bluuebunny/crossref_metadata_2025 huggingface dataset:
Reexamining BSA as a Preoperative Predictor of Risk of Prosthetic Joint Infection
Authors: Russell Celeste , Nocon Allina , Mayman David , Westrich Geoffrey , Miller Andy , Brause Barry , Henry Michael
Published: October 2017

Background

Prosthetic joint infection (PJI), a dreaded complication of arthroplasty, has been found to correlate with increasing body mass index (BMI) and body surface area (BSA). Recent data suggest that BSA may be a better predictive tool for assessing infection risk. We further evaluated this association in an orthopedic specialty hospital arthroplasty cohort to evaluate whether BSA is a predictor of prosthetic joint infection.

Methods

A retrospective cohort of hip and knee arthroplasty patients between 2009 and 2014 was identified through administrative hospital data using ICD-9 codes. Patients with a BMI <14 or >60 kg/m2, height <142 or >200 cm, and weight <36 or >226 kg were excluded. BSA was calculated using the DuBois formula, and assessed both as a continuous and as a categorical variable. Univariate analyses were done using χ 2 tests and adjusted models were assessed using logistic regression.

Results

17,859 knee and 18,128 hip patients were identified. 1.1% of knees and 0.74% of hips were infected.]Mean BSA was 1.9 m2 (±0.2 m2). BSA was significantly associated with PJI in hips (P = 0.004), but not knees, when analyzed as a continuous variable in unadjusted models. However, this association lost its significance after adjusting for PJI risk factors. Additionally, when assessed as a categorical variable in a multivariate model, BSA in the highest quartile (>2.11) was not associated with PJI.

Conclusion

After evaluating BSA as a continuous and categorical variable, we failed to find an association between BSA and infection risk in THA or TKA. The impact of BSA decreased after multivariate adjustment. BSA may not be optimal as a predictor of preoperative risk.

Disclosures

All authors: No reported disclosures.
Efficacy and Safety of Dalbavancin for the Treatment of Acute Bacterial Skin and Skin Structure Infection (ABSSSI) in Patients with Diabetes Mellitus
Authors: Nowak Michael , Rappo Urania , Gonzalez Pedro L , Chen Jie , McGregor Jennifer S , Bryowsky Jason , Talan David
Published: October 2017

Background

ABSSSIs are common in patients with diabetes and have an increased risk of complications. Dalbavancin is a long-acting lipoglycopeptide with potent activity against Gram-positive pathogens responsible for ABSSSI, including methicillin-resistant Staphylococcus aureus (MRSA), and has demonstrated activity in ABSSSI with single-dose administration. We assessed outcomes in patients with and without diabetes in a clinical trial evaluating the efficacy of dalbavancin for ABSSSI.

Methods

In a double-blind, phase 3 trial, adult patients with ABSSSI involving deeper soft tissue or requiring significant surgical intervention, defined as major abscess, cellulitis, and traumatic wound/surgical site infection were randomized 1:1 to dalbavancin as a single-dose (1500 mg) or as a two-dose regimen (1000 mg on Day 1 and 500 mg on Day 8). The primary endpoint was ≥20% reduction in erythema at 48–72 hours; clinical success on Days 14 and 28 was defined as improvement in lesion size and signs and symptoms. P-values were obtained using Fisher’s exact test for categorical variables and Wilcoxon rank-sum test for continuous variables. In a post-hoc subgroup analysis, outcomes were compared among the subgroups of participants with and without diabetes.

Results

There were 76/698 (10.9%) participants with diabetes and 622/698 (89.1%) participants without diabetes. Participants with diabetes were more likely to be older or obese, and had higher rates of cellulitis, while participants without diabetes had higher rates of abscess (Figure 1). At Days 14 and 28, clinical success was achieved in ≥84% of participants with diabetes, and investigator assessment of cure was achieved in ≥95% of participants with diabetes (Figure 2). Drug-related adverse events were observed in 7 (9.2%) patients with and 44 (7.1%) participants without diabetes.

Conclusion

Dalbavancin has similar rates of clinical response and success for the treatment of ABSSSI in patients with or without diabetes.

Disclosures

M. Nowak, Allergan plc: Employee, Salary. U. Rappo, Allergan plc: Employee and Shareholder, Salary. P. L. Gonzalez, Allergan plc: Employee and Shareholder, Salary. J. Chen, Allergan plc: Employee, Salary. J. S. McGregor, Allergan plc: Employee, Salary. J. Bryowsky, Allergan plc: Employee and Shareholder, Salary.
Clinical Characteristics and Treatment Outcomes of Patients with Sternoclavicular Septic Arthritis Caused by Staphylococcus aureus
Authors: Ryu Byunghan , Jang Young-Rock , Lee Seung Hyun , Hong Jeongmin , Kim Min-Chul , Kim Min Jae , Sung Heungsup , Kim Mi-Na , Kim Sung-Han , Lee Sang-Oh , Choi Sang-Ho , Jeong Jin-Yong , Kim Yang Soo , Woo Jun Hee , Chong Yong Pil
Published: October 2017

Background

Aggressive surgical therapy such as en-bloc resection of the joint is favored in the treatment of sternoclavicular (SC) septic arthritis. However, this practice is based on expert opinion and small case series. We analyzed the clinical characteristics and treatment outcomes of patients with S. aureus SC septic arthritis treated with medical therapy alone or with limited surgical therapy.

Methods

All adult patients with SC septic arthritis caused by S. aureus at the Asan Medical Center between September 2009 and December 2016 were retrospectively reviewed. Demographic characteristics, laboratory results, underlying diseases/conditions, patient management, and treatment outcomes were assessed. SC septic arthritis due to S. aureus was defined if patients had positive cultures of specimens from the SC joint, or if blood cultures yielded S. aureus, together with physical findings and imaging studies supporting the diagnosis of SC septic arthritis. Limited surgical therapy was defined as simple incision, drainage, and debridement of infected SC joint.

Results

In total, 22 cases of S. aureus SC septic arthritis were enrolled. Of these 22 patients, 11 received medical therapy alone, 11 underwent limited surgical therapy, and none underwent aggressive surgery. Most patients (73%) had underlying predisposing conditions such as infection at a distant site, diabetes, and liver cirrhosis, and none had IV drug abuse or HIV infection. Complications such as chest wall and/or neck abscess, clavicular and/or sternal osteomyelitis were identified in 18 patients (82%). Patients with chest wall and/or neck abscess had a tendency to be treated with limited surgery than patients without them (73% vs. 27%, P = 0.09). The median duration of intravenous antibiotics in all patients was 35 days (IQR 25–46 days). After a median follow-up of 31 months (IQR 2–40 months), there was no relapse of SC septic arthritis or deterioration of joint function.

Conclusion

Medical therapy alone or with limited surgical therapy appears to be a successful therapeutic strategy for the complicated S. aureus SC septic arthritis in a selected patient.

Disclosures

All authors: No reported disclosures.
Predictive Factors for Successful Treatment in Candidial Bone and Joint Infection
Authors: Jeong Wooyong , Jung In Young , Choi Heun , Kim Jinnam , Lee Se Ju , Seong Hye , Kim Jung Ju , Ku Nam Su , Choi Jun Yong , Song Young Goo , Kim June Myung , Jeong Su Jin
Published: October 2017

Background

Candidiasis is a major cause of morbidity and mortality, causing a diverse spectrum of clinical diseases. Candidial bone and joint infection (CBJI) is a rare clinical disease, although it is one associated with significant morbidity. As most prior studies were limited to individual cases and small case series, there were insufficient data on the epidemiology and outcome of CBJI. The aim of this study is to identify the predictive factors for successful treatment in CBJI.

Methods

A retrospective review was performed on 33 patients with Candida confirmed on culture, among patients diagnosed with bone and joint infection between January 2006 and December 2016 at a 2400-bed tertiary hospital in South Korea. Unfavorable outcome was defined as recurrence following completion of treatment or mortality. Clinical characteristics, treatment outcome, and medical records were reviewed.

Results

Of the 33 patients, 15 (45.5%) had unfavorable outcomes; recurrence (n = 9) and mortality (n = 6). Median age was 64.0 years (range, 50.5–71.5 years) and there were 14 (42.4%) males. Seventeen (51.5%) patients had arthritis and 16 (48.5%) osteomyelitis. Candida albicans constituted 48.5%, C. parapsilosis 24.2%, C. tropicalis 6.1%, and C. glabrata6.1%. Mechanisms of infection were hematogenous dissemination (57.6%) and direct inoculation (42.4%). There were no significant differences between the favorable outcome group and the unfavorable outcome group for the underlying diseases. The neutrophil percentage in complete blood count at the time of diagnosis showed a difference between the two groups (68.0% vs. 79.6%, P = 0.016). There was a significant difference in neutrophil-lymphocyte ratio (2.2 vs. 4.8, P = 0.023), erythrocyte sedimentation rate (ESR) (40.5 vs. 72.4, P = 0.024) and C-reactive protein (CRP) (15.3 vs. 86.3, P = 0.001) at the end of treatment. The duration of antifungal therapy showed a significant difference (124.9 days vs. 44.3 days, P = 0.041), but there was no difference in the operation. In the multivariate analysis, CRP at the end of treatment  (P = 0.028) ws found to be a predictive factor for successful treatment.

Conclusion

CBJI is a rare disease but associated with high treatment failure. Prolonged antifungal treatment is essential for successful treatment of CBJI, and CRP at the end of treatment is a key predictive marker of successful treatment.

Disclosures

All authors: No reported disclosures.
Microbiologic Predictors of Pelvic Osteomyelitis Related to Decubitus Ulcers
Authors: Sharma Neha , Clark Abbye , Derrick Caroline , Al-Hasan Majdi N , Weissman Sharon , Sanasi-Bhola Kamla
Published: October 2017

Background

Management of pelvic osteomyelitis related to decubitus ulcers (PODU) remains challenging, whereas definitive therapy is based on blood, bone, or deep tissue cultures, empirical therapy prior to culture results may be indicated in patients with sepsis or cellulitis surrounding PODU. The objective of this retrospective case series is to develop an institutional protocol for empirical therapy of PODU when indicated based on local microbiology results.

Methods

Hospitalized adults with PODU from 1 August 2005 to 1 August 2015 at Palmetto Health hospitals in Columbia, SC were identified. PODU was defined based on clinical, radiographic, and microbiology criteria. Descriptive statistical methods (Fisher’s exact) were used for preliminary analysis.

Results

Seventy-five cases with PODU were included with a mean age of 53 years and male predominance (48; 64%). The most common comorbidities were paraplegia (45, 60%), diabetes (23, 31%) and previous strokes (17, 23%). Forty-nine cases (65%) received antibiotics within a year of PODU. Prior infections or colonization with P. aeruginosa within the past year was present in 24/75 (32%) cases. Most cases had multiple sources of cultures: blood (61; 81%), bone/deep tissue (37; 49%), and/or superficial (73; 97%). Among a total of 99 clinical isolates, 56 (57%) were Gram-positive cocci (GPC) and 43 (43%) were Gram-negative bacilli (GNB). The most common organisms were Enterobacteriaceae (26; 26%), coagulase negative staphylococci (CONS) (20, 20%), Stapylococcus aureus (19, 19%), [12 (12%) methicillin-resistant S. aureus], and P. aeruginosa (9, 9%). Of the Enterobacteriaceae, 69% (18/26) were susceptible to ciprofloxacin and 88% (23/26) to ceftriaxone. All cases (9/9) of PODU due to P. aeruginosa had a prior infection/colonization with P. aeruginosa within 1 year as compared with 15/66 (23%) in those with PODU due to other organisms (P = 0.001).

Conclusion

The microbiology of PODU is diverse (including GPC and GNB). Prior positive P. aeruginosa culture was a predictor of P. aeruginosa PODU. When empirical antimicrobial therapy is indicated, data support the use of intravenous vancomycin plus ceftriaxone in the absence of prior infection/colonization with P. aeruginosa, or intravenous vancomycin plus an anti-pseudomonal agent in the presence of prior P. aeruginosa within the past year.

Disclosures

All authors: No reported disclosures.
Comparative In Vitro Activity of Ciprofloxacin and Sitafloxacin Against Neisseria gonorrheae
Authors: Thamlikitkul Visanu , Tiengrim Surapee
Published: October 2017

Background

Most of Neisseria gonorrhoeae strains isolated from Thai patients are resistant to ciprofloxacin and ciprofloxacin is no longer recommended for therapy of gonococcal infection in Thailand. Sitafloxacin is a new generation of fluoroquinolones that contains in vitro activities against many bacteria that are resistant to ciprofloxacin. Sitafloxacin has a high concentration in urine. The objective of the study was to determine in vitro activity of sitafloxacin against ciprofloxacin-resistant N.gonorrheae.

Methods

Antimicrobial susceptibility tests for 52 strains of Neisseria gonorrhoeae isolated from patients attended Bangrak Hospital in Bangkok were performed. The tested antibiotics were ceftriaxone, cefixime, ciprofloxacin, and sitafloxacin. The minimum inhibitory concentrations (MICs) and inhibition zone diameters were determined by standard agar dilution and disk diffusion method, respectively, according to the Clinical and Laboratory Standards Institute (CLSI) 2013.

Results

All 52 N.gonorrheae isolates were susceptible to ceftriaxone (MIC < 0.025 mg/l, zone diameter > 35mm) and cefixime (MIC < 0.025 mg/l, zone diameter > 31mm). All N. gonorrheae isolates were resistant to ciprofloxacin (MIC > 1 mg/l, zone diameter < 27 mm). The inhibition zone diameters of sitafloxacin (5 microgram disk) against 52 isolates of N. gonorrhoeae were > 41 mm in 35 isolates (67%) and between 28 and 40 mm in 17 isolates (33%). If the cut-off value of inhibition zone diameter of resistance to ciprofloxacin (<27 mm) is applied, no isolates of N. gonorrheae is considered to be resistant to sitafloxacin.

Conclusion

Sitafloxacin seems to be active against ciprofloxacin-resistant N. gonorrheae. A clinical study on therapy of gonococcal urethritis due to ciprofloxacin-resistant N. gonorrheae should be considered.

Disclosures

All authors: No reported disclosures.
The Impact of Recent Antibiotic Usage on Oropharyngeal Neisseria spp. in MSM of Hanoi, Vietnam
Authors: Dong Huan , Nguyen Hoa Thi , Nguyen Minh Binh Xuan , Nguyen Trung Vu , May Folasade , Le Giang Minh , Klausner Jeffrey
Published: October 2017

Background

Neisseria gonorrhea (NG) has a long history of gaining resistance to nearly all antimicrobials used for treatment since the 1930s, which makes susceptibility to last-line cephalosporins of dire importance. Horizontal gene transmission is highly prevalent among the Neisseria genus, with genetic fragments from common commensal Neisseria having been found in resistant NG strains. Globally, NG disproportionately affects men-who-have-sex-with-men (MSM) and nearly all ceftriaxone-resistant cases have been reported from pharyngeal samples. Our study aims to assess the impact of antibiotic usage on the antimicrobial susceptibility of oropharyngeal Neisseria spp.

Methods

MSM from Hanoi, Vietnam, were surveyed regarding antibiotic usage. Pharyngeal swabs were collected and cultured on chocolate and modified-Thayer–Martin agar. Neisseria spp. were subcultured, identified using MALDI-TOF, and antimicrobial susceptibility determined by E-test using NG CLSI MIC breakpoints to ciprofloxacin (CIP), cefixime (CFM), ceftriaxone (CRO), and cefpodoxime (CPD).

Results

The 225 MSM surveyed were young (mean age 23.9 years, std 4.4). In the past 6 months: 41.6% participants used any antibiotics, among whom 62.4% did not have a prescription; 6.6% used CFM (16.4% more were unsure), among whom 55.6% did not have a prescription; and 4.5% received CRO.

From 72 swabs, 102 Neisseria isolates were obtained; N. flavescens (n = 59), N. perflava (n = 14), N. macacae (n = 8), N. sublfava (n = 7), N. gonorrhoeae (n = 5), N. mucosa (n = 3), N. meningitides (n = 3), N. cinerea (n = 2), and N. lactamica (n = 1).  “Reduced susceptibility” status for any Neisseria spp. was 35.3, 10, 8, and 30% to CIP, CFM, CRO, and CPD, respectively; 61.8% were “resistant” to CIP. MSM who took any antibiotics in the past 6 months were almost twice as likely to have Neisseria spp. with reduced susceptibility to cephalosporins (CFM, CRO, or CPD), RR 1.8 (95% CI 1.1–3.2; P = 0.026) compared with non-antibiotic users.

Conclusion

Many MSM in Hanoi used antibiotics recently, often without a prescription. Antibiotic use was associated with antimicrobial “reduced susceptibility” of commensal Neisseria spp. to cephalosporins, possibly potentiating resistance acquisition by NG.

Disclosures

All authors: No reported disclosures.
Risk factors for healthcare-associated Clostridium difficile infection in pediatric hematopoietic stem cell transplant recipients
Authors: Drew Richard H , Ni Clara , Kelly Matthew , Wilson Dustin , Sarubbi Christina , Steinbach William
Published: October 2017

Background

Limited published literature exists to identify unique risk factors for Clostridium difficile infection (CDI) in pediatric hematopoietic stem cell transplantation (HSCT) recipients. Our objective was to describe the epidemiology of CDI in pediatric patients undergoing HSCT and to identify potential risk factors for CDI.

Methods

This IRB-waived, single-center retrospective review included Duke University Hospital (DUH) patients 12 months of age or older admitted to pediatrics between March 1, 2012 and August 23, 2016 undergoing initial HSCT during the index hospitalization. The primary endpoint (PCR-confirmed CDI within 100 days post-transplantation) was characterized using descriptive statistics. Transplant type, prior CDI history, days of total parenteral nutrition (TPN), and antibiotic use intensity scores were compared between occurrence groups using Pearson’s chi-square, Wilcoxon rank-sum or Student’s t tests as appropriate.

Results

207 subjects (most Caucasian [55%] and male [61%]) were included, and 15 (7.2%) died. CDI occurred in 24 (12%) within a median (interquartile range) of 35 (9, 47) days since HSCT, and most (92%) were hospital-onset. All cases were healthcare-associated and mild-moderate in severity. None of the patients experienced CDI-related complications. CDI-positive and CDI-negative patients were similar with regards to demographics. Higher median (adjusted) days of TPN (80.6 vs. 29, P < 0.0001) and antibiotic use intensity scores (382.8 vs. 191.0, P < 0.0001), respectively, were associated with CDI. No significant differences between these groups were observed with regard to transplant type (P = 0.28) and prior CDI history (P = 0.10).

Conclusion

CDI occurred in 12% of pediatric patients within 100 days of undergoing initial HSCT. Onset of this mild-moderate, uncomplicated disease occurred within a median of 35 days and commonly during hospitalization. Patients with CDI were more likely to have increased use of TPN and a higher antibiotic use intensity score.

Disclosures

All authors: No reported disclosures.
Use of Electronic Data to Identify Risk Factors Associated with Clostridium difficile Infection (CDI) and to Develop CDI Risk Scores
Authors: Aukes Laurie , Fireman Bruce , Lewis Edwin , Timbol Julius , Hansen John , Yu Holly , Cai Bing , Gonzalez Elisa , Lawrence Jody , Klein Nicola P
Published: October 2017

Background

Clostridium difficile is a major cause of severe diarrhea in the U.S. We described characteristics of Kaiser Permanente Northern California (KPNC) members with C. difficile infection (CDI), identified risk factors associated with CDI, and developed risk scores to predict who may develop CDI.

Methods

Retrospective cohort study with all KPNC members ≥18 years old from May 2011 to July 2014 comparing demographic and clinical characteristics for those with and without lab-confirmed incident CDI. We included CDI risk factors in logistic regression models to estimate the risk of developing future CDI after an Identification Recruitment Date (IRD), a time when an individual might be a good candidate for a C. difficile vaccine clinical trial. Two risk score models were created and cross validated (70% of the data used for development and 30% for testing).

Results

During the study period, there were 9,986 CDI cases and 2,230,354 members without CDI. CDI cases tended to be ≥65 years old (59% vs.. 21%), female (61% vs. 53%), and white race (70% vs. 53%), with more hospitalizations (42% vs. 3%), emergency room visits (51% vs. 14%), and skilled nursing facility stays (25% vs. 0.6%) in the year prior to CDI compared with members without CDI. At least 10 office visits within the prior year (53% vs. 16%), use of antibiotics in last 12 weeks (81% vs. 11%), proton pump inhibitors in the last year (36% vs. 7%), and multiple medical conditions within the prior year (e.g., chronic kidney disease, congestive heart failure, and pneumonia) were important risk factors for CDI. Using a hospital discharge event as the IRD, our risk score model yielded excellent performance in predicting the likelihood of developing CDI in the subsequent 31 – 365 days (C-statistic of 0.851). Using a random date as the IRD, our model also predicted CDI risk in the subsequent 1–30 days (C-statistic 0.658) and 31–365 days (C-statistic 0.722) reasonably well.

Conclusion

CDI can be predicted by increasing age, medications, comorbidities and healthcare exposure, particularly ≥10 office visits, hospitalizations, and skilled nursing stays in the prior year and recent antibiotics. Such risk factors can be used to identify high-risk populations for C. difficile vaccine clinical studies.

Disclosures

H. Yu, Pfizer, Inc.: Employee, Salary; B. Cai, Pfizer, Inc.: Employee, Salary; E. Gonzalez, Pfizer, Inc.: Employee, Salary; J. Lawrence, Pfizer, Inc.: Employee, Salary; N. P. Klein, GSK: Investigator, Grant recipient; sanofi pasteur: Investigator, Grant recipient; Merck & Co: Investigator, Grant recipient; MedImmune: Investigator, Grant recipient; Protein Sciences: Investigator, Grant recipient; Pfizer: Investigator, Grant recipient
A Multi-Pronged Approach to Control Healthcare Facility-Onset Clostridium difficile Infection in a Tertiary Care Community Hospital
Authors: Chinn Raymond , Wyatt Jennifer , Wells Pam , Fox Tracy , Daley Jacqueline , Willon Judy , Magdaluyo Patty , Mabalot Shannon , Kramer Janie , Tarrac Shauna , Vasina Logan , Angus Gene , Guerra Tony , Rodean Kathy , Stiles Geoffrey , Woerle Cathy , Knier Susan , Tomac Chris , Gutierrez Katherine
Published: October 2017

Background

Clostridium difficile infection (CDI) contributes to significant increases in healthcare-associated morbidity and mortality. Multiple strategies have been promulgated to accurately diagnose and to control healthcare facility-onset (HO) CDI. Sharp Memorial Hospital is a 438-bed tertiary care community hospital. In 2014, the standardized infection ratio (SIR) CDI was 1.406 (2006–2008 baseline) with a p value of 0.0005. We report the results of a multi-disciplinary approach that has reduced our HO-CDI SIR. The National Healthcare Safety Network definitions and methodologies were used throughout the study.

Methods

Various multi-disciplinary interventions were implemented over a 12 month period from April 2015 through March 2016 that included enhanced administrative support and the creation of a multi-disciplinary CDI Steering Committee (Figure 1). A Lean Six Sigma approach was launched that included a two-day rapid process improvement (RPI) workshop in July 2015 with participation of an interdisciplinary team of frontline staff, leaders from the 2 units with high CDIs, Infection Prevention, and Environmental Services. Subsequently, lessons learned from the RPI were disseminated throughout the hospital. The laboratory and information technology staff and the antimicrobial stewardship program also contributed.

Results

Compared with the intervention period, the post intervention period (April 2016 through March 2017) documented a significant increase in the number of samples submitted for CDI testing ≤ 3 days after admission and a significant decrease in the number of samples submitted > 3 days after admission. There were significant decreases in the HO-CDI SIR from 0.947 to 0.676 (p value 0.0485) and in quinolone days of therapy from 265 to 246 (p value 0.0001).

Conclusion

We have demonstrated a significant decrease in our HO-CDI using a multi-pronged approach that highlighted a return and reinforcement of back to basics infection prevention. High HO-CDI SIR in previous years might indicate missed community-onset, community-onset healthcare facility-associated cases. We did not employ other technologies such as the hands-free disinfection devices. Sustainability remains a future challenge.

Disclosures

All authors: No reported disclosures.
A Successful Strategy to Reduce Hospital-Onset Clostridium difficile
Authors: Bruno-Murtha Lou Ann , Osgood Rebecca , Alexandre Casey , Mahmood Rumel
Published: October 2017

Background

Our goal was to reduce the rate of hospital-onset (HO) C. difficile (CD) by prompt testing in patients with diarrhea on hospital day (HD) 1–3 using a nurse-driven testing protocol (NTP) with PCR and improve identification of disease after HD 3 using a combined toxin/antigen assay (TAA).

Methods

An automated best practice advisory/NTP was developed in Epic, triggered by documentation of diarrhea during HD 1–3, to facilitate prompt stool collection, testing and initiation of contact precautions. Education was provided. The NTP was fully implemented at 2 community-teaching hospitals mid-February 2016. The TAA was adopted 7/27/16 for testing after HD 3.

Results

In 2016, the standardized infection ratio (SIR) at Cambridge and Everett was 0.43 (P = 0.009) and 0.5 (P = 0.017), respectively, reflecting a 48–61% decrease from 2015. There was a 14–28% improvement in identifying cases as community-onset. The TAA led to a further decline in HO-CD by 10–61%. Refer to the graph for quarterly SIRs before and after implementation. Despite a 26% increase in testing volume, costs are less with the current strategy.

Conclusion

Prompt identification of CD improves care and prevents inflation of HO-CD. This strategy has enhanced our efforts to reduce our SIR (observed/expected cases) and resulted in a substantial incentive payment for CHA.

Disclosures

All authors: No reported disclosures.
Alcohol-based Hand Rubs Are Effective for Reduction of Multi-Drug Resistant Candida
Authors: Edmonds-Wilson Sarah , Yeik Alyssa
Published: October 2017

Background

Hand hygiene is one of the most important measures for preventing the spread of infection. However as new, multi-drug resistant organisms emerge there is the question as to whether marketed products are effective against them. Multi-drug resistant Candida auris(MDRCA) was first reported as an infectious agent in humans in 2009 and has since been implicated in a growing number of infections. In June 2016 the US CDC issued a clinical alert to healthcare facilities warning of the potential for MDRCA transmission and infection within healthcare facilities and the importance of infection control measures. To date, data on the effectiveness alcohol-based hand rubs (ABHRs) against MDRCA has been lacking. The objective of the study was to test the fungicidal efficacy of three commercial ABHRs against MDRCA.

Methods

Three test products, two ABHR foams and one gel, each containing 70% ethanol, were evaluated for fungicidal activity against MDRCA (AR-Bank #0390) using an in vitrotime kill method (ASTM E2783-11). Reductions of the microorganism were determined following exposure to test products for 15 and 30 seconds.

Results

Each of the three ABHR achieved complete reduction, 6.7889 log10(≥99.9999%) of MDRCA at the 15 and 30 seconds exposure times.

Conclusion

Health care workers should continue to use ABHRs as indicated for preventing the transmission of infection. This data indicates these products effectively kill MDRCA, and further highlights the importance of compliance with hand hygiene guidelines in healthcare settings.

Disclosures

S. Edmonds-Wilson, GOJO Industries: Employee, Salary
Comparison of Two Glove-Sampling Methods to Discriminate Between Study Arms of a Hand Hygiene and Glove-Use Study.
Authors: Blanco Natalia , Robinson Gwen L , Otieno Linda , Johnson J Kristie , Li Shanshan , Chanyasubkit Soraya , Harris Anthony D , Thom Kerri A
Published: October 2017

Background

Our group will be assessing in a randomized trial whether the use of alcohol-based hand rub (ABHR) to clean non-sterile gloved hands (instead of performing hand hygiene (HH) and changing gloves) for the WHO 5 Moments of HH during a single patient encounter is an efficient and effective practice. In preparation for this future study and in the absence of a well-established gold standard, this pilot study aimed to identify an effective glove-sampling method with the ability to detect a difference between our two study arms.

Methods

Healthcare workers (HCWs) entering Contact Precaution rooms were recruited and randomized into the intervention arm (HCWs directed to clean gloves with ABHR at each opportunity) or the usual care arm (HCWs behavior is silently recorded at each opportunity). In both arms, HCWs individual gloved hands were randomized then sampled, using both sponge stick and direct imprint methodology (Fig 1–2). The outcome of interest was total bacterial colony forming units (CFUs). A Wilcoxon rank-sum test was performed to compare the median distribution of CFUs recovered by each sampling method between study arms. Sampled gloved hands were also categorized by level of bacterial detection (0 CFUs vs. more than 0 CFUs). For each sampling method, the proportional difference between categories was analyzed using a Fisher exact test.

Results

42 unique HCWs participated in the study (25 intervention, 17 usual care). For each HCW interaction an average of 3 HH moments were recorded. Using the direct imprint technique, the median CFUs in the intervention arm compared with the usual care arm were 2 vs. 31, P < 0.01. Using the sponge stick technique, the median CFUs were 1 vs. 6, P = 0.25. (Fig 3). Using the agar method, bacteria was detected on 16/25 (64%) of gloved hands in the intervention arm compared with 17/17 (100%) in the usual care arm (P < 0.05). Using the sponge-stick method, bacteria was detected 16/25 (64%) of gloved hands in the intervention arm and on 15/17 (88%) in the usual care arm (P = 0.15).

Conclusion

The direct imprint method is an effective method to discriminate between our intervention arms. In addition, this method is more affordable and less work-intensive in the lab and as a sampling method than the sponge-stick method.

Disclosures

A. D. Harris, CDC Epicenter Program: Grant Investigator, Grant recipient; K. A. Thom, AHRQ: Grant Investigator, Grant recipient
Patients’ Family Empowering to Increase Hand Hygiene (HH) Compliance in Health-Care Workers (HCW) from a Hematology-Oncology Ward in Mexico City
Authors: Molina-Jaimes Aaron , Cueto Fuensanta Guerrero Del , Roman-Lopez Cristina , Sandoval-Hernández Silvia , Garcia-Pineda Bertha , Compte Diana Vilar
Published: October 2017

Background

HH is a key component to decrease infections in hospitals, but compliance in HCW remains low. We present a six-month strategy to empower patients’ caregivers on HCW HH compliance.

Methods

HH compliance in HCWs was evaluated between June 1 and August 31, 2017 as recommended by WHO. Between September 1, 2016 and March 31, 2017 we undertook the empowering in the hematology-oncology ward (50 beds) from Instituto Nacional de Cancerologia, a cancer referral, teaching hospital in Mexico. To empower patients and their caregivers, a member of the team visited the patient and their relatives during the first 24h of hospital admission. Standarized information on HH and the importance of HCW compliance was given, along with a printed cartoon on HH opportunities (5 moments from WHO). Patients and their caregivers were trained to observe and record HH opportunties, an were invited to remind HCWs if HH omissions were observed. Data on HH compliance was collected monthly during the empowerment and 1 month after. Data was compared with the HH compliance from the 6 previous. We compared overall compliance and for each 5 HH moments before and after the empowering (chi 2 test).

Results

We empowered 82 caregivers (M: 25.6%) and F: 74.4%), mean age 44 years. 24.4% had completed primary education, and 13.1% had higher education. Mothers and spouses were the primary caregivers (28.1% and 36.6%). HH compliance increased in all 5 moments: Before touching a patient (M1) (B: 9.5%, A: 57.6%, P = 0.005); before a clean or aseptic procedure (M2) (B: 7.9%, A: 48%, P = 0.002); after body fluid exposure (M3) (B: 10%, A: 59%, P = 0.0005), after touching a patient (M4) (B: 7.4%, A: 57.9%, P = 0.0005), and after touching patient surroundings (M5) (B: 2.4%, A: 77.4%, P = 0.0008). Nurses achieved a higher increase on compliance compared with physicians. Caregivers recognition on HH increased for each opporunity, being more notorious for M2 (B:31.7%, A: 61.5%); M3 (B: 7.3%, A: 31.5%), and M4, (B: 36.5%, A: 68.7%). Perception on the importance of preventing health-care-related infections increased from 80.5% to 90.3%.

Conclusion

Empowering patients’ primary caregivers was an effective intervention to increase HCWs HH compliance at a hematology-oncology ward. The effect of this intervention remains to be evaluated on the long-term basis, but demonstrate the importance of involving patients and their relatives on health-care delivery.

Disclosures

All authors: No reported disclosures.
Persistence of Immune Response to an Adjuvanted Varicella-Zoster Virus Subunit Candidate Vaccine for up to Year 9 in Older Adults
Authors: Pauksens Karlis , Volpe Stephanie , Schwarz Tino F , Smetana Jan , Toursarkissian Nicole , Rombo Lars , Ravault Stéphanie , David Marie-Pierre , Bastidas Adriana , Oostvogels Lidia
Published: October 2017

Background

In the ZOE-50 and ZOE-70 clinical trials, the candidate herpes-zoster subunit vaccine (HZ/su; 50µg varicella-zoster virus glycoprotein E [gE] and AS01B Adjuvant System) demonstrated high efficacy against HZ, with limited waning over 4 years and consistent efficacy across age cohorts. In adults ≥60 years of age, the immune responses elicited by 2 HZ/su doses administered 2 months apart persisted for at least 6 years.1 Here we report immunogenicity and safety 9 years post-initial vaccination.

Methods

This Phase IIIB, open, long-term extension study (NCT02735915) followed 70 participants who received 2 HZ/su doses in the initial trial (NCT00434577). Blood samples to evaluate the persistence of cellular (intracellular cytokine staining) and humoral (ELISA) immune responses were taken at 9 years post-initial vaccination. Limited safety follow-up was performed (1 visit).

Results

All 70 participants (mean age at dose 1: 72.3 years; 61.4% female) were included in the according-to-protocol analysis. The fold increases over pre-vaccination in the frequency of gE-specific CD4+ T-cells expressing ≥2 activation markers plateaued after 4 years post-dose 1 (year 4: 3.4, year 5: 3.0, year 6: 3.4, year 9: 3.4). Anti-gE antibody geometric mean concentrations were also stable from year 4 onwards (Table 1) and remained above the pre-vaccination value of 1213.1mIU/mL. Cellular and humoral responses at year 9 were similar across age strata (60–69, ≥70 years). No vaccine-related serious adverse events nor suspected HZ episodes were reported.

Conclusion

In adults ≥60 years of age, HZ/su-induced cellular and humoral immune responses remained above pre-vaccination levels for at least 9 years post-initial vaccination, confirming immune persistence predictions2 based on 6-year data.

Disclosures

S. Volpe, GSK: Employee, Salary; T. F. Schwarz, GSK: Investigator and Scientific Advisor, Consulting fee; J. Smetana, GSK: Investigator, personal fees;  S. Ravault, GSK: Employee, GSK shares and Salary; M. P. David, GSK: Employee, Salary and stock; A. Bastidas, GSK: Employee, Salary; L. Oostvogels, GSK: Employee and Shareholder, Salary and shares
Lymphogranuloma Venereum: a Croatian Case Report of a Patient with Proctitis and Concurrent Cervical Lymphadenitis
Authors: Gjurasin Branimir , Begovac Josip
Published: October 2017

Background

Lymphogranuloma venereum (LGV) can present with genital ulcers, proctitis, or femoral/inguinal lymphadenopathy with or without constitutional symptoms. There have been reports on the infection characterized by supraclavicular or cervical lymphadenopathy, although there is no published data on the detection of Chlamydia trachomatis (CT) in the affected lymph node.

Methods

We report a patient with pharyngitis, proctitis and cervical lymphadenitis, in whom LGV specific DNA was detected by polimerase chain reaction (PCR) in both the rectal swab and cervical lymph node fine needle aspirate.

Results

A 48-year-old Croatian HIV-positive male patient attended our outpatient HIV clinic complaining of a 10-day perianal pain, bloody rectal discharge with normal stool consistency and painful and enlarged cervical lymph node. On the first day he had fever, which subsided on the following day. Clinical examination demonstrated exudate on the right tonsil, painful, and enlarged right cervical lymph node (5 × 2 cm, Figure 1), perianal pain on palpation and rectal purulent discharge. During the preceding 10-year period, the patient was taking his antiretroviral therapy regularly and had an undetectable HIV RNA by PCR. We started treatment with ceftriaxone and doxycycline. The fine needle aspirate of the affected lymph node showed a pyogranulomatous inflammation. Indirect immunofluorescence assay on CT antibodies detected positive titers in IgG (>512) and IgA (256) classes. LGV-specific DNA was detected in both the rectal swab and the cervical lymph node fine needle aspirate. Ceftriaxone was discontinued after 5 days and doxycycline therapy was continued for a total of 6 weeks because of the persistence of the cervical lymphadenopathy. The patient came to a full recovery.

Conclusion

We found six published case reports on LGV with associated cervical lymphadenopathy in which the infection with CT was established by serologic testing and/or by nucleic acid amplification tests of the pharyngeal and/or rectal swabs. Some of the mentioned reports demonstrated granulomatous inflammation present in the affected cervical lymph node, as was evidenced in our patient. To our knowledge, this is the first case report of a patient with CT infection in whom LGV-specific DNA was detected in the cervical lymph node.

Disclosures

All authors: No reported disclosures.
Agar Gradient Diffusion Susceptibility Testing for Neisseria gonorrhoeae: A Reliable Alternative to Agar Dilution?
Authors: Desjardins Michaël , Lefebvre Brigitte , Labbé Annie-Claude , Martin Irene , Mauffrey Florian , Longtin Jean , Fortin Claude
Published: October 2017

Background

Antimicrobial susceptibility testing by agar dilution, the gold-standard for determination of minimal inhibitory concentration (MIC) for N. gonorrhoeae, is a labor intensive technique usually performed in reference laboratories. Agar gradient diffusion is a simpler alternative to obtain MICs. However, correlation of N. gonorrhoeae MIC values obtained by the two methods is not well established. The objective of this study is to evaluate performance of agar gradient diffusion compared with agar dilution for N. gonorrhoeae.

Methods

Fifty strains of N. gonorrhoeae (34 isolates from clinical specimens; 14 WHO reference and two ATCC strains), all confirmed to be genetically distinct using molecular typing (NG-MAST), were selected. Isolates with known high MICs were targeted. Agar gradient diffusion MIC testing was done in a clinical laboratory on all strains for ceftriaxone, cefixime, and azithromycin while comparing two different commercial antimicrobial strips (bioMérieux, Alere) on three different culture media (BD, Oxoid, CLSI’s recommended medium). Agar dilution MIC testing according to CLSI was done at the Québec provincial reference laboratory on all strains. Performance of agar gradient diffusion was assessed by accuracy, using essential and categorical agreements, and by precision (reproducibility).

Results

When comparing agar dilution and agar gradient diffusion using bioMérieux strips on CLSI testing medium, essential agreements (within 1-log2 dilution) were 94, 88, and 82% for ceftriaxone, cefixime, and azithromycin, respectively. Categorical agreements were 100, 94, and 94%. Agar gradient diffusion, compared with agar dilution, had a tendency to under-estimate MIC for third-generation cephalosporins, not classifying 86% of isolates with decreased susceptibility (MIC 0.12–0.25 mg/l for ceftriaxone, 0.25 mg/l for cefixime) as such. Overall precision of agar gradient diffusion was 96%.

Conclusion

Agar gradient diffusion using bioMérieux strips on CLSI testing medium shows satisfactory accuracy compared with agar dilution for N. gonorrhoeae MIC testing of third-generation cephalosporins and azithromycin even in a carefully selected panel of strains.

Disclosures

M. Desjardins, bioMerieux: Research Contractor, Research support. BD: Research Contractor, Research support. Alere: Research Contractor, Research support. Oxoid: Research Contractor, Research support. C. Fortin, Alere: Research Contractor, Research support. bioMerieux: Research Contractor, Research support. BD: Research Contractor, Research support

Oxoid: Research Contractor, Research support
Healthcare Engagement among Persons with HIV: More Than Just Viral Load and Clinic Attendance
Authors: Okeke Nwora Lance , Clement Meredith , McKellar Mehri , Stout Jason
Published: October 2017

Background

The traditional definition of engagement in HIV care in terms of only clinic attendance and viral suppression provides a limited understanding of how persons with HIV interact with the healthcare system.

Methods

We conducted a retrospective analysis of patients with ≥ 1 HIV clinic visit at the Duke Adult Infectious Diseases Clinic between 2008 and 2013. Healthcare utilization was characterized by four indicators: clinic attendance in each half of the calendar year (yes/no), number of emergency department (ED) visits (0, 1 or 2+), inpatient admissions per year (0, 1, 2+), and viral suppression (never, intermittent, always). Healthcare engagement patterns were modeled using latent class/latent transition analysis, with model fit assessed using the Bayesian Information Criterion.

Results

The cohort included 2686 patients (median age 42.9 years, 72% male, 56% black). A three-class model best fit the data: “Adherent” “Non-adherent” and “Sick”. “Adherent” patients had high rates of clinic attendance in each half of the year (84%), rarely visited the ED (3.6% with ≥1 ED visit per year), and moderate rates of (54%) viral suppression. “Non-adherent” patients rarely attended clinic visits in both halves of the year (1.5%), used the ED more than “adherent” patients (10.3% with ≥1 ED visit per year), and had low rates of viral suppression (19%). “Sick” patients also had high rates of clinic attendance (75%), were frequent users of the ED (53% with ≥1 ED visit per year), and comparable rates of viral suppression to the “adherent” group (55%) viral suppression. Non-white race (OR 1.9) and age ≤ 40 (OR 3.76) were associated with membership in the “non-adherent” class. Movement between classes was dynamic, especially in the “sick” group (30–40% of whom moved to a different class the following year). Across all years, persons in the “non-adherent” class were more likely to completely disengage from care the following year than “adherent” persons (23.6% v. 0.2%, P <0.001).

Conclusion

A broader definition of healthcare engagement revealed distinct and dynamic patterns among persons with HIV that would have been hidden had only clinic attendance and viral suppression been considered. These patterns may be useful for designing engagement-targeted interventions.

Disclosures

All authors: No reported disclosures.
High Correlation of Visual Inspection and a Smartphone-Based Electronic Reader of Two Dual Rapid Diagnostic HIV/Syphilis Assays
Authors: Allan-Blitz Lao-Tzu , Rivera Silver Vargas , Konda Kelika , De Cortina Sasha Herbst , Caceres Carlos , Klausner Jeffrey
Published: October 2017

Background

The HRDR-200 automated reader (Cellmic, LLC, CA, USA) is an opto-mechanical smartphone attachment that reads lateral flow-based rapid HIV/Syphilis combo assays. The reader may minimize human errors in interpreting rapid tests as well as provide a centralized data system for epidemiologic monitoring.

Methods

We enrolled men who have sex with men and transgender women >18 years old seeking services at a sexually transmitted disease clinic in Lima between October 2016 and April 2017. Venous blood was tested using two dual HIV and Syphilis rapid tests (SD BIOLINE HIV/Syphilis Duo (SD), Republic of Korea; and First Response HIV 1 + 2/Syphilis Combo (FR), India). HIV infection was confirmed with fourth-generation EIA tests, while Syphilis was confirmed with RPR, TPPA, and TPHA titers. Clinic staff visually inspected rapid tests, after which the tests were read by the HRDR-200. To assess how well the reader results correlated with visual inspection we calculated negative and positive percent agreement, concordance, and kappa statistic.

Results

Of 283 participants, 34% were HIV-infected and 46% had treponemal antibodies (69% of whom had reactive RPR titers). The concordance of reader results with visual inspection was high for both antibodies and both rapid assays (see Table).

Conclusion

Given the high correlation of the reader with visual inspection, further investigation is warranted into the potential utility of the reader for epidemiologic monitoring as well as for improving HIV and Syphilis diagnosis in areas without technicians trained in visual inspection of rapid tests.

Disclosures

All authors: No reported disclosures.
Transmitted Drug Resistance in Treatment-naïve HIV-Infected VCT clients in Taiwan, 2007–2016
Authors: Tsai Hung-Chin , Chen I-Tzu , Lee Susan Shin-Jung , Chen Yao-Shen
Published: October 2017

Background

The transmission of drug-resistant HIV-1 strains might compromise the efficacy of antiretroviral treatment. The aim of this study was to monitor the prevalence of transmitted drug resistance (TDR) in Taiwan, where free highly active antiretroviral therapy (HAART) was provided since 1997.

Methods

A cohort study on TDR was conducted in antiretroviral therapy -naïve HIV-1 ¡Vinfected voluntary counseling and testing (VCT) clients from 2007 to 2016 in southern Taiwan. Genotypic drug resistance testing to PR/RT (pol gene) were determined by ViroSeqTM system and drug resistance testing to integrase inhibitors (INSTI) was done by in house PCR. Antiretroviral resistance was interpreted using the HIVdb program of the Stanford University HIV Drug Resistance Database. The patients classified as having low-level resistance, intermediate resistance and high-level resistance were defined as having drug resistance. Resistance-associated mutations were defined by the presence of at least one mutation included in the 2017 drug resistance mutation list of the International AIDS Society-USA consensus guidelines.

Results

A total of 29384 individuals received a free HIV anonymously screening test during 2007 to 2016. The positive rate for HIV-1 infection was 2%. Sequences were obtained from 407 individuals, of whom 90% were infected by MSM, and 10% were infected by heterosexually. Subtype B HIV-1 strains were found in 97%, subtype C in 0.3% and subtype CRF01_AE in 2.7%. A total of 6% was found to harbor drug resistance strains. The most common NRTI resistance associated mutation was D67N, M184V, K219N, Y118I and T215S/P. The most common NNRTI resistance associated mutation was Y181C, K103N, V179D and Y318F. No any one harbored resistance to INSTI inhibitors (n = 188).

Conclusion

The resistance prevalence (6%) in this study supported the WHO guideline to prescribe pol resistance testing before initiation of HAART therapy in the treatment naïve patients.

Disclosures

All authors: No reported disclosures.