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svs. weekday (OR=0.91, p=0.004), or if insured by Medicaid (OR=0.84, p=0.004) or privateinsurance vs. Medicare (OR=0.69, p,0.001). Patients were more likely to die if older (OR=1.05, p,0.0001) or if sicker (CCI≥3; OR=1.21, p=0.002). Conclusions: CDI constitutes aconsiderable burden on resources in the ED. Policies should be implemented to ensureequal access and care across all population strata.

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Predictors for All-Cause Mortality Following Clostridium Diffcile AssociatedDiarrhoeaSreedhari Thayalasekaran, Jenny Cuthbertson, Venkataraman Subramanian

Background: Severe Clostridium difficile associated diarrhoea (CDAD) has become an impor-tant and frequent nosocomial infection, often resulting in severe morbidity or death. Therates of CDAD have increased significantly in the last 2 decades, but predictors of outcomeare poorly understood. Methods: A retrospective cohort study was performed in patientswith a diagnosis of CDAD hospitalized at Leeds Teaching Hospitals NHS Trust (LTHT)between January 2011 and December 2011. The data on these cases was collected fromboth electronic patient records as well as the medical notes. Data collected included generaldemographics, underlying medical conditions, Horn Index, Charlson co-morbidity score,clinical and laboratory data, and type of medical treatment. Death due to any cause eitherduring that hospital stay or within 30 days of discharge from hospital was the primaryoutcome. Severe CDAD was defined according to the UK Health Protection Agency (HPA)guidelines as WCC .15 X 109/L, or an acute rising serum creatinine (i.e. .50% increaseabove baseline), or a temperature of .38.5°C, or evidence of severe colitis (abdominal orradiological signs). Logistic Regression analysis was used to identify parameters associatedwith mortality. SPSS version 17 (IBM Corp, NY) was used to perform the statistical analysis.Results: There were 247 patients with a diagnosis of CDAD made in 2011 at LTHT of which16 were wrongly coded, 5 were treated in the community, 12 had insufficient informationin the notes and in 68 the medical notes could not be traced. A total of 170 episodes in146 patients were finally analyzed. There were 36 deaths in this group. Patients who weredead were older (mean age 78±12.9 vs 76.6±17.6) Independent predictors of mortality onmultivariate analysis included age (OR 1.051, 95% CI 1.009-1.095), Charlson co-morbidityscore of ≥3 (OR 3.036, 95% CI 1.209-7.622), Horn Index (Major or Extreme) (OR 4.725,95% CI 1.818-12.283), severe CDAD (OR 3.454, 95% CI 1.222-9.760) and inappropriatetreatment of severe CDAD with metronidazole as first line therapy (OR 4.642, 95% CI1.213-19.193). Factors not found significant included gender, prior use of antibiotics, protonpump inhibitor use, opioid use, prior episodes of CDAD and treatment with vancomycin.Conclusions: Predictors of all-cause mortality in patients with CDAD include older age,Charlson score ≥3, Horn index ≥3, severe CDAD as defined by the UK HPA and inappropriateuse of metronidazole in severe CDAD. Patients with severe CDAD should not be treatedwith Metronidazole as first line therapy. Further prospective validation of these results isneeded in a multicenter setting.

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Adverse Outcomes in Patients With Clostridium difficile Enteritis - A Case-Control StudySaurabh Mukewar, Johnathon Markus, Xianrui Wu, Bo Shen

Background: Few cases of Clostridium difficile infection (CDI) of the small bowel or C.difficile enteritis in patients with ileostomy have been described. Whether patients with C.difficile enteritis have to better or worse outcomes than inflammatory bowel disease (IBD)patients with CDI is not known. Aim: To compare the risk factors for developing CDI andtheir outcomes in CDI enteritis and colitis. Methods: Patients with CDI affecting small bowel(CDI enteritis) were retrospectively identified from electronic medical records from 2001to 2012. These were compared with IBD patients who developed CDI colitis randomlyselected from out IBD database. Nineteen demographic and clinical variables were studied,including predisposing medical conditions such as malignancy, solid organ, transplant recipi-ent, liver cirrhosis, end-stage renal disease, HIV and active tuberculosis on treatment. Adverseoutcomes from CDI were defined as outpatients getting admitted to hospital or inpatientsrequiring transfer to intensive care unit (ICU). Results: As noted in table below. Conclusions:Patients with CDI enteritis have greater use of proton pump inhibitors (PPIs) and a historyof predisposing medical conditions. They have higher rates of adverse outcomes than IBDpatients with CDI colitis.

S-240AGA Abstracts

Abbreviation: CDI: Clostridium difficle infecton; IBD: Inflammatory bowel disease

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Drift in Physicians' Behavior in Antibiotics Choice and Compliance toGuidelines for Hospital-Onset Clostridium difficile InfectionSubhash Chandra, Rameet Thapa, Nyan L. Latt, Ahmad Ramy Elashery, Margarita Noel,Surendra Marur, Niraj Jani

Background & Objective: Guidelines in treatment of Clostridium difficile infection (CDI)from the Society for Healthcare Epidemiology of America in collaboration with the InfectiousDiseases Society of America endorsed oral metronidazole as first line treatment for mild-to-moderate CDI and judicious use of oral vancomycin to avoid development of vancomycinresistant enterococci. Appropriate choice of antibiotics is recommended performancemeasurein CDI management. In this study, we aim to determine change physicians' behavior inchoosing antibiotics and compliance to current guidelines in hospital-onset CDI. Methods:This observational study was conducted at a 360-bed community hospital. Electronic medicalrecords of all the patients admitted to adult medical service including intensive care unitover 7 years period from October 2005 through October 2012, were reviewed. The CDIwas considered hospital-onset if patients develops diarrhea after 24-hours of hospital admis-sion and stool was tested positive for C. difficile toxin or polymerase chain reaction assayfor toxin gene in absence of CDI in preceding 8 weeks. We reviewed the antibiotics use inthese cases. Severe episodes of CDI were identified as per the Center of Disease Controlendorsed definition, leucocytosis .15000/mm3 or 1.5 time or more rise in serum creatininefrom premorbid condition. A main outcome measured was compliance with recommendationof vancomycin use in severe CDI. Trends of antibiotics use was analyzed using Cochran-Armitage test and a two-tailed p value of less than 0.05 was considered significant. Results:Over the period of 7 years, 59,898 patients were admitted to medical service, of which 307(0.50%) patients developed hospital-onset CDI. Enteric vancomycin was initiated in 163(52.4%) and enteric metronidazole was initiated in 213 (69.4%) cases. In 84 patients (28.1%), both enteric vancomycin and metronidazole have been used and not treatment wasinitiated in 15 patients. The reason for not starting treatment were, expired , made comfortcare only or discharged before stool test report came back. On plotting it overtime, use ofvancomycin has significantly increased, z= 7.43, p ,0.0001 and conversely the use ofmetronidazole has decreased, z=3.24, p=0.0006 (See figure 1) without change in severityof hospital-onset CDI. On other hand, among severe hospital-onset CDI cases, entericvancomycin was used only in 55% cases. Its use has increased over time, 0% in 2006compared to 85.7% in 2012, z = 5.07, p ,0.0001. Conclusion: Use of enteric vancomycinhas increased, both in severe and mild-to-moderate hospital-onset CDI cases. Complianceto use of enteric vancomycin with guidelines in severe hospital-onset CDI is improving butstill not optimal.