Amit K Pahwa, MD

With more than 3 million people diagnosed and more than 200,000 deaths worldwide at the time this article was written, coronavirus disease of 2019 (COVID-19) poses an unprecedented challenge to the public and to our healthcare system.¹ The United States has surpassed every other country in the total number of COVID-19 cases. Hospitals in hotspots are operating beyond capacity, while others prepare for a predicted surge of patients suffering from COVID-19. Now more than ever, clinicians need to prioritize limited time and resources wisely in this rapidly changing environment. Our most precious limited resource, healthcare workers (HCWs), bravely care for patients while trying to avoid acquiring the infection. With each test and treatment, clinicians must carefully consider harms and benefits, including exposing themselves and other HCWs to SARS-CoV-2, the virus causing this disease.

Delivering any healthcare service in which the potential harm exceeds benefit represents one form of overuse. In the era of COVID-19, the harmful consequences of overuse go beyond the patient to the healthcare team. For example, unnecessary chest computed tomography (CT) to help diagnose COVID-19 comes with the usual risks to the patient including radiation, but it may also reveal a suspicious nodule. That incidental finding can lead to downstream consequences, such as more imaging, blood work, and biopsy. In the current pandemic, however, that CT comes with more than just the usual risk. The initial unnecessary chest CT can risk exposing the transporter, the staff in the hallways and elevator en route, the radiology staff operating the CT scanner, and the maintenance staff who must clean the room and scanner afterward. Potential downstream harms to staff include exposure of the pulmonary and interventional radiology consultants, as well as the staff who perform repeat imaging after the biopsy. Evaluation of the nodule potentially prolongs the patient’s stay and exposes more staff. Clinicians must weigh the benefits and harms of each test and treatment carefully with consideration of both the patient and the staff involved. Moreover, it may turn out that the patient and staff without symptoms of COVID-19 may pose the most risk to one another.

Choosing Wisely® partnered with patients and clinician societies to develop a Top 5 recommendations list for eliminating unnecessary testing and treatment. Our multi-institutional group from the High Value Practice Academic Alliance proposed this Top 5 list of overuse practices in hospital medicine that can lead to harm of both patients and HCWs in the COVID-19 era (Table). The following recommendations apply to all patients with unsuspected, suspected, or confirmed SARS-CoV-2 infection in the hospital setting.

• Do not obtain nonurgent labs in separate blood draws if they can be batched together.

This recommendation expands on the original Society of Hospital Medicine Choosing Wisely recommendation: Don’t perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability.² Aside from patient harms such as pain and hospital-acquired anemia, the risk of exposure to HCWs who perform phlebotomy (phlebotomists, nurses, and other clinicians), as well as staff who transport, handle, and process the bloodwork in the lab, must be minimized. Most prior interventions to eliminate unnecessary bloodwork focused on the number of lab tests,³ but some also aimed to batch nonurgent labs together to effectively reduce unnecessary needlesticks (“think twice, stick once”).⁴ This concept can be brought into this pandemic to provide safe and appropriate care for both patients and HCWs.

• Do not use bronchodilators unless there is active obstructive airway disease, and if needed, use metered dose inhalers instead of nebulizers.

We do not recommend using bronchodilators to treat COVID-19 symptoms unless patients develop acute bronchospastic symptoms of their underlying obstructive airway disease.⁵ When needed, use metered dose inhalers (MDIs),⁶ if available, instead of nebulizers because the latter potentiates aerosolization that could lead to higher risk of spreading the infection. The risk extends to respiratory technicians and nurses who administer the nebulizer, as well as other HCWs who enter the room during or after administration. The Centers for Disease Control and Prevention (CDC) considers nebulized bronchodilator therapy a “high-risk” exposure for HCWs not wearing the proper personal protectvie equipment.⁷ Moreover, MDI therapy produces equivalent outcomes to nebulized treatments for patients who are not critically ill.⁶ Unfortunately, the supply of MDIs during this crisis has not kept up with the increased demand.⁸

There are no clear guidelines for reuse of MDIs in COVID-19; however, options include labeling patients’ MDIs to use for hospitalization and discharge or labeling an MDI for use during hospitalization and then disinfecting for reuse. For safety reasons, MDIs of COVID-19 patients should be reused only for other patients with COVID-19.⁸

• Do not use posteroanterior and lateral chest X-ray as initial imaging. Use a portable chest X-ray instead.

The CDC does not currently recommend diagnosing COVID-19 by chest X-ray (CXR).⁷ When used appropriately, CXR can provide information to support a COVID-19 diagnosis and rule out other etiologies that cause respiratory symptoms.⁹ Posteroanterior (PA) and lateral CXR are more sensitive than portable CXR for detecting pleural effusions, and lateral CXR is needed to examine structures along the axis of the body. Portable CXR also may cause the heart to appear magnified and the mediastinum widened, the diaphragm to appear higher, and vascular shadows to be obscured.¹⁰ The improved ability to detect these subtle differences should be weighed against the increased risk to HCWs required to perform PA and lateral CXR. A portable CXR exposes a relatively smaller number of staff who come to the bedside versus the larger number of people exposed in transporting the patient out of the room and into the hallway, elevator, and the radiology suite for a PA and lateral CXR.

• Avoid in-person evaluations in favor of virtual communication unless necessary.

To minimize HCW exposure to COVID-19 and optimize infection control, the CDC recommends the use of telemedicine when possible.⁷ Telemedicine refers to the use of technology to support clinical care across some distance, which includes video visits and remote clinical monitoring. At the time of writing, the Centers for Medicare & Medicaid Services had waived the rural site of care requirement for Medicare beneficiaries, granted 49 Medicaid waivers to states to enhance flexibility, and (at least temporarily) added inpatient care to the list of reimbursed telemedicine services.¹¹ Funding for expanded coverage under Medicare is included in the recent Coronavirus Preparedness and Response Supplemental Appropriations Act.¹² These federal changes open the door for commercial payers and state Medicaid programs to further boost telemedicine through reimbursement parity to in-person visits and other coverage policies. Hospitalists can ride this momentum and learn from ambulatory colleagues to harness the power of telemedicine and minimize unnecessary face-to-face interactions with patients who are suspected or confirmed to have COVID-19.¹³ Even if providers have to enter the patient’s room, telemedicine may still allow for large virtual family meetings despite strict visitor restrictions and physical distance with loved ones. If in-person visits are necessary, only one designated person should enter the patient’s room instead of the entire team.

• Do not delay goals of care conversations for hospitalized patients who are unlikely to benefit from life-sustaining treatments.

The COVID-19 pandemic amplifies the need for early goals of care discussions. Mortality rates range higher with acute respiratory distress syndrome from COVID-19, compared with other etiologies, and is associated with extended intensive care unit stays.¹⁴ The harms extend beyond the patient and families to our HCWs through psychological distress and heightened exposure from aerosolization during resuscitation. Advance care planning should center on the values and preferences of the patient. Rather than asking if the patient or family would want certain treatments, it is crucial for clinicians to be direct in making do-not-resuscitate recommendations if deemed futile care.¹⁵ This practice is well within legal confines and is distinct from withdrawal or withholding of life-sustaining resources.¹⁵

HCWs providing inpatient care during this pandemic remain among the highest risk for contracting the infection. As of April 9, 2020, nearly 9,300 HCWs in the United States have contracted COVID-19.¹⁶ One thing remains clear: If we want to protect our patients, we must start by protecting our HCWs. We must think critically to evaluate the potential harms to our extended healthcare teams and strive further to eliminate overuse from our care.

The authors represent members of the High Value Practice Academic Alliance. The High Value Practice Academic Alliance is a consortium of academic medical centers in the United States and Canada working to advance high-value healthcare through collaborative quality improvement, research, and education. Additional information is available at http://www.hvpaa.org.

With more than 3 million people diagnosed and more than 200,000 deaths worldwide at the time this article was written, coronavirus disease of 2019 (COVID-19) poses an unprecedented challenge to the public and to our healthcare system.¹ The United States has surpassed every other country in the total number of COVID-19 cases. Hospitals in hotspots are operating beyond capacity, while others prepare for a predicted surge of patients suffering from COVID-19. Now more than ever, clinicians need to prioritize limited time and resources wisely in this rapidly changing environment. Our most precious limited resource, healthcare workers (HCWs), bravely care for patients while trying to avoid acquiring the infection. With each test and treatment, clinicians must carefully consider harms and benefits, including exposing themselves and other HCWs to SARS-CoV-2, the virus causing this disease.

Delivering any healthcare service in which the potential harm exceeds benefit represents one form of overuse. In the era of COVID-19, the harmful consequences of overuse go beyond the patient to the healthcare team. For example, unnecessary chest computed tomography (CT) to help diagnose COVID-19 comes with the usual risks to the patient including radiation, but it may also reveal a suspicious nodule. That incidental finding can lead to downstream consequences, such as more imaging, blood work, and biopsy. In the current pandemic, however, that CT comes with more than just the usual risk. The initial unnecessary chest CT can risk exposing the transporter, the staff in the hallways and elevator en route, the radiology staff operating the CT scanner, and the maintenance staff who must clean the room and scanner afterward. Potential downstream harms to staff include exposure of the pulmonary and interventional radiology consultants, as well as the staff who perform repeat imaging after the biopsy. Evaluation of the nodule potentially prolongs the patient’s stay and exposes more staff. Clinicians must weigh the benefits and harms of each test and treatment carefully with consideration of both the patient and the staff involved. Moreover, it may turn out that the patient and staff without symptoms of COVID-19 may pose the most risk to one another.

Choosing Wisely® partnered with patients and clinician societies to develop a Top 5 recommendations list for eliminating unnecessary testing and treatment. Our multi-institutional group from the High Value Practice Academic Alliance proposed this Top 5 list of overuse practices in hospital medicine that can lead to harm of both patients and HCWs in the COVID-19 era (Table). The following recommendations apply to all patients with unsuspected, suspected, or confirmed SARS-CoV-2 infection in the hospital setting.

• Do not obtain nonurgent labs in separate blood draws if they can be batched together.

This recommendation expands on the original Society of Hospital Medicine Choosing Wisely recommendation: Don’t perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability.² Aside from patient harms such as pain and hospital-acquired anemia, the risk of exposure to HCWs who perform phlebotomy (phlebotomists, nurses, and other clinicians), as well as staff who transport, handle, and process the bloodwork in the lab, must be minimized. Most prior interventions to eliminate unnecessary bloodwork focused on the number of lab tests,³ but some also aimed to batch nonurgent labs together to effectively reduce unnecessary needlesticks (“think twice, stick once”).⁴ This concept can be brought into this pandemic to provide safe and appropriate care for both patients and HCWs.

• Do not use bronchodilators unless there is active obstructive airway disease, and if needed, use metered dose inhalers instead of nebulizers.

We do not recommend using bronchodilators to treat COVID-19 symptoms unless patients develop acute bronchospastic symptoms of their underlying obstructive airway disease.⁵ When needed, use metered dose inhalers (MDIs),⁶ if available, instead of nebulizers because the latter potentiates aerosolization that could lead to higher risk of spreading the infection. The risk extends to respiratory technicians and nurses who administer the nebulizer, as well as other HCWs who enter the room during or after administration. The Centers for Disease Control and Prevention (CDC) considers nebulized bronchodilator therapy a “high-risk” exposure for HCWs not wearing the proper personal protectvie equipment.⁷ Moreover, MDI therapy produces equivalent outcomes to nebulized treatments for patients who are not critically ill.⁶ Unfortunately, the supply of MDIs during this crisis has not kept up with the increased demand.⁸

There are no clear guidelines for reuse of MDIs in COVID-19; however, options include labeling patients’ MDIs to use for hospitalization and discharge or labeling an MDI for use during hospitalization and then disinfecting for reuse. For safety reasons, MDIs of COVID-19 patients should be reused only for other patients with COVID-19.⁸

• Do not use posteroanterior and lateral chest X-ray as initial imaging. Use a portable chest X-ray instead.

The CDC does not currently recommend diagnosing COVID-19 by chest X-ray (CXR).⁷ When used appropriately, CXR can provide information to support a COVID-19 diagnosis and rule out other etiologies that cause respiratory symptoms.⁹ Posteroanterior (PA) and lateral CXR are more sensitive than portable CXR for detecting pleural effusions, and lateral CXR is needed to examine structures along the axis of the body. Portable CXR also may cause the heart to appear magnified and the mediastinum widened, the diaphragm to appear higher, and vascular shadows to be obscured.¹⁰ The improved ability to detect these subtle differences should be weighed against the increased risk to HCWs required to perform PA and lateral CXR. A portable CXR exposes a relatively smaller number of staff who come to the bedside versus the larger number of people exposed in transporting the patient out of the room and into the hallway, elevator, and the radiology suite for a PA and lateral CXR.

• Avoid in-person evaluations in favor of virtual communication unless necessary.

To minimize HCW exposure to COVID-19 and optimize infection control, the CDC recommends the use of telemedicine when possible.⁷ Telemedicine refers to the use of technology to support clinical care across some distance, which includes video visits and remote clinical monitoring. At the time of writing, the Centers for Medicare & Medicaid Services had waived the rural site of care requirement for Medicare beneficiaries, granted 49 Medicaid waivers to states to enhance flexibility, and (at least temporarily) added inpatient care to the list of reimbursed telemedicine services.¹¹ Funding for expanded coverage under Medicare is included in the recent Coronavirus Preparedness and Response Supplemental Appropriations Act.¹² These federal changes open the door for commercial payers and state Medicaid programs to further boost telemedicine through reimbursement parity to in-person visits and other coverage policies. Hospitalists can ride this momentum and learn from ambulatory colleagues to harness the power of telemedicine and minimize unnecessary face-to-face interactions with patients who are suspected or confirmed to have COVID-19.¹³ Even if providers have to enter the patient’s room, telemedicine may still allow for large virtual family meetings despite strict visitor restrictions and physical distance with loved ones. If in-person visits are necessary, only one designated person should enter the patient’s room instead of the entire team.

• Do not delay goals of care conversations for hospitalized patients who are unlikely to benefit from life-sustaining treatments.

The COVID-19 pandemic amplifies the need for early goals of care discussions. Mortality rates range higher with acute respiratory distress syndrome from COVID-19, compared with other etiologies, and is associated with extended intensive care unit stays.¹⁴ The harms extend beyond the patient and families to our HCWs through psychological distress and heightened exposure from aerosolization during resuscitation. Advance care planning should center on the values and preferences of the patient. Rather than asking if the patient or family would want certain treatments, it is crucial for clinicians to be direct in making do-not-resuscitate recommendations if deemed futile care.¹⁵ This practice is well within legal confines and is distinct from withdrawal or withholding of life-sustaining resources.¹⁵

HCWs providing inpatient care during this pandemic remain among the highest risk for contracting the infection. As of April 9, 2020, nearly 9,300 HCWs in the United States have contracted COVID-19.¹⁶ One thing remains clear: If we want to protect our patients, we must start by protecting our HCWs. We must think critically to evaluate the potential harms to our extended healthcare teams and strive further to eliminate overuse from our care.

The authors represent members of the High Value Practice Academic Alliance. The High Value Practice Academic Alliance is a consortium of academic medical centers in the United States and Canada working to advance high-value healthcare through collaborative quality improvement, research, and education. Additional information is available at http://www.hvpaa.org.

With more than 3 million people diagnosed and more than 200,000 deaths worldwide at the time this article was written, coronavirus disease of 2019 (COVID-19) poses an unprecedented challenge to the public and to our healthcare system.¹ The United States has surpassed every other country in the total number of COVID-19 cases. Hospitals in hotspots are operating beyond capacity, while others prepare for a predicted surge of patients suffering from COVID-19. Now more than ever, clinicians need to prioritize limited time and resources wisely in this rapidly changing environment. Our most precious limited resource, healthcare workers (HCWs), bravely care for patients while trying to avoid acquiring the infection. With each test and treatment, clinicians must carefully consider harms and benefits, including exposing themselves and other HCWs to SARS-CoV-2, the virus causing this disease.

Delivering any healthcare service in which the potential harm exceeds benefit represents one form of overuse. In the era of COVID-19, the harmful consequences of overuse go beyond the patient to the healthcare team. For example, unnecessary chest computed tomography (CT) to help diagnose COVID-19 comes with the usual risks to the patient including radiation, but it may also reveal a suspicious nodule. That incidental finding can lead to downstream consequences, such as more imaging, blood work, and biopsy. In the current pandemic, however, that CT comes with more than just the usual risk. The initial unnecessary chest CT can risk exposing the transporter, the staff in the hallways and elevator en route, the radiology staff operating the CT scanner, and the maintenance staff who must clean the room and scanner afterward. Potential downstream harms to staff include exposure of the pulmonary and interventional radiology consultants, as well as the staff who perform repeat imaging after the biopsy. Evaluation of the nodule potentially prolongs the patient’s stay and exposes more staff. Clinicians must weigh the benefits and harms of each test and treatment carefully with consideration of both the patient and the staff involved. Moreover, it may turn out that the patient and staff without symptoms of COVID-19 may pose the most risk to one another.

Choosing Wisely® partnered with patients and clinician societies to develop a Top 5 recommendations list for eliminating unnecessary testing and treatment. Our multi-institutional group from the High Value Practice Academic Alliance proposed this Top 5 list of overuse practices in hospital medicine that can lead to harm of both patients and HCWs in the COVID-19 era (Table). The following recommendations apply to all patients with unsuspected, suspected, or confirmed SARS-CoV-2 infection in the hospital setting.

• Do not obtain nonurgent labs in separate blood draws if they can be batched together.

This recommendation expands on the original Society of Hospital Medicine Choosing Wisely recommendation: Don’t perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability.² Aside from patient harms such as pain and hospital-acquired anemia, the risk of exposure to HCWs who perform phlebotomy (phlebotomists, nurses, and other clinicians), as well as staff who transport, handle, and process the bloodwork in the lab, must be minimized. Most prior interventions to eliminate unnecessary bloodwork focused on the number of lab tests,³ but some also aimed to batch nonurgent labs together to effectively reduce unnecessary needlesticks (“think twice, stick once”).⁴ This concept can be brought into this pandemic to provide safe and appropriate care for both patients and HCWs.

• Do not use bronchodilators unless there is active obstructive airway disease, and if needed, use metered dose inhalers instead of nebulizers.

We do not recommend using bronchodilators to treat COVID-19 symptoms unless patients develop acute bronchospastic symptoms of their underlying obstructive airway disease.⁵ When needed, use metered dose inhalers (MDIs),⁶ if available, instead of nebulizers because the latter potentiates aerosolization that could lead to higher risk of spreading the infection. The risk extends to respiratory technicians and nurses who administer the nebulizer, as well as other HCWs who enter the room during or after administration. The Centers for Disease Control and Prevention (CDC) considers nebulized bronchodilator therapy a “high-risk” exposure for HCWs not wearing the proper personal protectvie equipment.⁷ Moreover, MDI therapy produces equivalent outcomes to nebulized treatments for patients who are not critically ill.⁶ Unfortunately, the supply of MDIs during this crisis has not kept up with the increased demand.⁸

There are no clear guidelines for reuse of MDIs in COVID-19; however, options include labeling patients’ MDIs to use for hospitalization and discharge or labeling an MDI for use during hospitalization and then disinfecting for reuse. For safety reasons, MDIs of COVID-19 patients should be reused only for other patients with COVID-19.⁸

• Do not use posteroanterior and lateral chest X-ray as initial imaging. Use a portable chest X-ray instead.

The CDC does not currently recommend diagnosing COVID-19 by chest X-ray (CXR).⁷ When used appropriately, CXR can provide information to support a COVID-19 diagnosis and rule out other etiologies that cause respiratory symptoms.⁹ Posteroanterior (PA) and lateral CXR are more sensitive than portable CXR for detecting pleural effusions, and lateral CXR is needed to examine structures along the axis of the body. Portable CXR also may cause the heart to appear magnified and the mediastinum widened, the diaphragm to appear higher, and vascular shadows to be obscured.¹⁰ The improved ability to detect these subtle differences should be weighed against the increased risk to HCWs required to perform PA and lateral CXR. A portable CXR exposes a relatively smaller number of staff who come to the bedside versus the larger number of people exposed in transporting the patient out of the room and into the hallway, elevator, and the radiology suite for a PA and lateral CXR.

• Avoid in-person evaluations in favor of virtual communication unless necessary.

To minimize HCW exposure to COVID-19 and optimize infection control, the CDC recommends the use of telemedicine when possible.⁷ Telemedicine refers to the use of technology to support clinical care across some distance, which includes video visits and remote clinical monitoring. At the time of writing, the Centers for Medicare & Medicaid Services had waived the rural site of care requirement for Medicare beneficiaries, granted 49 Medicaid waivers to states to enhance flexibility, and (at least temporarily) added inpatient care to the list of reimbursed telemedicine services.¹¹ Funding for expanded coverage under Medicare is included in the recent Coronavirus Preparedness and Response Supplemental Appropriations Act.¹² These federal changes open the door for commercial payers and state Medicaid programs to further boost telemedicine through reimbursement parity to in-person visits and other coverage policies. Hospitalists can ride this momentum and learn from ambulatory colleagues to harness the power of telemedicine and minimize unnecessary face-to-face interactions with patients who are suspected or confirmed to have COVID-19.¹³ Even if providers have to enter the patient’s room, telemedicine may still allow for large virtual family meetings despite strict visitor restrictions and physical distance with loved ones. If in-person visits are necessary, only one designated person should enter the patient’s room instead of the entire team.

• Do not delay goals of care conversations for hospitalized patients who are unlikely to benefit from life-sustaining treatments.

The COVID-19 pandemic amplifies the need for early goals of care discussions. Mortality rates range higher with acute respiratory distress syndrome from COVID-19, compared with other etiologies, and is associated with extended intensive care unit stays.¹⁴ The harms extend beyond the patient and families to our HCWs through psychological distress and heightened exposure from aerosolization during resuscitation. Advance care planning should center on the values and preferences of the patient. Rather than asking if the patient or family would want certain treatments, it is crucial for clinicians to be direct in making do-not-resuscitate recommendations if deemed futile care.¹⁵ This practice is well within legal confines and is distinct from withdrawal or withholding of life-sustaining resources.¹⁵

HCWs providing inpatient care during this pandemic remain among the highest risk for contracting the infection. As of April 9, 2020, nearly 9,300 HCWs in the United States have contracted COVID-19.¹⁶ One thing remains clear: If we want to protect our patients, we must start by protecting our HCWs. We must think critically to evaluate the potential harms to our extended healthcare teams and strive further to eliminate overuse from our care.

The authors represent members of the High Value Practice Academic Alliance. The High Value Practice Academic Alliance is a consortium of academic medical centers in the United States and Canada working to advance high-value healthcare through collaborative quality improvement, research, and education. Additional information is available at http://www.hvpaa.org.

Clostridium difficile, now referred to as Clostridioides difficile (C. difficile), is the most commonly identified cause of healthcare-associated infection among adults in the United States.¹ Because C. difficile infection results in significant mortality and inpatient costs, its persistence threatens to undermine patient safety and the value of healthcare delivery.¹ A standardized, evidence-based approach to diagnosis and management is crucial. However, inconsistencies remain with regard to the appropriate threshold for testing, the type of diagnostic tests used, and treatment. Knowledge of these areas has progressed since the publication of the previous C. difficile guidelines in 2010. These guidelines contain 53 recommendations across 35 sections based on a systematic weighting of the strength of recommendation and quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation system. Herein, we have chosen to highlight five of these recommendations most relevant to hospitalists.

Recommendation 1. Patients with unexplained and new-onset ≥3 unformed stools within 24 hours are the preferred target population for testing for C. difficile infection (weak recommendation, very low quality of evidence). Do not perform repeat testing (within seven days) during the same episode of diarrhea and do not test stool from asymptomatic patients (strong recommendation, moderate quality of evidence).

In the recent past, healthcare facilities employed C. difficile tests with limited sensitivity, leading to frequent and repeat testing of hospitalized patients. Excess testing puts patients at risk for false positive results and unnecessary or prolonged treatment courses. Proper testing requires consideration of pretest probability, including analysis of the alternative causes of diarrhea. Duration of hospitalization and antibiotic exposure are the most significant modifiable risk factors for C. difficile infection in adult inpatients.² Laxative use within the previous 48 hours, enteral tube feeding, and underlying medical conditions, such as inflammatory bowel disease (IBD), are common causes of improper testing.³ This decision may be difficult, as some underlying causes of diarrhea, such as IBD and enteral tube feeding, also increase the risk of C. difficile infection.³ Laboratories can help by rejecting specimens that are not liquid or soft and employing a multistep algorithm using a combination of nucleic acid testing, antigen testing, and toxin detection to maximize sensitivity and specificity. Because recurrent C. difficile infection is relatively common, repeat testing is appropriate only for recurrence of symptoms following successful treatment and should focus on detection of C. difficile toxin because the persistence of the organism itself can occur after successful treatment.⁴

Recommendation 2. Either vancomycin (125 mg orally four times per day for 10 days) or fidaxomicin (200 mg twice daily for 10 days) is recommended over metronidazole for an initial episode of nonsevere or severe C. difficile infection (strong recommendation, high quality of evidence). For fulminant C. difficile infection, the regimen of choice is a vancomycin dosage of 500 mg orally four times per day (per rectum every six hours if with ileus) in addition to intravenous metronidazole (strong recommendation, moderate quality of evidence).

For several decades now, metronidazole has been the primary antibiotic agent for initial treatment of nonsevere C. difficile infection. Two recent randomized, placebo-controlled trials, however, have found oral vancomycin to be superior to metronidazole for producing a clinical cure and resolution of diarrhea without recurrence.^5,6 Oral vancomycin remains the treatment of choice for severe C. difficile infection. Fidaxomicin, a recently FDA-approved antibiotic, can also be used as initial treatment in place of oral vancomycin. One study found fidaxomicin to be superior to oral vancomycin for producing a sustained clinical response, that is, resolution of diarrhea at the end of treatment without recurrence 25 days later.⁷ Fulminant disease, which is characterized by hypotension or shock, ileus, or megacolon, requires a higher dose of oral vancomycin (or vancomycin enema if with ileus) in addition to intravenous metronidazole.

Recommendation 3. Treat a first recurrence of C. difficile infection with oral vancomycin as a tapered and pulsed regimen rather than a second standard 10-day course of vancomycin or metronidazole (weak recommendation, low quality of evidence).

Despite the improved treatment response with oral vancomycin, one in four patients will experience recurrence. For a first recurrence of C. difficile infection after a 10-day course of oral vancomycin, an extended taper or pulsed course of vancomycin should be attempted. Various regimens have been tried and found to be effective. For a second recurrence, providers can consider addition of rifaximin following oral vancomycin. Fecal microbiota transplantation is recommended for patients with multiple recurrences of C. difficile infection who have failed these antibiotic treatments.

Recommendation 4. Minimize the frequency and duration of high-risk antibiotic therapy (based on local epidemiology) and the number of antibiotic agents prescribed to reduce C. difficile infection risk (strong recommendation, moderate quality of evidence).

Antibiotic stewardship is a necessary component of any successful effort to reduce C. difficile infections. Antibiotic stewardship programs, which are now commonplace in US hospitals, largely rely on educational initiatives or committee-based order review. Hospitalists should take a structured approach emphasizing the four critical questions of antibiotic prescribing: Does this infection require antibiotics? Have I ordered appropriate cultures and the correct empiric therapy? Can I stop, narrow, or switch to oral agents? Finally, what duration of therapy is needed at discharge?⁸ Initial efforts should focus on the restriction of fluoroquinolones, clindamycin, and cephalosporins (except for surgical antibiotic prophylaxis) given their known risk to cause C. difficile infection.

Recommendation 5. Contact precautions should be maintained for at least 48 hours after diarrhea has resolved (weak recommendation, low quality of evidence).

Although C. difficile is undetectable in stool samples from most patients by the time diarrhea has resolved, skin and environmental contaminations remain high. No studies demonstrating a benefit to further extending contact precautions beyond 48 hours after resolution of diarrhea are yet available.

Methods in Preparing Guidelines

The guideline committee consisted of an interdisciplinary team of healthcare providers with extensive experience in the diagnosis, infection control, treatment, and management of C. difficile. The literature search accessed five different databases (Medline, Embase, Cochrane, Health Technology Assessment, and Database of Abstracts of Reviews and Effects), relevant journals, conference proceedings, and regulatory websites published over the search period of 2009-2016.

A major strength of these guidelines is the extensive work that went into their preparation. The committee reviewed over 14,000 pieces of literature and performed a detailed analysis of each one to determine the quality of evidence in support of each recommendation.

Sources of Potential Conflict of Interest or Bias

To reduce bias, the committee’s work was funded by Infectious Disease Society of America and Society for Healthcare Epidemiology of America. Some authors received funding for work outside of this guideline by companies that manufacture diagnostic assays, vancomycin, and fidaxomicin. These potential conflicts were listed at the end of the article.

Generalizability of the Guideline

Not all studies included in the guideline contain exclusively hospitalized patients, but much of the guideline content is applicable to hospitalized patients. Because C. difficile infection is such a widespread public health problem and these guidelines represent a significant update in knowledge since 2010, the specific recommendations highlighted in this review will impact numerous hospitalists, regardless of the practice setting.

Areas in Need of Future Study

Based on the current literature, as well as statements in the guideline, we expect future guidance around potential screening for and isolation of asymptomatic carriers, including closer guidance on stool transplantation focusing on timing and route, as further data emerge in these areas.

Other Resources

• Grading of Recommendations Assessment, Development, and Evaluation system (http://www.gradeworkinggroup.org)
• Universal Screening for C. difficile in a Tertiary Hospital: risk factors for carriage and clinical disease (Color/Blackhttps://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(19)30048-5/fulltext)
• Effectiveness of Isolating Clostridium Difficile Asymptomatic Carriers on the Incidence of Infections (Color/Blackhttps://clinicaltrials.gov/ct2/show/NCT03223415)
• Effect of Detecting and Isolating Clostridium difficile Carriers at Hospital Admission on the Incidence of C difficile Infections (Color/Blackhttps://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2516765)
• Clinical Trial Testing Fecal Microbiota Transplant for Recurrent Diarrheal Disease Begins (Color/Blackhttps://www.nih.gov/news-events/news-releases/clinical-trial-testing-fecal-microbiota-transplant-recurrent-diarrheal-disease-begins)

Clostridium difficile, now referred to as Clostridioides difficile (C. difficile), is the most commonly identified cause of healthcare-associated infection among adults in the United States.¹ Because C. difficile infection results in significant mortality and inpatient costs, its persistence threatens to undermine patient safety and the value of healthcare delivery.¹ A standardized, evidence-based approach to diagnosis and management is crucial. However, inconsistencies remain with regard to the appropriate threshold for testing, the type of diagnostic tests used, and treatment. Knowledge of these areas has progressed since the publication of the previous C. difficile guidelines in 2010. These guidelines contain 53 recommendations across 35 sections based on a systematic weighting of the strength of recommendation and quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation system. Herein, we have chosen to highlight five of these recommendations most relevant to hospitalists.

Recommendation 1. Patients with unexplained and new-onset ≥3 unformed stools within 24 hours are the preferred target population for testing for C. difficile infection (weak recommendation, very low quality of evidence). Do not perform repeat testing (within seven days) during the same episode of diarrhea and do not test stool from asymptomatic patients (strong recommendation, moderate quality of evidence).

In the recent past, healthcare facilities employed C. difficile tests with limited sensitivity, leading to frequent and repeat testing of hospitalized patients. Excess testing puts patients at risk for false positive results and unnecessary or prolonged treatment courses. Proper testing requires consideration of pretest probability, including analysis of the alternative causes of diarrhea. Duration of hospitalization and antibiotic exposure are the most significant modifiable risk factors for C. difficile infection in adult inpatients.² Laxative use within the previous 48 hours, enteral tube feeding, and underlying medical conditions, such as inflammatory bowel disease (IBD), are common causes of improper testing.³ This decision may be difficult, as some underlying causes of diarrhea, such as IBD and enteral tube feeding, also increase the risk of C. difficile infection.³ Laboratories can help by rejecting specimens that are not liquid or soft and employing a multistep algorithm using a combination of nucleic acid testing, antigen testing, and toxin detection to maximize sensitivity and specificity. Because recurrent C. difficile infection is relatively common, repeat testing is appropriate only for recurrence of symptoms following successful treatment and should focus on detection of C. difficile toxin because the persistence of the organism itself can occur after successful treatment.⁴

Recommendation 2. Either vancomycin (125 mg orally four times per day for 10 days) or fidaxomicin (200 mg twice daily for 10 days) is recommended over metronidazole for an initial episode of nonsevere or severe C. difficile infection (strong recommendation, high quality of evidence). For fulminant C. difficile infection, the regimen of choice is a vancomycin dosage of 500 mg orally four times per day (per rectum every six hours if with ileus) in addition to intravenous metronidazole (strong recommendation, moderate quality of evidence).

For several decades now, metronidazole has been the primary antibiotic agent for initial treatment of nonsevere C. difficile infection. Two recent randomized, placebo-controlled trials, however, have found oral vancomycin to be superior to metronidazole for producing a clinical cure and resolution of diarrhea without recurrence.^5,6 Oral vancomycin remains the treatment of choice for severe C. difficile infection. Fidaxomicin, a recently FDA-approved antibiotic, can also be used as initial treatment in place of oral vancomycin. One study found fidaxomicin to be superior to oral vancomycin for producing a sustained clinical response, that is, resolution of diarrhea at the end of treatment without recurrence 25 days later.⁷ Fulminant disease, which is characterized by hypotension or shock, ileus, or megacolon, requires a higher dose of oral vancomycin (or vancomycin enema if with ileus) in addition to intravenous metronidazole.

Recommendation 3. Treat a first recurrence of C. difficile infection with oral vancomycin as a tapered and pulsed regimen rather than a second standard 10-day course of vancomycin or metronidazole (weak recommendation, low quality of evidence).

Despite the improved treatment response with oral vancomycin, one in four patients will experience recurrence. For a first recurrence of C. difficile infection after a 10-day course of oral vancomycin, an extended taper or pulsed course of vancomycin should be attempted. Various regimens have been tried and found to be effective. For a second recurrence, providers can consider addition of rifaximin following oral vancomycin. Fecal microbiota transplantation is recommended for patients with multiple recurrences of C. difficile infection who have failed these antibiotic treatments.

Recommendation 4. Minimize the frequency and duration of high-risk antibiotic therapy (based on local epidemiology) and the number of antibiotic agents prescribed to reduce C. difficile infection risk (strong recommendation, moderate quality of evidence).

Antibiotic stewardship is a necessary component of any successful effort to reduce C. difficile infections. Antibiotic stewardship programs, which are now commonplace in US hospitals, largely rely on educational initiatives or committee-based order review. Hospitalists should take a structured approach emphasizing the four critical questions of antibiotic prescribing: Does this infection require antibiotics? Have I ordered appropriate cultures and the correct empiric therapy? Can I stop, narrow, or switch to oral agents? Finally, what duration of therapy is needed at discharge?⁸ Initial efforts should focus on the restriction of fluoroquinolones, clindamycin, and cephalosporins (except for surgical antibiotic prophylaxis) given their known risk to cause C. difficile infection.

Recommendation 5. Contact precautions should be maintained for at least 48 hours after diarrhea has resolved (weak recommendation, low quality of evidence).

Although C. difficile is undetectable in stool samples from most patients by the time diarrhea has resolved, skin and environmental contaminations remain high. No studies demonstrating a benefit to further extending contact precautions beyond 48 hours after resolution of diarrhea are yet available.

Methods in Preparing Guidelines

The guideline committee consisted of an interdisciplinary team of healthcare providers with extensive experience in the diagnosis, infection control, treatment, and management of C. difficile. The literature search accessed five different databases (Medline, Embase, Cochrane, Health Technology Assessment, and Database of Abstracts of Reviews and Effects), relevant journals, conference proceedings, and regulatory websites published over the search period of 2009-2016.

A major strength of these guidelines is the extensive work that went into their preparation. The committee reviewed over 14,000 pieces of literature and performed a detailed analysis of each one to determine the quality of evidence in support of each recommendation.

Sources of Potential Conflict of Interest or Bias

To reduce bias, the committee’s work was funded by Infectious Disease Society of America and Society for Healthcare Epidemiology of America. Some authors received funding for work outside of this guideline by companies that manufacture diagnostic assays, vancomycin, and fidaxomicin. These potential conflicts were listed at the end of the article.

Generalizability of the Guideline

Not all studies included in the guideline contain exclusively hospitalized patients, but much of the guideline content is applicable to hospitalized patients. Because C. difficile infection is such a widespread public health problem and these guidelines represent a significant update in knowledge since 2010, the specific recommendations highlighted in this review will impact numerous hospitalists, regardless of the practice setting.

Areas in Need of Future Study

Based on the current literature, as well as statements in the guideline, we expect future guidance around potential screening for and isolation of asymptomatic carriers, including closer guidance on stool transplantation focusing on timing and route, as further data emerge in these areas.

Other Resources

• Grading of Recommendations Assessment, Development, and Evaluation system (http://www.gradeworkinggroup.org)
• Universal Screening for C. difficile in a Tertiary Hospital: risk factors for carriage and clinical disease (Color/Blackhttps://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(19)30048-5/fulltext)
• Effectiveness of Isolating Clostridium Difficile Asymptomatic Carriers on the Incidence of Infections (Color/Blackhttps://clinicaltrials.gov/ct2/show/NCT03223415)
• Effect of Detecting and Isolating Clostridium difficile Carriers at Hospital Admission on the Incidence of C difficile Infections (Color/Blackhttps://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2516765)
• Clinical Trial Testing Fecal Microbiota Transplant for Recurrent Diarrheal Disease Begins (Color/Blackhttps://www.nih.gov/news-events/news-releases/clinical-trial-testing-fecal-microbiota-transplant-recurrent-diarrheal-disease-begins)

Clostridium difficile, now referred to as Clostridioides difficile (C. difficile), is the most commonly identified cause of healthcare-associated infection among adults in the United States.¹ Because C. difficile infection results in significant mortality and inpatient costs, its persistence threatens to undermine patient safety and the value of healthcare delivery.¹ A standardized, evidence-based approach to diagnosis and management is crucial. However, inconsistencies remain with regard to the appropriate threshold for testing, the type of diagnostic tests used, and treatment. Knowledge of these areas has progressed since the publication of the previous C. difficile guidelines in 2010. These guidelines contain 53 recommendations across 35 sections based on a systematic weighting of the strength of recommendation and quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation system. Herein, we have chosen to highlight five of these recommendations most relevant to hospitalists.

Recommendation 1. Patients with unexplained and new-onset ≥3 unformed stools within 24 hours are the preferred target population for testing for C. difficile infection (weak recommendation, very low quality of evidence). Do not perform repeat testing (within seven days) during the same episode of diarrhea and do not test stool from asymptomatic patients (strong recommendation, moderate quality of evidence).

In the recent past, healthcare facilities employed C. difficile tests with limited sensitivity, leading to frequent and repeat testing of hospitalized patients. Excess testing puts patients at risk for false positive results and unnecessary or prolonged treatment courses. Proper testing requires consideration of pretest probability, including analysis of the alternative causes of diarrhea. Duration of hospitalization and antibiotic exposure are the most significant modifiable risk factors for C. difficile infection in adult inpatients.² Laxative use within the previous 48 hours, enteral tube feeding, and underlying medical conditions, such as inflammatory bowel disease (IBD), are common causes of improper testing.³ This decision may be difficult, as some underlying causes of diarrhea, such as IBD and enteral tube feeding, also increase the risk of C. difficile infection.³ Laboratories can help by rejecting specimens that are not liquid or soft and employing a multistep algorithm using a combination of nucleic acid testing, antigen testing, and toxin detection to maximize sensitivity and specificity. Because recurrent C. difficile infection is relatively common, repeat testing is appropriate only for recurrence of symptoms following successful treatment and should focus on detection of C. difficile toxin because the persistence of the organism itself can occur after successful treatment.⁴

Recommendation 2. Either vancomycin (125 mg orally four times per day for 10 days) or fidaxomicin (200 mg twice daily for 10 days) is recommended over metronidazole for an initial episode of nonsevere or severe C. difficile infection (strong recommendation, high quality of evidence). For fulminant C. difficile infection, the regimen of choice is a vancomycin dosage of 500 mg orally four times per day (per rectum every six hours if with ileus) in addition to intravenous metronidazole (strong recommendation, moderate quality of evidence).

For several decades now, metronidazole has been the primary antibiotic agent for initial treatment of nonsevere C. difficile infection. Two recent randomized, placebo-controlled trials, however, have found oral vancomycin to be superior to metronidazole for producing a clinical cure and resolution of diarrhea without recurrence.^5,6 Oral vancomycin remains the treatment of choice for severe C. difficile infection. Fidaxomicin, a recently FDA-approved antibiotic, can also be used as initial treatment in place of oral vancomycin. One study found fidaxomicin to be superior to oral vancomycin for producing a sustained clinical response, that is, resolution of diarrhea at the end of treatment without recurrence 25 days later.⁷ Fulminant disease, which is characterized by hypotension or shock, ileus, or megacolon, requires a higher dose of oral vancomycin (or vancomycin enema if with ileus) in addition to intravenous metronidazole.

Recommendation 3. Treat a first recurrence of C. difficile infection with oral vancomycin as a tapered and pulsed regimen rather than a second standard 10-day course of vancomycin or metronidazole (weak recommendation, low quality of evidence).

Despite the improved treatment response with oral vancomycin, one in four patients will experience recurrence. For a first recurrence of C. difficile infection after a 10-day course of oral vancomycin, an extended taper or pulsed course of vancomycin should be attempted. Various regimens have been tried and found to be effective. For a second recurrence, providers can consider addition of rifaximin following oral vancomycin. Fecal microbiota transplantation is recommended for patients with multiple recurrences of C. difficile infection who have failed these antibiotic treatments.

Recommendation 4. Minimize the frequency and duration of high-risk antibiotic therapy (based on local epidemiology) and the number of antibiotic agents prescribed to reduce C. difficile infection risk (strong recommendation, moderate quality of evidence).

Antibiotic stewardship is a necessary component of any successful effort to reduce C. difficile infections. Antibiotic stewardship programs, which are now commonplace in US hospitals, largely rely on educational initiatives or committee-based order review. Hospitalists should take a structured approach emphasizing the four critical questions of antibiotic prescribing: Does this infection require antibiotics? Have I ordered appropriate cultures and the correct empiric therapy? Can I stop, narrow, or switch to oral agents? Finally, what duration of therapy is needed at discharge?⁸ Initial efforts should focus on the restriction of fluoroquinolones, clindamycin, and cephalosporins (except for surgical antibiotic prophylaxis) given their known risk to cause C. difficile infection.

Recommendation 5. Contact precautions should be maintained for at least 48 hours after diarrhea has resolved (weak recommendation, low quality of evidence).

Although C. difficile is undetectable in stool samples from most patients by the time diarrhea has resolved, skin and environmental contaminations remain high. No studies demonstrating a benefit to further extending contact precautions beyond 48 hours after resolution of diarrhea are yet available.

Methods in Preparing Guidelines

The guideline committee consisted of an interdisciplinary team of healthcare providers with extensive experience in the diagnosis, infection control, treatment, and management of C. difficile. The literature search accessed five different databases (Medline, Embase, Cochrane, Health Technology Assessment, and Database of Abstracts of Reviews and Effects), relevant journals, conference proceedings, and regulatory websites published over the search period of 2009-2016.

A major strength of these guidelines is the extensive work that went into their preparation. The committee reviewed over 14,000 pieces of literature and performed a detailed analysis of each one to determine the quality of evidence in support of each recommendation.

Sources of Potential Conflict of Interest or Bias

To reduce bias, the committee’s work was funded by Infectious Disease Society of America and Society for Healthcare Epidemiology of America. Some authors received funding for work outside of this guideline by companies that manufacture diagnostic assays, vancomycin, and fidaxomicin. These potential conflicts were listed at the end of the article.

Generalizability of the Guideline

Not all studies included in the guideline contain exclusively hospitalized patients, but much of the guideline content is applicable to hospitalized patients. Because C. difficile infection is such a widespread public health problem and these guidelines represent a significant update in knowledge since 2010, the specific recommendations highlighted in this review will impact numerous hospitalists, regardless of the practice setting.

Areas in Need of Future Study

Based on the current literature, as well as statements in the guideline, we expect future guidance around potential screening for and isolation of asymptomatic carriers, including closer guidance on stool transplantation focusing on timing and route, as further data emerge in these areas.

Other Resources

• Grading of Recommendations Assessment, Development, and Evaluation system (http://www.gradeworkinggroup.org)
• Universal Screening for C. difficile in a Tertiary Hospital: risk factors for carriage and clinical disease (Color/Blackhttps://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(19)30048-5/fulltext)
• Effectiveness of Isolating Clostridium Difficile Asymptomatic Carriers on the Incidence of Infections (Color/Blackhttps://clinicaltrials.gov/ct2/show/NCT03223415)
• Effect of Detecting and Isolating Clostridium difficile Carriers at Hospital Admission on the Incidence of C difficile Infections (Color/Blackhttps://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2516765)
• Clinical Trial Testing Fecal Microbiota Transplant for Recurrent Diarrheal Disease Begins (Color/Blackhttps://www.nih.gov/news-events/news-releases/clinical-trial-testing-fecal-microbiota-transplant-recurrent-diarrheal-disease-begins)