bluuebunny/crossref_metadata_2025_split huggingface dataset:
2360. Impact of a Two-Step Antimicrobial Stewardship Intervention on C. difficile Infection Diagnosis at an Urban Veteran’s Affairs Medical Center
Authors: Kuhn Ryan T , Johnson Jennifer L , Nelson Virginia , Fitzpatrick Dustin , Ahmad Syed , Whittington Sylvia , Dhar Sorabh 
Published: October 2019

Abstract

Background
C. difficile infection (CDI) is a common healthcare-associated infection and quality measure for hospitals. Diagnosis of CDI is challenging as testing modalities, i.e., nucleic acid amplification test (NAAT), are highly sensitive but cannot differentiate between colonization and infection. Therefore, judicious use of testing is critical to avoid unnecessary diagnosis and treatments.

Methods
This single-center, retrospective chart review evaluated the impact of a two-step diagnostic stewardship intervention on C. difficile diagnosis and use of oral vancomycin in the inpatient setting. For the first step of the intervention, providers were educated on appropriate diagnosis and treatment, and given access to an optional electronic CDI clinical decision support system (CDSS). For the second step of the intervention, the CDI NAAT stand-alone testing option was removed from the lab ordering menu and providers were required to use the CDSS to order testing. Clinical data including bed-days of care (BDOC), total number tests ordered, number of positive tests and use of oral vancomycin was collected for the pre-intervention period (1/1/16 – 3/31/17), post intervention period 1 (April 1, 2017–October 31/18) and post-intervention period 2 (November 1, 2018–March 31, 2019).

Results
Compared with the pre-intervention group, there were no significant differences in the number of total CDI NAATs ordered, positive CDI NAATs or vancomycin DOT/10,000 BDOC in post-intervention group 1. There was a reduction in the number of total CDI NAATs ordered (341 vs. 42 [87.7%]) and the number of positive CDI NAATs (56 vs. 7 [87.5%]) in post-intervention group 2, respectively. When this data were normalized based on bed days of care (BDOC), there were still significant reductions in NAATs ordered and number of positive CDI NAATs (64 vs. 27 [57.8%]; 11 vs. 5, respectively, [54.5%]) and with vancomycin oral DOT/10,000 BDOC (72 vs. 7 [90.3%]) (Table 1).

Conclusion
Provider education and an optional CDSS did not significantly impact CDI NAAT ordering or use of oral vancomycin for CDI. However, implementation of a mandatory CDSS for CDI testing was shown to significantly decrease the number of tests ordered, the number of positive tests, and the use of oral vancomycin.

Disclosures
All authors: No reported disclosures.
2361. Evaluation of a 2-Step Testing Algorithm for Clostridioides difficile Infection
Authors: Zuccaro Patricia , Son Andrea , Conti Jennifer , Hecker Michelle 
Published: October 2019

Abstract

Background
Clinical data describing use of a multistep algorithm for diagnosis of Clostridioides difficile infection (CDI) is limited. In June 2018 we implemented a 2-step testing algorithm in which PCR testing (Aries® assay) is performed for all specimens followed by EIA toxin testing (TOX A/B QUIK CHEK® assay) when PCR is positive. We sought to describe outcomes for patients with PCR+/EIA+ vs. PCR+/EIA− results. Outcomes evaluated included frequency of CDI treatment, retesting and retreatment within 3 months, and investigator determined categorization of C. difficile results by an investigator blinded to the EIA result.

Methods
A retrospective cohort study was performed on a random sample of 85 unique patients with a PCR+ stool sample from July 2018 through December 2018. Demographic and clinical data were abstracted from the medical record during the index encounter and for 3 months thereafter. Based on predetermined criteria, index encounter results were categorized as representing probable, possible, unlikely, or indeterminate cases of symptomatic CDI.

Results
For the 85 study patients, 42%, 27%, and 31% were tested in the inpatient, outpatient, and ED/urgent care settings. Twenty-seven patients (32%) were EIA+, all of whom received CDI treatment. Fifty-eight (68%) were EIA-, of which 79% received treatment. Of the 12 EIA- patient who did not receive treatment two had retesting within 3 months; one of whom subsequently tested EIA+ and was treated and the other tested PCR-. At least 1 C. difficile test was repeated within 3 months in 48% of EIA+ and 33% of EIA- patients. Based on repeat testing CDI treatment was prescribed for 12% of EIA+ subjects and for 11% of EIA- subjects. For the EIA+ patients, 70%, 19%, 7%, and 4% were classified as probable, possible, unlikely and indeterminate cases of symptomatic CDI when compared with 38%, 34%, 22%, and 5% for EIA- patients.

Conclusion
During the first 6 months of a 2-step testing algorithm, we found that patients with EIA- test results were frequently treated for CDI and that 72% of EIA- cases were classified as probably or possibly having symptomatic CDI. Further study is needed to determine whether patients with EIA- results categorized with probable or possible symptomatic CDI would improve without CDI treatment.

Disclosures
All authors: No reported disclosures.
2366. PCR Followed by Toxin EIA for the Diagnosis of C. difficile Infection
Authors: Zhang Yu , Mohadjer Kiya , McCombs Amy , Thompson Jessica 
Published: October 2019

Abstract

Background
In June 2017 for the diagnosis of Clostridioides difficile infection (CDI), Renown Health transitioned from utilizing polymerase chain reaction (PCR) to a two-step algorithm of PCR followed by toxin enzyme immunoassay (EIA) if PCR was positive. Providers were encouraged to forgo treatment in patients that were PCR-positive and EIA-negative as recent literature suggests this may indicate colonization rather than infection. The purpose of this study was to assess the impact of implementation of the two-step algorithm for the diagnosis of CDI on antibiotic usage and patient outcomes.

Methods
This was a retrospective quasi-experimental study of adult inpatients at Renown Regional and South Meadows Medical Centers that were PCR positive before and after implementation of a two-step algorithm for the diagnosis of CDI. The pre-implementation period was defined between May 8, 2016 and May 7, 2017, and the post-implementation period was May 8, 2017 to May 7, 2018. Patients were excluded if they were admitted to a pediatric ward, tested for CDI at an outside facility, or if results were available following discharge. The primary outcome was inpatient days of metronidazole and non-parenteral vancomycin per PCR positive patient. Secondary outcomes included defined daily doses of therapy, proportion of untreated patients, time to resolution of diarrhea, all-cause in-hospital mortality, 30-day recurrence, all-cause 30-day readmission, length of stay, and 30-day CDI-related complications. CDI-related complication was a composite of ICU care, megacolon, ileus, surgical intervention. It was calculated that 242 patients were required to achieve at least 80% power to detect a 30% difference in antibiotic days between pre- and post-implementation of two-step C. difficile testing. Wilcoxon two-sample test was used for continuous data, and χ 2 or Fisher exact test were used for categorical data.

Results
See figures.

Conclusion
Incorporation of C. difficile toxin EIA to PCR for the diagnosis of CDI resulted in a significant reduction in non-parenteral vancomycin and metronidazole days of therapy. Patient outcomes were not adversely affected by the addition of toxin EIA. The results suggests that toxin EIA may help differentiate between C. difficile colonization and active infection.

Disclosures
All authors: No reported disclosures.
2372. PCR Ribotype and Antimicrobial Susceptibility of Clostridioides (Formerly Clostridium) difficile in Korea
Authors: Hoo Jeon Cheon , Mi Wi Yu 
Published: October 2019

Abstract

Background
Clostridioides difficile infection is a leading cause of healthcare-associated diarrhea. The epidemiology and characteristics of C. difficile vary geographically. We performed toxin enzyme immunoassay (EIA), toxigenic gene analysis, antimicrobial susceptibility tests (AST), and PCR ribotyping to elucidate the characteristics of C. difficile in Korea.

Methods
Between July 2017 and June 2018, C. difficile was prospectively isolated in 128 specimens from the culture of 1,182 unduplicated specimens. Seventy-five stool specimens with a positive toxin EIA between July 2016 and June 2017 were also included. We performed PCR for the tcdA and tcdB genes on these isolates, and AST and PCR ribotyping on the isolates with a positive toxin EIA.

Results
Older patients tended to have a higher rate of positive toxin EIA and positive cultures than did younger patients. Ribotype 018 was predominantly identified (48.6%), followed by ribotype 014/020 (9.9%), and ribotype 002 (8.3%). All of A-B+ isolates were either ribotype 017 or B-2. Ribotypes 017, 018, and B-2 showed high resistance to various antibiotics. In contrast, ribotypes 002, 014/020 and C-4 demonstrated low resistance rates, except that to moxifloxacin in ribotype 002. Clindamycin and erythromycin showed a positive correlation. Most of the isolates resistant to rifampicin or tetracycline showed a high MIC to both erythromycin and clindamycin.

Conclusion
Ribotype 018, which is highly transmissible and resistant to various antimicrobial agents, is predominant in Korea. Ribotype 002 has also been increasing in prevalence in Korea.

Disclosures
All authors: No reported disclosures.
2378. Corticosteroid Use Prevents Primary Clostridioides difficile Infection in the Setting of Broad-Spectrum Antibiotic Use Among Hospitalized Patients
Authors: Carlson Travis J , Wilcox Melissa F , Theriault Sarah G , Alnezary Faris S , Gonzales-Luna Anne J , Zasowski Evan J , Garey Kevin W 
Published: October 2019

Abstract

Background
Clostridioides difficile is the most common pathogen causing healthcare-associated infections in the United States and a Centers for Disease Control and Prevention urgent threat-level pathogen. The pathophysiology of C. difficile infection (CDI) involves neutrophil invasion of the colon associated with an inflammatory response. Previous case–control studies investigating an anti-inflammatory corticosteroid (CS) effect on CDI risk demonstrated conflicting results but were unable to control for antibiotic use. We hypothesized that CS use would decrease the risk of CDI in a well-matched, high-risk population.

Methods
This nested case–control study included hospitalized patients admitted to a single quaternary care hospital in the Texas Medical Center. The case population included adults who were diagnosed with CDI and received at least one dose of an antibiotic of interest (piperacillin–tazobactam, cefepime, or meropenem) in the 90 days prior to CDI diagnosis. The control population included hospitalized adults who received one of the same antibiotics during their hospital stay but did not develop CDI in the 90 days following their first dose. Patients were excluded if they had a documented history of CDI. CS use was defined as ≥ 20 mg prednisone or equivalent administered in the 48 hours prior to CDI diagnosis (cases) or antibiotic start (controls). The primary study outcome was the development of CDI. A logistic regression model was developed modeling CDI diagnosis as a function of available patient covariates.

Results
A total of 321 patients met the inclusion criteria; 56 patients had a history of CDI, leaving a final study cohort of 265 patients (104 cases and 161 controls). Antibiotic days of therapy were significantly higher in the control group (8 vs. 6 days; P = 0.02). The odds of CDI diagnosis were lower among patients administered CS (OR, 0.17; 95% CI, 0.08–0.38; P < 0.001), which remained protective in the multivariable model after adjusting for age, gender, and invasive GI surgery within 6 months.

Conclusion
We observed an association between CS use and decreased risk of developing primary CDI in hospitalized patients receiving broad-spectrum antibiotics. Future studies are needed to delineate the dose and duration of CS needed to realize this effect.

Disclosures
All authors: No reported disclosures.
2411. One Dose Vancomycin Prophylaxis for In-Hospital Clostridioides difficile - Associated Disease
Authors: Papic Neven , Stemberger Maric Lorna , Dusek Davorka , Vince Adriana 
Published: October 2019

Abstract

Background
Clostridioides difficile - associated disease (CDAD) is the most common cause of healthcare-associated diarrhea with increasing prevalence and mortality rates. Recent reports suggest that prophylactic administration of vancomycin or fidaxomicin might reduce in-hospital CDAD incidence. The aims of this study were to examine whether primary oral vancomycin prophylaxis (OVP) reduces the in-hospital incidence of CDAD in elderly patients treated with systemic antibiotics and its impact on 90-day readmission rate.

Methods
This single-center, retrospective cohort study included 484 patients ≥ 65 years who received antimicrobial therapy for ≥ 24 hours and were hospitalized for ≥ 72 hours during a 24-month period. Patients diagnosed with CDAD within the first 48 hours of hospitalization were excluded. OVP group received ≥ 1 dose of vancomycin 125 mg once per day.

Results
Patients within OVP group (122; 25.2%) had higher age adjusted Charlson comorbidity index (CCI) (8; IQR 6–10 vs. 6; 5–8), were more often hospitalized within 3 months (62; 50.8% vs. 121; 33.4%), more commonly received piperacillin/tazobactam (60; 49.2% vs. 81; 22.4%) and carbapenems (27; 22.1% vs. 43; 11.9%) with longer duration of antibiotic therapy (14; 10–20 vs 10; 10–14 days). CDAD was diagnosed in 3 (2.5%) patients in OVP, compared with 45 patients (12.4%, p = 0.0011) in control group. In logistic regression analysis CCI > 6 (OR 3.54; 95% CI 1.79–6.87), OVP (0.19; 0.06–0.57), nursing home residency (4.10; 2.40–7.02), carbapenems (3.14; 1.60–6.15) and piperacillin/tazobactam (5.43; 2.87–10.14) were associated with CDAD. In this cohort, 28 (23.7%) patients from OVP and 69 (21.7%) patients from control group had 90-day readmission. 6 patients in OVP (4 new episodes) and 21 (14 new episodes) in control group were admitted for CDAD. Only CDAD during index hospitalization was associated with 90-day readmission (HR 4.60; 95% CI 1.93–10.96).

Conclusion
Primary OVP was highly effective in reducing the risk of in-hospital CDAD in elderly patients treated with systemic antimicrobial therapy. Prospective studies with follow-up are needed to define long-term efficacy and potential risks of this strategy.

Disclosures
All authors: No reported disclosures.
2414. Effectiveness of Oral Vancomycin for Prevention of Healthcare Facility-Onset Clostridioides difficile Infection in High-Risk Patients
Authors: Johnson Steven W , Priest David H , Brown Shannon V 
Published: October 2019

Abstract

Background
Studies suggest oral vancomycin prophylaxis may be effective in preventing Clostridioides difficile infection. These studies are limited by their retrospective design, reliance on local clinical practice patterns, lack of intervention standardization, and limited risk stratification. We sought to evaluate the effectiveness of oral vancomycin for the prevention of healthcare facility-onset CDI (HCFO-CDI) in high-risk patients.

Methods
We conducted a randomized, prospective, open-label study at Novant Health Forsyth Medical Center in Winston-Salem, North Carolina between October 2018 and April 2019. Admitted high-risk patients (defined as: ≥ 60 years of age, hospitalized ≤ 30 days prior to the index hospitalization and received systemic antibiotics during that prior hospitalization and currently receiving systemic antibiotics) were randomized 1:1 to either oral vancomycin (dosed at 125 mg once daily while receiving systemic antibiotics and continued for 5 days post completion of systemic antibiotics [OVP]), or no prophylaxis. The primary endpoint was incidence of HCFO-CDI. Secondary endpoints included incidence of community-onset healthcare facility-associated CDI (CO-HCFA-CDI), development of VRE colonization after receiving OVP, and adverse effects and cost of OVP.

Results
A total of 100 patients were evaluated, 50 patients in each group. Baseline and hospitalization characteristics were similar in each group. No incidents of HCFO-CDI were diagnosed in the OVP group compared with 6 (12%) in the no prophylaxis group (P = 0.03). CO-HCFA-CDI was not observed in either group. No patients developed new VRE colonization with only 1 patient reporting mild gastrointestinal side-effects to OVP. A total of 600 doses of OVP were given during the study, with each patient receiving an average of 12 doses. Total acquisition cost of OVP was $728.25, $60.69 per patient.

Conclusion
OVP was highly effective in preventing HCFO-CDI. OVP was well tolerated with no apparent risk for VRE colonization. Further prospective investigation is warranted to determine the impact and cost-effectiveness of routine use of OVP in high-risk patients.

Disclosures
All authors: No reported disclosures.
2416. Effect of Sequential Universal Bleach Cleaning and Best Practice Alerts on Clostridioides difficile Infection Rates
Authors: Gand Kari , Helmin Derrek , Johnson Shawnda , Kline Susan E , Galdys Alison 
Published: October 2019

Abstract

Background
A gap analysis prompted consideration of expanded bleach disinfection beyond rooms housing patients in isolation for Clostridioides difficile infection (CDI) and emphasis on CD testing stewardship at the University of Minnesota Medical Center (UMMC), a tertiary care center spanning two campuses in close proximity with adult patients on the East Bank (EB), adult and pediatric patients on West Bank (WB).

Methods
An electronic best practice advisory (BPA) went live in April 2018 on both the EB and WB (Figure 1). The BPA first discourages CD testing in the event of a prior positive within 10 days or a prior negative within 7 days. Second, the BPA discourages CD testing in patients with fewer than 3 loose stools in a 24 hour period, who have received laxatives in the last 48 hours, or who lack CDI symptoms (fever > 38C, abdominal pain, or leukocytosis > 11,000). Providers can bypass the BPA based on clinical judgment; those who override the BPA are provided just-in-time education via email.
Following a successful pilot in three wards, the EB Environmental Services (ES) team expanded the use of bleach to include all terminal cleaning regardless of isolation status in June 2018 (Figure 1). Daily cleaning on the EB was excluded from universal bleach utilization, as were daily and terminal cleaning on the WB.
CD testing throughout the study period occurred via polymerase chain reaction (PCR) of the toxin B gene. ES performance, assessed by adenosine triphosphate (ATP) bioluminescence testing, and hand hygiene rates were unchanged throughout the study period.

Results
Adult-only hospital-onset (HO)-CDI rates decreased during the study period on both hospital campuses, with the EB exhibiting a greater decrease, (Fig 1), while community-onset (CO) and community-onset healthcare facility associated (CO-HCFA) rates remained steady during the study period (Fig 3). Whole-house (adult and pediatric) CD testing was largely unchanged while the proportion of tests triggering the BPA decreased (Fig 2).

Conclusion
Universal bleach utilization during terminal cleaning combined with an electronic BPA were associated with decreased adult HO-CDI rates. However, the BPA did not impact CD testing rates, suggesting that decreased HO-CDI rates may be unattributable to testing stewardship.

Disclosures
All authors: No reported disclosures.
2427. A Laboratory Simulation and Field Study of Simplified Qualitative and Quantitative Environmental Cultures for Clostridioides difficile
Authors: Curry Scott R , Vanderhorst Aisha , Zhao Yujing , Steed Lisa , Salgado Cassandra 
Published: October 2019

Abstract

Background
Reliable, simple methods to assess environmental contamination with Clostridioides difficile are needed for studies of terminal disinfection effectiveness and transmission of C. difficile from fomites. We compared two novel sampling methods for assessment of C. difficile contamination: (1) isopropanol wipe sampling with broth enrichment (IW), where alcohol wipes are used to sample surfaces followed by immersion in CDBB-TC broth and (2) ethanol-shock hand imprint sampling (HI), where surfaces are sampled by gloved hands moistened with ethanol hand sanitizer followed by imprinting hands on selective agar (CDBA-TC). Both methods allow for sampling of complex surfaces common in hospital environments.

Methods
We performed a laboratory simulation study using six 10-fold dilutions (101–106) of C. difficile spores from two strains sampled from fiberglass surfaces by IW and HI. We then performed a field study of 10 sites in 11 hospital rooms of patients with C. difficile infection (CDI) diagnosed < 48 hours prior to sampling. Results for the HI and IW method were quantitative and qualitative, respectively. We compared room contamination prevalence (total CFU per room by HI and sites positive/total sites per room) to the cycle crossing threshold (CT) from the diagnostic C. difficile PCR test (Cepheid) from the room occupant.

Results
The IW laboratory limit of detection was 101 spores compared with 104 spores for HI. In the field study, IW and HI detected C. difficile contamination in 9/11 (82%) rooms at 22/110 (20%) sites and 5/11 (45%) rooms at 22/110 (20%) sites, respectively (Table 1). Six rooms with no detection by the HI method had a lower median number of sites positive per room compared with the 5 rooms with ≥1 cfu (1 vs 6, P < 0.05) (Table 1). The most commonly contaminated sites were linens (53%), call bells (43%), toilets (40%), blood pressure cuffs (40%), over-bed tables (38%), and bedrails (30%) (Table 2). Higher tcdB CT was associated with a lower total room contamination prevalence (Figures 1 and 2).

Conclusion
Our data suggest that the IW method is more sensitive for detection of C. difficile in the hospital environment, but the HI method offers quantitation. The prevalence of hospital room contamination for CDI patients appears to correspond with their toxin burden as estimated by PCR.

Disclosures
All authors: No reported disclosures.