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Sasaki Y, Yano M, Umehara A, Tagashira Y. Implementation of multifaceted diagnostic stewardship for Clostridioides difficile infection during the COVID-19 pandemic at a small Japanese hospital. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e96. [PMID: 38836045 PMCID: PMC11149025 DOI: 10.1017/ash.2024.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/19/2024] [Accepted: 04/23/2024] [Indexed: 06/06/2024]
Abstract
Objective Clostridioides difficile infection (CDI) is a common, healthcare-associated infection. However, in Japan, testing for CDI is infrequent, suggesting that its incidence may be underestimated. This study aimed to examine the implementation of a multifaceted, diagnostic stewardship (DS) for CDI in a small Japanese hospital during the coronavirus 2019 pandemic. Design Before-after study. Setting A small Japanese community hospital. Participants Healthcare workers including physicians, nurses, and pharmacists. Interventions A multifaceted intervention including (1) the addition of CD testing criteria to the hospital guidelines; (2) provision of a tutorial on CD testing to physicians, nurses, and pharmacists; (3) assessment by clinical pharmacists and nurses of the need for CD testing in patients with nosocomial diarrhea and issuance of recommendations for CD testing to physicians; (4) reporting of data on the CD testing rate and CDI incidence in the study center. Results The CD testing rate increased before the pandemic (+0.16/10,000 patient-days (PD); P = .28), decreased significantly during the pandemic (-0.79/10,000 PD; P = .02), and then increased significantly immediately after the implementation of the intervention (+29.6/10,000 PD; P < .01). Similarly, the CDI incidence increased significantly before the pandemic (+0.26/10,000 PD; P = .02) and decreased significantly during the pandemic (-0.49/10,000 PD; P = .01). Implementation of the intervention resulted in an immediate and significant increase in the CDI incidence (+6.2/10,000 PD; P < .01). Conclusion Multifaceted DS involving multidisciplinary specialists was effective in improving CD testing, suggesting that appropriate testing can contribute to diagnosing CDI accurately.
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Affiliation(s)
- Yasuhiro Sasaki
- Department of Infection Control, Tama-Nambu Chiiki Hospital, Tokyo, Japan
| | - Masataka Yano
- Department of Infection Control, Tama-Nambu Chiiki Hospital, Tokyo, Japan
| | - Ayumi Umehara
- Department of Infection Control, Tama-Nambu Chiiki Hospital, Tokyo, Japan
| | - Yasuaki Tagashira
- Department of Infection Control, Tama-Nambu Chiiki Hospital, Tokyo, Japan
- Department of Infectious Diseases, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
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2
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Shorten R, Pickering K, Goolden C, Harris C, Clegg A, J H. Diagnostic stewardship in infectious diseases: a scoping review. J Med Microbiol 2024; 73:001831. [PMID: 38722316 PMCID: PMC11165918 DOI: 10.1099/jmm.0.001831] [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: 11/22/2023] [Accepted: 04/11/2024] [Indexed: 06/13/2024] Open
Abstract
Introduction. The term 'diagnostic stewardship' is relatively new, with a recent surge in its use within the literature. Despite its increasing popularity, a precise definition remains elusive. Various attempts have been made to define it, with some viewing it as an integral part of antimicrobial stewardship. The World Health Organization offers a broad definition, emphasizing the importance of timely, accurate diagnostics. However, inconsistencies in the use of this term still persist, necessitating further clarification.Gap Statement. There are currently inconsistencies in the definition of diagnostic stewardship used within the academic literature.Aim. This scoping review aims to categorize the use of diagnostic stewardship approaches and define this approach by identifying common characteristics and factors of its use within the literature.Methodology. This scoping review undertook a multi-database search from date of inception until October 2022. Any observational or experimental study where the authors define the intervention to be diagnostic stewardship from any clinical area was included. Screening of all papers was undertaken by a single reviewer with 10% verification by a second reviewer. Data extraction was undertaken by a single reviewer using a pre-piloted form. Given the wide variation in study design and intervention outcomes, a narrative synthesis approach was applied. Studies were clustered around common diagnostic stewardship interventions where appropriate.Results. After duplicate removal, a total of 1310 citations were identified, of which, after full-paper screening, 105 studies were included in this scoping review. The classification of an intervention as taking a diagnostic stewardship approach is a relatively recent development, with the first publication in this field dating back to 2017. The majority of research in this area has been conducted within the USA, with very few studies undertaken outside this region. Visual inspection of the citation map reveals that the current evidence base is interconnected, with frequent references to each other's work. The interventions commonly adopt a restrictive approach, utilizing hard and soft stops within the pre-analytical phase to restrict access to testing. Upon closer examination of the outcomes, it becomes evident that there is a predominant focus on reducing the number of tests rather than enhancing the current test protocol. This is further reflected in the limited number of studies that report on test performance (including protocol improvements, specificity and sensitivity).Conclusion. Diagnostic stewardship seems to have deviated from its intended course, morphing into a rather rudimentary instrument wielded not to enhance but to constrict the scope of testing. Despite the World Health Organization's advocacy for an ideology that promotes a more comprehensive approach to quality improvement, it may be more appropriate to consider alternative regional narratives when categorizing these types of quality improvement interventions.
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Affiliation(s)
- Robert Shorten
- Department of Microbiology, Lancashire Teaching Hospitals NHS Foundation Trust, Foundation Trust, UK
- The University of Manchester, Manchester, UK
| | - Kate Pickering
- Department of Microbiology, Lancashire Teaching Hospitals NHS Foundation Trust, Foundation Trust, UK
| | - Callum Goolden
- Department of Microbiology, Lancashire Teaching Hospitals NHS Foundation Trust, Foundation Trust, UK
| | | | - Andrew Clegg
- University of Central Lancashire, Fylde Rd, Preston PR1 2HE, UK
| | - Hill J
- University of Central Lancashire, Fylde Rd, Preston PR1 2HE, UK
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3
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Singh HK, Claeys KC, Advani SD, Ballam YJ, Penney J, Schutte KM, Baliga C, Milstone AM, Hayden MK, Morgan DJ, Diekema DJ. Diagnostic stewardship to improve patient outcomes and healthcare-associated infection (HAI) metrics. Infect Control Hosp Epidemiol 2024; 45:405-411. [PMID: 38204365 PMCID: PMC11007360 DOI: 10.1017/ice.2023.284] [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: 11/06/2023] [Revised: 11/22/2023] [Accepted: 11/24/2023] [Indexed: 01/12/2024]
Abstract
Diagnostic stewardship seeks to improve ordering, collection, performance, and reporting of tests. Test results play an important role in reportable HAIs. The inclusion of HAIs in public reporting and pay for performance programs has highlighted the value of diagnostic stewardship as part of infection prevention initiatives. Inappropriate testing should be discouraged, and approaches that seek to alter testing solely to impact a reportable metric should be avoided. HAI definitions should be further adapted to new testing technologies, with focus on actionable and clinically relevant test results that will improve patient care.
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Affiliation(s)
- Harjot K. Singh
- Division of Infectious Diseases, Weill Cornell Medicine, New York City, New York
| | - Kimberly C. Claeys
- Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Sonali D. Advani
- Department of Medicine–Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Yolanda J. Ballam
- Infection Prevention and Control, Children’s Mercy Kansas City, Missouri
| | - Jessica Penney
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts
| | - Kirsten M. Schutte
- Medical Director, Infectious Disease, eviCore Healthcare, Bluffton, South Carolina
| | - Christopher Baliga
- Section of Infectious Diseases, Department of Medicine, Virginia Mason Hospital and Seattle Medical Center, Seattle, Washington
| | - Aaron M. Milstone
- Division of Pediatric Infectious Diseases, Johns Hopkins Medicine, Baltimore, Maryland
| | - Mary K. Hayden
- Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois
| | - Daniel J. Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
- Veterans’ Affairs Maryland Healthcare System, Baltimore, Maryland
| | - Daniel J. Diekema
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Division of Infectious Diseases, Department of Medicine, Maine Medical Center, Portland, Maine
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4
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Jhaveri TA, Weiss ZF, Winkler ML, Pyden AD, Basu SS, Pecora ND. A decade of clinical microbiology: top 10 advances in 10 years: what every infection preventionist and antimicrobial steward should know. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e8. [PMID: 38415089 PMCID: PMC10897726 DOI: 10.1017/ash.2024.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/22/2023] [Accepted: 12/28/2023] [Indexed: 02/29/2024]
Abstract
The past 10 years have brought paradigm-shifting changes to clinical microbiology. This paper explores the top 10 transformative innovations across the diagnostic spectrum, including not only state of the art technologies but also preanalytic and post-analytic advances. Clinical decision support tools have reshaped testing practices, curbing unnecessary tests. Innovations like broad-range polymerase chain reaction and metagenomic sequencing, whole genome sequencing, multiplex molecular panels, rapid phenotypic susceptibility testing, and matrix-assisted laser desorption ionization time-of-flight mass spectrometry have all expanded our diagnostic armamentarium. Rapid home-based testing has made diagnostic testing more accessible than ever. Enhancements to clinician-laboratory interfaces allow for automated stewardship interventions and education. Laboratory restructuring and consolidation efforts are reshaping the field of microbiology, presenting both opportunities and challenges for the future of clinical microbiology laboratories. Here, we review key innovations of the last decade.
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Affiliation(s)
- Tulip A. Jhaveri
- Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS, USA
| | - Zoe Freeman Weiss
- Division of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
- Division of Geographic Medicine & Infectious Disease, Tufts Medical Center, Boston, MA, USA
| | - Marisa L. Winkler
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Alexander D. Pyden
- Division of Pathology and Laboratory Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA
- Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA, USA
| | - Sankha S. Basu
- Division of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
| | - Nicole D. Pecora
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, USA
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5
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Hitchcock MM, Gomez CA, Pozdol J, Banaei N. Effective Approaches to Diagnostic Stewardship of Syndromic Molecular Panels. J Appl Lab Med 2024; 9:104-115. [PMID: 38167764 DOI: 10.1093/jalm/jfad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/08/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Syndromic molecular panels for the diagnosis of gastroenteritis, meningitis/encephalitis, and pneumonia are becoming routinely used for patient care throughout the world. CONTENT These rapid, sample-to-answer assays have great potential to improve patient care, infection control, and antimicrobial stewardship. However, diagnostic stewardship is essential for their optimal use and accuracy, and interventions can be applied at all phases of the diagnostic process. SUMMARY The aim of this review article is to describe effective approaches to diagnostic stewardship for syndromic molecular panels to ensure appropriate test utilization and quality assured results.
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Affiliation(s)
- Matthew M Hitchcock
- Department of Medicine, Division of Infectious Diseases, Central Virginia VA Health Care System, Richmond, VA, United States
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University School of Medicine, Richmond, VA, United States
| | - Carlos A Gomez
- Department of Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, United States
| | - Joseph Pozdol
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
- Clinical Microbiology Laboratory, Stanford University Medical Center, Palo Alto, CA, United States
| | - Niaz Banaei
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
- Clinical Microbiology Laboratory, Stanford University Medical Center, Palo Alto, CA, United States
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, United States
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6
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Campodónico VL, Hanlon A, Mikula MW, Miller JA, Gherna M, Carroll KC, Simner PJ. A diagnostic stewardship approach to prevent unnecessary testing of an enteric bacterial molecular panel. Microbiol Spectr 2023; 11:e0294523. [PMID: 37902336 PMCID: PMC10715171 DOI: 10.1128/spectrum.02945-23] [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: 07/28/2023] [Accepted: 10/03/2023] [Indexed: 10/31/2023] Open
Abstract
IMPORTANCE Testing for enteric bacterial pathogens in patients hospitalized for more than 3 days is almost always inappropriate. Our study validates the utility of the 3-day rule and the use of clinical decision support tools to decrease unnecessary testing of enteropathogenic bacteria other than C. difficile. Overriding the restriction was very low yield. Our study highlights the importance of diagnostic stewardship and further refines the criteria for allowing providers to override the restriction while monitoring the impact of the interventions.
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Affiliation(s)
- Victoria L. Campodónico
- Division of Medical Microbiology, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ann Hanlon
- Division of Medical Microbiology, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael W. Mikula
- Division of Medical Microbiology, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jo-Anne Miller
- Division of Medical Microbiology, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael Gherna
- Division of Medical Microbiology, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karen C. Carroll
- Division of Medical Microbiology, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Patricia J. Simner
- Division of Medical Microbiology, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Infectious Diseases, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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7
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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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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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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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10
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Role of diagnostic stewardship in reducing healthcare-facility–onset Clostridioides difficile infections. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2023; 3:e53. [PMID: 36970430 PMCID: PMC10031577 DOI: 10.1017/ash.2022.305] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 03/18/2023]
Abstract
Abstract
We describe the implementation of an electronic medical record “hard stop” to decrease inappropriate Clostridioides difficile testing across a 5-hospital health system, effectively reducing the rates of healthcare-facility–onset C. difficile infection. This novel approach included expert consultation with medical director of infection prevention and control for test-order override.
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11
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Krouss M, Israilov S, Alaiev D, Tsega S, Talledo J, Chandra K, Zaurova M, Manchego PA, Cho HJ. SEE the DIFFerence: Reducing unnecessary C. difficile orders through clinical decision support in a large, urban safety-net system. Am J Infect Control 2022:S0196-6553(22)00783-0. [PMID: 36370868 DOI: 10.1016/j.ajic.2022.11.003] [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] [Received: 08/29/2022] [Revised: 11/02/2022] [Accepted: 11/02/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Clostridioides difficile (C. difficile) is a hospital-acquired infection. Overtesting for C. difficile leads to false positive results due to a high rate of asymptomatic colonization, resulting in unnecessary and harmful treatment for patients. METHODS This was a quality improvement initiative to decrease the rate of inappropriate C. difficile testing across 11 hospitals in an urban, safety-net setting. Three best practice advisories were created, alerting providers of recent laxative administration within 48 hours, a recent positive test within 14 days, and a recent negative test within 7 days. The outcome measures were the number of C. difficile tests per 1,000 patient days, as well as the rate of hospital onset C. difficile infection was compared pre- and post-intervention. The process measures included the rate of removal of the C. difficile test from the best practice advisory, as well as the subsequent 24-hour re-order rate. RESULTS The number of C. difficile tests decreased by 27.3% from 1.1 per 1,000 patient days preintervention (May 25, 2020-May 24, 2021) to 0.8 per 1,000 patient days postintervention, (May 25, 2021-March 25, 2022), P < .001. When stratified by hospital, changes in testing ranged from an increase of 12.5% to a decrease of 60%. Analysis among provider type showed higher behavior change among attendings than compared to trainees or advanced practice providers. There was a 12.1%, nonsignificant decrease in C. difficile rates from preintervention, 0.33 per 1,000 patient days compared to postintervention, 0.29 per 1,000 patient days, P=.32. CONCLUSIONS Using only an electronic health record intervention, we successfully decreased C. difficile orders after 72 hours of admission in a large, safety-net system. Variation existed among hospitals and by provider type.
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Affiliation(s)
- Mona Krouss
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Sigal Israilov
- Department of Anesthesia, Icahn School of Medicine, New York, NY
| | - Daniel Alaiev
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY
| | - Surafel Tsega
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY; Department of Medicine, NYC Health + Hospitals/Kings County, New York, NY
| | - Joseph Talledo
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY
| | - Komal Chandra
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY
| | - Milana Zaurova
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter Alacron Manchego
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY; Department of Pediatrics, NYC Health + Hospitals/Kings County, New York, NY
| | - Hyung J Cho
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY; Department of Medicine, NYU School of Medicine, New York, NY
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12
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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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13
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Rock C, Abosi O, Bleasdale S, Colligan E, Diekema DJ, Dullabh P, Gurses AP, Heaney-Huls K, Jacob JT, Kandiah S, Lama S, Leekha S, Mayer J, Mena Lora AJ, Morgan DJ, Osei P, Pau S, Salinas JL, Spivak E, Wenzler E, Cosgrove SE. Clinical Decision Support Systems to Reduce Unnecessary Clostridoides difficile Testing Across Multiple Hospitals. Clin Infect Dis 2022; 75:1187-1193. [PMID: 35100620 DOI: 10.1093/cid/ciac074] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Inappropriate C. difficile testing has adverse consequences for the patient, hospital, and public health. Computerized Clinical Decision Supports (CCDS) in the Electronic Health Record (EHR) may reduce C. difficile test ordering; however, effectiveness of different approaches, ease of use, and best fit into the healthcare providers' (HCP) workflow, are not well understood. METHODS Nine academic and 6 community U.S. hospitals participated in this 2-year cohort study. CCDS (hard- or soft-stop) triggered when duplicate C. difficile test order attempted, or if laxatives were recently received. The primary outcome was the difference in testing rates pre- and post-CCDS interventions, using incident rate ratios (IRR) and mixed effect Poisson regression models. We performed qualitative evaluation (contextual inquiry, interviews, focus groups) based on a human factors model. We identified themes using a codebook with primary- and sub-nodes. RESULTS In 9 hospitals implementing hard-stop CCDS and 4 hospitals implementing soft-stop CCDS, C. difficile testing IRR reduction was 33% (95% CI, 30-36%), and 23% (95% CI 21-25%), respectively. Two hospitals implemented a non-EMR based human intervention with IRR reduction of 21% (95% CI 15-28%). HCPs reported generally favorable experiences, and highlighted time efficiencies such as inclusion of the patients most recent laxative administration on the CCDS. Organizational factors including hierarchical cultures, and communication between HCPs caring for the same patient, impact CCDS acceptance and integration. CONCLUSIONS CCDS reduced unnecessary C. difficile testing and were perceived positively by HCPs when integrated into their workflow, and when displayed relevant patient specific information needed for decision-making.
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Affiliation(s)
- Clare Rock
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Oluchi Abosi
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
| | - Susan Bleasdale
- University of Illinois College of Medicine at Chicago, Chicago, United States
| | - Erin Colligan
- NORC at the University of Chicago, Chicago IL 60603, United States
| | - Daniel J Diekema
- University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Prashila Dullabh
- NORC at the University of Chicago, Chicago IL 60603, United States
| | - Ayse P Gurses
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | | | - Jesse T Jacob
- Emory University School of Medicine, Atlanta, Georgia, United States
| | - Sheetal Kandiah
- Emory University School of Medicine, Atlanta, Georgia, United States
| | - Sonam Lama
- NORC at the University of Chicago, Chicago IL 60603, United States
| | - Surbhi Leekha
- University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Jeanmarie Mayer
- University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Alfredo J Mena Lora
- University of Illinois College of Medicine at Chicago, Chicago, United States
| | - Daniel J Morgan
- University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Patience Osei
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Sara Pau
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Jorge L Salinas
- University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Emily Spivak
- University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Eric Wenzler
- University of Illinois College of Pharmacy at Chicago, Chicago, United States
| | - Sara E Cosgrove
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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14
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Sullivan KV. Diagnostic Stewardship in Clinical Microbiology, Essential Partner to Antimicrobial Stewardship. Clin Chem 2021; 68:75-82. [DOI: 10.1093/clinchem/hvab206] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/02/2021] [Indexed: 12/26/2022]
Abstract
Abstract
Background
Diagnostic stewardship is an important partner to antimicrobial stewardship.
Content
Diagnostic stewardship focuses on ensuring correct diagnosis of infectious diseases while antimicrobial stewardship aims to optimize antimicrobial treatment. Both aim to improve patient outcomes. Diagnostic stewardship involves interventions that reduce testing in patients with low pretest probability, optimize a test’s likelihood ratio, and seek to warn providers when suboptimal test results might have been reported.
Conclusion
Diagnostic stewardship interventions have been described primarily in the areas of urinary tract infection, Clostridioides difficile infection, and bloodstream infection diagnosis. However, emerging areas include pneumonia and wound infections in addition to optimization of multiplexed panel-based testing.
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Affiliation(s)
- Kaede V Sullivan
- Department of Pathology & Laboratory Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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15
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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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16
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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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17
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Use of diagnostic and antimicrobial stewardship practices to improve Clostridioides difficile testing among SHEA Research Network hospitals. Infect Control Hosp Epidemiol 2021; 43:930-934. [PMID: 34376271 DOI: 10.1017/ice.2021.133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We surveyed acute-care hospitals on strategies to reduce inappropriate C. difficile testing and treatment of colonized patients. Decision support during C. difficile test ordering was common, but "hard stops" to prevent placement of inappropriate orders and active intervention of antimicrobial stewardship programs on positive C. difficile test reports were infrequent.
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18
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Curren EJ, Lutgring JD, Kabbani S, Diekema DJ, Gitterman S, Lautenbach E, Morgan DJ, Rock C, Salerno RM, McDonald LC. Advancing Diagnostic Stewardship for Healthcare Associated Infections, Antibiotic Resistance, and Sepsis. Clin Infect Dis 2021; 74:723-728. [PMID: 34346494 DOI: 10.1093/cid/ciab672] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Indexed: 01/14/2023] Open
Abstract
Diagnostic stewardship means ordering the right tests, for the right patient at the right time to inform optimal clinical care. Diagnostic stewardship is an integral part of antibiotic stewardship efforts to optimize antibiotic use and improve patient outcomes, including reductions in antibiotic resistance, and treatment of sepsis. CDC's Division of Healthcare Quality Promotion (DHQP) hosted a meeting on improving patient safety through diagnostic stewardship with a focus on the use of the laboratory. The meeting identified emerging issues in the field of diagnostic stewardship, raised awareness of these issues among stakeholders, and discussed strategies and interventions to address the issues-all with an emphasis on improved outcomes and patient safety. This white paper summarizes the key takeaways of the meeting including needs for diagnostic stewardship implementation, promising future avenues for diagnostic stewardship implementation, and areas of needed research.
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Affiliation(s)
- Emily J Curren
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Joseph D Lutgring
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Daniel J Diekema
- Division of Infectious Diseases, Department of Medicine and Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Steven Gitterman
- Veterans Affairs Medical Center, Washington, D.C.,The George Washington University, Washington, D.C
| | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Clare Rock
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Reynolds M Salerno
- Division of Laboratory Systems, Centers for Disease Control and Prevention, Atlanta, GA
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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19
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In pursuit of the holy grail: Improving C. difficile testing appropriateness with iterative electronic health record clinical decision support and targeted test restriction. Infect Control Hosp Epidemiol 2021; 43:840-847. [PMID: 34085622 DOI: 10.1017/ice.2021.228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the impact of electronic health record (EHR)-based interventions and test restriction on Clostridioides difficile tests (CDTs) and hospital-onset C. difficile infection (HO-CDI). DESIGN Quasi-experimental study in 3 hospitals. SETTING 957-bed academic (hospital A), 354-bed (hospital B), and 175-bed (hospital C) academic-affiliated community hospitals. INTERVENTIONS Three EHR-based interventions were sequentially implemented: (1) alert when ordering a CDT if laxatives administered within 24 hours (January 2018); (2) cancellation of CDT orders after 24 hours (October 2018); (3) contextual rule-driven order questions requiring justification when laxative administered or lack of EHR documentation of diarrhea (July 2019). In February 2019, hospital C implemented a gatekeeper intervention requiring approval for all CDTs after hospital day 3. The impact of the interventions on C. difficile testing and HO-CDI rates was estimated using an interrupted time-series analysis. RESULTS C. difficile testing was already declining in the preintervention period (annual change in incidence rate [IR], 0.79; 95% CI, 0.72-0.87) and did not decrease further with the EHR interventions. The laxative alert was temporally associated with a trend reduction in HO-CDI (annual change in IR from baseline, 0.85; 95% CI, 0.75-0.96) at hospitals A and B. The gatekeeper intervention at hospital C was associated with level (IRR, 0.50; 95% CI, 0.42-0.60) and trend reductions in C. difficile testing (annual change in IR, 0.91; 95% CI, 0.85-0.98) and level (IRR 0.42; 95% CI, 0.22-0.81) and trend reductions in HO-CDI (annual change in IR, 0.68; 95% CI, 0.50-0.92) relative to the baseline period. CONCLUSIONS Test restriction was more effective than EHR-based clinical decision support to reduce C. difficile testing in our 3-hospital system.
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20
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Jenkins TC, Tamma PD. Thinking Beyond the "Core" Antibiotic Stewardship Interventions: Shifting the Onus for Appropriate Antibiotic Use from Stewardship Teams to Prescribing Clinicians. Clin Infect Dis 2021; 72:1457-1462. [PMID: 32667974 DOI: 10.1093/cid/ciaa1003] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/10/2020] [Indexed: 01/31/2023] Open
Abstract
United States guidance for hospital antibiotic stewardship has emphasized prospective audit and feedback and prior authorization of select antibiotics as core interventions. These remain the most common interventions implemented by stewardship programs. Although these approaches have been shown to reduce unnecessary antibiotic use, they incorrectly put the onus for appropriate antibiotic use on the stewardship team rather than the prescribing clinician. We propose that a primary focus of stewardship programs should be implementation of broader interventions that engage frontline clinicians and equip them with tools to integrate antibiotic stewardship into their own daily practice, thus reducing the need for day-to-day stewardship team oversite. We discuss a framework of broader interventions and policies that will facilitate this paradigm shift.
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Affiliation(s)
- Timothy C Jenkins
- Department of Medicine and Division of Infectious Diseases, Denver Health, Denver, Colorado, USA.,Department of Patient Safety and Quality, Denver Health, Denver, Colorado, USA.,Department of Medicine and Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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21
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Dunn AN, Radakovich N, Ancker JS, Donskey CJ, Deshpande A. The Impact of Clinical Decision Support Alerts on Clostridioides difficile Testing: A Systematic Review. Clin Infect Dis 2021; 72:987-994. [PMID: 32060501 DOI: 10.1093/cid/ciaa152] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/12/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Several studies have investigated the utility of electronic decision support alerts in diagnostic stewardship for Clostridioides difficile infection (CDI). However, it is unclear if alerts are effective in reducing inappropriate CDI testing and/or CDI rates. The aim of this systematic review was to determine if alerts related to CDI diagnostic stewardship are effective at reducing inappropriate CDI testing volume and CDI rates among hospitalized adult patients. METHODS We searched Ovid Medline and 5 other databases for original studies evaluating the association between alerts for CDI diagnosis and CDI testing volume and/or CDI rate. Two investigators independently extracted data on study characteristics, study design, alert triggers, cointerventions, and study outcomes. RESULTS Eleven studies met criteria for inclusion. Studies varied significantly in alert triggers and in study outcomes. Six of 11 studies demonstrated a statistically significant decrease in CDI testing volume, 6 of 6 studies evaluating appropriateness of CDI testing found a significant reduction in the proportion of inappropriate testing, and 4 of 7 studies measuring CDI rate demonstrated a significant decrease in the CDI rate in the postintervention vs preintervention period. The magnitude of the increase in appropriate CDI testing varied, with some studies reporting an increase with minimal clinical significance. CONCLUSIONS The use of electronic alerts for diagnostic stewardship for C. difficile was associated with reductions in CDI testing, the proportion of inappropriate CDI testing, and rates of CDI in most studies. However, broader concerns related to alerts remain understudied, including unintended adverse consequences and alert fatigue.
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Affiliation(s)
- Aaron N Dunn
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Nathan Radakovich
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Jessica S Ancker
- Division of Health Informatics, Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Curtis J Donskey
- Geriatric Research, Education, and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Abhishek Deshpande
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA.,Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio, USA
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22
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Rock C, Maragakis LL. Diagnostic Stewardship for Clostridiodes difficile Testing: From Laxatives to Diarrhea and Beyond. Clin Infect Dis 2021; 71:1479-1480. [PMID: 31584627 DOI: 10.1093/cid/ciz982] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 10/01/2019] [Indexed: 12/27/2022] Open
Affiliation(s)
- Clare Rock
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lisa L Maragakis
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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23
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Mizusawa M, Carroll KC. Advances and required improvements in methods to diagnosing Clostridioides difficile infections in the healthcare setting. Expert Rev Mol Diagn 2021; 21:311-321. [PMID: 33682564 DOI: 10.1080/14737159.2021.1900737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Clostrididioides difficile is associated with adverse clinical outcomes and increased morbidity, mortality, length of hospital stay, and health-care costs.Areas Covered: We searched relevant papers in PubMed for the last 10 years. In major papers, we scanned the bibliographies to ensure that important articles were included. This review addresses the evolving epidemiology of Clostridioides difficile infection (CDI) and discusses novel methods/approaches for improving the diagnosis of this important disease. EXPERT OPINION No single diagnostic test to date has demonstrated optimum sensitivity and specificity for detection of CDI. Many institutions have developed multi-step algorithms consistent with guidelines established by various professional societies. Some institutions have successfully tried to improve the pretest probability of molecular assays by implementing appropriate sample rejection criteria and establishing best practice alerts at the time of electronic order entry. Others have established PCR cycle threshold cutoffs to attempt to differentiate symptomatic patients from asymptomatic carriers or to make predictions about severity of disease with variable success. As research advances our understanding of C. difficile pathogenesis and pathophysiology, more information on CDI specific biomarkers is emerging. Finally, assessments of the microbiome and metabolome may expand the diagnostic armamentarium with advances in mass spectrometry and sequencing technologies.
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Affiliation(s)
- Masako Mizusawa
- Section of Infectious Diseases, Department of Internal Medicine, University of Missouri, Kansas City, Missouri, Kansas City, MO, USA
| | - Karen C Carroll
- Director Division of Medical Microbiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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24
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Wang EW, Weekley A, McCarty J, Koo H, Lembcke B, Al Mohajer M. Impact of a division-wide bundle on hospital-acquired Clostridioides difficile cases, antibiotic days of therapy, testing appropriateness, and associated financial costs. Avicenna J Med 2021; 11:27-32. [PMID: 33520786 PMCID: PMC7839267 DOI: 10.4103/ajm.ajm_193_19] [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] [Indexed: 11/08/2022] Open
Abstract
Introduction: Updated international guidelines recommend the use of a two-step algorithm (glutamate dehydrogenase [GDH] or nucleic-acid amplification test [NAAT] plus toxin) rather than NAAT alone for the diagnosis of Clostridioides difficile (formerly Clostridium difficile) infections. The goal of our project was to evaluate the impact of a new bundle on the rate of hospital-acquired C. difficile infections (CDIs), hospital-acquired CDI standardized infection ratio (SIR), antibiotic days of therapy (DOT), and financial cost. Materials and Methods: The new bundle was implemented in April 2018. This bundle was implemented across five hospitals in Catholic Health Initiatives (CHI) Texas Division. The bundle included a switch from NAAT to a two-step process (GDH and toxin). We placed the new test in an order panel which included enteric isolation and required indications for C. difficile testing. We used quarterly data pre- and post-intervention to calculate SIR and DOT. Results: In the pre-intervention period, 15.5% of the total 3513 C. difficile NAAT was positive. In the post-intervention period, 5.7% of a total of 2845 GDH and toxin assays was positive for both GDH and toxin (P < 0.0001). SIR, which adjusts for denominator and change in testing methodology, also dropped from 1.02 to 0.43. The estimated cost associated with positive C. difficile cases dropped from 1,932,150 USD to 1,113,800 USD with an estimated yearly cost saving of 794,150 USD. Compliance with enteric isolation improved from 73.1% to 92.5% (P = 0.008). Conclusion: The new testing bundle led to a marked reduction in hospital-acquired CDI and unnecessary treatment, reduction in C. difficile testing, an increase in compliance with enteric isolation, and significant cost savings.
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Affiliation(s)
- Elizabeth Wenqian Wang
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Ashlee Weekley
- Department of Infection Prevention & Control, CHI Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Jennifer McCarty
- Department of Infection Prevention & Control, CHI Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Hoonmo Koo
- Department of Infection Prevention & Control, CHI Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Bradley Lembcke
- Department of Infection Prevention & Control, CHI Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Mayar Al Mohajer
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA.,Department of Infection Prevention & Control, CHI Baylor St. Luke's Medical Center, Houston, Texas, USA
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25
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Interventions to optimize antimicrobial stewardship. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e46. [PMID: 36168471 PMCID: PMC9495515 DOI: 10.1017/ash.2021.210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/27/2021] [Indexed: 12/14/2022]
Abstract
Abstract
Developing and improving an antimicrobial stewardship program successfully requires evaluation of numerous factors. As technology progresses and our understanding of antimicrobial resistance grows, careful consideration should be taken to ensure that a program meets the needs of the institution and is achievable given the available resources. In this review, we explore fundamental initiatives and strategies for both new and established antimicrobial stewardship programs, including the specific areas to target and key elements required for sustainable implementation.
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26
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Impact of a Clostridioides Difficile Testing Computerized Clinical Decision Support Tool on an Adult Stem Cell Transplantation and Hematologic Malignancies Unit. Transplant Cell Ther 2020; 27:94.e1-94.e5. [PMID: 33045386 DOI: 10.1016/j.bbmt.2020.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/03/2020] [Accepted: 10/04/2020] [Indexed: 12/19/2022]
Abstract
Clostridioides difficile infection rates are higher in hospitalized hematopoietic stem cell transplantation (HSCT) recipients and patients with hematologic malignancy (HM) compared with the general population. This is related both to extensive exposure to antibiotics as well as to frequent and often prolonged hospitalization. In this population, with numerous potential causes of diarrhea, a subset of C difficile detected is presumed to represent colonization rather than clinical infection. The use of decision support tools to guide ordering in hospitalized patients has been reported to decrease both C difficile testing and detection rates. Following implementation of a computerized decision support tool on our HSCT/HM unit, we observed a >2-fold decrease in C difficile testing volume and National Healthcare Safety Network-defined laboratory identifications of C difficile. Furthermore, the rate of oral vancomycin use, as well as the incidence of vancomycin-resistant enterococci colonization and bloodstream infection, decreased in the postintervention period.
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27
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Liu C, Lan K, Krantz EM, Kim HN, Zier J, Bryson-Cahn C, Chan JD, Jain R, Lynch JB, Pergam SA, Pottinger PS, Sweet A, Whimbey E, Bryan A. Improving Appropriate Diagnosis of Clostridioides difficile Infection Through an Enteric Pathogen Order Set With Computerized Clinical Decision Support: An Interrupted Time Series Analysis. Open Forum Infect Dis 2020; 7:ofaa366. [PMID: 33094113 PMCID: PMC7566360 DOI: 10.1093/ofid/ofaa366] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/13/2020] [Indexed: 12/16/2022] Open
Abstract
Background Inappropriate testing for Clostridioides difficile leads to overdiagnosis of C difficile infection (CDI). We determined the effect of a computerized clinical decision support (CCDS) order set on C difficile polymerase chain reaction (PCR) test utilization and clinical outcomes. Methods This study is an interrupted time series analysis comparing C difficile PCR test utilization, hospital-onset CDI (HO-CDI) rates, and clinical outcomes before and after implementation of a CCDS order set at 2 academic medical centers: University of Washington Medical Center (UWMC) and Harborview Medical Center (HMC). Results Compared with the 20-month preintervention period, during the 12-month postimplementation of the CCDS order set, there was an immediate and sustained reduction in C difficile PCR test utilization rates at both hospitals (HMC, -28.2% [95% confidence interval {CI}, -43.0% to -9.4%], P = .005; UWMC, -27.4%, [95% CI, -37.5% to -15.6%], P < .001). There was a significant reduction in rates of C difficile tests ordered in the setting of laxatives (HMC, -60.8% [95% CI, -74.3% to -40.1%], P < .001; UWMC, -37.3%, [95% CI, -58.2% to -5.9%], P = .02). The intervention was associated with an increase in the C difficile test positivity rate at HMC (P = .01). There were no significant differences in HO-CDI rates or in the proportion of patients with HO-CDI who developed severe CDI or CDI-associated complications including intensive care unit transfer, extended length of stay, 30-day mortality, and toxic megacolon. Conclusions Computerized clinical decision support tools can improve C difficile diagnostic test stewardship without causing harm. Additional studies are needed to identify key elements of CCDS tools to further optimize C difficile testing and assess their effect on adverse clinical outcomes.
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Affiliation(s)
- Catherine Liu
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Kristine Lan
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Elizabeth M Krantz
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - H Nina Kim
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jacqlynn Zier
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Chloe Bryson-Cahn
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jeannie D Chan
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Rupali Jain
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - John B Lynch
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Steven A Pergam
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Paul S Pottinger
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ania Sweet
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Estella Whimbey
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Andrew Bryan
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
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Kang M, Abeles SR, El-Kareh R, Taplitz RA, Nyheim E, Reed SL, Jenkins IH, Seymann GB, Myers FE, Torriani FJ. The Effect of Clostridioides difficile Diagnostic Stewardship Interventions on the Diagnosis of Hospital-Onset Clostridioides difficile Infections. Jt Comm J Qual Patient Saf 2020; 46:457-463. [PMID: 32576438 DOI: 10.1016/j.jcjq.2020.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/22/2020] [Accepted: 05/13/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Public reporting of Clostridioides difficile infection (CDI) using laboratory-identified events has led some institutions to revert from molecular-based tests to less sensitive testing modalities. At one academic medical center, researchers chose to use nucleic acid amplification test alone in CDI diagnosis with institutional protocols aimed at diagnostic stewardship. METHODS A single-center, quasi-experimental study was conducted to introduce and analyze the effects of various diagnostic stewardship interventions. In April 2017 an order report was created to inform providers of patients' recent bowel movements, laxative use, and prior Clostridioides difficile (CD) testing (Intervention 1). In November 2017 nursing staff were empowered to not send nondiarrheal stools for testing (Intervention 2). In February 2019, an interruptive alert was implemented to prevent testing that was not indicated (Intervention 3). CD testing rates and healthcare facility-onset CDI (HO-CDI) rates were compared before and after the interventions using one-way analysis of variance (ANOVA). RESULTS At baseline, testing for CD after 3 days of admission was performed at mean ± standard deviation of 15.9 ± 1.7 tests/1,000 patient-days. After Intervention 1, it decreased to 12.1 ± 1.1 tests. This further decreased to 10.6 ± 0.8 after Intervention 2 and to 8.1 ± 0.1 after Intervention 3 (p < 0.001). HO-CDI cases per 10,000 patient-days declined from 12.7 ± 1.4 cases at baseline to 10.7 ± 1.2 after Intervention 1, to 8.7 ± 2.4 after Intervention 2, and to 5.8 ± 0.2 after Intervention 3 (p = 0.03). CONCLUSION A multidisciplinary approach optimizing electronic health record support tools and leveraging nursing education can reduce both testing and HO-CDI rates while using the most sensitive testing modality.
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Modest Clostridiodes difficile infection prediction using machine learning models in a tertiary care hospital. Diagn Microbiol Infect Dis 2020; 98:115104. [PMID: 32650284 DOI: 10.1016/j.diagmicrobio.2020.115104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 12/18/2022]
Abstract
Previous studies have shown promising results of machine learning (ML) models for predicting health outcomes. We develop and test ML models for predicting Clostridioides difficile infection (CDI) in hospitalized patients. This is a retrospective cohort study conducted during 2015-2017. All inpatients tested for C. difficile were included. CDI was defined as having a positive glutamate dehydrogenase and toxin results. We restricted analyses to the first record of C. difficile testing per patient. Of 3514 patients tested, 136 (4%) had CDI. Age and antibiotic use within 90 days before C. difficile testing were associated with CDI (P < 0.01). We tested 10 ML methods with and without resampling. Logistic regression, random forest and naïve Bayes models yielded the highest AUC ROC performance: 0.6. Predicting CDI was difficult in our cohort of patients tested for CDI. Multiple ML models yielded only modest results in a real-world population of hospitalized patients tested for CDI.
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Incorporating preauthorization into antimicrobial stewardship pharmacist workflow reduces Clostridioides difficile and gastrointestinal panel testing. Infect Control Hosp Epidemiol 2020; 41:1136-1141. [PMID: 32489156 DOI: 10.1017/ice.2020.236] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate whether incorporating mandatory prior authorization for Clostridioides difficile testing into antimicrobial stewardship pharmacist workflow could reduce testing in patients with alternative etiologies for diarrhea. DESIGN Single center, quasi-experimental before-and-after study. SETTING Tertiary-care, academic medical center in Ann Arbor, Michigan. PATIENTS Adult and pediatric patients admitted between September 11, 2019 and December 10, 2019 were included if they had an order placed for 1 of the following: (1) C. difficile enzyme immunoassay (EIA) in patients hospitalized >72 hours and received laxatives, oral contrast, or initiated tube feeds within the prior 48 hours, (2) repeat molecular multiplex gastrointestinal pathogen panel (GIPAN) testing, or (3) GIPAN testing in patients hospitalized >72 hours. INTERVENTION A best-practice alert prompting prior authorization by the antimicrobial stewardship program (ASP) for EIA or GIPAN testing was implemented. Approval required the provider to page the ASP pharmacist and discuss rationale for testing. The provider could not proceed with the order if ASP approval was not obtained. RESULTS An average of 2.5 requests per day were received over the 3-month intervention period. The weekly rate of EIA and GIPAN orders per 1,000 patient days decreased significantly from 6.05 ± 0.94 to 4.87 ± 0.78 (IRR, 0.72; 95% CI, 0.56-0.93; P = .010) and from 1.72 ± 0.37 to 0.89 ± 0.29 (IRR, 0.53; 95% CI, 0.37-0.77; P = .001), respectively. CONCLUSIONS We identified an efficient, effective C. difficile and GIPAN diagnostic stewardship approval model.
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Emberger J, Hitchcock MM, Markley JD. Diagnostic Stewardship Approaches to Clostridioides difficile Infection in the Era of Two-Step Testing: a Shifting Landscape. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020. [DOI: 10.1007/s40506-020-00223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Adenaw N, Wen J, Pahwa AK, Sheth S, Johnson PT. Decreasing Duplicative Imaging: Inpatient and Emergency Medicine Abdominal Ultrasound Within 72 Hours of Abdominal CT. J Am Coll Radiol 2020; 17:590-596. [PMID: 32247697 DOI: 10.1016/j.jacr.2020.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 03/10/2020] [Accepted: 03/13/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this project was to reduce abdominal ultrasound examinations in patients who had undergone abdominal CT within 72 hours previously. METHODS A best practice advisory (BPA) was created in the electronic medical record to advise against the use of abdominal ultrasound in adult inpatients and emergency department patients who had undergone abdominal CT within the preceding 72 hours. Acceptable acknowledgment reasons to proceed with the order were made available if providers chose to override. Frequency of BPA firing and subsequent ordering behavior were evaluated 6 months after integration of the BPA into the electronic medical record. Chart review was conducted for 100 patients whose orders were placed through an override of the alert to determine if the ultrasound study added value and for all patients whose ultrasound studies were canceled to confirm that patient care was not compromised by omitting the ultrasound study. RESULTS In the first 6 months, a total of 614 inpatient and emergency department abdominal ultrasound orders triggered the BPA. A total of 16% of orders (n = 96) were canceled by the provider after the BPA, reflecting 518 overrides. The majority of retained orders were to evaluate the gallbladder (44% [227 of 518]). Chart review confirmed utility for gallbladder imaging and that the canceled ultrasound examinations would not have contributed value to patients' care. CONCLUSIONS A recently performed abdominal CT scan may obviate the need for inpatient and emergency department abdominal ultrasound, particularly in the setting of hospital-acquired acute kidney injury. A BPA resulted in only 16% of orders' being canceled, whereas chart review revealed a much larger opportunity to avoid duplicative imaging.
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Affiliation(s)
- Nebiyu Adenaw
- The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica Wen
- The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amit K Pahwa
- The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sheila Sheth
- The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pamela T Johnson
- The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Madden GR, Enfield KB, Sifri CD. Patient Outcomes With Prevented vs Negative Clostridioides difficile Tests Using a Computerized Clinical Decision Support Tool. Open Forum Infect Dis 2020; 7:ofaa094. [PMID: 32328506 PMCID: PMC7166115 DOI: 10.1093/ofid/ofaa094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/16/2020] [Indexed: 02/07/2023] Open
Abstract
Background Overtesting and overdiagnosis of Clostridioides difficile infection are suspected to be common. Reducing inappropriate testing through interventions designed to promote evidence-based diagnostic testing (ie, diagnostic stewardship) may improve C. difficile test utilization. However, the safety of these interventions is not well understood despite the potential risk for missed or delayed diagnoses. Methods This retrospective case-control study examined the outcomes of patients admitted to the University of Virginia Medical Center following introduction of a computerized clinical decision support tool without hard-stops designed to reduce inappropriate tests. Outcomes were compared between patients with a prevented C. difficile nucleic acid amplification test and those with a negative result. Chart reviews were performed for patients with a subsequent positive within 7 days, as well as those patients who received C. difficile-active antibiotics after implementation of the computerized clinical decision support tool. Results Multivariate analysis of 637 cases (490 negative, 147 prevented) showed that a prevented test was not significantly associated with the primary composite outcome (inpatient mortality or intensive care unit transfer) compared with a negative test (adjusted odds ratio, 0.912; P = .747). Fifty-four of 147 (37%) prevented tests were followed by a completed test within 7 days; 11 of these results were positive, resulting in a potential delay in diagnosis. Individual case reviews found that either clinical changes warranted the delay in testing or no adverse events occurred attributable to C. difficile infection. C. difficile treatment without a positive test was not identified. Conclusions Diagnostic stewardship of C. difficile testing using computerized clinical decision support may be both safe and effective for reducing inappropriate inpatient testing.
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Affiliation(s)
- Gregory R Madden
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Kyle B Enfield
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Costi D Sifri
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA.,Office of Hospital Epidemiology/Infection Prevention & Control, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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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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