Changing results to change results: Nudging antimicrobial prescribing for clostridium difficile

Abstract

Background: Patients who test positive for Clostridium difficile by polymerase chain reaction (PCR), with a negative toxin enzyme immunoassay (EIA), are commonly colonized and do not require treatment. However, clinicians often treat based on a positive PCR result regardless of the toxin EIA result. We evaluated the clinical impact of a microbiology reporting nudge, changing from a report that included both assay results along with treatment recommendations to one that suggested clinicians consider C difficile colonization or early infection. Methods: We conducted a retrospective cohort study of all adult patients admitted to a large multisite community hospital with a positive C difficile PCR result and negative toxin EIA from January 1, 2016 to June 30, 2018. We examined total days of therapy (DOT) and impacts on clinical outcomes. Results: One hundred ninety-nine episodes occurred preintervention and 165 episodes occurred postintervention. The mean DOTs per episode decreased from 13.6 to 7.9 days (difference-5.8 days; 95% confidence interval,-3.9 to-7.6) postintervention, with statistical process control charts suggesting special cause variation. Patients receiving no treatment increased from 6.5% to 23.6% postintervention (P