2341. Effectiveness of Interventions Targeting Stewardship of Clostridium difficile Testing

Abstract

Background Clostridium difficile infection (CDI) is the most common healthcare-associated infection. C. difficile PCR assays do not differentiate between colonization (seen in up to 21% of inpatients) and symptomatic disease, highlighting the importance of testing only symptomatic patients.MethodsInterventions included system-wide implementation of C. difficile testing guidelines, face-to-face education of licensed providers, and Best Practice Alerts (BPAs) embedded in the electronic health record (EHR) C. difficile PCR order. The guidelines recommend testing only when ≥ 3 liquid bowel movements within a 24-hour period, without laxatives, oral contrast or new enteral feeds in the preceding 24 hours, and without recent C. difficile PCR test (negative ≤ 7 days or positive < 30 days). We reviewed 100 consecutive C. difficile PCR orders across two hospitals pre- and post-intervention to assess compliance with guidelines; performed weekly review of all C. difficile PCRs, all BPA responses and all hospital-onset CDI. Cost savings were calculated based on published estimates of CDI attributable costs.ResultsHospital-onset CDI rates fell from 0.75 to 0.48 cases per 1000 patient-days, with an estimated costs savings of $259,555 per quarter and $1.04 million per year. There were no deaths due to CDI and no morbidity due to delayed CDI diagnosis. C. difficile PCR guideline compliance increased from 39% to 53%; orders decreased by 50% post-intervention. Receipt of laxatives and < 3 episodes of diarrhea were the most common reasons for guideline noncompliance. BPAs fired an average of 150 times/month. The most common trigger for BPA was laxative use. Providers canceled PCR orders in 40% of BPA events.ConclusionInterventions incorporating testing guidelines, face-to-face education, and EHR-embedded decision support resulted in fewer C. difficile PCRs orders, increased guideline compliance, lower rates of hospital-onset CDI and cost savings of $1 million per year without an increase in CDI-attributable death or morbidity.Disclosures All authors: No reported disclosures.