title: Clostridium difficile-associated disease: adherence with current guidelines at a tertiary medical center.
abstract: OBJECTIVE
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Bryan F Curtin, Yousef Zarbalian, Resident in Internal Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, United States.
authors.forename: Bryan F
authors.initials: BF
authors.lastname: Curtin
authors.affiliation: Bryan F Curtin, Yousef Zarbalian, Resident in Internal Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, United States.
authors.forename: Yousef
authors.initials: Y
authors.lastname: Zarbalian
authors.affiliation: Bryan F Curtin, Yousef Zarbalian, Resident in Internal Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, United States.
authors.forename: Mark H
authors.initials: MH
authors.lastname: Flasar
authors.affiliation: Bryan F Curtin, Yousef Zarbalian, Resident in Internal Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, United States.
authors.forename: Erik
authors.initials: E
authors.lastname: von Rosenvinge
mesh_terms: D000328:Adult; D000368:Aged; D015142:Baltimore; D016360:Clostridioides difficile / Q000302:isolation & purification* / Q000472:pathogenicity; D003428:Cross Infection / Q000175:diagnosis / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality; D004761:Enterocolitis, Pseudomembranous / Q000175:diagnosis / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality; D005243:Feces / Q000737:chemistry; D005260:Female; D019983:Guideline Adherence / Q000592:standards*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010043:Outcome and Process Assessment, Health Care / Q000592:standards*; D017410:Practice Guidelines as Topic / Q000592:standards*; D010818:Practice Patterns, Physicians' / Q000592:standards*; D058996:Quality Improvement / Q000592:standards; D019984:Quality Indicators, Health Care / Q000592:standards; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D012955:Societies, Medical / Q000592:standards; D062606:Tertiary Care Centers / Q000592:standards*; D013997:Time Factors; D016896:Treatment Outcome
keywords: Adherence to the Infectious Diseases Society of America Guidelines; Clostridium difficile; Hospital Acquired Infections; Metronidazole; Vancomycin