bluuebunny/crossref_metadata_2025 huggingface dataset:
1207. Acquisition and Quantification of Antimicrobial Resistance Genes in the Gut Microbiome of Ugandan Women Exposed to Small-Scale Chicken Farming
Authors: Debela Meti D , Muyanja Daniel M , Kakuhikire Bernard , Baguma Charles , Bangsberg David R , Tsai Alexander C , Weil Ana A , Lai Peggy S
Published: November 2018

Background

Antibiotic use in livestock farming is thought to be a major contributor to the spread of antimicrobial resistance (AMR) genes in humans. However, quantitative data in this in this field are rare. To address this gap in the literature, we examined the prevalence of clinically important AMR genes before and after the introduction of chicken farming among women in rural Uganda.

Methods

We recruited a subset of women participating in a waitlist-randomized controlled trial of small-scale hybrid chicken farming in rural Uganda. Tetracycline is routinely administered to chicks during brooding. Stool samples before and one year after chicken introduction were obtained from six women randomized to the control arm, from five women randomized to the intervention arm, and from chickens. Microbial DNA was extracted from chicken and human stool and screened for 87 AMR genes using validated qPCR arrays (Qiagen).

Results

The median age was 35 years. At baseline, 10 of the women reported animal contact, most commonly goats (n = 8), free ranging village chickens (n = 7), cats (n = 4), and dogs (n = 4). During baseline testing of the women’s stool, we detected 18 genes conferring AMR to aminoglycosides, fluoroquinolones, macrolides, lincosamides, streptogramin B, Class A-C β-lactamases and tetracycline efflux pumps. Chickens harbored 23 AMR genes from the same classes as found in humans, and were also found to have vancomycin resistance genes (Van B and C) and Group D β-lactamases (OXA-58 and OXA-10). At one year, six new AMR genes emerged in controls, including one present in chickens; CTX-M-1, a Class A β-lactamase. In contrast, seven new AMR genes emerged in the intervention group, including four present in chickens: SHV, SHV(238G240E), (Class A β lactamases) and QnrS, QnrB-5 (fluoroquinolone resistance genes). Two AMR genes gained by both control and intervention groups were not present in chickens.

Conclusion

Women exposed to small-scale chicken farming acquired more AMR genes compared with unexposed participants. Chickens harbored many of the genes that emerged in humans. Introduction of antibiotic-treated animals may result in the transfer of AMR genes from animals to humans, even among humans exposed to a wide range of animals at baseline.

Disclosures

All authors: No reported disclosures.
1208. Impact of Admission to an Inpatient Infectious Disease Unit on Methicillin-Resistant Staphylococcus aureus Bloodstream Infections
Authors: Mirza Zainab Farooqui , Bardossy Ana C , Misikir Helina , Hadid Hind , Baratz Nathalie , Rizvi Hira , Herc Erica , Chen Anne , Zervos Marcus
Published: November 2018

Background

Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infection (BSI) remains a condition with high mortality. Despite the introduction of new antibiotics, the mortality in the past 10 years at our institution remains unchanged. To evaluate measures that improve outcomes in these patients (patients), we studied the impact of admission to an inpatient infectious disease (ID) unit.

Methods

We identified a retrospective cohort of patients with MRSA BSI at an 800-bed hospital in urban Detroit from January 2013 to February 2017. Patients were assigned to one of the three groups: group 1 was admission to inpatient ID unit where the ID doctors were the attending physicians, group 2 was ID consultation (without admission to ID unit), and group 3 was no ID consultation. Demographics, clinical information, and 30 day mortality from index blood culture were collected. Source of BSI was classified into four categories: primary (endovascular infection); secondary (respiratory, skin, osteomyelitis, abdominal and genitourinary infections); central line associated; unknown. Unpaired t-test and Fisher’s exact test were used to compare groups.

Results

A total of 477 patients were identified with MRSA BSI during the study period. 89 (18.7%) were in group 1, 299 (62%) in group 2 and 89 (18.7%) in group 3. Pt clinical characteristics and outcomes are shown in Table 1. Overall 30-day mortality was 21.4%. Comparison of mortality between groups are shown in Table 2.

Conclusion

While it is well established that ID consultation has improved outcomes in MRSA BSI, this is the first study that shows that admission to an inpatient ID unit decreases mortality even further.

Disclosures

All authors: No reported disclosures.
1215. Geographic Distribution of Staphylococcus aureus With Reduced Sensitivity and Resistance to Vancomycin in the Dominican Republic
Authors: Mena Lora Alfredo J , Gonzalez Patricia , Lluberes Magnolia , Grau Gabriel , Bleasdale Susan C
Published: November 2018

Background

Resistant Staphylococcus aureus (SA) poses a major challenge to clinicians. The prevalence of methicillin-resistant SA (MRSA) has increased over the past decades, while vancomycin resistance remains rare. Only 14 cases of vancomycin-resistant SA (VRSA) have been described in the United States since 2002. VRSA and SA with reduced susceptibility to vancomycin (VISA) cause high morbidity and mortality. There is a paucity of data on VRSA in developing nations. We seek to define the prevalence and resistance profile of SA in the Dominican Republic (DR).

Methods

This is a retrospective review of resistance patterns of SA isolates from a clinical laboratory in the DR (Amadita Laboratories). Amadita provides services nationwide. Data collected from 2016 to 2017 included SA phenotypic sensitivity patterns and geographic location and income level. VISA and VRSA were defined as having minimum inhibitory (MIC) concentrations between 4 and 8 and MIC >16.

Results

Of 5,372 SA samples, 2,735 (51%) were MRSA, 21 were VISA and 39 were VRSA. VRSA samples were more commonly from Santo Domingo (SD) (Figure 1). Communities in SD with mixed and low incomes had greater burden of VRSA (Figure 2). Antimicrobial susceptibilities are shown in Table 1.

Conclusion

In this nationwide sample, we found an alarming number of VISA and VRSA. Most cases were in metropolitan SD, with lower income communities carrying a higher case burden. Linezolid and TMP-SMX retain activity against VISA and VRSA in the DR. The rise of vancomycin resistance in developing countries and the disproportionate burden on communities of low income is concerning and requires further study. Infection control measures and antimicrobial stewardship interventions may help prevent further spread of resistant strains.

Disclosures

All authors: No reported disclosures.
1217. Staphylococcus Protein A (spa) Typing Demonstrates Genetic Heterogeneity of Methicillin-Susceptible Staphyloccus aureus (MSSA) in a Neonatal Intensive Care Unit (NICU)
Authors: Hill-Ricciuti Alexandra , Ferguson Samantha , Geng Wenjing , Stump Stephania , Messina Maria , Zachariah Philip , Sahni Rakesh , Green Daniel , Whittier Susan , Saiman Lisa , Uhlemann Anne-Catrin
Published: November 2018

Background

In the NICU, MSSA is a more prevalent pathogen than MRSA, but optimal infection prevention and control strategies for MSSA are not yet well understood. There are likely multiple routes of MSSA acquisition given its role as normal flora and its detection in the anovaginal tract of pregnant women. We describe the molecular epidemiology of MSSA in our NICU during a yearlong surveillance effort.

Methods

Included infants were hospitalized in a university-affiliated level III-IV NICU from January to December 2017 (1032 admissions) and had positive clinical and/or surveillance cultures for MSSA. Infants admitted at ≥7 days of age were screened for MSSA colonization by culturing the anterior nares and three skin sites. All infants in the NICU were screened twice monthly. Spa typing was performed to genetically characterize isolates.

Results

During the study period, MSSA was identified in 187 infants (18 at admission, 145 by twice monthly surveillance, and 24 from clinical cultures). In all, 269 MSSA isolates (245 surveillance and 24 clinical isolates) from 166 infants were spa typed. Sixty-two MSSA spa types were identified; 31 (50%) were each detected in only one infant. The incidence of the nine most common spa types is shown (Figure 1); t279 (13%), t002 (8%), and t1451 (6%) had the highest incidence. t1451 and t571 belong to ST398, a common MSSA clone in the local community. The epidemiology of spa types varied; e.g., incident cases of t279 was detected in 10 months, t1451 was detected in 6 months and t148 in 3 months. Among the 14 sets of twins and triplets with MSSA isolates, 12 (86%) shared the same spa type as their sibling(s). Of the 58 infants with >1 MSSA isolate, 12 (21%) acquired new spa-types. No spa type(s) predominated in the 19 episodes of invasive infections. In 6 infants with both colonizing and invasive isolates, colonizing and invasive isolates were the same spa type(s) in 5.

Conclusion

Spa typing demonstrated that MSSA isolates in our NICU exhibited substantial genetic heterogeneity. While these data do not elucidate acquisition route(s), they suggest infants are acquiring MSSA from multiple sources, likely including family members and the local community. Ongoing sequencing studies are examining common spa types to further understand transmission dynamics.

Disclosures

A. C. Uhlemann, Merck: Investigator, Grant recipient
1225. High Rate of Linezolid (LZD) Nonsusceptibility (LNS) Among Enteric Vancomycin-Resistant Enterococci (VRE) Recovered From Hospitalized Patients Actively Screened for VRE Rectal Colonization (VREC)
Authors: Dilworth Thomas J , Beck Eric , Pedersen Rachel , Al-Karkokly Waseem , Cook Margaret , Aldag Erika , Kramer David J , Sahajpal Ajay , Nadeem Iram , Buggy Brian , Brummitt Charles F
Published: November 2018

Background

Select hospitalized patients are actively screened for VREC but VRE isolates may not undergo antibiotic susceptibility testing. We sought to identify predictors of daptomycin (DAP) nonsusceptibility (DNS, MIC > 4) and LNS (MIC > 2) among enteric VRE isolates recovered from patients actively screened for VREC for which antibiotic susceptibility testing was not preformed.

Methods

This was a retrospective study of consecutive adults admitted to a surgical intensive care unit (ICU) or associated medical unit between June 1, 2017 and March 1, 2018 who had a VRE isolate from active screening. Only index isolates were included. DAP and LZD MICs were determined by Etest. Patient- and antimicrobial-level data, including ambulatory prescriptions, dating back to January 1, 2016 were collected. Multivariable logistic regression models were used to determine predictors of DNS and LNS VRE.

Results

In total, 64 patients’ VRE rectal isolates were included. Fifty-nine (92.2%) were E. faecium and 50 (78.1%) were from ICU patients. Thirty-seven patients (57.8%) were female and the mean age ± SD was 60 ± 13 years. Five (7.8%) and 20 (31.3%) patients had previous abdominal transplant and VRE infection, respectively. DAP and LZD MIC distributions are shown in the table below. Forty-one (64.1%) VRE isolates were LNS, including five LZD-resistant isolates. Only one (1.6%) isolate was DNS precluding an analysis of DNS predictors; 12 (18.8%) isolates had a DAP MIC > 2 mg/L. Common antimicrobial exposures prior to index VRE isolate included: vancomycin (62.5%), ceftriaxone (64.1%), cefepime (53.1%), metronidazole (50%), and ciprofloxacin (50%). Previous LZD (17.2%) and DAP (15.6%) exposure were less common. In a multivariable model, number of previous cefazolin doses (adjusted odds ratio (aOR) 0.74 95% confidence interval (CI) 0.55–0.95), and previous tobramycin exposure (aOR 0.15, 95% CI 0.02–0.81) were inversely associated with LNS. Previous LZD exposure was not associated with LNS.

Conclusion

LNS was common amongst VRE isolates in this cohort. Previous LZD exposure was infrequent and not associated with LNS. LZD susceptibility testing among VRE isolates recovered from patients actively screened for VREC warrants clinical consideration.

Disclosures

All authors: No reported disclosures.
1226. Can Universal Decolonization Obviate the Need for Screening and Contact Precautions for Carriers of Methicillin-Resistant Staphylococcus aureus in a Medical Intensive Care Unit With MRSA Endemicity? An Interrupted Time Series Study
Authors: Lee Seung Soon , Kim Yong Kyun , Han Junhee , Jung Younghee
Published: November 2018

Background

Universal decolonization of patients in intensive care units (ICUs) has been identified to be an effective infection control strategy of methicillin-resistant Staphylococcus aureus (MRSA). However, it remains uncertain whether universal decolonization can obviate the need for active surveillance testing (AST) and contact precautions (CPs) for MRSA carriers.

Methods

We conducted an interrupted time series study to evaluate whether universal decolonization (daily chlorhexidine bathing plus twice-daily intranasal mupirocin ointment for 5 days) without AST and CPs did affect the incidence of MRSA acquisition on clinical specimen and MRSA bacteremia (the first positive blood culture obtained more than 48 hours after ICU admission) in a medical ICU. There was a 12-month control period of universal decolonization combined with AST and CPs, followed by a 12-month intervention period of universal decolonization without AST and CPs for MRSA carriers. Changes in incidence density (new cases of MRSA acquisition on clinical specimen per 1,000 eligible patient-days) of MRSA were evaluated by segmented Poisson regression, and the cox proportional-hazards regression model was used to compare the differences in incidence of MRSA bacteremia between the two periods.

Results

The median overall prevalence of MRSA did not differ between the two periods (25.3% vs. 23.4%, P = 0.55), and the segmented Poisson regression analysis revealed that there were no significant differences in both level and trend of MRSA prevalence (P = 0.43 and P = 0.27, respectively). The incidence density of MRSA acquisition on clinical specimen was lower during the intervention period (5.7 vs. 4.5, P = 0.039). However, both level and trend of MRSA incidence density did not differ significantly whether to perform active surveillance and contact precaution or not (P = 0.94 and P = 0.81, respectively). No patient developed MRSA bacteremia during the control period and there were only two patients of MRSA bacteremia during the intervention period, which showed no significant difference (Log rank test, P = 0.21).

Conclusion

Universal decolonization without AST and CPs for MRSA carriers do not increase the incidence of MRSA acquisition on clinical specimen and ICU-attributable MRSA bacteremia in ICU with high prevalence rate of MRSA.

Disclosures

All authors: No reported disclosures.
1229. Prevalence and Acquisition of MRSA in Females During Incarceration at a Large Inner-City Jail
Authors: Popovich Kyle J , Zawitz Chad , Aroutcheva Alla , Payne Darjai , Schoeny Michael , Diep Lisa , Hota Bala , Hayden Mary K , Weinstein Robert A
Published: November 2018

Background

USA300 MRSA is endemic in the community, with congregate settings such as urban jails potentially facilitating spread. It has been reported previously that males have a higher risk for MRSA carriage and bacteremia than females. However, it is unclear if there is differential risk for MRSA based on gender in high-risk populations. We determined the prevalence of MRSA colonization at jail entrance in females and defined an acquisition rate during incarceration.

Methods

Females incarcerated at the Cook County Jail, one of the largest US single-site jails, were enrolled within 72 hours of intake. Surveillance cultures (nares, throat, groin) were collected to determine prevalence of MRSA colonization. A survey was administered to identify predictors of colonization. Detainees in jail at Day30 had cultures repeated to determine MRSA acquisition. Univariate and multivariate analyses were performed to identify predictors of MRSA colonization.

Results

250 women were enrolled (70% AA, 15% Hispanic) with 70% previously in jail (21% in the past 6 months). The prevalence of MRSA colonization at intake was 20% (50/250), with 42% of those colonized solely in the throat or groin. This intake prevalence is comparable to the 19% for male detainees in a parallel study. 9% (2/23) of initially negative women who remained in jail for 30 days acquired MRSA; five remained colonized and no one lost colonization. Univariate predictors (table) of MRSA at entrance to the jail were: illicit drug use (including using needles), unstable housing, engaging in anal sex, and recent exchange of sex for drugs/money. Women who exchange sex for drugs/money (vs. not) reported higher rates of needle use (35% vs. 4%, P < 0.001) and unstable housing (80% vs. 20%, P < 0.001). With multivariate adjustment for race/ethnicity, needles for illicit drugs was a significant predictor of MRSA (OR 5.89, 95% CI, 1.66, 20.94, P = 0.006).

Conclusion

We found that a high proportion (20%) of females entered jail colonized with MRSA, comparable to rates in males, suggesting that previously reported gender disparities in MRSA may not exist in high-risk populations. Entrance colonization risk factors suggest high-risk activities or venues in the community, with potential for directing gender-specific interventions.

Disclosures

All authors: No reported disclosures.
1231. Patient-Level Factors Associated with Vancomycin-Resistant Enterococci Transmission to Healthcare Workers Gowns or Gloves
Authors: Blanco Natalia , Jackson Sarah S , Pineles Lisa , Thom Kerri A , Harris Anthony D
Published: November 2018

Background

Vancomycin-resistant Enterococcus (VRE) is transmitted from person-to-person, most commonly by healthcare workers (HCW) whose hands or attire have become contaminated while interacting with an infected or colonized patient. Our group recently found that VRE colonized patients transmitted this pathogen to HCW gowns or gloves 15% of the time. This study aims to describe patient-level factors associated with higher risk of transmission of VRE to HCW gowns or gloves and thus likely to subsequent patients.

Methods

We analyzed a prospective cohort that included 43 VRE-colonized patients and 215 HCW-patient interactions in medical or surgical intensive care units at the University of Maryland Medical Center. HCWs’ gowns and gloves were cultured for VRE after performing patient care and before doffing. Univariate and multivariable logistic regression models, using generalized estimating equations to account for patient clustering, were used to estimate the odds ratios associated with specific patient-level factors (i.e., age, race, Elixhauser comorbidity score components obtained by ICD-10 codes, diarrhea, and devices). Multivariable models with and without stool VRE burden were created.

Results

In the initial multivariable model, having a nasogastric tube, diarrhea, complicated diabetes, rheumatoid arthritis/collagen vascular diseases, neurological disorders or psychoses doubled (OR greater than 2) the patient’s risk of VRE transmission. After adjusting for VRE stool burden (OR 2.1 (95% CI 1.5–3.0)), having a nasogastric tube (OR 3.6 (95% CI 1.3–9.8)), diarrhea (OR 3.3 (95% CI 1.4–8.1)), or rheumatoid arthritis/collagen vascular diseases (OR 4.8 (95% CI 1.6–14.7)) remained significant in the model.

Conclusion

Patient-level factors associated with higher risk of VRE transmission to HCW gowns or gloves were identified even after adjusting for VRE stool burden, highlighting the importance of patient characteristics in VRE transmission. These patient-level factors may facilitate transmission by either increasing VRE stool shedding to the environment or the need for direct HCW-patient contact. These factors could be used to target more aggressive infection control interventions for these patients.

Disclosures

All authors: No reported disclosures.
1234. Racial Disparities in Invasive Staphylococcus aureus (iSA) Disease in Metropolitan Atlanta, a Population-Based Assessment, 2016
Authors: Overton Rahsaan , Fridkin Scott , Tunali Amy , Ray Susan M
Published: November 2018

Background

Disparities in incidence of invasive methicillin-resistant S. aureus (iMRSA) infections have been examined, suggesting that differences were in part driven by socio-economic factors. An analysis was conducted to determine whether similar disparities exist for invasive methicillin-susceptible S. aureus (iMSSA).

Methods

The Georgia Emerging Infections Program (GA EIP) conducts active, population-based surveillance for iSA within the 8-county area of Atlanta. Cases were defined as residents of the surveillance area with SA isolated from a normally sterile site, with cultures within a 30-day period considered a single case. Age- and race-specific incidence were calculated using 2016 US census data; other/unknown race were excluded from analysis (<5% of cases). Incidence rate ratios (RR) between stratum and summary adjusted rate ratios (aRR) were calculated with the Mantel–Hanzel method.

Results

During 2016, 1,958 cases were identified (42% iMRSA and 58% iMSSA); crude incidence was 48.5/100,000. Rates were highest among those ≥ 65 years of age for both blacks and whites (Figure 1). When compared with iMSSA, iMRSA incidence was consistently lower across all age groups (aRR: 0.7; 95% CI: 0.7–0.8) (Figure 2). However, the incidence of iMRSA among black cases was double that among white cases (aRR: 2.0; CI: 1.7–2.3) across all age groups. This racial disparity was less pronounced in iMSSA: among younger cases (<65 years old), iMSSA incidence among blacks was significantly higher than whites (aRR: 1.6; CI: 1.4–2.0), while rates were similar in older blacks and whites (≥65 years old) (aRR: 0.9; CI: 0.8–1.2). Bloodstream infections were the most common presentation overall; however, for iMSSA infections, joint/synovial infections were significantly less common among black cases than white cases (RR: 0.3; CI: 0.1–0.7).

Conclusion

In the Atlanta area, racial disparities in iSA were noted, with higher incidence among blacks than whites for both iMSSA and iMRSA. The racial disparity is more extreme for iMRSA. Notably the racial disparity is not observed in cases age 65 and over. Causes for these disparities should be investigated.

Disclosures

S. Fridkin, Pfizer Inc.: Grant Investigator, Research support.
1238. A National Comparison of Antibiograms Between Veterans Affairs Long-Term Care Facilities and Affiliated Hospitals
Authors: Tolg Maria-Stephanie , Caffrey Aisling , Appaneal Haley , Jump Robin , Lopes Vrishali , Dosa David , LaPlante Kerry
Published: November 2018

Background

Long-term care facilities (LTCFs) face several barriers to creating antibiograms. Here, we evaluate if LTCFs can use antibiograms from affiliated hospitals as their own antibiogram.

Methods

Facility-specific antibiograms were created for all Veterans Affairs (VA) LTCFs and VA Medical Centers (VAMCs) for 2017. LTCFs and affiliated VAMCs were paired and classified as being on the same campus or geographically distinct campuses based on self-report. For each pair, Escherichia coli susceptibility rates (%S) to cefazolin, ceftriaxone, cefepime, ciprofloxacin, nitrofurantoin, sulfamethoxazole/trimethoprim, ampicillin/sulbactam, piperacillin/tazobactam, and imipenem were compared. As guidelines discourage empiric use of antibiotics if susceptibility rates are <80%, we assessed clinical discordance between each LTCF and affiliated VAMC antibiogram at a threshold of 80% susceptible. The proportions of concordant susceptibilities between LTCFs and VAMCs on the same campus vs. geographically distinct campuses were compared using Chi-square tests.

Results

A total of 119 LTCFs and their affiliated VAMCs were included in this analysis, with 70.6% (n = 84) of facilities located on the same campus and 29.4% (n = 35) on geographically distinct campuses. The table below shows the overall clinical concordance (agreement) of LTCFs with their affiliated VAMC in regards to E. coli %S to the compared antibiotics. No significant differences were found when comparing LTCFs on the same campus vs. geographically distinct campuses.

Conclusion

Antibiograms between LTCFs and affiliated VAMCs had a high concordance, except for sulfamethoxazole/trimethoprim, cefazolin and ceftriaxone in regards to susceptibility rates of E. coli. Facilities on the same campus were found to have similar concordance rates to geographically distinct facilities. Future studies are needed to investigate how the various approaches to creating LTCF-specific antibiograms are associated with clinical outcomes.

Disclosures

M. S. Tolg, Veterans Affairs: Investigator, Research grant. A. Caffrey, Veterans Affairs: Investigator, Research grant. H. Appaneal, Veterans Affairs: Grant Investigator, Research grant. R. Jump, Veterans Affairs: Investigator, Research grant. V. Lopes, Veterans Affairs: Investigator, Research grant. D. Dosa, Veterans Affairs: Grant Investigator, Research grant. K. LaPlante, Veterans Affairs: Investigator, Research grant.
1240. Antibiotic Prescribing in US Nursing Homes Using National Pharmacy Transaction Data
Authors: Palms Danielle , Kabbani Sarah , Bartoces Monina , Hyun David Y , Baggs James , Stone Nimalie D , Hicks Lauri A
Published: November 2018

Background

Antibiotics are frequently prescribed inappropriately in nursing homes (NHs); however, national estimates of NH antibiotic use are limited. We aimed to describe antibiotic prescribing in US NHs to identify potential targets for antibiotic stewardship.

Methods

A descriptive analysis was conducted using the 2014 proprietary IQVIA long-term care (LTC) Xponent database, which captures oral and intravenous antibiotic prescription transactions from sampled LTC pharmacies representing 70–85% of the LTC market. The data are projected to 100% of the US LTC market. Denominators for rate calculations were captured from the 2014 Minimum Data Set as the number of residents with at least one resident day in an NH in 2014. Antibiotic transaction counts and rates were calculated by resident gender, age, US census region, route of administration, antibiotic class and agent, and total transaction counts were summarized by provider type. Prescribing patterns for antibiotic classes and agents stratified by resident age were also calculated.

Results

In 2014, there were over 14 million antibiotic transactions in LTC pharmacies, for a rate of 3,302 per 1,000 residents. Female residents accounted for 62% of antibiotic transactions at a rate of 3,305 transactions per 1,000 residents compared with 3,240 per 1,000 male residents. Antibiotic prescribing was highest in the South at 3,752 transactions per 1,000 residents (vs. 2,601 per 1,000 residents in the West). Oral antibiotics accounted for 85% of transactions. Fluoroquinolones were the most frequently prescribed antibiotic class (22%; 723 transactions per 1,000 residents) and the most common agents were levofloxacin, ciprofloxacin, and sulfamethoxazole–trimethoprim. Stratified by age, the percent change in prescribing rates among residents aged <85 to residents aged ≥85 was largest for fluoroquinolones (645 vs. 883) and urinary anti-infectives (210 vs. 319). Internal medicine and family practice providers accounted for 37% and 32% of all antibiotic transactions, respectively.

Conclusion

A potential antibiotic stewardship target in NHs is fluoroquinolone prescribing. Targeting states in the South for interventions may have the largest impact.

Figure. Antibiotic prescribing rates in long-term care by U.S. census regions

Disclosures

All authors: No reported disclosures.
1242. Quantitative Analysis of Microbial Burden on LTCF Environmental Surfaces
Authors: DiBiase Lauren , Powell Amy , Gergen Maria , Weber David J , Sickbert-Bennett Emily E , Rutala William A
Published: November 2018

Background

There is a lack of data on environmental surface contamination in long-term care facilities (LTCF), despite multiple reports of outbreaks of multi-drug-resistant organisms in these settings. Therefore, we conducted a quantitative analysis of the microbial burden and prevalence of epidemiologically important pathogens (EIP) found on LTCF environmental surfaces.

Methods

Microbiological samples were collected using Rodac plates from resident rooms and common areas in five LTCFs. At each facility, five samples from up to 10 different available environmental surfaces were collected from a room of a resident reported to be colonized with EIP, as well as from a room of a resident reported to be non-colonized. In addition, five samples from up to 10 different environmental surfaces were collected from two common areas in the facility. EIPs were defined as MRSA, VRE, C. difficile and multi-drug-resistant Gram negative bacilli. Data were analyzed for each environmental site sampled in a resident room or common area based on total bacterial colony forming units (CFU), mean CFU per Rodac, total EIP by site, and mean EIP counts per Rodac.

Results

The below table summarizes total EIP recovered from environmental sites by reported EIP colonization status of the resident. Rooms of residents with reported colonization had much greater EIP counts per Rodac (8.32, 95% CI 8.05, 8.60) than rooms of non-colonized residents (0.78, 95% CI 0.70, 0.86). MRSA was the most common EIP recovered from Rodacs, followed by C. difficile. Very few EIPs were recovered from the common areas sampled at these LTCFs.

Conclusion

We found varying levels of CFU and EIP on environmental sites at LTCFs. Colonization status of a resident was a strong predictor of higher levels of EIP being recovered from his/her room.

Disclosures

All authors: No reported disclosures.
1244. Evaluation of Antibiotic Prescribing Practices for Geriatric Patients in the Outpatient Setting in a Veterans Affairs Hospital: Identification of Stewardship Targets
Authors: Clark Collin , White Alexis , Sellick John , Mergenhagen Kari
Published: November 2018

Background

Antibiotics are frequently overused in the outpatient setting, however it is unknown how antibiotic use differs with age. Infections are a leading cause of hospitalization in elderly patients. Prescribing appropriateness for patients less than 65 years old was compared with patients at or above ≥65 years old in order to identify targets for antimicrobial stewardship in this population.

Methods

A retrospective review of all outpatient antibiotic prescriptions between June and September of 2017. Prescriptions were reviewed based on alerts in the electronic medical record when orders for antibiotics were signed by the provider. Appropriateness of antibiotics was assessed based on clinical practice guidelines. Retreatment and hospital admissions were documented. Those aged <65 were compared with those ≥65 years of age using Student’s t-test and chi-squared tests. A multivariate logistic regression model was constructed to identify risk factors for inappropriate use of antibiotics between the two age groups.

Results

The study period yielded 1,700 prescriptions after exclusions 1,063 were included in the analysis. Patients aged ≥65 comprised 51% of the population. Older patients had significantly more comorbidities than the younger population. No significant difference was observed for antibiotic indicated (60%), correct drug (50%), or correct duration (75%) between the two age groups. Patients in the ≥65 cohort were statistically significantly more likely to receive an inappropriate dose (86% vs. 76%, P < 0.002). In the multivariable analysis, patients with COPD were more likely to be appropriately with antibiotics OR 1.4 (95% CI: 1.03–1.9) compared with those without COPD. Older patients were not more likely to be retreated or admitted for the same indication within 30 days.

Conclusion

Antibiotics were frequently overused in the outpatient setting; however, they were not more frequently used in elderly patients. However, older adults were more likely to be prescribed an antibiotic at an inappropriate dose highlighting the need for increased caution with dosage selection in this population. Stewardship teams caring for elderly patients should be cognizant of dosing in this population.

Disclosures

All authors: No reported disclosures.
1247. Genomic Epidemiology of MRSA DURING Incarceration at a Large Inner-City Jail
Authors: Popovich Kyle J , Snitkin Evan S , Green Stefan J , Aroutcheva Alla , Schoeny Michael , Payne Darjai , Thiede Stephanie , Zawitz Chad , Hota Bala , Hayden Mary K , Weinstein Robert A
Published: November 2018

Background

Congregate settings may facilitate spread of USA300. Jails may be a location where individuals already colonized with MRSA (from preceding exposures) intermingle with others, potentially augmenting spread. We examined the rate of MRSA acquisition during incarceration and characterized the genomic epidemiology of MRSA strains entering the jail, MRSA acquisition isolates, and archived (2015–2017) clinical MRSA isolates from male detainees.

Methods

Males incarcerated at the Cook County Jail were enrolled within 72 hours of intake and surveillance cultures for MRSA carriage (nares, throat, groin) collected. Detainees in jail at Day 30 had cultures repeated to determine MRSA acquisition. A survey was administered and chart review performed to identify predictors of acquisition. Whole-genome sequencing and phylogenetic analysis of isolates were performed with integration of epidemiologic data.

Results

800 males were enrolled, with 19% colonized with MRSA at jail intake. 143 reached the Day30 visit (82% AA, 7% Hispanic), by which there were 12 MRSA acquisitions detected. Heroin use before entering the jail (OR 3.67, P = 0.04) and sharing personal items during incarceration (OR = 4.92, P = .01) were significant predictors of acquisition. Sequenced clinical isolates (n = 175) (largely skin infections) were more likely to resemble each other genetically than the diverse intake strains (P < 0.001) (figure), suggesting clinical isolates may originate from transmission within the jail or be due to more virulent strains. 7/12 (58%) acquisition isolates were within 40 SNVs from another isolate; five were genomically similar to intake isolates and two were similar to clinical isolates. Acquisition strains from those sharing personal items (vs. not) tended to have closer relatedness (19 SNVs vs. 56 SNVs, P = 0.22).

Conclusion

There is a high burden of MRSA entering jail. Genomic analysis of acquisition and clinical isolates suggests potential spread of incoming strains and possible networks spread of prevalent strains during incarceration. Sharing of personal items during incarceration is associated with MRSA acquisition and could be a focus of an intervention. Future study of epidemiologic and location data may inform targeting of interventions within the jail.

Disclosures

All authors: No reported disclosures.
1249. Emergence of Diverse Carbapenem-Resistant Enterobacteriaceae (CRE) in the Dominican Republic
Authors: Fermin Rita Rojas , Macesic Nenad , Tolari Gilda , Guzman Anel , Annavajhala Medini , Uhlemann Anne-Catrin
Published: November 2018

Background

Despite the global threat of CRE, data from resource-limited regions such as the Dominican Republic (DR) are limited. A lack of novel antibiotics and molecular diagnostic tools for outbreak detection, coupled with the role of travel in circulating CRE to and from the DR represent significant challenges to limiting their spread. Here, we report the first molecular characterization of DR CRE isolates and compared them to geographically diverse CRE.

Methods

Isolates from DR (one Citrobacter freundii, three Klebsiella pneumoniae), obtained from patients with bacteremia (one) and pneumonia (three), were compared with CRE from a New York City hospital in a Dominican neighborhood, including isolates (two Enterobacter cloacae, one K. pneumoniae) from a patient transferred to NYC from another DR institution. Whole genome sequencing was used to determine multi-locus sequence type (MLST) and resistance gene profiles. Phylogenetic analyses of isolates with same ST were performed.

Results

Isolates from the DR and the Dominican patient were of unique genomic backgrounds including pandemic (K. pneumoniae ST11) and novel sequence types, and harbored either blaKPC-2 or blaKPC-3 (Table 1). Replicon typing suggested that these carbapenemase genes were located on distinct plasmids. Phylogenetic analyses using the NYC collection of ~400 sequenced CRE isolates indicated that DR and NYC K. pneumoniae ST307 isolates were related (33 SNPs). Further review showed that both patients had recent admissions in Puerto Rico (PR), highlighting the role of regional spread. K. pneumoniae ST11 isolates from DR and NYC, on the other hand, were not found to be closely related (1,418–1,440 SNPs).

Conclusion

Genotyping of DR CRE isolates revealed a high genomic diversity, suggesting multiple introductions. Phylogenetics of K pneumoniae ST307 place these within a global context, demonstrating links across the Caribbean and North America. International surveillance studies integrating genomics are needed to track and limit the spread of CRE in resource-limited settings such as DR.

Disclosures

A. C. Uhlemann, Merck: Investigator, Grant recipient.
1254. Outbreak of Mycobacterium chelonae Skin Infections Associated With Human Chorionic Gonadotropin Injections at Weight Loss Clinics
Authors: Mody Rajal , Rainbow Jean , Ferguson Beth , Wiberg Cody , Kupferschmidt Trudy , Horn Liz , Walters Maroya Spalding , Fagan Ryan , Chen Greta , Rosenman Karla
Published: November 2018

Background

In December 2016, a dermatologist notified the Minnesota Department of Health (MDH) of three patients with skin lesions after self-administration of human chorionic gonadotropin (HCG) injections supplied by same weight loss clinic chain (Chain X); one lesion had been diagnosed as a nontuberculous mycobacteria (NTM) infection. We investigated to identify the etiology, determine contributing transmission factors, and to prevent additional cases.

Methods

We defined a case as a skin or soft tissue lesion with a suspected infectious etiology in a Minnesota resident occurring within three months after HCG injection at or near an injection site. To find cases we sent health alerts to clinicians and clinical laboratories throughout Minnesota with diagnostic guidance, and we requested Chain X to notify all exposed patients. We visited two Chain X clinics to assess infection control practices, to collect invoices for product traceback, and to collect products for microbiological testing. All NTM isolates were identified by line probe assay and subtyped by pulsed-field gel electrophoresis (PFGE) at MDH.

Results

We identified six cases with illness onset dates ranging from April to November 2016. All patients were adult women who did not share HCG vials. Four patients had clinical specimens that grew NTM; all isolates were identified as Mycobacterium chelonae that were indistinguishable by PFGE. Three patients with confirmed M. chelonae infection obtained HCG at Clinic A, and one from Clinic B, but sharing of reconstituted HCG by the two clinics could not be excluded. We identified several infection control breaches at both clinics including improper reconstitution of HCG and incorrect use of single use vials. The most likely source of the HCG was an unregistered out-of-state compounding pharmacy.

Conclusion

This common source outbreak was likely due to contamination introduced either at a weight loss clinic or a compounding pharmacy. HCG injections are not US FDA-approved for weight loss, and their use may involve compounded products dispensed by alternative care settings that lack infection control expertise and regulatory oversight. This outbreak highlights the important role physician reporting of disease clusters plays in uncovering unsafe practices.

Disclosures

All authors: No reported disclosures.
1266. Multifaceted Infection Control Strategies to Control Multidrug-Resistant Acinetobacter baumanii in Adult Intensive Care Unit in a Tertiary Hospital in Eastern Region, Saudi Arabia
Authors: Gammal Ayman
Published: November 2018

Background

Multidrug-resistant Acinetobacter baumanii (MDR-AB) has emerged globally as a significant pathogen in hospitals. During 2010, our hospital experienced an increase of MDR-AB in Adult intensive care unit (ICU). Our adult ICU is consists of 10 acute care beds. The hospital is a tertiary institution located in Eastern region of Saudi Arabia. Multidisciplinary team was formed to implement and determine the effect of multifaceted strategies in controlling MDR-AB.

Methods

Active surveillance culture (ASC) was initiated to determine the prevalence rate of MDR-AB per 1,000 patient-days (PD). Using ASC, which was done during admission in ICU, after 48 hours of admission and every week for all patients if there is a positive MDR-AB case, acquisition rate of MDR-AB was calculated per 1,000 PD. Average daily colonization pressure was also monitored. In addition, a multifaceted infection control strategies were carried out. These include hand hygiene, contact isolation, cohorting of patients, Chlorhexidine bath, and environmental cleaning and disinfection. Compliance with hand hygiene was observed using direct observation method. We use the Fluorescent Gel Method for evaluating the thoroughness of disinfection and cleaning for environmental surfaces.

Results

Hand hygiene compliance of HCWs initially was 89%, in 2017 was increased to 98%. Daily Chlorhexidine bath was adopted for all patients in ICU. Initially, the compliance for thoroughness of disinfection and cleaning is 84.6% it was increased to 92% in 2013–2017. Prevalence rate of MDR-AB was 20.7/1,000 PD in 2010, it was decreased by 50% in 2011–2012. In 2017, declined to 0.9/1,000 PD. MDR-AB acquisition rate was 11.8/1,000 PD in 2010, it was decreased by 57% in 2011–2012. In 2017, dropped to 0.6/1,000 PD. Average daily colonization pressure was 0.21 in 2010. In 2011–2012, it was decreased by 31%. In 2017, it was reduced to 0.02. Death rate among MDR-AB patient in 2010 was 25.7%. It was decreased to 14% in 2011–2012. In 2017, an enormous drop to 0% was achieved.

Conclusion

Implementing these multifaceted strategies help in controlling MDR-AB in our hospital. The commitment and adherence of the HCW to all infection control strategies are essential in sustaining low prevalence rate and acquisition rate of MDR-AB.

Disclosures

All authors: No reported disclosures.
1267. Nonventilator Hospital Acquired Pneumonia (NV-HAP) Prevention Initiative in Colombia, Bogotá
Authors: Valderrama Sandra , Miranda Claudia Janneth Linares , Soto Maria Juliana , Mckinley Estefania , Morcillo Juan Pablo , Alarcon Juan Pablo , Gonzalez Angela Patricia , Gamba Leidy
Published: November 2018

Background

Pneumonia is the second most common healthcare-associated infection worldwide. Non ventilator – Hospital Acquired Pneumonia (NV-HAP) affects more people than VAP, has a comparable mortality rate (18.7% vs. 18.9%), and has higher total costs ($156 million vs. $86 million), respectively. The objective of this study was to describe the result of the implementation of a bundle of measures for the prevention of NV-HAP in adult patients in a University Hospital in Colombia.

Methods

Descriptive study. In a period of 2 years, a care bundle for prevention of NV-HAP was implemented in adult patients in a university hospital that consisted of: (1) identification of patients at risk (patients over 60 years of age, or with altered consciousness, or swallowing disorder, or patients with tracheostomy), (2) marking the patient with a sticker on the head of the bed, and (3) implementation of the following measures: head of the bed elevation to 30°–45°, oral care every 12 hours, chlorhexidine oral rinse decontamination every 12 hours and aspiration of secretions as needed. In the first 6 months, training was carried out for all staff, the monthly adherence to the strategy was measured.

Results

During 2016, 1,045 patients were included, with 10,011 observations, bundle adherence during the first year was 33%. in the second year, 1,400 patiens were included, with 13,198 observations, the bundle adherence increased to 90% throughout the hospital. The rate of NV-HAP decreased from 4.2 (96 cases) to 3.4 (89 cases) per 1,000 patient-days, in the second year compared with the previous intervention year.

Conclusion

The strategy of prevention of NV-HAP decreased the cases of nosocomial pneumonia in a university hospital, through the education a high adherence to the strategy was achieved. Studies with a better design should be done to confirm the findings.

Disclosures

All authors: No reported disclosures.
1272. A Routine, HIV and HCV Testing and Treatment Program in a Large, Multi-Campus Emergency Department Finds High Prevalence of Acute HIV and Chronic Hepatitis C
Authors: Anson Ryan , Hall Christopher , Ivans Erica , Vassily Kara , Shaieb Annette , Berrol Ronn , Potts Brian , Bures Erin
Published: November 2018

Background

One in seven people living with HIV in the United States are unaware of their serostatus. Approximately 11,280 annual HIV infections (30.2%) are caused by this subset of individuals (CDC, 2017). In addition, acute HCV infections have nearly tripled since 2011, with many states seeing a dramatic increase in incidence among younger people outside the birth cohort (CDC, 2017). Because many individuals still use emergency departments (EDs) for their healthcare needs, these institutions play an increasingly important role in screening patients for HIV and HCV and linking them to medical services. Routine, opt-out testing initiatives are particularly effective at identifying new cases of HIV and HCV that could have otherwise been missed by a risk-based approach to screening.

Methods

In early May 2017, physicians and advanced practice nurses from Sutter Health’s Alta Bates Summit Medical Center (ABSMC) and a nearby outpatient HIV clinic implemented a routine HIV and HCV screening program at the hospital’s large, two-campus ED system in Oakland, CA. ED medical directors created a Nursing Standardized Procedure (NSP) to allow registered nurses (RNs) to independently order both blood tests using an automated, best practice authority (BPA) screen in the electronic health record (EHR) of any patient who met CDC-defined age criteria for testing.

Results

Of the 6,315 people screened for HIV between May 1, 2017 and March 31, 2018, 43 (0.7%) patients tested positive. Twelve (57%) of the 21 patients found to have a new HIV diagnosis also had symptomatic, acute HIV infection (AHI). All 12 patients with AHI initiated anti-retroviral therapy (ART) within five to 96 hours of their preliminary positive test result. Of the 5,820 patients screened for HCV, 424 (7.3%) were anti-HCV positive, while 185 (3.2%) patients had chronic infection. Thirty-nine percent of chronic HCV cases were among younger patients born before 1965. All patients with HIV or chronic HCV were referred to medical care at East Bay Advanced Care (EBAC).

Conclusion

An automated, routine HIV-HCV testing program integrated into standard nursing workflow at a community ED resulted in the timely screening, diagnosis, and treatment of many patients with acute HIV, and identified a high prevalence of chronic HCV infections among younger patients.

Disclosures

R. Anson, Frontline of Communities in the United States (Gilead, Inc.): Grant Investigator, Grant recipient. C. Hall, Frontline of Communities in the United States (Gilead, Inc.): Grant Investigator, Grant recipient.