Tag Archives: MPH

Changes In Electronic Health Records (EHR) To Guide Clinicians In C. diff. Diagnostic Stewardship – To Pause Testing When Not Clinically Indicated

An intervention that required administrative approval of all Clostridioides difficile testing after

hospital day 3 out-performed electronic health record-based support in reducing

C. difficile testing, according to a study.

“We made a series of changes in the electronic health records (EHRs) that we hoped would discourage clinicians from ordering C. difficile tests when testing was not clinically indicated, such as when patients with diarrhea had a more likely explanation such as recent laxative use, or when testing was ordered on patients who were not having diarrhea or other symptoms of C. difficile infection at all,” Lewis said. “In addition, one hospital in our system independently implemented a physician ‘gatekeeper’ to approve all C. difficile test orders for admitted patients.”

“We performed this work as part of a larger quality improvement initiative with the goal of improving the accuracy of diagnosis of C. difficile infection in order to improve quality of care for patients and decrease our health system’s publicly reported rates of C. difficile,” Sarah S. Lewis, MD, MPH, associate professor of medicine in the division of infectious diseases at Duke University Medical Center, told Healio.

“We made a series of changes in the electronic health records (EHRs) that we hoped would discourage clinicians from ordering C. difficile tests when testing was not clinically indicated, such as when patients with diarrhea had a more likely explanation such as recent laxative use, or when testing was ordered on patients who were not having diarrhea or other symptoms of
C. difficile infection at all,” Lewis said. “In addition, one hospital in our system independently implemented a physician ‘gatekeeper’ to approve all C. difficile test orders for admitted patients.”

Lewis and colleagues tested the three EHR-based interventions at three hospitals. The first intervention, initiated in January 2018, alerted clinicians ordering a test if laxatives were administered within 24 hours. The second, initiated in October 2018, canceled test orders after 24 hours. Implemented in July 2019, he third intervention involved “contextual rule-driven order questions” that required justification when laxatives were administered or there was a lack of EHR documentation of diarrhea. In February 2019, one of the three hospitals then implemented the “gatekeeper intervention” requiring approval for all C. difficile tests after 3 days in the hospital.

Sarah S. Lewis

Lewis and colleagues estimated the impact of the interventions on C. difficile testing and hospital-onset C. difficile infection (HO-CDI) using an interrupted time-series analysis. They found that C. difficile testing was already declining in the preintervention period (annual change in incidence rate [IR] = 0.79; 95% CI, 0.72-0.87) and did not decrease further with the EHR interventions.

The study demonstrated, however, that the laxative alert was temporally associated with a trend reduction in HO-CDI (annual change in IR from baseline = 0.85; 95% CI, 0.75-0.96) at two hospitals. Meanwhile, the gatekeeper intervention at the third hospital was associated with level (incidence rate ratio [IRR[ = 0.5; 95% CI, 0.42-0.6) and trend reductions in C. difficile testing (annual change in IR = 0.91; 95% CI, 0.85-0.98) and level (IRR = 0.42; 95% CI, 0.22-0.81) and trend reductions in HO-CDI (annual change in IR = 0.68; 95% CI, 0.5–0.92) relative to the baseline period, the researchers reported.

“Diagnostic stewardship, or the appropriate utilization of diagnostic tests, is important for improving quality of care. Electronic decision support in the form of alerts or background logic to reinforce the desired provider behavior is attractive because it is relatively low resource, easy to implement, and can be programmed in a way that is relatively unobtrusive to the clinical workflow,” Lewis said. “However, as we and others have seen, decision support often needs to be coupled with both provider education and some form of administrative restriction to achieve desired goals.”

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https://www.healio.com/news/infectious-disease/20210624/test-restrictions-more-effective-than-ehrbased-support-at-reducing-c-difficile-testing?utm_source=selligent&utm_medium=email&utm_campaign=topicalert&M_BT=7301325430025

C. diff. Researcher Leads Researchers To Suggest Secondary Bile Salts May Have Potential As a Novel Biomarker For CDI Recurrence

C.diff. Research and Development News:

Patients with recurrent Clostridium difficile infection had distinct bile acid and microbiome profiles compared with healthy controls and patients with first Clostridium difficile infection, according to research published in Alimentary Pharmacology and Therapeutics. These findings led researchers to suggest that secondary bile salts may have potential as a novel biomarker for recurrence.

“The mechanism of recurrent CDI remains unknown, though bile salts have been implicated. The intestinal microbiota metabolizes bile acids, a process that if disrupted by antibiotics may be critical to initiation of CDI,” Jessica R. Allegretti, MD, MPH, from the Crohn’s and Colitis Center and Harvard Medical School, Brigham and Women’s Hospital told Healio Gastroenterology. “This study aimed to assess bile salt profiles in three distinct groups of patients — recurrent CDI, first episode CDI and healthy controls — to better understand the role bile salts play in pathogenesis of recurrent CDI and to gain further understanding as to which bacteria may be responsible for this important function. Additionally, we performed random forest regression to identify predictors of group membership.”

Allegretti and colleagues collected blood and stool samples from 20 patients with first CDI, 19 patients with recurrent CDI being screened for fecal transplantation, and 21 controls. Samples from the first CDI arm were collected before patients received antibiotic treatment, whereas samples from the recurrent CDI arm were collected while they were receiving stable doses of chronic oral vancomycin. Participants in the control arm had not been exposed to antibiotics for at least 3 months.

Researchers then analyzed blood plasma and stool samples for bile salt metabolomics profiles, and performed 16S rRNA amplicon sequencing to determine the microbiota composition of the stool samples.

“We found that secondary bile acids, which are protective, were significantly elevated in controls compared with both CDI groups in stool and blood,” Allegretti said.

The median secondary bile acids lithocholate and deoxycholate were significantly higher in the stool samples of controls compared with both first CDI (P < .0001 and P = .0003, respectively) and recurrent CDI arms (both P < .0001). Deoxycholate was also significantly higher in first vs. recurrent CDI patients (P = .017).

Median deoxycholic acid was significantly higher in the blood samples of controls compared with both first CDI (P < .0001) and recurrent CDI patients (P = .05), and was also significantly higher in the blood samples of first vs. recurrent CDI patients (P = .003).

“Conversely, primary bile acids, which can induce germination, were elevated in the recurrent group,” Allegretti said.

The primary bile acids cholate and chenodeoxycholate were significantly higher in the stool samples of the recurrent CDI arm compared with controls (P = .0002 and P = .02, respectively).

16S rRNA gene analyses showed significant differences in microbial alpha diversity across groups, which were most pronounced in recurrent CDI patients vs. controls (adjusted P < .001), but also significant between first and recurrent CDI patients and between first CDI patients and controls (both adjusted P < .05). There were also significant differences in beta-diversity between all groups (P = .001) and significant differences in relative abundances at the taxa level.

Using PICRUSt analyses, the researchers also found significant differences in predicted abundances of bacterial bile salt hydrolase genes between groups. Finally, using random forest regression, the researchers differentiated recurrent and first CDI patients 84.2% of the time using bile acid ratios, with stool deoxycholate to glycoursodeoxycholate ratio as the best predictor.

“Plasma deoxycholate (a secondary bile acid) was a strong predictor of disease state and may be utilized as a possible biomarker of recurrence,” Allegretti said. “This study further elucidates the role of bile salts in the pathogenesis of recurrent CDI and identifies possible novel biomarkers for recurrent disease.”

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http://www.healio.com/gastroenterology/infection/news/online/%7B6ea00ba3-4f82-4541-8466-dd5ad2a3e34c%7D/secondary-bile-salts-may-be-novel-biomarkers-of-c-difficile-recurrence?utm_content=31543239&utm_medium=social&utm_source=twitter

by Adam Leitenberger

UV Room Disinfection: Scientific Evidence in Eliminating Healthcare-Associated Infections Worldwide

C. diff. Spores and More  #CdiffRadio

Tuesday, April 21st: UV Room Disinfection: Scientific Evidence in Eliminating Healthcare Associated Infections Worldwide

Listen in at 11:00 a.m. Pacific , 2 pm Eastern time

http://www.voiceamerica.com/episode/84813/uv-room-disinfection-scientific-evidence-in-eliminating-healthcare-associated-infections-worldwide

Guests:  Dr. Mark Stibich, PhD, is Chief Scientific Officer & Co-founder, Xenex. and
Ms. Sarah Simmons, MPH CIC, is Science Director, Xenex

Dr. Stibich and Ms. Simmons will discuss UV Room Disinfection, how pulsed UV disinfection works, the pulsed Xenon UV (PX-UV) difference, and the effectiveness against endospores like
C. diff.
and bacillus strains and the scientific evidence in eliminating
Healthcare-Associated Infections worldwide.

Dr. Mark Stibich, PhD, Chief Scientific Officer & Co-founder, Xenex
Dr. Stibich is a founder of Xenex and, as its Chief Scientific Officer, he oversees scientific research, product development, facility assessments, and protocol design. He leads new technology development and is an inventor on multiple patents. Dr. Stibich meets frequently with infection prevention representatives at healthcare facilities, helping them understand and solve their infection control challenges while analyzing hospital results. Dr. Stibich holds a doctoral degree from the Johns Hopkins University School of Public Health, a Masters in Health Science, also from Johns Hopkins, and a bachelor’s degree from Yale University. He has conducted research in Russia, Tajikistan, Afghanistan, South Africa, Kenya, the United States and Brazil.

Ms. Sarah Simmons,  Science Director, Xenex
As an epidemiologist, Sarah Simmons works with customers to implement Xenex’s pulsed xenon UV light room disinfection technology in their facility, provide support for customers’ Infection Prevention departments, and evaluate their infection reduction results for publication in scientific journals. Sarah worked as an Infection Preventionist for five years in San Antonio, with a focus on infection prevention in critical care. She is a member of the San Antonio APIC chapter and has served on the board in numerous roles. Sarah is a Doctoral Candidate at the University of Texas School of Public Health, has a Masters of Public Health in Epidemiology and Biostatistics from the Texas A&M School of Rural Public Health, and a Bachelors degree in Biology from Texas A&M University.