Treatment of Clostridioides difficile Infection and Non-compliance with Treatment Guidelines in Adults in 10 US Geographical Locations, 2013-2015

Shannon A Novosad^{1

2}, Yi Mu³, Lisa G Winston⁴, Helen Johnston⁵, Elizabeth Basiliere⁵, Danyel M Olson⁶, Monica M Farley^{7

8

9}, Andrew Revis^{9

10}, Lucy Wilson¹¹, Rebecca Perlmutter¹¹, Stacy M Holzbauer^{12

13}, Tory Whitten¹², Erin C Phipps^{14

15}, Ghinwa K Dumyati¹⁶, Zintars G Beldavs¹⁷, Valerie L S Ocampo¹⁷, Corinne M Davis¹⁸, Marion Kainer¹⁸, Dale N Gerding^{19

20}, Alice Y Guh³

Affiliations

¹ Division of Healthcare Quality Promotion, Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, 30329, USA. ydz1@cdc.gov.
² Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA. ydz1@cdc.gov.
³ Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
⁴ School of Medicine, University of California, San Francisco, San Francisco, CA, USA.
⁵ Colorado Department of Public Health and Environment, Denver, CO, USA.
⁶ Connecticut Emerging Infections Program, Yale School of Public Health, New Haven, CT, USA.
⁷ Emory University School of Medicine, Atlanta, GA, USA.
⁸ Veterans Affairs Medical Center, Atlanta, GA, USA.
⁹ Georgia Emerging Infections Program, Atlanta, GA, USA.
¹⁰ Atlanta Research and Education Foundation, Atlanta, GA, USA.
¹¹ Maryland Department of Health, Baltimore, MD, USA.
¹² Minnesota Department of Health, St. Paul, MN, USA.
¹³ Centers for Disease Control and Prevention, Atlanta, GA, USA.
¹⁴ New Mexico Emerging Infections Program, Albuquerque, NM, USA.
¹⁵ University of New Mexico, Albuquerque, NM, USA.
¹⁶ University of Rochester Medical Center, Rochester, NY, USA.
¹⁷ Oregon Health Authority, Portland, OR, USA.
¹⁸ Tennessee Department of Health, Nashville, TN, USA.
¹⁹ Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA.
²⁰ Edward Hines, Jr. Veterans Affairs Hospital, Hines, IL, USA.

PMID: 31768906
PMCID: PMC7018854
DOI: 10.1007/s11606-019-05386-9

Treatment of Clostridioides difficile Infection and Non-compliance with Treatment Guidelines in Adults in 10 US Geographical Locations, 2013-2015

Shannon A Novosad et al. J Gen Intern Med. 2020 Feb.

. 2020 Feb;35(2):412-419.

doi: 10.1007/s11606-019-05386-9. Epub 2019 Nov 25.

Authors

Affiliations

¹ Division of Healthcare Quality Promotion, Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, 30329, USA. ydz1@cdc.gov.
² Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA. ydz1@cdc.gov.
³ Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
⁴ School of Medicine, University of California, San Francisco, San Francisco, CA, USA.
⁵ Colorado Department of Public Health and Environment, Denver, CO, USA.
⁶ Connecticut Emerging Infections Program, Yale School of Public Health, New Haven, CT, USA.
⁷ Emory University School of Medicine, Atlanta, GA, USA.
⁸ Veterans Affairs Medical Center, Atlanta, GA, USA.
⁹ Georgia Emerging Infections Program, Atlanta, GA, USA.
¹⁰ Atlanta Research and Education Foundation, Atlanta, GA, USA.
¹¹ Maryland Department of Health, Baltimore, MD, USA.
¹² Minnesota Department of Health, St. Paul, MN, USA.
¹³ Centers for Disease Control and Prevention, Atlanta, GA, USA.
¹⁴ New Mexico Emerging Infections Program, Albuquerque, NM, USA.
¹⁵ University of New Mexico, Albuquerque, NM, USA.
¹⁶ University of Rochester Medical Center, Rochester, NY, USA.
¹⁷ Oregon Health Authority, Portland, OR, USA.
¹⁸ Tennessee Department of Health, Nashville, TN, USA.
¹⁹ Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA.
²⁰ Edward Hines, Jr. Veterans Affairs Hospital, Hines, IL, USA.

PMID: 31768906
PMCID: PMC7018854
DOI: 10.1007/s11606-019-05386-9

Abstract

Background: Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) guidelines describe recommended therapy for Clostridioides difficile infection (CDI).

Objective: To describe CDI treatment and, among those with severe CDI, determine predictors of adherence to the 2010 IDSA/SHEA treatment guidelines.

Design: We analyzed 2013-2015 CDI treatment data collected through the Centers for Disease Control and Prevention's Emerging Infections Program. Generalized linear mixed models were used to identify predictors of guideline-adherent therapy.

Patients: A CDI case was defined as a positive stool specimen in a person aged ≥ 18 years without a positive test in the prior 8 weeks; severe CDI cases were defined as having a white blood cell count ≥ 15,000 cells/μl.

Main measures: Prescribing and predictors of guideline-adherent CDI therapy for severe disease.

Key results: Of 18,243 cases, 14,257 (78%) were treated with metronidazole, 7683 (42%) with vancomycin, and 313 (2%) with fidaxomicin. The median duration of therapy was 14 (interquartile range, 11-15) days. Severe CDI was identified in 3250 (18%) cases; of 3121 with treatment data available, 1480 (47%) were prescribed guideline-adherent therapy. Among severe CDI cases, hospital admission (adjusted odds ratio [aOR] 2.48; 95% confidence interval [CI] 1.90, 3.24), age ≥ 65 years (aOR 1.37; 95% CI 1.10, 1.71), Charlson comorbidity index ≥ 3 (aOR 1.27; 95% CI 1.04, 1.55), immunosuppressive therapy (aOR 1.21; 95% CI 1.02, 1.42), and inflammatory bowel disease (aOR 1.56; 95% CI 1.13, 2.17) were associated with being prescribed guideline-adherent therapy.

Conclusions: Provider adherence to the 2010 treatment guidelines for severe CDI was low. Although the updated 2017 CDI guidelines, which expand the use of oral vancomycin for all CDI, might improve adherence by removing the need to apply severity criteria, other efforts to improve adherence are likely needed, including educating providers and addressing barriers to prescribing guideline-adherent therapy, particularly in outpatient settings.

Keywords: Clostridioides difficile; decision-making; epidemiology; infectious disease.

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Figures

**Figure 1**
*Clostridioides difficile* infection cases, 2013–2015. Single asterisk symbol indicates community-onset and 10% of healthcare facility–onset CDI cases. Dagger symbol indicates white blood cell ≥ 15,000 cells/μl within 1 calendar day of stool specimen collection in 2013–2014, and within 7 calendar days of stool specimen collection starting in 2015. CDI, *Clostridioides difficile* infection

See this image and copyright information in PMC

Comment in

Capsule Commentary on Novosad et al., Treatment of Clostridioides Difficile Infection and Non-compliance with Treatment Guidelines in Adults, 10 US Geographical Locations, 2013-2015.
Reveles KR. Reveles KR. J Gen Intern Med. 2020 Feb;35(2):618-619. doi: 10.1007/s11606-019-05494-6. J Gen Intern Med. 2020. PMID: 31667739 Free PMC article. No abstract available.

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Treatment of Clostridioides difficile Infection and Non-compliance with Treatment Guidelines in Adults in 10 US Geographical Locations, 2013-2015

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Treatment of Clostridioides difficile Infection and Non-compliance with Treatment Guidelines in Adults in 10 US Geographical Locations, 2013-2015

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