Hospital-onset Clostridium Difficile Infection Research Articles

Clostridioides difficile in calves, cattle and humans from Dutch dairy farms: Predominance of PCR ribotype 695 (clade 5, sequence type 11) in cattle

BackgroundClostridioides difficile is a leading cause of infectious diarrhea in both humans and livestock. In particular, C. difficile strains belonging to sequence type (ST) 11 are common enteropathogens. The aim of this study was to determine the presence and genetic relatedness of C. difficile types in dairy cattle and calves. MethodDutch dairy farms were visited between February and December 2021. Feces was collected from adult dairy cattle and calves of two age categories (<4 weeks and 4 weeks-4 months). Fecal samples were also requested from dairy farmers, family members and employees. Fecal samples were cultured in an enrichment medium for 10–15 days and subcultured on solid media for capillary PCR ribotyping and whole genome sequencing. ResultsC. difficile was detected on 31 out of 157 (19.8%) dairy farms. The highest prevalence was found in calves <4 weeks (17.5%). None of the 99 human samples collected were positive. Thirty-seven cultured isolates belonged to 11 different PCR ribotypes (RT) of which RT695 (56.8%) and RT078/126 (16.2%) were most abundant. In the database of the Netherlands National Expertise Centre for C. difficile infections (CDI, >10.000 patient isolates), RT695 was found in only two patients with hospital-onset CDI, diagnosed in 2020 and 2021. Sequence analysis of 21C. difficile RT695 from cattle revealed that all isolates belonged to clade 5, ST11 and contained genes encoding toxin A, toxin B and binary toxin. RT695 strains carried antimicrobial resistance genes typically found in clade 5C. difficile. Groups of genetically related RT695 isolates were found between dairy farms, whereas identical strains were only present in individual farms. ConclusionsC. difficile was found in ∼20% of dairy farms with a predominance of the relatively unknown RT695. Isolates of RT695 belonged to the same clade and sequence type as RT078/126, which is recognized as an important zoonotic type.

Case Series: Efficacy of Polyclonal Intravenous Immunoglobulin for Refractory Clostridioides difficile Infection.

Intravenous immunoglobulin (IVIg) for Clostridioides difficile infection (CDI) no longer features in treatment guidelines. However, IVIg is still used by some clinicians for severe or recurrent CDI (rCDI) cases. The main objective of this study was to investigate the efficacy of IVIg and to identify possible predictors of disease resolution post IVIg administration for patients with CDI. This retrospective observational cohort study of patients ≥2 years old hospitalised with severe, relapsing, or rCDI treated with IVIg therapy was performed in a large UK tertiary hospital between April 2018 and March 2023. Scanned electronic notes from patient admissions and clinical reporting systems were used to collect relevant data. In total, 20/978 patients diagnosed with CDI over the 5-year study were treated with IVIg. Twelve (60%) had hospital-onset CDI. Eleven of the twenty patients (55%) responded to treatment, with a mean of 8.6 (SD 10.7) days to disease resolution. Sixteen (80%) patients were treated for severe CDI and four (20%) for rCDI (n = 3) and relapsing CDI (n = 1). There were no statistically significant differences in possible independent predictors of disease resolution post IVIg administration between groups. There was an average of 6.2 (4.9) days to IVIg administration after diagnosis with no difference between responders and non-responders (p = 0.88) and no further significant difference in additional indicators. Four (36%) of the responders were immunosuppressed compared to just one (11%) of the non-responders (p = 0.15). Six of the responders (two with recurrent and four with severe CDI) improved rapidly within 2 days, and three of these were immunosuppressed. We observed disease resolution post IVIg therapy in over 50% of patients with refractory CDI. Our data also support a potential enhanced effect of IVIg in immunosuppressed individuals. Thus, the role of IVIg for CDI treatment, particularly in the immunosuppressed, warrants future case-control studies coupled to mechanistic investigations to improve care for this ongoing significant healthcare-associated infection.

CDC’s Hospital-Onset Clostridioides difficile Prevention Framework in a Regional Hospital Network

Despite modest reductions in the incidence of hospital-onset Clostridioides difficile infection (HO-CDI), CDI remains a leading cause of health care-associated infection. As no single intervention has proven highly effective on its own, a multifaceted approach to controlling HO-CDI is needed. To assess the effectiveness of the Centers for Disease Control and Prevention's Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities Framework (hereafter, the Framework) in reducing HO-CDI incidence. This quality improvement study was performed within the Duke Infection Control Outreach Network from July 1, 2019, through March 31, 2022. In all, 20 hospitals in the network participated in an implementation study of the Framework recommendations, and 26 hospitals did not participate and served as controls. The Framework has 39 discrete intervention categories organized into 5 focal areas for CDI prevention: (1) isolation and contact precautions, (2) CDI confirmation, (3) environmental cleaning, (4) infrastructure development, and (5) antimicrobial stewardship engagement. Monthly teleconferences supporting Framework implementation for the participating hospitals. Primary outcomes were HO-CDI incidence trends at participating hospitals compared with controls and postintervention HO-CDI incidence at intervention sites compared with rates during the 24 months before the intervention. The study sample included a total of 2184 HO-CDI cases and 7 269 429 patient-days. In the intervention cohort of 20 participating hospitals, there were 1403 HO-CDI cases and 3 513 755 patient-days, with a median (IQR) HO-CDI incidence of 2.8 (2.0-4.3) cases per 10 000 patient-days. The first analysis included an additional 3 755 674 patient-days and 781 HO-CDI cases among the 26 controls, with a median (IQR) HO-CDI incidence of 1.1 (0.7-2.7) case per 10 000 patient-days. The second analysis included an additional 2 538 874 patient-days and 1751 HO-CDI cases, with a median (IQR) HO-CDI incidence of 5.9 (2.7-8.9) cases per 10 000 patient-days, from participating hospitals 24 months before the intervention. In the first analysis, intervention sites had a steeper decline in HO-CDI incidence over time relative to controls (yearly incidence rate ratio [IRR], 0.79 [95% CI, 0.67-0.94]; P = .01), but the decline was not temporally associated with study participation. In the second analysis, HO-CDI incidence was declining in participating hospitals before the intervention, and the rate of decline did not change during the intervention. The degree to which hospitals implemented the Framework was associated with steeper declines in HO-CDI incidence (yearly IRR, 0.95 [95% CI, 0.90-0.99]; P = .03). In this quality improvement study of a regional hospital network, implementation of the Framework was not temporally associated with declining HO-CDI incidence. Further study of the effectiveness of multimodal prevention measures for controlling HO-CDI is warranted.

The role of the hospital bed in hospital-onset Clostridioides difficile: A retrospective study with mediation analysis.

To determine whether residing in a hospital bed that previously held an occupant with Clostridioides difficile increases the risk of hospital-onset C. difficile infection (HO-CDI). In this retrospective cohort study, we used a real-time location system to track the movement of hospital beds in 2 academic hospitals from April 2018 to August 2019. We abstracted patient demographics, clinical characteristics, and C. difficile polymerase chain reaction (PCR) results from the medical record. We defined patients as being exposed to a potentially "contaminated" bed or room if, within the preceding 7 days from their HO-CDI diagnosis, they resided in a bed or room respectively, that held an occupant with C. difficile in the previous 90 days. We used multivariable logistic regression to determine whether residing in a contaminated bed was associated with HO-CDI after controlling for time at risk and requiring intensive care. We assessed mediation and interaction from a contaminated hospital room. Of 25,032 hospital encounters with 18,860 unique patients, we identified 237 cases of HO-CDI. Exposure to a contaminated bed was associated with HO-CDI in unadjusted analyses (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.4-2.31) and adjusted analyses (OR, 1.5; 95% CI, 1.2-2.0). Most of this effect was due to both mediation from and interaction with a contaminated hospital room. Residing in a hospital bed or room that previously had a patient with C. difficile increases the risk of HO-CDI. Increased attention to cleaning and disinfecting the healthcare environment may reduce hospital transmission of C. difficile.

136. Impact of a Tele-Stewardship and Tele-Infection Prevention Program on Hospital-Onset Clostridioides Difficile Rates in a Community Three-Hospital Health System

Abstract Background Clostridioides difficile infection (CDI) is a common hospital-acquired infection (HAI) that can be difficult to diagnose accurately given the numerous test modalities with differing performance characteristics. Inaccurate diagnosis of CDI can negatively affect patient care decisions as well as reimbursement rates. Community and rural hospitals (CARH) may lack specialized personnel or knowledge to implement diagnostic best practices, but telehealth solutions like tele-infection prevention (TIP) and tele-antimicrobial stewardship (TASP) can provide specialist support for CARHs to optimize diagnostic pathways, improve accuracy, and reduce unnecessary treatment. Methods In June 2021 under the guidance of TIP and TASP recommendations, C. difficile testing was transitioned from a 1-step nucleic acid amplification test (NAAT)-only algorithm to a 2-step algorithm that included NAAT and toxin enzyme immunoassay (EIA) testing. A 6-month pre- and post-implementation assessment was conducted to assess the impacts of this change in hospital-onset CDI (HO-CDI) case rate. Additionally, total C. difficile (community- and hospital-onset CDI) rates per 1000 patient days (PD) and consumption of CDI therapeutics were assessed. For statistical analysis, Wilcoxon ranked-sum test to assess changes in CDI rates. Estimated annualized cost-savings for therapeutics were calculated based on institutional purchasing costs. Results Following implementation, a 35.9% reduction in HO-CDI was observed (pre 0.96 cases/1000PD vs. 0.61 cases/1000PD; p = 0.054). A 10.2% reduction was observed in total CDI (pre 3.66 cases/1000PD vs. 3.28 cases/1000PD; p = 0.37). Additionally, a 30.6% reduction was observed in consumption of CDI therapeutics (20.1 doses/1000PD vs. 14.0 doses/1000PD) resulting in an annualized cost-savings of approximately $9200. Conclusion Our TIP and TASP advised a community three-hospital health system on optimal diagnostics resulting in a change in their algorithm. Following this, considerable reductions were observed in HO-CDI, total CDI, consumption of CDI therapeutics, and the associated costs of care. Disclosures Erin K. McCreary, PharmD, Abbvie: Advisor/Consultant|Ferring: Advisor/Consultant|GSK: Honoraria|La Jolla (Entasis): Advisor/Consultant|LabSimply: Advisor/Consultant|Merck: Advisor/Consultant|Shionogi: Advisor/Consultant|Shionogi: Honoraria

Molecular characterization and genotyping of isolates from cancer patients with Clostridioides difficile infection or asymptomatic colonization.

Introduction. Cancer patients with Clostridioides difficile infection (CDI) are at a higher risk for adverse outcomes. In addition, a high prevalence of Clostridioides difficile asymptomatic colonization (CDAC) has been reported in this vulnerable population.Gap Statement. The molecular characteristics and potential role of CDAC in healthcare-related transmission in the cancer population have been poorly explored.Aim. We aimed to compare the molecular and genotypic characteristics of C. difficile isolates from cancer patients with CDAC and CDI.Method. We conducted a prospective cohort study of cancer patients with CDAC or CDI from a referral centre. Molecular characterization, typification and tcdC gene expression of isolates were performed.Results. The hospital-onset and community-onset healthcare facility-associated CDI rates were 4.5 cases/10 000 patient-days and 1.4 cases/1 000 admissions during the study period. Fifty-one C. difficile strains were isolated: 37 (72 %) and 14 (28 %) from patients with CDI or CDAC, respectively. All isolates from symptomatic patients were tcdA+/tcdB+, and four (10 %) were ctdA+/ctdB+. In the CDAC group, 10 (71 %) isolates were toxigenic, and none were ctdA+/ctdB+. The Δ18 in-frame tcdC deletion and two transition mutations were found in five isolates. After bacterial typing, 60 % of toxigenic isolates from asymptomatic carriers were clonal to those from patients with C. difficile-associated diarrhoea. No NAP1/027/BI strains were detected.Conclusions. We found a clonal association between C. difficile isolates from patients with CDAC and CDI. Studies are needed to evaluate the potential role of asymptomatic carriers in the dynamics of nosocomial transmission to support infection control measures and reduce the burden of CDI in high-risk groups.

A 7-year analysis of attributable costs of healthcare-associated infections in a network of community hospitals in the southeastern United States.

We calculated the attributable cost of several healthcare-associated infections in a community hospital network: central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), hospital-onset Clostridioides difficile infections (CDI-HOs) (43 hospitals); surgical site infections (SSIs) (40 hospitals). From 2016 to 2022, the total cost of CLABSIs, CAUTIs, CDI-HOs, and SSIs was $420,012,025.

Role of probiotics in preventing Clostridioides difficile infection in older adults: an integrative review.

Clostridioides difficile infection (CDI) is the leading cause of healthcare-associated diarrhea. This infection can particularly affect older adults, the most susceptible to CDI. Currently, the standard therapeutic measure is antibiotic therapy, which in turn increases the risk of recurrence of the infection by its collateral damage to the patient's microbiota. Probiotics are live microorganisms capable of maintaining balance in the intestinal microbiota. This study aims to perform an integrative review of the protective benefit of probiotics in CDI and diarrhea associated with C. difficile. The PubMed, Scopus, and Web of Science databases, the 10-year time cutoff, and the Prism Flow diagram were used for data collection. We observed no consensus among the studies; however, three of the seven evaluated studies demonstrated that the use of probiotics in older adults could contribute to reducing the incidence of hospital-onset CDI. We also found that the studies evaluated a wide variety of microorganisms, particularly Saccharomyces boulardii, associated with beneficial effects. More research is needed to understand the successful use of probiotics in the prevention of CDI in hospitalized older adults receiving antibiotics.

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

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

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.

Implementation of a multidisciplinary process to improve diagnostic stewardship of hospital-onset Clostridioides difficile infections

Testing inappropriate stool samples for Clostridioides (Clostridium) difficile can lead to theidentification of the patient colonized with Cdifficile and erroneous diagnosis of an active infection. We hypothesized that a multidisciplinary process to improve diagnostic stewardship could reduce our numbers of hospital-onset Cdifficile infection (HO-CDI). We created an algorithm describing appropriate stool specimens for polymerase chain reaction testing. The algorithm was converted into "ticket to test" checklist cards designed to accompany each specimen. Rejection of a specimen could occur via nursing staff or laboratory staff. A baseline period of comparison was established from January 1, 2017to June 30, 2017. Following implementation of all improvement strategies, a retrospective analysis was done, and the total number of HO-CDI cases in a 6-month period dropped from 57 to 32 cases. During the initial 3 months, the percentage of appropriate samples sent to the lab ranged from 41% to 65%. After the interventions were in place, the percentages improved between 71% and 91%. A multidisciplinary approach led to improved diagnostic stewardship to identify true CDI cases. This, in turn, reduced the number of reported HO-CDIs, and resulted in potentially more than $1,080,000 in patient care savings.

Assessing the Impact of 2-Step Clostridioides difficile Testing at the Healthcare Facility Level.

Two-step testing for Clostridioides difficile infection (CDI) aims to improve diagnostic specificity but may also influence reported epidemiology and patterns of treatment. Some providers fear that 2-step testing may result in adverse outcomes if C. difficile is underdiagnosed. Our primary objective was to assess the impact of 2-step testing on reported incidence of hospital-onset CDI (HO-CDI). As secondary objectives, we assessed the impact of 2-step testing on C. difficile-specific antibiotic use and colectomy rates as proxies for harm from underdiagnosis or delayed treatment. This longitudinal cohort study included 2 657 324 patient-days across 8 regional hospitals from July 2017 through March 2022. Impact of 2-step testing was assessed by time series analysis with generalized estimating equation regression models. Two-step testing was associated with a level decrease in HO-CDI incidence (incidence rate ratio, 0.53 [95% confidence interval {CI}, .48-.60]; P < .001), a similar level decrease in utilization rates for oral vancomycin and fidaxomicin (utilization rate ratio, 0.63 [95% CI, .58-.70]; P < .001), and no significant level (rate ratio, 1.16 [95% CI, .93-1.43]; P = .18) or trend (rate ratio, 0.85 [95% CI, .52-1.39]; P = .51) change in emergent colectomy rates. Two-step testing is associated with decreased reported incidence of HO-CDI, likely by improving diagnostic specificity. The parallel decrease in C. difficile-specific antibiotic use offers indirect reassurance against underdiagnosis of C. difficile infections still requiring treatment by clinician assessment. Similarly, the absence of any significant change in colectomy rates offers indirect reassurance against any rise in fulminant C. difficile requiring surgical management.

Impact of early identification of patients meeting testing criteria for Clostridioides difficile on standard infection ratios

Background:Clostridioides difficile infection (CDI) poses a health burden to patients and a financial burden to hospital systems. Timely identification of CDI patients can reduce the impacts by allowing for prompt treatment and ensuring that proper isolation precautions are in place to prevent spread. It also ensures correct CDI event categorization according to the NHSN. Community-onset (CO) CDI cases are tested on or prior to hospital day 3, and hospital-onset (HO) CDI are tested on or after hospital day 4. The objective of this study was to determine the effectiveness of utilizing an electronic health record (EHR) report to reduce CDI standard infection ratios (SIRs) by identifying potential CDI cases prior to hospital day 4. Methods: From August of 2021 to September 2022, an EHR report was implemented in a 5-hospital healthcare system in the Midwest to identify patients with 3 or more type 6 or 7 stools in a 24-hour period based on Bristol stool chart classification. All inpatients with 3 or more type 6 or 7 stools in 24 hours without an active order for a Clostridioides difficile test were listed. Patients with a laxative in the previous 48 hours, tube feedings without fever or leukocytosis, or a known cause of diarrhea were excluded. The attending provider of the patients meeting criteria were notified with a recommendation to test for C. difficile or provide alternative reason for symptoms. Results: In total, 26 patients were tested for C. difficile using polymerase chain reaction testing. Of those tested, 5 (19.2%) tested positive for C. difficile. There were 13 HO-CDI cases for the healthcare system during this period, for an SIR of 0.351. If the early identified cases were not identified until after hospital day 3, the SIR had the potential to have been 35.6% greater at 0.476. Conclusions: We were able to identify 5 CDI cases prior to hospital day 4 using an early identification report during this 13-month period. Although these cases may have been identified without the use of the EHR report, we were able to obtain a timely CDI diagnosis, potentially limiting the spread of C. difficile and preventing an increase in the CDI SIR by 35.6%. An EHR report to identify patients meeting C. difficile testing criteria may be an effective way to identify CO-CDI prior to HD 4 and thus reduce CDI SIRDisclosures: None

Risk factors for hospital-onset Clostridioides difficile infections before and during the severe acute respiratory syndrome coronavirus 2 pandemic

In this retrospective cohort from 3 Missouri hospitals from January 2017 to August 2020, hospital-onset Clostridioides difficile infectionswere more common during the severe acute respiratory syndrome coronavirus 2 pandemic at the tertiary care hospital. Risk factors associated with hospital-onset Cdifficileinfection included the year of hospitalization, age, high-risk antibiotic use, acid-reducing medications, chronic comorbidities, and severe acute respiratory syndrome coronavirus2 infection.

Utilization of a novel humble inquiry interview approach in assessing implementation barriers to a nurse-driven Clostridioides difficile test order set

Hospital onset Clostridioides difficile infection (CDI) causes significant disease burden and is associated with increased patient mortality. A nurse-driven CDI test order set had been implemented to reduce hospital-onset CDI, yet the order set was not being used. We employed a humble inquiry interview method to identify barriers to using the CDI test order set. The humble inquiry approach uncovered unexpected barriers and may be a robust method to identify additional infection prevention evidence-to-practice gaps.

Nurse Work Environment and Hospital-Onset Clostridioides difficile Infection.

Clostridioides difficile is the leading cause of hospital-onset diarrhea and is associated with increased lengths of stay and mortality. While some hospitals have successfully reduced the burden of C. difficile infection (CDI), many still struggle to reduce hospital-onset CDI. Nurses-because of their close proximity to patients-are an important resource in the prevention of hospital-onset CDI. Determine whether there is an association between the nurse work environment and hospital-onset CDI. Survey data of 2016 were available from 15,982 nurses employed in 353 acute care hospitals. These data, aggregated to the hospital level, provided measures of the nurse work environments. They were merged with 2016 hospital-onset CDI data from Hospital Compare, which provided our outcome measure-whether a hospital had a standardized infection ratio (SIR) above or below the national average SIR. Hospitals above the average SIR had more infections than predicted when compared to the national average. In all, 188 hospitals (53%) had SIRs higher than the national average. The odds of hospitals having higher than average SIRs were significantly lower, with odds ratios ranging from 0.35 to 0.45, in hospitals in the highest quartile for all four nurse work environment subscales (managerial support, nurse participation in hospital governance, physician-nurse relations, and adequate staffing) than in hospitals in the lowest quartile. Findings show an association between the work environment of nurses and hospital-onset CDI. A promising strategy to lower hospital-onset CDI and other infections is a serious and sustained commitment by hospital leaders to significantly improve nurse work environments.

Clostridioides difficile Infection: Clinical Practice and Health Outcomes in 6 Large Tertiary Hospitals in Eastern Australia.

Clostridioides difficile infection (CDI) is associated with significant morbidity and mortality in both healthcare and community settings. We aimed to define the predisposing factors, risks for severe disease, and mortality determinants of CDI in eastern Australia over a 1-year period. This is an observational retrospective study of CDI in hospitalized patients aged ≥18 years in 6 tertiary institutions from 1 January 2016 to 31 December 2016. Patients were identified through laboratory databases and medical records of participating institutions. Clinical, imaging, and laboratory data were input into an electronic database hosted at a central site. A total of 578 patients (578 CDI episodes) were included. Median age was 65 (range, 18-99) years and 48.2% were male. Hospital-onset CDI occurred in 64.0%. Recent antimicrobial use (41.9%) and proton pump inhibitor use (35.8%) were common. Significant risk factors for severe CDI were age <65 years (P < .001), malignancy within the last 5 years (P < .001), and surgery within the previous 30 days (P < .001). Significant risk factors for first recurrence included severe CDI (P = .03) and inflammatory bowel disease (P = .04). Metronidazole was the most common regimen for first episodes of CDI with 65.2% being concordant with Australian treatment guidelines overall. Determinants for death at 60 days included age ≥65 years (P = .01), severe CDI (P < .001), and antibiotic use within the prior 30 days (P = .02). Of those who received metronidazole as first-line therapy, 10.1% died in the 60-day follow-up period, compared to 9.8% of those who received vancomycin (P = .86). Patients who experience CDI are vulnerable and require early diagnosis, clinical surveillance, and effective therapy to prevent complications and improve outcomes.

Clostridioides difficile infection surveillance in intensive care units and oncology wards using machine learning.

Screening individuals admitted to the hospital for Clostridioides difficile presents opportunities to limit transmission and hospital-onset C. difficile infection (HO-CDI). However, detection from rectal swabs is resource intensive. In contrast, machine learning (ML) models may accurately assess patient risk without significant resource usage. In this study, we compared the effectiveness of swab surveillance to daily risk estimates produced by an ML model to identify patients who will likely develop HO-CDI in the intensive care unit (ICU) setting. A prospective cohort study was conducted with patient carriage of toxigenic C. difficile identified by rectal swabs analyzed by anaerobic culture and polymerase chain reaction (PCR). A previously validated ML model using electronic health record data generated daily risk of HO-CDI for every patient. Swab results and risk predictions were compared to the eventual HO-CDI status. Adult inpatient admissions taking place in University of Michigan Hospitals' medical and surgical intensive care units and oncology wards between June 6th and October 8th, 2020. In total, 2,979 admissions, representing 2,044 patients, were observed over the course of the study period, with 39 admissions developing HO-CDIs. Swab surveillance identified 9 true-positive and 87 false-positive HO-CDIs. The ML model identified 9 true-positive and 226 false-positive HO-CDIs; 8 of the true-positives identified by the model differed from those identified by the swab surveillance. With limited resources, an ML model identified the same number of HO-CDI admissions as swab-based surveillance, though it generated more false-positives. The patients identified by the ML model were not yet colonized with C. difficile. Additionally, the ML model identifies at-risk admissions before disease onset, providing opportunities for prevention.

SG-APSIC1166: Strategies to reduce hospital-onset Clostridioides difficile infections in an acute-care hospital in Singapore

Objectives: Control of Clostridioides difficile infections (CDIs) in healthcare facilities presents significant challenges to infectious disease physicians, infection prevention and control practitioners, and environmental services staff. CDI is a common cause of infectious diarrhea and is associated with significant morbidity, mortality, and healthcare cost. A high infection rate was documented in our institution in 2017, higher than the national infection rate. Strategies to reduce hospital-onset CDI were implemented after review of international guidelines and relevant literature. The impact on hospital-onset CDI was assessed. Methods: The following strategies were implemented beginning early in 2018: (1) contact precautions for patients with diarrhea; (2) early recognition and diagnosis of C. difficile infection; (3) prompt isolation of C. difficile patients; (4) emphasis on hand hygiene and contact precautions; (5) enhanced environmental cleaning with chlorine-based disinfectant and use of UV-C and ionized hydrogen peroxide for equipment disinfection; (6) enhanced cleaning and disinfection using sporicidal wipes for shared high-risk equipment; (7) audit and feedback regarding compliance with practices and environmental cleaning; and (8) collaboration with antibiotics stewardship program (ASP) to reduce inappropriate antibiotic use. Hospital-onset CDI cases were tracked by infection prevention and control nurses using definitions from the Singapore Ministry of Health. Results: In total, 135 hospital-onset C. difficile infection cases occurred in 2017, a rate of 4.2 per 10,000 patient days. This rate gradually decreased to 3.0 in 2018 and to 2.3 in 2020, with an average of 87 infections per year. This rate further decreased to 1.8 infections per 10,000 patient days in 2021, with 61 clinical infections. Conclusions: Using multimodal strategies, CGH achieved a gradual and steady reduction in hospital-onset CDI over several years. These strategies require close collaboration among various departments to achieve the desired outcome.

Predictors of hospital-onset Clostridioides difficile infection in children with antibiotic-associated diarrhea

BackgroundThis study aimed to determine the predictors of hospital-onset Clostridioides difficile infection (CDI) in pediatric patients with antibiotic-associated diarrhea (AAD) and to develop a predictive scoring system to identify at-risk patients. MethodsThis retrospective case-control study included patients aged ≥2-18 years with AAD who underwent C. difficile polymerase chain reaction testing >3 days after hospital admission. Patients with hospital-onset CDI were selected as cases and matched with the control patients without CDI. Univariate and multivariate logistic regressions were used to determine predictors of CDI and to construct a prediction score for the outcomes of interest. ResultsSixty-five patients with hospital-onset CDI and 130 controls were enrolled. Independent predictors for CDI identified and combined into the prediction score included abdominal pain (adjusted odds ratio [95% confidence interval]: 7.940 [3.254-19.374]), hospitalization for ≥14 days before the onset of diarrhea (3.441 [1.034-11.454]), antibiotic use for ≥10 days before the onset of diarrhea (6.775 [1.882-24.388]), receipt of meropenem (4.001 [1.098-14.577]) and clindamycin (14.842 [4.496-49.000]). The area under the receiver operating characteristic curve for this score was 0.883. ConclusionsThe presented scoring system can be easily applied by clinicians at the bedside to decide which patients with AAD are likely to have CDI.