence: 99%

Implementation of a Clinical Decision Support Tool for Stool Cultures and Parasitological Studies in Hospitalized Patients

et al. 2017

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“…1 Despite efforts on infection control and prudent antibiotic stewardship, the incidence of Clostridium difficile infection (CDI)…”

Section: Introductionmentioning

confidence: 99%

Risk for Clostridium difficile infection after radical cystectomy for bladder cancer: Analysis of a contemporary series

Liu

Shatagopam

Monn

et al. 2015

Urologic Oncology: Seminars and Original Investigations

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“…Besides the potential to induce colitis under certain circumstances, enteric carriage of K. oxytoca may be important for the transmission of antibiotic resistance genes to other bacteria and as a source of nosocomial infections (7,8). Indeed, this bacterium and the closely related species Klebsiella pneumoniae are important human pathogens causing hepatobiliary infections and infections of the urinary tract and soft tissue, in addition to nosocomial pneumonia (9)(10)(11). In recent years, multidrug-resistant strains of both species have emerged as an important problem in the health care system (7,12).…”

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confidence: 99%

Genotypes of Klebsiella oxytoca Isolates from Patients with Nosocomial Pneumonia Are Distinct from Those of Isolates from Patients with Antibiotic-Associated Hemorrhagic Colitis

et al. 2014

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Klebsiella oxytoca acts as a pathobiont in the dysbiotic human intestinal microbiota, causing antibiotic-associated hemorrhagic colitis (AAHC), but it also infects other organs, resulting in pneumonia and urinary tract and skin infections. The virulence of K. oxytoca is still poorly understood. The production of a specific cytotoxin has been linked to AAHC pathogenesis. To investigate the clonal relationships of K. oxytoca with regard to clinical origin and virulence attributes, we established a multilocus sequence typing (MLST) method and analyzed 74 clinical K. oxytoca isolates from asymptomatic carriers and patients with AAHC, respiratory infections, and other infections. The isolates were phenotypically characterized, typed, and compared phylogenetically based on the sequences of seven housekeeping genes. MLST analysis yielded 60 sequence types, 12 of which were represented by more than one isolate. The phylogenetic tree distinguished clusters of K. oxytoca isolates between patients with AAHC and those with respiratory infections. Toxin-positive and -negative strains were observed within one sequence type. Our findings indicate that AAHC isolates share a genetic background. Interestingly, K. oxytoca isolates from nosocomial pneumonia showed a different genetic clustering, suggesting that these strains do not originate from the intestines or that they are specialized for respiratory tract colonization. Our results further indicate a polyphyletic origin and possible horizontal transfer of the genes involved in K. oxytoca cytotoxin production. This work provides evidence that K. oxytoca isolates colonizing the two main clinically relevant habitats (lower gastrointestinal [GI] tract and respiratory tract) of the human host are genetically distinct. Applications of this MLST analysis should help clarify the sources of nosocomial infections.

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Nosocomial Diarrhea: Evaluation and Treatment of Causes Other Than Clostridium difficile

Cited by 152 publications

References 52 publications

Implementation of a Clinical Decision Support Tool for Stool Cultures and Parasitological Studies in Hospitalized Patients

Implementation of a Clinical Decision Support Tool for Stool Cultures and Parasitological Studies in Hospitalized Patients

Risk for Clostridium difficile infection after radical cystectomy for bladder cancer: Analysis of a contemporary series

Genotypes of Klebsiella oxytoca Isolates from Patients with Nosocomial Pneumonia Are Distinct from Those of Isolates from Patients with Antibiotic-Associated Hemorrhagic Colitis

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