Researchers Hope to Standardize Treatment for C. Difficile Infections

Yichun Fu, MD

A standardized treatment regimen implemented industry wide could be pay massive dividends in treating Clostridioides difficile infections (CDI).

A team of investigators, led by Yichun Fu, MD, Icahn School of Medicine at Mount Sinai, increased the amount of patients with severe and fulminant CDI receiving standard of care antibiotics in a quality improvement project at a tertiary academic center in data presented at the annual American College of Gastroenterology (ACG) 2020 conference.

Severe and fulminant C. diff infections are linked to significant morbidity and mortality. Currently, the standard of care for patients with infections includes oral vancomycin and intravenous metronidazole with optional vancomycin per rectum.

The investigators hosted 8 education sessions between January and March 2020 approved by the Department of Medicine at Mount Sinai Hospital to disseminate information on existing CDI order set and treatment algorithms. The project included 129 patients and 1 virtual session was held of the 8 total sessions because of the coronavirus disease 2019 (COVID-19) pandemic.

Each session emphasized recognizing patients with severe and fulminant disease and standard of care management. The participants included frontline providers of internal medicine, family medicine, emergency medicine and intensive care units.

The researchers targeted primary providers in intensive care, emergency department and ward teams. The researchers broke the study into a pre-intervention time interval from January to April 2019 and a post-intervention time period from January to April 2020. During these time periods, the investigators gathered metrics using electronic health records and used Student’s T-test and Fisher’s exact test in statistical analysis.

The investigators sought primary outcomes of usage and timeliness of the initial dose of standard of care antibiotics.

They also sought various secondary outcomes, including order set usage and length of stay.

In the analysis, the researchers identified 26 severe and fulminant cases in the pre-intervention period and 33 cases in the post-intervention group (P = 0.52).

There was no significant difference in the demographics and comorbidities of the pre- and post-intervention groups.

Each patient had comparable white blood cell counts (median, 19.4 vs 18.0; P = 0.16), creatinine (median, 1.58 vs 1.74; P = 0.38), and pressor use (median, 7.7% vs 24.2%; P = 0.16).

The investigators also found a non-significant increase in appropriate and timeliness of antibiotics usage in the post-intervention group (median, 92.3% vs 97.0%; P = 0.58).

In addition, there was a trend toward a lower mortality rate (median, 26.9% vs 9.1%; P = 0.08) and length of stay (median, 12 vs. 10 days, P = 0.12) in the post-intervention group.

“Education sessions to promote a standardized order set and treatment algorithm for severe and fulminant CDI may improve recognition of this disease as well as adherence to standard of care treatment,” the authors wrote. “There was increased understanding of clinical manifestation and appropriate antibiotic management.”

The investigators suggest a larger cohort of patients with a longer study period to determine the effectiveness and durability of standard of care regimens.

The study, “A Quality Improvement Project to Improve Standard of Care for Severe and Fulminant Clostridioides difficile Infection,” was published online by ACG 2020.