A qualitative study to identify reasons for Clostridium difficile testing in pediatric inpatients receiving laxatives or stool softeners

In pursuit of the holy grail: Improving C. difficile testing appropriateness with iterative electronic health record clinical decision support and targeted test restriction

OBJECTIVE

To determine the impact of electronic health record (EHR)-based interventions and test restriction on Clostridioides difficile tests (CDTs) and hospital-onset C. difficile infection (HO-CDI).

DESIGN

Quasi-experimental study in 3 hospitals.

SETTING

957-bed academic (hospital A), 354-bed (hospital B), and 175-bed (hospital C) academic-affiliated community hospitals.

INTERVENTIONS

Three EHR-based interventions were sequentially implemented: (1) alert when ordering a CDT if laxatives administered within 24 hours (January 2018); (2) cancellation of CDT orders after 24 hours (October 2018); (3) contextual rule-driven order questions requiring justification when laxative administered or lack of EHR documentation of diarrhea (July 2019). In February 2019, hospital C implemented a gatekeeper intervention requiring approval for all CDTs after hospital day 3. The impact of the interventions on C. difficile testing and HO-CDI rates was estimated using an interrupted time-series analysis.

RESULTS

C. difficile testing was already declining in the preintervention period (annual change in incidence rate [IR], 0.79; 95% CI, 0.72-0.87) and did not decrease further with the EHR interventions. The laxative alert was temporally associated with a trend reduction in HO-CDI (annual change in IR from baseline, 0.85; 95% CI, 0.75-0.96) at hospitals A and B. The gatekeeper intervention at hospital C was associated with level (IRR, 0.50; 95% CI, 0.42-0.60) and trend reductions in C. difficile testing (annual change in IR, 0.91; 95% CI, 0.85-0.98) and level (IRR 0.42; 95% CI, 0.22-0.81) and trend reductions in HO-CDI (annual change in IR, 0.68; 95% CI, 0.50-0.92) relative to the baseline period.

CONCLUSIONS

Test restriction was more effective than EHR-based clinical decision support to reduce C. difficile testing in our 3-hospital system.

Laxative Use Does Not Preclude Diagnosis or Reduce Disease Severity in Clostridiodes difficile Infection

BACKGROUND

To optimize utility of laboratory testing for Clostridiodes difficile infection (CDI), the 2017 Infectious Diseases Society of America-Society for Healthcare Epidemiology of America (IDSA-SHEA) clinical practice guidelines recommend excluding patients from stool testing for C. difficile if they have received laxatives within the preceding 48 hours. Sparse data support this recommendation.

METHODS

Patients with new-onset diarrhea (≥3 bowel movements in any 24-hour period in the 48 hours before stool collection) and a positive stool C. difficile nucleic acid amplification test were enrolled. Laxative use within 48 hours before stool testing, severity of illness (defined by 4 distinct scoring methods), and clinical outcomes were recorded.

RESULTS

209 patients with CDI were studied, 65 of whom had received laxatives. There were no significant differences in the proportion of patients meeting severe CDI criteria by 4 severity scoring methods in patients receiving versus not receiving laxatives (66.2% vs 56.3%, respectively; P = .224) by IDSA-SHEA, the primary scoring system. Similar rates of serious outcomes attributable to CDI, including death, intensive care unit admission, and colectomy, were observed in the laxative and no laxative groups.

CONCLUSIONS

Our study found similar rates of severe CDI and serious CDI-attributable clinical outcomes in CDI-diagnosed patients who did or did not receive laxatives. Precluding recent laxative users from CDI testing, as proposed by the IDSA-SHEA guideline, carries a potential for harm due to delayed diagnosis and treatment.

Why do clinicians order inappropriate Clostridium difficile testing? An exploratory study

BACKGROUND

The drivers behind Clostridium difficile testing are not well understood.

METHODS

C difficile testing orders were reviewed. An algorithm that sequentially considered the presence of diarrhea, leukocytosis, fever, and laxative use was created. Tests deemed potentially inappropriate were discussed with the ordering team.

RESULTS

Of 128 orders reviewed, 62% (n = 79) were appropriate. Patients whose testing was deemed inappropriate had longer lengths of stay. Diarrhea and laxative use were common and similarly distributed in those appropriately or inappropriately tested. The most commonly cited reason for ordering an inappropriate test was the reporting of diarrhea to the clinician by the patient or nursing that was not documented in the electronic health record. The next most common reason was clinician perception of risk. Demographics, laxative use, fever, leukocytosis, and diarrhea were similarly distributed between patients testing positive or negative by C difficile polymerase chain reaction.

DISCUSSION

The discriminating value of diarrhea or laxative use in assessing for C difficile infection is poor. Multiple streams of information add to the complexities of decision making around C difficile testing. Inconsistent definitions of diarrhea likely contribute to this complexity. Clinician-perceived risk to the patient, partially driven by length of stay, may be a large driver of testing practices.

CONCLUSIONS

Without understanding the knowledge, attitudes, and values that underlie clinician behavior, interventions targeting ordering practices may not succeed.

Laxative use and testing for Clostridium difficile in hospitalized adults: An opportunity to improve diagnostic stewardship

BACKGROUND

It is recommended that that only unformed stool from patients with diarrhea be tested for Clostridium difficile infection. We determined the prevalence of and patient characteristics associated with antecedent laxative receipt among hospitalized adults undergoing C difficile testing.

METHODS

In a case-control study of 5,452 C difficile tests from 5 hospitals in Southeast Michigan, patients who received laxatives (docusate, senna, polyethylene glycol 3350, bisacodyl, and magnesium hydroxide) in the 24 or 48 hours before testing were identified. Logistic regression was performed to identify patient characteristics associated with laxative receipt before testing.

RESULTS

In 535 (9.8%) and 707 (13%) tests, patients received laxatives in the 24 and 48 hours before testing, respectively. The odds of antecedent laxative receipt were significantly greater for patients residing on a surgical service than a medical service (24 hours odds ratio [OR], 2.5; 95% confidence interval [CI], 2.1-3.1; 48 hours OR, 2.7; 95% CI, 2.3-3.2), patients residing in an intensive care unit (ICU) than a non-ICU (24 hours OR, 1.3; 95% CI, 1.0-1.6; 48 hours OR, 1.3; 95% CI, 1.1-1.6), and patients whose Elixhauser Comorbidity Score was 4 or higher (24 hours OR, 1.4; 95% CI, 1.1-1.7; 48 hours OR, 1.4; 95% CI, 1.2-1.7).

CONCLUSIONS

Among patients tested for C difficile, antecedent laxative use was common. Improving diagnostic stewardship around C difficile testing, particularly in surgical and ICU patients, is a significant opportunity and priority for quality improvement.