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Background Interventions to reduce community-onset (CO) Clostridioides difficile Infection (CDI) are not usually hospital-based due to the perception that they are often acquired outside the hospital. We determined the proportion of admitted CO CDI that might be associated with previous hospitalization. Methods The CDC’s Emerging Infections Program conducts population-based CDI surveillance in 10 US sites. We defined an incident case as a C. difficile-positive stool collected in 2017 from a person aged ≥ 1 year admitted to a hospital with no positive tests in the prior 8 weeks. Cases were defined as CO if stool was collected within 3 days of hospitalization. CO cases were classified into four categories: long-term care facility (LTCF)-onset if patient was admitted from an LTCF; long-term acute care hospital (LTACH)-onset if patient was admitted from an LTACH; CO-healthcare-facility associated (CO-HCFA) if patient was admitted from a private residence but had a prior healthcare-facility admission in the past 12 weeks; or community-associated (CA) if there was no admission to a healthcare facility in the prior 12 weeks. We excluded hospitals with < 10 cases among admitted catchment-area residents. Results Of 4724 cases in 86 hospitals, 2984 (63.2%) were CO (median per hospital: 65.8%; interquartile range [IQR]: 58.3%-70.7%). Among the CO cases, 1424 (47.7%) were CA (median per hospital: 48.1%; IQR: 40.3%-57.7%), 1201 (40.3%) were CO-HCFA (median per hospital: 41.0%; IQR: 32.9%-47.8%), 350 (11.7%) were LTCF-onset (median per hospital: 10.0%; IQR: 0.6%-14.4%), and 9 (0.3%) were LTACH-onset. Of 1201 CO-HCFA cases, 1174 (97.8%) had a prior hospitalization; among these, 978 (83.3%) (median per hospital: 83.3%; IQR: 69.2%-90.6%), which consists of 32.8% of all hospitalized CO cases, had been discharged from the same hospital (Figure), and 84.4% of the 978 cases (median per hospital: 88.2%: IQR: 76.5%-100.0%) had received antibiotics sometime in the prior 12 weeks. Figure. Frequency of Cases Discharged in the 12 Weeks Prior to Readmission with Clostridioides difficile Infection (N=1138*) Conclusion A third of hospitalized CO CDI had been recently discharged from the same hospital, and most had received antibiotics during or soon after the last admission. Hospital-based and post-discharge antibiotic stewardship interventions could help reduce subsequent CDI hospitalizations. Disclosures Ghinwa Dumyati, MD, Roche Diagnostics (Consultant)

Background US laboratories are increasingly using nucleic acid amplification tests (NAAT) to diagnose Clostridium difficile infection (CDI) due to their increased sensitivity over toxin enzyme immunoassays (EIA), but NAATs may be more likely than toxin EIAs to detect colonization rather than true disease. Limited data indicate patients positive by toxin EIA (toxin+) have worse outcomes than those positive by NAAT (NAAT+) only, suggesting toxin EIA detects true infection more often than NAAT. We used multisite CDI surveillance data from the Centers for Disease Control and Prevention’s Emerging Infections Program to compare clinical course and outcomes between toxin+ and NAAT+ only patients. Methods A case was defined as a positive C. difficile test in a person ≥1 year old with no positive tests in the prior 8 weeks. Cases detected during 2014–2015 by a testing algorithm using toxin EIA and NAAT were classified as toxin+ or NAAT+ only. Medical charts were reviewed. Death data were obtained from state death registries. Multivariable logistic regression models were used to compare CDI recurrence and 90-day mortality between the two groups, adjusting for age, sex, race, Charlson comorbidity index, and receipt of oral vancomycin. For the outcome of recurrence, we also adjusted for history of CDI in the prior 6 months. Results Of 4,878 cases, 2160 (44%) were toxin+ and 2,718 (56%) were NAAT+ only. Toxin+ cases were more likely than NAAT+ only cases to be ≥65 years old (48% vs. 38%; P < 0.0001), have white blood cells ≥15,000/µL (483/1,539 [31%] vs. 423/1,978 [21%]; P < 0.0001), and have received oral vancomycin ≤3 days of diagnosis (32% vs. 29%; P = 0.03). Comparing toxin+ to NAAT+ only cases, 21% vs. 11% had a recurrence (P < 0.0001), of which 71% vs. 33% had a toxin+ recurrence (P < 0.0001), and 10% vs. 9% died ≤90 days of diagnosis (P = 0.12). In multivariable analysis, a toxin+ result was associated with recurrence (adjusted odds ratio [aOR]: 1.89, 95% CI: 1.61–2.22) but not with 90-day mortality (aOR: 0.99; 95% CI: 0.81–1.22). Conclusion Toxin+ CDI is more severe by some markers and more likely to recur as toxin+. However, there was no difference in adjusted mortality, which may reflect an effect on mortality in NAAT+ only cases from mild CDI, receipt of unnecessary CDI treatment, or other factors. Disclosures G. Dumyati, Seres: Scientific Advisor, Consulting fee.

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. Figure 1. Incidence and Mortality Rates of CDI Disclosures G. Dumyati, Seres: Scientific Advisor, Consulting fee.

OBJECTIVES To describe the characteristics and impact of Clostridium difficile infection (CDI) in a long-term acute-care hospital (LTACH). DESIGN Retrospective matched cohort study. SETTING A 38-bed, urban, university-affiliated LTACH. METHODS The characteristics of LTACH-onset CDI were assessed among patients hospitalized between July 2008 and October 2015. Patients with CDI were matched to concurrently hospitalized patients without a diagnosis of CDI. Severe CDI was defined as CDI with 2 or more of the following criteria: age ≥65 years, serum creatinine ≥2 mg/dL, or peripheral leukocyte count ≥20,000 cells/μL. A conditional Poisson regression model was developed to determine characteristics associated with a composite primary outcome of 30-day readmission to an acute-care hospital, or mortality. RESULTS The overall incidence of CDI was 21.4 cases per 10,000 patient days, with 27% of infections classified as severe. Patients with CDI had a mean age of 70 years (SD, 14 years), a mean Charlson comorbidity index of 3.6 (SD, 2.0), a median length of stay of 33 days (interquartile range [IQR], 24–45 days), and a median time between admission and CDI diagnosis of 16 days (IQR, 9–23 days). The most commonly prescribed antibiotic preceding a CDI diagnosis was a cephalosporin, with median duration of 8 days (IQR, 4–14 days). In multivariate analysis, CDI was not significantly associated with the primary outcome (relative risk, 0.97; 95% CI, 0.59–1.58). CONCLUSIONS Incidence of CDI in an urban, university-affiliated LTACH was high. Future research should focus on infection prevention measures to decrease the burden of CDI in this complex patient population. Infect Control Hosp Epidemiol 2017;38:294–299