Shannon A Novosad1,2, Yi Mu3, Lisa G Winston4, Helen Johnston5, Elizabeth Basiliere5, Danyel M Olson6, Monica M Farley7,8,9, Andrew Revis9,10, Lucy Wilson11, Rebecca Perlmutter11, Stacy M Holzbauer12,13, Tory Whitten12, Erin C Phipps14,15, Ghinwa K Dumyati16, Zintars G Beldavs17, Valerie L S Ocampo17, Corinne M Davis18, Marion Kainer18, Dale N Gerding19,20, Alice Y Guh3. 1. Division of Healthcare Quality Promotion, Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, 30329, USA. ydz1@cdc.gov. 2. Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA. ydz1@cdc.gov. 3. Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA. 4. School of Medicine, University of California, San Francisco, San Francisco, CA, USA. 5. Colorado Department of Public Health and Environment, Denver, CO, USA. 6. Connecticut Emerging Infections Program, Yale School of Public Health, New Haven, CT, USA. 7. Emory University School of Medicine, Atlanta, GA, USA. 8. Veterans Affairs Medical Center, Atlanta, GA, USA. 9. Georgia Emerging Infections Program, Atlanta, GA, USA. 10. Atlanta Research and Education Foundation, Atlanta, GA, USA. 11. Maryland Department of Health, Baltimore, MD, USA. 12. Minnesota Department of Health, St. Paul, MN, USA. 13. Centers for Disease Control and Prevention, Atlanta, GA, USA. 14. New Mexico Emerging Infections Program, Albuquerque, NM, USA. 15. University of New Mexico, Albuquerque, NM, USA. 16. University of Rochester Medical Center, Rochester, NY, USA. 17. Oregon Health Authority, Portland, OR, USA. 18. Tennessee Department of Health, Nashville, TN, USA. 19. Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA. 20. Edward Hines, Jr. Veterans Affairs Hospital, Hines, IL, USA.
Abstract
BACKGROUND: Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) guidelines describe recommended therapy for Clostridioides difficile infection (CDI). OBJECTIVE: To describe CDI treatment and, among those with severe CDI, determine predictors of adherence to the 2010 IDSA/SHEA treatment guidelines. DESIGN: We analyzed 2013-2015 CDI treatment data collected through the Centers for Disease Control and Prevention's Emerging Infections Program. Generalized linear mixed models were used to identify predictors of guideline-adherent therapy. PATIENTS: A CDI case was defined as a positive stool specimen in a person aged ≥ 18 years without a positive test in the prior 8 weeks; severe CDI cases were defined as having a white blood cell count ≥ 15,000 cells/μl. MAIN MEASURES: Prescribing and predictors of guideline-adherent CDI therapy for severe disease. KEY RESULTS: Of 18,243 cases, 14,257 (78%) were treated with metronidazole, 7683 (42%) with vancomycin, and 313 (2%) with fidaxomicin. The median duration of therapy was 14 (interquartile range, 11-15) days. Severe CDI was identified in 3250 (18%) cases; of 3121 with treatment data available, 1480 (47%) were prescribed guideline-adherent therapy. Among severe CDI cases, hospital admission (adjusted odds ratio [aOR] 2.48; 95% confidence interval [CI] 1.90, 3.24), age ≥ 65 years (aOR 1.37; 95% CI 1.10, 1.71), Charlson comorbidity index ≥ 3 (aOR 1.27; 95% CI 1.04, 1.55), immunosuppressive therapy (aOR 1.21; 95% CI 1.02, 1.42), and inflammatory bowel disease (aOR 1.56; 95% CI 1.13, 2.17) were associated with being prescribed guideline-adherent therapy. CONCLUSIONS: Provider adherence to the 2010 treatment guidelines for severe CDI was low. Although the updated 2017 CDI guidelines, which expand the use of oral vancomycin for all CDI, might improve adherence by removing the need to apply severity criteria, other efforts to improve adherence are likely needed, including educating providers and addressing barriers to prescribing guideline-adherent therapy, particularly in outpatient settings.
BACKGROUND: Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) guidelines describe recommended therapy for Clostridioides difficile infection (CDI). OBJECTIVE: To describe CDI treatment and, among those with severe CDI, determine predictors of adherence to the 2010 IDSA/SHEA treatment guidelines. DESIGN: We analyzed 2013-2015 CDI treatment data collected through the Centers for Disease Control and Prevention's Emerging Infections Program. Generalized linear mixed models were used to identify predictors of guideline-adherent therapy. PATIENTS: A CDI case was defined as a positive stool specimen in a person aged ≥ 18 years without a positive test in the prior 8 weeks; severe CDI cases were defined as having a white blood cell count ≥ 15,000 cells/μl. MAIN MEASURES: Prescribing and predictors of guideline-adherent CDI therapy for severe disease. KEY RESULTS: Of 18,243 cases, 14,257 (78%) were treated with metronidazole, 7683 (42%) with vancomycin, and 313 (2%) with fidaxomicin. The median duration of therapy was 14 (interquartile range, 11-15) days. Severe CDI was identified in 3250 (18%) cases; of 3121 with treatment data available, 1480 (47%) were prescribed guideline-adherent therapy. Among severe CDI cases, hospital admission (adjusted odds ratio [aOR] 2.48; 95% confidence interval [CI] 1.90, 3.24), age ≥ 65 years (aOR 1.37; 95% CI 1.10, 1.71), Charlson comorbidity index ≥ 3 (aOR 1.27; 95% CI 1.04, 1.55), immunosuppressive therapy (aOR 1.21; 95% CI 1.02, 1.42), and inflammatory bowel disease (aOR 1.56; 95% CI 1.13, 2.17) were associated with being prescribed guideline-adherent therapy. CONCLUSIONS: Provider adherence to the 2010 treatment guidelines for severe CDI was low. Although the updated 2017 CDI guidelines, which expand the use of oral vancomycin for all CDI, might improve adherence by removing the need to apply severity criteria, other efforts to improve adherence are likely needed, including educating providers and addressing barriers to prescribing guideline-adherent therapy, particularly in outpatient settings.
Authors: Stuart Johnson; Thomas J Louie; Dale N Gerding; Oliver A Cornely; Scott Chasan-Taber; David Fitts; Steven P Gelone; Colin Broom; David M Davidson Journal: Clin Infect Dis Date: 2014-05-05 Impact factor: 9.079