改变对不确定病例进行反射性到临床医生指令的聚合酶链反应（PCR）检测的影响：节省成本而没有相关不良事件。

The impact of changing reflexive to clinician-ordered polymerase chain reaction (PCR) testing for indeterminate cases: Cost savings without associated adverse events.

机构信息

Pharmacy Department, Scripps Mercy Hospital, San Diego, California.

Internal Medicine Department, Scripps Mercy Hospital, San Diego, California.

出版信息

Infect Control Hosp Epidemiol. 2020 Jun;41(6):684-690. doi: 10.1017/ice.2020.56.

DOI:10.1017/ice.2020.56

PMID:32279670

Abstract

OBJECTIVE

To evaluate changing Clostridioides difficile infection (CDI) testing among inpatients with indeterminate enzyme immunoassay (EIA) results (antigen+/toxin-) from reflexive polymerase chain reaction (PCR) testing to clinician-ordered PCR testing.

DESIGN

Multicenter, before-and-after, quasi-experimental study.

SETTING

Four large urban tertiary-care hospitals.

METHODS

We evaluated two 6-month periods before and after an intervention. The primary study outcome was the change in the number of CDI diagnoses between periods. Secondary outcomes included the number of PCR tests performed, adverse events, and healthcare cost savings.

RESULTS

In total, 500 EIA-indeterminate C. difficile test results were evaluated: 281 before the intervention and 219 thereafter. CDI was diagnosed by PCR among EIA-indeterminate cases in 182 in the preintervention period versus 94 patients in the postintervention period (48% reduction; P < .01). PCR testing was performed in 99.6% of indeterminate cases (280 of 281; 1 not performed due to an inhibitor) in the preintervention period versus 66% (144 of 219) in the postintervention period (34% reduction; P < .01). We observed no differences between study periods in 30-day all-cause (P = .96), GI-related (P = .93), or C. difficile (P = .47) readmissions, nor in 30-day C. difficile infections (P > .99). No patient without a PCR test in the postintervention period and not treated was later diagnosed with CDI. Each reflexive PCR test not performed led to a cost savings of $4,498 per patient.

CONCLUSIONS

Applying diagnostic stewardship to C. difficile PCR testing in the inpatient setting led to significant reductions in both testing and cases. Changing the C. difficile PCR testing algorithm for EIA-indeterminate cases from reflexive to clinician-required ordering resulted in valuable cost savings without associated adverse events.

摘要

目的

评估对不确定酶联免疫吸附测定（EIA）结果（抗原+/毒素-）的住院患者进行艰难梭菌感染（CDI）检测的变化，从反射性聚合酶链反应（PCR）检测改为临床医生要求的 PCR 检测。

设计

多中心、前后、准实验研究。

地点

四家大型城市三级保健医院。

方法

我们评估了干预前后两个 6 个月的时间。主要研究结果是两个时期之间 CDI 诊断数量的变化。次要结果包括进行的 PCR 检测数量、不良事件和医疗保健成本节约。

结果

共评估了 500 例 EIA 不确定的艰难梭菌检测结果：干预前 281 例，干预后 219 例。在干预前期间，EIA 不确定病例中通过 PCR 诊断出 CDI 者为 182 例，而干预后期间为 94 例（48%减少；P <.01）。在干预前期间，99.6%（281 例中的 280 例；1 例因抑制剂未进行）的不确定病例进行了 PCR 检测，而干预后期间为 66%（219 例中的 144 例）（34%减少；P <.01）。在研究期间，我们没有观察到 30 天全因（P =.96）、胃肠道相关（P =.93）或艰难梭菌（P =.47）再入院率之间的差异，也没有观察到 30 天内艰难梭菌感染（P >.99）的差异。在干预后期间没有进行 PCR 检测且未接受治疗的患者后来均未被诊断出 CDI。每进行一次不必要的反射性 PCR 检测，每位患者可节省 4498 美元的成本。