bluuebunny/crossref_metadata_2025 huggingface dataset:
776. The prevalence of HIV among hospitalized persons with acute febrile illness in rural Uganda, August 2019-June 2020
Authors: Blair Paul W , Kobba Kenneth , Robinson Matthew , Candia Emmanuel , Aniku Gilbert , Matovu Alphonsus , Kakooza Francis , Walwema Richard , Lamorde Mohammed , Manabe Yukari C
Published: January 2021

Background

In Uganda, in the early PEPFAR era, HIV coinfections were responsible for most hospitalizations with febrile illness (as high as 85% in 2006). Currently, national guidelines recommend universal antiretroviral therapy ideally before the development of AIDS. We evaluated the prevalence of HIV among patients admitted to two regional referral hospitals with febrile illness in the era of ‘Treat All.’

Methods

Participants admitted to two regional referral hospitals in Uganda were enrolled at emergency departments or medical wards. Participants uniformly received blood cultures, malaria (rapid diagnostic test), and tuberculosis (Xpert MTB/RIF Ultra), hepatitis A IgM, hepatitis B sAg, and HIV fourth generation testing were performed. Among participants with HIV, cryptococcal antigen testing and urine lipoarabinomannan (LAM) were performed.

Results

From August 2019-June 2020, 95 participants (58% female) with an average age of 36.2 (SD 14.1) years, presented from 11 districts in Uganda. Participants presented at facilities 4.9 days (SD: 2.5) after onset of symptoms. Additionally, 16.1% of participants had a qSOFA (quick Sepsis Related Organ Failure Assessment) severity score of 2 or greater. By 28 days, 11.0% (n=7) died and 10.8% were lost to follow-up. On admission, 25.3% (n=24) of participants had a known history of HIV, the majority (87.5%) were on ART on hospital presentation. Of the 9.5% (n=9) who were newly diagnosed with HIV during the admission 6 were started on ART during hospitalization or within a month after hospitalization. Microbiologic and rapid diagnostic test results included positive results for tuberculosis (2.1%, 2/95 PCR; 3/16 urine LAM), malaria (29.5%, 28/95), cryptococcal antigen positive (12.5%; 2/15), hepatitis A (1.1%, 1/95), and hepatitis B (5.3%, 5/95). Blood cultures were positive in 11.1% of patients (10/90) with S. pneumoniae being most common isolate (N=4).

Conclusion

In the universal ART era, the proportion of hospitalized febrile patients with HIV has decreased. Overall, 10% have newly diagnosed infection emphasizing the importance of continuing to test all hospitalized febrile patients. Diagnostic evaluations are needed to assess the burden of other causes of febrile illness in order to reprioritize potential differential diagnoses.

Disclosures

All Authors: No reported disclosures
777. Travel Destination, Demographics, and Underlying Medical Conditions Among Travelers Seeking Yellow Fever Vaccination at a Large Academic Medical Center in the U.S
Authors: Bandali Mehdi , Than Kimlien , Schultz Jonathan , McGregor Donna V , Archuleta Solana , Chadalawada Sindhu , Mundo William , Chastain Daniel B , Franco-Paredes Carlos , Reno Elaine , Henao-Martinez Andres
Published: January 2021

Background

Yellow fever (YF) vaccine has the potential to cause viscerotropic and neurotropic disease in at-risk individuals. Screening patients is necessary to prevent vaccine-related life-threatening complications. We lack data on the clinical features of patients seeking YF vaccination. We aim to describe the characteristics of a cohort of patients receiving the YF vaccine before travel.

Methods

A retrospective analysis of 964 patients receiving the YF vaccine (Stamaril®) from Oct 2016 to Jul 2019 was performed at the University of Colorado Hospital in the United States. Percentages, means, and standard deviations were calculated. A multivariate logistic regression model was built to evaluate the association between receiving YF vaccination less than 10 days before departure and visiting friends and relatives (VFR).

Results

The average age of patients was 39 ± 18 years with a range of 9 months to 83 years. Patients who were 60 years of age and older represented 17%. Women consisted of 52%, and most of the patients were Caucasians (64%). Patients reported traveling to Africa (57%) or South America (40%). The primary destination for patients overall was Kenya (19%), Uganda (11%), and Tanzania (11%) in Africa; and Peru (14%) and Brazil (13%) in South America. The most common reasons for travel included leisure (44%), VFR (18%), and mission trips (10%). Comorbidities included a history of hematologic disorders (4%), HIV infection (2%), and diabetes mellitus (3%). The average duration between vaccine administration and travel was 43 days. Those visiting friends and relatives were 2 times more likely to receive the YF vaccination less than 10 days before departure.

Table 1. A cohort of patients receiving the Yellow Fever vaccine at the University of Colorado Hospital.

Figure 1. Heat map of destinations among patients receiving the YF vaccine.

Figure 2. Reasons for travel among patients receiving the YF vaccine (n=964).

Conclusion

Identifying the type of travel, itinerary, and underlying medical conditions allows providers to administer the YF vaccine to travelers safely. There is a need to identify strategies to improve the timing of YF vaccination among travelers visiting friends and relatives.

Disclosures

All Authors: No reported disclosures
780. How Much Does Prior Hospitalization Contribute to Readmission with Community-onset Clostridioides difficile Infection?
Authors: Guh Alice , Korhonen Lauren C , Winston Lisa Gail , Martin Brittany , Johnston Helen , Brousseau Geoffrey , Basiliere Elizabeth , Olson Danyel M , Fridkin Scott , Wilson Lucy E , Perlmutter Rebecca , Holzbauer Stacy , Bye Maria , Phipps Erin C , Flores Kristina , Dumyati Ghinwa , Nelson Deborah , Hatwar Trupti , Ocampo Valerie , Kainer Marion , McDonald Clifford
Published: January 2021

Background

Interventions to reduce community-onset (CO) Clostridioides difficile Infection (CDI) are not usually hospital-based due to the perception that they are often acquired outside the hospital. We determined the proportion of admitted CO CDI that might be associated with previous hospitalization.

Methods

The CDC’s Emerging Infections Program conducts population-based CDI surveillance in 10 US sites. We defined an incident case as a C. difficile-positive stool collected in 2017 from a person aged ≥ 1 year admitted to a hospital with no positive tests in the prior 8 weeks. Cases were defined as CO if stool was collected within 3 days of hospitalization. CO cases were classified into four categories: long-term care facility (LTCF)-onset if patient was admitted from an LTCF; long-term acute care hospital (LTACH)-onset if patient was admitted from an LTACH; CO-healthcare-facility associated (CO-HCFA) if patient was admitted from a private residence but had a prior healthcare-facility admission in the past 12 weeks; or community-associated (CA) if there was no admission to a healthcare facility in the prior 12 weeks. We excluded hospitals with < 10 cases among admitted catchment-area residents.

Results

Of 4724 cases in 86 hospitals, 2984 (63.2%) were CO (median per hospital: 65.8%; interquartile range [IQR]: 58.3%-70.7%). Among the CO cases, 1424 (47.7%) were CA (median per hospital: 48.1%; IQR: 40.3%-57.7%), 1201 (40.3%) were CO-HCFA (median per hospital: 41.0%; IQR: 32.9%-47.8%), 350 (11.7%) were LTCF-onset (median per hospital: 10.0%; IQR: 0.6%-14.4%), and 9 (0.3%) were LTACH-onset. Of 1201 CO-HCFA cases, 1174 (97.8%) had a prior hospitalization; among these, 978 (83.3%) (median per hospital: 83.3%; IQR: 69.2%-90.6%), which consists of 32.8% of all hospitalized CO cases, had been discharged from the same hospital (Figure), and 84.4% of the 978 cases (median per hospital: 88.2%: IQR: 76.5%-100.0%) had received antibiotics sometime in the prior 12 weeks.

Figure. Frequency of Cases Discharged in the 12 Weeks Prior to Readmission with Clostridioides difficile Infection (N=1138*)

Conclusion

A third of hospitalized CO CDI had been recently discharged from the same hospital, and most had received antibiotics during or soon after the last admission. Hospital-based and post-discharge antibiotic stewardship interventions could help reduce subsequent CDI hospitalizations.

Disclosures

Ghinwa Dumyati, MD, Roche Diagnostics (Consultant)
781. C.difficile PCR+/ Toxin EIA- treat or not treat? A clinician survey
Authors: Nath Sarath G , Lee Francesca , Bararia Anjali , Nijhawan Ank E
Published: January 2021

Background

C.difficile Toxin Polymerase Chain Reaction (C.diff PCR) and C.difficile Toxin Enzyme Immunoassays (toxin EIA) are commonly used tests to diagnose Clostridoides difficile infection (CDI). C.diff PCR cannot differentiate between colonization and infection, leading to a higher false-positive diagnosis of CDI. Toxin EIA has low sensitivity leading to a missed diagnosis of CDI. In patients with C.diff PCR positive(+) and Toxin EIA negative(-), clinical judgment is often needed regarding the decision to treat or not to treat. C.diff cytotoxic assay (CCA), is a more sensitive method to detect the toxin but is time-consuming and not readily available.

Methods

Between 6/2019 and 12/2019, 83 patients who were admitted to the hospital, met our inclusion criteria (C.diff PCR+/EIA-). Clinicians who cared for these patients were contacted and surveyed with a predesigned questionnaire evaluating the rationale of treatment. Also, a simultaneous medical records review was done to ensure consistency. Along with this C.diff PCR+/EIA- stool samples were sent to ARUP laboratories for CCA. The CCA results were not available for clinicians and did not impact clinical care. Average cost for a CCA assay was $29

Results

Demographics of the clinicians were variable (Table 1). Several parameters were considered when making decisions regarding treatment and GI/ID were frequently involved (figure 1). Among the 83 patients, 41(49%) were CCA (+) and 42(51%) were CCA (-). 48 of 83 (58%) patients received treatment for CDI. 25 of 48 (52%) patients who were treated were CCA positive while 23 of 48 (48%) patients were CCA negative. Among the untreated patients, 16/35 (46%) were CCA+ while 19/35(54%) were CCA-. There was no statistically significant correlation between clinical judgment and CCA assay results (p: 0.56 on the Chi test).

Demographics of the clinicians

Clinician survey responses

CDI Treatment and by CCA positivity

Conclusion

Clinicians regardless of their background and training face challenges with the treatment of C.diff PCR+/EIA- patients. Patient outcomes based on the incorporation of CCA assay into an algorithm for C.diff PCR+/EIA- patients, need to be evaluated. But it has a potential role in stopping unnecessary CDI treatment as well as avoidance of missed treatment opportunities while possibly also being cost-effective.

Disclosures

Ank E. Nijhawan, MD, MPH, Gilead (Grant/Research Support, Scientific Research Study Investigator, Research Grant or Support)
783. Clostridioides difficile Infection among Maintenance Hemodialysis Patients
Authors: Radhakrishnan Parvathi , Vishwanath Manini , Shemin Douglas , Monteiro Joao Filipe G , D’Agata Erika M C
Published: January 2021

Background

Patients on maintenance hemodialysis (MHD) are 2-2.5 times more likely to develop Clostridioides difficile infection (CDI) with mortality rates 2-fold higher compared to the general population. The goal of this study was to determine factors and outcomes associated with severe/fulminant CDI among MHD patients.

Methods

A retrospective cohort study was performed among MHD patients admitted to 2 tertiary care hospitals, with first episodes of CDI between January 2015 and December 2018. MHD patients who had CDI at admission were identified through Theradoc® and confirmed by electronic medical records review. Using the Infectious Diseases Society of America criteria, non-severe CDI was defined as a white blood cell count ≤ 15000 cells/mL and severe/fulminant CDI was defined as a white blood cell count of ≥ 15000 cells/mL, hypotension, shock, megacolon and/or ileus. Creatinine values were not included. Patient demographics, comorbidities, antimicrobial exposure and 60-day mortality were collected on all patients.

Results

A total of 103 MHD patients with CDI were identified during the study period, of whom 68 (66%) had non-severe CDI and 35 (34%) had severe/fulminant CDI. The average age at admission was 65.3 years, 48.5% were female, and 59.2% were Caucasian. The average albumin level was 3.1 g/dL, and the average Charlson comorbidity index was 6.8. On univariate analyses, risk factors associated with severe/fulminant CDI as compared to non-severe CDI were older age at admission, elevated white blood cell count, exposure to extended-spectrum penicillins in the previous 90 days, and 60-day mortality after the first CDI (p-value ≤0.05). On multivariable logistic regression analysis, three factors remained significantly associated with severe/fulminant CDI (adjusted odds ratio [aOR], 95% confidence interval): 1] age ≥65 years (aOR=6.3 [2.25-17.45]), 2] extended-spectrum penicillins (aOR=2.7 [1.05-6.85], and 3] 60-day mortality after the first CDI (aOR=3.6 [1.11-11.74]).

Conclusion

A substantial proportion of patients requiring MHD with CDI present with severe/fulminant disease and are at increased risk of death. Reducing exposure to extended-spectrum penicillins may prevent severe/fulminant CDI in this patient population.

Disclosures

Joao Filipe G Monteiro, PhD, Brown Medicine (Consultant)
788. Evaluation of a Multiplex PCR Panel and Confirmatory Cytotoxin Testing on Clostridioides difficile at a Pediatric Hospital
Authors: Lauth Michael J , Cook Greg , Silio Margarita
Published: January 2021

Background

With the introduction of gastrointestinal multiplex PCR (mPCR) tests, clinicians have received an increased number of positive tests for Clostridioides difficile. Patients who test positive via mPCR may not have a positive toxin assay indicative of true infection and may not need antibiotics. The goal of this study was to assess the symptoms of patients who test positive for C. difficile and determine the impact on antibiotic use at a pediatric hospital.

Methods

A single-center, retrospective review was completed from May 2018 to March 2020. Initial C. difficile screening tests were performed via an mPCR test or a mono-PCR test. Patients > 1 year of age had a reflex cytotoxin assay performed. The primary outcome was the difference in symptoms between cytotoxin positive and negative patients. Secondary outcomes included co-pathogen detection on mPCR and C. difficile antibiotic days of therapy.

Results

Four hundred and sixty-one patients were included in our chart review. 49% of patients had a positive mPCR for a GI pathogen (n=229), and 18% (n=82) were positive for C. difficile. Cytotoxin was positive for 45% of patients that had C. difficile on mPCR. 34% of patients that had C. difficile detected on mPCR also had co-pathogens detected. No significant differences were present in symptomatology between cytotoxin positive and negative patients and no significant differences between white blood cell count (Table 1). There was a significant difference in the number of patients treated for the C. difficile between the cytotoxin populations (p-value< 0.05). The average duration of treatment with a negative test was significantly less than for positive cytotoxin test patients (7.5 vs 11 days, p-value< 0.05).

Table 1: Comparison of cytotoxin production in pediatric patients with Clostridioides difficile.

Conclusion

Our results show a significant amount of antibiotic use for patients with cytotoxin negative C. difficile and no differences in symptomatology or white blood cell count based on cytotoxin positivity. Diagnostic stewardship of mPCR tests may be needed to effectively impact this unneeded antibiotic use, specifically the duration.

Disclosures

All Authors: No reported disclosures
794. Healthcare-Associated Urinary Tract Infection (HA-UTI): A Risk Factor for Clostridioides difficile Infection (CDI)? Results of a Real-World Data Analysis
Authors: Kelly Timothy , Kelly Timothy , Ai ChinEn , Ai ChinEn , Murray John , Murray John , Xiong Yan , Xiong Yan , Jokinen-Gordon Hanna , Jokinen-Gordon Hanna
Published: January 2021

Background

It is estimated that 223,900 cases of CDI occur annually in hospitalized patients resulting in 12,800 deaths and $1 billion in attributable costs. Antimicrobial use is a risk factor for CDI and the antimicrobials ordered to treat urinary tract infections have been identified as a factor in both recurrent CDI and community-acquired CDI. This real-world data analysis seeks to explore the relationship between HA-UTI and hospital-onset CDI (HO-CDI).

Methods

An electronic infection surveillance system was the source of de-identified real-world data from 290 hospitals. Algorithmically-derived measures of healthcare-associated infections (ADM-HAIs), and records of all-cause antimicrobial orders, for all inpatient admissions for the period 10/1/18–9/30/19 were analyzed. All patients who presented with a urine ADM-HAI – suggestive of HA-UTI – and no other healthcare-associated infection (Urine+ patients), were observed for subsequent HO-CDI. Urine+ patients were compared to patients with no HAI of any type, other than CDI (HAI-free patients), and relative risk (RR) was estimated. The analysis was repeated for the subgroup of patients who received an antimicrobial order for any reason during their stay.

Results

3,050,525 inpatient admissions were analyzed. 26,634 were identified as Urine+ patients. 188 of those patients subsequently presented with HO-CDI. 2,978,507 were identified as HAI-free patients. 6,238 of those patients presented with HO-CDI. The incidence of HO-CDI was significantly higher in Urine+ patients compared to HAI-free patients (RR=3.37, 95% CL[2.92, 3.89], p< 0.0001). When the analysis was repeated to examine only patients who received antimicrobial orders, Urine+ patients continued to be at higher risk of subsequent HO-CDI compared to HAI-free patients (RR=3.28, 95% CL[2.74,3.92], p< 0.0001).

Conclusion

The presence of a urine ADM-HAI, suggestive of HA-UTI, was associated with an increased risk of subsequent HO-CDI. This held when only patients with antimicrobial orders were considered. These observations mirror findings from other published studies, however, other factors may have contributed to increased risk for both HA-UTI and HO-CDI.

Disclosures

Timothy Kelly, MS, MBA, BD (Employee) ChinEn Ai, MPH, BD (Employee) John Murray, MPH, BD (Employee) Yan Xiong, n/a, BD (Becton Dickinson) (Employee) Hanna Jokinen-Gordon, PhD, BD (Employee)
795. Impact of Revised Infectious Diseases Society of America and Society for Healthcare Epidemiology of America Guideline on the Classification of Clostridioides difficile Infection Severity
Authors: Carlson Travis J , Gonzales-Luna Anne J , Nebo Kimberly , Chan Hannah Y , Tran Ngoc-Linh T , Antony Sheena , Garey Kevin W
Published: January 2021

Background

The Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) revised their Clostridioides difficile infection (CDI) severity classification criteria in 2017 to include a serum creatinine (SCr) value above a threshold (≥ 1.5 mg/dL) rather than a relative increase from baseline (≥ 1.5 times the premorbid level). To date, these criteria have not been validated and may overestimate the number of severe CDI cases in patients with underlying renal insufficiency.

Methods

This multicenter, retrospective cohort study included all patients ≥ 18 years of age with CDI diagnosed in two large health systems in the Houston, Texas area between 2016 and 2018. Patients were assessed for presence of acute kidney injury (AKI) and chronic kidney disease (CKD), defined per the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, and IDSA/SHEA CDI severity classification criteria per the 2010 and 2017 CDI guidelines. The primary outcome was all-cause inpatient mortality.

Results

The study cohort consisted of 770 CDI episodes from 12 hospitals. A large proportion of episodes occurred in patients with preexisting CKD (36.5%) and concomitant AKI (29.6%). Eighty-two episodes (10.6%) showed discordant results when applying the 2017 revised severity classification criteria due to the identification of patients with preexisting CKD. However, the 2017 severity classification criteria were better correlated with all-cause mortality (OR, 5.40; 95% CI, 1.84-15.86; P = 0.002) than were the 2010 severity classification criteria (OR, 3.12; 95% CI, 1.35-7.19; P = 0.008) as the 2017 SCr criterion was an independent predictor of mortality (OR, 3.66; 95% CI, 1.66-8.05; P = 0.001) while the 2010 SCr criterion was not (OR, 1.47; 95% CI, 0.71-3.08; P = 0.30).

Conclusion

Our findings support the inclusion of the 2017 IDSA/SHEA CDI severity classification criteria in future CDI guideline updates.

Disclosures

Kevin W. Garey, PharmD, MS, FASHP, Merck & Co. (Grant/Research Support, Scientific Research Study Investigator)
797. Management of Patients with Multiple Clostridioides difficile Infection Recurrences using a Tapered-Pulsed Fidaxomicin Strategy
Authors: Tan Xing , Skinner Andrew M , Sirbu Benjamin , Danziger Larry H , Gerding Dale N , Johnson Stuart , Johnson Stuart
Published: January 2021

Background

There is a paucity of data assessing outcomes of alternate fidaxomicin strategies in patients with recurrent Clostridioides difficile infection (rCDI). The objective of our study is to evaluate a tapered-pulsed (T-P) fidaxomicin regimen that was administered immediately following a course of CDI treatment with initial symptom resolution in patients with multiple rCDI.

Methods

We reviewed the characteristics and outcomes of 46 consecutive patients who received T-P fidaxomicin between January 1, 2014-June 30, 2019 in a specialty CDI clinic. The first episode in which fidaxomicin T-P was administered was analyzed. Failure was defined as the persistence of diarrhea and/or the need for additional CDI treatment at any time on T-P fidaxomicin. Sustained clinical cure (SCC) was defined as resolution of diarrhea without recurrence. Recurrence was defined as the return of diarrhea requiring retreatment with CDI therapy after completion of T-P fidaxomicin. Both SCC and recurrence were evaluated at 30 and 90 days after completion of T-P fidaxomicin.

Results

The mean±SD age of the 46 patients was 63.2±19.9 years, 71.7% were female, and the mean±SD CDI episodes within the past year was 3±1.4 . Most patients (73.9%) had previously failed a vancomycin tapered and/or pulsed regimen. Prior to administering T-P fidaxomicin, a treatment regimen was given to ensure resolution of symptoms. The CDI treatment most commonly used (58.7%) was vancomycin. The T-P fidaxomicin regimen used consisted of 200 mg given once daily for 7 days followed by 200 mg every other day for a median (min-max) duration of 33 (6-120) days. Two patients (4%) failed to respond to T-P fidaxomicin; 34 (74%) and 28 (61%) achieved SCC at 30 and 90 days, respectively. Among the 44 patients that successfully completed the T-P fidaxomicin regimen, recurrence developed in 10 (22.7%) and 16 (36.4%) of patients at 30 and 90 days, respectively, with a median (min-max) time to recurrence of 20 (3-87) days (Figure 1). Four patients with recurrence had received subsequent systemic antibiotics.

Figure 1. Course of CDI therapy and follow-up

Conclusion

A tapered-pulsed fidaxomicin strategy may be effective in patients with multiply rCDI who are refractory to other treatments, including a vancomycin tapered and pulsed regimen.

Disclosures

Larry H. Danziger, PharmD, Merck (Speaker’s Bureau)
799. Mini Root Cause Analysis Reveals Opportunities for Reducing Clostridioides difficile Infection Rates
Authors: Turner Nicholas A , Seidelman Jessica L , Wrenn Rebekah , Anderson Deverick J , Lewis Sarah S , Smith Becky A
Published: January 2021

Background

C. difficile remains the single most common pathogen among healthcare-associated infections. We conducted a multi-center, prospective study using on-site, near real-time root cause analyses to identify opportunities for reducing hospital-onset C. difficile infection rates (HO-CID).

Methods

This prospective cohort study enrolled inpatients with HO-CDI admitted to one of 20 participating hospitals in the southeastern United States from July 2019 to June 2020. For each HO-CDI case, mini root cause analyses were conducted by on-site physicians, infection preventionists, or stewardship pharmacists to assess appropriateness of C. difficile testing and inpatient antibiotic use from the 30 days preceding HO-CDI diagnosis.

Results

The cohort captured 554 total HO-CDI cases and 956 antibiotic use events. 147 (26.5%) of HO-CDI cases were adjudicated as likely inappropriate and a further 51 (9.2%) as potentially inappropriate. Among inappropriately tested cases, 103 (52.0%) had received either laxatives or tube feeds in the preceding 48 hours. 132 (13.8%) of antibiotic use events were identified as potentially inappropriate. Among potentially inappropriate antibiotic use events, 40 (30.3%) received unnecessarily broad-spectrum antibiotics, 20 (15.2%) lacked a confirmed infectious diagnosis, and 4 (3.0%) received a longer than guideline-recommended duration. Risk of inappropriate antibiotic use varied by infection type, with treatment of urinary tract infection being associated with the highest risk of inappropriate antibiotic use (table 1).

Table 1: Relative Risk of Inappropriate Antibiotic Use by Indication

Conclusion

Mini root cause analyses may be a helpful tool for identifying -specific opportunities to reduce HO-CDI rates. We found a high rate of inappropriate testing, usually related to alternative causes for diarrhea such as laxative receipt or tube feeds. While rates of inappropriate antibiotic use were lower than has been reported elsewhere, the majority of opportunities for improvement related to overly broad-spectrum coverage. Urinary tract infections were most strongly associated with inappropriate antibiotic use preceding HO-CDI.

Disclosures

All Authors: No reported disclosures
801. Patients with Clostridioides difficile Infection Following Dental Antibiotic Prescription
Authors: Wilson Geneva M , Evans Charlesnika T , Fitzpatrick Margaret A , Poggensee Linda , Echevarria Kelly , Suda Katie J
Published: January 2021

Background

Dentists prescribe few broad-spectrum antibiotics but are the primary prescriber of clindamycin in the U.S. Data is scarce on the association of dental antibiotic prescribing and Clostridioides difficile infection (CDI). Here we present results from a longitudinal cohort of patients with a CDI positive diagnostic test 30 days after receiving an antibiotic prescribed by a dentist.

Methods

A cohort of patients with antibiotic prescriptions within 7 days of a dental visit were identified from 2015-2018. From this cohort, patients with positive C. difficile test 30 days after a dental antibiotic were included. Chart reviews obtained information about the dental visit, antibiotic prescribed, and CDI diagnosis. Descriptive statistics were used to describe characteristics of those with CDI following a dental antibiotic.

Results

212,763 Veterans received an antibiotic from a dentist between 2015-2018. Of them, 87 patients had a positive CDI test within 30 days of receiving their dental antibiotic. Over half (57.4%) of these patients had surgical dental visits and 45.9% had an oral infection coded. Dentists documented reasons for prescription was treatment of a local infection (40%) and post procedure prophylaxis (24%). Amoxicillin (54.0%) and clindamycin (40.2%) were the most commonly prescribed antibiotics. 65.7% of the patients that received clindamycin from the dentist had a documented penicillin allergy. 58.6% of patients had a preexisting gastrointestinal condition and 44.8% were taking gastric acid reducer medication. Only 19.5% of the antibiotic prescriptions met ADA guidelines for appropriate antibiotics (presence of gingival manipulation and a cardiac condition). CDI cases were treated with metronidazole (55.2%), or vancomycin (37.9%); 5.7% had no apparent treatment through the VA. The average number of days between the dental visit and CDI diagnosis was 18.9.

Conclusion

The occurrence of CDI was infrequent after a dental antibiotic. However, clindamycin was prescribed more frequently in this cohort than published literature on dentist prescribing. Approximately half had a gastrointestinal risk factor for CDI. More research is needed to determine the type of patient most at risk for CDI following a dental antibiotic.

Disclosures

All Authors: No reported disclosures
802. Proton Pump Inhibitors Increase Clostridioides difficile Disease Severity Controlling for Infecting Strains
Authors: Fallatah Saad , Almutairi Masaad , Alnezary Faris S , Gonzales-Luna Anne J , Garey Kevin W
Published: January 2021

Background

Proton pump inhibitors (PPI) display pleotropic properties that increase the risk of poor outcomes in patients with C. difficile infection (CDI). However, clinical data on PPI and CDI outcomes is controversial perhaps due to lack of knowledge of infecting strain. The purpose of this study was to assess CDI outcomes in hospitalized patients infected with known C. difficile ribotypes based on use of PPI.

Methods

This was a multicenter study (20 hospitals) of hospitalized patients infected with one of three C. difficile ribotypes (RT027, RT106, and RT014-020). Electronic medical records were reviewed by investigators blinded to RT that collected data on PPI use along with other clinical data. A composite endpoint of disease severity, mortality and 90-day CDI recurrence was assessed based on receipt of PPI and ribotype using multivariate logistic regression.

Results

A total of 380 patients with CDI aged 66±17 years (Female: 59.5%; White: 70.5%) infected with RT 106 (115/380; 30.3%), RT027 (116/380; 30.5%), and RT014-020 (149/380; 39.2%) were included. One hundred and ninety-nine patients (52.4%) were given a PPI at the time of CDI diagnosis and 129 patients (66.1%) experienced either severe disease or CDI recurrence. Disease severity differed significantly between ribotypes (p< 0.05) and increased in patients given PPI (p=0.08). CDI recurrence also differed significantly among ribotypes (p< 0.05) and increased in patients given PPI. Using the composite endpoint, receipt of PPIs significantly increased the likelihood of poor outcomes (OR:1.78; 95% CI: 1.17-2.73; p=0.007) after controlling for infecting ribotype.

Conclusion

In this multicenter study, receipt of PPIs increased the likelihood of poor outcomes in CDI patients after controlling for infecting ribotype.

Disclosures

Kevin W. Garey, PharmD, MS, FASHP, Merck & Co. (Grant/Research Support, Scientific Research Study Investigator)
803. Risk factors associated with Clostridioides difficile infection in hospitalized patients with community-acquired pneumonia
Authors: Moore William Justin , Jozefczyk Caroline C , Yarnold Paul R , Harkabuz Karolina , Widmaier Valerie , Silkaitis Christina , Qi Chao , Wunderink Richard G , Sutton Sarah , Postelnick Michael J , Zembower Teresa , Rhodes Nathaniel J
Published: January 2021

Background

Patients with community-acquired pneumonia (CAP) who are hospitalized and treated with antibiotics may carry an increased risk for developing Clostridioides difficile infection (CDI). Accurate risk estimation tools are needed to guide monitoring and CDI mitigation efforts. We aimed to identify patient-specific risk factors associated with CDI among hospitalized patients with CAP.

Methods

Design: retrospective case-control study of hospitalized patients who received CAP-directed antibiotic therapy between 1/1/2014 and 5/29/2018. Cases were hospitalized CAP patients who developed CDI post-admission. Control patients did not develop CDI and were selected at random from CAP patients hospitalized during this period. Variables: comorbidities, laboratory results, vital signs, severity of illness, prior hospitalization, and past antibiotic use. Propensity-score weights: identified via structural decomposition analysis of pre-treatment variables. Analysis: weighted classification tree models that predicted any CDI, hospital-onset CDI, and any healthcare-associated CDI according to CAP antibiotic treatment. Performance: percent accuracy in classification (PAC) and weighted positive (PPV) and negative predictive values (NPV). Modeling: completed using the ODA package (v1.0.1.3) for R (v3.5.1).

Results

A total of 32 cases and 232 controls were identified. Sixty pre-treatment variables were screened. Structural decomposition analysis, completed in two stages, identified prior hospitalization (OR 6.56, 95% CI: 3.01-14.31; PAC: 80.3%) and BUN greater than 29 mg/dL (OR 11.67, 95% CI: 2.41-56.5; PAC: 80.8%) as propensity-score weights. With respect to CDI, receipt of broad-spectrum anti-pseudomonal antibiotics was significantly (all P’s< 0.05) associated with any CDI (NPV: 90.29%, PPV: 27.94%), hospital-onset CDI (NPV: 97.53%, PPV: 26.86%), and healthcare-associated CDI (NPV: 92.89%, PPV: 27.94%).

Conclusion

We identified risk factors available at hospital admission and empiric use of broad-spectrum Gram-negative antibiotics as being associated with the development of CDI. Model PPVs were over two-fold greater than our sample base rate. Increased monitoring and avoidance of overly broad antibiotic use in high-risk patients appears warranted.

Disclosures

All Authors: No reported disclosures
805. A Single Institution Pre/Post Comparison After Introduction of an External Urinary Collection Device for Female Medical Patients
Authors: Jasperse Nathan , Hernandez-Dominguez Oscar , Deyell Jacob S , Prasad Janani P , Yuan Charlene , Tomy Meril , Kuza Catherine M , Grigorian Areg , Nahmias Jeffry
Published: January 2021

Background

Catheter associated urinary tract infections (CAUTIs) are the most common hospital acquired infections in the United States. External urinary collection devices (EUCDs) may serve as an alternative to indwelling urethral catheters (IUCs) and decrease the rate of CAUTIs. PureWick® is a novel female EUCD, with early case reports suggesting safe and efficacious use. However, no study has definitively proven benefit of PureWick® regarding reduction of CAUTIs. We sought to compare the CAUTI rate and median indwelling catheter days before and after availability of PureWick® at a single academic institution, as well as provide a descriptive analysis on female medical patients receiving an EUCD.

Methods

We performed a retrospective review of adult female patients admitted to our institution on a medical service who received an IUC and/or an EUCD. Patients admitted in the 3 months before (PRE) and 12 months after (POST) PureWick® availability were included. Two groups were compared: PRE patients who received an IUC vs. POST patients who received an IUC and/or EUCD.

Results

Out of 866 female patients, 296 received an EUCD in the POST cohort and overall, 673 received an IUC (261 (100%) PRE vs. 412 (68.1%) POST). There were no differences in the cohorts regarding age and comorbidities (all p >0.05). Compared to the PRE cohort, the POST cohort had a higher number of IUC days (median, 3 vs. 2 days, p< 0.001) and a higher rate of CAUTI (infections per 1,000 catheter days, 11.8 vs. 4.1, p=0.003) while overall UTI rate was similar (infections per 1,000 patient days, 19.1 vs. 14.12, p=0.410). In the POST cohort, the rate of UTI associated with EUCD use was 11.6 infections per 1,000 device days. Measurement of strict ins and outs (56.8%) was the most common indication for use of EUCD.

Table 1. Characteristics and comorbidities of female catheterized patients admitted to a medical service before (PRE) and after (POST) PureWick implementation.

Table 2. Urinary tract infection rates of female catheterized patients PRE and POST PureWick implementation.

Table 3. Characteristics of hospitalized female patients admitted to a medical service who received a PureWick catheter.

Conclusion

While EUCDs might appear to be a promising alternative to IUCs for female patients, this single center pre/post analysis found that both the median number of IUC days and the CAUTI rate increased after introduction of a single EUCD. This may be related to selection bias, with EUCDs being ordered for patients who would not have otherwise received an IUC. Further research is needed to clarify if female EUCDs can be effective in decreasing IUC days and/or CAUTI rates prior to any widespread adoption.

Disclosures

All Authors: No reported disclosures
806. Decreasing Central Line-associated Bloodstream Infections Through Quality Improvement Initiative on a High Acuity Transplant Unit
Authors: Ip Katie , Shayer Leah M , lerner susan m , Kim-Schluger Leona , Moon Jang
Published: January 2021

Background

Central line-associated blood stream infections (CLABSI) have a significant impact on mortality, morbidity and length of stay. Data collected by the Infection Prevention Department revealed progressive increases in the rate of CLABSI on an Abdominal Transplant Unit. Recognizing a drift from best practice, front line staff, the IP team and vascular access specialists, collaborated to identify opportunities for improving care of patients with vascular access devices.

Methods

An increase in CLABSI rate was observed on the Abdominal Transplant Unit beginning in 2016. An initiative began in 2017 to evaluate whether CLABSI rate reduction was sustainable for at least 1 year and to identify key determinants of this sustainability. Interventions were aimed at infection prevention best practices, care standardization, and team-based monitoring. Interventions included (1) re-education on CLABSI reduction, (2) two RN dressing changes to validate practice during central line dressing change, (3) blood draws from central lines (during non-emergent situations) had to be approved by nurse manager, physician lead and transplant quality physician, (4) CLABSI prevention nurses were chosen as designated phlebotomists for patients with prior approval, (5) daily line review was performed to address line days, indication of line (remove latent lines) and plan of care (transition to permanent access) and this information was shared with the unit physician lead and transplant quality team. Assuring compliance with audits and timely feedback with clinician accountability were vital with compliance with best practices.

Results

Conclusion

During the intervention, CLABSI infection rates dropped from 4.825 to 1.533 in 1,000 CVC days. The sustainability plan for this program is to continue line audits, assessing line necessity and review the effectiveness of the initiatives, review all new CLABSI data with staff and implement new changes as necessary. Joint, ongoing multidisciplinary collaboration is essential to reduce CLABSIs and optimize quality in a challenging, high-acuity patient population.

Disclosures

All Authors: No reported disclosures
809. Modified Laboratory Reporting to Prevent Catheter-Associated Urinary Tract Infections (CAUTIs)
Authors: Monsalud Cherie Faith , Singh Kamaljit , McElvania Erin , Schora Donna , Grant Jennifer , Lavin Mary Alice , Lim Rachel , Zelencik Shane
Published: January 2021

Background

Catheter-associated urinary tract infections (CAUTIs) are among the most common healthcare-associated infections. Many patients at our institution with a CAUTI do not have signs or symptoms of infection and bacterial growth likely represents asymptomatic bacteriuria (ASB). As a result, we implemented a Modified Lab Workflow (MLW) focused on diagnostic stewardship to improve urine culture (UCx) reporting and prevent misclassification and unnecessary treatment of CAUTIs.

Methods

On Sep. 1, 2019, laboratory reporting of Foley UCx was modified according to the protocol in Figure 1. UCx results were divided into 3 groups: (1) no growth, (2) mixed bacterial flora (≥3 organisms) not consistent with infection or (3) growth of ≤2 organisms with at least 1 organism ≥105 cfu/ml per National Healthcare Safety Network (NSHN) CAUTI definition. Group 3 UCx were resulted with instructions to the clinician (see Figure 1.). When requested, group 3 results were reviewed by Infection Prevention and released with organism identification and antibiotic susceptibility if it met Infectious Diseases Society of America (IDSA) CAUTI criteria. Otherwise they were resulted as: “Bacterial growth indicative of contamination or colonization.”

Figure 1. Modified Laboratory Workflow for Reporting Urine Cultures from Foley Catheters

Results

Between Sep. 1, 2019 to Mar. 1, 2020, a total of 134 UCx from catheterized patients were reviewed. Forty-two (31%) of UCx were from patients with a Foley in-situ ≥48 hours and processed through MLW; 92 UCx were from a Foley in place < 48 hours and excluded from the study. Of the 42 UCx processed via MLW, 16 (38%) were no growth and 7 (17%) had bacterial growth suggestive of contamination. For group 3, 19/42 (45%) had growth of significant bacteria but only 1(5%) met IDSA criteria for reporting. During the study, 6 additional CAUTIs were reported due to incorrect specimen labeling causing Foley urine specimens to subvert MLW.

Conclusion

During our study, we identified 1 CAUTI through apt MLW use. Seven total CAUTIs occurred (SIR=0.66); a majority due to incorrect UCx source labeling, resulting in missed MLW screening. Ten CAUTIs (SIR=0.97) were reported in the preceding 6 months. As part of a comprehensive CAUTI prevention program, a MLW can help reduce classification of ASB as a CAUTI. Education to providers on precise labeling of UCx source is a key component of a successful MLW.

Disclosures

All Authors: No reported disclosures
LB-4. Cefepime-Enmetazobactam Demonstrates Superiority to Piperacillin-Tazobactam in a Subgroup of Patients with Complicated Urinary Tract Infections/Acute Pyelonephritis Caused by Extended Spectrum β-Lactamase-Producing Enterobacterales
Authors: Belley Adam , Barth Philip , Kashyap Shikhar , Lahlou Omar , Motta Paola , Knechtle Philipp , Velicitat Patrick
Published: January 2021

Background

There is a critical need for carbapenem-sparing therapies for infections caused by extended spectrum β-lactamase (ESBL)-producing Enterobacterales. Enmetazobactam is a novel ESBL inhibitor combined with the cephalosporin cefepime. Treatment outcomes of cefepime-enmetazobactam (FPE) versus piperacillin-tazobactam (PTZ) were assessed in subgroups of patients with ESBL-producing baseline uropathogens (ESBL-BU) in the ALLIUM phase 3 trial of complicated urinary tract infections (cUTI)/acute pyelonephritis (AP).

Methods

1034 cUTI/AP patients randomized 1:1 in a double-blind, multicenter trial received either 2 g cefepime/0.5 g enmetazobactam or 4 g piperacillin/0.5 g tazobactam q8h by 2h infusion for 7 to 14 days. Enterobacterales with MICs ≥1 µg/ml to ceftazidime, ceftriaxone, cefepime, meropenem, or FPE were genotyped for β-lactamases. In addition to the primary analysis (by stratified Newcombe) of overall success (combination of clinical cure and microbiological eradication) in the microbiological modified intent to treat population (mMITT) at test-of-cure (TOC), subgroup analyses were performed on patients with ESBL-BU non-resistant to FPE (MIC≤8 µg/ml) and PTZ (MIC≤64 µg/ml) and a subgroup (mMITT+R) that also included the ESBL-BU resistant to either agent (FPE MIC ≥16 µg/ml or PTZ MIC≥128 µg/ml).

Results

In mMITT, FPE (273/345, 79.1%) demonstrated superiority to PTZ (196/333, 58.9%) at TOC (difference, 21.2%; 95% CI: 14.3, 27.9). The prevalence rate of ESBL-BU was 20.9% (142/678), with 99.3% (141/142) expressing a CTX-M-type (-1, -3, -9, -14, -15, -27, -55, -91, -169) and 3.5% (5/142) co-expressing AmpC (CMY-2/-59). FPE (56/76, 73.7%) demonstrated superiority to PTZ (34/66, 51.5%) in this subgroup at TOC (difference 30.2%; 95% CI: 13.4, 45.1; Table). In mMITT+R, the ESBL-BU prevalence rate was 22.3% (172/771), with 6.4% (11/172) co-expressing AmpC (CMY-2/-4/-59/-99), 4.7% (8/172) co-expressing a metallo-β-lactamase (VIM-1, NDM-1), and 2.3% (4/172) co-expressing OXA-48. Superiority of FPE (67/91, 73.6%) compared to PTZ (41/81, 50.6%) was also observed at TOC despite inclusion of ESBL-BU resistant to either agent (difference 30.0%; 95% CI: 14.9, 43.3).

Table

Conclusion

FPE may represent a new empiric carbapenem-sparing option in settings where ESBL are endemic.

Disclosures

Adam Belley, PHD, Allecra Therapeutics SAS (Consultant) Philip Barth, MD, Allecra Therapeutics SAS (Consultant) Shikhar Kashyap, n/a, Allecra Therapeutics SAS (Consultant)Allecra Therapeutics SAS (Consultant) Omar Lahlou, PhD, Allecra Therapeutics SAS (Employee) Paola Motta, PhD, Allecra Therapeutics SAS (Employee) Patrick Velicitat, MD, Allecra Therapeutics SAS (Employee)
LB-13. Economic and workload impact of COVID-19 pandemic on physicians in the United States: results of a national survey
Authors: Long Dustin , Long Dustin , Turner Wesli , Chapman Lambert Crystal , Creger Thomas , Mugavero Michael J , Burkholder Greer A
Published: January 2021

Background

The United States (US) healthcare system has experienced enormous economic impact due to the COVID-19 pandemic, driven by both loss of revenue related to shutdowns and increased strain on resources. These factors have impacted the workload and finances of physicians.

Methods

A 31-item anonymous survey evaluating the psychological impact of the COVID-19 pandemic on physicians was developed at the University of Alabama at Birmingham using QualtricsXM software and included questions on adverse economic impact (defined as selecting job loss, furlough or reduced income as a stressor), workload, and compensation. It was distributed via physician professional and social networks including email, Facebook groups, and #MedicalTwitter May 14-July 31, 2020.

Results

Among 597 respondents, 295 (49%) reported adverse economic impact, with the highest proportions among emergency medicine (71%), anesthesiologists (63%), and surgeons (60%) and lowest among infectious diseases (ID) (25%). In multivariable analysis (Table), physicians practicing in the Northeastern US saw the lowest economic impact versus the South (OR 3.44, 95% CI: 2.03–5.84), Midwest (2.62, 1.36–5.05) or West (1.98, 1.06–3.71). Physicians practicing in federal or academic settings experienced less economic impact than those in community settings (0.09, 0.03–0.30 and 0.61, 0.41–0.93 respectively). Increased work hours were identified by 185 (31%) of respondents as a stressor, with 169 (92%) reporting additional hours were partially or completely uncompensated. Among 584 respondents, 212 (36%) had new roles and responsibilities (Figure), with the highest proportion among ID physicians (75%).

Table 1: Characteristics and factors associated with reporting adverse economic impact of the COVID-19 pandemic among 597 physicians in the United States

Figure: New roles and responsbilities assumed by 212 physicians during the COVID-19 pandemic

Conclusion

The COVID-19 pandemic has increased physician workload, with approximately one-third of physicians taking on new responsibilities and a similar proportion reporting increased work hours. Much of this additional work is uncompensated due to the economic impact of the pandemic on the healthcare system. Simultaneously, many physicians across the US have suffered adverse economic consequences, especially in the South. ID physicians have experienced higher workload but less economic impact, related to increased need for their expertise and new roles and responsibilities.

Disclosures

Dustin Long, PhD, Nothing to disclose