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 < 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

scholarly journals Patient Outcomes With Prevented vs Negative Clostridioides difficile Tests Using a Computerized Clinical Decision Support Tool

2020 ◽  
Vol 7 (4) ◽  
Author(s):  
Gregory R Madden ◽  
Kyle B Enfield ◽  
Costi D Sifri
Keyword(s):  
Decision Support ◽  
Clinical Decision Support ◽  
Medical Center ◽  
Decision Support Tool ◽  
Clinical Decision ◽  
Nucleic Acid Amplification ◽  
Retrospective Case ◽  
Support Tool ◽  
Clostridioides Difficile ◽  
Clinical Decision Support Tool

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.

scholarly journals Dual Reporting of Clostridioides difficile PCR and Predicted Toxin Result Based on PCR Cycle Threshold Reduces Treatment of Toxin-Negative Patients without Increases in Adverse Outcomes

2019 ◽  
Vol 57 (11) ◽  
Author(s):  
Matthew M. Hitchcock ◽  
Marisa Holubar ◽  
Catherine A. Hogan ◽  
Lucy S. Tompkins ◽  
Niaz Banaei
Keyword(s):  
Nucleic Acid ◽  
Chart Review ◽  
Patient Characteristics ◽  
Adverse Outcomes ◽  
Nucleic Acid Amplification ◽  
Content Type ◽  
Cycle Threshold ◽  
Clostridioides Difficile ◽  
All Cause Mortality ◽  
High Negative Predictive Value

ABSTRACT Nucleic acid amplification tests are commonly used to diagnose Clostridioides difficile infection (CDI). Two-step testing with a toxin enzyme immunoassay is recommended to discriminate between infection and colonization but requires additional resources. Prior studies showed that PCR cycle threshold (CT) can predict toxin positivity with high negative predictive value. Starting in October 2016, the predicted toxin result (CT-toxin) based on a validated cutoff was routinely reported at our facility. To evaluate the clinical efficacy of this reporting, all adult patients with positive GeneXpert PCR results from October 2016 through October 2017 underwent a chart review to measure the recurrence of or conversion to a CT-toxin+ result and 30-day all-cause mortality. There were 482 positive PCR tests in 430 unique patients, 282 CT-toxin+ and 200 CT-toxin−. Patient characteristics were similar at testing, though CT-toxin+ patients had higher white blood cell (WBC) counts (12.5 × 103 versus 9.3 × 103 cells/μl; P = 0.001). All cases (n = 21) of fulminant CDI had a CT-toxin+ result. Index CT-toxin+ patients were significantly more likely to have a CT-toxin+ result within 90 days than CT-toxin− patients (17.4% [n = 49] versus 8.0% [n = 16], respectively; P = 0.003). Thirty-day all-cause mortality was higher in CT-toxin− patients (11.1% versus 6.8%; P = 0.1), though no deaths in CT-toxin− patients were directly attributable to CDI. Of the 200 CT-toxin− patients, 51.5% (n = 103) were treated for CDI. The rates of conversion to a CT-toxin+ result (8.8% versus 7.2%; P = 0.8) and all-cause mortality (8.8% versus 13.4%; P = 0.3) were similar between treated and untreated CT-toxin− patients, respectively. CT-based toxin prediction may identify patients at higher risk for CDI-related complications and reduce treatment among CT-toxin− patients.

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.

Clinical Impact of an Internet-Based Tool to Help Guide Therapeutic Changes While Monitoring Patients with Chronic Myeloid Leukemia Receiving First-Line Tyrosine Kinase Inhibitor Therapy

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 4279-4279
Author(s):  
Kevin L. Obholz ◽  
Daniel J. DeAngelo ◽  
Michael J. Mauro ◽  
Neil Shah ◽  
B. Douglas Smith ◽  
...  
Keyword(s):  
Research Funding ◽  
Kinase Inhibitor ◽  
Decision Support Tool ◽  
Treatment Decisions ◽  
Therapeutic Change ◽  
Management Approach ◽  
First Line ◽  
Specific Patient ◽  
Support Tool ◽  
Expert Recommendations

Abstract Abstract 4279 Background European LeukemiaNet (ELN) and National Comprehensive Cancer Network (NCCN) recommendations are important resources to help guide the management of patients with chronic myeloid leukemia (CML) treated with tyrosine kinase inhibitor (TKI) therapy. However, current guidelines are sometimes difficult to apply to all patient scenarios, particularly as they do not provide definite management recommendations for patients who have suboptimal responses to first-line TKI therapy. Furthermore, in a recent survey only 58% (N=132) of community oncologists made treatment decisions in line with expert recommendations for clinical scenarios in which patients had a suboptimal response to first-line therapy with imatinib. Online tools that provide expert clinical guidance have been proposed as one adjunctive approach to help clinicians make more informed treatment decisions. We previously reported that an online tool designed to provide expert guidance on adjuvant treatment of breast cancer may positively impact treatment decisions and thus potentially improve patient care (J Clin Oncol 29: 2011 [suppl; abstr 6063]). Aims/Objectives The goal was to determine whether an interactive online decision support tool providing expert guidance would help community practitioners make more informed therapeutic decisions for patients with CML who were receiving first-line TKI therapy. We sought to evaluate to what extent the expert recommendations changed the community practitioners' clinical approach. Methods An interactive decision support tool, developed with input from 5 CML experts who made treatment recommendations for 42 different patient scenarios, has been posted online at http://www.clinicaloptions.com/TreatingCML. Users of the tool enter specific factors such as patient age and duration of first-line TKI therapy, along with information on hematologic, cytogenetic, and/or molecular responses to first-line TKI therapy at 3, 6, 12 and 18 months. Before expert recommendations for that specific patient scenario are revealed, users are asked to enter their intended management approach. Once that is entered, the tool outputs a table showing the recommendations of the 5 CML experts based on the specific factors entered. Finally, the user is prompted to indicate whether the experts' recommendation confirmed or changed their intended management approach. User response data and intended treatment approaches will be tabulated and compared with the experts' recommendations. Results This resource was posted online July 2012 and had 161 unique users with 219 uses of the tool in the first 40 days. Among the users to date, 15% indicated that the experts' recommendations changed their intended management approach. A separate analysis of the in-tool recommendations showed that the experts considered not only guidelines, but also emerging data and their own clinical experience in making recommendations for specific patient scenarios. For example, ahead of similar recommendations included in the most recent update to the NCCN treatment guidelines for CML, the experts added a consideration in the tool suggesting a BCR-ABL/ABL ratio of 10% by QPCR as the threshold for guiding a therapeutic change at 3 months. Moreover, most of the experts (4 of 5) recommended a therapeutic change for patients in CCyR without MMR at 12 months if there was a concomitant increase in BCR-ABL ratio of 1 log or more and (3 of 5) also recommended a therapeutic change for patients without a MMR at 18 months regardless of whether their BCR-ABL/ABL ratio was increasing. Detailed comparisons of expert and user responses will be presented. Conclusions Preliminary data suggest that an online tool designed to provide customized, patient-specific expert advice may increase the number of clinicians who make optimal treatment decisions for patients with CML based on their response to first-line TKI therapy, and therefore, may be an important adjunct to the ELN and NCCN guidelines. Disclosures: Shah: ARIAD: Consultancy, Research Funding; Bristol Myers-Squibb: Consultancy, Research Funding; Novartis: Consultancy. Smith:Bristol-Myers Squibb: Consultancy; Novartis: Consultancy. Radich:Ariad: Consultancy; Bristol-Myers Squibb: Consultancy; Pfizer: Consultancy; Novartis: Consultancy, Research Funding.

scholarly journals Decision-making in the diagnosis of tuberculous meningitis

2020 ◽  
Vol 5 ◽  
pp. 11
Author(s):  
Tom H. Boyles ◽  
Lutgarde Lynen ◽  
James A. Seddon ◽  
Keyword(s):  
Decision Making ◽  
Tuberculous Meningitis ◽  
Threshold Model ◽  
Rapid Test ◽  
Bayes Theorem ◽  
Treatment Decisions ◽  
Nucleic Acid Amplification ◽  
Test Results ◽  
Diagnostic Strategies ◽  
Test Probability

Tuberculous meningitis (TBM) is the most devastating form of tuberculosis (TB) but diagnosis is difficult and delays in initiating therapy increase mortality. All currently available tests are imperfect; culture of Mycobacterium tuberculosis from the cerebrospinal fluid (CSF) is considered the most accurate test but is often negative, even when disease is present, and takes too long to be useful for immediate decision making. Rapid tests that are frequently used are conventional Ziehl–Neelsen staining and nucleic acid amplification tests such as Xpert MTB/RIF and Xpert MTB/RIF Ultra. While positive results will often confirm the diagnosis, negative tests frequently provide insufficient evidence to withhold therapy. The conventional diagnostic approach is to determine the probability of TBM using experience and intuition, based on prevalence of TB, history, examination, analysis of basic blood and CSF parameters, imaging, and rapid test results. Treatment decisions may therefore be both variable and inaccurate, depend on the experience of the clinician, and requests for tests may be inappropriate. In this article we discuss the use of Bayes’ theorem and the threshold model of decision making as ways to improve testing and treatment decisions in TBM. Bayes’ theorem describes the process of converting the pre-test probability of disease to the post-test probability based on test results and the threshold model guides clinicians to make rational test and treatment decisions. We discuss the advantages and limitations of using these methods and suggest that new diagnostic strategies should ultimately be tested in randomised trials.

scholarly journals 2344. Evaluation of a Best Practice Alert (BPA) to Reduce Inappropriate Testing for Clostridium difficile Infection (CDI) Within a Multi-Hospital System

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S805-S806
Author(s):  
Ryan K Dare ◽  
Claire E Bewley ◽  
Amanda J Novack ◽  
Jared M Heiles ◽  
Larissa K Chin
Keyword(s):  
Decision Support ◽  
Best Practice ◽  
Decision Support Tool ◽  
Medication Administration ◽  
Nucleic Acid Amplification ◽  
Or Education ◽  
Hospital System ◽  
Support Tool ◽  
Best Practice Alert ◽  
Hospital Acquired

Abstract Background Hospital-acquired CDI contribute to significant morbidity, mortality, and cost burden in hospitalized patients. Clinical practice guidelines recommend strict testing criteria when employing nucleic acid amplification testing alone as to not test asymptomatic carriers. A BPA within the electronic medical record (EMR) may assist with this screening. Methods At our 9-hospital system, we created a BPA to help identify patients who may not meet criteria for CDI testing. Initial BPA (January 2018) asked if patient had 3 or more stools (yes/no) and if laxatives were administered in the last 48 hours (yes/no). An expanded BPA was updated to pull medication administration records for use of laxatives in the prior 48 hours (August 2018) and notified providers of recent C. difficile testing in the past 7 days (January 2019). C. difficile orders from March 2017 (historical), March 2018 (intervention 1), and March 2019 (intervention 2) were evaluated to assess impact of these interventions. Results C. difficile testing during 30,621 (historical), 31,299 (intervention 1), and 31,960 (intervention 2) patient-days were evaluated. Rates of C. difficile orders and infections are reported in the table. Ratio of positive C. difficile specimens to tested specimens were similar between the historical arm (51 of 402; 12.7%) and both intervention 1 (42 of 271; 15.5%) and intervention 2 (45 of 316; 14.2%) arms (P = 0.3 and P = 0.5, respectively). Intervention 1 and intervention 2 arms were similar in all metrics. Statistical analysis was performed using Stata, v.14.2. Conclusion Implementation of a decision support tool to assist with C. difficile testing significantly decreased order rates in both the initial and expanded BPA intervention arms. Compared with historical rates, incidence of CDI decreased in both intervention arms though these were not statistically significant. Similarly, ratio of positive specimens to specimens tested increased in both intervention arms, though not significant, indicating a trend toward improved patient selection. To improve appropriate CDI testing, further oversight and/or education is needed to accompany implementation of an EMR decision support tool, such as BPAs. Disclosures All authors: No reported disclosures.

Sequential introduction of a multistep testing algorithm and nucleic acid amplification testing leading to an increase in Clostridioides difficile detection and a trend toward increased strain diversity

2020 ◽  
Vol 41 (10) ◽  
pp. 1148-1153
Author(s):  
Andrew M. Skinner ◽  
Brian Yu ◽  
Adam Cheknis ◽  
Susan M. Pacheco ◽  
Dale N. Gerding ◽  
...  
Keyword(s):  
Nucleic Acid ◽  
Restriction Endonuclease Analysis ◽  
Nucleic Acid Amplification ◽  
Toxin Concentration ◽  
Detection Rates ◽  
Strain Diversity ◽  
Clostridioides Difficile ◽  
Nucleic Acid Amplification Testing ◽  
Testing Algorithm

AbstractBackground:Most clinical microbiology laboratories have replaced toxin immunoassay (EIA) alone with multistep testing (MST) protocols or nucleic acid amplification testing (NAAT) alone for the detection of C. difficile.Objective:Study the effect of changing testing strategies on C. difficile detection and strain diversity.Design:Retrospective study.Setting:A Veterans’ Affairs hospital.Methods:Initially, toxin EIA testing was replaced by an MST approach utilizing a glutamate dehydrogenase (GDH) and toxin EIA followed by tcdB NAAT for discordant results. After 18 months, MST was replaced by a NAAT-only strategy. Available patient stool specimens were cultured for C. difficile. Restriction endonuclease analysis (REA) strain typing and quantitative in vitro toxin testing were performed on recovered isolates.Results:Before MST (toxin EIA), 79 of 708 specimens (11%) were positive, and after MST (MST-A), 121 of 517 specimens (23%) were positive (P < .0001). Prior to NAAT-only testing (MST-B), 80 of the 490 specimens (16%) were positive by MST, and after NAAT-only testing was implemented, 67 of the 368 specimens (18%) were positive (P = nonsignificant). After replacing toxin EIA testing, REA strain group diversity increased (8, 13, 13, and 10 REA groups in the toxin EIA, MST-A, MST-B, and NAAT-only periods, respectively) and in vitro toxin concentration decreased. The average log10 toxin concentration of the isolates were 2.08, 1.88, 1.20 and 1.55 ng/mL for the same periods, respectively.Conclusions:MST and NAAT had similar detection rates for C. difficile. Compared to toxin testing alone, they detected increased diversity of C. difficile strains, many of which were low toxin producing.

scholarly journals Factors Affecting Health Care Engagement of Patients With End-Stage Heart Failure: An Exploratory Survey Study

2019 ◽  
Vol 4 (2) ◽  
pp. 238146831986551
Author(s):  
Lisa Carey Lohmueller ◽  
Aakanksha Naik ◽  
Luke Breitfeller ◽  
Colleen K. McIlvennan ◽  
Manreet Kanwar ◽  
...  
Keyword(s):  
Heart Failure ◽  
Health Care ◽  
Decision Making ◽  
Decision Support ◽  
Information Seeking ◽  
Decision Support Tool ◽  
Treatment Decisions ◽  
Support Tool ◽  
End Stage Heart Failure ◽  
End Stage

Background. The decision to receive a permanent left ventricular assist device (LVAD) to treat end-stage heart failure (HF) involves understanding and weighing the risks and benefits of a highly invasive treatment. The goal of this study was to characterize end-stage HF patients across parameters that may affect their decision making and to inform the development of an LVAD decision support tool. Methods. A survey of 35 end-stage HF patients at an LVAD implant hospital was performed to characterize their information-seeking habits, interaction with physicians, technology use, numeracy, and concerns about their health. Survey responses were analyzed using descriptive statistics, grounded theory method, and Bayesian network learning. Results. Most patients indicated an interest in using some type of decision support tool (roadmap of health progression: 46%, n = 16; personal prognosis: 51%, n = 18; short videos of patients telling stories of their experiences with an LVAD: 57%, n = 20). Information patients desired in a hypothetical decision support tool fell into the following topics: prognoses for health outcomes, technical information seeking, expressing emotions, and treatment decisions. Desire for understanding their condition was closely related to whether they had difficult interpreting their electronic medical record in the past. Conclusions. Most patients reported interest in engaging in their health care decision making and seeing their prognosis and electronic health record information. Patients who were less interested in their own treatment decisions were characterized by having less success understanding their health information. Design of a decision support tool for potential LVAD patients should consider a spectrum of health literacy and include information beyond the technical specifications of LVAD support.

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