The ID team is also part of our gatekeeper strategy in that there are a myriad of questions that come in all the time and they emphasize when to appropriately test, when not to test, and also hammering home that you shouldn’ t be testing for cure, which is another thing that we’ ve been seeing.”— Trish Perl, MD
provider to avoid testing. We’ ve seen good uptake of that strategy, particularly from our GI colleagues who tend to be a group that would previously overtreat for C. diff. So, it’ s been a way to engage them in our diagnostic stewardship efforts.”
Matt Linam, MD, MS, of Emory University, reported that his institution has“ a lot of the same kind of guardrails to control testing.” He continued,“ If someone tries to order a C. diff test on a child under the age of 1, they receive an alert and they are supposed to get infectious disease’ s approval. We also do no repeat testing within a week, as you’ ll receive an alert if your patient has been on a laxative in the last 48 hours, and that you would need ID’ s approval to send this test. Formed stool is rejected by our microbiology lab, they won’ t conduct testing on it. We are currently using a single-step test where we are doing toxin BPCR, largely because of the guardrails we have in place and because we have a fairly low rate of C. diff in our hospital.”
Trish Perl, MD, of UT Southwestern Medical Center, said,“ We have very similar guidelines; in our ordering you are asked if the patient is on a laxative, so it’ s upfront where you have to confirm. And then we do have guardrails in our lab where they reject anything if it’ s formed stool, they reject any specimen that comes in within seven days, and we do not allow repeat testing. The ID team is also part of our gatekeeper strategy in that there are a myriad of questions that come in all the time and they emphasize when to appropriately test, when not to test, and also hammering home that you shouldn’ t be testing for cure, which is another thing that we’ ve been seeing. We use a two-step testing strategy.”
Drees reported that,“ When I first got here 18 years ago we were doing two-step with the common antigen and toxin EIA and if they were discordant, then we would do the PCR. And we actually had a couple cases that were missed by that strategy, so we ended up going to colectomy and having sentinel events. So, that convinced our lab director to switch to doing PCR first and then the toxin testing second. We don’ t count a lot of our toxin-negative cases. When we’ ve done focused deep dives, a lot of them still do get treated. As far as encouraging or discouraging testing, we have the same rules around laxatives and formed stools. We also have adopted a published C. diff calculator that we use; for a long time it was on paper and then we had it built into the C. diff order and it pulls what it can, such as age and albumin and other factors. We discourage testing. We look at the EHR to see if there is any comment that it was used or not and then we have an alert which fires in the first three days to encourage testing if there’ s documented diarrhea or even a history of diarrhea that’ s obtained when the nurse does the initial intake.”
Shenoy noted that at Mass General,“ We’ ve been integrating, which means standardizing our testing protocols across the site. So, we had versions of each of what’ s been described except the cycle threshold one, which I just learned about and which I think is really cool. We switched over entirely to a standardized order. And the order, when someone goes to order C. diff testing, includes things that they might want to know upfront, which is, are there any loose bowel
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jan-feb 2026 • www. healthcarehygienemagazine. com •
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