Evaluation of a Clostridium difficile infection management ... · Medical Microbiology and...

Evaluation of a Clostridium difficile infection management policy with clinicalpharmacy and medical microbiology involvement at a major Canadian teachinghospital

S. S. T. Yeung* BSc, (Pharm), ACPR, MSc, J. K. Yeung†,‡,§ BSc, (Pharm), ACPR, Pharm D, T. T. Y. Lau‡,§,¶ Pharm D, ACPR, FCSHP, L. A.Forresterk MA, MSc, T. S. Steiner¶,** MD, W. R. Bowie¶** MD, FRCPC and E. A. Bryce††,‡‡ MD, FRCPC*BC Provincial Academic Detailing Service,Fraser Health Authority,Vancouver,BC, , †Lower Mainland Pharmacy Services, Fraser Health Authority, VancouverCoastal, Providence Health Care, Provincial Health Services Authority, Vancouver, BC, ‡Pharmaceutical Sciences, Vancouver General Hospital (VGH),Vancouver, BC, §Faculty of Pharmaceutical Sciences,University of British Columbia (UBC),Vancouver, BC, ¶Division of Infectious Diseases, Department ofMedicine, Faculty of Medicine, UBC, Vancouver, BC, kInfection Control, Vancouver Coastal Health (VCH), Powell River, BC, **Division of Infectious Diseases,VGH, Vancouver, BC, ††Division of Medical Microbiology and Infection Control, VCH, Vancouver, BC, and ‡‡Department of Pathology & LaboratoryMedicine, Faculty of Medicine, UBC, Vancouver, BC, Canada

Received 20 July 2015, Accepted 28 September 2015

Keywords: antibiotics, antimicrobial stewardship, clinical pharmacy, clostridium difficile infection, evidence-based pharmacotherapy,guideline adherence, infection control, medical microbiology

SUMMARY

What is known and objective: Clostridium difficile infection(CDI) represents a spectrum of disease and is a significantconcern for healthcare institutions. Our study objective was toassess whether implementation of a regional CDI managementpolicy with Clinical Pharmacy and Medical Microbiology andInfection Control involvement would lead to an improvement inconcordance in prescribing practices to an evidence-based CDIdisease severity assessment and pharmacological treatmentalgorithm.Methods: Conducted at a tertiary care teaching hospital, thistwo-phase quality assurance study consisted of a baselineretrospective healthcare record review of patients with CDIprior to the implementation of a regional CDI managementpolicy followed by a prospective evaluation post-implementa-tion.Results and discussion: One hundred and forty-one CDIepisodes in the pre-implementation group were compared to283 episodes post-implementation. Overall treatment concor-dance to the CDI treatment algorithm was achieved in 48 of 141cases (34%) pre-implementation compared with 136 of 283 cases(48�1%) post-implementation (P = 0�01). The median time totreatment with vancomycin was reduced from five days to oneday (P < 0�01), with median length of hospital stay decreasingfrom 30 days to 21 days (P = 0�01) post-implementation. Therewas no difference in 30-day all-cause mortality.What is new and conclusion: A comprehensive approach withappropriate stakeholder involvement in the development ofclinical pathways, education to healthcare workers and prospec-tive audit with intervention and feedback can ensure patientsdiagnosed with CDI are optimally managed and prescribed themost appropriate therapy based on CDI disease severity.

WHAT IS KNOWN AND OBJECTIVE

Clostridium difficile infection (CDI) presents as a spectrum ofdisease, ranging from asymptomatic carriage to severe compli-cations such as pseudomembranous colitis, toxic megacolon,septic shock and death.1 CDI is a significant concern forhealthcare institutions as it is associated with increased morbid-ity, mortality, prolonged hospitalization and increased costs.1

The Society for Healthcare Epidemiology of America (SHEA)and the Infectious Diseases Society of America (IDSA) clinicalpractice guidelines for CDI in adults recommend patients to beappropriately stratified and treated based on disease severity.2

Metronidazole and vancomycin remain the mainstays of CDItreatment.2 For mild-to-moderate CDI cases, metronidazole is thepreferred agent, whereas vancomycin is the drug of choice insevere and fulminant cases.2 Newer agents such as fidaxomicinhave not yet gained widespread use, but may be considered inpatients with first or second episodes of CDI who are at high riskof relapse and recurrence. However, its high cost prohibits routineuse and its use for salvage cases is unfounded at this time due tolack of controlled clinical studies.3

To ensure patients with CDI are optimally managed and treated,a regional CDI management policy was developed at our institu-tion. This management policy is a comprehensive document thatincludes an evidence-based CDI disease severity assessment andpharmacological treatment algorithm, patient monitoring parame-ters and infection prevention and control procedures for managingpatients diagnosed with CDI (Appendix S1). This policy wasdeveloped collaboratively by a number of departments within ourinstitution, including Medical Microbiology and Infection Control,Clinical Pharmacy, Infectious Diseases, Gastroenterology, GeneralSurgery, Critical Care, Leukaemia/Bone Marrow Transplant andFamily Practice.2

The intent of the CDI management policy is to resolve gaps inclinical practice, with the specific goals of ensuring early patientisolation, rapid treatment initiation based on appropriate CDIdisease severity assessment and prompt identification of patientsrequiring escalation of treatment to vancomycin and/or surgicalintervention. (Appendix S1). The CDI disease severity assessment

Correspondence: Dr J. K. Yeung, Lower Mainland Pharmacy Services,#606 – 2733 Heather Pavilion, Level D, Vancouver General Hospital,Vancouver, BC V5Z1M9, Canada. Tel.: 604 875 4427; fax: 604 875 4380;e-mail: [email protected]

© 2015 John Wiley & Sons Ltd 655

Journal of Clinical Pharmacy and Therapeutics, 2015, 40, 655–660 doi: 10.1111/jcpt.12329

and pharmacological treatment algorithm, which is based on theSHEA and IDSA clinical practice guidelines, provides guidance onrisk-stratifying patients and initiating appropriate treatment witheither metronidazole or vancomycin based on disease severity(Fig. 1).2,4

The CDI management policy was disseminated institution-widevia print (i.e. newsletters and pocket reference cards) and madereadily accessible through the institution’s intranet (Appendix S2).To facilitate and encourage compliance among prescribers, ClinicalPharmacy and Medical Microbiology and Infection Controlinvolvement was simultaneously instituted.

When a CDI screening test is ordered for a patient, imbeddedlinks within the institution’s patient information systems pro-gram immediately prompt the prescriber to place the patient incontact isolation and to review the CDI management policyposted on the intranet (Appendices A2 and A3). ClinicalPharmacy and Medical Microbiology and Infection Controlpractitioners are notified of all positive C. difficile results, andclinical pharmacists are responsible for assessing all inpatientCDI treatment orders for adherence to the disease severityassessment and pharmacological treatment algorithm. If pre-scribed treatments are not concordant to the treatment algorithm,

clinical pharmacists are required to intervene and contactprescribers to optimize CDI therapy. As a result of promptimplementation of contact precautions and appropriate treat-ment, it is expected that patients will be at reduced risk foracquiring nosocomial CDI, extended durations of CDI andassociated symptoms, and mortality due to CDI.

Our study objective was to assess whether the implementationof a regional CDI management policy with Clinical Pharmacy andMedical Microbiology and Infection Control involvement wouldlead to an improvement in concordance in prescribing practices toa CDI disease severity assessment and pharmacological treatmentalgorithm in patients diagnosed with CDI at a major Canadianteaching hospital.

METHODS

This was a two-phase quality assurance study comparing theconcordance in prescribing practices to a CDI disease severityassessment and pharmacological treatment algorithm before andafter the implementation of a CDI management policy withClinical Pharmacy and Medical Microbiology and Infection Con-trol involvement. Conducted at a 830-bed tertiary care teaching

Fig. 1. Clostridium difficile infection (CDI)disease severity assessment and pharma-cological treatment algorithm. #In patientsunable to mount a blood cell count (WBC)response >15 000/mm3, an increasingWBC with pronounced left shift may alsobe considered in these criteria; thresholdof >15 000/mm3 is based on expert opin-ion. ^May change to vancomycin if patientintolerant to metronidazole. * Doses of125 to 500 mg may be considered;appropriate dose has not been establishedin clinical trials. ¶Vancomycin IV is noteffective for the treatment of CDI.†Tapering regimens may vary consider-ably, as clinical data are limited. Note:Physician assessment for perforation riskis required prior to rectal tube placement.Prophylactic treatment for patients onantibiotics who have previously hadC. difficile is not recommended. ConsiderInfectious Diseases consult.

© 2015 John Wiley & Sons Ltd Journal of Clinical Pharmacy and Therapeutics, 2015, 40, 655–660656

CDI management policy S. S. T. Yeung et al.

hospital in Canada, this study consisted of (i) a baselineretrospective healthcare record review (1 April 2008 to 31 March2009) of a random sample of patients with CDI prior to theimplementation of a regional CDI management policy followed by(ii) a prospective evaluation of patients with CDI post-implemen-tation. This post-implementation prospective review occurred overtwo periods, with the first being a pilot phase from 1 September2009 to 31 March 2010 immediately after the initial implementationof the policy and the second from 1 March 2011 to 31 March 2012when Clinical Pharmacy follow-up of CDI patients became amandatory requirement.

Prescribed treatments for patients diagnosed with CDI wereassessed for their concordance to the treatment algorithm andcompared between the pre-implementation and post-implementa-tion study groups. Treatment concordance was defined as thepatient being prescribed the correct drug, dose, route, frequencyand duration based on CDI disease severity. CDI severity wasassessed and determined by the patient’s baseline complete bloodcount (CBC), electrolytes, serum creatinine (SCr) and specifiedclinical criteria (Fig. 1).

Study objective

The primary objective of this study was to assess whether theimplementation of a regional CDI management policy withClinical Pharmacy and Medical Microbiology and InfectionControl involvement would lead to an improvement in concor-dance in prescribing practices to a disease severity assessmentand pharmacological treatment algorithm in patients diagnosedwith CDI.

Secondary objectives were to compare the median time fromC. difficile identification to initiation of pharmacological treatment,rates of CDI-related complications, length of hospital stay and all-cause mortality at 30 days after CDI diagnosis, transfer ordischarge (whichever occurred first) between the pre- and post-implementation study groups.

Phase I - pre-implementation

To assess the appropriateness of CDI treatment prior to theimplementation of a CDI management policy, a retrospectivehealthcare record review of a randomly selected cohort ofpatients diagnosed with CDI (using a random number sequencegenerated in Microsoft Excel, Microsoft, Redmond, WA, USA)was conducted. Adult inpatients with diarrhoea and at least onepositive test for C. difficile (by tcdB PCR) over a one-year period(1 April 2008 to 31 March 2009) were identified from ourinstitution’s Infection Control surveillance database and evalu-ated. Canadian Nosocomial Infection Surveillance Program(CNISP) definitions were used throughout the study,2 andpatients diagnosed with new or relapsed CDI were included.Patients were excluded if CDI was diagnosed as an outpatient, ifpatients were palliative, or if medical records were incomplete orunavailable to allow for assessment of CDI disease severity bythe study investigators.

Patient information collected included baseline characteristicsand demographics, initial white blood cell count (WBC), SCr,albumin, vital signs at time of CDI diagnosis, time from stoolspecimen identification of C. difficile to initiation of metronidazoleor vancomycin treatment and initially empirically prescribedpharmacological CDI treatment including drug, dose, dosingregimen, route and duration of therapy. The lead study investi-

gator individually assessed each study patient to determine CDIseverity and concordance of the prescribed treatment to thetreatment algorithm. Previous and concurrent use of antibiotics,promotility and antiperistaltic agents, histamine-2 receptor antag-onists (H2RA), and proton-pump inhibitors (PPI) were docu-mented. Clinical patient outcomes including the occurrence ofCDI-related complications, admission to the intensive care unit(ICU) for any indication, length of stay and all-cause mortality at30 days after CDI diagnosis, transfer or discharge (whicheveroccurred first) were collected by Medical Microbiology andInfection Control. CDI-related complications captured includedtoxic megacolon, total or partial colectomy, gastrointestinal bleed,bowel perforation and secondary bacteremia. Probiotic use andcompliance to specific infection control procedures and monitoringcould not be reliably collected and were therefore not evaluated inthis study.

Just prior to the implementation of the CDI management policy,educational sessions to familiarize all clinical pharmacists with thepolicy and treatment algorithm were provided by the lead studyinvestigator. Medical Microbiology and Infection Control reportsidentifying patients with PCR-positive CDI were generated dailyto alert clinical pharmacists of all inpatient cases of CDI and amonitoring form (Appendix S4) was developed to assist pharma-cists in their assessment and documentation. Clinical pharmacistswere required to complete a form for each CDI case identified andresolve any noted deviations from the treatment algorithm withthe medical team or prescriber.

Phase II - post-implementation

After completion of the retrospective review, adult inpatientswith diarrhoea and at least one positive test for C. difficile (bytcdB PCR) were prospectively evaluated over a 7-month pilotphase from 1 September 2009 to 31 March 2010 and again over a13-month period from 1 March 2011 to 31 March 2012 whenfollow-up of all inpatients diagnosed with CDI by clinicalpharmacists became a mandatory requirement. Patient informa-tion and clinical outcomes collected, and exclusion criteria wereidentical to that of the pre-implementation phase. Informationwas gathered from patient healthcare records, the InfectionControl surveillance database and the CDI monitoring formscompleted by Clinical Pharmacy. The lead study investigatoragain individually assessed each study patient to determine CDIseverity and concordance of the prescribed CDI treatment to thetreatment algorithm and reconciled this with the informationcollected on the CDI monitoring forms completed by the clinicalpharmacists.

Data were entered in Microsoft Excel 2007, and statisticalanalyses were performed using SPSS (version 17, Windows, SPSSInc., Chicago, IL, USA). Student t-tests and Fisher’s exact testswere used to assess the differences between means and differencesin proportions, respectively. Nonparametric tests were employedwhen assumptions for parametric tests were not met. P-valueswere corrected for multiple comparisons.

This study was approved by the University of British ColumbiaClinical Research Ethics Board and the Vancouver Coastal HealthResearch Institute.

RESULTS AND DISCUSSION

Between 1 April 2008 through to 31 March 2009, a total of 391 CDIepisodes were identified at our institution through the Infection



Control database. Using a generated random numbers list, arandom sample of 141 episodes (36�1%) was included in thepre-implementation group.

During the post-implementation pilot phase (1 September 2009and 31 March 2010), 140 CDI episodes were identified over a7-month period. One hundred and seventeen of these episodes(83�6%) were included, whereas 23 episodes were excludedbecause patients were palliative or medical records were incom-plete. When Clinical Pharmacy involvement became a mandatoryrequirement, a total of 266 CDI cases were identified over a 13-month period (1 March 2011 to 31 March 2012). Fifteen episodeswere excluded because 12 cases were from another hospital andthree were diagnosed prior to the study period, whereas another85 episodes were missing clinical outcome information. Overall, atotal of 283 episodes were included in the post-implementationgroup for analysis.

Baseline characteristics including age, sex and concurrentantibiotic use are summarized in Table 1 and were similarbetween the pre- and post-implementation groups. More casesof severe CDI were noted in the post-implementation group (P <0�01). Previous antibiotic use within 6 weeks prior to CDI

diagnosis was documented in 239 of the 283 patients (84�4%) inthe post-implementation group. Previous antibiotic use wasunavailable for an unknown proportion of the remaining 44patients, and therefore, the number of patients on previousantibiotics may be higher than the identified 84�4%. However,previous antibiotic use appears to be similar between groups.

Concordance in prescribing to the treatment algorithmimproved from 48 of 141 cases (34%) in the pre-implementationgroup to 136 of 283 cases (48�1%) post-implementation (P = 0�01).Concordance, as determined by each individual domain forappropriate drug, dose, dosing route, regimen and treatmentduration, is summarized in Table 2. When each domain isindependently assessed, the correct route of administration andrecommended duration of treatment appeared to improve themost post-implementation.

For patients treated with metronidazole, median time fromC. difficile identification to initiation of treatment was one day forboth groups. For patients prescribed vancomycin, median time toinitiation of treatment from CDI confirmation significantlyimproved from five days in the pre-implementation group toone day in the post-implementation (P < 0�01).

Table 1. Patient demographics

Pre-implementation n = 141 Post-implementation n = 283 Pre- vs. post-implementation (P-value)

Median age (range) 72�0 (17–98) 76�0 (16–98) 0�40Mean age (SD) 66�5 � 21�1 67�7 � 19�7Male (%) 71 (50�4) 115 (40�6) 0�06CDI severityMild/moderate (%) 126 (89�4) 202 (71�4) <0�01*Severe (%) 10 (7�1) 70 (24�7) <0�01*Fulminant (%) 5 (3�5) 8 (2�8) 0�77

Previous antibioticsa (%) 120 (85�1) 239 (84�4) 1�00Concurrent antibiotics (%) 87 (61�7) 166 (58�7) 0�60H2RA

b use (%) 22 (15�6) 53 (18�7) 0�50PPIc use (%) 68 (48�2) 112 (39�6) 0�10Antiperistaltic agent use (%) 11 (7�8) 17 (6�0) 0�53Motility agent use (%) 38 (27�0) 63 (22�3) 0�33

*P = 0�0001.aAntibiotic treatment in the previous 6 weeks prior to CDI diagnosis.bHistamine-2 receptor antagonists.cProton-pump inhibitors.

Table 2. Comparison of Clostridium difficile infection treatment concordance and patient clinical outcomes

Pre-implementation n = 141 Post-implementation n = 283 Pre- vs. post-implementation (P-value)

Overall treatment concordance (%) 48 (34�0) 136 (48�1) 0�01Correct drug (%) 118 (83�7) 233 (82�3) 0�79Correct dose (%) 115 (81�6) 223 (78�8) 0�52Correct route (%) 112 (79�4) 245 (86�6) 0�07Correct dosing interval (%) 112 (79�4) 216 (76�3) 0�54Correct duration (%) 58 (41�1) 146 (51�6) 0�05Median time to treatmentMetronidazole (days) 1 1 NSSVancomycin (days) 5 1 <0�01

All-cause mortality at day 30 (%) 16 (11�3) 32 (11�3) NSSMedian length of stay (range) 30 (1–210) 21 (1–299) 0�01



In the pre-implementation group, there were two cases of ICUadmissions, three cases of toxic megacolon, three cases of total/partial colectomy, seven cases of gastrointestinal bleed, one case ofbowel perforation and three cases of secondary bacteremia. In thepost-implementation group, there were four cases of ICU admis-sion, three cases of toxic megacolon, five cases of total/partialcolectomy, seven cases of gastrointestinal bleed, one case of bowelperforation and one case of secondary bacteremia. There was nostatistical difference in CDI-related complications between thegroups.

All-cause mortality at day 30 after CDI diagnosis was similarbetween the pre- and post-implementation groups and notstatistically significant. There was a statistically significant reduc-tion in median length of hospital stay from 30 days in the pre-implementation group compared to 21 days post-implementation(P = 0�01).

DISCUSSION

During the four years of this study (2008–2012), the CDI rateremained relatively stable at our institution, averaging 11�4 per10,000 patient-days in 2008–2009, 12�2 in 2010–2011 and 11�4 in2011–2012. These rates were higher than the CDI rate of 6�97 per10,000 patient-days reported by the CNISP for Western Canadaduring the study period.5 This may be partly accounted for by theuse of the more sensitive PCR molecular testing at our laboratorywhich has been reported in the literature to increase case detectionby approximately 35% compared to standard enzyme immunoas-say methods.6

Our program prompted clinical pharmacists to intervene within24 h and pharmacist recommendations made to optimize CDItherapies were generally well received and accepted by pre-scribers. Overall treatment concordance, defined as correct drug,dose, route, dosing regimen and duration, was 34% pre-imple-mentation and statistically improved to 48�1% post-implementa-tion of the CDI management policy. Incorrect treatment durationaccounted for the majority of algorithm discordance.

Although concordance rates improved only modestly, it isessential to note that rates are reflective of initial empiric regimensprescribed when all patient laboratory data may not have beenavailable to assess CDI severity. At our institution, there is anautomatic stop date of 7 days if a specific antibiotic treatmentduration is not indicated and this likely contributed to thediscordance in treatment duration. Our institution continues towork to improve concordance rates by prescriber educationalsessions, the use of preprinted orders and periodical reminders toensure appropriate CDI treatments are prescribed. It is howeverimportant to note that all CDI positive patients are assessedprospectively by clinical pharmacists, and all non-concordant casesare intervened upon to optimize their treatments. As a result, allpatients at our institution are on appropriate CDI treatmentswithin 48 hours of their CDI results.

There appeared to be an increase in the number of patients withsevere or fulminant CDI post-implementation. The epidemiologyof CDI has been changing since the early 2000s where a morehypervirulent strain, North American PFGE type 1 or NAP1/BI/027 (NAP1), is causing more severe disease and relapses comparedwith other C. difficile strains.2,7 Genotyping of CDI episodes wereonly selectively performed at our institution as part of a nationalsurveillance study; therefore, we were unable to determine theprevalence of the NAP1 strain during the study period. The post-implementation pilot phase was not randomized and depended on

the voluntary participation of clinical pharmacists. Pharmacistsmay have selectively monitored and followed patients with moresevere disease during this time immediately post-implementation,when clinical pharmacy follow-up of all CDI patients was not yetmandatory. This may have contributed to the increased number ofsevere CDI cases observed post-implementation, but cannot beascertained.

Those patients requiring escalation to treatment with van-comycin were treated more promptly after implementation of theCDI management policy with Clinical Pharmacy involvement.Median time to treatment with vancomycin significantly improvedfrom 5 days to 1 day post-implementation. This improvement intime to treatment with vancomycin in patients with more severeCDI may have contributed to the shorter median length of hospitalstay observed in our study, but again cannot be ascertained.

Our study did not demonstrate an effect on mortality, likely dueto our limited sample size and short follow-up period. Othertreatment options or the use of newer agents such as fidaxomicinwere not evaluated in our study. Adherence to specific infectioncontrol procedures and monitoring were also not evaluated, andwe are therefore unable to assess or quantify the impact theseinterventions may have contributed to patient outcomes.

The number of cases of CDI reviewed in our study was obtainedthrough random sampling of CDI patients during the study periodand did not include all consecutive CDI patients. This randomselection of patients is a limitation of the study, but we believe thesampling accurately reflects the changes associated with theincreasing prevalence of the NAP-1 strain of CDI. Despite havingmore severe cases, our CDI-associated complication ratesdecreased and are in part due to the more rapid initiation ofappropriate vancomycin treatment associated with our pharmacyand infection control CDI initiative.

We acknowledge that the experiences of our program occurredfrom 2008 to 2012; however, we believe that our approach ofreminding clinicians of infection control measures through elec-tronic prompts and having clinical pharmacists assess all CDI-positive inpatients for treatment optimization is a novel andinnovative initiative. This multidisciplinary strategy can beadopted by other institutions to enhance the management of CDIcases and improve patient care.

WHAT IS NEW AND CONCLUSION

The implementation of mandatory Clinical Pharmacy assessmentof all CDI patients follows the concept that prospective audit andfeedback is the most effective antimicrobial stewardship interven-tion in changing prescribing practices.8 Our CDI managementpolicy and infection control and antimicrobial stewardship initia-tives align directly with the responsibility of pharmacists tooptimize drug therapies in patients to improve health-relatedoutcomes. As a result of the successes of our program, our CDImanagement policy, along with Clinical Pharmacy and InfectionControl practitioner involvement, has been implemented at twoadditional hospital sites. Improved concordance to treatmentrecommendations has also been demonstrated with similar CDIstewardship initiatives.9 A recent antimicrobial stewardship pro-gram recently implemented at a rural hospital for the managementof CDI not only resulted in more appropriate antimicrobialprescribing, but also a reduction in costs.10

Our study suggests that a comprehensive approach withappropriate stakeholder involvement in the development ofclinical pathways, education to healthcare workers and prospec-



tive audit with intervention and feedback can improve themanagement of CDI and ensure patients receive the mostappropriate therapy based on disease severity. With the imple-mentation of a CDI management policy with mandatory ClinicalPharmacy follow-up and Medical Microbiology and InfectionControl involvement, concordance in prescribing practices to anevidence-based disease severity assessment and pharmacologicaltreatment algorithm increased significantly at our institution, withan observed reduction in the median time to initiation of treatmentfor those patients prescribed vancomycin and a decreased medianlength of hospital stay in those patients diagnosed with CDI.

ACKNOWLEDGEMENTS

We would like to thank Dr. Mandeep Saran and Ms. Jane Yu-ChenLin, the clinical pharmacists and the Infection Control Practitionersat Vancouver General Hospital for their assistance in datacollection; the CDI Stakeholder Group of Vancouver CoastalHealth – Providence Health Care for the development of theregional CDI Guideline; and Dr. Diane Roscoe for implementationof the automated messages linked with all inpatient CDI ordersand results.

CONFLICT OF INTEREST

Dr. Janice Yeung has served on an advisory board for Pfizer. Dr.Theodore Steiner has served on the advisory board for Merck,Iroko Pharmaceuticals, and Cubist and has received researchfunding from Cubist, Sanofi-Pasteur, and Merck. Shirley Yeungand Drs. Tim Lau, Elizabeth Bryce, Leslie Forrester and WilliamBowie have no conflicts of interests to declare.

SOURCE OF FUNDING

None.

SUPPORTING INFORMATION

Additional Supporting Information may be found in the onlineversion of this article:

Appendix S1 CDI Management Policy.Appendix S2 Screen display of intranet site for CDI managementpolicy.Appendix S3 Screen display of CDI toxin assay result.Appendix S4 CDI data collection form for clinical pharmacists.

REFERENCES

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