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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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Ray MJ, Lacanilao KL, Lazaro MR, Strnad LC, Furuno JP, Royster K, McGregor JC. Use of electronic health record data to identify hospital-associated Clostridioides difficile infections: a validation study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.10.24301118. [PMID: 38260609 PMCID: PMC10802632 DOI: 10.1101/2024.01.10.24301118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background Clinical research focused on the burden and impact of Clostridioides difficile infection (CDI) often relies upon accurate identification of cases using existing health record data. Use of diagnosis codes alone can lead to misclassification of cases. Our goal was to develop and validate a multi-component algorithm to identify hospital-associated CDI (HA-CDI) cases using electronic health record (EHR) data. Methods We performed a validation study using a random sample of adult inpatients at a large academic hospital setting in Portland, Oregon from January 2018 to March 2020. We excluded patients with CDI on admission and those with short lengths of stay (< 4 days). We tested a multi-component algorithm to identify HA-CDI; case patients were required to have received an inpatient course of metronidazole, oral vancomycin, or fidaxomicin and have at least one of the following: a positive C. difficile laboratory test or the International Classification of Diseases, Tenth Revision (ICD-10) code for non-recurrent CDI. For a random sample of 80 algorithm-identified HA-CDI cases and 80 non-cases, we performed manual EHR review to identify gold standard of HA-CDI diagnosis. We then calculated overall percent accuracy, sensitivity, specificity, and positive and negative predictive value for the algorithm overall and for the individual components. Results Our case definition algorithm identified HA-CDI cases with 94% accuracy (95% Confidence Interval (CI): 88% to 97%). We achieved 100% sensitivity (94% to 100%), 89% specificity (81% to 95%), 88% positive predictive value (78% to 94%), and 100% negative predictive value (95% to 100%). Requiring a positive C. difficile test as our gold standard further improved diagnostic performance (97% accuracy [93% to 99%], 93% PPV [85% to 98%]). Conclusions Our algorithm accurately detected true HA-CDI cases from EHR data in our patient population. A multi-component algorithm performs better than any isolated component. Requiring a positive laboratory test for C. difficile strengthens diagnostic performance even further. Accurate detection could have important implications for CDI tracking and research.
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Affiliation(s)
- Michael J. Ray
- Oregon State University College of Pharmacy, Department of Pharmacy Practice, Portland, Oregon
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon
| | - Kathleen L. Lacanilao
- Oregon State University College of Pharmacy, Department of Pharmacy Practice, Portland, Oregon
| | - Maela Robyne Lazaro
- Oregon State University College of Pharmacy, Department of Pharmacy Practice, Portland, Oregon
| | - Luke C. Strnad
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon
- Oregon Health & Science University School of Medicine, Division of Infectious Diseases, Portland, Oregon
| | - Jon P. Furuno
- Oregon State University College of Pharmacy, Department of Pharmacy Practice, Portland, Oregon
| | - Kelly Royster
- Oregon State University College of Pharmacy, Department of Pharmacy Practice, Portland, Oregon
| | - Jessina C. McGregor
- Oregon State University College of Pharmacy, Department of Pharmacy Practice, Portland, Oregon
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon
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Baker AW, Maged A, Haridy S, Stout JE, Seidelman JL, Lewis SS, Anderson DJ. Use of Statistical Process Control Methods for Early Detection of Healthcare Facility-Associated Nontuberculous Mycobacteria Outbreaks: A Single-Center Pilot Study. Clin Infect Dis 2023; 76:1459-1467. [PMID: 36444485 PMCID: PMC10319764 DOI: 10.1093/cid/ciac923] [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: 09/06/2022] [Revised: 11/17/2022] [Accepted: 11/23/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Nontuberculous mycobacteria (NTM) are emerging pathogens increasingly implicated in healthcare facility-associated (HCFA) infections and outbreaks. We analyzed the performance of statistical process control (SPC) methods in detecting HCFA NTM outbreaks. METHODS We retrospectively analyzed 3 NTM outbreaks that occurred from 2013 to 2016 at a tertiary care hospital. The outbreaks consisted of pulmonary Mycobacterium abscessus complex (MABC) acquisition, cardiac surgery-associated extrapulmonary MABC infection, and a bronchoscopy-associated pseudo-outbreak of Mycobacterium avium complex (MAC). We analyzed monthly case rates of unique patients who had positive respiratory cultures for MABC, non-respiratory cultures for MABC, and bronchoalveolar lavage cultures for MAC, respectively. For each outbreak, we used these rates to construct a pilot moving average (MA) SPC chart with a rolling baseline window. We also explored the performance of numerous alternative control charts, including exponentially weighted MA, Shewhart, and cumulative sum charts. RESULTS The pilot MA chart detected each outbreak within 2 months of outbreak onset, preceding actual outbreak detection by an average of 6 months. Over a combined 117 months of pre-outbreak and post-outbreak surveillance, no false-positive SPC signals occurred (specificity, 100%). Prospective use of this chart for NTM surveillance could have prevented an estimated 108 cases of NTM. Six high-performing alternative charts detected all outbreaks during the month of onset, with specificities ranging from 85.7% to 94.9%. CONCLUSIONS SPC methods have potential to substantially improve HCFA NTM surveillance, promoting early outbreak detection and prevention of NTM infections. Additional study is needed to determine the best application of SPC for prospective HCFA NTM surveillance in other settings.
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Affiliation(s)
- Arthur W Baker
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Ahmed Maged
- Department of Advanced Design and Systems Engineering, City University of Hong Kong, Kowloon, Hong Kong SAR, China
- Department of Mechanical Engineering, Benha University, Benha, Egypt
| | - Salah Haridy
- Department of Industrial Engineering and Engineering Management, College of Engineering, University of Sharjah, Sharjah, United Arab Emirates
- Benha Faculty of Engineering, Benha University, Benha, Egypt
| | - Jason E Stout
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jessica L Seidelman
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Sarah S Lewis
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Deverick J Anderson
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
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Kociolek LK, Gerding DN, Carrico R, Carling P, Donskey CJ, Dumyati G, Kuhar DT, Loo VG, Maragakis LL, Pogorzelska-Maziarz M, Sandora TJ, Weber DJ, Yokoe D, Dubberke ER. Strategies to prevent Clostridioides difficile infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:527-549. [PMID: 37042243 PMCID: PMC10917144 DOI: 10.1017/ice.2023.18] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Affiliation(s)
- Larry K. Kociolek
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, United States
| | - Dale N. Gerding
- Edward Hines Jr. Veterans’ Affairs (VA) Hospital, Hines, Illinois, United States
| | - Ruth Carrico
- Norton Healthcare, Louisville, Kentucky, United States
| | - Philip Carling
- Boston University School of Medicine, Boston, Massachusetts, United States
| | - Curtis J. Donskey
- Case Western Reserve University School of Medicine, Cleveland VA Medical Center, Cleveland, Ohio, United States
| | - Ghinwa Dumyati
- University of Rochester Medical Center, Rochester, New York, United States
| | - David T. Kuhar
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Vivian G. Loo
- McGill University, McGill University Health Centre, Montréal, Québec, Canada
| | - Lisa L. Maragakis
- Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | | | - Thomas J. Sandora
- Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - David J. Weber
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Deborah Yokoe
- University of California San Francisco, UCSF Health-UCSF Medical Center, San Francisco, California, United States and
| | - Erik R. Dubberke
- Washington University School of Medicine, St. Louis, Missouri, United States
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Hazleton KZ, Martin CG, Orlicky DJ, Arnolds KL, Nusbacher NM, Moreno-Huizar N, Armstrong M, Reisdorph N, Lozupone CA. Dietary fat promotes antibiotic-induced Clostridioides difficile mortality in mice. NPJ Biofilms Microbiomes 2022; 8:15. [PMID: 35365681 PMCID: PMC8975876 DOI: 10.1038/s41522-022-00276-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/21/2022] [Indexed: 11/15/2022] Open
Abstract
Clostridioides difficile infection (CDI) is the leading cause of hospital-acquired diarrhea, and emerging evidence has linked dietary components with CDI pathogenesis, suggesting that dietary modulation may be an effective strategy for prevention. Here, we show that mice fed a high-fat/low-fiber “Western-type” diet (WD) had dramatically increased mortality in a murine model of antibiotic-induced CDI compared to a low-fat/low-fiber (LF/LF) diet and standard mouse chow controls. We found that the WD had a pro- C. difficile bile acid composition that was driven in part by higher levels of primary bile acids that are produced to digest fat, and a lower level of secondary bile acids that are produced by the gut microbiome. This lack of secondary bile acids was associated with a greater disturbance to the gut microbiome with antibiotics in both the WD and LF/LF diet compared to mouse chow. Mice fed the WD also had the highest level of toxin TcdA just prior to the onset of mortality, but not of TcdB or increased inflammation. These findings indicate that dietary intervention to decrease fat may complement previously proposed dietary intervention strategies to prevent CDI in high-risk individuals.
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Affiliation(s)
- Keith Z Hazleton
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition. University of Colorado, Denver Anschutz Medical Campus, Aurora, CO, 80045, USA.,Digestive Health Institute, Children's Hospital Colorado, Aurora, CO, 80045, USA.,Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, University of Arizona, Tucson, AZ, 85719, USA
| | - Casey G Martin
- Department of Immunology and Microbiology, University of Colorado, Denver Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - David J Orlicky
- Department of Pathology, University of Colorado, Denver Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Kathleen L Arnolds
- Department of Immunology and Microbiology, University of Colorado, Denver Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Nichole M Nusbacher
- Department of Medicine, Division of Biomedical Informatics and Personalized Medicine, University of Colorado, Denver Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Nancy Moreno-Huizar
- Department of Medicine, Division of Biomedical Informatics and Personalized Medicine, University of Colorado, Denver Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Michael Armstrong
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Nichole Reisdorph
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Catherine A Lozupone
- Department of Medicine, Division of Biomedical Informatics and Personalized Medicine, University of Colorado, Denver Anschutz Medical Campus, Aurora, CO, 80045, USA.
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When is an outbreak an outbreak? Using literature and discharge data to define Clostridioides difficile incidence changes referred to as outbreaks. J Hosp Infect 2020; 105:225-231. [DOI: 10.1016/j.jhin.2020.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/16/2020] [Indexed: 11/24/2022]
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Boly FJ, Reske KA, Kwon JH. The Role of Diagnostic Stewardship in Clostridioides difficile Testing: Challenges and Opportunities. Curr Infect Dis Rep 2020; 22:7. [PMID: 33762897 PMCID: PMC7987129 DOI: 10.1007/s11908-020-0715-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Accurate and timely diagnosis of Clostridioides difficile infection (CDI) is imperative to prevent C. difficile transmission and reduce morbidity and mortality due to CDI, but CDI laboratory diagnostics are complex. The purpose of this article is to review the role of laboratory tests in the diagnosis of CDI, and the role of diagnostic stewardship in optimization of C. difficile testing. RECENT FINDINGS Results from C. difficile diagnostic tests should be interpreted with an understanding of the strengths and limitations inherent in each testing approach. Use of highly sensitive molecular diagnostic tests without accounting for clinical signs and symptoms may lead to over-diagnosis of CDI and increased facility CDI rates. Current guidelines recommend a two-step, algorithmic approach for testing. Diagnostic stewardship interventions, such as education, order sets, order search menus, reflex orders, hard and soft stop alerts, electronic references, feedback and benchmarking, decision algorithms, and predictive analytics may help improve use of C. difficile laboratory tests and CDI diagnosis. The diagnostic stewardship approaches with the highest reported success rates include computerized clinical decision support (CCDS) interventions, face-to-face feedback, and real-time evaluations. SUMMARY CDI is a clinical diagnosis supported by laboratory findings. Together, clinical evaluation combined with diagnostic stewardship can optimize the accurate diagnosis of CDI.
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Impact of an electronic hard-stop clinical decision support tool to limit repeat Clostridioides difficile toxin enzyme immunoassay testing on test utilization. Infect Control Hosp Epidemiol 2019; 40:1423-1426. [PMID: 31647044 DOI: 10.1017/ice.2019.275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We performed an intervention evaluating the impact of an electronic hard-stop clinical decision support tool on repeat Clostridioides difficile (CD) toxin enzyme immunoassay (T-EIA) testing. The CD testing rate and number of admissions with repeat tests decreased significantly postintervention (P < .01 for both); the percentage of positive tests was unchanged (P = .27).
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Fan Y, Zou J, Cao X, Wu Y, Gao F, Xiong L. Data on antibiotic use for detecting clusters of healthcare-associated infection caused by multidrug-resistant organisms in a hospital in China, 2014 to 2017. J Hosp Infect 2019; 101:305-312. [DOI: 10.1016/j.jhin.2018.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/12/2018] [Indexed: 01/09/2023]
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Gupta SB, Dubberke ER. Reprint of: Overview and changing epidemiology of Clostridium difficile infection. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2018.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Abstract
PURPOSE OF REVIEW Clostridium difficile infection (CDI) is one of the most common healthcare-associated infections, and the threat associated with CDI continues to grow in all patient populations. There is increasing evidence that CDI has a substantial impact on the morbidity and mortality in solid organ transplant (SOT) recipients. Furthermore, new diagnostic and treatment options and strategies for CDI have emerged over the last decade. The purpose of this review is to provide a general understanding of CDI and its evidence-based diagnosis and management strategies, with a focus on SOT recipients. RECENT FINDINGS The incidence and severity of CDI have significantly increased since the year 2000. Studies have identified novel risk factors for CDI, and a new epidemic strain, the NAP1/BI/027, has emerged. Despite the development of newer testing methods and approaches, including nucleic acid amplification tests and testing algorithms, the optimal method for diagnosing CDI is an area of controversy. New agents for treating CDI are being developed, and the use of fecal microbiota transplantation to treat recurrent CDI in SOT recipients is also evolving. SUMMARY CDI is a significant problem for SOT recipients. Further studies on diagnostic and therapeutic strategies with a focus on SOT recipients are needed to further improve patient outcomes.
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Silva ROS, Vilela EG, Neves MS, Lobato FCF. Evaluation of three enzyme immunoassays and a nucleic acid amplification test for the diagnosis of Clostridium difficile-associated diarrhea at a university hospital in Brazil. Rev Soc Bras Med Trop 2015; 47:447-50. [PMID: 25229284 DOI: 10.1590/0037-8682-0100-2014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 07/31/2014] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION Despite the known importance of Clostridium difficile as a nosocomial pathogen, few studies regarding Clostridium difficile infection (CDI) in Brazil have been conducted. To date, the diagnostic tests that are available on the Brazilian market for the diagnosis of CDI have not been evaluated. The aim of this study was to compare the performances of four commercial methods for the diagnosis of CDI in patients from a university hospital in Brazil. METHODS Three enzyme immunoassays (EIAs) and one nucleic acid amplification test (NAAT) were evaluated against a cytotoxicity assay (CTA) and toxigenic culture (TC). Stool samples from 92 patients with suspected CDI were used in this study. RESULTS Twenty-five (27.2%) of 92 samples were positive according to the CTA, and 23 (25%) were positive according to the TC. All EIAs and the NAAT test demonstrated sensitivities between 59 and 68% and specificities greater than 91%. CONCLUSIONS All four methods exhibited low sensitivities for the diagnosis of CDI, which could lead to a large number of false-negative results, an increased risk of cross-infection to other patients, and overtreatment with empirical antibiotics.
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Affiliation(s)
| | - Eduardo Garcia Vilela
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, BRAZIL
| | - Monique Silva Neves
- Faculdade de Medicina Veterinária, Universidade Federal de Minas Gerais, Belo Horizonte, MG, BRAZIL
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Murad YM, Perez J, Nokhbeh R, Ybazeta G, Dewar B, Lefebvre S, Diaz-Mitoma F. Impact of polymerase chain reaction testing on Clostridium difficile infection rates in an acute health care facility. Am J Infect Control 2015; 43:383-6. [PMID: 25687359 DOI: 10.1016/j.ajic.2014.12.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 12/19/2014] [Accepted: 12/22/2014] [Indexed: 11/26/2022]
Abstract
Two rapid methods of Clostridium difficile infection (CDI) diagnosis were compared between June 2012 and March 2013: a GeneXpert (Cepheid, Sunnyvale, Calif) polymerase chain reaction (PCR) test and an enzyme immunoassay (EIA). The influence of these methods on the detection of hospital-acquired CDI and identification of CDI outbreaks was evaluated. We tested 1,592 stool samples for C difficile. The GeneXpert PCR test identified 211 positive samples (68 determined to be hospital-acquired infection), whereas EIA identified 105 positive samples (36 determined to be hospital-acquired infection). The GeneXpert PCR method in contrast to the EIA method increased the detection rates of nosocomial CDI cases and contributed to the declaration of CDI outbreaks.
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Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2015; 35 Suppl 2:S48-65. [PMID: 25376069 DOI: 10.1017/s0899823x00193857] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their Clostridium difficile infection (CDI) prevention efforts. This document updates “Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Dubberke ER, Carling P, Carrico R, Donskey CJ, Loo VG, McDonald LC, Maragakis LL, Sandora TJ, Weber DJ, Yokoe DS, Gerding DN. Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 Update. Infect Control Hosp Epidemiol 2015; 35:628-45. [PMID: 24799639 DOI: 10.1086/676023] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Erik R Dubberke
- Washington University School of Medicine, St. Louis, Missouri
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Toltzis P, Nerandzic MM, Saade E, O'Riordan MA, Smathers S, Zaoutis T, Kim J, Donskey CJ. High Proportion of False-Positive Clostridium difficile Enzyme Immunoassays for Toxin A and B in Pediatric Patients. Infect Control Hosp Epidemiol 2015; 33:175-9. [DOI: 10.1086/663706] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objectives.To determine the frequency of false-positive Clostridium difficile toxin enzyme immunoassay (EIA) results in hospitalized children and to examine potential reasons for this false positivity.Design.Nested case-control.Setting.Two tertiary care pediatric hospitals.Methods.As part of a natural history study, prospectively collected EIA-positive stools were cultured for toxigenic C. difficile, and characteristics of children with false-positive and true-positive EIA results were compared. EIA-positive/culture-negative samples were recultured after dilution and enrichment steps, were evaluated for presence of the tcdB gene by polymerase chain reaction (PCR), and were further cultured for Clostridium sordellii, a cause of false-positive EIA toxin assays.Results.Of 112 EIA-positive stools cultured, 72 grew toxigenic C. difficile and 40 did not, indicating a positive predictive value of 64% in this population. The estimated prevalence of C. difficile infection (CDI) in the study sites among children tested for this pathogen was 5%–7%. Children with false-positive EIA results were significantly younger than those with true-positive tests but did not differ in other characteristics. No false-positive specimens yielded C. difficile when cultured after enrichment or serial dilution, 1 specimen was positive for tcdB by PCR, and none grew C. sordellii.Conclusions.Approximately one-third of EIA tests used to evaluate pediatric inpatients for CDI were falsely positive. This finding was likely due to the low prevalence of CDI in pediatric hospitals, which diminishes the test's positive predictive value. These data raise concerns about the use of EIA assays to diagnosis CDI in children.Infect Control Hosp Epidemiol 2012;33(2):175-179
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Dubberke ER, Carling P, Carrico R, Donskey CJ, Loo VG, McDonald LC, Maragakis LL, Sandora TJ, Weber DJ, Yokoe DS, Gerding DN. Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update. Infect Control Hosp Epidemiol 2015. [DOI: 10.1086/522262] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Tan BF, Chen YC, Lee CN, Chang LY, Hsieh WS, Tsao PN, Liu YC, Chen ML, Ho SY, Lu CY, Huang LM. Pseudo-outbreak of rotavirus infection in a neonatal intensive care unit. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2014; 49:947-954. [PMID: 25648669 DOI: 10.1016/j.jmii.2012.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 08/23/2014] [Accepted: 08/31/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND A rotavirus outbreak in a neonatal intensive care unit (NICU) may have catastrophic consequences for young infants receiving critical care. From May 13, 2011 to July 11, 2011, a significant increase in stool samples testing positive for rotavirus antigens in the NICU of a university affiliated hospital was observed. Due to lack of clinical presentations suggestive of rotavirus infection in the patients and the rarity of rotavirus infection in the NICU in the past, a pseudo-outbreak was suspected. METHODS Infection control measures were reinforced initially. To investigate the outbreak, a prospective laboratory-based active surveillance of all infants in the NICU was conducted right after the cluster was identified. Repeated testing using a modified enzyme immunoassay (EIA) kit, rotavirus RNA polyacrylamide gel electrophoresis (PAGE), reverse transcription polymerase chain reaction (RT-PCR), and retrospective chart review methods were used to confirm the pseudo-outbreak. RESULTS Seven infants in the NICU, with or without gastrointestinal symptoms, tested positive for the rotavirus antigen using the old version of an EIA kit, which indicated a possible outbreak. Active surveillance with repeated tests for recollected stool samples using a modified EIA kit showed negative results in all 24 infants in the NICU. Seven stored stool samples from four infants, which previously tested positive for the rotavirus antigen, tested negative for rotavirus using the modified EIA kit, PAGE, and RT-PCR. Chart reviews showed no clinical difference between index cases and controls. False positivity might arise from unsatisfactory specificity of the old EIA kit. After the introduction of the modified EIA kit, no rotavirus was detected in the NICU for at least 7 months. CONCLUSION This cluster of patients who tested positive for the rotavirus antigen in stools was confirmed to be a pseudo-outbreak. Interpretation of the old EIA for rotavirus in an NICU setting should be done with caution until the mechanism of the false-positive reaction is elucidated.
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Affiliation(s)
- Boon Fatt Tan
- Department of Pediatrics, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Yee-Chun Chen
- Center for Infection Control and Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Nan Lee
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Luan-Yin Chang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Wu-Shiun Hsieh
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Po-Nien Tsao
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Chieh Liu
- Center for Infection Control and Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Ling Chen
- Center for Infection Control and Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Yuan Ho
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Yi Lu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Li-Min Huang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.
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Gupta SB, Dubberke ER. Overview and changing epidemiology of Clostridium difficile infection. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Barbut F, Surgers L, Eckert C, Visseaux B, Cuingnet M, Mesquita C, Pradier N, Thiriez A, Ait-Ammar N, Aifaoui A, Grandsire E, Lalande V. Does a rapid diagnosis of Clostridium difficile infection impact on quality of patient management? Clin Microbiol Infect 2014; 20:136-44. [DOI: 10.1111/1469-0691.12221] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 02/27/2013] [Accepted: 03/09/2013] [Indexed: 02/04/2023]
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Wilcox MH. Overcoming barriers to effective recognition and diagnosis of Clostridium difficile infection. Clin Microbiol Infect 2013; 18 Suppl 6:13-20. [PMID: 23121550 DOI: 10.1111/1469-0691.12057] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
With the frequency of cases of Clostridium difficile infection (CDI) increasing in many developed countries, accurate and reliable laboratory diagnosis of CDI is more important than ever. However, the diagnosis of CDI has been handicapped by the existence of two reference standards, one of which detects C. difficile toxin (cytotoxin assay) and the other only toxigenic strains (cytotoxigenic culture). Being relatively slow and laborious to perform, these reference methods were largely abandoned as routine diagnostic methods for toxin detection in favour of stand-alone rapid enzyme immunoassays (EIAs), which have suboptimal sensitivity and specificity. The management of CDI is undermined by high rates of both false-positive and false-negative test results. More recently developed nucleic acid amplification tests (NAATs) for toxin gene detection offer improved sensitivity over immunoassays, but fail to discriminate between CDI and asymptomatic colonization with C. difficile, and have clear drawbacks as stand-alone diagnostic tests. Two-step or three-step diagnostic algorithms have been proposed as a solution. In a large study of the effectiveness of currently available tests, a diagnostic algorithm was developed that combines available tests to more effectively distinguish patients with CDI from uninfected patients. This two-test protocol, which is now used in National Health Service laboratories in England, comprises an EIA for glutamate dehydrogenase detection or NAATs for toxin gene detection, followed by a relatively sensitive toxin EIA. This algorithm also identifies 'potential C. difficile excretors', individuals with diarrhoeal samples that contain C. difficile but without demonstrable toxin, who may be a source of transmission of C. difficile to susceptible patients.
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Affiliation(s)
- M H Wilcox
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals NHS Trust & University of Leeds, Leeds General Infirmary, Leeds, UK.
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Mattner F, Winterfeld I, Mattner L. Diagnosing toxigenic Clostridium difficile: New confidence bounds show culturing increases sensitivity of the toxin A/B enzyme immunoassay and refute gold standards. ACTA ACUST UNITED AC 2012; 44:578-85. [DOI: 10.3109/00365548.2012.655772] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Lanzas C, Dubberke ER, Lu Z, Reske KA, Gröhn YT. Epidemiological model for Clostridium difficile transmission in healthcare settings. Infect Control Hosp Epidemiol 2011; 32:553-61. [PMID: 21558767 DOI: 10.1086/660013] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Recent outbreaks of Clostridium difficile infection (CDI) have been difficult to control, and data indicate that the importance of different sources of transmission may have changed. Our objectives were to evaluate the contributions of asymptomatic and symptomatic C. difficile carriers to new colonizations and to determine the most important epidemiological factors influencing C. difficile transmission. DESIGN, SETTING, AND PATIENTS Retrospective cohort study of all patients admitted to medical wards at a large tertiary care hospital in the United States in the calendar year 2008. METHODS Data from six medical wards and published literature were used to develop a compartmental model of C. difficile transmission. Patients could be in one of five transition states in the model: resistant to colonization (R), susceptible to colonization (S), asymptomatically colonized without protection against CDI (C(-)), asymptomatically colonized with protection against CDI (C(+)), and diseased (ie, with CDI; D). RESULTS The contributions of C(-), C(+), and D patients to new colonizations were similar. The simulated basic reproduction number ranged from 0.55 to 1.99, with a median of 1.04. These values suggest that transmission within the ward alone from patients with CDI cannot sustain new C. difficile colonizations and therefore that the admission of colonized patients plays an important role in sustaining transmission in the ward. The epidemiological parameters that ranked as the most influential were the proportion of admitted C(-) patients and the transmission coefficient for asymptomatic carriers. CONCLUSION Our study underscores the need to further evaluate the role of asymptomatically colonized patients in C. difficile transmission in healthcare settings.
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Affiliation(s)
- C Lanzas
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA.
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Dubberke ER, Butler AM, Nyazee HA, Reske KA, Yokoe DS, Mayer J, Mangino JE, Khan YM, Fraser VJ. The impact of ICD-9-CM code rank order on the estimated prevalence of Clostridium difficile infections. Clin Infect Dis 2011; 53:20-5. [PMID: 21653298 DOI: 10.1093/cid/cir246] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND US estimates of the Clostridium difficile infection (CDI) burden have utilized International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Whether ICD-9-CM code rank order affects CDI prevalence estimates is important because the National Hospital Discharge Survey (NHDS) and the Nationwide Inpatient Sample (NIS) have varying limits on the number of ICD-9-CM codes collected. METHODS ICD-9-CM codes for CDI (008.45), C. difficile toxin assay results, and dates of admission and discharge were collected from electronic hospital databases for adult patients admitted to 4 hospitals in the United States from July 2000 through June 2006. CDI prevalence per 1000 discharges was calculated and compared for NHDS and NIS limits and toxin assay results from the same hospitals. CDI prevalence estimates were compared using the χ(2) test, and the test of equality was used to compare slopes. RESULTS CDI prevalence measured by NIS criteria was significantly higher than that measured using NHDS criteria (10.7 cases per 1000 discharges versus 9.4 cases per 1000 discharges; P<.001) in the 4 hospitals. CDI prevalence measured by toxin assay results was 9.4 cases per 1000 discharges (P=.57 versus NHDS). However, the CDI prevalence increased more rapidly over time when measured according to the NHDS criteria than when measured according to toxin assay results (β=1.09 versus 0.84; P=.008). CONCLUSIONS Compared with the NHDS definition, the NIS definition captured 12% more CDI cases and reported significantly higher CDI rates. Rates calculated using toxin assay results were not different from rates calculated using NHDS criteria, but CDI prevalence appeared to increase more rapidly when measured by NHDS criteria than when measured by toxin assay results.
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Affiliation(s)
- Erik R Dubberke
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri 63110, USA.
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Haesebaert J, Bénet T, Vanhems P. Les épidémies d’infections nosocomiales : investigation et méthodes épidémiologiques. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.antib.2010.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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