bluuebunny/crossref_metadata_2025 huggingface dataset:
2305. Incidence of Active Cytomegalovirus Infection and Its Influence on Outcome Among Non-Immunosuppressed Cirrhotic Adults Requiring Critical Care in Liver-ICU
Authors: Shah Dhara B , Gupta Ekta , Ramalingam Archana , Siva Rao Pasupuleti Samba , Gauri Mitra Lalita , Maiwall Rakhi , Kumar Sarin Shiv
Published: October 2019

Background

Cytomegalovirus (CMV) infection is not very uncommon in critically ill patients as per the studies in past decade. However, the incidence of active CMV infection and its association with clinical outcomes have not been studied for critically ill non-immunosuppressed cirrhotic adults.

Methods

We prospectively evaluated active CMV infection (CMV-plasma-DNAemia; > 500 IU/mL) by real-time polymerase chain reaction and clinical outcome in sero-positive (anti CMV IgG-positive) critically ill non-immunosuppressed adults with chronic liver diseases (all cirrhotics) at day 0, 7, 14 and 21 in Liver-ICU. Patients with prior CMV infection (on day 0) were excluded.

Results

A total of 166 blood samples were collected from 84 enrolled Liver-ICU patients [73 men, median age: 49.5 years, interquartile range (IQR): 40–57.5]. Of 84, 29 died/discharged before day 7, leaving 55 patients in study. Cumulative incidence of active CMV infection was 30.9% (95% confidence interval, CI: 19.1–44.80) at 7-day follow-up. The incidence rate (or density) of active CMV infection was 2.75% per person-day (95% CI: 1.68–4.26% person-day) during 21-day follow-up. Acute on chronic liver failure (n = 12, 63.16%; P = 0.003) was the most common clinical presentation among patients with active CMV infection. On multivariate analysis, significant factors for active CMV infection were bacterial infections (P = 0.031, odds ratio (OR): 0.07, 95% CI: 0.01- 0.78) and leucocytosis (P = 0.047, OR: 1.15, 95% CI: 1.00–1.32). ICU-Mortality did not differ between patients with and without active CMV infection (90% vs. 88.57%, P = 1.00). In Cox-regression analysis, active CMV infection was not independently associated with time to death [Hazard Ratio (HR) = 1.18, 95% CI: 0.65 to 2.15, P = 0.58] as well as length of stay (LOS) in ICU (9.50, IQR 8–16.50 vs. 12, IQR 8–18 days; HR: 1.12; 95% CI: 0.64–1.97, P = 0.68).

Conclusion

Incidence rate of active CMV infection is considerable in critically ill non-immunosuppressed cirrhotic adults. This study did not find significant association of active CMV infection with ICU-mortality and LOS in ICU among critically ill cirrhotic patients. Further studies with optimum frequency for monitoring of active CMV infection are needed to clarify its impact on clinical outcomes.

Disclosures

All authors: No reported disclosures.
2310. No Recurrence in Recovered People with CCHF: A Cross-Sectional Study From Turkey, Preliminary Report
Authors: Koksal Iftihar , Aksoy Firdevs , Kaya Selcuk , Tas Mustafa , Yilmaz Gurdal
Published: October 2019

Background

Crimean-Congo hemorrhagic fever (CCHF) is a widespread, tick-borne disease of humans. CCHF is an endemic in Turkey, and since 2004 many cases have been reported from different regions in the country. CCHF infection in humans can lead to antibody responses that can be protective but there is limited data about the immunity of CCHF. The aim of this study was to investigate the possibility of recurrence of CCHF in people who previously had this disease.

Methods

The patients who were diagnosed with CCHF between 2005 and 2018 were followed up and contacted via phone in order to answer several survey questions about CCHF. Patients who still live in the same places, who have high risks of disease transmission because of husbandry or farming and high potential of contact with ticks were included in this study. Those who changed their living place and stopped husbandry or farming were excluded from this study. The questions in the survey are the following: Have you had CCHF after your discharge from the hospital?; Has there been any tick contact?; Did you ever get a tick removed from your body? Did you or your family members have CCHF at the same time or at different periods of time? Has anyone had CCHF in the area you live? Do your animals have ticks? Do you live in the same place? Have you changed your job?

Results

Ninety-nine out of 351 patients who were contacted via phone had data eligible to be included in the criteria. The amount of time elapsed after the discharge of the patients was between 1 and 14 years in average. None of the patients had experienced CCHF disease again. Also, 6 of these patients were bitten by ticks repeatedly (2–5 times). An average of 7–10 years had passed since the transmission of the disease by the patients.

Conclusion

The results show that the CCHF disease creates an immune response and this response continues for a long time. The findings will be more enlightening with the measurement of the serum antibody levels of patients.

Disclosures

All authors: No reported disclosures.
2316. RSV Mortality: 19 Years’ Experience in a Pediatric Hospital in Argentina
Authors: Gentile Angela , Florencia Lucion Maria , del Valle Juárez María , Soledad Areso María , Paglieri Lucia , Agustina Pirker María , Bakir Julia , Viegas Mariana , Goya Stephanie , Mistchenko Alicia S
Published: October 2019

Background

Respiratory syncytial virus (RSV) is the leading cause of acute lower respiratory infection (ALRI) in children. We aimed to describe the clinical–epidemiological pattern and risk factors for mortality associated with RSV infection.

Methods

Prospective, cross-sectional study of ALRI in children admitted to a Children’s Hospital among 2000–2018. Viral diagnosis was made by fluorescent antibody techniques or real-time PCR. We compared clinical–epidemiological characteristics of RSV infection in nonfatal vs. fatal cases. Multiple logistic regression was used to identify independent predictors of mortality.

Results

From a total 16,018 patients with ALRI, 13,545(84.6%) were tested for respiratory viruses, 6047 (45%) were positive: RSV 81.1% (4,907), influenza 7.5% (456), parainfluenza 6.9% (419) and adenovirus 4.4% (265). RSV had a seasonal epidemic pattern coinciding with months of lowest average temperature. RSV mortality rate: 1.7% (83/4,855). Fatal cases had a higher proportion of: prematurity (P < 0.01), perinatal respiratory history (P < 0.01), malnourishment (P < 0.01), congenital heart disease (P < 0.01), chronic neurological disease (P < 0.01) and pneumonia as clinical presentation (<0.01). No significant difference between gender was observed. The annual mortality rate distribution was not stable over the study period with the highest mortality in the year 2002. Most deaths occurred among children who had complications: respiratory distress (80.7%), sepsis (31.3%) and atelectasis (13.2%). Independent predictors of RSV mortality were: moderate to severe malnourishment OR 3.64 (95% CI 1.96–6.74)P < 0.01, chronic neurological disease OR 3.99 (95% CI 2.04–7.79) P < 0.01, congenital heart disease OR 4.10 (95% CI 2.36–7.15)P < 0.01 and age under 6 months OR 1.96 (95% CI 1.23–3.11)P < 0.01.

Conclusion

RSV showed an epidemic seasonal pattern. Malnourishment, chronic neurological disease, congenital heart disease, age under 6 months and pneumonia were the independent risk factors for RSV mortality.

Disclosures

All authors: No reported disclosures.
2322. Etiology, Severity of Illness, and Risk Factors for Patients Hospitalized with Acute Gastroenteritis from Multi-Site Veteran’s Affairs (VA) Surveillance, 2016–2018: Results from SUPERNOVA
Authors: Cardemil Cristina , Balachandran Neha , Kambhampati Anita , Grytdal Scott , Rodriguez-Barradas Maria C , Vargas Blanca , Beenhouwer David , Evangelista Karen , Marconi Vincent , Meagley Kathryn , Brown Sheldon T , Perea Adrienne , Lucero-Obusan Cynthia , Holodniy Mark , Browne Hannah , Gautam Rashi , Bowen Michael , Vinje Jan , Parashar Umesh D , Hall Aron
Published: October 2019

Background

The severity of acute gastroenteritis (AGE) in adult populations and the relative contribution of specific pathogens is not well characterized. In 2016, we implemented a multisite AGE surveillance platform in 4 VA hospitals (Atlanta, Bronx, Houston and Los Angeles), collectively serving > 320,000 patients annually.

Methods

Inpatient AGE cases and age- and time-matched non-AGE controls were identified through prospective screening of admissions using standardized case definitions. Stool samples were tested for 22 pathogens using the FilmArray® Gastrointestinal Panel. Medical conditions were analyzed as risk factors for AGE by multivariate logistic regression.

Results

From July 2016 to June 2018, 731 cases and 399 controls were enrolled. Risk factors for AGE cases included HIV-positive status (adjusted odds ratio [aOR] 4.6; 95% confidence interval [CI] 1.6–12.9; P < 0.01), severe kidney disease (aOR 4.5; 95% CI 2.0–9.8; P < 0.01), and immunosuppressive therapy (aOR 4.0; 95% CI 1.2–13.3]; P = 0.02). Clostridioides difficile and norovirus were the most commonly detected pathogens in cases (18% and 5%, respectively); detection of these pathogens in cases was significantly higher than detection in controls (8% and 2%, respectively; P < 0.01 for both). The median duration of hospital stay was longer for C. difficile compared with norovirus cases (5 vs. 3 days; P < 0.01), and cases with both pathogens had intensive care unit (ICU) stays (C. difficile: 18%; norovirus: 8%; P = 0.2). Fourteen deaths occurred among AGE cases; 2 were associated with C. difficile and 1 with norovirus; the remainder did not have a clear etiology or pathogen detected. C. difficile and norovirus were detected year-round with a fall and winter predominance; C. difficile prevalence was highest in October, while norovirus prevalence was six times higher in December than in summer months.

Conclusion

This surveillance platform captured cases of severe AGE, including ICU stays and deaths, among hospitalized US Veterans. C. difficile and norovirus were leading pathogens in AGE cases. These findings can help guide appropriate clinical management of AGE patients and inform public health efforts to quantify and address the associated burden of disease through targeted interventions.

Disclosures

All authors: No reported disclosures.
2330. Acute Flaccid Myelitis Recovery: Filling in the Gaps and Assessing Likelihood for Independent Living
Authors: Downey Quick Rachel , Murphey Donald , Fernandez Mariosl , Russo Susan , Hauger Sarmistha Bhaduri
Published: October 2019

Background

Reports of Acute Flaccid Myelitis (AFM) typically describe outcomes according to full recovery of strength and function. Full recovery rates remain low (20–30%), but most children with AFM show some degree of improvement. Data are lacking describing the ability of children with AFM to perform activities of daily living (ADL) needed to eventually live as independent adults.

Methods

This is telephone survey-based study of parents with children diagnosed with AFM in 2018 at a free-standing children’s hospital in Central Texas. The survey assesses the level of functional independence in areas of eating, bathing, dressing, toileting, and mobility. Cases diagnosed in 2018 were surveyed at 6 months from diagnosis.

Results

Four cases were diagnosed with AFM during the 2018 season. All four patients with AFM who were called to answer the survey consented to participation. Figure 1 shows degree of residual weakness and recovery in each area of ADL for all 4 patients. Despite residual weakness in half of the cases, three of the four cases had either no deficit or mild functional deficit in all areas of ADLs. One case continues to require moderate assistance in 4 areas of ADLS. Of note, this case was also the only case in the 2018 season with identified enterovirus D68 at our institution. None reported total deficit in any ADL.

Conclusion

In this sample significant functional deficits were seen in one of the four cases. This child continues to develop adaptive skills using stronger extremities to compensate for flaccid weakness. While the hope is always for full recovery, it is important to give parents a realistic picture of partial recovery and likelihood of independence. Given the success of the survey locally, we plan to expand the study to the Texas AFM Collaborative and prospectively survey cases diagnosed in 2018 every 6 months for a period of 2 years.

Disclosures

All authors: No reported disclosures.
2334. Saliva Screening for Congenital Cytomegalovirus Infection in the Neonatal Intensive Care Unit: Beware!
Authors: Medoro Alexandra , Shimamura Masako , Hanlon Cory T , Kaptsan Irina , Malhotra S , Findlen Ursula M , Hounam Gina , Adunka Oliver , Sanchez Pablo J
Published: October 2019

Background

Congenital cytomegalovirus (cCMV) infection is the most common cause of non-genetic sensorineural hearing loss in infancy. Screening of newborns for cCMV infection has been performed utilizing saliva due to ease of collection and high sensitivity. Positive saliva screens for CMV DNA by polymerase chain reaction (PCR) testing has been reported to occur secondary to breast milk feeding without signifying congenital infection. The NICUs of Nationwide Children’s Hospital recently began universal saliva screening of all admissions. We report 3 neonates whose saliva CMV screen was positive yet the urine CMV PCR test was negative in order to inform CMV screening strategies.

Methods

Retrospective review of the electronic health records of neonates admitted to the neonatal intensive unit (NICU) at Nationwide Children’s Hospital, Columbus, OH who had CMV detected by PCR from saliva specimens but not from urine. Pertinent demographic and clinical data were obtained.

Results

Three female neonates had a positive saliva CMV DNA PCR test but urine CMV PCR was negative. The first infant (gestational age [GA] 34 weeks, birth weight [BW]1790 Grams) was a monochorionic diamionic twin gestation and born vaginally with unknown duration of rupture of membranes (ROM). At 16 days of age, the infant had a positive saliva CMV PCR but a negative urine CMV PCR test. The infant received maternal milk. The twin’s CMV PCR tests of saliva and urine were negative. The second infant (GA 38 weeks, BW 2952 grams) was born vaginally after 9 hours of ROM. On the first day of age, the infant had a positive saliva CMV PCR test that was followed by a negative urine CMV PCR on the third day of age. The infant had not been breastfed. The third infant (GA 33 weeks, BW 1762 grams) was born by C-section delivery with ROM at delivery. Saliva CMV PCR screen was positive on the second day of age but urine PCR was negative twice (days 5 and 7). All 3 infants had no signs/symptoms of cCMV infection and passed the newborn hearing screen.

Conclusion

Testing of saliva for CMV DNA by PCR is not always confirmatory for cCMV infection as contamination of saliva specimens with CMV could result from exposure to maternal milk and possibly vaginal secretions. Definitive diagnosis of cCMV infection requires additional confirmatory testing preferably with urine.

Disclosures

All authors: No reported disclosures.
2337. Health Outcomes in Congenital Cytomegalovirus, a Systematized and Unbiased Approach in the Electronic Medical Record Era
Authors: Rochat Ryan H , Demmler-Harrison Gail J
Published: October 2019

Background

There is limited data on the indirect and non-medical costs associated with congenital cytomegalovirus (cCMV). Attempts to predict the economic impact of disease often rely on secondary analyses of large private databases, and may not capture the full spectrum of a disease. The granularity of billing codes in the Electronic Medical Record (EMR) make it possible to track health outcomes over time, however, with over 80,000 unique codes in ICD-10, selecting the appropriate codes requires specific content knowledge and can lead to bias in categorization. The Systematized Nomenclature of Medicine—Clinical Terms (SNOMED-CT)® provides physicians a tool to find specific ICD-10 on the basis of semantic terms. These terms can be used to build disease state-specific clusters of ICD-10 codes by which to study the economic impact of any disease, including this potentially devastating congenital infection.

Methods

Using a series of data parsing and processing scripts written in SAS V9.4 (Cary, NC), we extracted the diagnosis codes for 190 patients seen in our Congenital Cytomegalovirus Clinic at Texas Children’s Hospital in Houston, Texas. This data were consolidated into a relational database of clinical information. Through a second program we developed, clusters of ICD-10 codes were imputed from the SNOMED-CT® on the basis of semantic terms associated with cCMV (e.g., “hearing problem,” “developmental disability,” “neurological problem”).

Results

A total of 190 patients have been seen in our clinic with an ICD-10 diagnosis of CMV infection, 144 of these had cCMV, and 102 of these were born after 1/1/2008 (the inception date of our EMR). 60% of these patients were Caucasian (21% Hispanic), and 25% African American. 54 (53%) had hearing deficits, 17 (16%) had hearing aids, and 55 (54%) had developmental abnormalities. The average time (in years) to development of specific deficits are shown in Figure 1.

Conclusion

The spectrum of disease of cCMV is broad and has been well studied in the past. The EMR gives us the potential to further study this disease in finer detail and identify rates of disease progression by mining the ICD-10 codes associated with these patients throughout time. These results should prove invaluable for generating cost-models for the economic impact of cCMV.

Disclosures

All authors: No reported disclosures.
2341. Effectiveness of Interventions Targeting Stewardship of Clostridium difficile Testing
Authors: Sterling Stephanie , Sarah Hochman , Kappus Natalie , Reed Alexis , Kramer Preston
Published: October 2019

Background

Clostridium difficile infection (CDI) is the most common healthcare-associated infection. C. difficile PCR assays do not differentiate between colonization (seen in up to 21% of inpatients) and symptomatic disease, highlighting the importance of testing only symptomatic patients.

Methods

Interventions included system-wide implementation of C. difficile testing guidelines, face-to-face education of licensed providers, and Best Practice Alerts (BPAs) embedded in the electronic health record (EHR) C. difficile PCR order. The guidelines recommend testing only when ≥ 3 liquid bowel movements within a 24-hour period, without laxatives, oral contrast or new enteral feeds in the preceding 24 hours, and without recent C. difficile PCR test (negative ≤ 7 days or positive < 30 days). We reviewed 100 consecutive C. difficile PCR orders across two hospitals pre- and post-intervention to assess compliance with guidelines; performed weekly review of all C. difficile PCRs, all BPA responses and all hospital-onset CDI. Cost savings were calculated based on published estimates of CDI attributable costs.

Results

Hospital-onset CDI rates fell from 0.75 to 0.48 cases per 1000 patient-days, with an estimated costs savings of $259,555 per quarter and $1.04 million per year. There were no deaths due to CDI and no morbidity due to delayed CDI diagnosis. C. difficile PCR guideline compliance increased from 39% to 53%; orders decreased by 50% post-intervention. Receipt of laxatives and < 3 episodes of diarrhea were the most common reasons for guideline noncompliance. BPAs fired an average of 150 times/month. The most common trigger for BPA was laxative use. Providers canceled PCR orders in 40% of BPA events.

Conclusion

Interventions incorporating testing guidelines, face-to-face education, and EHR-embedded decision support resulted in fewer C. difficile PCRs orders, increased guideline compliance, lower rates of hospital-onset CDI and cost savings of $1 million per year without an increase in CDI-attributable death or morbidity.

Disclosures

All authors: No reported disclosures.
2345. Reduction in Testing and Change in Testing Algorithm Associated with Decrease in Number of Nosocomial Clostridium difficile Infections
Authors: Nichols Susan , Jordan Michelle D , Coogan Michael , Opera Jackie , Cook Paul P
Published: October 2019

Background

Previous data at our facility indicated 37% of patients with Clostridium difficile infection (CDI) were receiving at least one laxative at the time of testing, suggesting the possibility of false-positive results. Nucleic acid amplification testing (NAAT) does not distinguish between colonization and infection with C. difficile. We implemented two interventions to address these issues and evaluated our rates of nosocomial CDI before and after these changes.

Methods

This was a retrospective study of all positive test results for adult patients with nosocomial C. difficile from October 1, 2017 through March 31, 2019 at Vidant Medical Center, a 911-bed hospital. In June, 2018, we implemented a best practice advisory (BPA) in our electronic health record to recommend against testing for CDI in patients receiving laxatives. We reviewed the number of C. difficile tests ordered before and after initiating the BPA. In December, 2018, we removed NAAT and replaced it with a cell cytotoxicity assay (CCA) for specimens that were enzyme immunoassay (EIA) negative and glutamate dehydrogenase (GDH) positive. Antimicrobial use was measured in days of therapy (DOT) per 10,000 patient-days (PD). Mann–Whitney U test was used for continuous variables. Linear regression was used to monitor antimicrobial use.

Results

The number of C. difficile tests ordered per month decreased 19.5% after implementing the BPA (P < 0.0001). There was a 44% reduction in the number of EIA+/GDH+ specimens per month after the BPA intervention (P = 0.003). Following substitution of CCA for NAAT for EIA-/GDH+ specimens, there was a 61% reduction in the rate of nosocomial CDI (8.6 cases/10,000 PD to 3.3 cases/10,000 PD; P = 0.005). Total antimicrobial use was unchanged over the course of the study (673 to 677 DOT/10,000 PD). Carbapenem use decreased 56% (P = 0.009); cefepime use increased 85%(p = 0.002); quinolone and clindamycin use were unchanged.

Conclusion

Laxative use in hospitalized patients is common and likely contributes to a false elevation in the CDI rate by identifying carriers in addition to those who have true infection. Implementing a BPA to reduce inappropriate testing and changing our testing algorithm for Clostridium difficile by substituting CCA for NAAT has resulted in a lower rate of nosocomial CDI.

Disclosures

All authors: No reported disclosures.
2349. C. diff-erent results: Eliminating Inappropriate Stool PCR Tests Through an Interdisciplinary Infection Prevention and Mirobiology Collaboration
Authors: Farrell John J , Bowers Alex
Published: October 2019

Background

Diagnosis of Clostridium difficile infection (CDI) is based on symptoms and laboratory results. Distinguishing between CDI vs colonization or antibiotic-associated diarrhea is challenging. Widespread adoption of a highly sensitive real-time nucleic-acid amplification assay for toxin B DNA (Xpert CD assay, Cepheid) by US hospital-based microbiology labs has increased the challenge, resulting in overreporting of healthcare facility-onset CDI. Excess testing is inevitable in hospitals with EPIC electronic medical record (EMR) that incorporate best practice alerts (BPAs) prompting for C. difficile testing (CDT) when loose stools are charted by nursing staff.

Methods

Beginning October 1, 2018 microbiology and infection prevention (IP) staff at our 650 bed teaching hospital in central IL agreed to partner on a diagnostic stewardship effort to engage providers on potentially unnecessary or inappropriate CDTs. All stool samples sent to lab for CDT are held pending IP review. The IP review tool provides a guide for EMR review of contributing factors in diarrhea, including patient history, medications (e.g., laxatives, stool softeners), nutrition (e.g., tube feeds), symptoms (abdominal pain), and labs (e.g., serum creatinine, WBC count). Inappropriate CDT was defined as test of patients receiving pro-motility treatment, without signs of infection.

Results

Between October 1, 2018 and December 31, 2018, 383 CDT were ordered on inpatients. 196 were requested within 3 days of admission, and 187 were requested on beyond day 4. 56.6% (107/187) HO-CDTs were deemed inappropriate and canceled; 80 HO-CDT were deemed appropriate. 18.8% (15/80) of HO-CDTs were positive. Compared with October 1 - December 31, 2017, HO-CDI cases decreased by 66.7% (1.0 - 15/45) over the same period in 2018.

Conclusion

A 66.7% reduction in HO-CDI (vs. FY2017 cases) was seen in the first 3 months following adoption of a team-based (IPs, microbiology lab staff and MD director), CDT diagnostic stewardship intervention employing EMR review and patient provider engagement (RNs and MDs). Opportunities identified during the first 90 days of CDT stewardship: (a) Lack of provider awareness of pro-motility therapies; (b)inappropriate prompting for CDT generated by the EPIC EMR.

Disclosures

All authors: No reported disclosures.
2357. Toxin Detection Using Single Molecule Counting Technology: The Best of Both Worlds?
Authors: Perry Michael , Graham Lee , Parida Sweta , Katzenbach Phoebe , Luis Baptista Baeza Jose , Estis Joel , Sandlund Johanna , Anderson Bethan , Copsey Sarah , Scotford Selina , Morris Trefor
Published: October 2019

Background

Accurate diagnosis of CDI remains challenging as there is no standalone laboratory test with adequate clinical sensitivity and specificity. Thus, many clinical laboratories currently employ a multistep algorithm incorporating a sensitive screening test followed by a specific toxin test. An automated ultrasensitive toxin immunoassay (Singulex Clarity® C. difficile toxins A/B assay) has demonstrated excellent performance compared with cell cytotoxicity neutralization assay (CCNA). In this study, the Clarity assay was evaluated relative to glutamate dehydrogenase (GDH), toxin EIA, toxin B gene PCR, multistep algorithms, and C. difficile culture with ribotyping.

Methods

Residual clinical stool samples (n = 293) were collected from patients with suspected CDI. The samples were tested on-site with GDH (C. DIFF CHEK™-60), PCR (EntericBio realtime® C. difficile assay), a membrane-type toxin EIA (Tox A/B Quik Chek®), and culture and ribotyping. In total, 188 samples were tested with GDH and 239 samples were tested by PCR. All PCR-positive samples (n = 148) and prospectively tested GDH samples (n = 97) were tested with the toxin EIA. Culture and ribotyping information were available for 205 samples.

Results

Three of the samples tested gave no result using the Clarity assay and were excluded from the analysis. The Singulex Clarity C. difficile toxins A/B assay had high positive percent agreement (PPA) and low negative percent agreement (NPA) compared with toxin EIA and multistep algorithms ending with toxin EIA. The Clarity assay had high NPA and low PPA compared with PCR, GDH, and the multistep algorithm ending with PCR (figure). Less than 70% of the detected C. difficile PCR positive samples had toxins present. There was no difference in toxin concentration between the ribotypes.

Conclusion

The Clarity assay had strong PPA compared with toxin EIA and strong NPA compared with PCR. The low NPA and PPA compared with toxin EIA and PCR, respectively, may reflect the poor sensitivity of current toxin EIAs and low specificity of PCR. The Clarity assay detected 30 different ribotype strains, and less than 70% of samples (by PCR) or strains (by ribotyping) had toxins present. The Clarity assay may be considered for use as a standalone test for CDI diagnosis.

Disclosures

All authors: No reported disclosures.
2377. Social Determinants Impact Readmission Following Clostridioides difficile-Related Index Hospital Stay in Medicare Patients
Authors: Scaria Elizabeth , Powell Ryan , Birstler Jen , Alagoz Oguzhan , Shirley Daniel , Safdar Nasia
Published: October 2019

Background

Clostridioides difficile infection (CDI) is the leading cause of healthcare-associated diarrhea and recurs in up to 30% of patients, often requiring readmission. Socioeconomic factors, such as living in a disadvantaged neighborhood may impact readmission but have not been studied.

Methods

We examined the relationship between neighborhood disadvantage, as measured by the Singh validated area deprivation index (ADI), and 30-day all-cause readmission risk in patients with an index hospital stay with CDI. We analyzed a random 20% sample of national Medicare claims for patients’ initial index hospitalization with a CDI diagnosis in 2014 (n = 19,528) that included each patient’s neighborhood ADI national percentile. The most disadvantaged neighborhoods were categorized as those in the upper 35 percentile, while the least disadvantaged was defined as those in the bottom 65% of national ADI rankings. We evaluated the relationship between ADI percentile and 30-day readmission risk using multivariate logistic regression, controlling for key patient demographics, comorbidities, and hospital/stay characteristics.

Results

A total of 19,528 patients had an index stay with CDI, 4,899 were readmitted within 30 days. Patients from the most disadvantaged neighborhoods had a higher average rate of readmission compared with those living in the least disadvantaged neighborhoods (28% vs. 24% rate; unadjusted risk ratio = 1.16 [1.10, 1.21]). This relationship held after controlling for confounders. After adjustment, being a resident in the most disadvantaged neighborhoods was associated with a 10% increased risk of readmission (adjusted risk ratio = 1.10 [1.05, 1.16]), which was similar to the effect sizes associated with dual Medicaid-Medicare enrollment status (adjusted risk ratio = 1.09 [1.03, 1.15]) and renal failure (adjusted risk ratio = 1.14 [1.08, 1.21]).

Conclusion

Living in a disadvantaged neighborhood is associated with an increased 30-day readmission risk similar in magnitude to Medicaid status and renal failure in patients with index hospitalizations of CDI. Future studies should examine whether interventions such as post discharge support and care coordination for patients in disadvantaged neighborhoods may reduce readmissions in this patient population.

Disclosures

All authors: No reported disclosures.
2379. It’s Getting Complicated: Outcomes of Clostridiodes difficile PCR Positive/Toxin-Negative Patients
Authors: Morillas Jose A , Miller Ryan , Brizendine Kyle D , Fraser Thomas G
Published: October 2019

Background

The addition of toxin enzyme immunoassay to molecular tests creates challenges in the diagnosis and management of Clostridiodes difficile infection (CDI). In limited samples of PCR+/ toxin- patients, CDI-attributable complications are thought to be rare, even nonexistent. We aimed to characterize outcomes of a large PCR+/ toxin− cohort within 60 days of initial testing date.

Methods

We conducted a retrospective cohort study on all PCR+/toxin- adult inpatients from June–December 2018. Patients were placed into 3 groups to analyze outcomes: (1) complete treatment (guideline concordant); (2) incomplete treatment; and (3) no treatment. The primary outcome in group (1) was CDI-related complication, defined as megacolon, colectomy, or ICU care. For groups (2) and (3), clinical failure was defined as a composite of: need for repeat CDI testing or subsequent treatment.

Results

We identified 240 individuals (Figure 1). Mean age was 60 years, and 122 (51%) were female. 173 (72%) received complete treatment (85% vancomycin monotherapy), 41 (17%) incomplete treatment, and 26 (11%) none. Baseline conditions included high severity comorbidities (Figure 2). In the complete treatment group, 10/173 (5.8%) patients met criteria for fulminant colitis. 21/173 (12%) experienced CDI-attributable complications (2 megacolon, 1 colectomy, 18 ICU care). A significantly higher proportion of these patients had leukocytosis >15,000 (57 vs. 23%; P = 0.001), creatinine >1.5 (57 vs. 27%; P = 0.005), and were receiving concomitant proton pump inhibitors (65 vs. 43%; P = 0.05) and antibiotics (65 vs 44%; P = 0.05) compared with those without CDI-related complications. In patients who received incomplete treatment, there were 10 clinical failures (7 had repeat testing; 3 were administered complete treatment) compared with 4 in the no treatment group (Figure 3). Interestingly, 4/9 (44%) patients who had incomplete or no treatment and underwent repeat testing were found to be PCR+/ toxin+. There were 4 (1.7%) deaths related to CDI in the cohort. All occurred in the complete treatment group.

Conclusion

CDI-attributable complications and clinical failure occur in PCR+/toxin− patients. The challenge of distinguishing colonization from disease remains. Additional studies are needed to identify predictors of disease in PCR+/ toxin− patients.

Disclosures

All authors: No reported disclosures.
2393. Dimensions of Cumulative Antibiotic Exposure and Risk of Hospital Onset Clostridiodes Difficile
Authors: Song Jiyoun , Zachariah Philip , Cohen Bevin , Liu Jianfang , Larson Elaine
Published: October 2019

Background

The association between antibiotic exposure (AE) and healthcare-associated Clostridiodes difficile infection (HA-CDI) has been mostly quantified using cumulative AE as the predictor. However, patients receive similar durations of antibiotics in a variety of ways. We examine the relationship between HA-CDI and other dimensions of AE.

Methods

Retrospective cohort study was conducted with pediatric and adult inpatients at three New York City hospitals between 2011- 2016 who were prescribed at least one dose of antibiotic, excluding those used to treat CDI. Patient data were collected until the first diagnosis of HA-CDI (a positive CDI test > 3 days after admission), or alternatively at the end of the study period. Four dimensions of AE were calculated: 1) duration – cumulative total calendar days of antibiotics use, 2) discontinuity – the number of separate antibiotic courses that contributed to the duration (a course defined as antibiotics given over ≥ 2 consecutive calendar days separated by at least 24 hours), (3) antibiotic free days – days without antibiotic use, and (4) use of ‘high-risk’ antibiotics – use of antibiotics known for increasing C. difficile risk. We measured the association between each AE dimension and HA-CDI, mutually controlling for each dimension, in a multivariable logistic regression model adjusted for age, sex, comorbidities (e.g., malignancy, transplant status), length of hospitalization, and use of proton pump inhibitors (PPI).

Results

Of 227,967 hospitalized patients, 104,705 (45.9%) received antibiotics and 1,618 had HA-CDI. In regression analysis, adjusted for cumulative duration, discontinuous antibiotic therapy (OR = 2.02, 95% CI: 1.49–2.74, P < .0001) and high-risk antibiotics (OR = 1.639, 95% CI: 1.45–1.85, P < .0001) both increased HA-CDI risk. A longer antibiotic free interval between courses decreased HA-CDI risk (OR = 0.998, 95% CI: 0.997–0.998, P < .0001). In addition, both PPI use and being immunocompromised were significantly associated with HA-CDI.

Conclusion

Multiple dimensions of AE in addition to cumulative duration were collectively associated with CDI risk. This has implications for designing accurate CDI prediction models implementing antibiotic stewardship interventions.

Disclosures

All authors: No reported disclosures.
2412. Oral Vancomycin Prophylaxis Against Recurrent Clostridioides difficile Infection: Efficacy and Side-effects: Two Hospitals Experience
Authors: Zacharioudakis Ioannis , Zervou Fainareti , Dubrovskaya Yanina , Phillips Michael
Published: October 2019

Background

Clostridioides difficile is the most common hospital-acquired pathogen with an unchanged infection prevalence between 2011–2015. The data regarding the effectiveness of chemical prophylaxis to prevent recurrent C. difficile infection (CDI) are conflicting.

Methods

We conducted a retrospective study of hospitalized patients with CDI history in 2 New York academic hospitals over a 4.5-year period to determine the effectiveness of vancomycin prophylaxis for CDI prevention. The participating hospitals implemented an automated alert to providers recommending oral vancomycin 125 mg twice daily in patients with a history of CDI scheduled to receive any systemic antimicrobials for the duration of therapy and 5 days thereafter. Measured outcomes included the rate of breakthrough and recurrent CDI, defined as CDI during and in the one-month following prophylaxis, respectively. A self-controlled, before and after study design was employed to examine whether the use of oral vancomycin was associated with an increase in the prevalence of vancomycin-resistant Enterococcus species (VRE) both in absolute numbers and in comparison to vancomycin-sensitive Enterococcus species (VSE) in the period following vancomycin prophylaxis.

Results

264 patients were included in the final analysis. Breakthrough CDI was identified in 17 (6.4%; 95% CIs 3.8%–10.1%) and recurrent CDI in 22 (8.3%; 95% CIs 5.3%–12.3%) patients. Of the 102 patients with a history of CDI within the 3 months preceding the administration of prophylaxis 4 (3.9%, 95% CIs 1.1%-9.7%) had breakthrough CDI and 9 had recurrent disease (8.3%, 95% CIs 5.3%–12.3%). In the 3 months following vancomycin prophylaxis there was an increase in both the absolute number of VRE and the ratio of VRE to VSE isolates compared with the combined period of 1.5 months preceding and the 3–4.5 months following the administration of prophylaxis. The increase in the absolute number of VRE colonized patients remained in the extended period of 6 months following prophylaxis.

Conclusion

Prophylactic vancomycin is an effective strategy to prevent CDI recurrence, but is associated with an increase in VRE colonization in the immediate period after administration. The risk of VRE infection should lead to careful selection of patients at the highest risk for CDI recurrence.

Disclosures

All authors: No reported disclosures.
2423. Cost-effectiveness of core and emerging infection control interventions to reduce hospital-onset Clostridioides difficile infection: An agent-based simulation modeling approach
Authors: Alagoz Oguzhan , Barker Anna K , Scaria Elizabeth , Safdar Nasia
Published: October 2019

Background

Multiple infection control interventions have been recommended to reduce hospital-onset Clostridioides difficile infection (C. difficile; HO-CDI), including contact isolation, environmental disinfection, and hand hygiene. These interventions have differential effects on reducing HO-CDI that change for each hospital setting. In the context of today’s constrained resources, with trade-offs a necessary part of any prevention plan, infection control personnel need information regarding intervention cost-effectiveness that is tailored to their unique hospital setting.

Methods

We evaluated the cost-effectiveness of nine infection control interventions and eight multiple-intervention bundles using our group’s agent-based model of C. difficile transmission. This previously developed model represents a general 200-bed acute-care adult hospital. Effectiveness was measured from the hospital perspective in terms of both quality-adjusted life years (QALYs) and HO-CDIs.

Results

Six interventions reduced cost while increasing QALYs and averting HO-CDI, compared with baseline standard hospital practices: daily cleaning (saved an average of $407,854 and 36.8 QALYs annually in a 200-bed hospital), HCW hand hygiene ($181,767; 17.7 QALYs), patient hand hygiene ($25,700; 6.3 QALYs), terminal cleaning ($64,986; 12.8 QALYs), screening at admission ($9,083; 18.5 QALYs), and reducing patient transfers ($27,514; 3.1 QALYs). Adding patient hand hygiene to the HCW hand hygiene intervention was cost saving. When screening, HCW hand hygiene, and patient hand hygiene interventions were sequentially added to daily cleaning to form two, three, and four-pronged bundles, the incremental cost-effectiveness ratios for these additions were $26,588, $44,173, and $123,379 per QALY, respectively.

Conclusion

Using cost-effectiveness data, institutions may consider streamlining their infection control initiatives and prioritizing a smaller number of highly effective interventions. Our model could be used to evaluate the cost-effectiveness of existing core and emerging infection control interventions for specific hospital settings.

Disclosures

All authors: No reported disclosures.
2432. Durability Against Antibiotics After Response to Fecal Microbiota Transplantation in Recurrent Clostridioides difficile Infection
Authors: Saha Srishti , Tariq Raseen , Pardi Ryan , Pardi Darrell , Khanna Sahil
Published: October 2019

Background

Fecal microbiota transplantation (FMT) cures ~90% of patients with recurrent Clostridioides difficile infection (rCDI). Ongoing or repeated exposure to risk factors, especially antibiotics (a modifiable risk factor but often necessary), may lead to future CDI. However, it is not known if FMT provides durable protection against future CDI despite subsequent antibiotic exposure. We studied the long-term durability of FMT against antibiotic exposure post-FMT.

Methods

A retrospective cohort study of patients undergoing FMT via colonoscopy for rCDI from Sep 2012 - Jun 2018 was performed. Patients were followed up for 1 year after FMT; data regarding future CDI episodes (watery diarrhea with positive stool test after interim symptom resolution), healthcare exposure, systemic non-CDI antibiotics and acid blocker therapy were collected. Primary outcome was ‘durability’ of response to FMT (defined as no CDI within 1 year post-FMT). Descriptive statistics, Chi square test, Wilcoxon test and multivariate logistic regression were used as appropriate.

Results

The study included 460 patients; median age 57 years (range 18–94 years), 65.2% (300) female. Overall 31.6% (144) received antibiotics; median number of courses of antibiotics, 2 (range 1–7). Of those who received antibiotics, the incidence of future CDI was 24.3% (n = 34), compared with 9% (n = 28) of those who did not receive antibiotics (P < .001). Median time to first CDI episode post-FMT was 103 (range 5–338) days. Incremental antibiotic courses did not lead to increased risk of future CDI (comparing 1, 2 or ≥3 courses, p = .68). In patients with antibiotic exposure, age and risk factors were similar in patients with and without future CDI (Table 1). Amongst those without antibiotic exposure, inflammatory bowel disease (IBD) predicted future CDI (p = .02). After controlling for risk factors and comorbidities, antibiotic use (p = .004) and IBD (p = .02) independently increased risk of future CDI.

Conclusion

The majority of patients with rCDI have a durable response to FMT despite ongoing risk factors. These data suggest that three-fourth of patients who receive antibiotics after FMT do not develop future CDI. IBD and antibiotic exposure independently increase the risk of future CDI.

Disclosures

All authors: No reported disclosures.
2450. A data-driven model of the economic burden of healthcare-associated infections as impacted by use of comprehensive genomic analysis of bacteria
Authors: Wong Brian E , Carmona Juan J , Fortunato-habib Mary M , van Aggelen Helen C , Doty Alan J , Gross Brian D
Published: October 2019

Background

Each year, nearly 2 million patients contract and are affected by healthcare-associated infections (HAIs) in the United States alone, resulting in nearly 100K deaths. According to the Centers for Disease Control and Prevention (CDC), more patients die from HAIs in the United States per year than all breast and prostate cancer cases combined (National Vital Statistics Report, 2016). In addition to the mortality burden, the financial impact of HAIs within the hospital ecosystem is estimated to total between $28–45 billion. However, no economic model has demonstrated how early effective identification and mitigation of infection clusters can result in cost savings for hospitals until now.

Methods

As there is no publicly available data for infection cluster rates, we based our analysis on anonymized real-world retrospective data spanning 18 months (November 2016 to June 2018) from two US-based academic tertiary hospitals with a combined total of about 1,700 beds, then normalized to 800 beds. A cloud-computing platform (Philips IntelliSpace Epidemiology) was used for whole-genome sequence analysis and cluster identification. We determined that an average 800-bed facility would have an occurrence of 46 genetically related infectious clusters involving 2 or more patients (mean of 7.9, median of 3), affecting 180 patients in total.

Results

Given the average HAI treatment cost of $24,512 (average costs rescaled from literature to 2019 USD using PPI data), this represents a total cost of $4,412,160. If these clusters could have been limited to 2 patients, an additional 96 infections might have been prevented, representing a potentially avoidable economic burden of $2,353,152 for this 800-bed institution. Our data show that a 20% reduction in transmissions would drive a 3% overall reduction in HAIs, but results in savings of over $450,000.

Conclusion

Active, genomic-based surveillance can inform timely and precise preventative steps to help lower the size of infectious clusters. This health economic modeling shows that such measures can result in significant cost savings. As such, it recommends that prompt, dynamic detection of infectious clusters via genomics and active surveillance offers a relevant and timely strategy for cost savings within the healthcare ecosystem.

Disclosures

All authors: No reported disclosures.
2456. Stenotrophomonas maltophilia (SM) Pseudo-outbreak Associated with Bronchoscope
Authors: Eichenblat Siobhan , Campbell Eileen , Kester Shelley , Layell Jessica , Passaretti Catherine
Published: October 2019

Background

Stenotrophomonas maltophilia (SM) is a multi-drug-resistant Gram-negative organism that typically impacts patients with long hospital stays or severe immunocompromise. In Q4 2017, an increase in rates of SM from adult bronchoscopic alveolar lavage (BAL) specimens was detected.

Methods

The charts of all patients with SM from BAL specimens during the time frame in question were reviewed for commonalities, clinical symptoms and antibiotic treatment for Stenotrophomonas. Incidence rate ratios for the 21 months prior to, 3 months during and 15 months after the increase were compared using Fisher exact test.

Results

Quarter 4 2017 rates of SM isolated from BALs performed in patients >/ = 18 years of age increased significantly from baseline of 0.46 to 2.22 per 10,000 patient-days. Upon chart review 75% (12/16) of patients with SM during the increase had BALs performed with a specific bronchoscope. Q4 2017, 22 patients had a BAL performed with the scope in question with 16 sent for culture. 75% (12/16) of the BALs done with this scope during Q4 2017 grew SM. The scope was pulled from use once the association was identified. ATP and high-level disinfection records were reviewed with no failures noted. The scope was sent to an independent lab where boroscope evaluation showed epoxy lifting. Cultures from the scope were unrevealing. After the scope was removed from service, rates of SM from adult BALs dropped significantly back to 0.58 per 10,000 patient-days (Figure 1). Upon clinical review, SM was deemed clinically insignificant in all but 1 case, however, 8 of the 12 patients received antibiotic treatment for this pathogen. To date, none of the patients in question had subsequent cultures with SM. No adverse events due to antibiotic therapy have been noted 10 of the patient isolates were retrieved and sent for pulsed-field gel electrophoresis testing. All came back with identical PFGE patterns strongly suggesting a point source.

Conclusion

While the bronchoscope culture did not grow SM, the identical PFGE patterns in patients without evidence of active infection suggested a point source. Return of SM rates to baseline following removal of the scope from service strongly suggest a pseudo-outbreak resulting from a reusable bronchoscope.

Disclosures

All authors: No reported disclosures.