Healthcare-associated Clostridium Difficile Infection Research Articles

Impact of COVID19 pandemic on the incidence of health-care associated Clostridioides difficile infection

ObjectiveTo investigate the impact of COVID19 pandemic on the incidence of health-care associated Clostridioides difficile infection (HA-CDI). MethodsRetrospective study conducted in the Hospital Universitario de Valme (HUV) and the Hospital General Universitario de Alicante (HGUA) in Spain between January 2019 and February 2021. The study period was divided into non-COVID19 period (2019 and months from 2020 to 2021 with ≤30 hospitalized COVID19 patients) and COVID19 period (months from 2020 to 2021 with >30 COVID19 patients). HA-CDI incidence rates (IR) were calculated as the number of new CDI cases per 10.000 occupied bed-days (OBD) and antimicrobial consumption by means of the defined daily dose (DDD) per 1000 OBD. ResultsDuring the COVID19 period, HA-CDI IR in the HUV was 2.6 per 10.000 OBD, which was lower than what was observed during the non-COVID19 period (4.1 per 10.000 OBD; p = 0.1). In the HGUA, HA-CDI IR during COVID19 period was 3.9 per 10.000 OBD, which was not significantly different to the IR observed during the non-COVID19 period (3.7 per 10.000 OBD; p = 0.8). There was a slight increase in the total antibiotic consumption during COVID19 period in both hospitals, with significant increases of certain high-risk antibiotics as cephalosporins. ConclsusionsHA-CDI incidence has not increased during the COVID19 pandemic in two tertiary centers in Spain, in spite of a slightly higher antibiotic consumption during the COVID19 period in both hospitals. These findings suggest that, in the presence of strict infection control measures, hospital antibiotic consumption might have a lower impact than expected on HA-CDI.

Risk of Healthcare-Associated Clostridioides difficile Infection During Pandemic Preparation: A Retrospective Cohort Study.

Risk of Healthcare-Associated Clostridioides difficile Infection During Pandemic Preparation: A Retrospective Cohort Study.

Clostridium Difficile and COVID-19: General Data, Ribotype, Clinical Form, Treatment-Our Experience from the Largest Infectious Diseases Hospital in Western Romania.

Background and Objectives: In Coronavirus Disease 2019 (COVID-19), which is caused by the infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the clinical manifestations are primarily related to the pulmonary system. Under 10% of cases also develop gastrointestinal events such as diarrhea, nausea, vomiting and abdominal pain. Materials and Methods: We conducted an observational, retrospective study in the Infectious Diseases Clinic of “Victor Babes” Hospital, Timis County, in order to assess the incidence, outcome and risk factors for clostridium difficile infection (CDI) in COVID-19 patients. Results: Out of 2065 COVID-19 cases, hospitalized between 1st September 2020 and 30th April 2021, 40 cases of CDI were identified with 32 cases of hospital-onset of CDI and eight cases of community-onset and healthcare-associated CDI. By randomization, polymerase chain reaction ribotyping of Clostridium Difficile was performed in six cases. All the randomized cases tested positive for ribotype 027. The percentage of cases recovered with complications at discharge was higher among COVID-19 patients and CDI (p = 0.001). The in-hospital stay, 36 days versus 28 days, was longer among COVID-19 patients and CDI (p = 0.01). The presence of previous hospitalization (p = 0.004) and administration of antibiotics during the hospital stay, increased the risk of CDI among COVID-19 patients. The mean adjusted CCI at admission was lower among controls (p = 0.01). In two cases, exitus was strictly CDI-related, with one case positive for 027 ribotype. Conclusions: CDI has complicated the outcome of COVID-19 patients, especially for those with comorbidities or previously exposed to the healthcare system. In the face of the COVID-19 pandemic and the widespread, extensive use of antibiotics, clinicians should remain vigilant for possible CDI and SARS-CoV-2 co-infection.

Potential Cost Savings Associated with Targeted Substitution of Current Guideline-Concordant Inpatient Agents with Omadacycline for the Treatment of Adult Hospitalized Patients with Community-Acquired Bacterial Pneumonia at High Risk for Clostridioides difficile Infections: Results of Healthcare-Decision Analytic Model from the United States Hospital Perspective

Introduction: Approximately 3% of hospitalized patients with community-acquired bacterial pneumonia (CABP) develop healthcare-associated Clostridioides difficile infection (HCA-CDI). The validated Davis risk score (DRS) indicates that patients with a DRS ≥ 6 are at an increased risk of 30-day HCA-CDI. In the phase 3 OPTIC CABP study, 14% of CABP patients with DRS ≥ 6 who received moxifloxacin developed CDI vs. 0% for omadacycline. This study assessed the potential economic impact of substituting current guideline-concordant CABP inpatient treatments with omadacycline in hospitalized CABP patients with a DRS ≥ 6 across US hospitals. Methods: A deterministic healthcare-decision analytic model was developed. The model population was hospitalized adult CABP patients with a DRS ≥ 6 across US hospitals (100,000 patients). In the guideline-concordant arm, 14% of CABP patients with DRS ≥ 6 were assumed to develop an HCA-CDI, each costing USD 20,100. In the omadacycline arm, 5 days of therapy was calculated for the entire model population. Results: The use of omadacycline in place of guideline-concordant CABP inpatient treatments for CABP patients with DRS ≥ 6 was estimated to result in cost savings of USD 55.4 million annually across US hospitals. Conclusion: The findings of this simulated model suggest that prioritizing the use of omadacycline over current CABP treatments in hospitalized CABP with a DRS ≥ 6 may potentially reduce attributable HCA-CDI costs. The findings are not unique to omadacycline and could be applied to any antibiotic that confers a lower risk of HCA-CDI relative to current CABP inpatient treatments.

Clostridioides difficile

Abstract The purpose of this article is to present an exemplar related to diagnostic testing whereby reasoned decisions can assist the pediatric surgical clinician in the expeditious screening, diagnosis, and management of Clostridioides difficile infection (CDI). In 2017, the Emerging Infections Program for CDI reported that the incidence of healthcare-associated CDI was 9.03 in 100,000 and 26.70 for community-associated CDI in the 1- to 17-year age group. Multistate prevalence data looking at healthcare-associated infections (HCAIs) in acute care hospitals showed that C. difficile was the most common pathogen, causing 12.1% of HCAIs. Given the current trends, defining the pediatric epidemiological characteristics of CDI, which is less common than in adults, is vital. Consequently, clinicians need to know when to suspect CDI; however, classic risks associated with this HCAI are considered to be a moving target leading to challenges in the diagnosis, management, and ability to control the disease. Because the diagnosis of CDI is based on clinical and laboratory findings and precludes management, a sensitive and specific diagnostic test with rapid turnaround time is imperative. The use of probabilities is discussed in the context of the threshold approach in clinical decision making.

An evaluation of toxigenic Clostridioides difficile positivity as a patient outcome metric of antimicrobial stewardship in Saudi Arabia.

Antimicrobial stewardship has been associated with a reduction in the incidence of healthcare-associated Clostridium difficile infection (HA-CDI). However, CDI remains under-recognised in many low and middle-income countries where clinical and surveillance resources required to identify HA-CDI are often lacking. The rate of toxigenic C. difficile stool positivity in the stool of hospitalised patients may offer an alternative metric for these settings, but its utility remains largely untested. To examine the impact of antimicrobial stewardship on the rate of toxigenic C. difficile positivity among hospitalised patients presenting with diarrhea. A 12-year retrospective review of laboratory data was conducted to compare the rates of toxigenic C. difficile in diarrhoea stool of patients in a hospital in Saudi Arabia, before and after implementation of an antimicrobial stewardship programme. There was a significant decline in the rate of toxigenic C. difficile positivity from 9.8 to 7.4% following the implementation of the antimicrobial stewardship programme, and a reversal of a rising trend. The rate of toxigenic C. difficile positivity may be a useful patient outcome metric for evaluating the long-term impact of antimicrobial stewardship on CDI, especially in settings with limited surveillance resources. The accuracy of this metric is, however, dependent on the avoidance of arbitrary repeated testing of a patient for cure, and testing only unformed or diarrhoea stool specimens. Further studies are required within and beyond Saudi Arabia to examine the utility of this metric.

Burden of Clostridioides difficile infection (CDI) - a systematic review of the epidemiology of primary and recurrent CDI

BackgroundClostridioides difficile is a Gram-positive anaerobic bacterium, which causes Clostridioides difficile infection (CDI). It has been recognised as a leading cause of healthcare-associated infections and a considerable threat to public health globally. This systematic literature review (SLR) summarises the current evidence on the epidemiology and clinical burden of CDI.MethodsA SLR was conducted to identify CDI and recurrent CDI (rCDI) epidemiology studies, to evaluate patient and disease characteristics, incidence rates, epidemiological findings and risk factors. Embase, MEDLINE and the Cochrane Library databases were searched for English articles from 2009 to 2019. Included territories were the United Kingdom, France, Germany, Italy, Spain, Poland, US, Canada, Australia, Japan and China.ResultsOf 11,243 studies identified, 165 fulfilled the selection criteria. An additional 20 studies were identified through targeted review of grey literature. The most widely reported findings were incidence and risk factors for CDI and rCDI.Among key studies reporting both healthcare-associated (HA-CDI) and community-associated CDI (CA-CDI) incidence rates for each country of interest, incidence rates per 10,000 patient days in the US were 8.00 and 2.00 for HA-CDI and CA-CDI, respectively. The highest incidence in Europe was reported in Poland (HA-CDI: 6.18 per 10,000 patient days, CA-CDI: 1.4 per 10,000 patient days), the lowest from the UK, at 1.99 per 10,000 patient days and 0.56 per 10,000 patient days for HA-CDI and CA-CDI, respectively.No clear trend for incidence over time emerged, with most countries reporting stable rates but some either a decrease or increase.Rates of recurrent CDI varied based on geographical setting. The rate of recurrence was lower in community-associated disease compared to healthcare-associated disease.Independent CDI risk factors identified common to both initial CDI and recurrent CDI included increasing age, antibiotic use, recent hospitalisation, and proton pump inhibitor (PPI) use. In addition, leukocyte count, length of hospital stays, and Charlson comorbidity index score featured as statistically significant risk factors for recurrent CDI, but these are not reported among the most common statistically significant risk factors for initial CDI.ConclusionsDespite considerable heterogeneity, evidence suggests substantial incidence of recurrent and primary CDI, even after considerable efforts in the last decade.

Enhanced Clostridioides difficile Infection Prevention With a Pharmacy-Controlled Policy That Adds a 3-Strain Lactobacillus Probiotic Concomitantly to Antibiotic Therapy.

When 70% of antibiotic users took a 3-strain Lactobacillus probiotic preparation the hospital-wide rate of healthcare-associated Clostridioides difficile infection improved significantly. The incidence of C. difficile infection for those taking the probiotic along with multiple antibiotics or a single high-risk antibiotic was decreased by at least half.

803. Risk factors associated with Clostridioides difficile infection in hospitalized patients with community-acquired pneumonia

BackgroundPatients with community-acquired pneumonia (CAP) who are hospitalized and treated with antibiotics may carry an increased risk for developing Clostridioides difficile infection (CDI). Accurate risk estimation tools are needed to guide monitoring and CDI mitigation efforts. We aimed to identify patient-specific risk factors associated with CDI among hospitalized patients with CAP.MethodsDesign: retrospective case-control study of hospitalized patients who received CAP-directed antibiotic therapy between 1/1/2014 and 5/29/2018. Cases were hospitalized CAP patients who developed CDI post-admission. Control patients did not develop CDI and were selected at random from CAP patients hospitalized during this period. Variables: comorbidities, laboratory results, vital signs, severity of illness, prior hospitalization, and past antibiotic use. Propensity-score weights: identified via structural decomposition analysis of pre-treatment variables. Analysis: weighted classification tree models that predicted any CDI, hospital-onset CDI, and any healthcare-associated CDI according to CAP antibiotic treatment. Performance: percent accuracy in classification (PAC) and weighted positive (PPV) and negative predictive values (NPV). Modeling: completed using the ODA package (v1.0.1.3) for R (v3.5.1).ResultsA total of 32 cases and 232 controls were identified. Sixty pre-treatment variables were screened. Structural decomposition analysis, completed in two stages, identified prior hospitalization (OR 6.56, 95% CI: 3.01-14.31; PAC: 80.3%) and BUN greater than 29 mg/dL (OR 11.67, 95% CI: 2.41-56.5; PAC: 80.8%) as propensity-score weights. With respect to CDI, receipt of broad-spectrum anti-pseudomonal antibiotics was significantly (all P’s< 0.05) associated with any CDI (NPV: 90.29%, PPV: 27.94%), hospital-onset CDI (NPV: 97.53%, PPV: 26.86%), and healthcare-associated CDI (NPV: 92.89%, PPV: 27.94%).ConclusionWe identified risk factors available at hospital admission and empiric use of broad-spectrum Gram-negative antibiotics as being associated with the development of CDI. Model PPVs were over two-fold greater than our sample base rate. Increased monitoring and avoidance of overly broad antibiotic use in high-risk patients appears warranted.Disclosures All Authors: No reported disclosures

Hospital-acquired Clostridioides difficile infection among patients at an urban safety-net hospital in Philadelphia: Demographics, neighborhood deprivation, and the transferability of national statistics.

To investigate associations between healthcare-associated Clostridioides difficile infection and patient demographics at an urban safety-net hospital and compare findings with national surveillance statistics. Study participants were selected using a case-control design using medical records collected between August 2014 and May 2018 at Hahnemann University Hospital in Philadelphia. Controls were frequency matched to cases by age and length of stay. Final sample included 170 cases and 324 controls. Neighborhood-level factors were measured using American Community Survey data. Multilevel models were used to examine infection by census tract, deprivation index, race/ethnicity, insurance type, referral location, antibiotic use, and proton-pump inhibitor use. Patients on Medicare compared to private insurance had 2.04 times (95% CI, 1.31-3.20) the odds of infection after adjusting for all covariables. Prior antibiotic use (2.70; 95% CI, 1.64-4.46) was also associated with infection, but race or ethnicity and referral location were not. A smaller proportion of hospital cases occurred among white patients (25% vs 44%) and patients over the age of 65 (39% vs 56%) than expected based on national surveillance statistics. Medicare and antibiotics were associated with Clostridioides difficile infection, but evidence did not indicate association with race or ethnicity. This finding diverges from national data in that infection is higher among white people compared to nonwhite people. Furthermore, a greater proportion of hospital cases were aged <65 years than expected based on national data. National surveillance statistics on CDI may not be transportable to safety-net hospitals, which often disproportionately serve low-income, nonwhite patients.

Impact of COVID-19 prevention measures on risk of health care-associated Clostridium difficile infection

Clostridium difficile is the most common pathogen between health care-associated infections and its incidence has increased during the last years. lack of enough evidence about effective hygiene interventions to prevent this disease. Due to the coronavirus disease 2019 (COVID‑19) pandemic, several strategies to reduce microorganism spread were adopted in hospital setting. The objective of this study was to establish whether such strategies can reduce health care associated C difficile infection (HA-CDI) incidence. We found that, during the pandemic (2020) HA-CDI incidence was significantly lower with respect to the previous years. This work demonstrates that maintaining this level of attention regarding control activities related to prevention of microorganism transmission significantly reduce HA-CDI and related expenses in terms of health costs and human lives.

Effect of Testing Methods on Incidence of Clostridioides difficle Infection Rates in Veterans’ Affairs Medical Centers

Background: Healthcare-associated Clostridioides difficile infection (CDI) rates have been decreasing in Department of Veterans’ Affairs (VA) acute-care medical facilities since the CDI Prevention Initiative began in 2012. Assessment of rates, however, is complicated by changing surveillance definitions and diagnostics. Over the past 2 years, the VA has adopted the less stringent surveillance definitions of the NHSN for hospital-onset healthcare-facility–associated (HO-HCFA) CDI (onset on or after day 4 of hospitalization) than was originally used (&gt;48 hours after admission). New diagnostic testing methods have been developed, but variabilities in the reliability of testing methods for the diagnosis of CDI in patients have been detected, thus not yielding a gold standard test. As a result, some facilities use nucleic acid amplification testing (NAAT) for CDI diagnosis and reporting whereas others use a 2-step process of NAAT followed by a toxin enzyme immunoassay (EIA) test, with the latter determining positivity for reporting (as allowed by the NHSN). We reviewed CDI rates at facilities performing one-step and two-step testing to determine whether the testing protocol may be influencing CDI rate reporting. Methods: Data on HO-HCFA CDI rates entered monthly in fiscal year (FY) 2018 (October 2017 through September 2018) and FY2019 (October 2018 through September 2019) by each acute-care facility into the VA Inpatient Evaluation Center (IPEC) database were analyzed. HO-HCFA CDI rates in facilities that used NAAT in FY2018 and switched to in the 2-step NAAT plus EIA in FY2019 were compared to rates in facilities used NAAT alone for both FY2018 and FY2019. Statistical regression analysis was performed. Results: From FY 2018 through FY2019, 70 facilities performed NAAT for the entire 2-year period. Overall, 7 facilities performed NAAT for FY 2018 and then switched to NAAT + EIA in FY2019. We detected no significant decrease in HO-HCFA CDI rates in FY 2018 when both groups were using NAAT (P = 0.21) (Fig. 1). However, in FY2019, there was a significant decrease in HO-HCFA CDI rates for those facilities that performed the 2-step testing versus those facilities that continued to use strictly NAAT alone (P &lt; .0001). Conclusions: HO-HCFA CDI rates decreased for those VA acute-care facilities that switched to 2-step testing, and this finding highlights implications for assessing rates over time. Given the variable reliability of the toxin test, individual patient consideration for therapeutic decisions is reasonable.Funding: NoneDisclosures: None

Tube Feeding: A Risk Factor for Clostridioides difficile Infection Among Long-Term Care Facility Residents Hospitalized at a Tertiary-Care Hospital in Detroit

Objective: We investigated the epidemiology of Clostridioides difficile infection (CDI) in long-term care facility (LTCF) patients admitted to a tertiary-care center in Detroit. Methods: A retrospective case-control study was conducted of LTCF residents who were hospitalized with CDI at the Detroit Medical Center between January 1, 2009, and December 31, 2016. Case patients (LTCF residents admitted with CDI) were compared to 2 sets of inpatient controls. The first set of controls included inpatients presenting from the same LTCFs without CDI (control A). Second set included inpatients admitted from non-LTCF (home, community, hospital) who acquired CDI &gt; 48 hours after admission or those who acquired CDI within 48 hours of admission but were exposed to an acute-care hospital within 4 weeks prior to admission (control B). Cases were matched (1:3 ratio) to the 2 sets of controls (control A and control B) based on year of admission. Matched multivariable analyses using conditional logistic regression were performed to identify independent predictors of CDI. Results: In total, 85 cases were matched to 2 sets of controls. For the first multivariate logistic regression model performed on cases and control A (n1 = 255), significant risk factors identified included tube feeding (OR, 3.60; 95% CI, 1.43–9.02; P = .006) and albumin ≤2.5 g/dL (OR, 4.98; 95% CI, 2.02–12.31; P &lt; .001). For the second multivariate logistic regression model performed on cases and control B (n2 = 255), significant risk factors identified included Charlson comorbidity index score (OR, 1.25; 95% CI, 1.12–1.40; P &lt; .001), tube feeding (OR, 3.63; 95% CI, 1.81–7.25; P &lt; .001), prior use of PPI (OR, 0.37; 95% CI, 0.20–0.68; P = .001), prior use of H2 blockers (OR, 0.34; 95% CI, 0.16–0.69; P = .003), and prior use of antibiotics (OR, 0.12; 95% CI, 0.06–0.24; P &lt; .001). Cases were more likely to have complicated CDI (OR, 7.02; P &lt; .001) and recurrent CDI (OR, 2.63; P =.02) when compared to control B. Conclusions: Patients who acquired CDI at LTCFs experienced more severe CDI and were at greater risk for recurrent CDI than patients with other healthcare-associated CDI. For the regression model performed on cases and control A as well as that performed on cases and control B, tube feeding was the only variable that consistently predicted CDI among LTCF patients.Funding: This study was supported by Pfizer Inc (Collegeville, PA).Disclosures: None

Risk of Hospital-Onset C. difficile Infection Increases With Prior Inpatient and Outpatient Visits

Background:Clostridioides difficile is a leading cause of healthcare-associated infections, and greater healthcare exposure is a primary risk factor for Clostridioides difficile infection (CDI). Longer hospital stays and greater CDI pressure, both at the hospital level and the level, have been linked to greater risk. In addition, symptoms associated with healthcare-associated CDI often do not present until a patient has been discharged. Our study objective was to estimate the extent to which exposure to different types of healthcare settings (eg, prior hospitalization, emergency department [ED], outpatient or long-term care) increase risk for hospital-onset CDI. Methods: We conducted a case-control study using the Truven Marketscan Commerical Claims and Medicare Supplemental databases from 2001 to 2017. Case patients were selected as all inpatient visits with a secondary diagnosis of CDI and no previous CDI diagnosis in the prior 90 days. Controls were selected from all inpatient admissions without any CDI diagnosis during the current admission or prior 90 days. A logistic regression model was used to estimate risk associated with prior healthcare exposure. Indicators were created for prior exposure to different healthcare settings: separate indicators were used to indicate transfer, exposure to that setting in the prior 1–30 days, 31–60 days and 61–90 days. Separate indicators were created for prior hospitalization, ED, outpatient clinic, nursing home or long-term care facilities (LTCFs), psychiatric or substance-abuse facility or other outpatient facility. We also included an indicator for prior exposure to a family member with CDI and prior outpatient antibiotics. Results: Estimates for selected variables (odds ratios) are presented in Table 1. Prior hospitalization, ED visits, outpatient clinics, nursing home and LTCFs were all associated with increased risk of secondary diagnosed CDI. Prior hospitalization and nursing home/LTCF conveyed the greatest risk. In addition, a ‘dose-–response’ relationship occurred for each of these exposure settings, with exposure nearest the admission date having the largest risk. Prior exposure to psychiatric , substance abuse, or other outpatient facilities were not risk factors for CDI. Having a family member with prior CDI and both low-risk and high-risk outpatient antibiotics were associated with increased risk. These factors also exhibited a ‘dose–response’ pattern. Conclusions: Exposure to various healthcare settings significantly increased risk for secondary CDI. Prior healthcare exposures occurring nearest to the point of admission conveyed the greatest risk. These results suggest that many hospital-associated CDI cases attributed to a current hospital stay may actually be acquired from prior healthcare settings.Funding: CDC Modeling Infectious Diseases (MInD) in Healthcare NetworkDisclosures: None

S0193 Outcomes of Pediatric Hospital and Community-Associated Clostridioides difficile Infection

INTRODUCTION: Incidence of Clostridioides difficile infection (CDI) in pediatric population is increasing, with paucity of data on CDI outcomes in this population, particularly in community-associated cases. METHODS: A population-based cohort study of the pediatric age group (< 18 years) from 2006 to 2017 was conducted using the Rochester Epidemiology Project. CDI was diagnosed with watery diarrhea and a positive stool assay, after exclusion of other causes of diarrhea. CDI was defined as healthcare-associated (HA) if symptoms occurred >48 hours after admission to or < =4 weeks of hospital discharge; community-acquired (CA) if there was no discharge from a hospital in the past 12 weeks; rest were indeterminate. CDI was considered severe if WBC ≥15000/µL or creatinine ≥1.5mg/dL, fulminant if there was ileus, megacolon, ICU admission, colectomy, hypotension or sepsis. Recurrence was defined with recurrent diarrhea within 8 weeks of the last episode, with positive stool assay and interim symptom resolution. Chi-square/Fischer’s exact tests were used for comparison of baseline characteristics and outcomes. P < 0.05 was considered statistically significant. RESULTS: From 2006 to 2017, 157 pediatric patients were identified with median age 3.6 years (range, 0.2–17.9), 54% (85) were female. Overall 12 patients with indeterminate CDI were excluded. Of the remaining patients, majority [67.6% (98)] had CA-CDI. Baseline characteristics of CA and HA CDI are outlined in Table 1; 48.3% (70) patients had antibiotic exposure, more in HA than CA CDI. Overall, 2.1% patients (3) had severe CDI, 9.6% (14) had fulminant CDI; 6.9% (10) required ICU admission. Overall, 8.3% (12) patients needed a change in treatment due to non-response or adverse events. Recurrence occurred in 20.1% (29) patients. Patients with CA-CDI were less likely to have fulminant disease and ICU admission compared to HA-CDI (Table 2). There were no CDI-related deaths. CONCLUSION: Community-acquired infection accounts for a majority of CDI in the pediatric age group, and is associated with better outcomes compared to healthcare-associated CDI.Table 1.: Baseline characteristics by mode of acquisition of CDI* *data presented as n (%) for categorical and median (min-max) for continuous variables) ^risk factor exposure within 90 days prior to CDI is reportedTable 2.: Outcome of CDI by mode of acquisition

Dynamic Duos and Where to Find Them: Infection Prevention and Infectious Disease Pharmacist Collaboration to Prevent Clostridium Difficile Infections

<h3>Background</h3> Healthcare associated Clostridium difficile infections (HAI CDI) can be challenging to prevent in acute care hospitals. Innovative strategies, beyond the basics of prevention, are needed in small community hospitals with limited resources to further reduce the number of infections. CDI Stewardship in a 158-bed community hospital mediated by Infection Prevention (IP) and Infectious Disease Pharmacist (IDP) evaluates the appropriateness of CDI testing in real time. <h3>Methods</h3> Beginning January 2018 IP and IDP conducted nursing rounds to evaluate inpatients with CDI test orders for clinical symptoms as well as medications or nutrition factors that may cause loose stools. On the spot education on CDI symptoms and other causes of diarrhea was provided to nurses and clinicians. After patient assessment a recommendation to continue or stop testing was made to the ordering provider. We then compared the incidence of HAI CDI and the number of CDI orders in 2017 and 2019. <h3>Results</h3> Comparing data in the pre-intervention period of 2017 and post-intervention period of 2019 we identified a 25% reduction in orders for CDI (340 vs 255), and a 25% increase in the proportion of canceled orders (28% vs 35%). A corresponding decrease in the number of HAI CDI pre vs post-intervention occurred (18 vs 9 cases, p>0.05). We also noted an increase in the number of consultations sought by nursing staff to review CDI testing appropriateness. <h3>Conclusions</h3> Though not statistically significant, real-time CDI Stewardship intervention by IP and IDP reduced the number of HAI CDI by 50% in our hospital. Increased awareness among clinical staff of the need to assess patient clinical symptoms, medications and nutrition to ensure appropriate identification of HAI CDI contributed to the reduction in unnecessary orders. With minimal resources in a community setting, CDI Stewardship is a feasible intervention in the prevention of CDI and other antimicrobial resistant infections.

Healthcare associated Clostridioides difficile infection in adult surgical and medical patients hospitalized in tertiary hospital in Belgrade, Serbia: a seven years prospective cohort study

ABSTRACT Introduction: Clostridioides difficile (C. difficile) infection (CDI) is one of the most common healthcare-associated (HA) infections in contemporary medicine. The risk factors (RFs) for HA CDI in medical and surgical patients are poorly investigated in countries with a limited resource healthcare system. Therefore, the aim of the study was to investigate differences in patients’ characteristics, factors related to healthcare and outcomes associated with HA CDI in surgical and medical patients in tertiary healthcare centre in Serbia. Materials and Methods: A prospective cohort study was conducted including adult patients diagnosed with initial episode of HA CDI, first recurrence of disease, readmission to hospital, while deaths within 30 days of CDI diagnosis and in-hospital mortality were also recorded. Patients hospitalized for any non-surgical illness, who developed initial HA CDI were assigned to medical group, whereas those who developed initial HA CDI after surgical procedures were in surgical group. The data on patients’ characteristics and factors related to healthcare were collected, too. Results: During 7-year period, from 553 patients undergoing in-hospital treatment and diagnosed with CDI, 268 (48.5%) and 285 (51.5%) were surgical and medical patients, respectively. Age ≥ 65 years, use of proton pump inhibitors, chemotherapy and fluoroquinolones were positively associated with being in medical group, whereas admission to intensive care unit and use of second- and third-generation cephalosporins were positively associated with being in surgical group. Conclusions: Based on obtained results, including significant differences in 30-day mortality and in-hospital mortality, it can be concluded that medical patient were more endangered with HA CDI than surgical ones.

Application of a new methodology and R package reveals a high burden of healthcare-associated infections (HAI) in Germany compared to the average in the European Union/European Economic Area, 2011 to 2012.

BackgroundHealthcare-associated infections (HAIs) pose a major challenge to health systems. Burden of disease estimations in disability-adjusted life years (DALYs) are useful for comparing and ranking HAIs.AimTo estimate the number of five common HAIs, their attributable number of deaths and burden for Germany.MethodsWe developed a new method and R package that builds on the approach used by the Burden of Communicable Diseases in Europe (BCoDE) project to estimate the burden of HAIs for individual countries. We used data on healthcare-associated Clostridioides difficile infection, healthcare-associated pneumonia, healthcare-associated primary bloodstream infection, healthcare-associated urinary tract infection and surgical-site infection, which were collected during the point prevalence survey of HAIs in European acute-care hospitals between 2011 and 2012.ResultsWe estimated 478,222 (95% uncertainty interval (UI): 421,350–537,787) cases for Germany, resulting in 16,245 (95% UI: 10,863–22,756) attributable deaths and 248,920 (95% UI: 178,693–336,239) DALYs. Despite the fact that Germany has a relatively low hospital prevalence of HAIs compared with the European Union/European Economic Area (EU/EEA) average, the burden of HAIs in Germany (308.2 DALYs/100,000 population; 95% UI: 221.2–416.3) was higher than the EU/EEA average (290.0 DALYs/100,000 population; 95% UI: 214.9–376.9). Our methodology is applicable to other countries in or outside of the EU/EEA. An R package is available from https://CRAN.R-project.org/package=BHAI.ConclusionThis is the first study to estimate the burden of HAIs in DALYs for Germany. The large number of hospital beds may be a contributing factor for a relatively high burden of HAIs in Germany. Further focus on infection prevention control, paired with reduction of avoidable hospital stays, is needed to reduce the burden of HAIs in Germany.

Correlation of prevention practices with rates of health care-associated Clostridioides difficile infection.

We examined Clostridioides difficile infection (CDI) prevention practices and their relationship with hospital-onset healthcare facility-associated CDI rates (CDI rates) in Veterans Affairs (VA) acute-care facilities. Cross-sectional study. From January 2017 to February 2017, we conducted an electronic survey of CDI prevention practices and hospital characteristics in the VA. We linked survey data with CDI rate data for the period January 2015 to December 2016. We stratified facilities according to whether their overall CDI rate per 10,000 bed days of care was above or below the national VA mean CDI rate. We examined whether specific CDI prevention practices were associated with an increased risk of a CDI rate above the national VA mean CDI rate. All 126 facilities responded (100% response rate). Since implementing CDI prevention practices in July 2012, 60 of 123 facilities (49%) reported a decrease in CDI rates; 22 of 123 facilities (18%) reported an increase, and 41 of 123 (33%) reported no change. Facilities reporting an increase in the CDI rate (vs those reporting a decrease) after implementing prevention practices were 2.54 times more likely to have CDI rates that were above the national mean CDI rate. Whether a facility's CDI rates were above or below the national mean CDI rate was not associated with self-reported cleaning practices, duration of contact precautions, availability of private rooms, or certification of infection preventionists in infection prevention. We found considerable variation in CDI rates. We were unable to identify which particular CDI prevention practices (i.e., bundle components) were associated with lower CDI rates.

2440. Using a geospatially explicit agent-based model of a regional healthcare network to assess varied antibiotic risk on Clostridioides difficile infection incidence

BackgroundDifferent antibiotic classes are associated with different Clostridioides difficile infection (CDI) risk. The impact of varied antibiotic risk on CDI incidence can be explored using agent-based models (ABMs). ABMs can simulate complete systems (e.g., regional healthcare networks) comprised of discrete, unique agents (e.g., patients) which can be represented using a synthetic population, or model-generated representation of the population. We used an ABM of a North Carolina (NC) regional healthcare network to assess the impact of increasing antibiotic risk ratios (RRs) across network locations on healthcare-associated (HA) and community-associated (CA) CDI incidence.MethodsThe ABM describes CDI acquisition and patient movement across 14 network locations (i.e., nodes) (11 short-term acute care hospitals, 1 long-term acute care hospital, 1 nursing home, and the community). We used a sample of 2 million synthetic NC residents as ABM microdata. We updated agent states (i.e., location, antibiotic exposure, C. difficile colonization, CDI status) daily. We applied antibiotic RRs of 1, 5, 8.9 (original model RR), 15, and 20 to agents across the network to simulate varied risk corresponding to different antibiotic classes. We determined network HA-CDI and CA-CDI incidence and percent mean change for each RR.ResultsIn this simulation study, HA-CDI incidence increased with increasing antibiotic risk, ranging from 11.3 to 81.4 HA-CDI cases/100,000 person-years for antibiotic RRs of 1 to 20, respectively. On average, the per unit increase in antibiotic RR was 33% for HA-CDI and 6% for CA-CDI (figure).ConclusionWe used a geospatially explicit ABM to simulate increasing antibiotic risk, corresponding to different antibiotic classes, and to explore the impact on CDI incidence. The per unit increase in antibiotic risk was greater for HA-CDI than CA-CDI due to the higher probability of receiving antibiotics and higher concentration of agents with other CDI risk factors in the healthcare facilities of the ABM. These types of analyses, which demonstrate the interconnectedness of network healthcare facilities and the associated community served by the network, might help inform targeted antibiotic stewardship efforts in certain network locations. Disclosures All authors: No reported disclosures.