A Multi-Faceted Approach to Reducing the SIR for Clostridioides difficile Healthcare Associated Infections

Abstract

<h3>Background</h3> In February 2018, The Society for Healthcare Epidemiology of America (SHEA) published updated clinical practice guidelines for Clostridiodes difficile (C. diff). The Standardized Infection Ratio (SIR) at our acute care facility was noted to be above the national average of 0.924. The updated guidelines included recommendations to only test patients with new onset and unexplained diarrhea consisting of three or more unformed stools within a twenty-four period, and the addition of a confirmation test to differentiate active infection from colonization. <h3>Methods</h3> As a result of the SHEA recommendations, two questions were added to the electronic medical records system when a C. diff test is ordered: 1.Has the patient reported three or more unformed stools in the past twenty-four hours? 2.Has the patient received a laxative or stool softener in the past forty-eight hours? Staff education was provided system-wide on both proper specimen collection and appropriate test ordering. The Microbiology lab performed a comparison study between two enzyme immunoassay (EIA) tests and the gold standard cytotoxin assay. The study found that both EIA tests had low sensitivity and consequently, all positive C. diff PCR specimens were sent for confirmation by cytotoxin assay. <h3>Results</h3> The SIR pre-implementation (October 2017 to September 2018) to post-implementation (October 2018 to September 2019) demonstrated a reduction from 1.200 to 0.716 (p=0.0003), and has remained below the benchmark since that time. About 57% of positive C. diff PCR specimens confirmed with cytotoxin assay. <h3>Conclusions</h3> The implementation of the two-step process and the addition of the questions regarding specimen appropriateness is believed to have contributed to a significantly reduced SIR for C. diff. This has also led to a reduction in unnecessary antibiotic treatment and isolation of patients.