Laxative Use in the Setting of Positive Testing for<i>Clostridium difficile</i>Infection

Ahmad, Syed Mustafa Ali; Blanco, Natalia; Dewart, Courtney; Dobosz, Anna Jerzak vel; Malani, Anurag N.

doi:10.1017/ice.2017.221

Cited by 7 publications

(3 citation statements)

References 10 publications

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“…We did not formally capture the reasons behind lack of compliance to recommendations among the providers who did not accept them; however, expectation that a test will detect subclinical disease, poor understanding of the limitations of the test, defensive medicine, and overestimation of signs and symptoms and subsequent classification of patients as having severe disease are some explanations for medical overdoing [ 16 , 17 ]; these could have contributed to our findings. In agreement with other reports [ 5 ], we also observed a significant number of CD NAAT–positive patients with concomitant laxative use, a practice that did not change over time despite the CDAT’s advice to discontinue laxatives and the electronic hard stop limiting CD testing in patients with concomitant laxative use. We suspect that there is a disconnect in communication among prescribers and nurses regarding laxative use because laxatives are regularly ordered as “as necessary” medications upon admission, given by nurses without communication back to prescribers and without prescribers screening for their use to discontinue them if a patient develops diarrhea.…”

Section: Discussionsupporting

confidence: 92%

Impact of Case-Specific Education and Face-to-Face Feedback to Prescribers and Nurses in the Management of Hospitalized Patients With a Positive Clostridium difficile Test

Fabre

Markou

Sick-Samuels

et al. 2018

Open Forum Infectious Diseases

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BackgroundApproaches to changing providers’ behavior around Clostridium difficile (CD) management are needed. We hypothesized that case-specific teaching points and face-to-face discussions with prescribers and nurses would improve management of patients with a positive CD test.MethodsCharts of patients age ≥18 years with positive CD tests hospitalized July 2016 to May 2017 were prospectively reviewed to assess CD practices and generate management recommendations. The study had 4 periods: baseline (pre-intervention), intervention #1, observation, and intervention #2. Both interventions consisted of an in-person, real-time, case-based discussion and education by a CD Action Team (CDAT). Assessment occurred within 24 hours of a positive CD test for all periods; during the intervention periods, management was also assessed within 48 hours after CDAT-delivered recommendations. Outcomes included proportion of patients receiving optimized treatment and incidence rate ratios of practice changes (both CDAT-prompted and CDAT-independent).ResultsOverall, the CDAT made recommendations to 84 of 96 CD cases during intervention periods, and providers accepted 43% of CDAT recommendations. The implementation of the CDAT led to significant improvement in bowel movement (BM) documentation, use of proton pump inhibitors, and antibiotic selection for non-CD infections. Selection of CD-specific therapy improved only in the first intervention period. Laxative use and treatment of CD colonization cases remained unchanged. Only BM documentation, a nurse-driven task, was sustained independent of CDAT prompting.ConclusionsA behavioral approach to changing the management of positive CD tests led to self-sustained practice changes among nurses but not physicians. Better understanding of prescribers’ decision-making is needed to devise enduring interventions.

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Section: Discussionsupporting

confidence: 92%

Impact of Case-Specific Education and Face-to-Face Feedback to Prescribers and Nurses in the Management of Hospitalized Patients With a Positive Clostridium difficile Test

Fabre

Markou

Sick-Samuels

et al. 2018

Open Forum Infectious Diseases

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“…This recommendation is in accordance with Infectious Diseases Society of America and Society for Healthcare Epidemiology of America guidelines ( 55 ). The rationale behind the recommendation is that patients taking laxatives may be asymptomatically colonized with C. difficile , resulting in unnecessary antibiotic treatment ( 56 – 58 ). Furthermore, some studies identified laxatives as a risk factor for developing CDIs or recurrent CDIs ( 59 – 61 ), and a recent study found that the proportions of severe CDIs were similar between patients taking and those not taking laxatives ( 62 ).…”

Section: Discussionmentioning

confidence: 99%

An Osmotic Laxative Renders Mice Susceptible to Prolonged Clostridioides difficile Colonization and Hinders Clearance

Tomkovich

Taylor

King

et al. 2021

mSphere

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“…This recommendation is in accordance with the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America guidelines (54). The rationale behind the recommendation is that patients taking laxatives may be asymptomatically colonized with C. difficile, resulting in unnecessary antibiotic treatment (55)(56)(57). Furthermore, some studies identified laxatives as a risk factor for developing CDIs or recurrent CDIs (58-60) and a recent study found the proportion of severe CDIs was similar between patients taking and not taking laxatives (61).…”

Section: Discussionmentioning

confidence: 94%

An osmotic laxative renders mice susceptible to prolonged Clostridioides difficile colonization and hinders clearance

Tomkovich

Taylor

King

et al. 2021

Preprint

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Antibiotics are a major risk factor for Clostridioides difficile infections (CDIs) because of their impact on the microbiota. However, non-antibiotic medications such as the ubiquitous osmotic laxative polyethylene glycol (PEG) 3350 also alter the microbiota. Clinicians also hypothesize that PEG helps clear C. difficile. But whether PEG impacts CDI susceptibility and clearance is unclear. To examine how PEG impacts susceptibility, we treated C57Bl/6 mice with 5-day and 1-day doses of 15% PEG in the drinking water and then challenged the mice with C. difficile 630. We used clindamycin-treated mice as a control because they consistently clear C. difficile within 10 days post-challenge. PEG treatment alone was sufficient to render mice susceptible and 5-day PEG-treated mice remained colonized for up to 30 days post-challenge. In contrast, 1-day PEG treated mice were transiently colonized, clearing C. difficile within 7 days post-challenge. To examine how PEG treatment impacts clearance, we administered a 1-day PEG treatment to clindamycin-treated, C. difficile-challenged mice. Administering PEG to mice after C. difficile challenge prolonged colonization up to 30 days post-challenge. When we trained a random forest model with community data from 5 days post-challenge, we were able to predict which mice would exhibit prolonged colonization (AUROC = 0.90). Examining the dynamics of these bacterial populations during the post-challenge period revealed patterns in the relative abundances of Bacteroides, Enterobacteriaceae, Porphyromonadaceae, Lachnospiraceae, and Akkermansia that were associated with prolonged C. difficile colonization in PEG-treated mice. Thus, the osmotic laxative, PEG, rendered mice susceptible to C. difficile colonization and hindered clearance.

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Laxative Use in the Setting of Positive Testing forClostridium difficileInfection

Cited by 7 publications

References 10 publications

Impact of Case-Specific Education and Face-to-Face Feedback to Prescribers and Nurses in the Management of Hospitalized Patients With a Positive Clostridium difficile Test

Impact of Case-Specific Education and Face-to-Face Feedback to Prescribers and Nurses in the Management of Hospitalized Patients With a Positive Clostridium difficile Test

An Osmotic Laxative Renders Mice Susceptible to Prolonged Clostridioides difficile Colonization and Hinders Clearance

An osmotic laxative renders mice susceptible to prolonged Clostridioides difficile colonization and hinders clearance

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