Background: Group A Streptococcus (GAS; Streptococcus pyogenes) is an important human pathogen that can cause life-threatening invasive disease, ranging from skin/soft tissue infections to infective endocarditis. In the fall of 2022, the Center for Disease Control & Prevention (CDC) issued an alert due to a global increase in invasive GAS infections, particularly among children and adults with co-morbidities. An increase in invasive disease was observed at our five-hospital healthcare system in Southeast Michigan. The objective of this study was to describe characteristics of patients with invasive GAS and characterize treatment and outcomes of disease. Methods: This was a retrospective cross-sectional study of patients from June 2013 to August 2023 with positive blood cultures for GAS. Patients were identified using a data query for positive blood cultures for GAS through Microsoft SQL Server. Patients with age < 1 8 years, polymicrobial bacteremia, incomplete data, or who were enrolled in hospice and/or died within 48-hours of admission were excluded. Collected variables included: demographics, infection characteristics (syndrome, duration of bacteremia), microbiological characteristics (antimicrobial susceptibility testing; AST), antimicrobial treatment (empiric and final, antitoxin therapy), and clinical outcomes (length of hospital stay [LOS], treatment-associated adverse events, 30-day mortality and infection-related readmission). Results: 250 patients were included (Table 1). More than half were male with median age of 57.5 years. Diabetes mellitus (38%) and chronic kidney disease (23%) were common comorbidities [Table 1]. Persons experiencing homelessness and persons who use injection drugs accounted for 9% and 13% of the cases, respectively. The most common infective syndrome accompanying bacteremia was cellulitis (57%). The majority of patients received vancomycin for empiric therapy (81%) and penicillin (38%) or cephalosporin (36%) for final regimen [Table 2]. A total of 79 GAS isolates (32%) were clindamycin resistant. Clindamycin was included in the empiric regimen of 20 (8%) patients, the final regimen in 44 (18%) of patients, and as antitoxin adjunct therapy in 135 (54%) of patients. A third (33%) of patients received no antitoxin. The average duration of antitoxin therapy was 3.6 days and antimicrobial therapy 19.9 days. The mean LOS was 11.4 days (Table 3). Thirty nine (16%) patients had treatment failure and 8 (3%) experienced C. difficile infection within 30 days of antimicrobial treatment. Thirty-day mortality was 11%; of these, 9% had in-hospital mortality. Conclusions: Invasive GAS infection confers significant morbidity and mortality, and ongoing research is needed to determine the best treatment regimens in the era of increasing clindamycin resistance.

Between May and June 2021, healthcare personnel at two long-term care facilities underwent SARS-CoV-2 anti-nucleocapsid immunoglobulin G testing and completed a survey on COVID-19 exposures and symptoms. Antibody positivity rate was 8.9%. Similar rates of COVID-19 exposure occurred in non-occupational and occupational settings, with high self-reported adherence to workplace infection prevention practices.

The escalating threat of antimicrobial resistance (AMR) necessitates impactful, reproducible, and scalable antimicrobial stewardship strategies. This review addresses the critical need to enhance the quality of antimicrobial stewardship intervention research. We propose five considerations for authors planning and evaluating antimicrobial stewardship initiatives. Antimicrobial stewards should consider the following mnemonic ABCDE: (A) plan Ahead using implementation science; (B) Be clear and thoroughly describe the intervention by using the TidIER checklist; (C) Use a Checklist to comprehensively report study components; (D) Select a study Design carefully; and (E) Assess Effectiveness and implementation by selecting meaningful outcomes. Incorporating these recommendations will help strengthen the evidence base of antimicrobial stewardship literature and support optimal implementation of strategies to mitigate AMR.

Background: Increased antibiotic resistance is a rising global health problem that can result from overprescribing and misusing antibiotics. The impact of antibiotic overprescribing is significant, particularly among the older adult population due to increased adverse reactions. The objective of this study is to identify higher volume antibiotic outpatient prescribers and their antibiotic prescription rates by region and provider specialties in Arizona. Methods: Publicly available data from the Center for Medicare and Medicaid Services Part D Prescriber database during 2021 was analyzed. Those prescribers who had beneficiaries and antibiotic claims of fewer than 11 were excluded from the analysis. Higher-volume prescribers were identified by estimating the providers who prescribed the highest 10th percentile of antibiotic volume. The cumulative percentage of antibiotic prescriptions and prescriber’s antibiotic volume per 1000 beneficiaries (prescribing rate) were compared between the higher volume prescribers and lower volume prescribers by the EMS region and specialty. Median prescribing rates among prescribers were compared using the Wilcoxon rank-sum test. All analyses were performed using SAS (version 9.4; SAS Institute, NC). Results: The number of Arizona prescribers included in the dataset during 2021 was 27,124. After excluding prescribers with fewer than 11 antibiotic prescriptions, 14,410 prescribers were included in the analysis. These providers prescribed a total of 1,095,559 antibiotic prescriptions, with a median of 45 antibiotic prescriptions per prescriber. Thirty-nine percent of antibiotic prescriptions were written by the higher volume prescribers and prescribed a median of 236 antibiotic prescriptions. Higher-volume prescribers had a 52% higher median antibiotic prescribing rate compared with lower-volume prescribers (600 versus 396 prescriptions per 1,000 beneficiaries) (p < 0.01). The median antibiotic prescribing rate among higher volume prescribers was highest in the central region (602 antibiotic prescriptions per 1,000 beneficiaries) compared with other regions (581 prescriptions per 1,000 beneficiaries in the north region) (p < 0.01). The top two specialties that higher volume prescribers practiced were family practice and nurse practitioners. Antibiotic prescribing rates of higher-volume prescribers were highest among dentists (1,118 prescriptions per 1,000 beneficiaries).

Background: Automated sepsis alerts have become a widely implemented screening tool aimed at early detection of clinically unstable patients. Prior research has shown mixed results depending on the type of screening tools used and the patient population studied. This study aimed to evaluate the predictive value of an alert system created for identifying patients with sepsis to determine utility in clinical practice prior to implementation. Additionally, clinical management of those with and without sepsis was compared to measure potential added benefit of this system in clinical decision making. Methods: A TheraDoc® software sepsis alert was generated for non-ICU patients meeting >2 SIRS criteria within a 24-hour time period (temperature >38°C or 90, respiratory rate >20 or partial pressure CO2 12,000 or 10% bands/immature cells) during March 2023. Alerts were excluded if they were duplicates (using identical criteria or a second alert within 24 hours), triggered by labs collected >48 hours prior, or death or discharge occurred before the time of alert. The primary outcome was positive predictive value (PPV) of sepsis identification, confirmed by ICD-10 codes and diagnostic studies (cultures, imaging). Secondary outcomes included clinical management (antibiotic utilization [AU] and choice, infectious disease [ID] consultations and culture collection). Antibiotics were categorized as broad-spectrum using National Healthcare Safety Network (NSHN) criteria. Secondary outcomes were compared between sepsis and SIRS without infection groups (SIRS) by chi-square analysis. Results: After applying exclusion criteria, 116 of 166 alerts were analyzed; 55 of 116 alerts had confirmed sepsis (PPV 47.4%). Patients with sepsis were more likely to have an ID consult (16% [9/55] vs 7% [4/61]) and cultures collected (70.9% [39/55] vs 39.3% [24/61]) compared to SIRS patients, however these differences were not statistically significant. AU was higher with confirmed infections compared to SIRS patients (94.5% [52/55] vs 32.8% [20/61], p < 0 .05) along with use of broad-spectrum antibiotics (73% [38/52] vs 40% [ 8/20] p < 0 .05). Conclusions: While automated alerts may enable early identification of sepsis, use of SIRS criteria alone has poor specificity, which was borne out by the low PPV in this study. Our study found that management of sepsis patients (as measured by AU and culture ordering) was better than expected and combined with the low PPV of this alert system resulted in our team rejecting widespread adoption of SIRS-based sepsis alerts.

This study evaluating the efficacy of coronavirus disease 2019 contact tracing in the hospital setting during the omicron variant era found a high incidence of nosocomial severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission in outbreaks, especially among individuals having close contact with infected persons. Identifying close contacts and outbreaks is essential to prevent nosocomial SARS-CoV-2 transmission.

Background: For preoperative antimicrobials to be most effective in preventing surgical site infection, they must be administered early enough to reach a minimum tissue concentration that is specific to each drug. However, antibiotics have widely ranging infusion durations, from intravenous push over a few minutes to slow infusion over two hours. Heterogeneity in recommended infusion administration instructions, importance of infusion completion prior to incision, and complexity of healthcare systems present just some of the barriers to achieving appropriate preoperative antibiotic prophylaxis. We compared the percentage of infusion completion prior to case start before and after a multidisciplinary intervention. Methods: We performed a retrospective analysis of all patients undergoing a colorectal surgical procedure as defined by the National Healthcare Safety Network at a single university hospital from 10/19/22-10/18/23. A recognition that some antimicrobials were not finished infusing prior to surgery start prompted a multidisciplinary group including antibiotic stewardship, colorectal surgery, perioperative nursing, and anesthesiology to create and deploy an order set shortening metronidazole infusion duration from 60 to 30 minutes and initiating infusion in the preoperative area instead of the operating room. No change to the cefazolin intravenous push over 3-5 minutes was made. Goal antimicrobial infusion was defined as completed infusion within 120 minutes prior to incision, and calculations were made based on infusion start time and case start times. Rate of infusion completion was compared from the pre-intervention period to a post-intervention period from 10/19/23 through the end of the year. Results: For all colorectal surgeries in the pre-intervention period, 95% (n=418/440) of cefazolin doses and 0.002% (n=1/427) doses of metronidazole met goal infusion timing. At-goal infusion timing increased to 99% (n=84/85) of cefazolin doses and 68% (n=56/82) of metronidazole doses in the post-intervention period, resulting in a statistically significant improvement for metronidazole (Fischer’s exact test p < 0 .00001). The average time to metronidazole infusion completion changed from 45 minutes after procedure start to 58 minutes before procedure start. Conclusions: Multidisciplinary team engagement and deployment of an order set incorporating changes in duration and workflow for metronidazole infusion improved all antimicrobial preoperative infusions for colorectal procedures. Increased awareness of completing antimicrobial infusion prior to the incision may improve preoperative antimicrobial administration.

Disclosure: Lindsay Donohue: Advisor - Abbvie

Background: Medicare claims are frequently used to study Clostridioides difficile infection (CDI) epidemiology. Categorizing CDI based on location of onset and potential exposure is critical in understanding transmission patterns and prevention strategies. While claims data are well-suited for identifying prior healthcare utilization exposures, they lack specimen collection and diagnosis dates to assign likely location of onset. Algorithms to classify CDI onset and healthcare association using claims data have been published, but the degree of misclassification is unknown. Methods: We linked patients with laboratory-confirmed CDI reported to four Emerging Infections Program (EIP) sites from 2016-2020 to Medicare beneficiaries using residence, birth date, sex, and hospitalization and/or healthcare exposure dates. Uniquely linked patients with fee-for-service Medicare A/B coverage and complete EIP case report forms were included. Patients with a claims CDI diagnosis code within ±28 days of a positive CDI test reported to EIP were categorized as hospital-onset (HO), long-term care facility onset (LTCFO), or community-onset (CO, either healthcare facility-associated [COHCFA] or community-associated [CA]) using a previously published algorithm based on claim type, ICD-10-CM code position, and duration of hospitalization (if applicable). EIP classifies CDI into these categories using positive specimen collection date and other information from chart review (e.g. admit/discharge dates). We assessed concordance of EIP and claims case classifications using Cohen’s kappa. Results: Of 10,002 eligible EIP-identified CDI cases, 7,064 were linked to a unique beneficiary; 3,451 met Medicare A/B fee-for-service coverage inclusion criteria. Of these, 650 (19%) did not have a claims diagnosis code ±28 days of the EIP specimen collection date (Table); 48% (313/650) of those without a claims diagnosis code were categorized by EIP as CA CDI. Among those with a CDI diagnosis code, concurrence of claims-based and EIP CDI classification was 68% (κ=0.56). Concurrence was highest for HO and lowest for COHCFA CDI. A substantial number of EIP-classified CO CDIs (30%, Figure) were misclassified as HO using the claims-based algorithm; half of these had a primary ICD-10 diagnosis code of sepsis (226/454; 50%). Conclusions: Evidence of CDI in claims data was found for 81% of EIP-reported CDI cases. Medicare classification algorithms concurred with the EIP classification in 68% of cases. Discordance was most common for community-onset CDI patients, many of whom were hospitalized with a primary diagnosis of sepsis. Misclassification of CO-CDI as HO may bias findings of claims-based CDI studies.

Age related Antibiotic Prescribing Trends of Clostridioides Difficile Incident Cases within Davidson County Tennessee 2012-2020 Michael Norris, MSN, Priscilla Pineda, MPH, Malakai Miller, MPH, Raquel Villegas, PhD, MS Background: Clostridioides difficile infection (CDI) is one of the most common healthcare-associated infections in the United States. Antibiotic use is considered a predisposing factor for CDI. The State of Tennessee collaborates with the CDC as part of an ongoing Emerging Infections Program (EIP). We sought to better understand the impact of antimicrobial use prior to the date of incident of CDI within the defined age groups of Davidson County, Tennessee. Methods: Surveillance data from the years 2012–2020 were examined for all positive CDI cases within Davidson County. A positive CDI case was defined as a laboratory confirmed case who is ≥ 1 year old living in Davidson County, Tennessee. Antibiotic use was assessed in the 12 weeks prior to CDI. Trends of overall antibiotic use, including the top five antibiotics prescribed by our defined age groups were examined. Analyses were performed using SAS version 9.4. Only fully abstracted cases are included in the study. Results: Among 7,346 positive CDI incident cases identified between 2012–2020, 5,467 (74.4%) received antibiotics 12 weeks prior to a confirmed infection. We looked at the trend of antibiotic prescription over time from 2012-2020 (77.0%, 76.7%, 74.3%, 80.7%, 76.3%, 75.1%, 73.7%, 74.8% and 71.5%) which has decreased since 2015. The prevalence of antibiotic use by age group 1-18 years, 19-44 years, 45-64 years, 65-74 years, and 75+ years was 53.4%, 68.8%, 74.5%, 79.2% and 83.1% respectively. The five most prescribed antibiotics were ceftriaxone ((11.1%), followed by vancomycin IV (10.9%), ciprofloxacin (10.2%), metronidazole (9.1%), and piperacillin (8.6%). Cases in the 45-64 years age group were more likely to be prescribed vancomycin IV, ciprofloxacin, metronidazole, and piperacillin-tazobactam compared to other age groups (p < 0.0001). There was no statistically significant association between ceftriaxone prescription and our defined age groups. Conclusion: In this study, almost three quarters of the CDI cases had received antimicrobial therapy in the 12 weeks prior to infection. Since antibiotic prescription is a potentially modifiable risk factor for CDI, a more in-depth study, combined with an antibiotic stewardship program implementation in all settings would be beneficial to reduce the risk of CDI complications of antibiotic usage.

Background: Gastrointestinal conditions are common in hospitalized patients. Decreased mobility, dietary changes, medications and their underlying illness may alter patients’ bowel movements. It’s important for health care providers to be aware of patient’s bowel habits, especially for early identification of Clostridiodies difficile infection (CDI). Prior research has shown that patient modesty may be a barrier to discussing bowel habits with nurses and providers. This can lead to delay in diagnosis of CDI, lack of timely isolation and possible misclassification of community onset CDI cases as hospital onset (HO-CDI). Methods: A Bowel Habits Assessment Tool (BHAT) was developed to assist health care providers in learning skills to assess and document patient bowel habits accurately. The tool provides a structured approach to help clinicians gather relevant information, identify abnormalities, and promote effective communication with patients. The tool was developed by an infectious disease physician and modeled on existing tools utilized to take a sexual history. A team of infectious disease physicians, nurses and a gastroenterologist reviewed the tool and provided feedback. See Table 1. The tool was introduced as a pilot program at a 180 bed academically affiliated Veterans Affairs Hospital. Micro educational sessions were held to provide education about the importance of a bowel habit history, introduce the tool and teach its use in clinical care. The teaching sessions were led by an Infectious Disease physician and a nurse infection preventionist. An anonymous pre and post survey employing a 5-point Likert scale was administered to participants. All participation was voluntary. This project was reviewed and approved as a Quality Improvement by the VA Research Office, Eastern Colorado Health Care System. Results: Twenty nine healthcare personnel participated in the pilot. Participants included nurses (13), resident physicians (13), medical students (2) and nursing assistants (1). 59% of participants stated that they strongly agree with the statement “I am comfortable discussing patient’s bowel habits” on the pre-survey. (Question 1). This increased to 73% after the BHAT educational session. The mean difference between pre and post survey responses for question one was 0.45 (CI 0.08761 to 0.8089, p= 0.0167). All participants found the BHAT related to their work and useful, with 41% strongly agreeing and 52% somewhat agreeing that the BHAT was useful. See figure 1: Survey Responses. Conclusions: The effectiveness of a bowel habit assessment tool was demonstrated using a pre and post survey. BHAT improved clinicians comfort level discussing patient’s bowel habits.

COVID-19 vaccine uptake in healthcare personnel (HCP) is poor. A cross-sectional survey study of behavioral health HCP was performed. Commonly identified reasons for vaccination were protecting others and oneself. Reasons against were a lack of perceived protection, dosing intervals, and side effects. Assessing vaccination attitudes can assist in uptake strategy.

Background: In August 2021, Saint Luke’s Health System (SLHS) transitioned Clostridioides difficile (C. diff.) testing from polymerase chain reaction (PCR)-only to two-step enzyme immunoassay (EIA) reflex following PCR+ for suspected C. diff. infection. Uncertainty in patient management may arise when PCR and EIA testing differ. Previous studies suggested that disease severity varies when a patient’s results demonstrate PCR+ and EIA- due to possible colonization. Clinicians may not treat if diarrhea self-resolves, patients remain stable, or alternate causes of diarrhea exist. We compared clinical outcomes of patients who received treatment to those who did not. Methods: This was a retrospective cross-sectional study from August 2021-August 2023 in a multi-site, integrated health system, comparing 181 inpatients with PCR+/EIA- C. diff. test results stratified by no treatment (0-48 hours of C. diff. targeted treatment), partial treatment (2-9 days), or full treatment (10+ days). The primary outcome was length of stay. Secondary outcomes were readmission rates, need for colectomy, intensive care unit (ICU) admission, and diarrhea resolution on day of discharge. 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 treatment. 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-

Background: Previous studies have found that solely relying on molecular testing is likely to result in the overdiagnosis and overtreatment of C. difficile infections (CDI). Comparable outcomes have been demonstrated in patients with a positive molecular test (C. difficile PCR) result and a negative 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 testing 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, observational study conducted from January 1, 2023 through March 31, 2023 (pre-intervention) and July 1, 2023 through September 31, 2023 (post-intervention) which included hospitalized adult patients with a C. difficile test ordered within the study period. Intervention included a change in reporting 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-intervention 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 administered 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.

Levofloxacin prophylaxis reduces bloodstream infections in neutropenic patients with acute myeloid leukemia or relapsed acute lymphoblastic leukemia. A retrospective, longitudinal cohort study compares incidence of bacteremia, multidrug-resistant organisms (MDRO), and Clostridioides difficile (CDI) between time periods of levofloxacin prophylaxis implementation. Benefits were sustained without increasing MDRO or CDI.

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) metrics. Diagnostic stewardship is essential to avoid inappropriate testing, but limited data exists on optional interventions. Methods: A diagnostic stewardship 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 indications for CDI testing was provided in pre-intervention (9/2022 to 5/2023) and intervention periods (6/2023 to 12/2023). During the intervention period, all CDI tests (positive or negative) were audited after completion 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 disease. 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-intervention and intervention periods, and ordering appropriateness was compared 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 inappropriate 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 inappropriate 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-intervention, 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.