Diagnostic Stewardship for Healthcare-Associated Infections: Opportunities and Challenges to Safely Reduce Test Use

Impact of customized electronic duplicate order alerts on microbiology test ordering: Financial and environmental cost savings

OBJECTIVE

To estimate cost savings after implementation of customized electronic duplicate order alerts.

DESIGN

Alerts were implemented for microbiology tests at the largest public hospital in Victoria, Australia. These alerts were designed to pop up at the point of test ordering to inform the clinician that the test had previously been ordered and to suggest appropriate reordering time frames and indications.

RESULTS

In a 6-month audit of urine culture (our most commonly ordered test) after alert implementation, 2,904 duplicate requesters proceeded with the request and 2,549 tests were cancelled, for a 47% reduction in test ordering. For fecal polymerase chain reaction (PCR), our second most common test, there was a 54% reduction in test ordering. For our most commonly ordered expensive test, hepatitis C PCR, there was a 42% reduction in test ordering: 25 tests were cancelled.Cancelled tests resulted in estimated savings of AU$52,382 (US$33,960) for urine culture, AU$34,914 (US$22,442) for fecal PCR, AU$4,506 (US$2,896) for hepatitis C PCR. For cancelled hepatitis B PCR and Epstein-Barr virus (EBV) and cytomegalovirus (CMV) serology, the cost savings was AU$8,472 (US$5445). The estimated financial cost saving in direct hospital costs for these 6 assays was AU$100,274 (US$67,925) over the 6-month period. Environmental waste cost saving by weight was estimated to be 280 kg. Greenhouse gas footprint, measured in carbon dioxide equivalent emissions for cancelled EBV and CMV serology tests, resulted in a saving of at least 17,711 g, equivalent to driving 115 km in a standard car.

CONCLUSION

Customized alerts issued at the time of test ordering can have enormous impacts on reducing cost, waste, and unnecessary testing.

Improving antimicrobial use through better diagnosis: The relationship between diagnostic stewardship and antimicrobial stewardship

Antimicrobial stewardship programs (ASPs) exist to optimize antibiotic use, reduce selection for antimicrobial-resistant microorganisms, and improve patient outcomes. Rapid and accurate diagnosis is essential to optimal antibiotic use. Because diagnostic testing plays a significant role in diagnosing patients, it has one of the strongest influences on clinician antibiotic prescribing behaviors. Diagnostic stewardship, consequently, has emerged to improve clinician diagnostic testing and test result interpretation. Antimicrobial stewardship and diagnostic stewardship share common goals and are synergistic when used together. Although ASP requires a relationship with clinicians and focuses on person-to-person communication, diagnostic stewardship centers on a relationship with the laboratory and hardwiring testing changes into laboratory processes and the electronic health record. Here, we discuss how diagnostic stewardship can optimize the "Four Moments of Antibiotic Decision Making" created by the Agency for Healthcare Research and Quality and work synergistically with ASPs.

Estimating the effect of active detection and isolation on Clostridioides difficile infections in a bone marrow transplant unit

OBJECTIVE

To model the effects of active detection and isolation (ADI) regarding Clostridioides difficile infection (CDI) in the bone marrow transplant (BMT) unit of our hospital.

SETTING

ADI was implemented in a 21-patient bone marrow unit.

PATIENTS

Patients were bone marrow recipients on this unit.

INTERVENTIONS

We compared active ADI, in which patients who tested positive for colonization of C. difficile before their hospital stay were placed under extra contact precautions, with cases not under ADI.

RESULTS

Within the BMT unit, ADI reduced total cases of CDI by 24.5% per year and reduced hospital-acquired cases by ∼84%. The results from our simulations also suggest that ADI can save ∼$67,600 per year in healthcare costs.

CONCLUSIONS

Institutions with active BMT units should consider implementing ADI.

Implementation of a Structured Process for Clinically Indicated Testing for Clostridioides difficile Infections in Pediatric Oncology and Stem Cell Transplant

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.

Recommendations for change in infection prevention programs and practice

Fifty years of evolution in infection prevention and control programs have involved significant accomplishments related to clinical practices, methodologies, and technology. However, regulatory mandates, and resource and research limitations, coupled with emerging infection threats such as the COVID-19 pandemic, present considerable challenges for infection preventionists. This article provides guidance and recommendations in 14 key areas. These interventions should be considered for implementation by United States health care facilities in the near future.

An interprofessional approach to reducing hospital-onset Clostridioides difficile infections

BACKGROUND

Clostridioides difficile is the most prevalent hospital-onset (HO) infection. There are significant financial and safety impacts associated with HO-C. difficile infections (HO-CDIs) for both patients and health care organizations. The incidence of HO-CDIs at our community hospital within an academic acute health care system was continuously above the national benchmark.

METHODS

In response to the high HO-CDI rates at our facility, an interprofessional team selected evidence-based interventions with the goal of reducing HO-CDI incidence rates. Interventions included: diagnostic stewardship, enhanced environmental cleaning, antimicrobial stewardship and education and accountability.

RESULTS

After one year, we achieved a 63% reduction in HO-CDI and have sustained a 77% reduction. The infection rate remained below national benchmark for HO-CDI for over 4 years at a rate of 2.80 per 10,000 patient days and a SIR of 0.43 in 2020.

DISCUSSION

Multiple evidence-based interventions were successfully implemented over several service lines over a 4-year period through the collaboration of an interprofessional team. The addition of an accountability processes further improved compliance with standards of practice.

CONCLUSIONS

Collaboration of an interprofessional team led to substantial and sustained reductions in HO-CDI.

The potential of digital molecular diagnostics for infectious diseases in sub-Saharan Africa

There is a large gap between diagnostic needs and diagnostic access across much of sub-Saharan Africa (SSA), particularly for infectious diseases that inflict a substantial burden of morbidity and mortality. Accurate diagnostics are essential for the correct treatment of individuals and provide vital information underpinning disease surveillance, prevention, and control strategies. Digital molecular diagnostics combine the high sensitivity and specificity of molecular detection with point-of-care format and mobile connectivity. Recent developments in these technologies create an opportunity for a radical transformation of the diagnostic ecosystem. Rather than trying to emulate diagnostic laboratory models in resource-rich settings, African countries have the potential to pioneer new models of healthcare designed around digital diagnostics. This article describes the need for new diagnostic approaches, highlights advances in digital molecular diagnostic technology, and outlines their potential for tackling infectious diseases in SSA. It then addresses the steps that will be necessary for the development and implementation of digital molecular diagnostics. Although the focus is on infectious diseases in SSA, many of the principles apply to other resource-limited settings and to noncommunicable diseases.

Blood Culture Utilization in the Hospital Setting: a Call for Diagnostic Stewardship

There has been significant progress in detection of bloodstream pathogens in recent decades with the development of more sensitive automated blood culture detection systems and the availability of rapid molecular tests for faster organism identification and detection of resistance genes. However, most blood cultures in clinical practice do not grow organisms, suggesting that suboptimal blood culture collection practices (e.g., suboptimal blood volume) or suboptimal selection of patients to culture (i.e., blood cultures ordered for patients with low likelihood of bacteremia) may be occurring. A national blood culture utilization benchmark does not exist, nor do specific guidelines on when blood cultures are appropriate or when blood cultures are of low value and waste resources. Studies evaluating the potential harm associated with excessive blood cultures have focused on blood culture contamination, which has been associated with significant increases in health care costs and negative consequences for patients related to exposure to unnecessary antibiotics and additional testing. Optimizing blood culture performance is important to ensure bloodstream infections (BSIs) are diagnosed while minimizing adverse events from overuse. In this review, we discuss key factors that influence blood culture performance, with a focus on the preanalytical phase, including technical aspects of the blood culture collection process and blood culture indications. We highlight areas for improvement and make recommendations to improve current blood culture practices among hospitalized patients.

Sampling Multiple Catheter Lumens to Improve Detection of Bloodstream Infection in Pediatric Oncology Patients

Current guidelines recommend sampling each central-access lumen during the initial evaluation of febrile pediatric oncology patients. We investigated this recommendation's validity at centers implementing a diagnostic stewardship program to reduce blood cultures in critically ill children. Among 146 oncology patients admitted to the intensive care unit, there were 34 eligible blood culture-sets. Eleven (34%) sets yielded discordant results, most commonly cultivating a likely pathogen from one lumen and no growth from another. As hospitals move toward reducing testing overuse, these results emphasize the continued importance of culturing each central-access lumen to optimize the detection of bacteremia in the initial evaluation of critically ill pediatric oncology patients.

Diagnostic Stewardship: Appropriate Testing and Judicious Treatments

Diagnostic stewardship encompasses the entire diagnosis-to-treatment paradigm in the intensive care unit (ICU). Initially born of the antimicrobial stewardship movement, contemporary diagnostic stewardship aims to promote timely and appropriate diagnostic testing that directly links to management decisions. In the stewardship framework, excessive diagnostic testing in low probability cases is discouraged due to its tendency to generate false-positive results, which have their own downstream consequences. Though the evidence basis for diagnostic stewardship initiatives in the ICU is nascent and largely limited to retrospective analyses, available literature generally suggests that these initiatives are safe, feasible, and associated with similar patient outcomes. As diagnostic testing of critically ill patients becomes increasingly sophisticated in the ensuing decade, a stewardship mindset will aid bedside clinicians in interpreting and incorporating new diagnostic strategies in the ICU.

Assessment of Federal Value-Based Incentive Programs and In-Hospital Clostridioides difficile Infection Rates

IMPORTANCE

Health care facility-onset Clostridioides difficile infection (HO-CDI) rates reported to the US Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) became a target quality metric for 2 Centers for Medicare & Medicaid Services (CMS) value-based incentive programs (VBIPs) in October 2016. The association of VBIPs with HO-CDI rates is unknown.

OBJECTIVE

To examine the association between VBIP implementation and HO-CDI rates.

DESIGN, SETTING, AND PARTICIPANTS

This interrupted time series study evaluated HO-CDI rates among adults hospitalized from January 2013 to March 2019 at 265 acute-care hospitals.

INTERVENTIONS

Implementation of VBIPs in October 2016.

MAIN OUTCOMES AND MEASURES

Quarterly rates of HO-CDI per 10 000 patient-days, as reported to NHSN by participating hospitals, were evaluated. Generalized estimating equations were used to fit negative binomial regression models to estimate immediate program effect size (ie, level change) and changes in the slope of HO-CDI rates, controlling for each hospital's predominant method of CDI testing (ie, nucleic acid amplification test [NAAT], enzyme immunoassay [EIA] for toxin, or other testing methods).

RESULTS

The study cohort included 24 332 938 admissions, 109 371 136 patient-days, and 74 681 HO-CDI events at 265 hospitals (145 [55%] with 100-399 beds; 205 [77%] not-for-profit hospitals; 185 [70%] teaching hospitals; 229 [86%] in metropolitan areas). Compared with EIA, rates of HO-CDI were higher when detected by NAAT (adjusted incidence rate ratio [aIRR], 1.55; 95% CI, 1.40-1.70; P < .001) and other testing methods (aIRR, 1.47; 95% CI, 1.26-1.71; P < .001). There were no significant changes in testing methods used by hospitals immediately after VBIP implementation. Controlling for CDI testing method, VBIP implementation was associated with a 6% level decline in HO-CDI rates in the immediate postpolicy quarter (aIRR, 0.94; 95% CI, 0.89-0.99; P = .01) and a 4% decline in slope per quarter (aIRR, 0.96; 95% CI, 0.95-0.97; P < .001). Results were similar in a sensitivity analysis using a 1-year roll-in period accounting for the period after the announcement of the HO-CDI VBIP policy and prior to its implementation.

CONCLUSIONS AND RELEVANCE

In this study, VBIP implementation was associated with improvements in HO-CDI rates, independent of CDI testing method. Given that CMS payment policies have not previously been associated with improvements in other targeted health care-associated infection rates, future research should focus on elucidating the specific processes that contributed to improvement in HO-CDI rates to inform the design of future VBIP interventions.

Culture Ordering for Patients with New-onset Fever: A Survey of Pediatric Intensive Care Unit Clinician Practices

INTRODUCTION

Accurate assessment of infection in critically ill patients is vital to their care. Both indiscretion and under-utilization of diagnostic microbiology testing can contribute to inappropriate antibiotic administration or delays in diagnosis. However, indiscretion in diagnostic microbiology cultures may also lead to unnecessary tests that, if false-positive, would incur additional costs and unhelpful evaluations. This quality improvement project objective was to assess pediatric intensive care unit (PICU) clinicians' attitudes and practices around the microbiology work-up for patients with new-onset fever.

METHODS

We developed and conducted a self-administered electronic survey of PICU clinicians at a single institution. The survey included 7 common clinical vignettes of PICU patients with new-onset fever and asked participants whether they would obtain central line blood cultures, peripheral blood cultures, respiratory aspirate cultures, cerebrospinal fluid cultures, urine cultures, and/or urinalyses.

RESULTS

Forty-seven of 54 clinicians (87%) completed the survey. Diagnostic specimen ordering practices were notably heterogeneous. Respondents unanimously favored a decision-support algorithm to guide culture specimen ordering practices for PICU patients with fever (100%, N = 47). A majority (91.5%, N = 43) indicated that a decision-support algorithm would be a means to align PICU and consulting care teams when ordering culture specimens for patients with fever.

CONCLUSION

This survey revealed variability of diagnostic specimen ordering practices for patients with new fever, supporting an opportunity to standardize practices. Clinicians favored a decision-support tool and thought that it would help align patient management between clinical team members. The results will be used to inform future diagnostic stewardship efforts.

Interventions to optimize antimicrobial stewardship

Developing and improving an antimicrobial stewardship program successfully requires evaluation of numerous factors. As technology progresses and our understanding of antimicrobial resistance grows, careful consideration should be taken to ensure that a program meets the needs of the institution and is achievable given the available resources. In this review, we explore fundamental initiatives and strategies for both new and established antimicrobial stewardship programs, including the specific areas to target and key elements required for sustainable implementation.

Propensity-Matched Cost of Clostridioides difficile Infection Overdiagnosis

Background

Clostridioides difficile is the leading health care–associated pathogen, but clinicians lack a test that can reliably differentiate colonization from infection. Health care costs attributed to C. difficile are substantial, but the economic burden associated with C. difficile false positives is poorly understood.

Methods

A propensity score matching model for cost per hospitalization was developed to estimate the costs of both true infection and false positives. Predictors of C. difficile positivity used to estimate the propensity score were age, Charlson comorbidity index, white cell count, and creatinine. We used polymerase chain reaction (PCR) cycle threshold to identify and compare 3 groups: (1) true infection, (2) C. difficile colonization, and (3) C. difficile negative.

Results

A positive test was associated with $3018 higher unadjusted hospital cost. Among the 3 comparisons made with propensity-matched negative controls (all positives [+$179; P = .934], true positives [–$1892; P = .100], and colonized positives), only colonization was associated with significantly increased (+$3418; P = .012) cost. Differences in lengths of stay (all positives 0 days, P = .126; true 0 days, P = .919; colonized 1 day, P = .019) appeared to underly cost differences.

Conclusions

In the first C. difficile cost analysis to utilize PCR cycle threshold to differentiate colonization, we found high propensity-matched hospital costs associated with colonized but not true positives. This unexpected finding may be due to misdiagnosis of non–C. difficile diarrhea or unadjusted factors associated with colonization.

Impact of a Clostridioides Difficile Testing Computerized Clinical Decision Support Tool on an Adult Stem Cell Transplantation and Hematologic Malignancies Unit

Clostridioides difficile infection rates are higher in hospitalized hematopoietic stem cell transplantation (HSCT) recipients and patients with hematologic malignancy (HM) compared with the general population. This is related both to extensive exposure to antibiotics as well as to frequent and often prolonged hospitalization. In this population, with numerous potential causes of diarrhea, a subset of C difficile detected is presumed to represent colonization rather than clinical infection. The use of decision support tools to guide ordering in hospitalized patients has been reported to decrease both C difficile testing and detection rates. Following implementation of a computerized decision support tool on our HSCT/HM unit, we observed a >2-fold decrease in C difficile testing volume and National Healthcare Safety Network-defined laboratory identifications of C difficile. Furthermore, the rate of oral vancomycin use, as well as the incidence of vancomycin-resistant enterococci colonization and bloodstream infection, decreased in the postintervention period.

A rapid model for developing dry surface biofilms of Staphylococcus aureus and Pseudomonas aeruginosa for in vitro disinfectant efficacy testing

Background

Bacterial biofilms persistent on dry environmental surfaces in healthcare facilities play an important role in the occurrence of healthcare associated infections (HAI). Compared to wet surface biofilms and planktonic bacteria, dry surface biofilms (DSB) are more tolerant to disinfection. However, there is no official method for developing DSB for in vitro disinfectant efficacy testing. The objectives of this study were to (i) develop an in vitro model of DSB of S. aureus and P. aeruginosa for disinfectant efficacy testing and (ii) investigate the effect of drying times and temperatures on DSB development. We hypothesized that a minimum six log₁₀ density of DSB could be achieved on glass coupons by desiccating wet surface biofilms near room temperatures. We also hypothesized that a DSB produced by the model in this study will be encased in extracellular polymeric substances (EPS).

Methods

S. aureus ATCC-6538 and P. aeruginosa ATCC-15442 wet surface biofilms were grown on glass coupons following EPA MLB SOP MB-19. A DSB model was developed by drying coupons in an incubator and viable bacteria were recovered following a modified version of EPA MLB SOP MB-20. Scanning electron microscopy was used to confirm the EPS presence on DSB.

Results

Overall, a minimum of six mean log₁₀ densities of DSB for disinfectant efficacy were recovered per coupon after drying at different temperatures and drying times. Regardless of strain, temperature and dry time, 86% of coupons with DSB were confirmed to have EPS.

Conclusion

A rapid model for developing DSB with characteristic EPS was developed for disinfectant efficacy testing against DSB.

Who to Test, When, and for What: Why Diagnostic Stewardship in Infectious Diseases Matters

New rapid molecular diagnostic technologies for infectious diseases provide faster diagnostic test results and, if used correctly, will enable more rapid delivery of care to patients. This perspective piece outlines how this new technology can be used more effectively-with a focus on collaborative team approaches and tools clinicians and laboratorians can use to optimally affect patient care. This article also showcases a patient case, outlining problems with the diagnostic process as it currently stands, and poses potential strategies on how this process may be improved.

Smartphone technology facilitates point-of-care nucleic acid diagnosis: a beginner's guide

The reliable detection of nucleic acids at low concentrations in clinical samples like blood, urine and saliva, and in food can be achieved by nucleic acid amplification methods. Several portable and hand-held devices have been developed to translate these laboratory-based methods to point-of-care (POC) settings. POC diagnostic devices could potentially play an important role in environmental monitoring, health, and food safety. Use of a smartphone for nucleic acid testing has shown promising progress in endpoint as well as real-time analysis of various disease conditions. The emergence of smartphone-based POC devices together with paper-based sensors, microfluidic chips and digital droplet assays are used currently in many situations to provide quantitative detection of nucleic acid targets. State-of-the-art portable devices are commercially available and rapidly emerging smartphone-based POC devices that allow the performance of laboratory-quality colorimetric, fluorescent and electrochemical detection are described in this review. We present a comprehensive review of smartphone-based POC sensing applications, specifically on microbial diagnostics, assess their performance and propose recommendations for the future.

Utilizing a real-time discussion approach to improve the appropriateness of Clostridioides difficile testing and the potential unintended consequences of this strategy

We report electronic medical record interventions to reduce Clostridioides difficile testing risk 'alert fatigue.' We used a behavioral approach to diagnostic stewardship and observed a decrease in the number of tests ordered of ~4.5 per month (P < .0001). Although the number of inappropriate tests decreased during the study period, delayed testing increased.

Patient Outcomes With Prevented vs Negative Clostridioides difficile Tests Using a Computerized Clinical Decision Support Tool

Background

Overtesting and overdiagnosis of Clostridioides difficile infection are suspected to be common. Reducing inappropriate testing through interventions designed to promote evidence-based diagnostic testing (ie, diagnostic stewardship) may improve C. difficile test utilization. However, the safety of these interventions is not well understood despite the potential risk for missed or delayed diagnoses.

Methods

This retrospective case-control study examined the outcomes of patients admitted to the University of Virginia Medical Center following introduction of a computerized clinical decision support tool without hard-stops designed to reduce inappropriate tests. Outcomes were compared between patients with a prevented C. difficile nucleic acid amplification test and those with a negative result. Chart reviews were performed for patients with a subsequent positive within 7 days, as well as those patients who received C. difficile-active antibiotics after implementation of the computerized clinical decision support tool.

Results

Multivariate analysis of 637 cases (490 negative, 147 prevented) showed that a prevented test was not significantly associated with the primary composite outcome (inpatient mortality or intensive care unit transfer) compared with a negative test (adjusted odds ratio, 0.912; P = .747). Fifty-four of 147 (37%) prevented tests were followed by a completed test within 7 days; 11 of these results were positive, resulting in a potential delay in diagnosis. Individual case reviews found that either clinical changes warranted the delay in testing or no adverse events occurred attributable to C. difficile infection. C. difficile treatment without a positive test was not identified.

Conclusions

Diagnostic stewardship of C. difficile testing using computerized clinical decision support may be both safe and effective for reducing inappropriate inpatient testing.

Essential role of laboratory physicians in transformation of laboratory practice and management to a value-based patient-centric model

The laboratory is a vital part of the continuum of patient care. In fact, there are few programs in the healthcare system that do not rely on ready access and availability of complex diagnostic laboratory services. The existing transactional model of laboratory "medical practice" will not be able to meet the needs of the healthcare system as it rapidly shifts toward value-based care and precision medicine, which demands that practice be based on total system indicators, clinical effectiveness, and patient outcomes. Laboratory "value" will no longer be focused primarily on internal testing quality and efficiencies but rather on the relative cost of diagnostic testing compared to direct improvement in clinical and system outcomes. The medical laboratory as a "business" focused on operational efficiency and cost-controls must transform to become an essential clinical service that is a tightly integrated equal partner in direct patient care. We would argue that this paradigm shift would not be necessary if laboratory services had remained a "patient-centric" medical practice throughout the last few decades. This review is focused on the essential role of laboratory physicians in transforming laboratory practice and management to a value-based patient-centric model. Value-based practice is necessary not only to meet the challenges of the new precision medicine world order but also to bring about sustainable healthcare service delivery.

Atypical presentation of Clostridioides difficile pseudomembranous colitis with laboratory rejection of stool specimen

Clostridioides (formerly Clostridium) difficile is a major cause of nocosomial infection in the USA and worldwide. It has a wide spectrum of presentation, ranging from an asymptomatic carrier state to fulminant colitis. Pseudomembranous colitis is a manifestation of severe C. difficile infection (CDI), typically with progressive symptoms including watery diarrhoea, abdominal cramping and fevers and elevated white cell count and/or creatinine. It is diagnosed on three levels, including clinical assessment, stool assays and visualisation of the colonic mucosa. Laboratories will reject stools that do not meet criteria for testing. In the era of molecular testing for the presence of toxigenic C. difficile DNA, which only indicates the potential for infection, it is vital to use clinical evaluation in the diagnosis of CDI. We present an atypical case of pseudomembranous colitis affecting the right colon in a patient whose stools were rejected multiple times for C. difficile testing.

Urine test stewardship for catheterized patients in the critical care setting: Provider perceptions and impact of electronic order set interventions

We implemented an electronic medical record (EMR) decision support tool for ordering urine cultures per evidence-based guidelines. Following the EMR change, we found a significant increase in proportion of cultures ordered for catheterized intensive care unit (ICU) patients meeting guidelines. We surveyed providers and found poor understanding of urine culture guidelines for catheterized ICU patients. EMR-based interventions and educational opportunities have potential to improve urine culture guideline adherence and reduce unnecessary testing and antibiotic use.

Trends in Collection of Microbiological Cultures Across Veterans Affairs Community Living Centers in the United States Over 8 Years

OBJECTIVES

To describe and evaluate changes in the collection of microbiological cultures across Veterans Affairs (VA) Community Living Centers (CLCs) nationally.

DESIGN

Descriptive study.

SETTING

146 VA CLCs.

PARTICIPANTS

We identified both positive and negative microbiological cultures collected during VA CLC admissions from January 2010 through December 2017.

MEASURES

We measured the average annual percentage change (AAPC) in the rate of cultures collected per 1000 bed days and per admission, overall and stratified by culture type (ie, urine, blood, skin and soft tissue, and respiratory tract). AAPCs were also calculated for the proportion and rate of positive cultures collected, overall and stratified by culture type and organism (ie, Escherichia coli, Proteus mirabilis, Staphylococcus aureus, Enterococcus spp, Pseudomonas aeruginosa, Klebsiella spp, Enterobacter spp, Morganella morganii, Citrobacter spp, Serratia marcescens, and Streptococcus pneumoniae). Joinpoint regression software was used to assess trends and estimate AAPCs and 95% confidence intervals (CIs).

RESULTS

Over 8 years, 355,329 cultures were collected. The rate of cultures collected per 1000 bed days of care decreased significantly by 6.0% per year (95% CI -8.7%, -3.2%). The proportion of positive cultures decreased by 0.9% (95% CI -1.4%, -0.4%). The most common culture types were urine (48.4%), followed by blood (27.7%). The rate of cultures collected per 1000 bed days of care decreased per year by 6.3% for urine, 5.0% for blood, 4.4% for skin and soft tissue, and 4.9% for respiratory tract. In 2010, S aureus was the most common organism identified, and in all subsequent years E coli was the most common.

CONCLUSION AND IMPLICATIONS

We identified a significant reduction in the number of cultures collected over time among VA CLCs. Our findings may be explained by decreases in the collection of unnecessary cultures in VA CLCs nationally due to increased antibiotic stewardship efforts targeting unnecessary culturing and antibiotic treatment.

Reduced Clostridioides difficile Tests Among Solid Organ Transplant Recipients Through a Diagnostic Stewardship Bundled Intervention

BACKGROUND Clostridioides difficile infection (CDI) is a frequent complication of solid organ transplantation, especially in the early post-transplantation period. Overdiagnosis of CDI is likely common in hospitals using nucleic acid amplification testing (NAAT), potentially leading to unnecessary iatrogenesis and cost. Recently, multiple studies have shown that computerized clinical decision support (CCDS)-based interventions can significantly reduce inappropriate C. difficile testing and healthcare facility-onset CDI events across hospitals and health systems. We aimed to determine if a CCDS-based intervention could reduce C. difficile testing and surveillance infection events among recent solid organ transplant recipients, a population at high risk for CDI. We also sought to determine the safety of the CCDS intervention. MATERIAL AND METHODS Quasi-experimental census-adjusted interrupted time-series analyses were performed retrospectively to examine testing and CDI events pre- and post-intervention. Mortality and readmissions rates were also examined. RESULTS A significant 33% relative reduction in tests and a nonsignificant trend towards fewer CDI events were observed following the intervention, without significant differences in mortality or 30-day readmission. A review of patients with positive C. difficile NAATs after prevented tests revealed no specific adverse events attributable to a possible delay in CDI diagnosis. CONCLUSIONS CCDS may be a helpful and safe adjunctive strategy to reduce unnecessary testing in accordance with guideline recommendations among solid organ transplant recipients.

Test stewardship, frequency and fidelity: Impact on reported hospital-onset Clostridioides difficile

We assessed the impact of an embedded electronic medical record decision-support matrix (Cerner software system) for the reduction of hospital-onset Clostridioides difficile. A critical review of 3,124 patients highlighted excessive testing frequency in an academic medical center and demonstrated the impact of decision support following a testing fidelity algorithm.

Hospital Infection Prevention: How Much Can We Prevent and How Hard Should We Try?

PURPOSE OF REVIEW

To summarize the extent to which hospital-acquired infections (HAIs) are preventable and to assess expectations, challenges, and barriers to improve patient outcomes.

RECENT FINDINGS

HAIs cause significant morbidity and mortality. Getting to zero HAIs is a commonly stated goal yet leads to unrealistic expectations. The extent to which all HAIs can be prevented remains debatable and is subject to multiple considerations and barriers. Current infection prevention science is inexact and evolving. Evidence-based infection prevention practices are often incompletely implemented and at times controversial. Highly sensitive surveillance results in overdiagnosis, calling into question the real incidence of HAIs. Perceived reductions in HAIs by gaming the system lead to false conclusions about preventability and may cause harm. Successful HAI reduction programs require executive oversight yet keeping hospital leaders engaged in infection prevention is a challenge given competing priorities. Medicine is not a physical science with precisely defined laws; thus, infection prevention interventions are subject to variable outcomes. Perhaps up to 55-70% of HAIs are potentially preventable. This is subject to a law of diminishing returns as the preventable proportion of HAIs may reduce over time with improvements in patient safety. As the principle tenet of medicine is first do no harm, infection prevention programs should relentlessly pursue reliable, sustainable, and practical strategies for heightened patient safety.

Clostridioides difficile-Associated Diarrhea: Infection Prevention Unknowns and Evolving Risk Reduction Strategies

PURPOSE OF REVIEW

New controversies in the diagnosis and prevention of Clostridiodes difficile are challenging and at times changing infection control practice at many medical centers.

RECENT FINDINGS

Molecular epidemiologic studies are changing our understanding of C. difficile and its spectrum of disease. C. difficile as a hospital-acquired infection is likely largely overdiagnosed given overly sensitive molecular testing and widespread colonization of ill or debilitated patients. Clostridiodes difficile infection continues to challenge infection prevention programs. Shifts in our understanding of the epidemiology of this organism and its spectrum of clinical presentations are changing the approach to prevention efforts. Nevertheless, cleanliness of the healthcare environment and antimicrobial stewardship remain core risk reduction strategies. Other strategies such as screening and isolation are inciting controversy. The optimal infection prevention strategies for C. difficile remain the subject of intense study and debate.

Diagnostic stewardship and the 2017 update of the IDSA-SHEA Clinical Practice Guidelines for Clostridium difficile Infection

Diagnostic stewardship is an increasingly recognized means to reduce unnecessary tests and diagnostic errors. As a leading cause of healthcare-associated infection for which accurate laboratory diagnosis remains a challenge, Clostridium difficile offers an ideal opportunity to apply the principles of diagnostic stewardship. The recently updated 2017 Infectious Diseases Society of America (IDSA)-Society for Healthcare Epidemiology of America (SHEA) Clinical Practice Guidelines for C. difficile infection now recommend separate diagnostic strategies depending on whether an institution has adopted diagnostic stewardship in test decision making. IDSA-SHEA endorsement of diagnostic stewardship for C. difficile highlights the increasing role of diagnostic stewardship in hospitals. In this opinion piece, we introduce the concept of diagnostic stewardship by discussing the new IDSA-SHEA diagnostic recommendations for laboratory diagnosis of C. difficile. We outline recent examples of diagnostic stewardship, challenges to implementation, potential downsides and propose future areas of study.

The Current State of Antimicrobial Stewardship: Challenges, Successes, and Future Directions

PURPOSE OF REVIEW

The aim of this study is to examine the current state of the field of antimicrobial stewardship (AS) by highlighting key challenges and successes, as well as exciting future directions.

RECENT FINDINGS

AS mandates from the Centers for Medicare and Medicaid (CMS) and the Joint Commission (TJC) will stimulate increased compliance with current AS standards, but overall compliance is currently poor. Key challenges to progress in the field of AS include insufficient workforce and monetary resources, poorly defined AS metrics, and much needed expansion beyond the inpatient hospital setting. Despite these challenges, massive progress has been made in the last two and a half decades since the field of AS emerged. AS metrics are rapidly evolving and transforming the way antimicrobial stewardship programs (ASPs) measure success. Rapid diagnostics and diagnostic test stewardship are proving to be extremely effective when coupled with an ASP. Telehealth may improve access to ASP expertise in resource poor settings, and the role of bedside nurses as ASP team members has the potential to greatly augment ASP efforts. Allergy testing as an ASP strategy remains largely underutilized. ASPs have made significant gains in the battle against antimicrobial resistance (AR), but considerable advancement is still needed. Awareness of current challenges is critical to ensure progress in the field. The field of AS is expanding and transforming rapidly through integration, technology, and improved processes.

Reduced Clostridium difficile Tests and Laboratory-Identified Events With a Computerized Clinical Decision Support Tool and Financial Incentive

We hypothesized that a computerized clinical decision support tool for Clostridium difficile testing would reduce unnecessary inpatient tests, resulting in fewer laboratory-identified events. Census-adjusted interrupted time-series analyses demonstrated significant reductions of 41% fewer tests and 31% fewer hospital-onset C. difficile infection laboratory-identified events following this intervention.

Infect Control Hosp Epidemiol 2018;39:737–740