Reducing overdiagnosis and overtreatment of c. difficile

WHY: Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. However, with the availability of highly sensitive molecular tests, restricting testing to symptomatic patients is essential to prevent the overdiagnosis and overtreatment of CDIs. A chart review of hospital onset CDI at Johns Hopkins revealed 42% were inappropriately tested, 90% of which received treatments (Rock et al, 2018). Reducing overtreatment of C. difficile shows up on Choosing Wisely lists for the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and AMDA – The Society for Post-Acute and Long-Term Care Medicine.

WHAT: Implement a systems-based project to reduce both overdiagnosis and overtreatment of C. difficile. Project goals are to support appropriate antimicrobial stewardship, decrease inappropriate treatment of C. difficile colonization, standardize laboratory policies, and improve lab stewardship.

HOW: Multimodal approach to include three components:

• Education (HVC web site info, posters, pocket cards)

• Audit and feedback (HVC teams, attending physicians, ID specialists)

• Clinical decision support algorithms

  • Require clinician to indicate symptoms of C. difficile; OR

  • Require clinician to indicate high risk patient category (unexplained fever, leukocytosis, neutropenia, transplant patient)

  • Nursing is permitted to cancel order if unable to obtain specimen or if stool is not liquid (using objective measures such as the Bristol index)

  • Lab rejects specimen if stool is formed (fails the ‘stick test’)