Whole-genome sequencing (WGS) has yielded new insights into the transmission patterns of healthcare facility-onset Clostridioides difficile infection (HO-CDI). WGS results prompted a focused diagnostic stewardship program, which was associated with a significant and sustained decrease in HO-CDI at large, urban hospital.

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BACKGROUND: Adolescents bear a large burden of TB but high-prevalence countries differ significantly in their approach to address the specific needs of adolescent patients. We explore the national approaches to TB care in adolescents and compare them to the recommendations of the WHO.METHODS: We conducted a scoping review to describe the country-level guidelines to TB care in adolescents in high-burden countries. These guidelines were obtained through open sources. Information on TB care in adolescents were extracted from guidelines and compared to WHO recommendations.RESULTS: We found a lack of consensus in defining adolescents and that many national guidelines do not address the special healthcare needs of adolescents nor align with the WHO recommendations. Recently updated country guidelines are more likely to recommend short-course regimens for TB preventive treatment and countries with a higher level of income were more likely to follow WHO guidance for microbiological confirmation of TB disease in adolescents.CONCLUSION: A clear understanding of the burden of TB in adolescents that is reflected in disaggregated data reported at the country level is imperative in order to address the specific challenges to care in this high-risk group

At least a third of tuberculosis (TB) cases remain undiagnosed, disproportionately so in children and adolescents, which is hampering global elimination goals. Prolonged symptom duration presents a high-risk scenario for childhood TB in endemic areas, but the prolonged period of symptoms and its impact on educational attainment are rarely documented. Using a mixed method approach, we aimed to quantify the duration of respiratory symptoms and describe their impact on education among children from a rural area of Tanzania. We used data from a prospectively enrolled cohort of children and adolescents aged 4–17 years in rural Tanzania at the start of active TB treatment. We report on the cohort’s baseline characteristics and explore the correlation between duration of symptoms and other variables. In-depth qualitative interviews were designed on the basis of a grounded theory approach to explore the impact of TB on educational attainment among school-aged children. In this cohort, children and adolescents diagnosed with TB experienced symptoms for a median of 85 days (interquartile range: 30, 231 days) prior to treatment initiation. In addition, 56 participants (65%) had a TB exposure in the household. Of the 16 families with school-aged children who were interviewed, 15 (94%) reported a significant negative impact of TB on the schooling of their children. Children in this cohort experienced a long duration of TB symptoms; the extent of illness impacted absenteeism at school. Screening initiatives for households affected by TB may lead to a shortened duration of symptoms and may minimize the impact on school attendance.

BackgroundHospital-onset C. difficile infection (HO-CDI) has been problematic at our hospital, with rates almost 50% greater than predicted. C. difficile whole-genome sequencing (WGS) data were used to define the transmission pattern, followed by a diagnostic stewardship intervention.MethodsIsolates from CDI cases were sequenced for strain relatedness and epidemiologically analyzed using a single nucleotide polymorphism (SNP)-based approach. In June 2017, a diagnostic stewardship intervention began which included provider education and a weekday review of CDI orders placed after hospital day 3 for the following indications: >3 stools/24 hours, the absence of laxative administration, the presence of fever/leukocytosis or a history of inflammatory bowel disease. In November 2017, an EMR-based testing algorithm was introduced to supplement the review process. Orders not meeting testing criteria were discussed with the ordering provider, with a suggestion to cancel orders without appropriate indications.ResultsWGS assigned 36 isolates to 19 different multi-locus sequence types (ST), including five assigned to ST-1, a sequence that encompasses the ribotype 027 clade (Figure 1). SNP-based analysis indicated closely related, but non-identical strains, inconsistent with nosocomial transmission. Six hundred forty-six CDI orders were reviewed, of which 421 (65%) met criteria and 64 (15%) were positive. Two hundred twenty-five (35%) of orders were recommended for cancellation. The HO-CDI rate decreased from 11.67/10k in the 5-month baseline period to 7.13/10k in the 9-month intervention period (P = 0.0008) (Figure 2).ConclusionWGS revealed that nosocomial transmission of C. difficile was an unlikely cause for our elevated CO-CDI rate. A diagnostic stewardship intervention which focused on identifying community-acquired infection and avoiding over-testing was associated with a sustained decrease in the HO-CDI rate which has persisted for 9 months.Figure 1.Figure 2.Disclosures All authors: No reported disclosures.

Background: Children aged 5-14 years who are household contacts of index pulmonary TB cases have limited coverage for TB preventive therapy (TPT) due to variable uptake of the national guideline recommendations in the Philippines. We conducted a cost effectiveness analysis evaluating the expansion of latent TB testing and treatment among pediatric (5-14 years) household contacts of index TB patients in the Philippines. Methods: Using a Markov state transition model, eligible household contacts (HHCs) age 5-14 years are screened for latent TB infection (LTBI) with either the tuberculin skin test (TST) or interferon gamma release assay (IGRA). Those who test positive are then simulated to receive one of the following TPT strategies: 6 months of daily isoniazid (6H), 3 months of weekly isoniazid and rifapentine (3HP), 3 months of daily isoniazid plus rifampicin (3HR) and the current practice of no testing or treatment for LTBI (NTT). The analysis assesses the projected cost and quality-adjusted life years (QALY) gained for every strategy from the perspective of the Philippines public healthcare system over a time horizon of 20 years. The total cost and gain in QALYs are presented as an incremental cost-effectiveness ratio (ICER) comparing cost per QALY gained for each strategy over NTT. Results: Our model estimates that expanding TPT coverage to HHCs aged 5-14 years would be cost effective with incremental cost-effectiveness ratios (ICERs) ranging from 1,024 $/QALY gained when using TST and 6H (Uncertainty range: 497 - 2,334) to 2,293 $/QALY gained when IGRA and 3HR are used (Uncertainty range: 1,140 – 5,203). IGRA cost would have to drop to $5.50 to achieve similar results to strategies using TST. These findings were robust to sensitivity analyses over a wide range of parameter values. Conclusion: Expanding TPT coverage to HHCs aged 5-14 years is cost effective when using TST and 6H closely followed by a strategy combining TST and 3HP. IGRA cost will require significant reduction to achieve results similar to TST.

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