Stewardship / Resistance Scan for Apr 13, 2020

C diff testing stewardship
Improved UK antibiotic prescribing

Study: Diagnostic stewardship tied to benefits for C diff testing

Applying diagnostic stewardship to molecular testing for Clostridioides difficile infection (CDI) at a hospital system in California was associated with to a significant reduction in testing, cases, and costs, researchers reported today in Infection Control and Hospital Epidemiology.

In the multicenter study, researchers at Scripps Mercy Hospital in San Diego evaluated two 6-month periods before and after an intervention at the four-hospital Scripps Healthcare system in which polymerase chain reaction (PCR) testing for C difficile had to be separately ordered by a clinician if enzyme immunoassay (EIA) test results were indeterminate.

Prior to the intervention, the hospital system's C difficile testing algorithm reflexively ordered PCR tests as a "tie breaker" in indeterminate cases, but PCR tests can lead to overdiagnosis because they don't distinguish between C difficile colonization and active infection. The primary outcome of the study was the change in the number of CDI diagnoses between periods, and secondary outcomes included the number of PCR tests performed, adverse events, and healthcare cost savings.

In total, 500 EIA-indeterminate C difficile test results were evaluated: 281 before the intervention and 219 thereafter. CDI was diagnosed by PCR among EIA-indeterminate cases in 182 (64.8%) in the preintervention period versus 94 patients (42.9%) in the postintervention period (48.4% reduction; P < .01). PCR testing was performed in 99.6% of indeterminate cases (280 of 281) in the preintervention period versus 65.8% (144 of 219) in the postintervention period (33.8-percentage-point reduction; P < .01). Researchers observed no differences between study periods in 30-day all-cause (P = .96), gastrointestinal illness-related (P = .93), or C difficile (P = .47) hospital readmissions, nor in 30-day C difficile infections (P > .99).

No patient without a PCR test in the postintervention period and not treated was later diagnosed as having CDI. Each reflexive PCR test not performed led to a cost savings of $4,498 per patient.

"The study results presented here highlight the importance of diagnostic stewardship in ordering C. difficile PCR tests in the inpatient setting and the benefits of a simple change from reflexive to clinician-required ordering for PCR testing among EIA antigen+/toxin− cases," the researchers write.
Apr 13 Infect Control Hosp Epidemiol abstract


Quality improvement linked to appropriate prescribing in Scotland

Prescribing of gentamicin and vancomycin in Scotland improved following the development of revised guidelines and other quality improvement (QI) resources, Scottish researchers reported recently in the Journal of Antimicrobial Chemotherapy.

The QI resources were developed by five pharmacists in collaboration with Scottish antimicrobial stewardship teams following studies in 2011 that showed the limitations of national guidance on gentamycin and vancomycin prescribing introduced in 2009. Among the findings of those studies were that only 44% of gentamicin dosage recommendations and 55% of vancomycin dosage recommendations were in accordance with the guidelines, that the existence of guidelines alone was insufficient to ensure appropriate prescribing and monitoring, and that poor communication, unmet educational needs, and inappropriate staffing were some of the obstacles.

Through a series of meetings, workshops, and face-to-face discussions, the team developed revised guidelines, online and mobile dose calculators, educational material, and specialized prescribing and monitoring charts that were implemented from 2013 through 2016. An online survey conducted in 2017 found that 80% of the Scottish health boards that responded (12 of 15) were using the revised guidelines, electronic calculators, and gentamicin prescription chart (8 used the vancomycin chart).

A before-and-after point prevalence study to evaluate the impact of the QI resources found that, from 2011 to 2018, the percentage of patients who received the recommended dose of gentamicin increased from 44% to 89% (odds ratio [OR], 10.99; 95% confidence interval [CI], 6.37 to 18.95). For vancomycin, the correct loading dose increased from 50% to 85% (OR, 5.69; 95% CI, 2.76 to 11.71) and the correct maintenance dose rose from 55% to 90% (OR, 7.17; 95% CI, 3.01 to 17.07).

"Strong leadership from a dedicated team of healthcare professionals in collaboration with national and local multidisciplinary networks facilitated the success of these developments," the authors of the study write. "This improvement methodology could be adapted for other areas of prescribing practice with the aim of improving the use of antimicrobial prescribing at scale within the hospital setting."
Apr 11 J Antimicrob Chemother abstract

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