bluuebunny/crossref_metadata_2025 huggingface dataset:
1190. Nudging Away from Alert Fatigue: A Novel Method for Tracking the Impact of Integrated Clinical Decision Support on Meropenem Order Rates
Authors: Ezran Camille , Mercuro Nicholas J , Rokas Kristina E , Dryer Vince , Rawlings Stephen , Herrle Elizabeth
Published: November 2023

Background

The electronic health record (EHR) has streamlined quality of care and hospital prescribing; however, interruptive alerts and hard restrictions on antibiotic ordering can disrupt clinical workflow, often without significant benefit. This study aimed to determine the impact of permissive restriction on meropenem orders with embedded clinical decision support and prescriber attestation.

Methods

A quality improvement intervention implemented at Maine Medical Center (MMC, a 700-bed academic medical center) was evaluated through a multisite, quasiexperimental study within MaineHealth Hospitals. The intervention consisted of a provider-facing summary of guideline-directed indications for empiric and culture-directed uses of meropenem attached alongside the EHR order, and a required attestation button. To track meropenem order rates for adult patients prior to (Oct – Dec 2022) and after (Jan – Mar 2023) the intervention, the EHR was configured to fire a “silent” Best Practice Advisory behind-the-scenes when a provider opened the meropenem order. Rates of ordering were also monitored at other sites in MaineHealth, where the intervention was not implemented. The primary endpoint was the rate of “back-out” events, defined as a prescriber beginning a meropenem order but not signing it, and the secondary endpoint was the meropenem administration rate within 24 hours of opening an order.

Results

A meropenem order was initiated in 824 unique encounters during the study period; following the intervention at MMC, the back-out rate for orders increased from 20.3% (n =291) to 32.7% (n= 147, p = .01), while there was no significant difference during the same period at institutions where the intervention was not implemented (Table 1). The rate of patients who received meropenem within 24 hours following an order being opened decreased from 90.0% pre-intervention to 74.8% post-intervention (p < 0.01).

Conclusion

This study suggests that simple, non-resource intensive antimicrobial stewardship ‘nudges’ can simultaneously be implemented and monitored through creative EHR design, leading to a reduction in overall completion of meropenem orders and a decrease in inappropriate antibiotic prescribing. Similar interventions can be implemented in all fields of healthcare stewardship.

Disclosures

All Authors: No reported disclosures
1200. Evaluation of Pharmacist-Driven Azithromycin Dose Optimization Protocol for Respiratory Tract Infections as an Antimicrobial Stewardship Initiative
Authors: Kaur Satwinder S , Adams David T , Schrank Casey L
Published: November 2023

Background

Azithromycin is a macrolide antibiotic commonly used empirically to treat atypical pathogens in CAP and acute COPD exacerbations. Due to its longer half-life and high tissues concentrations, a total treatment dose of 1.5 g (given over either 3 or 5 days) provides therapeutic exposure lasting approximately 10 days. Multiple randomized studies demonstrated similar treatment efficacy between 3 days and 5 days of azithromycin. Due to the increased rates of macrolide-resistant Streptococcus pneumoniae strains, shorter courses of azithromycin may decrease the emergence of more bacterial resistance, improve patient compliance, and decrease antibiotic-associated adverse events.

Methods

A retrospective cohort study conducted from March 2022 to March 2023 at Texas Health Harris Methodist Hospital Fort Worth. Pharmacists automatically adjusted azithromycin orders to a duration of 3 days and a dose of 500 mg for CAP and acute COPD exacerbations. Patients were excluded if treatment indications were for prophylaxis, mycobacterial disease, or Legionnaires disease. The primary outcome was azithromycin duration of therapy (DOT) after protocol implementation and secondary outcomes included 30-day all-cause in-hospital mortality and 30-day hospital readmission.

Results

507 patients were included in the final analysis with 267 patients in the pre- and 240 patients in the post-group. After protocol implementation, a statistically significant reduction in mean azithromycin DOT was observed in the post- compared to the pre-group (3 days vs 5 days), p < .0001. No increase in 30-day all-cause in-hospital mortality (2.1% vs. 7.1%, p = .008) or 30-day hospital re-admission rates (5.4% vs. 15.3%, p = .001) were observed in the post- compared to the pre-group.

Conclusion

Based on the results of this study, implementation of a pharmacist-driven azithromycin dose optimization protocol is an effective antimicrobial stewardship initiative that can decrease unnecessary azithromycin DOT. The 3-day duration of high dose azithromycin was not associated with increased rates of mortality or hospital re-admissions compared to longer durations.

Disclosures

All Authors: No reported disclosures
1208. Impact of Selected Antimicrobial Stewardship and Infection Control Strategies in Carbapenem Resistance in a Third Level Public Hospital in Colombía.
Authors: MUÑETON G E R A R D O A , SOLORZANO C A R L O S A , CARDENAS J U L E I M A , CASTRO E L E N A V , MORALES J E S S I C A L
Published: November 2023

Background

Antimicrobial Stewardship (AMS) Programs and Infection prevention and control (IPC) strategies have been shown to effectively reduce antimicrobial resistance. The resources required for the implementation of these programs in low-resource settings could be limited. This study aimed to assess the impact of a few AMS and IPC strategies on carbapenem resistance in a third-level public hospital in Colombia.

Methods

A retrospective before-and-After study was completed. The baseline period consisted of 6 months (January 2021-Jun 2021) and the intervention period consisted of 18 months (July 2021-December 2022) The AMS intervention consisted of the implementation of prospective audits on prescriptions of meropenem, cefepime, and piperacillin-tazobactam, along with educational seminars. The IPC intervention consisted of screening for carbapenemase-producing-Enterobacterales (CPE) through rectal swabs for every patient transferred to the ICU and weekly for all patients in the ICU. A cohorting area with 24 beds was also established to isolate CPE colonized/infected patients

Results

During the intervention period, 886 prospective audits were made. We suspended 208, 111, and 55 prescriptions of Meropenem, piperacillin-tazobactam, and cefepime respectively. The length of therapy was shortened in 239, 290, and 99 prescriptions of Meropenem, piperacillin-tazobactam, and cefepime respectively.

The antimicrobial consumption was lower in the intervention period for meropenem (24,8 DDD/100 patients-days Vs 74.3 DDD/100 patients-days baseline period). Figure 1

The prevalence of positive rectal swabs showed a downward trend during the intervention period. Figure 2. The prevalence of CPE also decreased and was 0,45 during the baseline period and 0,28 during the last semester of the intervention period. Figure 3

The carbapenem resistance K. pneumoniae laboratory-confirmed bloodstream infection rate also decreased during the intervention period, going from 15.4/10.000 patients-days to 1.17/10.000 patient-days. Figure 4

Conclusion

The implementation of selected AMS and IPC strategies in a resource limited third level hospital reduced the prevalence of carbapenemase-producing Enterobacterales and the rate of Carbapenem-resistant K. pneumoniae bloodstream infections.

Disclosures

GERARDO A. MUÑETON, Infectious diseases and Internal Medicine Specialist, PFIZER: Advisor/Consultant
1213. Application of Short Course Criteria for Community-Acquired Pneumonia (CAP) Among Patients Admitted Within a 17-community Hospital Telehealth Antimicrobial Stewardship Program (Tele-ASP)
Authors: Rasmussen Aunalia , May Stephanie Shealy , May Stephanie Shealy , Veillette John J , Vento Todd J , Webb Brandon J
Published: November 2023

Background

A recent randomized controlled trial by Dinh et al. found three days of antibiotics was appropriate for certain community-acquired pneumonia (CAP) patients, but the real-world applicability of this study remains to be evaluated. In February 2022, a telehealth antimicrobial stewardship program (Tele-ASP) intervention was implemented across 17 small community hospitals to identify patients meeting clinical stability criteria used by Dinh et al. for short course therapy (3 days). An alert was implemented to notify the infectious diseases telehealth (Tele-ID) pharmacist of patients on room air for whom an antibiotic was ordered for pneumonia.

Methods

This IRB-approved study aimed to evaluate feasibility and impact of the intervention. Patients with severe or complicated CAP, known immunosuppression, or who were transferred were excluded. The primary outcome was total antibiotic duration. Secondary outcomes included whether the total duration was greater than 5 and 7 days and total IV antibiotic duration. Continuous antibiotic duration endpoints were assessed using Mann Whitney U and Fisher's Exact tests were used for categorical endpoints.

Results

Of 480 patients screened, only 148 (31%) patients met early clinical stability criteria. The primary reason for not meeting criteria was requirement of supplemental oxygen on Day 3 or greater on antibiotics (n=145). This proportion is far lower than previous studies, including that by Dinh et al., which found 60-70% patients met stability criteria. Of the 90 patients included, 27 patients had a Tele-ID review. Patients with an intervention were less likely to receive > 5 days of antibiotics (59% vs 73%) and > 7 days of antibiotics (19% vs. 32%), although these differences were not statistically significant.

Conclusion

This study relied on accuracy of oxygen charting, which may partly explain relatively lower proportion of patients meeting strict clinical stability criteria and likely limits feasibility of a scalable intervention. A pragmatically modified approach for this Tele-ASP intervention (i.e. allowance for no more than 1 unmet criterion) is an important area for further exploration and could improve the feasibility of a scalable telehealth intervention.

Disclosures

All Authors: No reported disclosures
1953. Impact of Baseline Nutritional Status on Tuberculosis Severity in India: a multicenter prospective cohort analysis
Authors: Du Xinyi , Ponnuraja Chinnaiyan , Gupte Nikhil , Sarkar Sonali , Gupta Amita , Christopher Devasahayam J , Kornfeld Hardy , Viswanathan Vijay , Ellner Jerrold , Horsburgh C Robert , Padmapriyadarsini Chandrasekaran , Sinha Pranay
Published: November 2023

Background

India bears a quarter of the global tuberculosis (TB) burden. Previous studies have shown that more than 50% of persons with TB in India are undernourished and that undernutrition is associated with increased risk of unfavorable TB outcomes and mortality. The effect of nutritional status may be explained by its effect on other factors associated with poor outcomes. In this study, we assessed the impact of undernutrition at TB detection on markers of TB severity.

Methods

We analyzed prospectively collected data for persons with TB aged ≥ 18 years from five Regional Prospective Observational Research for Tuberculosis (RePORT) - India sites. We built multivariable regression models to assess relationships between undernutrition at TB detection (baseline body mass index (BMI), kg/m2) and markers of severity. We used logistic regression for lung cavitation and high-grade sputum smear positivity (defined as smear grade ≥ 2+), and linear regression for percentage of lung affected and time to positivity of Mycobacteria Growth Indicator Tube (MGIT; weeks). The models included age, sex, symptom duration a priori and all variables with p< 0.2 in univariate analysis.

Results

We had baseline BMI on 2898 persons with TB and 1132 (39.06%) of participants had moderate-severe undernutrition (BMI< 17kg/m2) at treatment initiation. After adjusting for age, sex, symptom duration, income, HIV status, diabetes, smoking, and alcohol misuse (defined as having an AUDIT-c score ≥ 3 for females and ≥ 4 for males), baseline BMI< 17kg/m2 was associated with increased odds of lung cavitation (aOR 1.67, 95% confidence interval [CI]: 1.32, 2.10), increased odds of high bacillary sputum grade (aOR 1.33, 95%CI: 1.12, 1.60), an average 7.13% (95%CI: 5.11, 9.16) more lung affected, and an average 0.045 (95%CI: -0.024, 0.11) longer time to liquid culture positivity.

Conclusion

To our knowledge, this is the largest prospective cohort study evaluating the association between undernutrition and markers of TB severity. While our analysis cannot account for the bidirectional relationship between TB disease and nutritional status, it does highlight the impact of systematic nutritional assessment in persons with TB.

Disclosures

Devasahayam J. Christopher, DNB, FRCP, Abbot, India: Honoraria|Astra Zeneca: Honoraria|Cipla, India: Honoraria|JB Chemicals: Honoraria|Lupin pharmaceuticals: Honoraria|Pfizer: Honoraria|Zydus Cadila: Honoraria
1235. A Retrospective Review of Antimicrobial Stewardship Audit and Feedback: Assessing Acceptance of Stewardship Recommendations During the COVID-19 Pandemic
Authors: Colaluca Melissa A , Korson Michelle , Wiskirchen Dora E , Abrantes-Figueiredo Jessica
Published: November 2023

Background

Antimicrobial stewardship is an underutilized strategy to mitigate the impact of antimicrobial resistance. It is well documented that many Antimicrobial Stewardship Programs (ASPs) were tasked with assisting healthcare teams in navigating the COVID-19 pandemic, leaving less time/fewer resources for day-to-day ASP activities. The aim of this study was to evaluate the acceptance of stewardship recommendations during a season when the ASP had less time to perform regular educational activities and handshake stewardship.

Methods

A retrospective study of patients receiving antimicrobial therapy at Saint Francis Hospital during 12/30/2020-10/01/2022, for which audit and feedback by the ASP was conducted. A well-established ASP existed prior to the pandemic. Independent variables included the reason for intervention, type of infection by organ system, and type of intervention. Interventions included recommendations to stop antibiotics, de-escalation, duration of therapy, ID consultation, or change the route of administration. The primary outcome was the audit and feedback acceptance rate, and the secondary outcome was whether the intervention resulted in infectious disease consultation.

Results

297 patients underwent audit and feedback. Interventions most accepted by providers included changing the route of administration (100%) and consulting ID formally (92%). Adjusting the duration of therapy was the least accepted intervention at 78%. Regardless of intervention, 33% of providers requested a formal ID consult. The number of interventions varied sporadically, coinciding with periods of decreased availability by the ASP team and during peak waves of the COVID-19 pandemic.

Conclusion

Our ASP team, despite decreased resources while battling an ongoing pandemic, were still able to perform audit and feedback to providers with a good acceptance rate of recommendations, consistent with current literature. Having not only an existing but robust ASP prior to the pandemic, allowed continued success with ASP intervention acceptance rates, despite less dedicated time for typical ASP activities during the pandemic. Fostering good relationships between providers and ASP teams, as well as continued support and funding from hospital leadership, are vital to ongoing success.

Disclosures

All Authors: No reported disclosures
1243. Acceptable susceptibility thresholds reported in hospital antibiograms for Gram-negative rod infections: a survey and contingent valuation study of infectious diseases providers
Authors: Hasegawa Shinya , Perencevich Eli N , Dukes Kimberly , Goto Michihiko
Published: November 2023

Background

Clinical guidelines recommend an antibiogram as a key component when making empiric therapy decisions. However, little is known about how clinicians utilize antibiograms. We aimed to assess the interpretation thresholds of hospital antibiograms among infectious diseases (ID) providers when making empiric therapy decisions for Gram-negative rods (GNRs) infections.Figure 1.Relationship between randomly generated percentages on antibiograms in each scenario and the distribution of participants willing to accept the threshold.Abbreviations: GNR-BSI, Gram-negative rod bloodstream infection; ICU, intensive care unit; UTI, urinary tract infection.

Methods

We conducted an email-based survey of ID providers practicing at Veterans Health Administration (VHA) facilities. We included four scenarios: i) a patient with urinary tract infection (UTI) in an outpatient setting, ii) a patient with UTI in an inpatient setting, iii) a patient with GNR bloodstream infection (GNR-BSI) in a non-intensive care unit (ICU) setting, and iv) a patient with GNR-BSI in an ICU setting. Each scenario randomly assigned antibiogram percentages and asked providers if they would feel comfortable selecting a hypothetical empiric therapy agent with the given value. Contingent valuation analyses were done by logistic regression models to evaluate the relationship between the percentages offered to providers and their willingness to use offered agents.

Results

In the preliminary analysis, 112 of 599 providers (18.7%) responded and 104 provided effective responses. Hospital antibiograms are generally used infrequently, and only 30.8% of providers indicated that they use antibiograms more than once a month. The estimated median interpretation thresholds, meaning half of the ID providers would prescribe the hypothetical antibiotic in each case with the values given on antibiograms, were significantly higher for patients with more severe illnesses (85.6% [95% confidence interval [CI] 83.1-88.1] for an inpatient with UTI vs 74.1% [95%CI 69.7-77.6] for an outpatient with UTI; 86.0% [95%CI 83.1-89.4] for a patient with GNR-BSI in ICU vs 77.9% [95%CI 74.2-81.2] for a patient with GNR-BSI in non-ICU) (Figure 1).

Conclusion

This study demonstrated that ID providers rarely utilized antibiograms and the median thresholds for hospital antibiograms influencing empiric antibiotic selection ranged from 74-86%, depending on the severity but not by the type of infection (UTI vs. BSI). Further analyses after we receive more responses will be completed.

Disclosures

Michihiko Goto, MD MSCI, Merck & Co.: Grant/Research Support
1249. Stealth Stewardship: Compliance with Antimicrobial Restriction Processes at an Academic Medical Center
Authors: Kim Jihye , Greenfield Adam , Deja Erin N , Lee Kimberly B , Rittmann Barry , Bearman Gonzalo , Sastry Sangeeta
Published: November 2023

Background

The 2023 Joint Commission Elements of Performance (EPs) for Antibiotic Stewardship (ASP) document includes a new requirement to implement preauthorization for antimicrobial use in hospitals. At VCUHS, a preauthorization process for restricted antimicrobials has existed since 2000. Prescribers must obtain formal approval for dose and duration of antimicrobials from an ASP or Infectious Diseases (ID) team member to allow inpatient pharmacy to dispense the drug. We employed a stealth stewardship strategy to assess compliance to the antimicrobial preauthorization process and identified opportunities for improvement.

Methods

Pharmacy orders for adult hospitalized patients who received at least one dose of select restricted antimicrobials between August 1, 2022 and October 31, 2022 were reviewed for a documented formal approval in the electronic medical record (EMR). Orders were excluded if not subject to antimicrobial restriction; placed at VCUHS satellite campuses or during de-restricted overnight hours. Stealth use of antimicrobials was defined as the use of a restricted agent without a formal ASP or ID approval.

Results

A total of 179 restricted antimicrobial orders were reviewed during the study period. Of those, 43 (24%) lacked documented approval in the EMR. Of these orders, 20/43 (46.5%) were for patients seen by the ID service, 16/43 (37.2%) were restricted agents continued beyond the initial approval duration, 5/43 (11.6%) were prophylactic antifungal agents approved during prior admissions, and 2/43 (4.7%) were home antimicrobial agents (Fig 1).

Conclusion

With a stealth stewardship review of restricted antimicrobials, we identified gaps in our stewardship process. Surprisingly, 46% of undocumented restricted antimicrobial use was under the guidance of the ID service. High staff turnover rates, frequent pharmacy and prescriber hand-offs, and lack of persistent education on the restriction process are probable drivers of noncompliance. These breaches in our approval process highlight opportunities for heightened education and feedback. We encourage other institutions to consider similar strategies to evaluate their established processes and ensure compliance with the current Joint Commission requirements.

Disclosures

All Authors: No reported disclosures
1253. Optimization of empiric gram-negative infections with the combination antibiogram
Authors: Leung Anthony K , Harrington Susan , Dumford Donald , Shrestha Kasturi , Mistry Bhavin , wong Ken
Published: November 2023

Background

Anti-pseudomonal beta-lactam drugs such as aztreonam (AZR), cefepime (CEF), piperacillin-tazobactam (P/T), meropenem (MER) are drugs used for empiric gram-negative (GN) infections. They are used with other drugs as empiric combination therapy (CT) for patients with sepsis. The antibiogram is used to provide data for empiric therapy and gauge susceptibility pattern shifts over time. Combining different classes of drugs might enhance the susceptibility to various pathogens. This project assessed which empiric combination of drugs will yield optimal coverage for various GN pathogens from different sources.

Methods

In 2022 antimicrobial susceptibility data from 8288 isolates from blood, respiratory, wound and urine sources were collected and analyzed. Percent susceptibility was calculated for 11 gram-negative species with >30 isolates. Susceptibility testing was done by BD Phoenix™ automated identification and susceptibility testing system. A threshold of >90% susceptibility was used to indicate optimal coverage for the antimicrobial agents. CT is calculated as the % susceptible to either of two antibiotics.

Results

In respiratory sources AZR, CEF and P/T were the lowest at 73%, 83% and 77% susceptible. MER had the best overall coverage for all specimen types. Adding either an aminoglycoside (AG) or fluoroquinolone (FQ) increased susceptibility in all sources. AGs had a slightly better coverage than FQs. For blood isolates > 90% susceptibility was attained for single antibiotics without combination. CT was often required to achieve optimal coverage for respiratory sources, specifically for Pseudomonas, Enterobacter, E coli, Klebsiella and Proteus species.Figure 1.Combination antibiogram for beta-lactam agents for gram-negative respiratory isolates as monotherapy or in combination with ciprofloxacin, gentamicin, or tobramycin.*All gram-negative isolates included Serratia and Providencia species that were not included in the subgroups.

Conclusion

Using > 90% susceptibility as cut-off, monotherapy AZR and P/T are suboptimal for empiric coverage for certain GN respiratory infections. Blood specimens may not require CT. Adding either AGs or FQs enhanced susceptibility coverage to all tested pathogens but not uniformly. AGs enhancement was slightly better than FQs. Respiratory infections with Pseudomonas, Enterobacter cloacae, E coli, Proteus and Klebsiella species all showed enhanced coverage with CT especially for P/T and AZR. Every hospital should create a combination antibiogram to gain insight into whether empiric coverage with CT is needed.

Disclosures

All Authors: No reported disclosures
1269. Prospective Evaluation of a Machine Learning Model that Guides Indication for Antibiotics in Lower Respiratory Tract Infections
Authors: Tang Sarah , Chlebicki Maciej Piotr , Chung Shimin Jasmine , Chin De Zhi , Chang Daniel , Kwa Andrea
Published: November 2023

Background

Over-prescribing of antibiotics for suspected acute bacterial lower respiratory tract infections (abLRTI) is prevalent. A classification model that can identify instances when antibiotics should be initiated or withheld was previously developed with promising results (80% accuracy). This, however, was based on a retrospective dataset. We conducted a prospective evaluation of this model in the hospital antimicrobial stewardship unit (ASU) to validate its performance and compare its effectiveness against current ASU strategies.

Methods

Inpatients audited by the hospital ASU between 10 January and 23 March 2023 (twice weekly) were enrolled into this study. Relevant patient information (e.g., clinical notes, radiology reports, vital signs) was extracted from our hospital’s electronic data repository for model inference. The presence of abLRTI as determined by the model, the patient’s primary care team and ASU review were compared. Cases that saw differing opinions between any of the three operators were subsequently reviewed by an independent Infectious Diseases physician, who provided the ground truth for that case.

Results

A total of 851 cases were included, of which 235 (27.6%) had true abLRTI. The model was most accurate in determining the presence versus absence of abLRTI (734/851, 86.3%), while ASU review and primary care team were correct in only 698 (82.0%) and 677 (79.6%) cases respectively. Primary care team demonstrated greatest sensitivity in the suspicion for abLRTI (91.9%); unfortunately, it also over-diagnosed abLRTI in 155 (42%) patients. Among these false-positive cases, the model rightly rejected presence of abLRTI in 126 (81.3%) patients whereas only 66 (64.1%) of them were identified by ASU. ASU outperformed the model in having a lower false-negative rate when abLRTI is suspected (17.3% vs. 22.0%).

Conclusion

The model displayed consistent performance in a prospective cohort. Findings support its value in guiding decisions on antibiotic initiation for suspected abLRTI. Deploying this model to augment current ASU capabilities should be strongly considered.

Disclosures

All Authors: No reported disclosures
1291. Malignant Otitis Externa With Facial Nerve Paralysis : Comparative Analysis
Authors: Hammami Fatma , Koubaa Makram , Rekik Khaoula , Chakroun Amal , Smaoui Fatma , Marrakchi Chakib , Jemaa Mounir Ben
Published: November 2023

Background

Malignant otitis externa (MOE) is a life-threatening invasive infection of the external auditory canal with varying outcomes. Facial nerve paralysis (FP) is usually a sign of progression of the disease. We aimed to compare the characteristics and prognosis of patients with MOE with and without FP.

Methods

We conducted a retrospective study including all patients hospitalized for MOE in the infectious diseases department between 2000 and 2022.

Results

We encountered 114 cases among which 17 had a FP (14.9%). Median C-reactive protein levels (36[30-81] mg/L vs 14[7-37] mg/L ; p=0.002) and white blood cells count (9600[7800-11300] /mm3 vs 8270[7037-10070] /mm3 ; p=0.04) were significantly higher among patients with FP. Otalgia (94.1% vs 87.6% ; p=0.688), otorrhea (64.7% vs 71.1% ; p=0.593) and cephalalgia (47.1% vs 49.5% ; p=0.854) were the revealing symptoms among patients with or without FP, with no significant difference. Otoscopic examination revealed the presence of polyp in the external auditory canal more frequently among patients with FP (47.1% vs 21.6% ; p=0.036). Bone osteolysis was significantly more frequent among patients with FP (88.2% vs 54.2% ; p=0.008). Fungal species were isolated more frequently among cases with FP (70.6% vs 40.2% ; p=0.020). Complications were significantly more frequent among patients with FP (64.7% vs 26.8% ; p=0.002). Favorable evolution of the disease was more frequent among patients without FP (87.2% vs 62.5% ; p=0.024).

Conclusion

MOE with FP, caused more often by fungal species, were characterised by higher inflammatory markers, the presence of polyp in otoscopic examination and bone osteolysis on imaging results. FP worsened the prognosis of the disease. Prompt and aggressive diagnosis and management are crucial.

Disclosures

All Authors: No reported disclosures
1303. Pelvic Acute Hematogenous Osteomyelitis in Children, from 2012-2020
Authors: Clemente Adriana Sarmiento , Chase McNeil J , Hulten Kristina G , Vallejo Jesus G , Kaplan Sheldon L
Published: November 2023

Background

Pelvic osteomyelitis has been reported to account for 1-11% of acute hematogenous osteomyelitis (AHO) cases in children. Higher complication rates and need for longer antibiotic courses have been suggested by experts, but recent data is lacking. In our retrospective study from 2012-2020, pelvis and tibia were the most frequent AHO sites (24.6% of cases each). We describe the clinical course of children admitted to Texas Children’s Hospital (TCH) with pelvic AHO.

Methods

A retrospective review of patients with diagnosis of AHO admitted to TCH from Jan. 2012 - Dec. 2020 was conducted. Patients 6 mo-< 19 years-old and with ≤ 14 days of symptoms on admission were eligible. Patients with sickle cell disease or those immunocompromised were excluded. Wilcoxon rank sum test for continuous variables and Fisher’s exact for categorical variables were performed using STATA 17.

Results

103 cases of pelvic AHO were compared to 315 cases of non-pelvic AHO (Table 1). The pelvis areas involved were reviewed (Fig. 1). Fever was present in 91 cases of pelvis AHO (88.4%), localized pain in 78 (75.7%) and refusal to bear weight in 64 (62.1%). All patients with pelvic AHO had an abnormal C reactive protein ( > 0.5 mg/dl).

Patients with pelvic AHO had overall similar microbiology (Fig. 2), length of stay and complication rates as non-pelvic AHO. Pelvic AHO patients had pyomyositis more often (29.1 vs 9.2%) and bone abscess less often (22.3 vs 46.3%). Need for bone debridement or bone abscess drainage was less common (17.5 vs 51.1%), but muscle abscess drainage (16.5 vs 5.1%) and percutaneous bone biopsy (22.3 vs 13.7%) were more common in pelvic AHO. 22 cases of pelvic AHO had bone biopsy only, leading to identification of etiology in 27% of them with no complications.

Patients were treated with antibiotics for a similar time (median 41 vs. 38 days). 21 patients with pelvic AHO (20.4%) were treated for ≤ 30 days with no complications (2 were lost to follow up).

Figure 1.

Percentage of each area of pelvic bone involved in patients with pelvic AHO. Patients may have more than one area involved.

Figure 2.

Causative organism recovery and etiology of pediatric cases with pelvic and non-pelvic acute hematogenous osteomyelitis, Texas Children’s Hospital 2012-2022.

Conclusion

Pelvic AHO in children may be more frequent than previously reported but is not associated with more chronic complications. MRI use can aid in the prompt identification of associated pyomyositis and timely intervention. A conservative approach of bone biopsy in cases with a small bone abscess and no pyomyositis should be considered. 4 weeks of therapy may be sufficient.

Disclosures

J. Chase McNeil, MD, Allergan: Grant/Research Support|Nabriva Therapeutics: Grant/Research Support Kristina G. Hulten, PhD, Pfizer: Grant/Research Support Sheldon L. Kaplan, MD, MeMed: Grant/Research Support|Pfizer: Grant/Research Support|Pfizer: Honoraria
1311. Mycoplasma and Ureaplasma Septic Arthritis - A Diagnostic Challenge
Authors: Murugan Lalithaa Thirunavukarasu , Cober Eric , Johnson Lucileia
Published: November 2023

Background

Mycoplasma and ureaplasma septic arthritis (MUSA) is difficult to diagnose as these usually require special media or polymerase chain reaction (PCR) to identify. Empiric antibiotics for septic arthritis do not cover these organisms, causing treatment delays. We aimed to study the characteristics and outcomes of patients with MUSA.

Methods

This is a retrospective review of patients (pts) with MUSA admitted to Cleveland Clinic from January 2005 to June 2022. We included pts, 18 years or older, with culture or PCR positive for mycoplasma or ureaplasma from joint tissue or synovial fluid (SF). 7 pts met inclusion criteria.

Results

Median age at diagnosis was 29 years (range 23 - 59). 4/7 pts were male. All had one or more underlying immunocompromising condition and received immunosuppressants within a year prior to diagnosis, 4/7 received rituximab. Immunoglobulin G levels were checked in 5/7 pts within a month around diagnosis, and 3/5 had a level below 500 mg/dl (reference range 717 - 1411).

It took a median of 54 days (range 3 - 402) from initial encounter concerning septic arthritis to diagnosis of MUSA. 5/7 had monoarticular MUSA. 4/7 had native joint arthritis and 3 had periprosthetic joint infection.

SF study closest to diagnosis had a median total nucleated cells of 126,000/µL (range 59 – 204,498), with median neutrophil of 86% (range 62 - 98). Diagnosis was made by culture and PCR in 5 and 2 pts, respectively. Median C- reactive protein around diagnosis was 10.5 mg/dl (range 1.5 - 29.7).

Of the 7 pts, 6 required surgical intervention, with 3 requiring multiple surgeries. Gross purulence was a hallmark intra-operative finding in all patients. 1 out of 7 pts was on indefinite doxycycline suppression. Another one died of advanced AIDS after 2 days of MUSA treatment. Remaining 5/7 received antibiotics for a median of 108 days (range 61 – 1027), of which 3 received dual antibiotics. Excluding the patient who died of AIDS, the remaining recovered completely without relapse during a minimum 4-year follow up.

Conclusion

To our knowledge, this is the largest case series of MUSA. All affected patients were immunocompromised, highlighting the need for high index of clinical suspicion in this population to avoid diagnostic delays. Although challenging to diagnose, it appears that MUSA can be effectively treated.

Disclosures

All Authors: No reported disclosures
1315. Clinical, Radiological and Serologic Characteristics of Patients with Subarachnoid Neurocysticercosis: A Large Series from a Single Center in New York City
Authors: Berto Cesar G , Sacchi Robert , Levitt Alexander , O’Connell Elise , Coyle Christina
Published: November 2023

Background

Subarachnoid neurocysticercosis (SANCC) is the most severe and difficult-to-treat form of neurocysticercosis (NCC).

Methods

We describe the clinical, radiologic, and serologic characteristics of the largest series of patients with SANCC in a non-endemic area by reviewing the medical records of patients seen at Jacobi Medical Center in New York.

Results

From 313 cases of NCC, 103 patients (32.9%) had subarachnoid involvement. Most individuals were male (65.1%) and born in Mexico (37.9%); the mean age was 41.4 years. Thirty-seven patients had only subarachnoid involvement, 50 patients had both parenchymal and SANCC, 5 patients had both intraventricular and SANCC, and 11 patients had all three spaces involved. Seventy-one patients (68.9%) presented with headaches. Of these, 35 patients had intracranial hypertension, and 27 required shunt placement. Thirty patients (29.1%) presented with seizures, most of whom had concomitant parenchymal disease. Fourteen patients (13.6%) presented as an ischemic event, 12 patients (11.7%) had symptoms due to spinal disease, and 8 patients (7.8%) had aseptic meningitis. Screening for spinal disease was performed on 61 patients. Of these, 14 patients (23.0%) had asymptomatic spinal involvement. Delay in diagnosis was found in 48 patients (49.0%) with a median of 12 months; chronic headache was the most common missed symptom (48.2%). Calcified SANCC was found in 37 patients (35.9%). Of these, 18 patients (18.4%) did not receive previous antiparasitic. Based on both CT scans and MRIs, 14 of these patients were categorized as completely calcified, and 23 patients were partially calcified with a cystic component seen on MR T2 images. The cysticercosis antigen in serum and CSF were negative in all cases of completely calcified and only in one partially calcified SANCC.

Conclusion

This is the largest series of SANCC reported from a single center in the US and highlights the clinical spectrum. Our data also shows an important under-recognition of this severe form by the clinician and reports that calcified SANCC is common and can occur before and after treatment.

Disclosures

All Authors: No reported disclosures
1330. Characteristics and Outcomes of External Ventricular Drain Infections
Authors: Tran Lucy B , Converse Curtis , Costales-Cantrell Jessica
Published: November 2023

Background

External ventricular drain (EVD)-related ventriculitis is a serious complication associated with poor patient outcomes. We aim to: (1) characterize patient-level factors and outcomes of individuals with EVD-related ventriculitis and (2) identify differences by type of infection and indication of EVD-placement.

Methods

This study is a single center, case series of adults hospitalized with a diagnosis of EVD-related ventriculitis between January 2018 to February 2023. EVD-related ventriculitis was defined as having a positive cerebrospinal fluid culture from an EVD consistent with CDC/NHSN criteria for ventriculitis. Several covariates were extracted from patient charts to characterize patient outcomes. Further stratification by type of infection (gram-positive versus gram-negative ventriculitis) and indication (traumatic versus non-traumatic EVD placement) were performed to identify any differences in characteristics between the two groups.

Results

Twenty-two patients were identified in the study. The majority of patients were infected with gram-positive bacteria (54.5%) rather than gram-negative bacteria (41%) with 1 case of fungus. The most common indication for EVD placement was trauma (59%) and most were placed at bedside (91%) rather than an operating room (9%). The mean length of stay (LOS) was 42.14 days. (Table 1)

There was a statistically significant difference in the CSF to serum glucose ratio between gram-negative and gram-positive infections with gram negative ventriculitis having a lower ratio compared to patients with gram positive ventriculitis (0.23 vs 0.59, p=0.0005). However, LOS, interval from catheterization to infection, and other CSF parameters were similar between the two groups as well as those whose EVDs were placed in the setting of traumatic vs non-traumatic settings. (Table 2 and 3)Table 1.Demographics and characteristics of 22 patients with EVD-associated infectionsTable 2.Characteristics stratified by bacterial organism type

Characteristics stratified by trauma vs non-trauma patients

Conclusion

Patients with EVD-related ventriculitis had double the LOS compared to neurosurgical patients without EVD-related ventriculitis reported in the literature. Patients with gram-negative ventriculitis had a lower CSF to serum glucose ratio than those with gram-positive ventriculitis. Otherwise, patient characteristics and outcomes were similar when stratified by type of infection and indication.

Disclosures

All Authors: No reported disclosures
1343. Drug Education Needs of HCPs and Patients During the COVID-19 Pandemic Based on Over 60,000 Unsolicited Medical Information Requests Globally Over 3 Years (2020-2022)
Authors: Sandhu Sonia K , Chen Linda
Published: November 2023

Background

The COVID-19 pandemic has resulted in 600 million cases and 6 million deaths globally since December 2019. Medical Information (MI) departments are critical during public health emergencies, providing factual, balanced and non-promotional information to healthcare providers (HCPs) and patients on new treatments, in compliance with industry codes of conduct.

Methods

Unsolicited MI requests for COVID-19 treatment from Jan 2020 to Dec 2022 were analyzed to show the customer journey and evolving needs for drug education. Data gathering and metric analysis were collected from MI databases with interaction dates, countries, contact channels, and responses.

Results

MI received 60,000+ unsolicited requests globally from Jan 2020 to Dec 2022, including 4,400 from patients. Pharmacists (60%) and physicians (15%) were the primary HCPs who contacted MI. Japan and US had the highest number of HCP questions. Changes in HCP questions over time reflected external events such as regulatory approvals and guideline updates, with initial questions related to medication access and clinical trials in 2020, transitioning to medication dosing and preparation in 2021, and new interests emerging in special populations including renal impairment, pediatrics, and pregnancy in 2022. These results suggest that HCPs used MI to help make clinical decisions about which medications are right for their patients.

Patients preferred to contact MI by phone (71%), followed by email (25%) and digital channels (4%). Most patient questions came from US, Mexico, and India. Patients were interested in safety, drug interactions, ingredients, and mechanism of action. Nonclinical topics included drug availability, cost, clinical trial enrollment, and patient assistance programs. Increased patient questions were observed during changes in the medical landscape due to external events (label changes, data updates, and new variants).

Conclusion

Analyzing MI requests is a valuable tool for understanding and meeting the evolving customer needs for drug education. MI insights provide valuable information that informs targeted communications, data-generation priorities to address unmet needs, and educational opportunities that impact clinical decision making and lead to improved patient outcomes.

Disclosures

All Authors: No reported disclosures
1358. Persistence of Omicron-Related Long COVID: Examining Prevalence and Impact at 12 Months Post-Acute Infection
Authors: Kim Yoonjung , Kim Shin-Woo , Chang Hyun-Ha , Bae Sohyun
Published: November 2023

Background

As the COVID-19 pandemic continues, there is a growing interest in the long-term effects that follow COVID-19 infection, commonly known as long COVID. However, there is limited research on the long-term effects of the Omicron variant. Therefore, this prospective cohort study aimed to investigate the clinical characteristics of long COVID symptoms related to Omicron infection 12 months after the initial acute infection.

Methods

The study included 94 adult patients diagnosed with COVID-19 between February 1, 2022, and March 2, 2022. Participants were scheduled to visit the study hospital four times, at 3, 6, 9, and 12 months after the acute COVID-19 infection, in order to assess their symptoms, quality of life, and mental health. The study investigated the clinical characteristics of the patients, self-reported long COVID symptoms, and measured quality of life using the EuroQol 5-dimension 5-level (EQ-5D-5L) index.

Results

Out of the 94 respondents, 80 (85.1%) completed the study visits. Among them, 63 (78.8%) were female, and the median age was 36.0 [27.5; 48.5]. Long COVID symptoms still affected 42 (52.5%) patients 12 months after the acute infection. Four (5.0%) patients were diagnosed with new diseases following their COVID-19 infection. The most commonly reported long COVID symptoms after 12 months were fatigue, concentration difficulties, and amnesia (Figure 1). Insomnia and depression showed a gradual improvement in symptoms over time (Figure 2). Although the EQ-5D-5L index for the anxiety/depression dimension improved over time, it still affected 15.0% of the respondents (Figure 3).Figure 1.Distribution of 40 symptoms or signs at 12 months after acute COVID-19 infectionFigure 2.Prevalence difference of long COVID over time: acute COVID-19 period, 3, 6, 9, and 12 months from acute COVID-19 infectionFigure 3.Assessment of quality of life (EQ-5D) at 3, 6, 9 and 12 months after acute COVID-19 infection

Conclusion

This study highlights that neuropsychological symptoms may persist for a long time, even after Omicron variant infection. The study suggests that these symptoms can continue to be problematic, despite changes in the virus variant.

Disclosures

All Authors: No reported disclosures
1387. Vaccination against respiratory pathogens during pretravel consultations at US Global TravEpiNet Sites: interventions and missed opportunities.
Authors: Kakoullis Loukas , Rao Sowmya R , Ryan Edward T , LaRocque Regina C , Chen Lin H
Published: November 2023

Background

We sought to evaluate the contribution of Global TravEpiNet (GTEN) sites in providing influenza and pneumococcal vaccinations during pretravel visits.

Methods

We analyzed prospectively-collected data from 31 GTEN sites between 07/01/2012 -06/31/2022 and included demographics, travel-related characteristics and vaccines administered at the visit. Vaccine eligibility was based on CDC recommendations. Influenza seasonality at the destination was determined based on WHO data1. We conducted descriptive analyses on vaccinations and reasons for non-administration (SAS v9.4; Cary, NC).

Results

The 10-year study period included 116,865 pretravel visits during which clinics administered 1,732 pneumococcal and 15,658 influenza vaccines (Table 1) and referred an additional 3,588 patients to their PCPs for pneumococcal and 6,955 for influenza vaccination.

Of travelers eligible for pneumococcal vaccination, 49.9% were not recognized as having indications for vaccination. In the case of influenza, the vaccine was not offered to 14.3% of eligible travelers due to unavailability (6.9%) or because the provider did not consider it to be indicated based on the itinerary (7.4%).

Among 66,056 travelers with an itinerary falling within an area with active influenza transmission, the vaccine was unavailable for 10% and not considered indicated in 9.5% (Figure 1). These issues occurred mostly during the summer months in the USA. Specifically, 89.8% of travelers for whom there was no available vaccine, and 83.4% of travelers not recognized as eligible for the vaccine, were traveling between April and September.

Conclusion

GTEN clinics provide routine vaccinations against respiratory pathogens, but some missed opportunities are identified. GTEN providers often referred patients to their PCPs for pneumococcal vaccination, perhaps reflecting issues of insurance coverage. The influenza vaccine expiration dates lead to lack of the vaccine for almost 3 months, during summer in the USA. Finally, persons traveling between April and September or to areas with year round transmission may not be recognized to have potential influenza exposure, despite traveling to destinations with active influenza transmission.

References:

1. WHO Global Influenza Programme. https://www.who.int/tools/flunet

Disclosures

Lin H. Chen, MD, Merck: Honoraria|Sanofi: Honoraria|Shoreland Inc: Advisor/Consultant|Valneva: Advisor/Consultant