Low adherence to institutional clinical practice guideline in patients diagnosed with Clostridioides difficile infection

Objective: Previous antimicrobial therapy is a common risk factor for Clostridioides difficile infections (CDIs). Clinical practice guidelines (CPGs) assist clinicians in prescribing the correct antibiotics for various clinical syndromes to avoid unnecessary or overly broad-spectrum antibiotic use. Understanding adherence to CPGs can help determine the preventability of CDIs. Design: Quality improvement project. Setting: Tertiary military medical hospital. Patients or Participants: All patients with positive test for Clostridioides difficile at Brooke Army Medical between November 2022 and October 2023. Results: During the evaluation period, 128 positive cases were identified. In the three months prior to a positive test, 85 (67%) of patients had at least one day of antibiotic exposure. For those receiving antibiotics, the median number [Interquartile Range (IQR)] of total antibiotic days within 30, 60, and 90 days of a positive test was 6 [2 – 9], 7 [4.5 – 13.5], and 7 [5 – 14] days, respectively. In these cases, all antibiotic indications appeared on the CPG for 50 (59%) cases. However, prescribers did not adhere to the CPG in 23 (46%) of these cases. Overall, 58 cases (45%) were considered preventable due to clinicians not following the CPG or a condition not appearing on the CPG. Conclusions: In this single center study, retrospective analysis of individual CDI provided direction for the antimicrobial stewardship team by identifying CPG recommendations that were not followed as well as identifying conditions not on previous CPGs. Tying patient harm from CDIs with inappropriate antimicrobial use builds the local evidence base to prevent future CDIs.