National Healthcare Safety Network laboratory-identified Clostridium difficile event reporting: A need for diagnostic stewardship

Rock, Clare; Pana, Zoi Dorothea; Leekha, Surbhi; Trexler, Polly; Andonian, Jennifer; Gadala, Avinash; Carroll, Karen C.; Maragakis, Lisa L.; Program, Cdc Prevention Epicenters

doi:10.1016/j.ajic.2017.10.011

Cited by 31 publications

(16 citation statements)

References 7 publications

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“…However, although rigorous stool submission criteria were in place, more than two-thirds of NAAT ϩ /toxin Ϫ patients had other causes of diarrhea, thereby not fulfilling the ESCMID definition of a CDI case. In this study, 96.9% of NAAT ϩ patients were treated, indicating that almost all patients are treated based on a NAAT result, which is in line with previous reports (16,(28)(29)(30). Clinical and laboratory parameters related to disease severity had limited value in distinguishing carriers from CDI patients, and there was no difference in WBC or creatinine levels.…”

Section: Discussionsupporting

confidence: 88%

Increased Clinical Specificity with Ultrasensitive Detection of Clostridioides difficile Toxins: Reduction of Overdiagnosis Compared to Nucleic Acid Amplification Tests

Sandlund¹,

Estis²,

Katzenbach³

et al. 2019

J Clin Microbiol

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Clostridioides difficile infection (CDI) is one of the most common health care-associated infections, resulting in significant morbidity, mortality, and economic burden. Diagnosis of CDI relies on the assessment of clinical presentation and laboratory tests. We evaluated the clinical performance of ultrasensitive single-molecule counting technology for detection of C. difficile toxins A and B. Stool specimens from 298 patients with suspected CDI were tested with the nucleic acid amplification test (NAAT; BD MAX Cdiff assay or Xpert C. difficile assay) and Singulex Clarity C. diff toxins A/B assay. Specimens with discordant results were tested with the cell cytotoxicity neutralization assay (CCNA), and the results were correlated with disease severity and outcome. There were 64 NAAT-positive and 234 NAAT-negative samples. Of the 32 NAAT+/Clarity− and 4 NAAT−/Clarity+ samples, there were 26 CCNA− and 4 CCNA− samples, respectively. CDI relapse was more common in NAAT+/toxin+ patients than in NAAT+/toxin− and NAAT−/toxin− patients. The clinical specificity of Clarity and NAAT was 97.4% and 89.0%, respectively, and overdiagnosis was more than three times more common in NAAT+/toxin− than in NAAT+/toxin+ patients. The Clarity assay was superior to NAATs for the diagnosis of CDI, by reducing overdiagnosis and thereby increasing clinical specificity, and the presence of toxins was associated with negative patient outcomes.

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Section: Discussionsupporting

confidence: 88%

Increased Clinical Specificity with Ultrasensitive Detection of Clostridioides difficile Toxins: Reduction of Overdiagnosis Compared to Nucleic Acid Amplification Tests

Sandlund¹,

Estis²,

Katzenbach³

et al. 2019

J Clin Microbiol

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“…Overall, 10,686 HO-CDI orders were placed during the preintervention period and 7,008 orders were placed during the postintervention period. The median number of HO-CDI orders placed per an individual's hospital admission was 1 (IQR, 1-2), with a median time between admission and HO-CDI order of 10 days (IQR, [6][7][8][9][10][11][12][13][14][15][16]. The most common laxative or stool softener administered in the 24 hours prior to an inappropriate HO-CDI order was docusate (387, 30%) followed by bisacodyl (185, 14%) and lactulose (161, 13%).…”

Section: Patient and C Difficile Order Characteristicsmentioning

confidence: 99%

“…3 However, laxatives are frequently prescribed in hospitalized patients, and several studies have indicated that 19%-44% of all C. difficile tests may be inappropriately ordered on patients receiving laxatives. [7][8][9][10] This scenario provides an opportunity for intervention.…”

mentioning

confidence: 99%

The impact of an electronic medical record nudge on reducing testing for hospital-onset Clostridioides difficile infection

Howard‐Anderson

Sexton

Robichaux

et al. 2020

Infect. Control Hosp. Epidemiol.

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Objective:To determine the effect of an electronic medical record (EMR) nudge at reducing total and inappropriate orders testing for hospital-onset Clostridioides difficile infection (HO-CDI).Design:An interrupted time series analysis of HO-CDI orders 2 years before and 2 years after the implementation of an EMR intervention designed to reduce inappropriate HO-CDI testing. Orders for C. difficile testing were considered inappropriate if the patient had received a laxative or stool softener in the previous 24 hours.Setting:Four hospitals in an academic healthcare network.Patients:All patients with a C. difficile order after hospital day 3.Intervention:Orders for C. difficile testing in patients administered a laxative or stool softener in <24 hours triggered an EMR alert defaulting to cancellation of the order (“nudge”).Results:Of the 17,694 HO-CDI orders, 7% were inappropriate (8% prentervention vs 6% postintervention; P < .001). Monthly HO-CDI orders decreased by 21% postintervention (level-change rate ratio [RR], 0.79; 95% confidence interval [CI], 0.73–0.86), and the rate continued to decrease (postintervention trend change RR, 0.99; 95% CI, 0.98–1.00). The intervention was not associated with a level change in inappropriate HO-CDI orders (RR, 0.80; 95% CI, 0.61–1.05), but the postintervention inappropriate order rate decreased over time (RR, 0.95; 95% CI, 0.93–0.97).Conclusion:An EMR nudge to minimize inappropriate ordering for C. difficile was effective at reducing HO-CDI orders, and likely contributed to decreasing the inappropriate HO-CDI order rate after the intervention.

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“…Overdiagnosis of Clostridioides difficile as a cause of healthcare-associated diarrhea is a prevalent problem in the USA due to increasing use of highly sensitive nucleic acid amplification tests, combined with a low threshold for testing of patients in the absence of significant diarrhea and in the presence of laxatives. [1][2][3] Others have reported on efforts at reducing unnecessary C. difficile testing through computerized clinical decision support (CCDS), with variable results. 4,5 We conducted a quasi-experimental study to evaluate the impact of CCDS on appropriateness of C. difficile testing.…”

Section: Introductionmentioning

confidence: 99%

Use of Computerized Clinical Decision Support for Diagnostic Stewardship in Clostridioides difficile testing: an Academic Hospital Quasi-Experimental Study

et al. 2018

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National Healthcare Safety Network laboratory-identified Clostridium difficile event reporting: A need for diagnostic stewardship

Cited by 31 publications

References 7 publications

Increased Clinical Specificity with Ultrasensitive Detection of Clostridioides difficile Toxins: Reduction of Overdiagnosis Compared to Nucleic Acid Amplification Tests

Increased Clinical Specificity with Ultrasensitive Detection of Clostridioides difficile Toxins: Reduction of Overdiagnosis Compared to Nucleic Acid Amplification Tests

The impact of an electronic medical record nudge on reducing testing for hospital-onset Clostridioides difficile infection

Use of Computerized Clinical Decision Support for Diagnostic Stewardship in Clostridioides difficile testing: an Academic Hospital Quasi-Experimental Study

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