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Development and Implementation of Cost-effective Guidelines in the Laboratory Investigation of Diarrhea in a Community Hospital

Development and Implementation of Cost-effective Guidelines in the Laboratory Investigation of... Abstract Background: Fecal cultures are often inappropriately requested in the investigation of diarrhea. Objectives: To develop and determine the efficacy of practice guidelines for the ordering and processing of stool cultures that are submitted for the diagnosis of community-acquired diarrhea. Methods: The results of stool cultures that were submitted to the microbiology laboratory of a tertiary care nonteaching community hospital were retrospectively reviewed. Following the implementation of guidelines, the efficacy was evaluated by comparison of fecal culture results in a prospective manner. Results: Analysis of results of stool cultures that were obtained from 3072 patients during a 3-year period revealed that (1) the sensitivity (40%) and predictive value (20%) of finding neutrophils in smear preparations were too low to be clinically useful, (2) routine cultures from patients with nosocomial diarrhea were uniformly negative, and (3) multiple specimens from a patient rarely provided additional information. Based on these findings, new guidelines were developed and implemented with the cooperation of clinical staff. Three-month follow-up results showed that the total number of specimens, the number of specimens from patients with nosocomial diarrhea, and multiple specimens declined by 37.7%, 70.6%, and 50%, respectively. However, the isolation rate of pathogens increased from 11.7% to 18.7%. Conclusions: The application of practice guidelines that include elimination of smear examination of rectal swabs, exclusion of routine cultures from patients with nosocomial diarrhea, and rejection of repeated cultures can result in significant cost savings without adversely affecting patient care.Arch Intern Med. 1996;156:1445-1448 References 1. Guerrant RL, Bobak DA. Bacterial and protozoal gastroenteritis . N Engl J Med. 1991;325:327-340.Crossref 2. Fan K, Morris AJ, Reller LB. Application of rejection criteria for stool cultures for bacterial enteric pathogens . J Clin Microbiol. 1993;31:22332235. 3. Brady MT, Pacini DL, Budde CT, Connell MJ. Diagnostic studies of nosocomial diarrhea in children: assessing their use and value . Am J Infect Control. 1989;17:77-82.Crossref 4. Koplan JP, Fineberg HV, Ferraro MJB, Rosenberg ML. Value of stool cultures . Lancet. 1980;2:413-416.Crossref 5. Bowman RA, Bowman JM, Arrow SA, Riley TV. Selective criteria for the microbiological examination of faecal specimens . J Clin Pathol. 1992;45:838839. 6. Siegel DA, Edelstein PH, Nachamkin I. Inappropriate testing for diarrheal diseases in the hospital . JAMA. 1990;263:979-982.Crossref 7. Church DL, Cadrain G, Kabani A, Jadavji T, Trevenen C. Practice guidelines for ordering stool cultures in a pediatric population . Am J Clin Pathol. 1995;103:149-153. 8. Harris JC, DuPont HL, Hornick RB. Fecal leukocytes in diarrheal illness . Ann Intern Med. 1972;76:697-703.Crossref 9. Peirce JE, DuPont HL, Lewis KR. Acute diarrhea in a residential institution for the retarded: usefulness of fecal leukocyte examination . AJDC. 1974;128:772775. 10. Cheney CP, Wong RKH. Acute infectious diarrhea . Med Clin North Am. 1993; 77:1169-1196. 11. Chitkara YK, Gill MK. Outbreak of gastroenteritis due to Salmonella weltevreden in a hospital . Indian J Med Res. 1976;64:1280-1287. 12. Korzeniowski OM, Barada FA, Rouse JD, Guerrant RL. Value of examination of fecal leukocytes in the early diagnosis of shigellosis . Am J Trop Med Hyg. 1979;28:1031-1035. 13. Tarr PI, Clausen CR, Christie DL. Bacterial and protozoal gastroenteritis . N Engl J Med. 1992;326:489.Crossref 14. Pickering LK, Dupont HL, Olarte J, Conklin R, Ericsson C. Fecal leukocytes in enteric infections . Am J Clin Pathol. 1977;68:562-565. 15. Morris AJ, Wilson ML, Reller LB. Application of rejection criteria for stool ovum and parasite examinations . J Clin Microbiol. 1992;30:3213-3216. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Development and Implementation of Cost-effective Guidelines in the Laboratory Investigation of Diarrhea in a Community Hospital

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References (15)

Publisher
American Medical Association
Copyright
Copyright © 1996 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1996.00440120103011
Publisher site
See Article on Publisher Site

Abstract

Abstract Background: Fecal cultures are often inappropriately requested in the investigation of diarrhea. Objectives: To develop and determine the efficacy of practice guidelines for the ordering and processing of stool cultures that are submitted for the diagnosis of community-acquired diarrhea. Methods: The results of stool cultures that were submitted to the microbiology laboratory of a tertiary care nonteaching community hospital were retrospectively reviewed. Following the implementation of guidelines, the efficacy was evaluated by comparison of fecal culture results in a prospective manner. Results: Analysis of results of stool cultures that were obtained from 3072 patients during a 3-year period revealed that (1) the sensitivity (40%) and predictive value (20%) of finding neutrophils in smear preparations were too low to be clinically useful, (2) routine cultures from patients with nosocomial diarrhea were uniformly negative, and (3) multiple specimens from a patient rarely provided additional information. Based on these findings, new guidelines were developed and implemented with the cooperation of clinical staff. Three-month follow-up results showed that the total number of specimens, the number of specimens from patients with nosocomial diarrhea, and multiple specimens declined by 37.7%, 70.6%, and 50%, respectively. However, the isolation rate of pathogens increased from 11.7% to 18.7%. Conclusions: The application of practice guidelines that include elimination of smear examination of rectal swabs, exclusion of routine cultures from patients with nosocomial diarrhea, and rejection of repeated cultures can result in significant cost savings without adversely affecting patient care.Arch Intern Med. 1996;156:1445-1448 References 1. Guerrant RL, Bobak DA. Bacterial and protozoal gastroenteritis . N Engl J Med. 1991;325:327-340.Crossref 2. Fan K, Morris AJ, Reller LB. Application of rejection criteria for stool cultures for bacterial enteric pathogens . J Clin Microbiol. 1993;31:22332235. 3. Brady MT, Pacini DL, Budde CT, Connell MJ. Diagnostic studies of nosocomial diarrhea in children: assessing their use and value . Am J Infect Control. 1989;17:77-82.Crossref 4. Koplan JP, Fineberg HV, Ferraro MJB, Rosenberg ML. Value of stool cultures . Lancet. 1980;2:413-416.Crossref 5. Bowman RA, Bowman JM, Arrow SA, Riley TV. Selective criteria for the microbiological examination of faecal specimens . J Clin Pathol. 1992;45:838839. 6. Siegel DA, Edelstein PH, Nachamkin I. Inappropriate testing for diarrheal diseases in the hospital . JAMA. 1990;263:979-982.Crossref 7. Church DL, Cadrain G, Kabani A, Jadavji T, Trevenen C. Practice guidelines for ordering stool cultures in a pediatric population . Am J Clin Pathol. 1995;103:149-153. 8. Harris JC, DuPont HL, Hornick RB. Fecal leukocytes in diarrheal illness . Ann Intern Med. 1972;76:697-703.Crossref 9. Peirce JE, DuPont HL, Lewis KR. Acute diarrhea in a residential institution for the retarded: usefulness of fecal leukocyte examination . AJDC. 1974;128:772775. 10. Cheney CP, Wong RKH. Acute infectious diarrhea . Med Clin North Am. 1993; 77:1169-1196. 11. Chitkara YK, Gill MK. Outbreak of gastroenteritis due to Salmonella weltevreden in a hospital . Indian J Med Res. 1976;64:1280-1287. 12. Korzeniowski OM, Barada FA, Rouse JD, Guerrant RL. Value of examination of fecal leukocytes in the early diagnosis of shigellosis . Am J Trop Med Hyg. 1979;28:1031-1035. 13. Tarr PI, Clausen CR, Christie DL. Bacterial and protozoal gastroenteritis . N Engl J Med. 1992;326:489.Crossref 14. Pickering LK, Dupont HL, Olarte J, Conklin R, Ericsson C. Fecal leukocytes in enteric infections . Am J Clin Pathol. 1977;68:562-565. 15. Morris AJ, Wilson ML, Reller LB. Application of rejection criteria for stool ovum and parasite examinations . J Clin Microbiol. 1992;30:3213-3216.

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jul 8, 1996

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