bluuebunny/crossref_metadata_2025 huggingface dataset:
1356. Ribavirin Use in Hospitalized Children
Authors: Otto William R , Lee Giyoung , Thurm Cary , Gerber Jeffrey , Hersh Adam
Published: January 2021

Background

Respiratory syncytial virus (RSV) infection is a significant cause of morbidity and mortality in immunocompromised children. Aerosolized ribavirin is approved for treatment of RSV lower respiratory tract infections. However, due to high cost, challenges to administration and uncertainty about benefit, use is limited. Recent studies in adult patients have reported similar outcomes between patients treated with aerosolized and oral ribavirin. We sought to characterize trends in use of ribavirin for hospitalized children.

Methods

We used the Pediatric Health Information System (PHIS), an administrative database which contains resource utilization data from 52 children’s hospitals, to perform a retrospective analysis of children hospitalized between January 1, 2010 through December 31, 2019 who were billed for ribavirin treatment. Data related to ribavirin use (number of courses, route of administration) and clinical characteristics were abstracted. International Classification of Diseases, 9th Revision (ICD-9) or 10th Revision (ICD-10) codes and All Patients Refined Diagnosis Related Groups (APR DRG) classifications were used to define underlying clinical conditions and illness severity. Summary statistics were used to describe patient characteristics and the use of ribavirin.

Results

Thirty-eight hospitals reported ribavirin use; 1 hospital was excluded due to inaccuracies in charge coding. We identified 837 children who received 937 courses of ribavirin (Table 1). The overall frequency of ribavirin use was unchanged over the study period, and the number of ribavirin treatment courses per hospital ranged from 1 to 228 (Figure 1). The most frequent routes of administration were inhalation (603/937, 64%) and oral (322/937, 34%). There was a decrease in the use of aerosolized ribavirin over time, with a corresponding increase in the use of oral ribavirin (Figure 2).

Table 1: Patient demographics (N=837)

Figure 1: Total ribavirin treatment courses over the study period (a) by year and (b) by treating hospital

Figure 2: (a) Route of administration (inhalation versus oral), by year during the study period and (b) use of oral ribavirin over time during the study period

Conclusion

Although overall prescribing rates of ribavirin in hospitalized children have remained stable, use varies widely across centers and the proportion of oral ribavirin use has increased over time. Comparative effectiveness studies are needed in the pediatric population to evaluate outcomes of children treated with aerosolized vs. oral ribavirin.

Disclosures

All Authors: No reported disclosures
1359. Utilization of West Virginia Pediatric Medicaid Claims Data to Guide Outpatient Antimicrobial Stewardship Interventions
Authors: Kilgore Jacob T , Piazzon Mariana M Lanata , Willis Jonathan M , Evans Joseph , Smith Michael J
Published: January 2021

Background

Antimicrobial resistance is a significant public health risk with overuse and misuse of antibiotics as primary drivers. West Virginia (WV) leads the nation in per capita prescribing in the outpatient setting, where the majority of antibiotic use occurs.

Methods

We analyzed outpatient pharmacy and medical claims for WV Medicaid recipients age < 20 years from 1/1/2018 – 12/31/2019. Dental claims were excluded. Oral antibiotics were identified using National Drug Codes (NDCs). Key demographic variables extracted from the claims include patient age (as of December 31st of that calendar year [CY]), sex, race, ethnicity, Medicaid region, place of medical service, provider, and cost. Rates of prescribing were calculated as the number of prescriptions per 1,000 children and stratified by age, race/ethnicity, sex, and WV Medicaid region. We used geographic information system (GIS) mapping to depict geographic variation in prescribing by county. Oral antibiotic prescriptions were compared across CY 2018 and 2019 including spectrum of antibiotic coverage.

Results

In CY 2018, 204,576 pediatric patients received 237,759 antibiotics (1,162 prescriptions/1,000 children). In 2019, 201,520 pediatric patients received 227,440 antibiotics (1,129 prescriptions/1,000 children). Prescription rates were higher among females, Caucasians and a younger (0-2) age group (Table 1). Antibiotics were more commonly prescribed by non-physician (e.g. nurse practitioner, etc.), non-pediatric specialty providers. Amoxicillin, cefdinir, and azithromycin were the most commonly prescribed antibiotics across CYs. Table 2 summarizes commonly prescribed antibiotics and their associated cost. Medicaid region 4 encompassed the highest prescription rates. Figure 1 is a GIS map of prescription rates by WV county.

Table 1. West Virginia pediatric (0 – 19 years*) Medicaid patient population demographic summary by calendar year (CY).

Table 2. Oral antibiotic prescription review including cost, CY 2018-2019.

Figure 1. Geographic information system (GIS) mapping of prescriptions per 1,000 children by WV county.

Conclusion

There is significant variation in antibiotic prescribing across WV. Potential areas of stewardship intervention should focus on non-physician, non-pediatric providers in Medicaid Region 4, the southern and arguably most rural portion of the state. Secondary analysis revealed an alarmingly high total number of broad-spectrum antibiotic use compared to narrow-spectrum. Further data analysis will examine diagnosis-specific prescription practices within this population.

Disclosures

Michael J. Smith, MD, MSC.E, Kentucky Medicaid (Grant/Research Support)Merck (Grant/Research Support)
1361. Variation in Perioperative Antibiotic Use for Children Undergoing Congenital Heart Disease Surgery in U.S. Academically Affiliated Centers
Authors: Cooch Peter B , Wattier Rachel , Steurer-Muller Martina
Published: January 2021

Background

Perioperative antibiotics (PA) are routinely given to children undergoing congenital heart disease (CHD) surgery to prevent surgical site infection. National guidelines recommend narrow-spectrum PA (such as Cefazolin) for most CHD procedures. However, indications for broad-spectrum PA are not well established, and limited literature suggests high exposure to broad-spectrum PA in this population. We performed a contemporary, multicenter description of prevalence and variability of broad-spectrum PA exposure within the pediatric CHD surgical population.

Methods

We identified children 0-17 years admitted to U.S. academically-affiliated centers participating in the Vizient Clinical Database/Resource Manager from 2011-2018. Patients who had ICD-9 and ICD-10 codes indicating a CHD surgical procedure with intravenous antibiotics initiated the day of surgery were eligible for inclusion. Antibiotics broader than first- and second-generation cephalosporins were designated broad-spectrum. We excluded centers with 5 or fewer annual procedures. We excluded patients undergoing heart transplant, concurrent non-cardiac procedures, and those with missing medication data.

Results

19,152 hospital admissions from 24 centers met inclusion criteria. 55% of patients were male, 18% were under 30 days of age at time of surgery, and 5.1% had diagnosis codes for prematurity. Broad spectrum antibiotics were administered in 21.4% of CHD procedures during the study period. Between the 24 centers, the proportion of surgical cases given broad-spectrum PA ranged from 1.5% to 95%, which was unrelated to center annual surgical volume. Children under 30 days of age and those with prematurity were significantly more likely to receive broad-spectrum agents. Vancomycin was the primary antibiotic contributing to broad-spectrum PA exposure.

Conclusion

Substantial variation in broad-spectrum PA use was observed among children undergoing congenital heart disease surgery in academically affiliated United States centers from 2011-2018. Neonates and premature infants have the highest rates of exposure to broad-spectrum antibiotics. Standardization of perioperative antibiotics in CHD surgery is a potential intervention to limit antibiotic exposure in young infants.

Disclosures

All Authors: No reported disclosures
1362. Antibiotic Prescribing for Acute Otitis Media in Commercially Insured Pediatric Patients in the United States
Authors: Smolinski Nicole , Antonelli Patrick , Winterstein Almut
Published: January 2021

Background

Overprescribing of antibiotics to treat conditions that are self-limiting and do not always require antibiotics is a well-recognized concern in pediatric care. The 2013 American Academy of Pediatrics (AAP) acute otitis media (AOM) guidelines reinforced previous recommendations regarding watchful waiting for three days among patients with non-recurrent uncomplicated AOM and provided more explicit diagnostic criteria.

Methods

We conducted a retrospective cohort study using the IBM Marketscan Commercial Claims Research Databases (2008-2018). Pediatric patients 1 to 12 years old were included. We required a primary diagnosis of AOM in an outpatient setting, without AOM or other complicated ear infections within 6 months prior and no other acute infections in the 2 weeks prior to or 1 week after AOM diagnosis. Patients were classified as treated (pharmacy dispensing record of antibiotics within 3 days of diagnosis) or watchful waiting (no treatment or treatment after > 3 days). We used segmented linear regression to examine changes in treatment proportions across the study period.

Results

We identified 2,640,920 pediatric AOM episodes, of which 2,033,697 (77.0%) were treated within 3 days. The majority of episodes were treated with amoxicillin (51.3%), followed by amoxicillin/clavulanate (15.3%) and cephalosporins (22.0%). Among episodes in the watchful waiting group, 18,793 (3.1%) filled a prescription within 4-7 days of diagnosis. Most patients saw a pediatrician (62.7%). A larger proportion of otolaryngologists adopted watchful waiting approaches compared to other physician types. There was no difference in chronic conditions or regional variation between the two groups. There was no immediate (p=0.31) or gradual change in treatment proportion (p=0.49) after release of the 2013 guidelines.

Conclusion

Most pediatric patients continue to be treated with antibiotics within three days of AOM diagnosis, reflecting no impact of the 2013 AAP guidelines. Physician specialty but not patient characteristics appear to determine treatment approaches.

Disclosures

Nicole Smolinski, PharMD, Nothing to disclose
1367. Reduced Ceftaroline Susceptibility Among Invasive MRSA Isolates at a Tertiary Children’s HospitalReduced Ceftaroline Susceptibility Among Invasive MRSA Isolates at a Tertiary Children’s Hospital
Authors: Sommer Lauren , Vallejo Jesus G , Hulten Kristina G , Kaplan Sheldon L , McNeil Jonathon C
Published: January 2021

Background

The emergence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) in the late 1990s-early 2000s complicated the empiric management of suspected staphylococcal infection in children. Rising clindamycin resistance rates in many communities adds further to management challenges. Ceftaroline, an anti-MRSA cephalosporin, represents an attractive therapy option. Little data are available, however, regarding the frequency of reduced susceptibility (RS) to ceftaroline among MRSA isolates from a general pediatric population.

Methods

Isolates were selected from an ongoing S. aureus surveillance study at Texas Children’s Hospital. Invasive MRSA isolates from 2015-2018 were included. Isolates were initially screened for ceftaroline RS with E-test; all isolates with a ceftaroline E-test MIC ≥ 1.5µg/ml underwent ceftaroline broth dilution. Ceftaroline RS was regarded as an MIC ≥ 2 µg/ml; full ceftaroline resistance was defined as an MIC ≥ 8 μg/ml. Accessory gene regulator (agr) groups were characterized by PCR.

Results

201 viable isolates were included. The ceftaroline MIC50 and MIC90 were 0.5 and 1 µg/ml, respectively (Figure 1). Six isolates had MIC ≥ 2 µg/ml (2.9%) with two having MIC ≥ 8 µg/ml (0.9%). All ceftaroline RS isolates were from healthcare associated infections. Ceftaroline RS isolates were more often associated with clindamycin-resistance and agr group II (Figure 2). Infections with ceftaroline RS were associated with central venous lines, recent ICU admission, preceding antibiotic exposure (specifically cephalosporins) and prior MRSA infection. One subject with MRSA CLABSI had a ceftaroline susceptible MRSA infection followed < 1 month later by a ceftaroline resistant infection (MIC =32 μg/ml); the isolates were identical by PFGE. Only 3 subjects had previously received ceftaroline, none of which subsequently developed a ceftaroline RS isolate.

Figure 1. Ceftaroline MIC Distribution

Figure 2. Clinical And Microbiologic Associations with Reduced Ceftaroline Susceptibility

Conclusion

Ceftaroline RS occurs in 2.9% of invasive MRSA isolates in children and is most prominent among healthcare-associated infections. These isolates were associated with clindamycin resistance and agr group II. While ceftaroline RS is rare among invasive MRSA infections, the lack of preceding ceftaroline exposure is concerning and warrants careful surveillance.

Disclosures

Sheldon L. Kaplan, MD, Allergan (Research Grant or Support)Pfizer (Grant/Research Support) Jonathon C. McNeil, MD, Allergan (Research Grant or Support, Allergan provided ceftaroline powder for use in studies described in this abstract)
110. Impact of Diagnostic and Antimicrobial Stewardship on Time-to-Appropriate Therapy and Clinical Outcomes in Multi-Drug Resistant Pseudomonas Infections
Authors: McCrink Katie A , DeRonde Kailynn , Jimenez Adriana , Rosello Gemma , Natori Yoichiro , Claeys Kimberly C , Martinez Octavio , De Pascale Biagio , Perez-Cardona Armando , Abbo Lilian M , Abbo Lilian M , Vega Ana
Published: January 2021

Background

Timely effective therapy in multi-drug resistant (MDR) Pseudomonas (PsA) infections has a direct impact on patient survival. We aimed to determine the impact of diagnostic and antimicrobial stewardship (AMS) on time-to-appropriate therapy (TAP) and clinical outcomes of patients with MDR PsA infections utilizing novel beta-lactam/beta-lactamase inhibitors (BL/BLIs).

Methods

Retrospective cohort study of adult patients with MDR PsA infections at a 1,500-bed University-affiliated public hospital in Miami, Florida who received ≥72 hours of ceftazidime-avibactam (C/A) or ceftolozane-tazobactam (C/T). During the pre-intervention period (12/2017-12/2018), additional susceptibilities for C/A and C/T were performed upon providers’ request. In the post intervention period (01/2019 – 12/2019), we implemented automatic reflex algorithms (Figure 1) for faster identification and susceptibilities for MDR PsA, including carbapenemase producers. Results were communicated in real-time to the AMS team.

Figure 1. Reflex Testing Algorithm for MDR Pseudomonas Isolates from Any Source

Results

Seventy-six patients were included; median age was 56 years (IQR 37.5–67.0), 40 (52.6%) were in an intensive care unit at time of culture collection; median APACHE II score was 20 (IQR 15.0 – 26.0). Three isolates were carbapenemase producers (VIM = 2; KPC = 1). The most common infections were pneumonia (56.6%) and bacteremia (18.4%). We found a significant decrease in median TAP (120.1 [IQR 82.5–164.6] vs 75.9 [IQR 51.3–101.7] hours, p = 0.003). Median time from culture collection to final susceptibility results was shorter in the post-intervention group (122.2 vs 90.5 hours; p < 0.001). Median length-of-stay after culture collection was numerically lower in the post-intervention group (26.0 [11.6–59.4] vs 19.7 [12.9–37.8] days; p = 0.33). Controlling for ICU admission, our intervention was not associated with decreased 30-day inpatient mortality (OR = 1.62, 95% CI 0.45–5.79).

Conclusion

Our study identified an improvement in TAP in MDR PsA infections with implementation of diagnostic and AMS initiatives. In an adequately powered study, our intervention could potentially impact patient survival through timely initiation of effective therapy with novel BL/BLIs.

Disclosures

All Authors: No reported disclosures
1368. The Clinical Impact of BioFire BCID2 Compared to BCID in a U.S. Pediatric Hospital
Authors: Graff Kelly E , Palmer Claire , Anarestani Toraj , Velasquez Darcy , Hamilton Stacey , Pretty Kristin , Dominguez Samuel
Published: January 2021

Background

Multiplex PCR panels, particularly BioFire FilmArray Blood Culture Identification (BCID), have been shown to decrease time to pathogen identification and time to effective and optimal antimicrobial therapy. BioFire Blood Culture Identification 2 (BCID2) has an additional 17 targets and resistance genes compared to BCID. There is limited data on the impact of these expanded targets in pediatric populations.

Methods

We performed a head-to-head comparison between BioFire BCID2 with BCID when compared to standard culture. From January 2020- May 2020, we ran BCID2 simultaneously as a research use only prototype with the current standard of care on all blood culture specimens at Children’s Hospital Colorado. Percent agreement was calculated with BCID2 compared to standard culture and BCID compared to standard culture. Time to positivity, time to optimal therapy, and time to effective therapy were also calculated.

Results

We performed an interim analysis halfway through the study with 86 unique positive blood cultures. We found equal organism detection rates between BCID and BCID2 when compared to standard culture (88% each). BCID2 correctly identified 100% of target organisms. There were 10 (12%) isolates that only grew in culture that were not BCID or BCID2 targets. Compared to BCID, BCID2 was able to detect to the species level on 23 additional isolates. Most notably, 3 Enterococcus faecalis isolates were detected on BCID2, which would have resulted in a theoretical decrease in time to optimal antimicrobial therapy. Three CTX-M genes were detected on the resistance panels for Enteric bacteria, which could have resulted in a theoretical decrease in time to effective therapy.

Conclusion

BioFire BCID2 had equal rates of detection when compared to BCID in pediatric patients. It has the additional advantage of detecting more organisms at the species level, with clinical significance for Enterococcus faecalis specifically. With the additional resistance genes, it also has the potential to impact care with early identification of ESBL-producing Enteric pathogens.

Disclosures

Kelly E. Graff, MD, BioFire Diagnostics, LLC (Grant/Research Support) Claire Palmer, MS, BioFire Diagnostics, LLC (Grant/Research Support) Toraj Anarestani, MT(ASCP), BioFire Diagnostics, LLC (Grant/Research Support) Darcy Velasquez, MS, MB (ASCP)CM, BioFire Diagnostics, LLC (Grant/Research Support) Stacey Hamilton, MT(ASCP)SM, BioFire Diagnostics, LLC (Grant/Research Support) Kristin Pretty, n/a, BioFire Diagnostics, LLC (Grant/Research Support) Samuel Dominguez, MD, PhD, BioFire (Consultant, Research Grant or Support)
1369. The Spectrum of Chronic Osteomyelitis in Children
Authors: Joseph Marritta , Sommer Lauren , Vallejo Jesus G , McNeil Jonathon C
Published: January 2021

Background

While the majority of pediatric osteomyelitis cases are acute in nature, a significant subset present with prolonged symptoms often associated with substantial morbidity. Little data exist to guide clinicians in the management of these infections. We sought to describe the epidemiology, clinical features and management of chronic osteomyelitis in children.

Methods

We reviewed hospital admissions with an ICD10 code for chronic osteomyelitis from 2011-2018 at Texas Children’s Hospital. Cases were included if symptoms lasted >28 days on presentation. Patients diagnosed with chronic recurrent multifocal osteomyelitis were excluded. Cases were classified as those 1) associated with a contiguous focus (CoF), 2) penetrating or open trauma, 3) orthopedic hardware (OH), 4) post-acute chronic osteomyelitis (PACO, those occurring after >28 days of therapy for acute osteomyelitis) and 5) primary hematogenous chronic osteomyelitis (PHCO, those with 28 days of symptoms without other clear risk factors).

Results

114 cases met inclusion criteria. The median patient age is 11.8 years and 35.9% patients had underlying comorbidities. 83% of patients underwent a surgical procedure. Cases were diverse in terms of pathogenesis (Figure 1). A microbiologic etiology was identified in 72.8% of cases and was polymicrobial in 20.2% of cases; Staphylococcus aureus was the single most common etiology (Figure 2). CoF infection was more often associated with polymicrobial etiology with or without Pseudomonas (P< 0.001) and disease of the foot. PACO was caused by S. aureus in 95% of cases (p< 0.001, Figure 3). The overall median duration of total therapy was 210 days. 41% were discharged from hospital on OPAT with or without later transition to oral antibiotics. 26.3% of patients had persistent functional limitations at time of last follow-up of which 46% experienced repeat hospital admission/surgery. There was no association between duration of intravenous therapy and persistent functional limitations.

Figure 1. Categories of Chronic Osteomyelitis

Figure 2. Microbiology of Pediatric Chronic Osteomyelitis

Figure 3. Clinical Features of Pediatric Chronic Osteomyelitis

Conclusion

Children with chronic osteomyelitis are diverse both in terms of pathogenesis and microbiology. Pathogenesis and clinical presentation can provide clues to microbiologic etiology. Prolonged intravenous therapy does not appear to improve functional outcomes in chronic osteomyelitis

Disclosures

Jonathon C. McNeil, MD, Allergan (Research Grant or Support, Allergan provided ceftaroline powder for use in studies described in this abstract)
1371. Trends in Antibiotic Resistance Among Uropathogens in the Pediatric Population: A Single Center Experience in the US
Authors: Mithal Leena B , Otero Sebastian , Sun Shan , Arshad Mehreen
Published: January 2021

Background

Urinary tract infections (UTIs) are common infections in children. Overuse of antibiotics has led to an increasing prevalence of antibiotic resistance among uropathogens in adults; however, data on pediatric trends have not been previously reported. Our objective was to characterize antibiotic resistance trends in uropathogens among children at a tertiary care hospital in a diverse urban US city.

Methods

Positive urine culture data (>20,000 CFU/ml) from January 1st, 2010 through December 31st, 2019 were obtained from the electronic medical records (inpatient and outpatient). Yearly antibiotic agent-specific resistance rates were calculated based on culture, patient, and organism level data.

Results

A total of 7,512 patients had ≥1 positive urine culture, with 13,327 positive individual cultures. The average age at sample collection was 6 yrs (IQR 2-11). Overall, 66% of cultures showed resistance to at least 1 antibiotic. Ampicillin resistance (50.1% IQR: 48.2%-52.4%) was the most common and remained stable over the study period. However, resistance against amoxicillin-sulbactam, third and fourth generation cephalosporins, and fluoroquinolones has increased significantly over this period (Figure 1). There was also a corresponding increase in the prevalence of extended spectrum beta-lactamase (ESBL) Enterobacteriaceae (Figure 2). Among infants < 1 year, a similar trend in increasing resistance against beta-lactams was noted (ampicillin-sulbactam 0% to 38%, ceftriaxone 0% to 9% and cefepime 0% to 4%, Figure 3).

Figure 1

Figure 2

Figure 3

Conclusion

There are rising rates of antibiotic resistance to broad spectrum antibiotics, including beta-lactams and quinolones, in a pediatric population over the last 10 years, with a notable increase in resistance starting in 2015-2016. While we were not able to distinguish patients with community acquired UTI, the increase in resistance among infants < 1 year suggests a community reservoir of multi-drug resistant gram-negative bacteria. Colonization by resistant uropathogens has implications for empiric antibiotic choice, limited oral therapy options, and clinical outcomes which necessitate further study.

Disclosures

All Authors: No reported disclosures
1372. Urinary Tract Infections Caused by Gram-Positive Bacteria in Patients Younger than 19 Years: Prediction Analysis in a 13-year Hospital-Based Cohort
Authors: Hsu Yu-Lung , Chang Shih-Ni , Kuo Chin-Chi , Lin Che-Chen , Lin Hsiao-Chuan , Lai Huan-Cheng , Hwang Kao-Pin , Chiang Hsiu-Yin
Published: January 2021

Background

Urinary tract infection (UTI) is one of the common pediatric bacterial infections. Gram positive (GP) pathogens, in contrast to gram negative (GN) bacilli such as E. coli, are less accounted for pediatric UTI. The aim of this study was to identify predictors to enable clinicians to detect GP uropathogens from mostly causative GN bacteria in children with UTI.

Methods

This retrospective cohort study identified 26,066 paired urinalysis and urine culture obtained from the pediatric patients during 2003-2016. Of patients with UTI meeting our criterial, we included children with first-time UTI and classified them into GP-UTI and GN-UTI (Figure 1). Demographic, clinical and laboratory data were collected into analysis. We built a multivariable logistic regression model to predict the GP-UTI. The model performance was examined by using calibration and discrimination plots. We demonstrated a nomogram to predict GP-UTI that could be feasible in the clinical practice.

Figure 1. Flowchart of the Selection Process of the Study Population (N = 3,783 patients).

Results

Of 3,783 children with first-time UTIs, 166 (4.4%) were infected by GP and 3,617 (95.6%) by GN bacteria. The top 3 pathogens for GP uropathogens were vancomycin-resistant (VR) E. faecalis, S. saprophyticus, and coagulase-negative Staphylococcus. Significant risk factors associated with GP-UTI in the multivariable analysis were: age >= 24 months [odds ratio (OR) 3.40, 95% confidence interval (CI) 1.40-8.26], serum white blood cell (WBC) (compared to ≥14.4 x 103/μL) [OR 2.18, 95% CI 1.26-3.77], hemoglobin (compared to < 11.3 g/dL) [OR 1.89, 95% CI 1.04-3.45], negative urine leukocyte esterase [OR 3.12, 95% CI 1.83-5.33], negative urine nitrite [OR 4.14, 95% CI 1.88-9.14] and urine WBC (compared to ≥420/μL) [OR 2.16, 95% CI: 1.09, 4.26] (Table 1). This model had good discrimination (C-statistic 0.874; 95% CI 0.839-0.908) and calibration performance (Figure 2). By using our nomogram, physicians can estimate the probability of UTI that is caused by a GP pathogen, with a probability ranges from 0.04% to 55% (Figure 3).

Table 1. Multivariable Prediction Model for Pediatric Urinary Tract Infections Caused by Gram-Positive Bacteria.

Figure 2. Discrimination Plot (A) and Calibration Plot (B) of the Prediction Model for Pediatric Urinary Tract Infections Caused by Gram-Positive Bacteria.

Figure 3. Nomogram of the Prediction Model for Pediatric Urinary Tract Infections Caused by Gram-Positive Bacteria.

Conclusion

VR E. faecalis is the leading GP uropathogen in the children less than two years of age which need notice of infection control. Our proposed prediction model for GP UTI in children could help clinicians detect potential GP uropathogen and enable them to choose adequate antibiotic regimen early.

Disclosures

All Authors: No reported disclosures
1374. Carbapenem-Resistant Enterobacterales Infection in Children: Clinical and Molecular Data from a Prospective Multicenter Cohort Study
Authors: Fisher Matthew , Dai Weixiao , Doi Yohei , Doi Yohei , Komarow Lauren , Patel Gopi , Revolinski Sara , Huskins W Charles , Fries Bettina C , Banerjee Ritu , Banerjee Ritu
Published: January 2021

Background

Carbapenem Resistant Enterobacterales (CRE) are an urgent public health threat. We describe the clinical and molecular epidemiology of CRE infection in a multicenter pediatric cohort.

Methods

Patients under 18 years of age with CRE positive cultures between April 30 2016 and August 31 2017 were identified from among 49 hospitals participating in the Consortium on Resistance Against Carbapenems in Klebsiella and Other Enterobacteriaceae. Isolates representing colonization or infection were included. Bacterial identification and antimicrobial susceptibility testing were performed in each contributing clinical microbiology laboratory. Carbapenem resistance was defined per CDC criteria as those isolates displaying imipenem, doripenem, or meropenem MIC ≥4 μg/mL or ertapenem MIC ≥2 μg/mL. Clinical and epidemiological data were obtained from the electronic health record. Carbapenemase genes were detected using PCR.

Results

51 pediatric patients with CRE were identified at 17 hospitals. All regions of the United States were represented, with highest prevalence in the South (46%), followed by the Northeast (24%), Midwest (20%) and West (10%). The mean age at time of positive culture was 4 years. 66% of children were under age 2. 53% were male. 40% were white, 38% black, and 18% Hispanic. Mean time from admission to culture was 25 days. 72% of children were in an ICU at the time of culture, including 18% in the neonatal ICU. 42% required mechanical ventilation prior to culture. History of malignancy was present in 14% of children. The most common source was urine (31%), followed by respiratory (25%), and blood (18%). The most common species were Enterobacter cloacae (29%), Klebsiella pneumoniae (24%) and E. coli (20%). Carbapenemase genes were detected in 8 out of 35 (23%) isolates tested. 90-day mortality was 18%. Mortality was highest for K. pneumoniae (42%). The majority of subjects (88%) did not receive effective antibiotic therapy on the day of culture collection.

Table 1

Table 2

Conclusion

CRE infection or colonization in children in the U.S. was geographically widespread, likely hospital-acquired, and associated with high mortality. A significant portion of patients were infants. Ineffective antibiotic therapy was common at illness onset.

Disclosures

W. Charles Huskins, MD, MSc, ADMA Biologics (Consultant)Pfizer, Inc (Consultant)
1375. Characterization of Recurrent Central Line-associated Bloodstream Infections at Texas Children’s Hospital
Authors: Foster Catherine , Marquez Lucila , Koy Tjin , Campbell Judith
Published: January 2021

Background

Recurrent central line-associated bloodstream infections (CLABSI) in children present a unique challenge to infection prevention efforts but guidelines for management are lacking.

Methods

We reviewed CLABSI data at Texas Children’s Hospital (TCH) from fiscal years (FY) 2017-2019. A chart review to characterize clinical features, risk factors, and outcomes of patients with recurrent CLABSIs in FY2019 was performed. Descriptive statistics and Fisher’s exact test were used.

Results

Recurrent CLABSIs increased from FY 2017-2019 [20% (26/126) to 33% (44/131)] (P=0.03). In FY2019, 15 patients accounted for 44 CLABSIs (Figure 1). Underlying conditions included aplastic anemia (4), hemophagocytic lymphohistiocytosis (3), malignancy (4), genetic disease (2), congenital heart disease (1) and biliary atresia (1). Two-thirds of the CLABSIs occurred in the setting of severe neutropenia (ANC < 100 cells/mm3) though only 16 (36%) were classified as mucosal barrier injury. The median time between line insertion and date of infection was 41 days (range 1-105). Line type included central venous catheters (25, 57%), peripherally inserted central catheters (17, 39%) and implantable ports (2, 5%). Most lines (80%) had double lumens. The most common organisms included: Gram-negative bacilli (15), coagulase negative staphylococci (14), viridans group streptococci (6) Candida spp. (5), Enterococcus faecalis (3) and Staphylococcus aureus (3). Four CLABSIs were polymicrobial. Patients with >2 CLABSIs were more likely to have subsequent infections with the same organism as compared to patients with only 2 CLABSIs (P=0.01). Lines were removed promptly (19, 43%), had delayed removal (removal >72 hours from infection date) (10, 23%) or remained in place (15, 34%). Lines were removed for all episodes of fungemia (5/44) and for most Gram-negative infections (10/12). Six of 7 Escherichia coli CLABSIs were breakthrough fluoroquinolone-resistant infections in patients on levofloxacin.

Single Episode and Recurrent CLABSIs at Texas Children’s Hospital for Fiscal Year 2019

Conclusion

Recurrent CLABSI accounted for a third of CLABSIs in FY2019. Line mismanagement was not a key contributor to recurrent CLABSI. Breakthrough CLABSIs in patients on levofloxacin prophylaxis need further investigation. For patients with CLABSIs due to Staphylococci decolonization may be considered.

Disclosures

All Authors: No reported disclosures
111. Impact of Microbiology Laboratory Result Presentation on Antibiotic Stewardship: Process Use Evaluation
Authors: Brummett Christina M , Harding Stephanie , Beadle Kathy , Jones Shelley
Published: January 2021

Background

Advancements in laboratory diagnostics are constantly occurring and accuracy in interpreting results directly affects optimal patient care. The purpose of this process use evaluation was to assess the efficacy of our current presentation of microbiology results in facilitating appropriate clinical decisions and antibiotic stewardship.

Methods

A six question multiple choice survey was sent to prescribers and pharmacists. Each question used our healthcare system’s current presentation of microbiology results. The recipients were asked to make a clinical decision based on patient history and results presented. The topics surveyed included de-escalation of antibiotics based on polymerase chain reaction (PCR) for positive blood cultures (Image 1), evaluation of C. difficile PCR and enzyme immunoassays (Image 2), impact of recent immunization on results of S. pneumoniae urine antigen (Image 3), susceptibilities of Group C Streptococcus and H. influenzae (Images 4 and 5), and understanding of minimum inhibitory concentrations (MIC, Image 6). The anonymous surveys were collected either electronically or by paper.

Image 1

Image 2

Results

Several trends were seen in the 64 responses received (n, %). Questions with lab results containing detailed comments with guidance on how to interpret the results had the highest percentage of correct responses. This included our C. difficile (59, 92%) and S. pneumoniae urine antigen (61, 95%) results. Culture results with presumed susceptibilities and/or lack of guidance (H. influenzae (55, 86%); Group C Streptococcus (46, 72%)) had lower rates of correct interpretation and resulted in provider reluctance to de-escalate antibiotics. A similar trend was seen with the word “presumptive” on blood culture results by PCR (37, 58%). MICs were frequently misinterpreted as being able to compare activity between antibiotics (46, 72%).

Image 3

Image 4

Image 5

Conclusion

This study highlights that stewardship programs should focus on how lab results are reported and interpreted and should work with their microbiology lab to determine the presentation of results. Additions of detailed interpretations to Microbiology results may lead to improved de-escalation and antibiotic selection.

Image 6

Disclosures

All Authors: No reported disclosures
1378. Reservoirs of Transmission of Resistant Gram-negative Pathogens Responsible for Neonatal Sepsis among Hospitalized Neonates in Pune, India
Authors: Johnson Julia , Johnson Julia , Robinson Matthew , Naik Shilpa Nandkumar , Patil Sunil , Kulkarni Rajesh , Kinikar Aarti , Dohe Vaishali , Mudshinkar Swati , Smith Rachel , Westercamp Matthew , Randive Bharat , Kadam Abhay , Kulkarni Vandana , Mave Vidya , Gupta Amita , Milstone Aaron , Milstone Aaron , Manabe Yukari C
Published: January 2021

Background

Neonatal infections with resistant Gram-negative (GN) organisms are associated with high rates of mortality, with limited antibiotic treatment options. The role of maternal colonization and environmental GN organisms as reservoirs for transmission to neonates has not been well described.

Methods

We performed a prospective cohort study from October 12, 2018, until October 31, 2019, to describe the role of maternal and environmental GN colonization in BSI among neonates admitted to the neonatal intensive care unit (NICU) at a tertiary care center in Pune, India. Women admitted to Labor & Delivery with risk factors for neonatal sepsis who provided consent were enrolled and their neonates were followed until hospital discharge. For neonates who developed bloodstream infection (BSI), colonization with resistant GN organisms was assessed in their mothers from frozen vaginal and rectal swabs collected at enrollment and at delivery and in the neonates from frozen skin swabs and peri-rectal swabs collected at day of life (DOL) 0, 3, 7, and weekly until discharge. Environmental colonization was assessed with weekly sampling of unit sinks and the immediate neonatal care environment. Colonization samples were processed to identify organisms that matched neonatal blood culture isolates.

Results

953 women were enrolled, of whom 741 (78%) received antepartum antibiotics. Among 987 live born neonates, 12 (1%) died in the delivery room and 257 (26%) required NICU admission. Among neonates admitted to the NICU, 143 (56%) had at least one blood culture, of which 28 (20%) were positive; 21 (75%) had a GN BSI. The most common cause of neonatal BSI was Klebsiella pneumoniae, and 8 (38%) GN BSI were due to a carbapenem-resistant organism. No organism isolated from maternal samples matched organism and resistance pattern from neonatal blood culture. Matching strains were found in unit sinks and neonatal rectal and skin samples (Figure 1).

Organism recovery from swabs and match to bloodstream isolate by sample source and time of collection from birth

Conclusion

Among neonates born to mothers with risk factors for neonatal sepsis, GN organisms were the most common cause of neonatal BSI. Environmental and neonatal colonization may represent important reservoirs of transmission for these pathogens among neonates hospitalized in a tertiary care NICU in Pune, India.

Disclosures

All Authors: No reported disclosures
1379. Caregiver Burden related to Rotavirus Gastroenteritis: a systematic literature review
Authors: Carias Cristina , Hu Tianyan , Chen Ya-Ting
Published: January 2021

Background

The health and economic impact of rotavirus gastroenteritis (RGE) is well researched, but the burden of RGE on caregivers and remaining family spillover effects has only been recognized recently. Efforts to quantify caregiver burden allow for a more holistic understanding of RGE’s disease burden; such an understanding is relevant when evaluating interventions to diminish RGE. In this review, we identified the methods used to quantify caregiver burden of RGE and summarize the findings.

Methods

We performed a systematic literature review on caregiver and family burden of RGE using PubMed and Scopus, combining MESH and free-range terms. We selected studies that estimated or conveyed the impact of RGE on the family via interviews, and administration of surveys or instruments. We focused on the caregiver and family’s subjective experience and included studies that quantified caregiver associated disutility weights, reports, stress, or emotional outcomes.

Results

After compiling the results of our search, we selected 10 publications (Figure 1). Four studies used the EQ-5D and the VAS to measure caregiver burden (Table 1). Caregiver utility at time of illness varied between 0.61 (caregivers of hospitalized children, Thailand), and 0.88 (caregivers of children enrolled at outpatient clinics, Canada). Caregiver burden was also measured in Spain (2 studies), Italy (3 studies), Belgium, France, Germany, Latvia, Poland, United States, Sweden, Taiwan and Vietnam, via stress scales (2 studies), especially designed questionnaires (2 studies), and interviews (2 studies). Using a questionnaire, RGE was found to disrupt family activities, cause stress and worry on caregivers; a 10-point stress scale revealed high levels of stress among caregivers in other countries. Using different instruments, the impact of RGE was found to increase with the severity of RGE.

Results of the systematic literature review on caregiver burden.

Caregiver utility for caring for patients with Rotavirus Gastroenteritis (RGE) obtained using the EQ-5D and the Visual Analogue Scale (VAS).

Conclusion

RGE in infants was found to significantly disrupt the quality of life of caregivers, and to impact family activities and routine. Methods to quantify caregiver burden vary often without a validated disease-specific instrument which hinders comparison between different countries and incorporating the results in economic models.

Disclosures

Cristina Carias, PhD, Merck (Employee, Shareholder) Tianyan Hu, PhD, Merck (Employee, Shareholder) Ya-Ting Chen, PhD, Merck & Co., Inc. (Employee, Shareholder)
1381. Rotavirus Gastroenteritis among older adults: discussion based on a systematic literature review
Authors: Carias Cristina , Hartwig Susanne , Kanibir M Nabi , Chen Ya-Ting
Published: January 2021

Background

While the burden of Rotavirus Gastroenteritis (RGE) is well recognized in young children, it is less so in older adults. However, older adults are also at high-risk of Acute Gastroenteritis (AGE) severe outcomes. In this review, we thus aimed to comprehensively assess RGE burden and vaccination impact in older individuals.

Methods

We performed a systematic literature review with PubMed and Scopus, from 2000 to 2019, using MESH and free-range terms. We included only studies that reported the incidence, and/or RV vaccination impact, in adults aged 60 and above and using regional specific data-sources.

Results

We analyzed 11 manuscripts for individuals aged 60 and above (Figure 1). Studies spanned Australia, Sweden, Netherlands, Canada (2), Germany (2), UK (2), and the US (2). Yearly inpatient RV incidence varied between 1.6 per 100,000 in Australia for those 65+ (retrospective database analyses, pre-vaccine); and 26 per 100,000 for those 85+ in Canada (modeling estimates for 2006-10, pre-vaccine). The incidence rate ratio for inpatient RGE between the post and pre-vaccine periods for those 65+ was 0.57 [95% CI: 0.10 – 3.15] in Canada, but 2.24 [95%CI: 1.78-2.83] in Australia, which may be due to increased testing for RV in the elderly post-vaccine. Reductions in the post-vaccination burden of RV and AGE among 60+ were reported in the UK (2 studies), and the US (2 studies) via retrospective database analyses In the UK, post-vaccine reductions in AGE health care-utilization were reported in the Emergency Department (21%), and outpatient centers (walk-in centers: 47%; general practice consultations: 36%).

Retrospective database analyses documenting the incident rate ratio (IRR) of Rotavirus Gastroenteritis (RGE) and Acute Gastroenteritis (AGE) in older adults between the pre and post-vaccine period.

Retrospective database analyses documenting the incident rate ratio (IRR) of Rotavirus Gastroenteritis (RGE) and Acute Gastroenteritis (AGE) in older adults between the pre and post-vaccine period.

Conclusion

While the burden of RGE mainly falls on young children, it also affects older adults. Retrospective database analyses reveal that, likely due to indirect vaccination benefits, increases in RV vaccination coverage have had an impact on lowering RGE, and AGE cases and healthcare utilization in older adults, a group at high-risk of severe outcomes for AGE.

Disclosures

Cristina Carias, PhD, Merck (Employee, Shareholder) Susanne Hartwig, n/a, MSD Vaccins (Employee) M.Nabi Kanibir, MD, Merck/MSD (Employee, Shareholder) Ya-Ting Chen, PhD, Merck & Co., Inc. (Employee, Shareholder)
1387. Current practices in the diagnosis and treatment of varicella infections in the United States
Authors: Fergie Jaime , Pawaskar Manjiri D , Veerkani Phani , Samant Salome , Harley Carolyn , MacEwan Joanna , Schwartz Taylor T , Surati Shikha , Conway James H
Published: January 2021

Background

The Advisory Committee on Immunization Practices recommended a 1 dose varicella immunization program in 1996, expanding this to include 2 doses in 2006. As a result, more than 3.5 million cases of varicella, 9,000 hospitalizations, and 100 deaths are prevented annually in the United States. Since varicella infections have become uncommon, the response of health care providers (HCPs) to patients presenting with varicella symptoms may result in misdiagnosis and/ mistreatment. This study investigated the diagnostic and treatment strategies used by HCPs for managing varicella infections in US children.

Methods

An online cross-sectional survey of licensed HCPs was conducted, after an Institution review board approval and HCP consent. 8 clinical vignettes with information on patients with varying varicella symptoms (representing uncomplicated and complicated cases) were presented. For each vignette, HCPs selected a diagnosis and appropriate intervention(s) from pre-determined lists. Descriptive analyses were performed.

Results

A total of 153 HCPs (50 nurses, 103 doctors) completed the survey. Mean age was 44 years, 62% were female, and 82% were licensed after 1995. Varicella infection was correctly diagnosed 79% of the time. HCPs were able to recognize uncomplicated cases of varicella 85% of the time and complicated cases 61% of the time. HCPs recommended the correct intervention 43% of the time for uncomplicated cases and 25% of the time for complicated cases. For example, HCPs recommended antibiotics 17% of the time and/or antivirals 18% of the time (Table 1), of which 25% and 69% (respectively) were not appropriate per the American Academy of Pediatrics guidelines respectively. Antibiotics were incorrectly recommended 6% of the time for uncomplicated cases of varicella.

Table 1. Additional Diagnosis & Treatment Results

Conclusion

Given the low incidence of varicella infections in the US, complicated cases of varicella may be under-recognized or inappropriately treated by some HCPs. Additional training may help HCPs better recognize/ treat cases of varicella. Further, ensuring high rates of varicella vaccination is important to avoid vaccine preventable conditions and to minimize unnecessary exposure to antimicrobial and antiviral therapies.

Disclosures

Jaime Fergie, MD, AstraZeneca (Speaker’s Bureau)Sobi, Inc. (Speaker’s Bureau) Manjiri D. Pawaskar, PhD, Merck & Co., Inc (Employee, Shareholder) Phani Veerkani, MD, DrPH, Merck (Research Grant or Support) Salome Samant, MBBS, MPH, Merck & Co., Inc., Kenilworth, NJ, USA (Employee, Shareholder) Carolyn Harley, PhD, Merck (Consultant) Joanna MacEwan, PhD, PRECISIONheor (Employee) Taylor T. Schwartz, MPH, Merck (Consultant, Grant/Research Support, Scientific Research Study Investigator, Research Grant or Support) Shikha Surati, MPH, Merck & Co., Inc. (Employee, Shareholder)