C Difficile Stewardship Program Results in Cost Savings

Michael Kueht, MD

A stewardship program for clostridium difficile testing following a solid organ transplantation could result in significant cost savings without sacrificing care for C difficile patients.

A team, led by Michael Kueht, MD, Division of Transplant Surgery, Department of Surgery, University of Texas Medical Branch, examined the association of an institutional integrated stewardship program with C difficile testing following abdominal solid organ transplantation.

Solid organ transplant recipient commonly suffer from diarrhea. This problem is also often multifactorial in etiology.

“Owing to the combination of perioperative antibiotic administration and the immunosuppressed status of transplant recipients, a high degree of suspicion for Clostridioides difficile (C. difficile) colitis is prudent,” the authors wrote.

The Stewardship Program

The stewardship program was enacted in July 2017. The program involved ordering providers to answer a series of questions within the electronic medical record system prior to ordering a C difficile toxin test.

The investigators reviewed the charts for all solid organ transplant recipients for individuals a test was ordered for between January 2016 and September 2019.

Cost-Savings

Overall, orders for C difficile toxin per quarter dropped significantly in the post-intervention era (18 vs 8.5, P = .038), while the median cost of inpatient treatment and days of therapy per thousand patient days was significantly lower (median cost, $2,944.55 vs. $416.92; P = .01; days of therapy per thousand patient days, 521.9 vs. 300.5; P <.01).

The quarterly rates of negative tests were similar both before and after intervention (65% vs. 73%; P = .38).

“Although no orders were blocked based on the responses, this multilevel intervention was associated with a 47% decrease in C. difficile testing without effecting the rate of negative testing,” the authors wrote. “These results suggest that we have achieved significant cost savings, in testing and isolation, without sacrificing critical aspects of clinical care.”

The Risk of C Difficile Infections

It is widely known that solid organ transplant recipients are at an increased risk for CDI infections and other complications. For example, the rate of colectomy in this patient population is more than 3 times higher than the rate of post-CDI colectomy in the general population.

Earlier this year, investigators confirmed patients who receive a solid organ transplant (SOT) are at an increased risk of C difficile infections, which is associated with an increased mortality rate and other complications.

Overall, the 1-year CDI incidence increased throughout the duration of the study (from 23.1; 95% CI, 12.8-41.8 per 1000 person-years in 2004 to 46.7; 95% CI, 35.0-62.3 per 1000 person-years in 2017; P = .001).

C difficile infections was linked to a 16.8% (n = 122) 90-day mortality rate.

Specifically for the kidney transplant cohort, CDI was generally late-onset (median interval, 2.2; IQR, 0.4-6.0 years) compared with recipients of other organs.

In addition, AKI that required dialysis was significantly linked to short-term (aOR, 1.86; 95% CI, 1.07-3.26) and long-term (aHR, 1.89; 95% CI, 1.29-2.78) mortality.

Late-onset CDI was also significantly associated with a greater risk of both short-term (aOR, 4.26; 95% CI, 2.51-7.22) and long-term (aHR, 2.49; 95% CI, 1.78-3.49) mortality.

The study, “Antibiotic Stewardship and Inpatient Clostridioides difficile Testing in Solid Organ Transplant Recipients: The Need for Multilevel Checks and Balances,” was published online in Transplantation Proceedings.