Best Practices Advice Leads to Better C Difficile Outcomes

Tiffany Wu, PharmD

By implementing best practice advisory (BPA) principals, clinicians can help reduce the occurrence of recurrent clostridium difficile infections (CDI).

A team, led by Tiffany Wu, PharmD, Department of Pharmacy, Henry Ford Hospital, determined the impact of clinical decision support on guideline-concordant C difficile infection treatments.

The Study

In the quasi-experimental study, the investigators examined patients at more than 50 primary, specialty, and urgent-care clinics. Patients included in the analysis were diagnosed with and treated for a first episode of symptomatic C difficile infection at an ambulatory clinic between November 1, 2019 and November 30, 2020.

The investigators also implemented an outpatient best practice advisory (BPA) to notify prescribers that vancomycin or fidaxomicin are the preferred treatment over metronidazole for C difficile infections when metronidazole was prescribed to a patient with CDI.

There was a total of 189 patients included in the study, 92 prior to the best practice advisory and 97 after the best practice advisory. The median age of the patient population was 59 years and 31% of the participants were males.

Patient Background

In addition, 30% of the patients included in the study had CDI-related comorbidities, 35% had healthcare exposure, 65% had antibiotic exposure, and 44% had gastric acid suppression therapy within 90 days of their CDI diagnosis.

Best practice advisory was accepted 23 times out of 26 and was used to optimize therapy in 16 patients within 6 months.

Results

In addition, guideline-concordant therapy increased following the implementation of the best practice advisory (72% vs. 91%; P = .001).

The investigators also found trends with medications prescribed.

For example, vancomycin prescriptions increased, while metronidazole prescriptions decreased following best practice advisory. There was also no difference in clinical response or unplanned encounters within 14 days following treatment initiation.

CDI recurrence also decreased, where just 7% of the best practice advisory group had an infection recurrence within 14-56 days of the initial episode. This was compared to 27% of the non-BPA group (P <.001).

“Clinical decision support increased prescribing of guideline-concordant CDI therapy in the outpatient setting,” the authors wrote. “A targeted BPA is an effective stewardship intervention and may be especially useful in settings with limited antimicrobial stewardship resources.”

Data From ID Week

Recently, investigators presented new data during ID Week 2021 showing RBX2660, an investigational microbiota-based live biotherapeutic, showed the ability to reduce recurrent CDI.

Historically speaking, rCDI occurs in 20-30% of patients, and the rates can increase with each ensuing episode.

This reoccurrence has been difficult for patients who suffer from it causing it to have lingering effects and creating quality-of-life issues.

From the clinical perspective, providers who are seeing these patients are looking for additional therapeutics and modalities to treat it.

From the 5 prospective trials presented by Ferring Pharmaceuticals and Rebiotix, a Ferring Company, which included 723 actively-treated participants, RBX2660 reduced the recurrence of CDI, with up to 78.9% remaining recurrence-free for eight weeks post treatment.

The study, “Outcomes of clinical decision support for outpatient management of Clostridioides difficile infection,” was published online in Infection Control & Hospital Epidemiology.