bluuebunny/crossref_metadata_2025_split huggingface dataset:
788. Evaluation of a Multiplex PCR Panel and Confirmatory Cytotoxin Testing on Clostridioides difficile at a Pediatric Hospital
Authors: Lauth Michael J , Cook Greg , Silio Margarita 
Published: January 2021

Abstract

Background
With the introduction of gastrointestinal multiplex PCR (mPCR) tests, clinicians have received an increased number of positive tests for Clostridioides difficile. Patients who test positive via mPCR may not have a positive toxin assay indicative of true infection and may not need antibiotics. The goal of this study was to assess the symptoms of patients who test positive for C. difficile and determine the impact on antibiotic use at a pediatric hospital.

Methods
A single-center, retrospective review was completed from May 2018 to March 2020. Initial C. difficile screening tests were performed via an mPCR test or a mono-PCR test. Patients &gt; 1 year of age had a reflex cytotoxin assay performed. The primary outcome was the difference in symptoms between cytotoxin positive and negative patients. Secondary outcomes included co-pathogen detection on mPCR and C. difficile antibiotic days of therapy.

Results
Four hundred and sixty-one patients were included in our chart review. 49% of patients had a positive mPCR for a GI pathogen (n=229), and 18% (n=82) were positive for C. difficile. Cytotoxin was positive for 45% of patients that had C. difficile on mPCR. 34% of patients that had C. difficile detected on mPCR also had co-pathogens detected. No significant differences were present in symptomatology between cytotoxin positive and negative patients and no significant differences between white blood cell count (Table 1). There was a significant difference in the number of patients treated for the C. difficile between the cytotoxin populations (p-value&lt; 0.05). The average duration of treatment with a negative test was significantly less than for positive cytotoxin test patients (7.5 vs 11 days, p-value&lt; 0.05).
Table 1: Comparison of cytotoxin production in pediatric patients with Clostridioides difficile.

Conclusion
Our results show a significant amount of antibiotic use for patients with cytotoxin negative C. difficile and no differences in symptomatology or white blood cell count based on cytotoxin positivity. Diagnostic stewardship of mPCR tests may be needed to effectively impact this unneeded antibiotic use, specifically the duration.

Disclosures
All Authors: No reported disclosures
794. Healthcare-Associated Urinary Tract Infection (HA-UTI): A Risk Factor for Clostridioides difficile Infection (CDI)? Results of a Real-World Data Analysis
Authors: Kelly Timothy , Kelly Timothy , Ai ChinEn , Ai ChinEn , Murray John , Murray John , Xiong Yan , Xiong Yan , Jokinen-Gordon Hanna , Jokinen-Gordon Hanna 
Published: January 2021

Abstract

Background
It is estimated that 223,900 cases of CDI occur annually in hospitalized patients resulting in 12,800 deaths and $1 billion in attributable costs. Antimicrobial use is a risk factor for CDI and the antimicrobials ordered to treat urinary tract infections have been identified as a factor in both recurrent CDI and community-acquired CDI. This real-world data analysis seeks to explore the relationship between HA-UTI and hospital-onset CDI (HO-CDI).

Methods
An electronic infection surveillance system was the source of de-identified real-world data from 290 hospitals. Algorithmically-derived measures of healthcare-associated infections (ADM-HAIs), and records of all-cause antimicrobial orders, for all inpatient admissions for the period 10/1/18–9/30/19 were analyzed. All patients who presented with a urine ADM-HAI – suggestive of HA-UTI – and no other healthcare-associated infection (Urine+ patients), were observed for subsequent HO-CDI. Urine+ patients were compared to patients with no HAI of any type, other than CDI (HAI-free patients), and relative risk (RR) was estimated. The analysis was repeated for the subgroup of patients who received an antimicrobial order for any reason during their stay.

Results
3,050,525 inpatient admissions were analyzed. 26,634 were identified as Urine+ patients. 188 of those patients subsequently presented with HO-CDI. 2,978,507 were identified as HAI-free patients. 6,238 of those patients presented with HO-CDI. The incidence of HO-CDI was significantly higher in Urine+ patients compared to HAI-free patients (RR=3.37, 95% CL[2.92, 3.89], p&lt; 0.0001). When the analysis was repeated to examine only patients who received antimicrobial orders, Urine+ patients continued to be at higher risk of subsequent HO-CDI compared to HAI-free patients (RR=3.28, 95% CL[2.74,3.92], p&lt; 0.0001).

Conclusion
The presence of a urine ADM-HAI, suggestive of HA-UTI, was associated with an increased risk of subsequent HO-CDI. This held when only patients with antimicrobial orders were considered. These observations mirror findings from other published studies, however, other factors may have contributed to increased risk for both HA-UTI and HO-CDI.

Disclosures
Timothy Kelly, MS, MBA, BD (Employee) ChinEn Ai, MPH, BD (Employee) John Murray, MPH, BD (Employee) Yan Xiong, n/a, BD (Becton Dickinson) (Employee) Hanna Jokinen-Gordon, PhD, BD (Employee)
795. Impact of Revised Infectious Diseases Society of America and Society for Healthcare Epidemiology of America Guideline on the Classification of Clostridioides difficile Infection Severity
Authors: Carlson Travis J , Gonzales-Luna Anne J , Nebo Kimberly , Chan Hannah Y , Tran Ngoc-Linh T , Antony Sheena , Garey Kevin W 
Published: January 2021

Abstract

Background
The Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) revised their Clostridioides difficile infection (CDI) severity classification criteria in 2017 to include a serum creatinine (SCr) value above a threshold (≥ 1.5 mg/dL) rather than a relative increase from baseline (≥ 1.5 times the premorbid level). To date, these criteria have not been validated and may overestimate the number of severe CDI cases in patients with underlying renal insufficiency.

Methods
This multicenter, retrospective cohort study included all patients ≥ 18 years of age with CDI diagnosed in two large health systems in the Houston, Texas area between 2016 and 2018. Patients were assessed for presence of acute kidney injury (AKI) and chronic kidney disease (CKD), defined per the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, and IDSA/SHEA CDI severity classification criteria per the 2010 and 2017 CDI guidelines. The primary outcome was all-cause inpatient mortality.

Results
The study cohort consisted of 770 CDI episodes from 12 hospitals. A large proportion of episodes occurred in patients with preexisting CKD (36.5%) and concomitant AKI (29.6%). Eighty-two episodes (10.6%) showed discordant results when applying the 2017 revised severity classification criteria due to the identification of patients with preexisting CKD. However, the 2017 severity classification criteria were better correlated with all-cause mortality (OR, 5.40; 95% CI, 1.84-15.86; P = 0.002) than were the 2010 severity classification criteria (OR, 3.12; 95% CI, 1.35-7.19; P = 0.008) as the 2017 SCr criterion was an independent predictor of mortality (OR, 3.66; 95% CI, 1.66-8.05; P = 0.001) while the 2010 SCr criterion was not (OR, 1.47; 95% CI, 0.71-3.08; P = 0.30).

Conclusion
Our findings support the inclusion of the 2017 IDSA/SHEA CDI severity classification criteria in future CDI guideline updates.

Disclosures
Kevin W. Garey, PharmD, MS, FASHP, Merck & Co. (Grant/Research Support, Scientific Research Study Investigator)
797. Management of Patients with Multiple Clostridioides difficile Infection Recurrences using a Tapered-Pulsed Fidaxomicin Strategy
Authors: Tan Xing , Skinner Andrew M , Sirbu Benjamin , Danziger Larry H , Gerding Dale N , Johnson Stuart , Johnson Stuart 
Published: January 2021

Abstract

Background
There is a paucity of data assessing outcomes of alternate fidaxomicin strategies in patients with recurrent Clostridioides difficile infection (rCDI). The objective of our study is to evaluate a tapered-pulsed (T-P) fidaxomicin regimen that was administered immediately following a course of CDI treatment with initial symptom resolution in patients with multiple rCDI.

Methods
We reviewed the characteristics and outcomes of 46 consecutive patients who received T-P fidaxomicin between January 1, 2014-June 30, 2019 in a specialty CDI clinic. The first episode in which fidaxomicin T-P was administered was analyzed. Failure was defined as the persistence of diarrhea and/or the need for additional CDI treatment at any time on T-P fidaxomicin. Sustained clinical cure (SCC) was defined as resolution of diarrhea without recurrence. Recurrence was defined as the return of diarrhea requiring retreatment with CDI therapy after completion of T-P fidaxomicin. Both SCC and recurrence were evaluated at 30 and 90 days after completion of T-P fidaxomicin.

Results
The mean±SD age of the 46 patients was 63.2±19.9 years, 71.7% were female, and the mean±SD CDI episodes within the past year was 3±1.4 . Most patients (73.9%) had previously failed a vancomycin tapered and/or pulsed regimen. Prior to administering T-P fidaxomicin, a treatment regimen was given to ensure resolution of symptoms. The CDI treatment most commonly used (58.7%) was vancomycin. The T-P fidaxomicin regimen used consisted of 200 mg given once daily for 7 days followed by 200 mg every other day for a median (min-max) duration of 33 (6-120) days. Two patients (4%) failed to respond to T-P fidaxomicin; 34 (74%) and 28 (61%) achieved SCC at 30 and 90 days, respectively. Among the 44 patients that successfully completed the T-P fidaxomicin regimen, recurrence developed in 10 (22.7%) and 16 (36.4%) of patients at 30 and 90 days, respectively, with a median (min-max) time to recurrence of 20 (3-87) days (Figure 1). Four patients with recurrence had received subsequent systemic antibiotics.
Figure 1. Course of CDI therapy and follow-up

Conclusion
A tapered-pulsed fidaxomicin strategy may be effective in patients with multiply rCDI who are refractory to other treatments, including a vancomycin tapered and pulsed regimen.

Disclosures
Larry H. Danziger, PharmD, Merck (Speaker’s Bureau)
799. Mini Root Cause Analysis Reveals Opportunities for Reducing Clostridioides difficile Infection Rates
Authors: Turner Nicholas A , Seidelman Jessica L , Wrenn Rebekah , Anderson Deverick J , Lewis Sarah S , Smith Becky A 
Published: January 2021

Abstract

Background
C. difficile remains the single most common pathogen among healthcare-associated infections. We conducted a multi-center, prospective study using on-site, near real-time root cause analyses to identify opportunities for reducing hospital-onset C. difficile infection rates (HO-CID).

Methods
This prospective cohort study enrolled inpatients with HO-CDI admitted to one of 20 participating hospitals in the southeastern United States from July 2019 to June 2020. For each HO-CDI case, mini root cause analyses were conducted by on-site physicians, infection preventionists, or stewardship pharmacists to assess appropriateness of C. difficile testing and inpatient antibiotic use from the 30 days preceding HO-CDI diagnosis.

Results
The cohort captured 554 total HO-CDI cases and 956 antibiotic use events. 147 (26.5%) of HO-CDI cases were adjudicated as likely inappropriate and a further 51 (9.2%) as potentially inappropriate. Among inappropriately tested cases, 103 (52.0%) had received either laxatives or tube feeds in the preceding 48 hours. 132 (13.8%) of antibiotic use events were identified as potentially inappropriate. Among potentially inappropriate antibiotic use events, 40 (30.3%) received unnecessarily broad-spectrum antibiotics, 20 (15.2%) lacked a confirmed infectious diagnosis, and 4 (3.0%) received a longer than guideline-recommended duration. Risk of inappropriate antibiotic use varied by infection type, with treatment of urinary tract infection being associated with the highest risk of inappropriate antibiotic use (table 1).
Table 1: Relative Risk of Inappropriate Antibiotic Use by Indication

Conclusion
Mini root cause analyses may be a helpful tool for identifying -specific opportunities to reduce HO-CDI rates. We found a high rate of inappropriate testing, usually related to alternative causes for diarrhea such as laxative receipt or tube feeds. While rates of inappropriate antibiotic use were lower than has been reported elsewhere, the majority of opportunities for improvement related to overly broad-spectrum coverage. Urinary tract infections were most strongly associated with inappropriate antibiotic use preceding HO-CDI.

Disclosures
All Authors: No reported disclosures
801. Patients with Clostridioides difficile Infection Following Dental Antibiotic Prescription
Authors: Wilson Geneva M , Evans Charlesnika T , Fitzpatrick Margaret A , Poggensee Linda , Echevarria Kelly , Suda Katie J 
Published: January 2021

Abstract

Background
Dentists prescribe few broad-spectrum antibiotics but are the primary prescriber of clindamycin in the U.S. Data is scarce on the association of dental antibiotic prescribing and Clostridioides difficile infection (CDI). Here we present results from a longitudinal cohort of patients with a CDI positive diagnostic test 30 days after receiving an antibiotic prescribed by a dentist.

Methods
A cohort of patients with antibiotic prescriptions within 7 days of a dental visit were identified from 2015-2018. From this cohort, patients with positive C. difficile test 30 days after a dental antibiotic were included. Chart reviews obtained information about the dental visit, antibiotic prescribed, and CDI diagnosis. Descriptive statistics were used to describe characteristics of those with CDI following a dental antibiotic.

Results
212,763 Veterans received an antibiotic from a dentist between 2015-2018. Of them, 87 patients had a positive CDI test within 30 days of receiving their dental antibiotic. Over half (57.4%) of these patients had surgical dental visits and 45.9% had an oral infection coded. Dentists documented reasons for prescription was treatment of a local infection (40%) and post procedure prophylaxis (24%). Amoxicillin (54.0%) and clindamycin (40.2%) were the most commonly prescribed antibiotics. 65.7% of the patients that received clindamycin from the dentist had a documented penicillin allergy. 58.6% of patients had a preexisting gastrointestinal condition and 44.8% were taking gastric acid reducer medication. Only 19.5% of the antibiotic prescriptions met ADA guidelines for appropriate antibiotics (presence of gingival manipulation and a cardiac condition). CDI cases were treated with metronidazole (55.2%), or vancomycin (37.9%); 5.7% had no apparent treatment through the VA. The average number of days between the dental visit and CDI diagnosis was 18.9.

Conclusion
The occurrence of CDI was infrequent after a dental antibiotic. However, clindamycin was prescribed more frequently in this cohort than published literature on dentist prescribing. Approximately half had a gastrointestinal risk factor for CDI. More research is needed to determine the type of patient most at risk for CDI following a dental antibiotic.

Disclosures
All Authors: No reported disclosures
802. Proton Pump Inhibitors Increase Clostridioides difficile Disease Severity Controlling for Infecting Strains
Authors: Fallatah Saad , Almutairi Masaad , Alnezary Faris S , Gonzales-Luna Anne J , Garey Kevin W 
Published: January 2021

Abstract

Background
Proton pump inhibitors (PPI) display pleotropic properties that increase the risk of poor outcomes in patients with C. difficile infection (CDI). However, clinical data on PPI and CDI outcomes is controversial perhaps due to lack of knowledge of infecting strain. The purpose of this study was to assess CDI outcomes in hospitalized patients infected with known C. difficile ribotypes based on use of PPI.

Methods
This was a multicenter study (20 hospitals) of hospitalized patients infected with one of three C. difficile ribotypes (RT027, RT106, and RT014-020). Electronic medical records were reviewed by investigators blinded to RT that collected data on PPI use along with other clinical data. A composite endpoint of disease severity, mortality and 90-day CDI recurrence was assessed based on receipt of PPI and ribotype using multivariate logistic regression.

Results
A total of 380 patients with CDI aged 66±17 years (Female: 59.5%; White: 70.5%) infected with RT 106 (115/380; 30.3%), RT027 (116/380; 30.5%), and RT014-020 (149/380; 39.2%) were included. One hundred and ninety-nine patients (52.4%) were given a PPI at the time of CDI diagnosis and 129 patients (66.1%) experienced either severe disease or CDI recurrence. Disease severity differed significantly between ribotypes (p&lt; 0.05) and increased in patients given PPI (p=0.08). CDI recurrence also differed significantly among ribotypes (p&lt; 0.05) and increased in patients given PPI. Using the composite endpoint, receipt of PPIs significantly increased the likelihood of poor outcomes (OR:1.78; 95% CI: 1.17-2.73; p=0.007) after controlling for infecting ribotype.

Conclusion
In this multicenter study, receipt of PPIs increased the likelihood of poor outcomes in CDI patients after controlling for infecting ribotype.

Disclosures
Kevin W. Garey, PharmD, MS, FASHP, Merck & Co. (Grant/Research Support, Scientific Research Study Investigator)
803. Risk factors associated with Clostridioides difficile infection in hospitalized patients with community-acquired pneumonia
Authors: Moore William Justin , Jozefczyk Caroline C , Yarnold Paul R , Harkabuz Karolina , Widmaier Valerie , Silkaitis Christina , Qi Chao , Wunderink Richard G , Sutton Sarah , Postelnick Michael J , Zembower Teresa , Rhodes Nathaniel J 
Published: January 2021

Abstract

Background
Patients with community-acquired pneumonia (CAP) who are hospitalized and treated with antibiotics may carry an increased risk for developing Clostridioides difficile infection (CDI). Accurate risk estimation tools are needed to guide monitoring and CDI mitigation efforts. We aimed to identify patient-specific risk factors associated with CDI among hospitalized patients with CAP.

Methods
Design: retrospective case-control study of hospitalized patients who received CAP-directed antibiotic therapy between 1/1/2014 and 5/29/2018. Cases were hospitalized CAP patients who developed CDI post-admission. Control patients did not develop CDI and were selected at random from CAP patients hospitalized during this period. Variables: comorbidities, laboratory results, vital signs, severity of illness, prior hospitalization, and past antibiotic use. Propensity-score weights: identified via structural decomposition analysis of pre-treatment variables. Analysis: weighted classification tree models that predicted any CDI, hospital-onset CDI, and any healthcare-associated CDI according to CAP antibiotic treatment. Performance: percent accuracy in classification (PAC) and weighted positive (PPV) and negative predictive values (NPV). Modeling: completed using the ODA package (v1.0.1.3) for R (v3.5.1).

Results
A total of 32 cases and 232 controls were identified. Sixty pre-treatment variables were screened. Structural decomposition analysis, completed in two stages, identified prior hospitalization (OR 6.56, 95% CI: 3.01-14.31; PAC: 80.3%) and BUN greater than 29 mg/dL (OR 11.67, 95% CI: 2.41-56.5; PAC: 80.8%) as propensity-score weights. With respect to CDI, receipt of broad-spectrum anti-pseudomonal antibiotics was significantly (all P’s&lt; 0.05) associated with any CDI (NPV: 90.29%, PPV: 27.94%), hospital-onset CDI (NPV: 97.53%, PPV: 26.86%), and healthcare-associated CDI (NPV: 92.89%, PPV: 27.94%).

Conclusion
We identified risk factors available at hospital admission and empiric use of broad-spectrum Gram-negative antibiotics as being associated with the development of CDI. Model PPVs were over two-fold greater than our sample base rate. Increased monitoring and avoidance of overly broad antibiotic use in high-risk patients appears warranted.

Disclosures
All Authors: No reported disclosures
805. A Single Institution Pre/Post Comparison After Introduction of an External Urinary Collection Device for Female Medical Patients
Authors: Jasperse Nathan , Hernandez-Dominguez Oscar , Deyell Jacob S , Prasad Janani P , Yuan Charlene , Tomy Meril , Kuza Catherine M , Grigorian Areg , Nahmias Jeffry 
Published: January 2021

Abstract

Background
Catheter associated urinary tract infections (CAUTIs) are the most common hospital acquired infections in the United States. External urinary collection devices (EUCDs) may serve as an alternative to indwelling urethral catheters (IUCs) and decrease the rate of CAUTIs. PureWick® is a novel female EUCD, with early case reports suggesting safe and efficacious use. However, no study has definitively proven benefit of PureWick® regarding reduction of CAUTIs. We sought to compare the CAUTI rate and median indwelling catheter days before and after availability of PureWick® at a single academic institution, as well as provide a descriptive analysis on female medical patients receiving an EUCD.

Methods
We performed a retrospective review of adult female patients admitted to our institution on a medical service who received an IUC and/or an EUCD. Patients admitted in the 3 months before (PRE) and 12 months after (POST) PureWick® availability were included. Two groups were compared: PRE patients who received an IUC vs. POST patients who received an IUC and/or EUCD.

Results
Out of 866 female patients, 296 received an EUCD in the POST cohort and overall, 673 received an IUC (261 (100%) PRE vs. 412 (68.1%) POST). There were no differences in the cohorts regarding age and comorbidities (all p &gt;0.05). Compared to the PRE cohort, the POST cohort had a higher number of IUC days (median, 3 vs. 2 days, p&lt; 0.001) and a higher rate of CAUTI (infections per 1,000 catheter days, 11.8 vs. 4.1, p=0.003) while overall UTI rate was similar (infections per 1,000 patient days, 19.1 vs. 14.12, p=0.410). In the POST cohort, the rate of UTI associated with EUCD use was 11.6 infections per 1,000 device days. Measurement of strict ins and outs (56.8%) was the most common indication for use of EUCD.
Table 1. Characteristics and comorbidities of female catheterized patients admitted to a medical service before (PRE) and after (POST) PureWick implementation.

Table 2. Urinary tract infection rates of female catheterized patients PRE and POST PureWick implementation.

Table 3. Characteristics of hospitalized female patients admitted to a medical service who received a PureWick catheter.

Conclusion
While EUCDs might appear to be a promising alternative to IUCs for female patients, this single center pre/post analysis found that both the median number of IUC days and the CAUTI rate increased after introduction of a single EUCD. This may be related to selection bias, with EUCDs being ordered for patients who would not have otherwise received an IUC. Further research is needed to clarify if female EUCDs can be effective in decreasing IUC days and/or CAUTI rates prior to any widespread adoption.

Disclosures
All Authors: No reported disclosures