Background Treatment of suspected methicillin-resistant Staphylococcus aureus (MRSA) is a cornerstone of many antibiotic regimens; however, there is associated toxicity. The Department of Veterans Affairs (VA) hospitals screen each patient for MRSA nares colonization on admission and transfer. The objective was to determine the negative predictive value (NPV) of MRSA screening in the determination of subsequent positive clinical culture for MRSA. High NPVs with MRSA nares screening may be used as a stewardship tool. Methods This was a retrospective cohort study across VA medical centers nationwide from 1 January 2007 to 1 January 2018. Data from patients with MRSA nares screening were obtained from the VA Corporate Data Warehouse. Subsequent clinical cultures within 7 days of the nares swab were evaluated for the presence of MRSA. Sensitivity, specificity, positive predictive values, and NPVs were calculated for the entire cohort as well as subgroups for specific culture sites. Results This cohort yielded 561 325 clinical cultures from a variety of anatomical sites. The sensitivity and specificity for positive MRSA clinical culture were 67.4% and 81.2%, respectively. The NPV of MRSA nares screening for ruling out MRSA infection was 96.5%. The NPV for bloodstream infections was 96.5%, for intraabdominal cultures it was 98.6%, for respiratory cultures it was 96.1%, for wound cultures it was 93.1%, and for cultures from the urinary system it was 99.2%. Conclusion Given the high NPVs, MRSA nares screening may be a powerful stewardship tool for deescalation and avoidance of empirical anti-MRSA therapy.

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Background C. difficile infection (CDI) is an important infectious disease and a reportable hospital metric that results in significant healthcare expenditures. Understanding the epidemiology of CDI is pivotal to the implementation of future preventative measures.MethodsThis was a retrospective data analysis of admitted patients treated at Veteran Health Administration (VHA) hospitals within the United States from 2006 to 2016 using the VHA’s national Corporate Data Warehouse (CDW). All patients with stool testing for C. difficile were identified via laboratory codes associated with C. difficile. CDI is defined as any stool positive laboratory-identified (LabID) event for C. difficile via PCR, Toxin, GDH + (Toxin or PCR), or culture. Hospital-onset healthcare facility-associated (HO-HCFA) CDI is defined as a positive LabID event collected after 48 hours from admission. Incidence is reported as cases per 100,000 admission-days. Recurrent CDI episodes were excluded from incidence analysis. Data were extracted using SQL management studio and analyzed in Excel and JMP.ResultsA total of 389,512 patients were tested for C. difficile. Overall incidence of CDI increased from 2006 (67.6) to 2016 (127.7). This rise in total CDI incidence correlates positively with rise of PCR (P < 0.0001) and 30-days CDI mortality (P < 0.0001). In July 2012, VHA implemented reporting of HO-HCFA CDI. Incidence of HO-HCFA CDI and 30-day CDI mortality increased from 2006 (45.6 and 12.3) to 2013 (69.2 and 17.1) with the rise of PCR (P < 0.001) but decreased from 2013 (69.2 and 17.1) to 2016 (59.9 and 14.1) after implementation of HO-HCFA reporting (P = 0.0058 and P = 0.0068). The median time to testing has also been decreasing from 2006 (78.5 hours) to 2016 (45.5 hours). Amongst all patients with stool positive C. difficile LabID event, the frequency of ICD-9/10 discharge diagnosis code for CDI was 83.3%.ConclusionThe incidence of CDI increased significantly as the use of PCR rose within the VHA. Increased incidence of CDI had a significant impact on mortality. Reporting of HO-HCFA CDI led to a downward trend in the incidence of HO-HCFA CDI and 30-days CDI mortality. Whether this is a true decrease or an improvement in testing programs is unclear as the time to C. difficile testing also declined over the study period. ICD-9/10 discharge diagnosis codes are not representative of all cases of CDI.Disclosures All authors: No reported disclosures.

Background:Clostridium difficile infection (CDI) is a reportable hospital metric associated with significant healthcare expenditures. The epidemiology of CDI is pivotal to the implementation of preventative measures.Objective:To portray temporal CDI trends in Veterans Health Administration (VA) hospitals.Design:A retrospective analysis of veterans who had stool testing for C. difficile.Setting:VA acute-care hospitals within the continental United States.Methods:Data were mined from the VA’s Corporate Data Warehouse. CDI is reported per 10,000 patient days.Results:From 2006 to 2016, 472,346 patients had C. difficile testing. Overall, decreases in incidence of total CDI (16.81 to 13.66) and hospital-onset healthcare facility-associated (HO-HCFA) CDI (10.87 to 6.41) were observed. Temporal increases in the incidence of total and HO-HCFA CDI were associated with the increased use of molecular testing (P < .0001). Decreased use of fluoroquinolones (P < .0001), clindamycin (P = .0006), and third-generation cephalosporins (P = .0002) correlated with decreased rates of CDI, but VA mandatory reporting did not influence CDI rates (P = .24). The overall crude 30-day mortality of patients with CDI decreased from 2.17 deaths per 10,000 patient days in 2006 to 1.41 in 2016. The frequency of International Classification of Disease, Ninth/Tenth Revision (ICD-9/10) discharge diagnosis for CDI was 73.3%.Conclusion:Molecular testing was associated with increased incidence of CDI. Controlling CDI is likely multifactorial. Although the VA initiative to report cases of hospital-acquired CDI was not significant in our model, the advent of stewardship programs throughout the VA and reductions in the use of third-generation cephalosporins, fluoroquinolones, and clindamycin were significantly associated with reduced rates of CDI.