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Is a "Hard Stop" Method the Key to Reducing Inappropriate C. difficile Testing?

NOV 16, 2017 | KRISTI ROSA
Classified by the Centers for Disease Control and Prevention (CDC) as an urgent threat to public health, Clostridium difficile (C. difficile) infections (CDIs) continue to pose a huge challenge in health care facilities everywhere.

As such, practitioners have been openly sharing with each other different methods that they have tried in their own facilities to get a leg-up on a disease that results in about 14,000 deaths per year and $1 billion in excess medical costs.

At ID Week 2017 in San Diego, California, Marci Drees, MD, MS, FACP, DTMH, infection prevention officer and hospital epidemiologist for Christiana Care Health System, delivered a short presentation as part of an Oral Abstract Session discussing a testing stewardship approach involving a “hard stop” to reduce inappropriate CDI testing.

“Testing, or diagnostic stewardship, involves modifying the process of ordering, performing, and reporting diagnostic tests to improve treatment of infections,” Dr. Drees said. She then explained how modifying the process of ordering tests, specifically, is a way to reduce inappropriate testing in health care facilities. 

Dr. Dree’s community-based academic tertiary care system located in northern Delaware consists of 2 facilities: a large suburban hospital consisting of 913 beds, and a small urban acute care hospital consisting of only 241 beds. The care system recently transitioned from a 2-step algorithm for CDI testing that included an enzyme immunoassay (EIA) and polymerase chain reaction (PCR) testing to PCR testing only in January 2015. Immediately after this transition, the hospital reported a 20%-25% increase in positive CDI tests.

“Of course, we did, at the time, educate our clinicians about this new testing algorithm—that it was going to be sensitive and that we should be smart about how we’re testing,” Dr. Drees added. “But, as we were starting to see these cases rolling in, the infection preventionist that reviews all the cases noted that many of them that were turning positive were tested in a setting of recent laxative use.”

She noted that to ensure diagnostic accuracy, patients who are tested should:
  1. Have documented diarrheal disease
  2. Have not received laxatives in the past 48 hours
To ensure testing appropriateness, Dr. Drees’ institution introduced multiple initiatives. One such initiative was a laxative alert, kicked off in March 2015, which Dr. Drees described as a “soft stop” approach. “The alert was designed to inform the ordering provider of laxatives that had been administered in the prior 24 hours,” she explained. “It initially reduced orders [for tests] by 25%.” However, the approach lost effect over time.

Another initiative included the development of a multidisciplinary “Tiger Team” that would meet intensively—at least 1 or 2 times a week—to discuss and devise new ways to improve appropriate testing. The team’s initial analysis of CDI testing in the care system showed that about 50% of the cases identified as hospital-onset CDI were likely only cases of C. difficile colonization. In addition, those cases had “either received laxatives prior to testing positive or did not have documentation of significant diarrhea, as determined by case review,” said Dr. Drees.

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