Know When to Test: Optimizing Diagnostic Practices for Clostridium difficile Infection (CDI) Among Patients at a Tertiary-Care Cancer Center

Abstract Background Polymerase chain reaction (PCR) based diagnostic testing for the detection of toxigenic Clostridium difficile infection (CDI) does not distinguish between carriers and patients with true CDI. As a result, CDI is over-diagnosed in hospitalized patients with diarrhea. Unnecessary testing generates false positives and several downstream sequelae. Aim: The aim of this study was to reduce unnecessary testing for CDI through an electronic alert, targeted education, and implementation of evidence-based laboratory testing policy. Methods In order to quickly identify laxative induced diarrhea and avoid CDI testing, an electronic alert was created in the electronic medical record (EMR) system. The alert was built on a logic that identified patients who had received laxatives within 48 hours of a CDI PCR test order. The alert additionally provided the rationale for avoiding testing in patients on laxatives and guidance on appropriate testing for CDI. The following steps were taken simultaneously to complement these efforts: 1) Infection Control conducted hospital-wide education for licensed independent practitioners on a CDI testing algorithm 2) Laboratory based policy was instated to reject all formed stools (Bristol Stool Chart types 1 through 4) for CDI testing. Results In the 6 month pre-intervention period, there were 29 CDI tests per 1000 patient-days. In the post-intervention period, CDI tests decreased to 19 per 1000 patient-days, a 35% decrease (P < 0.0001). The decline in testing has been sustained for 7 months. The following observations were also made: 1) HAI rate reduction of 28%; 2) decrease in oral vancomycin use. Conclusion Decreasing inappropriate testing has several distinct advantages, including reducing excessive and unnecessary antibiotic use, avoiding misclassification of carriers as CDI cases, normalizing healthcare-associated CDI rates, and diminishing healthcare costs associated with preventable tests. Laboratories that use PCR only testing for CDI diagnosis should follow stringent policies to ensure that only patients with high pretest probability are tested. EMR systems are a useful and effective resource to achieve this for patients with laxative induced diarrhea. Disclosures All authors: No reported disclosures.

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Effectiveness of a Two-Step Testing Algorithm for Reliable and Cost-Effective Detection of Clostridium difficile Infection in a Tertiary Care Hospital in Saudi Arabia

Medical Sciences ◽

10.3390/medsci7010006 ◽

2019 ◽

Vol 7 (1) ◽

pp. 6

Author(s):

Mohammed Qutub ◽

Prasanth Govindan ◽

Anupama Vattappillil

Keyword(s):

Clostridium Difficile ◽

Clostridium Difficile Infection ◽

Tertiary Care ◽

Care Hospital ◽

Predictive Values ◽

Stool Samples ◽

Step Algorithm ◽

Testing Algorithm ◽

Sensitivity Specificity ◽

Pcr Test

The aim of this study was to evaluate the effectiveness of a two-step algorithm for the detection of Clostridium difficile infection. Setting and Design: A two-step testing algorithm was evaluated for testing stool samples from patients suspected of Clostridium difficile infection (CDI). A total of 103 stool specimens were tested using the C. diff Quik Chek Complete enzyme immunoassay (EIA) test and the Xpert C. difficile PCR test. A two-step algorithm was implemented, and data from 3518 patient samples tested during a two-year period after implementation were analyzed to evaluate the effectiveness. The sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of the Quik Chek Complete EIA test were calculated using the Xpert C. difficile PCR test as a reference method. The sensitivity, specificity, PPV, and NPV of the Quik Chek Complete EIA test for C. difficile toxin were 46.7%, 100%, 100%, and 91%, respectively. The two-step algorithm, which combined the Quik Chek Complete EIA with Xpert C. difficile PCR, improved the sensitivity and also provided rapid detection. When algorithm-based testing was performed daily, there was a 66% reduction in turnaround time compared to batch testing using a lengthy ELISA procedure. Postimplementation data analysis showed that almost 89% of the samples could be reported immediately by initial screening with Quik Chek Complete EIA. Only 11% of the samples gave discrepant results and required PCR confirmation. According to our results, the two-step algorithm is an effective tool for the rapid and reliable detection of toxigenic C. difficile from stool samples.

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Risk Factors for Acquisition of Clostridium difficile–Associated Diarrhea among Outpatients at a Cancer Hospital

Infection Control and Hospital Epidemiology ◽

10.1086/502602 ◽

2005 ◽

Vol 26 (8) ◽

pp. 680-684 ◽

Cited By ~ 68

Author(s):

Tara N. Palmore ◽

SeJean Sohn ◽

Sharp F. Malak ◽

Janet Eagan ◽

Kent A Sepkowitz

Keyword(s):

Risk Factors ◽

Clostridium Difficile ◽

Case Control Study ◽

Tertiary Care ◽

Antibiotic Use ◽

Generation Cephalosporin ◽

Case Control ◽

Cancer Center ◽

Care Hospital ◽

Control Study

AbstractBackground:Clostridium difficile-associated diarrhea (CDAD) is an important infection in hospital settings. Its impact on outpatient care has not been well defined.Objective:To examine risk factors of ambulatory cancer patients with CDAD.Design:Case-control study.Setting:Memorial Sloan-Kettering Cancer Center, a tertiary-care hospital.Methods:Cases of CDAD among oncology outpatients from January 1999 through December 2000 were identified via positive C. difficile toxin assay results on stool specimens sent from clinics or the emergency department. A 1:3 matched case-control study examined exposures associated with CDAD.Results:Forty-eight episodes of CDAD were identified in cancer outpatients. The mean age was 51 years; 44% were female. Forty-one (85%) had received antibiotics within 60 days of diagnosis, completing courses a median of 16.5 days prior to diagnosis. Case-patients received longer courses of first-generation cephalosporins (4.8 vs 3.2 days; P = .03) and fluoroquinolones (23.6 vs 8 days; P < .01) than did control-patients. Those receiving clindamycin were 3.9-fold more likely to develop CDAD (P < .01). For each additional day of clindamycin or third-generation cephalosporin exposure, patients were 1.29- and 1.26-fold more likely to develop CDAD (P < .01 and .04, respectively). The 38 CDAD patients hospitalized during the risk period (79.2%) spent more time as inpatients than did control-patients (19.3 vs 9.7 days; P <. 001).Conclusions:Antibiotic use, especially with cephalosporins and clindamycin, and prolonged hospitalization contributed to the development of CDAD. Outpatient CDAD appears to be most strongly related to inpatient exposures; reasons for the delayed development of symptoms are unknown.

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Using Clinical Decision Support to Improve Evidence Based Testing and Diagnosis of Clostridium difficile Infection

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.988 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S396-S396

Author(s):

Bahnsen Miller ◽

Catherine O’Neal ◽

Diana Hamer

Keyword(s):

Decision Support ◽

Clostridium Difficile ◽

Clinical Decision Support ◽

Clostridium Difficile Infection ◽

Diagnostic Testing ◽

Clinical Decision ◽

Evidence Based ◽

Post Intervention ◽

Improvement Project ◽

Asymptomatic Patients

Abstract Background Diagnosing Clostridium difficile infection (CDI) requires clinical understanding of the disease and knowledge of diagnostic testing limitations. It is important for providers to utilize CDI testing only in patients with suspected disease. Real-time polymerase chain reaction (PCR) assays are sensitive but cannot differentiate between symptomatic and asymptomatic patients. Individual hospitals have reported a 50% to 100% increase in the rate of CDI after substituting toxin tests with molecular tests such as PCR. We conducted a quality improvement project, implementing clinical decision support in ordering diagnostic testing of CDI, while measuring the number of diagnostic tests ordered and positive results. Methods We implemented evidence based clinical decision support into Cerner order entry system on March 1, 2016. The Cepheid Xpert C. difficile molecular test is used for diagnosis of CDI at our facility. The decision support included a message stating Òuse the test with caution in patients who are receiving tube feeds or recent laxative useÓ and prompted ordering providers to select one of three indications for using the test: 3 or more diarrheal stools per 24 hour period, leukocytosis with abdominal pain, or ileus. A control chart was used to monitor the number of tests ordered and positive tests per month (inpatient adults) for a total of 24 months; 14 months pre-intervention and 10 months post-intervention. Results A decrease in the number of tests ordered per month was seen post intervention. Average number of monthly tests ordered was 207 pre-intervention and 163 post-intervention. After controlling for patient-days per month, there was a 13.5% decrease in the number of tests ordered from a mean of 14.29 vs.. 12.37 tests per thousand patient-days per month. This resulted in special cause variation (Figure 1). There was no special cause variation detected with the number of positive PCRs per month, pre and post intervention. Conclusion Implementing decision support into the electronic medical record may assist providers with evidence-based utilization of the C. difficile PCR by decreasing unnecessary testing. This decrease may also have an impact on overall hospital costs, antibiotic utilization, and public reporting related to CDI. Disclosures All authors: No reported disclosures.

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A Multi-Pronged Approach to Control Healthcare Facility-Onset Clostridium difficile Infection in a Tertiary Care Community Hospital

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.1013 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S405-S405

Author(s):

Raymond Chinn ◽

Jennifer Wyatt ◽

Pam Wells ◽

Tracy Fox ◽

Jacqueline Daley ◽

...

Keyword(s):

Clostridium Difficile ◽

Clostridium Difficile Infection ◽

Infection Prevention ◽

Community Hospital ◽

Tertiary Care ◽

Healthcare Facility ◽

P Value ◽

Intervention Period ◽

Care Community ◽

Community Onset

Abstract Background Clostridium difficile infection (CDI) contributes to significant increases in healthcare-associated morbidity and mortality. Multiple strategies have been promulgated to accurately diagnose and to control healthcare facility-onset (HO) CDI. Sharp Memorial Hospital is a 438-bed tertiary care community hospital. In 2014, the standardized infection ratio (SIR) CDI was 1.406 (2006–2008 baseline) with a p value of 0.0005. We report the results of a multi-disciplinary approach that has reduced our HO-CDI SIR. The National Healthcare Safety Network definitions and methodologies were used throughout the study. Methods Various multi-disciplinary interventions were implemented over a 12 month period from April 2015 through March 2016 that included enhanced administrative support and the creation of a multi-disciplinary CDI Steering Committee (Figure 1). A Lean Six Sigma approach was launched that included a two-day rapid process improvement (RPI) workshop in July 2015 with participation of an interdisciplinary team of frontline staff, leaders from the 2 units with high CDIs, Infection Prevention, and Environmental Services. Subsequently, lessons learned from the RPI were disseminated throughout the hospital. The laboratory and information technology staff and the antimicrobial stewardship program also contributed. Results Compared with the intervention period, the post intervention period (April 2016 through March 2017) documented a significant increase in the number of samples submitted for CDI testing ≤ 3 days after admission and a significant decrease in the number of samples submitted > 3 days after admission. There were significant decreases in the HO-CDI SIR from 0.947 to 0.676 (p value 0.0485) and in quinolone days of therapy from 265 to 246 (p value 0.0001). Conclusion We have demonstrated a significant decrease in our HO-CDI using a multi-pronged approach that highlighted a return and reinforcement of back to basics infection prevention. High HO-CDI SIR in previous years might indicate missed community-onset, community-onset healthcare facility-associated cases. We did not employ other technologies such as the hands-free disinfection devices. Sustainability remains a future challenge. Disclosures All authors: No reported disclosures.

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Faculty Opinions recommendation of Impact of an electronic sepsis initiative on antibiotic use and health care facility-onset Clostridium difficile infection rates.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.727710237.793555276 ◽

2019 ◽

Author(s):

Pranavi Sreeramoju

Keyword(s):

Health Care ◽

Clostridium Difficile ◽

Clostridium Difficile Infection ◽

Care Facility ◽

Health Care Facility ◽

Antibiotic Use ◽

Infection Rates

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Enhanced Cleaning and Education to Prevent Transmission of Clostridium difficile in Pediatrics

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.1016 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S406-S406

Author(s):

Anoshé Aslam ◽

Giselle Melendez ◽

Min Wang ◽

Frederic Stell ◽

Paulette Kelly ◽

...

Keyword(s):

Clostridium Difficile ◽

Tertiary Care ◽

Educational Interventions ◽

Cancer Center ◽

Phase 2 ◽

Communication Plan ◽

Effective Strategies ◽

Key Stakeholders ◽

Patient Representatives ◽

Healthcare Associated

Abstract Background Transmission of healthcare-associated Clostridium difficile infection (HA-CDI) has been shown to occur directly or indirectly through a contaminated environment. At a tertiary-care cancer center, HA-CDI rates were higher for pediatric units than for other general oncology units. To address the problem, a multidisciplinary team, including Infection Control, Nursing, and Environmental Services (EVS), was convened and identified refusals and room clutter as barriers to proper cleaning of rooms on the unit. Aim: The aim of this study seeks to reduce HA-CDI in the inpatient pediatrics setting through environmental and educational interventions. Methods In the first phase of the study from February to April 2016, a baseline assessment of prevalent environmental disinfection practices was made among Nursing, EVS, Physicians, and Patient Representatives. Based on this feedback, the following were implemented during Phase 2, from June through October 2016: 1) Unit-wide disinfection with bleach twice a day including common and high traffic areas; 2) Initiation of a “preferred time for cleaning” program to engage families; 3) Enhanced visitor and family education on PPE use; 4) Creation of a communication plan in case of refusal to clean rooms; and 5) Dedicated use of diaper scales. Results During the first phase of the study, the following barriers to cleaning were identified: 1) High refusal rate as cleaning was perceived as inconvenient by families due to timing; 2) Common perception among EVS staff that multiple requests for cleaning the room may appear intrusive to the families; 3) Excessive clutter in the room; 4) Lack of education regarding PPE use; and 5) Shared equipment for diapers. To overcome these barriers, several interventions as outlined in methods were implemented. In Phase 2, there were 0 cases of HA-CDI identified in pediatric patients starting in July through October, 2016. Conclusion Control of CDI on pediatric units poses unique challenges. Engagement of key stakeholders is essential to identify and meet these challenges and to devise effective strategies that will ultimately lead to reduced hospital-based transmission of CDI. Disclosures All authors: No reported disclosures.

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