1
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Eckardt P, Guran R, Jalal AT, Krishnaswamy S, Samuels S, Canavan K, Martinez EA, Desai A, Miller N, Cano Cevallos EJ. Impact of an electronic smart order-set for diagnostic stewardship of Clostridiodes difficile infection (CDI) in a community healthcare system in South Florida. Am J Infect Control 2024; 52:893-899. [PMID: 38935020 DOI: 10.1016/j.ajic.2024.04.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/12/2024] [Accepted: 04/13/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Inappropriate testing for Clostridiodes difficile infection (CDI) increases health care onset cases and contributes to overdiagnosis and overtreatment of patients in a community health care system. METHODS An electronic smart order set for the testing of CDI was created and implemented to improve the appropriateness of testing. A retrospective review of patients who were tested for CDI, pre and post, was conducted to determine if inappropriate stool testing for CDI decreased post-implementation of the order set. RESULTS 224 patients were tested for CDI during the study period with the post-implementation period having a higher proportion of patients who met appropriate testing criteria defined by presence of diarrhea (80.5% vs 61.3%; P = .002). The rate of inappropriate CDI stool testing decreased from 31.1% to 11.0% after implementation (P < .001). A higher proportion of CDI patients were readmitted within 30 days of discharge (54.2% vs 33.0%; P = 0.001) during the post-implementation period. CONCLUSIONS There was a significant reduction in inappropriate CDI testing following the implementation of the order set. There was an observed increase in the proportion of patients who underwent recent gastrointestinal surgery which may have contributed to the increase in 30-day readmission rates during the post-implementation period.
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Affiliation(s)
- Paula Eckardt
- Division of Infectious Disease, Medical Director of Antimicrobial Stewardship and Infection Control, Medical Director of MHS Ryan White Clinic, Memorial Healthcare System, Hollywood, FL
| | - Rachel Guran
- Director of Epidemiology and Infection Prevention, Memorial Healthcare System, Hollywood, FL.
| | - Ayesha T Jalal
- Graduate Medical Education, Memorial Healthcare System, Hollywood, FL
| | - Shiv Krishnaswamy
- Graduate Medical Education, Memorial Healthcare System, Hollywood, FL
| | - Shenae Samuels
- Office of Human Research, Memorial Healthcare System, Hollywood, FL
| | - Kelsi Canavan
- Office of Human Research, Memorial Healthcare System, Hollywood, FL
| | - Elsa A Martinez
- Graduate Medical Education, Memorial Healthcare System, Hollywood, FL
| | - Ajay Desai
- Florida Atlantic University, Boca Raton, FL
| | - Nancimae Miller
- Microbiology and Molecular Infectious Disease, Pathology Consultants of South Broward at Memorial Healthcare System, Hollywood, FL
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2
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Graham M, Gugasyan R, Dharmaraj D, Yap G, Webb B, Dhulia A, Kumar B. Impact of customized electronic duplicate order alerts on microbiology test ordering: Financial and environmental cost savings. Infect Control Hosp Epidemiol 2024; 45:343-350. [PMID: 37887261 PMCID: PMC10933501 DOI: 10.1017/ice.2023.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/10/2023] [Accepted: 07/26/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVE To estimate cost savings after implementation of customized electronic duplicate order alerts. DESIGN Alerts were implemented for microbiology tests at the largest public hospital in Victoria, Australia. These alerts were designed to pop up at the point of test ordering to inform the clinician that the test had previously been ordered and to suggest appropriate reordering time frames and indications. RESULTS In a 6-month audit of urine culture (our most commonly ordered test) after alert implementation, 2,904 duplicate requesters proceeded with the request and 2,549 tests were cancelled, for a 47% reduction in test ordering. For fecal polymerase chain reaction (PCR), our second most common test, there was a 54% reduction in test ordering. For our most commonly ordered expensive test, hepatitis C PCR, there was a 42% reduction in test ordering: 25 tests were cancelled.Cancelled tests resulted in estimated savings of AU$52,382 (US$33,960) for urine culture, AU$34,914 (US$22,442) for fecal PCR, AU$4,506 (US$2,896) for hepatitis C PCR. For cancelled hepatitis B PCR and Epstein-Barr virus (EBV) and cytomegalovirus (CMV) serology, the cost savings was AU$8,472 (US$5445). The estimated financial cost saving in direct hospital costs for these 6 assays was AU$100,274 (US$67,925) over the 6-month period. Environmental waste cost saving by weight was estimated to be 280 kg. Greenhouse gas footprint, measured in carbon dioxide equivalent emissions for cancelled EBV and CMV serology tests, resulted in a saving of at least 17,711 g, equivalent to driving 115 km in a standard car. CONCLUSION Customized alerts issued at the time of test ordering can have enormous impacts on reducing cost, waste, and unnecessary testing.
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Affiliation(s)
- Maryza Graham
- Department of Microbiology, Monash Health Pathology, Monash Health, Clayton, Victoria, Australia
- Monash Infectious Diseases, Monash Health, Clayton, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
- Victorian Infectious Diseases Reference Laboratory, Peter Doherty Institute for Infection and Immunity, Victoria, Australia
| | - Robert Gugasyan
- Monash Health Pathology, Monash Health, Clayton, Victoria, Australia
| | - Devisri Dharmaraj
- Office of Chief Medical Officer, Monash Health, Clayton, Victoria, Australia
| | - Gillian Yap
- Office of Chief Medical Officer, Monash Health, Clayton, Victoria, Australia
| | - Brooke Webb
- Department of Microbiology, Monash Health Pathology, Monash Health, Clayton, Victoria, Australia
| | - Anjali Dhulia
- Chief Medical Officer, Monash Health, Clayton, Victoria, Australia
| | - Beena Kumar
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
- Monash Health Pathology, Monash Health, Clayton, Victoria, Australia
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McCormick WL, Jackson G, Andrea SB, Whitehead V, Chargualaf TL, Touzard-Romo F. Impact of mandatory nucleic acid amplification test (NAAT) testing approval on hospital-onset Clostridioides difficile infection (HO-CDI) rates: A diagnostic stewardship intervention. Infect Control Hosp Epidemiol 2024; 45:106-109. [PMID: 37424227 PMCID: PMC10782198 DOI: 10.1017/ice.2023.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 03/14/2023] [Accepted: 03/25/2023] [Indexed: 07/11/2023]
Abstract
Misclassification of Clostridioides difficile colonization as hospital-onset C. difficile infection (HO-CDI) can lead to unnecessary treatment of patients and substantial financial penalties for hospitals. We successfully implemented mandatory C. difficile PCR testing approval as a strategy to optimize testing, which was associated with a significant decline in the monthly incidence of HO-CDI rates and lowering of our standardized infection ratio to 0.77 (from 1.03) 18 months after this intervention. Approval request served as an educational opportunity to promote mindful testing and accurate diagnosis of HO-CDI.
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Affiliation(s)
| | - Gail Jackson
- Department of Infection Control, Newport Hospital, Newport, Rhode Island
| | - Sarah B. Andrea
- OHSU-PSU School of Public Health, Portland, Oregan
- Lifespan Biostatistics Epidemiology and Research Design Core, Rhode Island Hospital, Rhode Island
| | | | | | - Francine Touzard-Romo
- Division of Infectious Diseases, Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Infection Control, Newport Hospital, Newport, Rhode Island
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4
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Advani SD, Claeys K. Behavioral Strategies in Diagnostic Stewardship. Infect Dis Clin North Am 2023; 37:729-747. [PMID: 37537001 DOI: 10.1016/j.idc.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Diagnostic stewardship refers to the responsible and judicious use of diagnostic tests to reduce low value care and improve patient outcomes. This article provides an overview of behavioral strategies, their relevance to diagnostic stewardship and highlights behavioral determinants that drive diagnostic testing behavior, drawing on theoretic frameworks. Additionally, we provide concrete examples of evidence-based behavioral strategies for promoting appropriate diagnostic testing while acknowledging associated challenges. Finally, we highlight the significance of evaluating these strategies and provide an overview of evaluation frameworks and methods.
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Affiliation(s)
- Sonali D Advani
- Department of Internal Medicine-Infectious Diseases, Duke University School of Medicine, 315 Trent Drive, Hanes House, Suite 154, Durham, NC 27710, USA.
| | - Kimberly Claeys
- Department of Pharmacy Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
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5
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Berg ML, Baxter C, Ayres AM, Chung A, Slaughter J, Bilderback A, Feterik K, Ambrosino R, Wagester S, Snyder GM. The impact of autocancellation of uncollected Clostridioides difficile specimens after 24 hours on reported healthcare-associated infections: A quality improvement intervention. Infect Control Hosp Epidemiol 2023; 44:1942-1947. [PMID: 37332187 PMCID: PMC10755141 DOI: 10.1017/ice.2023.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/18/2023] [Accepted: 05/07/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVE To assess the impact of a 24-hour autocancellation of uncollected Clostridioides difficile samples in reducing reported healthcare-associated infections (HAIs). DESIGN Quality-improvement, before-and-after implementation study. SETTING The study was conducted in 17 hospitals in Pennsylvania. INTERVENTIONS Clostridioides difficile tests that are not collected within 24 hours are automatically canceled ("autocancel") through the electronic health record. The intervention took place at 2 facilities (intervention period November 2021-July 2022) and subsequently at 15 additional facilities (April 2022-July 2022). Quality measures included percentage of orders canceled, C. difficile HAI rate, percent positivity of completed tests, and potential adverse outcomes of canceled or delayed testing. RESULTS Of 6,101 orders, 1,090 (17.9%) were automatically canceled after not being collected for 24 hours during the intervention periods. The reported C. difficile HAI rates per 10,000 patient days did not significantly change. These rates were 8.07 in the 6-month preintervention period and 8.77 in the intervention period for facilities A and B combined (incidence rate ratio [IRR], 1.09; 95% CI, 0.88-1.34; P = .43), and were 5.23 HAIs per 10,000 patient days in the 6-month preintervention period and 5.33 in the intervention period for facilities C-Q combined (IRR, 1.02; 95% CI, 0.79-1.32; P = .87). From the preintervention to the intervention periods, the percent positivity rates of completed C. difficile tests increased by 1.1% for facilities A and B and by 1.4% for facilities C-Q. No adverse outcomes were observed. CONCLUSIONS The 24-hour autocancellation of uncollected C. difficile orders reduced testing but did not result in reported HAI reduction.
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Affiliation(s)
- Madeline L. Berg
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, Pennsylvania
| | - Carla Baxter
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ashley M. Ayres
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, Pennsylvania
| | - Ashley Chung
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Julie Slaughter
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, Pennsylvania
| | - Andrew Bilderback
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kristian Feterik
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richard Ambrosino
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Suzanne Wagester
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Graham M. Snyder
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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6
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Maves RC. Biomarkers of Infection and Diagnostic Stewardship: Are We Doing It Wrong? Crit Care Med 2023; 51:1607-1609. [PMID: 37902348 DOI: 10.1097/ccm.0000000000005981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Affiliation(s)
- Ryan C Maves
- Sections of Infectious Diseases and Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
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7
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Lin MY, Stein BD, Kothadia SM, Blank S, Schoeny ME, Tomich A, Hayden MK, Segreti J. Impact of Mandatory Infectious Disease Specialist Approval on Hospital-Onset Clostridioides difficile Infection Rates and Testing Appropriateness. Clin Infect Dis 2023; 77:346-350. [PMID: 37157903 DOI: 10.1093/cid/ciad250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 04/12/2023] [Accepted: 04/21/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Inappropriate Clostridioides difficile testing is common in the hospital setting, leading to potential overdiagnosis of infection when single-step nucleic acid amplification testing is used. The potential role of infectious diseases (ID) specialists in enforcing appropriate C. difficile testing is unclear. METHODS At a single 697-bed academic hospital, we performed a retrospective study from 1 March 2012 to 31 December 2019 comparing hospital-onset C. difficile infection (HO-CDI) rates during 3 consecutive time periods: baseline 1 (37 months, no decision support), baseline 2 (32 months, computer decision support), and intervention period (25 months, mandatory ID specialist approval for all C. difficile testing on hospital day 4 or later). We used a discontinuous growth model to assess the impact of the intervention on HO-CDI rates. RESULTS During the study period, we evaluated C. difficile infections across 331 180 admission and 1 172 015 patient-days. During the intervention period, a median of 1 HO-CDI test approval request per day (range, 0-6 alerts/day) was observed; adherence by providers with obtaining approval was 85%. The HO-CDI rate was 10.2, 10.4, and 4.3 events per 10 000 patient-days for each consecutive time period, respectively. In adjusted analysis, the HO-CDI rate did not differ significantly between the 2 baseline periods (P = .14) but did differ between the baseline 2 period and intervention period (P < .001). CONCLUSIONS An ID-led C. difficile testing approval process was feasible and was associated with a >50% decrease in HO-CDI rates, due to enforcement of appropriate testing.
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Affiliation(s)
- Michael Y Lin
- Departments of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian D Stein
- Departments of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Sonya M Kothadia
- Departments of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Samantha Blank
- Departments of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Alexander Tomich
- Infection Prevention and Control, Rush University Medical Center, Chicago, Illinois, USA
| | - Mary K Hayden
- Medicine and Pathology, Rush University Medical Center, Chicago, Illinois, USA
| | - John Segreti
- Departments of Medicine, Rush University Medical Center, Chicago, Illinois, USA
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8
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Ziegler MJ, Flores EJ, Epps M, Hopkins K, Glaser L, Mull NK, Pegues DA. Clostridioides difficile dynamic electronic order panel, an effective automated intervention to reduce inappropriate inpatient ordering. Infect Control Hosp Epidemiol 2023; 44:1294-1299. [PMID: 36927512 PMCID: PMC10750561 DOI: 10.1017/ice.2022.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Ordering Clostridioides difficile diagnostics without appropriate clinical indications can result in inappropriate antibiotic prescribing and misdiagnosis of hospital onset C. difficile infection. Manual processes such as provider review of order appropriateness may detract from other infection control or antibiotic stewardship activities. METHODS We developed an evidence-based clinical algorithm that defined appropriateness criteria for testing for C. difficile infection. We then implemented an electronic medical record-based order-entry tool that utilized discrete branches within the clinical algorithm including history of prior C. difficile test results, laxative or stool-softener administration, and documentation of unformed bowel movements. Testing guidance was then dynamically displayed with supporting patient data. We compared the rate of completed C. difficile tests after implementation of this intervention at 5 hospitals to a historic baseline in which a best-practice advisory was used. RESULTS Using mixed-effects Poisson regression, we found that the intervention was associated with a reduction in the incidence rate of both C. difficile ordering (incidence rate ratio [IRR], 0.74; 95% confidence interval [CI], 0.63-0.88; P = .001) and C. difficile-positive tests (IRR, 0.83; 95% CI, 0.76-0.91; P < .001). On segmented regression analysis, we identified a sustained reduction in orders over time among academic hospitals and a new reduction in orders over time among community hospitals. CONCLUSIONS An evidence-based dynamic order panel, integrated within the electronic medical record, was associated with a reduction in both C. difficile ordering and positive tests in comparison to a best practice advisory, although the impact varied between academic and community facilities.
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Affiliation(s)
- Matthew J Ziegler
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Healthcare Epidemiology, Infection Prevention and Control, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emilia J Flores
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania, Pennsylvania
| | - Mika Epps
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathleen Hopkins
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurel Glaser
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nikhil K Mull
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania, Pennsylvania
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David A Pegues
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Healthcare Epidemiology, Infection Prevention and Control, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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9
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Doolan CP, Sahragard B, Leal J, Sharma A, Kim J, Spackman E, Hollis A, Pillai DR. Clostridioides difficile Near-Patient Testing Versus Centralized Testing: A Pragmatic Cluster Randomized Crossover Trial. Clin Infect Dis 2023; 76:1911-1918. [PMID: 36718646 PMCID: PMC10249988 DOI: 10.1093/cid/ciad046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Management of suspected Clostridioides difficile infection (CDI) in the hospital setting typically results in patient isolation, laboratory testing, infection control, and presumptive treatment. We investigated whether implementation of rapid near-patient testing (NPT) reduced patient isolation time, hospital length of stay (LOS), antibiotic usage, and cost. METHODS A 2-period pragmatic cluster randomized crossover trial was conducted. Thirty-nine wards were randomized into 2 study arms. The primary outcome measure was effect of NPT on patient isolation time using a mixed-effects generalized linear regression model. Secondary outcomes examined were hospital LOS and antibiotic therapy based on a negative binomial regression model. Natural experiment (NE), intention-to-treat (ITT), and per-protocol (PP) analyses were conducted. RESULTS During the entire study period, a total of 656 patients received NPT for CDI and 1667 received standard-of-care testing. For the primary outcome, a significant decrease of patient isolation time with NPT was observed (NE, 9.4 hours [P < .01]; ITT, 2.3 hours [P < .05]; PP, 6.7 hours [P < .1]). A significant reduction in hospital LOS was observed with NPT for short stay (NE, 47.4% [P < .01]; ITT, 18.4% [P < .01]; PP, 34.2% [P < .01]). Each additional hour delay for a negative result increased metronidazole use (24 defined daily doses per 1000 patients; P < .05) and non-CDI-treating antibiotics by 70.13 mg (P < .01). NPT was found to save 25.48 US dollars per patient when including test cost to the laboratory and patient isolation in the hospital. CONCLUSIONS This pragmatic cluster randomized crossover trial demonstrated that implementation of CDI NPT can contribute to significant reductions in isolation time, hospital LOS, antibiotic usage, and healthcare cost. Clinical Trials Registration. NCT03857464.
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Affiliation(s)
- Cody P Doolan
- Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, Alberta, Canada
| | - Babak Sahragard
- Department of Economics, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Jenine Leal
- Infection Prevention and Control, Alberta Health Services, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Anuj Sharma
- Ephicacy Canada Inc., Toronto, Ontario, Canada
| | - Joseph Kim
- Infection Prevention and Control, Alberta Health Services, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eldon Spackman
- Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Aidan Hollis
- Department of Economics, University of Calgary, Calgary, Alberta, Canada
| | - Dylan R Pillai
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Precision Laboratories, Calgary, Alberta, Canada
- Department Pathology and Laboratory Medicine, University of Calgary, Alberta, Canada
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10
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Claeys KC, Johnson MD. Leveraging diagnostic stewardship within antimicrobial stewardship programmes. Drugs Context 2023; 12:dic-2022-9-5. [PMID: 36843619 PMCID: PMC9949764 DOI: 10.7573/dic.2022-9-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/16/2022] [Indexed: 02/17/2023] Open
Abstract
Novel diagnostic stewardship in infectious disease consists of interventions that modify ordering, processing, and reporting of diagnostic tests to provide the right test for the right patient, prompting the right action. The interventions work upstream and synergistically with traditional antimicrobial stewardship efforts. As diagnostic stewardship continues to gain public attention, it is critical that antimicrobial stewardship programmes not only learn how to effectively leverage diagnostic testing to improve antimicrobial use but also ensure that they are stakeholders and leaders in developing new diagnostic stewardship interventions within their institutions. This review will discuss the need for diagnostic and antimicrobial stewardship, the interplay of diagnostic and antimicrobial stewardship, evidence of benefit to antimicrobial stewardship programmes, and considerations for successfully engaging in diagnostic stewardship interventions. This article is part of the Antibiotic stewardship Special Issue: https://www.drugsincontext.com/special_issues/antimicrobial-stewardship-a-focus-on-the-need-for-moderation.
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Affiliation(s)
- Kimberly C Claeys
- University of Maryland School of Pharmacy, Department of Practice Science and Health Outcomes Research, Baltimore, MD, USA
| | - Melissa D Johnson
- Division of Infectious Diseases & International Health, Duke University School of Medicine, Durham, NC, USA,Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center Durham, NC, USA
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11
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Berg ML, Ayres AM, Weber DR, McCullough M, Crall VD, Lewis CL, Valek AL, Vincent LA, Penzelik J, Sasinoski CA, Cheng AL, Bradford CF, Bell EO, Edwards KM, Castronova IA, Brady MB, Slaughter J, Oleksiuk LM, Snyder GM. Diagnostic stewardship for Clostridioides difficile testing in an acute care hospital: A quality improvement intervention. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2023; 3:e67. [PMID: 37113206 PMCID: PMC10127245 DOI: 10.1017/ash.2023.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 02/17/2023] [Indexed: 04/09/2023]
Abstract
Abstract
Objective:
To evaluate the impact of a diagnostic stewardship intervention on Clostridioides difficile healthcare-associated infections (HAI).
Design:
Quality improvement study.
Setting:
Two urban acute care hospitals.
Interventions:
All inpatient stool testing for C. difficile required review and approval prior to specimen processing in the laboratory. An infection preventionist reviewed all orders daily through chart review and conversations with nursing; orders meeting clinical criteria for testing were approved, orders not meeting clinical criteria were discussed with the ordering provider. The proportion of completed tests meeting clinical criteria for testing and the primary outcome of C. difficile HAI were compared before and after the intervention.
Results:
The frequency of completed C. difficile orders not meeting criteria was lower [146 (7.5%) of 1,958] in the intervention period (January 10, 2022–October 14, 2022) than in the sampled 3-month preintervention period [26 (21.0%) of 124; P < .001]. C. difficile HAI rates were 8.80 per 10,000 patient days prior to the intervention (March 1, 2021–January 9, 2022) and 7.69 per 10,000 patient days during the intervention period (incidence rate ratio, 0.87; 95% confidence interval, 0.73–1.05; P = .13).
Conclusions:
A stringent order-approval process reduced clinically nonindicated testing for C. difficile but did not significantly decrease HAIs.
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12
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Husson J, Bork JT, Morgan D, Baddley JW. Is diagnostic stewardship possible in solid organ transplantation? Transpl Infect Dis 2022; 24:e13899. [DOI: 10.1111/tid.13899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 06/08/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Jennifer Husson
- Institute of Human Virology Department of Medicine University of Maryland School of Medicine Baltimore Maryland USA
| | - Jacqueline T. Bork
- Department of Medicine University of Maryland School of Medicine and VA Maryland Healthcare System Baltimore Maryland USA
| | - Daniel Morgan
- Department of Epidemiology and Public Health VA Maryland Healthcare System University of Maryland School of Medicine Baltimore Maryland USA
| | - John W. Baddley
- Department of Medicine University of Maryland School of Medicine and VA Maryland Healthcare System Baltimore Maryland USA
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13
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So M, Tsai H, Swaminathan N, Bartash R. Bring it on: Top five antimicrobial stewardship challenges in transplant infectious diseases and practical strategies to address them. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e72. [PMID: 36483373 PMCID: PMC9726551 DOI: 10.1017/ash.2022.53] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 06/17/2023]
Abstract
Antimicrobial therapies are essential tools for transplant recipients who are at high risk for infectious complications. However, judicious use of antimicrobials is critical to preventing the development of antimicrobial resistance. Treatment of multidrug-resistant organisms is challenging and potentially leads to therapies with higher toxicities, intravenous access, and intensive drug monitoring for interactions. Antimicrobial stewardship programs are crucial in the prevention of antimicrobial resistance, though balancing these strategies with the need for early and frequent antibiotic therapy in these immunocompromised patients can be challenging. In this review, we summarize 5 frequently encountered transplant infectious disease stewardship challenges, and we suggest strategies to improve practices for each clinical syndrome. These 5 challenging areas are: asymptomatic bacteriuria in kidney transplant recipients, febrile neutropenia in hematopoietic stem cell transplantation, antifungal prophylaxis in liver and lung transplantation, treatment of left-ventricular assist device infections, and Clostridioides difficile infection in solid-organ and hematopoietic stem-cell transplant recipients. Common themes contributing to these challenges include limited data specific to transplant patients, shortcomings in diagnostic testing, and uncertainties in pharmacotherapy.
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Affiliation(s)
- Miranda So
- Sinai Health-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Helen Tsai
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Neeraja Swaminathan
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Rachel Bartash
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
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14
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Khuvis J, Alsoubani M, Mae Rodday A, Doron S. Impact of Diagnostic Stewardship Interventions on Clostridiodes difficile test ordering practices and results. Clin Biochem 2022; 117:23-29. [DOI: 10.1016/j.clinbiochem.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 11/24/2022]
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15
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Sick-Samuels AC, Woods-Hill C. Diagnostic Stewardship in the Pediatric Intensive Care Unit. Infect Dis Clin North Am 2022; 36:203-218. [PMID: 35168711 PMCID: PMC8865365 DOI: 10.1016/j.idc.2021.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the pediatric intensive care unit (PICU), clinicians encounter complex decision making, balancing the need to treat infections promptly against the potential harms of antibiotics. Diagnostic stewardship is an approach to optimize microbiology diagnostic test practices to reduce unnecessary antibiotic treatment. We review the evidence for diagnostic stewardship of blood, endotracheal, and urine cultures in the PICU. Clinicians should consider 3 questions applying diagnostic stewardship: (1) Does the patient have signs or symptoms of an infectious process? (2) What is the optimal diagnostic test available to evaluate for this infection? (3) How should the diagnostic specimen be collected to optimize results?
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Affiliation(s)
- Anna C. Sick-Samuels
- The Johns Hopkins University School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD,The Johns Hopkins Hospital, Department of Hospital Epidemiology and Infection Control, Baltimore, MD
| | - Charlotte Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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16
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Rock C, Perlmutter R, Blythe D, Bork J, Claeys K, Cosgrove SE, Dzintars K, Fabre V, Harris AD, Heil E, Hsu YJ, Keller S, Maragakis LL, Milstone AM, Morgan DJ, Dullabh P, Ubri PS, Rotondo C, Brooks R, Leekha S. Impact of Statewide Prevention and Reduction of Clostridioides difficile (SPARC), a Maryland public health-academic collaborative: an evaluation of a quality improvement intervention. BMJ Qual Saf 2021; 31:153-162. [PMID: 34887357 PMCID: PMC8784990 DOI: 10.1136/bmjqs-2021-014014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/04/2021] [Indexed: 11/04/2022]
Abstract
To evaluate changes in Clostridioides difficile incidence rates for Maryland hospitals that participated in the Statewide Prevention and Reduction of C. difficile (SPARC) collaborative. Pre-post, difference-in-difference analysis of non-randomised intervention using four quarters of preintervention and six quarters of postintervention National Healthcare Safety Network data for SPARC hospitals (April 2017 to March 2020) and 10 quarters for control hospitals (October 2017 to March 2020). Mixed-effects negative binomial models were used to assess changes over time. Process evaluation using hospital intervention implementation plans, assessments and interviews with staff at eight SPARC hospitals. Maryland, USA. All Maryland acute care hospitals; 12 intervention and 36 control hospitals. Participation in SPARC, a public health-academic collaborative made available to Maryland hospitals, with staggered enrolment between June 2018 and August 2019. Hospitals with higher C. difficile rates were recruited via email and phone. SPARC included assessments, feedback reports and ongoing technical assistance. Primary outcomes were C. difficile incidence rate measured as the quarterly number of C. difficile infections per 10 000 patient-days (outcome measure) and SPARC intervention hospitals' experiences participating in the collaborative (process measures). SPARC invited 13 hospitals to participate in the intervention, with 92% (n=12) participating. The 36 hospitals that did not participate served as control hospitals. SPARC hospitals were associated with 45% greater C. difficile reduction as compared with control hospitals (incidence rate ratio=0.55, 95% CI 0.35 to 0.88, p=0.012). Key SPARC activities, including access to trusted external experts, technical assistance, multidisciplinary collaboration, an accountability structure, peer-to-peer learning opportunities and educational resources, were associated with hospitals reporting positive experiences with SPARC. SPARC intervention hospitals experienced 45% greater reduction in C. difficile rates than control hospitals. A public health-academic collaborative might help reduce C. difficile and other hospital-acquired infections in individual hospitals and at state or regional levels.
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Affiliation(s)
- Clare Rock
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rebecca Perlmutter
- Emerging Infections Program, Maryland Department of Health, Baltimore, Maryland, USA
| | - David Blythe
- Emerging Infections Program, Maryland Department of Health, Baltimore, Maryland, USA
| | - Jacqueline Bork
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kimberly Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kate Dzintars
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Valeria Fabre
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Emily Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sara Keller
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lisa L Maragakis
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron M Milstone
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA.,VA Maryland Health Care System, Baltimore, Maryland, USA
| | | | | | | | - Richard Brooks
- Emerging Infections Program, Maryland Department of Health, Baltimore, Maryland, USA.,Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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17
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Krishna A, Chopra T. Prevention of Infection due to Clostridium (Clostridioides) difficile. Infect Dis Clin North Am 2021; 35:995-1011. [PMID: 34752229 DOI: 10.1016/j.idc.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Clostridium (Clostridioides) difficile infection (CDI) causes significant morbidity and mortality in the United States every year. Prevention of CDI is difficult because of spore durability and requires implementation of multipronged strategies. Two categories of prevention strategies are infection control and prevention and risk factor reduction. Hand hygiene, contact precautions, patient isolation, and environmental decontamination are cornerstones of infection control and prevention. Risk factor reduction should focus on antibiotic stewardship to reduce unnecessary antibiotic use. If CDI incidence remains higher than the institution's goal despite these measures, then special measures should be considered.
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Affiliation(s)
- Amar Krishna
- Internal Medicine, Norther Light AR Gould Hospital, 140 Academy Street, Presque Isle, ME 04769, USA.
| | - Teena Chopra
- Infectious Diseases, Wayne State University/Detroit Medical Center, UHC-2B, 4201 St Antoine, Detroit, MI 48201, USA
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18
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Petersen MR, Cosgrove SE, Klein EY, Zhu X, Quinn TC, Patel EU, Grabowski MK, Tobian AAR. Clostridioides difficile Prevalence in the United States: National Inpatient Sample, 2016 to 2018. Open Forum Infect Dis 2021; 8:ofab409. [PMID: 34671694 PMCID: PMC8522265 DOI: 10.1093/ofid/ofab409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 07/27/2021] [Indexed: 02/04/2023] Open
Abstract
Data from the National Inpatient Sample indicate that Clostridioides
difficile prevalence decreased from 10.1 (95% confidence interval
[CI] = 9.9–10.3) to 8.6 (95% CI = 8.5–8.8) per 1000 hospital
discharges between 2016 and 2018, after accounting for age, sex, and race. There
was heterogeneity in the prevalence and decrease in prevalence by geographic
region in the United States.
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Affiliation(s)
- Molly R Petersen
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Xianming Zhu
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas C Quinn
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Eshan U Patel
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - M Kate Grabowski
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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19
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Mizusawa M, Carroll KC. The future of Clostridioides difficile diagnostics. Curr Opin Infect Dis 2021; 34:483-490. [PMID: 34524199 DOI: 10.1097/qco.0000000000000754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Although the epidemiology of Clostridioides difficile has changed, this organism continues to cause significant morbidity and mortality. This review addresses current and future approaches to the diagnosis of C. difficile disease. RECENT FINDINGS Over the last several years, large prospective studies have confirmed that there is no single optimal test for the diagnosis of C. difficile disease. The pendulum has swung from a focus on rapid molecular diagnosis during the years of the ribotype 027 epidemic, to a call for use of algorithmic approaches that include a test for toxin detection. In addition, diagnostic stewardship has been shown to improve test utilization, especially with molecular methods. Advances in testing include development of ultrasensitive toxin tests and an expansion of biomarkers that may be more C. difficile specific. Microbiome research may be leveraged to inform novel diagnostic approaches based on measurements of volatile and nonvolatile organic compounds in stool. SUMMARY As rates of C. difficile infection decline, emphasis is now on improving test utilization and a quest for improved diagnostic approaches. These approaches may involve implementation of technologies that improve toxin testing, predict patients likely to have disease and/or a severe outcome, and harnessing research on changes in the microbiome to advance metabolomics.
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Affiliation(s)
- Masako Mizusawa
- Section of Infectious Diseases, Department of Internal Medicine, University of Missouri, Kansas City, Missouri
| | - Karen C Carroll
- Division of Medical Microbiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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