Healthcare Facility-onset Clostridioides Difficile Infection Research Articles

The National Healthcare Safety Network's digital quality measures: CDC's automated measures for surveillance of patient safety.

This article presents the National Healthcare Safety Network (NHSN)'s approach to automation for public health surveillance using digital quality measures (dQMs) via an open-source tool (NHSNLink) and piloting of this approach using real-world data in a newly established collaborative program (NHSNCoLab). The approach leverages Health Level Seven Fast Healthcare Interoperability Resources (FHIR) application programming interfaces to improve data collection and reporting for public health and patient safety beginning with common, clinically significant, and preventable patient harms, such as medication-related hypoglycemia, healthcare facility-onset Clostridioides difficile infection, and healthcare-associated venous thromboembolism. The NHSN's FHIR dQMs hold the promise of minimizing the burden of reporting, improving accuracy, quality, and validity of data collected by NHSN, and increasing speed and efficiency of public health surveillance.

Incidence, Clinical Characteristics, and Outcomes of Clostridium difficile Infection in a Tertiary Care Center in Bahrain.

Background Clostridioides difficile infection (CDI) represents a significant healthcare challenge associated with antibiotic use and healthcare settings. While healthcare facility-onset CDI (HO-CDI) rates have been extensively studied, the incidence and risk factors of CDI in various settings, including the community, require further investigation. Aim This study aims to examine the incidence rates of CDI in a major governmental hospital in Bahrain, identify risk factors for CDI, and assess the effectiveness of infection control measures. Method We conducted a retrospective study at the Salmaniya Medical Complex (SMC), analyzing all confirmed cases of CDI over a 30-month period from January 2021 to June 2023. CDI cases were screened using glutamine dehydrogenase antigen detection and confirmed using molecular assays like polymerase chain reaction and/or toxin assaysfor confirmation.The study categorized CDI cases based on their onset (hospital or community) and explored associated risk factors, including antibiotic use, proton pump inhibitor (PPI) therapy, and patient demographics. Infection control practices were also evaluated for their role in managing CDI. Results About 57 new CDI cases were identified during the study period, with a HO-CDI incidence rate of 0.5 per 10,000 patient days. While HO-CDI rates remained stable, community-onset (CO)-CDI cases increased. The median patient age was 61.8 years, without notable differences between genders. Key risk factors for CDI were antimicrobial therapy, use of acid-reducing agents, age, and underlying comorbidities. The mortality rate stood at 35.1%. The ATLAS score (i.e., age, treatment with antibiotics, leukocyte count, albumin level, and serum creatinine) was a reliable predictor of mortality. Critical care admission and low albumin levels emerged as significant independent risk factors for mortality. Conclusions The study demonstrates a low incidence rate of HO-CDI at SMC, attributed to effective infection control and antibiotic stewardship programs. The overall CDI rate increased during the study period, driven by a rise in CO cases; further investigating the risk factors among this category in our study revealed that most patients were exposed to antibiotic therapy within the past three months of their CDI diagnosis. The rise in CO-CDI cases underscores the need for broader community-based interventions and awareness regarding antibiotic and PPI use.

The incidence of Clostridium difficile infection in children with and without inflammatory bowel diseases: A single-center study in Taiwan from 2006 to 2019

BackgroundThe incidence of Clostridium difficile infection (CDI) is increasing around the world, and patients with inflammatory bowel disease (IBD) have a higher risk of obtaining CDI. The data on the incidence rate of CDI in the Asian pediatric IBD population was lacking. MethodsWe retrospectively collected data from a tertiary medical center in Taipei, Taiwan. All patients aged 1–18 years old who visited the outpatient department or were admitted to our hospital between 2006 and 2019 were included. CDI was defined as positive stool C. difficile toxin or C. difficile culture results with appropriate antibiotic use within the range of 7 days prior or 14 days after the result. ResultsWe compared the average annual incidence of CDI before and after 2013. The average incidence of community-acquired CDI (CA-CDI) increased from 0.063 to 0.564 cases per 1,000 visits, with a rate ratio (RR) of 8.82 (95% CI 5.74-14.38). In patients with IBD, the rate increased from 26.738 to 278.873 cases per 1,000 visits (RR=10.12, 95% CI: 4.57-29.02). The average incidence rate increased from 0.685 to 1.874 cases per 1,000 admissions in pediatric general patients (RR = 2.72, 95% CI 1.82-4.20) and from 14.706 to 62.500 cases per 1,000 admissions in pediatric IBD patients (RR = 3.77, 95% CI 0.71-93.53). ConclusionsBoth CA-CDI and healthcare facility-onset CDI (HO-CDI) were increasing substantially in the pediatric population over the past decade in Taiwan. Compared to the general pediatric population, pediatric IBD patients had a much higher incidence of CDI.

Comparison of Cefazolin and Ceftriaxone Enterobacterales Susceptibilities for Inpatient Treatment of Urinary Tract Infections and Risk of Hospital-onset Clostridioides difficile Infection

Purpose: Urinary tract infection (UTI) is the second most common indication for antibiotic therapy among inpatients in the United States. Ceftriaxone, a third-generation cephalosporin, is habitually chosen to treat inpatient UTIs due to familiarity, cost and perceived safety. However, third-generation cephalosporins increase the risk of healthcare facility-onset Clostridioides difficile infection (HOCDI) more than any other antibiotic group, while no statistical risk exists for first-generation cephalosporins. Recent evidence comparing Enterobacterales susceptibility for first- and third-generation cephalosporins in urinary specimens in the United States does not exist. This analysis assesses comparative activity of cefazolin and ceftriaxone for Enterobacterales urinary isolates and incidence of HOCDI to determine the usefulness of cefazolin as an empiric agent to manage inpatient UTI and limit ceftriaxone collateral damage.Methods: This is a retrospective single center observational study. Microbiologic susceptibility data was analyzed for E. coli, K. pneumoniae, and P. mirabilis urinary specimens taken from adult inpatients admitted January 1, 2022 to December 31, 2022. Primary outcome is incidence of E. coli, K. pneumoniae, and P. mirabilis susceptibility to cefazolin in uncomplicated UTI (MIC < 16 mcg/mL). Secondary outcomes include susceptibility for complicated UTI and HOCDI risk associated with cefazolin and ceftriaxone. A larger time frame, January 1, 2016 to December 31, 2022, was used to assess HOCDI risk associated with cefazolin and ceftriaxone. HOCDI risk assessment included adults administered at least one dose of either cefazolin or ceftriaxone during a minimum of four-day hospitalization.Findings: A total of 1150 urine samples were identified as E. coli, K. pneumoniae, and P. mirabilis in 2022. Susceptibility to cefazolin was observed in 1064/1150 (92.5%) isolates using the MIC breakpoint for uncomplicated UTI, and to ceftriaxone in 1115/1150 (97.0%) isolates (p < 0.001). From 2016-2022, either cefazolin or ceftriaxone was administered in 26,462 inpatient admissions with an HOCDI diagnoses occurring in 89 admissions. HOCDI developed in 78 admissions (0.40%) with ceftriaxone exposure and 11 cases (0.15%) developed in cefazolin exposed admissions (p < 0.001, adjusted OR 2.44, 95% CI 1.25 – 4.76).Implications: Cefazolin demonstrates high susceptibility for uropathogens commonly implicated in uncomplicated UTI, the predominant UTI managed inpatient. While ceftriaxone demonstrates a higher susceptibility rate against these common uropathogens, it more than doubles the risk for HOCDI compared to cefazolin. For institutions evaluating opportunities to reduce ceftriaxone use to limit associated collateral damage like HOCDI, use of cefazolin for uncomplicated urinary tract infection may be evaluated using local susceptibility data.

Increased Incidence and Risk of Septicemia and Urinary Tract Infection After Clostridioides difficile Infection.

Although increased occurrence of septicemia in persons with Clostridioides difficile infection (CDI) has been reported, incidence rates and risk of septicemia and urinary tract infection (UTI) after CDI are unclear. The first episode of CDI was identified using 2011-2017 MarketScan and CMS Medicare data and CDI cases categorized by standard surveillance definitions. Uninfected persons were frequency matched 4:1 to cases by the CDI case surveillance definition. Multivariable Cox proportional hazards models were used to identify risk factors for septicemia and UTI within 90 days of CDI onset, accounting for the competing risk of death in the Medicare population. The incidence of septicemia was highest after hospital-onset CDI in the Medicare, younger commercial, and younger Medicaid populations (25.5%, 15.7%, and 19.5%, respectively) and lowest in those with community-associated CDI (3.8%, 4.3%, and 8.3%, respectively). In contrast, the incidence of UTI was highest in those with other healthcare facility onset CDI in all 3 populations (32.1%, 24.2%, and 18.1%, respectively). Hospital-onset CDI was associated with highest risk of septicemia compared with uninfected controls in all 3 populations. In the younger populations, risk of septicemia was more uniform across the CDI surveillance definitions. The risk of UTI was significantly higher in all CDI surveillance categories compared to uninfected controls, and among CDI cases it was lowest in those with community-associated CDI. The incidence of septicemia is high after CDI, particularly after hospital-onset infection. Additional preventive measures are needed to reduce infectious complications of CDI.

Surveillance and epidemiology of Clostridioides difficile infection using the national health surveillance network criteria: A 7-year study from Mumbai, India

IntroductionClostridioides difficile (CD) is a significant cause of morbidity and mortality. While considerable data is available in the developed world regarding Clostridioides difficile infection (CDI), Indian data is sparse especially using the standardized surveillance systems. Aim and objectives of the studyTo identify the incidence, risk factors, and mortality rate associated with CDI in a tertiary care hospital based on the Laboratory-Identified (LabID) event criteria of the Centers for Disease Control and Prevention (CDC) National Health Surveillance Network (NHSN). Materials and methodsDuring a 7- year prospective observational study, CDI was diagnosed using CD polymerase chain reaction (PCR). CDI Laboratory-Identified (LabID) events were classified using the CDC NHSN surveillance definition, and CDI incidence was calculated per 10,000 Patient Days (PDs). Clinical details were collected as part of healthcare-associated infection (HCAI) surveillance. Healthcare Facility-Onset (HO) and Community-Onset Healthcare Facility-Associated (CO-HCFA) incident CDI events were analyzed further. ResultsAmong 898 tested stool samples, 77 CDI LabID events were observed, with 68 being Incident events. Of 68 events, 76.5% (52/68), 19.1% (13/68), and 4.4% (3/68) were HO, Community-Onset (CO), and CO-HCFA CDI events respectively. The overall incidence of CDI events was 1.66 per 10,000 PDs. Risk factors observed were antibiotics exposure (100%), comorbidities (87.3%), antacids exposure (87.3%), age over 60 years (80%), and hospitalization within the past 6 months (67.3%). The crude mortality rate was 25.5% (14/55). ConclusionThese findings highlight the predominance of HO-CDI and the need for further investigation into CO-CDI in the Indian context to identify at-risk populations. Utilizing standardized surveillance methods such as NHSN definitions can facilitate accurate disease burden estimation, trend monitoring, and meaningful comparisons with global data.

Impact of the COVID-19 pandemic on the incidence of healthcare facility-onset Clostridioides difficile infection in hospitalized patients with sepsis: Interrupted time series analysis using Japanese Diagnosis Procedure Combination data

ObjectivesHealthcare facility-onset Clostridioides difficile infection (HO-CDI) is a major nosocomial infection associated with high mortality and healthcare costs. We aimed to determine if HO-CDI incidence decreased due to the COVID-19 pandemic. We hypothesized that the pandemic decreased HO-CDI as healthcare workers became more diligent in handwashing and sanitization. MethodsIn this retrospective cohort study, adult patients with sepsis hospitalized in general wards from January 2018 to February 2021 were identified using a nationwide Japanese administrative database. Patients were divided into two groups according to the hospitalization date (before and after the first declaration of a state of emergency). The primary outcome was a change in the level of the HO-CDI monthly incidence ratio (per 10000 patient-days). ResultsOf the 49,156 eligible hospitalizations for sepsis, 41,870 were before and 7,283 were after the first state of emergency declaration. Interrupted time-series (ITS) analysis showed no significant difference in the HO-CDI incidence ratio after Japan's first state of emergency declaration (level change −1.0, 95% confidence interval (CI) −8.6 to 6.6, p = 0.8, slope change 0.06, 95% CI -0.17 to 0.3, p = 0.6). The overall HO-CDI incidence ratio was 3.86/10000 patient-days (interquartile range 2.97–4.53); higher incidence existed in subgroups with older adults or a lower Barthel index at admission. ConclusionsNo significant change in HO-CDI incidence was observed in patients with sepsis hospitalized in general wards before and after Japan's first state of emergency declaration. Our study revealed that HO-CDI in general wards in Japan had been consistently decreasing since before the COVID-19 pandemic.

Lack of correlation between standardized antimicrobial administration ratios (SAARs) and healthcare-facility-onset Clostridioides difficile infection rates in Veterans Affairs medical facilities.

We detected no correlation between standardized antimicrobial administration ratios (SAARs) and healthcare facility-onset Clostridioides difficile infection (HO-CDI) rates in 102 acute-care Veterans Affairs medical centers over 16 months. SAARs may be useful for investigating trends in local antimicrobial use, but no ratio threshold demarcated HO-CDI risk.

Costs Attributable to Clostridioides difficile Infection Based on the Setting of Onset.

Although hospital-onset Clostridioides difficile infection (CDI) is associated with significant healthcare costs, the economic burden of CDI with onset in other facilities or the community has not been well studied. Incident CDI cases were identified using 2011-2017 Medicare fee-for-service data. Controls were randomly selected in a 4:1 ratio matching to the CDI case surveillance definition. Inverse probability of exposure weights were used to balance on measured confounders. One-, 3-, and 5-year cumulative costs attributable to CDI were computed using a 3-part estimator (parametric survival model and pair of 2-part models predicting costs separately in intervals where death did and did not occur). A total of 60 492 CDI cases were frequency-matched to 241 968 controls. One-, 3-, and 5-year adjusted attributable costs were highest for hospital-onset CDI at $14 257, $18 953, and $21 792, respectively, compared with hospitalized controls and lowest for community-associated CDI compared with community controls at $1013, $3161, and $6454, respectively. Adjusted 1-, 3-, and 5-year costs attributable to community-onset healthcare facility-associated CDI were $8222, $13 066, and $16 329 and for other healthcare facility-onset CDI were $5345, $6764, and $7125, respectively. Economic costs attributable to CDI in elderly persons were highest for hospital-onset and community-onset healthcare facility-associated CDI. Although lower, attributable costs due to CDI were significantly higher in cases with CDI onset in the community or other healthcare facility than for comparable persons without CDI. Additional strategies to prevent CDI in the elderly are needed to reduce morbidity and healthcare expenditures.

Saccharomyces boulardii prophylaxis for targeted antibiotics and infectious indications to reduce healthcare facility-onset Clostridioides difficile infection

BackgroundProbiotic prophylaxis for Clostridioides difficile infection (CDI) is controversial stemming from deficits in strain and disease specificity considerations and concern for adverse effects. Here risk for healthcare facility-onset CDI (HO-CDI) dependent on concomitant antibiotic and infectious indication is assessed to identify opportunities for targeted prophylaxis. MethodsRetrospective matched-cohort study from January 2016 through March 2019. Patient-admissions administered high risk antibiotics were categorized by Saccharomyces boulardii administration and matched 1:1 to non-recipients. Unadjusted and adjusted HO-CDI risk estimated using Cox proportional hazards regression. ResultsS. boulardii administration was associated with 48% risk reduction for HO-CDI compared to non-recipients (aHR 0.52, 95% CI: 0.31–0.87). Patient-admissions administered antibiotics and S. boulardii for a pneumonia indication exhibited a 57% reduction in risk for HO-CDI (aHR 0.43, 95% CI: 0.19–0.95). Administration of S. boulardii with ceftriaxone was associated with a 76% reduced risk of HO-CDI (aHR 0.24, 95% CI: 0.11–0.53) compared to ceftriaxone without S. boulardii, number needed to treat of 100. ConclusionsS. boulardii administration is associated with a significant HO-CDI risk reduction for inpatients receiving antibiotics associated with CDI. Institutions interested in targeted use of S. boulardii to limit potential adverse effects may consider prophylaxis for inpatients with pneumonia or receiving ceftriaxone.

Trends in Clostridioides difficile infection across a public health hospital system in New York City 2019-2021: A cautionary note

Contrary to national reports, rates of healthcare facility-onset Clostridioides difficile infection across an 11-hospital system rose after the spring of 2020, when New York City was the epicenter for the COVID-19 pandemic. Antibiotic pressure from an escalation in cephalosporin usage correlated with this increase. The majority of cases of Clostridioides difficile were in patients without COVID-19, suggesting the pandemic has adversely impacted the healthcare of other inpatients.

Assessment of independent comorbidities and comorbidity measures in predicting healthcare facility-onset Clostridioides difficile infection in Kenya.

Clostridioides difficile is primarily associated with hospital-acquired diarrhoea. The disease burden is aggravated in patients with comorbidities due to increased likelihood of polypharmacy, extended hospital stays and compromised immunity. The study aimed to investigate comorbidity predictors of healthcare facility-onset C. difficile infection (HO-CDI) in hospitalized patients. We performed a cross sectional study of 333 patients who developed diarrhoea during hospitalization. The patients were tested for CDI. Data on demographics, admission information, medication exposure and comorbidities were collected. The comorbidities were also categorised according to Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI). Comorbidity predictors of HO-CDI were identified using multiple logistic regression analysis. Overall, 230/333 (69%) patients had comorbidities, with the highest proportion being in patients aged over 60 years. Among the patients diagnosed with HO-CDI, 63/71(88.7%) reported comorbidities. Pairwise comparison between HO-CDI patients and comparison group revealed significant differences in hypertension, anemia, tuberculosis, diabetes, chronic kidney disease and chronic obstructive pulmonary disease. In the multiple logistic regression model significant predictors were chronic obstructive pulmonary disease (odds ratio [OR], 9.51; 95% confidence interval [CI], 1.8-50.1), diabetes (OR, 3.56; 95% CI, 1.11-11.38), chronic kidney disease (OR, 3.88; 95% CI, 1.57-9.62), anemia (OR, 3.67; 95% CI, 1.61-8.34) and hypertension (OR, 2.47; 95% CI, 1.-6.07). Among the comorbidity scores, CCI score of 2 (OR 6.67; 95% CI, 2.07-21.48), and ECI scores of 1 (OR, 4.07; 95% CI, 1.72-9.65), 2 (OR 2.86; 95% CI, 1.03-7.89), and ≥ 3 (OR, 4.87; 95% CI, 1.40-16.92) were significantly associated with higher odds of developing HO-CDI. Chronic obstructive pulmonary disease, chronic kidney disease, anemia, diabetes, and hypertension were associated with an increased risk of developing HO-CDI. Besides, ECI proved to be a better predictor for HO-CDI. Therefore, it is imperative that hospitals should capitalize on targeted preventive approaches in patients with these underlying conditions to reduce the risk of developing HO-CDI and limit potential exposure to other patients.

764. Will the Addition of Probiotics to Patients Receiving Intravenous Antimicrobial Therapy Reduce the Incidence of Healthcare Facility-Onset Clostridium difficile Infection?

Abstract Background Exposure to antimicrobials is a known risk factor for Clostridium difficile infection (CDI). Antimicrobials cause collateral damage by disrupting the natural intestinal microbiota allowing for C.difficile to thrive and production of C.difficile toxins. Probiotics could modulate the onset and course of CDI. However, the data on probiotics for the prevention of CDI is conflicting. Methods We conducted an IRB approved retrospective cohort study at a 340-bed community hospital. All hospitalized patients from August 1, 2017 through July 31, 2020 were evaluated for enrollment. Patients were included if they received at least one dose of intravenous (IV) antibiotic and had a length of stay of at least 3 days. Patients were excluded if they were younger than 18 years, or if they had a positive C.difficile polymerase chain reaction test before antibiotics were started. The primary outcome was the incidence of healthcare facility-onset Clostridium difficile infection (HO-CDI). Descriptive statistics were used to analyze demographics data, and the primary outcome of HO-CDI was analyzed using Fisher’s exact test and multiple logistic regression. Results A total of 20,257 patients received IV antibiotics during the study time frame. Of these, 2,659 patients received probiotics. Primary outcome of HO-CDI occurred in 46 patients in the IV antibiotics alone cohort (0.26%) and 5 patients in the probiotics plus IV antibiotics cohort (0.19%). The difference in HO-CDI between these two groups was not statistically significant, p=0.677. A multiple logistic regression was performed to see the impact of proton pump inhibitor use, age, ICU admission, Charlson Comorbidity Index, probiotic use and CDI in the past 12 months on the primary outcome. C.difficile infection in prior 12 months [OR 3.37, 95%CI 1.04-10.97] and ICU admission [OR 1.81, 95%CI 1.02-3.19] were associated with higher CDI. The addition of probiotics to patients on IV antibiotics did not exhibit a protective effect [OR 0.72, 95% CI 0.28-1.81]. Conclusion The addition of probiotics to standard of care was not beneficial in the prevention of HO-CDI. We endorse robust antibiotic stewardship practices as part of the standard of care bundle that institutions should employ to decrease the incidence of HO-CDI. Disclosures All Authors: No reported disclosures

Reduction in Health Care Facility-Onset Clostridioides difficile Infection: A Quality Improvement Initiative.

ObjectiveTo reduce health care facility–onset (HCFO) Clostridioides difficile infection (CDI) incidence by improving diagnostic stewardship and reducing the inappropriate testing of C difficile assays.Patients and MethodsA multidisciplinary team conducted a quality improvement initiative from January 1, 2020, through March 31, 2021. Clostridioides difficile infection and inappropriate testing were identified via electronic health records using predefined criteria related to stool quantity/caliber, confounding medications, and laboratory data. An intervention bundle was designed including (1) provider education, (2) implementation of an appropriate testing algorithm, (3) expert review of C difficile orders, and (4) batch testing of assays to facilitate review and cancellation if inappropriate.ResultsCompared with a baseline period from January to September 2020, implementation of our intervention bundle from December 2020 to March 2021 resulted in an 83.6% reduction in inappropriate orders tested and a 41.7% reduction in HCFO CDI incidence.ConclusionA novel prevention bundle improved C difficile diagnostic stewardship and HCFO CDI incidence by reducing testing of inappropriate orders. Such initiatives targeting HCFO CDI may positively affect patient safety and hospital reimbursement.

Assessment of Federal Value-Based Incentive Programs and In-Hospital Clostridioides difficile Infection Rates

Health care facility-onset Clostridioides difficile infection (HO-CDI) rates reported to the US Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) became a target quality metric for 2 Centers for Medicare & Medicaid Services (CMS) value-based incentive programs (VBIPs) in October 2016. The association of VBIPs with HO-CDI rates is unknown. To examine the association between VBIP implementation and HO-CDI rates. This interrupted time series study evaluated HO-CDI rates among adults hospitalized from January 2013 to March 2019 at 265 acute-care hospitals. Implementation of VBIPs in October 2016. Quarterly rates of HO-CDI per 10 000 patient-days, as reported to NHSN by participating hospitals, were evaluated. Generalized estimating equations were used to fit negative binomial regression models to estimate immediate program effect size (ie, level change) and changes in the slope of HO-CDI rates, controlling for each hospital's predominant method of CDI testing (ie, nucleic acid amplification test [NAAT], enzyme immunoassay [EIA] for toxin, or other testing methods). The study cohort included 24 332 938 admissions, 109 371 136 patient-days, and 74 681 HO-CDI events at 265 hospitals (145 [55%] with 100-399 beds; 205 [77%] not-for-profit hospitals; 185 [70%] teaching hospitals; 229 [86%] in metropolitan areas). Compared with EIA, rates of HO-CDI were higher when detected by NAAT (adjusted incidence rate ratio [aIRR], 1.55; 95% CI, 1.40-1.70; P < .001) and other testing methods (aIRR, 1.47; 95% CI, 1.26-1.71; P < .001). There were no significant changes in testing methods used by hospitals immediately after VBIP implementation. Controlling for CDI testing method, VBIP implementation was associated with a 6% level decline in HO-CDI rates in the immediate postpolicy quarter (aIRR, 0.94; 95% CI, 0.89-0.99; P = .01) and a 4% decline in slope per quarter (aIRR, 0.96; 95% CI, 0.95-0.97; P < .001). Results were similar in a sensitivity analysis using a 1-year roll-in period accounting for the period after the announcement of the HO-CDI VBIP policy and prior to its implementation. In this study, VBIP implementation was associated with improvements in HO-CDI rates, independent of CDI testing method. Given that CMS payment policies have not previously been associated with improvements in other targeted health care-associated infection rates, future research should focus on elucidating the specific processes that contributed to improvement in HO-CDI rates to inform the design of future VBIP interventions.

Correlation between antibiotic consumption and the incidence of healthcare facility-onset Clostridioides difficile infection: a retrospective chart review and analysis

BackgroundHealthcare facility-onset Clostridioides difficile infection is the leading cause of antibiotic-associated diarrhea, and is associated with morbidity and mortality. The use of antibiotics is an important risk factor for healthcare facility-onset C. difficile infection. We evaluated the correlation between the incidence of healthcare facility-onset C. difficile infection and antibiotic consumption, according to antibiotic class.MethodsPatients with healthcare facility-onset C. difficile infection from January 2017 to December 2018 at Konkuk University Medical Center (a tertiary medical center) were included. We evaluated changes in the incidence of healthcare facility-onset C. difficile infection and antibiotic consumption. The correlation between the incidence of healthcare facility-onset C. difficile infection and antibiotic consumption was evaluated two ways: without a time interval and with 1-month interval matching.ResultsA total of 446 episodes of healthcare facility-onset C. difficile infection occurred during the study period. The incidence of healthcare facility-onset C. difficile infection was 9.3 episodes per 10,000 patient-days, and increased significantly. We observed an increase in the consumption of β-lactam/β-lactamase inhibitors, and a decrease in the consumption of other classes of antibiotics, with a significant decrease in the consumption of fluoroquinolones, glycopeptides, and clindamycin (P = 0.01, P < 0.001, and P = 0.001, respectively). The consumption of β-lactam/β-lactamase inhibitors was independently correlated with the incidence of healthcare facility-onset C. difficile infection in the analysis without a time interval. When the analysis was conducted with 1-month interval matching, glycopeptide consumption was independently associated with the incidence of healthcare facility-onset C. difficile infection.ConclusionsDespite the reduction in fluoroquinolone and clindamycin consumption, the incidence of healthcare facility-onset C. difficile infection increased during the study period, and was correlated with increased consumption of β-lactam/β-lactamase inhibitors. Reduced consumption of specific antibiotics may be insufficient to reduce the incidence of healthcare facility-onset C. difficile infection.

Evaluation of a risk assessment model to predict infection with healthcare facility-onset Clostridioides difficile.

DisclaimerIn an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.PurposeWe evaluated a previously published risk model (Novant model) to identify patients at risk for healthcare facility–onset Clostridioides difficile infection (HCFO-CDI) at 2 hospitals within a large health system and compared its predictive value to that of a new model developed based on local findings.MethodsWe conducted a retrospective case-control study including adult patients admitted from July 1, 2016, to July 1, 2018. Patients with HCFO-CDI who received systemic antibiotics were included as cases and were matched 1 to 1 with controls (who received systemic antibiotics without developing HCFO-CDI). We extracted chart data on patient risk factors for CDI, including those identified in prior studies and those included in the Novant model. We applied the Novant model to our patient population to assess the model’s utility and generated a local model using logistic regression–based prediction scores. A receiver operating characteristic area under the curve (ROC-AUC) score was determined for each model.ResultsWe included 362 patients, with 161 controls and 161 cases. The Novant model had a ROC-AUC of 0.62 in our population. Our local model using risk factors identifiable at hospital admission included hospitalization within 90 days of admission (adjusted odds ratio [OR], 3.52; 95% confidence interval [CI], 2.06-6.04), hematologic malignancy (adjusted OR, 12.87; 95% CI, 3.70-44.80), and solid tumor malignancy (adjusted OR, 4.76; 95% CI, 1.27-17.80) as HCFO-CDI predictors and had a ROC-AUC score of 0.74.ConclusionThe Novant model evaluating risk factors identifiable at admission poorly predicted HCFO-CDI in our population, while our local model was a fair predictor. These findings highlight the need for institutions to review local risk factors to adjust modeling for their patient population.

Epidemiology and Outcomes of Patients With Healthcare Facility-Onset Clostridioides difficile Infection.

Clostridioides difficile infection (CDI) has become a rising public health threat. Our study aims to characterize the epidemiology and measure the attributable cost, length of stay, and in-hospital mortality of healthcare facility-onset Clostridioides difficile infection (HO-CDI) among patients in the U.S. Military Health System (MHS). We performed a case-control and cross-sectional inpatient study of HO-CDI using MHS database billing records. Cases included those who were at least 18 years of age admitted to a military treatment facility with a stool sample positive for C. difficile obtained >3 days after admission. Risk factors in the preceding year were identified. Patient case-mix adjusted outcomes including in-hospital mortality, length of stay, and hospitalization cost were evaluated by high-dimensional propensity score adjusted logistic regression. Among 474,518 admissions within the MHS from 2008 to 2015, we identified 591 (0.12%) patients with HO-CDI and found a significant increase in the trend of HO-CDI over the 7-year study period (P < .001). Patients with HO-CDI had significantly higher hospitalization cost (attributable difference $66,044, P < .001), prolonged hospital stay (attributable difference 12.4 days, P < 0.001), and increased odds of in-hospital mortality (case-mix adjusted odds ratio 1.98; 95% CI, 1.43-2.74). Healthcare facility-onset Clostridioides difficile infection is rising in patients within the MHS and is associated with increased length of stay, hospital costs, and in-hospital mortality. We identified a significantly increased burden of hospitalization among patients admitted with HO-CDI, highlighting the importance of infection control and antimicrobial stewardship initiatives aimed at decreasing the spread of this pathogen.

Trends in Healthcare Facility-Onset Clostridioides difficile Infection and the Impact of Testing Schemes in an Acute Care Hospital System in New York City, 2016-2019

Healthcare facility-onset Clostridioides difficile infection is associated with adverse clinical outcomes and hospital reimbursement. A four-year review involving eleven hospitals of the NYC Health + Hospital system was undertaken. From 2016-2019, infection rates and standardized infection ratios (SIRs) were gathered from National Healthcare Safety Network. The C. difficile testing scheme at each facility was recorded. For the eleven hospitals, declines in rates of C. difficile infection and SIRs were documented. However, this decline was driven by two hospitals that had high rates of infection in 2016; for the remaining nine hospitals, rates of infection and SIRs were at a plateau. Most hospitals used a testing scheme that fell into the nucleic acid amplification test (NAAT) category for SIR risk adjustment. Hospitals that used the algorithm glutamate dehydrogenase (GDH) and toxin A/B immunoassay (EIA) followed by NAAT for discrepant results had significantly lower rates of C. difficile infection but similar SIRs. For most hospitals in this system, rates of C. difficile remained level. Within the NAAT test categories, SIRs may not correlate with infection rates. Given the controversies regarding testing and calculation of SIRs, alternatives to C. difficile infection should be sought as a hospital quality measurement.

Cost and length of hospital stay for healthcare facilityonset Clostridioides Difficile infection in pediatric wards: a prospective cohort analysis.

Clostridioides difficile (C. difficile) is a well-known causative agent of healthcare associated infection, it increases medical cost besides increasing morbidity and mortality. This study was conducted to determine the incidence, and economic burden of healthcare facility-onset C. difficile infection (HO-CDI) in children. Data was acquired with a prospective cohort study conducted in pediatric wards of a tertiary university hospital between August 2015 to August 2016. The HO-CDI was defined as diarrhea that began after 48 hours of admission with a positive cytotoxic stool assay for the presence of toxin A and/or B of C. difficile. In the 3172 admissions in one year, 212 (7%) healthcare associated diarrhea (HAD) episodes were observed, in 25 (12%) of them C. difficile was identified in which 6 (25%) cases < 2-year-old. The incidence of HOCDI was estimated as 8.8/10,000 patient-days. Cases with HO-CDI (n=19) were compared with cases with non- CDI-HAD (n=102); the presence of one of the risk factors for CDI increased the risk for HO-CDI (5,05; 95% Cl: 1.10-23.05; P 0,037), the median length of stay (LOS) attributable HO-CDI was 7 days (IQR,5-10) per admission, whereas for non-CDI-HAD was 2 days (IQR,0-4) (p=0.036). General hospitalization costs in the two groups were similar, specifically estimated costs attributable to HO-CDI and non-CID-HAD were $294.0 and $137.0 per hospitalization respectively (p= < 0.0001). Although in children the incidence of HO-CDI is increasing, its clinical manifestation is still milder and effective infection control measures with antibiotic stewardship can limit related morbidly, mortality, LOS, and cost.