title: High frequency of nonadherence to Clostridium difficile treatment guidelines.
abstract: OBJECTIVE
  The 2010 Infectious Diseases Society of America/Society for Healthcare Epidemiology of America treatment guidelines for Clostridium difficile infections (CDI) recommend oral metronidazole for mild-to-moderate disease and oral vancomycin for severe disease. Given that disease severity is easily determined by the peripheral white blood cell count and serum creatinine level, a computerized decision support (CDS) pathway to guide treatment is inherently appealing. Because providers often override or ignore the computer-based alerts, the proposed CDS pathway should be justified before implementation.
  
  
  METHODS
  We undertook this study to ascertain the frequency of nonadherence to CDI guidelines. Between October 1, 2007 and September 30, 2008, a total of 229 cases were screened and 78 cases were included in the study, which took place at a 661-bed acute tertiary care teaching hospital.
  
  
  RESULTS
  During the year-long study of CDI cases at our tertiary care hospital, 61.5% (48/78) of the patients received an antibiotic regimen that was not recommended by the 2010 guidelines. Among the 35 patients with mild-to-moderate CDI, 85.7% (30/35) received the recommended treatment of oral metronidazole monotherapy; in contrast, among the 43 patients with severe disease, none (0/43) received the recommended treatment of oral vancomycin monotherapy (P < 0.01). Moreover, 17.9% (14/78) of patients received concurrent oral metronidazole and vancomycin, a regimen that is not recommended anywhere in the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America guidelines and which may be associated with a poor outcome. Patients who received combination oral metronidazole and vancomycin were not more likely to have comorbidities or severe CDI compared with those who received a single antibiotic agent.
  
  
  CONCLUSIONS
  As a result of this study, we plan to educate our providers on the treatment of CDI through a CDS pathway in an effort to increase guideline adherence, decrease inappropriate antibiotic use, and potentially improve patient outcomes.
authors.affiliation: From the Veterans Affairs Pittsburgh Healthcare System, and Allegheny General Hospital, Pittsburgh, Pennsylvania.
authors.forename: M Catherine
authors.initials: MC
authors.lastname: McEllistrem
authors.affiliation: From the Veterans Affairs Pittsburgh Healthcare System, and Allegheny General Hospital, Pittsburgh, Pennsylvania.
authors.forename: Molly
authors.initials: M
authors.lastname: McGraw
authors.affiliation: From the Veterans Affairs Pittsburgh Healthcare System, and Allegheny General Hospital, Pittsburgh, Pennsylvania.
authors.forename: Andrew G
authors.initials: AG
authors.lastname: Sahud
authors.affiliation: From the Veterans Affairs Pittsburgh Healthcare System, and Allegheny General Hospital, Pittsburgh, Pennsylvania.
authors.forename: Noreen H
authors.initials: NH
authors.lastname: Chan-Tompkins
authors.affiliation: From the Veterans Affairs Pittsburgh Healthcare System, and Allegheny General Hospital, Pittsburgh, Pennsylvania.
authors.forename: Raktima
authors.initials: R
authors.lastname: Goswami
authors.affiliation: From the Veterans Affairs Pittsburgh Healthcare System, and Allegheny General Hospital, Pittsburgh, Pennsylvania.
authors.forename: Nitin
authors.initials: N
authors.lastname: Bhanot
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016360:Clostridioides difficile; D003015:Clostridium Infections / Q000188:drug therapy*; D019091:Critical Pathways; D020000:Decision Support Systems, Clinical; D019983:Guideline Adherence; D006801:Humans; D008795:Metronidazole / Q000627:therapeutic use*; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D012720:Severity of Illness Index; D014640:Vancomycin / Q000627:therapeutic use*
chemical_list: D000900:Anti-Bacterial Agents; D008795:Metronidazole; D014640:Vancomycin