Skip to main content Accessibility help
×
Home

Inappropriate Clostridium difficile Testing and Consequent Overtreatment and Inaccurate Publicly Reported Metrics

  • Sean G. Kelly (a1), Michael Yarrington (a2), Teresa R. Zembower (a1) (a3), Sarah H. Sutton (a1) (a3), Christina Silkaitis (a3), Michael Postelnick (a4), Anessa Mikolajczak (a5) and Maureen K. Bolon (a1) (a3)...

Abstract

BACKGROUND

The nationally reported metric for Clostridium difficile infection (CDI) relies solely on laboratory testing, which can result in overreporting due to asymptomatic C. difficile colonization.

OBJECTIVE

To review the clinical scenarios of cases of healthcare facility-onset CDI (HO-CDI) and to determine the appropriateness of C. difficile testing on the basis of presence of symptomatic diarrhea in order to identify areas for improvement.

DESIGN

Retrospective cohort study.

SETTING

Northwestern Memorial Hospital, a large, tertiary academic hospital in Chicago, Illinois.

PATIENTS

The cohort included all patients with a positive C. difficile test result who were reported to the National Healthcare Safety Network as HO-CDI during a 1-year study period.

METHODS

We reviewed the clinical scenario of each HO-CDI case. On the basis of documentation and predefined criteria, appropriateness of C. difficile testing was determined; cases were deemed appropriate, inappropriate, or indeterminate. Statistical analysis was performed to compare demographic and clinical parameters among the categories of testing appropriateness.

RESULTS

Our facility reported 168 HO-CDI cases to NHSN during the study period. Of 168 cases, 33 (19.6%) were judged to be appropriate tests, 25 (14.8%) were considered inappropriate, and 110 (65.5%) were indeterminate. Elimination of inappropriate testing would have improved our facility’s standardized infection ratio from 0.962 to 0.819.

CONCLUSION

Approximately 15% of HO-CDI cases were judged to be tested inappropriately. Testing only patients with clinically significant diarrhea would more accurately estimate CDI incidence, reduce unnecessary antibiotic use, and improve facilities’ performance of reportable CDI metrics. Improved documentation could facilitate targeted interventions.

Infect Control Hosp Epidemiol 2016;1395–1400

Copyright

Corresponding author

Address correspondence to Sean G. Kelly, MD, 1161 21st Ave South, Ste A2200, Nashville, TN 37232 (sean.g.kelly@vanderbilt.edu).

References

Hide All
1. Miller, BA, Chen, LF, Sexton, DJ, Anderson, DJ. Comparison of the burdens of hospital-onset, healthcare facility-associated Clostridium difficile infection and of healthcare-associated infection due to methicillin-resistant Staphylococcus aureus in community hospitals. Infect Control Hosp Epidemiol 2011;32:387390.
2. Dubberke, ER, Carling, P, Carrico, R, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:628645.
3. Longtin, Y, Trottier, S, Brochu, G, et al. Impact of the type of diagnostic assay on Clostridium difficile infection and complication rates in a mandatory reporting program. Clin Infect Dis 2013;56:6773.
4. Polage, CR, Gyorke, CE, Kennedy, MA, et al. Overdiagnosis of Clostridium difficile infection in the molecular test era. JAMA Intern Med 2015;175:17921801.
5. Centers for Disease Control and Prevention (CDC). Multidrug-resistant organism & Clostridium difficile infection (MDRO/CDI) module. CDC website. http://www.cdc.gov/nhsn/PDFs/pscManual/12pscMDRO_CDADcurrent.pdf. Accessed April 12, 2016.
6. Centers for Disease Control and Prevention (CDC). Clostridium difficile infection (CDI) prevention primer. CDC website. http://www.cdc.gov/hai/pdfs/toolkits/CDI-Primer-2-2016.pdf. Published 2016. Accessed April 13, 2016.
7. Dubberke, ER, Han, Z, Bobo, L, et al. Impact of clinical symptoms on interpretation of diagnostic assays for Clostridium difficile infections. J Clin Microbiol 2011;49:28872893.
8. Peterson, LR, Manson, RU, Paule, SM, et al. Detection of toxigenic Clostridium difficile in stool samples by real-time polymerase chain reaction for the diagnosis of C. difficile-associated diarrhea. Clin Infect Dis 2007;45:11521160.
9. Olans, RN, Olans, RD, DeMaria, A Jr. The critical role of the staff nurse in antimicrobial stewardship—unrecognized, but already there. Clin Infect Dis 2016;62:8489.
10. Lewis, BB, Buffie, CG, Carter, RA, et al. Loss of microbiota-mediated colonization resistance to Clostridium difficile infection with oral vancomycin compared with metronidazole. J Infect Dis 2015;212:16561665.
11. Shim, JK, Johnson, S, Samore, MH, Bliss, DZ, Gerding, DN. Primary symptomless colonisation by Clostridium difficile and decreased risk of subsequent diarrhoea. Lancet 1998;351:633636.
12. Tschudin-Sutter, S, Carroll, KC, Tamma, PD, et al. Impact of toxigenic Clostridium difficile colonization on the risk of subsequent C. difficile infection in intensive care unit patients. Infect Control Hosp Epidemiol 2015;36:13241329.
13. Pepin, J, Routhier, S, Gagnon, S, Brazeau, I. Management and outcomes of a first recurrence of Clostridium difficile-associated disease in Quebec, Canada. Clin Infect Dis 2006;42:758764.
14. Shivashankar, R, Khanna, S, Kammer, PP, et al. Clinical predictors of recurrent Clostridium difficile infection in out-patients. Aliment Pharmacol Ther 2014;40:518522.
15. Cohen, SH, Gerding, DN, Johnson, S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010;31:431455.

Inappropriate Clostridium difficile Testing and Consequent Overtreatment and Inaccurate Publicly Reported Metrics

  • Sean G. Kelly (a1), Michael Yarrington (a2), Teresa R. Zembower (a1) (a3), Sarah H. Sutton (a1) (a3), Christina Silkaitis (a3), Michael Postelnick (a4), Anessa Mikolajczak (a5) and Maureen K. Bolon (a1) (a3)...

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed