George Psevdos

Introduction: Clostridioides difficile is a highly transmissible bacterium that causes diarrhea and colitis, particularly in patients recently treated with antibiotics. Because inappropriate testing may identify patients who are colonized rather than infected, the Infectious Diseases Society of America recommends targeted testing only in patients with symptoms consistent with C. difficile infection (CDI). In our institution, we implemented a templated note-order to reduce the increasing rates of tests that identified colonization rather than true infection. Methods: A templated note-order was created in our electronic records and implemented in late 2022. A provider, resident in training, or attending physician must complete this note first to generate an order for stool C. difficile testing. The microbiology laboratory hid the result of the C. difficile polymerase chain reaction (PCR) result, which is part of the GI PCR panel. Only the GDH/C-diff toxin assay can be ordered through the template note. Results: We compared C. difficile testing rates from 2019 to 2022 with those from 2023 to 2025. There was a significant reduction in the median tests ordered (250 vs. 187, P =0.017). A spike in inappropriate testing occurred in 2022, with 13 colonization cases; targeted education for acute care and nursing home staff was provided to reinforce appropriate testing criteria. Our antimicrobial stewardship program, initiated in 2016, has contributed to sustained reductions in CDI. Conclusions: The implementation of a templated note-order significantly reduced unnecessary C. difficile testing and lowered the number of positive results attributable to colonization. Diagnostic stewardship continues to play a critical role in our infection prevention and control efforts.

Background: Sodium-glucose cotransporter 2 inhibitors are important therapies to control blood glucose levels in patients with type 2 diabetes mellitus. The mechanism by which they achieve this is through the excretion of glucose in urine, which can promote an environment for genitourinary infections. The incidence of such infections is more common in geriatric patients, which make up most of the patients in Veteran Affairs medical centers. The aim of this study is to evaluate the incidence of cystitis, vaginitis, and balanitis in Veterans on SGLT-2 therapy. Methods: We did a retrospective chart review of Veterans who received at least 6 months of SGLT-2 empagliflozin for diabetes. Indication for heart failure only was an exclusion. The study years were 2018 to 2023. Demographic data, urine cultures, and medical charts were reviewed for documentation of cystitis and clinical diagnosis of vaginitis and balanitis. Results: A total of 400 Veterans were analyzed. The median age was 74.5 years. Most of the patients were men. There were 43 (10.75%) occasions of infectious complications: 32 cystitis, 6 balanitis, and 5 fungal vaginitis. There were no multidrug-resistant organisms isolated. There were no differences in the 2 groups (infectious complications versus noninfectious) in terms of age, hemoglobin A1C, body mass index, or duration of treatment. However, benign prostatic hyperplasia was more common in the infectious group. Conclusions: The incidence of infectious complications in our diabetic Veterans was minimal in number, with cystitis being at 8% and observed more in men with prostatomegaly. E. coli was the most frequent isolate in urine cultures. Isolation of multidrug-resistant organisms was not observed.

Increased utilization of antibiotics leads to decreased antimicrobial susceptibility, a well-established phenomenon. Antimicrobial stewardship programs (ASP) promote appropriate prescribing of antibiotics by decreasing inappropriate use, aiming to improve patient outcomes and reducing antimicrobial resistance. Fluroquinolones (FQ) are among the most prescribed antibiotics. We describe out institutional FQ use since inception of our ASP and followed the trend for susceptibility of Enterobacteriaceae and Pseudomonas Northport Veterans Affairs Medical Center (VAMC) provides care for over 30000 Veterans in Long Island, New York, with emergency room, acute care hospital, nursing homes and outpatient clinics A Retrospective review investigated FQ use by total refills per year and by days of therapy per 1000 patient days at Northport VAMC from 2012 to 2022, along with review of local annual antibiograms focusing on ciprofloxacin susceptibility to E. coli, K. pneumoniae, P. mirabilis and P. aeruginosa. An ASP in our facility was initiated in 2016. FQs are restricted antibiotics and require approval by the infectious diseases team (attendings, fellows, pharmacist) Figure 1 provides the outpatient total fills per year for Ciprofloxacin, Levofloxacin, Moxifloxacin. Inpatient FQ use during the ASP years was low: Figure 2 shows the FQ inpatient use (days of therapy/1000days) from 2019 to 2022. Comparing years 2012-2016 vs 2017-2022 there was a decrease in fills of ciprofloxacin (median 604 vs. 308 fills, P: 0.009), levofloxacin (276 vs. 116, P: 0.032), and moxifloxacin (116 vs. 14, P: 0.015). By same period comparison (see figure 3), Ciprofloxacin susceptibility for E. coli ranged median 66.5% to 61.5%, P: 0.126, K. pneumoniae 67% vs. 75.5% P: 0.086, P. mirabilis 45% vs. 47.5% P: 0.451, and P. aeruginosa 63% vs. 68.5% P: 0.308 inpatient FQ use 2019 to 2022 There was a statistically significant decrease in the use of FQ in the outpatient setting after ASP was initiated in our facility. Although there was a trend in improvement in ciprofloxacin susceptibilities for Klebsiella, Proteus, and Pseudomonas, it was not statistically significant. Nevertheless, our results show that reducing FQ consumption can prevent worsening susceptibility trends for enteric gram negatives and Pseudomonas. All Authors: No reported disclosures

Infectious gastroenteritis remains a common cause of morbidity in the US. While stool culture had been the standard tool for microbiological diagnosis, known for its time consuming and often lower yields, rapid diagnostic tests have now been developed. Individual and multiplex gastrointestinal (GI) polymerase chain reaction (PCR) are commercially available that can provide rapid and accurate results. We reviewed the GI infections in US Veterans (VET) assessing the use of GI PCR Retrospective chart review from 10/1/2021 to 3/31/2023 of US VET at Northport VAMC who had positive results on Biofire® GI PCR panel; positive ova and parasites (O+P), positive stool cultures, C-difficile GDH/toxin B assays and H.pylori stool antigens In the study period there were 264 GI PCR and 224 O+P tests. 86 VET had GI infections. GI PCR identified 26 viral infections with norovirus being the most common. 16 coinfections identified. The median age was 58.5 years. 77% White, 19% Black. 81 were men. 78/86 had presented with diarrhea, 31 with abdominal pain/dyspepsia. 30 VET were treated as inpatient. 18/86 had Diabetes, 32, GERD, 11 Asthma, 13 COPD, 45 HTN, 46 HLD, 3 HIV, 20 CAD, 7 with malignancies (carcinoid, MALT lymphoma, Non-Hodgins lymphoma, lung, tonsil, prostate, multiple myeloma). 25 VET had recent exposure to antibiotics. 10 had recent travel. 59 received antibiotic therapy. 25 had prior history of C. difficile infection (CDI). Of the 30 positive tests by GI PCR, 19 were clinically treated for CDI: 14 with oral vancomycin 5 with fidaxomicin. Of the 6 campylobacter infections by GI PCR, 4 were confirmed by culture. Of the 2 positive vibrio spp by GI PCR: one vibrio cholera was not confirmed by culture and toxin assay (this patient was not included in the analysis); the other vibrio spp by PCR, culture confirmed V. parahaemolyticus. 1 VET with multiple myeloma and CDI died due to multiorgan failure. One dual infection with salmonella and Yersinia by PCR: only salmonella (non typhi) was confirmed by culture GI PCR can offer a rapid diagnosis for viral etiologies and can be more sensitive as compared to culture for campylobacteriosis. However, vibrio and Yersinia spp results would need to be confirmed by culture. Also diagnosis of CDI would need interpretation of GDH/toxin and clinical judgement All Authors: No reported disclosures