Diff Testing Research Articles

P-216. Using an EHR Tool to “Nudge” Earlier C. difficile Testing

Abstract Background After observing an increase in hospital-onset Clostridioides difficile infections (HO-CDI), case review revealed that 50% had community-onset (CO) symptoms, but testing had not been performed until after hospital day 3. An interdisciplinary group convened to determine methods to encourage earlier testing in symptomatic patients and implemented a “Smart Zone Alert” (SZA) in our electronic health record (EHR; Cerner). Methods ChristianaCare is a 3-hospital, > 1200-bed community-based academic health system based in northern Delaware. The SZA is an integrated, real-time notification that encourages frontline providers to order C. diff testing if nursing documents ≥ 3 loose stools/24 hours during the first 3 hospital days. The SZA does not interfere with workflow and can be dismissed or acted upon. The SZA was piloted during Dec 2022 – Feb 2023, initially on 2 but expanding to 12 units at 2 hospitals. A PowerInsight report was built to allow tracking of SZAs and whether testing was ordered. In Mar 2023, the SZA went live across all 3 hospitals. We calculated rates of HO, CO, and community-onset healthcare-facility-associated (COHCFA) CDI for each period (pre-, pilot, and post-SZA) using NHSN definitions, and number and rates of C diff tests obtained before (CO) and after (HO) hospital day 3. We calculated rate-ratios (RR) and standardized infection ratios (SIR) comparing the 10-month pre-SZA-implementation period to the 10-month post-implementation period. Results Comparing the pre-SZA and post-SZA periods, the total number of C. diff tests performed increased from 1800 (4.4/1000 pt-days) to 2265 (5.6/1000 pt-days), and the proportion of CO tests increased from 60.2% to 71.5% (RR 1.6, 95% CI 1.5, 1.8) (Table). The HO-CDI rate decreased 30% (RR 0.7, 95% CI 0.45, 1.1), although not statistically significant; while COHCFA-CDI doubled (RR 2.0, 95% CI 1.1, 3.7). As of Dec 2023, the SZA had fired 2876 times and prompted earlier testing that avoided 25 HO-CDI. The SIR decreased from 0.35 (95% CI, 0.26, 0.46) to 0.27 (95% CI 0.19, 0.38). Conclusion The SZA is an integrated real-time tool that provides actionable and trackable information about patients’ stooling patterns and encourages earlier C. diff testing, enabling earlier isolation and treatment and avoiding falsely attributing CDI cases as HO. Disclosures All Authors: No reported disclosures

P-206. Reducing Hospital Acquired Clostridioides difficile Infections: A Comparison of Two Equally Effective Testing Strategies

Abstract Background A positive Clostridioides difficile (C. diff) test obtained after day three of admission qualifies as hospital acquired C. diff infection (HA-CDI). Given PCR’s high sensitivity for C. diff, the decision to test necessitates clinical judgement to avoid false positive results that may lead to increased nosocomial infection rates, unnecessary treatment, and increased financial burden. This study investigated two interventions to decrease unnecessary C. diff testing after day three of admission. Methods A multistep testing algorithm, which consists of an initial enzyme immunoassay for glutamate dehydrogenase (GDH) and Toxin A/B testing followed by C. diff PCR test by a reflex, is utilized in our institution. To ensure appropriate C. diff test ordering, our Infection Control (IC) team implemented two stages of interventions during a span of five years. In June 2019, Stage 1 involved a hard stop and manual review of all C. diff test orders placed after three midnights from Monday through Friday, requiring an IC or infectious diseases team member to approve these C. diff testing requests. Orders were cancelled if all established testing criteria were not met (Figure 1). In January 2023, Stage 2 was implemented which replaced manual review with an algorithm in electronic medical record (EMR). Outcomes were measured by examining National Healthcare Safety Network (NHSN) LabID data and the standardized infection ratio (SIR) before and after each stage implementation. Stage 1 SIR Results From 2019 to 2023, our testing interventions resulted in a reduction in HA-CDI incidence. Stage 1 implementation significantly decreased average HA-CDI incidence from 9.3 to 4.06 infections/1000 patient days (PD) (p< 0.0001) resulting in a decreased average HA-CDI SIR from 1.25 to 0.52 (p< 0.0001). Further HA-CDI decrease resulted after Stage 2 implementation with HA-CDI rate decreasing from 4.06 to 3.29 infections/1000 PD (p=0.656) and with HA-CDI SIR decreasing from 0.52 to 0.48 (P =0.172) (Figure 2, 3). This decline was not statistically significant. Stage 2 SIR Conclusion Manual testing review and EMR-based HA-CDI algorithm implementation effectively decreased the number of positive HA-CDI test results. Use of the electronic algorithm greatly reduced the workload burden on our IC team with no increase in HA-CDI. Disclosures Elizabeth Nothdurft, PharmD, BCPS, BCIDP, Abbvie: Honoraria Nirmol Philip, MD, MPH, Nestle: Honoraria

P-205. Investigating PCR (Polymerase Chain Reaction) Cycle Threshold’s Utility in Diagnosing and Treating Clostridioides difficile Infections

Abstract Background Clostridioides difficile (C diff) is a pathobiont bacteria in the human gastrointestinal tract that can cause morbidity and mortality and has public health implications. Guidelines suggest two-step testing to diagnose C diff infection (CDI). However, since polymerase chain reaction (PCR) tests can be positive in persons with colonization and no active disease, management of discordant results is challenging. Usage of facility-onset CDI as a quality metric further raises the need to accurately differentiate infection from colonization. We hypothesize PCR cycle threshold (Ct) values may be useful for quantifying C diff disease burden and differentiation of infection from colonization. However, Cts are currently unvalidated and are not currently approved for use for clinical decision making. Sample and results data for C diff infection and C diff PCR CT correlation This table provides an overview of our data investigating the usage of C diff PCR CT to better diagnose CDI Methods We performed a retrospective, single center chart review of patients who tested positive for C diff, and analyzed clinical and laboratory data in 2022. We excluded minors, outpatients, and repeat C diff episodes, and performed multi variable analyses. Results 70 patients met inclusion criteria. This cohort consisted of 37 (52.86%) male and 33 (47%) female patients. The mean and median ages were 70 and 73 years old respectively. Approximately 30 percent of our cohort was immunocompromised, and 90 percent of our patients were on antibiotics within 30 days of CDI testing. Using a Ct of 26.35, a cutoff used in previous studies to indicate infection, 30 patients (42.9%) had a positive Ct, and of these, 16 (53%), had a positive confirmatory enzyme immunoassay (EIA) . Ct of less than cutoff had a positive predictive value of 53%, and negative predictive value of 85%, for positive EIA. All patients analyzed underwent C diff treatment, with a mean length of treatment of 10 days. Mean time to recovery, classified as less than three documented bowel movements, or hospital discharge, was 4.6 days. Nine patients (13%) in our cohort died within 30 days of C diff testing. Conclusion This data show that C diff PCR Ct value threshold of < 26.35 combined with EIA positivity may be a helpful parameter for evaluating possible C diff. The demonstrated high negative predictive value may show a utility for high Ct values in ruling out active disease. Disclosures Roderick Go, DO, Aptose Biosciences: Stocks/Bonds (Private Company)|Bristol Meyers Squibb: Stocks/Bonds (Private Company)|Cytodyn Inc.: Stocks/Bonds (Private Company)|Scynexis: Grant/Research Support|Shionogi, Inc: Grant/Research Support

P-219. A Comparison of Clinical Outcomes for Polymerase Chain Reaction-positive (PCR) Enzyme Immunoassay-negative (EIA) Patients to PCR+/ EIA + Patients Diagnosed with Clostridioides difficile

Abstract Background In August 2021, Saint Luke’s Health System transitioned Clostridioides difficile (C. diff.) testing from polymerase chain reaction (PCR) only to two-step enzyme immunoassay (EIA) reflex following PCR+ for suspected C. diff. infection. Uncertainty in management may arise when PCR and EIA test results differ. Previous studies suggested that disease severity varies when results return as PCR+/EIA- due to possible colonization. Clinicians may treat patients if there is no other explanation for diarrhea, clinical instability, previous antibiotic use, immunocompromised status, or if recommended by infectious diseases/gastroenterology consultants. We compared clinical outcomes of patients with PCR+/EIA+ to those with PCR+/EIA- results.Table 1:Patient DemographicsContinuous variables compared using Student's T-test. Categorical variables compared using chi-square or Fisher's exact test. W = Wilcoxon rank-sum test. Methods This was a retrospective cohort study from August 2021 to August 2023 in a multi-site, integrated health system, comparing patients with PCR+/EIA- C. diff. test results to those with PCR+/EIA+ results. Patients were included if they were 18 years or older and needed C diff testing. Patients with incomplete data were excluded. We defined full treatment as 10 or more days of C. diff. treatment, partial as 2 to 9 days and no treatment as 2 or fewer days. The primary outcome was length of stay. Secondary outcomes were readmission rates, colectomy rates, intensive care unit (ICU) admission, and the percentage of patients with resolved diarrhea on day of discharge. An additional subgroup analysis compared fully treated PCR+/EIA+ patients to patients with partially or untreated PCR+/EIA- results.Table 2:Outcomes in PCR + / EIA- vs. PCR +/ EIA + GroupsContinuous variables compared using Student's T-test. Categorical variables compared using chi-square or Fisher's exact test. W = Wilcoxon rank-sum test. Results 222 patients had PCR+/EIA- and 180 patients had PCR+/EIA+ results. For the primary outcome, no difference was detected between cohorts including the subgroup analysis. Diarrhea resolution occurred less often in the PCR+/EIA- group, including the subgroup analysis. See Tables 1-4 for more information.Table 3:Outcomes in PCR+/EIA- vs. PCR+/EIA+ Groups Analyzed by Treatment GroupsContinuous variables compared using one-way analysis of variance. Categorical variables compared using chi-square or Fisher's exact test. K = Kruskal-Wallis test. Conclusion This study found no difference in length of stay, but lower diarrhea resolution in PCR+/EIA- patients. Notably, high treatment rates occurred in both cohorts, limiting generalizability. More research should be conducted to help clinicians discern treatment of discordant two-step test results, particularly in settings with lower treatment rates of PCR+/EIA- results.Table 4:Outcomes in PCR+/EIA+ Full Treatment Group vs. PCR+/EIA- (Partial + No Treatment) GroupContinuous variables compared using Student's T-test. Categorical variables compared using chi-square or Fisher's exact test.W = Wilcoxon rank-sum test. Disclosures All Authors: No reported disclosures

Breaking the Reflex: Impact in Hospital-Acquired Infection Incidence for Clostridioides difficile Infection

Background: Nucleic acid amplification tests (NAAT) do not distinguish between colonization and Clostridioides difficile (C.diff) associated diarrhea. On April 5th 2023 our laboratory introduced a new C. diff testing methodology. Previously, if a C. diff screen result was negative for toxin and positive for glutamate dehydrogenase (GDH), a second confirmatory test was conducted with NAAT. This confirmatory test was removed from our testing algorithm. NAAT testing may be ordered ad hoc when clinically relevant diarrhea persists, and alternative etiologies have been excluded. We wanted to evaluate the impact of change with testing methods. Method: Retrospective review of all inpatient hospital-acquired C.diff infections reported to NHSN database from Ascension Michigan Market which comprises 14 acute care hospitals from June 2019 to August 2023. Data for C diff was analyzed every quarter. The risk adjustments used to calculate the Standardized Infection Ratios (SIRs) for C. diff infections was set at 0.48 based on CDC mean SIR established for acute care hospitals in 2022. Results: A total of 14 acute care hospitals were included from which 866 C.diff cases were reported during this period. Overall, the SIR dropped from 0.59 from June-August 2019 to 0.32 reported from March-May 2023; 45.7 % decrease. The maximum reduction in SIR was seen post intervention at 0.21 from June-August 2023 which was 78.3% below the benchmark of 0.48. (Figure) Conclusions: Strategies to optimize current laboratory tests are critical to differentiate C. diff infection from colonization. The current strategy by changing the testing method led to substantial reduction in C-diff. Diagnostic stewardship studies should ideally include outcome measures targeted to post-intervention patients to determine clinical relevance and patient safety. Optimizing test utilization remains a critical component of quality healthcare delivery. Future NHSN updated surveillance definition will require incorporating clinical decision-making into the metric; that is including a combination of any positive C-diff test plus initiation of antibiotic therapy for C-diff.Disclosure: Reese Cosimi: Advisory Board - Abbvie

Reducing Clostridioides difficile Infections in a Medical Intensive Care Unit: A Multimodal Quality Improvement Initiative.

Clostridioides difficile (C. diff) infection causes significant morbidity for hospitalized patients. A large medical intensive care unit had an increase in C. diff infection rates. The aim of this project was to reduce the C. diff polymerase chain reaction (PCR) test positivity rate and the rate of C. diff PCR tests ordered. Rates were compared between preintervention (July 2017 to December 2019) and postintervention (January 2021 to December 2022) timeframes. Unit leadership led a robust quality improvement project, including use of quality improvement tools such as A3, Gemba walks, and plan-do-study-act cycles. Interventions were tailored to the barriers identified, including standardization of in-room supply carts; use of single-packaged oral care kits; new enteric precautions signage; education to staff, providers, and visitors; scripting for patients and visitors; and use of a C. diff testing algorithm. Statistical process control charts were used to assess for improvements. The average rate of C. diff PCR test positivity decreased from 34.9 PCR positive tests per 10 000 patient days to 12.3 in the postintervention period, a 66% reduction. The average rate of PCR tests ordered was 28 per 1000 patient days in the preintervention period; this decreased 44% to 15.7 in the postintervention period. We found clinically significant improvements in the rate of C. diff infection and PCR tests ordered as a result of implementing tailored interventions in a large medical intensive care unit. Other units should consider using robust quality improvement methods and tools to conduct similar initiatives to reduce patient harm and improve care and outcomes.

QAPI 141 - Infection Preventionist Involvement Enhances Electronic Health Record Prompts for Appropriate C. diff Testing

QAPI 141 - Infection Preventionist Involvement Enhances Electronic Health Record Prompts for Appropriate C. diff Testing

A-151 Evaluation of Monocyte Distribution Width as an Early Marker for Diagnosis of Sepsis

Abstract Background Since sepsis has a high mortality rate, early diagnosis and treatment can increase the survival rate and improve prognosis. However, it is difficult to diagnose sepsis accurately in actual clinical practice. Determination of Procalcitonin or C-reactive protein (CRP) levels, which are conventionally used for diagnosing sepsis, are time-consuming. Recent studies have shown that monocyte distribution width (MDW), which is observed simultaneously during the complete blood count (CBC)/diff test in Beckman Coulter DxH900, is a potential marker for the early detection of patients with or developing sepsis. This study evaluated MDW for early detection of sepsis in patients visiting the emergency department. Methods This study enrolled a total of 1167 patients (>18 and ≤80 years of age) who visited the emergency department of a single institution from August 4, 2020 to March 31, 2021, whose initial evaluation included CBC with differential tests and other blood tests (CRP and Procalcitonin). Samples for CBC and MDW were collected in K3-EDTA tubes and analyzed in a UniCel DxH 900 analyzer (Beckman Coulter, Inc., USA). Sepsis was diagnosed according to the sepsis-3 definition through a medical record review. All patients were grouped into no sepsis, sepsis, and septic shock. The diagnostic performance of MDW and other biomarkers for the detection of sepsis was evaluated through statistical analysis. The subgroup analysis for diagnostic performance was performed in subjects with malignancy or without malignancy. All statistical analyses were carried out using Analyze-it, and P < 0.05 was considered statistically significant. Results Of the 1167 patients enrolled, 156 patients (13.4%) were diagnosed with sepsis (135 (11.6%) sepsis and 21 (1.8%) septic shock). Among sepsis patients, those with positive culture results were 46.8%, and the rest either had negative culture results (43.6%) or did not proceed with culture testing (9.6%). The MDWs of the no sepsis group, sepsis group, and septic shock group were 19.70, 27.20, and 31.10, respectively, CRPs were 1.82 mg/dL, 8.84 mg/dL, and 20.44 mg/dL, and Procalcitonins were 0.19 ng/mL, 1.72 ng/mL, and 18.20 ng/mL (median, P < 0.0001). All biomarkers showed a higher value in the sepsis group compared to the no sepsis group. Median MDW showed an increasing trend in patients with malignancy and without malignancy. The AUC of MDW, WBC, CRP, and Procalcitonin for the prediction of sepsis were 0.869, 0.604, 0.773, and 0.868, respectively (P < 0.0001), thus MDW and Procalcitonin showed similar diagnostic performance. At the cutoff of MDW (21.5), the sensitivity was 91.0% and the negative predictive value (NPV) was 98%. The diagnostic performance of MDW showed similar results in cancer patients and cancer-negative patients (AUC 0.873 vs 0.869). Conclusions MDW, which is automatically measured in Beckman Coulter DxH900 hematology analyzer without the requirement of additional reagents during CBC/diff test, has high accuracy in detecting patients with sepsis and could be a reliable tool for early detection of patients with sepsis in the emergency department compared to results of culture or other biomarkers which take longer time to get the result. Furthermore, high NPV may help clinicians rule out sepsis.

399. Reducing Hospital-Onset C. diff with a Provider-Driven Emergency Department Ordering Algorithm

Abstract Background Clostridoides difficile (C. diff) can cause diarrhea and inflammation of the colon. It is one of the most common causes of heathcare-associated infections (HAIs), estimated to cause almost half a million illnesses and thousands of deaths in the United States each year. Studies have estimated that this HAI costs up to $4.8 billion each year in excess healthcare costs for acute care facilities. Early identification, treatment and initiation of isolation precautions is crucial to patient care and transmission reduction, making the Emergency Department ideal partners in efforts to reduce C. diff infections. Methods A C. diff testing algorithm was introduced specific to the Emergency Department in March, 2021, promoting earlier testing and isolation of patients suspected of having C. diff. Emergency medicine clinicians were awarded the "Golden Spore" Award weekly when appropriately initiating the C. diff testing and isolation, provided the patients met criteria, or were clinically suspected of having a C. diff infection. C. diff ordering algorithm Ordering algorithms were printed and placed in the clinician's work area to facilitate increased ordering of isolation and testing of potentially infected patients. GoldenSporeAward The Golden Spore is awarded weekly to emergency clinicians who successfully identify and isolate C. diff patients prior to admission. Results As a result of the COVID-19 pandemic, there were varying degrees of challenges for implementation of the program. Emergency clinicians sent 199 C. diff tests pre-intervention (3/15/20-3/14/21) and 234 tests post-intervention (3/15/21-3/14/22). Pre-intervention, 44 patients were found to be C. diff positive prior to admission, compared to 62 post-intervention. Clinicians enjoyed the "golden spore" award and were excited to participate. Conclusion The program is ongoing, though the initial results are encouraging. There was an immediate increase in the testing and subsequent isolation of patients while in the ED. Infection prevention and emergency medicine clinicians worked together to boost their numbers, and the "golden spore" continues to be awarded in weekly newsletters. Clinicians indicated they enjoyed the engagement, and found that the small change in a routine process improved their baseline awareness of potential C. diff patients, leading to an increase in the number of tests and subsequent discovery of C. diff positive patients. C. diff champions were also named and the algorithm will be shared with additional emergency departments within our system to continue to improve detection and prevention of hospital associated infections. Disclosures All Authors: No reported disclosures.

88. A Behavioral Economic Approach to C. difficile Testing Stewardship

BackgroundTo decrease inappropriate testing for C. difficile patients, we first employed an alert, followed by a hard stop (based on lack of documented diarrhea or laxative use), that could be overridden only by calling the laboratory. We describe a behavioral economic approach to test overrides that decreased the burden on both clinicians and laboratory staff without encouraging unnecessary testing.MethodsOur 2-hospital, > 1200-bed community-based academic healthcare system has performed PCR-only C. diff testing since January 2015. We implemented our initial laxative alert, which did not prohibit testing, in March 2015. In April 2017, we launched a “hard-stop” alert that cancelled orders without documented diarrhea or recent laxative use. The provider could override by calling the laboratory and documenting the laboratorian’s name in the order; no further justification was required, but entries were intermittently monitored. In August 2019, we allowed clinicians to document their clinical justification instead of making this additional call, while emphasizing that rationales would be monitored for validity (Fig 1). We measured number of C. diff tests completed/month, overrides, and CDI standardized infection ratios (SIRs). We performed time-series analysis to account for each of these test ordering changes.Figure 1: Image of C. diff alert ResultsAt baseline, we observed a mean of 448 (SD, ±25) C. diff orders per month. The initial laxative alert led to a sustained decrease in monthly C. diff orders by 17% (p < 0.001; Fig 2). Another sustained decrease in monthly C. diff orders of an additional 29% (p< 0.001) occurred after the “hard stop” alert. Overall, C. diff orders decreased by 40% (3.5% per month). After introduction of the clinical justification documentation, to date we have not observed significant trends in C. diff override rates. The CDI SIR decreased from 0.9 (95% CI, 0.77- 1.04) in 2016 to 0.52 (0.42–0.64) in 2019.Figure 2: Interrupted time series analysis ConclusionAn iterative process to improve C. diff testing stewardship resulted in sustained improvements in C. diff ordering and hospital onset CDI cases. Behavioral economic approaches emphasizing the importance of clinical reasoning allowed us to reduce burden on clinicians and laboratory staff without increasing inappropriate testing.Disclosures All Authors: No reported disclosures

S2301 COVID-19 and Ulcerative Colitis in Pregnancy

INTRODUCTION: Impacts of the novel Coronavirus (SARS-CoV-2) are widespread, range in severity, and vastly unknown. Inflammatory bowel disease (IBD) patients are often treated with immunosuppressive medications which can increase risk of viral infections and associated morbidity and mortality. We present a case of a pregnant patient with pan-colonic ulcerative colitis (UC) who was infected with SARS-CoV-2. CASE DESCRIPTION/METHODS: A 29-year-old female with pan-colonic UC, at 22 weeks’ gestation, presented with bloody diarrhea, fecal urgency, and incontinence. She was diagnosed in 2015 and established care with us in 2018 while on balsalazide. During initial attempt to stage her UC with a colonoscopy, she became pregnant but unfortunately had a miscarriage. Her colonoscopy revealed Mayo 1 activity in the left colon with decreased vascular pattern (Figures 1 and 2). She had a disease flare 1 year ago which resolved with transrectal 5-mesalamine. During a pre-conception planning IBD visit, given her clinical course (disease flares, lack of complete mucosal healing with moderate histological activity), targeted immune-modifying biologic was recommended. After much discussion, she elected to stay the course with close surveillance. Her current presentation was consistent with another disease flare. Evaluation revealed fecal calprotectin of 700.4mcg/gm and CRP of 14.4mg/L with negative C. diff testing. She was started on budesonide 9mg daily, however due to persistent symptoms 2 weeks later, was switched to prednisone 40mg daily with clinical response within 72 hours. One week later, she developed rhinorrhea and myalgias and tested positive for SARS-CoV-2. As she was clinically stable, she was advised to self-quarantine without need for hospitalization. Prednisone dose was immediately decreased to 20mg daily with a 4-week taper. The UC flare symptoms resolved and her viral symptoms improved after 3 weeks. She is currently back to her baseline health with no known adverse effects to her pregnancy, which is currently at 38 weeks’ gestation. With collaboration with her obstetrics team, the decision was made to proceed with vedolizumab after delivery. DISCUSSION: Pre-pregnancy IBD control is predictive of IBD-related pregnancy outcomes. Our case demonstrates treatment of an intrapartum UC exacerbation in the setting of maternal infection with SARS-CoV-2. Cautious treatment of maternal IBD is necessary. A multidisciplinary approach between IBD gastroenterology and Obstetrics is critical in safely managing these patients.Figure 1.: Decreased vascular pattern seen in the rectum on white light (left) and narrow-band imaging (right).Figure 2.: Mucosal erythema demonstrated in the sigmoid colon.

The Impact of Changing to an Algorithm-Based Clostridioides difficile Test on the Decision to Treat Clostridioides difficile

Background: Polymerase chain reaction (PCR) testing for the diagnosis of Clostridioides difficile infection (CDI) detects the presence of the organism; a positive result therefore cannot differentiate between colonization and the pathogenic presence of the bacterium. This may result in overdiagnosis, overtreatment, and risking disruption of microbial flora, which may perpetuate the CDI cycle. Algorithm-based testing offers an advantage over PCR testing as it detects toxin, which allows differentiation between colonization and infection. Although previous studies have demonstrated the clinical utility of this testing algorithm in differentiating infection from colonization, it is unknown whether the test changes CDI treatment decisions. Our facility switched from PCR to an algorithm-based testing method for CDI in June 2018. Objective: In this study, we evaluated whether clinicians’ decisions to treat patients are impacted by a test result that implies colonization (GDH+/Tox−/PCR+ test), and we examined the impact of this decision on patient outcomes. Methods: This is a retrospective cohort study of inpatients with a positive C. diff test between June 2017 and June 2019. The primary outcome was the proportion of patients treated for CDI. We compared this outcome in 3 groups of patients: those with a positive PCR test (June 2017–June 2018), those who had a GDH+/Tox−/PCR+ or a GDH+/Tox+ test result (June 2018–June 2019). Secondary outcomes included toxic megacolon, critical care admission, and mortality in patients with GDH+/Tox−/PCR+ who were treated versus those who were untreated. Results: Of patients with a positive PCR test, 86% were treated with CDI-specific antibiotics, whereas 70.4% with GDH+/Tox+ and 29.25% with GDH+/Tox−/PCR+ result were treated (P &lt; .0001). Mortality was not different between patients with GDH+/Tox−/PCR+ who were treated versus those who were untreated (2.7% vs 3.4%; P = .12), neither was critical care admission within 2 or 7 days of test result (2% vs 1.4%; P = .15) and (4.1% vs 5.4%, P = .39), respectively. There were no cases of toxic megacolon during the study period. Conclusions: The change to an algorithm-based C. difficile testing method had a significant impact on the clinicians’ decisions to treat patients with a positive test, as most patients with a GDH+/Tox−/PCR+ result did not receive treatment. These patients did not suffer more adverse outcomes compared to those who were treated, which has implications for testing practices. It remains to be explored whether clinicians are using clinical criteria to decide whether or not to treat patients with a positive algorithm-based test, as opposed to the more reflexive treatment of patients with a positive PCR test.Funding: NoneDisclosures: None

S3394 A Case Report of Atypical Ulcerative Colitis

INTRODUCTION: Ulcerative colitis(UC) and Crohns disease usually have specific presentation on colonoscopy with some overlap seen in select cases. UC predominantly involves colon, with almost always involving the rectum and rarely involving the ileum. However, in about 5% of the cases, IBD can present in atypical way labelled as “indeterminate” or “unclassified”. In these cases, UC can present with skip lesions with rectal sparing which can pose a diagnostic challenge if only visual diagnosis is focused upon. CASE DESCRIPTION/METHODS: 27 year old female presented to GI clinic with rectal pain and diarrhea for several months. On the rectal exam, there was pinhole like opening and ulceration. Outpatient colonoscopy was performed and revealed few skip lesions of erythematous, friable and ulcerated mucosa in the transverse colon and terminal ileum. The pathology showed mild acute, focal inflammation and crypt abscess in terminal ileum, transverse, descending and sigmoid colon. Rectal biopsy showed normal findings. The stool studies were sent and C diff test came positive. After the 2week course of oral vancomycin, symptoms were significantly improved. Subsequently, she was placed on Mesalamine. 8 months later, repeat colonoscopy revealed inflamed, erythematous, congested skip lesions at terminal ileum and transverse colon. UC was confirmed again with the presence of mild inflammation and cryptitis. DISCUSSION: Patients who have RST(rectal sparing of UC) represent resistance to treatment, prolong duration of active disease and increased rate of recurrence. It might be a prediction for future colectomy given the severity of the disease. Severity of the disease was significantly worse in patients with RST compared to the control group and 24/46 pts with RST required urgent surgery compared with 107/436 non RST group. These patients have also seen to have a lack of response to conventional pharmacotherapy. Frequency of PSC (primary sclerosing cholangitis) with and without rectal sparing is also studied. The reported incidence showed a mean(30.9% vs 9.9%) in PSC with rectal sparing, compared with the group without rectal sparing. Overall, incidence of PSC was 3 times higher in rectal sparing group. In conclusion, the presence of relative or absolute RST in patients with UC is an atypical presentation. This group of patients should be selectively reclassified due to worse prognosis with higher incidence rate of emergent surgery, primary sclerosing cholangitis and refractoriness of pharmacologist therapies.Figure 1.: Congested, erythematous, friable and inflamed terminal ileum.Figure 2.: Rectum with normal appearing mucosa.

A Multi-Faceted Approach to Reducing the SIR for Clostridioides difficile Healthcare Associated Infections

<h3>Background</h3> In February 2018, The Society for Healthcare Epidemiology of America (SHEA) published updated clinical practice guidelines for Clostridiodes difficile (C. diff). The Standardized Infection Ratio (SIR) at our acute care facility was noted to be above the national average of 0.924. The updated guidelines included recommendations to only test patients with new onset and unexplained diarrhea consisting of three or more unformed stools within a twenty-four period, and the addition of a confirmation test to differentiate active infection from colonization. <h3>Methods</h3> As a result of the SHEA recommendations, two questions were added to the electronic medical records system when a C. diff test is ordered: 1.Has the patient reported three or more unformed stools in the past twenty-four hours? 2.Has the patient received a laxative or stool softener in the past forty-eight hours? Staff education was provided system-wide on both proper specimen collection and appropriate test ordering. The Microbiology lab performed a comparison study between two enzyme immunoassay (EIA) tests and the gold standard cytotoxin assay. The study found that both EIA tests had low sensitivity and consequently, all positive C. diff PCR specimens were sent for confirmation by cytotoxin assay. <h3>Results</h3> The SIR pre-implementation (October 2017 to September 2018) to post-implementation (October 2018 to September 2019) demonstrated a reduction from 1.200 to 0.716 (p=0.0003), and has remained below the benchmark since that time. About 57% of positive C. diff PCR specimens confirmed with cytotoxin assay. <h3>Conclusions</h3> The implementation of the two-step process and the addition of the questions regarding specimen appropriateness is believed to have contributed to a significantly reduced SIR for C. diff. This has also led to a reduction in unnecessary antibiotic treatment and isolation of patients.

Using Power BI to Inform Clostridioides difficile Ordering Practices at an Acute Care Hospital in Central Florida

<h3>Background</h3> Positive Clostridioides difficile (C. diff) laboratory results likely overestimate the true incidence of C. diff cases. In 2015, a multi-campus intervention that reduced hospital-onset C. diff consisted of diverting automatic reflex polymerase chain reaction test (PCR) testing for negative enzyme immunoassay toxin tests (EIA) to requiring a separate order. Rates initially decreased, but have since increased, suggesting a need to improve C. diff surveillance and track ordering patterns of providers and C. diff trends across our campuses. <h3>Methods</h3> A C. diff dashboard was developed using Microsoft Power BI, consisting of information on test type, test order counts, and rates per 100 patient (pt) days by month/year and campus/unit. Data analysis focused on one facility comprising 237 beds. A root-cause database in Microsoft Access was used to track risk factors that may have contributed to C. diff infection. <h3>Results</h3> From January 2017 to November 2019, C. diff test (EIA and PCR) order rate per 100 pt days was 1.24 in 2017, 1.42 in 2018, and 1.09 in 2019, correlating with C. diff rates per 100 pt days, 1.76 in 2017, 3.80 in 2018, and 1.42 in 2019 respectively (r=0.94). PCR ordering rates increased throughout the years. Review of risk factors in the root-cause database did not appear to significantly contribute to the increase in C. diff rate seen in 2018. <h3>Conclusions</h3> C. diff testing rates highly correlate with positive C. diff results. The construction of a C.diff dashboard and the root-cause database allows us to analyze diagnostic ordering trends in real time in order to identify gaps to reduce unnecessary testing.This can be accomplished through feedback, education, and changes in processes.

Implementing Hard Stops in the Electronic Record to Decrease Hospital Acquired C-Diff Infections

<h3>Background</h3> Background: Clostridioides difficile is the leading cause of health care- associated infections. C diff infection data are publicly reported and value- based purchasing can impact a hospital's financial reimbursement if these goals are not met. After experiencing increases in C-diff rates at our organization, testing procedures and patient selection were reviewed. The purpose of our work was to decrease hospital acquired C-diff rates by 30 % by mid-December 2019 through implementing the Centers for Disease Control and Prevention recommendations and Society for Healthcare Epidemiology of America (SHEA) practice guidelines. <h3>Methods</h3> Methods: All adult patients that C diff testing ordered were compared to recommendations by CDC and SHEA. We implemented the following changes to align with the recommendations: isolation at time of suspicion of C diff, daily review of all specimens ordered, automatic cancellation of specimen after 24 hours if not sent, bleach disinfection twice a day on all C diff patients, education of all staff that are involved in patient care, and electronic hard stops for all laxative use and inappropriate testing <h3>Results</h3> Results: These interventions resulted in significant improvement in C-diff rates, and several process measures. C-diff rates decreased from 9.33 per month during the first quarter of calendar year 2019 to an average of 6.8 infections per month during the fourth quarter. All patients with diarrhea on admission began having testing within 48 hours of admission to identify infection and decreased day 4 testing. These processes also eliminated testing with patients receiving laxatives within 48 hours. <h3>Conclusions</h3> Conclusion: Results of this project demonstrate how aligning testing practices with CDC and SHEA guidelines and electronic hard stops can effectively decrease hospital-acquired C-Diff rates. It is recommended organizations adopt standardized practices for testing and utilize available technology to eliminate inappropriate testing and unnecessary treatment.

2387. Learning the Influence of Individual Clostridioides difficile Infections

BackgroundHealthcare-associated Clostridioides difficile infection (C diff infection, or CDI) imposes a substantial burden on the healthcare system. The impact of an individual C diff infection on onward transmission is not well understood. We developed a model of incident infections using self-exciting stochastic processes, known as Hawkes processes. These models can be used to improve our understanding of the factors that affect the likelihood of new infections to result in additional infections.MethodsAll patients admitted to a large urban hospital between January 2013 and June 2014 were included. We used Hawkes processes to model the influence of each new CDI case (index infection) on transmission to other patients resulting in additional CDI. We developed separate Hawkes processes for each unit in the hospital to understand the differential impact of a C diff case across units. Units included both semi- and private-room wards, intensive care units, an emergency department, and specialty units such as oncology.ResultsThe magnitude of influence of an index infection on additional infections in the 2 days prior to a C diff test being sent varied across units. Results for an oncology unit, the emergency department, and an all private-room unit are provided (Table 1). An index infection in the emergency department demonstrated the greatest influence, leading to the largest number of additional infections, and increasing in the days leading up to the C diff test being sent. The impact 2 days prior to sample collection was similar across all unit types, and remained constant for oncology unit patients.ConclusionWe used Hawkes processes to model the impact of an index C diff infection on onward transmission. We identified differential impacts associated with the unit where the index patient was located in the days leading up to diagnosis. These differences, which could relate to unit-specific factors such as cleaning practices, patient turnover rates, use of portable medical equipment, antibiotic use, and other factors that vary across units, suggest that interventions aimed at controlling CDI may need to consider unit-specific approaches. Disclosures All authors: No reported disclosures.

3057 Unusual Presentation of MRSA Colitis Complicated With Acute Appendicitis

INTRODUCTION: Clostridium difficile colitis has been the most aware bacterial enterocolitis for years and other bacteria been relegated such as Staphylococcus colitis. Staphylococcus enterocolitis following antibiotics had been one of the most frequent complications in surgical patients in 1950s and 1960s and now reappear with more resistance such as Methicillin-Resistant Staphylococcus Aureus (MRSA) colitis which brings a new challenge. CASE DESCRIPTION/METHODS: A 32-year-old Hispanic female with a history of Type I Diabetes Mellitus presenting with altered sensorium and a 2-day history of watery, non-bloody diarrhea, intractable emesis and diffuse crampy abdominal pain. About a month before the presentation, the patient had a soft-tissue laceration on left foot requiring a 7-day course of Cephalexin and Clindamycin that healed appropriately. On physical exam, she was tachycardic with HR of 110 bpm and tachypneic with RR of 28, somnolent but arousable with GCS &gt;12. The abdomen was soft, tender diffusely to palpation without rebound or guarding. On the biochemical analysis, her blood glucose was 968 mg/dL with anion-gap metabolic acidosis (AG 46). In the ICU, she initiated on IV fluids, insulin and IV antibiotics for suspicion of colitis. C. diff testing was negative, but stool cultures grew MRSA for which she was started on Vancomycin and TMP-SMX. Due to continued abdominal pain on antibiotics, CT-Abdomen with Contrast showed acute appendicitis with inflammatory debris and without perforation or abscess (Figure 1) requiring laparoscopic appendectomy. DISCUSSION: Although Staphylococcal species are known to cause of antibiotic-associated colitis, MRSA colitis cases are unique and can pose a challenge in treatment if not ruled out and managed. When patients present with watery diarrhea, it is common to order C. diff testing, and stool culture is delayed or performed in an inappropriate time manner resulting in inconclusive cultures. Our case presented with DKA, which complicates the etiology of abdominal pain on admission for the clinician masking MRSA colitis associated with a rare complication of appendicitis double challenge and difficult to diagnose as most DKA patients present with abdominal pain. Oral Vancomycin is the treatment of choice, but our patient required coverage with TMP-SMX that proves to be effective double coverage. There were no case reports previously presenting with DKA or complication of acute appendicitis, which provides a learning opportunity in varied presentations.

Inappropriate Testing for Clostridioides difficile in Long-Term Care: Implications Highlight the Need for an Algorithm

This article provides clear guidance related to appropriate testing for Clostridioides difficile (C. diff) and identifies the negative implications of inappropriate testing, repeat testing, and testing for cure. Residents of long-term care (LTC) facilities are at increased risk for developing C. diff. Complications can arise if a resident does not have an active C. diff infection (colonization) and has a positive C. diff laboratory test result. The authors share a fictional bedside story illustrating the negative consequences that can result from inappropriate C. diff testing, and present a decision tree that promotes mindful application of testing, which may result in cost savings and prevent adverse resident outcomes. Keywords: C. diff, long-term care, test, diarrhea, stool, algorithm, treatment, diagnosis

Standardizing the Care of Acute Severe Ulcerative Colitis Inpatients at an Inflammatory Bowel Disease Referral Hospital

Patients who present with acute severe ulcerative colitis (ASUC) are at high risk for short-term colectomy. Despite consensus guidelines on the management of inpatient ASUC, variations in practice exist that can delay time-sensitive therapy. The variability in practice patterns at our institution has previously been published. The aim of this project is to implement a standardized care pathway for patients who present with ASUC, leveraging our EMR to decrease time to IV steroid and infliximab administration with the goal of decreasing colectomy rate and length of stay. Process mapping was used to evaluate current institutional ASUC care and to identify variation and delays in care. AGA, ACG, ECCO, and Toronto consensus guidelines were used to critically evaluate the process map. Causal factor analysis was used to identify the root cause of delays. Stakeholder meetings were held with gastroenterology, Emergency Department (ED), nursing, and colorectal surgery leadership. An ED Severe Ulcerative Colitis Order Set was designed and implemented, featuring 6 time-sensitive orders to initiate the pathway (see Figure). Review of 10 baseline pre-intervention charts and all 19 post-intervention charts focused on the following outcomes: (a) C. Diff ordering in ED, (b) time to C. Diff order, (c) time to C. diff collection, (d) C Diff collection in ED, (e) abdominal x-ray in ED, (f) time to IV steroids, (g) time to infliximab (f) hospital length of stay. Chi-squared test was used to determine significance for binary data. Mann-Whitney test was used for non-parametric time data. With use of the ED order set, time to C. Diff ordering and time to infliximab administration were significantly reduced (2.9 hours to 1 hour, P=0.02 and 111 hours to 57.5 hours, P=0.004 respectively). Post-intervention, there were non-significant trends towards improvement in the ordering and successful collection of C. Diff stool, time to C. Diff stool collection, completion of abdominal X-rays and decrease in hospital length of stay (see Table). The care processes for patients with ASUC were critically evaluated using process mapping and causal factor analysis. A successful Epic based Order Set was implemented in the ED with significant improvement in the rapidity of ordering C. Diff testing and decreased time to infliximab administration. Current efforts are focused on implementation of an inpatient admission order set. Future outcomes of interest include colectomy rate and time to colectomy.TablePre-InterventionPost-InterventionP-ValueC Diff Ordered in ED8 of 10= 80%19 of 19= 100%P=0.05Time Until C Diff Ordered (Median)2.9 hours1 hourP=0.02Time Until C Diff Collected (Median)7.9 hours5.7 hoursP=0.25# of C Diff Collected in ED3 of 8 = 38%14 of 19 = 74%P=0.08Abdominal X-rays done in ED5 of 10 = 50%16 of 19 = 84%P=0.06Time to IV Steroids (Median)6.6 hours10.8 hoursP=0.80Time to Infliximab (Median)111.6 hours57.5 hoursP=0.004Length of Stay for Patients Receiving Infliximab (Median)163.5 hours137.9 hoursP=0.18 Open table in a new tab