Brief Article
Copyright ©2013 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Gastroenterol. Dec 14, 2013; 19(46): 8647-8651
Published online Dec 14, 2013. doi: 10.3748/wjg.v19.i46.8647
Clostridium difficile-associated disease: Adherence with current guidelines at a tertiary medical center
Bryan F Curtin, Yousef Zarbalian, Mark H Flasar, Erik von Rosenvinge
Bryan F Curtin, Yousef Zarbalian, Resident in Internal Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, United States
Mark H Flasar, Erik von Rosenvinge, Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine and VA Maryland Health Care System, Baltimore, MD 21201, United States
Author contributions: Curtin BF and Zarbalian Y performed the majority of data collection and chart review; von Rosenvinge E was instrumental in obtaining IRB approval for the study and also provided essential oversight and editing; Flasar MH was responsible for the statistical analysis that is included in the study.
Correspondence to: Bryan F Curtin, MD, Resident in Internal Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, United States. bcurtin1@gmail.com
Telephone: +1-301-5384390 Fax: +1-410-3288315
Received: June 19, 2013
Revised: September 21, 2013
Accepted: September 29, 2013
Published online: December 14, 2013
Abstract

AIM: To assess adherence with the the Society for Healthcare Epidemiology of America (SHEA)/ the Infectious Diseases Society of America (IDSA) guidelines for management of Clostridium difficile (C. difficile)-associated disease (CDAD) at a tertiary medical center.

METHODS: All positive C. difficile stool toxin assays in adults between May 2010 and May 2011 at the University of Maryland Medical Center were identified. CDAD episodes were classified as guideline adherent or non-adherent and these two groups were compared to determine demographic and clinical factors predictive of adherence. Logistic regression analysis was performed to assess the effect of multiple predictors on guideline adherence.

RESULTS: 320 positive C. difficile stool tests were identified in 290 patients. Stratified by disease severity criteria set forth by the SHEA/IDSA guidelines, 42.2% of cases were mild-moderate, 48.1% severe, and 9.7% severe-complicated. Full adherence with the guidelines was observed in only 43.4% of cases. Adherence was 65.9% for mild-moderate CDAD, which was significantly better than in severe cases (25.3%) or severe-complicated cases (35.5%) (P < 0.001). There was no difference in demographics, hospitalization, ICU exposure, recurrence or 30-d mortality between adherent and non-adherent groups. A multivariate model revealed significantly decreased adherence for severe or severe-complicated episodes (OR = 0.18, 95%CI: 0.11-0.30) and recurrent episodes (OR = 0.46, 95%CI: 0.23-0.95).

CONCLUSION: Overall adherence with the SHEA/IDSA guidelines for management of CDAD at a tertiary medical center was poor; this was most pronounced in severe, severe-complicated and recurrent cases. Educational interventions aimed at improving guideline adherence are warranted.

Keywords: Clostridium difficile, Metronidazole, Vancomycin, Adherence to the Infectious Diseases Society of America Guidelines, Hospital Acquired Infections

Core tip: This study assesses a tertiary care medical center’s adherence with updated guidelines on the management of Clostridium difficile (C. difficile)-associated diseases in adults. We found that overall adherence is poor, especially in patients with severe disease. Factors associated with poor adherence and limitations of current guidelines are identified. Our data suggests that educational interventions aimed at improving C. difficile guideline adherence are warranted.