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

Published online by Cambridge University Press:  21 February 2019

Alyssa B. Christensen ,
Viktorija O. Barr ,
David W. Martin ,
Morgan M. Anderson ,
Amanda K. Gibson ,
Brian M. Hoff ,
Sarah H. Sutton ,
Valerie Widmaier ,
Asra A. Salim  and
Christina Silkaitis
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Alyssa B. Christensen
Affiliation:
Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois Department of Pharmacy Practice, Rosalind Franklin University, North Chicago, Illinois
Viktorija O. Barr
Affiliation:
Department of Pharmacy Practice, Rosalind Franklin University, North Chicago, Illinois
David W. Martin
Affiliation:
Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois
Morgan M. Anderson
Affiliation:
Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois Department of Pharmacy Practice, Midwestern University, Downers Grove, Illinois
Amanda K. Gibson
Affiliation:
Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois
Brian M. Hoff
Affiliation:
Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois
Sarah H. Sutton
Affiliation:
Division of Infectious Diseases, Department of Medicine, Feinberg School of Medicine, Northwestern University, Illinois Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, Illinois
Valerie Widmaier
Affiliation:
Department of Microbiology, Northwestern Memorial Hospital, Chicago, Illinois
Asra A. Salim
Affiliation:
Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, Illinois
Christina Silkaitis
Affiliation:
Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, Illinois
Chao Qi
Affiliation:
Department of Microbiology, Northwestern Memorial Hospital, Chicago, Illinois Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Teresa R. Zembower
Affiliation:
Division of Infectious Diseases, Department of Medicine, Feinberg School of Medicine, Northwestern University, Illinois Department of Microbiology, Northwestern Memorial Hospital, Chicago, Illinois Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, Illinois
Michael J. Postelnick
Affiliation:
Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois
Nathaniel J. Rhodes*
Affiliation:
Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois Department of Pharmacy Practice, Midwestern University, Downers Grove, Illinois Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, Illinois
*
Author for correspondence: Nathaniel J. Rhodes, Email: nrhode@midwestern.edu
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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.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 40 , Issue 3 , March 2019 , pp. 269 - 275
Copyright
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved. 

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Footnotes

a

Present affiliation: Department of Pharmacy, Providence St. Vincent Medical Center, Portland, Oregon.

b

Present affiliation: Syneos Health/GlaxoSmithKline, Parsippany, New Jersey.

c

Present affiliation: Department of Pharmacy, Advocate Aurora Health, Chicago, Illinois.

d

Present affiliation: Department of Pharmacy, University of Utah Health, Salt Lake City, Utah.

e

Present affiliation: Division of Infection Prevention, VigiLanz, Chicago, Illinois.

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