Diferencias entre las recomendaciones y la práctica clínica en la infección por Clostridium difficile / Identifying gaps between guidelines and clinical practice in Clostridium difficile infection

Objetivos. Primero, valorar la adherencia a las recomendaciones de la guía de práctica clínica de manejo de la infección por Clostridium difficile de las sociedades americanas de enfermedades infecciosas y epidemiología de 2010 y evaluar su influencia en la evolución de los pacientes. Segundo, identificar las recomendaciones no aplicadas en la práctica para su posterior implementación. Material y métodos. Estudio retrospectivo, descriptivo, de pacientes con síntomas clínicos compatibles y positividad para toxinas A y/o B de C. difficile en heces, en un servicio de medicina interna de un hospital de tercer nivel, en un período de 36 meses. Se recogieron datos clínicos, demográficos, evolutivos, factores de riesgo y la adherencia a las recomendaciones de la guía de práctica clínica. Resultados. Se identificaron 77 pacientes con infección por C. difficile (87 episodios). La estratificación por gravedad mostró un 49,3% de pacientes leves-moderados, 35,1% graves y 15,6% graves-complicados. La adherencia completa a las recomendaciones terapéuticas se observó en 40,2% de pacientes y fue significativamente mejor en los leves-moderados (71,0%), que en los graves (7,4%) o graves complicados (16,6%) (p < 0,003). La adherencia se asoció significativamente a una mayor probabilidad de curación (57% vs 42%) y menor de recurrencia (22,2% vs 77,7%) y mortalidad (25% vs 75%) (p < 0,01). Las recomendaciones no implementadas fueron la estratificación de la gravedad de los pacientes y la adecuación del tratamiento antibiótico a la categoría de gravedad clínica. Conclusiones. La adherencia a las recomendaciones terapéuticas de las guías es baja, especialmente en pacientes graves y graves complicados, asociándose a un peor curso evolutivo. Se precisan intervenciones educacionales para mejorar su aplicación (AU)

Objectives. The first aim was to determine whether patients are being treated in accordance with the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America (IDSA/SHEA) Clostridium difficile guidelines and whether adherence impacts patient outcomes. The second aim was to identify specific action items in the guidelines that are not being translated into clinical practice, for their subsequent implementation. Material and methods. A retrospective, descriptive study was conducted over a 36 month period, on patients with compatible clinical symptoms and positive test for C. difficile toxins A and/or B in stool samples, in an internal medicine department of a tertiary medical centre. Patient demographic and clinical data (outcomes, comorbidity, risk factors) and compliance with guidelines, were examined. Results. A total of 77 patients with C. difficile infection were identified (87 episodes). Stratified by disease severity criteria, 49.3% of patients were mild-moderate, 35.1% severe, and 15.6% severe-complicated. Full adherence with the guidelines was observed in only 40.2% of patients, and was significantly better for mild-moderate (71.0%), than in severe (7.4%) or severe-complicated patients (16.6%) (P < .003). Adherence was significantly associated with clinical cure (57% vs 42%), fewer recurrences (22.2% vs 77.7%), and mortality (25% vs 75%) (P < .01). The stratification of severity of the episode, and the adequacy of antibiotic to clinical severity, need improvement. Conclusions. Overall adherence with the guidelines for management of Clostridium difficile infection was poor, especially in severe and severe-complicated patients, being associated with worse clinical outcomes. Educational interventions aimed at improving guideline adherence are warranted (AU)

[Identifying gaps between guidelines and clinical practice in Clostridium difficile infection]. / Diferencias entre las recomendaciones y la práctica clínica en la infección por Clostridium difficile.

OBJECTIVES: The first aim was to determine whether patients are being treated in accordance with the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America (IDSA/SHEA) Clostridium difficile guidelines and whether adherence impacts patient outcomes. The second aim was to identify specific action items in the guidelines that are not being translated into clinical practice, for their subsequent implementation. MATERIAL AND METHODS: A retrospective, descriptive study was conducted over a 36 month period, on patients with compatible clinical symptoms and positive test for C. difficile toxins A and/or B in stool samples, in an internal medicine department of a tertiary medical centre. Patient demographic and clinical data (outcomes, comorbidity, risk factors) and compliance with guidelines, were examined RESULTS: A total of 77 patients with C. difficile infection were identified (87 episodes). Stratified by disease severity criteria, 49.3% of patients were mild-moderate, 35.1% severe, and 15.6% severe-complicated. Full adherence with the guidelines was observed in only 40.2% of patients, and was significantly better for mild-moderate (71.0%), than in severe (7.4%) or severe-complicated patients (16.6%) (P<.003). Adherence was significantly associated with clinical cure (57% vs 42%), fewer recurrences (22.2% vs 77.7%), and mortality (25% vs 75%) (P<.01). The stratification of severity of the episode, and the adequacy of antibiotic to clinical severity, need improvement. CONCLUSIONS: Overall adherence with the guidelines for management of Clostridium difficile infection was poor, especially in severe and severe-complicated patients, being associated with worse clinical outcomes. Educational interventions aimed at improving guideline adherence are warranted.