ADS 26 - Enhanced Surveillance Can Identify Opportunities for Diagnostic Stewardship for Healthcare Facility-onset Clostridioides difficile Infections in a Pediatric Hospital

Background: While Clostridioides difficile infections (CDI) remain a serious public health threat in healthcare facilities, this organism can also cause asymptomatic colonization and infections may be over-diagnosed, especially in pediatrics. Over-diagnosis can lead to inappropriate antibiotic prescriptions, additional testing, increased use of isolation precautions, and inflated rates of healthcare facility-onset (HFO) CDI. There may be opportunities to reduce over-diagnosis of HFO-CDI in a pediatric hospital through diagnostic stewardship.

Methods: At one 490-bed quaternary care pediatric hospital a retrospective cohort of all HFO-CDI from 2019-2022 was described using enhanced surveillance. Data collection included review of the electronic health record (EHR) for information on the indications and appropriateness of testing based on evidence-based criteria. Inappropriate indication for testing was defined by at least one of the following criteria: laxative use on the day of testing, an identified alternative infectious cause for diarrhea, more than 24 hours between test order and test collection, fewer than three watery bowel movements in 24 hours, and age less than one year. Quantitative variables were described as median with interquartile range and categorical variables as frequency and proportion.

Results: There were 143 HFO-CDI events during this period (4.1 per 10,000 patient-days). The EHR contained the information needed to make the assessment on appropriateness of diagnostic testing in all cases. Of the 143 events, 68 (47.6%) had an inappropriate indication for testing. The most common reasons for inappropriate testing were laxative use (30.8%), and stool quality/quantity (11.9%).

Conclusions: This study found that surveillance for appropriateness of CDI testing is feasible using EHR data, and that nearly half of all HFO-CDI events in a pediatric hospital do not meet indications for testing. There are opportunities to implement diagnostic stewardship standards to reduce over-diagnosis of HFO-CDI.