Reducing Unnecessary C diff Tests Aids in Diagnostic Stewardship, Overtreatment


A Florida hospital takes a novel approach for the healthcare-associated infection and reduced inappropriate testing by setting up guidelines.

patient in bed; Image credit: pexels-enginakyurt

Clinicians found a 20.1% reduction in C diff test orders deemed inappropriate under the new system compared to the year prior to implementation, from 31.1% of tests before the new guidelines to just 11% with them.

Image credit: pexels-enginakyurt

A new study conducted at Memorial Healthcare System in Hollywood, Fla, revised rules for when Clostridioides difficile (C diff) tests could be ordered for inpatients, which helped to reduce inappropriate testing by 20%. Along with the reduction of tests, the other goal was to help prevent the overtreatment of patients.

The study was published today in the American Journal of Infection Control (AJIC).

“The goal of diagnostic stewardship is to use the right test for the right patient at the right time, and that means we must use tests appropriately and judiciously to ensure they provide results that can help guide patient care,” said Rachel Guran, MPH, BSN, RN, CIC, FAPIC, director of epidemiology and infection prevention at Memorial Healthcare System and an author of the study.

The new ordering approach involved 2 sets of rules: one for patients admitted within the last 72 hours, for whom C diff testing could be ordered without restriction for any patient who recently had at least 3 loose or unformed stools, and the other for patients who had been in the hospital for 4 days or more.

For the latter group, C diff testing could not be ordered for patients who had been given laxatives within 48 hours, who had been treated for C. diff 14 to 24 days prior, or who had tested positive for C diff within 14 days. Patients who had been tested for C diff in the past 4 days, even if they received a negative result, were also not eligible for a new test.

For high-risk patients, such as those who were immunocompromised or had recently undergone gastrointestinal surgery, C diff tests could be given even if other eligibility guidelines were not met. The new system was integrated with the hospital’s electronic health records to ensure consistency and documentation, and educational resources were distributed to staff members.

What You Need to Know

The study implemented new guidelines for C diff testing based on diagnostic stewardship principles.

Inappropriate testing was defined when patients lacked sufficient diarrhea incidence or had recent laxative use without other signs of infection.

Post-guideline adoption, 30-day readmission rates increased, particularly for patients with recent gastrointestinal surgery.

Clinicians found a 20.1% reduction in C diff test orders deemed inappropriate under the new system compared to the year prior to implementation, from 31.1% of tests before the new guidelines to just 11% with them. Testing was defined as inappropriate when patients did not have enough incidence of diarrhea reported or when there was recent laxative use without other signs of infection.

Investigators also noted:

  • Following the adoption of new guidelines, clinicians saw an increase in 30-day readmission rates for patients in the study. An investigation noted a higher proportion of patients with recent gastrointestinal surgery in the post-intervention group compared to the pre-intervention group, and it was those patients who were more likely to be readmitted. Rates of readmission at 60 days remained higher for the post-intervention group, but the difference was no longer statistically significant.
  • Differences in 30-day and 60-day mortality across the 2 groups were not considered statistically significant.
  • Despite the ordering restrictions for patients who had taken laxatives in the previous 48 hours, there was no significant difference in exposure to laxatives in the groups of patients studied before and after the new ordering system was put in place.

“We are very pleased that our new guidelines for C diff testing led to a clear decrease in inappropriate test ordering, which has benefits for reducing unnecessary treatment and associated healthcare costs,” Guran said.

Diagnostic Stewardship Approach to C. diff Reduces Unnecessary Testing.APIC press release. June 27, 2024. Accessed June 27, 2024.

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