bluuebunny/crossref_metadata_2025 huggingface dataset:
P-110. Promoting Optimal Treatment for Community-Acquired Pneumonia in the Emergency Room: a Before-After Study of a Novel Care Pathway
Authors: Pernica Jeffrey , Kam April J , Eltorki Mohamed , Ewusie Joycelyne , Khan Sarah , Goldfarb David M , Smaill Fiona , Elliott Shakeap , Wong Jacqueline , Sung Melani , Smieja Marek , Mertz Dominik , Thabane Lehana , Loeb Mark
Published: January 2025

Background

Community-acquired pneumonia (CAP) in young children is mainly caused by viral pathogens; for this reason, Infectious Disease Society of America guidelines explicitly state that antibiotic treatment of non-severe CAP in this population is not obligatory. However, the vast majority of non-severe pediatric CAP episodes diagnosed in North America prompt antibiotic prescription anyway.

Methods

A before-after prospective study was done in a Canadian emergency department (ED) enrolling children aged 6+ months without comorbidities diagnosed with CAP and managed as outpatients. In the before (control) phase, participants were managed as per routine care. In the after (intervention) phase, participants were managed using a novel care pathway. This care pathway used imaging results, a point-of-care C-reactive protein (POC CRP) assay, and other already-available data (eg. O2 saturation, respiratory rate, age) to categorize participants as ‘appreciable risk’ or ‘low risk.’ Those at ‘appreciable risk’ were given a prescription for antibiotics, whereas those at ‘low risk’ were simply discharged home. The next day, caregivers of ‘low-risk’ participants were informed of results of nasopharyngeal viral/atypical pathogen testing. Follow-up was done at day 2-5, 14-21, and 30.

Results

There were 84 participants recruited in the control phase (Mar-Nov 2022) and 78 in the intervention phase (Nov 2022-Mar 2024). Control phase participants had a median age of 2.8 y (IQR 2.1 – 4.4y) and 13% had normal chest imaging, whereas intervention phase participants had a median age of 3.7 y (IQR 1.9 – 6 y) and 5.1% had normal chest imaging. All 84 of the participants in the control phase were prescribed antibiotics at ED discharge, as compared to only 51% of those in the intervention phase (49% less, 95%CI 38-60% less, p< 0.001). There were no significant differences in clinical cure at day 2-5, re-presentation to the ED, later hospitalization, or caregiver satisfaction with the care plan.

Conclusion

A simple novel care pathway incorporating POC CRP testing as well as other available data facilitated a very clinically important decrease in antibiotic prescribing without compromising clinical outcomes. This care pathway should be evaluated in the context of a multicentre randomized trial.

Disclosures

Jeffrey Pernica, MD, MSc, FRCPC, DTMH, MedImmune: Grant/Research Support|Merck: Grant/Research Support Dominik Mertz, MD, MSc, KCI Inc. USA: Grant/Research Support
P-136. Epidemiological Shifts in Histoplasmosis Hospitalizations Across the United States, 2012-2021: A Retrospective Analysis
Authors: Barghout Mohamed , Almaghlouth Nouf K
Published: January 2025

Background

Histoplasmosis represents a substantial public health concern in the United States, especially prevalent in the Ohio and Mississippi River Valleys where seroprevalence rates range from 60% to 90%. Building on data indicating rising hospitalization rates from earlier studies covering 2001 to 2012, this research aims to further investigate the trends in histoplasmosis-associated hospitalizations post-2012, focusing particularly on mortality outcomes.Table 1:Demographic and Clinical Characteristics of Patients with Histoplasmosis (Unweighted) Categorized by Mortality

Methods

We conducted a retrospective cohort study using the National Inpatient Sample (NIS) to assess trends in histoplasmosis-associated hospitalizations from 2012 to 2021. We analyzed a total of 351,321,656 hospitalizations, identifying cases of histoplasmosis either as a primary or any diagnosis. Histoplasmosis diagnoses were identified using ICD codes, and trends were analyzed using simple linear regression to calculate annual rates per 100,000 hospitalizations, with significance tested at a p-value ≤ 0.05.Figure 1:Trend of Histoplasmosis as Primary Diagnosis per 100,000 Hospitalizations (2012 - 2021)

Results

There were 50,860 weighted hospitalizations with histoplasmosis listed as any diagnosis and 7,616 as the primary diagnosis over the study period. Analysis revealed a significant decline in hospitalizations, from an annual rate of 2.9 per 100,000 in 2012 to 1.9 in 2021 (p=0.0118). Patients who died were older on average compared to those who survived (59.86 years vs. 54.45 years, p< 0.001) and had significantly longer hospital stays and higher healthcare costs. The overall mortality rate was 4.7%. The most common presentations were pulmonary (5.8% died, p=0.0054) and disseminated forms (6.0% died, p=0.0436). Comorbid conditions had varied impacts on patient outcomes; particularly, patients with HIV had a higher mortality rate (6.67%, p=0.0031). Notably, an upward trend was observed in the incidence of histoplasmosis among diabetic patients (p=0.0113), while other comorbidities did not show significant trends.Figure 2:Trend of Histoplasmosis in Diabetic Patients per 100,000 Hospitalizations (2012 - 2021)

Conclusion

The significant reduction in histoplasmosis-associated hospitalizations between 2012 and 2021 reflects advancements in public health initiatives and enhancements in clinical management. Nonetheless, our study highlights an increased mortality rate linked to older age, the presence of comorbidities such as HIV, prolonged hospital stays, and elevated healthcare cost.

Disclosures

All Authors: No reported disclosures
P-137. Contención de la resistencia a los antimicrobianos en entornos de recursos limitados: la experiencia de Argentina en la Red de Acción Global en Salud - Módulo de Resistencia a los Antimicrobianos
Authors: Colque Angel M , Alonso Laura , Barcelona Laura , Pagano Irene , Iantorno Paula , Mann Smith Rachel , Ines Staneloni Maria , Berdiñas Veronica , Echave Cecilia , Gonzalez Andrea , Velasquez Carretero Claudia , Fueyo Nora , Ponce Fabiana , Fueyo Tomas , Corso Alejandra , Pasteran Fernando
Published: January 2025

Background

The Global Action in Healthcare Network, antimicrobial resistance module (GAIHN-AR) is a CDC-led global network that partners with PAHO and Ministries of Health (MOH) in Argentina and Chile. Its goals are to prevent, detect, and respond to healthcare-related AR threats; it is a part of the CDC Global AR Laboratory and Response Network. We describe the containment response experience in 2 Argentine public hospitals participating in GAIHN-AR.

Methods

GAIHN-AR containment guidance was adapted to the local context and targeted carbapenemase-producing Enterobacterales (CP-CRE) carrying novel (Tier 1) or known, but rare, carbapenemases (Tier 2: non-OXA-163 OXA-48 variants, VIM, multiple carbapenemases, and pan-drug-resistant [PDR]). Hospital laboratories implemented new diagnostics for carbapenemase identification and developed protocols to communicate alerts of potential Tier 1 or 2 CP-CRE to hospital infection prevention and control (IPC) teams, MOH, and the National Reference Lab (NRL). Hospitals received training and support from MOH GAIHN-AR staff to conduct containment and IPC activities. Containment activities continued while alert organisms were confirmed or discarded by the NRL.

Results

During Jan 2023 -- March 2024, 20 alerts were generated (all Tier 2); 19 were not confirmed (17 were OXA-163, 1 was PDR non-confirmation, 1 was mixed culture). The remaining confirmed alert (NDM+KPC) generated a successful containment response with 7/7 contacts screening negative. With each alert, gaps were identified, particularly in communication across stakeholders and hospital IPC activities. In response, enhanced monitoring was implemented for hand hygiene, contact precautions and environmental hygiene, and the MOH developed a new informatic system to facilitate stakeholder communication.

Conclusion

Combating AR threats requires support and integration of IPC programs and clinical laboratories to ensure rapid communication and action when target organisms are detected. Support from CDC and PAHO was critical for implementation and MOH involvement is key for successful responses to AR threats. Although vital learning experiences, steps to limit false alerts are key to prevent response fatigue moving forward.

Disclosures

All Authors: No reported disclosures
P-147. Exploring the Complexity of Brucellosis: Findings from a Prospective Observational Study at AIIMS, Jodhpur
Authors: Naguthevar Santhanam , Ravindra Akshatha , Kumar Deepak , Kumar Midha Naresh , Shankar Meena Durga , Krishna Bohra Gopal , Tak Vibhor , Gadepalli Ravisekhar
Published: January 2025

Background

Brucellosis, a global health concern, is often misidentified due to diagnostic complexities. In India, its prevalence is estimated at 13.5%. This study examines its microbiological and clinical spectrum for improved management.

Methods

AIIMS, Jodhpur, conducted a prospective observational study from April 2021 to March 2024, examining patient records for demographic data, clinical presentations, laboratory and microbiological findings, treatment approaches, outcomes, and excluding alternative causes of pyrexia of unknown origin (PUO)

Results

Among 1142 cases analyzed, 43 were confirmed positive for brucellosis subsequent to thorough exclusion criteria. The most common age group affected by brucellosis, intriguingly, was those under 20 years, comprising 53.49% of the cases, followed by individuals aged 21 to 50 years at 30.23%, with those over 50 years representing 16.27% of the cases. The study unveiled a spectrum of clinical presentations, including 34 cases of PUO, 3 instances of spinal involvement, 5 cases with Central Nervous System (CNS) manifestations, as well as isolated occurrences of Endocarditis and Kikuchi Disease, underscoring the diverse clinical manifestations associated with brucellosis. Noteworthy clinical indicators included a high prevalence of unpasteurized milk consumption (76.74%), fever (88.37%), and joint pain (62.79%). Predominantly, B. Melitensis accounted for 30 cases, followed by B. Abortus with 11 cases and B. Suis with 2 cases.

Conclusion

This study reaffirms the significant diagnostic challenge posed by brucellosis, particularly within the spectrum of PUO. Blood culture emerges as a cornerstone in the reliable diagnosis of the infection.

Disclosures

All Authors: No reported disclosures
P-148. Melioidosis: A Seven-Year Review (2017-2023)
Authors: Thangaraju Deepak , Sundaramoorthy Varun , Thiagarajan Vigna
Published: January 2025

Background

Melioidosis, caused by Burkholderia pseudomallei (B pseudomallei), is a severe disease endemic to Southeast Asia and northern Australia. A high index of clinical suspicion is required for diagnosis. In resource-limited settings, a lack of training and expertise leads to the misidentification of this pathogen. Delay in laboratory diagnosis and non-compliance with treatment can have devastating consequences. A study on the epidemiology of melioidosis will help in training, raising awareness, and improving the disease management. Therefore, this study was done to describe the clinical findings of melioidosis diagnosed at our center in south India.

colonies of Burkholderia pseudomallei on sheep blood agar and MacConkey agar

Methods

A retrospective study was done from 2017 to 2023 (7 years). Patients’ data were obtained from medical records. Quantitative variables were expressed as means, and qualitative variable as frequencies.

Results

During the study period, 70 patients were diagnosed with melioidosis. The mean age group was 52 years. Ninety-one percent of them were men. Except for two patients, none of the other patients (97%) were residents of coastal areas. The risk factors were diabetes mellitus (the most common), chronic kidney disease, steroid use, cirrhosis, alcoholism, and others. In 5 patients, more than one organ system was involved. In 43% of patients, the organism was isolated in more than one sample. B pseudomallei was isolated in 71% of patients from the blood, 39% of patients from the musculoskeletal system, 21% of patients from the respiratory system, 9% of patients from the liver and spleen each, 4% of patients from the central nervous system, 3% of patients from ascitic fluid, and urine in one patient (1%). All the isolates were sensitive to ceftazidime. Twenty-three percent of patients died due to the infection.

Conclusion

Our institute is one of the high-volume centers for melioidosis. Diabetes mellitus is the most common risk factor. In contrast to data from other endemic countries, musculoskeletal involvement is the most common in our study. This is probably because of a delay in contacting health care or because the diagnosis is missed during the acute phase of illness, when the pulmonary system is commonly affected. B pseudomallei should be actively looked for while investigating infections in diabetic patients from India.

Disclosures

All Authors: No reported disclosures
P-150. Antibiogram Creation at King Faisal Hospital in Kigali, Rwanda to Inform Antimicrobial Stewardship Priorities
Authors: Sous Jinan , Rafiki Gatera Michel , Nduwayezu Richard , Kreuger Mariska , Uwizeyimana Jean-Pierre , Muvunyi Thierry , Siraj Dawd , Shirley Daniel
Published: January 2025

Background

Antimicrobial resistance (AMR) is a major global health challenge. King Faisal Hospital (KFH) in Kigali, Rwanda, is the country’s quaternary referral hospital. Creating antibiograms provides useful information for assessing the burden of resistance and for establishing pertinent antimicrobial use guidance.Figure 1:Susceptibility Patterns of Select Gram Negative Bacteria to Common Antibiotics

Methods

We analyzed all positive cultures at KFH from January 1, 2018 – December 3, 2023. An electronic laboratory system was used to extract data. Duplicate samples were excluded based on CLSI guidelines. Data were organized by organism and susceptibility to reported antibiotics was recorded. Using this raw data, we created yearly antibiograms that showcased susceptibility patterns over time.

Results

Susceptibilities of key Enterobacterales species were relatively low for ceftriaxone and cefepime but higher for piperacillin-tazobactam and meropenem; all were generally stable over time (Figure 1). Ciprofloxacin susceptibility for these organisms decreased over time. Methicillin (oxacillin) resistance in Staphylococcus aureus and vancomycin resistance in Enterococcus species were relatively rare and stable over time.

Conclusion

Antimicrobial resistance is increasing worldwide and determining local resistance patterns through antibiograms is one important step to impacting this global problem. Decreased susceptibility to some antibacterial drugs was noted at KFH which helps inform areas for future study and intervention. Challenges to data collection were variations in lab reporting, data, and storage collection systems in the past five years. These findings also provide a basis for the creation of an antimicrobial stewardship program at KFH.

Disclosures

All Authors: No reported disclosures
P-152. Chitinase-3-like Protein 1 is Associated with Stunting and Neurodevelopmental Delay in Ugandan Children Who Are HIV Exposed But Uninfected
Authors: MacBain Elspeth , Conroy Andrea , Namasopo Sophie , Opoka Robert , Hawkes Michael
Published: January 2025

Background

Children who are HIV exposed but uninfected (cHEU) are at risk for impaired linear growth and neurodevelopment, which evolving evidence suggests may be associated with elevated inflammatory biomarkers. Chitinase-3-like protein 1 (CHI3L1) is produced by activated neutrophils and has been linked to clinical manifestations of systemic inflammation in children living with HIV. We aimed to explore CHI3L1 as a potentially relevant marker for adverse growth and neurodevelopment outcomes experienced by cHEU.

Methods

This was a prospective cohort study conducted at two pediatric HIV centres in Uganda (Jinja Regional Referral Hospital and Kambuga District Hospital). We enrolled children at birth, born to mothers living with HIV, diagnosed prior to the pregnancy or at the time of delivery. We excluded children who were subsequently found to be vertically infected (n=8), children who died before 18 month of age (n=3), as well as those lost-to-follow-up and those with missing CHI3L1 measurement. Neurodevelopmental ability (rank) was assigned based on the standardized score of Malawi Developmental Assessment Tool (MDAT) milestones achieved at 18 months of age. CHI3L1 levels were quantified by ELISA (R&D Duoset, Minneapolis, MN, USA).

Results

We included 153 cHEU (53% female) born between March 2016 and June 2018. At 18 months of age, 42%, 0.7%, and 2.8%, were severely stunted, wasted, and underweight, respectively. Performance on the MDAT was similar to Malawian norms. The median CHI3L1 level was 30 µg/L (IQR 18-47). CHI3L1 levels were inversely correlated with weight-for-age (ρ= -0.22, p=0.0091) and height-for-age (ρ= -0.24, p=0.0039) z-scores, but not the weight-for-height or head circumference-for-age z-scores. CHI3L1 levels were higher in children with severe stunting (median 40 µg/L, IQR 26-86) than those without severe stunting (median 27 µg/L, IQR 16-39, p=0.0010). CHI3L1 was inversely correlated with the standardized MDAT scores (ρ= -0.29, 0.00023). Lower scores in the language and gross motor domains were associated with higher CHI3L1 whereas scores in the fine motor and social domains were not associated with CHI3L1.

Conclusion

CHI3L1 was associated with severe stunting and neurodevelopmental delay in our cHEU cohort in Uganda.

Disclosures

All Authors: No reported disclosures
P-169. Comprehensive Sexuality Education in Secondary Schools and Syphilis Incidence by Country: An Ecological Study
Authors: Davidson Michelle C , Ikuta Kevin
Published: January 2025

Background

Comprehensive sexuality education (CSE) is essential curriculum covering sexual and reproductive health topics, including transmission of sexually transmitted infections. CSE has been added as a Sustainable Development Goal (SDG) indicator (4.7.2) and is becoming more widespread, but the relationship between degree of CSE implementation and incidence of STIs has not been previously described. The aim of this study was to investigate whether countries with more widespread CSE in secondary schools have lower incidence rates of syphilis than those with limited CSE.Table 1:Percent of secondary schools implementing CSE in 2018 vs. median syphilis incidence in 2019.

Methods

We used CSE implementation estimates from WHO as described in the 2021 UNESCO report: The Journey Towards Comprehensive Sexuality Education. This report utilizes data from multiple surveys to produce an estimate of the percent of secondary schools providing CSE by country in 2018, categorized as “0-25%”, “26-50%”, “51-75%”, or “76-100%”. We used syphilis incidence rates from the Global Burden of Disease Study 2019. We conducted a multivariable Poisson regression evaluating the relationship between percent of schools with CSE and syphilis incidence, adjusting for WHO region and income level.

Results

CSE data were available for 66 countries, all of which had syphilis incidence estimates available (Table 1). Countries that reported CSE in fewer than 25% of secondary schools had a syphilis incidence that was 1.83 (95% CI 1.78 – 1.89) fold higher than countries with CSE in greater than 25% of schools. This difference was attenuated but remained significant after adjusting for region and income level with a relative rate of 1.40 (CI 1.36 – 1.44). Each increase in CSE category was associated with a 26.6% (CI 25.9 – 27.4) relative reduction in syphilis incidence rate (Figure 1). This reduced to 7.1% (CI 6.2 – 8) when adjusted for region and income level.

Conclusion

More widespread CSE is associated with lower syphilis incidence, likely by reducing unsafe sex practices, although a causal relationship cannot be inferred given study design. These findings suggest that countries with the greatest need for CSE are the ones with the most limited availability. Further research on this topic would be beneficial to more thoroughly evaluate how CSE programs impact rates of syphilis and other STIs.

Disclosures

All Authors: No reported disclosures
P-192. Evaluating the Association of Unnecessary Antibiotic Use with Hospital-Onset Clostridioides difficile Infection at a New York City Hospital
Authors: John Amie , Acbo Antoinette M , Cowman Kelsie , Guo Yi , Nori Priya , Weston Gregory D
Published: January 2025

Background

Hospital Onset-Clostridioides difficile infection (HO-CDI) is defined as collection of a positive C. difficile lab result on or after day 4 of a patient’s hospital admission. Reduction of HO-CDI remains a multidisciplinary effort. Prior studies have demonstrated frequent inappropriate antibiotic use among patients with CDI. The objective of this study is to evaluate unnecessary antibiotic use in patients with cases of National Healthcare Safety Network (NHSN)-defined HO-CDI compared to non-CDI controls.

Methods

This case-control study included inpatient adult patients, from 1/1/23 – 2/28/24. HO-CDI cases were selected from standard institutional review. Non-CDI controls were selected based on hospital admission and negative CDI test sent on or later than day 4 of their admission. Cases and controls were matched 2:1 using patient location and index tests within the same month. Antibiotic use (AU) rate of cefepime, ciprofloxacin, levofloxacin, ceftriaxone, and piperacillin-tazobactam 30 days prior to index test was calculated using NHSN definitions. Primary exposure of interest was inappropriate antibiotic use. Outcomes including hospital length of stay (LOS), all-cause mortality, and subsequent recurrent CDI were recorded. A secondary analysis assessed the relationship between race/ethnicity, inappropriate antibiotic use and HO-CDI.

Results

Two hundred ninety-six patients were included. AU rate was greater in controls compared to HO-CDI cases (p = 0.01) (Table 1). Inappropriate AU was observed in 24% of cases and 28% of controls (p = 0.48). The most common category of inappropriate AU was inappropriate spectrum, 55% in cases and 81% in controls (Fig 1). There were no statistically significant differences in outcomes.

Conclusion

HO-CDI cases did not have greater exposure to antibiotic therapy and did not have a higher proportion of inappropriate antibiotic use compared to patients who tested negative for C. difficile. This demonstrates an opportunity to improve antibiotic use, but does not show an association between inappropriate antibiotic use and C. difficile infection.

Disclosures

All Authors: No reported disclosures
P-202. 7- Year experience with Clostridioides difficile Infection (CDI): pre- and post-COVID-19 pandemic, effect of diagnostic stewardship and the gender difference
Authors: Younas Mariam , Newell Ann , Armor Anthony , Rios-Bedoya Carlos
Published: January 2025

Background

Diagnostic stewardship interventions, such as order sets, reflex orders, hard and soft stop alerts and decision algorithms have shown to improve facility C. difficile rates. We aimed to examine the impact of COVID-19 infection and diagnostic stewardship on incidence and prevalence of CDI at our institution, based on gender.

Methods

Using National Healthcare Safety Network (NHSN) surveillance Laboratory Identification (Lab ID) events, 926 CDI cases, ≥ 18 years of age were identified among patients hospitalized at Hurley Medical Center from 01/2015 to 07/2022. NHSN surveillance definitions were used to describe the incident, recurrent cases and determine the epidemiologic categories. Hospital onset (HO) incident rate is described as per 10,000 patient days and inpatient community-onset (CO) CDI prevalence rate described as per 10,000 admissions (Figure 1).Table 1:Diagnostic stewardship and infection control interventions

Results

During the 7.6-year study period, overall HO CDI incident rate and inpatient CO CDI prevalence rate decreased, a percentage decrease of 34% and 53% respectively. The rates were lowest in 2020, onset of COVID-19 pandemic (percentage decrease of 22% for HO CDI incident and 7% for CO CDI prevalence rates as compared to 2019 pre-COVID-19 pandemic). There was a transient increase in 2021 (percentage increase of 36% for HO CDI incident and 14% for CO CDI prevalence rates as compared to 2019) (Figure 2, 3). HO CDI incident rates were slightly higher in men (average 11.4% difference) as compared to women except in 2017. CO CDI prevalence rates were much higher in women as compared to the men (average 13.4% difference) with the exception of 2017 and 2022.Figure 2:HO CDI Incidence rate 2015-2022, with 95% confidence intervals

Conclusion

HO CDI incident rate and inpatient CO CDI prevalence rates were lowest in 2020 (the onset of COVID-19 pandemic), likely secondary to computerized clinical decision support (CCDS) interventions introduced in 2019 (Table 1). The transient increase in rates seen in 2021, was likely due to increase in antibiotic utilization during the pandemic. Diagnostic stewardship played a key role in optimizing the diagnosis of CDI and improving CDI rates at our institution. There was a discrepancy of the CO CDI and HO CDI rates between the sexes, likely owing to the higher outpatient antibiotic use in women as compared to men, highlighting the importance of ambulatory stewardship.Figure 3:Inpatient CO CDI prevalence rate, with 95% confidence intervals

Disclosures

All Authors: No reported disclosures
P-203. Successful Elimination of Clostridioides difficile Admission Surveillance in favor of a Two Step Stool Algorithm and Early Detection Stool Counter
Authors: Schora Donna , Hines Carolyn , Faith Monsalud Cherie , Muthiah Chethra , Grant Jennifer , Kharasch Maureen
Published: January 2025

Background

We began Clostridioides difficile (Cdif) admission surveillance (CDAS) in 2017 to decrease the rate of hospital onset (HO) Cdif across our hospital system. We created an algorithm to screen patients with a high risk of Cdif colonization and flag them by a best practice alert in the electronic medical record (EMR). The surveillance program helped to mitigate the spread of Cdif as evidenced by our HO Cdif rate the following 6 years. In 2023, we adopted a 2 step Cdif testing algorithm for symptomatic patients featuring a stool Cdif PCR test followed by EIA testing for PCR positives. This program reduced our hospital onset Cdif rate by 60% (unpublished data). We also reviewed lab test utilization and wondered if the admission screen test could be eliminated in favor of the 2 step system and an early detection stool counter. The goal of the trial was to determine if elimination of the admission testing can keep our Cdif HO rate at the level of our 2023 performance ( >75% of NHSN benchmark).

Number of Clostridioides difficile admission tests and Standardized Infection Ratio

Methods

The CDAS algorithm identifies hospitalized patients with prior nursing home or hospital admission, history of Cdif disease/colonization and a control group. A rectal sample was collected and tested with PCR. In June of 2023 the algorithm was updated to include ‘the receipt of antibiotics within the past 24 hours’.

The 2 step Cdif testing for symptomatic patients is a stool Cdif PCR test followed by EIA testing for PCR positives.

In November 2023, we stopped the admission testing at 1 of 4 hospitals, and in March 2024, testing stopped at all 4 hospitals.

A stool counter in the EMR tells the number of bowel movements in the first 48 hours of admission.

The standardized infection ratio (SIR) of hospital onset Cdif infection is used to measure the success of the trial.

Results

Results of the trial are shown in Figure 1. The modified algorithm reduced the tests by half. The rate of HO Cdif infection has remained below the SIR goal for fiscal years 2023 (0.26) and 2024 (0.21). Estimated savings for calendar year 2023 was $210,000 as provided by the financial department.

Conclusion

Replacing the Cdif admission surveillance with a 2 step test process for symptomatic patients did not affect the SIR for HO Cdif during the trial period. Eliminating the admission screen test will help to save financial resources while maintaining patient wellbeing.

Disclosures

All Authors: No reported disclosures
P-205. Investigating PCR (Polymerase Chain Reaction) Cycle Threshold’s Utility in Diagnosing and Treating Clostridioides difficile Infections
Authors: Carey Edward , Maramara Bennadette , Jacob Matthew , Totten Arthur H , Go Roderick
Published: January 2025

Background

Clostridioides difficile (C diff) is a pathobiont bacteria in the human gastrointestinal tract that can cause morbidity and mortality and has public health implications.

Guidelines suggest two-step testing to diagnose C diff infection (CDI). However, since polymerase chain reaction (PCR) tests can be positive in persons with colonization and no active disease, management of discordant results is challenging. Usage of facility-onset CDI as a quality metric further raises the need to accurately differentiate infection from colonization.

We hypothesize PCR cycle threshold (Ct) values may be useful for quantifying C diff disease burden and differentiation of infection from colonization. However, Cts are currently unvalidated and are not currently approved for use for clinical decision making.

Sample and results data for C diff infection and C diff PCR CT correlation

This table provides an overview of our data investigating the usage of C diff PCR CT to better diagnose CDI

Methods

We performed a retrospective, single center chart review of patients who tested positive for C diff, and analyzed clinical and laboratory data in 2022. We excluded minors, outpatients, and repeat C diff episodes, and performed multi variable analyses.

Results

70 patients met inclusion criteria. This cohort consisted of 37 (52.86%) male and 33 (47%) female patients. The mean and median ages were 70 and 73 years old respectively. Approximately 30 percent of our cohort was immunocompromised, and 90 percent of our patients were on antibiotics within 30 days of CDI testing.

Using a Ct of 26.35, a cutoff used in previous studies to indicate infection, 30 patients (42.9%) had a positive Ct, and of these, 16 (53%), had a positive confirmatory enzyme immunoassay (EIA) . Ct of less than cutoff had a positive predictive value of 53%, and negative predictive value of 85%, for positive EIA.

All patients analyzed underwent C diff treatment, with a mean length of treatment of 10 days. Mean time to recovery, classified as less than three documented bowel movements, or hospital discharge, was 4.6 days. Nine patients (13%) in our cohort died within 30 days of C diff testing.

Conclusion

This data show that C diff PCR Ct value threshold of < 26.35 combined with EIA positivity may be a helpful parameter for evaluating possible C diff. The demonstrated high negative predictive value may show a utility for high Ct values in ruling out active disease.

Disclosures

Roderick Go, DO, Aptose Biosciences: Stocks/Bonds (Private Company)|Bristol Meyers Squibb: Stocks/Bonds (Private Company)|Cytodyn Inc.: Stocks/Bonds (Private Company)|Scynexis: Grant/Research Support|Shionogi, Inc: Grant/Research Support
P-208. Does an electronic alert for secondary C. difficile prophylaxis result in vancomycin prophylaxis and reduction in recurrent CDI?
Authors: Singh Harjot K , Gouveia Adam L , Ross Barbara , Kuang David , wang shirley , Horowitz Harold , Simon Matthew , Nelson Brian , Torres Heidi M , Kaplan Steven , Furuya E Yoko , Calfee David P
Published: January 2025

Background

Secondary vancomycin prophylaxis (VP) is one strategy to reduce recurrent C. difficile infection (CDI). Clinical decision support (CDS) was implemented in the electronic health record (Epic®) in 2020 to remind providers about eligibility for VP at time of prescription of broad-spectrum antibiotics in patients with a history of CDI. The effectiveness of this strategy was assessed.

CDIFF BPA

CDIFF Secondary Prophylaxis Best Practice Alert

Methods

Retrospective review of an interruptive best practice alert (BPA) for VP at 8 hospitals from 2021-2022. Patients were classified via manual chart review as immunocompetent (immune) or immunocompromised, and were eligible for 3 months and 12 months respectively after an episode of CDI. Demographic characteristics, immune status, receipt of VP, and outcomes (30-day recurrence CDI, death during hospitalization or within 30 days of discharge) were collected. Only the first BPA per patient was included in the demographic and death analysis. Only one alert per hospitalization was included in the VP use and recurrence analysis. Patients with CDI within 10 days prior to the BPA and on the same day as BPA alert were excluded. Descriptive statistics were used to analyze differences.

Results

Among 616 unique hospitalized patients for whom the BPA was triggered, median age was 64 years; 40% were immune. Approximately 50% were women, with 24% African American and 24% Hispanic. After 1562 BPAs, 13% of immunocompromised and 10% of immune patients were prescribed VP within 24 hours. Median days from previous CDI to BPA was 97 days for immunocompromised and 45 days for immune patients. For immunocompromised patients, frequency of CDI recurrence (11% versus 6%) and frequency of death (14% versus 18%) were not statistically different in the group that got VP and the group that didn’t. Similarly for immune patients, frequency of recurrent CDI (7% versus 8%) or death (16% versus 13%) were not statistically different in the group that got VP and the group that didn’t.

Conclusion

VP was infrequently initiated despite an interruptive BPA that identified patients with recent history of CDI at the time of prescription of broad-spectrum antibiotics. In this limited sample size, patients had similar outcomes regardless of VP. Further research is needed to understand the barriers for the low uptake, including CDS design and efficacy of VP.

Disclosures

All Authors: No reported disclosures
P-209. Evaluation of Hospitalized Clostridioides difficile (C. difficile) Polymerase Chain Reaction (PCR) Positive/Enzyme Immunoassay (EIA) Negative Patients
Authors: Harrington Nicole , Patel Drashti , Kelly Jennifer , Borja Clint
Published: January 2025

Background

Differentiating true infection versus colonization is challenging in C. difficile PCR positive/EIA negative patients. Prior studies estimate 50% of these patients have true infection and warrant treatment. The aim of this study was to describe treatment practices for hospitalized C. difficile PCR positive/EIA negative patients at ChristianaCare.

Methods

A single health system, retrospective study was conducted between January to December 2022. PCR positive/EIA negative patients were categorized as treated or not treated for C. difficile infection (CDI). The primary outcome was the percentage of patients treated for CDI. Secondary outcomes that influence the decision to treat including age, sex, immunocompromised status, white blood cell (WBC) count, systemic antibiotic use, Infectious Diseases (ID) consultation, or recurrent CDI were evaluated. Hospital length of stay (LOS) and 30-day hospital readmission rates were also collected. ChristianaCare’s C. difficile scoring tool was used to categorize patients as low, medium, and high risk for true CDI.

Results

Of the 101 patients included in this study, 82 (81%) of PCR positive/EIA negative patients were treated for CDI (95% CI [0.73, 0.89]). Treated patients were more likely to have received antibiotics within the last 30 days (p=0.014) and have an ID consultation (p=0.013). There were no statistically significant differences between treated and not treated groups based on age, sex, immunocompromised status, elevated WBC, recurrent CDI, hospital LOS, 30-day hospital readmission, and inpatient all-cause mortality. No patients had real-time documentation of the C. difficile scoring tool score. All retrospective, manually calculated high risk patients utilizing the C. difficile scoring tool were treated (20.7%).

Conclusion

We observed a higher percentage of treatment in patients who were C. difficile PCR positive and EIA negative compared to prior studies. Treated patients were more likely to have antibiotic use within the last 30 days and an ID consultation. Other risk factors commonly used to diagnose CDI did not impact treatment decisions. Opportunity to improve education using the ChristianaCare C. difficile scoring tool to assess CDI risk in patients and guide testing and treatment decisions is warranted.

Disclosures

All Authors: No reported disclosures
P-210. Real-World Utilization and Cost of Fidaxomicin versus Oral Vancomycin: A Comparative Analysis of Outpatient Medicaid Prescription Reimbursements
Authors: O’Neil Jessica C , Lautenbach Ebbing
Published: January 2025

Background

Clostridioides Difficile Infection (CDI) is a leading cause of infectious diarrhea in the United States. In 2017, the Infectious Diseases Society of America (IDSA) and Society of Healthcare Epidemiology of America (SHEA) joint guidelines added fidaxomicin (FX) as a first line therapy for initial and first recurrence of non-fulminant CDI alongside oral vancomycin (OV). Under a 2021 guideline revision FX became the preferred therapy based on lower CDI recurrence among those treated with FX. Multiple analyses have attempted to predict the economic impact of increased FX use but have yielded conflicting results. The use of real-world data on actual cost and utilization has been limited.Figure 1:Total Annual Outpatient Medicaid CDI Therapy Prescription CountCDI: Clostridioides Difficile Infection

Methods

We conducted a retrospective analysis of utilization and cost of FX and OV between January 1st, 2013 and December 31st, 2022 in the Medicaid State Drug Utilization Database (SDUD). The SDUD contains covered outpatient medications excluding those reimbursed under bundled services. Prescriptions for OV were distinguished from other vancomycin formulations using national drug codes. Utilization was estimated by the number of prescriptions reimbursed. Total cost was calculated as the sum of Medicaid and non-Medicaid reimbursement. We approximated the annual per prescription cost (APPC) as the quotient of total cost and prescription count.Figure 2:Total Annual Outpatient Medicaid CDI Therapy Prescription CostCDI: Clostridioides Difficile Infection

Results

Following the 2017 guidelines the average annual FX prescription count (Figure 1) increased by 32% compared to a 2013-2016 baseline. After the 2021 guideline revision, average annual FX prescription count grew by 113% as compared to a 2017-2020 baseline. The total annual cost of FX (Figure 2) surpassed the total annual cost of OV in 2019 with FX reaching $17,984,998 in 2022 as compared to $3,135,523 for OV. Throughout the study period the FX APPC (Figure 3) was substantially greater ($2,614-$3,956) than the OV APPC ($134-$1,579).Figure 3:Annual Per Prescription Cost of Outpatient Medicaid CDI TherapyCDI: Clostridioides Difficile Infection

Conclusion

Among Medicaid beneficiaries, outpatient FX use increased in time periods following the 2017 and 2021 guideline changes. While FX use was significantly lower than OV from 2013-2022, FX total cost and APPC far outweighed that of OV. Further analysis is necessary to determine the real-world cost effectiveness of FX, but our results highlight the budgetary impact associated with these IDSA/SHEA guideline changes.

Disclosures

All Authors: No reported disclosures
P-218. Treatment of Healthcare Facility-Onset Clostridioides difficile Infection Among Patients with Toxin Negative Stool Molecular Assay Results
Authors: Mobarakai Olivia Z , van den Berg Polly , Reid Kara , Terico Adrienne , Nwankwo Onyeka
Published: January 2025

Background

CDC's National Healthcare Safety Network (NHSN) defines a healthcare facility-onset Clostridioides difficile (C. diff) infection (HO-CDI) as a positive stool test result for C. diff toxin collected on or after hospital day (HD) 4. Currently, using two-stage algorithm testing, a nucleic acid amplification test (NAAT) that results positive for C. diff gene and negative for C. diff toxin (NAAT+/Toxin-) does not meet the HO-CDI definition as this may represent colonization. However, many NAAT+/Toxin- patients receive treatment given concern for clinical CDI. NHSN has proposed updating the healthcare facility-onset definition to include NAAT+/Toxin- patients who receive ≥ 5 days of antibiotic treatment for CDI within 2 calendar days (HT-CDI). To understand the increase in healthcare facility-onset CDI that may occur following this definition change, we describe the incidence of treated NAAT+/Toxin- patients at our hospital and examine factors associated with treatment.

Methods

Retrospective, observational cohort study evaluating patients ≥ 18 yo admitted between 7/2019 and 6/2023 with a NAAT+/Toxin- test collected on or after HD 4. Patients were identified using Theradoc software and variables were extracted by chart review. Comparisons between groups were performed using Fisher’s exact test.

Results

49 of 79 (62.0%) patients with NAAT+/Toxin- results received treatment for CDI and met the HT-CDI definition. There would have been 9, 14, 9, and 17 cases added during FY 2020, 2021, 2022, 2023 respectively (Figure 1). WBC was the only variable associated with treatment of NAAT+/Toxin- diarrhea (Table 1).

Conclusion

62.0% of patients with C.diff NAAT+/Toxin- diarrhea were treated for suspected CDI. The majority (64.6%) of patients had a documented alternative etiology for diarrhea and often lacked associated symptoms of CDI (e.g., fever, colitis). While the purpose of NHSN’s creation of the HT-CDI definition was to improve upon the existing measure of HO-CDI, our data suggests that incorporating a provider’s decision to treat may not be the best way to discern if NAAT+/Toxin- patients have CDI. Our study highlights the importance of diagnostic stewardship and provider education on incorporating relevant signs and symptoms of CDI into decision making regarding treatment.

Disclosures

All Authors: No reported disclosures
P-223. Risk Factors for Community-Associated Clostridium difficile Infection: A Retrospective Study
Authors: Mizrahi Barak , Weinberger Miriam , Lidar Shira , Ben David Shirley Shapiro
Published: January 2025

Background

Community-associated Clostridium difficile infection (CA-CDI) has emerged as a significant public health concern in recent years. The objective of this study was to evaluate the risk factors for CA-CDI including antibiotics-specific regimen and duration.Table 1Baseline characteristics of study cohort1- Tests were sent but rejected by the laboratory due to non-diarrheic stool; 2- SES socioeconomic status; 3- Based on registries; 4- minimum three sequential monthly purchases

Methods

Data from a large health maintenance organization was extracted between 2001-2023. The study population included patients who were sent to their first Clostridium difficile (CD) test ever, with no records of hospital admission within 84 days preceding the test. Patients with positive CD test were considered CA-CDI cases. They were compared to patients with negative tests and to patients whose test was rejected due to non-diarrheic stool. Correlates of CD were detected using multivariate logistic regression. Inverse probability weighting was used to examine the associations between exposure to different antibiotic regimes, types or durations, after controlling for potential confounders.Figure 1Risk factors for CA-CDICA-CDI, Community-associated Clostridium difficile infection

Results

During 2001-2023 25,274 patients with first CD tests were identified, of whom 940 (3.7%) were CA-CDI cases, 12,704 (50.3%) were CD test-negative, and 11,630 (46.0%) patients had rejected tests (Table 1). The mean age was 53.2 (22.7), 50.6 (21.3), and 48.0 (20.4), respectively, and the number of females was 614 (65.2%), 7395 (58.2%), and 7147 (61.5%), respectively. Various conditions or exposures were associated with increased risk for CA-CDI, including inflammatory bowel disease, dementia, homebound status, and proton pump inhibitor) (use, whereas metformin was associated with reduced risk of CA-CDI (Figure 1). The number of different antibiotic agents was a significant risk factor, with risk increasing twofold for 1 agent vs. none, and additional increments with each additional antibiotic (Figure 2). When the exposure was five days the risk was elevated only for clindamycin and quinolones, while with ≥10 days-exposure, the risk was significantly elevated for all antibiotics agents (Figure 3).Figure 2Risk of CA-CDI according to number of antibiotic exposure (7-90 days before infection)

Conclusion

This study provides insights into the risk factors for CA-CDI in the community setting and underscores the importance of judicious antibiotic prescribing practices and specifically longer duration of antibiotic use.Figure 3Risk of CA-CDI according to antibiotic exposure*- regimen and duration*7-90 days before infection

Disclosures

Shirley Shapiro Ben David, MD, GSK: Lecturer|Pfizer: Grant/Research Support|Pfizer: Lecturer
P-235. Non-utility of Catheter Tip Cultures in the Diagnosis of Catheter-related Bloodstream Infections
Authors: Jonnalagadda Kirtana , Goel Ayush , Ajayababu Anuj , Mohapatra Sarita , Gautam Hitender , Kumar Das Bimal , Soneja Manish , Wig Naveet , Dhawan Benu
Published: January 2025

Background

Catheter-related bloodstream infections (CRBSIs) affect approximately 3 to 27% of patients. As per IDSA (2009) criteria, concordant organisms from blood and catheter tip cultures, or specific criteria met by two blood samples are required for CRBSI diagnosis. Catheter tip cultures necessitate removal of the line and entail increased healthcare costs. Emerging evidence questions the reliability of this labor-intensive practice in diagnosing CRBSI. We aimed to determine the utility of catheter tip cultures in diagnosing CRBSI at our Institute.

Catheter tip culture and Blood culture results

CRBSI: Catheter-related Bloodstream Infection; TC: Catheter tip culture; BC: Blood culture; + or - , growth or no growth

Methods

We conducted a prospective observational study in patients with suspected CRBSI. Catheter tips and paired blood samples collected within 48 hours, were sent for culture. CRBSI was diagnosed as per IDSA 2009 guidelines. The utility of catheter tip cultures in diagnosing CRBSI was calculated.

Results

One-hundred and thirty events of suspected CRBSI were included in 116 patients. Sixty-two percent of patients were male with a mean age of 43.75 ± 16.5 years. The prevalence of CRBSI was 16.9%, of which only 27% of CRBSI were identified by catheter tip cultures. The sensitivity, specificity, positive predictive value, and negative predictive value of catheter tip cultures in diagnosing CRBSI were 27.3% (10.7- 50.2), 77.8% (68.8-85.2), 20.0% (10.4- 35.0) and 84.0% (79.9-87.4) respectively. Catheter tip colonization was observed in 20.8% of catheter tip cultures. All repeat blood cultures sent in the following two weeks in patients with catheter-tip colonization, were sterile. Amongst patients with CRBSI, Multidrug-Resistant Acinetobacter baumanii and Klebsiella pneumoniae were the most frequently isolated organisms, followed by Candida spp (predominantly Candida auris), accounting for 27% of CRBSI cases.

Conclusion

Our study showed poor sensitivity and low positive predictive value of catheter tip cultures in diagnosing CRBSI. Employing catheter-sparing methods, such as evaluation of differential time to positivity and quantitative paired blood cultures, will improve the diagnosis of CRBSI, and can lower hospital expenses.

Disclosures

All Authors: No reported disclosures