Successful diagnostic stewardship for Clostridioides difficile testing in pediatrics

Objective: To reduce both inappropriate testing for and diagnosis of healthcare-onset (HO) Clostridioides difficile infections (CDIs). Design: We performed a retrospective analysis of C. difficile testing from hospitalized children before (October 2017-October 2018) and after (November 2018-October 2020) implementing restrictive computerized provider order entry (CPOE). Setting: Study sites included hospital A (a similar to 250-bed freestanding children's hospital) and hospital B (a similar to 100-bed children's hospital within a larger hospital) that are part of the same multicampus institution. Methods: In October 2018, we implemented CPOE. No testing was allowed for infants aged <= 12 months, approval of the infectious disease team was required to test children aged 13-23 months, and pathology residents' approval was required to test all patients aged >= 24 months with recent laxative, stool softener, or enema use. Interrupted time series analysis and Mann-Whitney U test were used for analysis. Results: An interrupted time series analysis revealed that from October 2017 to October 2020, the numbers of tests ordered and samples sent significantly decreased in all age groups (P < .05). The monthly median number of HO-CDI cases significantly decreased after implementation of the restrictive CPOE in children aged 13-23 months (P < .001) and all ages combined (P = .003). Conclusion: Restrictive CPOE for CDI in pediatrics was successfully implemented and sustained. Diagnostic stewardship for CDI is likely cost-saving and could decrease misdiagnosis, unnecessary antibiotic therapy, and overestimation of HO-CDI rates.

Automated summary

The objective of this study was to reduce inappropriate testing for and diagnosis of healthcare-onset (HO) Clostridioides difficile infections (CDIs). By implementing restrictive computerized provider order entry (CPOE), the study successfully reduced the number of tests ordered and samples sent in all age groups and significantly decreased the monthly median number of HO-CDI cases in children aged 13-23 months and all ages combined.