Using diagnostic stewardship to reduce rates, healthcare expenditures and accurately identify cases of hospital-onset Clostridioides difficile infection

Abstract

Objective: Lack of judicious testing can result in the incorrect diagnosis of Clostridioides difficile infection (CDI), unnecessary CDI treatment, increased costs and falsely augmented hospital-acquired infection (HAI) rates. We evaluated facility-wide interventions used at the VA San Diego Healthcare System (VASDHS) to reduce healthcare-onset, healthcare-facility–associated CDI (HO-HCFA CDI), including the use of diagnostic stewardship with test ordering criteria. Design: We conducted a retrospective study to assess the effectiveness of measures implemented to reduce the rate of HO-HCFA CDI at the VASDHS from fiscal year (FY)2015 to FY2018. Interventions: Measures executed in a stepwise fashion included a hand hygiene initiative, prompt isolation of CDI patients, enhanced terminal room cleaning, reduction of fluoroquinolone and proton-pump inhibitor use, laboratory rejection of solid stool samples, and lastly diagnostic stewardship with C. difficile toxin B gene nucleic acid amplification testing (NAAT) criteria instituted in FY2018. Results: From FY2015 to FY2018, 127 cases of HO-HCFA CDI were identified. All rate-reducing initiatives resulted in decreased HO-HCFA cases (from 44 to 13; P ≤ .05). However, the number of HO-HCFA cases (34 to 13; P ≤ .05), potential false-positive testing associated with colonization and laxative use (from 11 to 4), hospital days (from 596 to 332), CDI-related hospitalization costs (from $2,780,681 to $1,534,190) and treatment cost (from $7,158 vs $1,476) decreased substantially following the introduction of diagnostic stewardship with test criteria from FY2017 to FY2018. Conclusions: Initiatives to decrease risk for CDI and diagnostic stewardship of C. difficile stool NAAT significantly reduced HO-HCFA CDI rates, detection of potential false-positives associated with laxative use, and lowered healthcare costs. Diagnostic stewardship itself had the most dramatic impact on outcomes observed and served as an effective tool in reducing HO-HCFA CDI rates.

Role of diagnostic stewardship in reducing healthcare-facility–onset Clostridioides difficile infections

“…7 In this population, CDI accounts for just 10%-20% of cases of diarrhea, whereas medications, including promotility agents, antimicrobials, and tube feeding account for the overwhelming majority. 8 Due to highly sensitive NAAT that cannot distinguish colonization from infection, restricting testing to patients with no alternative causes for diarrhea is essential in preventing inappropriate diagnosis of CDI and overtreatment.…”

“…Diagnostic stewardship is an effective strategy for reducing inappropriate C. difficile testing in inpatient settings. [8][9][10] Soft stops, such as clinical decision support algorithms and best practice alerts (BPAs), are commonly used to mitigate unnecessary testing, especially in the setting of promotility agents. However, hard stops that actively block orders are underutilized despite being more effective.…”

“…However, clinicians were able to order testing even if criteria were not met. 8 In another study, a BPA was triggered in various settings, including laxative administration in the preceding 48 hours. Overriding the BPA activated a hard stop in which testing could not proceed without microbiology laboratory approval.…”

Trends in facility-level rates of Clostridioides difficile infections in US hospitals, 2019–2020

“…Diagnostic stewardship of C. difficile testing has become increasingly important as clinicians attempt to optimize NAAT testing to reduce inappropriate diagnoses, unnecessary treatment, and facility HAI rates. 19,20 Trends in C. difficile testing should be monitored because focus on diagnostic stewardship for C. difficile testing has increased. Further study is needed to assess appropriateness of C. difficile testing during the COVID-19 pandemic.…”

Assessment of Federal Value-Based Incentive Programs and In-Hospital Clostridioides difficile Infection Rates

“…33,34 A third potential explanation for the decline we observed in HO-CDI rates relates to implementation of better diagnostic stewardship by the health care facilities in our cohort. 35 Solanky et al 36 showed that diagnostic stewardship had the most substantial association with reductions in HO-CDI rates among other interventions, including prompt isolation of patients with CDI, optimal environmental cleaning, hand hygiene, fluoroquinolone and proton-pump inhibitor stewardship, and the rejection of solid stool samples by the laboratory. Several other studies that used diagnostic stewardship interventions significantly reduced unnecessary testing using a variety of approaches, such as health care professional education, decision-making algorithms, and the deployment of what are known as hard stops requiring a specialist consultation or laboratory approval prior to test ordering.…”