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Treatment of Clostridioides difficile Infection and Non-compliance with Treatment Guidelines in Adults in 10 US Geographical Locations, 2013–2015

  • Shannon A. NovosadEmail author
  • Yi Mu
  • Lisa G. Winston
  • Helen Johnston
  • Elizabeth Basiliere
  • Danyel M. Olson
  • Monica M. Farley
  • Andrew Revis
  • Lucy Wilson
  • Rebecca Perlmutter
  • Stacy M. Holzbauer
  • Tory Whitten
  • Erin C. Phipps
  • Ghinwa K. Dumyati
  • Zintars G. Beldavs
  • Valerie L. S. Ocampo
  • Corinne M. Davis
  • Marion Kainer
  • Dale N. Gerding
  • Alice Y. Guh
Original Research

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.

KEY WORDS

infectious disease decision-making epidemiology Clostridioides difficile 

Notes

Acknowledgments

We would like to acknowledge Lucy Fike for her assistance in data analysis and Deborah Nelson, Rebecca Tsay, Olivia Almendares, Zirka Smith, Catherine Espinosa, Michelle Wiles, and Wendy Bamberg for their assistance in collecting and managing EIP data.

Conflict of Interest

D.N.G. is a member of the Scientific Advisory Boards of Merck, Rebiotix, Actelion, DaVolterra, and Summit; is a consultant for Pfizer, MGB Pharma, and Sanofi Pasteur; holds a research grant from Seres Therapeutics; and holds patents and technology for the prevention of CDI. G.K.D. serves on the Drug Safety Monitoring Board for a C. difficile treatment study by Seres. All other authors have no known conflicts of interest.

Disclaimer

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention.

Compliance with Ethical Standards

This surveillance activity underwent ethical review by CDC and all EIP sites and either was deemed non-research or received an institutional review board approval with a waiver of informed consent.

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Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  • Shannon A. Novosad
    • 1
    • 2
    Email author
  • Yi Mu
    • 2
  • Lisa G. Winston
    • 3
  • Helen Johnston
    • 4
  • Elizabeth Basiliere
    • 4
  • Danyel M. Olson
    • 5
  • Monica M. Farley
    • 6
    • 7
    • 8
  • Andrew Revis
    • 8
    • 9
  • Lucy Wilson
    • 10
  • Rebecca Perlmutter
    • 10
  • Stacy M. Holzbauer
    • 11
    • 12
  • Tory Whitten
    • 11
  • Erin C. Phipps
    • 13
    • 14
  • Ghinwa K. Dumyati
    • 15
  • Zintars G. Beldavs
    • 16
  • Valerie L. S. Ocampo
    • 16
  • Corinne M. Davis
    • 17
  • Marion Kainer
    • 17
  • Dale N. Gerding
    • 18
    • 19
  • Alice Y. Guh
    • 2
  1. 1.Division of Healthcare Quality PromotionEpidemic Intelligence Service, Centers for Disease Control and PreventionAtlantaUSA
  2. 2.Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious DiseasesCenters for Disease Control and PreventionAtlantaUSA
  3. 3.School of MedicineUniversity of California, San FranciscoSan FranciscoUSA
  4. 4.Colorado Department of Public Health and EnvironmentDenverUSA
  5. 5.Connecticut Emerging Infections ProgramYale School of Public HealthNew HavenUSA
  6. 6.Emory University School of MedicineAtlantaUSA
  7. 7.Veterans Affairs Medical CenterAtlantaUSA
  8. 8.Georgia Emerging Infections ProgramAtlantaUSA
  9. 9.Atlanta Research and Education FoundationAtlantaUSA
  10. 10.Maryland Department of HealthBaltimoreUSA
  11. 11.Minnesota Department of HealthSt. PaulUSA
  12. 12.Centers for Disease Control and PreventionAtlantaUSA
  13. 13.New Mexico Emerging Infections ProgramAlbuquerqueUSA
  14. 14.University of New MexicoAlbuquerqueUSA
  15. 15.University of Rochester Medical CenterRochesterUSA
  16. 16.Oregon Health AuthorityPortlandUSA
  17. 17.Tennessee Department of HealthNashvilleUSA
  18. 18.Loyola University Chicago Stritch School of MedicineMaywoodUSA
  19. 19.Edward Hines, Jr. Veterans Affairs HospitalHinesUSA

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