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intensive care unit (ICU) admission, and diarrhea resolution on day of dis-
charge. Results: Of the 181 patients, 144 received full treatment, 17 had
partial, and 20 had no treatment. Baseline characteristics were similar
between groups. No significant difference was found for length of stay
or any secondary outcomes (Table 1). Table 2 provides a subgroup of
patients who received no treatment vs those receiving partial or full treat-
ment. Conclusion: In this study, treatment exposure did not affect clinical
outcomes for patients with PCR+/EIA- results, though sample sizes may
limit generalizability. Further research is warranted regarding the clinical
approach to PCR+/EIA-
Antimicrobial Stewardship & Healthcare Epidemiology 2024;4(Suppl. S1):s63–s64
doi:10.1017/ash.2024.183
Presentation Type:
Poster Presentation - Poster Presentation
Subject Category: C. difficile
Impact of Clostridioides difficile Reporting on Antimicrobial Therapy
Days Directed at Treatment of C. difficile Infections
Ardath Plauche, Memorial Hermann Health System; Edward Septimus,
Harvard Medical School and Harvard Pilgrim Health Care Institute and
Jamie Thomas, Memorial Hermann Southwest
Background: Previous studies have found that solely relying on molecular
testing is likely to result in the overdiagnosis and overtreatment of C. dif-
ficile infections (CDI). Comparable outcomes have been demonstrated in
patients with a positive molecular test (C. difficile PCR) result and a neg-
ative toxin immunoassay (C. difficile toxin) compared to patients without
CDI by either testing Method: In 2021 Memorial Hermann Healthcare
System converted from C. difficile PCR testing only to C. difficile PCR test-
ing with reflex to C. difficile toxin if positive. A previous internal audit
revealed that despite this change in testing, patients who were C. difficile
PCR positive and C. difficile toxin negative were still receiving treatment.
This study aimed to evaluate the impact of C. difficile reporting on the total
days of therapy directed at the treatment of CDI of an 11-hospital health
care system in patients who testing C. difficile PCR positive/C. difficile
toxin negative. Methods: Pre-post, multicenter, retrospective, observatio-
nal study conducted from January 1, 2023 through March 31, 2023 (pre-
intervention) and July 1, 2023 through September 31, 2023 (post-interven-
tion) which included hospitalized adult patients with a C. difficile test
ordered within the study period. Intervention included a change in report-
ing of C. difficile PCR positive/C. difficile toxin negative results to display a
laboratory comment. The comment notifies providers of the positive C.
difficile PCR result while highlighting this probably reflects colonization
with C. difficile as the C. difficile toxin is negative and treatment is rarely
indicated. Results: In total, 989 C. difficile PCR were order in the pre-inter-
vention cohort compared to 1009 in post-intervention. The overall rate of
patients that received therapy directed at CDI decreased from 14% to 10%
after the implementation of reporting change. Total days of therapy (DOT)
also decreased by 29% from 482 to 342. Days of therapy that were admin-
istered to patients with C. difficile PCR positive/negative C. difficile toxin
test decreased from 183 to 91. Conclusions: Adjusting the reporting of C.
difficile results led to an overall numerical decrease of antimicrobial DOT
directed at CDI treatment. In particular, among patients with a positive C.
difficile PCR/C. difficile toxin negative test a 50% reduction in DOT was
observed. Further data are required to assess the overall clinical impact of
adjusting CDI reporting methods.
Antimicrobial Stewardship & Healthcare Epidemiology 2024;4(Suppl. S1):s64
doi:10.1017/ash.2024.184
Presentation Type:
Poster Presentation - Poster Presentation
Subject Category: C. difficile
Audit and Feedback to Ordering Providers to Reduce Inappropriate C.
difficile Testing and Hospital Onset C. difficile Rate
Elise Martin, VA Pittsburgh Healthcare System; Vanessa Kung, Pittsburgh
VA Hospital; Jody Feigel, VA Pittsburgh Healthcare System;
Kristin Nagaro, VA Pittsburgh Healthcare System and Deanna Buehrle,
VA Pittsburgh Healthcare System
Background: Inappropriate Clostridioides difficile (C. difficile) laboratory
testing is common in hospitals and leads to over diagnosis, unnecessary
treatment, and elevated hospital onset C. difficile infection (HO-CDI) met-
rics. Diagnostic stewardship is essential to avoid inappropriate testing, but
limited data exists on optional interventions. Methods: A diagnostic stew-
ardship intervention targeting CDI testing comprised of education and
prospective audit with feedback was performed a VA facility (inpatient,
outpatient, and long-term care units). Education on appropriate indica-
tions for CDI testing was provided in pre-intervention (9/2022 to
5/2023) and intervention periods (6/2023 to 12/2023). During the inter-
vention period, all CDI tests (positive or negative) were audited after com-
pletion in real-time by an Infectious Diseases physician and feedback was
given to ordering providers and/or their supervising physician (if trainee)
for all tests not meeting an appropriate indication. Appropriate indication
was defined as ≥3 liquid stools in 24 hours or symptoms of fulminant dis-
ease. Testing was considered inappropriate if no clinical symptoms, patient
received laxatives within 48 hours, test was performed for test-of-cure or
within 7 days of a prior test with no clinical change, or delayed testing in
patients with diarrhea on admission. The rate of HO-CDI per 10,000 bed
days of care (BDOC) per LabID event was compared during the pre-inter-
vention and intervention periods, and ordering appropriateness was com-
pared for all tests and hospital onset tests before (3/2023-5/2023) and after
(6/2023-12/2023) feedback was performed. Results: After starting audit
and feedback, HO-CDI rate decreased from 3.92 per 10,000 BDOC to
0.99 per 10,000 BDOC (p=0.03). HO-CDI rate among tests that were inap-
propriate was 2.19 and 0.80 per 10,000 BDOC during the pre-intervention
and intervention periods, respectively (p=0.40). Average overall tests per
month decreased from 37.8 to 28.1 after the intervention. Rate of all inap-
propriate tests decreased from 16.25 to 7.96 per 10,000 BDOC (p=0.04)
and rate of hospital onset inappropriate tests trended toward decrease from
9.29 to 4.77 tests per 10,000 BDOC (p=0.07). The most common reasons
for inappropriate testing were <3 episodes of diarrhea in 24 hours (54%
pre-intervention, 65% intervention) and laxative use (57% pre-interven-
tion, 45% intervention). No cases of delayed testing leading to worsened
disease were identified during the intervention. Cost savings for decreased
tests were estimated at $150-300 per month. Conclusion: An intervention
comprised of education and real-time audit and feedback of all CDI tests
obtained at a VA facility resulted in decreased inappropriate testing and
reduced the rate of HO-CDI.
Antimicrobial Stewardship & Healthcare Epidemiology 2024;4(Suppl. S1):s64
doi:10.1017/ash.2024.185
Presentation Type:
Poster Presentation - Poster Presentation
Subject Category: C. difficile
Leveraging the Electronic Medical Record in C. difficile Diagnostic
Stewardship
Vijay Duggirala, The Ohio State University Wexner Medical Center;
Jamaal Saleh, The Ohio State University Wexner Medical Center;
Justin Smyer, The Ohio State University Wexner Medical Center;
Courtney Hebert, The Ohio State University Wexner Medical Center;
Christina Liscynesky, The Ohio State University; Nora Colburn, The
Ohio State University and Shandra Day, The Ohio State University
Background: Clostridioides difficile PCR is extremely sensitive but cannot
differentiate colonization versus active disease. Over diagnosis of C. diffi-
cile infection (CDI) has negative consequences including overuse of anti-
biotics targeting C. difficile, increased hospital-acquired (HA)-CDI rates,
and increased healthcare costs. We describe the implementation of a
Clinical Decision Support tool embedded in the C. difficile order and
the result on testing, HA-CDI rates and healthcare costs. Methods: The
C. difficile order was updated in June 2023 with 4 dynamic questions that
SHEA Spring 2024 Abstracts
S64 2024;4 Suppl 1
reflex if specific criteria are identified in the electronic medical record in the
prior 24 hours: less than 3 loose stools documented, receipt of laxative,
opioid antagonist, oral contrast, or tube feed initiation. If any criteria
are identified, an embedded alert triggers and the provider must choose
“yes, high clinical suspicion”or “no (exit and cancel order)”in addition
to providing an order indication. All inpatient C. difficile tests were
reviewed from July 1 to Sept 30, 2022 (pre-update) and July 1 to Sept
30, 2023 (post-update). An order rate was calculated per 10,000 patient
days as well as HA-CDI rate. Cost analysis was completed using direct
lab costs and published costs of $35,000 per HA-CDI. Results of the order
questions were reviewed post-update. Incident rate comparison was com-
pleted using medcalc. Results: Pre-update, 1147 tests were conducted, with
an order rate of 104.3. Post-update, 919 tests were performed, with an order
rate of 86.6. The positivity rate was 16.1% pre-update and 14.7% post-
update. The incidence rate difference was 0.00177 (P 15 (145, 16%). 166
(18%) patients who received laxatives (18 positive, positivity rate 11%)
were still tested. Conclusion: Implementation of a dynamic order led to
a significant reduction in the total number of C. difficile PCR tests per-
formed with associated reduction in HA-CDI and cost savings. Despite
this, patients receiving laxatives were still being tested for C. difficile, high-
lighting the need for ongoing education and feedback. These results sup-
port the use of dynamic ordering for diagnostic stewardship, which can
benefit both patients and hospitals.
Antimicrobial Stewardship & Healthcare Epidemiology 2024;4(Suppl. S1):s64–s65
doi:10.1017/ash.2024.186
Presentation Type:
Poster Presentation - Poster Presentation
Subject Category: C. difficile
Underlying Conditions in Community-associated Clostridioides diffi-
cile Infections in Davidson County, Tennessee
Marissa Turner, Tennessee Department of Health; Kristina
McClanahan, Tennessee Department of Health; Frederick Thompson,
TN DEPT OF HEALTH CEDEP/HAI, Tennessee Department of
Health; Zelda Foster, state of TN and Raquel Villegas, state of TN
Background: Clostridioides difficile infections (CDI) are a crucial public
health threat becoming a worldwide problem. In 2017, there were 223,900
incident cases and 12,800 deaths in the United States. Underlying condi-
tions, such as diabetes mellitus (DM), put individuals at a greater risk for
developing an infection. Whereas CDI was once believed to be mostly
healthcare-associated, increasing evidence points to transmission in com-
munity settings (CA). We investigated characteristics of CA CDI and asso-
ciations between pre-existing conditions and CA incident CDI cases using
data from Tennessee’s CDI surveillance program, an active population-
and laboratory-based surveillance system conducted through CDC’s
Emerging Infections Program. CA incident CDI case data were down-
loaded from the Incident Case Management System from 2017 to 2021.
Count and percentages were determined for each underlying condition,
number of underlying conditions, and biological sex. Chi-square analyses
determined associations between underlying conditions and sex. Statistical
analyses were conducted using SAS v9.4. 2,326 CA incident CDI cases were
identified from the catchment area. The case rates per 100,000 population
between 2017 and 2021 were 79.7, 81.9, 73.7, 50.7, and 49.6. A total of 39%
of the cases were 65 years or older. Most cases were women (64.8%). The
overall prevalence for any underlying condition among CA CDI cases was
67.4%. A total of 29.4% of incident cases had one condition, 18.5% had two
conditions, and 19.4% had three or more conditions. The most frequently
reported pre-existing conditions was DM (22.9%) and gastrointestinal dis-
ease (21.7%). We looked at the prevalence of underlying conditions sepa-
rated in men and women. Men with CA CDI were more likely to have
chronic kidney disease (CKD) (19.1% vs 12.7%), DM (26.0% vs 21.2%),
immunocompromised conditions (6.4% vs 3.6%), liver diseases (6.5% vs
2.8%), and plegias (1.0% vs 0.2%) than women with CA CDI. Women with
CA CDI were more likely to have chronic lung diseases (17.4% vs 12.6%)
and connective tissue diseases (4.9% vs 2.2%) than men with CA CDI.
Although the incident CA CDI case rate in Davidson County decreased
from 2018 to 2021, it remains a significant threat. In this analysis, under-
lying conditions in persons with CA CDI were highly prevalent. Men were
more likely to have underlying conditions in general, and specifically CKD
and DM, than women. Improving understanding of the prevalence of these
conditions with CA CDI cases, along with their antibiotic use and commu-
nity exposures, can help drive prevention strategies to mitigate CA CDI
transmission.
Antimicrobial Stewardship & Healthcare Epidemiology 2024;4(Suppl. S1):s65
doi:10.1017/ash.2024.187
Presentation Type:
Poster Presentation - Poster Presentation
Subject Category: C. difficile
Resetting the environmental reservoir; evaluating the impact of a new
hospital building on Clostridioides difficile infection
Liam Giberson, Hospital of the University of Pennsylvania; Brendan Kelly,
University of Pennsylvania; Pam Tolomeo, University of Pennsylvania
Perelman School of Medicine; Leigh Cressman, University of
Pennsylvania/Dept. of Biostatistics, Epidemiology and Informatics;
Laura Cowden, University of Pennsylvania; Laurel Glaser, Hospital of
the University of Pennsylvania and Matthew Ziegler, University of
Pennsylvania
Background: Prior research has implicated contaminated surfaces in the
transmission of Clostridioides difficile within the hospital. To reduce the
risk of transmission, enhanced environmental hygiene is performed in
rooms of patients with known C.difficile infection (CDI). We wished to
evaluate the residual impact of environmental surfaces on hospital-onset
CDI (HO-CDI) by comparing HO-CDI rates before and after the opening
of a new 504-bed hospital building, HUP Pavilion (PAV). We hypothesized
that we would observe a reduction in HO-CDI after opening of PAV due to
a reduced burden of C.difficile spores in the environment. Methods: We
included NHSN reported HO-CDI rates for 28 months prior and 24
months after opening of PAV. Upon opening, patients were divided
between the old building (HUP) and PAV. We included all patient units
before and after opening. We created hierarchical models of HO-CDI rates
using Stan Hamiltonian Monte Carlo (HMC) version 2.30.1, via the
“cmdstanr”and “brms”packages with a GAM smooth function by month
and intervention period with default, weakly-informative priors. Results:
At baseline, there was an average of approximately 20,100 patient days per
month, subsequently divided between HUP and PAV (mean 10,100 and
12,100 patient days per month). After opening of PAV, we observed a
reduced HO-CDI rate (mean 0.21 vs 0.31 per 1000 patient days,
P=0.01). When comparing the two specific buildings after opening of
PAV, there was a greater reduction noticed in the old building (HUP)
as compared to the new building (PAV) (0.12 vs 0.29 per 1000 patient days)
SHEA Spring 2024 Abstracts
2024;4 Suppl 1 S65