803. Risk factors associated with Clostridioides difficile infection in hospitalized patients with community-acquired pneumonia

Abstract Background Patients with community-acquired pneumonia (CAP) who are hospitalized and treated with antibiotics may carry an increased risk for developing Clostridioides difficile infection (CDI). Accurate risk estimation tools are needed to guide monitoring and CDI mitigation efforts. We aimed to identify patient-specific risk factors associated with CDI among hospitalized patients with CAP. Methods Design: retrospective case-control study of hospitalized patients who received CAP-directed antibiotic therapy between 1/1/2014 and 5/29/2018. Cases were hospitalized CAP patients who developed CDI post-admission. Control patients did not develop CDI and were selected at random from CAP patients hospitalized during this period. Variables: comorbidities, laboratory results, vital signs, severity of illness, prior hospitalization, and past antibiotic use. Propensity-score weights: identified via structural decomposition analysis of pre-treatment variables. Analysis: weighted classification tree models that predicted any CDI, hospital-onset CDI, and any healthcare-associated CDI according to CAP antibiotic treatment. Performance: percent accuracy in classification (PAC) and weighted positive (PPV) and negative predictive values (NPV). Modeling: completed using the ODA package (v1.0.1.3) for R (v3.5.1). Results A total of 32 cases and 232 controls were identified. Sixty pre-treatment variables were screened. Structural decomposition analysis, completed in two stages, identified prior hospitalization (OR 6.56, 95% CI: 3.01-14.31; PAC: 80.3%) and BUN greater than 29 mg/dL (OR 11.67, 95% CI: 2.41-56.5; PAC: 80.8%) as propensity-score weights. With respect to CDI, receipt of broad-spectrum anti-pseudomonal antibiotics was significantly (all P’s< 0.05) associated with any CDI (NPV: 90.29%, PPV: 27.94%), hospital-onset CDI (NPV: 97.53%, PPV: 26.86%), and healthcare-associated CDI (NPV: 92.89%, PPV: 27.94%). Conclusion We identified risk factors available at hospital admission and empiric use of broad-spectrum Gram-negative antibiotics as being associated with the development of CDI. Model PPVs were over two-fold greater than our sample base rate. Increased monitoring and avoidance of overly broad antibiotic use in high-risk patients appears warranted. Disclosures All Authors: No reported disclosures

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

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa537 ◽

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.

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Burden and risk factors for inappropriate Clostridioides Difficile infection testing among hospitalized patients

Diagnostic Microbiology and Infectious Disease ◽

10.1016/j.diagmicrobio.2020.115283 ◽

2021 ◽

Vol 99 (4) ◽

pp. 115283

Author(s):

Ellen Axenfeld ◽

William G. Greendyke ◽

Jianhua Li ◽

Daniel A. Green ◽

Susan Whittier ◽

...

Keyword(s):

Risk Factors ◽

Hospitalized Patients ◽

Clostridioides Difficile ◽

Clostridioides Difficile Infection

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Clostridioides difficile infection in patients with end stage renal disease. Is it preventable?

Przeglad Epidemiologiczny ◽

10.32394/pe.74.02 ◽

2020 ◽

pp. 11-21

Keyword(s):

Risk Factors ◽

Renal Disease ◽

End Stage Renal Disease ◽

Significant Risk ◽

Medical Personnel ◽

Clostridioides Difficile ◽

Clostridioides Difficile Infection ◽

Stage Renal Disease ◽

End Stage ◽

Healthcare Associated

Clostridioides difficile infection (CDI) is a leading cause of a healthcare-associated diarrhea worldwide. Recently, an increased number of new cases and growing mortality due to CDI have been observed. Patients suffering from end-stage renal disease (ESRD) are most exposed to CDI. It has been proven that CDI in patients receiving renal replacement therapy (RRT) significantly increases mortality, prolongs hospitalization and increases the cost of treatment. Important risk factors of CDI in ERSD patients include hospitalization or stay in an intensive care unit in the last 90 days, HIV infection, bacteremia, prolonged antibiotic therapy and hypoalbuminemia. Cirrhosis, age over 65 years, hypoalbuminemia, longer hospitalization time and use of antibiotics are significant risk factors of death. Effective methods of preventing CDI include hand hygiene with soap and water, isolation of infected patients in a private room with a dedicated toilet, the use of masks, gloves, disinfection of the environment and systematic education and control of medical personnel, as well as rational antibiotic policy. In addition, it is important to avoid antibiotics with a proven risk of CDI, caution use of proton pump inhibitors (PPI) and H2 receptor antagonists. It is also important in the prevention of CDI in people with ERSD, to apply a fast diagnostic since the onset of the first symptoms. The use of probiotics and bile acids in the primary prevention of CDI requires further research. It seems that knowledge of these factors and methods of prevention will significantly reduce morbidity and mortality due to CDI.

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Risk for Clostridioides difficile infection among hospitalized patients associated with multiple healthcare exposures prior to admission

The Journal of Infectious Diseases ◽

10.1093/infdis/jiaa773 ◽

2020 ◽

Author(s):

Aaron C Miller ◽

Daniel K Sewell ◽

Alberto M Segre ◽

Sriram V Pemmaraju ◽

Philip M Polgreen ◽

...

Keyword(s):

Hospitalized Patients ◽

Healthcare Associated Infection ◽

Case Definitions ◽

Multiple Exposures ◽

Clostridioides Difficile ◽

Increased Risk ◽

Increase Risk ◽

Clostridioides Difficile Infection ◽

Degree Of Association ◽

Healthcare Associated

Abstract Purpose Clostridioides difficile infections (CDIs) are a common healthcare-associated infection and often used as indicators of hospital safety or quality. However, healthcare exposures occurring prior to hospitalization may increase risk for CDI. We conduct a case-control study comparing hospitalized patients with and without CDI to determine if healthcare exposures prior to hospitalization (i.e., clinic visits, antibiotics, family members with CDI) were associated with increased risk for hospital onset CDI, and how risk varied with time between exposure and hospitalization. Methods Records were collected from a large insurance-claims database from 2001-2017 for hospitalized adult patients. Prior healthcare exposures were identified using inpatient, outpatient, emergency department, and prescription drug claims; results were compared between various CDI case definitions. Results Hospitalized patients with CDI had significantly more frequent healthcare exposures prior to admission. Healthcare visits, antibiotics and family exposures were associated with greater likelihood of CDI during hospitalization. The degree of association diminished with time between exposure and hospitalization. Results were consistent across CDI case definitions. Conclusions Many different prior healthcare exposures appear to increase risk for CDI presenting during hospitalization. Moreover, patients with CDI typically have multiple exposures prior to admission, confounding the ability to attribute cases to a particular stay.

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1016. Standardized Antimicrobial Administration Ratio (SAAR) and Clostridioides difficile Infection Standardized Infection Ratio (SIR): Are they connected? An Evaluation of 28 Hospitals

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.880 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S357-S357

Author(s):

Danielle Sebastian ◽

Florian Daragjati ◽

Karl Saake ◽

Lisa K Sturm ◽

Mohamad G Fakih

Keyword(s):

Antimicrobial Agent ◽

Broad Spectrum ◽

Antibacterial Agents ◽

Control Strategies ◽

Antibiotic Use ◽

Healthcare Associated Infection ◽

Clostridioides Difficile ◽

Clostridioides Difficile Infection ◽

Healthcare Associated ◽

Antimicrobial Administration

Abstract Background Clostridioides difficile infections (CDIs) are the most prevalent healthcare-associated infection in the U.S. Of all CDIs, most are related to healthcare exposures and are potentially preventable by reducing unnecessary antibiotic use and interrupting patient-to-patient transmission of CDI. Methods The adult SAARs for 4 antimicrobial agent categories were compared with the CDI SIR at 28 facilities with greater than 100 beds across the health system for the calendar year of 2018. The 4 adult antimicrobial agent categories chosen for comparison were: antibacterial agents posing the highest risk for CDI, broad-spectrum antibacterial agents predominantly used for hospital-onset infections (BSHO), broad-spectrum antibacterial agents predominantly used for community-acquired infections (BSCA) and all antibacterial agents. Results The 2018 aggregate CDI SIR for the 28 facilities was 0.609. The aggregate SAAR for the adult antimicrobial agent categories were 1.05 for the antibacterial agents posing the highest risk for CDI, 1.05 for BSHO, 0.88 for BSCA, and 1.03 for all antibacterial agents. No correlation was seen between any of the 4 adult SAAR antimicrobial agent categories and the facility CDI SIR (Figure 1–4). Conclusion While reducing unnecessary antibiotics is an important strategy in preventing CDIs, having a higher observed vs. predicted administration ratio in the four antimicrobial agent categories studied was not correlated with a higher CDI SIR, including the CDI SAAR category. Reduction of CDI is challenging requiring a multipronged approach to include infection control strategies, appropriate testing, and antimicrobial stewardship. Disclosures All authors: No reported disclosures.

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The Burden of Clostridioides Difficile Infection during the COVID-19 Pandemic: A Retrospective Case-Control Study in Italian Hospitals (CloVid)

Journal of Clinical Medicine ◽

10.3390/jcm9123855 ◽

2020 ◽

Vol 9 (12) ◽

pp. 3855

Author(s):

Guido Granata ◽

Alessandro Bartoloni ◽

Mauro Codeluppi ◽

Ilaria Contadini ◽

Francesco Cristini ◽

...

Keyword(s):

Risk Factors ◽

Bacterial Infections ◽

Infection Prevention And Control ◽

Retrospective Case ◽

Clostridioides Difficile ◽

Clostridioides Difficile Infection ◽

Hospital Stays ◽

Healthcare Associated ◽

Hospital Acquired ◽

And Control

Data on the burden of Clostridioides difficile infection (CDI) in Coronavirus Disease 2019 (COVID-19) patients are scant. We conducted an observational, retrospective, multicenter, 1:3 case (COVID-19 patients with CDI)-control (COVID-19 patients without CDI) study in Italy to assess incidence and outcomes, and to identify risk factors for CDI in COVID-19 patients. From February through July 2020, 8402 COVID-19 patients were admitted to eight Italian hospitals; 38 CDI cases were identified, including 32 hospital-onset-CDI (HO-CDI) and 6 community-onset, healthcare-associated-CDI (CO-HCA-CDI). HO-CDI incidence was 4.4 × 10,000 patient-days. The percentage of cases recovering without complications at discharge (i.e., pressure ulcers, chronic heart decompensation) was lower than among controls (p = 0.01); in-hospital stays was longer among cases, 35.0 versus 19.4 days (p = 0.0007). The presence of a previous hospitalisation (p = 0.001), previous steroid administration (p = 0.008) and the administration of antibiotics during the stay (p = 0.004) were risk factors associated with CDI. In conclusions, CDI complicates COVID-19, mainly in patients with co-morbidities and previous healthcare exposures. Its association with antibiotic usage and hospital acquired bacterial infections should lead to strengthen antimicrobial stewardship programmes and infection prevention and control activities.

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Durability of Response to Fecal Microbiota Transplantation After Exposure to Risk Factors for Recurrence in Patients With Clostridioides difficile Infection

Clinical Infectious Diseases ◽

10.1093/cid/ciaa1457 ◽

2020 ◽

Author(s):

Srishti Saha ◽

Kristin Mara ◽

Darrell S Pardi ◽

Sahil Khanna

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Fecal Microbiota Transplantation ◽

Multivariable Analysis ◽

Antibiotic Use ◽

Fecal Microbiota ◽

Additional Risk Factor ◽

Durable Response ◽

Clostridioides Difficile ◽

Clostridioides Difficile Infection

Abstract Background Fecal microbiota transplantation (FMT) is highly effective for preventing recurrent Clostridioides difficile infection (CDI). Durability (no recurrence despite additional risk factor exposure) of FMT protection is largely unknown. We studied the durability of FMT in patients with recurrent CDI. Methods We conducted a retrospective study of adults undergoing FMT for recurrent CDI. Data collected included demographics, CDI risk factors (comorbidities, healthcare exposure, non-CDI antibiotic use, acid suppressant medications), and future CDI episodes. Durable response to FMT was defined as lack of CDI episodes within 1 year post-FMT despite risk factor exposure. Results Overall, 460 patients were included (median age, 57 years [18–94]; 65.2% female). Comorbidities included chronic liver disease, 12.8% (n = 59); cancer, 11.7% (n = 54); chronic kidney disease, 3.9% (n = 18); and inflammatory bowel disease, 21.9% (n = 101). Overall, 31.3% (n = 144) received antibiotics, 21.7% (n = 100) received acid suppressants, and 76.8% (n = 350) had healthcare exposure after FMT. Of 374 patients with risk factor exposure, 78.1% (95% confidence interval [CI], 72.7%–84.0%) had durable response to FMT at 1 year. On multivariable analysis, antibiotic use was independently associated with decreased durability of FMT (hazard ratio, 0.27; 95% CI, .15–.49; P < .001). Conclusions The majority of patients had a durable response to FMT despite exposure to CDI risk factors. Antibiotic exposure after FMT independently predicted loss of durability of FMT. Larger studies are needed to define predictors of durable response in patients with and without exposure to antibiotics.

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Clostridium difficile Infection: An Epidemiology Update

Clinics in Colon and Rectal Surgery ◽

10.1055/s-0040-1701229 ◽

2020 ◽

Vol 33 (02) ◽

pp. 049-057 ◽

Cited By ~ 5

Author(s):

Ana C. De Roo ◽

Scott E. Regenbogen

Keyword(s):

Risk Factors ◽

Antibiotic Use ◽

Recurrence Risk ◽

Epidemiologic Studies ◽

High Morbidity ◽

Healthcare Associated Infection ◽

Clostridioides Difficile ◽

Increased Risk ◽

Hospitalized Older Adults ◽

Healthcare Associated

Abstract Clostridium (reclassified as “Clostridioides”) difficile infection (CDI) is a healthcare-associated infection and significant source of potentially preventable morbidity, recurrence, and death, particularly among hospitalized older adults. Additional risk factors include antibiotic use and severe underlying illness. The increasing prevalence of community-associated CDI is gaining recognition as a novel source of morbidity in previously healthy patients. Even after recovery from initial infection, patients remain at risk for recurrence or reinfection with a new strain. Some pharmaco-epidemiologic studies have suggested an increased risk associated with proton pump inhibitors and protective effect from statins, but these findings have not been uniformly reproduced in all studies. Certain ribotypes of C. difficile, including the BI/NAP1/027, 106, and 018, are associated with increased antibiotic resistance and potential for higher morbidity and mortality. CDI remains a high-morbidity healthcare-associated infection, and better understanding of ribotypes and medication risk factors could help to target treatment, particularly for patients with high recurrence risk.

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S1238 Risk Factors for Inappropriate Clostridioides difficile Infection Testing Among Hospitalized Patients

The American Journal of Gastroenterology ◽

10.14309/01.ajg.0000707000.11722.d7 ◽

2020 ◽

Vol 115 (1) ◽

pp. S621-S621

Author(s):

Ellen Axenfeld ◽

William G. Greendyke ◽

Jianhua Li ◽

Daniel Green ◽

Susan S. Whittier ◽

...

Keyword(s):

Risk Factors ◽

Hospitalized Patients ◽

Clostridioides Difficile ◽

Clostridioides Difficile Infection

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2890. Antibiotic Overuse at Discharge in Hospitalized Patients with Bacteriuria or Treated for Pneumonia: A Multi-Hospital Cohort Study

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz359.168 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S78-S79

Author(s):

Valerie M Vaughn ◽

Lindsay A Petty ◽

David Ratz ◽

Anurag N Malani ◽

Elizabeth Mclaughlin ◽

...

Keyword(s):

Asymptomatic Bacteriuria ◽

Antibiotic Use ◽

Community Acquired Pneumonia ◽

Hospitalized Patients ◽

Disease State ◽

Antibiotic Overuse ◽

Antibiotic Duration ◽

Stopping Treatment ◽

Healthcare Associated ◽

Alternative Antibiotic

Abstract Background Antibiotics prescribed at hospital discharge account for half of antibiotic use related to hospitalization for urinary tract infection or bacterial pneumonia. It is unclear how much antibiotic use at discharge represents overuse, and thus, could potentially be improved through antibiotic stewardship. Methods From July 2017 to December 2018, trained abstractors at 46 Michigan hospitals collected detailed data on a sample of adult, nonintensive care, hospitalized patients with bacteriuria or treated for community-acquired or healthcare-associated pneumonia (discharge diagnosis of pneumonia plus antibiotic treatment). Antibiotic prescriptions at discharge were assessed for overuse using a guideline-based hierarchical algorithm: evaluating first for unnecessary antibiotics (noninfectious/nonbacterial syndrome), then excess duration (antibiotics needed, but prescribed for longer than necessary), and finally avoidable fluoroquinolones (safer alternative antibiotic available) (Figure 1). For each disease state, descriptive results are shown with comparisons by t- or Fisher’s exact tests. Results Of 17,157 patients (7,283 with bacteriuria; 9,874 treated for pneumonia), 30.1% of patients with bacteriuria had asymptomatic bacteriuria and 11.4% of patients treated for pneumonia did not meet diagnostic criteria for pneumonia. The most common antibiotics prescribed at discharge were fluoroquinolones. Nearly half (43.6%) of patients had antibiotic overuse at discharge (33.8% bacteriuria, 50.9% pneumonia), with a median 4 days of overuse after discharge (Table 1). For bacteriuria, 45.0% of overuse days at discharge were due to unnecessary antibiotics; for pneumonia, 61.2% were due to excess antibiotic duration (Figure 2). Patients with community-acquired pneumonia and those with sepsis on admission had the highest rates of antibiotic overuse at discharge (Table 2). Conclusion In the largest assessment of antibiotics at discharge to-date, antibiotic overuse at discharge was extremely common. Specific targets for discharge stewardship vary by disease state. Notably, interventions may be more effective at reducing fluoroquinolone prescribing at discharge indirectly by stopping treatment for asymptomatic bacteriuria and reducing excess duration in pneumonia. Disclosures All Authors: No reported Disclosures.

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