Incorporating preauthorization into antimicrobial stewardship pharmacist workflow reduces Clostridioides difficile and gastrointestinal panel testing
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Updated: Dec 19, 2025
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Published on: April 18, 2019
Nikki N Tran1, John P Mills2, Christopher Zimmerman3
1Department of Pharmacy, University of Michigan, Ann Arbor, Michigan.
Objective:
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.
Insights
Implementing mandatory prior authorization for Clostridioides difficile testing significantly reduced diagnostic test orders. This antimicrobial stewardship strategy proved effective in a tertiary care setting.
Area of Science:
- Infectious Diseases
- Antimicrobial Stewardship
- Diagnostic Stewardship
Background:
- Clostridioides difficile infection (CDI) diagnosis relies on specific testing, but inappropriate utilization can occur.
- Alternative etiologies for diarrhea are common, leading to potential overuse of CDI diagnostic tests.
- Antimicrobial stewardship programs (ASPs) aim to optimize antimicrobial use and diagnostic test appropriateness.
Purpose of the Study:
- To assess the impact of mandatory prior authorization for Clostridioides difficile testing on diagnostic test utilization.
- To evaluate the effectiveness of integrating prior authorization into an antimicrobial stewardship pharmacist workflow.
- To determine if this intervention reduces testing in patients with non-CDI diarrhea causes.
Main Methods:
- A quasi-experimental, before-and-after study design was employed at a single tertiary-care academic medical center.
- A best-practice alert was implemented, requiring antimicrobial stewardship program (ASP) pharmacist approval for C. difficile enzyme immunoassay (EIA) and gastrointestinal pathogen panel (GIPAN) testing.
- Approval necessitated direct communication between the ordering provider and the ASP pharmacist to discuss testing rationale.
Main Results:
- The weekly rate of EIA orders per 1,000 patient days decreased significantly from 6.05 to 4.87 (IRR 0.72, P = .010).
- The weekly rate of GIPAN orders per 1,000 patient days also decreased significantly from 1.72 to 0.89 (IRR 0.53, P = .001).
- An average of 2.5 requests per day were managed by the ASP during the 3-month intervention period.
Conclusions:
- Mandatory prior authorization integrated into ASP workflow is an efficient and effective model for diagnostic stewardship.
- This intervention successfully reduced the utilization of C. difficile and GIPAN testing.
- The study highlights a practical approach to improve appropriate diagnostic test ordering in healthcare settings.
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