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Background Antibiotic use is the strongest modifiable risk factor for the development of Clostridioides difficile infection, but prescribers lack quantitative information on comparative risks of specific antibiotic courses. Our objective was to estimate risks of C. difficile infection associated with receipt of specific antibiotic courses. Methods We conducted a longitudinal case-cohort analysis representing over 90% of Ontario nursing home residents, between 2012 and 2017. Our primary exposure was days of antibiotic receipt in the prior 90 days. Adjustment covariates included: age, sex, prior emergency department or acute care stay, Charlson comorbidity index, prior C. difficile infection, acid suppressant use, device use, and functional status. We examined incident C. difficile infection, including cases identified within the nursing home, and those identified during subsequent hospital admissions. Adjusted and unadjusted regression models were used to measure risk associated with 5- to 14-day courses of 18 different antibiotics. Results We identified 1708 cases of C. difficile infection (1.27 per 100 000 resident-days). Longer antibiotic duration was associated with increased risk: 10- and 14-day courses incurred 12% (adjusted relative risk [ARR] = 1.12, 95% confidence interval [CI]: 1.09, 1.14) and 27% (ARR = 1.27, 95% CI: 1.21,1.30) more risk compared to 7-day courses. Among 7-day courses with similar indications: moxifloxacin resulted in 121% more risk than amoxicillin (ARR = 2.21, 95% CI: 1.67, 3.08), ciprofloxacin engendered 89% more risk than nitrofurantoin (ARR = 1.89, 95% CI: 1.45, 2.68), and clindamycin resulted in 112% (ARR = 2.12, 95% CI: 1.32, 3.78) more risk than cloxacillin. Conclusions C. difficile infection risk increases with antibiotic duration, and there are wide disparities in risks associated with antibiotic courses used for similar indications. [ABSTRACT FROM AUTHOR]

Background Rates of antibiotic use vary widely across nursing homes and cannot be explained by resident characteristics. Antibiotic prescribing for a presumed urinary tract infection is often preceded by inappropriate urine culturing. We examined nursing home urine-culturing practices and their association with antibiotic use. Methods We conducted a longitudinal, multilevel, retrospective cohort study based on quarterly nursing home assessments between April 2014 and January 2017 in 591 nursing homes and covering >90% of nursing home residents in Ontario, Canada. Nursing home urine culturing was measured as the proportion of residents with a urine culture in the prior 14 days. Outcomes included receipt of any systemic antibiotic and any urinary antibiotic (eg, nitrofurantoin, trimethoprim/sulfonamides, ciprofloxacin) in the 30 days after the assessment and Clostridiodes difficile infection in the 90 days after the assessment. Adjusted Poisson regression models accounted for 14 resident covariates. Results A total of 131 218 residents in 591 nursing homes were included; 7.9% of resident assessments had a urine culture in the prior 14 days; this proportion was highly variable across the 591 nursing homes (10th percentile = 3.4%, 90th percentile = 14.3%). Before and after adjusting for 14 resident characteristics, nursing home urine culturing predicted total antibiotic use (adjusted risk ratio [RR] per doubling of urine culturing, 1.21; 95% confidence interval [CI], 1.18–1.23), urinary antibiotic use (RR, 1.33; 95% CI, 1.28–1.38), and C. difficile infection (incidence rate ratio, 1.18; 95% CI, 1.07–1.31). Conclusions Nursing homes have highly divergent urine culturing rates; this variability is associated with higher antibiotic use and rates of C. difficile infection. [ABSTRACT FROM AUTHOR]

Background and Aims The number of inflammatory bowel disease [IBD]-related visits to the emergency department [ED] is increasing in North America. This study evaluates the relationship between access to specialists and utilization of ED services. Methods We conducted a population-based study of all IBD patients in Ontario in 2014–2015 to measure utilization of non-emergency IBD care by specialists [NICS] and ED visits. After characterizing regional variation in access to gastroenterologists and region-wide implementation of NICS, we constructed regression models to determine whether they were predictors of individual utilization of NICS and ED services. Results The number of gastroenterologists per 1000 IBD patients varied geographically, ranging from 1.13 to 10.65, as did the region-wide proportion of patients who received NICS, ranging from 21% to 52%. Compared with those with low access to gastroenterologists, those living in areas with moderate (odds ratio [OR], 2.37; 95% confidence interval [CI]: 2.27–2.47) and high [OR, 1.83; 95% CI: 1.71–1.95] access were more likely to receive NICS. The risk of visits to the ED was lower among those residing in regions with moderate [OR, 0.78; 95% CI: 0.75–0.82] and high access [OR, 0.74; 95% CI: 0.69–0.80] to gastroenterologists and in regions where implementation of NICS was not low [OR, 0.78; 95% CI: 0.75–0.81]. Conclusions Poor access to outpatient IBD specialist care contributes to IBD-related ED visits. Strategies to increase specialist access may reduce the utilization of emergency services. [ABSTRACT FROM AUTHOR]

Background Antibiotics are the primary modifiable risk factor for C. difficile infection (CDI). However, the comparative risks of different prescribing choices are not known. Our objective was to quantify the benefits of: (1) preventing antibiotic initiation, (2) substituting high-risk antibiotics for low-risk antibiotics, (3) reducing antibiotic duration. Methods We conducted a cohort study of residents of over 600 Ontario nursing homes in the 2014 to 2017 period. All non-acute care hospital antibiotic exposures were identified from the Ontario Drug Benefit database, while CDI was identified using outpatient billings and/or hospital ICD-10 codes. Logistic regression models were used to examine the risk of CDI as a function of time-varying antibiotic exposures, while controlling for 14 different risk factors. Based on the models, we estimated the comparative risks of specific antibiotic regimens. Results We identified 1,944 cases of CDI, for an incidence of 1.60 per 100,000 person-days. The 90-day risk among residents without antibiotics was 0.84 per 1,000 residents (‰), compared with 1.85‰ in those with a 7-day course of antibiotics. Preventing a 7-day course reduced CDI risk by 45% (see table, adjusted relative risk [RR] = 0.55, 95% confidence interval [CI] = 0.50, 0.60). The antibiotics conferring the highest risks were clindamycin at 4.1‰, moxifloxacin at 3.2‰, and amoxiclav at 3.0‰. Comparing 7-day courses of antibiotics with similar indications: nitrofurantoin engendered 37% less risk than ciprofloxacin, amoxicillin resulted in 31% less risk than amoxicillin-clavulanate, and cephalexin had 51% less risk than clindamycin. Reduced antibiotic durations were associated with less C. difficile risk. Compared with a 10-day course, a 7-day course was associated with 12% less risk, while a 5-day course was associated with 21% less risk. Conclusion We have quantified, using a real-world population-based cohort of nursing home residents, the reduction in CDI risk incurred by preventing unnecessary antibiotic initiations, preferring low-risk agents over high-risk agents, and reducing duration. These figures will help clinicians compare risks and benefits of different prescribing choices with regards to CDI prevention. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Decreased severe respiratory illness was observed during the first 2 years of the COVID-19 pandemic, with a relatively smaller decrease among children with medical complexity (CMC) compared to non-CMC. We extended this analysis to the third pandemic year (April 1, 2022, to March 31, 2023) when pandemic public health measures were loosened. A population-based repeated cross-sectional study evaluated respiratory hospitalizations among CMC and non-CMC (<18 years) in Ontario, Canada. Among the 67,517 CMC and 3,006,504 non-CMC in Ontario, there were more CMC respiratory hospitalizations compared with the expected prepandemic levels (n = 3145 hospitalizations, corresponding to rate ratio [RR], 1.20; 95% confidence interval [CI], 1.16-1.25) with an even larger relative increase among non-CMC (n = 6653, RR, 1.36; 95% CI, 1.34-1.38). Increased intensive care unit admissions for respiratory illness were also observed (CMC: RR, 1.44; 95% CI, 1.31-1.59; non-CMC: RR, 2.02; 95% CI, 1.89-2.16). Understanding respiratory surge drivers may provide insights to protect at-risk children from respiratory morbidity., (© 2024 Society of Hospital Medicine.)

Background: The effects of the decline in health care use at the start of the COVID-19 pandemic on the health of children are unclear. We sought to estimate changes in rates of severe and potentially preventable health outcomes among children during the pandemic., Methods: We conducted a repeated cross-sectional study of children aged 0-17 years using linked population health administrative and disease registry data from January 2017 through August 2022 in Ontario, Canada. We compared observed rates of emergency department visits and hospital admissions during the pandemic to predicted rates based on the 3 years preceding the pandemic. We evaluated outcomes among children and neonates overall, among children with chronic health conditions and among children with specific diseases sensitive to delays in care., Results: All acute care use for children decreased immediately at the onset of the pandemic, reaching its lowest rate in April 2020 for emergency department visits (adjusted relative rate [RR] 0.28, 95% confidence interval [CI] 0.28-0.29) and hospital admissions (adjusted RR 0.43, 95% CI 0.42-0.44). These decreases were sustained until September 2021 and May 2022, respectively. During the pandemic overall, rates of all-cause mortality, admissions for ambulatory care-sensitive conditions, newborn readmissions or emergency department visits or hospital admissions among children with chronic health conditions did not exceed predicted rates. However, after declining significantly between March and May 2020, new presentations of diabetes mellitus increased significantly during most of 2021 (peak adjusted RR 1.49, 95% CI 1.28-1.74 in July 2021) and much of 2022. Among these children, presentations for diabetic ketoacidosis were significantly higher than expected during the pandemic overall (adjusted RR 1.14, 95% CI 1.00-1.30). We observed similar time trends for new presentations of cancer, but we observed no excess presentations of severe cancer overall (adjusted RR 0.91, 95% CI 0.62-1.34)., Interpretation: In the first 30 months of the pandemic, disruptions to care were associated with important delays in new diagnoses of diabetes but not with other acute presentations of select preventable conditions or with mortality. Mitigation strategies in future pandemics or other health system disruptions should include education campaigns around important symptoms in children that require medical attention., Competing Interests: Competing interests: Natasha Saunders reports receiving grants from the Sickkids Foundation and the Ontario Ministry of Health, and personal fees from the BMJ Group. Eyal Cohen is a paid member of the Committee to Evaluate Drugs, which provides advice to the Ontario Ministry of Health on public drug-funding decisions. Rayzel Shulman reports speaking fees from, and participation on an advisory board with, Dexcom Canada. No other competing interests were declared., (© 2024 CMA Impact Inc. or its licensors.)

Objective: Interfacility patient movement plays an important role in the dissemination of antimicrobial-resistant organisms throughout healthcare systems. We evaluated how 3 alternative measures of interfacility patient sharing were associated with C. difficile infection incidence in Ontario acute-care facilities., Design: The cohort included adult acute-care facility stays of ≥3 days between April 2003 and March 2016. We measured 3 facility-level metrics of patient sharing: general patient importation, incidence-weighted patient importation, and C. difficile case importation. Each of the 3 patient-sharing metrics were examined against the incidence of C. difficile infection in the facility per 1,000 stays, using Poisson regression models., Results: The analyzed cohort included 6.70 million stays at risk of C. difficile infection across 120 facilities. Over the 13-year period, we included 62,189 new cases of healthcare-associated CDI (incidence, 9.3 per 1,000 stays). After adjustment for facility characteristics, general importation was not strongly associated with C. difficile infection incidence (risk ratio [RR] per doubling, 1.10; 95% confidence interval [CI], 0.97-1.24; proportional change in variance [PCV], -2.0%). Incidence-weighted (RR per doubling, 1.18; 95% CI, 1.06-1.30; PCV, -8.4%) and C. difficile case importation (RR per doubling, 1.43; 95% CI, 1.29-1.58; PCV, -30.1%) were strongly associated with C. difficile infection incidence., Conclusions: In this 13-year study of acute-care facilities in Ontario, interfacility variation in C. difficile infection incidence was associated with importation of patients from other high-incidence acute-care facilities or specifically of patients with a recent history of C. difficile infection. Regional infection control strategies should consider the potential impact of importation of patients at high risk of C. difficile shedding from outside facilities.