bluuebunny/crossref_metadata_2025_split huggingface dataset:
2381. Epidemiology of Clostridium difficile Infection in Patients Receiving Interleukin-2 Therapy
Authors: Li Aldon , Nguyen Nga 
Published: October 2019

Abstract

Background
Clostridium difficile infection (CDI) has been associated with interleukin-2 (IL2) therapy, possibly leading to unnecessary testing and treatment of colonized patients receiving IL2 therapy. Since the debut of IL2 therapy for renal cell carcinoma (RCC) and metastatic melanoma (MM), only one study with 6 patients has shown a relationship between CDI and IL2 treatment, and no mortality data were reported. Because of the rising concern for appropriate testing and treatment of CDI, further studies looking at the correlation between IL2 therapy and CDI are needed. This study aims to describe CDI rates among a larger cohort of IL2 treated patients and to include mortality data.

Methods
Retrospective case series. A case of CDI was defined as (1) Bowel movements >3 or stool output >600 mL WITH, (2) positive laboratory test, either through toxin detection via ELISA prior to 2010 or molecular testing via PCR after 2010.

Results
During the study period from 2008 to 2015, 359 patients with RCC or MM receiving IL2 treatment were evaluated with a total of 294 patients undergoing Clostridium difficile testing (CDT). Median age was 52 (range 24–69), 33% female. An average IL2 dose of 27 million international units (MIU) was given in this population. 15% (45/294) had a positive CDT, but 7% (21/294) were found to have CDI. All patients with CDI had antibiotic exposure within the last 30 days of diagnosis. Of the patients who developed CDI, 24% (5/21) had a previous CDI episode within the last 90 days. None of the patients developed megacolon. Developing CDI lead to an all-cause mortality of 24% (5/21).

Conclusion
The results of this study show a lower CDI rate (7%, 21/294) than previously reported in IL2-treated patients (66%, 4/6), but this difference is likely due to the difference in population size. In addition to CDI rate, this study adds information about mortality in IL2-treated patients with CDI, which was not previously described in the literature. Applying a clinical criterion to laboratory testing results revealed a difference in laboratory testing positivity and actual infection rates, suggesting 8% of this population maybe colonized with Clostridium difficile, providing further evidence for Antibiotic Stewardship Committees to put in place local guidelines to avoid indiscriminate CDT in this population.

Disclosures
All authors: No reported disclosures.
2384. The Relationship Between Rifaxamin Use and the Prevalence of Clostridiodes difficile and Vancomycin-Resistant Enterococcus in Patients with Advanced Liver Disease
Authors: Alberto. De Jesus Francisco , Kuper Kristi , Haider Alyzeh , Sackey Joachim , Finkel Diana 
Published: October 2019

Abstract

Background
Rifaximin (RFX) is a minimally absorbed antibiotic that achieves high concentrations after administration in the gut lumen. Previously, RFX showed activity against Clostridiodes difficile (C. difficile) recurrences post treatment with little overall impact on the normal fecal microbiota. Additional studies have found that while exposure to systemic antibiotics was associated with infection with multi drug-resistant organisms, such as VRE, exposure to only RFX was not. RFX has become widely used in hospitalized patients with advanced liver disease (ALD) who have refractory hepatic encephalopathy, but the impact of therapy on the occurrence of C. difficile and VRE is not well established.

Methods
ALD patients in the Vizient Clinical Database-Resource Manager (CDB-RM®) were identified based on ICD 10 and MS-DRG codes from January to December 2018. The data were further stratified based on receipt of RFX, documentation of C. difficile or VRE, and hospital type (academic medical centers, complex care medical centers or community hospitals). Wilcoxon signed-rank test was used to compare C. difficile rates while paired samples t-test was used to compare VRE. Chi-square analysis was used to evaluate differences in RFX use by hospital type.

Results
A total of 527,534 cases from 419 acute care hospitals were included in the ALD cohort. The frequency of C. difficile occurrence in patients who received RFX was lower than those who did not receive RFX (3.8% vs 4.3%, respectively, P = 0.25), However, VRE frequency was significantly lower in those that received RFX (0.43 cases per 10,000 patient-days) vs. the overall ALD population (2.3 cases per 10,000 patient-days) (P < 0.05). Percentage of ALD cases receiving RFX in the academic medical centers, complex care medical centers and community hospitals was 11.94%, 4.87%, and 8.76%, respectively (P < 0.05).

Conclusion
Patients with ALD who received RFX had a significantly lower frequency of documented VRE. There was a trend in the reduction in documented C. difficile, but this did not reach statistical significance. Utilization of RFX varied significantly by institutional type. These results support further studies on the relationship between receipt of RFX and protective effects against C. difficile and VRE in patients with ALD.

Disclosures
All authors: No reported disclosures.
2386. Mortality reduction with implementation of a standardized approach of surveillance, diagnosis and treatment of Clostridioides difficile infections.
Authors: Molina Aaron , Olmedo-Reneaum Alejandro , Garfias Yanelly , Carmona Paulette A , Constantino Andrea , Piñera Mariana 
Published: October 2019

Abstract

Background
Clostridioides difficile (C. difficile) infection is the main cause of nosocomial diarrhea in the world. In our hospital, there was no standardized protocol for diagnosis and treatment of this infection. The aim of this study was to measure the impact of implementing a multimodal strategy of active surveillance, diagnosis and treatment in the clinical outcome of patients with C. difficile infection.

Methods
Observational, retrospective, and analytical study that compared a multimodal strategy for the treatment of C. difficile infection against a traditional strategy, which consisted of treatment with either metronidazole or vancomycin with variable duration of therapy depending on the physician’s choice. The multimodal strategy consisted of active surveillance of cases of nosocomial diarrhea, timely diagnosis (<12 hours), and standard treatment with oral vancomycin for a minimum of 10 days (125 mg po qid in mild and moderate illness, and 250 mg qid in severe disease). Patients with a confirmed diagnosis of C. difficile infection (PCR- Gene Xpert Cepheid) and inflammatory diarrhea were included. The study was carried out in a third-level hospital, in the period between September 2017 and December 2018.

Results
In 15 month study period, 92 cases of C. difficile infection were documented. All cases were caused by strain NAP1 / B1 / 027. Twenty-three patients (25%) had mild disease, 28 (30.4%) moderate illness and 41 (44.56%) complicated illness. Thirty-four patients were evaluated with multimodal strategy and 58 according to the traditional treatment. Only 24 patients (41%) in the traditional treatment group received treatment with oral vancomycin. The clinical outcomes of patients in the multimodal strategy against patients with the tradional strategy were: clinical cure 85.3% vs 37.9% (P = 0.02), recurrence 2.9% vs 17.2% (p = < 0.05) and death 11.8% vs 44.8%(p = < 0.05), respectively.

Conclusion
Unfortunately, in our country, there are no guidelines for the management of C. difficile infection, and in many hospitals, metronidazole is the most prescribed treatment. In this study, we documented that implementing a standardized strategy of surveillance, diagnosis and adequate treatment, reduced mortality related to C. difficile infection, recurrence, and achieved greater clinical cure.

Disclosures
All authors: No reported disclosures.
2387. Learning the Influence of Individual Clostridioides difficile Infections
Authors: Mu Emily , Makar Maggie , West Lauren R , Guttag John , Rosenberg David C , Shenoy Erica S 
Published: October 2019

Abstract

Background
Healthcare-associated Clostridioides difficile infection (C diff infection, or CDI) imposes a substantial burden on the healthcare system. The impact of an individual C diff infection on onward transmission is not well understood. We developed a model of incident infections using self-exciting stochastic processes, known as Hawkes processes. These models can be used to improve our understanding of the factors that affect the likelihood of new infections to result in additional infections.

Methods
All patients admitted to a large urban hospital between January 2013 and June 2014 were included. We used Hawkes processes to model the influence of each new CDI case (index infection) on transmission to other patients resulting in additional CDI. We developed separate Hawkes processes for each unit in the hospital to understand the differential impact of a C diff case across units. Units included both semi- and private-room wards, intensive care units, an emergency department, and specialty units such as oncology.

Results
The magnitude of influence of an index infection on additional infections in the 2 days prior to a C diff test being sent varied across units. Results for an oncology unit, the emergency department, and an all private-room unit are provided (Table 1). An index infection in the emergency department demonstrated the greatest influence, leading to the largest number of additional infections, and increasing in the days leading up to the C diff test being sent. The impact 2 days prior to sample collection was similar across all unit types, and remained constant for oncology unit patients.

Conclusion
We used Hawkes processes to model the impact of an index C diff infection on onward transmission. We identified differential impacts associated with the unit where the index patient was located in the days leading up to diagnosis. These differences, which could relate to unit-specific factors such as cleaning practices, patient turnover rates, use of portable medical equipment, antibiotic use, and other factors that vary across units, suggest that interventions aimed at controlling CDI may need to consider unit-specific approaches.

Disclosures
All authors: No reported disclosures.
2392. Identifying Associations Between Clostridium difficile Infection Incidence and Cancer Patients Receiving Chemotherapy
Authors: Louie Mendiola Vincent , Kesireddy Meghana , Suthar Krishna , Willis Maurice 
Published: October 2019

Abstract

Background
Clostridium difficile infection (CDI) is a known major financial burden. In the cancer population, CDI, was identified to have a peak incidence of 17.2 per 1000 patients with increased morbidity, mortality and hospital length of stay. The need to further elucidate chemotherapy (CTX) with vs. without ABX usage as risk factors among other variables in cancer patients arises since this population is already baseline immunocompromised.

Methods
A retrospective case–control study (total of 1989 cancer patients who received CTX and had diarrhea at UTMB through 1/2016–1/2018) was completed. Subjects were screened using extensive inclusion and exclusion criteria, and assigned as CASES (with symptomatic (s) diarrhea from proven CDI) and as CONTROLS (had diarrhea but not attributed to CDI). A 1:1 subject matching using age, sex and past medical histories was completed and a total of 46 patients: 23 cases and 23 controls were compared and analyzed. McNemar’s and independent t test of equal variance were used for association and comparing means/medians, respectively. Two-sided P value ≤ 0.05 was considered significant.

Results
The use of ABX (OR = 16, P = 0.0007) and having any degree of neutropenia at the time of diarrhea (OR = 12, P = 0.0055) among CTX patients had significant associations with having sCDI. Although no significant association between sCDI and # of days post CTX exposure (≥7 days (P = 0.1138) and ≥14 days post CTX (P = 0.1489) was identified, a mean of 12.83 ± 7.69 days passed before sCDI diagnosis in cases, compared with diarrhea diagnosis (7.46 ± 6.1 days) in controls (P = 0.0119). Meanwhile, receiving >1 CTX cycle (P = 1.000) and particular CTX types (P = ~ 0.0771–1.000) had no significant associations with sCDI diagnosis.

Conclusion
Any ABX usage post CTX exposure heavily predisposes to sCDI among cancer patients likely due to elimination of gut flora on an already predisposed population. Having any degree of neutropenia was also associated with having sCDI likely due to significant immunosuppression on top of being baseline cancer patients receiving CTX, and may have predictability benefits. The other variables may have not been significant due to expected limited cases because of low CDI incidence.

Disclosures
All authors: No reported disclosures.
2394. A Longitudinal Study of the Effect of Renal Failure on Readmission Rates of Patients with Clostridioides difficile
Authors: Destache Christopher J , Detweiler Brian , Vivekanandan Renuga 
Published: October 2019

Abstract

Background
Clostridioides difficile Infection (CDI) is a highly contagious bacterium that can be transferred from an infected surface. In this study, the Nationwide Readmissions Database was used to assess the risk of 30-, 60-, and 90-day readmissions in patients with comorbid CDI and renal failure (RF).

Methods
Using the Nationwide Inpatient Sample (NIS, 35 million hospitalizations/year) and the Nationwide Readmissions Database (NRD, 36 million/year), CDI in renal insufficient patients were identified. Years 2001–2014 of the NIS, as well as years 2010–2014 of the NRD were used for analysis. Chronic kidney disease (CKD) was based on the stage of the disease using IDC-9-CM coding (585.1–585.5). ICD-9-CM 585.6 was used for end-stage renal disease (ESRD). All analyses were done in R version 3.4.3.

Results
Over the 14 year period, the proportion of inpatients with CDI and RF increased from 0.004% (95% CI, 0.0038%-0.0042%) to 0.010% (95% CI, 0.0100%-0.0104%) in 2014. Inpatient RF and CDI increased a mean of 220,827 people over the 14 years. Inpatient CDI and RF prevalence is described as linearly increasing trend (Figure 1). Median age (2001–2014) for RF patients with CDI decreased 5 years to 68 (95% CI, 68–69). Using this model, expected CDI infections in RF to increase to 437,605.1 (95% CI, 427,984.2–447,380.8) hospital inpatients in 2018. In patients with CDI and CKD, ESRD is a significant predictor of 30-, 60-, and 90-day readmission.

Conclusion
Using the NIS and NRD identified ESRD patients as a significant predictor of readmission for 30-, 60-, and 90-days. CDI infections in ESRD are expected to increase substantially by 2018.

Disclosures
All authors: No reported disclosures.
2397. Effects of antimicrobial surgical prophylaxis on rates of Clostridioides difficile infection
Authors: Hayes Sarah K , Cooper Mandelin , Goldin Laurel , Fraker Sarah , Greer Nickie 
Published: October 2019

Abstract

Background
Studies have demonstrated short courses of antibiotics, including surgical site infection (SSI) prophylaxis, can increase the risk of Clostridioides difficile infection (CDI). The purpose of this study was to evaluate the incidence of CDI associated with antibacterial perioperative prophylaxis.

Methods
In a retrospective analysis of affiliated hospitals from a large healthcare system, aggregate data from 156 acute care facilities across the United States was analyzed for the time period of July 2017 through July 2018. Patients were included if they were 18 years and older, admitted to an inpatient unit, and underwent a surgical procedure requiring antibiotic prophylaxis. Patients were excluded if they received antibiotics more than 24 hours prior to procedure start, received antibiotics more than 72 hours after procedure stop, or had more than one procedure with antibiotic prophylaxis within 30 days. Patients were divided into three groups based on the duration of antibiotic prophylaxis received: preoperative only (Pre-op only), pre-op plus postoperative for 24 hours or less (Short Post-op), and pre-op plus post-op for 25 to 72 hours (Long Post-op). The primary outcome was the incidence of CDI within 30 days of surgical procedure. Study design was approved by the University of Tennessee Institutional Review Board.

Results
The final analysis included 230,524 patients: 68,307 Pre-op Only, 123,185 Short Post-op, and 39,032 Long Post-op. Overall, 195 cases of CDI were identified during the study period, for a rate of 0.8 cases per 1000 procedures. The highest incidence occurred in the Long Post-op group (1.3 cases per 1000 procedures). A pairwise comparison demonstrated the incidence of CDI is statistically higher in the Long Post-op group compared with both the Pre-op Only (P = 0.005) and the Short Post-op (P = 0.003) groups. There was no significant difference between the Pre-op Only and the Short Post-op groups<./p>

Conclusion
Patients who received antibiotics for more than 24 hours post-op had a higher incidence of CDI. No statistically significant difference in CDI between pre-op only and less than 24 hours post-op was found.

Disclosures
All authors: No reported disclosures.
2401. Epidemiology of Clostridium difficile Infection in Intestinal and Multivisceral Transplant Patients at a Single Transplant Center
Authors: Modi Anita R , Gonzalez Blanca E , Brizendine Kyle D 
Published: October 2019

Abstract

Background
Clostridium difficile infection (CDI) is the leading cause of infectious diarrhea in the healthcare setting. Solid-organ transplant (SOT) recipients are at increased risk compared with the general hospitalized population (7.4–20% vs. 0.9%). Our center recently expanded its intestinal and multivisceral transplant (IMVT) program, providing the opportunity to examine the epidemiology of CDI in this vulnerable population.

Methods
We conducted a retrospective study of all IMVT recipients between 2009 and 2018. CDI was defined as presence of diarrhea with a positive polymerase chain reaction (PCR) test for the toxin B gene. Early CDI constituted an episode of CDI within the first 6 months post-transplant. Data were collected on demographics, transplant characteristics, CDI episode, and outcomes.

Results
We identified 86 patients who underwent a total of 94 transplants: 60 (64%) isolated intestinal transplants, 21 (22%) intestine/liver/pancreas, 10 (11%) intestine/pancreas, two (2%) intestine/liver/pancreas/kidney, and one (1%) intestine/kidney transplant. All but three patients received perioperative metronidazole. Four patients (5%) had CDI prior to transplant, but none of them recurred in the first 6 months post-transplant. Five patients developed a total of seven mild-moderate episodes of early CDI (attack rate = 5.9%). Three patients (60%) with early CDI developed rejection, similar to the incidence (70%) in patients without CDI. Two patients with early CDI developed recurrence; both underwent intestinal re-transplantation. One-year mortality was similar among patients with and without early CDI (20% vs. 23%).

Conclusion
CDI is associated with allograft loss, rejection, and mortality in some SOT recipients. Although limited by sample size, we observed that early CDI was not associated with those outcomes in our population. Multicenter studies are merited to explore risk factors for CDI and associations with outcomes in IMVT.

Disclosures
All authors: No reported disclosures.
2402. Clinical Outcomes Associated with an Emerging Clostridioides difficile Ribotype 255 in Texas
Authors: Gonzales-Luna Anne J , Carlson Travis J , Lancaster Chris , Miranda Julie M , Garey Kevin W 
Published: October 2019

Abstract

Background
PCR ribotyping of Clostridioides difficile strains is commonly used to describe the epidemiology of C. difficile infection (CDI). Certain ribotypes (RT) have been associated with more severe disease and clinical outcomes, such as RT 027, while others are considered less virulent, such as RT 014-020. Texas statewide surveillance identified the emergence of a rarely-described RT 255 beginning in 2015, which now represents the fifth most common ribotype across the state. Here we describe clinical outcomes associated with an emergent RT 255 in Texas.

Methods
A retrospective cohort study was conducted including patients from two tertiary care centers in Houston, Texas. Patients infected with C. difficile strains of either RT 255, 014-020, or 027 between 2016–18 were included. The primary outcome was disease severity as classified by the 2017 IDSA guidelines. Multivariable logistic regression analysis was done to control for other patient factors. Results were significant at P < 0.05, and all statistical analyses were completed using SPSS, version 25.

Results
A total of 150 patients were included (50 patients infected with each RT). Overall, 53% of the patients had severe or fulminant disease most commonly due to RT 027 (80%) followed by RT 014-020 (40%) and RT 255 (38%). Patients infected with RT 255 or 014-020 had a 75% relative reduction in the odds of severe disease compared with RT 027 after controlling for patient age and serum albumin level (OR, 0.25; 95% CI, 0.86–0.74; P = 0.12;). No differences were seen in the rates of 30- or 90-day recurrence between RTs.

Conclusion
Although RT 255 is becoming increasingly common across Texas, it does not appear to be associated with more severe disease when compared with other common ribotypes. Further studies are warranted to determine contributing factors for its increasing prevalence.

Disclosures
All authors: No reported disclosures.
2420. Reduced hospital-onset Clostridium difficile infection incidence following Saccharomyces boulardii co-administration with broad-spectrum antibiotics during hospitalization.
Authors: Wombwell Eric , Patterson Mark E , Bransteitter Bridget , Gillen Lisa 
Published: October 2019

Abstract

Background
Conflicting evidence in smaller randomized trials and meta-analyses regarding the protective effects of probiotics against Clostridium difficile infection underscore the need for further study. Our objective was to evaluate the effect of a single probiotic strain, Saccharomyces boulardii, at a standardized dose on hospital-onset C. difficile (HO-CDI) rates within hospitalizations administered broad-spectrum antibiotics.

Methods
Retrospective cohort study merging hospital prescribing data with C. difficile case data from the National Health Safety Network at a 220-bed level-2 trauma center nonacademic hospital. A convenience sample of 8,763 hospital admissions administrated at least one dose of a fluoroquinolone, clindamycin, or β-lactam class antibiotic during hospitalization was assessed. Hospitalizations were categorized by whether antibiotics were administered alone (control) or in conjunction with S. boulardii 20 billion colony-forming units daily (intervention). Associations between S. boulardii administration and HO-CDI incidence was evaluated by multivariate logistic regression. A sub-group analysis evaluated the extent to which administering S. boulardii within or after 24-hours of antibiotic start changed the effect. Propensity scores incorporated to account for selection bias.

Results
Hospitalizations where S. boulardii was co-administered with antibiotics had a reduced likelihood of HO-CDI (OR = 0.56, 95% CI 0.32 – 0.93) compared with control hospitalizations. S. boulardii administered within 24-hours of antibiotic start had a reduced likelihood of HO-CDI (OR = 0.40, 95% CI 0.21 – 0.75). No effect observed if S. boulardii administered after 24-hours (OR = 0.86, 95% CI 0.45 – 1.64). Post-hoc analysis for disease latency, the average number of days to HO-CDI onset was 5.6, 6.4, and 8.0 days for antibiotic only, S. boulardii after 24-hours, and S. boulardii within 24-hours of antibiotic, respectively (P < 0.04).

Conclusion
Co-administering S. boulardii with broad-spectrum antibiotics is associated with a reduced risk of C. difficile in hospitalized patients, especially if started within 24-hours of antibiotic initiation. S. boulardii should be considered as preventative intervention to reduce the risk of HO-CDI.

Disclosures
All authors: No reported disclosures.