760. Incidence, Predictors and 30-Day Outcomes of Clostridoides difficile Infection in Patients Undergoing Cystectomy: A Nationwide Analysis Using the ACS-NSQIP Database

Abstract Background Clostridoides difficile infection is the second most common healthcare acquired infection (HAI) and the most common gastrointestinal HAI, with an estimated 365,200 cases reported by the CDC in 2017. CDI continues to remain a major cause of inpatient admission and utilization of healthcare resources. The exact incidence of peri-procedural CDI with cystectomy is unknown, and reported incidence of CDI in literature vary widely Methods We conducted an analysis of patients undergoing cystectomy between 2015 and 2017 using the ACS National Surgical Quality Improvement Program (NSQIP) to study the incidence, risk factors and 30-day post-surgical outcomes associated with CDI following cystectomy. Developed by the American College of Surgery, this is a nationally validated, risk-adjusted, outcomes-based program designed to determine and improve the quality of surgical and post-surgical care. Results The incidence of CDI following cystectomy was 3.6% in our patient cohort. 18.8% of patients developed CDI following hospital discharge. Non-elective surgeries, and complete cystectomy procedures had higher rate of CDI. 48.4% of patients with CDI had a preceding post-operative infection. Post-operative organ space infections (OR 1.95), post-operative renal failure (OR 2.38), post-operative sepsis (OR 2.49) and septic shock (OR 2.33) were independently associated with development of CDI, (all p values < 0.05). Patients who developed post-operative CDI during hospitalization had lengthier hospital admissions than those who did not develop a CDI (OR 2.29) and had a higher risk of DVT formation (2.48), and were also more likely to have unplanned readmissions (OR 7.8) Conclusion This is the first nationwide study looking at inpatient and 30-day post-operative CDI after cystectomy in the US. A sizable number of patients experience CDIs after cystectomy procedures, and CDI development is associated with an increase in length of stay and unplanned readmissions. This study lends further evidence to the need for continued interventions and initiatives to reduce this burden of post-operative CDI. Disclosures All Authors: No reported disclosures


Host Intestinal Defenses Against Clostridioides difficile Infection in Chemotherapy Patients
Claire Weinstein, BA 1 ; Racheal Wilkinson, BS, MLS 1 ; Senu Apewokin, MD 1 ; 1 University of Cincinnati, Cincinnati, Ohio Session: P-36. HAI: C. difficile Background. Clostridioides difficile infection (CDI) is a common complication in patients undergoing cancer treatment with cytotoxic chemotherapy. Exposure to antibiotics or chemotherapy disrupts the microbiome by killing protective intestinal flora which consequently promotes C. difficile spore germination and disease. The host defense against CDI includes colonization resistance conferred by the healthy microbiome and innate defenses provided by intestinal epithelial cells. One protective factor secreted by Paneth cells of the intestinal epithelium is lysozyme, an enzyme that degrades the cell walls of Gram-positive bacteria such as C. difficile. We hypothesized that chemotherapy-induced mucosal barrier injury and the resultant death of Paneth cells leads to decreased production of lysozyme. We thus sought to examine changes in lysozyme concentration in stools of chemotherapy patients.
Methods. We collected stool samples from six patients undergoing cancer treatment at four different time points. The first stool sample corresponded to the day prior to the start of chemotherapy (day zero). We then performed ELISA assays to determine the lysozyme concentration for each stool sample.
Results. On day zero, the lysozyme levels (n=6) averaged 268.1 ± 131.7 ng/mL. Over the course of chemotherapy, the lysozyme levels decreased 78.70 ± 24.19% from the starting value. The lowest values were observed around days 5 through 11 for most patients, coinciding with when they were most neutropenic around day 11. One of the patients developed CDI on day 5 and experienced more fluctuating lysozyme levels thereafter. On the day that the patient developed CDI, lysozyme was measured as 6.63 ng/mL. Throughout treatment, 3/6 patients showed recovery of lysozyme production with white blood cell recovery.
Conclusion. Our data indicate that chemotherapy causes decreased concentrations of lysozyme in stool. Low lysozyme levels could in part account for the increased susceptibility to CDI during chemotherapy. Future experiments will include bioinformatics analyses to determine how the microbiome changes in response to chemotherapy. Together, these experiments will inform our approach to determining patient susceptibility to chemotherapy-associated CDI.
Disclosures. Background. IDSA recommends use of fidaxomicin or oral vancomycin for treatment of initial episode or first recurrence of Clostridioides difficile infection (CDI). This study aimed to evaluate impact of a clinical decision support order set driving appropriate use of fidaxomicin on utilization of CDI drug treatments and associated clinical outcomes.
Methods. This was a retrospective, quasi-experimental study evaluating CDI therapies pre-(8/2016-11/2017) and post-(5/2018-1/2020) CDI order set implementation at a level-one trauma center located in Virginia. Admitted adult patients were included if CDI testing was positive for a 1 st or 2 nd episode and received active CDI treatment. Exclusions included fulminant CDI and CDI diagnosis by PCR with < 3 bowel movements or laxative use within 24 hours. The primary outcome was CDI recurrence within 30 days of completing therapy in patients who achieved clinical cure. Secondary outcomes were evaluated at 30 and 90 days and included sustained response and CDI-related readmissions.