Diff Testing Research Articles

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

Appropriate Patient Selection Leads to Improvement in Healthcare Facility-Onset C. diff Rates

BACKGROUND Healthcare facility-onset Clostridium difficile infections (HO CDI) are potentially preventable events associated with increased cost, morbidity, and mortality in adult patients. Struggling with a high HO CDI rate, our facility identified appropriate patient selection for testing as an improvement opportunity. Careful patient selection for C. diff testing is vital to improve the sensitivity and specificity of HO CDI diagnosis. METHODS A dyad approach was developed to improve CDI testing practices. A rule was built into the electronic medical record that automatically cancelled C. diff orders if the sample was not ?collected within 24?hours of order. A C. diff Ticket-to-Lab (TTL) form with an accompanying testing algorithm was developed to guide clinicians through determining whether or not a patient should be tested for C. diff based on clinical criteria. All C. diff tests were required to have a TTL form filled out before submission to the laboratory. RESULTS Cancellation of outdated results reduced the average amount of C. diff tests performed monthly by 40%. After implementation of TTL, our HO CDI standardized infection ratio (SIR) dropped by 42% from 1.29 during the baseline period to 0.552 post intervention (p-value 0.0094, 95% confidence interval 0.209, 0.821). CONCLUSIONS A combination of electronic and manual tools can be used to assist providers in identifying patients with clinical criteria that warrants C. diff testing. Improving patient selection for C. diff testing is an effective strategy to reduce HO CDI. Detection of C. diff colonization is prevented along with unnecessary antibiotic use, prolonged length of stay and hospital penalties associated with falsely inflated HO CDI rates.

Implementation of Clostridium difficile Algorithm for Reduction of Inappropriate Testing in a Community Hospital

Introduction: Our hospital has a C. diff Infection (CDI) Stool Collection Algorithm (figure 1) in place to promote effective testing. In the previous year, data showed that there was an increase in stool samples collected more than 24 hours after order was placed. This delay in collection is likely due to lack of watery bowel movements since the order was placed. Any positive results from these orders are likely false positive. This leads to unwarranted treatment and inaccurate labeling of a hospital acquired infection if positive more than 48 hours after admission. Methods: CDI Stool Collection Algorithm was posted at all nursing stations and educational sessions were held. Message explaining the collection algorithm including a request to reevaluate the necessity of the order was sent to providers of patients with a C. diff order uncollected for more than 24 hours.1061_A Figure 1. Clostridium difficile Infection Stool Collection Algorithm1061_B Figure 2. Comparison of order breakdown during comparison and intervention period. Orders collected over 24 hours decreased (p=0.001)Results: Data was retrieved from the hospital database for the time period of this study and the corresponding time period last year for comparison. Last year, a total of 896 C. diff tests were ordered. This year, a total of 688 C. diff tests were ordered. This decrease is statistically significant with a p value of 0.002. Therefore, the interventions of implementing the collection algorithm led to more appropriate ordering (figure 3). Last year, the total number of C. diff orders collected after 24 hours was 84 and after the intervention this year, it was 34. The reduction was statistically significant with a p value of 0.001. This could be a reflection of the educational messaging system. (figure 2). The total number of positive results occurring from orders collected more than 24 hours from placement of order was 7 last year and it was 1 this year. There was no statistical difference between these numbers (p value = 0.15). The percentage was however reduced in half (8 to 4% of total results). Hospital acquired infection total number and rate were unchanged. Conclusion: This intervention may have led to more appropriate testing for CDIs through implementation of the CDI Algorithm and educational sessions. This was demonstrated in an overall decrease in orders. A reduction in collection of orders pending for 24 hours or more was achieved; through educational message system if deemed clinically appropriate. Despite this reduction, positive results from these collections were not reduced statistically and may not have led to improvement of unwarranted treatment of carrier patients.1061_C Figure 3. Comparison of Total C. Diff orders during comparison and intervention period (p=0.002)

Testing Stewardship: A ‘Hard Stop’ to Reduce Inappropriate C. diff Testing

BackgroundPatients may be over-diagnosed with C. difficile infection (CDI) due to colonization, especially if laxatives are used. We had implemented an alert to prompt providers to discontinue C. diff orders in the setting of laxative use. This initially decreased orders by about 25%, but became less effective over time. Our objective was to strengthen our C. diff testing stewardship by creating a “hard stop” to require providers to think critically about C. diff testing in the presence of laxative use or the absence of documented diarrhea.MethodsOur two-hospital, >1100-bed community-based academic healthcare system performs all C. diff testing via PCR. We implemented our initial laxative alert, which notified providers but did not prohibit testing, in March 2015. In April 2017, we launched a new alert that fired >36 hours after admission, and assessed for documented diarrhea (>2 episodes/24 hours). If diarrhea was present, it would assess for any administered laxative within prior 24 hours. If neither criterion was met, the provider could only order C. diff testing by calling the laboratory and documenting the staff person’s name in the order; no further justification was required. We measured the number of C. diff tests completed per day, the number of calls made to lab, and CDI rates (using NHSN LabID definition). Balancing measures included monitoring oral vancomycin orders without C. diff testing, and delayed CDI diagnoses.ResultsAt baseline, we observed a mean of 9 (SD, 4–14) C. diff orders daily. After initiating the hard stop alert, daily testing decreased by 30% (Fig. 1). Frequency of hospital-onset CDI dropped by 45% during first month of implementation (Fig. 2), from mean 3.6/week to 2/week. To date we have not detected delayed diagnoses or empiric treatment without testing; 18 override laboratory calls have been documented.ConclusionGiven PCR’s high sensitivity for C. diff, testing stewardship is critical to minimize false-positive cases of CDI, which lead to inappropriate treatment, prolonged length of stay, and hospital penalties. Requiring a phone call to order C. diff testing in the setting of laxative use or minimal diarrhea effectively reduced testing, and was well-accepted by nurses and providers. To date, no adverse effects have been detected.Disclosures All authors: No reported disclosures.

Implementation of Electronic Medical Record Hard Stop Alerts for Inappropriate Clostridium difficile Tests in Academic and Community Hospital Setting; Impact on Testing Rates and Clinical Outcomes

BackgroundEnsuring appropriate C. diff nucleic acid amplification testing is increasingly important. We implemented electronic medical record (EMR) hard stop alerts across our health-system to reduce inappropriate tests. We review the impact on testing rates and outcome of those where testing was not pursed.Methods C. diff order in a patient with previous test (14 or 7 days for positive or negative), or receipt of laxative in past 48 hours triggered an EMR alert; test could only proceed with micro lab approved test code. The initiative was rolled out at an academic (October 2016) and two community hospitals (December 2016, January 2017). Statistical control charts (SPC) tracked changes in number of tests over time. Wilcoxon rank-sum tests were used to examine pre-post changes. Forward stepwise logistic regression models was used to explore factors associated pursuit of testing post EMR alert. Clinical outcomes of patients at the academic hospital whose testing attempt triggered an alert and testing was not pursued were reviewed.ResultsFor the 3 hospitals, mean weekly C. diff testing rate pre and post-intervention was 146 (SD 12.5) and 119 (SD 12.9), P <0.001. Average number of weekly EMR alerts was 51; 26 for laxative, 14 for previous negative, 3 for previous positive est, 8 for undetermined reason. Figure shows SPC chart weekly testing rate for each hospital.Table shows factors associated with C. diff test pursuit at the academic hospital.OR95% CI P value≥3 unformed stools within 24 hours5.55(2.84 − 10.81)<0.001ID consult team following No1.00 Yes, agreed/recommended test11.33(2.73 − 47.01)0.001 Yes, disagreed/did not recommend test3.42(1.36 − 8.61)0.009Order reason: leukocytosis3.14(1.45 − 6.80)0.004Alert reason: laxatives3.15(1.41 − 7.03)0.005Comorbidity: cirrhosis2.32(1.15 − 4.67)0.019Outcome review of 83 patients who had EMR alert and did not pursue testing was as follows: 36 diarrhea resolved, 21 an alternate cause found, 3 died from non CDI related etiology, 11 had subsequent c diff testing later in the admission (6 negative, 5 positive results), 12 patients were discharged home.ConclusionIn academic and community hospital setting, EMR hard stop alerts educed inappropriate C. diff test, without impact on patient outcomes.Disclosures K. C. Carroll, GenePOC, Inc.: Grant Investigator, Grant recipient