Evaluating Adherence to Guideline-Directed C Difficile Infection Management Pre- and Postimplementation of an Electronic Order Set

2020 ◽  
pp. 089719002090385
Author(s):  
Aamer Attaar ◽  
Juanqin Wei ◽  
Luigi Brunetti
Keyword(s):  
Infectious Disease ◽  
Primary Outcome ◽  
Secondary Outcome ◽  
Single Center ◽  
Clostridioides Difficile ◽  
Order Sets ◽  
Before And After ◽  
Clostridioides Difficile Infection ◽  
Electronic Order ◽  
Order Set

Background: After publication of the Clostridioides difficile infection (CDI) guidelines by the Infectious Disease Society of America (IDSA) in early 2018, we identified that many prescribers at our institution continued to practice using the older guidelines. Objective: This study aimed to determine whether the implementation of an electronic order set for CDI would increase prescriber compliance to current IDSA recommendations for CDI management. Methods: This was a single-center, prospective cohort study of adult inpatients with a confirmed CDI. The study was conducted between March 1, 2018, and April 1, 2019. Patients were stratified into a preintervention and postintervention group before and after order set implementation. The primary outcome was a composite of appropriate CDI therapy selection and discontinuation of nonessential antimicrobials and acid-suppressive agents. The secondary outcome evaluated appropriate CDI therapy medications prescribed at hospital discharge. Results: Of the 149 patients included in this study, 96 were included in a preintervention group and 53 included in a postintervention group. The primary outcome was met in 45% of patients in the preintervention group and 66% of patients in the postintervention group ( P = .01). The secondary outcome occurred in 86% of patients in the preintervention group and 100% of patients in the postintervention group ( P = .02). Conclusion: Implementation of a CDI electronic order set and alert bundle was associated with enhanced prescriber adherence to guideline-directed therapy. Our results suggest that order sets not only improve inpatient compliance to guidelines but may also improve medication-related adherence to guideline recommendations upon discharge.

Dose addition of intravenous metronidazole to oral vancomycin improve outcomes in Clostridioides difficile infection?

2019 ◽  
Author(s):  
Ying Wang ◽  
Aaron Schluger ◽  
Jianhua Li ◽  
Angela Gomez-Simmonds ◽  
Hojjat Salmasian ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Primary Outcome ◽  
Time Window ◽  
Dual Therapy ◽  
Secondary Outcome ◽  
Index Test ◽  
Oral Vancomycin ◽  
Clostridioides Difficile ◽  
Improved Outcomes ◽  
Clostridioides Difficile Infection

Abstract Background Guidelines recommend adding intravenous (IV) metronidazole to oral vancomycin for fulminant Clostridioides difficile infection (CDI). This study compared dual therapy with IV metronidazole and oral vancomycin versus vancomycin monotherapy. It assessed prevalence of use and effectiveness of dual therapy in non-fulminant and fulminant CDI. Methods This was a two-center retrospective study conducted from 2010 to 2018. Adult inpatients were included if they had a positive C. difficile PCR performed on an unformed stool and received oral vancomycin within two days (either before or after) of testing. Patients were classified as having received dual therapy if IV metronidazole was given within the same time window, and otherwise as having received vancomycin monotherapy. The primary outcome was  death or colectomy within 90 days after the index test. Logistic regression modeling was used to adjust for CDI severity and other established predictors of CDI outcomes. CDI recurrence was examined as a secondary outcome, adjusting for death as a competing risk. Results The study included 2,114 patients (dual therapy: 993; monotherapy: 1,121) of whom 23% met the primary outcome. There was no association between dual therapy and the primary outcome (adjusted OR (aOR) 1.07, 95% CI 0.79-1.45) which remained true when the analysis was restricted to patients with fulminant CDI (aOR 1.17, 95% CI 0.65-2.10). There was also no association between dual therapy and CDI recurrence. Conclusions Dual therapy with IV metronidazole and oral vancomycin was common for non-fulminant and fulminant CDI, but was not associated with improved outcomes compared to vancomycin alone.

scholarly journals 236. Incorporating Clinical Guidance into Computerized Prescriber Order Entry May Reduce Fluoroquinolone Utilization for the Treatment of Diverticulitis at a Rural Community Health System

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S118-S119
Author(s):  
Raghavendra Tirupathi ◽  
Benton Miller ◽  
Jarett Logsdon
Keyword(s):  
Time Frame ◽  
Secondary Outcome ◽  
Control Group ◽  
Order Entry ◽  
Clinical Guidance ◽  
Clostridioides Difficile ◽  
Days Of Therapy ◽  
Order Sets ◽  
Computerized Prescriber Order Entry ◽  
Order Set

Abstract Background Fluoroquinolones are associated with many adverse effects. As a result, many hospitals are investigating methods to reduce fluoroquinolone use. Computerized prescriber order entry (CPOE) provides an opportunity to develop and implement clinically guided order sets that discourage the use of fluoroquinolones. To date, there are few studies investigating the effect of clinically guided order sets on medication utilization. This study aims to investigate the hypothesis that incorporating clinical guidance and leveraging antimicrobial stewardship into a CPOE diverticulitis order set would reduce fluoroquinolone use in the treatment of diverticulitis. Methods A diverticulitis order set was revised to provide guided antibiotic selection based on a patient’s penicillin allergy. Patients were split into two groups based on admission date relative to the implementation date of the revised order set. Fluoroquinolone use was compared between both groups. The primary outcome was the percentage of patients who were ordered a fluoroquinolone-containing regimen during their stay. The secondary outcome was the percentage of regimens that contained a fluoroquinolone. A subgroup analysis was conducted exclusively on patients whose antibiotics were ordered with the diverticulitis order set. Results 494 patients were included in the study. 316 patients in the pre-order set group, 178 patients in the post-order set group. 56% of patients in the pre-group received a fluoroquinolone in their regimen versus 46% of patients in the post-group (RR=0.82; 95% CI 0.68–0.99, p = 0.028). 49% of regimens in the control group contained a fluoroquinolone versus 39% of regimens in the experimental group (RR=0.78; 95% CI 0.64–0.95; p = 0.012). 77.5% of patients in the control subgroup received a fluoroquinolone in their regimen versus 42.4% of patients in the experimental subgroup (RR=0.55; 95% CI 0.36–0.84, p = 0.0062). Fluoroquinolone days of therapy decreased from 90.6 to 58.6 from 2018–2019. Clostridioides difficile infections also decreased during this time frame. Table 1: Average fluoroquinolone days of therapy per 1000 patient days Figure 1: Percentage of Diverticulitis Orders by Antibiotic Regimen: Pre- and Post-Order Set Change. CFP=cefepime, Metro=metronidazole, PIP-TZ=piperacillin-tazobactam, AM-SB=ampicillin-sulbactam, CIP=ciprofloxacin, Levo=levofloxacin, FQ=fluoroquinolone Figure 2: Fluoroquinolone days of therapy per 1000 patient days from 2016–2020. Conclusion Our findings support the hypothesis that incorporating clinical guidance into a CPOE order set would reduce fluoroquinolone use for the treatment of diverticulitis. Figure 3: Indicence of Clostridioides difficile infection per 1000 patient days Disclosures All Authors: No reported disclosures

scholarly journals A preliminary study of bowel rest strategy in the management of Clostridioides difficile infection

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Hiroshi Sugimoto ◽  
Ayaka Yoshihara ◽  
Takao Yamamoto ◽  
Keisuke Sugimoto
Keyword(s):  
Secondary Outcome ◽  
Control Group ◽  
Matched Cohort ◽  
Full Cohort ◽  
Clostridioides Difficile ◽  
Significant Difference ◽  
All Cause Mortality ◽  
Clostridioides Difficile Infection ◽  
Bowel Rest ◽  
Preliminary Study

AbstractClostridioides difficile infection (CDI) is an important nosocomial infection and is the leading cause of infectious diarrhea in hospitalized patients. We aimed to assess the effect of bowel rest on the management of CDI. A single-center retrospective cohort study was conducted. The primary outcome was the composite of the all-cause mortality and CDI recurrence within 30 days. The main secondary outcome was switching from metronidazole to vancomycin. Of the 91 patients with CDI enrolled as the full cohort, 63 patients (69%) and 28 patients (31%) constituted the control group and the bowel rest group, respectively. After one-to-one propensity score matching, a total of 46 patients were included as the matched cohort. In the full cohort, the composite outcome occurred in 19.0% and 14.3% of the patients in the control and the bowel rest group, respectively (p = 0.768). In the matched cohort, it was 17.4% in each group. Although there was no statistically significant difference, the trend of switching was lower in the bowel rest group. The bowel rest may not affect the all-cause mortality and CDI recurrence within 30 days. However, in those prescribed bowel rest, switching from metronidazole to vancomycin may reduce.

scholarly journals 2373. Impact of a Change in Testing Strategy for Clostridioides difficile Infection on a Publicly Reported Metric and Treatment Days of Therapy

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S818-S819
Author(s):  
Ryan Miller ◽  
Jose A Morillas ◽  
Joanne Sitaras ◽  
Jacob Bako ◽  
Elizabeth A Neuner ◽  
...  
Keyword(s):  
Health System ◽  
Diagnostic Testing ◽  
Cleveland Clinic ◽  
Public Reporting ◽  
Testing Strategy ◽  
Clostridioides Difficile ◽  
Days Of Therapy ◽  
Before And After ◽  
Clostridioides Difficile Infection ◽  
The Impact

Abstract Background In an effort to optimize diagnostic testing for Clostridioides difficile infection (CDI) our health system changed from stand-alone PCR testing to a “2-step” approach wherein all positive PCR results reflexed to an EIA. We report the effects of this change on publicly reported CDI metrics and treatment days of therapy (DOT). Methods The setting includes 10 Cleveland Clinic Health System hospitals in northeast Ohio and one in Florida. On June 12, 2018, 9 NE Ohio hospitals changed from PCR alone to PCR followed by EIA. Stand-alone PCR testing remained at one and GDH / EIA / PCR for discordant for another. Testing volumes were obtained from the microbiology laboratory. C. difficile LabID event SIRs were obtained from NHSN. Public reporting interpretative categories were identified based on SIR for second half of 2018. DOT for CDI agents were obtained from an antimicrobial stewardship database. Results Among hospitals that changed strategy the volume of PCR testing and the percent PCR + was similar between time periods. EIA positivity ranged from 23% to 53%. 4/11 hospitals improved their public reporting category: 3/9 that changed testing strategy and 1/2 that did not (Table 1). Two of 3 that changed strategy and improved public reporting also had a decrease in DOT. DOT increased in the 2 hospitals that did not change strategy. Conclusion Six months after adopting a 2-step CDI testing strategy 7 of 9 hospitals had a lower SIR with 3 also demonstrating an improvement in public reporting category favorably impacting reputational and reimbursement risk for our healthcare system. CDI agent DOT was similar before and after the change. The impact of choice of test on publicly reported metrics demonstrates the difficulty of utilizing a proxy for hospital onset CDI, the CDI LabID event, as a measure of quality of care provided. Disclosures All authors: No reported disclosures.

scholarly journals MP011: Using GRADE-based recommendations for analgesia and antiemetics in electronic order sets to influence physician behaviour towards best practice and cost-savings

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S69-S70
Author(s):  
R.J. Hartmann ◽  
E. Lang ◽  
T. Rich ◽  
B. Ford ◽  
K. Lonergan ◽  
...  
Keyword(s):  
Best Practices ◽  
Working Group ◽  
Cost Savings ◽  
Sufficient Evidence ◽  
New Order ◽  
Order Entry ◽  
Physician Behaviour ◽  
Order Sets ◽  
Electronic Order ◽  
Order Set

Introduction: The addition of computerized physician order entry (CPOE) to Emergency Departments in recent years has led to speculation over potential benefits and pitfalls. Recent studies have shown benefits to CPOE, though there lacks sufficient evidence on how it could change physician behaviour. Physician practices are known to be difficult to change, with getting evidence into daily practice being the main challenge of knowledge translation. Our study aims were to determine if well-designed electronic order sets for CPOE improved MD practices. Methods: The Calgary Zone Pain Management in the Emergency Department Working Group relied on a GRADE-based literature review for identifying best practices for analgesia and antiemetics, resulting in soft changes to the dedicated analgesia and antiemetic electronic order set noting working group preference, and emphasizing hydromorphone over morphine, as well as 4 mg ondansetron over 8 mg. The new electronic order set was started in the only Calgary Region order entry system on December 11th, 2014. Data was collected from July 2014 - May 2015. A Yates chi-squared analysis was completed on all orders in a category, as well as the subgroups of ED staff and residents, and orders placed using the new order set. Results: A total of 100460 orders were analyzed. The use of hydromorphone increased significantly across all 4 EDs. IV hydromorphone use increased (5.82% of all opioid orders up to 26.93%, P<0.0001) with a reciprocal decline in IV morphine (67.81% of all opioid orders down to 46.56%, P<0.0001). Similar effects were observed with ondansetron 4 mg IV orders increasing (1.37% of all ondansetron orders to 18.64%, P<0.0001) with a decrease in 8 mg dosing (15.75% of all ondansetron orders to 7.23%, P<0.0001). These results were replicated to a lesser degree in the non-ED staff and non-order set subgroups. Implementation of the new order set resulted in an increase of its use (37.64% of all opioid orders up to 49.29%, P<0.0001). Finally, a cost-savings analysis was completed showing a projected annual savings of $185,676.52 on medications alone. Conclusion: This data supports the manipulation of electronic order sets to help shape physician behaviour towards best practices. This provides another strong argument towards the benefits of CPOE, and can help maintain best practices in Emergency Medicine.

scholarly journals Risk Factors for BI/NAP1/027 Clostridioides difficile Infections and Clinical Outcomes Compared With Non-NAP1 Strains

2019 ◽  
Vol 6 (12) ◽  
Author(s):  
Nandita S Mani ◽  
John B Lynch ◽  
Ferric C Fang ◽  
Jeannie D Chan
Keyword(s):  
Risk Factors ◽  
Proton Pump Inhibitor ◽  
Clinical Outcomes ◽  
Case Control ◽  
Nursing Facilities ◽  
Single Center ◽  
Retrospective Case ◽  
Skilled Nursing ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection

Abstract We aim to describe the characteristics, risk factors, and clinical outcomes associated with NAP1 strain Clostridioides difficile infection (CDI) in this single-center, retrospective, case–control (1:1) study. We found that the NAP1 strain accounted for 19.7% of CDI, and risk factors for acquisition included residence in skilled nursing facilities, previous CDI, and proton pump inhibitor use.

scholarly journals Microbiota-based markers predictive of development of Clostridioides difficile infection

2021 ◽  
Vol 12 (1) ◽  
Author(s):  
Matilda Berkell ◽  
◽  
Mohamed Mysara ◽  
Basil Britto Xavier ◽  
Cornelis H. van Werkhoven ◽  
...  
Keyword(s):  
Antibiotic Treatment ◽  
Intestinal Microbiota ◽  
Healthcare Costs ◽  
Beta Lactams ◽  
Clostridioides Difficile ◽  
Before And After ◽  
Clostridioides Difficile Infection ◽  
Patients At Risk ◽  
Risk Patients ◽  
Considerable Morbidity

AbstractAntibiotic-induced modulation of the intestinal microbiota can lead to Clostridioides difficile infection (CDI), which is associated with considerable morbidity, mortality, and healthcare-costs globally. Therefore, identification of markers predictive of CDI could substantially contribute to guiding therapy and decreasing the infection burden. Here, we analyze the intestinal microbiota of hospitalized patients at increased CDI risk in a prospective, 90-day cohort-study before and after antibiotic treatment and at diarrhea onset. We show that patients developing CDI already exhibit significantly lower diversity before antibiotic treatment and a distinct microbiota enriched in Enterococcus and depleted of Ruminococcus, Blautia, Prevotella and Bifidobacterium compared to non-CDI patients. We find that antibiotic treatment-induced dysbiosis is class-specific with beta-lactams further increasing enterococcal abundance. Our findings, validated in an independent prospective patient cohort developing CDI, can be exploited to enrich for high-risk patients in prospective clinical trials, and to develop predictive microbiota-based diagnostics for management of patients at risk for CDI.

“If the glove fits”: Hospital-wide universal gloving is associated with improved hand hygiene and may reduce Clostridioides difficile infection

2021 ◽  
pp. 1-5
Author(s):  
Paritosh Prasad ◽  
Lynne Brown ◽  
Shiyang Ma ◽  
Andrew McDavid ◽  
Andrew Rudmann ◽  
...  
Keyword(s):  
Hand Hygiene ◽  
Hand Hygiene Compliance ◽  
Fold Increase ◽  
Credible Interval ◽  
Clostridioides Difficile ◽  
Before And After ◽  
Clostridioides Difficile Infection ◽  
Quasi Experimental ◽  
Hygiene Compliance ◽  
Hospital Acquired

Abstract Objective: To determine whether a hospital-wide universal gloving program resulted in increased hand hygiene compliance and reduced inpatient Clostridioides difficile infection (CDI) rates. Design: We carried out a multiple-year before-and-after quasi-experimental quality improvement study. Gloving and hand hygiene compliance data as well as hospital-acquired infection rates were prospectively collected from January 1, 2015, to December 31, 2017, by secret monitors. Settings: The University of Rochester Strong Memorial Hospital, an 849-bed quaternary-care teaching hospital. Patients: All adult inpatients with the exception of patients in the obstetrics unit. Interventions: A hospital-wide universal gloving protocol was initiated on January 1, 2016. Results: Hand hygiene compliance increased from 68% in 2015 reaching an average of 88% by 2017 (P < .0002). A 10% increase in gloving per unit was associated with a 1.13-fold increase in the odds of hand hygiene (95% credible interval, 1.12–1.14). The rates of CDI decreased from 1.05 infections per 1,000 patient days in 2015 to 0.74 in 2017 (P < .04). Conclusion: A universal gloving initiative was associated with a statistically significant increase in both gloving and hand hygiene compliance. CDI rates decreased during this intervention.

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