scholarly journals Successful Diagnostic Stewardship for Clostridioides difficile Testing in Pediatrics

2020 ◽  
Vol 41 (S1) ◽  
pp. s394-s394
Author(s):  
Katia Halabi ◽  
Lisa Saiman ◽  
Philip Zachariah ◽  
Karen Acker ◽  
Jean-Marie Cannon ◽  
...  
Keyword(s):  
Healthcare Facility ◽  
Nucleic Acid Amplification ◽  
Clinical Microbiology Laboratory ◽  
Free Standing ◽  
Children's Hospital ◽  
Clostridioides Difficile ◽  
Young Infants ◽  
Before And After ◽  
Children’S Hospital ◽  
Testing Algorithm

Background: As many as 40% of infants aged ≤12 months and 10%–28% of children aged 13–24 months are colonized by Clostridioides difficile. The IDSA and the SHEA recommend that testing should never be routinely recommended for infants ≤12 months of age and should not be routinely performed for children 1–2 years of age unless other causes are excluded. We report implementation of C. difficile diagnostic stewardship at 2 children’s hospitals. Methods: We implemented age-based restrictions for C. difficile testing at hospital A (∼200-bed, free-standing, children’s hospital) and hospital B (∼100-bed children’s hospital within a larger hospital). Both sites are part of the same multicampus institution, and both used nucleic acid amplification testing to detect C. difficile throughout the study. In May 2018, we implemented an electronic order set for C. difficile that provided alerts to avoid testing young infants and patients with recent use of laxatives, stool softeners, or enemas, but providers could order C. difficile testing at their discretion. In October 2018, we implemented a more restrictive diagnostic stewardship algorithm for C. difficile. No testing was allowed for infants aged ≤12 months. Approval pediatric infectious diseases staff was required to test children aged 13–24 months. Pathology resident approval was required to test children aged ≥24 months who had received laxatives, stool softeners, or enemas within ≤24 hours. Clinical microbiology laboratory supervisors reinforced rejection of nondiarrheal stool specimens for testing. Providers at both campuses were informed about the new testing guidelines by e-mail. We compared the number of tests sent and positive cases of healthcare facility-onset C. difficile (HO-CDI) by age strata before and after the implementation of the restrictive testing algorithm. Results: After the intervention, the number of tests in infants significantly declined; 2 infants aged ≤12 months and 4 infants aged 13–24 months were tested for C. difficile (Table). After the intervention, the number of tests per month declined at hospital A, as did the number of HO-CDI cases at both hospitals. Rejections of nondiarrheal stools significantly increased after the intervention (P < .001). Conclusions:C. difficile diagnostic stewardship for children was successfully implemented using a rule-based alert system in the electronic health record. This intervention was associated with a reduced number of tests sent and cases of HO-CDI. This strategy was cost-saving and prevented misdiagnosis, unnecessary antibiotic therapy, and overestimation of HO-CDI rates.Funding: NoneDisclosures: None

scholarly journals Analysis of National Healthcare Safety Network Clostridioides difficile Infection Standardized Infection Ratio by Test Type

2020 ◽  
Vol 41 (S1) ◽  
pp. s116-s118
Author(s):  
Qunna Li ◽  
Andrea Benin ◽  
Alice Guh ◽  
Margaret A. Dudeck ◽  
Katherine Allen-Bridson ◽  
...  
Keyword(s):  
Risk Adjustment ◽  
Healthcare Facility ◽  
Directional Pattern ◽  
Incidence Rates ◽  
Nucleic Acid Amplification ◽  
Test Type ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
The Mean ◽  
The Difference

Background: The NHSN has used positive laboratory tests for surveillance of Clostridioides difficile infection (CDI) LabID events since 2009. Typically, CDIs are detected using enzyme immunoassays (EIAs), nucleic acid amplification tests (NAATs), or various test combinations. The NHSN uses a risk-adjusted, standardized infection ratio (SIR) to assess healthcare facility-onset (HO) CDI. Despite including test type in the risk adjustment, some hospital personnel and other stakeholders are concerned that NAAT use is associated with higher SIRs than are EIAs. To investigate this issue, we analyzed NHSN data from acute-care hospitals for July 1, 2017 through June 30, 2018. Methods: Calendar quarters for which CDI test type was reported as NAAT (includes NAAT, glutamate dehydrogenase (GDH)+NAAT and GDH+EIA followed by NAAT if discrepant) or EIA (includes EIA and GDH+EIA) were selected. HO CDI SIRs were calculated for facility-wide inpatient locations. We conducted the following analyses: (1) Among hospitals that did not switch their test type, we compared the distribution of HO incident rates and SIRs by those reporting NAAT vs EIA. (2) Among hospitals that switched their test type, we selected quarters with a stable switch pattern of 2 consecutive quarters of each of EIA and NAAT (categorized as pattern EIA-to-NAAT or NAAT-to-EIA). Pooled semiannual SIRs for EIA and NAAT were calculated, and a paired t test was used to evaluate the difference of SIRs by switch pattern. Results: Most hospitals did not switch test types (3,242, 89%), and 2,872 (89%) reported sufficient data to calculate SIRs, with 2,444 (85%) using NAAT. The crude pooled HO CDI incidence rates for hospitals using EIA clustered at the lower end of the histogram versus rates for NAAT (Fig. 1). The SIR distributions of both NAAT and EIA overlapped substantially and covered a similar range of SIR values (Fig. 1). Among hospitals with a switch pattern, hospitals were equally likely to have an increase or decrease in their SIR (Fig. 2). The mean SIR difference for the 42 hospitals switching from EIA to NAAT was 0.048 (95% CI, −0.189 to 0.284; P = .688). The mean SIR difference for the 26 hospitals switching from NAAT to EIA was 0.162 (95% CI, −0.048 to 0.371; P = .124). Conclusions: The pattern of SIR distributions of both NAAT and EIA substantiate the soundness of NHSN risk adjustment for CDI test types. Switching test type did not produce a consistent directional pattern in SIR that was statistically significant.Disclosures: NoneFunding: None

scholarly journals Diagnostic Stewardship Effectively Reduces Healthcare-Onset Clostridioides difficile Infections and Concurrent Laxative Use

2020 ◽  
Vol 41 (S1) ◽  
pp. s189-s191
Author(s):  
Dipesh Solanky ◽  
Ian Drobish ◽  
Derek Juang ◽  
Scott Johns ◽  
Sanjay Mehta ◽  
...  
Keyword(s):  
Enteral Feeding ◽  
Demographic Data ◽  
Healthcare Facility ◽  
The United States ◽  
Nucleic Acid Amplification ◽  
Fiscal Year ◽  
Medication Cost ◽  
Laxative Use ◽  
Clostridioides Difficile ◽  
Test Ordering

Background:Clostridioides difficile infection (CDI) accounts for >500,000 community-, nursing-, and hospital-acquired infections (HAIs), as well as 15,000–30,000 deaths, and =$4.8 billion in the United States annually. C. difficile toxin B gene nucleic acid amplification testing (NAAT) cannot distinguish between active CDI and colonization, particularly in the setting of laxative use or enteral feeding. Lack of judicious testing can result in the incorrect diagnosis of CDI, unnecessary CDI treatment, increased costs, and falsely augmented HAI rates. Like many healthcare facilities, the VA San Diego Healthcare System (VASDHS) solely utilizes C. difficile NAAT for CDI diagnosis. The aim of this study was to implement and evaluate a facility-wide initiative at the VASDHS to reduce healthcare onset, healthcare facility associated CDI (HO-HCFA CDI), including the use of a test ordering algorithm. Methods: From fiscal year (FY) 2015–2018, various measures were implemented including a hand hygiene initiative, reduction in fluoroquinolone usage, prompt isolation of patients with CDI, thorough terminal cleaning of rooms, and, lastly, a test-ordering algorithm starting FY2018. A retrospective study was performed to assess VASDHS HO-HCFA CDI case incidence, risk factors for infection, laxative or enteral feeding use at the time of testing, and CDI treatment. Results: Patient demographic data, medical history, CDI history, laxative use, treatment, and cost of CDI treatment were reviewed. From 2015 to 2018, 127 cases of HO-HCFA CDI were identified. The total number of HO-HCFA CDI cases and medication cost for CDI treatment were dramatically reduced from 2017 to 2018 following implementation of the test-ordering algorithm (Table 1, Fig. 1). This trend corresponded to a significant reduction in median HO-HCFA CDI cases per month (P = .02), medication cost of CDI treatment (P = .02), and proton pump inhibitor (PPI) use at the time of testing (P = .01). The number of positive HO-HCFA CDI cases associated with laxative use or escalation at the time of CDI testing (accounting for those on chronic laxatives) also decreased across the study period—most dramatically from 2015 vs 2016 (20 vs 14) and 2017 vs 2018 (11 vs 4) (Table 1). Conclusions: At the VASDHS, diagnostic stewardship of C. difficile NAAT with the use of a test-ordering algorithm significantly reduced HO-HCFA CDI incidence and treatment cost. This trend also corresponded with significantly less PPI use at the time of testing and reduced detection of colonization among patients with laxative-induced diarrhea. Diagnostic stewardship may serve as an effective tool to correctly diagnose and treat HO-HCFA CDI, while significantly reducing treatment costs.Funding: NoneDisclosures: None

scholarly journals 2345. Reduction in Testing and Change in Testing Algorithm Associated with Decrease in Number of Nosocomial Clostridium difficile Infections

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S806-S806
Author(s):  
Susan Nichols ◽  
Michelle D Jordan ◽  
Michael Coogan ◽  
Jackie Opera ◽  
Paul P Cook
Keyword(s):  
Clostridium Difficile ◽  
Best Practice ◽  
Medical Center ◽  
Nucleic Acid Amplification ◽  
Antimicrobial Use ◽  
Continuous Variables ◽  
Laxative Use ◽  
Days Of Therapy ◽  
Before And After ◽  
Testing Algorithm

Abstract Background Previous data at our facility indicated 37% of patients with Clostridium difficile infection (CDI) were receiving at least one laxative at the time of testing, suggesting the possibility of false-positive results. Nucleic acid amplification testing (NAAT) does not distinguish between colonization and infection with C. difficile. We implemented two interventions to address these issues and evaluated our rates of nosocomial CDI before and after these changes. Methods This was a retrospective study of all positive test results for adult patients with nosocomial C. difficile from October 1, 2017 through March 31, 2019 at Vidant Medical Center, a 911-bed hospital. In June, 2018, we implemented a best practice advisory (BPA) in our electronic health record to recommend against testing for CDI in patients receiving laxatives. We reviewed the number of C. difficile tests ordered before and after initiating the BPA. In December, 2018, we removed NAAT and replaced it with a cell cytotoxicity assay (CCA) for specimens that were enzyme immunoassay (EIA) negative and glutamate dehydrogenase (GDH) positive. Antimicrobial use was measured in days of therapy (DOT) per 10,000 patient-days (PD). Mann–Whitney U test was used for continuous variables. Linear regression was used to monitor antimicrobial use. Results The number of C. difficile tests ordered per month decreased 19.5% after implementing the BPA (P < 0.0001). There was a 44% reduction in the number of EIA+/GDH+ specimens per month after the BPA intervention (P = 0.003). Following substitution of CCA for NAAT for EIA-/GDH+ specimens, there was a 61% reduction in the rate of nosocomial CDI (8.6 cases/10,000 PD to 3.3 cases/10,000 PD; P = 0.005). Total antimicrobial use was unchanged over the course of the study (673 to 677 DOT/10,000 PD). Carbapenem use decreased 56% (P = 0.009); cefepime use increased 85%(p = 0.002); quinolone and clindamycin use were unchanged. Conclusion Laxative use in hospitalized patients is common and likely contributes to a false elevation in the CDI rate by identifying carriers in addition to those who have true infection. Implementing a BPA to reduce inappropriate testing and changing our testing algorithm for Clostridium difficile by substituting CCA for NAAT has resulted in a lower rate of nosocomial CDI. Disclosures All authors: No reported disclosures.

Using diagnostic stewardship to reduce rates, healthcare expenditures and accurately identify cases of hospital-onset Clostridioides difficile infection

2020 ◽  
Vol 42 (1) ◽  
pp. 51-56
Author(s):  
Dipesh Solanky ◽  
Derek K. Juang ◽  
Scott T. Johns ◽  
Ian C. Drobish ◽  
Sanjay R. Mehta ◽  
...  
Keyword(s):  
Healthcare Facility ◽  
Nucleic Acid Amplification ◽  
Fiscal Year ◽  
Hospital Acquired Infection ◽  
Laxative Use ◽  
Clostridioides Difficile ◽  
Hospitalization Costs ◽  
Clostridioides Difficile Infection ◽  
Hospital Acquired ◽  
Hospital Days

AbstractObjective:Lack of judicious testing can result in the incorrect diagnosis of Clostridioides difficile infection (CDI), unnecessary CDI treatment, increased costs and falsely augmented hospital-acquired infection (HAI) rates. We evaluated facility-wide interventions used at the VA San Diego Healthcare System (VASDHS) to reduce healthcare-onset, healthcare-facility–associated CDI (HO-HCFA CDI), including the use of diagnostic stewardship with test ordering criteria.Design:We conducted a retrospective study to assess the effectiveness of measures implemented to reduce the rate of HO-HCFA CDI at the VASDHS from fiscal year (FY)2015 to FY2018.Interventions:Measures executed in a stepwise fashion included a hand hygiene initiative, prompt isolation of CDI patients, enhanced terminal room cleaning, reduction of fluoroquinolone and proton-pump inhibitor use, laboratory rejection of solid stool samples, and lastly diagnostic stewardship with C. difficile toxin B gene nucleic acid amplification testing (NAAT) criteria instituted in FY2018.Results:From FY2015 to FY2018, 127 cases of HO-HCFA CDI were identified. All rate-reducing initiatives resulted in decreased HO-HCFA cases (from 44 to 13; P ≤ .05). However, the number of HO-HCFA cases (34 to 13; P ≤ .05), potential false-positive testing associated with colonization and laxative use (from 11 to 4), hospital days (from 596 to 332), CDI-related hospitalization costs (from $2,780,681 to $1,534,190) and treatment cost (from $7,158 vs $1,476) decreased substantially following the introduction of diagnostic stewardship with test criteria from FY2017 to FY2018.Conclusions:Initiatives to decrease risk for CDI and diagnostic stewardship of C. difficile stool NAAT significantly reduced HO-HCFA CDI rates, detection of potential false-positives associated with laxative use, and lowered healthcare costs. Diagnostic stewardship itself had the most dramatic impact on outcomes observed and served as an effective tool in reducing HO-HCFA CDI rates.

Criteria for assessing operating room utilization in a free-standing children’s hospital

2011 ◽  
Vol 22 (7) ◽  
pp. 696-706 ◽  
Author(s):  
Lynne R. Ferrari ◽  
Anne Micheli ◽  
Christopher Whiteley ◽  
Raoul Chazaro ◽  
David Zurakowski
Keyword(s):  
Operating Room ◽  
Free Standing ◽  
Children's Hospital ◽  
Children’S Hospital

scholarly journals Comparative study of Pre and Post-operative Drug Costs in Patients with Refractory Epilepsy Undergoing Hemispherectomy and Temporal Lobectomy at the National Children’s Hospital Dr. Carlos Sáenz Herrera

2020 ◽  
pp. 1-3
Author(s):  
Juan L Segura Masís ◽  
◽  
Rodrigo Masís Mejías ◽  
Katherine Alfaro Navas ◽  
Santiago Rodríguez Picado ◽  
...  
Keyword(s):  
Antiepileptic Drugs ◽  
Surgical Procedures ◽  
Refractory Epilepsy ◽  
Epileptic Seizures ◽  
Clinical Results ◽  
Temporal Lobectomy ◽  
Surgical Interventions ◽  
Children's Hospital ◽  
Before And After ◽  
Children’S Hospital

Introduction: Refractory epilepsy can be defined as a failure of adequate trials of antiepileptic drug programs tolerated and appropriately chosen and used (either as monotherapy or in combination) to achieve sustained freedom from seizures. Surgical procedures for the control of epileptic seizures have spread throughout the world, however, large medical centers have mainly focused on studying and analyzing the clinical results of their surgical interventions. For this reason, this study aims to analyze the cost of pre and post-surgical anticonvulsant medications in patients. Objective: To analyze the relationship between preoperative cost / postoperative cost of antiepileptic drugs in patients undergoing hemispherectomy or temporary lobectomy at the National Children’s Hospital (Hospital Nacional de Niños-HNN). Materials and methods: This study is a retrospective, descriptive, quantitative and longitudinal type of a series of patients who were operated in the Epilepsy Monitoring and Surgery Unit (UMCE) of Costa Rica, between November 2000 and December 2018. Information on the history of medications is obtained from patients before and after having undergone hemispherectomy or temporal lobectomy to assess whether or not there is an economic saving in this aspect when comparing both periods of time. Results: 69 patients have undergone hemispherectomy and temporal lobectomy since the creation of the UMCE in November 2000. Of these, 18 (26%) underwent hemispherectomy and 51 (74%) underwent temporary lobectomy. A sample of 31 patients (45%) were obtained, which met the inclusion criteria. The average age of initiation of treatment at the HNN was 5.5 years old (66 months) and the average age at which they underwent surgery was 10.8 years old (130 months). There was one patient in the sample who received 9 anticonvulsant medications before undergoing the surgical procedure and the average number of medications used pre-surgically was 4.45 anticovulsivants per patient. The average postoperative medication was 2.35 anticonvulsivants per patient. The average monthly preoperative cost was $50.17, while the postoperative period was $31.26, with a difference of $18.91. A total of 9 patients in the sample increased the monthly postoperative cost. The total savings per month in the patients included in the sample was $586.36 and extrapolated to the population of 69 patients resulting in a saving of $1,305.14 per month. The projection according to the life expectancy of the patients in the sample translates into a saving of $409,188.59 while the projection to the 69 patients would result in a saving of $910,774.60 for the Caja Costarricense del Seguro Social (CCSS - Costa Rican Social Security Fund). Discussion: The effectiveness of these two surgeries in suitably selected patients is reflected in the economic savings represented by antiepileptic drugs administered after these surgical procedures. Conclusion: we consider that in this center the patients who have been operated have meant a saving for the Caja Costarricense del Seguro Social (CCSS) since they have diminished or completely eliminated the anti-epileptic medical treatment

scholarly journals 754. A Two-step Testing Algorithm for Hospital-onset Clostridioides difficile Infection (CDI) Reduces Prescribing of C. difficile (CD) Therapy but Its Ability to Guide Treatment Decisions Remains Unclear

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S474-S474
Author(s):  
Mackenzie Dolan ◽  
Heather Cox ◽  
Cirle A Warren ◽  
Costi Sifri ◽  
Melinda Poulter ◽  
...  
Keyword(s):  
Decision Support Tool ◽  
Treatment Decisions ◽  
Adverse Outcomes ◽  
Nucleic Acid Amplification ◽  
Test Results ◽  
Patient Death ◽  
Support Tool ◽  
Clostridioides Difficile ◽  
Days Of Therapy ◽  
Testing Algorithm

Abstract Background Determining true CDI versus CD colonization through CD testing is a continuing challenge. A previously introduced decision support tool at UVA Health significantly reduced inappropriate testing without adverse outcomes. More recently, our methodology changed from nucleic acid amplification test (NAAT) alone to an initial NAAT followed by ELISA for toxin to improve specificity. The purpose of this analysis was to assess provider interpretation of test results, using targeted CD therapy as a surrogate. Methods This single-center, retrospective study evaluated all patients with a positive NAAT (Cepheid Xpert® C. difficile) on day 4 or later of hospitalization following 2-step algorithm implementation from Feb 2020 through Feb 2021. Toxin negative (TOX-) test results (C. DIFF QUIK CHEK COMPLETE®) were accompanied by a comment that discordance may represent colonization or CDI and to consider ID consult. The proportion of toxin positive (TOX+) versus TOX- patients receiving ≥ 1 dose of CD therapy served as the primary outcome with partial courses considered &lt; 10 days. Clinical outcomes were also compared. Results Ninety patients with NAAT+ results were included, of whom 58 (64%) were TOX-. Thirty-two (100%) TOX+ (median days of therapy [IQR] = 14 [11-17]) versus 51 (88%) TOX- patients (median days of therapy [IQR] = 11 [7-14]) received CD therapy (p=0.04). Treatment decisions were guided by ID physicians for 32 (63%) TOX- patients; ID recommendations to discontinue CD therapy were followed in 2 out of 9 (22%) cases. TOX- patients received partial therapy due to patient death (n=5), presumptive colonization (n=3), and provider error (n=1). Of TOX- patients receiving partial or no treatment, there were no CDI-related adverse outcomes during the admission. CDI-related colectomy occurred in 2 (6%) and 1 (2%) TOX+ and TOX- patients, respectively. Five in-hospital deaths with CDI as a contributing factor occurred in the TOX+ group. Conclusion Adoption of a 2-step NAAT plus toxin testing algorithm for hospital-onset CDI reduced the frequency with which TOX- patients received CD therapy but the vast majority were still treated. Most providers considered a positive NAAT indicative of CDI, regardless of TOX status. Disclosures All Authors: No reported disclosures

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