scholarly journals 104. Evaluation of a 2-Step Testing Algorithm for Clostridioides difficile Infection

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S66-S67
Author(s):  
Caitlin C Bettger ◽  
Stephanie Giancola ◽  
Robert Cybulski ◽  
Jason Okulicz ◽  
Alice Barsoumian
Keyword(s):  
Medical Center ◽  
Laboratory Data ◽  
Antibiotic Use ◽  
Treatment Decisions ◽  
High Rate ◽  
Clinical Criteria ◽  
Treatment Status ◽  
Clostridioides Difficile ◽  
Stewardship Program ◽  
Clostridioides Difficile Infection

Abstract Background A 2-step testing strategy for diagnosis of Clostridioides difficile infection (CDI) is recommended to limit over-diagnosis when clinical criteria requirements for stool sample submission cannot be enforced. Real-world evaluations of this strategy are limited. Methods The Antimicrobial Stewardship Program at Brooke Army Medical Center, San Antonio, TX, implemented a 2-step CDI algorithm: polymerase chain reaction (PCR) testing followed by toxin enzyme immunoassay (EIA). The goal was to improve diagnosis of CDI and reduce unnecessary antibiotic use. Patients with PCR+ tests from August 2018 to September 2019 were included. Charts were reviewed for demographics, laboratory data, treatment, and outcomes. Cases were grouped based on concordant (PCR+/EIA+) or discordant (PCR+/EIA-) results. To determine factors contributing to treatment decisions, an analysis of discordant cases were compared by treatment status. Groups were compared by Chi-squared, Fisher’s exact, or Mann-Whitney U tests. Results A total of 216 PCR+ tests from 215 patients were recorded. Of these, 155 (71.8%) were discordant. Demographics, laboratory data, and risk factors for CDI were similar between groups (Table 1; p >0.05 for all). Compared to discordant cases, concordant cases were more frequently hospitalized (59% vs 43.9%; p=0.05), had a higher median daily stool count (5 [4–7] vs 4 [2–6], p=0.03), met criteria for severe CDI (33.3% vs 18.7%; p=0.05), received treatment (95.1% vs 66.5%; p< 0.01) and were readmitted in 30 days with CDI (8.3% vs 1.3%; p=0.02). Among discordant cases, median daily stool count was higher in treated vs untreated cases (4 [3–7] vs 3 [1–5], p=0.02). Otherwise, there was no difference in variables according to treatment status (Table 2; p >0.05 for all). Discordant cases with infectious disease (ID) or gastroenterology (GI) consultation had a high rate of treatment (73.9% and 61.1%, respectively). Table 1. Characteristics and outcomes of patients with concordant and discordant tests. Table 2. Characteristics and outcomes of treated and untreated patients with discordant tests. Conclusion Implementation of 2-step strategy reduced antibiotic treatment by nearly 30%. However, the majority of discordant cases were deemed clinically significant and received treatment by providers, including ID or GI specialists. Further studies are needed to determine the unmeasured factors that guide treatment decisions in discordant cases. Disclosures All Authors: No reported disclosures

scholarly journals Evaluation of Cycle Threshold, Toxin Concentration, and Clinical Characteristics of Clostridioides difficile Infection in Patients with Discordant Diagnostic Test Results

2020 ◽  
Vol 58 (5) ◽  
Author(s):  
Megan D. Shah ◽  
Joan-Miquel Balada-Llasat ◽  
Kelci Coe ◽  
Erica Reed ◽  
Johanna Sandlund ◽  
...  
Keyword(s):  
Clinical Characteristics ◽  
Laboratory Data ◽  
Antibiotic Use ◽  
Neutralization Assay ◽  
Test Results ◽  
Toxin Concentration ◽  
Content Type ◽  
Cycle Threshold ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection

ABSTRACT Clostridioides difficile infection (CDI) is one of the most common health care-associated infections that can cause significant morbidity and mortality. CDI diagnosis involves laboratory testing in conjunction with clinical assessment. The objective of this study was to assess the performance of various C. difficile tests and to compare clinical characteristics, Xpert C. difficile/Epi (PCR) cycle threshold (CT), and Singulex Clarity C. diff toxins A/B (Clarity) concentrations between groups with discordant test results. Unformed stool specimens from 200 hospitalized adults (100 PCR positive and 100 negative) were tested by cell cytotoxicity neutralization assay (CCNA), C. diff Quik Chek Complete (Quik Chek), Premier Toxins A and B, and Clarity. Clinical data, including CDI severity and CDI risk factors, were compared between discordant test results. Compared to CCNA, PCR had the highest sensitivity at 100% and Quik Chek had the highest specificity at 100%. Among clinical and laboratory data studied, prevalences of leukocytosis, prior antibiotic use, and hospitalizations were consistently higher across all subgroups in comparisons of toxin-positive to toxin-negative patients. Among PCR-positive samples, the median CT was lower in toxin-positive samples than in toxin-negative samples; however, CT ranges overlapped. Among Clarity-positive samples, the quantitative toxin concentration was significantly higher in toxin-positive samples than in toxin-negative samples as determined by CCNA and Quik Chek Toxin A and B. Laboratory tests for CDI vary in sensitivity and specificity. The quantitative toxin concentration may offer value in guiding CDI diagnosis and treatment. The presence of leukocytosis, prior antibiotic use, and previous hospitalizations may assist with CDI diagnosis, while other clinical parameters may not be consistently reliable.

scholarly journals 799. Mini Root Cause Analysis Reveals Opportunities for Reducing Clostridioides difficile Infection Rates

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S443-S443
Author(s):  
Nicholas A Turner ◽  
Jessica L Seidelman ◽  
Rebekah Wrenn ◽  
Deverick J Anderson ◽  
Sarah S Lewis ◽  
...  
Keyword(s):  
Urinary Tract ◽  
Broad Spectrum ◽  
Infection Type ◽  
Antibiotic Use ◽  
High Rate ◽  
Infection Rates ◽  
Root Cause ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Tract Infections

Abstract Background C. difficile remains the single most common pathogen among healthcare-associated infections. We conducted a multi-center, prospective study using on-site, near real-time root cause analyses to identify opportunities for reducing hospital-onset C. difficile infection rates (HO-CID). Methods This prospective cohort study enrolled inpatients with HO-CDI admitted to one of 20 participating hospitals in the southeastern United States from July 2019 to June 2020. For each HO-CDI case, mini root cause analyses were conducted by on-site physicians, infection preventionists, or stewardship pharmacists to assess appropriateness of C. difficile testing and inpatient antibiotic use from the 30 days preceding HO-CDI diagnosis. Results The cohort captured 554 total HO-CDI cases and 956 antibiotic use events. 147 (26.5%) of HO-CDI cases were adjudicated as likely inappropriate and a further 51 (9.2%) as potentially inappropriate. Among inappropriately tested cases, 103 (52.0%) had received either laxatives or tube feeds in the preceding 48 hours. 132 (13.8%) of antibiotic use events were identified as potentially inappropriate. Among potentially inappropriate antibiotic use events, 40 (30.3%) received unnecessarily broad-spectrum antibiotics, 20 (15.2%) lacked a confirmed infectious diagnosis, and 4 (3.0%) received a longer than guideline-recommended duration. Risk of inappropriate antibiotic use varied by infection type, with treatment of urinary tract infection being associated with the highest risk of inappropriate antibiotic use (table 1). Table 1: Relative Risk of Inappropriate Antibiotic Use by Indication Conclusion Mini root cause analyses may be a helpful tool for identifying -specific opportunities to reduce HO-CDI rates. We found a high rate of inappropriate testing, usually related to alternative causes for diarrhea such as laxative receipt or tube feeds. While rates of inappropriate antibiotic use were lower than has been reported elsewhere, the majority of opportunities for improvement related to overly broad-spectrum coverage. Urinary tract infections were most strongly associated with inappropriate antibiotic use preceding HO-CDI. Disclosures All Authors: No reported disclosures

scholarly journals 697. Outcomes of Tigecycline Use for Clostridioides difficile Infection: A Case Series of 28 Patients

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S449-S449
Author(s):  
Emma C Phillips ◽  
Cirle A Warren ◽  
Gregory Madden
Keyword(s):  
Medical Center ◽  
Significant Proportion ◽  
Case Series ◽  
Recurrent Infection ◽  
Initial Therapy ◽  
High Rate ◽  
Controlled Clinical Trials ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection

Abstract Background Clostridioides difficile infection remains a highly morbid or lethal condition in an unacceptably large proportion of patients. To date, there are limited and conflicting data to support the use of tigecycline for C. difficile infection and the optimal stratification approach, timing (i.e., initial vs. salvage therapy), and duration are unclear. Methods We describe in detail a retrospective cohort of 28 C. difficile inpatients treated with tigecycline at UVA Medical Center. We stratify each patient by the Infectious Diseases Society of America’s guidelines on severity of infection and detail the timing and duration of tigecycline therapy in each case. We further characterize the effect of tigecycline on 90-day mortality and recurrence. Results 9/28 (32.1%) patients were treated with tigecycline for fulminant (presence of hypotension, shock, ileus, or megacolon), and 12/28 (42.9%) for severe (white blood cell count over 15x109/L or creatinine over 1.5mg/dL) C. difficile infection. Tigecycline was used in all cases in combination with oral vancomycin +/- metronidazole. The average duration of therapy was 7.6 days, with tigecycline as initial therapy (use within the first 72 hours of the start of directed antimicrobial therapy) in 7/28 (25%) cases. 90-day mortality occurred in 10/26 (35.7%) patients (two did not reach 90-day follow-up), all 10 of which were in-hospital mortalities and 5/10 (50%) occurred in patients with fulminant infection. 7 of the 16 (43.8%) surviving patients that reached 90-day follow-up had recurrent C. difficile infection. Conclusion Patients selected for treatment with tigecycline for C. difficile infection suffered a high rate of in-hospital mortality, especially among the significant proportion with fulminant disease. The rate of recurrent infection was substantial, contrary to some reports of reduced recurrence with tigecycline from the literature. The outcomes of tigecycline (as adjunct or monotherapy) for treatment of severe/fulminant and refractory infection versus standard treatments warrant further retrospective analysis and the benefit of tigecycline in these settings remains to be proven in well-controlled clinical trials. Disclosures All Authors: No reported disclosures

scholarly journals Infection Preventionist Run Clostridioides difficile Testing Diagnostic Stewardship Protocol- Experience From a Rural Community Hospital

2020 ◽  
Vol 41 (S1) ◽  
pp. s484-s485
Author(s):  
Raghavendra Tirupathi ◽  
Ruth Freshman ◽  
Norma J Montoy ◽  
Melissa Gross
Keyword(s):  
Cost Savings ◽  
Antibiotic Use ◽  
First Year ◽  
Multiple Parameters ◽  
Clostridioides Difficile ◽  
Stewardship Program ◽  
Commercial Company ◽  
Surgical History ◽  
Test Ordering ◽  
Infection Preventionists

Background: Distinguishing active Clostridioides difficile infection (CDI) from asymptomatic colonization remains a challenging task in the era of PCR testing. Inappropriate testing leads to overtesting and overdiagnosis, inadvertent treatment, and isolation in addition to laboratory identified (LabID) events, leading to increased incidence to hospital-onset CDI (HO-CDI). The institution has a nurse-driven C. difficile test ordering protocol, and we noted a significant increase in the HO-CDI incidence in 2017 due to inappropriate testing, with rates as high as 0.94 per 1,000 patient days. Methods: In September 2017, a multidisciplinary team reviewed and initiated algorithm-based testing with mandatory audit and review by infection preventionists (IPs) under the guidance of an ID physician of all ordered tests. They reviewed the adequacy and legitimacy of order for multiple parameters, including minimum 3 loose stools in 24 hours, use of laxatives in last 24 hours, consistency of the sample, presence of at least 1 clinical parameters (ie, fever, abdominal pain, leukocytosis, sepsis, or septic shock), recent or concomitant antibiotic use, recent PCR testing in the last 14 days, and chart review for medical and/or surgical history. The IPs served as the gatekeepers to testing and rejected the samples that were deemed inappropriate. Ambiguous cases were discussed with the ID specialist. On the microscope lab side, all specimens sent were batched to be run twice a day at 8:30 a.m. and 2:30 p.m., and testing was performed only on the samples cleared by infection preventionists. Results: The number of PCR tests completed in the comparison quarter of 2016 was 220, which decreased to 157 tests in 2017 with a reduction of 28%. After a full year of implementation of the diagnostic stewardship protocol, the number of completed PCR tests decreased to 626 from 940 PCR tests in 2016, with an overall 34% decrease in testing. In the year following the implementation of diagnostic stewardship, HO-CDI decreased from 60 events in 2017 to 43 events in 2018, with a reduction of 28%. Subsequently, HO-CDI further decreased in 2019 from 43 to 28, with a reduction of 35%. Since the implementation of the project in 2017, HO-CDIs have decreased by 54% overall. The reduction in 314 C. difficile PCR tests in the first year led to a savings of $8,300 in laboratory testing supplies. The reduction of HO CDI by 17 led to cost avoidance of $293,420. Conclusions: Our experience shows that the IP-run diagnostic stewardship program was highly successful in streamlining testing, with cost savings on several fronts.Funding: NoneDisclosures: NoneDisclosures:Commercial Company : If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principals and methods, and will not promote the commercial interest of the funding company.DisagreeRaghavendra Tirupathi

scholarly journals Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department

2020 ◽  
Vol 7 (12) ◽  
Author(s):  
Lindsay A Petty ◽  
Valerie M Vaughn ◽  
Scott A Flanders ◽  
Twisha Patel ◽  
Anurag N Malani ◽  
...  
Keyword(s):  
Emergency Department ◽  
Antibiotic Treatment ◽  
Asymptomatic Bacteriuria ◽  
Antibiotic Use ◽  
Altered Mental Status ◽  
Estimating Equation ◽  
Hospitalized Patients ◽  
Clostridioides Difficile ◽  
Cord Injury ◽  
Clostridioides Difficile Infection

Abstract Background Reducing antibiotic use in patients with asymptomatic bacteriuria (ASB) has been inpatient focused. However, testing and treatment is often started in the emergency department (ED). Thus, for hospitalized patients with ASB, we sought to identify patterns of testing and treatment initiated by emergency medicine (EM) clinicians and the association of treatment with outcomes. Methods We conducted a 43-hospital, cohort study of adults admitted through the ED with ASB (February 2018–February 2020). Using generalized estimating equation models, we assessed for (1) factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, (2) the effect of treatment on outcomes. Results Of 2461 patients with ASB, 74.4% (N = 1830) received antibiotics. The EM clinicians ordered urine cultures in 80.0% (N = 1970) of patients and initiated treatment in 68.5% (1253 of 1830). Predictors of EM clinician treatment of ASB versus no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993 of 1253) of patients remained on antibiotics for at least 3 days. Antibiotic treatment was associated with a longer length of hospitalization (mean 5.1 vs 4.2 days; relative risk = 1.16; 95% confidence interval, 1.08–1.23) and Clostridioides difficile infection (CDI) (0.9% [N = 11] vs 0% [N = 0]; P = .02). Conclusions Among hospitalized patients ultimately diagnosed with ASB, EM clinicians commonly initiated testing and treatment; most antibiotics were continued by inpatient clinicians. Antibiotic treatment was not associated with improved outcomes, whereas it was associated with prolonged hospitalization and CDI. For best impact, stewardship interventions must expand to the ED.

scholarly journals The Importance of Abnormal Platelet Count in Patients with Clostridioides difficile Infection

2021 ◽  
Vol 10 (13) ◽  
pp. 2957
Author(s):  
Shira Buchrits ◽  
Anat Gafter-Gvili ◽  
Jihad Bishara ◽  
Alaa Atamna ◽  
Gida Ayada ◽  
...  
Keyword(s):  
Platelet Count ◽  
Medical Center ◽  
Multivariable Analysis ◽  
Kidney Injury ◽  
Innate And Adaptive Immunity ◽  
Clostridioides Difficile ◽  
All Cause Mortality ◽  
Clostridioides Difficile Infection ◽  
Multivariable Analyses ◽  
Wbc Count

Background: Clostridium difficile infection (CDI) causes morbidity and mortality. Platelets have been increasingly recognized as an important component of innate and adaptive immunity. We aimed to assess the incidence of thrombocytopenia and thrombocytosis in CDI and the effect of an abnormal platelet count on clinical outcomes. Methods: This single-center, retrospective cohort study consisted of all adult patients hospitalized in Rabin Medical Center between 1 January 2013 and 31 December 2018 with laboratory confirmed CDI. The primary outcome was 30-day all-cause mortality. Risk factors for 30-day all-cause mortality were identified by univariable and multivariable analyses, using logistic regression. Results: A total of 527 patients with CDI were included. Among them 179 (34%) had an abnormal platelet count: 118 (22%) had thrombocytopenia and 61 (11.5%) had thrombocytosis. Patients with thrombocytosis were similar to control patients other than having a significantly higher white blood cell count at admission. Patients with thrombocytopenia were younger than control patients and were more likely to suffer from malignancies, immunosuppression, and hematological conditions. In a multivariable analysis, both thrombocytosis (OR 1.89, 95% CI 1.01–3.52) and thrombocytopenia (OR 1.70, 95% CI 1.01–2.89) were associated with 30-days mortality, as well as age, hypoalbuminemia, acute kidney injury, and dependency on activities of daily living. A sensitivity analysis restricted for patients without hematological malignancy or receiving chemotherapy revealed increased mortality with thrombocytosis but not with thrombocytopenia. Conclusions: In this retrospective study of hospitalized patients with CDI, we observed an association between thrombocytosis on admission and all-cause mortality, which might represent a marker for disease severity. Patients with CDI and thrombocytopenia also exhibited increased mortality, which might reflect their background conditions and not the severity of the CDI. Future studies should assess thrombocytosis as a severity marker with or without the inclusion of the WBC count.

scholarly journals 785. Association between Prevalence of Laboratory-Identified Clostridioides difficile Infections (CDIs) and CDI Antibiotic Treatment in U.S. Acute Care Hospitals, 2018

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S437-S437
Author(s):  
Kerui Xu ◽  
Andrea L Benin ◽  
Hsiu Wu ◽  
Jonathan R Edwards ◽  
Qunna Li ◽  
...  
Keyword(s):  
Acute Care ◽  
Acute Care Hospitals ◽  
Antibiotic Use ◽  
Prevalence Rates ◽  
Hospital Level ◽  
First Line ◽  
Oral Vancomycin ◽  
Patient Admissions ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection

Abstract Background Clostridioides difficile infections (CDIs) are an urgent public health threat, accounting for 223,900 infections and 12,800 deaths in hospitalized patients annually. In early 2018, the Infectious Disease Society of America (IDSA) recommended oral vancomycin or fidaxomicin as the first-line antibiotics for CDIs. To track the uptake of IDSA’s recommendations, we evaluated the association between CDI prevalence and use of first-line antibiotics in hospitals reporting to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN). Methods We matched 2018 hospital-level, NHSN data on laboratory-identified CDIs with NHSN antimicrobial use (AU) data for the same time period. Hospitals that submitted < 6 months of either data type in 2018 were excluded. The association between quarterly hospital-level CDI prevalence rates per 100 patient-admissions and use of CDI antibiotics (oral vancomycin plus fidaxomicin) per 1,000 days-present was evaluated using Pearson’s linear correlation coefficient and using Goodman and Kruskal’s gamma (G) on ordinal quartiles to assess rates of discordant pairs. Results Among the 2735 hospital-level quarters based on 714 hospitals included in the study, CDI prevalence (median: 0.46 per 100 patient-admissions) and CDI antibiotic use (median: 8.85 antibiotic-days per 1,000 days-present) demonstrated only a moderately positive correlation (r = 0.48). Among hospitals in the highest quartile for CDI prevalence, 5.1% were in the lowest quartile for antibiotic use. Among hospitals in the highest quartile for antibiotic use, 5.3% were in the lowest quartile for CDI prevalence, and 54.2% were in the highest quartile for CDI prevalence (G = 0.60; 95% CI: 0.57–0.63). Correlation of hospital-level Clostridioides difficile infection (CDI) prevalence rates and oral vancomycin and fidaxomicin use in U.S. acute care hospitals, 2018 Distribution of hospital-level Clostridioides difficile infection (CDI) prevalence rates and oral vancomycin and fidaxomicin use in ordinal quartiles (Q1–Q4) to access rates of discordant pairs Conclusion The moderate correlation and discordant rates suggest that vancomycin and fidaxomicin are less frequently used as primary antibiotics in some hospitals; whereas in others, CDI antibiotic use is occurring in the absence of positive laboratory tests for CDI. To further investigate this discordance, there is a need to assess hospitals’ prescribing and testing practices in an ongoing manner. These findings may be useful to serve as baseline for measuring progress of appropriateness of treatment and testing for CDIs. Disclosures All Authors: No reported disclosures

scholarly journals An evaluation of toxigenic Clostridioides difficile positivity as a patient outcome metric of antimicrobial stewardship in Saudi Arabia

2021 ◽  
Author(s):  
Christopher A. Okeahialam ◽  
Ali A. Rabaan ◽  
Albert Bolhuis
Keyword(s):  
Patient Outcome ◽  
Saudi Arabia ◽  
Antimicrobial Stewardship ◽  
Laboratory Data ◽  
Hospitalized Patients ◽  
Antimicrobial Stewardship Program ◽  
Repeated Testing ◽  
Clostridioides Difficile ◽  
Stewardship Program ◽  
The Impact

AbstractBackgroundAntimicrobial stewardship has been associated with a reduction in the incidence of health care associated Clostridium difficile infection (HA-CDI). However, CDI remains under-recognized in many low and middle-income countries where clinical and surveillance resources required to identify HA-CDI are often lacking. The rate of toxigenic C. difficile stool positivity in the stool of hospitalized patients may offer an alternative metric for these settings, but its utlity remains largely untested.Aim/ObjectiveTo examine the impact of an antimicrobial stewardship on the rate of toxigenic C. difficile positivity among hospitalized patients presenting with diarrhoeaMethodsA 12-year retrospective review of laboratory data was conducted to compare the rates of toxigenic C. difficile in diarrhoea stool of patients in a hospital in Saudi Arabia, before and after implementation of an antimicrobial stewardship programResultThere was a significant decline in the rate of toxigenic C difficile positivity from 9.8 to 7.4% following the implementation of the antimicrobial stewardship program, and a reversal of a rising trend.DiscussionThe rate of toxigenic C. difficile positivity may be a useful patient outcome metric for evaluating the long term impact of antimicrobial stewardship on CDI, especially in settings with limited surveillance resources. The accuracy of this metric is however dependent on the avoidance of arbitrary repeated testing of a patient for cure, and testing only unformed or diarrhoea stool specimens. Further studies are required within and beyond Saudi Arabia to examine the utility of this metric.

Sign in / Sign up

Export Citation Format

Share Document