bluuebunny/crossref_metadata_2025 huggingface dataset:
1212. Whole Genome Sequencing for High-Resolution Methicillin-Resistant Staphylococcus aureus Outbreaks Tracing in Neonatal Intensive Care Units and In silico Resistance and Virulence Markers Detection
Authors: Durand Geraldine , Javerliat Fabien , Bes Michele , Laurent Frédéric , Vandenesch Francois , Tristan Anne
Published: November 2018

Background

The French National Reference Center for Staphylococci used whole genome sequencing (WGS) to investigate outbreaks due to a virulent MRSA clone containing the toxic shock syndrome toxin-1 (TSST-1+, sequence type 5, Geraldine clone) increasingly reported in neonatal intensive care units (ICUs).

Methods

We analyzed 48 isolates previously characterized by spa typing: 31 isolates from outbreak 1 (infected or colonized patients, healthcare workers carriage and environment), 12 isolates from four distinct outbreaks (2, 3, 4, and 5) that occurred in geographically independent neonatal ICUs, and five sporadic strains. We performed WGS using a de novo assembly approach to perform comparisons between isolates (EpiSeq®, bioMérieux). A phylogenetic analysis was constructed by comparing single nucleotide variations (SNVs) in 2020 core-genes using a cutoff of 40 SNVs for defining isolates belonging to the same transmission cluster. We detected in silico resistance and virulence markers using the same bioinformatic pipeline.

Results

For outbreak 1, 25/31 isolates with two distinct but related spa types t002 and t111 were highly related (<13 SNVs), suggesting the transmission of the same strain; 6/31 isolates were genetically distinct (>80 SNVs) from the previous cluster of 25 isolates suggesting their origin from separate sources. Interestingly the three isolates of outbreak 2 with a spa t111 differed by less than 22 SNVs from the main cluster of the 25 isolates of outbreak 1. This suggested origin from the same transmission cluster. The other three outbreaks showing respectively a spa t002 for outbreak 3 and outbreak 4 and a spa t045 for outbreak 5 were not affiliated to the main cluster of outbreak 1. The isolates carry numerous virulence factors (including TSST-1) and resistance markers confering a peculiar antibiotic resistance profile to the Geraldine clone.

Conclusion

WGS provides the resolution power to reveal unsuspected transmission events not indicated by conventional methods (different spa type). Based on its high resolution WGS is an all in one tool for epidemiology, virulence and resistance analysis. It really transforms outbreak management and infection control practice for an early response and should replace conventional methods for detection of MRSA transmission.

Disclosures

G. Durand, bioMérieux: Employee, Salary. F. Javerliat, bioMérieux: Employee, Salary.
1221. Genetic Characteristics of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus (HA-MRSA) Belonging to Clonal Complex 5 (CC5) in Latin-America
Authors: Reyes Jinnethe , Carvajal Lina P , Rios Rafael , Echeverri Aura , Rincon Sandra , Munita Jose M , Tran Truc , Panesso Diana , Arias Cesar , Diaz Lorena
Published: November 2018

Background

MRSA are responsible for a high proportion of healthcare-associated infections. HA-MRSA is multidrug resistant, and infections occur most frequently among inpatients, for example, those who have undergone invasive medical procedures or those aged 50 to 60 years and older. Dominance of multidrug-resistant CC5 (Chilean and New York/Japan clones) was prevalent in infections in Latin America with the notable exception of Colombia and Ecuador where USA300-LV isolates dominate. We performed genetic characterization of HA-MRSA-CC5 isolates recovered from infections in nine countries (12 hospitals).

Methods

Species identification of S. aureus and presence of mecA were performed by PCR. We determined MICs to common anti-MRSA antibiotics and performed screening for VISA phenotype. Molecular characterization included detection of lukSF-PV and SCCmec typing. PFGE and MLST were performed in selected MRSA isolates with susceptibility patterns typical of the Chilean (ST5-MRSA-I) and USA300-LV (ST8-MRSA-IV) lineages.

Results

A total of 665 S. aureus isolates were prospectively recovered from 592 patients. A high frequency of methicillin resistance (>40%) was observed in all countries (62%, 55%, 44%, and 40% in BRA, PER, CHI and ARG, respectively). Decreased susceptibility to VAN was not observed and VAN MIC90 was 1 µg/mL. In PER and CHI, the overwhelming majority of isolates (89%) belonged to the Chilean/Cordobes clone (CC5) with susceptibility patterns typical of this lineage (Resistance to β-lactams, MLSB-type, quinolones, and aminoglycosides). The New York/Japan clone (ST5-MRSA-II) was predominant in Brazil, replacing the prevalent hospital-associated Brazilian (ST239-MRSA-III) lineage. Most Argentinian MRSA isolates exhibiting a CA (ST5-IV) pattern, previously described in this country.

Conclusion

A variety of MRSA genetic lineages are circulating in Latin America with geographic clustering and clonal replacement. Dissemination of the CA-USA300-LV has not occurred beyond the northern region of the subcontinent.

Disclosures

J. M. Munita, Pfizer: Grant Investigator, Research grant. C. Arias, Merck & Co., Inc.: Grant Investigator, Research support. MeMed: Grant Investigator, Research support. Allergan: Grant Investigator, Research support.
1224. Drug-Resistance Dynamics of Staphylococcus aureus at a Tertiary Hospital, Beijing, China: 2013–2017
Authors: Zhang Yuzheng , Johnston Janice Mary , Fu Qiang
Published: November 2018

Background

To understand the drug-resistance dynamics of Staphylococcus aureus and provide references for effective control of methicillin-resistant Staphylococcus aureus (MRSA) infection.

Methods

All data were obtained from the healthcare-associated infection surveillance system. Different strains of S. aureus were identified using the VITEK-2 automated system, the drug susceptibility results of resistance and intermediate were classified into resistance. Chi-square test and variation analyses of S. aureus drug-resistant rate were performed.

Results

From 2013 to 2017, 2,289 strains of S. aureus were isolated, and the specimen were mostly collected from sputum (721, 31.50%), wound secretion (211, 9.22%), and blood (210, 9.17%). The resistance rate of S. aureus was highest for tigecycline (94.43% in 2013, 100% in 2017) and penicillin (96.49% in 2013, 95.60% in 2017) (P = 0.028). The resistance rates among other drugs such as clindamycin (65.28% in 2013, 71.39% in 2017) and erythromycin (69.62% in 2013, 62.59% in 2017) were more stable (P = 0.056). However, oxacillin (from 73.68% to 34.47%), gentamicin (from 51.51% to 24.13%), and tetracycline (from 46.78% to 30.81%) showed a declining trend (P = 0.017). Meanwhile, there were almost no S. aureus resistance to linezolid, vancomycin, and nitrofurantoin. During the previous 5-year period, MRSA rates decreased sharply and in 2017 rate was 34.47%. In 2017, MRSA was most frequently isolated in orthopedics, emergency ICU, and respiratory.

Conclusion

The reduction in drug-resistant MRSA may be evidence of effective antibiotic administration practice. Whereas more comprehensive infection control measures are needed to prevent the transmission of S. aureus and MRSA.

Disclosures

All authors: No reported disclosures.
1228. Incidence of Staphylococcus aureus Infection after Elective Surgeries Among Adults in US Hospitals
Authors: Dreyfus Jill , Begier Elizabeth , Yu Holly , Quintana Alvaro , Gayle Julie , Olsen Margaret A
Published: November 2018

Background

Staphylococcus aureus is a leading cause of postsurgical infections. National estimates of these infections after elective surgeries based on microbiology data are limited. This study assessed 180-day postsurgical S. aureus incidence in real-world hospital settings.

Methods

Adults (≥18 years) who underwent elective surgery during a hospital-based outpatient or inpatient encounter from July 1, 2010–June 30, 2015 at one of 181 hospitals reporting microbiology results in the Premier Healthcare Database (PHD). Eighty-seven surgical categories were defined using ICD-9-CM and CPT procedure codes according to National Hospital Surveillance Network groupings plus additional categories. Microbiology results and ICD-9-CM diagnosis codes were used to identify invasive (e.g., deep incisional and organ-space SSI, bloodstream) and overall (i.e., invasive, superficial incisional, urinary tract, respiratory) S. aureus infections. Cumulative 180-day S. aureus infection rates were calculated as number of infections divided by number of discharges with elective surgeries. National infection volumes were calculated by multiplying infection rates by national inpatient elective surgery estimates using surgery counts in the entire PHD (665 hospitals) and weights based on hospital characteristics.

Results

Following 1,116,994 hospital-based outpatient elective surgeries, 180-day S. aureus incidence was 1.19% overall, with 0.38% complicated by invasive S. aureus infections. Among 884,803 inpatient elective surgeries, overall and invasive 180-day S. aureus infection incidence was 1.35% and 0.53%, respectively. This translated to an estimated 57,200 S. aureus infections (22,400 invasive) among an estimated 4.2 million elective inpatient surgeries annually in the US methicillin-resistance (MRSA) was observed in 45% and 46% of S. aureus infections after inpatient and outpatient surgeries, respectively. Figure 1 shows cumulative S. aureus incidence rates at each time point after outpatient and inpatient elective surgeries. Figure 2 delineates the incidence rates for each type of S. aureus infection.

Conclusion

Our study indicated similar S. aureus infection rates after inpatient and outpatient elective surgeries. The results highlight the much larger burden of disease of S. aureus infection in the United States beyond inpatient surgeries.

Disclosures

J. Dreyfus, Premier, Inc.: Employee and Shareholder, Salary. E. Begier, Pfizer, Inc.: Employee and Shareholder, Salary. H. Yu, Pfizer, Inc.: Employee and Shareholder, Salary. A. Quintana, Pfizer, Inc.: Employee and Shareholder, Salary. J. Gayle, Premier, Inc.: Employee, Salary. M. A. Olsen, Pfizer: Consultant, Consulting fee.
1233. An Automated E-mail Notification Systemic to Infectious Disease Specialists and Effect on the Management of Staphylococcal aureus Bacteremia in a Community Hospital setting
Authors: Roe Nicole , Wang Michael , Douce Richard
Published: November 2018

Background

Staphylococcus aureus is the leading cause of community and healthcare-associated bacteremia and carries a high burden with a substantial mortality, ranging from 20 to 40 %. Evidence suggests infectious disease (ID) consultation improves mortality and adherence to the Infectious Diseases Society of America (IDSA) guidelines. Due to complications from a lack of ID consultation, a notification system consisting of automated e-mails to ID providers was implemented. The objective of this study was to review the impact of the automatic notification to ID consultants with positive blood culture results in a community hospital system.

Methods

Cases of staphylococcus aureus bacteremia were identified from the microbiology database by at least one positive blood culture. The automated e-mail notification system was implemented in December 2014. ID providers were encouraged to verbally contact primary providers for positive results. Cases of bacteremia prior to implementation of the automated notification system were compared with those post-intervention. Patients under age 18 were excluded. Data gathered included mortality, re-admission rates, and compliance with IDSA guidelines.

Results

There were no significant differences in inpatient mortality (9 vs. 18%, P = 0.180). 30-day mortality between the two groups (18 vs. 20%, P = 0.815). The 30-day readmission rate among surviving patients was reduced by 50% (40% vs. 19%, P = 0.014). Compliance with antibiotic duration in complicated bacteremia increased post-intervention (57% vs. 85%, P = 0.04).

Conclusion

An automatic notification to ID specialists reporting patients with Staphylococcus aureus bacteremia led to improved compliance with IDSA guidelines regarding antibiotic duration and reduced re-admission rates. There was no effect on overall mortality.

All authors: No reported disclosures.
1236. Infection Control Risk Mitigation and Implementation of Best Practice Recommendations in Long-Term Care Facilities
Authors: Fitzgerald Teresa , Nailon Regina , Tyner Kate , Beach Sue , Drake Margaret , Micheels Teresa , Rupp Mark E , Schwedhelm Michelle , Tierney Maureen , Ashraf Muhammad Salman
Published: November 2018

Background

Nebraska (NE) Infection Control Assessment and Promotion Program (ICAP) is a quality improvement initiative supported by the NE Department of Health and Human Services. This initiative utilizes subject matter experts (SMEs) including infectious diseases physicians and certified infection preventionists (IP) to assess and improve infection prevention and control programs (IPCP) in various healthcare settings. NE ICAP conducted on-site surveys and observations of IPCP in many volunteer facilities to include long-term care facilities (LTCF) between November 2015 and July 2017. SMEs provided on-site coaching and made best practice recommendations (BPR) for priority implementation. Impact of this intervention on LTCF IPCP was examined.

Methods

Using a standardized questionnaire, follow-up phone calls were made with LTCF to evaluate implementation of the BPR one-year post-assessment. Descriptive analyses were performed to examine BPR implementation in LTCF that had follow-up between 4/4/17 to 4/17/18 and to identify factors that promoted or impeded BPR implementation.

Results

Overall, 45 LTCF were assessed. The top 5 IC categories requiring improvement were audit and feedback practices (28 of 45, 62%), PPE supplies at point of use (62%), IC risk assessments (58%), TB risk assessments (56%), and supply and linen storage practices (56%). Follow-up assessments were completed for 270 recommendations in 25 LTCF. Recommendations reviewed ranged from three to 26 per LTCF (median = 15). The majority of the 270 recommendations (n = 162, 60%) had been either completely (35%) or partially (25%) implemented by the time of the follow-up calls. The ICAP visit itself was reported as the most helpful resource for BPR implementation (77 of 162). Lack of staffing was the most commonly mentioned barrier to implementation when LTCF implemented BPR partially or implementation was not planned (37 of 85). BPR Implementation most frequently involved additional staff training (64 of 162), review of policies and procedures (38 of 162), and implementing audit (34 of 162) and/or feedback (23 of 162) programs.

Conclusion

Numerous IC gaps exist in LTCF. Peer-to-peer feedback and coaching by SMEs facilitated implementation of many BPR directed toward mitigating identified IC gaps.

Disclosures

All authors: No reported disclosures.
1243. Comparative Analysis of Antimicrobial-related Adverse Events in the Outpatient Treatment of Staphylococcal Infections
Authors: Smith Bradley , Rivera Christina , Dierkhising Ross , Estes Lynn , O’Horo John , Tande Aaron , Zeuli John , Virk Abinash
Published: November 2018

Background

Limited data exist to evaluate safety-related outcomes in Outpatient Parenteral Antimicrobial Therapy (OPAT) patients treated with antimicrobial agents for Gram-positive infections.

Methods

This retrospective, single-center study enrolled Mayo Clinic OPAT patients between 2013 and 2017. The primary objective of the study compared rates of therapy modification due to drug-related toxicity for staphylococcal infections treated with ceftriaxone, cefazolin, nafcillin, oxacillin, vancomycin, daptomycin, ceftaroline, linezolid, or ertapenem. Secondary objectives included determination of the frequency and type of adverse drug events (ADEs) attributed to OPAT and rate of readmission due to ADEs attributed to OPAT.

Results

One hundred seventy-two patients were identified (cefazolin n = 54, ceftriaxone n = 49, vancomycin n = 30, daptomycin n = 16, nafcillin n = 9, ertapenem n = 6, ceftaroline n = 4, oxacillin n = 3, linezolid n = 1). The overall treatment completion rates were high (153/172, 89.0%). Patients completed an average of 35.3 days (7 to 95) of therapy with their original antibiotic. Fourteen patients required change to a different antibiotic due to antimicrobial toxicity (ceftriaxone=5; vancomycin=2; cefazolin = 2; daptomycin = 2; ceftaroline = 1; nafcillin = 1; oxacillin = 1) and five patients experienced treatment failure required an additional agent (ceftriaxone = 2; nafcillin = 2; linezolid = 1). Adverse drug events (ADEs) were the most common reason for antimicrobial adjustment (14/19, 73.7%). The most common ADEs were hypokalemia (28/172, 16.3%) and diarrhea (25/172, 14.5%). There were only two cases of Clostridium difficile. Thirty-day readmissions due to antimicrobial therapy were low with 11 patients.

Conclusion

OPAT with Gram-positive agents used for staphylococcal infections is effective, but antimicrobial modifications still occur. Clinicians should be aware of the risk of ADEs and readmissions in OPAT patients. A multidisciplinary approach may enhance management of ADEs and possibly preventing readmissions

Disclosures

All authors: No reported disclosures.
1251. Contaminated Sinks May be an Environmental Source for Serial Transmission of Carbapenem-Resistant Enterobacteriaceae (CRE) to ICU Patients
Authors: Lewis Sarah S , Seidelman Jessica , Huslage Kirk , Carriker Charlene , Hnat Amy , Lobaugh-Jin Erica , Sova Christopher , Taylor Bonnie , Strittholt Nancy , Vereen Sheila , Willis Robbie , Campbell Christy , Addison Rachel , Hazen Kevin , Mathers Amy , Vegesana Kasi , Carroll Joanne , Kotay Shireen , Baker Arthur W , Sexton Daniel , Anderson Deverick J , Smith Becky
Published: November 2018

Background

We performed an investigation after noting an increase in hospital-onset (HO) KPC-producing Enterobacteriaceae (KPC-E) infections in patients admitted to a tertiary referral hospital in North Carolina.

Methods

We defined pre-outbreak (January 1, 2017–June 30, 2017), outbreak (July 1, 2017–October 31, 2017), and post-outbreak (November 1, 2017–March 31, 2018) phases. A clinical case was defined as any positive clinical culture for KPC-E. HO was defined as a positive clinical or surveillance culture collected on hospital day ≥3. Patients were mapped in space and time to inform targeted environmental sampling. Whole-genome sequencing (WGS) was performed on selected KPC K. pneumoniae environmental and patient isolates to determine relatedness.

In October 2017, a CRE prevention bundle was implemented that included daily communication of CRE patient movement, increased audits/feedback of HCW compliance with hand hygiene, enhanced cleaning and disinfection in CRE rooms and high-risk units with bleach and UVC disinfection, and weekly rectal surveillance screens in four adult ICUs.

Results

0.67 clinical cases of KPC-E per month were observed during the pre-outbreak period compared with 3.75 clinical cases of KPC-E per month during the outbreak period. K. pneumoniae was the most common species (Figure 1). Mapping of patients revealed probable direct and indirect transmission between patients in multiple hospital units (Figure 2). three patients who were non-sequentially admitted to the same ICU room over a 12-week span acquired KPC K. pneumoniae (Figure 2). Environmental cultures from the in-room sink drain and P-trap grew KPC K. pneumoniae that was related to the patient isolates by WGS; the sink was removed. Although no additional clinical cases of KPC-E occurred after full implementation of the bundle and sink removal, we continued to observe acquisition of KPC-E rectal colonization in all four ICUs (Figure 3).

Conclusion

We describe a multispecies outbreak of KPC-E that was mitigated through evidence-based CRE control measures and removal of a colonized sink. However, ongoing low-level presumed transmission of KPC points to persistent environmental sources. Additional study is needed to understand the prevalence of CRE in hospital sinks, factors that drive drain colonization, and contribution of CRE in a sink to nosocomial transmission.

Disclosures

All authors: No reported disclosures.
1253. Healthcare-Associated Transmission of Burkholderia cepacia Complex Associated With Extrinsically Contaminated Nasal Spray
Authors: Tran Dat , Cassidy Maureen , Buehring Tara , Pierce Rebecca
Published: November 2018

Background

Burkholderia cepacia complex (Bcc) species can contaminate medical devices and water-based products, resulting in outbreaks of healthcare-associated infections. In March 2018, we investigated a cluster of 20 patients with a sinus culture positive for Bcc seen at two affiliated ENT clinics in Oregon over a 2-month period, based on reporting by a laboratorian in a central laboratory external to the clinics.

Methods

We conducted an epidemiologic investigation to identify potential causes for an apparent outbreak of Bcc, including review of health records and microbiologic reports, site visits, staff interviews, and cultures of common equipment and products.

Results

20 patients (9 were female; age range 10 to 72 years, median age 54.5 years) had new positive Bcc cultures from the sinus. The absence of cystic fibrosis, immunosuppression or sinonasal polyposis in all patients, scant growth of Bcc in most cases with isolation of another organism in some, and the use of Bcc-directed antibiotics in a minority of patients suggested the presence of a contamination source. All patients had received lidocaine/phenylephrine (L/P) via multidose nasal spray atomizers prior to endoscopically-directed sinus cultures. Site visits revealed improper medication dispensing and storage practices (e.g., no expiration date for L/P stock, storage of L/P-containing atomizers at room temperature), and inadequate instrument reprocessing and environmental cleaning. Cultures of L/P in 2/2 in-use atomizers and 1/1 opened stock bottle, as well as swabs of 3/3 spray mechanisms, grew Bcc. Cultures of L/P from the unopened, refrigerated stock bottle, a flexible endoscope and a rigid endoscope did not yield Bcc. No negative clinical sequelae in these patients were reported.

Conclusion

Contaminated multidose L/P nasal spray with Bcc resulted in nosocomial transmission at these clinics. This investigation highlights the important role of laboratorians in detecting Bcc contamination events that lead to colonization, and suboptimal reporting by clinicians in the outpatient setting. It also raises the question of how often such contamination events go undetected. Injection safety training needs to be broadened to “medication administration safety” training as one and only principles could have prevented this incident.

Disclosures

All authors: No reported disclosures.
1255. First Outbreak Due to Vancomycin-Resistant Enterococcus Epidemic Clone ST796 in Europe
Authors: Wassilew Nasstasja , Rolli Eveline , Fietze Yvonne , Casanova Carlo , Seth-Smith Helena , Egli Adrian , Marschall Jonas , Buetti Niccolo
Published: November 2018

Background

A large outbreak with different clones of vancomycin-resistant enterococci (VRE) affected the Bern University Hospital group for several months. The aim of this study was to describe the extent of the outbreak, using whole-genome sequencing (WGS).

Methods

Triggered by two cases of VRE bloodstream infections on our hemato-oncology ward, an outbreak investigation was started. Microbiological diagnosis of VRE was obtained by culture and PCR. Epidemiological links were assessed by meticulous chart review and supplemented with WGS analyses. Multiple infection control measures were implemented to avoid further transmissions.

Results

Between December 2017 and April 2018, 2,877 screening samples were obtained from 1,200 patients. Three out of six hospitals within the Bern University Hospital group were affected. Eighty-three patients (6.9%) were colonized with VR Enterococcus faecium. Of those, 76 (91.6%) had a strain carrying vanB, with 70 (84%) isolates virtually identical (separated by up to two alleles) by cgMLST and identified as MLST type ST796 (figure). The remaining seven patients (8.4%) were colonized with vanA carrying strains from five different STs. Five patients (7%) developed an invasive infection with VRE ST796. Temporo-spatial links were found in most patients carrying the outbreak strain. In order to control the outbreak, extensive infection control measures were implemented. By April 2018 the outbreak was contained with these specific measures.

Conclusion

This VRE outbreak was characterized by a rapid intra- and inter-institutional spread of the emergent clone ST796. This clone was recently described in Australia and New Zealand but never before in Europe.1,2 A multi-faceted infection control led to the containment of the outbreak.

References

1. Mahony AA, et al. Vancomycin-resistant Enterococcus faecium sequence type 796—rapid international dissemination of a new epidemic clone. Antimicrob Resist Infect Control. 2018:7:44.

2. Leong KWC, et al. Emergence of vancomycin-resistant Enterococcus faecium at an Australian Hospital: a whole genome sequencing analysis. Sci Rep. 2018:8(1):6274.

3. de Been M, et al. Core genome multilocus sequence typing scheme for high- resolution typing of Enterococcus faecium. J Clin Microbiol. 2015:53(12):3788–97.

Disclosures

All authors: No reported disclosures.
1265. Application of the ALERT Influenza Trigger for Enhanced Prevention Activities
Authors: Veach Lisa , Gibbons Julie , Smolka Katarina , Ramachandran Veena
Published: November 2018

Background

Accurate prediction of the onset of increased influenza activity in a healthcare setting can allow for optimal use of enhanced prevention activities. The ALERT (Above Local Elevated Respiratory Illness Threshold) algorithm, described by Reich et al. (2015), utilizes historical weekly case counts of laboratory-confirmed influenza infections to set a trigger point of cases/week that anticipates elevated disease incidence. This can then be used in real-time, during subsequent influenza seasons, for initiation of enhanced prevention, including masking by nonvaccinated healthcare workers.

Methods

Historical data collected from UnityPoint Health-Des Moines (3-hospital, 800-bed system), between 2011 and 2014, was analyzed using the ALERT method (Reich et al. 2015) to set a threshold number of diagnosed influenza cases per week to predict the start of the influenza season. Each following year the threshold was re-analyzed, adding the most recent year’s data to the historical data set. Our goal was to capture at least 80% of influenza cases within our “ALERT period,” without prolonging the duration of heightened prevention efforts.

Results

For the initial year of real-time application (2015–2016), the threshold was defined as seven cases. In subsequent years, the threshold was 5. Compared with the 3 years prior, use of the ALERT method resulted in more accurate and consistent identification of the influenza season, including anticipating the increase in cases and defining the total duration of the season.

Conclusion

The ALERT method utilizes health system specific historical data to more precisely define the period of high influenza incidence allowing for focused utilization of enhanced measures to prevent transmission. This results in a safer environment, optimal use of resources and improved employee and patient satisfaction.

Disclosures

All authors: No reported disclosures.
1268. Transmissibility of Candida auris by Type of Inpatient Healthcare Facility
Authors: Paul Prabasaj , Forsberg Kaitlin , Vallabhaneni Snigdha , Lockhart Shawn R , Litvintseva Anastasia P , Kerins Janna L , Tang Angela S , Jegede Olufemi , Barrett Patricia M , Ross Kathleen , Slayton Rachel , Jernigan John A
Published: November 2018

Background

Candida auris is a multidrug-resistant yeast causing outbreaks in healthcare settings. Stopping the spread of C. auris requires rapid identification of healthcare facilities at risk of higher transmission to help targeted implementation of infection control measures. We used data collected during public health investigations to quantify transmissibility of C. auris by type of healthcare facility.

Methods

In two states, 3,159 patient swabs were collected during 96 C. auris point prevalence surveys conducted at 36 inpatient healthcare facilities in November 2016 and April 2018. We estimated facility transmissibility and facility reproduction number (number infected by one index colonized patient per day, and per stay, respectively, at the facility) of C. auris based on estimated colonization pressure, a count of newly colonized patients between successive surveys at the same facility, and mean lengths of stay at facilities (estimated from CMS administrative data). The results were summarized by facility type: acute care hospital (ACH), long-term acute care hospital (LTACH) or ventilator unit at skilled nursing facility (VSNF), and were compared with previous estimates for transmissibility of carbapenem-resistant Enterobacteriaceae (CRE).

Results

Swabs were collected from 13 ACHs, 12 LTACHs, and 11 VSNFs. The C. auris facility reproduction number may exceed the critical value of 1 in both ACHs and VSNFs, and may exceed that for CRE in ACHs (table).

Conclusion

Transmissibility of C. auris is comparable to that of CRE. The transmissibility within VSNFs emphasizes their potential role as amplifiers in the outbreak. Understanding transmissibility by facility type helps evaluate the potential impact of interventions in various settings.

Disclosures

All authors: No reported disclosures.
1269. HIV Testing in a Large Community Health Center Serving a Multi-cultural Population: A Qualitative Study of Providers
Authors: James Anthony , Marable Danelle , Cubbison Caroline , Tarbox Andrew , Oo Sarah , Freedberg Kenneth , Levison Julie
Published: November 2018

Background

In the United States, 15% of people with HIV (PWH) do not know their serostatus, leading to both individual morbidity and HIV transmission to others. While CDC guidelines recommend HIV screening for all individuals aged 13–64 years, racial and ethnic minorities in the United States continue to present to care with advanced HIV infection.

Methods

Our objective was to assess providers’ perspectives on barriers to and facilitators of HIV testing at an urban community health center serving a predominantly racial/ethnic minority population of low socio-economic status. Study staff conducted five focus groups from January 2017 to November 2017 with 74 health center staff: 20 adult medicine/primary care providers, 28 community health workers (CHWs), six urgent care physicians, six community health administrators, and 14 behavioral health providers. Each focus group ranged from six to 20 participants. In addition to exploring participants’ views on HIV testing in this setting, we also explored potential interventions to improve HIV testing. Interviews were digitally recorded. Data were analyzed using a grounded theory approach. We used open coding to develop themes and compared themes among provider groups.

Results

The main facilitators of routine HIV testing were clinical training in HIV/hepatitis care and CHWs engaging patients in topics that intersect with HIV risk factors. Providers’ perceptions of key barriers were patients’ cultural perceptions of HIV (e.g. HIV-related stigma), patients’ concerns about test confidentiality, competing medical and social issues, and provider lack of HIV knowledge. All groups agreed that HIV testing should occur through the primary care provider though acknowledged that patients may be seeking healthcare more frequently through mental health, urgent care, or social services than primary care. Primary care physicians wanted easier mechanisms to identify patients in need of HIV testing and assistance with offering the test to non-English language speaking patients.

Conclusion

Specific, focused efforts can lead to improved HIV testing in racial ethnic minorities in community health centers. Training to improve provider comfort, increasing CHW engagement, and a focus on patients’ cultural beliefs may all have an impact.

Disclosures

All authors: No reported disclosures.
1270. Are HIV-Related Diagnostics Excessively Ordered? A Pilot Intervention Study to Improve Test Use in the Inpatient Setting
Authors: Asl Daryush Tabatabai , Sikand Harminder , Sullivan Eva , Crum-Cianflone Nancy
Published: November 2018

Background

Excessive ordering of HIV-related laboratory tests (CD4 counts, HIV RNA levels, and HIV genotypes) may result in increased healthcare costs, unneeded interventions (e.g., response to low CD4 in acute illness), and patient anxiety. Recent data have evaluated methods to reduce excessive testing in outpatients, but there are limited data in the inpatient setting. The purpose of this study was to evaluate if implementation of a pharmacist-driven intervention protocol based on published guidelines improved utilization of HIV-related diagnostics in the inpatient setting.

Methods

A pre-interventional study performed on HIV diagnostics usage over a 1-year period, followed by a 3-month post-interventional study at a large academic medical center to evaluate and improve HIV test ordering. Patients were included if ≥18 years old with suspected or documented HIV infection and CD4 count, HIV RNA level, or HIV genotype ordered. A pharmacist-driven intervention was undertaken in which ordered tests were evaluated and canceled if deemed inappropriate per pre-specified criteria based on CDC and DHHS guidelines, and clinicians were provided education on appropriate ordering. Results were tabulated and presented as descriptive statistics, and financial data were calculated based on in-hospital costs.

Results

In the pre-intervention arm, 87% (296/341) of total tests ordered did not meet criteria for appropriate ordering (160 unneeded CD4 counts, 126 RNA levels, and 10 genotypes). These tests resulted in excessive financial burden of $24,600. Post-intervention, 63% (32/51) of HIV-related tests were canceled netting an initial savings of $2,700. Most common cancelation reason was recent outpatient laboratories readily available. Post-intervention, HIV-related testing decreased over time, likely due to the intervention audit and feedback provided to clinicians.

Conclusion

A pharmacist-driven intervention reduced the number of unnecessary HIV-associated tests by 63% and offered significant cost savings. These data suggest the importance of evaluating the appropriateness of HIV-related diagnostic testing in the inpatient setting to improve test usage and reduce excessive healthcare costs.

Disclosures

All authors: No reported disclosures.
1271. Prevalence and Factors Associated With HIV Testing Among Sexually Experienced 18–49-Year-Old Hong Kong Residents
Authors: Zhao Yanping , Parish William , Yang Li-Gang , Emch Michael , Ho King Man , Fong Francois Yeung , Miu Heidi Yin Hai , Tucker Joseph D , Wong William Chi Wai
Published: November 2018

Background

The main HIV transmission route in Hong Kong is sex, accounting for 78.0% of the total reported cases. The majority of HIV cases were identified among those 20 to 49 years of age. In this study, we explored the prevalence and factors associated with HIV testing among 18 to 49 years old residents in Hong Kong.

Methods

A population-based survey on sexual practice and health behavior was conducted in Hong Kong with a sample of 881 participants drawn from geospatial modeling, proportional to the district population sizes. Invitation letters were sent to selected households and interviewers were sent to recruit one subject per household. Once recruited, face-to-face interviews were carried out with a computer-assisted self-interview. The final data were weighted according to the 2011 Hong Kong census and factors identified through logistic regression.

Results

Among 881 participants, 81.6% reported having sex before, among whom, 19.5% (137) had ever taken HIV tests. The main reasons for the 75.5% of participants not taking HIV testing are they do not think they are at risk of HIV infection (59.1%) or think they are very healthy (29.4%). The main places for HIV testing among those tested were public hospital/clinic (39.7%), private clinic/hospital (34.7%), and another 22.0% was tested in antenatal check-up or Hong Kong Red Cross. Among the sexually experienced residents, factors associated with HIV testing include marital status and number of sexual partners. Compared with single participants, those cohabiting, married, or with marital history were about seven times more likely to be tested (aOR = 6.73, 95% CI 2.23–20.31). Those who had >1 sexual partners were about twice as likely to be tested (aOR = 1.84, 95% CI 1.05–3.25). Other factors such as condom use, sexual orientation, anal sex behaviors or sexually transmitted infections history were not associated with HIV testing.

Conclusion

HIV testing among Hong Kong residents is comparatively low. Though those with more than one sexual partner are more likely to be tested, those single, nonconsistent condom users, or with risky behavior such as anal sex behaviors do not associate with higher HIV testing. More HIV testing campaign and awareness raising shall be targeted toward people with at-risk behaviors.

Disclosures

All authors: No reported disclosures.
1274. Universal HIV and HCV Screening in San Diego Emergency Departments: Implications for Other Settings With a High Density of Free of Charge HIV Screening Programs
Authors: Hoenigl Martin , Coyne Chris , Blumenthal Jill , Vilke Gary , Little Susan
Published: November 2018

Background

While HIV and HCV testing targeted to high-risk groups results in substantially higher proportions of HIV diagnoses, universal HIV and HCV screening in emergency department (ED) settings is expected to reach populations who do not perceive themselves to be at risk or are otherwise less likely to participate in HIV and HCV testing. As a consequence the CDC recommends routine HIV screening for persons 13–64 years of age, and routine HCV screening for the birth cohort (born between 1945–1965). The objective of this analysis was to evaluate the yield of universal opt-out HIV and HCV screening in the two EDs at the University of California San Diego (UCSD).

Methods

In July 2017, electronic medical record (EMR) based universal opt-out HIV screening (Architect HIV antibody [Ab]/HIV p24 antigen detection) for persons aged 13–64 years (excluding persons known HIV+ or reporteing an HIV test within the last 12 months) was implemented in our EDs. The EMR algorithm also identified HIV+ individuals who had been out of care for >12 months. In March 2018, EMR based universal HCV screening for birth cohort was added in both EDs.

Results

Over a period of 9 months 7,303 HIV tests were conducted, resulting in 24 (0.3%) new HIV diagnoses, of which 21 were successfully linked to care. In five individuals without HIV infection Architect gave a false-positive result (specificity 99.93%). In addition, the EMR algorithm identified 38 out of care HIV+ individuals of which 21 were successfully relinked to care. During the 1-month HCV birth cohort screening 963 HCV Ab tests were conducted, of which 106 (11%) resulted positive. At the time being 78 of those seropositive individuals had HCV RNA testing, of which 36 (53%) resulted positive (3.7% of all participants).

Conclusion

In San Diego, a setting with a high density of free-of charge HIV screening programs, 1/300 HIV tests in the ED yielded a new HIV diagnosis and in total 21 newly diagnosed individuals were linked to care. Identification of HIV+ out of care individuals yielded in an equivalent number of individuals relinked to care. The rate of newly diagnosed HCV infections exceeded the rate of newly diagnosed HIV infections by >10-fold outlining the importance of screening for HCV in the ED.

Disclosures

All authors: No reported disclosures.
1288. Adolescents’ Knowledge and Acceptance of Pre-exposure Prophylaxis (PrEP) in the Capital District Region of New York
Authors: Santos Roberto P , Adams Mary Ellen , Lepow Martha , Tristram Debra
Published: November 2018

Background

In 2015, adolescents 13–24 years were disproportionately affected and accounted for 22% of new HIV infections in the United States. In New York State (NYS), the rate of adolescents (13–19 years) living with HIV infection is more than twice the national rate (44.4 vs. 19.4 per 100,000 population). As part of the ending the epidemic (ETE) program, the NYS Department of Health spearheaded access to pre-exposure prophylaxis (PrEP) for high-risk individuals to keep them HIV negative. This study aims to test the hypothesis that adolescents at risk may not be utilizing PrEP and that there are barriers to adopting it.

Methods

A cross-sectional survey (Qualtrics) was conducted from Aug 2017 to May 2018 using a 13-item multiple choice and Lickert scale validated questionnaire that takes <5 minutes to complete. Descriptive and nonparametric tests (GraphPad Prism v5.04) were used to characterize knowledge and acceptance of PrEP among adolescents in Capital District NY after the initiation of the ETE program in NYS.

Results

There were 97 respondents and 89 (92%) completed all questions. Most of the respondents identify themselves as female (36%), straight (27%), middle aged adolescents 15–17 years (64%), African American (46%) and currently in high school (69%). Majority have seen a medical provider in the past 12 months (90%), at the doctor’s office (61%), and majority have never been offered HIV test (60%). Majority have not heard of a medicine that can prevent HIV infection (58%), most have not heard of PrEP (57%), and many do not know where to go to learn more about PrEP (56%). Most have not been offered PrEP (86%) and respondents were split in adopting PrEP (yes 49% vs. no 51%). The reasons for not agreeing to start PrEP are shown in Figure 1. Majority are interested in attending educational program on PrEP (57%). Adolescents are likely to adopt PrEP if they heard about it (P = 0.01), if they know where to go to learn about it (P = 0.02), and if someone offered it (P = 0.03).

Conclusion

Adolescent knowledge of PrEP may be suboptimal and presents barriers to adopting it. However, they are willing to accept PrEP if offered. This study demonstrates potential avenues for intervention and provider-initiated programs should be evaluated in scaling-up PrEP into adolescent health services.

Disclosures

All authors: No reported disclosures.
1293. The Next Step in PrEP: Evaluating Outcomes of a Pharmacist-Run HIV Pre-Exposure Prophylaxis (PrEP) Clinic
Authors: Ryan Keenan , Lewis Jessica , Sanchez Daniel , Anderson Beverly , Mercier Renee-Claude
Published: November 2018

Background

PrEP has been proven as an effective option for preventing the transmission of HIV; however, there are limited numbers of providers willing to prescribe PrEP. Pharmacists are an underutilized resource that are able to provide PrEPservices in many states. In Albuquerque, New Mexico, one of the nation’s first pharmacy-run HIV PrEP clinics was established in July 2015. The objective of this study was to describe the outcomes of an alternative model for HIV prevention.

Methods

The electronic medical record was used to identify and retrospectively review patients of the PrEP clinic from July 2015 to July 2017. Pertinent information including: risk factors for HIV acquisition, sexually transmitted infections (STIs) history, laboratory and medication-related data were captured. Data on partner HIV status and HAART regimen was collected when available. Adherence was evaluated by self-reported missed doses and the compliance rate was calculated from the patient’s medication fill history. Descriptive statistics was performed using SPSS.

Results

The first PrEP appointment was attended by 136 patients during study period. Baseline demographics are reported in Table 1. Two patients tested positive for HIV at baseline. PrEP was started in 127 patients with tenofovir/emtricitabine(TDF/FTC). There were no HIV seroconversions among those who started PrEP. Only one patient discontinued due to side effects. No significant elevation in Scr was noted over time. Overall, patients demonstrated a high adherence rate with an average of <1 missed doses per month and a median compliance rate of 0.99.

Conclusion

A pharmacist run PrEP clinic is an alternative model to increase patient access to PrEP. TDF/FTC was provided to high-risk individuals and well-tolerated. Providers were able to promote high level of adherence.

Disclosures

All authors: No reported disclosures.
1294. Acceptability and Feasibility of a Pharmacist-led Pre-exposure Prophylaxis Program in the Midwestern United States
Authors: Bares Sara , Havens Joshua , Scarsi Kimberly , Klepser Donald , Swindells Susan
Published: November 2018

Background

Despite evidence that HIV pre-exposure prophylaxis (PrEP) substantially reduces the risk of infection in at-risk populations, significant barriers exist to its prescription and use. Utilizing pharmacists may help increase patient access to PrEP services. We designed and implemented a novel pharmacist-led PrEP program in Omaha, Nebraska.

Methods

Our pharmacist-led PrEP program was developed in the fall of 2016. Six pharmacists from four sites (one community pharmacy, two community-based clinics and one HIV-specialized clinic) were selected for participation based on interest, senior management support, and availability of appropriate infrastructure. All pharmacists received training for the provision of PrEP. Through a collaborative practice agreement, pharmacists met with patients individually, obtained a medical history, performed a risk assessment and point-of-care laboratory testing (HIV screen, creatinine, and syphilis), and collected samples for gonorrhea and chlamydia. They also provided medication and adherence counseling, and prescribed emtricitabine-tenofovir DF when appropriate. Pharmacists completed a survey reporting their experience after each visit. Presented here are patient demographics, retention rates, and pharmacist-reported experience from the first 6 months of the program.

Results

Sixty patients enrolled in the pharmacist-led PrEP program between January and June 2017 and completed 139 visits. 95% of participants were men, 83% were white, 80% were privately insured, and 90% had completed some college or higher. The mean age of participants was 34 years (range 20–61 years) and 88% identified as men who have sex with men. 73% were retained in care at 3 months and 58% were retained in care at 6 months. To date, no patient has seroconverted. Pharmacists reported feeling comfortable performing point-of-care testing at all visits and only reported feeling uncomfortable counseling patients on three occasions (2.2%). Finally, pharmacist-reported workflow disruption only occurred on 1 occasion (0.7%).

Conclusion

Implementation of a pharmacist-led PrEP program is feasible, associated with high rates of pharmacist acceptability, and results in retention rates that are comparable to other real-world PrEP programs.

Disclosures

S. Bares, Gilead: Grant Investigator, Grant recipient. S. Swindells, Merck: Investigator, Research support. ViiV: Investigator, Research support.