bluuebunny/crossref_metadata_2025 huggingface dataset:
1763. Estimating Median Survival Time to Central Line-Associated Bloodstream Infection (CLABSI) Among Patients in Intensive Care Units Reported to National Healthcare Safety Network (NHSN)
Authors: Soe Minn , Edwards Jonathan R
Published: November 2018

Background

Duration free of central line-associated bloodstream infection (CLABSI) in a hospital may vary by type of patient population. We estimated patients’ median time to CLABSI by intensive care unit (ICU) type among acute care hospitals.

Methods

The study population was ICU patients whose CLABSI data were reported to National Healthcare Safety Network (NHSN) in 2016 under the reporting requirement of the Centers for Medicare and Medicaid. The unit of analysis was ICU location, not an individual patient. We conducted counting process survival analysis method to compute time (day) to a CLABSI beginning from day 1 of first reporting month in 2016 in a given ICU location. Once a CLABSI occurred in a location, the start time of follow-up was reset to day 1 after the date of event. The Cox regression method was used to explore the hospital and location-level characteristics that are potentially associated with the daily hazard of CLABSI for an ICU. We also assessed the proportionality hazard assumption of these factors. Adjusting for the vector of means of covariates, we then estimated median time to CLABSI by ICU location type, which is defined as follow-up time (days) by which 50% of events have happened in a given ICU type.

Results

In 2016, 6,935 ICUs at 3,384 hospitals reported CLABSI data to NHSN, with a total of 10,985 CLABSIs and 2,449,361 follow-up time in days. Factors associated with an increased daily hazard of CLABSI were the following: admission to a hospital with a large bed size, major teaching status, and admission to a patient care location with a higher device utilization ratio (Table 1). Adjusted survival curves showed that median time to event (median CLABSI-free time) among ICUs ranged from 66 days (level III neonatal ICU), 90 days (burn units) to 275 days (oncology units), and 284 days (cardiothoracic units) (Table 2, Figure 1).

Conclusion

The study demonstrated that ICUs with level III care for neonatal patients and ICUs with burn patients were least likely to achieve the target of “zero” infection in a defined period and may warrant further targeted interventions. Similar research to investigate infection control performance through estimating median infection-free time is needed beyond ICUs and across multiple HAI types and facility settings.

Disclosures

All authors: No reported disclosures.
1766. Sustained Viral Suppression with Dolutegravir and Boosted Darunavir Dual Therapy Among Highly Treatment-Experienced Individuals
Authors: Hawkins Kellie , Montague Brian , Rowan Sarah , Mclees Margaret , Beum Robert , Johnson Steven C , Gardner Edward
Published: November 2018

Background

The use of antiretroviral (ARV) dual therapy for treatment of HIV is increasing; raltegravir with boosted darunavir (bDRV) is recommended in certain clinical situations in DHHS guidelines. Dolutegravir (DTG) with bDRV has not been widely studied. We sought to determine the effectiveness of DTG/bDRV in treatment experienced patients.

Methods

This retrospective cohort study evaluated viral suppression in patients prescribed DTG/bDRV dual therapy within a large urban health system. Data collected included demographics, cumulative ARV exposure, reasons for use, regimen start/stop dates, and viral suppression (HIV-RNA ≤200). Follow-up was defined as the number of days from start of regimen until last HIV-RNA determination on the study regimen.

Results

From January 1, 2013 to December 31, 2017, 60 patients received DTG/bDRV dual therapy: 15% were female, median age was 56, 83% were ≥3 class ARV-experienced, and median time since starting ARVs was 20 years. Median follow-up on DTG/bDRV was 444 days (IQR 273–808). Viral suppression was achieved by 59 of 60 (98%) patients at some point on DTG/bDRV. When stratified by baseline viral suppression, 46 of 46 (100%) who had baseline viral suppression maintained viral suppression in comparison to 11 of 14 (79%) without baseline viral suppression (table). The most common reasons for DTG/bDRV were simplification in setting of prior resistance (47%), toxicity reduction (39%), and virologic failure (15%). At study end, 53 of 60 (88%) were still on DTG/bDRV and the most common reason for stopping was drug interactions.

Conclusion

In a highly treatment-experienced cohort of patients, DTG/bDRV dual therapy demonstrated sustained rates of viral suppression, even in those who were failing therapy prior to initiating the regimen. Further study of this potent, simple, high-barrier dual class regimen is warranted.

Disclosures

S. Rowan, Gilead Sciences: Investigator, Research grant. S. C. Johnson, Viiv Healthcare: Scientific Advisor, Consulting fee.
1770. The Association of Unmet Needs With Subsequent Retention in Care and HIV Suppression Among Hospitalized Patients With HIV Who Are Out of Care
Authors: Dandachi Dima , May Sarah , Davila Jessica , Cully Jeffrey , Amico K Rivet , Kallen Michael A , Giordano Thomas P
Published: November 2018

Background

Unmet needs among hospitalized patients with HIV may prevent engagement in HIV care leading to worse clinical outcomes. Our aim was to examine the role of unmet subsistence needs (e.g., housing, transportation, food) and medical needs (e.g., mental health, substance abuse treatment) as barriers for retention in HIV care and viral load (VL) suppression.

Methods

We utilized data from the Mentor Approach for Promoting Patients’ Self-Care intervention study, the enrolled hospitalized HIV-patients at a large publicly funded hospital between 2010 and 2013, who were out-of-care. We examined the effect of unmet needs on retention in HIV care (attended HIV appointments within 0–30 days and 30–180 days) and viral load suppression, 6 months after discharge.

Results

A total of 417 participants were enrolled, 78% reported having ≥1 unmet need at baseline, most commonly dental care (55%), financial (43%), or housing needs (34%). Participants with unmet needs at baseline, compared with those with no needs, were more likely to be African American, have an existing HIV diagnosis, and be uninsured. Among participants who completed a baseline and 3-month survey (n = 320), 45% reported a need for dental care, 42% reported financial needs, and 32% reported housing needs that were unmet at either time point (Figure 1). Having a dental care need at baseline that was met was significantly associated with higher odds of VL improvements at 6-month follow-up (OR: 2.2; 95% CI: 1.04–4.50, P = 0.03) and higher odds for retention in care (OR: 2.06; 95% CI: 1.05–4.07, P = 0.04). An unmet need for transportation was associated with lower odds of retention in care (OR: 0.5; 95% CI: 0.34–0.94, P = 0.03), even after adjusting for other factors. Compared with participants with no need, those who reported ≥3 unmet subsistence needs were less likely to demonstrate viral load improvement (OR: 0.51; 95% CI: 0.28–0.92; P = 0.03) and to be retained in care (OR: 0.52; 95% CI: 0.28–0.95; P = 0.03).

Conclusion

An important and novel finding in our study is that the number of unmet subsistence needs had a significant effect on retention in care and VL suppression. Broader access to programs that can assist in meeting subsistence needs among hospitalized patients could have significant individual and public health benefits.

Disclosures

All authors: No reported disclosures.
2559. Incidence and Clinical Impact of Discordant Genotypic and Phenotypic Categorization of Methicillin Susceptibility in Staphylococcus aureus Bacteremia
Authors: Gulliver Jessica , Jung-Hynes Brittney , Chen Derrick
Published: November 2018

Background

Methicillin-susceptible/methicillin-resistant Staphylococcus aureus (MSSA/MRSA) can be directly identified from positive blood culture bottles using molecular methods. This provides faster results than traditional phenotypic testing, but discrepancies between the two are occasionally found. We sought to determine the incidence and clinical impact of such discrepancies.

Methods

Positive blood culture bottles are routinely tested in the hospital clinical laboratory for mecA via Xpert MRSA/SA BC (PCR), and antimicrobial susceptibility testing (AST) via MicroScan PC33 is performed on recovered S. aureus isolates; discrepancies between PCR and AST are resolved by repeat and supplemental (Kirby-Bauer) testing. A retrospective review of medical and laboratory data from January 2015 to December 2017 was performed on all patients that had discordant PCR and AST results.

Results

Approximately 1,200 PCR assays were performed from January 2015 to December 2017, and there were 5 (0.4%) cases with discordant AST Results. Four cases were classified as MSSA by PCR but MRSA by AST, and 1 case was classified as MRSA by PCR but MSSA by AST. For the former group, antimicrobial therapy was changed in 2 patients to cover MRSA and 1 patient was readmitted, while the remaining 2 patients were already being treated for MRSA; for the latter case, this patient was treated for MRSA during the initial hospitalization, but was readmitted with disseminated MSSA and subsequently deceased. Based on genetic targets identified by PCR and cefoxitin and oxacillin AST, discrepancies were likely due to borderline oxacillin resistance (BORSA) (n = 1), presence of an SCCmec variant not detected by PCR (n = 1), or undetermined (n = 3).

Conclusion

Rapid identification of MRSA bacteremia via PCR provides actionable information to direct empiric treatment. While highly accurate, PCR results are infrequently not corroborated by AST. This rare possibility should be considered when modifying therapy based on initial PCR results, and there should be close communication between the clinical team and laboratory for these challenging cases.

Disclosures

All authors: No reported disclosures.
2560. Multispecies Outbreak of KPC-2 Producing Enterobacteriaceae in a Chilean Pediatric Hospital
Authors: Rojas Laura J , Marshall Steven H , Rivas Lina M , Spencer Maria , Rutter Joseph , Jacobs Michael R , Perez Federico , Coria Paulina , Valdivieso Francisca , Bralic Rafael Araos , Munita Jose M , Bonomo Robert A
Published: November 2018

Background

Carbapenem-resistant Enterobacteriaceae (CRE) are a critical global health problem. We detected a surge of CRE cases in a pediatric hospital in Chile, a country with a low endemicity of KPC-producing organisms. Herein, we describe the molecular epidemiology of this outbreak.

Methods

CRE isolates from clinical specimens and surveillance rectal swabs (obtained using chromID CARBA SMART agar, BioMerieux) of pediatric patients were collected from July 2015 to January 2017. Species identity was confirmed by MALDI-TOF. Carbapenemase genes (blaKPC, blaNDM, blaVIM, blaIMP, and blaOXA-48-like) were detected by multiplex PCR, followed by amplification and sequencing of the blaKPC allele. Conjugation experiments were conducted with representative species as donors and sodium azide-resistant E. coli J53 as recipient. PCR-based plasmid typing (PBRT Diatheva kit) was then performed on donors and recipients. For K. pneumoniae, genetic relatedness was investigated by PFGE, multilocus sequence typing and wzi typing.

Results

Sixty-one CRE clinical and surveillance isolates were obtained from 49 patients aged 17 days to 16 years. blaKPC-2 was present in 57/62 isolates; no other carbapenemases were found. For 11 patients, multiple cultures were obtained; 4/11 had more than one KPC-harboring species. KPC-harboring isolates displayed ertapenem MICs ranging from 1 to >8 mg/L. Preliminary analyses suggest that blaKPC-2 is contained within a nonclassical Tn4401 structure (lacking the upstream promoter). Mating experiments indicate that blaKPC-2 is carried by a conjugative IncN backbone plasmid. Interestingly, K. pneumoniae isolates were nonclonal by PFGE and belonged to multiple STs unrelated to CG258 (ST34, ST36, among others) and different wzi types (37, 154, among others).

Conclusion

We report a multispecies outbreak of KPC-2 producing CRE in children mainly driven by horizontal dissemination of a promiscuous IncN plasmid. The nonclonal, multispecies nature of this outbreak provides insights into the complex dynamics of KPC dissemination in countries like Chile, where the clonal spread of highly successful clones like CG258 is not the predominant dissemination vehicle, and instead HGT-related spread could be playing a more important role.

Disclosures

All authors: No reported disclosures.
2565. A Novel Prognostic Gene Set for the Prediction of Severe Dengue
Authors: Robinson Makeda L , Sweeney Timothy E , Barouch-Bentov Rina , Sahoo Malaya K , Sanz Ana Maria , Pu Szu-Yuan , Ortiz Eliana , Albornoz Luis , Suarez Fernando Rosso , Montoya Jose G , Pinsky Benjamin , Khatri Purvesh , Einav Shirit
Published: November 2018

Background

There is an urgent need for the identification of biomarkers predictive of severe dengue. Single cohort transcriptomic studies have not yielded a parsimonious gene set predictive of severe dengue. We hypothesized that integration of gene expression data from heterogeneous patient populations with dengue infection would yield a set of conserved genes that is predictive of severe dengue and generalizable across cohorts.

Methods

Ten dengue gene expression datasets were identified in publicly available microarray repositories. A novel integrated multicohort platform was used to detect differentially expressed gene transcripts between uncomplicated and severe dengue patients and validate the identified putative signature in silico and prospectively in a new cohort of 34 dengue patients in Colombia. Dengue diagnosis was made by NS1 antigen and anti-DENV IgM antibody and confirmed by RT-PCR assays, ELISA, and IgG avidity measurements. The expression level of the signature genes was measured via microfluidic qRT-PCR assays in blood samples collected longitudinally during the course of illness.

Results

Using the multicohort analysis to analyze 446 peripheral blood samples of patients with dengue infection from 7 publicly available gene expression datasets, we identified a 20 gene set that predicts the development of severe dengue. We in silico validated the diagnostic power of this gene set to separate severe dengue from dengue with or without warning signs in 3 independent datasets composed of 84 samples with a global area under the ROC curve (AUC) of 0.80 [95% CI 0.68–0.88]. We prospectively validated the gene set in a new cohort composed of 34 dengue patients from Colombia with an AUC of 0.89 [95% CI 0.81–0.97]. The severity scores measured in patients with severe dengue progressively declined in longitudinal samples.

Conclusion

Our data indicate that the identified 20 gene signature predicts the development of severe dengue in patients prior to its onset and suggest that dengue infection itself triggers this host response. These findings may provide new insight into the pathogenesis of severe dengue and have implications for the development of a prognostic molecular assay to identify patients at risk to develop severe dengue.

Disclosures

T. E. Sweeney, Inflammatix, Inc.: Employee and Shareholder, Salary. P. Khatri, Inflammatix, Inc: Scientific Advisor and Shareholder, Licensing agreement or royalty.
2572. Decreased T-Cell Response, but Appropriate Antibody Production to Tetanus Vaccine Among HIV-Exposed Uninfected Infants in Botswana
Authors: Smith Christiana , Moraka Natasha , Ibrahim Maryanne , Moyo Sikhulile , Mayondi Gloria , Kammerer Betsy , Leidner Jean , Gaseitsiwe Simani , Shapiro Roger , Lockman Shahin , Weinberg Adriana
Published: November 2018

Background

In Botswana, more than 10% of HIV-exposed, uninfected infants (HEU) are hospitalized or die in the first 6 months of life, largely due to infectious causes. Vaccine responses can act as a marker of the immune response to infectious antigens. Previous studies of vaccine responses in HEU have had conflicting results. We compared T-cell responses to tetanus and purified protein derivative (PPD), and antibody titers to tetanus, between HEU and HIV-unexposed infants (HUU).

Methods

A total of 443 HIV-infected and 451 HIV-uninfected mothers and their 453 HEU/457 HUU live-born infants were followed from pregnancy/delivery through 24 months postpartum in a prospective observational study in Botswana (“Tshipidi”). T-cell expression of interferon (IFN)-γ and interleukin (IL)-2 were measured at 6 months using FluoroSpot after stimulation with tetanus toxoid or PPD. Quantitative tetanus toxoid IgG was measured in plasma at 18 months using ELISA. Mean spot-forming units (sfu) per 105 cells and geometric mean antibody titers were compared between HEU and HUU infants who had received 3 doses of tetanus and 1 dose of Bacille Calmette–Guérin (BCG) vaccines by 6 months, and 3 or 4 doses of tetanus vaccine by 18 months.

Results. Peripheral blood mononuclear cells were available at 6 months for 63 HEU and 18 HUU. Plasma was available at 18 months for 39 HEU and 42 HUU. HEU infants had significantly lower IL-2 expression after tetanus stimulation than HUU infants (4.4 vs. 16.1 sfu/105 cells, P = 0.004; figure), but no difference in IFNγ expression. There were no differences in T-cell responses to PPD between HEU and HUU. There were no differences in tetanus geometric mean antibody titers between HEU and HUU.

Conclusion. In this cohort of infants from Botswana, we found decreased T-cell responses, but not antibody responses, to tetanus toxoid and no differences in T-cell responses to PPD. Cell-mediated immune defects may play a greater role than humoral immune defects in the increased susceptibility to infection among HEU. BCG vaccine produces robust T-helper 1 responses, which may overcome cell-mediated immune defects in HEU.

Disclosures

All authors: No reported disclosures.
1171. Impact on Mortality, Length of Stay, and Antibiotic Use in Allogenic and Autologous Stem Cell Transplant Patients Colonized With Carbapenemase-Producing Enterobacteriaceae
Authors: Ghani Rohma , Mookerjee Siddharth , Mullish Benjamin , Thursz Mark , Marchesi Julian , Pavlu Jiri , Davies Frances
Published: November 2018

Background

Carbapenemase producing Enterobacteriaceae (CPE) are increasingly impacting on patient management and hospital infection control practice. Stem cell transplant patients are among the most susceptible to invasive infections. Here we explored how this cohort are affected by CPE colonization.

Methods

All patients who underwent an autologous or allograft stem cell transplant (SCT) between September 15 and December 17 at a large tertiary hospital who were CPE positive on routine rectal screening were reviewed. Length of stay (LoS) post SCT, including readmissions for sepsis and number of days of antibiotics therapy, was assessed. Controls were matched for time and type of SCT in a three controls to one case ratio. T-test was performed to analyze differences between groups (statistical significance attributed when P < 0.05).

Results

The case sample had 20 SCT CPE-positive patients, of which allograft (n = 9) and autograft (n = 11). The control sample was made up of 59 SCT CPE-negative patients, allograft (n = 27), and autograft (n = 32). All patients had antibiotic therapy post SCT. Average LoS for the case sample was significantly longer in the autograft group (41.7 vs. 23.6 days, case vs. control, P = 0.01), but not significant in the allograft group (75.1 vs. 58 days, P = 0.12). Both autograft and allograft case samples had significantly longer duration of meropenem therapy, 24.8 vs. 14.4 days for allograft (P = 0.03) and 9.4 vs. 5.5 days for autograft (P = 0.03), cases vs. control. Colistin therapy was longer in both case samples (P = 0.03 in autograft and P = 0.006 in allograft). Tigecycline therapy was significantly longer in the autograft case vs. control sample (P = 0.006), with teicoplanin and piperacillin–tazobactam therapy significantly longer in the autograft case vs. control sample, P = 0.015 and P = 0.03, respectively.

Conclusion

The LoS post SCT and duration of antibiotic therapy were found to be key proxy measures of worsening outcomes for CPE-positive patients vs. CPE-negative patients who had undergone SCT. Although reasons for CPE colonization vary, there appears to be an overall negative impact on patient outcomes and increased use of more toxic agents, demonstrating the need for early directed CPE decontamination therapy of these at-risk patients, such as use of Faecal Microbiota Transplant (FMT).

Disclosures

All authors: No reported disclosures.
1173. A Cluster of Carbapenemase-Producing Acinetobacter baumannii
Authors: Young Heather , Croyle Caroline , Janelle Sarah J , Knepper Bryan , Kurtz Jennifer , Miller Amber , Reese Sara , Schutz Kyle , Bamberg Wendy
Published: November 2018

Background

Carbapenem-resistant A. baumannii (CRAB) is reportable in Colorado with three to 11 cases detected annually. Between December 2017 and February 2018, Denver Health Medical Center (DHMC) detected two inpatients with CRAB in urine. The hospital and the Colorado Department of Public Health and Environment (CDPHE) conducted an investigation to determine epidemiologic links and molecular relatedness of the isolates.

Methods

We reviewed medical records and performed infection control observations among staff. Pulsed-field gel electrophoresis (PFGE) was performed at CDPHE; antimicrobial susceptibility (AST) and carbapenemase testing was performed at CDC.

Results

Epidemiologic investigation: Both patients had neurogenic bladders managed by suprapubic catheters, stage IV decubitus ulcers, and recent surgery. Neither had traveled outside of Colorado. Although both received recent antibiotics, neither received a carbapenem in the 6 previous months. Both isolates were regarded to be asymptomatic bacteriuria. In November 2017, the patients overlapped for 7 days at DHMC on different units. During this week, the same nurse provided wound care for both patients on the same day. Observations of the wound care team revealed opportunities to improve hand hygiene prior to donning and after doffing gloves, the use of single-use scissors on multiple patients, and inconsistent cleaning of a mobile device used to photograph wounds. Microbiologic and molecular investigations: Isolates from the two patients were indistinguishable by PFGE. AST found both isolates susceptible to colistin, but resistant to all other antimicrobials tested (Table 1); both harbored OXA-23-like genes by a Research Use Only assay performed at CDC.

Conclusion

These are the first carbapenemase-producing A. baumannii strains identified in Colorado. We suspect that they were transmitted during the overlapping hospital admission, although we could not determine where the organism originated or the route of transmission. Opportunities to improve hand hygiene and low-level disinfection were identified. The emergence of previously undetected carbapenemases in Colorado is of great public health concern; collaboration between public health and healthcare facilities is critical to halt transmission of novel regional pathogens.

Disclosures

All authors: No reported disclosures.
1174. Epidemiology of Carbapenem-Resistant Enterobacteriaceae, a 5-Year Experience at a Tertiary Care Hospital
Authors: Chotiprasitsakul Darunee , Srichatrapimuk Sirawat , Kirdlarp Suppachok , Santanirand Pitak
Published: November 2018

Background

Carbapenem-resistant Enterobacteriaceae (CRE) has been increasing worldwide. Our objectives were to study the epidemiology of CRE and compare risk factors and mortality of carbapenem nonsusceptibility to ertapenem alone Enterobacteriaceae (NSEE) with nonsusceptibility to other carbapenems (imipenem, meropenem, or doripenem) Enterobacteriaceae (NSOCE) at a tertiary care hospital in Thailand.

Methods

All CRE isolated from clinical and surveillance cultures were identified from December 2011 to December 2016. Quarterly incidence rate per 100,000 patient-days was estimated. Hospital-wide carbapenem consumption were calculated as defined daily doses (DDD) per 1,000 patient-days. Relationships between hospital-wide carbapenem consumption and incidence of CRE were tested using Poisson regression. Comparative analysis of factors associated with NSEE and NSOCE, and risk factors associated with 14- and 30-day mortality in patients with CRE infection was conducted in adult patients.

Results

The quarterly CRE incidence of unique patients increased significantly from 3.37 per 100,000 patient-days in the last quarter of 2011 to 32.49 per 100,000 patient-days in the last quarter of 2016. Quarterly CRE incidence increased 1.07 per 100,000 patient-days (95% confidence interval [CI], 0.49–1.06; P-value for trend <0.001). Quarterly hospital-wide carbapenem consumption increased 1.58 DDD per 1,000 patient-days (95% CI, 0.56–2.59; P-value for trend = 0.004). The expected increase of CRE incidence was 1.02 per 100,000 patient-days for a one DDD per 1,000 patient-days increase in carbapenem consumption (95% CI, 1.01–1.03; P < 0.001). There were 40 patients with NSEE and 134 patients with NSOCE. In the multivariate analysis, lower carbapenem exposure was significantly associated with the NSEE group (adjusted odds ratio: 0.25; 95% CI, 0.11–0.56). No difference in 14-day and 30-day all-cause mortality between NSEE group and NSOCE group was observed.

Conclusion

The incidence of CRE has risen significantly over a 5-year period at our institution. The important risk factor for nonsusceptibility to other carbapenems compared with nonsusceptibility to ertapenem alone was previous carbapenem use. Our hospital-wide carbapenem use has significantly increased over time, and associated with the increasing incidence of CRE.

Disclosures

All authors: No reported disclosures.
1177. Carbapenemase-Producing Carbapenem-Resistant Organism Colonization Screening Surveys, Maryland, April 2017–April 2018
Authors: Brooks Richard B , Vaeth Elisabeth , Jani Niketa M , Dominguez Catherine E , Johnston Jonathan R
Published: November 2018

Background

In April 2017, the Maryland Department of Health (MDH) began screening healthcare contacts of confirmed cases of carbapenemase-producing carbapenem-resistant organisms (CP-CROs) to identify potential transmission, per guidance published by the Centers for Disease Control and Prevention. The results of MDH’s CP-CRO colonization screening surveys (CSSs) conducted as of April 1, 2018, are summarized.

Methods

Rectal swabs were collected on epidemiologically linked CP-CRO contacts and sent to the MDH Laboratories Administration, where the Cepheid Xpert® Carba-R assay was used to detect five carbapenemases: Klebsiella pneumoniae carbapenemase (KPC), New Delhi metallo-β-lactamase (NDM), Verona integron encoded metallo-β-lactamase (VIM), imipenemase (IMP), and oxacillinase-48-like carbapenemase (OXA-48). Identification of CP-CROs in contacts sometimes resulted in additional CSSs to ensure complete case detection. Non-KPC cases were combined for analysis.

Results

During April 1, 2017–April 1, 2018, MDH received reports of 278 incident cases of confirmed CP-CROs. Of these, 16 (6%) expressed non-KPC carbapenemases. The 7 (3%) cases with healthcare contacts prompting CSSs led to screening of 132 first-round contacts, with additional CP-CROs identified in 13 (10%), all of which had KPC. Of these, 12 (92%) resided in ventilator units of skilled nursing facilities (vSNFs). In the first-round CSS at one vSNF, 64% of screened contacts were positive for KPC, which had not been identified in the index case. Weekly follow-up CP-CRO admission screenings and serial follow-up CSSs at the vSNF resulted in screening of a total of 72 unique patients; 38 (53%) were KPC-positive. Of these 38 cases, 32 (89%) were previously unidentified and were placed on contact precautions if not already on them. Staff were re-trained in infection prevention (IP) techniques, and staff and KPC-positive patients were cohorted.

Conclusion

Detection of CP-CROs that express non-KPC carbapenemases in Maryland is rare, and transmission of these carbapenemases has not been identified. However, CSSs identified previously unknown cases of KPC, most commonly in vSNFs, demonstrating the utility of CSSs to detect CP-CROs, and resulting in important IP interventions.

Disclosures

All authors: No reported disclosures.
1186. Prevalence of Carbapenemase-Producing Enterobacteriaceae (CPE) in Hospital Drains in Southern Ontario
Authors: Jamal Alainna , Baqi Mahin , Borgia Sergio , Cicotelli William , Delibasic Kornelija , Katz Kevin , Johnstone Jennie , Melano Roberto , Muller Matthew , O’Grady Sharon , Patel Samir , Richardson David , Paterson Aimee , Li Angel , McGeer Allison
Published: November 2018

Background

Hospital waste water systems are an emerging reservoir for CPE. We aimed to describe the prevalence of CPE in hospital drains in southern Ontario, where patients are rarely colonized/infected by CPE.

Methods

Ten Ontario hospitals identified rooms occupied by CPE+ inpatients from 2007 to 2017. Drain swabs from patient rooms and communal shower rooms were inoculated into BHI + 10% Dey-Engley neutralizing broth and incubated overnight, then PCR on enriched broth for carbapenemase genes as well as culture on McPOD/McMEM were performed.

Results

Over 10 years in 10 hospitals, 343 CPE+ inpatients exposed 1,205 drains (852 sinks, 353 bathtub/shower drains) in 501 patient rooms and 71 communal shower rooms. 53 (4%) drains in 40 (8%) patient rooms and 10 (14%) communal shower rooms were CPE+ by PCR and culture. CPE+ drains were from 15/475 (3%) hand hygiene sinks, 4/352 (1%) bathroom sinks, 23/272 (9%) bathtubs/showers, and 11/81 (13.6%) communal showers. Eleven (21%) of the CPE+ drains contained 31 CPE gene/species combinations. Patient room drain CPE gene/species combinations are shown in Figure 1: eight (15%) matched the CPE gene/species combination of a room occupant, 23 (43%) matched gene only, and 23 (43%) did not match. 54% of drain isolates were Enterobacter spp. but 9% of patient isolates were Enterobacter spp. There were 155 (13%) additional drains with one or more genes detected by PCR but not culture; 94 (61%) contained VIM (88 bathtub, one bathroom sink, and five hand hygiene sink drains), 33 GES, 17 OXA, 16 IMP, 10 KPC, and five NDM. There were six drains where one or more genes were detected by culture but not PCR; four (67%) were bathtub/shower drains containing an OXA, one bathtub/shower drain containing an NDM, and one hand hygiene sink drain containing a KPC.

Conclusion

Hospital drains may become a reservoir for CPE, which may persist for years. Sensitivity of PCR and culture for detection of CPE and CP organisms may differ. The presence of “unmatched” drains suggests undetected patient colonization. Risk of transmission from drains to room occupants requires investigation.

Disclosures

All authors: No reported disclosures.
1188. Could Chlorehexidine (CHX) Bathing Decrease the Incidence of Carbapenem-Resistant Enterobacteria (CRE) Bacteremia in Previously Colonized CRE Hematopoietic Stem Cell Transplant Recipients (HSCT)?
Authors: Velez Juan Diego , Rosso Fernando , Cedano Jorge , Mora Barbara Lucia , Orrego Marly , Estacio Mayra , Beltran Ivan Andres
Published: November 2018

Background

CRE colonized patients that undergo HSCT have a higher incidence of CRE bacteremia, especially during the initial neutropenic period, with a high mortality rate. This situation is critical in countries highly endemic for CRE such as Colombia. It is necessary to find measures that decrease the occurrence of this infection, permitting a safer transplant. Daily CHX bathing could be effective reducing this risk.

Methods

Since March 2014 in our hospital in Cali, Colombia, all adult patients admitted to the HSCT unit were peri-rectal screened for CRE colonization, and then CHX daily bathing (CHX 4% soap or CHX 2% pads) was used regardless of the screening results. Prospectively all type of microorganism bacteremia were recorded from 2014 to 2017. We compare bacteremia, and CRE bacteremia rates between CRE colonized vs. non-colonized patients. We compared the annual proportion of CRE bacteremia in this two groups. Nonparametrical statistic χ2 for trend was used to compare the difference.

Results

We analyzed data collected from 155 patients from July 2014 to June 2017. There were 39.5% females, and the average age was 42 years, 60% were autologous, and 40% were allogeneic. The total of CRE colonized patients was 25/155 (16%), and the overall of bacteremia was 54/155 (34%). All type of microorganism bacteremia and CRE bacteremia were more frequent in CRE Colonized patients. (52% vs. 31% and 24% vs. 3,8%, RR: 6.24, 95% CI 2.06–18.8, P = 0.002). With the increase in compliance with CHX bathing, there was a decreasing trend in CRE bacteremia in the colonized patient, dropping from 50% during 2014, to 14% in 2017 (OR 0.167; P = 0.21).

Conclusion

Daily CHX bathing in the CRE colonized patient reduce the incidence of CRE bacteremia in HSCT patients. We propose this intervention as a significant protective measure in CRE colonized hospitalized patients.

Disclosures

All authors: No reported disclosures.
1189. A Comprehensive Characterization of the Emerging Carbapenem-Resistant Klebsiella pneumoniae Clinical Isolates From a Public Hospital in Lima, Peru
Authors: Krapp Fiorella , Amaro Catherine , Ocampo Karen , Astocondor Lizeth , Hinostroza Noemi , Riveros Maribel , Garcia Coralith
Published: November 2018

Background

In contrast with other countries in Latin America, Peru had been notoriously spared by the global dissemination of carbapenem-resistant Klebsiella pneumoniae (CR-Kp), until recently. Even though, isolated cases of KPC-producing K. pneumoniae had been reported since 2013, it was not until 2016 that the first outbreak of NDM- producing K. pneumoniae was described in Peru. By 2017, rapid emergence of CR-Kp took place in Hospital Cayetano Heredia (HCH), a tertiary care hospital in Lima. Here, we provide a description of clinical, microbiological and molecular characteristics of CR-Kp isolates recovered at HCH.

Methods

Retrospective review of all CR-Kp clinical isolates recovered at HCH until December 2017. Antibiotic susceptibility data were obtained during routine care (Vitek or disc diffusion) and was assessed using CLSI breakpoints. DNA extraction was performed by heat shock, and PCR was performed to assess carriage of blaNDM gene. String test was performed to detect hypermucoviscosity.

Results

The first case of CR-Kp in HCH dated from July 2015. Since then, a total of 69 CR-Kp clinical isolates, from 60 patients have been recovered until December 2017. A significant increase in the number of cases was observed during 2017 (Figure 1). The average age of patients was 55. Urinary, and respiratory sources of infection or colonization were the most common ones (35% and 30%, respectively), followed by blood stream (17%) and intraabdominal (10%) infections. Isolate recovery and DNA extraction was achieved in 40 cases. Of these, 15 (38%) had a positive PCR for blaNDM carbapenemase gene (Figure 2). Antibiotic susceptibility testing revealed that amikacin was the most effective antimicrobial with the rest of antimicrobials having extremely high rates of resistance (Figure 3). String test was positive in two of these isolates, suggesting that hypervirulent CR-KP might be emerging in this region.

Conclusion

An epidemic of CR-Kp has established in our hospital, representing the first one reported in Peru. The different mechanisms of carbapenem resistance found suggest a polyclonal expansion. Amikacin remains the only active antimicrobial within the routinely tested antibiotics, highlighting the need to add other antimicrobials to the routine panel.

Disclosures

All authors: No reported disclosures.
1191. Prevalence and Microbiology of Carbapenem Resistance Among Six Gram-Negative Pathogens in Bloodstream Infections in US Hospitals, 2010–2015
Authors: Lodise Thomas P , Echols Roger , Wang Weiying , Corvino Frank , Cai Bin
Published: November 2018

Background

Carbapenem resistance (CR) is a growing threat in hospitals in the United States and worldwide. We evaluated the prevalence and geographic distribution of CR among six most common Gram-negative (GN) bloodstream infection (BSI) pathogens in US hospitals.

Methods

We analyzed microbiology data in a cohort of adults (≥18 years) hospitalized in 181 US hospitals contributing microbiology data to the Premier Healthcare Database (October 2010–September 2015) with blood cultures positive for six most common GN pathogens (S. maltophilia assumed 100% CR). We report CR prevalence by pathogen, hospital ward (ICU vs. floor), and census region.

Results

Of the 43,095 GN BSIs included, 1,513 (3.5%) were caused by the six most common CR pathogens (Figure 1). CR was more frequently isolated from patients with an ICU stay (4.7%) vs. those without (2.7%). Nearly 75% (n = 1,100) of CR occurred in nonfermenters (S. maltophilia, P. aeruginosa, and A. baumannii). Among individual organisms, the prevalence of CR—outside of S. maltophilia—was highest among A. baumannii, 35.1%, and lowest among E. coli, 0.2% (Figure 2). Geographically, CR prevalence ranged from highest in the Mountain region (7.1%) to lowest in the West North Central (2.3%) (Figure 3). The maximum CR prevalence occurred in A. baumannii from the East North Central (55.7%), and the minimum in E. coli from the West North Central (0.05%) regions.

Conclusion

Among six most frequently isolated pathogens in BSI, the overall CR prevalence is 3.5%. The wide variations in prevalence based on organism, location in the hospital, and geography emphasize the clinical importance of knowing local pathogen and resistance patterns in order to optimize empiric treatment.

Disclosures

A. F. Shorr, Astellas: Consultant and Speaker’s Bureau, Consulting fee, Research support and Speaker honorarium. Cidara: Consultant, Consulting fee. Merck & Co.: Consultant and Speaker’s Bureau, Consulting fee, Research support and Speaker honorarium. T. P. Lodise Jr., Motif BioSciences: Board Member, Consulting fee.
1196. Serratia marcescens Strains Carrying blaKPC-2 and blaKPC-3 Carbapenemase Associated With Chronic Mechanical Ventilation
Authors: Fisher Matthew , Diago-Navarro Elizabeth , Kaplun Olga , Sin Eric , Fries Bettina C
Published: November 2018

Background

Carbapenem resistance (CR) in Enterobacteriaceae is a growing concern which the CDC has designated as an urgent threat. At our institution we have noted emergence of CR strains in clinical isolates including a growing number of Serratia marcescens. CR in Serratia marcescens in the United States is mostly reported to be encoded by the SME family of chromosomally encoded carbapenemases, while in Asia it has been described being mediated by transmissible plasmids such as KPC. Here we describe the emergence and characteristics of CR Serratia marcescens at an academic tertiary care hospital in New York.

Methods

Serratia marcescens isolates demonstrating in vitro carbapenem resistance were recovered over a 12-month period from six distinct patients. Antibiotic resistance was determined by standard methods. Real-time PCR for bla(KPC), mcr gene, bla(NDM-1), bla(VIM), and bla(OXA-48) was performed. Patient comorbidities, source of culture, location in the hospital, and co-infection with other CR organisms were investigated.

Results

Fourteen S. marcescens isolates demonstrating in vitro carbapenem resistance were recovered from six individual patients. All six patients had a history of chronic respiratory failure with tracheostomy and at least partial ventilator dependence. Five of the patients were located on the pulmonary intermediate care unit, and one in the pediatric intensive care unit. Twelve of the 14 isolates were tracheal or sputum cultures. Five of the sputum cultures from two patients were co-infected with CR Pseudomonas, and one sputum culture was simultaneously positive for CR Klebsiella pneumoniae and Enterobacter Cloacae. Nine out of 14 isolates were positive for blaKPC-3, two were blaKPC-2 positive, and three were blaKPC-negative, with no mechanism of carbapenem resistance determined yet. None of the other genes were detected.

Conclusion

Most carbapenem-resistant Serratia isolates were derived from respiratory tract and were found to be positive for blaKPC-3. This suggests that plasmid encoded carbapenemases are emerging among Serratia in the United States, which is already being reported in China. Genomic sequencing may establish whether this represents a clonal expansion and whether the blaKPC plasmid was transferred from Klebsiella or Enterobacter to Serratia in one of the patients.

Disclosures

All authors: No reported disclosures.
1201. A Prolonged Multispecies Outbreak of Carbapenemase-Producing Enterobacteriaceae Due to Transmissible Plasmid With Carbapenemase Gene
Authors: Yamagishi Takuya , Matsui Mari , Sekizuka Tsuyoshi , Ito Hiroaki , Fukusumi Munehisa , Uehira Tomoko , Tsubokura Miyuki , Tawa Akio , Nakamori Shoji , Miyamoto Atsushi , Yoshida Hideki , Suzuki Satowa , Shibayama Keigo , Kuroda Makoto , Matsui Tamano , Oishi Kazunori
Published: November 2018

Background

In 2010, a multispecies outbreak of IMP type carbapenemase-producing Enterobacteriaceae (IMP-CPE) occurred at a large acute care hospital in Japan. The outbreak continued for years involving more than 100 patients mainly in surgical wards.

Methods

Because of the long period of the outbreak, investigation were focused on hospitalized patients whose clinical samples were positive for IMP-CPE between July 2013 and March 2014. A case–control study was conducted for cases who underwent abdominal surgery with controls from whom meropenem-susceptible Enterobacteriaceae were isolated. Pulsed-field gel electrophoresis (PFGE) was used for molecular typing. To evaluate genetic relationship among IMP-CPE isolates of different species, plasmid analysis using S1 nuclease to separate plasmid and chromosomal DNA followed by plasmid DNA extraction and whole-genome sequencing (WGS) was conducted.

Results

During the study period, 22 cases were identified and 22 IMP-CPE isolates which consisted of eight Escherichia coli, five Klebsiella oxytoca, five Enterobacter cloacae, three Klebsiella pneumoniae and one Enterobacter aerogenes were obtained. All five isolates of K. oxytoca had similar PFGE profiles which suggested clonal transmission. However, PFGE profiles of E. coli, E. cloacae and K. pneumoniae isolates were diverse. Plasmid analysis revealed that all 22 isolates shared ca. 50 kb IncN plasmid with blaIMP-6 which implies interspecies transmission of it The case–control study which adjusted by days of hospitalization with 11 cases and 24 controls revealed that pancreato-duodenectomy (adjusted odds ratio (aOR) = 6.4, 95% confidence interval (CI) 1.3–32.4) and enteric fistula (aOR = 8.0, 95% CI 1.5–41.9) were associated with IMP-CPE acquisition. Use of endoscopy within the past six months was not associated with IMP-CPE (aOR = 0.8 95% CI 0.2–4.2). With a bundled infection control with Osaka City Public Health Office, the outbreak was contained in July 2016.

Conclusion

Dissemination of carbapenemase gene by transmissible plasmid can play a critical role to complicate epidemiology of CPE outbreak and made it difficult to control. Plasmid analysis using WGS technology is a promising tool to untangle it.

Disclosures

All authors: No reported disclosures.
1202. Multimodal Sequencing of a Clonal Case Cluster of Carbapenem-Resistant Citrobacter Reveals Unexpectedly Rapid Dynamics of KPC3-Containing Plasmids
Authors: Bhattacharyya Roby , Pironti Alejandro , Walker Bruce J , Manson Abigail , Pierce Virginia , Ferraro Mary Jane , Shenoy Erica , Hooper David C , Earl Ashlee
Published: November 2018

Background

Carbapenem-resistant Enterobacteriaceae (CRE) are a major public health threat. We report four clonally related Citrobacter freundii isolates harboring the blaKPC-3 carbapenemase in April–May 2017 that are nearly identical to a strain from 2014 at the same institution. Despite differing by ≤5 single nucleotide polymorphisms (SNPs), these isolates exhibited dramatic differences in carbapenemase plasmid architecture.

Methods

We sequenced four carbapenem-resistant C. freundii isolates from 2017 and compared them with an ongoing CRE surveillance project at our institution. SNPs were identified from Illumina MiSeq data aligned to a reference genome using the variant caller Pilon. Plasmids were assembled from Illumina and Oxford Nanopore sequencing data using Unicycler.

Results

The four 2017 isolates differed from one another by 0–5 chromosomal SNPs; two were identical. With one exception, these isolates differed by >38,000 SNPs from 25 C. freundii isolates sequenced from 2013 to 2017 at the same institution for CRE surveillance. The exception was a 2014 isolate that differed by 13–16 SNPs from each 2017 isolate, with 13 SNPs common to all four. Each C. freundii isolate harbored wild-type blaKPC-3. Despite the close relationship among the 2017 cluster, the plasmids harboring the blaKPC-3 genes differed dramatically: the carbapenemase occurred in one of the two different plasmids, with rearrangements between these plasmids across isolates. The related 2014 isolate harbored both plasmids, each with a separate copy of blaKPC-3. No transmission chains were found between any of the affected patients.

Conclusion

WGS confirmed clonality among four contemporaneous blaKPC-3-containing C. freundii isolates, and marked similarity with a 2014 isolate, within an institution. That only 13–16 SNPs varied between the 2014 and 2017 isolates suggests durable persistence of the blaKPC-3 gene within this lineage in a hospital ecosystem. The plasmids harboring these carbapenemase genes proved remarkably plastic, with plasmid loss and rearrangements occurring on the same time scale as two to three chromosomal point mutations. Combining short and long-read sequencing in a case cluster uniquely revealed unexpectedly rapid dynamics of carbapenemase plasmids, providing critical insight into their manner of spread.

Disclosures

M. J. Ferraro, SeLux Diagnostics: Scientific Advisor and Shareholder, Consulting fee. D. C. Hooper, SeLux Diagnostics: Scientific Advisor, Consulting fee.