Clostridioides Difficile Infection Rates Research Articles

P684 Multiplex Gastrointestinal Pathogen Panel Testing is Associated with Higher Rates of Inflammatory Bowel Disease Therapy Escalation in Patients Hospitalised with Flare

Abstract Background Although the role of Clostridioides difficile infection (CDI) testing in inflammatory bowel disease (IBD) flare is well established, the function of additionally testing for non-CDI enteric infections (EI) via multiplex gastrointestinal pathogen polymerase chain reaction (GI panel) stool tests remains unclear. Patients with PCR-confirmed EI are less likely to have IBD therapy escalated; however, it is unknown whether performing testing itself affects IBD-related decision-making and outcomes. This is vital given the similar clinical presentations of flare and EI. We examined differences in IBD outcomes among patients who – in addition to testing for CDI – were and were not co-tested for EI during hospitalisation for flare. Methods We conducted a retrospective cohort study of IBD patients hospitalised with flare and tested for CDI at an urban academic medical centre. We collected data on demographics, IBD disease severity, IBD therapy, and antibiotic therapy. Patients were cohorted by co-testing for EI using a GI panel. The primary outcome was escalation of IBD therapy within 24 hours of emergency department presentation. Each IBD therapy was also studied separately. Secondary outcomes were antibiotic therapy, length of stay, and colectomy. Results Of 134 patients, 66 (49.3%) were co-tested and 7 (10.6%) had an EI detected. Disease severity and CDI rates were comparable between groups (Table 1). Co-tested patients were more likely to receive a new IBD therapy (92.4% vs. 75.0%, p=0.006), specifically intravenous (IV) steroids (89.4% vs. 36.8%, p=<0.001; Table 2). Patients who were not co-tested were more likely to have their existing IBD therapy continued on admission. Co-tested patients were less likely to undergo colonoscopy during admission and had lower rates of prolonged antibiotic therapy (>10 days; 4.5% vs. 14.7%, p=0.047), although prolonged antibiotic use was comparable between groups after excluding patients treated for CDI (5.1% co-tested vs. 1.8% not co-tested, p=0.276). Colectomy rates and length of stay were comparable between groups. Conclusion Co-testing for non-CDI enteric pathogens by GI panel was associated with a greater degree of inpatient IBD flare management – especially IV steroids. Patients not co-tested were more likely to stay on their existing IBD therapy regimen despite similar flare severities at presentation. Given the low pathogen detection rates, early negative testing for EI may promote provider confidence in intensifying IBD therapy. Early clinical improvement after therapy escalation may obviate the need for colonoscopy in these patients. Use of the GI panel may affect IBD decision-making during relapse, and should be considered in all IBD patients hospitalised with flare.

The efficacy and safety of oral levofloxacin therapy for overall infection prophylaxis in cancer patients with neutropenia in outpatient settings.

e18681 Background: Patients undergoing chemotherapy treatment are at risk for bacterial infection during their period of neutropenia. However, not all neutropenic patients are at high risk for developing infection. The purpose of this study was to evaluate the efficacy and safety of prophylactic oral levofloxacin in high, intermediate, and low infection risk patients with cancer in the ambulatory care setting. Methods: This was a retrospective chart review of 100 cancer patients with high, intermediate, and low overall infection risk who were prescribed outpatient oral levofloxacin prophylaxis between October 2019 and July 2020. This quality improvement project included adults with a history of malignancy and presence of neutropenia who have received chemotherapy treatment and oral levofloxacin therapy for overall infection prophylaxis. The primary efficacy outcome was the rate of hospital admission due to febrile neutropenia. The primary safety outcome was the occurrence of side effects of levofloxacin therapy. Secondary outcomes evaluated the duration of levofloxacin therapy, the rate of fluoroquinolone resistance in positive bacterial cultures, progression to sepsis in hospitalized patients and the rate of death due to mult-idrug resistance including fluoroquinolones. Results: Hospital admission due to febrile neutropenia after a chemotherapy cycle occurred in 18% of patients prescribed levofloxacin. Among hospitalized patients due to febrile neutropenia, 2% had low to intermediate overall infection risk and 16% had high overall infection risk. The primary safety outcome occurred in 25% of patients. The incidence of QTc prolongation occurred in 8% of patients; dermatologic side effects occurred in 9% of patients; the rate of Clostridioides difficile infection was 6%, and the rate of tendon rupture was 2%. Median duration of levofloxacin prophylaxis in the low overall infection risk group was 7 days, compared to the intermediate overall infection risk group (8.5 days) and the high overall infection risk group (14 days) with Kruskal-Wallis test p-value of 0.0009. The rate of fluoroquinolone resistance in positive bacterial cultures was 10%. Progression to sepsis in hospitalized patients occurred in 17% of patients. The rate of death due to multi-drug resistance including fluoroquinolone was 2%. Conclusions: Our findings signify preserved efficacy of levofloxacin prophylaxis in the ambulatory setting. Our findings should be considered to develop rational strategies to reduce fluoroquinolone overprescribing or limit duration of levofloxacin prophylaxis. If patients present with solid tumors and experience neutropenia, the use of antibacterial prophylaxis is not recommended because in general, patients recover from neutropenia quickly.

Retrospective study of the efficacy and safety of metronidazole and vancomycin for Clostridioides difficile infection

IntroductionAccording to the Japanese guidelines for the management of Clostridioides difficile infection (CDI), the first choice is metronidazole (MNZ) for non-severe cases and vancomycin (VCM) for severe cases. However, the appropriateness of this first choice in Japanese patients is unclear. We therefore evaluated the appropriateness of the CDI management guidelines and the incidence of adverse drug reactions. MethodsThe electronic chart data at Keio University Hospital between January 2012 and June 2019 were retrospectively reviewed. The response rate, the relapse rate, and the adverse reaction rate of treatment for CDI using MNZ or VCM were investigated according to the disease severity. Factorial analysis associated with the response, relapse, and adverse reaction was also performed. ResultsIn the 352 patients surveyed, no significant difference was observed in the response rate between MNZ and VCM regardless of the severity of CDI. The presence of cancer was a factor related to the persistence of diarrheal symptoms and older age was a risk factor for relapse. MNZ induced nausea significantly more frequently than VCM, and young age and female sex were risk factors for nausea. ConclusionAs no significant difference was observed in the response rate of CDI between MNZ and VCM, the Japanese CDI management guidelines, which recommend MNZ as the first choice, were demonstrated to be appropriate. Attention to nausea was also suggested to be necessary when administering MNZ to young females.

Evaluation of a Pharmacist-Led Penicillin Allergy Assessment Program and Allergy Delabeling in a Tertiary Care Hospital

Penicillin allergies are frequently mislabeled, which may contribute to use of less-preferred alternative antibiotics. To evaluate a pharmacist-led allergy assessment program's association with antimicrobial use and clinical outcomes. A pharmacist-led allergy assessment program was launched in 2 phases (June 1, 2015, and November 2, 2016) at a single-center tertiary referral hospital. The longitudinal cross-sectional study included all study period adult admissions; hospitalwide outcomes were assessed by segmented regression. Individual outcomes were assessed within an embedded propensity score-matched case-control study of inpatients undergoing comprehensive allergy assessment following self-report of penicillin allergy. Analysis occurred from March 1, 2020, to February 29, 2020. The longitudinal study analyzed hospital-level outcomes over 3 periods: preintervention (15 months), phase 1 (structured allergy history alone, 16 months), and phase 2 (comprehensive assessment including penicillin skin testing, 52 months). The case-control study defined cases as individuals undergoing comprehensive allergy assessment. Hospital-level outcomes included antibiotic days of therapy per 1000 patient-days and hospital-acquired Clostridioides difficile infection (CDI) incidence per 10 000 patient-days. Individual outcomes included antibiotic selection, overall survival, and CDI-free survival. Longitudinal analysis spanned 2014-2020 (median admissions, 46 416 per year; interquartile range [IQR], 46 001-50 091 per year). Hospitalwide, allergy histories were temporally associated with decreased use of nonpenicillin alternative antibiotics (rate ratio, 0.87; 95% CI, 0.79-0.97) and high-CDI-risk antibiotics (rate ratio, 0.91; 95% CI, 0.85-0.98). Penicillin skin testing was temporally associated with lower hospital-acquired CDI rates (rate ratio, 0.61; 95% CI, 0.43-0.86). The embedded case-control study included 272 cases and 819 controls. Median age was 63 years (interquartile range, 51-73 years), 553 (50.7%) patients were women, and 229 (21.0%) patients were Black. Allergy-assessed patients were less likely to receive high-CDI-risk antibiotics at discharge (odds ratio, 0.66; 95% CI, 0.44-0.98). Estimated reductions in mortality (hazard ratio, 0.77; 95% CI, 0.55-1.07) and hospital-acquired CDI risk (hazard ratio, 0.53; 95% CI, 0.18-1.55) were not statistically significant. Pharmacist-led allergy assessments may be associated with reduced high-CDI-risk antibiotic use at both hospitalwide and individual levels. Although individual reductions in mortality and CDI risk did not achieve significance, divergence of survival curves suggest longer-term benefits of allergy delabeling warrant future study.

A Multicenter Evaluation of Probiotic Use for the Primary Prevention of Clostridioides difficile Infection.

Primary prevention of Clostridioides difficile infection (CDI) is a priority for hospitals. Probiotics have the potential to interfere with colonization and CDI. In this study, we evaluated the impact of a computerized clinical decision support (CCDS) tool to prescribe probiotics for primary prevention of CDI among adult hospitalized patients. A CCDS tool was implemented into the electronic medical record at 4 hospitals to prompt prescription of a probiotic preparation at the time of antibiotic prescription in high-risk patients in May 2019. Interrupted time series using segmented regression analysis was conducted to evaluate hospital-wide CDI incidence for the year pre- and post-CCDS implementation. In addition, multivariable logistic regression was used to evaluate CDI incidence in patients who qualified for probiotics in the pre- vs post-intervention periods, adjusting for potential confounders. To adjust for potential differences in patients who received probiotics in the post-intervention period, propensity score-matched pairs were developed to evaluate CDI risk by receipt of probiotics. Quarterly CDI incidence increased over time post-intervention relative to baseline trends (slope change, 1.4; 95% confidence interval [CI], .9-1.9). The odds ratio (OR) of CDI was 1.41 in eligible patients post-intervention compared with pre-intervention (adjusted OR, 1.41; 95% CI, 1.11-1.79). Propensity score-matched analysis showed that patients who received probiotics did not have lower rates of CDI compared with those who did not receive probiotics (OR, 1.46; 95% CI, .87-2.45). Use of probiotics for primary prevention of CDI among adult inpatients receiving antibiotics is not supported.

"If the glove fits": Hospital-wide universal gloving is associated with improved hand hygiene and may reduce Clostridioides difficile infection.

To determine whether a hospital-wide universal gloving program resulted in increased hand hygiene compliance and reduced inpatient Clostridioides difficile infection (CDI) rates. We carried out a multiple-year before-and-after quasi-experimental quality improvement study. Gloving and hand hygiene compliance data as well as hospital-acquired infection rates were prospectively collected from January 1, 2015, to December 31, 2017, by secret monitors. The University of Rochester Strong Memorial Hospital, an 849-bed quaternary-care teaching hospital. All adult inpatients with the exception of patients in the obstetrics unit. A hospital-wide universal gloving protocol was initiated on January 1, 2016. Hand hygiene compliance increased from 68% in 2015 reaching an average of 88% by 2017 (P < .0002). A 10% increase in gloving per unit was associated with a 1.13-fold increase in the odds of hand hygiene (95% credible interval, 1.12-1.14). The rates of CDI decreased from 1.05 infections per 1,000 patient days in 2015 to 0.74 in 2017 (P < .04). A universal gloving initiative was associated with a statistically significant increase in both gloving and hand hygiene compliance. CDI rates decreased during this intervention.

A163 MAJORITY OF INFLAMMATORY BOWEL DISEASE PATIENTS WITH RECURRENT CLOSTRIDIOIDES INFECTION DO NOT REQUIRE FECAL MICROBIOTA TRANSPLANTATION

Abstract Background Patients with inflammatory bowel disease (IBD) are at increased risk of developing Clostridioides difficile infection (CDI) and have worse outcomes including higher rates of colectomy and death, and experience higher rates of recurrent CDI (rCDI). However, it is still not clear whether rCDI is a cause of refractory IBD or a consequence of the inflammatory state in the colon. Aims We aimed to assess the outcomes of rCDI in patients with active IBD compared to inactive IBD in the era of fecal microbiota transplantation (FMT) Methods This is a retrospective cohort of adult IBD patients with rCDI at the IBD centre at the University of Alberta hospital between 2014–2017. rCDI was defined as a recurrent episode occurring within 60 days of the prior after successful treatment with antibiotics. We collected demographic and clinical characteristics, along with the rCDI-related and FMT outcomes in patients with active and inactive IBD. Active IBD was based on clinical assessment using a combination of disease severity scores (Harvey Bradshaw Index, partial Mayo scores), presence of active disease on colonoscopy, clinical symptoms and/or treatment escalation or change in the month leading up to rCDI diagnosis. Results Over the study period, 56 IBD patients (50% ulcerative colitis, 28/56) had a total of 85 rCDI episodes. Thirty-four percent (19/56) of patients had two or more rCDI episodes. Forty-one percent (35/85) of rCDI episodes were toxin positive while the remainder were only PCR positive. Thirty-nine percent (33/85) had active IBD at the time of CDI diagnosis. Patients with active IBD were more likely to have rCDI (1.7 rCDI episodes vs. 1.5, p=0.018). IBD treatment escalation was also more likely in the active IBD cases (79% vs. 44%, p = 0.002) with the use of steroids (27% vs 2%, p = 0.001) and addition of biologics (18% vs. 2%, p = 0.013). Active IBD cases were also more likely to be hospitalized (30% vs. 10%, p = 0.02) and were more likely to receive FMT (27% vs. 4%, p = 0.003). There was no difference in the time between rCDI episodes, antibiotic exposure or colectomy rates between the two groups. Conclusions Compared to IBD patients in remission, patients with active IBD are more likely to experience rCDI, IBD treatment escalation and FMT. It is interesting to note that only 27% of patients with recurrent CDI required FMT suggesting CDI may be a marker of active or refractory disease rather than a cause. Larger, prospective studies are needed to help clarify this association. Funding Agencies None

Clostridioides difficile infection in patients with hematological malignancy: A multicenter study in Taiwan.

Among the individuals with hematological malignancy (HM) complicated with Clostridioides difficile infection (CDI), the variables associated with in-hospital mortality and recurrence of CDI were investigated. Including adults with HM and those without malignancy suffering from CDI from January 2015 to December 2016 in three hospitals in Taiwan. Totally 314 patients including 77 with HM and 237 patients without malignancy were included. HM patients more often had low leukocyte counts (<500cells/mL: 28.6% vs. 2.1%) than those without malignancy and more patients without malignancy had severe CDI than patients with HM (31.6% vs. 14.3%, P=.003), according to the severity score of IDSA/SHEA. Patients with HM had a higher recurrence rate of CDI (14.3%, 11/77 vs. 7.2%, 17/237; P=.07) and longer hospital stay (47.2±40.8 days vs. 33.3±37.3 days; P=.006) than those without malignancy. In the multivariate analyses for those with HM and CDI, the in-hospital mortality was associated with vancomycin-resistant Enterococcus (VRE) colonization or infection (odds ratio [OR] 7.72; P=.01), and C. difficile ribotype 078 complex infection (OR 9.22; P=.03). Moreover underlying hematological malignancy (OR 2.74; P=.04) and VRE colonization/infection (OR 2.71; P=.02) were independently associated with CDI recurrence. Patients with HM complicated with CDI were often regarded as non-severe infection, but had a similar in-hospital mortality rate as those without malignancy. CDI due to ribotype 078 complex isolates heralded a poor prognosis among HM patients.

Evaluating Initial Empiric Therapy for Neutropenic Fever in Vancomycin-Resistant Enterococcus-Colonized Patients.

ObjectivesVancomycin-resistant enterococcus infections impact mortality in oncology patients. Given the low rate of vancomycin-resistant enterococcus bacteremia, low virulence of vancomycin-resistant enterococcus, and advent of rapid diagnostic systems, vancomycin-resistant enterococcus-directed empiric therapy in vancomycin-resistant enterococcus-colonized patients with neutropenic fever may be unnecessary, promoting increased antimicrobial resistance, drug-related toxicity, and cost.MethodsVancomycin-resistant enterococcus-colonized adults admitted for hematopoietic stem cell transplantation or induction therapy for acute leukemia/myeloid sarcoma with neutropenic fever were stratified by vancomycin-resistant enterococcus bacteremia development and empiric vancomycin-resistant enterococcus-directed antimicrobial strategy for first neutropenic fever (Empiric Therapy vs. non-Empiric Therapy). Primary endpoints included vancomycin-resistant enterococcus-related, in-hospital, and 100-day mortality rates. Secondary outcomes included vancomycin-resistant enterococcus bacteremia incidence for first neutropenic fever and the entire hospitalization, length of stay, Clostridioides difficile infection rate, and duration and cost of vancomycin-resistant enterococcus-directed therapy.ResultsDuring first neutropenic fever, 3 of 70 eligible patients (4%) developed vancomycin-resistant enterococcus bacteremia. Although all 3 (100%) were non-Empiric Therapy, no mortality (0%) occurred. Of 67 patients not developing vancomycin-resistant enterococcus bacteremia, 42 (63%) received Empiric Therapy and 25 (37%) non-Empiric Therapy. Empiric Therapy had significantly greater median duration (3 days vs. 0 days; P<.001) and cost ($1604 vs. $0; P<.001) of vancomycin-resistant enterococcus-directed therapy but demonstrated no significant differences in clinical outcomes.ConclusionAvailable data suggest Empiric Therapy may offer no clinical benefit to this population, regardless of whether vancomycin-resistant enterococcus is identified in blood culture or no pathogen is found. Such an approach may only expose the majority of patients to unnecessary vancomycin-resistant enterococcus-directed therapy and drug-related toxicities while increasing institutional drug and monitoring costs. Even in the few patients developing vancomycin-resistant enterococcus bacteremia, waiting until the organism is identified in culture to start directed therapy likely makes no difference in mortality. This lack of benefit warrants consideration to potentially omit empiric vancomycin-resistant enterococcus-directed therapy in first neutropenic fever in many of these patients.

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

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

174. Impact of Cascade Reporting of Antimicrobial Susceptibility on Antimicrobial Consumption at a Veterans Affairs Medical Center

BackgroundCascade reporting (CR) is a strategy of reporting antimicrobial susceptibility test results in which secondary agents are only reported if an organism is resistant to primary, narrow spectrum agents within a drug class. A multidisciplinary team developed CR algorithms for Gram-negative bacteria based on the local antibiogram and infectious diseases practice guidelines.MethodsCR was implemented at a 399-bed tertiary care VAMC in March 2018. In a quasi-experimental study, antimicrobial use data across 8 inpatient units were extracted from the CDC’s NHSN AU module from April 2017 – March 2019 (12 months pre- and post-implementation of CR), reported as antimicrobial days of therapy (DOT) per 1000 days present (DP). T-tests and linear mixed models accounting for seasonal and random unit effects were used to compare antimicrobial use pre- and post-CR implementation.Figure 1A. Cascade reporting algorithm for antimicrobial susceptibility reporting for Enterobacteriaceae Figure 1B. Cascade reporting algorithm for antimicrobial susceptibility reporting for Pseudomonas aeruginosa ResultsFollowing CR implementation, mean monthly meropenem (p=0.005) and piperacillin/tazobactam (p=0.002) use decreased, while cefepime use increased (p< 0.001). The slope of ciprofloxacin use decreased by 2.16 DOTs/1,000 DP per month (SE=0.25, p< 0.001). The slope of cefpodoxime and moxifloxacin use decreased by 18% (p< 0.001), and 7% (p< 0.001), respectively. The slope of cephalexin use decreased by 0.55 DOTs/1,000 DP (SE=0.26, p< 0.001). The slope of ceftriaxone and cefepime use increased by 1.51 (SE=0.59, p=0.011) and 1.06 (SE=.32, p=0.002) DOTs/1000 DP per month, respectively. There were no significant changes in the slope of amoxicillin/clavulanate, levofloxacin, or meropenem consumption. Rates of Clostridioides difficile infection did not significantly change.Figure 2A. Average monthly use of oral antibiotics across all units in average days of therapy (DOTs) per 1000 days present. CR = Cascade reporting. *For Cefpodoxime and moxifloxacin medians were reported as data was not normally distributed. Figure 2B. Average monthly use of intravenous antibiotics across all units in average days of therapy (DOTs) per 1000 days present. CR = Cascade reporting. Table 1. Slope of Antimicrobial Utilization Pre and Post-Cascade Reporting Implementation. ConclusionAfter implementation of CR, the slope of ciprofloxacin use decreased and mean monthly meropenem use decreased. CR is a valuable tool that can be employed by ASPs to encourage optimal use of antibiotics.Disclosures All Authors: No reported disclosures

83. Staff Pharmacist-driven Prospective Audit and Feedback at a Community Hospital: Assessing an all Hands on Deck Approach to Antimicrobial Stewardship

BackgroundFacilities with robust antimicrobial stewardship programs often have infectious disease (ID) pharmacists with devoted time to complete antimicrobial stewardship initiatives. Smaller facilities with limited resources or lacking ID pharmacists, may encounter challenges meeting antimicrobial stewardship regulatory requirements. The goal of this study is to assess the impact of a staff pharmacist-driven prospective audit and feedback program in a small community hospital.MethodsA pre- and post-intervention study was performed to assess the primary outcome of days of therapy per 1,000 patient days (DOT) for targeted antimicrobials (ciprofloxacin, levofloxacin, piperacillin/tazobactam, cefepime, ceftazidime). Secondary outcomes were antibiotic expenditures and rates of Clostridioides difficile infection (CDI).ResultsSignificant decreases in DOT were observed for piperacillin/tazobactam (29.88 vs. 9.25; p < 0.001), ciprofloxacin (23.22 vs. 9.97; p < 0.001), levofloxacin (11.2 vs. 5.07; p < 0.001) and overall antipseudomonal DOT (62.91 vs. 51.67; p < 0.001). There was no difference in ceftazidime DOT (8.75 vs. 6.47; p= 0.083) and an increase in cefepime DOT (20.47 vs. 34.35; p < 0.001). A trend towards decreased rates of CDI was seen (4.9/10,000 patient days vs. 2.64/10,000 patient days; p= 0.931). There were significant decreases in antibiotic expenditures for piperacillin/tazobactam ($52,498 vs. $10,937; p < 0.001), levofloxacin ($2,168 vs. $672; p < 0.001), ciprofloxacin ($6,700 vs. $1,954; p < 0.001). Lower expenditures for ceftazidime were seen ($9,952 vs. $7,457; p= 0.29). Cefepime expenditures increased ($25,638 vs. $40,097; p= 0.001). An overall decrease in the expenditure for the targeted antibiotics was seen ($95,715 vs. $62,837; p < 0.001).ConclusionImplementation of a staff pharmacist-driven prospective authorization and feedback program led to a significant decrease in DOT and antibiotic expenditures for several targeted antibiotics and a trend towards decreased rates of CDI. Despite increased DOT and expenditures for cefepime, there was an overall decrease amongst the targeted antibiotics. With proper implementation, staff pharmacists can significantly benefit antimicrobial stewardship initiatives.Disclosures All Authors: No reported disclosures

216. Are Automatic Antimicrobial Stop Orders an Effective Stewardship Tool for Urinary Tract and Intra-Abdominal Infections?

BackgroundAutomatic antimicrobial stop orders (ASOs) are a stewardship initiative used to decrease days of therapy, prevent resistance, and reduce drug costs. Limited evidence outside of the perioperative setting exists on the effects of ASOs on broad spectrum antimicrobial use, discharge prescription duration, and effects of missed doses. This study aims to evaluate the impact of an ASO policy across a health system of adult academic and community hospitals for treatment of intra-abdominal (IAI) and urinary tract infections (UTI).ASO Outcome Definitions ASO Outcomes MethodsThis multicenter retrospective cohort study compared patients with IAI and UTI treated before and after implementation of an ASO. Patients over the age of 18 with a diagnosis of UTI or IAI and 48 hours of intravenous (IV) antimicrobial administration were included. Patients unable to achieve IAI source control within 48 hours or those with a concomitant infection were excluded. The primary outcome was the difference in sum length of antimicrobial therapy (LOT). Secondary endpoints include length and days of antimicrobial therapy (DOT) at multiple timepoints, all cause in hospital mortality and readmission, and adverse events such as rates of Clostridioides difficile infection. Outcomes were also evaluated by type of infection, hospital site, and presence of infectious diseases (ID) pharmacist on site.ResultsThis study included 119 patients in the pre-ASO group and 121 patients in the post-ASO group. ASO shortened sum length of therapy (LOT) (12 days vs 11 days respectively; p=0.0364) and sum DOT (15 days vs 12 days respectively; p=0.022). This finding appears to be driven by a decrease in outpatient LOT (p=0.0017) and outpatient DOT (p=0.0034). Conversely, ASO extended empiric IV LOT (p=0.005). All other secondary outcomes were not significant. Ten patients missed doses of antimicrobials due to ASO. Subgroup analyses suggested that one hospital may have influenced outcomes and reduction in LOT was observed primarily in sites without an ID pharmacist on site (p=0.018).ConclusionWhile implementation of ASO decreases sum length of inpatient and outpatient therapy, it may not influence inpatient length of therapy alone. Moreover, ASOs prolong use of empiric intravenous therapy. Hospitals without an ID pharmacist may benefit most from ASO protocols.Disclosures All Authors: No reported disclosures

793. Expert Panel Consensus Ranking of Comorbid Conditions Causally Related to Clostridioides difficile Infection

BackgroundNumerous studies have identified comorbidities that are associated with Clostridioides difficile infection (CDI), but current CDC and CMS models for risk adjusting hospital CDI rates do not include patient comorbid conditions. Incorporating patient-level data could improve CDI risk adjustment, but comorbidities would need to be easily electronically available for widescale implementation. Ideally, they would also be causally related to CDI — i.e., true risk factors, not confounders — to facilitate more unbiased inter-hospital comparisons. The current study aimed to determine which comorbid conditions are causally related to CDI based upon expert consensus.MethodsWe used Delphi methodology to administer an iterative, two-round survey with an intervening teleconference, to eight infectious disease experts. Experts evaluated 40 comorbid conditions included in Charlson and Elixhauser comorbidity indices (and thus validated for electronic capture through administrative data), as well as other comorbidities commonly associated with CDI. Experts rated comorbid conditions from 1 (not at all related) to 5 (strongly related), based upon perceived relatedness with CDI. To assign causal relatedness, the following criteria had to be met at the end of round two: 1) majority (> 50%) of experts rating the condition at 3 (somewhat related) or higher; 2) inter-quartile range (IQR) < = 1; and 3) standard deviation (SD) < = 1.Results8/40 (20%) comorbid conditions were ranked as causally related to CDI, including patient age, three malignancy comorbidities, two transplant-related comorbidities, HIV/AIDS, and inflammatory bowel disease. A further 18/40 (45%) qualified as indeterminately related, and 14/40 (35%) were ranked as not causally related to CDI (Table). Three of the eight causally related factors were not components of Elixhauser or Charlson indices.Table ConclusionWe identified comorbid conditions that may be appropriate candidates to consider for inclusion in patient-level risk adjustment models. Some causal factors did not originate from established comorbidity indices. Thus, future work to validate electronic capture of these conditions could further reduce barriers to risk-adjustment implementation.Disclosures All Authors: No reported disclosures

Impact of a Clostridioides Difficile Testing Computerized Clinical Decision Support Tool on an Adult Stem Cell Transplantation and Hematologic Malignancies Unit

Clostridioides difficile infection rates are higher in hospitalized hematopoietic stem cell transplantation (HSCT) recipients and patients with hematologic malignancy (HM) compared with the general population. This is related both to extensive exposure to antibiotics as well as to frequent and often prolonged hospitalization. In this population, with numerous potential causes of diarrhea, a subset of C difficile detected is presumed to represent colonization rather than clinical infection. The use of decision support tools to guide ordering in hospitalized patients has been reported to decrease both C difficile testing and detection rates. Following implementation of a computerized decision support tool on our HSCT/HM unit, we observed a >2-fold decrease in C difficile testing volume and National Healthcare Safety Network-defined laboratory identifications of C difficile. Furthermore, the rate of oral vancomycin use, as well as the incidence of vancomycin-resistant enterococci colonization and bloodstream infection, decreased in the postintervention period.

Substantial reduction of healthcare facility-onset Clostridioides difficile infection (HO-CDI) rates after conversion of a hospital for exclusive treatment of COVID-19 patients

Healthcare facility-onset Clostridioides difficile infection rates substantially dropped in a Mexican hospital after its conversion to a full COVID-19 setting, despite heavy contamination of the environment the previous year. Better adherence to hand hygiene and contact precautions may help explain this finding.

Assessment of antimicrobial stewardship programs within governmental hospitals in Qatar: a SWOC analysis.

Antimicrobial resistance is a worldwide public health issue that requires emergent action. Antimicrobial stewardship programs (ASPs) have been proposed as a strategy to minimise resistance. Although ASPs were implemented in governmental hospitals in Qatar since 2015, a formal evaluation of these programs has not been conducted. We aimed to assess the status of ASPs in Qatar and to identify strengths, weaknesses, opportunities and challenges (SWOC) to further enhance ASPs within Hamad Medical Corporation (HMC). Lead stakeholders of ASPs in HMC filled a questionnaire adapted from the 2019 Centers for Disease Control Prevention checklist for ASPs. Notes were taken by research team to assist in formulating a SWOC analysis. All hospitals (12/12) had an infectious diseases physician and pharmacist designated as an ASP leader (major strength identified). Almost all hospitals lack a financial statement and information technology resources to support ASPs (major weaknesses identified). Nine hospitals had an antibiotic pre-authorisation policy and adopted a prospective audit with feedback strategy. Among hospitals surveyed, 11 hospitals tracked antibiotic use by measuring the defined daily dose, and only four hospitals tracked rates of Clostridioides difficile infection. Qatar's rich economy supports the allocation of financial resources and budgeting to improve ASPs despite the increased emergence of resistant organisms and the limited resources currently available to expand ASPs across the country's healthcare settings. Although ASPs were implemented in all governmental hospitals in Qatar, national efforts and more resources are needed to further develop and improve these programs.

The use of laboratory-identified event surveillance to classify adverse outcomes due to Clostridioides difficile infection in Canadian long-term care facilities.

Adverse outcomes following Clostridioides difficile infection (CDI) are not often reported for long-term care facility (LTCF) residents. We focused on the adverse outcomes due to CDI identified in Alberta LTCFs. All positive Clostridioides difficile stool specimens identified by laboratory-identified (LabID) event surveillance in Alberta from 2011 to 2018, along with Alberta Continuing Care Information System, were used to define CDI in Alberta LTCFs. CDI cases were classified as long-term care onset, hospital onset, and community onset. Laboratory records were linked to provincial databases to analyze acute-care admissions and mortality within 30-day post CDI. Age, sex, case classification, episode, and operator type, were investigated using logistic regression. Overall, 902 CDI cases were identified in 762 LTCF residents. Of all CDI events, 860 (95.3%) were long-term care onset, 38 (4.2%) were hospital onset, and 4 (0.4%) were community onset. The CDI rate was 2.0 of 100,000 resident days. In total, 157 residents (20.6%) had 30-day all-cause mortality, 126 CDI cases (14.0%) had 30-day all-cause acute-care admissions. The 30-day all-cause mortality rate was significantly higher in residents aged >80 versus ≤80 years (24.9 vs 12.3 per 100 residents; P < .05). Residents aged >80 years, with hospital-onset CDI, and those staying in private or voluntary LTCFs were more likely to have 30-day all-cause acute-care admissions. The prevalence of CDI adverse outcomes is in LTCFs was found to be high using LabID event surveillance. Annual review of CDI adverse outcomes using LabID event can minimize the burden of surveillance and standardize the process across all Alberta LTCFs.

Effect of Testing Methods on Incidence of Clostridioides difficle Infection Rates in Veterans’ Affairs Medical Centers

Background: Healthcare-associated Clostridioides difficile infection (CDI) rates have been decreasing in Department of Veterans’ Affairs (VA) acute-care medical facilities since the CDI Prevention Initiative began in 2012. Assessment of rates, however, is complicated by changing surveillance definitions and diagnostics. Over the past 2 years, the VA has adopted the less stringent surveillance definitions of the NHSN for hospital-onset healthcare-facility–associated (HO-HCFA) CDI (onset on or after day 4 of hospitalization) than was originally used (&gt;48 hours after admission). New diagnostic testing methods have been developed, but variabilities in the reliability of testing methods for the diagnosis of CDI in patients have been detected, thus not yielding a gold standard test. As a result, some facilities use nucleic acid amplification testing (NAAT) for CDI diagnosis and reporting whereas others use a 2-step process of NAAT followed by a toxin enzyme immunoassay (EIA) test, with the latter determining positivity for reporting (as allowed by the NHSN). We reviewed CDI rates at facilities performing one-step and two-step testing to determine whether the testing protocol may be influencing CDI rate reporting. Methods: Data on HO-HCFA CDI rates entered monthly in fiscal year (FY) 2018 (October 2017 through September 2018) and FY2019 (October 2018 through September 2019) by each acute-care facility into the VA Inpatient Evaluation Center (IPEC) database were analyzed. HO-HCFA CDI rates in facilities that used NAAT in FY2018 and switched to in the 2-step NAAT plus EIA in FY2019 were compared to rates in facilities used NAAT alone for both FY2018 and FY2019. Statistical regression analysis was performed. Results: From FY 2018 through FY2019, 70 facilities performed NAAT for the entire 2-year period. Overall, 7 facilities performed NAAT for FY 2018 and then switched to NAAT + EIA in FY2019. We detected no significant decrease in HO-HCFA CDI rates in FY 2018 when both groups were using NAAT (P = 0.21) (Fig. 1). However, in FY2019, there was a significant decrease in HO-HCFA CDI rates for those facilities that performed the 2-step testing versus those facilities that continued to use strictly NAAT alone (P &lt; .0001). Conclusions: HO-HCFA CDI rates decreased for those VA acute-care facilities that switched to 2-step testing, and this finding highlights implications for assessing rates over time. Given the variable reliability of the toxin test, individual patient consideration for therapeutic decisions is reasonable.Funding: NoneDisclosures: None

Antimicrobial Stewardship Programs and Antibiotic Usage and Resistance in Department of Veterans’ Affairs Medical Centers

Background: Implementation of antimicrobial stewardship programs (ASPs) in acute-care facilities may optimize antibiotic use and decrease antibiotic resistance. To explore the relationship between ASPs and clinical outcomes, we reviewed bivariate relationships between VA Medical Center (VAMC) complexity level and presence of an ASP, presence of an ASP and inpatient antibiotic use, and antibiotic use and antibiotic resistance or Clostridioides difficile infection (CDI). Methods: We conducted a cross-sectional study of national data using the following elements: a detailed survey of antimicrobial stewardship practices at VAMCs in 2012 which included facility complexity designations; data from the VA national Electronic Health Record (EHR) for inpatient antibiotic use (2009–2012 in days of therapy per 1,000 bed days of care); EHR laboratory data in 2013 for antibiotic resistance in E. coli isolates; and 2013 CDI rate data from the VA Inpatient Evaluation Center. These data were reviewed for assessment of the presence of ASPs and for antibiotic use and resistance. We assessed 4 groups of antibiotics for use and resistance: total antibiotics, fluoroquinolones, cephalosporins, and carbapenems. Categorical, t test, or nonparametric analyses were performed, as appropriate. Results: 120 VAMCs were evaluated; 71% had ASPs. Proportions of VAMCs with ASPs were not significantly different by facility complexity level. Differences were observed between presence or absence of ASP and some antibiotic use groups (Table). Presence or absence of an ASP was not statistically associated with a difference in E. coli resistance (any antibiotic group examined) or CDI rates. In addition, antibiotic use (any group) did not statistically associate with E. coli resistance rates, and this result remained unchanged when stratified by presence or absence of an ASP. Conclusions: Total antibiotic use and fluroquinolone use were lower among facilities with ASPs than without, a finding consistent with ASP implementation reducing the amount of antibiotics prescribed. Although we did not find an association between facilities with an ASP and antibiotic resistance or CDI rates in this preliminary review, it sets the stage for future multivariate analyses. Furthermore, given the years of antibiotic use needed for development of resistance, the limited years evaluated may not have been sufficient to determine an impact, highlighting the need for further research into understanding clinical outcomes.Funding: NoneDisclosures: None