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Eckardt P, Guran R, Jalal AT, Krishnaswamy S, Samuels S, Canavan K, Martinez EA, Desai A, Miller N, Cano Cevallos EJ. Impact of an electronic smart order-set for diagnostic stewardship of Clostridiodes difficile infection (CDI) in a community healthcare system in South Florida. Am J Infect Control 2024; 52:893-899. [PMID: 38935020 DOI: 10.1016/j.ajic.2024.04.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/12/2024] [Accepted: 04/13/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Inappropriate testing for Clostridiodes difficile infection (CDI) increases health care onset cases and contributes to overdiagnosis and overtreatment of patients in a community health care system. METHODS An electronic smart order set for the testing of CDI was created and implemented to improve the appropriateness of testing. A retrospective review of patients who were tested for CDI, pre and post, was conducted to determine if inappropriate stool testing for CDI decreased post-implementation of the order set. RESULTS 224 patients were tested for CDI during the study period with the post-implementation period having a higher proportion of patients who met appropriate testing criteria defined by presence of diarrhea (80.5% vs 61.3%; P = .002). The rate of inappropriate CDI stool testing decreased from 31.1% to 11.0% after implementation (P < .001). A higher proportion of CDI patients were readmitted within 30 days of discharge (54.2% vs 33.0%; P = 0.001) during the post-implementation period. CONCLUSIONS There was a significant reduction in inappropriate CDI testing following the implementation of the order set. There was an observed increase in the proportion of patients who underwent recent gastrointestinal surgery which may have contributed to the increase in 30-day readmission rates during the post-implementation period.
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Affiliation(s)
- Paula Eckardt
- Division of Infectious Disease, Medical Director of Antimicrobial Stewardship and Infection Control, Medical Director of MHS Ryan White Clinic, Memorial Healthcare System, Hollywood, FL
| | - Rachel Guran
- Director of Epidemiology and Infection Prevention, Memorial Healthcare System, Hollywood, FL.
| | - Ayesha T Jalal
- Graduate Medical Education, Memorial Healthcare System, Hollywood, FL
| | - Shiv Krishnaswamy
- Graduate Medical Education, Memorial Healthcare System, Hollywood, FL
| | - Shenae Samuels
- Office of Human Research, Memorial Healthcare System, Hollywood, FL
| | - Kelsi Canavan
- Office of Human Research, Memorial Healthcare System, Hollywood, FL
| | - Elsa A Martinez
- Graduate Medical Education, Memorial Healthcare System, Hollywood, FL
| | - Ajay Desai
- Florida Atlantic University, Boca Raton, FL
| | - Nancimae Miller
- Microbiology and Molecular Infectious Disease, Pathology Consultants of South Broward at Memorial Healthcare System, Hollywood, FL
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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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Vehreschild MJGT, Schreiber S, von Müller L, Epple HJ, Weinke T, Manthey C, Oh J, Wahler S, Stallmach A. Trends in the epidemiology of Clostridioides difficile infection in Germany. Infection 2023; 51:1695-1702. [PMID: 37162717 PMCID: PMC10170422 DOI: 10.1007/s15010-023-02044-5] [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: 04/16/2023] [Accepted: 04/25/2023] [Indexed: 05/11/2023]
Abstract
PURPOSES Despite reports of a declining incidence over the last decade, Clostridioides difficile infection (CDI) is still considered the most important healthcare-associated causes of diarrhea worldwide. In Germany, several measures have been taken to observe, report, and influence this development. This report aims to analyze the development of hospital coding for CDI in Germany over the last decade and to use it to estimate the public health burden caused by CDI. METHODS Reports from the Institute for Hospital Remuneration Systems, German Federal Statistical Office (DESTATIS), the Robert-Koch-Institute (RKI), Saxonian authorities and hospital quality reports during 2010-2021 were examined for CDI coding and assessed in a structured expert consultation. Analysis was performed using 2019 versions of Microsoft Excel® and Microsoft Access®. RESULTS Peaks of 32,203 cases with a primary diagnosis (PD) of CDI and 78,648 cases with a secondary diagnosis (SD) of CDI were observed in 2015. The number of cases had decreased to 15,412 PD cases (- 52.1%) and 40,188 SD cases (- 48.9%) by 2021. These results were paralleled by a similar decline in notifiable severe cases. However, average duration of hospitalization of the cases remained constant during this period. CONCLUSIONS Hospital coding of CDI and notification to authorities has approximately halved from 2015 to 2021. Potential influential factors include hospital hygiene campaigns, implementation of antibiotic stewardship programs, social distancing due to the COVID-19 pandemic, and a decrease in more pathogenic subtypes of bacteria. Further research is necessary to validate the multiple possible drivers for this development.
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Affiliation(s)
| | - Stefan Schreiber
- Department Medicine I, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Rosalind-Franklin-Str. 12, 24105 Kiel, Germany
| | - Lutz von Müller
- Christophorus-Kliniken GmbH, Südring 41, 48653 Coesfeld, Germany
| | - Hans-Jörg Epple
- Charité, Universitätsmedizin Berlin, Campus Benjamin Franklin, Antibiotic Stewardship, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Thomas Weinke
- Ernst Von Bergmann Klinikum gGmbH, Charlottenstraße 72, 14467 Potsdam, Germany
| | - Carolin Manthey
- Gemeinschaftspraxis Innere Medizin (GIM), Pferdebachstr. 29, 58455 Witten, Germany
| | - Jun Oh
- Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Steffen Wahler
- St. Bernward GmbH, Friedrich-Kirsten-Str. 40, 22391 Hamburg, Germany
| | - Andreas Stallmach
- Klinik Für Innere Medizin IV, Universitätsklinikum Jena, Am Klinikum 1, 07747 Jena, Germany
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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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Trirattanapikul A, Pasomsub E, Siriyotha S, Pattanaprateep O, Phuphuakrat A. Diagnostic stewardship to limit repeat plasma cytomegalovirus viral load testing. BMC Infect Dis 2023; 23:387. [PMID: 37296377 DOI: 10.1186/s12879-023-08355-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Frequent serial monitoring of plasma cytomegalovirus (CMV) viral load caused unnecessary budgets for laboratory testing without changes in treatment. We aimed to implement diagnostic stewardship to limit CMV viral load testing at appropriate intervals. METHODS A quasi-experimental study was performed. To avoid unnecessary plasma CMV viral load testing, the inpatient electronic pop-up reminder was launched in 2021. In cases with plasma CMV viral load testing was ordered in intervals of less than five days, telephone interview and feedback were performed. Pre-post intervention data was compared in terms of clinical and monetary outcomes. The rate of plasma CMV viral load testing performed in intervals of less than five days was compared between 2021 and 2019 using the Poisson regression model. RESULTS After the protocol implementation, there was a significant decrease in the rate of plasma CMV viral load test orders in intervals of less than five days from 17.5% to 8.0% [incidence rate ratio 0.40, p < 0.001]. There was no statistically significant difference in the incidence of CMV DNAemia and CMV disease (p = 0.407 and 0.602, respectively). As a result, the hospital could save the costs of plasma CMV viral load testing per 1,000 patients performed with intervals of less than five days from 2,646,048.11 to 1,360,062.89 Thai Baht. CONCLUSIONS The diagnostic stewardship program is safe and helpful in reducing unnecessary plasma CMV viral load testing and costs.
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Affiliation(s)
- Akeatit Trirattanapikul
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Ekawat Pasomsub
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sukanya Siriyotha
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Oraluck Pattanaprateep
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Angsana Phuphuakrat
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand.
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Successful diagnostic stewardship for Clostridioides difficile testing in pediatrics. Infect Control Hosp Epidemiol 2023; 44:186-190. [PMID: 35702900 DOI: 10.1017/ice.2022.117] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To reduce both inappropriate testing for and diagnosis of healthcare-onset (HO) Clostridioides difficile infections (CDIs). DESIGN We performed a retrospective analysis of C. difficile testing from hospitalized children before (October 2017-October 2018) and after (November 2018-October 2020) implementing restrictive computerized provider order entry (CPOE). SETTING Study sites included hospital A (a ∼250-bed freestanding children's hospital) and hospital B (a ∼100-bed children's hospital within a larger hospital) that are part of the same multicampus institution. METHODS In October 2018, we implemented CPOE. No testing was allowed for infants aged ≤12 months, approval of the infectious disease team was required to test children aged 13-23 months, and pathology residents' approval was required to test all patients aged ≥24 months with recent laxative, stool softener, or enema use. Interrupted time series analysis and Mann-Whitney U test were used for analysis. RESULTS An interrupted time series analysis revealed that from October 2017 to October 2020, the numbers of tests ordered and samples sent significantly decreased in all age groups (P < .05). The monthly median number of HO-CDI cases significantly decreased after implementation of the restrictive CPOE in children aged 13-23 months (P < .001) and all ages combined (P = .003). CONCLUSION Restrictive CPOE for CDI in pediatrics was successfully implemented and sustained. Diagnostic stewardship for CDI is likely cost-saving and could decrease misdiagnosis, unnecessary antibiotic therapy, and overestimation of HO-CDI rates.
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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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Antibiotic Stewardship and Inpatient Clostridioides difficile Testing in Solid Organ Transplant Recipients: The Need for Multilevel Checks and Balances. Transplant Proc 2022; 54:605-609. [DOI: 10.1016/j.transproceed.2021.10.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/29/2021] [Accepted: 10/11/2021] [Indexed: 12/14/2022]
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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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