Successful diagnostic stewardship for Clostridioides difficile testing in pediatrics

Abstract

Objective: To reduce both inappropriate testing for and diagnosis of healthcare-onset (HO) Clostridioides difficile infections (CDIs). Design: We performed a retrospective analysis of C. difficile testing from hospitalized children before (October 2017–October 2018) and after (November 2018–October 2020) implementing restrictive computerized provider order entry (CPOE). Setting: Study sites included hospital A (a ∼250-bed freestanding children’s hospital) and hospital B (a ∼100-bed children’s hospital within a larger hospital) that are part of the same multicampus institution. Methods: In October 2018, we implemented CPOE. No testing was allowed for infants aged ≤12 months, approval of the infectious disease team was required to test children aged 13–23 months, and pathology residents’ approval was required to test all patients aged ≥24 months with recent laxative, stool softener, or enema use. Interrupted time series analysis and Mann-Whitney U test were used for analysis. Results: An interrupted time series analysis revealed that from October 2017 to October 2020, the numbers of tests ordered and samples sent significantly decreased in all age groups (P < .05). The monthly median number of HO-CDI cases significantly decreased after implementation of the restrictive CPOE in children aged 13–23 months (P < .001) and all ages combined (P = .003). Conclusion: Restrictive CPOE for CDI in pediatrics was successfully implemented and sustained. Diagnostic stewardship for CDI is likely cost-saving and could decrease misdiagnosis, unnecessary antibiotic therapy, and overestimation of HO-CDI rates.

Diagnostic stewardship to improve patient outcomes and healthcare-associated infection (HAI) metrics

“…17 Recent studies in children have shown that diagnostic stewardship addressing the ordering stage using CDS can reduce inappropriate C. difficile testing and observed HO-CDI cases. 18,19 To help account for the increased sensitivity of NAATs, 20 the CDC updated the LabID-event surveillance definition by basing the metric on the last test result in a HO-CDI multistep testing algorithm. For example, if an initial NAAT is positive but a subsequent toxin assay is negative, this would not be counted as a HO-CDI LabID-event.…”

“… 17 Recent studies in children have shown that diagnostic stewardship addressing the ordering stage using CDS can reduce inappropriate C. difficile testing and observed HO-CDI cases. 18 , 19 …”

Breaking Boundaries in Pneumonia Diagnostics: Transitioning from Tradition to Molecular Frontiers with Multiplex PCR

“…Using C. difficile as an example, pre-analytic interventions limiting unnecessary stool testing and subsequent false positives improved CDI diagnosis. Diagnostic stewardship algorithms for pneumonia testing could effectively be modeled after these protocols [65][66][67][68]. For example, Sick-Samuels et al implemented a clinical decision support system (CDSS) for ETA culture testing on ventilated patients in the pediatric ICU.…”