Real-Time Electronic Tracking of Diarrheal Episodes and Laxative Therapy Enables Verification of Clostridium difficile Clinical Testing Criteria and Reduction of Clostridium difficile Infection Rates

Abstract

Health care-onset health care facility-associated <i>Clostridium difficile</i> infection (HO-CDI) is overdiagnosed for several reasons, including the high prevalence of <i>C. difficile</i> colonization and the inability of hospitals to limit testing to patients with clinically significant diarrhea. We conducted a quasiexperimental study from 22 June 2015 to 30 June 2016 on consecutive inpatients with <i>C. difficile</i> test orders at an academic hospital. Real-time electronic patient data tracking was used by the laboratory to enforce testing criteria (defined as the presence of diarrhea [≥3 unformed stools in 24 h] and absence of laxative intake in the prior 48 h). Outcome measures included <i>C. difficile</i> test utilization, HO-CDI incidence, oral vancomycin utilization, and clinical complications. During the intervention, 7.1% (164) and 9.1% (211) of 2,321 <i>C. difficile</i> test orders were canceled due to absence of diarrhea and receipt of laxative therapy, respectively. <i>C. difficile</i> test utilization decreased upon implementation from an average of 208.8 tests to 143.0 tests per 10,000 patient-days (<i>P</i> < 0.001). HO-CDI incidence rate decreased from an average of 13.0 cases to 9.7 cases per 10,000 patient-days (<i>P</i> = 0.008). Oral vancomycin days of therapy decreased from an average of 13.8 days to 9.4 days per 1,000 patient-days (<i>P</i> = 0.009). Clinical complication rates were not significantly different in patients with 375 canceled orders compared with 869 episodes with diarrhea but negative <i>C. difficile</i> results. Real-time electronic clinical data tracking is an effective tool for verification of <i>C. difficile</i> clinical testing criteria and safe reduction of inflated HO-CDI rates.