Clostridium Difficile Infection Infection Research Articles

Guidelines for diagnosis,treatment and prevention of clostridium difficile infection in China(2024)

Clostridium difficile infection(CDI) is an intestinal infection caused by Clostridium difficile,characterized by clinical symptoms such as fever,abdominal pain,watery diarrhea,and loose stools. Mild cases present with diarrhea,while severe cases can progress to pseudomembranous colitis,often accompany by complications such as toxic megacolon,intestinal perforation,and septic shock. CDI is a significant cause of complications and mortality,especially among elderly patients,and is one of the most common hospital-acquired infections. The purpose of this guideline is to provide guidance on the diagnosis,treatment,and prevention of CDI,covering a total of 20 clinical questions across three domains: diagnosis,treatment,and prevention. The guideline was developed by a collaborative effort of a guideline expert group and a guideline working group. The guideline expert group consists of 37 clinical experts in 18 specialties related to the diagnosis and treatment of CDI and healthcare associated infection control. This guideline was developed using the internationally recognized GRADE method. It includes evidence evaluation and recommendation grading. It categorizes the quality of evidence into four levels: high,medium,low and very low. When formulating recommendations,it considers factors such as the balance of benefits and harms of intervention,quality of evidence,values and preferences,as well as cost and resource consumption. The recommendations are classified into strong and weak recommendations(conditional recommendations). The target audience of this guideline includes Chinese doctors and patients.

A Complex Relationship between Clostridium Difficile Infection and Graft Versus Hoste Disease: Fundeni Clinical Institute Experience

Introduction: Clostridium difficile infection (CDI) is a common complication in patients who have undergone hematopoietic stem cell transplantation (HSCT) due to prolonged hospitalization, prolonged neutropenia, use of broad-spectrum antibiotics, mucosal damage, changes in gut microbiota and compromised immunity. The incidence of CDI in patients undergoing allogeneic HSCT varies between 12 and 34% in the literature and has gradually increased in recent years in Europe North America due to the NAP1 strain. In the patient who has experienced allogeneic HSCT, diagnostic testing for CDI should include both nucleic acid amplification test (NAAT) and enzyme immunoassays (EIA) for toxins A and B, because detection of toxins A and B tests have a sensitivity of 75-80%. 5 In HSCT patients, CDI appears to be strongly associated with graft versus host disease (GVHD), gut GVHD and/or severe GVHD, but this has not been universally demonstrated. The aim: For this reason, we wanted to see whether patients who developed a CDI between day 0 and day 100 were at higher risk for gut GVHD or for severe GVHD. Results: Between January 2017 and August 2022, we performed 290 of allogeneic hematopoietic stem cell transplant procedures, in the Fundeni Clinical Institute. 50/290 developed CDI within the first 100 days after HSCT and before the diagnosis of intestinal GVHD, and 240/290 did not develop CDI. 16/50 (32%) of those with CDI developed acute GVHD, respectively 402/240 (43%) of those without CDI. From these 13/16, respectively 50/102 hade gut involvement. Of the 118 patients with acute GVHD, 13/16 in the group with CDI, respectively 30/102 in the group without CDI were assigned to severe acute GVDH (grade III and IV). Mortality due to gut GVHD in the group with CDI was 46%, respectively 14% in the group without CDI. In conclusion: CDI is not a risk factor for GVHD, but gut damage is usually associated. CDI infection is associated with severe forms of GVHD, and the implication of the digestive tract in these patients increases mortality. Also, often in the patient with digestive GVHD, CDI can coexist, making them difficult to treat.

Prevalence of Clostridium Difficile Infection (CDI) among Inflammatory Bowel Disease (IBD) Patients in Comparison to Non-IBD Patients in King Abdulaziz Medical City in Jeddah.

The prevalence of Clostridium difficile infection (CDI) as a common complication among inflammatory bowel disease (IBD) has been reported to increase worldwide and has been associated with a poor IBD outcome. In this study, our aim was to report on the prevalence of CDI among IBD vs. non-IBD patients in King Abdulaziz Medical City (KAMC). This retrospective descriptive study was carried out between 2016 and 2020. Data of 89 patients reported with CDI in KAMC were analyzed for demographics and correlations between various characteristics such as BMI, personal/family history of IBD, infection with CDI, diagnosis, method of diagnosis, and treatment modalities. Of the total 89 CDI patients, 59 (66.3%) were adults and 30 (33.7%) were pediatric, of which 36 (40.4%) were females and 53 (59.6%) were males. PCR was the main method of choice for the diagnosis of CDI (89.9%) followed by a positive-culture result (10.0%). Seventy-eight (87.6%) CDI patients were found to be immunocompromised, with two patients diagnosed with IBDs, one with UC, and one with CD. The recurrence rate was 38.4 (30 patients) among the immunocompromised group in comparison to 27.2 (3 patients) in the immunocompetent group (p=0.584). In this study, we found that adults were more prone to CDI infection, especially within hospital settings, and most of the CDI infections occurred in immunocompromised individuals, with cancer as the most common cause of it.

C. DIFFICILE INFECTION AS A MAKER FOR DYSBIOSIS IS LONGITUDINALLY ASSOCIATED WITH COGNITIVE DECLINE AND DEMENTIA

Abstract Disruption of the gut microbiome (dysbiosis) is associated with cognitive decline and dementia; however, there is a lack of findings demonstrating how dysbiosis is longitudinally associated with cognitive outcomes. This study aimed to quantitatively assess whether there is an association between Clostridium difficile infection (CDI) as a marker for dysbiosis and cognitive decline and dementia. We used 6,147 older adults from the Health and Retirement Study and the Centers for Medicare and Medicaid Services from 1999-2012. Outcome variables included cognitive scores (0-27) and dementia (8 or less). The exposure was time-varying ICD-9 CDI. Generalized estimating equation were used for the main analysis. Having at least one CDI infection was associated with -2.85 (B = -2.85; 95% CI: -4.43, -0.26) at 2000 (baseline) and at 2002 (B = -2.85; 95% CI: -4.43, -0.26), 2004 (B = -2.85; 95% CI: -4.43, -0.26), 2006 (B = -2.85; 95% CI: -4.43, -0.26), and 2008 (B = -2.85; 95% CI: -4.43, -0.26), after adjusting. Those having at least one CDI had 6.62 greater odds (OR = 6.62; 95% CI: 1.68, 26.05) of dementia at 2000 and was associated with time points 2002 (OR = 4.12; 95% CI: 1.48, 11.52) and 2004 (OR = 2.57; 95% CI: 1.14, 5.81). This study indicated that those with a CDI had a greater cognitive decline and a greater probability dementia. These findings provide evidence that dysbiosis has a larger impact on cognitive outcomes closest to the initial disruption and is less impactful further on.

S151 The Effects of COVID-19 Precautions on the Rates of Clostridium difficile Infection

Introduction: Clostridium difficile infection (CDI) is one of the most common hospital-acquired infections and has been increasing in frequency and severity worldwide. Not only does CDI cause significant patient morbidity and mortality, but it also causes an increase in hospital length of stay and healthcare costs. The primary objective of this study is to identify if increased use of personal protective equipment (PPE) and proper hand hygiene decreased the rates of CDI amidst the Covid-19 pandemic. The secondary objective is to determine if patients infected with Covid-19 were at increased risk of contracting Clostridium difficile (CD). Methods: Our study is a retrospective, single-center analysis identifying the rates of CDI in a hospital setting six months (August 2019-January 2020) before the pandemic and six months (February 2020-July 2020) from the first encountered Covid-19 positive patient at our institution. RStudio software was utilized to query all patients in which CD enzyme immunoassay analysis (EIA) was ordered. Chart review was performed to identify test result outcomes along with Covid-19 status history. Outcomes of interest included rates of CDI between the two specified time periods and rates of CDI in patients that had tested positive for Covid-19. Significance of outcomes was analyzed using Chi-square tests. Results: Patient data is summarized in Table. A total of 776 CD EIA labs were ordered during the pre-pandemic (n=372) and pandemic (n=404) time period of interest For CD, 46 patients tested positive pre-pandemic and 51 patients tested positive during the pandemic. There was no statistical significance in the rate of CDI (P=0.91). Subgroup analysis showed that 35 patients tested positive for Covid-19 of which 6 patients also tested positive for CDI. There was no statistical significance between the rate of CDI and Covid-19 infection (P=0.42). Conclusion: Our retrospective study did not demonstrate a significance that the use of PPE during the Covid-19 pandemic affected overall rates of CDI at our institution. We think that this may demonstrate the true potency of a CD. Our theory is that despite proper PPE, hand hygiene with alcohol-based solutions was commonly used during the pandemic rather than the recommended soap and water required for proper CD hygiene. In future analysis, we hope to increase the power of our study by adjusting our time interval to mirror peak Covid-19 infection rates at our institution.Table 1.: Rates of Clostridium difficile infection and associative Covid-19 positivity.

71. Impact of Prospective Audit and Feedback on Fluoroquinolone Use: A Large Academic Medical Center Experience

BackgroundFluoroquinolones are an effective class of antimicrobials; however, their use is not without consequence. Recent warnings have resulted in the FDA recommending to reserve this class for infections lacking alternative options. Antimicrobial stewardship significantly reduces targeted antimicrobial use, improves susceptibility patterns, decreases rates of Clostridium difficile infection (CDI), and reduces healthcare-associated costs. Literature on fluoroquinolone stewardship by antimicrobial stewardship programs report similar outcomes in addition to reductions in rates of extended-spectrum beta-lactamase (ESBL)-producing and methicillin-resistant S. aureus (MRSA) infection.MethodsThis study was a retrospective cohort study of adult patients receiving at least 3 days of a fluoroquinolone for an indication of pneumonia or urinary tract infection. Retrospective orders were assessed for prescribing patterns, duration of therapy, and antibiotic choice by indication. The primary outcome was reduction of fluoroquinolone consumption as a result of a prospective audit and feedback intervention, determined with days of therapy (DOT) and DOT per 1000 patient days. Secondary outcomes included hospital length-of-stay (LOS), 3-month post-exposure incidence of CDI, ESBL and MRSA infections, percentage of interventions accepted, and QT prolongation events. Mann-Whitney U was used to determine statistical significance for DOT and LOS, unpaired student t-test was used for DOT per 1000 patient days.Results333 patients were reviewed. Fluoroquinolone median days-of-therapy (DOT) was significantly reduced in the intervention phase (7 vs. 4 days, P < 0.001). Median LOS was 8 days for the cohort and did not differ between groups. After adjusting for identifiable alternative causes, no difference in QT prolongation, CDI or ESBL infection was observed. However, these results were limited by lack of diagnostic testing for QT prolongation and inability to assess for other contributing factors related to infection control.ConclusionAntimicrobial stewardship is an effective intervention to reduce fluoroquinolone use. An increased LOS was not observed despite patients switching to parenteral therapies. More data is needed to assess differences related to adverse events.Disclosures All Authors: No reported disclosures

Impact of Revised Infectious Diseases Society of America and Society for Healthcare Epidemiology of America Clinical Practice Guidelines on the Treatment of Clostridium difficile Infections in the United States.

Our objective was to determine if oral vancomycin, fidaxomicin, and oral metronidazole use in the United States changed after publication of revised clinical practice guidelines for Clostridium difficile infection (CDI) in February 2018. We obtained US antibiotic prescription data (IQVIA) from 2006-August 2019 and used guideline-recommended dosing regimens to estimate monthly numbers of 10-day treatment courses of vancomycin, fidaxomicin and metronidazole. Interrupted time-series analyses were performed, adjusted by month. We compared linear trends for monthly numbers of treatment courses in different time periods. Cumulative treatment courses of oral vancomycin and fidaxomicin increased by 54% (n = 226 166) and 48% (n = 18 518), respectively, in 18 months following guidelines compared with 18 months before; those of oral metronidazole decreased by 3% (n = 238 372). Monthly vancomycin and fidaxomicin use significantly increased throughout the period following revised guidelines (P < .0001 and P = .0002, respectively), whereas that of metronidazole decreased significantly (P < .0001). Monthly vancomycin use increased and metronidazole use decreased to a significantly greater extent after publication of revised guidelines than after publication of clinical trials establishing superiority of vancomycin over metronidazole (P < .0001). Revised practice guidelines have had a significant impact on CDI treatment in the US. Clinical trial data used for the revised guidelines were available since 2007-2014 and 2011-2012 for oral vancomycin and fidaxomicin, respectively. Guidelines or guidance documents for treating CDI and other infections should be updated in more timely fashion.

Clostridium difficile caused changes in fatty acids profile and resolvin D1 content in plasma of infected patients.

Clostridium difficile infection (CDI) is an acute gastrointestinal infection caused by anaerobic, toxin-producing bacteria. During the course of CDI, there is a general inflammatory state. In order to gain a deeper understanding of the role of fatty acids (FAs) in the pathogenesis of acute infection we analyzed their plasma content in both patients with CDI and controls. The study groups included 40 patients with CDI and 40 healthy volunteers. Plasma FA content was analyzed by gas chromatography, resolvin D1 (RvD1) level using ELISA assay, and we assessed the white blood cell (WBC) count, neutrophil count and C-reactive protein (CRP) level. Patients with CDI were characterized by significantly higher values of WBC, neutrophils, platelets and CRP compared with the control group. The saturated FA index was statistically higher and total n-3 FA was significantly decreased in the plasma of CDI patients as compared with the control group. RvD1 content was significantly higher in the control group as compared with patients with CDI. In patients with good outcomes, we probably observed the effective resolution of inflammation, as reflected in n-3 FA metabolism and their significant decrease in plasma. This may indicate the therapeutic role of n-3 FA in CDI infection.

Predicting hospital-onset Clostridium difficile using patient mobility data: A network approach.

To examine the relationship between unit-wide Clostridium difficile infection (CDI) susceptibility and inpatient mobility and to create contagion centrality as a new predictive measure of CDI. Retrospective cohort study. A mobility network was constructed using 2 years of patient electronic health record data for a 739-bed hospital (n = 72,636 admissions). Network centrality measures were calculated for each hospital unit (node) providing clinical context for each in terms of patient transfers between units (ie, edges). Daily unit-wide CDI susceptibility scores were calculated using logistic regression and were compared to network centrality measures to determine the relationship between unit CDI susceptibility and patient mobility. Closeness centrality was a statistically significant measure associated with unit susceptibility (P < .05), highlighting the importance of incoming patient mobility in CDI prevention at the unit level. Contagion centrality (CC) was calculated using inpatient transfer rates, unit-wide susceptibility of CDI, and current hospital CDI infections. The contagion centrality measure was statistically significant (P < .05) with our outcome of hospital-onset CDI cases, and it captured the additional opportunities for transmission associated with inpatient transfers. We have used this analysis to create easily interpretable clinical tools showing this relationship as well as the risk of hospital-onset CDI in real time, and these tools can be implemented in hospital EHR systems. Quantifying and visualizing the combination of inpatient transfers, unit-wide risk, and current infections help identify hospital units at risk of developing a CDI outbreak and, thus, provide clinicians and infection prevention staff with advanced warning and specific location data to inform prevention efforts.

Incidence of Clostridium difficile Infection After Sepsis Protocol Antibiotics.

IntroductionThe management of sepsis includes the prompt administration of intravenous antibiotics. There is concern that sepsis treatment protocols may be inaccurate in identifying true sepsis and exposing patients to potentially harmful antibiotics, sometimes unnecessarily. This study was designed to investigate those concerns by focusing on in-hospital Clostridium difficile infection (CDI), which is a known complication of exposure to antibiotics.MethodsOur emergency department (ED) recently implemented a protocol to help combat sepsis and increase compliance with the 2017 Sepsis CMS Core Measures (SEP-1) guidelines. In this single-center, retrospective cohort analysis we queried the electronic health record to gather data on nosocomial CDI and antibiotics prescribed over a five-year period to analyze the effect of the introduction of a sepsis protocol order set. The primary goal of this study was to measure the hospital-wide CDI rate for three years prior to implementation of the sepsis bundle, and then compare this to the hospital-wide CDI rate two years post-implementation. As a secondary outcome, we compared the number of antibiotics prescribed in the ED 12 months prior to administration of the sepsis protocol vs 12 months post-initiation.ResultsOver the course of five years, the hospital averaged 9.4 nosocomial CDIs per 10,000 patient hours. Prior to implementation of the sepsis bundle, the average CDI rate was 11.6 (±1.11, 95%) and after implementation the average rate dropped to 6.2 (±1.27, 95%, p<0.01). The mean number of antibiotics ordered per patient visit was 0.33 (±0.015, 95%) prior to bundle activation, and, following sepsis bundle activation, the rate was 0.38 (±0.019, 95%, p<0.01). This accounted for 38% of all ED patient visits receiving antibiotics, a 5% increase after the sepsis bundle was introduced.ConclusionIn this study, we found that CDI infections declined after implementation of a sepsis bundle. There was, however an increase in the number of patients being exposed to antibiotics after this hospital policy change. There are more risks than just CDI with antibiotic exposure, and these were not measured in this study. Subsequent studies should focus on the ongoing effects of timed, protocolized care and the associated risks.

133 Impact of Clostridium difficile Infection in Patients With Ulcerative Colitis and Crohn's Disease: A Comparative Analysis

INTRODUCTION: Patients with Inflammatory bowel disease (IBD) are at increased risk of acquiring Clostridium difficile infection (CDI) that leads to an increased in morbidity and mortality. The aim of our study is to compare the outcomes of CDI on in-hospital mortality and resource utilization among adult hospitalized patients with Ulcerative colitis (UC) and Crohn's disease (CD) without CDI in the USA. METHODS: A retrospective cohort analysis using the 2004–2014 Nationwide Inpatient Sample is performed. Adult hospitalized patients with IBD (subgrouped into UC and CD) with CDI were identified using validated ICD-9 codes. Outcomes include in-patient mortality, hospital charges, and length of stay (LOS) among two groups. Confounding factors such as age, sex, ethnicity, insurance status, hospital characteristics, and CDI are adjusted with univariate and multivariate regression models. RESULTS: Out of total 514,889 UC patient's hospitalizations, 24,783 (4.81%) discharges were related to CDI with mean age 60 ± 3 years and 60% female population. In comparison to that, out of 878,896 CD hospitalizations, 13,120 (1.49%) were related to CDI (see Table 1). In terms of outcomes, patients with UC + CDI had increased mortality (adjusted OR 3.003, 95% CI 2.65–3.39), P = 0.00 and LOS (8.0 days vs 6.5 days) and mean total charges difference of $16,739.33 as compared to UC patients without CDI. However, in contrast to CD patients with CDI, there was no significant difference in mortality (adjusted OR 0.60, 95% CI 0.40–0.90, P = 0.021), mean LOS (6.57 days vs 6.15 days) and total hospitalization charges ($34,137.16 VS $33,020.09) in comparison to CD patients without CDI. CONCLUSION: Our study results provide important insight on the effect of CDI on the outcome in patients with IBD. Surprisingly, we found that among US adults with UC and CD-related hospitalizations, CDI is associated with significantly subgrouped in-hospital mortality and healthcare utilization only in patients with UC and CDI infection did not appear to affect the outcomes in the CD-related hospitalizations.

Time-Series Analysis of Health Care–Associated Infections in a New Hospital With All Private Rooms

Health care-associated infections are often caused by multidrug-resistant organisms and substantially factor into hospital costs and avoidable iatrogenic harm. Although it is recommended that new facilities be built with single-room, low-acuity beds, this process is costly and evidence of reductions in health care-associated infections is weak. To examine whether single-patient rooms are associated with decreased rates of common multidrug-resistant organism transmissions and health care-associated infections. A time-series analysis comparing institution-level rates of new multidrug-resistant organism colonization and health care-associated infections before (January 1, 2013-March 31, 2015) and after (April 1, 2015-March 31, 2018) the move to the hospital with 100% single-patient rooms. In the largest hospital move in Canadian history, inpatients in an older, tertiary care, 417-bed hospital in Montréal, Canada, that consisted of mainly mixed 3- and 4-person ward-type rooms were moved to a new 350-bed facility with all private rooms. A synchronized move of all patients on April 26, 2015, to a new hospital with 100% single-patient rooms equipped with individual toilets and showers and easy access to sinks for hand washing. Rates of nosocomial vancomycin-resistant Enterococcus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) colonization, VRE and MRSA infection, and Clostridioides difficile (formerly known as Clostridium difficile) infection (CDI) per 10 000 patient-days. Compared with the 27 months before, during the 36 months after the hospital move, an immediate and sustained reduction in nosocomial VRE colonization (from 766 to 209 colonizations; incidence rate ratio [IRR], 0.25; 95% CI, 0.19-0.34) and MRSA colonization (from 129 to 112 colonizations; IRR, 0.57; 95% CI, 0.33-0.96) was noted, as well as VRE infection (from 55 to 14 infections; IRR, 0.30, 95% CI, 0.12-0.75). Rates of CDI (from 236 to 223 infections; IRR, 0.95; 95% CI, 0.51-1.76) and MRSA infection (from 27 to 37 infections; IRR, 0.89, 95% CI, 0.34-2.29) did not decrease. The move to a new hospital with exclusively single-patient rooms appeared to be associated with a sustained decrease in the rates of new MRSA and VRE colonization and VRE infection; however, the move was not associated with a reduction in CDI or MRSA infection. These findings may have important implications for the role of hospital construction in facilitating infection control.

Proton pump inhibitors and 180-day mortality in the elderly after Clostridium difficile treatment

BackgroundThere is a reported association between proton pump inhibitor (PPI) exposure and increased risk of Clostridium difficile infection (CDI), but less is known about how this class of medications taken during treatment might influence mortality after CDI. Here we examine 180-day mortality rates in a cohort of CDI elders and its association with exposure to PPIs. We conducted a retrospective cohort study of elderly patients (> 65 years of age) diagnosed and treated for CDI in the years 2014–2016 (n = 874) in the Umass Memorial Health Care system, which represents both academic and community healthcare. Patient characteristics and medication use was extracted from the electronic medical record (EMR) and 6 month mortality data was obtained via the Center for Disease Control National Death Index. A Cox proportional hazards model was used to estimate hazard ratios associated with medication exposures and other relevant variables.ResultsOf the 874 elderly adults treated for CDI, 180-day all-cause mortality was 12.4%. Exposure to a PPI was associated with a 55% reduced risk of mortality (adjusted hazard ratio (aHR) 0.45; 95% confidence interval (CI) 0.28–0.72). In our Cox model, increasing age (aHR 1.45; 95% CI 1.14–1.84), those with severe CDI infections (aHR 1.87; 95% CI 1.22–2.88), and those with hospital acquired CDI (aHR 3.01; 95% CI 1.81–4.99) also had increased 180 day mortality risk. There were similar associations noted with both 90 day and 1-year mortality.ConclusionUse of PPIs during CDI treatment in elderly patients is associated with decreased 180-day mortality. Although use of PPIs has been associated with an increased risk of CDI, it appears to be protective against mortality when used during the treatment phase.

Extended-pulsed fidaxomicin versus vancomycin for Clostridium difficile infection: EXTEND study subgroup analyses

Poor outcomes following Clostridium difficile infection (CDI) have been associated with advanced age, presence of cancer and C. difficile PCR-ribotype 027. The impact of baseline risk factors on clinical outcomes was evaluated using data from the EXTEND study, in which rate of sustained clinical cure (SCC) in the overall population was significantly higher with an extended-pulsed fidaxomicin (EPFX) regimen than with vancomycin. Patients aged ≥ 60 years received EPFX (fidaxomicin 200 mg twice daily, days 1–5; once daily on alternate days, days 7–25) or vancomycin (125 mg four times daily, days 1–10). We analysed outcomes by advanced age, cancer diagnosis, CDI severity, prior CDI occurrence and infection with PCR-ribotype 027. The primary endpoint was SCC 30 days after end of treatment (EOT; clinical response at test-of-cure with no subsequent recurrence). SCC rates 30 days after EOT did not differ significantly between EPFX (124/177, 70.1%) and vancomycin (106/179, 59.2%) regardless of age, cancer diagnosis, CDI severity and prior CDI. In patients with PCR-ribotype 027, SCC rate 30 days after EOT was significantly higher with EPFX (20/25, 80%) than with vancomycin (9/22, 40.9%) (treatment difference, 39.1%; 95% CI, 13.2–64.9; P = 0.006). Subgroup analyses from the EXTEND study suggest that EPFX is efficacious as a potential treatment for CDI regardless of age, cancer diagnosis, infection with PCR-ribotype 027, CDI severity or prior CDI. ClinicalTrials.gov identifier: NCT02254967.

Single centre clinical experience with fidaxomicin in the treatment of Clostridium difficile infection in Slovakia

Clostridium difficile infection (CDI) has become one of the most common causes of hospital-acquired infections. Fidaxomicin is one of the latest antibiotics used in the treatment of CDI, however, treatment cost affects recommendations for its use in several countries. We have analysed the treatment of our patients with CDI, treated by fidaxomicin since it was introduced to the market in 2018 and became available in the second biggest Slovak hospital, University Hospital of L. Pasteur. Our aim was to determine efficacy and safety of fidaxomicin in the treatment of CDI in Slovak patients. We reviewed all courses of fidaxomicin use in our hospital (n = 60). Fidaxomicin was used for first recurrence (12 times), second recurrence (4 times), third recurrence (2 times), and fifth recurrence (1 patient). 41 patients received fidaxomicin first-line. Success of fidaxomicin treatment was recorded at 86.7% within the whole cohort. In the recurrent Clostridium difficile infection (rCDI) subgroup, fidaxomicin was 63% effective with three patients dying (15.7%) and two patients developing subsequent rCDI. During the duration of the study, 6 patients in total died. Only one of three patients, with three or more recurrences of CDI, had no further presentations after eight weeks of completion of treatment. The biggest benefit from fidaxomicin treatment was shown in a cohort of patients with primary CDI infection demonstrating a low recurrence rate and significant reduction of fidaxomicin effectiveness in preventing a recurrence when treating patients with multiple rCDI.

Evaluating the efficacy of best practice alerts to improve Clostridium difficile early detection in hospital settings: A 6-month interim analysis of the 2-year prospective study.

Introduction:Clostridium difficile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness with high burden on the health-care system.Design:Observational, retrospective, prospective, pre- and post-intervention study on the incidence and prevalence rates of CDIs. The primary outcome is the healthcare-onset CDIs (HO-CDIs) incidence rate and proportion.Methods:Best practice alerts (BPAs) for CDI were developed in electronic medical records and released on July 13, 2016. When high-risk patients for CDI are identified, BPAs are triggered requiring nurses to order contact isolation and stool studies followed by other subsequent BPAs encouraging providers to de-escalate antibiotics and order probiotics. Data on admission count, patient-days, CDIs categories prevalence, and incidence rates were collected for the 24-month preintervention and will be collected for the 24-month postintervention period.Results:An interim analysis comparing the data from the first 6-month postintervention period with the average 6-month data of the preintervention period showed that short-term BPAs use is associated with significant increase in the overall CDI infection rate (71.47 vs. 38.38, P < 0.0001), incidence rate (53.81 vs. 28.76, P < 0.0001), overall prevalence rate (1.86 vs. 1.32, P = 0.001), and admission prevalence rate (1.10 vs. 0.70, P < 0.0001). Despite the observed overall shift from HO toward CO; no statistically significant difference in the HO-CDI event number and proportion was detected (28 [21.4%] vs. 22 [29.1%], P = 0.094).Conclusion:Short-term BPAs use is associated with significant increase in the overall CDI incidence and prevalence along with a non-statistically significant decline in HO-CDI proportion. Final analysis with full sample size is essential to provide a better picture about the long-term effect.

Clostridium difficile Infection in Inflammatory Bowel Disease Patients: Influence of Antibiotic Choice on Adverse Outcomes

Introduction: Inflammatory bowel disease (IBD) is an independent risk for developing Clostridium difficile infection (CDI), which often precipitates an IBD flare. The influence of CDI treatment on IBD outcomes is not well understood. We evaluated the outcomes of CDI treatment in IBD patients to identify factors associated with adverse outcomes. Methods: Data abstracted from patients with IBD and CDI from 2008 to 2013 included CDI severity and management as well as rates of subsequent CDI episodes, CDI-related hospitalizations, IBD flares and colectomy at 1 year. Severe CDI was defined as WBC >15,000/μL or serum creatinine ≥ 1.5 times baseline and severe complicated was defined as hypotension, shock, ileus, megacolon, bowel perforation, ICU admission or bowel resection for IBD management at the time of active CDI. Subsequent CDI episodes were defined as return of symptoms with a positive stool test after completing CDI therapy. IBD flares post-CDI were defined as symptom recurrence, exacerbation or persistence with negative stool CDI. Statistical analyses comprised of descriptive statistics and one-way ANOVA. Results: Overall, 137 IBD patients (median age, 46.4 years; 55% female) were included; 51% with ulcerative colitis, 46% with Crohn's disease & 3% with indeterminate colitis. Infections were classified as mild-moderate (71%), severe (14%) and severe complicated (15%). Table 1 shows CDI severity and outcomes by CDI treatment regimen. About 40% of CDI from each severity cohort was treated with metronidazole. Treatment with both vancomycin and metronidazole was the second most commonly used regimen for severe or severe complicated CDI. No significant difference was observed among the different CDI treatments and infection severity (p=0.27). Further, CDI treatment choice did not significantly influence the rate of subsequent CDI (p=0.56), CDI-related hospitalization (p=0.15), IBD flare (p=0.54), or colectomy (p=0.42) 1 year post-CDI.Table. CDI: Severity and Outcomes by Antibiotic RegimenConclusion: IBD patients with CDI were most commonly treated with only metronidazole for their infection. The type or combination of antibiotics to treat CDI in these patients did not influence the rate of adverse events of subsequent CDI, CDI-related hospitalization, IBD flares, or colectomy at 1 year follow-up. There was no relationship between CDI severity and type of antibiotic regimen among IBD patients. Prospective studies are needed to further elucidate optimal CDI management in this high-risk group.

Impact of an Automatic Hospital Probiotic Protocol on Clostridium difficile Infection Rates and Antibiotic Usage Patterns

BackgroundThe use of probiotics in hospitalized patients ordered antibiotics has been associated with a preventative effect against Clostridium difficile infection (CDI) in a few small studies and meta-analyses. Starting in 2014, all adult patients admitted to our 330-bed community hospital who were started on an antibiotic automatically received a course of the probiotic Saccharomyces boulardii (SB). Our study provides a much larger experience with which to assess the preventative use of SB in patients receiving concomitant antibiotics.MethodsRates of CDI were compared during the 3-year periods before and after the automatic SB protocol implementation. CDI infection rates using ICD-9 code and CDC hospital-associated infection (HAI) definitions were compared. The use of CDI treatment agents (oral vancomycin and oral metronidazole) expressed in DDD/1,000 patient-days, and rates of SB infections/cultures were also assessed. All rates were standardized per hospital census. Clostridium difficile laboratory detection was performed by PCR analysis throughout the study period.ResultsCase rates of CDI using ICD-9 or CDC HAI definitions did not differ before and after protocol implementation (P = 0.165 and P = 0.521, respectively). The use of CDI treatment antibiotics were also similar; oral metronidazole (P = 0.269), oral vancomycin (P = 0.938), total CDI agents (P = 0.633). Positive specimen cultures for SB where identified in two patients prior to protocol and in 27 patients during the protocol years. Actual SB infections from sterile body sites were identified in five patients during the protocol vs. only one case in the pre-protocol years (P = 0.035). The average yearly cost of SB prophylaxis was $63,000.ConclusionIn our global assessment of this data, the use of an automatic SB protocol at our community hospital was not associated with a protective effect against CDI. The use of SB was associated with an increased risk of SB infections. Further study of SB and other probiotic formulations for CDI prevention are warranted.Disclosures All authors: No reported disclosures.

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OBJECTIVES/SPECIFIC AIMS: Inflammatory bowel disease (IBD) patients are at an increased risk of Clostridium difficile infection (CDI) but the impact of CDI on disease severity is unclear. The aim of this study was to determine the effect of CDI on long-term disease outcome in a cohort of IBD patients. METHODS/STUDY POPULATION: We analyzed patients enrolled in a prospective IBD natural history registry. Patients who tested positive at least once formed the CDI positive group. We generated a 2:1 propensity matched control cohort based on risk factors of CDI in the year before infection. Healthcare utilization data (emergency department use, subsequent hospitalizations, telephone encounters), medications, labs, disease activity, and quality of life metrics were temporally organized. RESULTS/ANTICIPATED RESULTS: A total of 198 patients (66 CDI, 132 matched controls) were included [56.6% female; 60.1% Crohn’s disease (CD), 39.9% ulcerative colitis (UC)]. Groups were not significantly different in the year before infection in all metrics but in the year of infection, having CDI was significantly associated with more steroid and antibiotic exposure, elevated C-reactive protein or erythrocyte sedimentation rate, and low vitamin D (all p&lt;0.01). Infection was associated with increased disease activity metrics (UC: p=0.036, CD: p=0.003), worse disease-related quality of life (p=0.003), and increased healthcare utilization (p&lt;0.001). In the next year after infection those with prior CDI continued to have increased exposure to vancomycin or fidaxomicin (p&lt;0.001) and all other antibiotics (p=0.01). They also continued to have more clinic visits (p=0.006), telephone encounters (p=0.001), and worse disease-related quality of life (p=0.03), but disease activity and biomarkers of severity were not significantly different between groups. DISCUSSION/SIGNIFICANCE OF IMPACT: CDI infection in IBD is significantly associated with various surrogate markers of disease severity, increased healthcare utilization and poor quality of life during the year of infection. CDI patients continue to experience poor quality of life after infection with increased clinic visits and antibiotic exposure while disease activity is no longer significantly increased. These findings suggest that CDI infection may have a lasting effect on healthcare utilization beyond the acute treatment period.

DB1 Mortality Excess Due To Clostridium Difficile Infection - A National Database Analysis

Several researches have led to contradictory results on the question whether there was an excess mortality rate in CDI patients. The objective of this study was to estimate the increase of mortality attributable to Clostridium difficile infection (CDI). A French cohort of patients with a first episode of ICD hospitalized between 2007 and 2014 was extracted from a 1% representative sample of subjects covered by the general health insurance (EGB database, ≈600,000 patients). The one year incidence of deaths was estimated and compared to a control group with no CDI (2 controls per case) matched on a propensity score (PS). PS was calculated with the variables: age, gender, Charlson index, duration of stay, year of index stay and main comorbidities. A cox and a Poisson models were used to estimate the increase risk of death while adjusting on the PS. Sensitivity analyses were performed to explore the robustness of the results. Data from 482 ICD and 964 PS matched controls were extracted. The 2 groups were very similar when compared with the variables used to calculate the PS. Significant increase of death rates was found in CDI patients with HRs of 1.65 (CI95%=[1.33;2.04]) unadjusted and 1.58 (CI95%=[1.27;1.97]) adjusted on PS. The PS adjusted RRs were 1.78 (CI95%=[1.18;2.70]) at 28 days, 1.52 (CI95%=[1.17;1.98]) at 3 months, 1.52 (CI95%=[1.20;1.93]) at 6 months and 1.64 (CI95%=[1.32;2.03]) at 12 months. Sensitivity analyses were performed and lead to similar result : patients for whom the CDI infection was coded as the main diagnosis (HR=1.90 (CI95%=[1.27;2.86]) ; Matched controls hospitalized for a disease with diarrhea (HR=1.44 (CI95%=[1.15;1.79])) ; Patients not rehospitalized for CDI after the index stay (HR=1.73 (CI95%=[1.37;2.18])). CDI infection leads to a significant one year increase of death rate when compared to similar patients in terms of age, gender, comorbidities and length of stay.