title: Assessment of treatment patterns and patient outcomes before vs after implementation of a severity-based Clostridium difficile infection treatment policy.
abstract: BACKGROUND
  National guidelines recommend oral vancomycin for severe Clostridium difficile infection (CDI) based on results from recent clinical trials demonstrating improved clinical outcomes. However, real-world data to support these clinical trials are scant.
  
  
  OBJECTIVE
  To compare treatment patterns and patient outcomes of those treated for CDI before and after implementation of a severity-based CDI treatment policy at a tertiary teaching hospital.
  
  
  METHODS
  This study evaluated adult patients with a positive C. difficile toxin before and after implementation of a policy where patients with severe CDI given metronidazole were switched to oral vancomycin unless contra-indicated. Patients were stratified according to disease severity using a modified published severity score. Treatment patterns based on CDI severity and rates of refractory CDI were assessed.
  
  
  RESULTS
  In total, 256 patients with CDI (mean age 66 years, standard deviation 17, 52% female) were evaluated (before implementation: N = 144; after implementation: N = 112). Use of oral vancomycin for severe CDI increased significantly from 14% (N = 8) to 91% (N = 48) following implementation of the policy (P < 0.0001). Refractory disease in patients with severe CDI decreased significantly from 37% to 15% following implementation of the policy (P = 0.035). No significant differences were noted among patients with mild to moderate CDI.
  
  
  CONCLUSIONS
  A severity-based CDI treatment policy at a tertiary teaching hospital increased the use of oral vancomycin and was associated with decreased rates of refractory CDI.
authors.affiliation: St. Luke's Episcopal Hospital, Houston, TX, USA.
authors.forename: C G M
authors.initials: CG
authors.lastname: Jardin
authors.forename: H R
authors.initials: HR
authors.lastname: Palmer
authors.forename: D N
authors.initials: DN
authors.lastname: Shah
authors.forename: F
authors.initials: F
authors.lastname: Le
authors.forename: N D
authors.initials: ND
authors.lastname: Beyda
authors.forename: Z
authors.initials: Z
authors.lastname: Jiang
authors.forename: K W
authors.initials: KW
authors.lastname: Garey
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D016360:Clostridioides difficile / Q000302:isolation & purification*; D003015:Clostridium Infections / Q000188:drug therapy* / Q000382:microbiology / Q000473:pathology*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008795:Metronidazole / Q000627:therapeutic use*; D008875:Middle Aged; D016134:Organizational Policy; D012720:Severity of Illness Index; D016896:Treatment Outcome; D014640:Vancomycin / Q000627:therapeutic use*
chemical_list: D000890:Anti-Infective Agents; D008795:Metronidazole; D014640:Vancomycin
keywords: Antibiotic stewardship; Clostridium difficile; Cohort study; Disease severity; Metronidazole; Oral vancomycin