Background: Effective strategies to improve diagnostic stewardship around C. difficile infection (CDI) remain elusive. Electronic medical record-based solutions, such as ‘hard’ and ‘soft’ stops, have been associated with reductions in testing, but may not be sustainable due to alert fatigue. Additionally, data on the potential for undertesting, missed diagnoses, and the implications regarding patient harm or clusters of transmission are limited. In this study, we assessed the efficacy of a behavioral approach to diagnostic stewardship, while monitoring for unintended consequences. Methods: This quality improvement study was conducted January 2018–May 2019; baseline period: January–April 2018, implementation period: May–December 2018, sustainment period: January 2019–May 2019. First, we conducted an internal analysis and identified 3 barriers to appropriate testing: clinician’s perceived risk of CDI, inconsistent definition of diarrhea, and lack of involvement of nurses in diagnostic stewardship. A multidisciplinary team to address these barriers was then convened. The team utilized the Bristol stool scale to improve the reliability of diarrhea description, and created a guideline-concordant testing algorithm with clinicians and nurses. The primary outcome was the number of tests ordered. The secondary outcomes were the proportion of inappropriate tests and the proportion of delayed tests. Delayed tests were defined as CDI-compatible diarrhea based on the algorithm where the test was sent >24 hours after symptom onset. Results: During the baseline period, we detected no significant change in number of tests ordered month to month, with 194.2 tests ordered per month on average. During the postimplementation period, the number of tests ordered decreased by ~4.5 each month between January 2018 and May 2019 (P < .0001). The proportion of inappropriate tests steadily decreased from 54% to 30% across the 3 study periods, and the number of delayed testing changed from 11% to 1% then increased to 20% in the sustainment period. There were no cases of toxic megacolon associated with delayed testing. Conclusions: The decision to test for CDI is complex. Interventions that address this issue as a simple ‘right’ and ‘wrong’ fail to address the root cause of CDI overdiagnosis, and they have no embedded mechanism to detect unintended consequences. Our study demonstrates that by taking a behavioral approach and addressing clinicians’ safety concerns, we were able to sustain a significant reduction in testing. We could not determine the significance of the increase in delayed testing given the low numbers; however, further studies are needed to evaluate the safety of CDI reduction strategies through diagnostic stewardship only.

Funding: None

Disclosures: None

Background: Although guidelines recommend the use of chlorhexidine gluconate (CHG) for hand hygiene (HH), the impact of its routine use on antimicrobial resistance is not clear. Objective: To analyze the impact on the CHG susceptibility among isolates obtained from hands of HCW during its routine use for HH. Methods: We conducted a crossover study at 4 medical-surgical wards of a tertiary-care hospital in São Paulo, Brazil. In 2 units (intervention group), we established routine use of CHG for HH. For the other 2 units (control group), regular soap was provided. The availability of alcohol formulation for HH was not changed during the study. Every 4 months we swapped the units, ie, those using CHG changed for regular soap and vice versa. At baseline, we cultured the hands of HCWs. Only nursing staff hands were investigated. For hand culturing, HCWs placed their hands inside a sterile bag containing a solution of phosphate-buffered saline, Tween 80, and sodium thiosulfate. After the solution incubated overnight, it was inoculated onto brain-heart infusion. Next, it was plated on McConkey and Mannitol agar. MALDI-TOF was used for identification. Agar dilution was performed for Staphylococcus spp. We selected all Staphylococcus spp with MIC ≥ 8 and performed inhibition of efflux pump test. For isolates that showed a decrease of 2 dilutions, we searched the gene qacA/B by polymerase chain reaction. Results: We obtained 262 samples from HCW hands yielding 428 isolates. The most frequent genera were Staphylococcus spp (58%), Acinetobacter spp (8%), Enterobacter spp (8%), Stenotrophomonas spp (5%), Klebsiella spp (4%), Pseudomonas spp (3%), and others (14%). Staphylococcus spp were less frequent in the intervention compared to control group (43% vs 61%; OR, 0.48; 95% CI, 0.29–0.69; P = .005). Among all Staphylococcus spp, the proportion of chlorhexidine resistance (RCHG; MIC ≥ 8) was 12%. All resistant isolates recovered susceptibility after inoculation with pump-efflux inhibitor. For pump-inhibited isolates, 53% had the gene qacA/B amplified by PCR. We did not investigate RCHG among gram-negative isolates. There was a nonsignificant increase in Staphylococcus spp RCHG in the intervention group (4% to 6%; P = .90). Healthcare-acquired infection rates did not change significantly during the intervention. The consumption of CHG increased from 7.3 to 13.9 mL per patient day. Conclusions: We did not detect a significant difference in RCHG during the routine use of CHG for HH, although we observed increasing resistance. Further investigation is needed to clarify other reasons for increasing MIC to CHG.

Funding: None

Disclosures: None

This is an observational cohort study comparing 156 patients evaluated for acute stroke between March 30 and May 31, 2020 at a comprehensive stroke center with 138 patients evaluated during the corresponding time period in 2019. During the pandemic, the proportion of COVID-19 positive patients was low (3%), the time from symptom onset to hospital presentation was significantly longer, and a smaller proportion of patients underwent reperfusion therapy. Among patients directly evaluated at our institution, door-to-needle and door-to-recanalization metrics were significantly longer. Our findings support concerns that the current pandemic may have a negative impact on the management of acute stroke.

We report electronic medical record interventions to reduce Clostridioides difficile testing risk ‘alert fatigue.’ We used a behavioral approach to diagnostic stewardship and observed a decrease in the number of tests ordered of ~4.5 per month (P < .0001). Although the number of inappropriate tests decreased during the study period, delayed testing increased.

OBJECTIVES/GOALS: Precision care may engage smokers and providers in treatment but is understudied in the community. We piloted guideline-based care (GBC) alone or with Respiragene, a lung cancer polygenic risk score (PRS, 1-10), or metabolism-informed choice of medication using the nicotine metabolite ratio (NMR). METHODS/STUDY POPULATION: Daily smokers (n = 58) with stored biospecimens in the Southern Community Cohort Study were randomized 1:1:1 to GBC, PRS, or NMR, counseled to quit smoking, and co-selected FDA-approved cessation medication (nicotine replacement, varenicline) with a tobacco counselor. In PRS, precision motivational counseling was guided by PRS (i.e., lung cancer risk 10-40-fold that of never-smokers). In NMR, precision medication recommendations consisted of varenicline for faster metabolizers (NMR≥0.31) and nicotine replacement for slow metabolizers (NMR<0.31). Feasibility was defined as achieving at least 50% provider engagement (med prescription) and at least 50% patient engagement (self-reported med use). RESULTS/ANTICIPATED RESULTS: Participants were median age 59, 72% female, 81% Black, 60% with incomes <$15,000; median cigarettes/day was 15 (IQR 8-20) and 52% reported time-to-first cigarette <5 minutes, illustrating moderate nicotine dependence. Providers confirmed medication prescriptions for 40% of patients (32% GBC, 50% PRS, 37% NMR) and 83% of patients reported using medication (prescribed or unprescribed) during the study (90% GBC, 80% PRS, 79% NMR). At 6-month follow-up, 27% (n = 15) reported cessation (39% GBC, 16% PRS, 26% NMR). Among persistent smokers, 46% reported smoking at least 50% fewer cigarettes/day compared to baseline (45% GBC, 38% PRS, 57% NMR). Small sample size precluded statistical comparisons. DISCUSSION/SIGNIFICANCE OF IMPACT: Precision interventions to quit smoking are feasible for community smokers, who engaged at high rates. However, only 40% of providers supported patients’ quit attempts with medication prescriptions. Future research should test strategies to raise provider engagement in precision smoking treatment. CONFLICT OF INTEREST DESCRIPTION: R.F.T. has consulted for Quinn Emmanual and Apotex on unrelated topics. H.A.T. reported providing input on design for a phase 3 trial of cytisine proposed by Achieve Life Sciences and being a principal investigator of National Institutes of Health–sponsored studies for smoking cessation that include medications donated by the manufacturers. Other authors declare no potential conflicts of interest.

We present the analysis of global sympagic primary production (PP) from 300 years of pre-industrial and historical simulations of the E3SMv1.1-BGC model. The model includes a novel, eight-element sea ice biogeochemical component, MPAS-Seaice zbgc, which is resolved in three spatial dimensions and uses a vertical transport scheme based on internal brine dynamics. Modeled ice algal chlorophyll-a concentrations and column-integrated values are broadly consistent with observations, though chl-a profile fractions indicate that upper ice communities of the Southern Ocean are underestimated. Simulations of polar integrated sea ice PP support the lower bound in published estimates for both polar regions with mean Arctic values of 7.5 and 15.5 TgC/a in the Southern Ocean. However, comparisons of the polar climate state with observations, using a maximal bound for ice algal growth rates, suggest that the Arctic lower bound is a significant underestimation driven by biases in ocean surface nitrate, and that correction of these biases supports as much as 60.7 TgC/a of net Arctic PP. Simulated Southern Ocean sympagic PP is predominantly light-limited, and regional patterns, particularly in the coastal high production band, are found to be negatively correlated with snow thickness.

This article aims to evaluate and assess the health issues of Calgarians over the age of 50 who are experiencing chronic homelessness, determine their unmet service needs, and assess whether there are predictors of chronic homelessness (such as childhood trauma) that could be addressed with changes to policy or service delivery. Three hundred participants were recruited from emergency shelters, as well as a from a small group of rough sleepers in Calgary, Canada in the winter of 2016. Excel and SPSS were used for analysis beginning with descriptive statistics for the samples of respondents who are 50 and older (n = 142) and under the age of 50 (n = 158). More than half of participants had been homeless continually for more than 10 years. Older adults reported complex health issues and significant barriers to accessing health care including finances, wait lists, and asking for help but not receiving it. Older adults reported lower rates of childhood trauma than their younger counterparts, yet the average was two and half times that of the general population. Recognition of the intersecting and cumulative effects of long-term homelessness and age could inform changes to policy to reduce siloes around public systems. Given that older adults are at higher risk for an early death, they should be prioritized for housing programs. Culturally appropriate and trauma-informed interventions are necessary to address the diverse and complex needs of this vulnerable group.

As urbanization increases in low- and middle-income countries (LMICs), urban populations will be increasingly exposed to a range of environmental risk factors for non-communicable diseases. Inadequate living conditions in urban settings may influence mechanisms that regulate gene expression, leading to the development of non-communicable respiratory diseases. We conducted a systematic review of the literature to assess the relationship between respiratory health and epigenetic factors to urban environmental exposures observed in LMICs using MEDLINE, PubMed, EMBASE, and Google Scholar searching a combination of the terms: epigenetics, chronic respiratory diseases (CRDs), lung development, chronic obstructive airway disease, and asthma. A total of 2835 articles were obtained, and 48 articles were included in this review. We found that environmental factors during early development are related to epigenetic effects that may be associated with a higher risk of CRDs. Epigenetic dysregulation of gene expression of the histone deacetylase (HDAC) and histone acetyltransferase gene families was likely involved in lung health of slum dwellers. Respiratory-related environmental exposures influence HDAC function and deoxyribonucleic acid methylation and are important risk factors in the development of CRD. Additional epigenetic research is needed to improve our understanding of associations between environmental exposures and non-communicable respiratory diseases.

OBJECTIVES/SPECIFIC AIMS: To identify cardiac structural and function parameters, obtained on usual stroke-care TTE evaluation, associated with cardioembolic stroke (CE) in patients without AF. Hypothesis—left atrial (LA) size and valve dysfunction will be strongly associated with incident CE. METHODS/STUDY POPULATION: Inclusion criteria: July 1, 2013 to July 1, 2015 admission with imaging-confirmed ischemic stroke, no AF, TTE within 1st 7 days. TTE structure/function parameters were recorded. Stroke subtype (CE vs. other) defined using TOAST criteria, blinded to TTE. New AF definition: AF on ECG, telemetry or event monitor. CE/New AF outcome of interest in separate multivariable logistic regression models testing associations with TTE parameters (adjusting for demographics/vascular risk factors). RESULTS/ANTICIPATED RESULTS: Participants (n=332) were ~60 years hypertensive black males with moderate NIHSS and normal ejection fraction. In adjusted models, odds of CE increased with increasing LA systolic diameter (per 0.1 cm), mitral E point velocity(cm/s), mitral valve dysfunction, wall motion abnormality. New AF also associated with increasing LA systolic diameter. DISCUSSION/SIGNIFICANCE OF IMPACT: These findings may suggest cardiac structural changes independent of AF that are on the CE causal pathway. Understanding the relationship between such TTE parameters and stroke subtype would impact clinical practice, as such TTE data is underutilized when considering stroke mechanism and management.

Metallic silver nanoparticles were synthesized using a hydrothermal route for use in high throughput biosensing applications. Particle shape was engineered by varying polyvinyl pyrollidone (PVP) concentration in the precursor mixture, resulting in the emergence of flat triangular shaped nanoparticles with increasing PVP content. The hydrothermal method was found to yield particles with better particle size distribution and longer shelf life relative to polyol synthesis particles.