Hospital-onset Clostridioides Difficile Infection Rates Research Articles

Impact of mandatory nucleic acid amplification test (NAAT) testing approval on hospital-onset Clostridioides difficile infection (HO-CDI) rates: A diagnostic stewardship intervention.

Misclassification of Clostridioides difficile colonization as hospital-onset C. difficile infection (HO-CDI) can lead to unnecessary treatment of patients and substantial financial penalties for hospitals. We successfully implemented mandatory C. difficile PCR testing approval as a strategy to optimize testing, which was associated with a significant decline in the monthly incidence of HO-CDI rates and lowering of our standardized infection ratio to 0.77 (from 1.03) 18 months after this intervention. Approval request served as an educational opportunity to promote mindful testing and accurate diagnosis of HO-CDI.

Impact of Mandatory Infectious Disease Specialist Approval on Hospital-Onset Clostridioides difficile Infection Rates and Testing Appropriateness.

Inappropriate Clostridioides difficile testing is common in the hospital setting, leading to potential overdiagnosis of infection when single-step nucleic acid amplification testing is used. The potential role of infectious diseases (ID) specialists in enforcing appropriate C. difficile testing is unclear. At a single 697-bed academic hospital, we performed a retrospective study from 1 March 2012 to 31 December 2019 comparing hospital-onset C. difficile infection (HO-CDI) rates during 3 consecutive time periods: baseline 1 (37 months, no decision support), baseline 2 (32 months, computer decision support), and intervention period (25 months, mandatory ID specialist approval for all C. difficile testing on hospital day 4 or later). We used a discontinuous growth model to assess the impact of the intervention on HO-CDI rates. During the study period, we evaluated C. difficile infections across 331 180 admission and 1 172 015 patient-days. During the intervention period, a median of 1 HO-CDI test approval request per day (range, 0-6 alerts/day) was observed; adherence by providers with obtaining approval was 85%. The HO-CDI rate was 10.2, 10.4, and 4.3 events per 10 000 patient-days for each consecutive time period, respectively. In adjusted analysis, the HO-CDI rate did not differ significantly between the 2 baseline periods (P = .14) but did differ between the baseline 2 period and intervention period (P < .001). An ID-led C. difficile testing approval process was feasible and was associated with a >50% decrease in HO-CDI rates, due to enforcement of appropriate testing.

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

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

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

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

Making a C-DIFFerence: Implementation of a prevention collaborative to reduce hospital-onset Clostridioides difficile infection rates.

To assist hospitals in reducing Clostridioides difficile infections (CDI), the Centers for Disease Control and Prevention (CDC) implemented a collaborative using the CDC CDI prevention strategies and the Targeted Assessment for Prevention (TAP) Strategy as foundational frameworks. Acute-care hospitals. We invited 400 hospitals with the highest cumulative attributable differences (CADs) to the 12-month collaborative, with monthly webinars, coaching calls, and deployment of the CDC CDI TAP facility assessments. Infection prevention barriers, gaps identified, and interventions implemented were qualitatively coded by categorizing them to respective CDI prevention strategies. Standardized infection ratios (SIRs) were reviewed to measure outcomes. Overall, 76 hospitals participated, most often reporting CDI testing as their greatest barrier to achieving reduction (61%). In total, 5,673 TAP assessments were collected across 46 (61%) hospitals. Most hospitals (98%) identified at least 1 gap related to testing and at least 1 gap related to infrastructure to support prevention. Among 14 follow-up hospitals, 64% implemented interventions related to infrastructure to support prevention (eg, establishing champions, reviewing individual CDIs) and 86% implemented testing interventions (eg, 2-step testing, testing algorithms). The SIR decrease between the pre-collaborative and post-collaborative periods was significant among participants (16.7%; P < .001) but less than that among nonparticipants (25.1%; P < .001). This article describes gaps identified and interventions implemented during a comprehensive CDI prevention collaborative in targeted hospitals, highlighting potential future areas of focus for CDI prevention efforts as well as reported challenges and barriers to prevention of one of the most common healthcare-associated infections affecting hospitals and patients nationwide.

In pursuit of the holy grail: Improving C. difficile testing appropriateness with iterative electronic health record clinical decision support and targeted test restriction.

To determine the impact of electronic health record (EHR)-based interventions and test restriction on Clostridioides difficile tests (CDTs) and hospital-onset C. difficile infection (HO-CDI). Quasi-experimental study in 3 hospitals. 957-bed academic (hospital A), 354-bed (hospital B), and 175-bed (hospital C) academic-affiliated community hospitals. Three EHR-based interventions were sequentially implemented: (1) alert when ordering a CDT if laxatives administered within 24 hours (January 2018); (2) cancellation of CDT orders after 24 hours (October 2018); (3) contextual rule-driven order questions requiring justification when laxative administered or lack of EHR documentation of diarrhea (July 2019). In February 2019, hospital C implemented a gatekeeper intervention requiring approval for all CDTs after hospital day 3. The impact of the interventions on C. difficile testing and HO-CDI rates was estimated using an interrupted time-series analysis. C. difficile testing was already declining in the preintervention period (annual change in incidence rate [IR], 0.79; 95% CI, 0.72-0.87) and did not decrease further with the EHR interventions. The laxative alert was temporally associated with a trend reduction in HO-CDI (annual change in IR from baseline, 0.85; 95% CI, 0.75-0.96) at hospitals A and B. The gatekeeper intervention at hospital C was associated with level (IRR, 0.50; 95% CI, 0.42-0.60) and trend reductions in C. difficile testing (annual change in IR, 0.91; 95% CI, 0.85-0.98) and level (IRR 0.42; 95% CI, 0.22-0.81) and trend reductions in HO-CDI (annual change in IR, 0.68; 95% CI, 0.50-0.92) relative to the baseline period. Test restriction was more effective than EHR-based clinical decision support to reduce C. difficile testing in our 3-hospital system.

Associations of facility-level antibiotic use and hospital-onset Clostridioides difficile infection in US acute-care hospitals, 2012-2018.

Previously reported associations between hospital-level antibiotic use and hospital-onset Clostridioides difficile infection (HO-CDI) were reexamined using 2012-2018 data from a new cohort of US acute-care hospitals. This analysis revealed significant positive associations between total, third-generation, and fourth-generation cephalosporin, fluoroquinolone, carbapenem, and piperacillin-tazobactam use and HO-CDI rates, confirming previous findings.

Reductions in inpatient fluoroquinolone use and postdischarge Clostridioides difficile infection (CDI) from a systemwide antimicrobial stewardship intervention.

To determine the impact of an inpatient stewardship intervention targeting fluoroquinolone use on inpatient and postdischarge Clostridioides difficile infection (CDI). We used an interrupted time series study design to evaluate the rate of hospital-onset CDI (HO-CDI), postdischarge CDI (PD-CDI) within 12 weeks, and inpatient fluoroquinolone use from 2 years prior to 1 year after a stewardship intervention. An academic healthcare system with 4 hospitals. All inpatients hospitalized between January 2017 and September 2020, excluding those discharged from locations caring for oncology, bone marrow transplant, or solid-organ transplant patients. Introduction of electronic order sets designed to reduce inpatient fluoroquinolone prescribing. Among 163,117 admissions, there were 683 cases of HO-CDI and 1,104 cases of PD-CDI. In the context of a 2% month-to-month decline starting in the preintervention period (P < .01), we observed a reduction in fluoroquinolone days of therapy per 1,000 patient days of 21% after the intervention (level change, P < .05). HO-CDI rates were stable throughout the study period. In contrast, we also detected a change in the trend of PD-CDI rates from a stable monthly rate in the preintervention period to a monthly decrease of 2.5% in the postintervention period (P < .01). Our systemwide intervention reduced inpatient fluoroquinolone use immediately, but not HO-CDI. However, a downward trend in PD-CDI occurred. Relying on outcome measures limited to the inpatient setting may not reflect the full impact of inpatient stewardship efforts.

88. Impact of a Computerized Clinical Decision Support Tool on clostridioides Difficile Testing and Oral Vancomycin Utilization as a Balancing Metric

BackgroundOver diagnosis of hospital-onset Clostridioides difficile infection (HO-CDI) is directly tied to inappropriate C. difficile testing which does not distinguish between infected or colonized individuals. This can lead to inappropriate therapy. Multiple studies have utilized Computerized Clinical Decision Support (CCDS) tools to reduce inappropriate C. difficile testing. Our study looks at the impact of a Self-Assessment CCDS tools on C. difficile testing for HO-CDI and oral vancomycin utilization as a balancing metric.MethodsOur institution utilizes a two-step test to diagnose HO-CDI that consists of toxin A/B enzyme immunoassay followed by a confirmatory PCR. We applied a self-assessment driven CCDS approach to reduce testing for HO-CDI. Our intervention was deployed in the 3rd quarter of 2018. It asked 3 questions about stool frequency, laxative use and previous C. difficile testing in the order itself. Inappropriate indications for testing included any of the following: < 3 bowel movements within 24 hours, receipt of a laxative within the past 48 hours, or a previous C. difficile test within the previous 7 days. Ordering providers would self-answer these questions. A ‘yes’ response to any of the three questions prevented further test ordering; though respondents had the freedom to change the answer and still proceed with the test order. We evaluated 3 metrics that were all calculated per 1000 inpatient census days: oral vancomycin usage, HO-CDI rates and C. difficile testing rates.ResultsCompared to baseline, our intervention resulted in a significant reduction of C. difficile testing and HO-CDI rates (Figure 1, Table 1). Oral vancomycin usage also decreased significantly (Figure 2, Table 1).Figure 1. C. difficile testing and Hospital Onset C. difficile Infection Rates by Month, Before and After Intervention Figure 2. Oral Vancomycin Utilization by Month, Before and After Intervention Table 1. Changes in Median Rates of C. difficile testing, Hospital Onset C. difficile Infections and Vancomycin Utilization, Before and After Intervention. ConclusionOur self-assessment driven CCDS-based diagnostic stewardship resulted in a significant reduction in inappropriate C. difficile testing for HO-CDI and HO-CDI rates. Oral vancomycin utilization as a balancing metric also decreased significantly. This was despite the use of a self-assessment driven approach with the freedom to change the answers in order to proceed with the test order.Disclosures All Authors: No reported disclosures

Association Between Federal Value-Based Incentive Program Implementation and Hospital-Onset C. difficile Infection Rates

Background: The Hospital-Acquired Conditions Reduction Program (HACRP) and Hospital Value-Based Purchasing (HVBP) are federal value-based incentive programs that financially reward or penalize hospitals based on quality metrics. Hospital-onset C. difficile infection (HO-CDI) rates reported to the CDC NHSN became a target quality metric for both HACRP and HVBP in October 2016, but the impact of these programs on HO-CDI rates is unknown. Methods: We used an interrupted time-series design to examine the association between HACRP/HVBP implementation in October 2016 and quarterly rates of HO-CDI per 10,000 patient days among incentive-eligible acute-care hospitals conducting facility-wide HO-CDI NHSN surveillance between January 2013 and March 2019. Generalized estimating equations were used to fit negative binomial regression models to assess for immediate program impact (ie, level change) and changes in the slope of HO-CDI rates, controlling for each hospital’s predominant method for CDI testing (nucleic acid amplification including PCR (NAAT), enzyme immunoassay for toxin (EIA), or other testing method including cell cytotoxicity neutralization assay and toxigenic culture). Results: Of the 265 study hospitals studied, most were medium-sized (100–399 beds, 55%), not-for-profit (77%), teaching hospitals (70%), and were located in a metropolitan area (87%). Compared to EIA, rates of HO-CDI were higher when detected by NAAT (incidence rate ratio [IRR], 1.55; 95% CI, 1.41–1.70) or other testing methods (IRR, 1.47; 95% CI, 1.26–1.71). Controlling for CDI testing methods, HACRP/HVBP implementation was associated with an immediate 6% decline in HO-CDI rates (IRR, 0.94; 95% CI, 0.89–0.99) and a 4% decline in slope per year-quarter thereafter (IRR, 0.96; 95% CI, 0.95–0.97) (Fig. 1). Conclusions: HACRP/HVBP implementation was associated with both immediate and gradual improvements in HO-CDI rates, independent of CDI testing methods of differing sensitivity. Future research may evaluate the precise mechanisms underlying this improvement and if this impact is sustained in the long term.Funding: NoneDisclosures: None

Trends in Hospital Onset Clostridioides difficile Infection Incidence, National Healthcare Safety Network, 2010–2018

Background:Clostridioides difficile infection (CDI) is one of the most common laboratory-identified (LabID) healthcare-associated events reported to the National Healthcare Safety Network (NHSN). CDI prevention remains a national priority, and efforts to reduce infection burden and improve antibiotic stewardship continue to expand across the healthcare spectrum. Beginning in 2013, the Centers for Medicare and Medicaid Services (CMS) required acute-care hospitals participating in CMS’ Inpatient Quality Reporting program to report CDI LabID data to NHSN and, in 2015, extended this reporting requirement to emergency departments (ED) and 24-hour observation units. To assess national progress, we evaluated changes in hospital onset CDI (HO-CDI) incidence during 2010–2018. Methods: Cases of HO-CDI were reported to NHSN by hospitals using the NHSN’s LabID criteria. Generalized linear mixed-effects modeling was used to assess trends of HO-CDI by treating the hospital as a random intercept to account for the correlation of the repeated responses over time. The data were summarized at the quarterly level, the main effect was time, and the covariates of interest were the following: CDI test type, inpatient community-onset (CO) infection rate, hospital type, average length of stay, medical school affiliation, number of beds, number of ICU beds, number of infection control professionals, presence of an ED or observation unit , and an indicator for 2015 to account for CDI protocol changes that required hospitals to conduct surveillance in both inpatient and ED or observation unit setting. Results: During 2010–2013, the number of hospitals reporting CDI increased and then stabilized after 2013 (Table 1). Crude HO-CDI rates decreased over time, except for an increase in 2015 and steeper reduction thereafter. (Table 2). During 2010–2014, the adjusted quarterly rate of change was −0.45% (95% CI, −0.57% to −0.33%; P &lt; .0001). The rate of reduction was smaller in 2010–2014 compared to those of 2015–2018 (−2.82%; 95% CI, −3.10% to −2.54%; P &lt; .0001). Compared to 2014, the adjusted rate in 2015 increased by 79.14% (95% CI, 72.42%–86.11%; P &lt; .0001). Conclusions: The number of hospitals reporting CDI LabID data grew substantially in 2013 as a result of the CMS requirement for reporting. Adjusted HO-CDI rates decreased over time, with a rate hike in the year of 2015 and a rapid decrease thereafter. The increase in 2015 may be explained by changes in the NHSN CDI surveillance protocol and better test type classification in later years. Overall decreases in HO-CDI rates may be influenced by prevention strategies.Funding: NoneDisclosures: None

Improving Appropriate Diagnosis of Clostridioides difficile Infection Through an Enteric Pathogen Order Set With Computerized Clinical Decision Support: An Interrupted Time Series Analysis.

BackgroundInappropriate testing for Clostridioides difficile leads to overdiagnosis of C difficile infection (CDI). We determined the effect of a computerized clinical decision support (CCDS) order set on C difficile polymerase chain reaction (PCR) test utilization and clinical outcomes.MethodsThis study is an interrupted time series analysis comparing C difficile PCR test utilization, hospital-onset CDI (HO-CDI) rates, and clinical outcomes before and after implementation of a CCDS order set at 2 academic medical centers: University of Washington Medical Center (UWMC) and Harborview Medical Center (HMC).ResultsCompared with the 20-month preintervention period, during the 12-month postimplementation of the CCDS order set, there was an immediate and sustained reduction in C difficile PCR test utilization rates at both hospitals (HMC, −28.2% [95% confidence interval {CI}, −43.0% to −9.4%], P = .005; UWMC, −27.4%, [95% CI, −37.5% to −15.6%], P < .001). There was a significant reduction in rates of C difficile tests ordered in the setting of laxatives (HMC, −60.8% [95% CI, −74.3% to −40.1%], P < .001; UWMC, −37.3%, [95% CI, −58.2% to −5.9%], P = .02). The intervention was associated with an increase in the C difficile test positivity rate at HMC (P = .01). There were no significant differences in HO-CDI rates or in the proportion of patients with HO-CDI who developed severe CDI or CDI-associated complications including intensive care unit transfer, extended length of stay, 30-day mortality, and toxic megacolon.ConclusionsComputerized clinical decision support tools can improve C difficile diagnostic test stewardship without causing harm. Additional studies are needed to identify key elements of CCDS tools to further optimize C difficile testing and assess their effect on adverse clinical outcomes.

Chasing the rate: An interrupted time series analysis of interventions targeting reported hospital onset Clostridioides difficile, 2013-2018.

To assess the impact of major interventions targeting infection control and diagnostic stewardship in efforts to decrease Clostridioides difficile hospital onset rates over a 6-year period. Interrupted time series. The study was conducted in an 865-bed academic medical center. Monthly hospital-onset C. difficile infection (HO-CDI) rates from January 2013 through January 2019 were analyzed around 5 major interventions: (1) a 2-step cleaning process in which an initial quaternary ammonium product was followed with 10% bleach for daily and terminal cleaning of rooms of patients who have tested positive for C. difficile (February 2014), (2) UV-C device for all terminal cleaning of rooms of C. difficile patients (August 2015), (3) "contact plus" isolation precautions (June 2016), (4) sporicidal peroxyacetic acid and hydrogen peroxide cleaning in all patient areas (June 2017), (5) electronic medical record (EMR) decision support tool to facilitate appropriate C. difficile test ordering (March 2018). Environmental cleaning interventions and enhanced "contact plus" isolation did not impact HO-CDI rates. Diagnostic stewardship via EMR decision support decreased the HO-CDI rate by 6.7 per 10,000 patient days (P = .0079). When adjusting rates for test volume, the EMR decision support significance was reduced to a difference of 5.1 case reductions per 10,000 patient days (P = .0470). Multiple aggressively implemented infection control interventions targeting CDI demonstrated a disappointing impact on endemic CDI rates over 6 years. This study adds to existing data that outside of an outbreak situation, traditional infection control guidance for CDI prevention has little impact on endemic rates.

Impact of an automated hand hygiene monitoring system combined with a performance improvement intervention on hospital-acquired infections.

Hand hygiene adherence has been associated with reductions in nosocomial infection. We assessed the effect of improvements in electronically measured hand hygiene adherence on the incidence of hospital-acquired infections. This quasi-experimental study was conducted in a 555-bed urban safety-net level I trauma center. The preintervention period was January 2015 through June 2016. Baseline electronic hand hygiene data collection took place from April through June 2016. The intervention period was July 2016 through December 2017. An electronic hand hygiene system was installed in 4 locations in our hospital. Performance improvement strategies were implemented that included education, troubleshooting, data dissemination, and feedback. Adherence rates were tracked over time. Rates of hospital-acquired infections were evaluated in the intervention units and in control units selected for comparison. The intervention period was subdivided into the initial and subsequent 9-month periods and were compared to the baseline period. Electronically measured hand hygiene rates improved significantly from baseline to intervention, from 47% 77% adherence. Rates >70% continued to be measured 18 months after the intervention. Interrupted time series analysis indicated a significant effect of hand hygiene on healthcare facility-onset Clostridioides difficile infection rates during the first 9 months of the intervention. This trend continued during the final 9 months of the intervention but was nonsignificant. No effects were observed for other hospital-acquired infection rates. Implementation of electronic hand hygiene monitoring and performance improvement interventions resulted in reductions in hospital-onset Clostridioides difficile infection rates.

1986. Impact of Two-Step Testing on the Diagnosis and Management of Clostridium difficile in a Multi-Hospital Healthcare System

BackgroundDistinguishing active C. difficile infection (CDI) from asymptomatic colonization remains a significant challenge. A multi-step testing algorithm can improve the diagnostic accuracy of CDI and associated antibacterial prescribing. This study evaluated the impact of two-step testing on CDI rates and management in a multi-hospital community health system.MethodsTwo-step C. difficile testing (PCR for initial screening followed by EIA for toxin detection) was implemented in 6 acute care community hospitals in April 2018. EIA testing was automatically performed on all stool samples with a positive C. difficile PCR result. Prior to implementation, PCR alone was used to identify CDI. Messaging attached to the PCR laboratory report alerted prescribers of discrepant results (PCR +/EIA -). Anti-C. difficile therapy was at the discretion of the prescriber. We performed a retrospective cohort analysis over a 2-year period to evaluate the effect of two-step testing on system-wide hospital-onset CDI (HO-CDI) per 10,000 patient-days (PD) and anti-CDI antimicrobial use (AU) in days of therapy (DOT) per 1,000 PD. Segmented negative binomial regression with hospital clustering was used to estimate predicted HO-CDI rate for the baseline period between April 1, 2017 through March 31, 2018 and the post-intervention between May 1, 2018 through March 31, 2019. The implementation date at all sites in April 2018 was unknown; therefore, this month was removed from the analysis. Anti-CDI agents included fidaxomicin, metronidazole, and oral vancomycin, but may have included non-CDI indications for metronidazole.ResultsA total of 115 HO-CDI cases were identified; 91 (79%) before and 24 (21%) after. Prior to implementation of two-step testing, CDI rates declined at 4% per month (P = NS). The rate immediately dropped by 36% (P = 0.004) after two-step testing was implemented, but the trend did not significantly change (P = 0.52, Figure 1). Community-onset CDI rates also decreased during this time period. Combined facility-wide anti-CDI agent use was 824.87 before and 838.21 DOT/1,000 PD after and did not significantly change.ConclusionUse of a two-step approach for CDI testing reduced HO-CDI rates, but did not have a significant impact on anti-CDI antibiotic use in a multi-hospital community health system. Disclosures All authors: No reported disclosures.

151 Teaching Hospitals Have Lower Adjusted Rates of Hospital-Onset C. difficile Infection Compared to Non-Teaching Hospitals

INTRODUCTION: Hospital-onset Clostridioides difficile infection (HoCDI) is a preventable but significant cause of morbidity among patients hospitalized at teaching hospitals (THs; Consumer Reports 2016). Prior research that did not adjust for patients' disease severity demonstrated higher HoCDI rates in THs compared to non-THs (Open Forum Inf Dis 2016, 3(suppl_1):2062). We therefore attempted to determine the impact of hospital teaching status (HTS) on HoCDI rates while adjusting for underlying disease severity using the Vizient clinical database. METHODS: In this cross-sectional study, we used the Vizient database to analyze all adult hospitalizations from 10/1/2014 to 3/31/2018. Vizient includes &gt;90% of academic centers and their affiliated community hospitals in the US. Vizient hospitals (n = 369) were grouped into major THs (members of Council of THs), minor THs (medical school affiliation only), and non-THs (all other hospitals), as defined by the 2016 American Hospital Association (AHA) Survey. We excluded hospitals missing from the AHA survey and discharges to another hospital or against medical advice. We used multivariable linear regression (MVLR) of aggregated data to assess the impact of HTS on HoCDI rates while adjusting for demographics, comorbidities, severity of illness indices, case mix, and hospital factors. MVLR was also performed using hospital resident-to-bed ratios (RTBR) to reflect teaching intensity. Final models were generated using step-wise backward elimination of covariates using P &lt; 0.05. RESULTS: We identified 18,247,643 hospitalizations among 337 hospitals (132 major THs, 110 minor THs, 95 non-THs) from 10/1/2014 to 3/31/2018. Hospitalization characteristics are presented in Table 1. Unadjusted rates of HoCDI were higher in major THs compared to non-THs (median 0.4% vs. 0.2%, P &lt; 0.01). After MVLR to adjust for confounders, major and minor HTS (Table 2) and RTBR (Table 3) were negatively correlated with HoCDI. Because mean length of stay and ICU stay reflect not only disease severity but also effects of HoCDI, they were added separately to the final models and the negative correlations between HTS and HoCDI persisted. CONCLUSION: After adjusting for metrics of disease severity and complexity, THs may have lower rates of HoCDI compared to non-THs. Additional research is needed to determine how inpatient practices that may contribute to HoCDI differ in THs vs. non-THs.

Association Between Antibiotic Use and Hospital-onset Clostridioides difficile Infection in US Acute Care Hospitals, 2006-2012: An Ecologic Analysis.

Unnecessary antibiotic use (AU) contributes to increased rates of Clostridioides difficile infection (CDI). The impact of antibiotic restriction on hospital-onset CDI (HO-CDI) has not been assessed in a large group of US acute care hospitals (ACHs). We examined cross-sectional and temporal associations between rates of hospital-level AU and HO-CDI using data from 549 ACHs. HO-CDI was defined as a discharge with a secondary International Classification of Diseases, Ninth Revision, Clinical Modification code for CDI (008.45), and treatment with metronidazole or oral vancomycin > 3 days after admission. Analyses were performed using multivariable generalized estimating equation models adjusting for patient and hospital characteristics. During 2006-2012, the unadjusted annual rates of HO-CDI and total AU were 7.3 per 10 000 patient-days (PD) (95% confidence interval [CI], 7.1-7.5) and 811 days of therapy (DOT)/1000 PD (95% CI, 803-820), respectively. In the cross-sectional analysis, for every 50 DOT/1000 PD increase in total AU, there was a 4.4% increase in HO-CDI. For every 10 DOT/1000 PD increase in use of third- and fourth-generation cephalosporins or carbapenems, there was a 2.1% and 2.9% increase in HO-CDI, respectively. In the time-series analysis, the 6 ACHs with a ≥30% decrease in total AU had a 33% decrease in HO-CDI (rate ratio, 0.67 [95% CI, .47-.96]); ACHs with a ≥20% decrease in fluoroquinolone or third- and fourth-generation cephalosporin use had a corresponding decrease in HO-CDI of 8% and 13%, respectively. At an ecologic level, reductions in total AU, use of fluoroquinolones, and use of third- and fourth-generation cephalosporins were each associated with decreased HO-CDI rates.

Prevention of Hospital-Onset Clostridium difficile Infection in the New York Metropolitan Region Using a Collaborative Intervention Model

The incidence, severity, and associated costs of Clostridium difficile (C. difficile) infection (CDI) have dramatically increased in hospitals over the past decade, indicating an urgent need for strategies to prevent transmission of C. difficile. This article describes a multifaceted collaborative approach to reduce hospital-onset CDI rates in 35 acute care hospitals in the New York metropolitan region. Hospitals participated in a comprehensive CDI reduction intervention and formed interdisciplinary teams to coordinate their efforts. Standardized clinical infection prevention and environmental cleaning protocols were implemented and monitored using checklists. Monthly data reports were provided to hospitals for facility-specific performance evaluation and comparison to aggregate data from all participants. Hospitals also participated in monthly teleconferences to review data and highlight successes, challenges, and strategies to reduce CDI. Incidence of hospital-onset CDI per 10,000 patient days was the primary outcome measure. Additionally, the incidence of nonhospital-associated, community-onset, hospital-associated, and recurrent CDIs were measured. The use of a collaborative model to implement a multifaceted infection prevention strategy was temporally associated with a significant reduction in hospital-onset CDI rates in participating New York metropolitan regional hospitals.