Compliance with Clostridium difficile treatment guidelines: effect on patient outcomes

Abstract

Guidelines for the severity classification and treatment of Clostridium difficile infection (CDI) were published by Infectious Diseases Society of America (IDSA)/Society for Healthcare Epidemiology of America (SHEA) in 2010; however, compliance and efficacy of these guidelines has not been widely investigated. This present study assessed compliance with guidelines and its effect on CDI patient outcomes as compared with before these recommendations. A retrospective study included all adult inpatients with an initial episode of CDI treated in a single academic center from January 2009 to August 2014. Patients after guideline publication were compared with patients treated in 2009-2010. Demographic, clinical, and laboratory data were collected to stratify for disease severity. Outcome measures included compliance with guidelines, mortality, length of stay (LOS), and surgical intervention for CDI. A total of 1021 patients with CDI were included. Based upon the 2010 guidelines, 42 (28·8%) of 146 patients treated in 2009 would have been considered undertreated, and treatment progressively improved over time, as inadequate treatment decreased to 10·0% (15/148 patients) in 2014 (P = 0·0005). Overall, patient outcomes with guideline-adherent treatment decreased CDI attributable mortality twofold (P = 0·006) and CDI-related LOS by 1·9 days (P = 0·0009) when compared with undertreated patients. Compliance with IDSA/SHEA guidelines was associated with a decreased risk of mortality and LOS in hospitalized patients with CDI.

Keywords: Clostridium difficile; Adherence to guidelines; overtreatment; undertreatment.

Fig. 1.

Disease severity by year. Each bar represents the proportion of patients assigned to the severity of CDI episode, mild–moderate (mild), severe, or severe-complicated (severe), in each year of the study (P = 0·16 by one-way ANOVA).

Fig. 2.

Treatment adherence improved after guideline publication. Bars represent the number of patients classified by guideline adherence retrospectively applied before (2009–2010) or after (2011–2014) guideline publication (P < 0·0001 by χ² test). The percentage of patients in each time frame is noted within the bar. Undertreatment improved from 25% before to 13% after publication of guidelines.