Adherence to Clostridium difficile Infection Treatment Guidelines at a Tertiary Care Hospital: A Retrospective Chart Review

Abstract

Morbidity secondary to Clostridium difficile infection (CDI) places a burden on the health care system. Updated practice guidelines for CDI have been published by the Infectious Diseases Society of America in 2010, with a supplement published in 2013 by the American College of Gastroenterology on recommendations for diagnosis, management, and prevention of CDI. Both guidelines identify a scoring system to calculate the severity of CDI, with recommended antibiotic choices based on CDI severity. The aim of this study was to evaluate the adherence to guidelines for the management of severe CDI in hospitalized patients at an academic medical center. A retrospective chart review on hospitalized patients fulfilling criteria for severe CDI was completed from 2011 to 2014. Inclusion criteria were positive C difficile toxin A or B enzyme immunoassay or C difficile toxin polymerase chain reaction, albumin <3 g/dL, and white blood cell count ≥15,000 cells/μL. Age, sex, timing of diagnosis, method of diagnosis, previous CDI, antibiotic use at time of diagnosis or within the previous 4 weeks, hospitalization within the past 6 months, labs (including serum albumin, white blood cells, lactate, creatinine), vitals, hospital location (floor vs intensive care unit), hospital service (medicine, surgery, nonteaching service), presence of ileus, time to initiate antibiotics, antibiotic choice, and time to specialty consult (gastrointestinal, infectious diseases, and colorectal surgery) were also collected. A total of 178 patients met inclusion criteria. Mean age was 64 years, with equal numbers of male and female patients (48.9% and 51.1%). The majority (56%) of patients developed CDI >72 hours from admission, with the remainder on admission (23%) and <72 hours from admission (21%). Fifty-three percent (94 of 178) of patients were not started on the appropriate antibiotic regimen for the treatment of severe CDI at the time of diagnosis. Of those patients with severe CDI on the medicine housestaff service, 49% were not started on appropriate antibiotics at the time of diagnosis, compared with 53% on the nonteaching service, and 58% on the surgery housestaff service. Hospital service was not a significant predictor of appropriate antibiotic selection (P = .59). Sixty percent of patients with severe CDI hospitalized on a non−intensive care unit floor were not started on the appropriate antibiotic regimen at the time of diagnosis, compared with 41% in the intensive care unit. Hospital location was a significant predictor of appropriate antibiotic selection (P = .02). Our data indicate a need for better recognition and management of patients with severe CDI. In an effort to improve outcomes, we have developed hospital-based guidelines that represent a fusion of the American College of Gastroenterology/Infectious Diseases Society of America guidelines, including age ≥60 years as a risk factor, and removing oral vancomycin pharmacy restriction within our institution. Implementation of an educational program on the appropriate treatment of severe CDI is also underway, with development of electronic medical record alerts to identify patients at risk for severe CDI.