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We evaluated the impact of test-order frequency per diarrheal episodes on Clostridioides difficile infection (CDI) incidence estimates in a sample of hospitals at 2 CDC Emerging Infections Program (EIP) sites.
Inpatients at 5 acute-care hospitals in Rochester, New York, and Atlanta, Georgia, during two 10-workday periods in 2020 and 2021.
We calculated diarrhea incidence, testing frequency, and CDI positivity (defined as any positive NAAT test) across strata. Predictors of CDI testing and positivity were assessed using modified Poisson regression. Population estimates of incidence using modified Emerging Infections Program methodology were compared between sites using the Mantel-Hanzel summary rate ratio.
Surveillance of 38,365 patient days identified 860 diarrhea cases from 107 patient-care units mapped to 26 unique NHSN defined location types. Incidence of diarrhea was 22.4 of 1,000 patient days (medians, 25.8 for Rochester and 16.2 for Atlanta; P < .01). Similar proportions of diarrhea cases were hospital onset (66%) at both sites. Overall, 35% of patients with diarrhea were tested for CDI, but this differed by site: 21% in Rochester and 49% in Atlanta (P < .01). Regression models identified location type (ie, oncology or critical care) and laxative use predictive of CDI test ordering. Adjusting for these factors, CDI testing was 49% less likely in Rochester than Atlanta (adjusted rate ratio, 0.51; 95% confidence interval [CI], 0.40–0.63). Population estimates in Rochester had a 38% lower incidence of CDI than Atlanta (summary rate ratio, 0.62; 95% CI, 0.54–0.71).
Accounting for patient-specific factors that influence CDI test ordering, differences in testing practices between sites remain and likely contribute to regional differences in surveillance estimates.
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.
In total, 13 facilities changed C. difficile testing to reflexive testing by enzyme immunoassay (EIA) only after a positive nucleic acid-amplification test (NAAT); the standardized infection ratio (SIR) decreased by 46% (range, −12% to −71% per hospital). Changing testing practice greatly influenced a performance metric without changing C. difficile infection prevention practice.
Background: Historically, metronidazole was first-line therapy for Clostridioides difficile infection (CDI). In February 2018, the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) updated clinical practice guidelines for CDI. The new guidelines recommend oral vancomycin or fidaxomicin for treatment of initial episode of CDI in adults. We examined the changes in treatment of CDI during 2018 across all types of healthcare settings in metropolitan Atlanta. Methods: Cases were identified through the Georgia Emerging Infections program (funded by the Centers for Disease Control and Prevention), which conducts active population-based surveillance in an 8-county area including Atlanta, Georgia (population, 4,126,399). An incident case was a resident of the catchment area with a positive C. difficile toxin test and no additional positive test in the previous 8 weeks. Recurrent CDI was defined as >1 incident CDI episode in 1 year. Clinical and treatment data were abstracted on a random 33% sample of adult (>17 years) cases. Definitive treatment categories were defined as the single antibiotic agent, metronidazole or vancomycin, used to complete a course. We examined the effect of time of infection, location of treatment, and number of CDI episodes on the use of metronidazole only. Results: We analyzed treatment information for 831 adult sampled cases. Overall, cases were treated at 29 hospitals (568 cases), 4 nursing homes (6 cases), and 101 outpatient providers (257 cases). The mean age was 60 (IQR, 34–86), and 111 (13.4%) had recurrent infection. Moreover, ∼28% of first-incident CDI episodes, 8% of second episodes, and 6% of third episodes were treated with metronidazole only. Compared to facility-based providers, outpatient providers were more likely to treat initial CDI episodes with metronidazole only (44% vs 21%; relative risk [RR], 2.1; 95% CI, 1.7–2.7). Treatment changed over time from 56% metronidazole only in January to 10% in December (Fig. 1). First-incident cases in the first quarter of 2018 were more likely to be treated with metronidazole only compared to those in the fourth quarter (RR, 2.76; 95% CI, 1.91–3.97). Conclusions: Preferential use of vancomycin for initial CDI episodes increased throughout 2018 but remained <100%. CDI episodes treated in the outpatient setting and nonrecurrent episodes were more likely to be treated with metronidazole only. Additional studies on persistent barriers to prescribing oral vancomycin, such as cost, are warranted.
Disclosures: Scott Fridkin reports that his spouse receives a consulting fee from the vaccine industry.
Background: Nursing home (NH) residents are at high risk for Clostridioides difficile infection (CDI) due to older age, frequent antibiotic exposure, and previous healthcare exposure. Incidence of CDI attributed to NHs is not well established, but it is hypothesized to be related to the magnitude of transfers. We evaluated the relationship between NH CDI incidence and facility characteristics to explain variability in rates in Atlanta, Georgia. Methods: Incident C. difficile cases from 2016 to 2018 were identified through the Georgia Emerging Infections Program (funded by the Centers for Disease Control and Prevention), which conducts active population-based surveillance in the 8-county metro Atlanta area. An incident case was defined as an NH resident with a toxin-positive stool specimen (without a positive test within 8 weeks). Sampled (1 to 3 on age and gender) incident cases were attributed to a NH if a patient was an NH resident within 4 days of specimen collection. Facility characteristics (beds, resident days, admissions, and average length of stay [ALOS]) were obtained from NH cost reports, and facility-specific connectivity metrics were calculated (indegree and betweenness) from 2016 Medicare claims data. Case counts were aggregated to estimate yearly incidence and correlated with facility characteristics and location within the healthcare network using the Spearman correlation. A negative binomial model was used to assess residual variability in NH CDI incidence. Results: In total, 386 incident CDI cases were attributed to 64 NHs (range, 0–27). Approximately half (54.7%) resided in the NH at the time of specimen collection; however, 33.7% were in inpatient units (≤4 days of admission), and 10.9% were in an emergency room (ER). The frequency of NH CDI cases correlated strongly with admissions (r = .70; P < .01), inversely with ALOS (r = −0.53; P < .01), and moderately with resident days (r = .38; P < .01). After accounting for admissions, incidence (per 1,000 admissions) still varied (Fig. 1) (median 14; range, 0–34). The inverse association with ALOS decreased and incidence no longer correlated with the remaining facility characteristics or location within the healthcare transfer network (P > .05, all comparisons). However, there was residual correlation with connectivity metrics (indegree r = 0.26; P = .04). Conclusions: Our data suggest that attributing CDI to NHs requires the inclusion of hospital and ER-based specimen collection. NH CDI incidence appears highest among facilities with a low ALOS and a high number of admissions; incidence rates calculated per 1,000 admissions may best account for infection risk inherent early in a resident’s stay. Residual variability attributed to connectivity to the healthcare network was of borderline significance and should be further explored in the NH setting.
Disclosures: Scott Fridkin, consulting fee, vaccine industry (spouse)
Background: US hospitals are required to report C. difficile infections (CDIs) to the NHSN as a performance measure tied to payment penalties for poor scores. Currently, only the charted CDI test results performed last in reflex testing scenarios are reported to the NHSN (CDI events). We describe the reduction in NHSN CDI events from the addition of a reflex toxin enzyme immunoassay (EIA) after a positive nucleic acid amplification test (NAAT) in teaching and nonteaching hospitals, and we estimate the impact on standardized infection ratios (SIR). Methods: Reporting of all CDI test results, by test method, occurred during April 2018–July 2019 to the Georgia Emerging Infections program (funded by the Centers for Disease Control and Prevention), which conducts active population-based surveillance in an 8-county Atlanta area (population, 4 million). Among facilities starting reflex EIA testing, results were aggregated by test method during months of reflex testing to calculate facility-specific reduction in NHSN CDI events (% reduction; 1-[no. EIA+/no. NAAT+]). Differences in percent reduction between facilities by characteristic were compared using the Kruskal-Wallis test. We simulated expected changes in the SIR for a range of reductions, assuming equal effect on both community-onset (CO) and hospital-onset (HO) tests. Each facility’s historical NHSN CDI events prior to reflex testing were used to estimate changes to facility-specific SIRs by reducing values by the corresponding facility’s percent reduction. Results: Overall, 13 acute-care hospitals (bed size, 52–633; ICU bed size, 6–105) started reflex testing during the study period (mean, 7 months, 15,800 admissions, 66,400 patient days), resulting in 550 +NAAT tests reflexing to 180 +EIA tests (pooled mean 58% reduction). Percent reduction varied (mean, 67%; range, 42%–81%) but did not differ between larger (≥217 beds) and smaller hospitals (61 vs 50% reduction; P > .05) or by outsourced versus inhouse testing (65% vs 54% reduction; P > .05). Simulations identified a threshold reduction at which point effect on HO counteract the effects on CO events enough to reduce the SIR; thresholds for nonteaching and teaching were 26% and 32% reduction, respectively (Fig. 1). The estimated reductions in facility-specific SIRs using measured percent reductions on historic NHSN CDI events closely paralleled the simulation, and the mean estimated change in SIR was −46% (range, −12% to −71%) (Fig. 1). Conclusions: Although the magnitude of the effect varied, all 13 facilities experienced dramatic reductions in CDI events reportable to NHSN due to reflex testing; applying these reductions to historical NHSN data illustrates anticipated reductions in their facility-specific SIRs due to this testing change.
Disclosures: Scott Fridkin, consulting fee, vaccine industry (various) (spouse)
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