Real-Time Electronic Tracking of Diarrheal Episodes and Laxative Therapy Enables Verification of Clostridium difficile Clinical Testing Criteria and Reduction of Clostridium difficile Infection Rates

Abstract

Health care-onset health care facility-associated Clostridium difficile infection (HO-CDI) is overdiagnosed for several reasons, including the high prevalence of C. difficile colonization and the inability of hospitals to limit testing to patients with clinically significant diarrhea. We conducted a quasiexperimental study from 22 June 2015 to 30 June 2016 on consecutive inpatients with C. difficile test orders at an academic hospital. Real-time electronic patient data tracking was used by the laboratory to enforce testing criteria (defined as the presence of diarrhea [Ն3 unformed stools in 24 h] and absence of laxative intake in the prior 48 h). Outcome measures included C. difficile test utilization, HO-CDI incidence, oral vancomycin utilization, and clinical complications. During the intervention, 7.1% (164) and 9.1% (211) of 2,321 C. difficile test orders were canceled due to absence of diarrhea and receipt of laxative therapy, respectively. C. difficile test utilization decreased upon implementation from an average of 208.8 tests to 143.0 tests per 10,000 patient-days (P Ͻ 0.001). HO-CDI incidence rate decreased from an average of 13.0 cases to 9.7 cases per 10,000 patient-days (P ϭ 0.008). Oral vancomycin days of therapy decreased from an average of 13.8 days to 9.4 days per 1,000 patient-days (P ϭ 0.009). Clinical complication rates were not significantly different in patients with 375 canceled orders compared with 869 episodes with diarrhea but negative C. difficile results. Realtime electronic clinical data tracking is an effective tool for verification of C. difficile clinical testing criteria and safe reduction of inflated HO-CDI rates.KEYWORDS Clostridium difficile, data tracking, evidence-based medicine, verification C lostridium difficile is the most common identifiable cause of antibiotic-associated diarrhea (1). Clostridium difficile infection (CDI) is estimated to be the most expensive health care-associated infection, costing the U.S. health system $5.4 billion annually (2). A major challenge with accurate diagnosis of CDI is the high prevalence of C. difficile colonization. Studies indicate that 4.4% to 21% of hospitalized patients are asymptomatically colonized with toxigenic C. difficile (3-10, 30). In the absence of disease-specific

Clostridium difficile PCR Cycle Threshold Predicts Free Toxin

“…Overall, with the approach undertaken in this study, PCR could sensitively detect presence of toxigenic C. difficile (4), sensitively predict fecal free toxin, and predict toxin-negativity with a high NPV. Compared to current practices at our institution and other U.S. hospitals where nearly all patients with positive C. difficile PCR results are treated for CDI (16,17), reporting C T toxin result in addition to PCR result has the potential to reduce anti-C. difficile therapy by 45.8% based on results of this study (143 of 312 PCR-positive samples were C T toxin negative), if only toxin-positive patients are treated. This approach has the potential to have far-reaching impact as stand-alone C. difficile NAAT has been widely adopted for CDI diagnosis in the United States (18).…”

Laxative Use in the Setting of Positive Testing forClostridium difficileInfection

“…4 Appropriate testing for CDI is critical given the inability of current testing to distinguish between asymptomatic carrier and disease state. Truong et al 9 recently reported a significant decrease in C. difficile test utilization from 208.8 to 143 tests per 10,000 patient days and a decrease in healthcare facility-onset CDI of >25% (ie, from 13.0 to 9.7 cases per 10,000 patient days) using real-time electronic data to enforce laboratory testing criteria, which they defined as the presence of diarrhea and absence of laxative use in the prior 48 hours. 9 In addition to improving testing cascades for CDI by limiting specimens from patients receiving laxatives, education must also engage the nursing staff.…”

“…3,7,8 Interventions to reduce the testing of inappropriate specimens, including those due to laxative use, have led to a reduction of CDI rates and treatment. 9 We further examined the relationship between laxative use and patients who tested positive for CDI.…”

“…3,7,8,9 We reviewed this association for those patients who tested positive for CDI. Surprisingly, 82 patients (39%) received laxatives within 1 week of CDI diagnosis; 29 (14%) received laxatives (usually ≥2) within 24 hours of positive testing.…”

Strategies for Optimizing the Diagnostic Predictive Value of Clostridium difficile Molecular Diagnostics

“…In this issue of the Journal of Clinical Microbiology, Truong et al (J. Clin. Microbiol., 55:1276 -1284, 2017, https://doi.org/10.1128/JCM.02319-16) report significant reductions in hospital-onset CDI and oral vancomycin utilization at their institution following implementation of a novel intervention that leveraged their clinical bioinformatics resources to prevent C. difficile testing of stools from patients without clinically significant diarrhea and in patients with recent laxative use. …”