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Implementation of a Structured Process for Clinically Indicated Testing for Clostridioides difficile Infections in
Molly Kusma1, Jeanne Little2, Larry Kociolek3
1Pediatric Hematology, Oncology, and Stem Cell Transplant Nurse Practitioner, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
Insights
A best practice advisory reduced Clostridioides difficile (C. difficile) testing in pediatric oncology and stem cell transplant patients. This led to fewer tests ordered but a higher proportion of positive results, indicating more accurate diagnosis of C. difficile infections (CDI).
Area of Science:
- Infectious Diseases
- Healthcare Management
- Pediatric Oncology
Background:
- Clostridioides difficile (C. difficile) causes healthcare-associated infectious diarrhea.
- Pediatric oncology and stem cell transplant (SCT) patients face higher risks of C. difficile infections (CDI) and colonization.
- Misdiagnosing colonization as infection leads to overtreatment, antibiotic resistance, and inflated CDI rates.
Purpose of the Study:
- To evaluate the impact of a best practice advisory (BPA) on C. difficile testing in high-risk pediatric populations.
- To reduce unnecessary C. difficile diagnostic testing while improving the accuracy of CDI identification.
Main Methods:
- Implemented an electronic medical record-based BPA to guide C. difficile testing decisions.
- Tests were ordered only if patients met predefined clinical criteria.
- Compared CDI test ordering rates, positive test rates, and test positivity proportion before and after BPA implementation.
Main Results:
- Total CDI tests ordered decreased from 8.2 to 5.7 per 1,000 patient days.
- Positive CDI tests increased from 2.2 to 3.5 per 1,000 patient days.
- The proportion of positive tests rose significantly from 27% to 61%.
Conclusions:
- The BPA effectively reduced C. difficile testing frequency in pediatric oncology/SCT patients.
- Increased test positivity suggests improved targeting of CDI testing and identification of true infections.
- Further investigation is needed to differentiate between improved diagnostics and actual changes in CDI incidence.
Abstract:
Background: Clostridioides difficile (C. difficile) is the primary cause of healthcare-associated infectious diarrhea. Pediatric patients with oncology and stem cell transplant (SCT) diagnoses are at greater risk of C. difficile infections (CDI) and C. difficile colonization than those without. Misdiagnosis of C. difficile colonization as infection and subsequent unnecessary treatment can lead to antibiotic resistance, increased healthcare costs, and an overestimation of CDI rates. Methods: A best practice advisory (BPA) was built into the electronic medical record to guide decision making regarding clinically indicated C. difficile testing. Tests for CDI were to be sent only if the patient met all the predefined clinical criteria for testing. The number of CDI tests ordered per 1,000 patient days, the number of tests positive per 1,000 patient days, and the proportion of positive tests were compared before and after implementation. Results: The number of tests ordered per 1,000 patient days declined from 8.2 to 5.7 after the intervention. Positive tests per 1,000 patient days increased from 2.2 to 3.5 after the intervention. This demonstrates an increase in the proportion of positive tests from 27% to 61%. Discussion: This intervention led to fewer CDI tests ordered, but CDI incidence and test positivity proportion increased. This is likely reflective of better-targeted testing for CDI and the identification of true-positive cases of infection, but we cannot rule out a coincident increase in CDI activity during the study period. Through education and electronic reminders of the clinical indicators for testing for CDI, the frequency of testing for C. difficile was reduced.
