scholarly journals 2416. Effect of Sequential Universal Bleach Cleaning and Best Practice Alerts on Clostridioides difficile Infection Rates

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S834-S834
Author(s):  
Kari Gand ◽  
Derrek Helmin ◽  
Shawnda Johnson ◽  
Susan E Kline ◽  
Alison Galdys
Keyword(s):  
Clinical Judgment ◽  
Best Practice ◽  
Gap Analysis ◽  
Medical Center ◽  
Care Center ◽  
Tertiary Care ◽  
Healthcare Facility ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Community Onset

Abstract Background A gap analysis prompted consideration of expanded bleach disinfection beyond rooms housing patients in isolation for Clostridioides difficile infection (CDI) and emphasis on CD testing stewardship at the University of Minnesota Medical Center (UMMC), a tertiary care center spanning two campuses in close proximity with adult patients on the East Bank (EB), adult and pediatric patients on West Bank (WB). Methods An electronic best practice advisory (BPA) went live in April 2018 on both the EB and WB (Figure 1). The BPA first discourages CD testing in the event of a prior positive within 10 days or a prior negative within 7 days. Second, the BPA discourages CD testing in patients with fewer than 3 loose stools in a 24 hour period, who have received laxatives in the last 48 hours, or who lack CDI symptoms (fever > 38C, abdominal pain, or leukocytosis > 11,000). Providers can bypass the BPA based on clinical judgment; those who override the BPA are provided just-in-time education via email. Following a successful pilot in three wards, the EB Environmental Services (ES) team expanded the use of bleach to include all terminal cleaning regardless of isolation status in June 2018 (Figure 1). Daily cleaning on the EB was excluded from universal bleach utilization, as were daily and terminal cleaning on the WB. CD testing throughout the study period occurred via polymerase chain reaction (PCR) of the toxin B gene. ES performance, assessed by adenosine triphosphate (ATP) bioluminescence testing, and hand hygiene rates were unchanged throughout the study period. Results Adult-only hospital-onset (HO)-CDI rates decreased during the study period on both hospital campuses, with the EB exhibiting a greater decrease, (Fig 1), while community-onset (CO) and community-onset healthcare facility associated (CO-HCFA) rates remained steady during the study period (Fig 3). Whole-house (adult and pediatric) CD testing was largely unchanged while the proportion of tests triggering the BPA decreased (Fig 2). Conclusion Universal bleach utilization during terminal cleaning combined with an electronic BPA were associated with decreased adult HO-CDI rates. However, the BPA did not impact CD testing rates, suggesting that decreased HO-CDI rates may be unattributable to testing stewardship. Disclosures All authors: No reported disclosures.

scholarly journals 752. Costs Attributable to Clostridioides difficile Infection in the Presence of Differential Mortality

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S473-S474
Author(s):  
John Sahrmann ◽  
Dustin Stwalley ◽  
Margaret A Olsen ◽  
Holly Yu ◽  
Erik R Dubberke
Keyword(s):  
Healthcare Facility ◽  
Differential Mortality ◽  
Fee For Service ◽  
Research Support ◽  
Cost Estimates ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Parametric Survival Model ◽  
Healthcare Associated ◽  
Community Onset

Abstract Background CDI imposes a major burden on the U.S. healthcare system. Obtaining accurate estimates of economic costs is critical to determining the cost-effectiveness of preventive measures. This task is complicated by differences in epidemiology, mortality, and baseline health status of infected and uninfected individuals, and by the statistical properties of costs data (e.g., right-skewed, excess of zeros costs). Methods Incident CDI cases were identified from Medicare 5% fee-for-service data between 2011 and 2017 and classified into standard surveillance definitions: hospital-onset (HO); other healthcare facility-onset (OHFO); community-onset, healthcare-associated (CO-HCFA); or community-associated (CA). Cases were frequency matched 1:4 to uninfected controls based on age, sex, and year of CDI. Controls were assigned to surveillance definitions based on location at index dates. Medicare allowed costs were summed in 30-day intervals up to 3 years following index. One- and 3-year cumulative costs attributable to CDI were computed using a 3-part estimator consisting of a parametric survival model and a pair of 2-part models predicting costs separately in intervals where death did and did not occur, adjusting for underlying acute and chronic conditions. Results 60,492 CDI cases (Figure 1) were matched to 241,968 controls. Three-year mortality was higher among CDI cases compared to matched controls for HO (45% vs 26%) and OHFO (42% vs 36%), whereas mortality was slightly lower for CDI cases compared to controls for those with community onset (CO-HCFA: 28% vs 32%; CA: 10% vs 11%). One- and 3-year attributable costs due to CDI are shown in Figure 2. Adjusted 1-year attributable costs amounted to &26,954 (95% CI: &26,154–&27,939) for HO; &10,539 (&9,564–&11,518) for OHFO; &6,525 (&5,012–&8,171) for CO-HCFA; and &3,171 (&1,841–&4,200) for CA. Adjusted 3-year attributable costs were &44,736 (&43,063–&46,483) for HO; &13,994 (&12,529–&15,975) for OHFO; &7,349 (&4,738–&10,246) for CO-HCFA; and &2,377 (&166–&4,722) for CA. Figure 1. Proportion of Cases by CDI Surveillance Definitions Abbreviations: HO: hospital-onset; OHFO: other healthcare facility-onset; CO-HCFA: community-onset, healthcare-associated; CA: community-associated. Figure 2. Estimates of Costs Attributable to CDI by CDI Surveillance Definitions at One and Three Years after Onset Top panels: One-year cost estimates. Bottom panels: Three-year cost estimates. Abbreviations: HO: hospital-onset; OHFO: other healthcare facility-onset; CO-HCFA:community-onset, healthcare-associated; CA:community-associated. Conclusion CDI was associated with increased healthcare costs across surveillance definitions in Medicare fee-for-service patients after adjusting for survival and underlying conditions. Disclosures Dustin Stwalley, MA, AbbVie Inc (Shareholder)Bristol-Myers Squibb (Shareholder) Margaret A. Olsen, PhD, MPH, Pfizer (Consultant, Research Grant or Support) Holly Yu, MSPH, Pfizer (Employee) Erik R. Dubberke, MD, MSPH, Ferring (Grant/Research Support)Merck (Consultant)Pfizer (Consultant, Grant/Research Support)Seres (Consultant)Summit (Consultant)

scholarly journals Correlation between antibiotic consumption and the incidence of healthcare facility-onset Clostridioides difficile infection: a retrospective chart review and analysis

2021 ◽  
Vol 10 (1) ◽  
Author(s):  
Ji Hyun Yun ◽  
Ga Eun Park ◽  
Hyun Kyun Ki
Keyword(s):  
Risk Factor ◽  
Chart Review ◽  
Medical Center ◽  
Retrospective Chart Review ◽  
Healthcare Facility ◽  
Antibiotic Consumption ◽  
Time Interval ◽  
Clostridioides Difficile ◽  
Antibiotic Associated Diarrhea ◽  
Clostridioides Difficile Infection

Abstract Background Healthcare facility-onset Clostridioides difficile infection is the leading cause of antibiotic-associated diarrhea, and is associated with morbidity and mortality. The use of antibiotics is an important risk factor for healthcare facility-onset C. difficile infection. We evaluated the correlation between the incidence of healthcare facility-onset C. difficile infection and antibiotic consumption, according to antibiotic class. Methods Patients with healthcare facility-onset C. difficile infection from January 2017 to December 2018 at Konkuk University Medical Center (a tertiary medical center) were included. We evaluated changes in the incidence of healthcare facility-onset C. difficile infection and antibiotic consumption. The correlation between the incidence of healthcare facility-onset C. difficile infection and antibiotic consumption was evaluated two ways: without a time interval and with 1-month interval matching. Results A total of 446 episodes of healthcare facility-onset C. difficile infection occurred during the study period. The incidence of healthcare facility-onset C. difficile infection was 9.3 episodes per 10,000 patient-days, and increased significantly. We observed an increase in the consumption of β-lactam/β-lactamase inhibitors, and a decrease in the consumption of other classes of antibiotics, with a significant decrease in the consumption of fluoroquinolones, glycopeptides, and clindamycin (P = 0.01, P < 0.001, and P = 0.001, respectively). The consumption of β-lactam/β-lactamase inhibitors was independently correlated with the incidence of healthcare facility-onset C. difficile infection in the analysis without a time interval. When the analysis was conducted with 1-month interval matching, glycopeptide consumption was independently associated with the incidence of healthcare facility-onset C. difficile infection. Conclusions Despite the reduction in fluoroquinolone and clindamycin consumption, the incidence of healthcare facility-onset C. difficile infection increased during the study period, and was correlated with increased consumption of β-lactam/β-lactamase inhibitors. Reduced consumption of specific antibiotics may be insufficient to reduce the incidence of healthcare facility-onset C. difficile infection.

scholarly journals 780. How Much Does Prior Hospitalization Contribute to Readmission with Community-onset Clostridioides difficile Infection?

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S434-S435
Author(s):  
Alice Guh ◽  
Lauren C Korhonen ◽  
Lisa Gail Winston ◽  
Brittany Martin ◽  
Helen Johnston ◽  
...  
Keyword(s):  
Care Facility ◽  
Healthcare Facility ◽  
Care Hospital ◽  
Emerging Infections ◽  
Post Discharge ◽  
Term Care ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Community Onset

Abstract Background Interventions to reduce community-onset (CO) Clostridioides difficile Infection (CDI) are not usually hospital-based due to the perception that they are often acquired outside the hospital. We determined the proportion of admitted CO CDI that might be associated with previous hospitalization. Methods The CDC’s Emerging Infections Program conducts population-based CDI surveillance in 10 US sites. We defined an incident case as a C. difficile-positive stool collected in 2017 from a person aged ≥ 1 year admitted to a hospital with no positive tests in the prior 8 weeks. Cases were defined as CO if stool was collected within 3 days of hospitalization. CO cases were classified into four categories: long-term care facility (LTCF)-onset if patient was admitted from an LTCF; long-term acute care hospital (LTACH)-onset if patient was admitted from an LTACH; CO-healthcare-facility associated (CO-HCFA) if patient was admitted from a private residence but had a prior healthcare-facility admission in the past 12 weeks; or community-associated (CA) if there was no admission to a healthcare facility in the prior 12 weeks. We excluded hospitals with &lt; 10 cases among admitted catchment-area residents. Results Of 4724 cases in 86 hospitals, 2984 (63.2%) were CO (median per hospital: 65.8%; interquartile range [IQR]: 58.3%-70.7%). Among the CO cases, 1424 (47.7%) were CA (median per hospital: 48.1%; IQR: 40.3%-57.7%), 1201 (40.3%) were CO-HCFA (median per hospital: 41.0%; IQR: 32.9%-47.8%), 350 (11.7%) were LTCF-onset (median per hospital: 10.0%; IQR: 0.6%-14.4%), and 9 (0.3%) were LTACH-onset. Of 1201 CO-HCFA cases, 1174 (97.8%) had a prior hospitalization; among these, 978 (83.3%) (median per hospital: 83.3%; IQR: 69.2%-90.6%), which consists of 32.8% of all hospitalized CO cases, had been discharged from the same hospital (Figure), and 84.4% of the 978 cases (median per hospital: 88.2%: IQR: 76.5%-100.0%) had received antibiotics sometime in the prior 12 weeks. Figure. Frequency of Cases Discharged in the 12 Weeks Prior to Readmission with Clostridioides difficile Infection (N=1138*) Conclusion A third of hospitalized CO CDI had been recently discharged from the same hospital, and most had received antibiotics during or soon after the last admission. Hospital-based and post-discharge antibiotic stewardship interventions could help reduce subsequent CDI hospitalizations. Disclosures Ghinwa Dumyati, MD, Roche Diagnostics (Consultant)

scholarly journals 2414. Effectiveness of Oral Vancomycin for Prevention of Healthcare Facility-Onset Clostridioides difficile Infection in High-Risk Patients

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S833-S833
Author(s):  
Steven W Johnson ◽  
David H Priest ◽  
Shannon V Brown
Keyword(s):  
High Risk ◽  
Medical Center ◽  
Healthcare Facility ◽  
Oral Vancomycin ◽  
High Risk Patients ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Risk Patients ◽  
Systemic Antibiotics ◽  
The Impact

Abstract Background Studies suggest oral vancomycin prophylaxis may be effective in preventing Clostridioides difficile infection. These studies are limited by their retrospective design, reliance on local clinical practice patterns, lack of intervention standardization, and limited risk stratification. We sought to evaluate the effectiveness of oral vancomycin for the prevention of healthcare facility-onset CDI (HCFO-CDI) in high-risk patients. Methods We conducted a randomized, prospective, open-label study at Novant Health Forsyth Medical Center in Winston-Salem, North Carolina between October 2018 and April 2019. Admitted high-risk patients (defined as: ≥ 60 years of age, hospitalized ≤ 30 days prior to the index hospitalization and received systemic antibiotics during that prior hospitalization and currently receiving systemic antibiotics) were randomized 1:1 to either oral vancomycin (dosed at 125 mg once daily while receiving systemic antibiotics and continued for 5 days post completion of systemic antibiotics [OVP]), or no prophylaxis. The primary endpoint was incidence of HCFO-CDI. Secondary endpoints included incidence of community-onset healthcare facility-associated CDI (CO-HCFA-CDI), development of VRE colonization after receiving OVP, and adverse effects and cost of OVP. Results A total of 100 patients were evaluated, 50 patients in each group. Baseline and hospitalization characteristics were similar in each group. No incidents of HCFO-CDI were diagnosed in the OVP group compared with 6 (12%) in the no prophylaxis group (P = 0.03). CO-HCFA-CDI was not observed in either group. No patients developed new VRE colonization with only 1 patient reporting mild gastrointestinal side-effects to OVP. A total of 600 doses of OVP were given during the study, with each patient receiving an average of 12 doses. Total acquisition cost of OVP was $728.25, $60.69 per patient. Conclusion OVP was highly effective in preventing HCFO-CDI. OVP was well tolerated with no apparent risk for VRE colonization. Further prospective investigation is warranted to determine the impact and cost-effectiveness of routine use of OVP in high-risk patients. Disclosures All authors: No reported disclosures.

Differences in time-to-testing and time-to-isolation between community-onset and hospital-onset Clostridioides difficile cases at a tertiary care VA medical center

2020 ◽  
Vol 48 (10) ◽  
pp. 1148-1151
Author(s):  
Christopher J. Hostler ◽  
J. Bradford Bertumen ◽  
Lawrence P. Park ◽  
Susan B. Wilkins ◽  
Christopher W. Woods
Keyword(s):  
Medical Center ◽  
Tertiary Care ◽  
Clostridioides Difficile ◽  
Community Onset

scholarly journals Community-Onset Clostridioides Difficile Infection in Hospitalized Patients in The Netherlands

2019 ◽  
Vol 6 (12) ◽  
Author(s):  
M J T Crobach ◽  
D W Notermans ◽  
C Harmanus ◽  
I M J G Sanders ◽  
S C De Greeff ◽  
...  
Keyword(s):  
The Netherlands ◽  
Healthcare Facility ◽  
Hospitalized Patients ◽  
Surveillance Program ◽  
Reference Laboratory ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Surveillance Programs ◽  
Outpatient Settings ◽  
Community Onset

Abstract Background Clostridioides difficile infection (CDI) is increasingly reported in the community. The aim of this study was to analyze characteristics of hospitalized patients with community-onset CDI (CO-CDI). Methods In the Netherlands, 24 hospitals (university-affiliated and general hospitals) participate in the sentinel CDI surveillance program. Clinical characteristics and 30-day outcomes of hospitalized patients &gt;2 years old diagnosed with CDI are registered. Samples of these patients are sent to the national reference laboratory for polymerase chain reaction ribotyping. Data obtained for this surveillance from May 2012 to May 2018 were used to compare CO-CDI with hospital-onset (HO)-CDI episodes. Results Of 5405 registered cases, 2834 (52.4%) were reported as HO-CDI, 2174 (40.2%) were CO-CDI, and 339 (6.3%) had onset of symptoms in another healthcare facility (eg, nursing home). The proportion of CO-CDI increased over the years and was lower during winter months. Hospitalized patients with CO-CDI were younger (63.8 vs 68.0 years, P &lt; .001) and more often females (53.0% vs 49.6%, P = .02) than patients with HO-CDI. Median time between onset of symptoms and CDI testing was longer in CO-CDI (4 vs 1 day, P &lt; .001). Similar ribotypes were found in CO-CDI and HO-CDI, but ribotype 001 was more frequent among HO-CDI, whereas ribotype 023 was more frequent in CO-CDI. Six of 7 (85.7%) surgeries due to CDI, 27 of 50 (54%) ICU admissions due to CDI, and 48 of 107 (44.9%) of CDI-associated deaths were attributable to CO-CDI. Conclusions Our study demonstrates that patients hospitalized with CO-CDI contribute substantially to the total number of CDI episodes and CDI-associated complications in hospitals, stressing the need for awareness and early testing for CDI in community and outpatient settings and also in patients admitted from community with diarrhoea. Surveillance programs that also target nonhospitalized CDI patients are needed to understand the true burden and dynamics of CDI.

scholarly journals 2353. Easy Does It: Decreasing and Sustained Hospital-Onset (HO) CDI Lab-ID Event Incidence Through a Series of Interventions

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S809-S810
Author(s):  
Rachael A Lee ◽  
Jeremey Walker ◽  
Elizabeth Freeze ◽  
Rashida Khalid ◽  
Bernard Camins
Keyword(s):  
Care Center ◽  
Tertiary Care ◽  
Diagnostic Testing ◽  
Computer Assisted ◽  
Oncology Patient ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
The Difference ◽  
Testing Algorithm ◽  
Main Component

Abstract Background Clostridioides difficile infection (CDI) Laboratory (Lab) identified (ID) events are reportable to CMS through the CDC’s NHSN. Prevention of transmission has been the main component of interventions; however, avoiding false-positive laboratory diagnoses can also lead to decreased incidence. Methods A retrospective analysis of HO-CDI Lab-ID events was conducted to evaluate the results of a series of interventions at the University of Alabama Hospital, a 1150-bed tertiary care center in Birmingham, AL. The study period was from the first quarter of 2013 (1Q 2013) until 1Q of 2019. Interventions were implemented in sequential order were: (i) CDI prevention bundle education (3Q 2014); (ii) two-step laboratory testing algorithm (2Q 2015); (iii) selective enhanced environmental disinfection on oncology units (2Q 2016); (iv) diagnostic stewardship by reminding providers to reconsider testing if the patient received a laxative within 48 hours (4Q 2016). Results At the beginning of the study period, the HO CDI Lab ID Event SIR was 0.96. The standard infection ratio (SIR) over the time period is shown in Figure 1. We observed a slight decrease in HO-CDI Lab ID event SIR after implementation of the CDI prevention bundle (0.96 vs. 0.77). A change in the diagnostic testing from PCR-based to a two-step algorithm (EIA testing for GDH and Toxin confirmed by PCR) resulted in a slight increase although not statistically significant (0.77 vs. 0.83). A downward trend was observed when selective enhanced terminal disinfection with hydrogen peroxide vapor was performed on all oncology patient rooms vacated by patients with CDI (0.83 vs. 0.72). The largest and sustained impact was observed after implementation of a computer-assisted diagnostic stewardship in which providers were reminded if the patient was administered any stool softener or laxative within 48 hours of the order for CDI testing (0.72 vs. 0.32). The institutions SIR value became significant in 2Q 2016 (P = 0.0014) and significance was maintained since that time. The difference between expected and observe HO-CDI Lab ID events is demonstrated in Figure 2. Conclusion Through a series of interventions, we observed a decrease in HO-CDI event rates. Diagnostic stewardship with academic detailing resulted in the most impactful and sustained improvement. Disclosures All authors: No reported disclosures.

scholarly journals Effectiveness of Oral Vancomycin for Prevention of Healthcare Facility–Onset Clostridioides difficile Infection in Targeted Patients During Systemic Antibiotic Exposure

2019 ◽  
Vol 71 (5) ◽  
pp. 1133-1139 ◽  
Author(s):  
Steven W Johnson ◽  
Shannon V Brown ◽  
David H Priest
Keyword(s):  
Medical Center ◽  
Healthcare Facility ◽  
Antibiotic Exposure ◽  
Oral Vancomycin ◽  
Open Label ◽  
Systemic Antibiotic ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Gastrointestinal Side Effects ◽  
Systemic Antibiotics

Abstract Background Limited retrospective data suggest prophylactic oral vancomycin may prevent Clostridioides difficile infection (CDI). We sought to evaluate the effectiveness of oral vancomycin for the prevention of healthcare facility–onset CDI (HCFO-CDI) in targeted patients. Methods We conducted a randomized, prospective, open-label study at Novant Health Forsyth Medical Center in Winston-Salem, North Carolina, between October 2018 and April 2019. Included patients were randomized 1:1 to either oral vancomycin (dosed at 125 mg once daily while receiving systemic antibiotics and continued for 5 days postcompletion of systemic antibiotics [OVP]) or no prophylaxis. The primary endpoint was incidence of HCFO-CDI. Secondary endpoints included incidence of community-onset healthcare facility–associated CDI (CO-HCFA-CDI), incidence of vancomycin-resistant Enterococci (VRE) colonization after receiving OVP, adverse effects, and cost of OVP. Results A total of 100 patients were evaluated, 50 patients in each arm. Baseline and hospitalization characteristics were similar, except antibiotic exposure. No events of HCFO-CDI were noted in the OVP group compared with 6 (12%) in the no-prophylaxis group (P = .03). CO-HCFA-CDI was identified in 2 patients who were previously diagnosed with HCFO-CDI. No patients developed new VRE colonization, with only 1 patient reporting mild gastrointestinal side effects to OVP. A total of 600 doses of OVP were given during the study, with each patient receiving an average of 12 doses. Total acquisition cost of OVP was $1302, $26.04 per patient. Conclusion OVP appears to protect against HCFO-CDI during in-patient stay in targeted patients during systemic antibiotic exposure. Further prospective investigation is warranted.

Incorporating preauthorization into antimicrobial stewardship pharmacist workflow reduces Clostridioides difficile and gastrointestinal panel testing

2020 ◽  
Vol 41 (10) ◽  
pp. 1136-1141
Author(s):  
Nikki N. Tran ◽  
John P. Mills ◽  
Christopher Zimmerman ◽  
Tejal N. Gandhi ◽  
Alison C. Tribble ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Best Practice ◽  
Medical Center ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
Oral Contrast ◽  
Prior Authorization ◽  
Panel Testing ◽  
Clostridioides Difficile ◽  
Stewardship Program

AbstractObjective: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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