2349. C. diff-erent results: Eliminating Inappropriate Stool PCR Tests Through an Interdisciplinary Infection Prevention and Mirobiology Collaboration

BACKGROUND: Diagnosis of Clostridium difficile infection (CDI) is based on symptoms and laboratory results. Distinguishing between CDI vs colonization or antibiotic-associated diarrhea is challenging. Widespread adoption of a highly sensitive real-time nucleic-acid amplification assay for toxin B DNA (Xpert CD assay, Cepheid) by US hospital-based microbiology labs has increased the challenge, resulting in overreporting of healthcare facility-onset CDI. Excess testing is inevitable in hospitals with EPIC electronic medical record (EMR) that incorporate best practice alerts (BPAs) prompting for C. difficile testing (CDT) when loose stools are charted by nursing staff. METHODS: Beginning October 1, 2018 microbiology and infection prevention (IP) staff at our 650 bed teaching hospital in central IL agreed to partner on a diagnostic stewardship effort to engage providers on potentially unnecessary or inappropriate CDTs. All stool samples sent to lab for CDT are held pending IP review. The IP review tool provides a guide for EMR review of contributing factors in diarrhea, including patient history, medications (e.g., laxatives, stool softeners), nutrition (e.g., tube feeds), symptoms (abdominal pain), and labs (e.g., serum creatinine, WBC count). Inappropriate CDT was defined as test of patients receiving pro-motility treatment, without signs of infection. RESULTS: Between October 1, 2018 and December 31, 2018, 383 CDT were ordered on inpatients. 196 were requested within 3 days of admission, and 187 were requested on beyond day 4. 56.6% (107/187) HO-CDTs were deemed inappropriate and canceled; 80 HO-CDT were deemed appropriate. 18.8% (15/80) of HO-CDTs were positive. Compared with October 1 - December 31, 2017, HO-CDI cases decreased by 66.7% (1.0 - 15/45) over the same period in 2018. CONCLUSION: A 66.7% reduction in HO-CDI (vs. FY2017 cases) was seen in the first 3 months following adoption of a team-based (IPs, microbiology lab staff and MD director), CDT diagnostic stewardship intervention employing EMR review and patient provider engagement (RNs and MDs). Opportunities identified during the first 90 days of CDT stewardship: (a) Lack of provider awareness of pro-motility therapies; (b)inappropriate prompting for CDT generated by the EPIC EMR. [Image: see text] [Image: see text] [Image: see text] [Image: see text] DISCLOSURES: All authors: No reported disclosures.