Non-severe Clostridioides Difficile Infection Research Articles

Secondary prophylaxis for Clostridioides difficile infection for patients on non-C. difficile antibiotics: a retrospective cohort study

ObjectivesRecurrent Clostridioides difficile infection (CDI) poses healthcare challenges and morbidity. Preventing recurrence with prophylactic oral CDI antibiotics lack consensus. MethodsWe used data from the largest healthcare provider in Israel to identify all adults aged 18 years or older diagnosed with a first episode of CDI (Index CDI) between February 2018 and December 2022 and subsequently received a non-CDI antibiotic within 2–8 weeks. Patients who received a concurrent prophylactic CDI antibiotic constituted the CDI prophylaxis group. Multivariable Cox proportional hazard regression models were used to examine the association of secondary CDI prophylaxis with CDI recurrence according to the severity of the index CDI (primary objective) and with 4- and 8-week all-cause mortality (secondary objective). ResultsA total of 434 eligible patients were included. Among them, 327 did not receive CDI antibiotic prophylaxis, while 107 did. CDI antibiotic prophylaxis was associated with a significant risk reduction of CDI recurrence with an adjusted HR of 0.51 (95% CI, 0.27–0.97). The magnitude of the association was modified by the severity of the index CDI episode (P for interaction 0.0182). Specifically, the HR for recurrence was 0.163 (95% CI 0.045–0.593) for non-severe CDI, and 1.242 (95% CI 0.524–2.946) for severe CDI. No significant association was found between CDI antibiotic prophylaxis and 4–8 weeks mortality. ConclusionSecondary prophylaxis with CDI antibiotics appears to be associated with a reduced risk of recurrence in patients with previous non-severe CDI episode. Further studies are needed to confirm this finding.

Efficacy Assessment of the Co-Administration of Vancomycin and Metronidazole in Clostridioides difficile-Infected Mice Based on Changes in Intestinal Ecology.

Vancomycin (VAN) and metronidazole (MTR) remain the current drugs of choice for the treatment of non-severe Clostridioides difficile infection (CDI); however, while their co-administration has appeared in clinical treatment, the efficacy varies greatly and the mechanism is unknown. In this study, a CDI mouse model was constructed to evaluate the therapeutic effects of VAN and MTR alone or in combination. For a perspective on the intestinal ecology, 16S rRNA amplicon sequencing and non-targeted metabolomics techniques were used to investigate changes in the fecal microbiota and metabolome of mice under the co-administration treatment. As a result, the survival rate of mice under co-administration was not dramatically different compared to that of single antibiotics, and the former caused intestinal tissue hyperplasia and edema. Co-administration also significantly enhanced the activity of amino acid metabolic pathways represented by phenylalanine, arginine, proline, and histidine, decreased the level of deoxycholic acid (DCA), and downregulated the abundance of beneficial microbes, such as Bifidobacterium and Akkermansia. VAN plays a dominant role in microbiota regulation in co-administration. In addition, co-administration reduced or increased the relative abundance of antibiotic-sensitive bacteria, including beneficial and harmful microbes, without a difference. Taken together, there are some risks associated with the co-administration of VAN and MTR, and this combination mode should be used with caution in CDI treatment.

Impact of time to treatment in first occurrence, non-severe Clostridioides difficile infection for elderly patients: are we waiting too long to treat?

Data evaluating timeliness of antibiotic therapy in Clostridioides difficile infections (CDI) are not well established. The study's purpose was to evaluate the impact of time-to-CDI treatment on disease progression. A case-control study was performed among hospitalized patients with CDI from 1/2018 to 2/2022. Inclusion criteria were age ≥65 years, first occurrence, non-severe CDI at symptom onset, and CDI treatment for ≥72 hours. Cases included patients who progressed to severe or fulminant CDI; controls were patients without CDI progression. Time to CDI treatment was evaluated in three ways: a classification and regression tree (CART)-defined threshold, time as a continuous variable, and time as a categorical variable. 272 patients were included; 136 with CDI progression, 136 patients without. The median (IQR) age was 74 (69-81) years, 167 (61%) were women, and 108 (40%) were immunosuppressed. CDI progression patients more commonly were toxin positive (66 [49%] vs 52 [38%], P = .087) with hospital-acquired disease (57 [42%] vs 29 [21%], P < 0.001). A CART-derived breakpoint for optimal time-to-CDI treatment of 64 hours established early (184, 68%) and delayed treatment (88, 32%). When accounting for confounding variables, delayed CDI treatment was associated with disease progression (adjOR, 4.6; 95%CI, 2.6-8.2); this was observed regardless of how time-to-CDI-active therapy was evaluated (continuous adjOR, 1.02; categorical adjOR, 2.11). Delayed CDI treatment was associated with disease progression and could represent an important antimicrobial stewardship measure with future evaluation.

673. Sniffing Out Adherence: Evaluation of a Clostridioides difficile guideline at a Tertiary Academic Medical Center

Abstract Background Tufts Medical Center’s (TMC) Antimicrobial Stewardship Team (AMT) in collaboration with gastroenterology (GI) developed an institutional treatment algorithm to guide appropriate inpatient management of Clostridioides difficile infection (CDI). The CD treatment algorithm was revised in April 2022 to reflect updated national clinical practice guidelines and disseminated to TMC providers. Our study aimed to assess provider compliance to TMC’s CD treatment algorithm. Methods A retrospective study of adult patients hospitalized from April 15, 2022 to October 31, 2022 and tested for CD was conducted. We collected patient demographics, white blood cell count, serum creatinine (SC), length of stay, CD treatment, Infectious Diseases (ID) &amp; GI consult, occurence of severe CDI (defined as white blood cell &amp;gt; 15 K/uL or SC &amp;gt; 1.5 mg/dL), occurrence of recurrent CDI, and immunocompromised status (defined by having had organ or bone marrow transplant, receiving immunomodulatory therapy or chronic steroids). A 2-step Clostridioides difficile (CD) testing algorithm was used. For CD toxin A/B &amp; glutamate dehydrogenase antigen (GDH) indeterminate results, reflex to nucleic amplification test (NAAT) was performed only with AMT approval. Results A total of 111 inpatients had CD toxin/GDH stool testing; 70 (63%) positive and 41 (37%) indeterminate. Of patients who had an indeterminate CD toxin/GDH, none had subsequent CD NAAT testing, and none receive CDI treatment. Of the others, 81 (73%), 23 (21%), and 7 (6%) were diagnosed with non-severe, severe, and fulminant CDI, respectively. The overall adherence to the institutional CD treatment algorithm was 58% (figure 1). More patients were appropriately treated with oral vancomycin (11, 65%) compared to those who were appropriately treated with fidaxomicin (9, 24%). Guidance adherence was (3) 38% among patients who had one or more recurrent episodes of CD, and none received suggested ID or GI consultation for additional CDI treatment consideration. Conclusion Adherence to institutional CD treatment algorithm was low. This study highlights opportunities to improve prescription of first line CDI therapy, especially among patients who are at higher risk for recurrence. Disclosures Maureen Campion, PharmD, BCIDP, Shinoigi: Speaker

Clostridioides Infection in Patients with Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), comprising Crohn's disease and ulcerative colitis, is a chronic inflammatory condition of the gastrointestinal tract, which is often accompanied by altered gut microbial composition. Gut dysbiosis in IBD is considered to be the reason for the high risk of Clostridioides difficile infection (CDI) in patients with IBD. Therefore, CDI should be evaluated in IBD patients with a symptom flare. Medical treatment of non-severe CDI in IBD is similar to that in non-IBD patients and includes oral vancomycin or fidaxomicin. The risk of recurrent CDI in IBD is higher than in non-IBD patients and this could be mitigated by fecal microbiota transplantation. As CDI may worsen the clinical outcomes of IBD, patients should be carefully monitored and an escalation of IBD therapy needs to be considered when there is no improvement seen with the antimicrobial treatment of CDI. This review discusses the risk, pathophysiology, diagnosis, and management of CDI in IBD.

Reappraisal of the clinical role of metronidazole therapy for Clostridioides difficile infection in Taiwan: A multicenter prospective study

Although metronidazole is not recommended to treat Clostridioides difficile infection (CDI) in Western countries, it was still to be recommended for the treatment of non-severe CDI among Taiwanese adults in 2020. This controversy in the clinical role of metronidazole therapy for CDI was examined in a prospective clinical study. The study was conducted from January 2015 to December 2016 in three hospitals in Taiwan. Metronidazole treatment failure (MTF) was defined as the persistence of diarrhea after six days of treatment, medication modification (shifting to oral vancomycin), or death after five days of therapy. Overall, 325 patients receiving metronidazole for CDI were included. The overall MTF rate was 48.6% (158 patients). Leukocyte counts of >15,000cells/mL in peripheral blood (odd ratio [OR] 1.81; P=0.04) and congestive heart failure (OR 3.26; P=0.02) were independently associated with MTF. The MTF rate for patients with leukocyte counts of ≤15,000cells/mL and no congestive heart failure, leukocyte counts of >15,000cells/mL and no congestive heart failure, leukocyte counts of ≤15,000cells/mL and congestive heart failure, and leukocyte counts of >15,000cells/mL and congestive heart failure were 44.2%, 51.8%, 73.3%, and 66.7%, respectively. Of note, patients who experienced MTF had a higher recurrence rate of CDI than those with metronidazole treatment success (13.9% vs. 6.0%, P=0.02). For Taiwanese adults with CDI, the failure rate of metronidazole therapy approached 50%, which suggests the reappraisal of the therapeutic role of metronidazole therapy, especially for patients with leukocytosis or underlying congestive heart failure.

Clinical and microbiological risk factors for severe Clostridioides difficile infections

Background: There has been a marked increase in the mortality rate associated with Clostridioides difficile infection (CDI) globally since 2003, with the emergence of binary toxinproducing ribotype 027 strains. However, the molecular epidemiology of C. difficile shows regional differences and ribotype 027 is not common in Korea. In this study, the risk factors for severe CDI were evaluated, while considering the region-specific molecular epidemiology. Methods: A retrospective case-control study was performed. Cases (n = 149) included patients with severe CDI or severe complicated CDI. Controls (n = 155) consisted of patients with nonsevere CDI. Results: Advanced age (odds ratio [OR] = 1.017, P = 0.0358), a history of chemotherapy (OR = 2.695, P = 0.0464), and ribotype 002 (OR = 3.406, P = 0.0231) were statistically significant factors associated with severe CDI in a multivariate analysis. Conclusion: Ribotype 002 was found to be a significant risk factor for severe CDI in this study. Therefore, the surveillance of C. difficile ribotypes is recommended to monitor the spread of high-risk clones.

Cost-effectiveness of Fecal Microbiota Transplantation for First Recurrent Clostridioides difficile Infection.

Both the American College of Gastroenterology and the Infectious Diseases Society of America (IDSA)/Society for Healthcare Epidemiology of America 2021 Clostridioides difficile infection (CDI) guidelines recommend fecal microbiota transplantation (FMT) for persons with multiple recurrent CDI. Emerging data suggest that FMT may have high cure rates when used for first recurrent CDI. The aim of this study was to assess the cost-effectiveness of FMT for first recurrent CDI. We developed a Markov model to simulate a cohort of patients presenting with initial CDI infection. The model estimated the costs, effectiveness, and cost-effectiveness of different CDI treatment regimens recommended in the 2021 IDSA guidelines, with the additional option of FMT for first recurrent CDI. The model includes stratification by the severity of initial infection, estimates of cure, recurrence, and mortality. Data sources were taken from IDSA guidelines and published literature on treatment outcomes. Outcome measures were quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). When FMT is available for first recurrent CDI, the optimal cost-effective treatment strategy is fidaxomicin for initial nonsevere CDI, vancomycin for initial severe CDI, and FMT for first and subsequent recurrent CDI, with an ICER of $27 135/QALY. In probabilistic sensitivity analysis at a $100 000 cost-effectiveness threshold, FMT for first and subsequent CDI recurrence was cost-effective 90% of the time given parameter uncertainty. FMT is a cost-effective strategy for first recurrent CDI. Prospective evaluation of FMT for first recurrent CDI is warranted to determine the efficacy and risk of recurrence.

Neutrophil Ratio of White Blood Cells as a Prognostic Predictor of Clostridioides difficile Infection.

IntroductionA leukocyte count ≥15,000 cells/mL and serum creatinine of >1.5 mg/dL have been reported as two important predictors of severe CDI. However, the association of the differential ratios of blood leukocytes, and the prognosis of Clostridioides difficile infection (CDI) is not clear.Materials and MethodsA clinical study was conducted at medical wards of Tainan Hospital, Ministry of Health and Welfare in southern Taiwan between January 2013 and April 2020. Hospitalized adults (aged ≥20 years) with hospital-onset CDI (ie, symptom onset after at least 48 hours of admission) were included.ResultsA total of 235 adults with an average age of 75.7 years and female predominance (51.5%), including 146 (62%) adults with non-severe CDI and 87 (38%) severe CDI, were included for analysis. Patients with severe CDI had a higher crude in-hospital mortality rate than patients with non-severe CDI (35.6% vs 18.5%, P = 0.005). Multivariate analysis revealed no association between a leukocyte count >15,000 cell/mL at the onset of CDI and in-hospital mortality (odds ratio [OR] 1.66, P = 0.21). In contrast, a neutrophil ratio >75% (OR 2.65, P = 0.02), serum creatinine >1.5 mg/L (OR 3.42, P = 0.03), and CDI caused by isolates harboring the tcdC gene (OR 3.54, P = 0.02) were independently associated with in-hospital mortality. Patients with a neutrophil ratio >85%, 80–85%, or 75–80% of serum leukocytes had a higher mortality rate (34.8%, 30.3%, or 34.4%, respectively) than patients with a neutrophil ratio of 70–75% or ≤75% (12.5% or 13.9%, respectively).ConclusionSerum creatinine >1.5 mg/L, a high neutrophil ratio of blood leukocytes (>75%), and the causative C. difficile harboring the tcdC gene was independent prognostic predictors in hospitalized adults with CDI.

Non-inferiority of metronidazole to vancomycin in the treatment of first episode non-severe Clostridioides difficile infection: a single center retrospective cohort study.

We sought to assess the effectiveness of oral vancomycin compared to metronidazole on recurrence and mortality among hospitalized patients with non-severe Clostridioides difficile infection (CDI). A single center retrospective cohort study was conducted, including adult patients hospitalized between 2015 and 2020 with a first episode of non-severe CDI, treated with metronidazole or vancomycin as monotherapy for at least 10days. We assessed recurrence of CDI requiring hospitalization (primary outcome) and all-cause mortality up to 8weeks, post discharge. Overall, 160 patients were treated with vancomycin and 149 treated with metronidazole. Re-hospitalization within 8weeks due to CDI occurred in 10 (6.2%) patients in the vancomycin group, and 13 (8.7%) in the metronidazole group (P value = 0.407). Eight-week mortality occurred in 39 patients (26.2%) in the metronidazole group and 46 patients (28.8%) in the vancomycin group (P value = 0.61). After adjusting for age, gender, Ischemic heart disease, white blood cell count, neutrophile count and CRP, there was no significant difference between the two treatments (Re-hospitalization in 8weeks due to CDI P = 0.5059; In-hospital death P = 0.7950; 4-week mortality P = 0.2988; 8-week mortality P = 0.8237). There is no benefit of using vancomycin compared to metronidazole concerning recurrence rate requiring hospitalization, in-hospital and up to 4- and 8-week mortality rate in non-severe first episode of CDI.

Antibiotic Therapies for Clostridioides difficile Infection in Children.

While rates of Clostridioides difficile infection (CDI) are increasing among children in the United States, studies assessing CDI treatment in children are severely lacking. Thus, treatment guidelines have historically relied on evidence from limited observational data in children and randomized controlled trials (RCTs) conducted in adults to form recommendations. Currently, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) recommend metronidazole and/or vancomycin for pediatric CDI depending on disease severity. Recently however, the first and only RCT of CDI treatment in children demonstrated fidaxomicin to be non-inferior to vancomycin, proving its safety and efficacy in this population. Additionally, observational data published since the IDSA/SHEA guidelines were released suggest metronidazole has lower rates of clinical improvement when compared to vancomycin in hospitalized children with non-severe CDI. Given these recent publications, fidaxomicin and vancomycin, instead of metronidazole, appear to be more appropriate, evidence-based options for the treatment of CDI in children.

Changes in Metronidazole and Vancomycin Utilization for Nonsevere Clostridioides difficile Infection Among Institutions Caring for Children.

Clostridioides difficile infection guidelines were published in final format on April 1, 2018. Among 4962 and 3545 C. difficile infection cases in children the year before and after publication, oral metronidazole use decreased from 63.0% to 44.3% (P < 0.001) and oral vancomycin use increased from 27.3% to 47.7% (P < 0.001). Quarterly metronidazole utilization decreased postguidelines among 117 institutions, incidence rate ratios 0.86 (95% confidence intervals: 0.78-0.96).

Outcomes associated with recent guideline recommendations removing metronidazole for treatment of non-severe Clostridioides difficile infection: a retrospective, observational, nationwide cohort study

ObjectivesThe 2017 Society for Healthcare Epidemiology of America (SHEA) and Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for Clostridioides difficile (C. difficile) infection (CDI) removed metronidazole as a preferred option for initial episodes of non-severe CDI. This study aimed to determine if the shift away from metronidazole improved clinical outcomes of initial episodes of non-severe CDI. MethodsThe study was a retrospective, observational, nationwide cohort study using a Veterans Health Administration national clinical administrative database. Adult patients treated for non-severe CDI before and after the February 2018 publication of the 2017 IDSA/SHEA C. difficile Clinical Practice Guidelines were included. The primary outcome was the composite of treatment failure or probable recurrence. ResultsA total of 3608 patients were included, with 1809 in the pre-guideline cohort (mean [SD] age, 65.5 [14.2] years; 1602 [88.6%] male) and 1799 in the post-guideline cohort (mean [SD] age, 64 [14.6] years; 1584 [88%] male). Overall composite of treatment failure or probable recurrence was similar between both cohorts (318 of 1809 [17.6%] pre-guideline cohort vs. 317 of 1799 [17.6%] post-guideline cohort [P = 0.97]). ConclusionThe shift away from metronidazole as a preferred option in initial non-severe Clostridioides difficile infection did not improve the composite of treatment failure or recurrence.

Initial vancomycin versus metronidazole for the treatment of first-episode non-severe Clostridioides difficile infection.

Clostridioides difficile infection (CDI) is the leading cause of infectious nosocomial diarrhea. Although initial fidaxomicin or vancomycin treatment is recommended by most major guidelines to treat severe CDI, there exists varied recommendations for first-episode non-severe CDI. Given the discrepancy in current treatment guidelines, we sought to evaluate the use of initial vancomycin versus metronidazole for first-episode non-severe CDI. We conducted a retrospective cohort study of all adult inpatients with first-episode CDI at our institution from January 2013 to May 2018. The initial vancomycin versus initial metronidazole cohorts were examined using a multivariate logistic regression model. The study cohort of 737 patients had a median age of 72.3 years, and 357 of these patients (48.4%) had hospital-acquired infection. Among 326 patients with non-severe CDI, recurrence, new incident infection, and 30-day mortality rates were 16.2%, 10.9%, and 5.3%, respectively, when treated with initial metronidazole, compared to 20.0%, 1.4%, and 10.0%, respectively, when treated with initial vancomycin. In an adjusted multivariable analysis, the use of initial vancomycin for the treatment of non-severe CDI was associated with a reduction in new incident infection (adjusted odds ratio [ORadj], 0.11; 95% confidence interval [CI], 0.02-0.86; P = .035), compared to initial metronidazole. Initial vancomycin was associated with a reduced rate of new incident infection in the treatment of adult inpatients with first-episode non-severe CDI. These findings support the use of initial vancomycin for all inpatients with CDI, when fidaxomicin is unavailable.

783. Clostridioides difficile Infection among Maintenance Hemodialysis Patients

BackgroundPatients on maintenance hemodialysis (MHD) are 2-2.5 times more likely to develop Clostridioides difficile infection (CDI) with mortality rates 2-fold higher compared to the general population. The goal of this study was to determine factors and outcomes associated with severe/fulminant CDI among MHD patients.MethodsA retrospective cohort study was performed among MHD patients admitted to 2 tertiary care hospitals, with first episodes of CDI between January 2015 and December 2018. MHD patients who had CDI at admission were identified through Theradoc® and confirmed by electronic medical records review. Using the Infectious Diseases Society of America criteria, non-severe CDI was defined as a white blood cell count ≤ 15000 cells/mL and severe/fulminant CDI was defined as a white blood cell count of ≥ 15000 cells/mL, hypotension, shock, megacolon and/or ileus. Creatinine values were not included. Patient demographics, comorbidities, antimicrobial exposure and 60-day mortality were collected on all patients.ResultsA total of 103 MHD patients with CDI were identified during the study period, of whom 68 (66%) had non-severe CDI and 35 (34%) had severe/fulminant CDI. The average age at admission was 65.3 years, 48.5% were female, and 59.2% were Caucasian. The average albumin level was 3.1 g/dL, and the average Charlson comorbidity index was 6.8. On univariate analyses, risk factors associated with severe/fulminant CDI as compared to non-severe CDI were older age at admission, elevated white blood cell count, exposure to extended-spectrum penicillins in the previous 90 days, and 60-day mortality after the first CDI (p-value ≤0.05). On multivariable logistic regression analysis, three factors remained significantly associated with severe/fulminant CDI (adjusted odds ratio [aOR], 95% confidence interval): 1] age ≥65 years (aOR=6.3 [2.25-17.45]), 2] extended-spectrum penicillins (aOR=2.7 [1.05-6.85], and 3] 60-day mortality after the first CDI (aOR=3.6 [1.11-11.74]).ConclusionA substantial proportion of patients requiring MHD with CDI present with severe/fulminant disease and are at increased risk of death. Reducing exposure to extended-spectrum penicillins may prevent severe/fulminant CDI in this patient population.DisclosuresJoao Filipe G Monteiro, PhD, Brown Medicine (Consultant)

Fidaxomicin versus metronidazole, vancomycin and their combination for initial episode, first recurrence and severe Clostridioides difficile infection — An observational cohort study

PurposeWe aimed to evaluate the efficacy of different antibiotic regimens for the treatment of Clostridioides difficile infection (CDI) with regard to the CDI episode number and disease severity. MethodsAn observation cohort study included 271 CDI patients hospitalised between 2013–2016. Univariate logistic regression was used to evaluate the association between patients’ clinical outcome (sustained clinical cure or recurrence) in a 60-day follow-up and the antibiotic regimen used (oral metronidazole, oral vancomycin, combination of oral vancomycin and metronidazole, oral fidaxomicin). Subgroup analyses, based on CDI episode number and severity, were performed. ResultsIn the overall population, fidaxomicin was superior to metronidazole, vancomycin or their combination, for a sustained clinical response and in the prevention of recurrent CDI (rCDI).In the subgroup analyses, fidaxomicin was superior to vancomycin or metronidazole for a sustained clinical response and in the prevention of rCDI in the initial episode, first recurrence and non-severe cases. In the oral treatment of severe CDI, fidaxomicin had a similar treatment outcome to vancomycin and none of the antibiotic treatments were superior in the prevention of rCDI. Fidaxomicin, vancomycin, or a combination of metronidazole and vancomycin, had similar outcomes for sustained clinical response and prevention of rCDI in patients with multiple rCDI. ConclusionFidaxomicin was superior to metronidazole or vancomycin for the treatment of the initial episode, first recurrence, and non-severe CDI.

Clinical outcomes after faecal microbiota transplant by retention enema in both immunocompetent and immunocompromised patients with recurrent Clostridioides difficile infections at an academic medical centre

Recurrent Clostridioides difficile infection (CDI) is one of the most common and challenging infections to treat in healthcare facilities. Faecal microbiota transplantation (FMT) is recommended as a definitive treatment option. We performed a retrospective review of 50 patients from January 2015 to December 2019 who underwent FMT for recurrent CDI. Primary outcome was recurrence of CDI within 12-weeks of FMT and secondary outcomes were the need for repeat FMT, serious adverse outcomes related to FMT and all-cause mortality. Fifty charts were reviewed, of which 47 cases comprising 17 immunocompromised patients treated with FMT via retention enema were included in the study. The majority of the patients had ≥3 recurrent CDIs (62%). Nine (19%) patients failed to respond to the first FMT and five underwent repeat FMT within four to 12 weeks. The cure rate was 81% after the first FMT (38/47) and 91% after the second FMT treatment (43/47). Serious adverse events occurred in 2% and all-cause mortality was 2% at 90-day follow up. Our study demonstrated the safety and efficacy of FMT administered via retention enema, a simple bedside procedure, for the treatment and prevention of recurrent non-severe and severe CDI with an overall cure rate of 91%.

Hospital acquired Clostridioides difficile infection and risk factors for severity in a university hospital: A prospective study

Clostridioides difficile infection (CDI) is a well-known cause of health care-associated diarrhea. Data about CDI epidemiology of Turkey is limited. This study investigates CDI incidence, clinical characteristics, and factors associated with severe CDI in a tertiary care center university hospital. This is a case control study was conducted between 2012 and 2016. We included all patients, 18 years of age or more, with CDI diagnosis. For each patient diagnosed with CDI, information was collected concerning the severity of disease, treatment regimen, treatment response, disease recurrence, 30-day case fatality. Cases defined as severe hospital acquired CDI (HA-CDI) and controls defined as non-severe CDI patients. We identified 100 cases of HA-CDI out of 111 patients. Total CDI incidence was 1.19/10,000 patient-days. The incidence decreased 32.5% during the study period. We identified severe CDI in 24% of patients. Age and admission to intensive care unit were independent risk factors for severe CDI. This study reports a 5-year prospective epidemiology of CDI in a tertiary care center in Istanbul, Turkey. The findings of this study suggest that HA-CDI incidence and proportion of severe CDI is low compared to European and US literature. We believe that CDI is underreported, neglected but still an important health care associated infection in Turkey.

Incidence of Clostridioides difficile infection at a Saudi Tertiary Academic Medical Center and compliance with IDSA/SHEA, ACG, and ESCMID guidelines for treatment over a 10-year period

BackgroundLimited data currently exist on the incidence of Clostridioides difficile infection (CDI) in Saudi Arabia. Compliance with CDI treatment guidelines is prudent for proper management of the infection and preventing recurrence. MethodsThis was an epidemiologic and retrospective cohort study to find the 10-year cumulative incidence of CDI (December 2007–January 2018) among patients presented with diarrhea or experienced diarrhea during hospitalization and the correlation between clinical outcomes and the compliance of treatment regimens with pertinent global guidelines (IDSA/SHEA, ACG, and ESCMID guidelines). ResultsAt our institution, the 10-year CDI cumulative incidence was 8.4%. A total of 170 patients were included in the analysis of compliance with the guidelines and clinical outcomes. Most patients had non-severe CDI according to all three guidelines. Clinical cure was found in 76.5% of the cases although all-cause mortality rate was 28.2%. Median (IQR) hospitalization period was 11 (5–29) days. Compliance with all three guidelines was significantly associated with clinical cure (R=0.24–0.27; P≤0.002). Lower mortality also significantly correlated with compliance with IDSA and ACG guidelines (P≤0.03), but not with ESCMID guidelines (P=0.05). While compliance with all three guidelines was associated with lower risk of recurrence, this finding was not statistically significant. ConclusionCDI rates reported in this study were very low reflecting a low incidence at our institution. As guidelines were prepared by a panel of experts using most reliable evidence, results shown in this study indicate the importance of following guidelines recommendations for better patient outcomes.

A100 ORAL VANCOMYCIN THERAPY FOR CLOSTRIDIOIDES DIFFICILE INFECTION AND RISK OF INFECTION WITH GRAM-NEGATIVE ORGANISMS

Abstract Background Vancomycin is the recommended first-line therapy for mild to severe Clostridioides difficile infection (CDI). However, oral vancomycin is associated with disruption of the indigenous microbiota, predisposing patients to overgrowth of endogenous pathogens such as vancomycin-resistant enterococci. Aims The primary objective of the study is to examine the effect of the treatment regimens of CDI on the risk of infection with gram-negative organisms in adult patients treated for CDI. Methods A retrospective cohort study of 319 adult patients treated for CDI at Hamilton Health Sciences in the year 2015. A multivariate logistic regression analysis was performed to determine if oral vancomycin-based therapy is associated with an increased risk of infection with gram-negative organisms after adjustment for other factors. Results Eighty-one patients were excluded because of recurrent episodes of CDI within the same year or missing information. 238 patients were included in the final analysis. 48 (20.2%) patients had positive culture for gram-negative organisms after onset of CDI. Urine was the most common source for gram-negative organisms (39/48, 81.3%) followed by blood (8/48,16.7%). The most common isolated gram-negative organisms were Escherichia coli (18/48, 37.5%) and Klebsiella pneumonia (9/48, 18.8%). The most common CDI treatment regimens were metronidazole monotherapy (137/238, 57.6%), vancomycin monotherapy (13/238, 5.5%), and combination therapy (88/238, 37.0%). Among patients who were treated with metronidazole monotherapy, vancomycin monotherapy, and combination therapy, 30(30/137, 21.9%), 3 (3/13,23.1%), and 15 (15/88, 17.1%) had positive culture for gram-negative organisms, respectively (P= 0.6). Ninety-seven (97/238,40.8%) patients had severe CDI, 40 (40/97, 41.2%) were treated with metronidazole monotherapy, 5(5/97, 5.2%) with vancomycin monotherapy, and 52 (52/97, 53.6%) with combination therapy. 26 (26/141,18.4%) and 22 (22/97, 22.7%) had positive culture for gram-negative organisms among patients with non-severe and severe CDI, receptively (P= 0.7). In the multivariate analysis, neither type of CDI treatment regimen (P=0.2, 95% CI 0.30–1.31) nor CDI severity (P=0.4, 95% CI 0.67–2.69) was associated an increased risk of infection with gram-negative organisms after CDI onset. Conclusions Contrary to the reported literature, we did not find that oral vancomycin-based CDI treatment was associated with increased risk of infection with gram-negative organisms. Funding Agencies None