Hospital-onset Clostridium Difficile Infection Research Articles

2425. Correlating Use of High-Risk Antimicrobials and the Incidence of Hospital-Onset Clostridium difficile Infection: Targeting Prescribing Trends for Antimicrobial Stewardship

BackgroundHospital-onset Clostridium difficile infection (HO-CDI) has a significant morbidity and mortality risk. It also poses increasing financial strain on the healthcare system. Certain antibiotics have been associated with increased HO-CDI incidence and novel strategies are needed to determine what modifiable risk factors exist. Choices of antibiotic have changed overtime time to overcome potential side effects, leading to a possibility that changed prescribing trends could be linked to significant differences in the rate of HO-CDI.MethodsThis study took place at a 971-bed community hospital from January 2016 to January 2018. Monthly utilization (grams) of 11 antimicrobials considered high risk of HO-CDI was collected, along with monthly HO-CDI rate. Antimicrobials included cephalosporins, carbapenems, fluoroquinolones and clindamycin. Correlational (Pearson’s) and logistic regression analyses were completed to identify association with HO-CDI. A P-value of < 0.05 was considered statistically significant.Results215 cases of HO-CDI were identified during the study period with 30 being classified as severe. The average HO-CDI rate was 4.3 cases/1000 patient-days. There were no significant correlations identified for any antimicrobials and HO-CDI rate (p> 0.05 for all interactions). Pearson’s correlation coefficients were not significant for any antimicrobial. The multivariable logistic regression model including all antimicrobials, indicated that only ceftazidime had a statistically significant positive effect on the HO-CDI rate. Bearing in mind that only a small number of ceftazidime was prescribed, additional univariate analysis was performed indicating that there was no significant linear association between the HO-CDI rate and ceftazidime utilization (P = 0.3527).ConclusionOur study shows that there is no significant correlation between specific antimicrobial use and HO-CDI rates, even though there has been a general increase in HO-CDI rates. Additional analysis involving control groups of antibiotic use in patients without HO-CDI as well as incidence of HO-CDI in patients without antibiotic use at all is required to further assess possible modifiable risk factors in the inpatient population. Disclosures All authors: No reported disclosures.

Network analysis of intra-hospital transfers and hospital onset clostridium difficile infection.

To explore how social network analysis (SNA) can be used to analyse intra-hospital patient networks of individuals with a hospital acquired infection (HAI) for further analysis in a geographical information systems (GIS) environment. A case and control study design was used to select 2008 patients. We retrieved locational data for the patients, which was then translated into a network with the SNA software and then GIS software. Overall metrics were calculated for the SNA based on three datasets and further analysed with a GIS. The SNA analysis compared cases to control indicating significant differences in the overall structure of the networks. A GIS visual representation of these metrics was developed, showing spatial variation across the example hospital floor. This study confirmed the importance that intra-hospital patient networks play in the transmission of HAIs, highlighting opportunities for interventions utilising these data. Due to spatial variation differences, further research is necessary to confirm this is not a localised phenomenon, but instead a common situation occurring within many hospitals. Utilising SNA and GIS analysis in conjunction with one another provided a data-rich environment in which the risk inherent in intra-hospital transfer networks was quantified, visualised and interpreted for potential interventions.

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.

Quantitative Results of a National Intervention to Prevent Clostridioides difficile Infection: A Pre-Post Observational Study.

Clostridioides difficile infection (CDI) is on the rise. To evaluate the effect of a tiered, evidence-based intervention to prevent CDI. Pre-post observational evaluation of a prospective, 12-month, national, nonrandomized, clustered quality improvement project to reduce hospital health care-associated infection. Acute care, long-term acute care, and critical access hospitals working with state partner organizations (state hospital associations and state health departments) to improve health care-associated infection prevention practices. Targeted hospitals had a high burden of CDI and another health care-associated infection. Other hospitals that did not meet these criteria volunteered to participate. Multimodal intervention that consisted of 1) on-demand educational modules and webinars, 2) in-person meetings facilitated by state-level partners, 3) feedback and recommendations for implementation of evidence-based recommendations (including a CDI-specific guide on which interventions to implement), and 4) guided facilitation through infection prevention resources and site visits. Pre- and postintervention CDI rates. Between November 2016 and May 2018, 387 hospitals (366 of which reported CDI data) in 23 states and the District of Columbia participated in the intervention. There was a statistically significant decrease in CDI incidence over the study period, from 7.0 cases per 10000 patient-days in the preintervention period to 5.7 cases per 10000 patient-days in the postintervention period. However, this decrease appeared to be part of a temporal trend rather than due to the study intervention. Commitment to and adherence with recommended infection prevention practices before and after the intervention were not assessed. The intervention period was relatively brief, and patient-level data were not available. Although a statistically significant decline in hospital-onset CDI was observed, this trend appears to be unrelated to the study intervention. Centers for Disease Control and Prevention.

Front-line education by infection preventionists helps reduce Clostridioides difficile infections

When implementing the latest innovations to reduce health care-associated infections, it is important not to overlook basic infection prevention principles such as hand hygiene, isolation precautions, use of personal protective equipment, and cleaning and low-level disinfection. Like many facilities, we implemented a multifaceted approach to reduce hospital-onset Clostridioides difficile infections. In this paper, we share simple tools that we found helpful in improving infection prevention practices by addressing knowledge gaps among staff, visitors, and patients.

Direct Measurement of Performance: A New Era in Antimicrobial Stewardship.

For decades, the performance of antimicrobial stewardship programs (ASPs) has been measured by incidence rates of hospital-onset Clostridioides difficile and other infections due to multidrug-resistant bacteria. However, these represent indirect and nonspecific ASP metrics. They are often confounded by factors beyond an ASP’s control, such as changes in diagnostic testing methods or algorithms and the potential of patient-to-patient transmission. Whereas these metrics remain useful for global assessment of healthcare systems, antimicrobial use represents a direct metric that separates the performance of an ASP from other safety and quality teams within an institution. The evolution of electronic medical records and healthcare informatics has made measurements of antimicrobial use a reality. The US Centers for Disease Control and Prevention’s initiative for reporting antimicrobial use and standardized antimicrobial administration ratio in hospitals is highly welcomed. Ultimately, ASPs should be evaluated based on what they do best and what they can control, that is, antimicrobial use within their own institution. This narrative review critically appraises existing stewardship metrics and advocates for adopting antimicrobial use as the primary performance measure. It proposes novel formulas to adjust antimicrobial use based on quality of care and microbiological burden at each institution to allow for meaningful inter-network and inter-facility comparisons.

You get back what you give: Decreased hospital infections with improvement in CHG bathing, a mathematical modeling and cost analysis

Multiple studies have shown that bathing with chlorhexidine gluconate (CHG) wipes reduces hospital-acquired infections (HAIs). We employed a mathematical model to assess the impact of CHG patient bathing on central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and hospital-onset Clostridium difficile (C diff) infections and the associated costs. Using a Markov chain, we examined the effect of CHG bathing compliance on HAI outcomes and the associated costs. Using estimates from 2 different studies on CHG bathing effectiveness for CLABSI, CAUTI, and C diff, the number of HAIs per year were estimated along with associated costs. The simulations were conducted, assuming CHG bathing at varying compliance rates. At 32% reduction in HAI incidence, increasing CHG bathing compliance from 60% to 90% results in 20 averted infections and $815,301.75 saved cost. As CHG bathing compliance increases, yearly HAIs decrease, and the overall cost associated with the HAIs also decreases.

Predictors of Clostridioides difficile Infection Among Asymptomatic, Colonized Patients: A Retrospective Cohort Study

Asymptomatic patients colonized with Clostridioides difficile are at risk of developing C. difficile infection (CDI), but the factors associated with disease onset are poorly understood. Our aims were to identify predictors of hospital-onset CDI (HO-CDI) among colonized patients and to explore the potential benefits of primary prophylaxis to prevent CDI. We conducted a retrospective cohort study in a tertiary academic institution. Colonized patients were identified by detecting the tcdB gene by polymerase chain reaction on a rectal swab. Univariate and multivariate logistic regression analyses were used to identify predictors of HO-CDI. There were 19 112 patients screened, from which 960 (5%) colonized patients were identified: 513 met the inclusion criteria. Overall, 39 (7.6%) developed a HO-CDI, with a 30-day attributable mortality of 15%. An increasing length of stay (adjusted odds ratio [aOR] per day, 1.03; P = .006), exposure to multiple classes of antibiotics (aOR per class, 1.45; P = .02), use of opioids (aOR, 2.78; P = .007), and cirrhosis (aOR 5.49; P = .008) were independently associated with increased risks of HO-CDI, whereas the use of laxatives was associated with a lower risk of CDI (aOR 0.36; P = .01). Among the antimicrobials, B-lactam with B-lactamase inhibitors (OR 3.65; P < .001), first-generation cephalosporins (OR 2.38; P = .03), and carbapenems (OR 2.44; P = .03) correlated with the greatest risk of HO-CDI. By contrast, patient age, the use of proton pump inhibitors, and the use of primary prophylaxis were not significant predictors of HO-CDI. This study identifies several factors that are associated with CDI among colonized patients. Whether modifying these variables could decrease the risk of CDI should be investigated.

Collect that Stool! The Impact of Delay in Specimen Collection to NHSN Lab ID C. difficile Events

BACKGROUND Despite multiple rapid laboratory tests available for Clostridium difficile infection (CDI), delays in specimen collection may contribute to delays in diagnosis and treatment. Additionally, specimen collection delays may contribute to falsely increased National Health and Safety Network (NHSN) laboratory-identified (Lab ID) hospital onset (HO) CDI rates. Time from order to specimen collection and the impact of collection delays on HO CDI rates is unknown. METHODS Two community hospitals (450 and 472 licensed beds) conducted a retrospective review of electronic data from March-October 2018, including date of order for C. difficile toxin assay and date of specimen collection. Time to collection was compared for hospital of admission, level of care (intensive care unit [ICU] versus other) and shift of order (day versus night) using Mann-Whitney U (SPSS) and Chi-square analysis (Epi Info). The impact of delay on HO CDI cases was assessed. RESULTS 1516 stool specimens were collected. On average, there were 7.7?hours between order and collection (maximum delay = 7.9 days). Hospital A, ICU level of care, and night shift were correlated with significantly shorter time to specimen collection (p = 0.01, 0.02. 0.02, respectively). 330 specimens (22%) were collected on a subsequent calendar day, although this was only significantly impacted by level of care (p = 0.04). Of the 31 cases determined to be HO-CDI per NHSN Lab ID definition, 4 (13%) would have been CO had they been collected on the day ordered. Conclusions In this sample, delay in specimen collection for C. difficile testing was common, with many tests delayed to the next day. This may have a considerable impact on HO CDI rates, impacting reimbursement and hospital reputation. Future research is needed to remedy these delays. Until that time, use of order date and time should be considered for inclusion into NHSN Lab ID event definitions.

Mandatory Pre-Authorization or “Hard Stop Order” to Decrease Inappropriate Testing for Clostridium difficile Infection. A Testing Stewardship at 2 Hospitals.

BACKGROUND Despite implementation of the Clostridium difficile Infection (CDI) algorithm in 2016, inappropriate testing remains an issue. To further reduce this problem, Mandatory Pre-Authorization (MPrA) or Hard Stop Order (HSO) was implemented in March 2017. MPrA/HSO requires the ordering physician to apply the criteria set in the algorithm and obtain approval from an Infectious Disease (ID) physician. The test is stopped if the criteria are not met and without approval. The objective of this review is to examine the effectiveness of the MPrA/HSO in our hospitals. METHODS An order set was built in the electronic medical record (EMR) identifying the ordering physician and ID attending approving the test. Educational sessions, posters and pocket size algorithm were provided. Orders without ID approval were referred back to the ordering physician or escalated to the Chief of Service or to the Director of Infection Prevention. Exclusion for the MPrA/HSO were Emergency Room patients suspected with CDI. National Healthcare Safety Network (NHSN) data from February 2016 to March 2018 were retrospectively analyzed. RESULTS Comparison of Pre and Post implementation data showed a decline of 68% in CDI testing for Hospital A and 61% for Hospital B. The Hospital-Onset CDI dipped to 74% in Hospital A and 61% in Hospital B and inappropriate testing decreased by 75% and 100% respectively. >97% met testing criteria and ID approval. Pre and Post MPrA/HSO Standard Infection Ratio (SIR) were statistically significant. CONCLUSIONS Testing stewardship accomplished a reduction of CDI testing without a corresponding increase in CDI, and without evidence of missed cases. Our goal of reducing inappropriate testing is achieved, thereby improving patient outcome as unnecessary isolation and exposure to antibiotics are avoided. Administrative support, interdisciplinary teamwork and integration of the MPrA/HSO in the EMR are essential in the success of this initiative.

IN4 REDUCING HOSPITAL-ONSET CLOSTRIDIUM DIFFICILE INFECTION: AN AGENT-BASED MODELING APPROACH TO EVALUATE INTERVENTION COST-EFFECTIVENESS

Clostridium difficile infection (C. difficile; CDI) is the most common hospital-acquired infection in the United States, where it is responsible for over 15,000 deaths and five billion dollars in direct healthcare costs annually. This study evaluates the cost effectiveness of nine infection control interventions at reducing the rates of hospital-onset CDI. Cost-effectiveness analyses were conducted from the hospital perspective, where all costs were converted into 2017 US dollars and effectiveness was measured using quality-adjusted life years (QALYs). The nine tested interventions include daily and terminal cleaning with sporicidal product, patient, visitor, and healthcare worker hand hygiene, reducing patient room transfers, screening for C. difficile colonization at admission, and visitor and healthcare worker contact precautions. Rates of hospital-onset CDI were estimated using our recently published agent-based simulation model of C. difficile transmission in a general 200-bed adult hospital. Cost and utility estimates were derived from the literature. Six interventions were dominant, compared to baseline standard hospital practices: daily cleaning (saved an average of $407,853 and 26.8 QALYs annually in a 200-bed hospital), screening at admission ($9,143; 13.5 QALYs), patient hand hygiene ($25,699; 4.6 QALYs), healthcare worker hand hygiene ($181,784; 12.9 QALYs), terminal cleaning ($65,007; 9.3 QALYs), and patient transfer ($25,677; 2.3 QALYs). Healthcare worker contact precautions had a mean ICER of $147,666/QALY. Visitor hand hygiene had a mean ICER of $8,541,937/QALY. Visitor contact precautions was dominated. Healthcare facilities are a major source of CDI and hospital prevention is critical to decreasing its overall incidence. This is the first study to compare the cost-effectiveness of patient-centered interventions, such as patient hand hygiene and screening at admission, with conventional hospital-centered strategies. Prioritizing highly effective, cost saving interventions such as daily and terminal cleaning is a promising strategy that should be further emphasized in future C. difficile prevention guidelines.

Outcome of Electronic Order Alert Intervention Relative to Toxigenic Clostridium difficile PCR Analysis and Hospital-Onset C difficile Infection in a Multihospital Health Care System

Concern exists regarding overdiagnosis of Clostridium difficile infection (CDI) via molecular modalities. We determined effects of a preanalytic order intervention on laboratory and CDI prevention measures in a multihospital system. Intervals before and following implementation of a CDI electronic order alert (relative to appropriate testing scenario) were assessed for C difficile test volume and positivity rate, hospital-onset CDI frequency, and hospital-onset C difficile standardized infection ratio (SIR). C difficile detection occurred by PCR throughout the study. During the first half of 2015, testing volume was 1,578, with 88 hospital-onset CDIs. Following implementation, 18.9% and 56.8% reductions in volume and hospital-onset CDIs were realized, respectively, in the first half of 2017. Regression analysis revealed decreasing trends in PCR volume, positivity rate, hospital-onset CDI frequency, and SIR in larger facilities. Preanalytic considerations affect not only the microbiology laboratory but also hospital infection prevention in the context of CDI.

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.

Diagnostic stewardship of C. difficile testing: a quasi-experimental antimicrobial stewardship study.

We evaluated whether a diagnostic stewardship initiative consisting of ASP preauthorization paired with education could reduce false-positive hospital-onset (HO) Clostridioides difficile infection (CDI). Single center, quasi-experimental study. Tertiary academic medical center in Chicago, Illinois. Adult inpatients were included in the intervention if they were admitted between October 1, 2016, and April 30, 2018, and were eligible for C. difficile preauthorization review. Patients admitted to the stem cell transplant (SCT) unit were not included in the intervention and were therefore considered a contemporaneous noninterventional control group. The intervention consisted of requiring prescriber attestation that diarrhea has met CDI clinical criteria, ASP preauthorization, and verbal clinician feedback. Data were compared 33 months before and 19 months after implementation. Facility-wide HO-CDI incidence rates (IR) per 10,000 patient days (PD) and standardized infection ratios (SIR) were extracted from hospital infection prevention reports. During the entire 52 month period, the mean facility-wide HO-CDI-IR was 7.8 per 10,000 PD and the SIR was 0.9 overall. The mean ± SD HO-CDI-IR (8.5 ± 2.0 vs 6.5 ± 2.3; P &lt; .001) and SIR (0.97 ± 0.23 vs 0.78 ± 0.26; P = .015) decreased from baseline during the intervention. Segmented regression models identified significant decreases in HO-CDI-IR (Pstep = .06; Ptrend = .008) and SIR (Pstep = .1; Ptrend = .017) trends concurrent with decreases in oral vancomycin (Pstep &lt; .001; Ptrend &lt; .001). HO-CDI-IR within a noninterventional control unit did not change (Pstep = .125; Ptrend = .115). A multidisciplinary, multifaceted intervention leveraging clinician education and feedback reduced the HO-CDI-IR and the SIR in select populations. Institutions may consider interventions like ours to reduce false-positive C. difficile NAAT tests.

Association of Community Factors with Hospital-onset Clostridioides (Clostridium) difficile Infection: A Population Based U.S.-wide Study

BackgroundClostridioides (Clostridium) difficile ranks first among the pathogens of hospital-acquired infections with hospital-based preventive strategies being only partially successful in containing its spread. MethodsWe performed a spatial statistical analysis to examine the association between population characteristics and parameters of community healthcare practice and delivery with hospital-onset Clostridioides (Clostridium) difficile infection (HO-CDI), using data from the Medicare Hospital Compare, Medicare Provider Utilization Part D, and other databases. Among the areas with the highest HO-CDI rates (“hot spots”), we conducted a geographically weighted regression (GWR) to quantify the effect of the decrease in the modifiable risk factors on the HO-CDI rate. FindingsPercentage of population > 85 years old, community claims of antimicrobial agents and acid suppressants, and density of hospitals and nursing homes within the hospital service areas (HSAs) had a statistically significant association with the HO-CDI incidence (p < 0.001). The model including the community claims of antimicrobial agents and number of hospital centers per HSA km2 was associated with 10% (R2 = 0.10, p < 0.001) of the observed variation in HO-CDI rate. The hot spots were organized into 5 Combined Statistical areas that crossed state borders. The association of the antimicrobial claims and HO-CDI rate was as high as 71% in the Boston–Worcester–Providence area (R2 = 0.71, SD 0.19), with a 10% decrease in the rate of antimicrobial claims having the potential to lead to up to 23.1% decrease in the HO-CDI incidence in this area. InterpretationThese results outline the association of HO-CDI with community practice and characteristics of the healthcare delivery system and support the need to further study the effect of community and nursing home-based antimicrobial and acid suppressant stewardship programs in the rate of HO-CDI in geographic areas that may cross state lines.

972. Asymptomatic Carriage of Clostridiodes difficile and Risk of Subsequent Infection

Background C. difficile is one of the most common healthcare-associated infections in the United States. Studies of patients with asymptomatic carriage of toxigenic C. difficile have reported conflicting results on the risk of subsequent C. difficile infection (CDI). Older studies suggest that the risk was low and colonization may be protective. Subsequent studies indicate that asymptomatic carriers have a 6-fold greater risk of developing CDI. The aims of our study were to assess the burden of asymptomatic C. difficile carriage and risk of subsequent CDI.MethodsAdult inpatients at NorthShore University HealthSystem, Illinois hospitals between August 1, 2017 and February 28, 2018 were eligible for the study. Focused admission screening of patients at high risk of C. difficile carriage was performed: (1) history of CDI or colonization, (2) prior hospitalization past 2 months, or (3) admission from a long-term care facility. A rectal swab was collected and tested using the cobas® Cdif Test (Roche) real-time PCR. The development of hospital onset CDI (HO-CDI) in colonized patients was monitored prospectively for at least 2 months. HO-CDI testing of colonized patients was performed using the Cepheid GeneXpert RT-PCR. HO-CDI was defined as patients hospitalized for at least 72 hours with 3 or more episodes of diarrhea/24 hours, in the absence of other potential causes of diarrhea. Patient demographics were collected using a standardized form and data analyzed using VassarStats.ResultsThere were 6,104 patients enrolled in the study and 528 (8.7%) were positive on admission for toxigenic C. difficile carriage. The mean age of colonized patients was 75.5 years (range 24–103) and 56.4% (298 patients) were females. Of 528 colonized patients, 21 (4%) had a positive CDI test. A total of 7 patients (1.3%) developed HO-CDI. Mean time to positive HO-CDI was 46.1 days (range 5–120 days). Of 5,576 patients that were negative for C difficile carriage on admission, 14 (0.3%) patients developed HO-CDI. The relative risk of HO-CDI was 5.28 (95% CI: 2.14–13.03, P = 0.05).ConclusionWe found that 8.7% of at-risk admissions were asymptomatic toxigenic C. difficile carriers. While only 1.3% developed HO-CDI, asymptomatic carriers had a 5 times higher risk of subsequent CDI compared with non-carriers.Disclosures All authors: No reported disclosures.

202. Implementation and Three-Year Results of Antimicrobial Stewardship Program in a Three Hospital Community Health System

BackgroundAntimicrobial Stewardship Programs (ASPs) have been shown to reduce hospital-onset Clostridium difficile infection (HO-CDI) rates and antimicrobial utilization (AU). The purpose of this study was to evaluate the implementation of multidisciplinary ASP targeted toward finding a direct correlation between AU and HO-CDI.MethodsThis is a 3-year review of implementation of ASP in late 2014 Q4 in three hospital health system. Multidisciplinary ASP committee was established with representation from infectious diseases, clinical pharmacy, infection control, nursing, microbiology, and informatics. Each of the three hospital implemented targeted stewardship efforts with an initial focus on monthly advanced education, daily audit and feedback for targeted antibiotics, and infectious diseases approved restricted antibiotics. We created a monthly checklist of CDC Core Elements for committee review. The primary objective of this initiative was to evaluate changes in total and targeted AU and HO-CDI within a program over a 3-year period. Subgroup analysis evaluated annual antimicrobial cost/patient day. The secondary objective was Spearman’s rank correlation analysis between AU and HO-CDI.ResultsBaseline overall AU analysis was based on 2014 and the intervention period included 2015, 2016, and 2017. Baseline overall AU in 2014 was 850 DOT/1,000PD. We observed a consistent decline in overall AU in 2015, 2016, and 2017 (740, 572, and 550 DOT/1,000PD, respectively). Targeted analysis revealed consistent decline from 2014 to 2017 in fluroquinolones (FQ) (140 vs. 35 DOT/1,000PD) and ceftriaxone (CTX) (85 vs. 65 DOT/1,000PD). Overall decline was also noted in rates of HO-CDI from 2014 to 2017 (5.75 vs. 3.38 per 10,000PD). Consistent decline in overall antimicrobial cost/patient day was noted from 2014 to 2017 ($13.76 vs. $13.41/patient day). Spearman’s rank correlation analysis showed positive correlation between decline in AU and HO-CDI in overall antibiotics (r = 0.58, P = 0.022), CTX (r = 0.61, P = 0.016), and FQ (r = 0.54, P = 0.038).ConclusionWe present implementation of an effective health system-wide multi-disciplinary ASP. With ASP efforts over 3 years, we were able to show decline and positive correlation in overall as well as targeted AU and HO-CDI. We also noticed a consistent decline in cost/patient day in this timeframe.Disclosures All authors: No reported disclosures.

1114. Utility of a Bedside Diagnostic Testing Algorithm to Screen for Hospital-Onset Clostridium difficile Infection

BackgroundMolecular assays have improved C. difficile detection in hospitalized patients. However, asymptomatic carriers have been misclassified as hospital onset C. difficile infection (HO-CDI), which has implications for management and infection prevention programs. At our facility, we implemented robust antibiotic stewardship policies in 2016 and had an SIR for HO-CDI of 0.73 for the year. In Q1 2017, this increased to 1.88. These cases revealed that nearly all tests, found positive for C. difficile, did not meet the standard definition of clinically significant diarrhea (CSD). Moreover, many patients did not have a clinical change in condition that supported a diagnosis of C. difficile. We reasoned that an algorithm for appropriate testing for C. difficile would significantly reduce our perceived rates of HO-CDI. We also reasoned that this tool could efficiently be used at the bedside during a clinical assessment.MethodsTo determine which patients had CSD, we designed, educated on and implemented an algorithm to screen for appropriate testing. It required three major elements: three or more loose stools in 24 hours, no gastric motility agents 48 hours prior, and a clinical change in condition (e.g., leukocytosis, fever, abdominal cramping). The completed algorithm accompanied the stool specimen and was required for testing. We evaluated each submitted algorithm for method validation. From this, we determined testing appropriateness and algorithm tool selectivity.ResultsOne year pre- and post-algorithm periods (PR-A and PO-A, respectively) were defined. Following its introduction, we noted a 57% decline in rates of HO-CDI (23 cases PR-A vs. 10 cases PO-A), and a 44% reduction in tests sent for C. difficile (average of 41 tests/month PR-A vs. 23 tests/month PO-A). We only used NAAT testing. We also noted a marked rise in adherence to the algorithm as time elapsed. The PDSA tool was used to refine the algorithm, with improved utilization by providers.ConclusionA simple bedside algorithm leads to more appropriate testing of patients for HO-CDI. A significant decline in reported rates of HO-CDI was noted. There is an additional benefit of diagnostic stewardship, as fewer tests are sent. This tool can be used immediately and independent of an electronic health record, is very cost effective, and is applicable to hospitals with low rates of HO-CDI.Disclosures R. V. Nathan, Merck, Allergan, The Medicines Co.: Speaker’s Bureau, Speaker honorarium.

2168. Regional Variation in Community-Onset and Hospital-Identified Clostridium difficile Infection, 2017

BackgroundU.S. regional variation in C. difficile infection (CDI) and specifically community-onset CDI (CO-CDI) is not well understood.MethodsCO-CDI was defined as a positive C. difficile stool test collected on or before hospital Day 3 (admission was Day 1), reported by acute care hospitals to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN) between January 1 and June 30, 2017. Hospital-onset CDI (HO-CDI) was similarly defined but with stool collection after hospital Day 3. Hospital referral regions (HRR) were previously defined by the Dartmouth Atlas of Health Care, and represent 306 U.S. tertiary healthcare markets. Standardized infection ratios (SIRs) were calculated using separate multivariable models for CO-CDI and HO-CDI, accounting for facility-level factors, and resulted in a ratio of observed to predicted infections, similar to previously established methods. SIRs were aggregated within each facility by summing the observed and predicted events across each testing location (emergency department + observation unit [ED/OBS], inpatient), then aggregated by state or HRR by summing all facility observed and predicted events within the region.ResultsA total of 92,683 CO-CDI events were reported from 4,241 acute care hospitals. C. difficile test type, hospital size, ICU bed size, and ED/OBS reporting were independently and significantly associated with CO-CDI incidence and included in SIR models. State-level CO-CDI SIRs ranged from 0.666 to 1.456 (mean 0.961 Figure 1). Among 306 HRRs, the mean number of CO-CDI reporting facilities was 12 (interquartile range [IQR] 5–14), with a mean of 303 (IQR 101–306) CO-CDI events per HRR. HRR SIRs ranged from 0 to 2.271 (median 0.958, Figure 1). An aggregate SIR of CO-CDI and HO-CDI, representing all hospital-identified CDI similarly is shown (Figure 2). ConclusionCO-CDI and HO-CDI reported by acute care hospitals to NHSN varied across the United States. Although adjustments were limited to only facility-level factors, aggregation of CDI SIR by HRR results in increased regional resolution of CO-CDI burden compared with state maps and may be a beneficial tool for infection preventionists and public health authorities to further understand regional CDI patterns.Disclosures All authors: No reported disclosures.

974. Impact of Mandatory Infectious Disease (ID) Specialist Approval on Hospital-Onset Clostridium difficile (HO-CDI) Testing and Infection Rates: Results of a Pilot Study

BackgroundThe 2017 IDSA C. difficile guidelines recommend the use of nucleic acid amplification testing alone for detection of HO-CDI if appropriate stool specimens are collected (e.g., patients not receiving laxatives and ≥3 unformed stools in 24 hours). The potential role of ID specialists in enforcing appropriate C. difficile testing is unclear.MethodsAt a single academic hospital, we performed a pilot study of an ID specialist-led approval process for C. difficile testing. During the baseline period (January 2016 and November 2017), HO-CDI testing appropriateness was enforced using a computerized decision support tool that discouraged inappropriate testing based on detected laxative use and stool frequency criteria; however, clinicians frequently ignored the computer alerts. During the intervention period (December 2017 and March 2018), all HO-CDI testing on hospital day 4 or later triggered a computer alert requesting mandatory testing approval by an ID specialist. Approvals were provided via telephone consultation 7 days a week between 8 a.m. and 5 p.m. (in both periods, CDI testing was not performed overnight). We analyzed differences HO-CDI testing and infection rates (defined by CDC’s LabID event) per 10,000 patient days using Poisson models. We also analyzed the number of approval pager calls, rates of C. difficile testing approval, and time burden.ResultsTwo infectious diseases specialists (M.Y.L.; J.S.) primarily answered C. difficile pager approval requests; the remainder of approvals were provided by ID specialists already consulted on the patients. During the intervention period, ordering providers made 159 calls to the approval pager; 119 (75%) received approval. HO-CDI testing and infection rates declined between the baseline and intervention periods (figure). There was a mean of 1.3 pager approval requests per day (range, 0–4) with an average of 3 minutes of time spent per request. ConclusionAn ID specialist-led C. difficile testing approval process was feasible and associated with a significant decrease in HO-CDI testing and infection rates, due to enforcement of appropriate testing. ID specialists can provide a key role in enforcing appropriate C. difficile testing, but more experience is needed with respect to sustainability.Disclosures M. Y. Lin, Stryker (Sage Products): Research support in the form of contributed product, Research support. OpGen, Inc: Research support in the form of contributed products, Research support. CareFusion Foundation (now BD): Grant Investigator, Research grant.