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90 Improved Diagnosis and Treatment of Clostridium difficile Infection in a Long-term Care Facility after Initiation of an On-Site Infectious Diseases Consultation Service

Saturday, April 2, 2011
Trinity Ballroom (Hilton Anatole)
Lucy A. Jury, NP , Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
Robin L.P. Jump, MD, PhD , Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
Brett M. Sitzlar, BS , Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
Dubert Guerrero, MD , Louis Stokes Cleveland VA Medical Center, Cleveland, OH
Sirisha Kundrapu, MD , Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
Curtis J. Donskey, MD , Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH

Background: Long-term care facilities (LTCFs) have borne a significant proportion of the increasing burden of Clostridium difficile infection (CDI) in recent years. In a previous study, we found that LTCF-onset CDI cases in our facility were more likely than hospital-onset cases to have delays in diagnosis and treatment. 

 

Objective: To test the hypothesis that implementation of an on-site Infectious Diseases (ID) consultation service would result in more prompt diagnosis and treatment of CDI and less inappropriate therapy.

 

Methods: We performed a 2-year retrospective study to compare LTCF-onset CDI cases diagnosed 1 year before versus 1 year after the initiation of an ID consult service at an LTCF affiliated with a tertiary-care VA hospital. The consult service was on-site 1 day per week and available for remote consultation for the remainder of the week. The service provided education and feedback to nurses and primary care providers on CDI management. We assessed time from onset of symptoms to laboratory diagnosis and to initiation of CDI therapy. Appropriateness of therapy (i.e., agent, dose, duration) was determined based on current CDI practice guidelines. Outcomes were evaluated 1 month after completion of treatment.  

Results: Of 66 total LTCF-onset CDI cases, 33 were diagnosed before and 33 after the initiation of the consult service. The mean time from symptom onset to diagnosis was 4.4 +/- 2.6 days before versus 2.1 +/-1 days after the intervention (P<0.001) and the mean time from symptom onset to treatment was 4.3 +/- 2.7 days (range, 2 to 11 days) before versus 1.6 +/-1.3 days (range, 0 to 5 days) after (P<0.001). The proportion of patients receiving appropriate treatment increased from 60% (20 of 33 patients) to 88% (29 of 33) after the intervention (P<0.01). Before versus after the intervention, there were no significant differences in the proportions of cases with severe disease (9% versus 3%, respectively; P =0.30) or with recurrences (21% versus 18%, respectively; P =0.76).

Conclusions: An intervention that provided on-site Infectious Diseases consultation resulted in significant improvements in diagnosis and treatment of CDI in an LTCF.