A national survey published in Gastro Hep Advances found differences among U.S. gastroenterologists, infectious diseases specialists and primary care physicians in their use of clinical practice guidelines, diagnostic and testing practices and knowledge of emerging therapies for Clostridioides difficile infection (CDI).
“Education around CDI guidelines and standardized diagnostic and treatment algorithms are needed to ensure consistent CDI management,” investigators wrote.
The online survey included 302 physicians—101 gastroenterologists, 101 infectious diseases specialists and 100 primary care physicians—and was conducted from Feb. 24 to March 13, 2023. Gastroenterologists and infectious diseases specialists were required to treat at least three to four patients with CDI per month, compared with one to two patients per month for primary care physicians.
Practice variations in CDI management
Physicians practicing in hospital or academic settings appeared to be more familiar with CDI guidelines than those from independent or group practices. Half of gastroenterologists reported using American College of Gastroenterology guidelines, while nearly all infectious diseases specialists (98%) reported following guidelines from the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The two sets of guidelines differ on some recommendations for CDI management.
Institutional CDI testing guidelines, either required or recommended, were reported by 90% of infectious diseases specialists and 80% of gastroenterologists, compared with 40% of primary care physicians who reported having no set protocols. Primary care physicians were less likely than specialists to use the recommended multistep algorithms for CDI testing (30% vs 51.5% of gastroenterologists and 74.3% of infectious diseases specialists; P < .001).
“The variation that concerns me most begins with diagnostic testing,” lead author Abhishek Deshpande, MD, PhD, FIDSA, of Alice L. Walton School of Medicine in Bentonville, Arkansas, and the Cleveland Clinic, said in an interview with this news organization. Because patients can be colonized without being infected, appropriate diagnostic testing helps distinguish active CDI from colonization and guide treatment, explained Dr. Deshpande in an interview. “That is why more consistent, standardized diagnostic and treatment care paths are the single most important opportunity to improve patient care.”
Gastroenterologists and infectious diseases specialists were more likely than primary care physicians to report prescribing vancomycin taper regimens (93%, 98% and 62%, respectively) and fidaxomicin (87%, 97% and 53%; P < .001 for both comparisons). Primary care physicians were more likely to report prescribing metronidazole (84%) than gastroenterologists (62%) or infectious diseases specialists (73%; P < .001).
Fewer than 10% of physicians indicated that they felt “very knowledgeable” about donor-derived microbiome therapies. Although 60% of gastroenterologists, 53% of infectious diseases specialists and 50% of primary care physicians agreed that donor-derived microbiome therapeutics “are essential to the future of CDI management,” more than half reported a need for additional real-world safety and efficacy data and published clinical guidelines from professional societies.
Interpreting the findings
Dr. Deshpande placed the observed practice differences in context. “Some variation is appropriate, because treatment should reflect individual patient risk factors, disease severity, and history of recurrence. But our findings suggest a meaningful portion reflects differences in local practice, familiarity with society guidelines and access rather than clinical need,” he said. “The goal is not identical treatment for every patient, but greater consistency in evidence-based care."
The investigators noted limitations, including the small sample size and uneven geographic representation, both of which may limit the generalizability of the findings. In addition, the survey was conducted approximately 3 years before publication, and the rapidly evolving CDI management landscape may have since shifted physician attitudes and practice patterns.
Dr. Deshpande said familiarity with donor-derived microbiome therapies would likely be higher if the survey were repeated today because the therapies had only recently entered clinical practice when the survey was conducted in early 2023. However, he added that “one thing would likely be unchanged: clinicians still want high-quality real-world evidence.”
The investigators concluded that the findings revealed opportunities for education and coordination around CDI testing and treatment guidelines. They called for standardized diagnostic and treatment algorithms paired with educational initiatives focused particularly on primary care physicians who see patients with CDI infrequently.
Full disclosures of the authors are available in the published study.
