Paul bruns steward healthcare8/26/2023 ![]() Once population-specific risk factors are defined, models that support clinical decision making can help narrow the pool of patients who require PCR testing for definitive diagnosis and prioritize testing for those who are high risk. difficile PCR testing.ĭiagnostic stewardship within hospitals can be achieved through an integrated approach supported by Antimicrobial Stewardship Programs (ASPs), Infection Prevention Programs, and the clinical microbiology laboratory. Thus, a need exists for population-specific test criteria in order to steward C. While the use of institutional testing criteria theoretically should improve PCR test utilization, applying one set of criteria to all hospitalized patients may constitute optimal test use. To address this gap in practice and thus reduce clinical false positive results, consensus guidelines recommend implementing institutional testing criteria or, alternatively, following a multistep laboratory testing algorithm ( 3). We and others have found inconsistent documentation of clinical disease and a high occurrence of alternate etiologies for diarrhea in hospitalized patients (e.g., laxative use, oral contrast, systemic chemotherapy) ( 7). difficile polymerase chain reaction nucleic acid amplification testing (i.e., PCR testing) on liquid stool specimens is a highly sensitive and specific test however, clinical false positive tests can occur in patients who are colonized by C. Strictly from an analytical perspective, C. The diagnosis of CDI relies on both clinical and microbiological evidence of disease. CDI most commonly presents as new onset diarrhea among patients with recent antibiotic exposure, but it can rarely present as ileus and toxic megacolon ( 3). ![]() difficile infection (CDI) is a significant complication of antibiotic treatment that is responsible for high morbidity. Overuse of broad-spectrum antibiotics, which are likely inappropriate for the majority of patients with community acquired pneumonia (CAP), is a major driver of infectious complications including Clostridioides difficile associated diarrhea ( 2). Pneumonia is the leading infectious cause of death and eighth leading cause of death overall among patients in the U.S. Prospective studies are needed to confirm the reproducibility and clinical utility of our model when used for diagnostic test stewardship. We conclude that broad-spectrum Gram-negative antibiotic use was the common factor in development of CDI in patients with CAP in all settings. Patients with m-APACHE II ≤ 8.5 who received broad-spectrum Gram-negative antibiotics were more likely (odds=1:2) to experience healthcare-associated CDI compared to those who did not receive these broad-spectrum agents (odds=1:125) and compared to those with m-APACHE II > 8.5 irrespective of treatment (odds=5:27). Modified-APACHE II > 8.5 (P=0.003) and broad-spectrum Gram-negative antibiotic use (P=0.002) were associated with healthcare-associated CDI and were robust in multiple validity analyses. After propensity score weighting, hospital-onset (HO) CDI was significantly associated with broad-spectrum Gram-negative antibiotic use (P=0.002) as was subsequent community-onset (CO) CDI (P=0.005). Thirty-two PCR confirmed CDI cases were identified and 232 randomly selected controls were drawn from the total CAP population. A series of predictive models and validity assessments were used to evaluate demographic and post-admission patient-specific risk factors as predictors of CDI case status among patients with CAP. The study was a single-center retrospective, case-control analysis of hospitalized adult patients empirically treated for CAP between Januand May 29, 2018. difficile polymerase chain reaction (PCR) testing. ![]() We developed and validated a CAP-specific clinical decision algorithm to facilitate optimal diagnostic stewardship of C. ![]() Adults hospitalized with community-acquired pneumonia (CAP) typically receive antibiotics and thus are at increased risk of developing Clostridioides difficile infection (CDI), a disease of significant morbidity.
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