Clostridioides Difficile Infection Rates Research Articles

Multicenter study on Clostridioides difficile infections in Mexico: exploring the landscape.

This study aims to outline Clostridioides difficile infection (CDI) trends and outcomes in Mexican healthcare facilities during the COVID-19 pandemic. Observational study of case series. Sixteen public hospitals and private academic healthcare institutions across eight states in Mexico from January 2016 to December 2022. CDI patients. Demographic, clinical, and laboratory data of CDI patients were obtained from clinical records. Cases were classified as community or healthcare-associated infections, with incidence rates calculated as cases per 10,000 patient days. Risk factors for 30-day all-cause mortality were analyzed by multivariate logistic regression. We identified 2,356 CDI cases: 2,118 (90%) were healthcare-associated, and 232 (10%) were community-associated. Common comorbidities included hypertension, diabetes, and cancer. Previous high use of proton-pump inhibitors, steroids, and antibiotics was observed. Recurrent infection occurred in 112 (5%) patients, and 30-day mortality in 371 (16%). Risk factors associated with death were a high Charlson score, prior use of steroids, concomitant use of antibiotics, leukopenia, leukocytosis, elevated serum creatine, hypoalbuminemia, septic shock or abdominal sepsis, and SARS-CoV-2 coinfection. The healthcare-associated CDI incidence remained stable at 4.78 cases per 10,000 patient days during the pre-and pandemic periods. However, the incidence was higher in public hospitals. Our study underscores the need for routine epidemiology surveillance and standardized CDI classification protocols in Mexican institutions. Though CDI rates in our country align with those in some European countries, disparities between public and private healthcare sectors emphasize the importance of targeted interventions.

Comparing rates of recurrent infection for first occurrence of Clostridioides difficile between tapered oral vancomycin and standard vancomycin: a retrospective, propensity matched cohort study.

To compare rates of Clostridioides difficile infection (CDI) recurrence following initial occurrence treated with tapered enteral vancomycin compared to standard vancomycin. Retrospective cohort study. Community health system. Adults ≥18 years of age hospitalized with positive C. difficile polymerase chain reaction or toxin enzyme immunoassay who were prescribed either standard 10-14 days of enteral vancomycin four times daily or a 12-week tapered vancomycin regimen. Retrospective propensity score pair matched cohort study. Groups were matched based on age < or ≥ 65 years and receipt of non-C. difficile antibiotics during hospitalization or within 6 months post-discharge. Recurrence rates were analyzed via logistic regression conditioned on matched pairs and reported as conditional odds ratios. The primary outcome was recurrence rates compared between standard vancomycin versus tapered vancomycin for treatment of initial CDI. The CDI recurrence rate at 6 months was 5.3% (4/75) in the taper cohort versus 28% (21/75) in the standard vancomycin cohort. The median time to CDI recurrence was 115 days versus 20 days in the taper and standard vancomycin cohorts, respectively. When adjusted for matching, patients in the taper arm were less likely to experience CDI recurrence at 6 months when compared to standard vancomycin (cOR = 0.19, 95% CI 0.07-0.56, p < 0.002). Larger prospective trials are needed to elucidate the clinical utility of tapered oral vancomycin as a treatment option to achieve sustained clinical cure in first occurrences of CDI.

Best Practices in the Management of Clostridioides difficile Infection in Developing Nations.

Clostridioides difficile infection (CDI) is a well-known cause of hospital-acquired infectious diarrhea in developed countries, though it has not been a top priority in the healthcare policies of developing countries. In the last decade, several studies have reported a wide range of CDI rates between 1.3% and 96% in developing nations, raising the concern that this could represent a healthcare threat for these nations. This review defines developing countries as those with a human development index (HDI) below 0.8. We aim to report the available literature on CDI epidemiology, diagnostics, management, and prevention in developing countries. We identify limitations for CDI diagnosis and management, such as limited access to CDI tests and unavailable oral vancomycin formulation, and identify opportunities to enhance CDI care, such as increased molecular test capabilities and creative solutions for CDI. We also discuss infection prevention strategies, including antimicrobial stewardship programs and opportunities emerging from the COVID-19 pandemic, which could impact CDI care.

Antibiotic use and risk of Clostridioides difficile infection in patients with inflammatory bowel disease.

Patients with inflammatory bowel disease (IBD) have an increased risk of Clostridioides difficile infection (CDI) compared with those without IBD, which is worsened with antibiotic usage. While prior studies have shown a correlation between CDI development and certain classes of antibiotics, the IBD population has not been well represented. This study evaluates the rates of CDI with outpatient antibiotic use in patients with IBD. We conducted a retrospective cohort study composed of patients with IBD and compared the incidence of CDI in patients who received an outpatient prescription for antibiotics (6694 patients) against those without prescriptions (6025 patients) from 2014 to 2020 at our institution. We compared CDI rates based on nine antibiotic classes: penicillins, cephalosporins, sulfonamides, tetracyclines, macrolides, quinolones, clindamycin, metronidazole, and nitrofurantoin. The risk of CDI was low (0.7%) but significantly higher for those with antibiotic exposure (0.9% vs 0.5%, P=0.005) and had a positive correlation with a smoking history. The increased risk of CDI in the IBD population was attributable to the clindamycin and metronidazole classes (odds ratio=4.7, 95% confidence interval: 1.9-11.9, P=0.001; odds ratio=3.6, 95% confidence interval: 2.1-6.2, P<0.0001, respectively). The use of clindamycin or metronidazole prescribed in an outpatient setting was associated with a statistically significant increased risk of CDI in patients with IBD. Although the association between clindamycin and CDI is a well-established and common finding, the association between metronidazole and CDI is unique in this study.

Organizational and infrastructural risk factors for health care–associated Clostridioides difficile infections or methicillin-resistant Staphylococcus aureus in hospitals

This study explores the infrastructural and organizational risk factors for healthcare-associated (HCA) Clostridioides difficile infections (CDIs) and methicillin-resistant Staphylococcus aureus (MRSA) in hospitals. This is a retrospective observational study involving all eligible inpatient units from 12 hospitals in British Columbia, Canada, from April 1, 2020 to September 16, 2021. The outcomes were the average HCA CDI or MRSA rates. Covariates included, but were not limited to, infection control factors (eg, hand hygiene rate), infrastructural factors (eg, unit age), and organizational factors (eg, hallway bed utilization). Multivariable regression was performed to identify statistically significant risk factors. Older units were associated with higher HCA CDI rates (adjusted relative risk [aRR]: 0.012; 95%confidence interval (CI) [0.004, 0.020]). Higher HCA MRSA rates were associated with decreased hand hygiene rate (aRR: -0.035; 95%CI [-0.063, -0.008]), higher MRSA bioburden (aRR: 9.008; 95%CI [5.586, 12.429]), increased utilization of hallway beds (aRR: 0.680; 95%CI [0.094, 1.267]), increased nursing overtime rate (aRR: 5.018; 95%CI [1.210, 8.826]), and not keeping the clean supply room door closed (aRR: -0.283; 95%CI [-0.536, -0.03]). The study confirmed the multifaceted nature of infection prevention and emphasized the importance of interdepartmental collaboration to improve patient safety.

Occurrence and trends of Clostridioides difficile infections in hospitalized patients: a prospective multi-centre cohort study in six German university hospitals, 2016–2020

For Clostridioides difficile infections (CDIs) in Germany no longitudinal multi-centre studies with standardized protocols for diagnosing CDI are available. Recent evaluations of general surveillance databases in Germany indicate a downward trend in CDI rates. We aimed to describe the actual burden and trends of CDI in German university hospitals from 2016 to 2020. Our study was a prospective multi-centre study covering six German university hospitals. We report the data in total, stratified by year, by medical specialty as well as by CDI severity. Multi-variable regression analyses were performed to assess risk factors for severe CDI. We registered 3780 CDI cases among 1,436,352 patients. The median length of stay (LOS) of CDI cases was 20 days (interquartile range 11-37) compared with a general LOS of 4.2 days. In-hospital all-cause mortality in CDI patients was 11.7% (N= 444/3780), while mortality attributed to CDI was 0.4% (N= 16/3761). CDI recurrence rate was comparatively low at 7.2%. The incidence density of severe healthcare-associated healthcare onset (HAHO)-CDI showed a significant decrease from 2.25/10,000 patient days (pd) in 2016 to 1.49/10,000 pd in 2020 (trend calculation P=0.032). Compared with a European point-prevalence study in 2013/2014, where overall CDI incidence density was 11.2 cases/10,000 pd in Germany (EUCLID), we see in our study halved overall CDI rates of 5.6 cases/10,000 pd in 2020. Our study shows current data on the distribution of CDI cases in German university hospitals and thus provides international comparative data on the key indicators of CDI.

Clinical Characteristics and Cycle Thresholds Among Discordant and True Positive Test Results for Clostridiodes difficile

Background: The diagnosis of Clostridioides difficile infection (CDI) is challenging. Despite guideline-directed, multistep testing algorithms and diagnostic stewardship, the treatment of C. difficile colonization persists. The testing algorithm at our system utilizes an initial real-time PCR test (PCR) for Toxin B gene, which if positive, reflexes to an enzyme immunoassay (EIA) for detecting Toxins A and B. Discordant results (PCR +/EIA -) are suggestive of colonization, but the majority of patients with discordant results are treated for CDI. Correlation of C. difficile EIA B polymerase chain reaction (PCR) cycle thresholds (Ct) with the presence of free EIA and disease severity has been observed, but the ability to use Ct in the decision to treat patients with discordant results is unclear. Our study assesses if Ct values and other clinical characteristics favor treatment in select patients with discordant Methods: A retrospective chart review was performed of adult patients (≥ 18-year-old) with positive C. difficile PCR results that were admitted to our health system between June 01 and August 31, 2023. C. difficile PCR and Ct results were obtained by Cepheid GeneXpert and Toxin A and B EIA results were obtained by Meridian Bioscience Immunocard. Patients with discordant (PCR+/EIA) and true positive (PCR+/EIA+) results were compared. We assessed demographics, past medical history, clinical characteristics, severity of illness, PCR Ct values, treatment, and clinical outcomes including: 30-day all-cause mortality and re-admission, and 60-day CDI repeat testing and treatment. Results Of the 122 patients identified, 89 patients had discordant results and 43 had true positive Results: Severity of illness and other clinical and laboratory characteristics were similar between both groups. Mean Ct values were significantly lower for true positive results compared to discordant results, 24.28 vs 29.27, respectively (p26 (p=.08). Of the patients with discordant results, 73 completed treatment for CDI and no difference in clinical outcomes was observed compared to patients with discordant results that were not treated. Conclusion Ct values were lower among patients with true positive results compared to patients with discordant Conclusion: There were no statistically significant different rates of severe or fulminant CDI among patients with discordant results and Ct values &lt; 26, although this finding may be limited by sample size and Ct may be helpful in deciding which discordant patients to treat.

Analysis of Clostridioides difficile infection characteristics and risk factors in patients hospitalized for diarrhea in 3 university hospitals in a mid-south city of China

To investigate the characteristics of Clostridioides difficile infection (CDI) in patients hospitalized for diarrhea and analyze the risk factors for CDI. Stool samples were collected from 306 patients with diarrhea hospitalized in 3 university hospitals in a mid-south city of China from October to December, 2020. C. difficile was isolated by anaerobic culture, and qRT-PCR was used to detect the expressions of toxin A (tcdA) and B (tcdB) genes and the binary toxin genes (cdtA and cdtB). Multilocus sequence typing (MLST) was performed for the isolated strains without contaminating strains as confirmed by 16S rDNA sequencing. Etest strips were used to determine the drug resistance profiles of the isolated strains, and the risk factors of CDI in the patients were analyzed. CDI was detected in 25 (8.17%) out of the 306 patients. All the patients tested positive for tcdA and tcdB but negative for the binary toxin genes. Seven noncontaminated C. difficile strains with 5 ST types were isolated, including 3 ST54 strains and one strain of ST129, ST98, ST53, and ST631 types each, all belonging to clade 1 and sensitive to metronidazole and vancomycin. Hospitalization within the past 6 months (OR= 3.675; 95% CI: 1.405-9.612), use of PPIs (OR=7.107; 95% CI: 2.575-19.613), antibiotics for ≥1 week (OR=7.306; 95% CI: 2.274-23.472), non-steroidal anti-inflammatory drugs (OR=4.754; 95% CI: 1.504-15.031) in the past month, and gastrointestinal disorders (OR=5.050; 95% CI: 1.826-13.968) were all risk factors for CDI in the patients hospitalized for diarrhea. The CDI rate remains low in the hospitalized patients with diarrhea in the investigated hospitals, but early precaution measures are recommended when exposure to the risk factors is reported to reduce the risk of CDI in the hospitalized patients.

Retrospective Analysis of Clostridioides difficile Infection Rates and Outcomes in Hospitalized Patients during the COVID-19 Pandemic: A Unicenter Study in Reus, Spain.

Background:Clostridioides difficile infections (CDI) vary in severity from mild diarrhea to life-threatening conditions like pseudomembranous colitis or toxic megacolon, often leading to sepsis and death. The COVID-19 pandemic prompted changes in healthcare practices, potentially affecting CDI incidence, though reported data are inconclusive. We studied factors influencing CDI incidence and outcomes at a university hospital throughout the COVID-19 pandemic years. Methods: We conducted a retrospective study on all adult hospitalized CDI cases from 1 January 2020 to 31 December 2022 in Hospital Universitari de Sant Joan in Reus. We collected demographic information, comorbid conditions, and concurrent infections. Results: While overall CDI and COVID-19 rates decreased in 2022, a notable increase in CDI infections was observed among oncological patients and those undergoing some aggressive treatments, such as colonoscopies or gastroscopies. The prevalence of comorbidities remained unmodified, and there were declines in prior gastrointestinal surgeries and proton pump inhibitor prescriptions. Factors associated with patient fatality or prolonged hospitalization included older age, cancer, chronic kidney disease, higher Charlson and McCabe indices, elevated C-reactive protein, and low albumin concentrations. Conclusions: Our study shows the evolving landscape of CDI during the COVID-19 pandemic and emphasizes the impact of delayed diagnoses and treatments exacerbated by telemedicine adoption. Identified risk factors for CDI-related mortality or prolonged hospital stays underscore the importance of targeted interventions in high-risk populations.

Impact of the Reverse 2-Step Algorithm for Clostridioides difficile Testing in the Microbiology Laboratory on Hospitalized Patients.

Multistep laboratory testing is recommended for the diagnosis of Clostridioides difficile infection (CDI). The aim of this study was to present the impact of multistep CDI diagnostic testing in an academic hospital system and evaluate the toxin B gene polymerase chain reaction (PCR) cycle threshold (Ct) values of PCR-positive tests. In October 2022, our system began reflex testing all PCR-positive stool samples with the C. DIFF QUIK CHEK COMPLETE (Techlab), an enzyme immunoassay-based test with results for the glutamate dehydrogenase antigen (GDH) and C difficile toxin A/B. Hospital-onset (HO) CDI and CDI antibiotic use before and after testing were tracked. Ct values were obtained from the Infectious Diseases Diagnostic Laboratory. Receiver operating curve analysis was used to examine the sensitivity and specificity for identifying GDH+/toxin+ and GDH-/toxin- at various Ct thresholds. The HO-CDI rate decreased from 0.352 cases per 1000 patient-days to 0.115 cases per 1000 patient-days post-reflex testing (P < .005). Anti-CDI antibiotics use decreased, but the decrease was not commensurate with CDI rates following reflex testing. PCR+/GDH+/toxin+ samples had a lower mean Ct value than PCR+/GDH-/toxin- samples (23.3 vs 33.5, P < .0001). A Ct value of 28.65 could distinguish between those 2 groups. Fifty-four percent of PCR+/GDH+/toxin- samples had a Ct value below that cut-off, suggesting the possibility of CDI with a negative toxin test. Reflex testing for a laboratory diagnosis of CDI results in rapid, systemwide decreases in the rate of HO-CDI. Additional research is needed to distinguish CDI from C difficile colonization in patients with discordant testing.

Incidence, Clinical Characteristics, and Outcomes of Clostridium difficile Infection in a Tertiary Care Center in Bahrain.

Background Clostridioides difficile infection (CDI) represents a significant healthcare challenge associated with antibiotic use and healthcare settings. While healthcare facility-onset CDI (HO-CDI) rates have been extensively studied, the incidence and risk factors of CDI in various settings, including the community, require further investigation. Aim This study aims to examine the incidence rates of CDI in a major governmental hospital in Bahrain, identify risk factors for CDI, and assess the effectiveness of infection control measures. Method We conducted a retrospective study at the Salmaniya Medical Complex (SMC), analyzing all confirmed cases of CDI over a 30-month period from January 2021 to June 2023. CDI cases were screened using glutamine dehydrogenase antigen detection and confirmed using molecular assays like polymerase chain reaction and/or toxin assaysfor confirmation.The study categorized CDI cases based on their onset (hospital or community) and explored associated risk factors, including antibiotic use, proton pump inhibitor (PPI) therapy, and patient demographics. Infection control practices were also evaluated for their role in managing CDI. Results About 57 new CDI cases were identified during the study period, with a HO-CDI incidence rate of 0.5 per 10,000 patient days. While HO-CDI rates remained stable, community-onset (CO)-CDI cases increased. The median patient age was 61.8 years, without notable differences between genders. Key risk factors for CDI were antimicrobial therapy, use of acid-reducing agents, age, and underlying comorbidities. The mortality rate stood at 35.1%. The ATLAS score (i.e., age, treatment with antibiotics, leukocyte count, albumin level, and serum creatinine) was a reliable predictor of mortality. Critical care admission and low albumin levels emerged as significant independent risk factors for mortality. Conclusions The study demonstrates a low incidence rate of HO-CDI at SMC, attributed to effective infection control and antibiotic stewardship programs. The overall CDI rate increased during the study period, driven by a rise in CO cases; further investigating the risk factors among this category in our study revealed that most patients were exposed to antibiotic therapy within the past three months of their CDI diagnosis. The rise in CO-CDI cases underscores the need for broader community-based interventions and awareness regarding antibiotic and PPI use.

Burden of Medically Attended Diarrhea and Outpatient Clostridioides difficile Infection Among Persons in 2 Large Integrated Healthcare Settings, 2016-2021.

Identification of Clostridioides difficile infection (CDI) in the community setting is increasing. We describe testing for CDI among patients with medically attended diarrhea (MAD) in the outpatient setting, and the incidence of outpatient CDI. This was a retrospective cohort study among members ≥18 years of age from Kaiser Permanente Southern California and Kaiser Permanente Northwest from 1 January 2016 through 31 December 2021. MAD was identified by outpatient diarrheal International Classification of Diseases, Tenth Revision diagnosis codes, and CDI through positive laboratory results. Outpatient CDI was defined by no hospitalization ≤7 days after specimen collection. Incidence rates (IRs) of outpatient CDI were stratified by select demographic and clinical variables. Outpatient CDI burden 12 months following index date was measured by CDI-associated healthcare visits, and CDI testing and treatment. We identified 777 533 MAD episodes; 12.1% (93 964/777 533) were tested for CDI. Of those tested, 10.8% (10 110/93 964) were positive. Outpatient CDI IR was 51.0 (95% confidence interval [CI], 49.8-52.2) per 100 000 person-years, decreasing from 58.2 (95% CI, 55.7-60.7) in 2016 to 45.7 (95% CI, 43.7-47.8) in 2021. Approximately 44% (n = 4200) received an antibiotic 30 days prior to index date and 84.1% (n = 8006) CDIs were "community-associated" (no hospitalizations 12 weeks prior to index date). Of outpatient CDIs, 6.7% (n = 526) had a CDI-associated hospitalization ≤12 months. There was a high incidence of outpatient CDI despite infrequent CDI testing among patients with MAD. The majority of those with outpatient CDI had no recent antibiotic use and no recent hospitalization. Further studies are needed to understand the source and management of medically attended outpatient CDI.

Efficacy of noncarbapenem therapy for the treatment of ceftriaxone-resistant Enterobacterales outside the urinary tract.

To determine the safety of noncarbapenem versus carbapenem antibiotics for treatment of adults with documented infection caused by ceftriaxone-resistant infections outside the urinary tract. Retrospective cohort of adult patients with a documented infection caused by an extended-spectrum β-lactamase (ESBL)-producing organism isolated between January 2018 and October 2021. An academic tertiary-care center. Adult patients with a documented infection caused by an ESBL-producing organism outside the urinary tract. The primary outcome was a composite of treatment failure defined as 30-day mortality, 30-day readmission, microbiological recurrence, and/or clinical worsening requiring antibiotic change. Secondary outcomes included differentiation of primary composite components and postantibiotic Clostridioides difficile infection (CDI). This study included 130 patients. The primary source of infections were bloodstream (67.7%) and caused by Escherichia coli (81.5%). Overall, 101 patients received carbapenem therapy and 29 received noncarbapenem therapy (NCT). NCT was comprised of mainly fluoroquinolones (18 of 29) followed by cefepime (7 of 29). Patients receiving NCT had shorter hospital stays (median, 7 days vs 9 days) and were more often discharged on antibiotics (79.3% vs 50.5%). We did not detect a significant difference in the primary composite outcome of treatment failure for carbapenem (23.8%) versus noncarbapenem treatment (24.2%; P = .967). Secondary outcomes included a numerically higher 30-day mortality rate in the noncarbapenem group compared to the carbapenem group: 4 (13.8%) of 29 versus 4 (3.9%) of 101. We did not detect a difference in rates of CDI. Noncarbapenem therapy may play a role for certain patients with infections caused by ESBL-producing organisms.

2486. Winners and Losers: MDROs In The Time of COVID-19

Abstract Background NUH is a 1200 bed academic medical center in Singapore, with endemic multi-drug resistant infections (MDROs) including carbapenemase-producing Enterobacterales (CPE), vancomycin-resistant Enterococci (VRE), Clostridioides difficile infection (CDI), and multi-drug resistant(MDR) Acinetobacter spp. (AB), and MDR Pseudomonas aeruginosa (PA). We studied the impact of COVID-19 (C19) restrictions on the prevalence of hospital acquired (HA) MDROs. Methods A HA infection is defined as a positive clinical culture after hospital day 3. The rates of key MDROs were reviewed from 2018 to the start of the zero C19 policy in Feb 2020 through the lifting of zero COVID in Aug 2021 (Delta Surge) with services still diverted until Jan 2022, when the hospital policy shifted to Endemic C19 (all clinical services resumed). Incidence rates (IR) are expressed per 10,000 patient days, and incidence rate ratios (IRR) estimated for each time period, with p&amp;lt; 0.05 considered statistically significant. We compared DDD per 100 patient days of carbapenem usage for each time period.Table 1:Incidence rates of HO CPE, VRE, CDI, and MDR AS, KP, PA, comparing pre-pandemic 2018-2019, pandemic 2020-2021, and post-pandemic 2022-March 2023Table 2:Incidence rate ratios of HO CPE, VRE, CDI, and MDR AS, KP, PA, comparing pre-pandemic 2018-2019, Zero-COVID 2020 July 2021, Delta surge Aug- Dec 2021-and Endemic COVID Jan 2022- 2023 Results While HA-MDRAB rates declined during the zero C19 period, VRE and CDI rates were stable. CPE rates decreased during the pandemic but have almost doubled post-pandemic from 0.37 in the pandemic to 0.69 post-pandemic (p&amp;lt; 0.05). The mean DDD per 100 patient days for carbapenem usage pre-pandemic was 5.24 and fell to 4.64 (p&amp;lt; 0.05) in 2020-2021.Figure 3:Incidence rates of MDROs that significantly trended downwards during the zero COVID and the Delta surge periods.Figure 4:Incidence rates of VRE and CDI appeared stable, while CPE increased post-pandemic 2022-March 2023Figure 5:Procurement of alcohol-based hand rub pre-pandemic, during pandemic, and post-pandemic Conclusion Studies globally report increased MDROs during the pandemic, purportedly due to reuse of PPE and other reasons. We experienced either a significant decrease or no change in many MDRO clinical infections, followed by a rebound since Jan 2022, when all hospital services resumed (Endemic C19). Our decrease in MDROs may be due to our zero C19 policy, increased hand hygiene, enhanced PPE adherence and cleaning regimens, a decrease in our carbapenem usage (p&amp;lt; 0.05 Table 6), and reduced elective surgeries and admissions, including overseas patients . After endemicity, we had a rebound in CPE infections, and other MDROs possibly triggered by HH and PPE fatigue (Fig. 5), the return of medical tourists and elective surgeries. Further prospective studies are needed to better understand the epidemiology of the various MDROs and the impact of draconian measures such as the Asian Zero C19 approach.Table 6:Defined daily dose of antibiotics per 100 patient days (by quarter) Disclosures All Authors: No reported disclosures

694. Impact of COVID-19 Pandemic on Clostridioides difficile Infection Rates and Risk Factors in Maryland

Abstract Background While many Healthcare Associated Infection (HAI) rates increased during the pandemic, inpatient C. difficile infection (CDI) rates declined. We compared pre-pandemic (2018-2019) to interpandemic (2020-2021) data, using Maryland’s population-based surveillance data collected through the Emerging Infections Program’s CDI HAIC project, to quantify the impact of COVID-19 on decreases in CDI within different epidemiologic classes (epi classes): HCFO, CO-HCFA, CA (Tables 1 &amp; 2).Table 1.Epidemiologic class definitions for Clostridioides difficile incident (CDI) case classifications determined by the Emerging Infection Program’s HAIC project.Table 2.Chi-square crosstabulation of Epidemiologic class Clostridioides difficile incident (CDI) case counts observed and expected pre- and interpandemic. Note: the turquoise-colored text is the expected chi-square case counts while the black text is the observed case counts. Methods Using logistic regression, we examined changes in epi class, prior antibiotic use, and basic demographics. We used crosstabulation chi-square analysis to determine proportional differences in case characteristics, pre- and interpandemic. All analyses were conducted using R version 4.2.2.Table 3.Three independent logistic regression models to determine if epidemiologic case classification is dependent on period of CDI case (Model: Interpandemic = HCFO, Interpandemic = HCFO-LTCF (HCFO-Hospital Ref.), Interpandemic = CA, Interpandemic = CO-HCFA). Results Between 2018-2021, we identified 3,822 CDI cases: 1,142 HCFO; 771 CO-HCFA; and 1,898 CA and 11 with incomplete data. Interpandemic cases were 24% less likely to be CA and 31% more likely to be CO-HCFA (Table 3, p&amp;lt; 0.001) than pre-pandemic cases. Though cases were 13% more likely to be classified HCFO, this increase was not significant between periods (Table 3, p=0.09). However, differences were identified between HCFO-LTCF and HCFO-Hospital where HCFO-LTCF cases were 26% less likely interpandemic than HCFO-Hospital cases (Table 4, p&amp;lt; 0.05; Table 3, p=0.04; respectively). Antibiotic use ≤12 weeks prior to collection did not change significantly (Table 5, p=0.7). All-cause hospital admission was 27% less likely interpandemic (p&amp;lt; 0.05). Though our catchment area is predominately White, Black/African American case counts increased while case counts in all other races declined and no differences were observed between sexes (Table 6, p&amp;lt; 0.001; Table 7, p=0.3; respectively).Table 4.Chi-square crosstabulation of HCFO Epidemiologic class Clostridioides difficile incident (CDI) case counts observed and expected pre- and interpandemic to determine where within HCFO classification between periods declines in CDI were more observed. Note: Not all HCFO designated cases are included ONLY those that were in a LTCF or Hospital 3 days prior to CDI collection date. Also, the turquoise-colored text is the expected chi-square case counts while the black text is the observed case counts.Table 5.Chi-square crosstabulation comparing CDI case counts with Antibiotic Use 12 weeks prior to C. difficile culture collection date pre-pandemic and interpandemic. Note: the turquoise-colored text is the expected chi-square case counts while the black text is the observed case counts.Table 6.Chi-square crosstabulation comparing CDI case counts of Race pre-pandemic and interpandemic. Maryland’s CDI cases are predominately White/Caucasian with the Black/African American group as the second highest racial group for our surveillance site. Comparing these two groups between these time periods is important to identify the total decline of CDI cases interpandemic. Further investigations should be conducted to better understand why this minority group’s CDI case counts increased during the COVID-19 Pandemic while all others declined. Note: the turquoise-colored text is the expected chi-square case counts while the black text is the observed case counts. Conclusion Overall CDI case counts declined during the COVID-19 pandemic across all epi classes. The rate of decline of CA was greater than the decrease in CO-HCFA cases. HCFO-LTCF cases declined more than HCFO-Hospital cases. Unexplained case rate differences between races raise health equity concerns needing exploration. Further investigation may determine whether changes in healthcare seeking behavior, changes in infection prevention methods in LTCFs, local COVID-19 restrictions, or other factors may have impacted CDI rates.Table 7.Chi-square crosstabulation comparing CDI case counts of Sex pre-pandemic and interpandemic. Note: the turquoise-colored text is the expected chi-square case counts while the black text is the observed case counts. Disclosures All Authors: No reported disclosures

Clostridioides difficile infection in neurosurgical patients in a national centre over 10 years: less common but associated with longer hospital stays.

Clostridioides difficile infection (CDI) is a leading cause of healthcare-associated (HA) diarrhoea, contributing to patient morbidity and prolonged length-of-stay (LOS). We retrospectively assessed CDI over a decade in a national neurosurgical centre, with a multi-disciplinary approach to CDI surveillance and antimicrobial stewardship, by comparing CDI patients with other patient groups. Data on CDI in neurosurgical inpatients between January 2012 and December 2021 were collated. Disease-specific variables were compared to other inpatients with CDI. Rates per 10,000 bed days used were calculated. Patient-specific differences were compared with neurosurgical patients without CDI. CDI rates by patient group were explored using odds ratio (OR) and χ2 analyses. Negative binomial regression was used to investigate CDI rates over time. Of 50 neurosurgical patients with CDI, all were HA; the average age was 53 years (standard deviation (SD) 16.3 years), 49 were first-episode CDI, and three had severe CDI. The majority (76.7%) had received recent antimicrobials. Compared with non-neurosurgical CDI patients, neurosurgical CDI rates differed significantly (1.9 versus 3.6 per 10,000 bed days used, p < 0.05), neurosurgical patients were younger (p ≤ 0.01), C. difficile testing was more likely to be requested by neurosurgeons (OR 2.4; p ≤ 0.01), and the proportion of severe CDI was higher (6% versus 2%, OR 3.0, p = 0.07, confidence interval (CI) 0.54 to 11.3). Within the neurosurgical cohort, CDI patients had an average LOS four times that of other patients (CI 15.2 to 35.1; p < 0.01) and were older (53.5 versus 47.8 years, CI 0.1 to 11 years; p < 0.05). Only one CDI outbreak was linked to neurosurgical patients. CDI in neurosurgery patients differed from the wider hospital, with greater awareness of CDI testing. Longer LOS impacted bed utilisation with limited capacity. Robust surveillance supports proactive antimicrobial stewardship programmes in this vulnerable population.

Identification of antibiotic consumption targets for the management of Clostridioides difficile infection in hospitals- a threshold logistic modelling approach

ABSTRACT Background This study aims to demonstrate the utility of a threshold logistic approach to identifying thresholds for specific antibiotic use associated with Clostridioides difficile infection (CDI) in an English teaching hospital. Methods A combined approach of nonlinear modeling and logistic regression, named threshold logistic, was used to identify thresholds and risk scores in hospital-level antibiotic use associated with hospital-onset, healthcare-associated (HOHA) CDI cases. Results Using a threshold logistic regression approach, an incidence greater than 0.2645 cases/1000 occupied bed-days (OBD; 85th percentile) was determined as the cutoff rate to define a critical (high) incidence rate of HOHA CDI. Fluoroquinolones and piperacillin-tazobactam were found to have thresholds at 84.8 and 54 defined daily doses (DDD)/1000 OBD, respectively. Analysis of data allowed calculating risk scores for HOHA CDI incidence rates exceeding the 85th percentile, i.e. entering critical incidence level. The threshold-logistic model also facilitated performing ‘what-if scenarios’ on future values of fluoroquinolones and piperacillin-tazobactam use to understand how HOHA CDI incidence rates may be affected. Conclusion Using threshold logistic analysis, critical incidence levels and antibiotic use targets to control HOHA CDI were determined. Threshold logistic models can be used to inform and enhance the effective design and implementation of antimicrobial stewardship programs.

Infections After Adoption of Antibiogram-directed Prophylaxis and Intracorporeal Urinary Diversion for Robot-assisted Radical Cystectomy

BackgroundEnhanced recovery after surgery (ERAS) has significantly decreased the morbidity associated with radical cystectomy. However, infectious complications including sepsis, urinary tract (UTIs), wound (WIs), and intra-abdominal (AIs) infections remain common. ObjectiveTo assess whether intracorporeal urinary diversion (ICUD) and antibiogram-directed antimicrobial prophylaxis would decrease infections after robotic-assisted radical cystectomy (RARC). Design, setting, and participantsA retrospective analysis was performed of a prospectively maintained database of patients undergoing RARC between 2014 and 2022 at a tertiary care institution, identifying two groups based on adherence to a prospectively implemented modified ERAS protocol for RARC: modified-ERAS—ICUD and antibiogram-directed ampicillin-sulbactam, gentamicin, and fluconazole prophylaxis were utilized (from January 2019 to present time), and unmodified-ERAS—extracorporeal urinary diversion (UD) and guideline-recommended cephalosporin-based prophylaxis regimen were utilized (from November 2014 to June 2018). Patients receiving other prophylaxis regimens were excluded. InterventionICUD and antibiogram-directed infectious prophylaxis. Outcome measurements and statistical analysisThe primary outcome was UTIs within 30 and 90 d postoperatively. The secondary outcomes were WIs, AIs, and sepsis within 30 and 90 d postoperatively, and Clostridioides difficile infection (CDI) within 90 d postoperatively. Results and limitationsA total of 396 patients were studied (modified-ERAS: 258 [65.2%], unmodified-ERAS: 138 [34.8%]). UD via a neobladder was more common in the modified-ERAS cohort; all other intercohort demographic differences were not statistically different. Comparing cohorts, modified-ERAS had significantly reduced rates of 30-d (7.8% vs 15.9%, p = 0.027) and 90-d UTIs (11.2% vs 25.4%, p = 0.001), and 30-d WIs (1.2% vs. 8.7%, p < 0.001); neither group had a WI after 30 d. Rates of AIs, sepsis, and CDI did not differ between groups. On multivariate regression, the modified-ERAS protocol correlated with a reduced risk of UTIs and WIs (all p < 0.01). The primary limitation is the retrospective study design. ConclusionsUtilization of ICUD and antibiogram-based prophylaxis correlates with significantly decreased UTIs and WIs after RARC. Patient summaryIn this study of infections after robotic radical cystectomy for bladder cancer, we found that intracorporeal (performed entirely inside the body) urinary diversion and an institution-specific antibiogram-directed antibiotic prophylaxis regimen led to fewer urinary tract infections and wound infections at our institution.

Association of Clostridioides difficile infection rates with social determinants of health in Denver area census tracts, 2016–2019

We evaluated the association between census tract measures of socioeconomic status and Clostridioides difficile infection (CDI) rates in the Denver metro area from 2016 to 2019. Social vulnerability index, poverty, and race were associated with CDI. Findings may relate to differences in chronic disease prevalence, antibiotic exposure, and access to quality care.

A retrospective study investigating the management, risk factors, and outcomes of patients diagnosed with Clostridioides difficile infection

AbstractBackgroundThe rate of clostridioides difficile infection (CDI) in Australia has increased by more than 8% between 2016–2018. This can be attributed to multiple factors including an ageing population, widespread antibiotic and proton‐pump‐inhibitor usage.AimThe aim of this study was to investigate the management, risk factors and outcomes for CDI to identify strategies to reduce its incidence.MethodA single‐centre retrospective audit was completed using medical records for patients admitted to a 250‐bed regional Queensland hospital with CDI in 2020–2021. Data surrounding CDI management for each patient was analysed against the Therapeutic Guidelines. This study was approved by The Prince Charles Hospital Human Research Ethics Committee (Reference No: LNR/HREC/QPCH/81287).ResultsThere were 72 cases with CDI during the study timeframe. Recent antibiotic prescription, proton‐pump‐inhibitor (PPI) use and antibiotic allergy labels were common. Thirty‐five per cent of cases were treated appropriately. Eight per cent died, and nine per cent had relapsed CDI within 12 weeks of diagnosis. Common gaps found in the results included inappropriate selection of antibiotics based on the severity of disease and lack of documentation surrounding CDI cases left untreated.ConclusionThere are multiple opportunities for pharmacists to improve the care of patients with CDI which range from promoting guideline adherence, influencing prescriber antibiotic selection based on disease severity, prompting review of PPIs upon CDI diagnosis and prompting provider follow‐up of CDI laboratory results pending at the point of patient discharge. The results of this study have prompted antimicrobial stewardship service review of all CDI admissions at the study site and indicates the need for a larger multiple‐site study to raise awareness of CDI risk factors and severity criteria.