Nonadherence to C. difficile Treatment Guidelines
Nonadherence to C. difficile Treatment Guidelines
This retrospective observational study of patients with CDI was conducted between October 1, 2007 and September 30, 2008 in a 661-bed, acute tertiary care teaching hospital after approval was granted by the institutional review board. This time period was chosen because the implementation of the Sunrise CPOE program was initiated in June 2007; however, antibiotic-based CDS pathways had been implemented. The cases were screened using the Infection Prevention database, with a positive C. difficile toxin assay during the study period being the criteria for initial inclusion. Medical history was obtained by chart review. Nonpregnant patients between the ages of 18 and 89 years were included if they received treatment with oral metronidazole alone, oral vancomycin alone, or a combination of oral metronidazole and oral vancomycin on day 1 of therapy. Although metronidazole is not approved by the US Food and Drug Administration for CDI, the IDSA/SHEA guidelines recommend its use for treatment of mild-to-moderate CDI. Cases were excluded for the following reasons:
Severe CDI was defined as a peripheral white blood cell count of ≥15,000 cells per microliter and/or a serum creatinine level ≥1.5 times the premorbid level; patients with mild-to-moderate CDI were defined as those with a white blood cell count <15,000 cells per microliter and a serum creatinine level <1.5 times the premorbid level. Comorbid conditions and laboratory data were compared between those who received oral metronidazole alone and those who received concomitant oral metronidazole and vancomycin on day 1 of therapy using χ and Fisher exact tests.
Methods
This retrospective observational study of patients with CDI was conducted between October 1, 2007 and September 30, 2008 in a 661-bed, acute tertiary care teaching hospital after approval was granted by the institutional review board. This time period was chosen because the implementation of the Sunrise CPOE program was initiated in June 2007; however, antibiotic-based CDS pathways had been implemented. The cases were screened using the Infection Prevention database, with a positive C. difficile toxin assay during the study period being the criteria for initial inclusion. Medical history was obtained by chart review. Nonpregnant patients between the ages of 18 and 89 years were included if they received treatment with oral metronidazole alone, oral vancomycin alone, or a combination of oral metronidazole and oral vancomycin on day 1 of therapy. Although metronidazole is not approved by the US Food and Drug Administration for CDI, the IDSA/SHEA guidelines recommend its use for treatment of mild-to-moderate CDI. Cases were excluded for the following reasons:
A history of CDI within the past 1 year, because this could represent recurrent CDI; beyond the first recurrence of CDI, metronidazole should be avoided because of the potential for cumulative neurotoxicity.
Receipt of antibiotics for CDI for <5 days, because a short treatment duration could indicate that the diarrhea was not actually caused by a CDI.
Sequential administration of metronidazole and vancomycin, because this could indicate that the metronidazole was ceased because of an adverse reaction.
Receipt of intravenous metronidazole or vancomycin enemas, because these treatments are given typically for cases of severe complicated CDI with the presence of ileus.
Severe CDI was defined as a peripheral white blood cell count of ≥15,000 cells per microliter and/or a serum creatinine level ≥1.5 times the premorbid level; patients with mild-to-moderate CDI were defined as those with a white blood cell count <15,000 cells per microliter and a serum creatinine level <1.5 times the premorbid level. Comorbid conditions and laboratory data were compared between those who received oral metronidazole alone and those who received concomitant oral metronidazole and vancomycin on day 1 of therapy using χ and Fisher exact tests.