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A newly developed compact AMS, LEA (Low Energy Accelerator), is tested and compared with a state-of-the-art AMS system MICADAS (Mini Carbon Dating System), which has a precision performance of better than 1‰ for modern 14C. The main difference between these two systems is the acceleration voltage, which has been reduced from 200 kV with the MICADAS system to 50 kV with the LEA system. In order to execute the final performance tests, exactly same samples (2 sets consisting of 7 standards, 4 blanks, 26 wood samples) are measured on both systems successively. The results show that the LEA system is fully operational, and the performance is entirely comparable with that of the MICADAS system.
Background: The CDC recommends routine use of contact precautions for patients infected or colonized with multidrug-resistant organisms (MDROs). There is variability in implementation of and adherence to this recommendation, which we hypothesized may have been exacerbated by the COVID-19 pandemic. Methods: In September 2022, we emailed an 8-question survey to Emerging Infections Network (EIN) physician members with infection prevention and hospital epidemiology responsibilities. The survey asked about the respondent’s primary hospital’s recommendations on transmission-based precautions, adjunctive measures to reduce MDRO transmission, and changes that occurred during the COVID-19 pandemic. We sent 2 reminder emails over a 1-month period. We used descriptive statistics to summarize the data and to compare results to a similar EIN survey (n = 336) administered in 2014 (Russell D, et al. doi:10.1017/ice.2015.246). Results: Of 708 EIN members, 283 (40%) responded to the survey, and 201 were involved in infection prevention. Most respondents were adult infectious diseases physicians (n = 228, 80%) with at least 15 years of experience (n = 174, 63%). Respondents were well distributed among community, academic, and nonuniversity teaching facilities (Table 1). Most respondents reported that their facility routinely used CP for methicillin-resistant Staphylococcus aureus (MRSA, 66%) and vancomycin-resistant Enterococcus (VRE, 69%), compared to 93% and 92% respectively, in the 2014 survey. Nearly all (>90%) reported using contact precautions for Candida auris, carbapenem-resistant Enterobacterales (CRE), and carbapenem-resistant Acinetobacter spp, but there was variability in the use of contact precautions for carbapenem-resistant Pseudomonas aeruginosa and extended-spectrum β-lactamase–producing gram-negative organisms. In 2014, 81% reported that their hospital performed active surveillance testing for MRSA, and in 2022 this rate fell to 54% (Table 2). The duration of contact precautions varied by MDRO (Table 3). Compared to 2014, in 2022 facilities were less likely to use contact precautions indefinitely for MRSA (18% vs 6%) and VRE (31% vs 11%). Also, 180 facilities (90%) performed chlorhexidine bathing in at least some inpatients and 106 facilities (53%) used ultraviolet light or hydrogen peroxide vapor disinfection at discharge in some rooms. Furthermore, 89 facilities (44%) reported institutional changes to contact precautions policies after the start of the COVID-19 pandemic that remain in place. Conclusions: Use of contact precautions for patients with MDROs is heterogenous, and policies vary based on the organism. Although most hospitals still routinely use contact precautions for MRSA and VRE, this practice has declined substantially since 2014. Changes in contact-precaution policies may have been influenced by the COVID-19 pandemic, and more specifically, contemporary public health guidance is needed to define who requires contact precautions and for what duration.
Social policies’ responsiveness to rising inflation depends in large part on whether they contain automatic indexation mechanisms, which ensure that the real value of wages and benefits expands during inflationary periods. Here we compare how the indexation of Canadian and U.S. policies on pensions, minimum wages, and food security have affected their responsiveness to the recent cost-of-living crisis. Three main conclusions emerge from our analysis. First, automatic indexation is not necessarily a silver bullet to avoid policy drift. Second, automatic indexation and its design are not the only factors that matter to determine whether high inflation leads to policy drift. Finally, in times of higher inflation, social programs that lack automatic indexation can avoid policy drift, as long as a strong political consensus allows for ad hoc social policy expansion capable of offsetting the negative effects of inflations on social benefits.
To determine the prevalence of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) IgG nucleocapsid (N) antibodies among healthcare personnel (HCP) with no prior history of COVID-19 and to identify factors associated with seropositivity.
Prospective cohort study.
An academic, tertiary-care hospital in St. Louis, Missouri.
The study included 400 HCP aged ≥18 years who potentially worked with coronavirus disease 2019 (COVID-19) patients and had no known history of COVID-19; 309 of these HCP also completed a follow-up visit 70–160 days after enrollment. Enrollment visits took place between September and December 2020. Follow-up visits took place between December 2020 and April 2021.
At each study visit, participants underwent SARS-CoV-2 IgG N-antibody testing using the Abbott SARS-CoV-2 IgG assay and completed a survey providing information about demographics, job characteristics, comorbidities, symptoms, and potential SARS-CoV-2 exposures.
Participants were predominately women (64%) and white (79%), with median age of 34.5 years (interquartile range [IQR], 30–45). Among the 400 HCP, 18 (4.5%) were seropositive for IgG N-antibodies at enrollment. Also, 34 (11.0%) of 309 were seropositive at follow-up. HCP who reported having a household contact with COVID-19 had greater likelihood of seropositivity at both enrollment and at follow-up.
In this cohort of HCP during the first wave of the COVID-19 pandemic, ∼1 in 20 had serological evidence of prior, undocumented SARS-CoV-2 infection at enrollment. Having a household contact with COVID-19 was associated with seropositivity.
Maternal fish consumption exposes the fetus to beneficial nutrients and potentially adverse neurotoxicants. The current study investigated associations between maternal fish consumption and child neurodevelopmental outcomes. Maternal fish consumption was assessed in the Seychelles Child Development Study Nutrition Cohort 1 (n 229) using 4-day food diaries. Neurodevelopment was evaluated at 9 and 30 months, and 5 and 9 years with test batteries assessing twenty-six endpoints and covering multiple neurodevelopmental domains. Analyses used multiple linear regression with adjustment for covariates known to influence child neurodevelopment. This cohort consumed an average of 8 fish meals/week and the total fish intake during pregnancy was 106·8 (sd 61·9) g/d. Among the twenty-six endpoints evaluated in the primary analysis there was one beneficial association. Children whose mothers consumed larger quantities of fish performed marginally better on the Kaufman Brief Intelligence Test (a test of nonverbal intelligence) at age 5 years (β 0·003, 95 % CI (0, 0·005)). A secondary analysis dividing fish consumption into tertiles found no significant associations when comparing the highest and lowest consumption groups. In this cohort, where fish consumption is substantially higher than current global recommendations, maternal fish consumption during pregnancy was not beneficially or adversely associated with children’s neurodevelopmental outcomes.
Previous studies have suggested that a hospital patient's risk of developing healthcare facility-onset (HCFO) Clostridioides difficile infections (CDIs) increases with the number of concurrent spatially proximate patients with CDI, termed CDI pressure. However, these studies were performed either in a single institution or in a single state with a very coarse measure of concurrence. We conducted a retrospective case-control study involving over 17.5 million inpatient visits across 700 hospitals in eight US states. We built a weighted, directed network connecting overlapping inpatient visits to measure facility-level CDI pressure. We then matched HCFO-CDIs with non-CDI controls on facility, comorbidities and demographics and performed a conditional logistic regression to determine the odds of developing HCFO-CDI given the number of coincident patient visits with CDI. On average, cases' visits coincided with 9.2 CDI cases, which for an individual with an average length of stay corresponded to an estimated 17.7% (95% CI 12.9–22.7%) increase in the odds of acquiring HCFO-CDI compared to an inpatient visit without concurrent CDI cases or fully isolated from both direct and indirect risks from concurrent CDI cases. These results suggest that, either directly or indirectly, hospital patients with CDI lead to CDIs in non-infected patients with temporally overlapping visits.
Bruineberg et al. provide compelling clarity on the roles Markov blankets could (and perhaps should) play in the study of life and mind. However, here we draw attention to a further role blankets might play: as a hypothesis about cognition itself. People and other animals may use blanket-like representations to model the boundary between themselves and their worlds.
In a prospective cohort of healthcare personnel (HCP), we measured severe acute respiratory syndrome coronavirus virus 2 (SARS-CoV-2) nucleocapsid IgG antibodies after SARS-CoV-2 infection. Among 79 HCP, 68 (86%) were seropositive 14–28 days after their positive PCR test, and 54 (77%) of 70 were seropositive at the 70–180-day follow-up. Many seropositive HCP (95%) experienced an antibody decline by the second visit.
Cognitive Bias Modification for paranoia (CBM-pa) is a novel, theory-driven psychological intervention targeting the biased interpretation of emotional ambiguity associated with paranoia. Study objectives were (i) test the intervention's feasibility, (ii) provide effect size estimates, (iii) assess dose–response and (iv) select primary outcomes for future trials.
In a double-blind randomised controlled trial, sixty-three outpatients with clinically significant paranoia were randomised to either CBM-pa or an active control (text reading) between April 2016 and September 2017. Patients received one 40 min session per week for 6 weeks. Assessments were given at baseline, after each interim session, post-treatment, and at 1- and 3-months post-treatment.
A total of 122 patients were screened and 63 were randomised. The recruitment rate was 51.2%, with few dropouts (four out of 63) and follow-up rates were 90.5% (1-month) and 93.7% (3-months). Each session took 30–40 min to complete. There was no statistical evidence of harmful effects of the intervention. Preliminary data were consistent with efficacy of CBM-pa over text-reading control: patients randomised to the intervention, compared to control patients, reported reduced interpretation bias (d = −0.48 to −0.76), improved symptoms of paranoia (d = −0.19 to −0.38), and lower depressed and anxious mood (d = −0.03 to −0.29). The intervention effect was evident after the third session.
CBM-pa is feasible for patients with paranoia. A fully powered randomised control trial is warranted.
Prisons are susceptible to outbreaks. Control measures focusing on isolation and cohorting negatively affect wellbeing. We present an outbreak of coronavirus disease 2019 (COVID-19) in a large male prison in Wales, UK, October 2020 to April 2021, and discuss control measures.
We gathered case-information, including demographics, staff-residence postcode, resident cell number, work areas/dates, test results, staff interview dates/notes and resident prison-transfer dates. Epidemiological curves were mapped by prison location. Control measures included isolation (exclusion from work or cell-isolation), cohorting (new admissions and work-area groups), asymptomatic testing (case-finding), removal of communal dining and movement restrictions. Facemask use and enhanced hygiene were already in place. Whole-genome sequencing (WGS) and interviews determined the genetic relationship between cases plausibility of transmission.
Of 453 cases, 53% (n = 242) were staff, most aged 25–34 years (11.5% females, 27.15% males) and symptomatic (64%). Crude attack-rate was higher in staff (29%, 95% CI 26–64%) than in residents (12%, 95% CI 9–15%).
Whole-genome sequencing can help differentiate multiple introductions from person-to-person transmission in prisons. It should be introduced alongside asymptomatic testing as soon as possible to control prison outbreaks. Timely epidemiological investigation, including data visualisation, allowed dynamic risk assessment and proportionate control measures, minimising the reduction in resident welfare.
We present the case of a 13-year-old male with a complex congenital cardiac history who was supported with extracorporeal membrane oxygenation for 394 days while awaiting cardiac transplantation. The patient underwent successful cardiac transplantation after 394 days of support with veno-arterial extracorporeal membrane oxygenation and is currently alive 2 years after cardiac transplantation. We believe that this case represents the longest period of time that a patient has been supported with extracorporeal membrane oxygenation as a bridge to cardiac transplantation.
We also review the literature associated with prolonged support with extracorporeal membrane oxygenation. This case report documents many of the challenges associated with prolonged support with extracorporeal membrane oxygenation, including polymicrobial bacterial and fungal infections, as well as renal dysfunction. It is possible to successfully bridge a patient to cardiac transplantation with prolonged support with extracorporeal membrane oxygenation of over 1 year; however, multidisciplinary collaboration is critical.
Background: Current literature suggests that older age, hypertension, and diabetes mellitus confer a significant increased risk of mortality among patients with COVID-19. The purpose of this study is to further characterize the predictors of mortality in patients with COVID-19 in residents of Flint, Michigan, based on variables such as gender, age, smoking status, health insurance plan, and comorbidities. Methods: Hurley Medical Center, is a 443-bed public, nonprofit, teaching medical center located in Flint, Michigan. In total, 289 consecutive adult patients (aged ≥18 years) with confirmed SARS-CoV-2 infection by nasal polymerase chain reaction (PCR), admitted and discharged from our facility from March 2020 through June 2020, were retrospectively analyzed. Results: During the 4-month study period, the overall in-hospital case fatality rate (CFR) was 18% (51 of 289), with highest CFR in the age group aged 60–69 years (36%; P = .06). Nonsurvivors tended to be older with mean age of 67 years (95% CI, 61.6–71.8) versus survivors with mean age of 60 years (95% CI, 57.7–62.4). Highest mortality was seen in patients with Medicare or Medicaid as their sole health plan (39%, P = .59). Men comprised 51% (148 of 289) of the cohort with CFR of 21% versus 14% in females. Females tended to be younger with a higher body mass index (BMI) than their male counterparts (mean age of 58 years, mean BMI of 35 in women vs a mean age of 62 and BMI of 29 in men). A higher proportion of deceased were active smokers (51%; P = .02). CFR was highest in patients with hypertension (92%,; P = .15), followed by diabetes (44%; P = .85), chronic kidney disease (CKD) (31%; P = .10), obstructive sleep apnea (OSA) (28%; P = .25), asthma (22%; P = .64), and coronary artery disease (22%; P = .34). It was lowest in patients with end-stage renal disease (3%; P = .69). Conclusions: Our study suggests trends towards higher mortality with male sex, hypertension and diabetes, along with other comorbidities. Smoking seems to be a strong predictor of mortality in this cohort. Further studies are needed to ascertain the relationship between possible risk factors with COVID-19 mortality in residents of Flint, Michigan. Describing and understanding the potential risk factors is the key to improving outcomes in this population.
Green tea is a popular drink used for therapeutic purposes to mitigate the consequences of diabetes. In this study, we aimed at evaluating the potential of green tea infusion to ameliorate structural and enzymatic damages caused by hyperglycemia in the testis and epididymis of Wistar rats. For that, nondiabetic and streptozotocin-induced diabetic rats (negative control and diabetes control, respectively) received 0.6 mL of water by gavage. Another set of diabetic animals received 100 mg/kg of green tea infusion diluted in 0.6 mL of water/gavage (diabetes + green tea) daily. After 42 days of treatment, the testes and epididymides were removed and processed for histopathological analysis, micromineral determination, and enzymatic assays. The results showed that treatment with green tea infusion preserved the testicular and epididymal histoarchitecture, improving the seminiferous epithelium and the sperm production previously affected by diabetes. Treatment with green tea reduced tissue damages caused by this metabolic condition. Given the severity of hyperglycemia, there was no efficacy of the green tea infusion in maintaining the testosterone levels, antioxidant enzyme activity, and microminerals content. Thus, our findings indicate a protective effect of this infusion on histological parameters, with possible use as a complementary therapy for diabetes.
Hispanic/Latino populations are disproportionately impacted by coronavirus disease 2019 (COVID-19) in the United States. The impact of state reopening on COVID-19 in this population after stay-at-home orders is unknown. We evaluated the incidence, prevalence and trends during reopening of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) at a major federally qualified health centre in Providence, Rhode Island. A total of 14 505 patients were tested for SARS-CoV-2 from 19 March to 18 August 2020, of which, data on 13 318 (91.8%) patients were available; 70.0% were Hispanic/Latino, and 2905 were positive for SARS-CoV-2 infection. The urban Hispanic/Latino population was almost five times more likely to test positive for SARS-CoV-2 (risk ratio 4.97, 95% CI 2.59–9.53, P < 0.001) compared to non-Hispanic White. The positivity rates among the urban Hispanic/Latino population remained >10% during all phases of reopening. The trends of the incidence rates showed similar associations to those we observed for positivity rates. Public health interventions to address SARS-CoV-2 in Hispanic/Latino communities are urgently needed, even in latter phases of state reopening.
Dietary protein is a pre-requisite for the maintenance of skeletal muscle mass; stimulating increases in muscle protein synthesis (MPS), via essential amino acids (EAA), and attenuating muscle protein breakdown, via insulin. Muscles are receptive to the anabolic effects of dietary protein, and in particular the EAA leucine, for only a short period (i.e. about 2–3 h) in the rested state. Thereafter, MPS exhibits tachyphylaxis despite continued EAA availability and sustained mechanistic target of rapamycin complex 1 signalling. Other notable characteristics of this ‘muscle full’ phenomenon include: (i) it cannot be overcome by proximal intake of additional nutrient signals/substrates regulating MPS; meaning a refractory period exists before a next stimulation is possible, (ii) it is refractory to pharmacological/nutraceutical enhancement of muscle blood flow and thus is not induced by muscle hypo-perfusion, (iii) it manifests independently of whether protein intake occurs in a bolus or intermittent feeding pattern, and (iv) it does not appear to be dependent on protein dose per se. Instead, the main factor associated with altering muscle full is physical activity. For instance, when coupled to protein intake, resistance exercise delays the muscle full set-point to permit additional use of available EAA for MPS to promote muscle remodelling/growth. In contrast, ageing is associated with blunted MPS responses to protein/exercise (anabolic resistance), while physical inactivity (e.g. immobilisation) induces a premature muscle full, promoting muscle atrophy. It is crucial that in catabolic scenarios, anabolic strategies are sought to mitigate muscle decline. This review highlights regulatory protein turnover interactions by dietary protein, exercise, ageing and physical inactivity.
Psychosis is associated with a reasoning bias, which manifests as a tendency to ‘jump to conclusions’. We examined this bias in people at clinical high-risk for psychosis (CHR) and investigated its relationship with their clinical outcomes.
In total, 303 CHR subjects and 57 healthy controls (HC) were included. Both groups were assessed at baseline, and after 1 and 2 years. A ‘beads’ task was used to assess reasoning bias. Symptoms and level of functioning were assessed using the Comprehensive Assessment of At-Risk Mental States scale (CAARMS) and the Global Assessment of Functioning (GAF), respectively. During follow up, 58 (16.1%) of the CHR group developed psychosis (CHR-T), and 245 did not (CHR-NT). Logistic regressions, multilevel mixed models, and Cox regression were used to analyse the relationship between reasoning bias and transition to psychosis and level of functioning, at each time point.
There was no association between reasoning bias at baseline and the subsequent onset of psychosis. However, when assessed after the transition to psychosis, CHR-T participants showed a greater tendency to jump to conclusions than CHR-NT and HC participants (55, 17, 17%; χ2 = 8.13, p = 0.012). There was a significant association between jumping to conclusions (JTC) at baseline and a reduced level of functioning at 2-year follow-up in the CHR group after adjusting for transition, gender, ethnicity, age, and IQ.
In CHR participants, JTC at baseline was associated with adverse functioning at the follow-up. Interventions designed to improve JTC could be beneficial in the CHR population.
Background:Clostridioides difficile infections (CDIs) present and are transmitted in both community and healthcare settings. Patients who become colonized or infected during hospitalization may be discharged into the community. Asymptomatic spread and/or community-based transmission have also been posited as alternative sources for healthcare-onset CDI cases. The objective of our study was to determine whether individuals are at greater risk for developing a CDI if they have a family member that spent time hospitalized in the prior 90 days, even if the hospitalized family member had no prior diagnosis of CDI. Methods: We conducted a retrospective cohort study using the Truven Marketscan database from 2001 through 2017; both commercial claims and Medicare supplemental data were included. We categorized enrollees by age, sex, month, year, exposure to a family member with CDI, hospitalization, or high- or low-risk antibiotic use in the prior 90 days. We then subdivided these groups based on the total amount of time that other family members spent hospitalized in the prior 90 days: ≤4 days, 5–10, 11–20, 21–30, 41–50 or >50 days. Within each subgroup, we computed the incidence of CDI. We then used a stratified regression model (log-linear quasi-Poisson) to estimate the incidence of CDI in each enrollment bin. Finally, we repeated our analysis using all CDI cases, CDI cases with no prior CDI in the family, and cases without prior hospitalization. Results: Over the 17-year study period, >5.1 billion enrollment months were represented in our dataset. We identified 224,818 cases of CDI, 223,744 cases without prior CDI in a family member and 164,650 CDI cases where the case patient had no prior hospitalization. Table 1 depicts the estimated risk (incident rate ratios) associated with the amount of time that other family members spent hospitalized in the prior 90 days. There is a very clear dose–response curve, and the relative risk for CDI increase as the amount of time other family members spent hospitalized increased. Other risk factors included prior hospitalization, low- and high-risk antibiotics, age, female sex and exposure to a family member with CDI. Conclusions: Having a family member who has been hospitalized in the prior 90 days significantly increases the risk for CDI, even if the family member did not have CDI. The total amount of time other family members spent in the hospital is positively associated with the level of risk.
Funding: CDC Modeling Infectious Diseases (MInD) in Healthcare Network
Colonization pressure at the unit level is known to be a risk factor for Clostridioides difficile infections in hospitals. Because C. difficile colonization is not routinely detected in clinical practice, only patients identified as having C. difficile infection (CDI) are included in these pressure calculations. We used data from the University of Iowa Hospitals and Clinics (UIHC) to determine whether highly local CDI pressure, due to patients in nearby rooms, is more strongly correlated with CDI than unit-level CDI pressure. Methods: We designed a base logistic regression model using variables known to be risk factors for CDI: age, antibiotic/gastric acid suppressor use, low albumin, prior hospitalization, comorbidities. To the base model, we add 2 measures, mean colonization pressure (MCP) and sum colonization pressure (SCP) of CDI at the unit level to obtain new models. To the base model, we also added CDI colonization pressure by considering CDI cases at different distance thresholds from the focal patient. Distances between patient rooms were extracted from hospital floor plans. Results: Adding unit-level CDI colonization pressures to the base model improved performance. However, adding CDI colonization pressures due to roommates and due to patients at different distances improved the model much more (Table 1). The top (resp. bottom) row shows in-sample (resp. out-of-sample) C-statistics for the base model, the base model with unit-level MCP, the base model with roommate MCP, and the base model with MCP from patients are different distances added as separate features. C-statistics for the base model and the base model with unit CDI pressure (SCP and MCP) are compared in Fig. 1 with C-statistics from the base model with CDI pressure from patients at distances D = 0, 1, 2, 3, 4, 5, 10, 15, 20 hops (1 hop = 5–6 meters). Conclusions: Our results support the hypothesis that unit CDI colonization pressure is a risk factor for CDI. However, by incorporating spatially granular notions of distances between patients in our analysis, we were able to demonstrate that the true source of CDI pressure at the UIHC is almost exclusively attributable to roommates and patients in adjacent rooms.
Background: Patient sharing between hospitals has long been known to be a contributor to the regional transmission of hospital-acquired infections. This inter–healthcare-facility connectedness suggests that regional, as opposed to local, control and surveillance strategies should be favored. However, the absence of easily and universally accessible patient transfer data hampers researchers and public health agencies who wish to build accurate network models of interfacility transmissions. Medicare data offer only a biased subsample of the full patient transfer network, but because it is widely available, this data source has historically been used for inference and simulation studies. Objective: The purpose of this study was to determine whether Medicare data could successfully be recalibrated to more closely resemble 100% inpatient capture data. Methods: We used data from the Healthcare Cost and Utilization Project (HCUP) to construct 100% capture and Medicare-only patient sharing networks among hospitals in Iowa, Wisconsin, and Nebraska. We used matrix decomposition techniques on the Medicare-only networks along with hospital characteristics from the American Hospital Association (AHA) data for feature construction in a truncated Poisson regression model, and we used Monte Carlo integration to obtain predicted values. These predicted values served as calibrated Medicare-only networks. We split the patient transfer data into training and testing sets and computed the mean squared prediction error (MSPE) for the testing data. We also built an individual based model (IBM) using HCUP and AHA data to perform epidemic simulations that depended on a matrix of patient transfer rates between hospitals. We then compared epicurves from these IBMs resulting from 100% capture networks, Medicare-only networks, and our calibrated networks. Results: Our calibrated networks reduced the MSPE with respect to Medicare-only networks by 84%, 47%, and 88% for Iowa, Wisconsin, and Nebraska, respectively. Although the epicurves from Medicare-only networks differed considerably from that from 100% capture networks, our calibrated networks retained high fidelity to the curves obtained from 100% capture networks. Conclusions: Medicare-only networks greatly underestimate the number of patients transferred between hospitals. Our approach allows us to use Medicare data to estimate networks when 100% inpatient capture is unavailable.
Background: As many as 40% of infants aged ≤12 months and 10%–28% of children aged 13–24 months are colonized by Clostridioides difficile. The IDSA and the SHEA recommend that testing should never be routinely recommended for infants ≤12 months of age and should not be routinely performed for children 1–2 years of age unless other causes are excluded. We report implementation of C. difficile diagnostic stewardship at 2 children’s hospitals. Methods: We implemented age-based restrictions for C. difficile testing at hospital A (∼200-bed, free-standing, children’s hospital) and hospital B (∼100-bed children’s hospital within a larger hospital). Both sites are part of the same multicampus institution, and both used nucleic acid amplification testing to detect C. difficile throughout the study. In May 2018, we implemented an electronic order set for C. difficile that provided alerts to avoid testing young infants and patients with recent use of laxatives, stool softeners, or enemas, but providers could order C. difficile testing at their discretion. In October 2018, we implemented a more restrictive diagnostic stewardship algorithm for C. difficile. No testing was allowed for infants aged ≤12 months. Approval pediatric infectious diseases staff was required to test children aged 13–24 months. Pathology resident approval was required to test children aged ≥24 months who had received laxatives, stool softeners, or enemas within ≤24 hours. Clinical microbiology laboratory supervisors reinforced rejection of nondiarrheal stool specimens for testing. Providers at both campuses were informed about the new testing guidelines by e-mail. We compared the number of tests sent and positive cases of healthcare facility-onset C. difficile (HO-CDI) by age strata before and after the implementation of the restrictive testing algorithm. Results: After the intervention, the number of tests in infants significantly declined; 2 infants aged ≤12 months and 4 infants aged 13–24 months were tested for C. difficile (Table). After the intervention, the number of tests per month declined at hospital A, as did the number of HO-CDI cases at both hospitals. Rejections of nondiarrheal stools significantly increased after the intervention (P < .001). Conclusions:C. difficile diagnostic stewardship for children was successfully implemented using a rule-based alert system in the electronic health record. This intervention was associated with a reduced number of tests sent and cases of HO-CDI. This strategy was cost-saving and prevented misdiagnosis, unnecessary antibiotic therapy, and overestimation of HO-CDI rates.