Hospital-acquired Clostridium Difficile Infection Research Articles

Implementation strategies for hospital-based probiotic administration in a stepped-wedge cluster randomized trial design for preventing hospital-acquired Clostridioides difficile infection

BackgroundClostridioides difficile infection (CDI) is associated with considerable morbidity and mortality in hospitalized patients, especially among older adults. Probiotics have been evaluated to prevent hospital-acquired (HA) CDI in patients who are receiving systemic antibiotics, but the implementation of timely probiotic administration remains a challenge. We evaluated methods for effective probiotic implementation across a large health region as part of a study to assess the real-world effectiveness of a probiotic to prevent HA-CDI (Prevent CDI-55 +).MethodsWe used a stepped-wedge cluster-randomized controlled trial across four acute-care adult hospitals (n = 2,490 beds) to implement the use of the probiotic Bio-K + ® (Lactobacillus acidophilus CL1285®, L. casei LBC80R® and L. rhamnosus CLR2®; Laval, Quebec, Canada) in patients 55 years and older receiving systemic antimicrobials. The multifaceted probiotic implementation strategy included electronic clinical decision support, local site champions, and both health care provider and patient educational interventions. Focus groups were conducted during study implementation to identify ongoing barriers and facilitators to probiotic implementation, guiding needed adaptations of the implementation strategy. Focus groups were thematically analyzed using the Theoretical Domains Framework and the Consolidated Framework of Implementation Research.ResultsA total of 340 education sessions with over 1,800 key partners and participants occurred before and during implementation in each of the four hospitals. Site champions were identified for each included hospital, and both electronic clinical decision support and printed educational resources were available to health care providers and patients. A total of 15 individuals participated in 2 focus group and 7 interviews. Key barriers identified from the focus groups resulted in adaptation of the electronic clinical decision support and the addition of nursing education related to probiotic administration. As a result of modifying implementation strategies for identified behaviour change barriers, probiotic adherence rates were from 66.7 to 75.8% at 72 h of starting antibiotic therapy across the four participating acute care hospitals.ConclusionsUse of a barrier-targeted multifaceted approach, including electronic clinical decision support, education, focus groups to guide the adaptation of the implementation plan, and local site champions, resulted in a high probiotic adherence rate in the Prevent CDI-55 + study.

Benefits of Accepting Infectious Diseases Pharmacist Recommendations: A 5-Year Outcome Study in a Multihospital System.

Background: Infectious diseases (ID) pharmacists are pivotal members of antimicrobial stewardship teams. Prospective audit and feedback is a strong recommendation by The Infectious Diseases Society of America Guidelines for Antimicrobial Stewardship Programs (ASP). Utilizing customized ASP intervention documentation tools known as "ivents" in Epic, we aimed to assess the impact of interventions by measuring outcomes that were accepted compared to those that were rejected in a multihospital health system over 5 years. Methods: A multicenter, retrospective cohort study was conducted to compare clinical outcomes among intensive care unit (ICU) and non-ICU patients with accepted and rejected ASP interventions over 5 years from October 2015 to December 2020. Outcomes measured included antibiotic days of therapy per 1000 patient days (DOT/1000 PD), antibiotic doses per 1000 patient days (doses/1000 PD), hospital length of stay (LOS), in-hospital mortality, hospital-acquired Clostridioides difficile infection (HA-CDI), community-onset C. difficile infection (CO-CDI) within 30 days, and hospital readmission within 30 days. Coarsened exact matching (CEM) was used as a non-parametric matching method to balance covariates between groups and to control for confounding. Results: ASP recommendations by ID pharmacists were well-received by providers in a multihospital system over 5 years as evidenced by an overall acceptance rate of 92%. Acceptance of ASP interventions was associated with substantial reductions in antibiotic utilization without adversely affecting mortality or hospital readmissions. While high-risk C. difficile antibiotic use increased significantly due to frequent de-escalation to ceftriaxone among non-ICU patients with accepted interventions, rates of HA-CDI and CO-CDI within 30 days did not worsen. Furthermore, hospital LOS was notably shorter by an average of 1 day for non-ICU patients with accepted interventions, which resulted in substantial cost avoidance of $7 631 400. Conclusion: Collaboration with ID pharmacists to optimize antimicrobial stewardship was associated with significant reductions in antibiotic utilization, costs, and hospital LOS without worsening patient outcomes.

Antistaphylococcal Efficacy of Cefepime, Meropenem, and Piperacillin-Tazobactam in Patients with Polymicrobial Infection with MSSA Bacteremia or Pneumonia

There is a paucity of literature describing de-escalation techniques in patients with polymicrobial infections with one offending organism being methicillin-susceptible Staphylococcus aureus (MSSA) being treated with β-lactam therapy. The purpose of this study is to determine treatment outcomes for patients with polymicrobial infections with MSSA bacteremia or pneumonia who are treated with cefepime (FEP), meropenem (MEM), or piperacillin-tazobactam (TZP). This trial design represents a retrospective observational three-group comparison study of patients at a community teaching hospital system. Patients reviewed included those who had a MSSA bacteremia or pneumonia in addition to a confirmed polymicrobial infection or presence of a coinfection and received definitive therapy with FEP, MEM, or TZP. The primary outcome is defined as the resolution of fever of ≥100.4°F, hypothermia (≤95°F), leukocytosis (WBC °>° 12,000 cells/mm3), and leukopenia with WBC °<° 4,000 cells/mm3. Secondary outcomes included duration of definite therapy, in-hospital mortality, hospital and ICU length of stay (LOS), 30-day readmission rates for a presumed infection, and hospital-acquired Clostridioides difficile infection (HCDI). From August 1, 2016, to August 30, 2019, 45 patients met eligibility criteria. There were no observed differences in primary endpoint ( p = 0.65) or secondary endpoints, i.e., in-hospital mortality ( p = 0.10), hospital LOS ( p = 0.75), ICU LOS ( p = 0.53), 30-day readmission rates for presumed infection ( p = 0.07), or HCDI ( p = 0.34). There was no difference in treatment success with FEP, MEM, or TZP for polymicrobial infections with one offending organism being MSSA. Due to the lack of evidence in this unique patient population and observed results of our study, randomized studies are warranted to determine appropriate therapy in this complex patient population.

1222. Impact of Microbiology Reporting Changes in Treatment of AmpC Bloodstream Infections

Abstract Background Recent literature suggests that AmpC production may be overcalled in Enterobacterales, leading to unnecessary broad-spectrum antimicrobial utilization. The Infectious Diseases Society of America (IDSA) has since reassessed classification of high and low risk organisms with inducible AmpC expression. With this updated guidance, our health system approved changes to our microbiology reporting of AmpC producers in an effort to guide prescribing of appropriate antibiotics. The primary objective of this project was to compare antibiotic prescribing patterns for high and low risk AmpC producers in patients with bloodstream infections (BSI) based on the addition of appended comments to antimicrobial susceptibility results. Methods This multicenter, retrospective, cohort study included patients with BSI from October 2022 to March 2023who received at least 48 hours of antimicrobial therapy for the following high and low risk AmpC producers: Citrobacter spp., Enterobacter spp., Klebsiella aerogenes, Serratia spp., Morganella spp., Providencia spp. The primary endpoint was the number of patients placed on optimal therapy based on adherence to the appended microbiology comment and IDSA guidance. Secondary endpoints included time to effective treatment, time to optimal treatment, duration of therapy, 30 day mortality, microbiological failure, microbiological relapse, 30 day readmission, length of stay, and hospital acquired Clostridioides difficile infection. Results A total of 191 positive blood cultures were identified with 93 patients (pre-appended comment = 57; post-appended comment = 36) meeting inclusion criteria. Patients were more likely to receive optimal therapy post-appended comment based on IDSA guidance for BSI (38.6% vs 72.2%, OR 4.14; 1.68-10.21). When stratified by high risk and low risk organism, the number of patients on optimal therapy increased in the post-appended comment group but was not statistically significant (high risk: 70.3% vs 88%, OR 3.08; 0.72-13.32; low risk: 10% vs 36.3%, 5.14; 0.92-28.50). No difference in secondary outcomes were detected. Conclusion Implementation of an appended microbiology note has the potential to have a positive impact on antimicrobial prescribing patterns in treatment of AmpC bloodstream infections. Disclosures All Authors: No reported disclosures

Limited reduction in Clostridioides difficile and Methicillin-Resistant Staphylococcus aureus with the use of an aerosolized hydrogen peroxide disinfection system in tertiary health care facilities in Alberta, Canada

Nonmanual room disinfection systems may reduce the transmission of infections. A variety of systems have emerged; however, a paucity of evidence exists to make an evidence-informed decision for the implementation of a specific system. Alberta Health Services assessed one of these systems. A quasi-experimental prepost design assessed an aerosolized hydrogen peroxide disinfection system on 6 units at 3 acute care facilities in Alberta. To assess clinical effectiveness an interrupted time-series analysis with Poisson distribution compared changes in hospital-acquired Clostridioides difficile infection (HA-CDI) and hospital-acquired Methicillin-resistant Staphylococcus aureus (HA-MRSA) between preintervention, intervention, and postintervention periods. To assess operational feasibility cleaning turnaround time, time to operate, and utilization were considered. A participatory research framework was used to understand the benefits and challenges of operationalization. Incidence rate ratio (IRR) of HA-CDI decreased by 25.7% on FMC-A and 6.9% on RAH-B. Following withdrawal, the IRR of HA-CDI continued to decrease. IRR of HA-MRSA decreased by 25.0% on RAH-B. Following withdrawal, the IRR of HA-MRSA continued to decrease. None of the results were statistically significant. The average time to operate was 3.2hours. Utilization was between 1.7% and 25.6%. Most staff reported benefits and challenges. None of the changes observed in HA-CDI and HA-MRSA after the introduction of the aerosolized hydrogen peroxide system were statistically significant. While most respondents reported multiple benefits and challenges in using the system, the core challenge was delays in inpatient admissions due to the time operate the system. Successful implementation of a nonmanual room disinfection system as an addition to standard cleaning and disinfection requires significant investment and must consider a variety of factors.

Clostridioides difficile Infections During the COVID-19 Pandemic

Objective To compare rates of prepandemic Clostridioides difficile infection (CDI) during the COVID-19 pandemic and the rates of antibacterial use prepandemic and during the COVID-19 pandemic. Design This was a retrospective data review. Setting This study was performed at an academic medical center. Patients Patients were all adult patients admitted to the hospital between April 1, 2019, and December 31, 2019, who were tested for CDI and admitted in the same time frame in 2020, and who were tested for CDI were included in the study. Methods Retrospective data analysis was conducted across 5 hospitals from April 1 to December 31, 2019 (prepandemic), and on the same dates in 2020 during the pandemic. The standardized infection ratio (SIR) for hospital-acquired CDI (HA-CDI) was calculated for both groups. The mean and normal distributions were calculated for all values in both the groups. The 2 groups were compared using unpaired t tests for continuous variables and χ 2 tests for discrete variables. Results Thirty-six patients were diagnosed with HA-CDI before the pandemic (2019), and 45 patients during the pandemic (2020). The 2019 HA-CDI SIRs were 0.47 in 2019 and 0.56 in 2020. Days of therapy per 1000 patient-days of antibiotics increased from 337.1 to 364.6 (P = 0.0057). Analysis of 153 inpatients with diarrhea revealed no positive association between COVID and CDI. Conclusion During the COVID-19 pandemic, empiric broad-spectrum antibacterial use increased in our system, as did HA-CDI SIR compared with the national standards. We did not observe a positive correlation between COVID-19 and CDI.

In vivo emergence of a still uncommon resistance to fidaxomicin in the urgent antimicrobial resistance threat Clostridioides difficile.

Fidaxomicin is a first-line treatment for Clostridioides difficile infections (CDIs). Fidaxomicin resistance has rarely been reported in this urgent antimicrobial resistance threat as defined by the CDC. To report a case of fidaxomicin-resistant C. difficile isolation in a patient treated by fidaxomicin, characterize the genetic determinant for resistance and the consequences on pathophysiological traits, and review the literature. A 38-year-old male patient with several risk factors for CDI experienced three episodes of hospital-acquired CDI and received fidaxomicin for the first episode. The successive isolates were subjected to phenotypic characterization (antimicrobial susceptibility, growth, sporulation ability and toxin production) and WGS analysis to evaluate clonality and modifications associated with resistance. Resistance to fidaxomicin arose in isolates from the recurrences of CDI (MIC: 16 mg/L). WGS analysis showed a close genetic link between strains suggestive of relapses in this patient. A T3428G mutation in the rpoB gene might be associated with fidaxomicin resistance. The resistance was associated with defects in growth, sporulation and production of toxins. A review of the literature found only three previous fidaxomicin-resistant C. difficile clinical strains. Although rarely reported, resistance to fidaxomicin may quickly emerge in vivo after a single course of treatment. This observation supports the need for prospective surveillance of the susceptibility of C. difficile to treatment antibiotics. However, the clinical relevance of fidaxomicin resistance still needs to be elucidated, particularly due to its apparent rareness and associated fitness cost.

Impact of Clostridioides difficile length of treatment on rates of recurrence in patients on concurrent antibiotics

Clostridioides difficile infection (CDI) is principally healthcare-associated with substantial impact on morbidity and mortality. Guidelines recommend CDI therapy for 10 days; however, it is often extended in practice when concurrent antibiotics are used. The impact of the extended duration of therapy remains unclear. To compare rates of CDI recurrence in patients receiving standard duration of therapy (SDT) compared to extended duration of therapy (EDT) for the treatment of hospital-acquired CDI (HA-CDI) while receiving concurrent antibiotics. A retrospective chart review was conducted between October 2017 and 2019. Adult HA - CDI patients who received a minimum 10 days of CDI therapy and were on concurrent antibiotics were stratified into SDT and EDT groups. Rates of CDI recurrence (at 90 and 180 days) and incidence of new onset vancomycin-resistant enterococcus (VRE) were compared. 223 patients met the inclusion criteria (SDT - 106, EDT - 117). CDI recurrence rates at 90 and 180 days were not statistically significant between SDT and EDT groups (22% vs 26%, p = 0.40 and 26% vs 31%, p = 0.47). Although the incidence of VRE within the extended group was higher, it was not statistically significant (6% vs 9%, p = 0.29). No significant difference in rates of recurrence or new onset VRE were observed between SDT and EDT in HA-CDI patients.

The impact of the COVID-19 pandemic on Clostridioides difficile infection and utilization of fecal microbiota transplantation

Previous research has demonstrated that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) gains cell entry through the angiotensin-converting enzyme 2 receptor, which is abundantly found throughout the gastrointestinal (GI) tract, resulting in a wide array of GI manifestations of coronavirus disease 2019 (COVID-19). By gaining entry into the intestinal epithelial and stromal cells, SARS-CoV-2 has been observed to cause intestinal inflammation and gut dysbiosis. Alterations in gut microbiota are known to be involved in the pathophysiology of Clostridioides difficile infection (CDI). During the initial stages of the COVID-19 pandemic, rates of CDI were similar to historical data despite the increased use of antibiotics. This may be due to increased emphasis on hygiene and protective equipment and reduced C. difficile testing as diarrhea was presumed to be COVID-19 related. Studies also demonstrated additional risk factors for CDI in COVID-19 patients, including length of hospitalization and new abdominal pain during admission. Although not associated with increased mortality, CDI was associated with increased length of hospital stay among patients admitted with COVID-19. Due to fecal viral shedding and concern of oral-fecal transmission of SARS-CoV-2, increased safety regulations were introduced to fecal microbiota transplantation (FMT) leading to reduced rates of this procedure during the COVID-19 pandemic. FMT for recurrent CDI during the COVID-19 pandemic remained highly effective without any reports of SARS-CoV-2 transmission. In addition, limited data show that FMT may be effective in treating COVID-19 and restoring healthy gut microbiota. The goal of this article is to review the impact that the COVID-19 pandemic has had on hospital-acquired CDI and the utilization of FMT.

182. Impact of Rapid Identification and Phenotypic Results on Clinical, Economic, Antimicrobial Stewardship Outcomes in Patients with Gram-Negative Bacteremia

Abstract Background Timely and effective antibiotic therapy is a critical determinant of clinical outcome in Gram-negative bacilli (GNB) bloodstream infections (BSI). Conventional antimicrobial susceptibility testing (AST) remains a rate-limiting step in determining targeted therapy. Accelerate Pheno™ (AP) is a novel system providing both identification (ID) and AST results within 8 hours. The primary objective of this study was to determine the impact of rapid ID and AST with AP on time to achieving targeted therapy (TTT). Methods This single center, quasi-experimental study compared outcomes with AP (POST; November 2020 to July 2021) versus a historical standard (PRE; November 2019 to July 2020) of rapid diagnostic testing (BioFire® FilmArray®BCID) and conventional AST (VITEK®2) with pharmacist-driven antimicrobial stewardship (AMS) intervention. PRE and POST BSI were retrospectively identified by positive blood culture (BCx) with an on-panel GNB. Inpatients were excluded if less than 18 years of age, pregnant, polymicrobial BCx, BCx with the same organism and source within 7 days, or if died or transitioned to palliative or hospice care before final AST results. Secondary outcomes included inpatient all-cause mortality, hospital and ICU length of stay, hospital-acquired Clostridioides difficile infection, antibiotic and microbiologic costs, days of anti-pseudomonal therapy, antibiotic intensity score, and time to first intervention following Gram stain, ID, and AST results. Results Overall, 373 BSI were screened and 294 were included [161 PRE vs 133 POST]. Baseline demographics and characteristics were similar between groups. Median TTT was shorter POST [50 hours (IQR 44–92) vs 28 hours (IQR 14–55), p < 0.05]. Median microbiology testing costs per episode were higher POST [Δ$40.33 (32%), p < 0.05]. Other secondary outcomes did not differ significantly between groups. Pharmacists intervened more POST [69 (43%) vs 77 (58%), p < 0.05]. AP completed ID and AST in 155 of 205 (76%) BSI. Off-panel GNB occurred in 26 (13%) BSI POST. Conclusion Implementing the AP system together with an established AMS program resulted in a shorter TTT and a higher cost to test. Clinical, AMS, and other economic outcomes were not impacted by the addition of AP. Disclosures All Authors: No reported disclosures.

Evaluation of a statewide collaborative focused on antibiotic usage surveillance and stewardship in New York State Hospitals

To prepare NYS hospitals for reporting in The National Health Care Safety Network's Antimicrobial Use and Resistance (AUR) Module, the Health care Association of New York State (HANYS) launched a voluntary Antibiotic Stewardship Collaborative (ASC) in late 2015 with 2 aims (1) assist hospitals in developing the infrastructure necessary to track and report antibiotic usage; (2) educate hospitals on antibiotic stewardship. This study evaluates the characteristics of hospitals opting to participate in the ASC and their experiences in the program, as well as the effects of one year of participation (2016) on hospital-acquired C. difficile infection (HA-CDI) rates. Difference in means testing of clinical and non-clinical characteristics were performed to understand the "type" of hospital joining the ASC; semi-structured interviews were conducted to understand reasons for opting in or out of the ASC and experiences in the program; and a multivariate regression analysis with a difference-in-differences approach was used to assess the impact on HA-CDI rates. Hospitals with a greater number of annual discharges (P < .001) located in urban areas (P=.03) were more likely to join the ASC. All participants in the ASC (N=44/184) successfully implemented the necessary infrastructure to track and report antibiotic usage data, despite this being the most cited challenge and main reason hospitals opted not to participate. While HA-CDI rates decreased to a greater extent for participating hospitals (β=-0.153), this was not statistically significant (P=.191). HANYS' ASC proved an effective and well-received strategy for encouraging hospitals, particularly large, urban facilities, to take concrete steps to strengthen their antibiotic stewardship efforts and prepare for potential mandates requiring antibiotic usage tracking and reporting. However, a reduction in HA-CDI resulting from these efforts remains to be seen.

Clostridioides difficile Infection in Children-An Update.

Clostridioides difficile Infection in Children-An Update.

Telestewardship programs support clinical care and improve fiscal outcomes across the continuum through partnership between hospitals and health systems: A systematic review.

A systematic review was performed to determine if remote stewardship (telestewardship) provides clinical and fiscal benefit and is a feasible alternative to local stewardship programs. Antibiotic resistance is an increasingly important national and global threat. US regulators have made antimicrobial stewardship programs a condition of participation in federally funded healthcare programs, and stewardship programs are surveyed during accreditation visits. Small and rural hospitals are at risk for stewardship noncompliance because lack of resources limits comprehensive stewardship program implementation. Remote stewardship programs are established to remedy this area of partial compliance. To characterize the impact of remote stewardship on selected clinical and fiscal outcomes, PubMed was searched for studies involving telestewardship that reported data on antimicrobial utilization, patient length of stay, mortality, bacterial susceptibility, hospital-acquired Clostridioides difficile infection (HA-CDI), and/or antimicrobial costs. A systematic approach was used to screen study titles, abstracts, and content and data extracted. Study quality was analyzed using Cochrane risk-of-bias assessment tools. Fourteen studies were included in the final review. Collectively, the antimicrobial utilization data was positive, with utilization of targeted antimicrobials decreasing after telestewardship implementation. Mixed (both positive and neutral) results were found for patient length of stay, mortality, and HA-CDI rates. Fiscal outcomes were consistently positive. Based on the reviewed evidence, remote antimicrobial stewardship programs may aid in the more judicious use of antimicrobials by decreasing utilization rates. More studies are needed to clarify patient-oriented outcomes. Telestewardship has positive effects in terms of cost savings, although savings may be offset by the structure of the program.

Sustained Improvements in Antimicrobial Therapy and Clinical Outcomes following a Pharmacist-Led Antimicrobial Stewardship Intervention: Uncontrolled Before-After Study.

Our antimicrobial pharmacist-led intervention included: (a) a structured review of antibiotic prescriptions; (b) educating prescribers on antimicrobial therapy; (c) monthly reporting of department-level rates of blood sampling for culture. Daily review began in May 2018 and was discontinued after 10 months; however, the other interventions were conducted throughout the study period. This study aimed to evaluate the sustained impact of pharmacist’s interventions on antimicrobial therapy and clinical outcomes between the baseline (May–December 2017), intervention (May–December 2018), and post-intervention (May–December 2019) periods. The rate of blood culture collections before starting antipseudomonal agent therapy was significantly increased from the baseline to post-intervention periods (71% vs. 85%, p < 0.001). Antipseudomonal agent therapy was more frequently de-escalated in the post-intervention period than in the baseline period (73% vs. 54%, p = 0.038). Total use of antipseudomonal agents was reduced from the baseline to intervention periods and persisted during the post-intervention period (50.5 vs. 41.8 and 42.6 DDD per 1000 patient-days, p = 0.016 and p = 0.022, respectively). During the study period, there were significant reductions in the incidence of hospital-acquired Clostridioides difficile infection (1.12, 0.54, and 0.51 per 10,000 patient-days, respectively, p = 0.031) and 30-day mortality with bacteremia (19%, 18%, and 12%, respectively, p = 0.005). Our pharmacist-led interventions sustainably achieved appropriate antimicrobial therapy and improved clinical outcomes.

Sustained reductions in unnecessary antimicrobial administration and hospital Clostridioides difficile rates via stewardship in a nonacademic setting.

A large community hospital sought to reduce its burden of hospital-acquired Clostridioides difficile infection (CDI). We implemented an antimicrobial stewardship program (ASP), resulting in marked reductions in unnecessary antimicrobial use, CDI rates, antimicrobial acquisition costs, with preservation of gram-negative susceptibilities. ASP programs are effective in a community setting.

Examining the Rate of Clostridioides (Formerly Clostridium) Difficile Infection Pre- and Post-COVID-19 Pandemic: An Institutional Review.

Background/ RationaleClostridioides difficile infection (CDI) is transmitted via the fecal-oral route and is implicated in antibiotic-associated colitis. Similar to CDI, patients with coronavirus disease 2019 (COVID-19) require early identification and isolation, appropriate personal protective equipment, and environmental disinfection to prevent further transmission. In light of this similarity between isolation and protective requirements to prevent transmission of these diseases, we aim to investigate whether there was a decrease in the incidence of CDI during the peak periods of the COVID-19 pandemic compared to historical rates.MethodsThis is a single-center retrospective analysis of the rates of CDI in our institution. COVID-19 time periods were identified from March 2020 to January 2021 and peak periods (with >50 active patients per day) were defined. The non-COVID-19 periods were July 2017 to February 2020. Rates of CDI were also directly compared across the yearly time period. CDI rates were presented in a per 1000 patient days format. Rates were analyzed per year and during the COVID-19 peaks at our institution. Mann-Whitney U test was used to compare rates between two time periods, while differences across multiple time intervals were analyzed using the Kruskal-Wallis test.ResultsThe median (interquartile range [IQR]) of CDI rates of infection per 1000 patient days for the non-COVID time period from July 2017 to February 2020 was 0.34 (0.23-0.45) while COVID time periods had higher 0.44 (0.25-0.51) rates of CDI although this was not statistically significant (p=0.224). However, there was a statistically significant difference (p=0.036) with COVID peak periods having higher rates of CDI 0.49(0.39-0.74) vs 0.34(0.23-0.44). Overall, there was no statistically significant difference in the rates of CDI across years or time periods (p=0.396).Discussion/ConclusionThere was no difference in the rates of hospital-acquired CDI between COVID-19 and non-COVID-19 time periods at our institution.

Epidemiology and risk factors for hospital acquired Clostridium difficile infection and colonization in emergency intensive care unit of a general hospital in Shanghai

To investigate the clinical features, risk factors and prognosis of Clostridium difficile infection/colonization (CDI/CDC) in emergency intensive care unit (EICU) of Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, then provides theoretical basis for clinical treatment. A retrospective case-control study was conducted. The data of EICU patients admitted to Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine from June 2016 to June 2020 were collected. Taking the CDI/CDC patients as research objects [Clostridium difficile (CD) positive group] and the CD negative patients with the same gender and age difference less than 5 years who were admitted to the hospital during the same period as the control (CD negative group). Demographic information, risk factors, prognosis and stool samples were collected. Single factor analysis and binary Logistic regression were used to analyze the CD positive infection rate, risk factors, and hospital death of patients with different clinical characteristics. About 487 patients in EICU were included, 76 cases were taken into CD positive group, CD positive rate was 15.6%, including CDI 11 cases, CDC 65 cases. Among the CD positive group, all of the cases used proton pump inhibitor (PPI), and 75 cases used at least one antibiotic. Seventy-six CD negative patients with or without diarrhea (CD negative group) were included in this study. Among them, 75 patients used PPI and 74 patients used at least one antibiotic. Univariate analysis showed that acute physiology and chronic health evaluation II (APACHE II), duration of hospitalization, and carbapenem use were the risk factors for CDI/CDC. There were significant differences in the above indicators between CD positive group and CD negative group [APACHE II: 18.0 (12.2, 25.8) vs. 10.0 (7.0, 14.0), duration of hospitalization (days): 46.0 (30.5, 72.5) vs. 18.5 (9.2, 37.0), proportion of carbapenems: 81.6% (62/76) vs. 64.5% (49/76), all P < 0.05]. Binary Logistic analysis regression analysis showed that APACHE II score [odds ratio (OR) = 0.802, 95% confidence interval (95%CI) was 0.730-0.882, P < 0.01] and duration of hospitalization (OR = 0.960, 95%CI was 0.942-0.978, P < 0.01) were independent risk factors for CDI/CDC. There was no difference in overall mortality between the CD positive group and CD negative group [27.6% (21/76) vs. 38.2% (29/76), P = 0.167]. Critically ill patients in EICU routinely use PPI and antibiotics, and the use of antibiotics does not affect the CD positive rate. The independent risk factors of CDI/CDC are the APACHE II score and the duration of hospitalization, but fecal CD positive has no obvious influence on death.

Characteristics, Risk Factors, and Prevalence of Clostridioides difficile Among Hospitalized Patients in a Tertiary Care Hospital in Palestine.

PurposeClostridioides difficile is one of the most important nosocomial infection pathogens. It is linked with many risk factors. Unfortunately, many studies have been conducted in different countries to address the Clostridioides difficile infections (CDI), and no studies have been conducted in Palestine. This study aims to identify the prevalence and possible risk factors associated with CDI.Patients and MethodsThis was a retrospective descriptive study conducted at the An-Najah National University Hospital (NNUH) in Palestine. Data were collected for patients diagnosed with CDI who tested positive for GDH, toxins A and B between January 2018 and April 30, 2021. In addition, patient characteristics and risk factors associated with CDI were analyzed.ResultsA total of 593 participants were included in the study; 53% had hospital-acquired CDI. There was an insignificant association between participant age and CDI risk. Most patients had mild to moderate infections. Sixty-three percent of the participants were immunocompromised. About 58.5% used an antibiotic agent two weeks before CDI, and 67% were on a proton pump inhibitor (PPI). About 61.3% of patients were treated according to IDSA 2017 guidelines, and 94% responded adequately to the treatment provided.ConclusionThere was an increased prevalence of community-acquired CDI, with a prevalence almost equal to that of hospital-acquired. In addition, most of the participants were immunocompromised. The risk factors for CDI, such as antibiotics and PPI use, were also observed with high prevalence among positive patients. Antimicrobial stewardship and the appropriate use of acid suppressors are warranted.

Genetic Relatedness of 5-Year Isolates of Clostridioides difficile Polymerase Chain Reaction Ribotype 017 Strains in a Hospital.

The objective of this study was to analyse the genetic relatedness of Clostridioides difficile polymerase chain reaction ribotype 017 (RT017) strains from patients with hospital-acquired C. difficile infection (HA-CDI) in a hospital with a high RT017 prevalence. From 2009 to 2013, 200 RT017 strains (26.8%) were collected from 745 HA-CDI patient isolates. They comprised 64 MLVA types, and 197 (98.5%) strains were genetically related to 5 clonal complexes (CCs). The largest cluster, CC-A, included 163 isolates of 40 MLVA types. CC-A accounted for 20% of RT017 strains in 2009 and sharply increased to 94.9% in 2010, 94% in 2011, 86.2% in 2012, and 73.5% in 2013. The other 4 CCs included 20 isolates with 7 MLVA types. The resistance rates of antimicrobials were as follows: clindamycin 100%, moxifloxacin 99%, rifaximin 88.5%, and vancomycin 1%. All isolates were susceptible to metronidazole and piperacillin/tazobactam. Comparing antibiotic resistance among CCs, the geometric mean of the minimum inhibitory concentrations of moxifloxacin, vancomycin, and piperacillin/tazobactam were significantly higher for CC-A isolates than for the other CCs. RT017 clones constantly evolved over the 5 years studied with regard to genetic relatedness. The levels of antibiotic resistance may contribute to the persistence of organisms in the institution.

S153 Examining the Rate of Clostridioides (formerly Clostridium) difficile Infection Pre and Post the COVID-19 Pandemic: An Institutional Review

Introduction: Clostridioides difficile infection (CDI) is transmitted via the fecal-oral route and is implicated in antibiotic-associated colitis. Similar to CDI, patients with COVID 19 require early identification and isolation, appropriate personal protective equipment, and environmental disinfection to prevent further transmission. In light of this similarity between isolation and protective requirements to prevent transmission of these diseases, we aim to investigate whether there was a decrease in the incidence of CDI during the peak periods of the COVID 19 pandemic compared to historical rates. Methods: This is a single center retrospective analysis of the rates of CDI in our institution. The rates of CDI are of reportable hospital acquired infections which is any patient who tests positive for CDI on or after day 3 of hospitalization. COVID-19 time periods were identified from March 2020 to January 2021 and peak periods (with >50 active patients per day) were identified. The non-COVID-19 time periods were July 2017 to February 2020. Rates of CDI were also directly compared across the yearly time period.CDI rates were presented in a per 1000 patient days format. Rates were analyzed per year and during the COVID-19 peaks at our institution. Mann Whitney U test was used to compare rates between 2 time periods while looking at differences across multiple time periods were done using Kruskal Wallis test. Results: The median(Interquartile Range-IQR) of CDI rates of infection per 1000 patient days for the non-COVID time period from July 2017 to February 2020 was 0.34 (0.23-0.45) while COVID time periods had higher 0.44(0.25-0.51) rates of CDI although this was not statistically significant P=0.224. However, there was a statistically significant difference with COVID peak periods having higher rates of CDI 0.49(0.39-0.74) vs 0.34(0.23-0.44) P=0.036. Overall, there was no statistically significant difference in the rates of CDI across years or time periods P=0.396. Conclusion: There was no difference in the rates of hospital-acquired CDI between COVID-19 and non-COVID-19 time periods at our institution. However, it should be acknowledged that hand washing recommendations for COVID 19 did not strictly rely on soap or water as is needed for CDI as alcohol-based products were also used.Figure 1.: Median Clostridioides difficile infection rates across time periods.