749. A Nurse-Driven Protocol for Early Detection of Clostridiodes difficile Infections

Abstract Background Clostridiodes difficile infections (CDI) are a significant cause of hospital acquired infections, resulting in significant morbidity and mortality. Early detection of CDI has been shown to reduce the spread of CDI within the hospital. As nurses are frequently at the patient’s bedside, we proposed to empower the nursing staff to assess, collect stool samples, and order C. difficile testing. Methods Rates of CDI were measured by our Infection Control Department. Hospital-onset CDI (HO-CDI) was defined as a positive C. difficile PCR assay after 3 days of admission, defined as a stay of at least 3 midnights. Community-onset CDI (CO-CDI) was defined as any case that was diagnosed in the Emergency Department or inpatient ward < 3 days of hospitalization based on stool testing as above. Nursing was instructed and empowered to assess, collect stool specimens, and place an order for C. difficile testing, based on the criteria of ≥3 loose or watery stools over 24 hours. Nursing was also educated to not order a test if patients had received stool softeners, enemas, or laxatives within 24 hours. The protocol was initiated in February 2019. Results Rates of HO-CDI increased during the intervention period, rising from 2.6 cases/10000 patient days and peaking at 17.7 cases/10000 patient days (average 6.7 vs. 12.1 monthly cases per 10,000 patient days. Rates of CO-CDI did not significantly change (12.4 vs. 11.5 monthly cases per 10000 patient days). Due to concerns of inappropriate testing, which included testing after laxatives, enemas, or sending specimens despite < 3 stools over 24 hours, the protocol was discontinued in June 2019. Although the HO-CDI rate remained elevated over the next month, the rate subsequently decreased over the next several months (12.1 vs. 8.0 cases per 10000 patient days). Overall testing also increased over the study period (148.3 vs. 169.9 cases/per 10000 patient days).Figure 1 - Clostridiodes difficile rates Figure 2 - CDI testing rates Conclusion A nursing driven protocol resulted in increased HO-CDI and overall CDI rates suggesting that the intervention may have been a factor in increasing the frequency of HO-CDI diagnoses, although the possibility of misdiagnosis of colonization for true CDI cannot be excluded. Further education of nursing staff may be a potential intervention in improving appropriate CDI testing. Disclosures All Authors: No reported disclosures

endonuclease analysis (REA) strain typing was performed on the recovered CD isolates.
Results. Toxin testing was positive in 19/50 (38%) cases. Compared to stool toxin-negative cases, toxin-positive cases were older (95% vs. 71% were age ≥ 65, p = 0.06), more likely to have a history of CDI (37% vs. 23%, p = 0.34), and have ≥ 1 CDI episodes within 6 months (37% vs. 19%, p = 0.26). Treatment for CDI was more common in patients who had a positive toxin text. (95% vs 61%, p= 0.009). Among the 38 patients that received treatment, 33 received vancomycin (87%) and 8 patients (21%) had rCDI at 30 days. Of the 8 patients with rCDI, 2 were re-admitted to the hospital for CDI. The average PCR cycle threshold was lower in the toxin-positive stools compared to toxin-negative stools (24.46 and 29.96, p< 0.001; Fig. 1) The endemic REA group Y was the most common CD strain recovered (30%) and the previously epidemic and virulent REA group BI strain was recovered in 11% of the cases.
Conclusion. CDI cases diagnosed by positive stool PCR and positive toxin tests had more typical risk factors for CDI, a lower PCR cycle threshold and were more likely to have been treated for CDI. Outcomes were similar in this setting where infection with the virulent BI strain was uncommon.
Disclosures Background. Clostridioides difficile is the leading cause of hospital associated infections. In 2017 it lead to an estimated 223,900 cases, 12,800 deaths and $1 billion in attributable healthcare costs. [1] Judicious use of antibiotics and good hand hygiene practices form the cornerstone of prevention. During the COVID-19 pandemic there has been a focus on infection control practices such as hand hygiene, which would also lead to decreased incidence of other contagious infections such as C. difficile diarrhea.
Methods. We looked at the incidence of C. difficile infection in a tertiary care hospital, 1 year before and 1 year after the start of the COVID-19 pandemic. We looked at the absolute number of hospital associated C. difficile infections and the rate per 1000 patient days. The testing methodology changed during the time of the study. Initially it included NAAT for C. difficile, however in March of 2020 the testing strategy included testing for GDH antigen and toxin A/B to differentiate between infection and asymptomatic colonization.
Results. From January 1 st and December 31 st 2019 there were a total of 182 C. difficile infections with a rate of 1.29% per 1000 patient days. Between January 1 st and December 31 st 2020 there were a total of 51 C. difficile infections with a rate of 0.39% per 1000 patient days. There was an absolute risk reduction of 0.9% and relative risk reduction of 69.7%. Hand hygiene audits did not show a difference in adherence between the two periods, with a compliance rate of 98% for both.
Conclusion. Our data suggests that there was a substantial reduction in C. difficile infection rate after widespread knowledge of COVID-19 and implementation of enhanced infection prevention strategies. These included frequent reminders of hand washing, gowning and social distancing to name some. This information was conveyed in the form of widely disseminated signs in highly visible areas, frequent reminders electronically and in person between staff and providers. There are limitations in our study, which include difficulty in longitudinally assessing the extent to which patient care providers adhered to infection prevention strategies and a change in testing strategy for C. difficile diagnosis during this time.
Disclosures. Background. In 2003, many hospitals in Québec, Canada experienced an increase in the incidence of healthcare-associated C. difficile infection (HA-CDI) associated with increased morbidity and mortality. This increase was associated with the dissemination of the NAP1/027 strain. The objective of this study was to describe the epidemiology of HA-CDI in two tertiary care hospitals based in Montréal from 2003 to 2019.
Methods. Surveillance for HA-CDI was performed using standard definitions from 2003 to 2019 at the Montreal General Hospital (MGH) and Royal Victoria Hospital (RVH), in Montréal, Québec. C. difficile was isolated from stool specimens using standard methods. Pulsed field gel electrophoresis and ribotyping were performed to determine genotype. Antibiotic utilization and infection control interventions implemented over the same time period were reviewed.
Results. A total of 4314 cases of CDAD were identified during the study period: 2295 at the RVH and 2019 at the MGH. The incidence decreased from 29.5 to 5.9 cases per 10,000 patient-days between 2003 and 2019 at the RVH and from 23.8 to 3.9 cases per 10,000 patient-days at the MGH. Of the 124 isolates available for genotyping in 2003, 112 were NAP1 (90.3%) compared to 5 out of 53 (9.4%) in 2019. Fluoroquinolone utilization decreased from 230 to 139 DDDs per 1,000 patient-days between 2003 and 2019, whereas total antibiotic utilization increased from 1296 to 1550 DDDs per 1,000 patient-days. Infection Control interventions included empirically placing patients with diarrhea on precautions, intensified cleaning measures, formal antibiotic stewardship, introduction of a real-time PCR C. difficile test in June 2010, and a move to a facility with only single rooms at the RVH in April 2015.

Incidence of HA-CDI at the RVH and MGH and antibiotic utilization between 2003 and 2019
Conclusion. An important change in HA-CDI epidemiology was observed in two Canadian tertiary care hospitals based in Montréal between 2003 and 2019. There was a significant decrease in incidence of HA-CDI and a genotype shift from a predominance of NAP1 strains to non-NAP1 strains. Utilization of fluoroquinolones, to which the NAP1 strain is resistant, concurrently decreased. Infection control interventions targeting isolation, diagnosis, disinfection, and antibiotic stewardship have contributed to the major observed reduction in HA-CDI incidence. Background. Clostridiodes difficile infections (CDI) are a significant cause of hospital acquired infections, resulting in significant morbidity and mortality. Early detection of CDI has been shown to reduce the spread of CDI within the hospital. As nurses are frequently at the patient's bedside, we proposed to empower the nursing staff to assess, collect stool samples, and order C. difficile testing.

A Nurse-Driven Protocol for Early Detection of Clostridiodes difficile Infections
Methods. Rates of CDI were measured by our Infection Control Department. Hospital-onset CDI (HO-CDI) was defined as a positive C. difficile PCR assay after 3 days of admission, defined as a stay of at least 3 midnights. Community-onset CDI (CO-CDI) was defined as any case that was diagnosed in the Emergency Department or inpatient ward < 3 days of hospitalization based on stool testing as above. Nursing was instructed and empowered to assess, collect stool specimens, and place an order for C. difficile testing, based on the criteria of ≥3 loose or watery stools over 24 hours. Nursing was also educated to not order a test if patients had received stool softeners, enemas, or laxatives within 24 hours. The protocol was initiated in February 2019.
Results. Rates of HO-CDI increased during the intervention period, rising from 2.6 cases/10000 patient days and peaking at 17.7 cases/10000 patient days (average 6.7 vs. 12.1 monthly cases per 10,000 patient days. Rates of CO-CDI did not significantly change (12.4 vs. 11.5 monthly cases per 10000 patient days). Due to concerns of inappropriate testing, which included testing after laxatives, enemas, or sending specimens despite < 3 stools over 24 hours, the protocol was discontinued in June 2019. Although the HO-CDI rate remained elevated over the next month, the rate subsequently decreased over the next several months (12.1 vs. 8.0 cases per 10000 patient days). Overall testing also increased over the study period (148.3 vs. 169.9 cases/per 10000 patient days).

Conclusion.
A nursing driven protocol resulted in increased HO-CDI and overall CDI rates suggesting that the intervention may have been a factor in increasing the frequency of HO-CDI diagnoses, although the possibility of misdiagnosis of colonization for true CDI cannot be excluded. Further education of nursing staff may be a potential intervention in improving appropriate CDI testing.
Disclosures. Background. Clostridium difficile infection (CDI) is the primary cause of infectious diarrhea in the United States. With an estimated 453,000-500,000 burden cases that are associated with 15,000-30,000 deaths annually in the United States. Because of its prevalence, there is a projected 3.2-4.8 billion dollar annual cost for inpatient care related to CDI. For these reasons, accurate and timely detection of CDI is crucial to reduce the morbidity, mortality, and medical costs.
Methods. This is a retrospective cohort study. Adult patients, aged 18 through 80 years, admitted between 9/1/2016 and 9/30/2017, who presented with diarrhea and received a CDI algorithm test. To assess bivariate associations between true positive and indeterminate positive groups, categorical variables were compared using Chi-Square or Fisher's exact tests when appropriate, and continuous variables were analyzed using independent samples t-tests.
In order to examine patient-level variables, the first positive from each patient was included to ensure independence of data points, resulting in 830 unique tests and patients. The true positive rate of this sub-sample was 9.4% (n = 78) and indeterminate positive rate was 8.7% (n = 72).
An important findings of the study is that of the patients who were GDH (+)/toxin (-), 87 (50.9%) were PCR (-) and 84 (49.1%) were PCR (+). Table 1 Conclusion. The study found that of the patients who are GDH (+) and Toxin (-), the PCR test serves as a proxy for the CDI test. In addition, we demonstrated that whether the patient was true positive by the GDH/Toxin test or indeterminate positive, the outcomes were the same. The only difference was the antibiotic selections for treatment. Performing PCR tests as a part of three-step algorithm prevented nearly half of discrepant patients from being unnecessarily treated with antibiotics and placed on enteric precaution, thereby extending their hospital stay. Finally, by preventing unnecessary antibiotic use, isolation and hospital length of stay, it is proposed that the three-step algorithm effectively reduces hospital cost.