bluuebunny/crossref_metadata_2025 huggingface dataset:
1256. Changes in Antimicrobial Stewardship (AS) Core Element Implementation among Oregon Hospitals following the COVID-19 Pandemic
Authors: McGregor Jessina C , Iguchi Lisa , Breitenstein Elizabeth
Published: November 2023

Background

The CDC established core elements for effective hospital AS programs, which includes a team with dedicated effort and appropriate experience. CDC further identified that AS leadership with infectious disease specialty training enhances quality and impact of AS. Since the COVID-19 pandemic, facilities have reported widespread challenges to maintaining healthcare worker staffing. Our objective was to compare AS core element implementation in Oregon hospitals before and after the pandemic.

Methods

We performed a secondary analysis of 2019 and 2022 NHSN annual facility survey data from acute care and critical access hospitals in the state of Oregon. The frequency of implementation of core elements was compared between time frames using the chi-square test. Secondary analyses were performed among acute care and critical access hospitals.

Results

Overall, 59 of 60 Oregon hospitals responded to the 2019 facility survey and 58 to the 2022 survey. In 2019, 76% reported having implemented all core elements compared to 95% in 2022 (p < 0.01; Figure 1). Among acute care hospitals, implementation of all elements was 77% (27/35) in 2019 and 100% (33/33) in 2022; among critical access hospitals, it was 75% (18/24) and 88% (22/25) respectively. Significantly more hospitals implemented the education core element in 2022 (100%) compared to 2019 (80%; p < 0.01). Hospitals, overall, had a decreased frequency of physician/pharmacist co-led AS programs in 2019 vs. 2022 (75% vs 66%, p = 0.28). Decreases of co-led programs were mainly observed in critical access hospitals (71% vs. 44%; p = 0.06), where both pharmacist (21% vs. 32%; p = 0.38) or physician-led programs (4% vs. 13%; p = 0.32) increased. The proportion of pharmacist leads/co-leads with infectious diseases specialty training also increased non-significantly (29% vs 36%, p = 0.39; Figure 2).Figure 1.Implementation of Antimicrobial Stewardship Core Elements in Oregon HospitalsFigure 2.Characteristics of Antimicrobial Stewardship Leadership

Conclusion

Despite challenges stemming from the COVID-19 pandemic, hospital commitment to antimicrobial stewardship increased as indicated by greater implementation of the core elements. Yet gaps persist for critical access hospitals; further efforts are needed to support to full implementation in this setting.

Disclosures

All Authors: No reported disclosures
1267. Implementation and Outcomes of Beta-lactam Allergy Management Protocol at a Comprehensive Cancer Center
Authors: Khalak Sohanabanu , So Wonhee , Ho Stephanie , Ross Justine Abella , Dadwal Sanjeet S , Puing Alfredo , Nanayakkara Deepa D , Taplitz Randy , Kaur Avneet , Dickter Jana
Published: November 2023

Background

Beta-lactam allergy (BLA) is associated with increased broad-spectrum antibiotic (Br-ABX) use, worse clinical outcomes, and higher costs. Our hospital-wide BLA protocol (BLA-P) was launched in 7/2021 with following categories: intolerance, low-risk (urticaria only >5 years ago, mild rash, remote childhood reaction with limited details), and high-risk (angioedema, anaphylaxis, severe rashes). Delabeling was done directly based on antibiotic history/interview alone (direct-delabeling), or via graded challenge for low-risk patients. We evaluated the delabeling rate and its impact on Br-ABX usage.

Methods

Hospitalized patients ≥ 18 years old with listed BLA during 10/2021-12/2022 were eligible. Exclusion criteria were critically ill, surgical, hospice or comfort care, or non-verbal patients. Assessment was counted each time a pharmacist evaluated BLA; multiple assessments could occur in case of prolonged hospital stay or multiple admissions. Interventions were categorized as no further action (due to high-risk allergy, patient refusal for any update, clinical status), updated allergy label, or delabeled. Missed assessments were reported due to logistical issues. Br-ABX usage was compared in the delabeled patients: the empiric antibiotic use 90 days post-intervention versus pre-intervention using McNemar test (SPSS).

Results

A total of 700 assessments in 631 unique patients with BLA were identified (Figure 1). 556 assessments in 489 unique patients (median age 63 years, 41% male, 46% hematological cancer) met inclusion criteria. In this cohort, the assessments revealed 8% intolerance, 54% low-risk, 17% high-risk and 21% unknown allergy. Interventions resulted in no further action 7%, updated label 72%, and delabeling 21%. 65% of the delabeling was done via direct-delabeling and 35% via graded challenge (Figure 1). Passing rate with graded challenge was 97%. The use of aztreonam and meropenem decreased significantly in delabeled patients compared to pre-delabeling while cefepime and piperacillin-tazobactam usage increased (Table 1).

Conclusion

Implementation of BLA-P led to 21% delabeling, which resulted in increased use of preferred Br-ABX and a significant decrease in meropenem and aztreonam use.

Disclosures

Sanjeet S. Dadwal, MD, FACP, FIDSA, Allovir: Advisor/Consultant|Allovir: Grant/Research Support|Ansun Biopharma: Grant/Research Support|Aseptiscope, Inc: Stocks/Bonds|Astellas: Honoraria|Karius: Grant/Research Support|Matinas Biopharma: Stocks/Bonds|Merck: Advisor/Consultant|Merck: Grant/Research Support|Pfizer/Amplyx: Grant/Research Support|Takeda: Advisor/Consultant|Takeda: Honoraria|Viracor: Honoraria Randy Taplitz, MD, Karius: Advisor/Consultant|Merck: Advisor/Consultant|SNIPR biome: Advisor/Consultant
1268. A retrospective observational study to evaluate the efficacy of antimicrobial time-out for optimizing the duration of antimicrobial administration in emergency abdominal surgery patients
Authors: Suenaga Takahiro , Hata Hiroaki
Published: November 2023

Background

Appropriate use of antibiotics is important for the prevention of antimicrobial-resistant organisms. However, prolonged administration of broad-spectrum antimicrobial agents is frequently used in surgery, especially in emergency surgery with infection. The low rate of the appropriate use of antimicrobial agents is regarded as a worldwide problem. In order to promote the proper use of antimicrobials, our department has administered daily antimicrobial time-outs to surgical patients as part of the Antimicrobial Stewardship Program since January 2018. This study investigates whether the Antimicrobial Time-out has led to appropriate use of antibiotics.

Methods

Patients aged 18 years and older who underwent emergency abdominal surgery in our department from May 2017 to August 2018 were included. Pre- and postoperative clinical information was extracted from the medical records.

Results

56 and 66 patients were treated before and after the introduction of antimicrobial time-out, respectively. The mean duration of antimicrobial use was 3.8 and 3.3 days before and after the introduction of antibiotic time-out. No significant difference was observed, but a 13.7% decrease was observed (P=0.51). Limiting the analysis to patients who received a minimum of two days of antimicrobial therapy, treated patients were 23 and 27, and the mean duration of antimicrobial use was 7.8 and 6.6 days(P=0.38) before and after the introduction of antibiotic time-out, respectively.

There were also no significant differences in the incidence of complications (Clavien-Dindo classification Grade II or higher) (28.6% vs. 25.8%, P=0.73) or length of hospital stay (17.2 vs. 14.0 days, P=0.38).

Conclusion

Antibiotic time-out in surgical practice may contribute to a reduction in antimicrobial use without increasing complication rates or length of hospital stay.

Disclosures

All Authors: No reported disclosures
1273. Use of an algorithm-based electronic application in the management of penicillin allergies
Authors: Vijayaraghavan Nimal , Otome Ohide
Published: November 2023

Background

Penicillin allergy "de-labelling" has shown to improve antibiotic stewardship. Knowledge gaps of antibiotic allergies amongst healthcare workers are well known. We attempt to evaluate the use of an algorithm-based electronic application as a point of care (POC) decision making tool in penicillin allergy management.

Methods

A 4 week prospective, randomized case-control study was conducted on healthcare workers in a tertiary care centre. Local general practitioners were included. Participants were randomized to the control and experimental arms. Both were required to complete a set of 8 case-based questions specific to penicillin reactions. The former was given access to an electronic application, while the latter were permitted to use alternative educational tools. Time of completion in one sitting and total number of correct answers of both groups were obtained and compared. The experimental arm's overall impressions of the electronic algorithm were defined by completion of an optional satisfaction survey. The assessment tools were created using REDcap software.

Algorithm-based electronic application

The algorithm-based electronic application was made available to the experimental arm to aid in completion of the questionnaire.

Case-based questionnaire

All candidates in the study were required to complete an assessment composed of 8 scenario-based questions (16 questions total) to evaluate the clinical understanding of antibiotic allergies.

Results

Only 68 out of 347 eligible healthcare workers responded to the invite to the study and questionnaire. From the selected group, 31 and 37 participants were randomized to the control and experimental arms respectively. Majority of participants were hospital-based practitioners (85%). A higher completion rate of the questionnaire was observed in the experimental group (73% vs 65%). The experimental arm completed 86% of the total allocated questions (516 out of 592) compared to 78% (386 out of 496) in the control (p< 0.001). Further observation revealed that the experimental group achieved correct answers in 69% (351) of the total attempted questions in contrast to 59% (228) correct answers in the control (p< 0.01). No statistically significant difference in mean times of completion were observed between the groups (p = 0.25). With regards to the survey, 96% found the electronic application useful, 84% would strongly recommend it to their peers, 88% would like to have access to it to support them in their POC decisions.

Conclusion

In this study, we demonstrate that an electronic POC allergy delabelling application may have the potential to support clinicians in the management of patients reporting penicillin allergy.

Disclosures

All Authors: No reported disclosures
1275. Impact of a bundled antimicrobial stewardship intervention leveraging frontline pharmacist response to rapid blood culture diagnostics at an academic medical center and community hospital
Authors: Bajer Kevin , Bertram Christie M , Weslander Erin , Qi Chao , Moore William J , Polisetty Radhika S , Postelnick Mike , Zembower Teresa , Wronkiewicz Stephanie , Rhodes Nathaniel J , Kling Kendall , Sutton Sarah
Published: November 2023

Background

Rapid Blood Culture Identification (BCID) panels have been shown to improve patient outcomes, including mortality and length of stay, when paired with antimicrobial stewardship (ASP) intervention. We report the results of a quality improvement initiative to expand to 24/7 pharmacist response to BCID results in a large academic medical center and a community hospital within the same health system.

Methods

A pre/post review was performed following a bundled stewardship intervention. Prior to the intervention, BCID results were addressed by the antimicrobial stewardship team Monday through Friday between 8am and 4pm. The bundled ASP intervention consisted of standardized treatment guidance, clinical education on result interpretation, frontline pharmacist evaluation of BCID results during off-peak hours to provide 24/7 response, and electronic health record documentation at each site. Clinical and microbiological data were collected for all patients. The primary outcome was time to optimal therapy (TTOT) for patients with a positive BCID within the first 72 hours of hospital admission. The secondary outcome assessed observed to expected length of stay (O/E LOS) ratios based on Vizient® Clinical Database estimates. The pre-intervention period included patients with a positive BCID between 1/1/2021 and 10/14/2022. The post-intervention period included patients with a positive BCID between 1/3/2023 and 3/31/2023.

Results

Clinical data and outcomes are reported in Table 1. During the first three months following ASP intervention, TTOT decreased at the academic medical center (15.0 to 6.4 hours) but did not change at the community hospital (25.9 to 25.1 hours). The O/E LOS ratio decreased for the academic medical center from 0.92 to 0.78 while the O/E LOS remained similar (0.85 to 0.83) for the community hospital.

Conclusion

A bundled ASP intervention utilizing frontline, non-ASP pharmacist review and prescriber outreach of BCID results quickly adopted. The intervention demonstrated benefit in the academic medical center, including quicker time to appropriate therapy and reduced length of hospitalization. Additional interventions may be needed for community sites depending on existing resources, staffing models and pharmacist/physician experience.

Disclosures

Nathaniel J. Rhodes, PharmD MS, Third Pole Therapeutics: Advisor/Consultant
1279. Vertebral Osteomyelitis due to Serratia spp: A Rare Entity Emerges as an Infection Linked to Injection Drug Use
Authors: Castillo Briana , Madeline McCrary L , Schranz Asher J
Published: November 2023

Background

Serratia spp. are environmental gram-negative bacilli known to cause invasive infection in the setting of injection drug use (IDU), but uncommonly associated with orthopedic infections. In recent years, in the setting of rising IDU, there have been mounting reports of bacteremia and endocarditis due to Serratia spp. Vertebral osteomyelitis (VO), another condition associated with IDU, has rarely been reported due to Serratia spp, with the largest published series reporting three cases. Given the rise of invasive Serratia infections and IDU, we characterized experience caring for VO due to Serratia spp. (S-VO).

Methods

This was a retrospective review of adults with S-VO admitted to UNC Health, a hospital network in North Carolina, from 4/2014 to 6/2022. We utilized EMERSE, a program that searches free text in the electronic medical record, to identify charts with the terms ‘Serratia’ and ‘vertebral osteomyelitis.’ We identified 31 patients and included 10 in the final analysis (Fig 1). Chart review was performed to confirm the presence of S-VO and to obtain demographic and clinical data.

Figure 1

Results

Cases overall increased over time; there were 0-1 per year until 6/2019, but 2 per year since (Fig 2). The median age was 45 years and 90% were White (Table 1). IDU was the main risk factor (8 of the 9 with risk factor information). There was a predilection for the thoracic spine (70%) and 50% were associated with epidural or paravertebral abscess. Although half had concomitant bacteremia, only one had concurrent endocarditis. The predominant species was S. marcescens (8 of the 9 with species-level identification), and the majority were monomicrobial. Most received ceftriaxone or fluoroquinolone monotherapy, and 30% underwent surgical management (Table 2). There were two confirmed failures or relapses and one death at 90 days after discharge.

Figure 2

Conclusion

Although considered a rare entity, we identified ten cases of vertebral osteomyelitis due to Serratia spp. within one health system over eight years. S-VO was largely linked with IDU, typically occurred in the absence of endocarditis and was frequently managed with a third-generation cephalosporin or fluoroquinolone. Further multicenter data is needed to define trends and elucidate management strategies for orthopedic infections due to Serratia spp.

Disclosures

Asher J. Schranz, MD, MPH, WoltersKluwer: Honoraria
1280. Retrospective Chart Review of Diabetic Foot Infection Microbiologic Data at UnityPoint Health Des Moines
Authors: Clouse Alexis , Blackmer Sydney , Holte Nathaniel , Olstinke Kayla , Passet Alivia , Bushman Amanda , Best Leyla Alexandra
Published: November 2023

Background

Foot infections are a common and serious complication in people with diabetes. Pseudomonas aeruginosa has traditionally been considered a common pathogen in diabetic foot infections (DFI). However, newer data has not found this to be true in clinical practice. In addition, the 2012 Infectious Diseases Society of America guideline for DFI states that “empiric therapy directed at Pseudomonas aeruginosa is usually unnecessary except for patients with risk factors for true infection with this organism”.

Methods

This study is a retrospective chart review of patients presenting with diabetic foot infections at regional teaching hospitals in the Midwest between August 1, 2021 and August 1, 2022. All the patients had either a bone, tissue, or wound culture obtained by podiatric medicine. Descriptive statistics were used to determine relationships between variables and the frequency of P. aeruginosa in culture. The primary objectives of this study were to quantify the prevalence of and determine predictors of pseudomonas DFI.

Results

There were 460 cultures reviewed in the specified time period with 168 cultures meeting criteria for inclusion in the final review. The most commonly isolated organisms were streptococci (29.8%) and methicillin-susceptible Staphylococcus aureus (26.2%). Pseudomonas was isolated in 21 of the 168 cultures reviewed (12.5%), with 17 of them being from non-bone cultures and 3 from bone cultures. The risk for pseudomonas appeared to increase with recurrent or relapsed diabetic foot infections (90.5%), having a previously isolated gram-negative pathogen in the last year (38%), and having a known pseudomonas colonization within one year (33.3%).

Conclusion

Streptococcus and Staphylococcus remain the most common organisms in DFI. Pseudomonas is a less common organism in DFIs; however, our study suggests rates of PSAR may be higher than previous studies have discovered. Risk factors for pseudomonas in our study appear to be recurrent or relapsed diabetic foot infections, having a previously isolated gram-negative pathogen in the last year, and having a known pseudomonas colonization within one year. Though some individualized risk factors can be useful, local epidemiology and resistance patterns remain essential for antibiotic treatment considerations.

Disclosures

All Authors: No reported disclosures
1281. Ongoing Transmission of Clonal Strains of Invasive Nontypeable Haemophilus influenzae Disproportionately Affecting Persons with HIV in Metropolitan Atlanta, 2019—2022
Authors: Collins Lauren F , Sefton Samantha , Thomas Stepy , Tunali Amy , Bombin Andrei , Read Timothy D , Satola Sarah W , Farley Monica M
Published: November 2023

Background

Nontypeable Haemophilus influenzae (NTHi) is a genetically diverse pathogen that typically causes mucosal infections or invasive NTHi (iNTHi) disease in persons at the extremes of age. In 2017-2018, we reported a significant increase in incident iNTHi in Atlanta among virally-suppressed persons with HIV (PWH) and identified two clonal strains associated with septic arthritis/polyarthritis among Black men who have sex with men.

Methods

Surveillance data from the CDC-funded Georgia Emerging Infections Program was used to assess interim iNTHi epidemiology in adults ≥ 18 years old in metropolitan Atlanta, including the potential for continued transmission of clonal strains in adults 18-55 years old. Overall incidence of iNTHi and by HIV status from 2019-2022 was determined and compared with prior years; and demographic and clinical data were collected. Whole genome sequencing assessed genetic relatedness of isolates, which were categorized as belonging to cluster 1 or 2 (C1, C2) or non-clustered (NC).

Results

From 2019-2022 in Atlanta, there were 157 iNTHi cases in adults ≥ 18 years old (median age 56 [Q1-Q3 36-72] years, 59% male, 44% Black), including 29 in PWH. The iNTHi incidence among PWH in 2019-2022 was lower than in 2017-2018 (18.8 vs 41.7 cases per 100,000, respectively, p< 0.01), and higher than in 2008-2016 (9.6 per 100,000; p< 0.01) (Figure). Among iNTHi cases 18-55 years old (2019-2022), 94/95 had isolates available for cluster analysis: 7/94 (7%) and 18/94 (19%) were identified as C1 and C2, respectively. Characteristics of cases differed by clonal status (Table 1): among C1, C2, and NC cases, 6/7 (86%), 7/18 (39%), and 15/69 (22%) involved PWH, respectively; and septic arthritis was present in 1/7 (14%), 8/18 (44%), and zero, respectively. Table 2 provides detailed data on PWH with clonal strains.

Conclusion

Ongoing transmission of two clonal NTHi strains that are associated with a relatively high prevalence of joint involvement in invasive disease and disproportionately affect Black men and PWH was noted in Atlanta. The C2 clonal strain became more prevalent in 2022. Additional studies are needed to better understand modes of transmission, geographic distribution of clones, and to explore the unusual clinical manifestations to optimize prevention and treatment measures.

Disclosures

Lauren F. Collins, MD, MSc, Curio Science: Honoraria
1304. Early Surgical Procedures and Clinical Outcomes Among Children Hospitalized with Acute Hematogenous Osteomyelitis
Authors: Searns Justin B , Hall Matt , Birkholz Meghan C , Hubbell Brittany , Kern-Goldberger Andrew S , Kronman Matthew , Markham Jessica , Rolsma Stephanie L , Shah Samir S , Wang Marie E , O’Leary Sean , Dominguez Samuel R , Parker Sarah K
Published: November 2023

Background

Surgical biopsy and drainage may have diagnostic and therapeutic benefits for children with acute hematogenous osteomyelitis (AHO). However, it remains unknown whether routinely expediting surgical procedures improves clinical outcomes compared to a “wait-and-see” approach. We aimed to determine whether hospitals that frequently perform early surgery for AHO have improved clinical outcomes compared to hospitals that rarely perform early surgery.

Methods

Admissions for AHO at 48 hospitals were identified in the Pediatric Health Information System from 1/2015 through 10/2022 for patients 6 months to 18 years with a discharge diagnosis of osteomyelitis using a previously validated algorithm to exclude chronic osteomyelitis, non-hematogenous infections, and significant comorbidities. Encounters assigned a surgical procedure code on hospital day 0 or 1 were classified as undergoing “early surgery” and hospitals were stratified based on proportion of AHO patients receiving early surgery. Clinical outcomes at the 16 hospitals with the lowest rates of early surgery (rare group) were compared to those from the 16 hospitals with the highest rates of early surgery (frequent group). Categorical variables were compared using chi-square tests and continuous with Wilcoxon Rank-Sum tests.

Results

There were 2102 encounters in the rare group and 2040 encounters in the frequent group. Median proportion of AHO patients undergoing early surgery was 20% in the rare group compared to 37% in the frequent group (Range 10% to 54%). Length of stay in the frequent group was marginally lower (4.4 vs 4.1 days, P < 0.001), as was length of intravenous antimicrobials (4.5 vs 4.3 days, P< 0.001). Patients were more likely to be critically ill at frequent early surgery hospitals (1% vs 5%, P< 0.001), more likely to have a central line placed (8% vs 11%, P=0.002), and more likely to have a pathogen identified (50% vs 59%, P< 0.001). Cost per admission was slightly higher in the frequent group ($12960 vs $13759, P< 0.001).

Conclusion

Frequency of early surgical procedures for pediatric AHO varies across institutions. Clinical outcomes and resource utilization for children with AHO are similar between institutions that rarely and frequently expedite surgical procedures.

Disclosures

Samuel R. Dominguez, MD, PhD, Biofire Diagnostics: Advisor/Consultant|Biofire Diagnostics: Grant/Research Support|Cobio Diagnostics: Board Member|Karius: Advisor/Consultant|Pfizer: Grant/Research Support
1314. Missed Opportunities for Early Treatment and Prevention of Community Acquired Bacterial Meningitis
Authors: Beard Glenn H , Hasbun Rodrigo
Published: November 2023

Background

Community acquired bacterial meningitis (CABM) is a life-threating infection with high rates of mortality and chronic neurological sequela. These rates increase significantly if antibiotic and steroid therapies are delayed. As such, taking every opportunity to quickly diagnosis and rapidly treat CABM is paramount to improving patient outcomes.

Methods

To identify such opportunities we performed a multicenter retrospective analysis of patients who had been hospitalized for CABM in Houston, TX, from 5/2004 to 2/2023. Exact dates and times were collected for initial presentations, initiation of medications, and if the patient had been evaluated by a medical provider prior to hospitalization. Delayed antibiotics and steroids were defined as administration > 6 hours after presentation. Steroids given after antibiotics were also classified as delayed. Patients lacking exact dates and times of these variables were omitted.

Results

100 CABM cases were reviewed and documentation showed that 36 patients (36%) were seen by a medical provider within 2 weeks prior to hospitalization. These patients’ chief complaints were most commonly ear pain, congestion, or dental pain. 12 patients received penicillins (4), fluoroquinolones (3), azithromycin (2), doxycycline (1), cephalosporin (1) and unspecified antibiotics (1). The other 24 patients were diagnosed with non-infectious causes (headaches, migraines, and muscle sprains).

Most hospitalizations had delayed antibiotics (53%) and steroids (73%). A significant number of patients did not receive steroids during their hospitalizations (21%). In total, 96% of patients missed opportunities for early interventions that improve outcomes.

Conclusion

It appears that there are many opportunities to improve early recognition of CABM and treatment of infections that lead to CABM in the outpatient setting. This is especially true when considering that this study is more likely to underestimate the number of patients who seek care prior to hospitalization. Regarding inpatient opportunities, increasing use of steroids in the acute workup phase of bacterial meningitis should be pursued given the high rate of delayed administration and severe neurological complications that are more likely to occur when it is not administered.

Disclosures

Rodrigo Hasbun, MD MPH FIDSA, BIOFIRE: Advisor/Consultant
1316. Clinical Utility of Pharmacogenomic Testing in Refractory Coccidioidal Meningitis
Authors: Blair Janis E , Kekic Adrijana , Grill Marie
Published: November 2023

Background

Coccidioidomycosis is an endemic fungal infection in the desert southwestern USA. Less than 1% of infections are complicated by coccidioidal meningitis (CM), which requires lifetime treatment, and has high morbidity. IDSA guidelines recommend high dose fluconazole (flu) as first line treatment, but up to 31% of CM patients (pts) fail flu. Guidelines have not yet articulated best subsequent therapy, but options include itraconazole (itra), voriconazole (vori), posaconazole and isavuconazole (isa). Excellent adherence to medications is imperative, and therapeutic fluconazole (flu) serum levels correlate with successful CM outcome. Many azoles are substrates of P450/CYP enzymes, and genetic alterations may influence medication levels. We have observed many CM pts who swear to adherence yet have low therapeutic azole levels. Our aim was to summarize our experience with pharmacogenomic (PGx) testing to guide treatment of CM.

Methods

We conducted a retrospective review of CM pts in our Coccidioidomycosis Clinic who underwent 1 of 2 targeted gene queries, either an internal 9-gene query or an external vendor 27 gene test. A PGx pharmacist interpreted results.

Results

From 1/1/2021 – 4/30/2023, we identified 6 pts with poorly controlled CM as manifested by repeated hospitalizations, progressively abnormal findings on lumbar puncture and/or magnetic resonance imaging of the central nervous system. Among the 6, 3 (50%) were male, 5 (83%) white, mean age 45 (28-71) years, with 34-month mean duration of illness. None were immunosuppressed. CM was complicated by strokes in 3, and hydrocephalus requiring ventriculoperitoneal shunt in 2. Five failed initial high dose flu and most had some low therapeutic levels without other medications acting as CYP inducers/inhibitors. 3 pts had the 9 gene test and 3 had the 27 gene test. Clinically relevant PGx abnormalities were identified in 5, including variants of CYP 2C19, 2C9, 3A4 and 3A5, which confer altered metabolism of vori, itra and isa, respectively. Following PGx, treatment was adjusted in 4 pts.

Conclusion

PGx testing is a potential adjunctive tool to avoid ineffective therapies or medication toxicity in an infection whose treatment success strongly depends on consistent therapeutic medication levels over a lifetime.

Disclosures

All Authors: No reported disclosures
1989. Surge in Group A Streptococcal Infections in England during 2022
Authors: Guy Rebecca L , Brown Colin S , Mason Emily L , Hughes Helen E , Demirjian Alicia , Mirfenderesky Mariyam , Anderson Sarah R , Ready Derren , Edeghere Obaghe , Lamagni Theresa
Published: November 2023

Background

Following removal of non-pharmaceutical interventions (NPI) to restrict SARS-CoV-2 transmission in England, large increases above seasonally expected levels of group A streptococcal (GAS) infections and associated deaths were seen, particularly in children, during 2022.

Methods

Nationwide data from UK Health Security Agency surveillance databases were extracted, including statutory clinical notifications of scarlet fever and laboratory-confirmed invasive GAS infections (iGAS; sterile-site specimens). Analyses compared infection and mortality rates in England for the pre-COVID-19 pandemic (2017-2019), pandemic-NPI (2020-2021), and post removal of COVID-19 NPI (post-NPI; 2022-2023) periods.

Results

Pre-pandemic, a mean of 2481 iGAS cases (range 2138-2921; 13%-14% < 15y; Figure) per-year were recorded in England (4.4/100,000 population; 95% confidence interval (CI):4.3-4.6). Case numbers fell markedly during the pandemic-NPI period, 1462 iGAS cases in 2020 (2.6/100,000; 7% aged < 15y) and 829 in 2021 (1.5/100,000; 6% < 15y; Figure). Post-NPI cessation, iGAS cases increased to 2892 (5.1/10,000; 24% < 15y) in 2022, remaining high into Jan-Mar 2023 (1361; 21% < 15y). Scarlet fever diagnoses similarly increased, with 54,630 (91.6/100,000; CI: 90.8-92.4) notified in 2022 (England & Wales), the highest number since 1953.

In 2022, 339 deaths (< 7d iGAS diagnosis) were reported (case-fatality rate (CFR) 11.7%; CI:10.6-13.0%; 16% deaths were aged < 15y), compared to 214-335 per-year pre-pandemic (8%-10% in < 15y) and 88 in 2021 (6%< 15y). Respiratory virus co-infections were identified in 19% iGAS aged < 15y during 2022, CFR: 19.8%.

Post-NPI cessation, strain typing identified increasing dominance of emm1 and emm12 (all ages: 35% and 18%) in 2022, compared with 3% and 2% in pandemic-NPI and 23% and 6% pre-pandemic (all-ages).

Conclusion

iGAS presentations showed a marked rebound in 2022, most notably in children, with re-emergence of emm1. The rapid, steep increase in morbidity was possibly driven by increased opportunities for exposure and sub-optimal immunity following COVID-19 NPI.

Disclosures

All Authors: No reported disclosures
1325. Neurodevelopmental outcomes in preschoolers following viral meningitis is Canterbury, New Zealand
Authors: Martin Natalie G , Williman Jonathan , Walls Tony , Sadarangani Manish , Grant Cameron
Published: November 2023

Background

Most childhood meningitis nowadays is caused by viruses in countries with widespread use of conjugate vaccines. There is limited knowledge about outcomes following childhood viral meningitis, necessary to inform clinical guidelines.

Methods

Children aged 19-42 months in Canterbury New Zealand, who had enterovirus (EV) or human parechovirus (HPEV) meningitis as infants were included. Clinical data was collected. Comprehensive neurodevelopmental assessments were completed using the Bayley Scale for Infant Development (BSID) Third Edition. Mean composite and scaled scores, and proportion below cutoff were assessed in each domain. Normative mean composite scores for any domain is 100. Expected scaled score range is 8-12. Mean scores between EV and HPEV meningitis were compared by t-tests, with P< 0.05 considered significant.

Results

BSID assessments were completed for 33 children (55% male) of mean age 31 months, from 2019-22, including 23 with EV and 10 with HPEV meningitis. There were 24 children of NZ European, 4 Māori, 4 Asian, and 1 Middle Eastern ethnicity. Mean age at diagnosis was 43 days, and mean length of admission was 2.79 days (CI 1.74-3.15). Of 33 children, 32 (97%) received intravenous or intramuscular antibiotics, 6 (18%) received a fluid bolus on arrival at hospital, and 9 (27%) required high dependency or intensive care. Following viral meningitis, parents reported developmental speech concerns in 6 children, and delayed motor milestones in 1 child. There was no reported sensorineural hearing loss. BSID mean composite scores were in expected range for cognition 102 (CI 98-106), language 96 (93-100) and motor 102 (98-106) domains. Mean scaled scores were in expected range for receptive language 9 (9-10), expressive language 9 (9-10), fine motor 11 (11-12) and gross motor 9 (9-10) domains. Overall, 12/33 (36%) children had below expected scores in one area of development including cognition (2/33; 6%), receptive language (6/33; 18%), expressive language (5/33; 15%), and gross motor (6/33; 18%). There were no significant differences between BSID scores in EV and HPEV meningitis.

Conclusion

Following viral meningitis, 36% percent of preschool children had findings below expected in at least one developmental domain, suggesting targeted follow-up should be considered.

Disclosures

Manish Sadarangani, BM BCh, FRCPC, DPhil, GlaxoSmithKline: Grant/Research Support|Merck: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support|Sanofi Pasteur: Grant/Research Support|Seqirus: Grant/Research Support|Symvivo: Grant/Research Support|VBI Vaccines: Grant/Research Support
1341. Clinico-demographic Features and Mortality of COVID-19 Patients in Southwest Michigan
Authors: Alves Alana Pinheiro , Johnson Alec , Bizer Benjamin I , Belardo Matthew , Garber Kathryn , Abbas Mujahed
Published: November 2023

Background

Since the beginning of the COVID-19 pandemic to May 2023, Michigan has had over 3 million confirmed or probable disease cases, with nearly 43 thousand deaths. Southwestern Michigan was significantly impacted and contributed to a high burden of the disease in the state. Our study objectives were to describe mortality rates and some of the demographic and clinical characteristics of COVID-19 in this area.

Methods

This is a retrospective cohort analysis in one community hospital in Kalamazoo County, Southwestern Michigan, United States. Institutional Review Board approval was obtained. Data was extracted from electronic medical records (EMR). Patients admitted to the hospital from March 2020 to December 2022 with a positive polymerase chain reaction (PCR) test for SARS-CoV-2 were included. Pregnant patients and those less than 18 years of age were excluded.

Results

A total of 426 patients were included in this study, mainly males. The median age of hospitalization was 65 years. The most prevalent co-morbidities were type 2 diabetes mellitus, hypertension, and coronary artery disease. The median length of hospital stay was ten days. 139 (32,6%) individuals died, the majority of whom were men aged between 50 and 80. At the same time, we noted higher death rates among American Indian or Alaskan Native individuals and Black or African American patients. Review Figures 1 and 2 for further details.

Conclusion

A high absolute number of deaths among Whites or Caucasians was noted, likely related to local demographics where most of the population self-identifies as so. They were the most prevalent group of hospitalized individuals in our cohort. All four American Indian and Alaskan Native individuals included in the results died. Like national and state data, Black or African Americans and Hispanic/Latinos had a higher death rate than Whites. Variables such as co-morbidities, length of stay, and need for mechanical ventilation within these groups were not considered when calculating such rates. A 32,6% percent of deaths in our cohort is more elevated than local and worldwide statistics. However, this is a small study with several confounding factors that lacked calculation of statistical significance.

Disclosures

All Authors: No reported disclosures
1342. The Utilization of Cycle Threshold Values in Hospitalized Veterans with Persistently Positive SARS CoV-2 RT-PCR for the Removal of COVID Precautions.
Authors: Belanger Debra , Bailey Lisa , Rahman Mahfuz , Thorne Monique , Ford Florence M , Psevdos George
Published: November 2023

Background

In the last 3 years the novel severe acute respiratory syndrome coronavirus 2 (SARS CoV-2), which causes coronavirus disease 2019 (COVID 19), has menaced the world causing morbidity and mortality. Infection control preventionists had stepped up and were instrumental in the prevention of hospital acquired COVID infections. Discontinuation of isolation precautions in prolonged hospitalized patients and with persistently positive reverse-transcriptase polymerase chain reaction (RT-PCR) can be quite challenging. Distinguishing prolonged viral shedding vs. detection of inactive viral remnant is not easy. Cycle threshold (Ct) values can be of help, knowing that Ct values > 35 are not related with viable virus. We reviewed our experience of using Ct for infection control decisions

Methods

Retrospective chart review of hospitalized Veterans (VETS) in Northport VAMC from 1/1/2021 to 3/31/23. Viral burden rebound was defined as a case of Ct showing the following trend: from low numbers to ≥35 and then decreasing to below 35. Ct values were obtained from SARS CoV-2 RT-PCR, Xpert® Xpress, Cepheid

Results

2730 VETS had COVID 19 during the pandemic. Of the 235 VETS hospitalized in the study period 20 had Ct values that remains ≤ 35 for > 14 days. All were men. 80% Caucasian. The median age was 78.5. 2 were unvaccinated. 3 had COVID in the past (5, 8, 20 months prior). See Table 1. 90% had hypertension and 30% had active malignancy. The median length of stay was 23 days (16-76). The median days duration of Ct being < 35 is 20 (16-45). The lowest Ct values ranged from 16 to 29.3. In 8 patients the lowest value was on admission, in the rest it ranged from hospital day 3 to 23. 7 patients showed evidence of viral burden rebound with 1/7 having a Ct < 35 for 45 days. 2/7 had received monoclonal antibody therapies, 1 molnupiravir, and 4 remdesivir/steroids. The median duration of COVID 19 precautions was 20, range 15 to 55. 1 VET required intubation. 2 died but did not have evidence for viral burden rebound. 3 remained asymptomatic and did not need treatment

Table 1

Demographics Table

Conclusion

Prolongation of COVID 19 precautions for more than 14 days were noted in elderly Veterans with comorbidities, with 1/3 having active malignancy. Utilization of Ct value was crucial in identifying cases of viral burden rebound and thus extending infection control measures

Disclosures

All Authors: No reported disclosures
1991. Cluster of Non-toxigenic Corynebacterium diphtheriae Infective Endocarditis Prompting Epidemiologic Investigation — Seattle, Washington 2020-2023
Authors: Karmarkar Ellora , Fitpatrick Tom , Himmelfarb Talia , Chow Eric J , Smith Hayden Z , Lan Kristine F , Matsumoto Jason I , Kim H Nina , Pottinger Paul S
Published: November 2023

Background

Non-toxigenic Corynebacterium diphtheriae (C. diphtheriae), an aerobic gram-positive bacillus, is often associated with wound infections. However, it can also cause outbreaks and invasive disease including infective endocarditis (IE). After identifying a cluster of C. diphtheriae IE cases, we conducted an epidemiologic investigation to identify additional C. diphtheriae detections within our university-affiliated hospital system from 2020-2023.

Methods

We performed retrospective chart review of any patients with C. diphtheriae detected in a clinical specimen (i.e. wound, blood, sputum) between 9/1/2020 and 4/1/2023. A confirmed case of C. diphtheriae IE was defined as at least two positive monomicrobial blood cultures with vegetation(s) on echocardiogram; probable IE was defined as positive monomicrobial blood cultures with embolic phenomena. We describe demographic and clinical characteristics of all patients with C. diphtheriae detection, including patients with C. diptheriae IE.

Results

Between 9/1/2020 to 4/1/2023, 45 patients (median age 44 years, range 23-75 years; 76% male, 64% non-Hispanic White, 80% unstably housed) had ≥ 1 clinical specimen with C. diphtheriae; 5 (11%) patients had confirmed (n=4) or probable (n=1) IE. The largest number of C. diphtheriae detections were in December 2022 (Figure 1). Forty-three patients (96%) reported substance use; 19 (42%) reported history of injection drug use (IDU). C. diphtheriae was detected in 34 (76%) polymicrobial wound cultures, 7 (16%) polymicrobial blood cultures with concomitant Staphylococcal or Streptococcal bacteremia, 5 (11%) blood cultures from C. diphtheriae IE, and one (2%) sputum specimen. The five IE cases (80% male, 60% unstably housed) were diagnosed between 5/2022-3/2023 and had current IDU (60%) or open wounds (40%). Four had embolic phenomena; two received cardiac surgery. Four (80%) patients with IE died: three from IE and one from COVID-19.Figure 1:Epidemiologic curve of C. diphtheriae cases in patients with positive wound cultures, blood cultures, endocarditis, and sputum cultures within a university-affiliated hospital system, September 1, 2020-April 1, 2023.

Conclusion

A cluster of C. diphtheriae IE cases and rising C. diphtheriae detections in our hospital system raise concern for a local outbreak disproportionately affecting patients who use substances and are unstably housed. Outbreak investigation and prevention efforts (wound care, linkage to care) are critical to prevent additional mortality.

Disclosures

H. Nina Kim, MD, MSc, Gilead: Grant/Research Support
1366. Temporal changes in Demographics, Characteristics and Treatments for Patients enrolled in the Canadian Treatments for COVID-19 Trial
Authors: Mohsen Samiha , Murthy Srinivas , Pinto Ruxandra , Fowler Robert
Published: November 2023

Background

Over 4 million Canadians have been infected with COVID-19. The risk to the Canadian population has been dynamic over time, with changing demographics of patients at risk, differential uptake of vaccination, and potentially differential presentation, access, or acceptance of evolving treatments. Our study aims to evaluate the temporal change in patient characteristics, process of care and outcomes over the pandemic for patients with COVID-19 admitted to hospitals and enrolled in the Canadian Treatments for COVID-19 trial (CATCO).

Methods

The study included all patients admitted to 52 participating Canadian hospitals with laboratory confirmed SARS-COV-2 infection and enrolled in the CATCO trial. Data was analyzed temporally over six periods of enrollment, corresponding to approximately every 242-294 patients (Figure 1). Patient characteristics and outcomes were summarized using descriptive statistics (i.e., median, proportions).

Results

Mean age (63 years) and sex (30% female) among enrolled patients were similar across six pandmiec periods. Patient admission to ICU was most common at the beginning of the pandemic (period 1 n=75, 30.4%; period 2 n=67, 27.2%; approximately 20% in subsequent periods [p< 0.001]). The proportion of patients who identified as Black decreased from 10.2% to 3.1% between the first and sixth period, while the proportion of other minority groups remained stable (Figure 2.). Treatment with corticosteroids increased substantially after the first period (41.2% to over 90% in each subsequent period). Unadjusted in-hospital and 60-day mortality was similar over periods (p=0.501).

Conclusion

There were changes in treatments and a decreasing proportion of enrolled patients admitted to ICU as enrollment in CATCO progressed. In contrast to epidemiological data that showed a change in demographics of hospitalized persons shifting from predominantly Caucasians to predominantly minority groups overtime, our study found that there was not increasing enrollment of minority groups over time. In a dynamic pandemic, it may be important to include the potential for temporal changes in patient characteristics, treatments, and support when investigating the effect of medications on clincial outcomes over time.

Disclosures

All Authors: No reported disclosures
1372. Impact of Age, Gender, Ethnicity, Comorbidities, and Vaccination Status on Long COVID in a Brooklyn Community
Authors: Ta Calvin
Published: November 2023

Background

A significant number of patients have been affected by COVID-19 and experience prolonged symptoms. Several studies have documented the long-term effects of COVID-19, however little is known about the symptom severity, expected clinical course, or how long it takes to return to baseline health. At our institution, we have continued to care for patients at Maimonides Medical Center Adult Post-COVID Clinic (MMCPCC) who have persistent post-COVID symptoms.

Methods

We conducted a retrospective chart review of patients at MMCPCC from November 2020 to June 2022. Patients 18 years or older, with confirmed or suspected COVID-19, and whose symptoms persisted beyond four weeks were included. We evaluated the demographics, comorbidities, vaccination status, reported post-COVID symptoms, the duration of these symptoms, and history of COVID-19 hospitalization. The average number of symptoms (ANOS) and hospitalization rate (HR) were measured.

Results

Twenty-five long COVID symptoms were reported and evaluated. The most common symptoms were malaise/fatigue, dyspnea, anxiety, arthralgia/myalgia, and headache. Of 173 patients that were included in our study, 49.7% (86) were white, 60.1% (104) were female, 42.2% (73) were 50-69 years old, and 80.9% (140) were unvaccinated at the time of COVID-19 infection. Of the vaccinated patients, 18.6% were white, 23.3% were Black, 23.5% were Hispanic, and 11.8% were Asian. The ANOS was 4.37 and the HR was 24.9%. 50 to 59-year-olds reported the highest ANOS (5.33). Asian patients reported the lowest ANOS (3.29). Minority patients and patients with obesity had higher HRs (35.1% and 35.2% respectively). Hispanic and Black patients with ≥ 2 comorbidities (41.2% and 25.6% respectively) had an ANOS of 5.57 and 4.55 respectively. 60.7% (105) of patients reported symptoms > 3 months and 24.3% (42) reported symptoms for over a year. Of those, 72.1% of Black and 70.6% of Hispanic patients had long COVID for > 3 months compared to 59.3% of white and 35.3% of Asian individuals.

Number of comorbidities among the racial groups with long COVID at MMCPCC.

Patients with long COVID greater than 3 and 12 months among the racial groups at MMCPCC.

List the most common long COVID symptoms that were evaluated.

Conclusion

Our study showed unvaccinated, 50 to 69 years old, white, and female patients were predominantly affected by long COVID. Hispanic and Black patients with multiple comorbidities have higher ANOS, 71.7% had long COVID for > 3 months, and 31.7% had long COVID over a year.

Disclosures

All Authors: No reported disclosures