Difficile Testing Research Articles

180. Impact of a two-step diagnostic bundle on hospital-onset Clostridioides difficile infection rates and treatment across a large health system.

Abstract Background Distinguishing true Clostridioides difficile Infection (CDI) from colonization is a challenge, with nearly 20% of hospitalized adults being carriers of C. difficile. Polymerase chain reaction (PCR) testing alone is not able to distinguish colonization from infection, leading to over-diagnosis and unnecessary treatment. Despite interventions including pre-approval by antimicrobial stewardship programs (ASP), reportable hospital-onset CDI (HO-CDI) rates across our health system remained high. In 2021, we implemented a C. difficile PCR with reflex toxin enzyme immunoassay (EIA) testing strategy to improve diagnostic accuracy and treatment outcomes. The purpose of this study was to evaluate the impact of this two-step testing algorithm bundled with education, ASP support and order set changes on HO-CDI rates and C. difficile treatment across our health system. Methods PCR with EIA testing algorithm was implemented between May and August 2021 across seven hospitals within the Northwestern Medicine Health System. Multifaceted education was delivered to leadership and clinicians in person and electronically to. ASP performed daily diagnostic prospective audit and management support. Clinical decision support (CDS) was incorporated into order sets to promote diagnostic stewardship (Table 1, Figure 1). Standardization of analyst-developed tracking reports allowed for longitudinal monitoring across the system and at each facility, including unit- and patient-level data. Figure 1C. Difficile Testing Algorithm PCR/Reflex Toxin EIA Results The HO-CDI standardized infection ratio (SIR) reduced significantly from 0.8 to 0.57 p< 0.001), and reportable HO-CDI cases reduced by 238 cases across the health system between May 2021 and March 2022. 6043 samples were tested, of which 282 (4.7%) were confirmed CDI cases (PCR+/toxin+) and 687 (11%) were non-CDI cases (PCR+/toxin-), of which 438 (67%) received CDI treatment. (Figure 2 and 3). Figure 3 Actual versus avoided HO C. difficile cases. Conclusion The two-step CDI diagnostic and treatment bundle significantly reduced the SIR of HO-CDI. Although treatment of colonized patients remained high, a large number of patients safely avoided CDI treatment. Testing and education bundles can help advance antimicrobial and diagnostic stewardship by improving detection, treatment, and tracking of CDI. Disclosures Asra Salim, MPH, CPH, FAPIC, IRhythym Technologies Inc: Stocks/Bonds.

SEE the DIFFerence: Reducing unnecessary C. difficile orders through clinical decision support in a large, urban safety-net system

Clostridioides difficile (C. difficile) is a hospital-acquired infection. Overtesting for C. difficile leads to false positive results due to a high rate of asymptomatic colonization, resulting in unnecessary and harmful treatment for patients. This was a quality improvement initiative to decrease the rate of inappropriate C. difficile testing across 11 hospitals in an urban, safety-net setting. Three best practice advisories were created, alerting providers of recent laxative administration within 48 hours, a recent positive test within 14 days, and a recent negative test within 7 days. The outcome measures were the number of C. difficile tests per 1,000 patient days, as well as the rate of hospital onset C. difficile infection was compared pre- and post-intervention. The process measures included the rate of removal of the C. difficile test from the best practice advisory, as well as the subsequent 24-hour re-order rate. The number of C. difficile tests decreased by 27.3% from 1.1 per 1,000 patient days preintervention (May 25, 2020-May 24, 2021) to 0.8 per 1,000 patient days postintervention, (May 25, 2021-March 25, 2022), P < .001. When stratified by hospital, changes in testing ranged from an increase of 12.5% to a decrease of 60%. Analysis among provider type showed higher behavior change among attendings than compared to trainees or advanced practice providers. There was a 12.1%, nonsignificant decrease in C. difficile rates from preintervention, 0.33 per 1,000 patient days compared to postintervention, 0.29 per 1,000 patient days, P=.32. Using only an electronic health record intervention, we successfully decreased C. difficile orders after 72 hours of admission in a large, safety-net system.Variation existed among hospitals and by provider type.

Prevalence and Seasonality of Clostridiodes difficile over 12Years at a Tertiary Hospital in Brazil.

Clostridioides difficile is the main pathogen responsible for antibiotic-associated diarrhea in adults. Besides its challenging diagnosis, C. difficile infection (CDI) causes substantial morbidity and mortality. Commercially, there are assays with different targets and performances in sensitivity and specificity. The objectives of this study were to: (1) evaluate the prevalence and seasonal variability of CDI rates at a tertiary hospital in southern Brazil over 12years and (2) determine the impact of using a two-step algorithm test in the laboratory diagnosis. Between January 2007 and May 2019, fecal samples from 2275 patients were analyzed in a cross-sectional study. Four commercial tests were adopted for the diagnosis of CDI, the immunochromatographic test for toxin A from 2007 to 2010; the enzyme-linked immunosorbent assay method for toxins A and B from 2011 to March 2017; and the rapid enzyme immunoassay (EIA) for GDH and toxins A and B, associated with a Polymerase Chain Reaction (PCR) for the toxin B gene from June 2017 to 2019. The annual prevalence was 8.7% from 2007 to March 2017, increasing between June 2017 and 2019 to 14.7% when the C. diff Quik Chek Complete + GeneXpert C. difficile (two-step algorithm) test was adopted. The number of samples (691) and percentage of CDI cases (10.5%) were higher in winter, but the difference has no statistical significance (P > 0.05). An accurate diagnosis and adequate knowledge of the local seasonality of CDI allow the effective implementation of prevention and control strategies for nosocomial CDI, in addition to effective treatment for patients.

Antibiotic review kit for hospitals (ARK-Hospital): a stepped-wedge cluster-randomised controlled trial

Strategies to reduce antibiotic overuse in hospitals depend on prescribers taking decisions to stop unnecessary antibiotic use. There is scarce evidence for how to support these decisions. We evaluated a multifaceted behaviour change intervention (ie, the antibiotic review kit) designed to reduce antibiotic use among adult acute general medical inpatients by increasing appropriate decisions to stop antibiotics at clinical review. We performed a stepped-wedge, cluster (hospital)-randomised controlled trial using computer-generated sequence randomisation of eligible hospitals in seven calendar-time blocks in the UK. Hospitals were eligible for inclusion if they admitted adult non-elective general or medical inpatients, had a local representative to champion the intervention, and could provide the required study data. Hospital clusters were randomised to an implementation date occurring at 1-2 week intervals, and the date was concealed until 12 weeks before implementation, when local preparations were designed to start. The intervention effect was assessed using data from pseudonymised routine electronic health records, ward-level antibiotic dispensing, Clostridioides difficile tests, prescription audits, and an implementation process evaluation. Co-primary outcomes were monthly antibiotic defined daily doses per adult acute general medical admission (hospital-level, superiority) and all-cause mortality within 30 days of admission (patient level, non-inferiority margin of 5%). Outcomes were assessed in the modified intention-to-treat population (ie, excluding sites that withdrew before implementation). Intervention effects were assessed by use of interrupted time series analyses within each site, estimating overall effects through random-effects meta-analysis, with heterogeneity across prespecified potential modifiers assessed by use of meta-regression. This trial is completed and is registered with ISRCTN, ISRCTN12674243. 58 hospital organisations expressed an interest in participating. Three pilot sites implemented the intervention between Sept 25 and Nov 20, 2017. 43 further sites were randomised to implement the intervention between Feb 12, 2018, and July 1, 2019, and seven sites withdrew before implementation. 39 sites were followed up for at least 14 months. Adjusted estimates showed reductions in total antibiotic defined daily doses per acute general medical admission (-4·8% per year, 95% CI -9·1 to -0·2) following the intervention. Among 7 160 421 acute general medical admissions, the ARK intervention was associated with an immediate change of -2·7% (95% CI -5·7 to 0·3) and sustained change of 3·0% (-0·1 to 6·2) in adjusted 30-day mortality. The antibiotic review kit intervention resulted in sustained reductions in antibiotic use among adult acute general medical inpatients. The weak, inconsistent intervention effects on mortality are probably explained by the onset of the COVID-19 pandemic. Hospitals should use the antibiotic review kit to reduce antibiotic overuse. UK National Institute for Health and Care Research.

S2729 Failed Tofacitinib Rescue Therapy in Acute Severe Ulcerative Colitis Refractory to Steroids and Anti-TNF Therapy

Introduction: Acute severe ulcerative colitis (ASUC) is a life-threatening condition that may lead to complications such as toxic megacolon, infection, perforation, or hemorrhage. Current medical therapy has a high failure rate with approximately a third of patients requiring colectomy. Case Description/Methods: A 60-year-old Indian man with a three-year history of ulcerative proctitis on mesalamine therapy was admitted to the hospital for diarrhea, abdominal pain, and hematochezia after failing outpatient oral prednisone and rectal budesonide foam. His vital signs on admission were normal. Labs showed WBC of 12.5, Hgb of 10.6, platelet count of 530, albumin of 2.7, CRP of 143.2, ESR of 75, and fecal calprotectin of 1860. C. difficile testing was negative. CT scan showed mild colonic wall thickening. The patient was started on IV methylprednisolone 60 mg/daily. Colonoscopy which showed severe (Mayo Score 3) pancolitis with negative CMV on biopsies. Surgery was consulted after his symptoms did not improve after five days of steroid therapy and he required several blood transfusions. Due to the unavailability of inpatient Infliximab use in our hospital at the time, he was started on Adalimumab and received 160 mg dose, followed by another 160 mg injection in 9 days due to the lack of significant improvement after first dose. The patient refused to undergo colectomy until all medical therapies failed. Given some data on the treatment of ASUC with Tofacitinib, he was started on a 10 mg dose three times daily. CRP declined initially but quickly worsened. Patient decided to transfer care to another tertiary center for colectomy. While awaiting transfer, he developed brisk lower GI bleeding and became hypotensive. He was moved to the ICU and required emergent exploratory laparotomy with colectomy and an end ileostomy, three weeks after his admission to the hospital. Discussion: Despite recent data demonstrating some efficacy of tofacitinib as a rescue therapy with concomitant IV steroids, our case failed to respond to this treatment. Further delay in surgical intervention likely resulted in the need for emergent surgery. Data to support rescue tofacitinib is based on observational and retrospective case-control data with several limitations. Clinicians should be cautious delaying a definitive surgical intervention until more robust data supports tofacitinib rescue therapy for this sick population. Fortunately, this patient had an uncomplicated post-op course and was discharged to rehab in ten days.

Is diagnostic stewardship possible in solid organ transplantation?

Diagnostic stewardship in solid organ transplant (SOT) recipients has the potential to help these vulnerable patients at risk for over-testing and overtreatment. Herein, we review potential targets for diagnostic stewardship in SOT, such as Clostridioides difficile testing, urine cultures, molecular diagnostics, as well as novel areas of diagnostic stewardship. Bundled interventions focused on appropriate C. difficile testing can result in a significant decrease in testing and clinical diagnosis of C. difficile infection without any harms related to delay in diagnosis. In otherwise stable renal transplant recipients after the first month of transplant, screening urine cultures have not been shown to improve outcomes. Novel targets that require additional study in the SOT population include noninvasive fungal diagnostics and cytomegalovirus testing strategies CONCLUSIONS: Diagnostic stewardship is an innovative approach to improve diagnosis and limit unnecessary antimicrobial use. While there has been little direct exploration of diagnostic stewardship in the SOT population, there is great potential for benefit given frequent testing with diagnostics that have imperfect sensitivity and specificity, and sometimes great cost. Diagnostic stewardship in the SOT population is indeed possible but will require a multidisciplinary effort to ensure that appropriates tests and benefits are realized.

S2053 Iso Painful in My Belli

Introduction: The etiology of diarrhea in patients with human immunodeficiency virus (HIV) is broad. Causes include antiretroviral therapy adverse events, opportunistic infections, malignancies, and progressive HIV. CD4 count and HIV viral load are important risk-assessment tools for infection. Stool studies including gastrointestinal pathogen polymerase chain reaction (GI PCR), C. difficile, and ova and parasites testing are instrumental. Microsporidia and Isospora are 2 causes of diarrhea in HIV patients for which testing is not included on GI PCR and ova and parasite testing. We present a case of a 57-year-old male with uncontrolled HIV and diarrhea found to have Isospora belli. Case Description/Methods: A 57-year-old male with a medical history of HIV on Descovy and Prezcovix (CD4 90, VL 154K) presented to the hospital with a 5-week course of watery non-bloody diarrhea with intermittent nausea, vomiting, and a 20 lb weight loss. He reported having up to 5 watery diarrheal movements daily. His last colonoscopy was 2 years prior with no acute findings. On exam, he was afebrile with no abdominal tenderness. Prior to presentation, the patient was seen by his primary care physician for diarrhea, with 2 GI PCR panels and ova and parasite testing negative. Patient was prescribed ciprofloxacin and metronidazole by his physician with no improvement in symptoms. On hospital admission, labs were significant for Na/K/Cl of 130/3.3/110, venous blood gas with pH 7.27, CO2 31, HCO3 14.2, and WBC of 6.0. C-diff, CMV, Cryptococcus and repeat GI PCR were negative. Stool examination was positive for Isospora. Patient was initially treated with Bactrim 800-160 twice daily for 10 days with resolution of his diarrea. His HIV regimen was adjusted from Descovy and Prezcovix to Biktarvy for concern for resistance and nonadherence. Discussion: Patients with HIV who present with diarrhea should be extensively worked up as etiology can be multifaceted with consideration for opportunistic infections, medication side effects, and worsening HIV disease burden. Isospora is an opportunistic protozoan parasite that can cause significant diarrhea and weight loss in HIV patients. It is more common in developing countries such as India and sub-saharan Africa and is rarely diagnosed in the United States. Thus, Isospora is not commonly part of the regular stool ova and parasite culture set and should be tested for in patients with high clinical suspicion.

Clostridioides difficile toxin is infrequently detected in inflammatory bowel disease and does not associate with clinical outcomes

IntroductionClostridioides difficile infection (CDI) rates and outcomes can vary based on differences in testing strategy. Our aim was to assess the prevalence of toxin detection in inflammatory bowel disease (IBD) when compared to those without IBD. Secondly, the clinical outcomes of CDI in IBD were assessed using two-step testing strategies.MethodsWe included patients undergoing CDI testing from four academic centers in the United States between January 1, 2018 and June 30, 2020. First the prevalence of toxin detection was compared between individuals with IBD and those without IBD. Secondly, among patients with IBD a primary composite outcome of abdominal colectomy, admission to an intensive care unit (ICU) or death within 30 days of C. difficile testing was assessed across the three categorical groups (screen positive/toxin positive, screen positive/toxin negative and screen negative assay) resulting from the two-step testing strategy.ResultsWhen comparing individuals with a positive screening assay, patients with IBD were less likely to have toxin detected by enzyme immunoassay (EIA) as compared to the non-IBD population (22/145 (15.2%) vs. 413/1144 (36.1%), p < 0.0001). Among all patients with IBD (n = 300), twenty-five (8.3%) had a screen positive assay/toxin positive assay, 136 (45.3%) had a screen positive/toxin negative assay and 139 (46.3%) had a negative screening assay. No significant difference in the primary composite outcome was detected across the three groups (p = 0.566).ConclusionWhen compared to those without IBD, patients with IBD have a reduced proportion of cases of C. difficile with toxin positivity. Differences in clinical outcomes among patients with IBD were not detected and limited by the infrequent detection of expressed toxin.

Application of consolidated framework for implementation research to improve Clostridioides difficile infection management in district hospitals

BackgroundClostridioides difficile infection (CDI) contributes the global threats of drug resistant infections, healthcare acquired infections and antimicrobial resistance. Yet CDI knowledge among healthcare providers in low-resource settings is limited and CDI testing, treatment, and infection prevention measures are often delayed.Objectives: to develop a CDI intervention informed by the local context within South African public district level hospitals, and analyze the CDI intervention and implementation process. MethodsA CDI checklist intervention was designed and implemented at three district level hospitals in the Western Cape, South Africa that volunteered to participate. Data collection included a retrospective medical records review of patients hospitalized with C. difficile test orders during the 90 days post-implementation. Patient outcomes and checklist components (e.g. antibiotics) were collected. Qualitative interviews (n = 14) and focus groups (n = 6) were conducted with healthcare providers on-site. The Consolidated Framework for Implementation Research (CFIR) and the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) were applied to collected data and observations in order to identify drivers and barriers to implementation and understand differences in uptake. ResultsOne of the three hospitals displayed high intervention uptake. Highly relevant CFIR constructs linked to intervention uptake included tension for change, strong peer intervention champions, champions in influential leadership positions, and the intervention's simplicity (CFIR construct: complexity). Tension for change, a recognized need to improve CDI identification and treatment, at the high uptake hospital was also supported by an academic partnership for antimicrobial stewardship. ConclusionsThis research provides a straight-forward health systems strengthening intervention for CDI that is both needed and uncomplicated, in an understudied low resource setting. Intervention uptake was highest in the hospital with tension for change, influential champions, and existing academic partnerships. Implementation in settings with fewer academic connections requires further testing of collaborative implementation strategies and proactive adaptations.

65-Year-Old Man With Weight Loss and Dyspnea on Exertion

65-Year-Old Man With Weight Loss and Dyspnea on Exertion

Successful diagnostic stewardship for Clostridioides difficile testing in pediatrics.

To reduce both inappropriate testing for and diagnosis of healthcare-onset (HO) Clostridioides difficile infections (CDIs). We performed a retrospective analysis of C. difficile testing from hospitalized children before (October 2017-October 2018) and after (November 2018-October 2020) implementing restrictive computerized provider order entry (CPOE). Study sites included hospital A (a ∼250-bed freestanding children's hospital) and hospital B (a ∼100-bed children's hospital within a larger hospital) that are part of the same multicampus institution. In October 2018, we implemented CPOE. No testing was allowed for infants aged ≤12 months, approval of the infectious disease team was required to test children aged 13-23 months, and pathology residents' approval was required to test all patients aged ≥24 months with recent laxative, stool softener, or enema use. Interrupted time series analysis and Mann-Whitney U test were used for analysis. An interrupted time series analysis revealed that from October 2017 to October 2020, the numbers of tests ordered and samples sent significantly decreased in all age groups (P < .05). The monthly median number of HO-CDI cases significantly decreased after implementation of the restrictive CPOE in children aged 13-23 months (P < .001) and all ages combined (P = .003). Restrictive CPOE for CDI in pediatrics was successfully implemented and sustained. Diagnostic stewardship for CDI is likely cost-saving and could decrease misdiagnosis, unnecessary antibiotic therapy, and overestimation of HO-CDI rates.

Trends in facility-level rates of Clostridioides difficile infections in US hospitals, 2019-2020.

The coronavirus disease 2019 pandemic caused substantial changes to healthcare delivery and antibiotic prescribing beginning in March 2020. To assess pandemic impact on Clostridioides difficile infection (CDI) rates, we described patients and trends in facility-level incidence, testing rates, and percent positivity during 2019-2020 in a large cohort of US hospitals. We estimated and compared rates of community-onset CDI (CO-CDI) per 10,000 discharges, hospital-onset CDI (HO-CDI) per 10,000 patient days, and C. difficile testing rates per 10,000 discharges in 2019 and 2020. We calculated percent positivity as the number of inpatients diagnosed with CDI over the total number of discharges with a test for C. difficile. We used an interrupted time series (ITS) design with negative binomial and logistic regression models to describe level and trend changes in rates and percent positivity before and after March 2020. In pairwise comparisons, overall CO-CDI rates decreased from 20.0 to 15.8 between 2019 and 2020 (P < .0001). HO-CDI rates did not change. Using ITS, we detected decreasing monthly trends in CO-CDI (-1% per month, P = .0036) and HO-CDI incidence (-1% per month, P < .0001) during the baseline period, prior to the COVID-19 pandemic declaration. We detected no change in monthly trends for CO-CDI or HO-CDI incidence or percent positivity after March 2020 compared with the baseline period. While there was a slight downward trajectory in CDI trends prior to March 2020, no significant change in CDI trends occurred during the COVID-19 pandemic despite changes in infection control practices, antibiotic use, and healthcare delivery.

Clostridioides difficile surveillance at the University Hospital in Košice reveals high prevalence of the ribotype 176

Background Clostridioides difficile infection (CDI) has become a serious health problem worldwide in recent years, the severity of which lies in the ability to spread epidemically in hospitals and in frequent diseases relapses. CDI Surveillance was performed at the Louis Pasteur University Hospital in Košice from January to February 2020 to analyse the molecular characteristics ofC. difficile(CD) isolates from local patients with CDI. Methods CDI was initially diagnosed using the C. difficile rapid test (for enzyme GDH and toxin A/B). A total of 36 stool samples (29 GDH and toxin positive, 7 GDH positive and toxin negative) were cultured anaerobically on selective media (Brazier’s agar). Culture was positive for CD in 31 samples. Bacterial DNA was extracted from all CD isolates. Genes tcdA, tcdB, cdtA and cdtB encoding toxin A, toxin B and binary toxin were detected by multiplex PCR and ribotypes of CD were analysed by capillary electrophoresis-based PCR. Results Molecular typing showed that toxin A as well as toxin B was confirmed in 30 of 31 isolates, binary toxin in 18 isolates. Ribotype 176, characterized by production of all 3 toxins, was the most prevalent and was detected in 18 isolates (58%). Toxin A and toxin B producing ribotypes 001, 014 and 020 were also confirmed. Conclusion The high incidence of epidemic ribotype 176 with higher capacity to spread in a hospital setting emphasises the need to implement strict epidemic measures and the importance of implementing continuous surveillance programmes for CDI in Slovakia.

Clostridioides difficile: A diagnostic intervention

Background:Clostridioides difficile infection (CDI) is a leading cause of healthcare-associated infection and is associated with increased morbidity and mortality. Multiple strategies have been implemented to optimize the diagnostic accuracy of CDI testing algorithms. However, overdiagnosis of C. difficile colonization remains a challenge especially in the era of highly sensitive Nucleic acid amplification testing (NAAT). We implemented 2 interventions to reduce the rates of inappropriate C. difficile orders and tests. Methods: We performed a quasi-experimental retrospective study to examine the rates of all inpatient C. difficile test orders and results relative to 2 interventions between January 2018 and February 2021. We defined 3 periods: preintervention, after the first intervention, and after the second intervention. The first intervention, implemented May 2019, was a clinical decision support system (CDSS) tool to guide clinicians to order testing only if CDI criteria were met. The second intervention, implemented July 2020, was the requirement of mandatory antimicrobial team approval of PCR reflex testing for indeterminate toxin or antigen test results. This intervention included a discussion between clinicians and members of stewardship team prior to approval. To evaluate the impact of interventions on ordering appropriateness, chart review was conducted on a random subsample of 100 orders from each period. Hospital-onset CDI (HO-CDI) was calculated using CDC criteria. Results: In total, 3,004 C. difficile test orders were placed during the study period. The rates of reportable HO-CDI were significantly reduced by 57.1% (P = .003). We detected a significant reduction in the number of tests ordered over time from 11.6 to 7.51 per 1,000 patient days. (p Conclusions: CDSS tools target patients at high pretest probability of CDI. The restriction of PCR-reflex testing to the antimicrobial stewardship team is a novel effective measure to minimize the misdiagnosis of CDI. The incorporation of multiple strategies is necessary to improve the diagnostic accuracy of C. difficile testing.Funding: NoneDisclosures: None

Role of diagnostic stewardship in reducing healthcare facility-onset Clostridioides difficile infections

Background:Clostridioides difficile infection (CDI) is the most common healthcare-associated infection (HAI) in the United States. Healthcare facility-onset (HO) CDI reporting is a laboratory-identified (LabID) event and does not rely on symptoms. Inappropriate testing can lead to overdiagnosis in patients who are colonized, especially in those receiving promotility agents. Approximately 45% of HO-CDI cases at our institution occurred in the setting of laxative use in 2019. We assessed the effectiveness of an electronic medical record (EMR) “hard stop” in reducing inappropriate CDI testing and its impact on HO-CDI rates. Methods: We conducted a pre–post quasi-experimental retrospective study comparing test order rates per 1,000 patient days, CDI rate per 1,000 patient days, and standardized infection ratio (SIR) in the preintervention period (January 2018–December 2019) to the intervention period (April 2020–September 2021), at a 5-hospital healthcare system in southeastern Michigan. In February 2020, we implemented a hard stop in Epic that was triggered &gt;3 days after admission for the following criteria: patients &lt;1 year of age; repeated testing within 7 days, and receipt of promotility agents within 48 hours. After discontinuing the promotility agents for at least 48 hours, providers were allowed to place an order if diarrhea persisted. The medical director of infection prevention and control or designee had the ability to override the hard stop when deemed necessary after reviewing the case upon provider request. All orders expired after 24 hours if a specimen was not collected. We retrospectively reviewed the number of overrides after the intervention to determine the positivity rate. Results: Our CDI rates per 1,000 patient days were 3.21 in the preintervention period and 1.48 in the postintervention period, a 54% reduction (Fig. 1). The test order rates were 119.4 in the preintervention period and 87.7 in the postintervention period, a 26.5% reduction (Fig. 2). The SIR decreased from 0.542 in the preintervention period to 0.361 in the postintervention period, a 33% reduction (95% CI, 0.54–0.82; P = .0001). After the intervention, 299 patients had an override. Of these, samples from 218 patients (72.9%) were negative, 50 orders (16.7%) were cancelled, and 28 samples (9%) were positive. Conclusions: Diagnostic stewardship, utilizing an electronic hard stop, was effective in reducing inappropriate C. difficile testing in the setting of promotility agents without delaying diagnosis of HO-CDI. This strategy combined with standard best practices can significantly reduce HO-CDI rates.Funding: NoneDisclosures: None

Prospective audit and feedback of Clostridioides difficile PCR at the time of ordering increases appropriateness of testing

Background: Over-testing for Clostridioides difficile infection outside acute diarrheal illness without a clear alternative cause can lead to inappropriate diagnosis and treatment with antibiotic therapy. Preanalytical interventions such as education, order restriction, and electronic order assistance are common but are limited in effectiveness. As an alternative approach, our antibiotic stewardship program (ASP) implemented prospective audit and feedback (PAF) on C. difficile PCR orders to reduce inappropriate testing.Methods: The study was conducted at a 399-bed, tertiary-care, Veterans’ Affairs Medical Center and included adult inpatients and outpatients for whom C. difficile PCR testing was ordered. In the preintervention period from June through September 2019, the ASP was alerted to C. difficile PCR tests and collected data but did not intervene. From October 2019 to January 2020, the ASP performed real-time PAF at the time of ordering. Appropriateness of testing was determined based on whether there was a negative result in the prior 7 days and a 3-step review of clinical factors (Fig. 1). When possible, a direct conversation took place with the ordering provider. If not possible, a general note delineating appropriate clinical criteria for testing was generated. No PAF was done outside standard hours. The ASP recommended cancelling tests deemed inappropriate. Monthly test rates during the pre- and postintervention periods were compared using the Student t test with α = .05, and test appropriateness was compared using the χ2 test. All analyses were conducted using Microsoft Excel software. Results: During the preintervention period, a total of 418 tests were ordered (104.5 per month). This number decreased to 276 (69 per month) during the intervention period. (p Conclusions: Direct PAF at the time of C. difficile PCR ordering may increase test appropriateness and is associated with a reduction in overall testing, primarily by reducing the number of tests that are considered not appropriate on clinical grounds. PAF is effective but requires significant time investment by ASP staff and may not be a sustainable intervention over time.Funding: NoneDisclosures: None

Prevalence of and factors associated with inappropriate Clostridioides difficile testing in a teaching hospital in Korea

BackgroundGiven the increasing incidence of Clostridioides difficile infections in Korea, there has been an increase in inappropriate testing for C. difficile, which has rendered overdiagnosis of asymptomatic colonisers common. We aimed to investigate the appropriateness of C. difficile testing and the related factors.MethodsWe retrospectively reviewed the medical records of patients who were admitted to a 1300-bed tertiary-care teaching hospital in Korea and were tested for C. difficile infection from September 2019 to November 2019. We performed logistic regression analysis to investigate factors related to inappropriate testing. Further, a survey was conducted on physicians to assess the knowledge and ordering patterns of C. difficile testing.ResultsWe included 715 tests from 520 patients in the analysis. Testing was classified as hospital-onset and community-onset and subclassified as appropriate and inappropriate following an algorithmic method. Among the 715 tests, 576 (80.6%) and 139 (19.6%) tests were classified as hospital-onset and community-onset, respectively. Among the hospital-onset tests, 297 (52%) were considered inappropriate. The risk of inappropriate testing increased when C. difficile tests were conducted in the emergency room (OR 24.96; 95% CI 3.12–199.98) but decreased in intensive care units (OR 0.36, 95% CI 0.19–0.67). The survey was conducted on 61 physicians. Internal medicine physicians had significantly higher scores than non-internal medicine physicians (7.1 vs. 5.7, p = 0.001). The most frequently ordered combination of tests was toxin + glutamate dehydrogenase (47.5%), which was consistent with the ordered tests.ConclusionAlmost half of the C. difficile tests were performed inappropriately. The patient being located in the emergency room and intensive care unit increased and decreased the risk of inappropriate testing, respectively. In a questionnaire survey, we showed that internal medicine physicians were more knowledgeable about C. difficile testing than non-internal medicine physicians. There is a need to implement the diagnostic stewardship for C. difficile, especially through educational interventions for emergency room and non-internal medicine physicians.

Improving Stewardship of Clostridioides difficile Testing with EMR and Provider Phone Calls.

IntroductionModern laboratory techniques cannot differentiate between Clostridium difficile colonization and infection; therefore, testing must be indicated clinically. To reduce hospital-onset of C. difficile infections (HO-CDI), Ascension Via Christi Hospitals (AVCH) in Wichita intervened in three stages by introducing: 1) a C. diflcile testing algorithm; 2) an electronic medical record (EMR)-based decision support system to enforce said algorithm; and 3) phone calls from the infection prevention department to providers to discontinue tests not collected within 24 hours of the order. The goal of this study was to determine if these interventions improved the HO-CDI rate.MethodsAt AVCH, the three study periods were compared: baseline with algorithm training only, the EMR intervention, and the EMR intervention with additional phone calls (EMR with phone calls). Data were abstracted from the hospital EMR.ResultsA total of 311 charts were reviewed. Adherence to the algorithm increased from 34% at baseline to 52% after the EMR intervention (p = 0.010). During the EMR with phone calls period, more tests were discontinued (87%; n = 39) compared to baseline (54%; n = 15) and EMR (54%; n = 15; p = 0.003). The HO-CDI rate ranged from 8.5 cases per 10,000 patient-days at baseline, to 7.9 during EMR, to 4.0 during EMR with phone calls (p = 0.007).ConclusionsThe EMR and EMR with phone call interventions were associated with a significant decrease in the HO-CDI rate and an increase in provider adherence to the algorithm.

Frequency of stool specimen collection and testing for Clostridioides difficile of hospitalized adults and long-term care facility residents with new-onset diarrhea in Louisville, Kentucky

ObjectivesThis study aimed to determine the stool specimen collection and Clostridioides difficile (C. difficile) testing frequency from inpatients and long-term care facility (LTCF) residents with new-onset diarrhea. MethodsA cross-sectional study was conducted in all wards of 9 adult hospitals (3532 beds) and 14 LTCFs (1205 beds) in Louisville, Kentucky to identify new-onset diarrhea (≥3 loose stools in the past 24 h and not present in the preceding 24 h) among Louisville adults via electronic medical record review, nurse interviews, and patient interviews during a 1–2 week observation period in 2018–2019. ResultsAmong Louisville-resident inpatients, 167 patients with 9731 inpatient-days had new-onset diarrhea (1.7/100 inpatient-days). Stool specimens were collected from 32% (53/167); 12 (23%) specimens were laboratory-confirmed for C. difficile infection (CDI) (12.3 cases/10,000 inpatient-days). Among LTCF residents, 63 with 10,402 LTCF resident-days had new-onset diarrhea (0.6/100 LTCF resident-days). Stool specimens were collected from 32% (20/63); 9 (45%) specimens were laboratory-confirmed for CDI (8.6 cases/10,000 LTCF resident-days). ConclusionsNew-onset diarrhea was common among inpatients and LTCF residents. Only one-third of patients with new-onset diarrhea had a stool specimen collected and tested for C. difficile—indicative of a potential CDI underdiagnosis—although, further studies are needed to confirm the extent of CDI underdiagnosis.

SEASON GAP score: A predictor of Clostridioides difficile infection among patients with tube feeding

IntroductionClostridioides difficile infection (CDI) is an important community- and hospital-acquired infection. Patients receiving tube feeding often have diarrhoea, and it is still unclear whether the traditional criteria for submitting samples for Clostridioides difficile (CD) testing as determined by the frequency of the diarrhoea apply to these patients. MethodsWe conducted a retrospective study comparing the clinical features of tube-fed inpatients with suspected CDI, with CDI, and those without CDI admitted between 2004 and 2020. Univariate associations were assessed using the chi-square test, Fisher's exact test, or student's t-test, and multivariate analysis was conducted using logistic regression analysis. ResultsAmong 805 tube-fed inpatients with and suspected CDI, 163 (20.2%) had CDI and 642 (79.8%) did not. The following seven predictors, independently associated with CDI, were used to develop the SEASON GAP score: male (Sex) (1 point), Emaciation (1 point), days from Admission to testing ≥21 days (2 points), Stool frequency/day ≥5 times (1 point), seasON (summer: 2 points, spring and winter: 1 point), GAstrostomy (2 points), and no prior Proton pump inhibitor use (1 point). In a receiver operating characteristic curve, the area under the curve was 0.77 (95% confidence interval: 0.73–0.80). The optimal cut-off point was 3.5. A score of ≤3 had a sensitivity, specificity, and negative predictive value of 81%, 60%, and 93%, respectively. ConclusionsThe SEASON GAP score is useful in ruling out CDI in patients with tube feeding, thus reducing unnecessary CD testing and antimicrobial use.