bluuebunny/crossref_metadata_2025_split huggingface dataset:
2344. Evaluation of a Best Practice Alert (BPA) to Reduce Inappropriate Testing for Clostridium difficile Infection (CDI) Within a Multi-Hospital System
Authors: Dare Ryan K , Bewley Claire E , Novack Amanda J , Heiles Jared M , Chin Larissa K 
Published: October 2019

Abstract

Background
Hospital-acquired CDI contribute to significant morbidity, mortality, and cost burden in hospitalized patients. Clinical practice guidelines recommend strict testing criteria when employing nucleic acid amplification testing alone as to not test asymptomatic carriers. A BPA within the electronic medical record (EMR) may assist with this screening.

Methods
At our 9-hospital system, we created a BPA to help identify patients who may not meet criteria for CDI testing. Initial BPA (January 2018) asked if patient had 3 or more stools (yes/no) and if laxatives were administered in the last 48 hours (yes/no). An expanded BPA was updated to pull medication administration records for use of laxatives in the prior 48 hours (August 2018) and notified providers of recent C. difficile testing in the past 7 days (January 2019). C. difficile orders from March 2017 (historical), March 2018 (intervention 1), and March 2019 (intervention 2) were evaluated to assess impact of these interventions.

Results
C. difficile testing during 30,621 (historical), 31,299 (intervention 1), and 31,960 (intervention 2) patient-days were evaluated. Rates of C. difficile orders and infections are reported in the table. Ratio of positive C. difficile specimens to tested specimens were similar between the historical arm (51 of 402; 12.7%) and both intervention 1 (42 of 271; 15.5%) and intervention 2 (45 of 316; 14.2%) arms (P = 0.3 and P = 0.5, respectively). Intervention 1 and intervention 2 arms were similar in all metrics. Statistical analysis was performed using Stata, v.14.2.

Conclusion
Implementation of a decision support tool to assist with C. difficile testing significantly decreased order rates in both the initial and expanded BPA intervention arms. Compared with historical rates, incidence of CDI decreased in both intervention arms though these were not statistically significant. Similarly, ratio of positive specimens to specimens tested increased in both intervention arms, though not significant, indicating a trend toward improved patient selection. To improve appropriate CDI testing, further oversight and/or education is needed to accompany implementation of an EMR decision support tool, such as BPAs.

Disclosures
All authors: No reported disclosures.
2348. Incorporating Electronic Medical Record Hard Stops to Reduce Inappropriate Clostridioides difficile Testing at an Academic Medical Center: A Quality Improvement Study
Authors: Lakshmi Seetha , Atrubin Kimberly , Myers Andrew , Teter Jonathan , Jariwala Ripal , Zeitler Kristen , Haubner Laura , Ashmeade Terri , Balakrishnan Maya 
Published: October 2019

Abstract

Background
Clostridioides difficile is the most common pathogen causing healthcare-associated infections. This study highlights the multi-disciplinary efforts to reduce C. difficile infections (CDI) at a large, tertiary care teaching facility.

Methods
A quality improvement study was performed between March 2017 and April 2018, using six Plan-Do-Study-Act cycles that included transmission prevention, diagnostic stewardship, education, and antimicrobial stewardship. Process measures included hand hygiene, isolation precautions, low-level disinfection compliance, number of tests ordered, lab cancelation of tests, and compliance with the Electronic Medical Record (EMR) hard stop for patients with laxative use, and negative C.difficile test in the past 7 days.

Results
A total of 2,046 C. difficile tests were ordered during the initiative. Of the 124 patients with a positive C. difficile LabID event, 50% were male with a median age of 65 years (range: 11–92 years). A 53% reduction in C. difficile LabID events (7.5 to 4 events per 10,000 patient-days, P < 0.001), with a pronounced decrease between cycle 4 and 5 (5.4 to 2.9 events per 10,000 patient-days, P < 0.001) was achieved. The largest decrease in C. difficile lab tests ordered was seen after implementation of the EMR hard-stop (cycle 5), with fewer than 0.5 LabID events per 1,000 patient-days for each subsequent month after EMR hard-stop implementation. Frequent reasons for physician phone calls to Infection prevention department was related to chronic use of lactulose in patients with cirrhosis (30%) and unexplained diarrhea (70%). Based on provider feedback, EMR changes were made to remove lactulose from the hard-stop and offer infectious disease consultation upfront. There was 99% compliance with electronic medical record hard stop. There was a nonsignificant increase in lab cancelations due to inappropriate stool specimens over time (1.9% to 3.1% from cycle 1 to 6, P = 0.28) A 55% reduction in hospital-onset CDI surveillance events (from 6.9 to 3.2 per 10,000 patient-days, P < 0.001) was noted.

Conclusion
A multi-disciplinary Quality Improvement initiative is a successful strategy in reducing CDI events, with the largest decrease seen with introduction of EMR hard stops.

Disclosures
All authors: No reported disclosures.
2353. Easy Does It: Decreasing and Sustained Hospital-Onset (HO) CDI Lab-ID Event Incidence Through a Series of Interventions
Authors: Lee Rachael A , Walker Jeremey , Freeze Elizabeth , Khalid Rashida , Camins Bernard 
Published: October 2019

Abstract

Background
Clostridioides difficile infection (CDI) Laboratory (Lab) identified (ID) events are reportable to CMS through the CDC’s NHSN. Prevention of transmission has been the main component of interventions; however, avoiding false-positive laboratory diagnoses can also lead to decreased incidence.

Methods
A retrospective analysis of HO-CDI Lab-ID events was conducted to evaluate the results of a series of interventions at the University of Alabama Hospital, a 1150-bed tertiary care center in Birmingham, AL. The study period was from the first quarter of 2013 (1Q 2013) until 1Q of 2019. Interventions were implemented in sequential order were: (i) CDI prevention bundle education (3Q 2014); (ii) two-step laboratory testing algorithm (2Q 2015); (iii) selective enhanced environmental disinfection on oncology units (2Q 2016); (iv) diagnostic stewardship by reminding providers to reconsider testing if the patient received a laxative within 48 hours (4Q 2016).

Results
At the beginning of the study period, the HO CDI Lab ID Event SIR was 0.96. The standard infection ratio (SIR) over the time period is shown in Figure 1. We observed a slight decrease in HO-CDI Lab ID event SIR after implementation of the CDI prevention bundle (0.96 vs. 0.77). A change in the diagnostic testing from PCR-based to a two-step algorithm (EIA testing for GDH and Toxin confirmed by PCR) resulted in a slight increase although not statistically significant (0.77 vs. 0.83). A downward trend was observed when selective enhanced terminal disinfection with hydrogen peroxide vapor was performed on all oncology patient rooms vacated by patients with CDI (0.83 vs. 0.72). The largest and sustained impact was observed after implementation of a computer-assisted diagnostic stewardship in which providers were reminded if the patient was administered any stool softener or laxative within 48 hours of the order for CDI testing (0.72 vs. 0.32). The institutions SIR value became significant in 2Q 2016 (P = 0.0014) and significance was maintained since that time. The difference between expected and observe HO-CDI Lab ID events is demonstrated in Figure 2.

Conclusion
Through a series of interventions, we observed a decrease in HO-CDI event rates. Diagnostic stewardship with academic detailing resulted in the most impactful and sustained improvement.

Disclosures
All authors: No reported disclosures.
2355. The Association Between Diagnostic Testing Method and Clostridium difficile Infection Severity
Authors: Menon Anitha , Perry Donald A , Motyka Jonathan , Weiner Shayna , Standke Alexandra , Penkevich Aline , Keidan Micah , Young Vincent B , Rao Krishna 
Published: October 2019

Abstract

Background
The optimal diagnostic strategy for Clostridium difficile infection (CDI) is not known, and no test is shown to clearly differentiate colonization from symptomatic infection. We hypothesized that detection and/or quantification of stool toxins would associate with severe disease and adverse outcomes.

Methods
We conducted a retrospective cohort study among subjects with CDI diagnosed in 2016 at the University of Michigan. The clinical microbiology laboratory tested for glutamate dehydrogenase antigen and toxins A/B by enzyme immunoassay (EIA). Discordant results reflexed to PCR for the tcdB gene. Stool toxin levels were quantified via a modified cell cytotoxicity assay (CCA). C. difficile was isolated by anaerobic culture and ribotyped. Severe CDI was defined by the IDSA criteria: white blood cell count >15,000 cells/µL or a 1.5-fold increase in serum creatinine above baseline. The primary outcomes were all-cause 30-day mortality and a composite of colectomy, ICU admission, and/or death attributable to CDI within 30 days. Analysis included standard bivariable tests and adjusted models via logistic regression.

Results
From 565 adult patients, we obtained 646 samples; 199 (30.8%) contained toxins by EIA. Toxin positivity associated with IDSA severity (Table 1), but not our primary outcomes on unadjusted analysis. After adjustment for putative confounders, we still did not observe an association between toxin positivity and our primary outcomes. Stool toxin levels by CCA >6.4 ng/mL associated with IDSA severity (Table 1), but not the primary outcomes. Compared with the period from 2010 to 2013, the circulating ribotypes of C. difficile at our institution changed in 2016. Notably ribotype 106 newly emerged, accounting for 10.6% of strains, and ribotype 027 fell to 9.3% (Table 2). The incidence of ribotype 014-027 has remained stable at 18.9%, but this strain was associated with both IDSA severity and 30-day mortality (OR = 3.32; P = 0.001).

Conclusion
Toxin detection by EIA/CCA associated with IDSA severity, but this study was unable to confirm an association with subsequent adverse outcomes. The molecular epidemiology of C. difficile has shifted, and this may have implications for the optimal diagnostic strategy for CDI.

Disclosures
All authors: No reported disclosures.
2365. Volatile Metabolite-Based Detection of Clostridium difficile Infection (CDI)
Authors: Aloum Obadah , Thalavitiya Acharige Mahesh J , Ismail Nour , Hejazi Mohamad , Al Kateb Mohamad , Zhao Yibai , Balasubramanian Raji , Koo Sophia 
Published: October 2019

Abstract

Background
CDI is a frequent cause of morbidity and mortality in hospitalized patients. Despite advances in rapid CDI testing, there are often delays between the onset of symptoms and receipt of test results. We sought to test the hypothesis that the altered CDI intestinal microbiome has a unique volatile metabolite profile, distinct from the profile of patients with other causes of antibiotic-associated diarrhea, which potentially can be used to identify patients with CDI.

Methods
We prospectively collected fresh stool samples from inpatients with suspected CDI at an academic tertiary care hospital from July 2015 to November 2017, adsorbed volatile metabolites from each sample onto sorbent tubes within an hour of sample collection, and used thermal desorption-gas chromatography/tandem mass spectrometry to identify each metabolite. All patients were exposed to at least one antibiotic agent in the prior 90 days, and only patients receiving empiric CDI treatment or with formed stool samples were excluded. We used logistic regression models, adjusting for prior anti-anaerobic antibiotic therapy and CDI severity (serum albumin <3 g/dL and WBC ≥ 15,000/mm3 or abdominal tenderness) and adjusting for multiple testing using Storey’s q-value procedure (with a threshold of q ≤ 0.05), to examine the relationship between CDI, as determined by the reference standard of the cell culture cytotoxicity neutralization assay, and each metabolite.

Results
In our 565-patient cohort, median age was 61 years (IQR 50, 70) and 277 (49%) were male; 173 (31%) had abdominal pain in the 24 hours before testing, 59 (10%) had fevers in the prior 24 hours, 22 (4%) had an ileus, 74 (13%) had mental status changes in the prior 24 hours, 89 (16%) were hospitalized in the ICU at the time of testing, 45 (7%) were receiving pressors, 82 (15%) had a WBC ≥ 15,000/mm3, and 137 (24%) had a serum lactate > 1.5 mmol/L. Ultimately, 155 patients were diagnosed with CDI. Ten metabolites (Table 1, Figure 1) were differentially distributed in patients with and without CDI.

Conclusion
We identified a suite of volatile metabolites that differentiates stool from patients with and without CDI; this profile may ultimately be used to identify patients with CDI.

Disclosures
All authors: No reported disclosures.
2368. Molecular Epidemiology of Clostridioides difficile Infections in Pediatric Oncology and Transplant Patients
Authors: Barbar Ruba , Hakim Hana , Hayden Randall , Hayden Randall , Garner Cherilyn D , Brazelton de Cardenas Jessica B , Carroll Karen C , Bourdas Dimitrios , Carroll Shawna Kimberly 
Published: October 2019

Abstract

Background
The incidence of Clostridioides difficile infection (CDI) has been rising among children, both in the community and hospital setting. The genomic variability and molecular epidemiology of CDI in children, especially with cancer are poorly understood. We aim to evaluate the molecular epidemiology and relatedness of C. difficile isolates among inpatient and outpatient pediatric oncology and stem cell transplant patients (POTP) using whole-genome sequencing (WGS).

Methods
This was a retrospective cohort study of CDI in POTP in 2016. CDI cases were identified by electronic medical record search for positive C. difficile toxin PCR tests. Retrieved residual stool specimens were cultured anaerobically using pre-reduced CCMB-TAL broth (Anaerobe Systems, Inc.), toxin-producing C. difficile isolates were determined using a cell culture cytotoxicity assay with neutralization (TechLab, Inc.), and WGS was performed, followed by core genome MLST (cgMLST). Variability of the isolates was summarized by strain type (ST), and a minimum spanning tree was constructed, defining clusters of genomically related isolates as those with < 7 alleles difference. Plausible epidemiologic links among the closely related strains such as receiving care on the same inpatient unit on the same day or on the same unit but on different days within 8 weeks before CDI were evaluated to identify potential transmission events.

Results
Among 141 CDI episodes in 89 patients; 103 stool samples were cultured, and 101 (98%) isolates were sequenced identifying 23 different strain types in 81 (80%) isolates. 34 (38%) patients had multiple episodes of CDI. 16 clusters of related isolates were identified (figure), 10 (62%) of which involved only multiple specimens from the same patient. For the 6 clusters involving multiple patients, epidemiologic investigation revealed only 2 (33%) potential transmission events.

Conclusion
WGS identified a highly diverse group of C. difficile isolates among POTP with CDI. Although WGS identified clusters of closely related isolates in multiple patients, epidemiologic investigation of shared inpatient exposures identified potential transmission in only two clusters. C. difficile transmission was uncommon.

Disclosures
Randall Hayden, MD, Abbott Molecular: Advisory Board; Quidel: Advisory Board; Roche Diagnostics: Advisory Board.
2370. Risk Factors for Clostridioides difficile Colonization Among Adult Inpatients: A Meta-Analysis
Authors: Brown Adam M , Anjewierden Scott , Deshpande Abhishek 
Published: October 2019

Abstract

Background
Clostridioides difficile is one of the most common causes of healthcare-associated infections in the United States. The prevalence of asymptomatic C. difficile colonization has been demonstrated to range from 3 to 21% for hospitalized adults. Patients colonized with C. difficile may serve as potential reservoirs for transmission of C. difficile infection (CDI) within inpatient units. The purpose of this meta-analysis was to identify the risk factors for colonization at hospital admission among adult patients, to inform strategies for infection prevention.

Methods
We searched MEDLINE, Scopus, Web of Science, and Embase from inception to 2019 for articles related to C. difficile colonization on hospital admission. Studies with multivariate analyses evaluating risk factors for asymptomatic colonization in adult inpatients were eligible. Odds ratios were pooled using a random effects model. Study quality and publication bias analyses were also conducted.

Results
Among 2,982 studies identified in the search, 21 studies met the inclusion criteria. Included studies reported 18,468 adult patients of which 1,243 were asymptomatically colonized with C.difficile. Factors associated with an increased risk of colonization were CDI in the last 3 months (OR 4.18, 95% CI 2.56–6.82, I2 = 0%), hospitalization in the last 6 months (OR 2.45, 95% CI 2.06–2.92, I2 = 0%) and use of gastric acid suppression therapy within the last 8 weeks (OR 1.46, 95% CI 1.17–1.73, I2 = 1%). Receipt of antibiotics in the last 3 months (OR 1.37, 95% CI 0.94–2.01, I2 = 48%) and use of non-steroidal anti-inflammatory drugs (OR 0.90, 95% CI 0.52–1.55, I2 = 65%) were not associated with statistically significant effects on risk of colonization. There were insufficient studies to determine the association between most antibiotic classes and the risk of colonization.

Conclusion
C.difficile colonization on hospital admission was significantly associated with previous CDI, recent hospitalization, and gastric acid suppression therapy. Recognition of these risk factors may assist in identifying potential carriers of C. difficile. These findings also emphasize the importance of judicious use of gastric acid suppression and other preventative measures in reducing C. difficile acquisition.

Disclosures
All authors: No reported disclosures.
2375. Association Between Clostridium difficile Colonization and Inflammatory Bowel Disease Activity
Authors: Morado-Aramburo Oscar , Ochoa-Hein Eric , Bobadilla-Del-Valle Miriam , Yamamoto-Furusho Jesus K , Ponce de Leon Alfredo , Sifuentes-Osornio Jose 
Published: October 2019

Abstract

Background
Clostridium difficile (CD) is a frequent cause of nosocomial infectious diarrhea. Despite no clear evidence has linked CD colonization (CDC) or CD infection (CDI) with inflammatory bowel disease activity (IBDA), data in our setting has suggested the contrary.

Methods
Prospective cohort study in a tertiary care hospital in Mexico City. Patients aged ≥18 years with IBD in clinical remission were included between April 2017 and April 2019. Demographic, clinical and laboratory variables, as well as three fecal samples, were collected at inclusion and during follow-up. CDC was defined as a positive GDH test without diarrhea. CDI was defined as diarrhea (as per IDSA criteria) plus positive GDH and PCR tests. IBDA was defined as bloody diarrhea plus a negative GDH test. The primary outcome was the association between CDC and IBDA. Secondary outcomes were incidence rates of CDC and CDI, including risk factors associated with CDC. Univariate and multivariable analyses were performed considering P < 0.05 as statistically significant.

Results
Out of 250 IBD patients, 101 cases met inclusion criteria and 85 completed follow-up (median = 420 days, IQR = 243–511 days). Twenty-three cases (27%) had IBDA during follow-up, eight cases had new CDC (incidence of 8.2/100 person-years), and one case developed CDI (incidence of 1.0/100 person-years). Figure 1 shows the cumulative percentage of cases without CDC during follow-up. In univariate analysis, the following were associated with CDC: decreasing age, decreasing age when IBD was diagnosed, residence in Mexico City or the State of Mexico, and hospitalization during follow-up. In Cox regression analysis, a decreasing age when IBD was diagnosed (HR = 0.92, CI95% = 0.87–0.98, p = 0.009) and residence in the State of Mexico (HR = 5.88, CI 95% = 1.21–28.60, p = 0.028) remained significantly associated with CDC. However, we did not find a statistically significant association between new CDC events and IBDA during a median follow-up period extending beyond 1 year.

Conclusion
We found no association between CDC and IBDA. Risk factors associated with CDC were residence in the State of Mexico and a decreasing age when IBD was diagnosed.

Disclosures
All authors: No reported disclosures.
2380. Fecal Collinsella Abundance is Negatively Associated with Toxin A/B Production in Cancer Patients with Clostridioides difficile
Authors: A. Francisco Denise Marie , Olvera Adilene , Zhang Liangliang , Yepez Guevara Eduardo , Garey Kevin W , Peterson Christine , Do Kim-Anh , Dillon Ryan J , Jenq Robert , Okhuysen Pablo C 
Published: October 2019

Abstract

Background
The detection of C. difficile (CDI) by nucleic acid amplification test (NAAT) with negative toxin enzyme immunoassay (EIA-) is difficult to interpret in cancer patients. Markers that differentiate true infection from colonization, and are associated with clinical outcomes are needed. We hypothesized that the microbiome composition and inflammatory fecal markers in EIA- patients differed from those who are EIA+ and were associated with disease severity and recurrence.

Methods
We studied the fecal microbiome composition (16s rRNA, V3) of 147 cancer patients with CDI diagnosed by a two-step testing algorithm. Clinical data, CDI bacterial quantity (BQ) by qPCR and markers of intestinal inflammation (calprotectin, lactoferrin, IL-1β and IL-8) were analyzed. Data were stratified according to cancer type [hematologic (H) n = 49, solid tumor (ST) n = 66, or stem cell transplant (SCT) n = 32].

Results
Demographic characteristics and symptoms were similar between the three groups. At baseline, species diversity by Shannon index was similar in all three groups regardless of EIA detection and did not correlate with clinical presentation, response to therapy or recurrence. Microbiome composition did not correlate with inflammatory response except in H in whom a higher diversity correlated with increased IL-8 (P = 0.021) and calprotectin (P = 0.01) levels. At the genus level across all strata and when compared with EIA- cases, EIA+ cases presented with a higher abundance of Peptoclostridium (P = 0.0008) which correlated with CDI BQ qPCR (log of BQ/mg 2.38 ± 1.49 vs 0.92 ± 1.28, P < 0.001). In contrast, EIA- cases had a higher abundance of Collinsella (P = 0.001). SCT patients carried fewer Peptoclostridium when compared with other groups, whereas all three patient groups carried similar amounts of Collinsella. The relative abundance of Peptoclostridium and Collinsella was not associated with response to therapy, or fecal markers of inflammation. Principal component analysis did not demonstrate differences between the three groups studied.

Conclusion
In this study, the presence of Collinsella, a known butyrate and bile salt hydrolase producer, was associated with the lack of CDI toxin A/B production. Loss of Collinsella may represent a novel risk factor for active CDI.

Disclosures
All authors: No reported disclosures.