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481. Implementation of a Prospective, Pharmacist-Driven Clostridium difficile PCR Pre-Authorization Process to Optimize Appropriate Testing

Abstract Background Since the implementation of more sensitive molecular diagnostics such as the Clostridium difficile PCR assay, hospitals have reported 50–100% increases in C. difficile infection (CDI) rates. Methods This single-center, quasi-experimental study assessed appropriateness of C. difficile PCR testing pre- and post-implementation of a prospective, pharmacist-led, pre-authorization process. The antimicrobial stewardship team prospectively reviewed all adult CDI-PCR cases sent to the laboratory prior to specimen processing twice daily, 7 days a week to assess for clinical appropriateness based on guideline criteria. Bone marrow transplant and pediatric patients were excluded. If a patient lacked appropriate CDI clinical criteria, the provider was contacted to discontinue the PCR. CDI-PCR appropriateness was assessed for all patients with a CDI-PCR during the preceding year as a retrospective, comparative cohort. The primary objective was to assess appropriateness of the CDI-PCR pre- and postintervention. Secondary objectives included intervention sensitivity, specificity, safety, total CDI-PCRs processed, and protocol adherence. Results A total of 714 patients were included (n = 360, preintervention; n = 354, postintervention). There were significantly more hospital-onset CDI cases and antimicrobial use within the past 30 days in the preintervention group [(248 vs. 133, respectively; P < 0.001) and (277 vs. 197, respectively; P < 0.0001)]. Appropriateness of the CDI-PCR significantly improved postintervention [n = 138 (38.3%) vs. n = 209 (59.1%), respectively; P < 0.001]. Prospective pharmacist intervention was required for 146 inappropriate CDI-PCRs resulting in 79 discontinued and 66 processed CDI-PCRs (n = 1 positive; n = 65 negative). No patient with a cancelled CDI-PCR required additional testing or escalation of care. When compared with the preintervention, the CDI-PCRs with pharmacist intervention demonstrated a significant increase in the sensitivity (64.7% vs. 98%; P < 0.0001) and decrease in specificity (66% vs. 48.3%; P = 0.015) with an improved NPV (91.9% vs. 99.3%; P = 0.035) and PPV (23.9% to 24.6%; P = 0.869). Conclusion Implementation of a pharmacist-led prospective CDI-PCR review improved PCR appropriateness and had no adverse clinical consequences although the PPV criteria remain low. Disclosures All authors: No reported disclosures.


Background.
Increases in the C. difficile infection (CDI) incidence, severity and mortality were reported in the early 2000s due to the emergence of the NAP1/027 strain. We evaluated the trends in incidence, mortality, hospitalization, and the prevalence of NAP1/027 strain in Monroe County, New York.
Methods. We conducted population and laboratory-based surveillance for CDI from 2011 to 2016 as part of the CDC Emerging Infections Program. An incident CDI case is defined as a positive C. difficile stool specimen from a resident of the county aged >1 year with no positive test in the prior 8 weeks. All the laboratories in our catchment area used nucleic acid amplification for diagnosis starting in 2011 as part of single or 2-step algorithm. A convenience sample of specimens were cultured and underwent molecular characterization. Mortality data was obtained via vital statistics databases and medical chart abstraction. Hospitalization within 2 days before to 7 days of diagnosis was collected.
Results. We identified 9189 incident CDI cases between 2011 and 2016. The CDI incidence decreased from 241 in 2011 to 175 cases per 100,000 persons in 2016, with the largest decrease among older adults aged ≥85 years. Similarly, the 30-day mortality rates decreased, with the largest decrease among persons aged ≥85 years: from 310 cases to 169 cases per 100,000 population ( Figure 1). The percentage of isolates due to NAP1/027 decreased from 20.3% in 2011 to 6.5% in 2016. There was no decrease in the proportion of cases that died within 7 (range: 2% to 3%) and 30 days (range: 7% to 8%) and no decrease in the proportion of patients hospitalized after their CDI diagnosis (range: 34% to 40%). These findings are similar in persons aged ≥85 years.

Conclusion.
From 2011 to 2016, the CDI incidence and mortality decreased concurrently with a decrease in the percentage of infections due to the NAP1/027 strain. Although NAP1/027 is known to be associated with more severe outcomes, we did not observe a reduction in the proportion of cases that died or the proportion of cases that were hospitalized.  Methods. We invited all 34 hospitals and 76 skilled nursing facilities (SNF) in OC to participate from June 2015 to June 2016. Participants received onsite infection control and antimicrobial stewardship assessments, trainings, and an interfacility transfer communication improvement initiative. We used an interrupted time-series design and segmented regression analysis to evaluate monthly hospital-onset (HO) and community-onset (CO) CDI rates for acute care hospitals (ACH) reporting HAI data to CDPH via the National Healthcare Safety Network. The baseline period included 17 months (January 2014-June 2015) and the collaborative period 28 months (September 2015-December 2017). All OC acute care hospitals were included in the CO-CDI model to account for direct and indirect effects of the collaborative. We included only participating ACH in the HO-CDI model. For informal comparisons, we assessed changes in CO-CDI for ACH in three San Francisco Bay Area counties and HO-CDI rates in nonparticipant OC acute care hospitals.
Conclusion. Our analysis of acute care hospitals in Orange County provides evidence that coordinated, regional multifacility initiatives can reduce CDI incidence.
Disclosures. All authors: No reported disclosures.
pharmacist-led, pre-authorization process. The antimicrobial stewardship team prospectively reviewed all adult CDI-PCR cases sent to the laboratory prior to specimen processing twice daily, 7 days a week to assess for clinical appropriateness based on guideline criteria. Bone marrow transplant and pediatric patients were excluded. If a patient lacked appropriate CDI clinical criteria, the provider was contacted to discontinue the PCR. CDI-PCR appropriateness was assessed for all patients with a CDI-PCR during the preceding year as a retrospective, comparative cohort. The primary objective was to assess appropriateness of the CDI-PCR pre-and postintervention. Secondary objectives included intervention sensitivity, specificity, safety, total CDI-PCRs processed, and protocol adherence.
Conclusion. Implementation of a pharmacist-led prospective CDI-PCR review improved PCR appropriateness and had no adverse clinical consequences although the PPV criteria remain low.
Disclosures.All authors: No reported disclosures.