bluuebunny/crossref_metadata_2025 huggingface dataset:
120. Stewardship Driven Reduction of Inappropriate Clostridioides difficile Testing at a Tertiary Military Medical Facility
Authors: Gilbert Laura , Robinson Sara , Raiciulescu Sorana , Ressner Roseanne
Published: January 2021

Background

C. difficile infection (CDI) is the leading hospital associated (HA) infection in an era of antibiotic overuse and highly-sensitive PCR-based diagnostics. PCR does not differentiate CDI versus colonization making over-reporting a concern. HA-CDI can impact hospital reimbursement, lead to unnecessary treatment, increase costs and length of stay. Our aim was to implement an intervention to target inappropriate C. difficile (CD) testing.

Methods

Two-tiered testing is not utilized at our facility. After provider education on guidelines for appropriate CD testing, prompts were introduced into the electronic medical record (EMR) for CD test orders. At order input, providers are prompted to answer “yes” or “no” to two questions; 1) receipt of stool softeners within the preceding 48 hours and 2) criteria of 3 loose stools within 24 hours. The test order was completed regardless of the responses to the prompted questions. Six-month post-intervention data was compared to the same timeframe during the year prior.

Results

A total of 334 and 236 tests were ordered in the pre- and post-intervention periods respectively. Accounting for inpatient bed days, the incidence reduction rate (IRR) was 0.75 (CI 0.63–0.89, p < 0.001) corresponding to an estimated hospital cost-savings of $12,250 based on testing costs alone. The majority of CD tests were ordered by IM providers, who also demonstrated the greatest reduction in tests ordered post-intervention. Patient characteristics were analyzed in the pre- and post-intervention periods finding significantly less positive CD tests ordered for patients with recurrent C. difficileduring the post-intervention period (2 vs 7, p = 0.04). Patients who were transferred from another institution had significantly more positive CD tests in the post-intervention period (19 vs 7, p = 0.02).

Conclusion

In conclusion, the results demonstrate that implementing a systems-based EMR initiative led to a 25% reduction in CD testing with a cost-savings of $12,250 not accounting for potential associated cost savings. This project suggests that even without restricting order access, educational prompts integrated in the EMR can have meaningful impact on stewardship endeavors to help reduce inappropriate CD testing. Sustained effect would be an area to explore.

Disclosures

All Authors: No reported disclosures
1469. Effect of pneumonia and pneumonia hospitalization episodes on mobility in older adults: results from the Lifestyle Interventions and Independence for Elders (LIFE) Study
Authors: Brown Joshua , Sato Reiko , Morley John
Published: January 2021

Background

Mobility is a cornerstone of healthy aging. Pneumonia may impact mobility through damage to physiological systems as well as increased inflammation, which has been associated with reduced physical functioning. The objective of this study was to assess the impact of pneumonia on objectively measured physical functioning in a sample of older adults.

Methods

This was a post-hoc analysis of the Lifestyle Interventions and Independence for Elders (LIFE) Study provided by the National Institute on Aging’s AgingResearchBiobank. Participants with pre-existing mobility concerns aged 70-89 years were randomized to physical activity or health education interventions. Outcomes included the ability to complete a 400-meter walk and gait speed (meters/second, m/s) and were assessed every 6 months from baseline up to 42 months. New health events were assessed at each visit including overall pneumonia events and pneumonia hospitalizations. Repeated measures regression models evaluated the ability to walk 400-meters and gait speed as separate outcomes controlling for age, sex, race, education, past medical history, the occurrence of other health events, and a cumulative deficit frailty index.

Results

There were 1,635 LIFE Study participants with N=9,872 follow-up measures during the study period. Among these, 174 (10.6%) had a pneumonia event which included 96 hospitalization events. Those with pneumonia events during follow-up were mostly similar to those without pneumonia events at baseline, except for higher prevalence of past hospitalizations and respiratory problems. Any pneumonia event was associated with an adjusted mean gait speed of 0.67 (0.63-0.71) m/s vs. 0.70 (0.66-0.73) m/s in those without pneumonia and 0.60 (0.55-0.64) in those with pneumonia hospitalization. Similarly, pneumonia events were associated with 84% [odds ratio = 1.84 (1.45-2.23)] and pneumonia hospitalizations with 200% [odds ratio = 3.00 (2.48-3.52)] increases in the odds of not being able to walk 400-meters compared to those without pneumonia events.

Conclusion

Pneumonia-related health events were associated with subsequent reduced mobility measured by 400-meter walk tests and gait speed. Preventing pneumonia may be an important component of maintaining physical functioning in older adults.

Disclosures

Joshua Brown, PharmD, PhD, Pfizer, Inc (Consultant, Grant/Research Support) Reiko Sato, PhD, Pfizer, Inc (Employee, Shareholder) John Morley, MD, Pfizer, Inc (Consultant)
1470. Epidemiology of Invasive Pneumococcal Disease (IPD) Following 18 years of Pneumococcal Conjugate Vaccine (PCV) Use in the United States
Authors: Pilishvili Tamara , Gierke Ryan , Farley Monica M , Schaffner William , Thomas Ann , Reingold Art , Harrison Lee , Holtzman Corinne , Burzlaff Kari , Petit Susan , Herlihy Rachel , Torres Salina , Beall Bernard
Published: January 2021

Background

PCVs have been recommended for U.S. children since 2000. A 7-valent vaccine (PCV7) was introduced in 2000. This was replaced by a 13-valent vaccine (PCV13) in 2010. PCV13 was also recommended for adults aged ≥ 65 years in August 2014. We evaluated PCV impact on IPD.

Methods

IPD cases (isolation of pneumococcus from sterile sites) were identified through CDC’s Active Bacterial Core surveillance during 1998-2018. Isolates were serotyped by Quellung or whole genome sequencing and classified as PCV13-type and non-vaccine-type (NVT). Incidence rates (cases/100,000) were calculated using U.S. Census Bureau population denominators.

Results

From 1998 through 2018, overall IPD rates among children aged < 5 years decreased by 93% (from 95 to 7 cases/100,000). PCV13-type IPD decreased by 98% (from 88 to 2 cases/100,000). Among adults aged ≥ 65 years, overall IPD rates decreased by 60% (from 61 to 25 cases/100,000). PCV13-type IPD rates declined 86% (from 46 to 7 cases/100,000). Declines were most dramatic in the years following PCV7 introduction, with additional declines after PCV13 introduction in children (Figures 1 and 2). Serotypes 3, 19A, and 19F caused most of the remaining PCV13-type IPD. NVT IPD rates did not change significantly among children. Among adults aged 50-64 years, NVT IPD increased by 83% (from 6 to 12 cases/100,000) (p< 0.01). Among adults aged ≥ 65 years, NVT IPD increased by 22% (from 15 to 18 cases/100,000) (p< 0.01). The most common NVTs in 2018 were 22F (10% of all IPD), 9N (7%) and 15A (5%). Among children, the proportion of cases with meningitis increased from 5% to 14% (p< 0.01), and the proportion with pneumonia/empyema increased from 17% to 31% (p< 0.01). Among adults, the proportion of cases with meningitis did not change (3%), while the proportion with pneumonia/empyema increased from 72% to 76% (p=0.01).

Figure 1: Incidence of invasive pneumococcal disease among children aged < 5 years, 1998-2018

Figure 2: Incidence of invasive pneumococcal disease among adults aged ≥ 65 years, 1998-2018

Conclusion

Overall IPD incidence among children and adults decreased following PCV introduction for children, driven primarily by reductions in PCV-type IPD. NVT IPD increased in older adults, but these increases did not eliminate reductions from PCV13-type IPD.

Disclosures

Lee Harrison, MD, GSK (Consultant)Merck (Consultant)Pfizer (Consultant)Sanofi Pasteur (Consultant)
1471. Evaluation of Antibiotic De-escalation in Post Cardiac Arrest Patients with Culture-Negative versus Culture-Positive Aspiration Pneumonia
Authors: Herzig Natasha R , Harpenau Tara L , Wohlfarth Kevin M , Hochanadel Alicia M
Published: January 2021

Background

Cardiac arrest patients are often empirically treated for aspiration pneumonia with broad-spectrum antibiotics. Previous literature has shown no difference in clinical outcomes when discontinuing antimicrobial therapy for suspected aspiration pneumonia with negative respiratory cultures, but the application is limited in this population. This study aimed to assess antibiotic de-escalation practices for suspected aspiration pneumonia in post cardiac arrest patients with respiratory cultures and explore clinical outcomes.

Methods

This retrospective cohort conducted at a level 1 trauma center included adult out-of-hospital cardiac arrest patients who received antimicrobial therapy for suspected aspiration pneumonia. The primary endpoint was incidence of antibiotic de-escalation before day seven comparing culture-negative and culture-positive patients. De-escalation included discontinuation of methicillin-resistant Staphylococcus aureus (MRSA) coverage, Pseudomonas aeruginosa coverage, atypical coverage or all antibiotics when respective pathogens were not identified from microbiologic or serologic methods. Secondary endpoints included type of de-escalation and clinical outcomes.

Results

Eighty-six patients were included: 45 culture-negative and 41 culture-positive. Figure 1 depicts the breakdown of organisms isolated. Guideline-directed empiric therapy was used in 18.6% of patients, with the remainder receiving excessively broad empiric coverage. Antibiotic de-escalation before day seven occurred in 28 (80%) culture-negative patients and 32 (82%) culture-positive patients (p = 0.82), excluding patients who died before day seven. Providers frequently stopped unnecessary MRSA coverage in both groups. In-hospital mortality was higher in the group of patients without antibacterial de-escalation (62% vs. 33%, p=0.03), but hospital length of stay, ICU length of stay, and number of ventilator-free days were not different between groups.

Figure 1: Epidemiology of Pathogens Isolated From Respiratory Cultures in Cardiac Arrest Patients

Conclusion

Culture results were not associated with antibiotic de-escalation in post cardiac arrest patients with suspected aspiration pneumonia. Opportunities exist for further de-escalation in this population, particularly patients with unnecessary pseudomonal coverage.

Disclosures

All Authors: No reported disclosures
1473. Guideline Adherence in Pediatric Ambulatory Visits for Acute Otitis Media
Authors: Herigon Joshua C , Mousseau Sarah , Kimia Amir , Hatoun Jonathan , Vernacchio Louis
Published: January 2021

Background

Acute otitis media (AOM) is the most common pediatric outpatient condition treated with antibiotics in the United States. Over 30% of children receive inappropriate antibiotics for AOM, contributing to increasing antimicrobial resistance and unnecessary adverse events. Strict adherence to diagnostic and treatment guidelines has been proposed by the American Academy of Pediatrics (AAP) Committee on Infectious Diseases as one strategy to combat inappropriate antibiotic use. Our objective was to describe adherence to the 2013 AAP guidelines on AOM.

Methods

We performed a cross-sectional study on a random sample of visit notes for patients 3 to 59 months old diagnosed with otitis media based on ICD-10-CM codes (H65, H66, H67) and treated with antibiotics between 9/1/2017 and 8/31/2018 in an association of pediatric practices across Massachusetts. Children with tympanostomy tubes or a chronic medical condition increasing their risk for AOM were excluded. Based on the 2013 AAP diagnostic criteria, tympanic membrane exam descriptions were reviewed and classified as describing AOM or not. Antibiotic choices were classified as appropriate or inappropriate. Notes were then labeled as “fully adherent” (exam consistent with AOM and appropriate antibiotic choice), “partially adherent” (exam inconsistent with AOM or inappropriate antibiotic choice), and “non-adherent” (exam inconsistent with AOM and inappropriate antibiotic choice).

Results

Three hundred and ninety-four visit notes from 39 different practices were analyzed. One hundred and sixty-six notes (42%) were “fully adherent” to the AAP guidelines, 183 (46%) were “partially adherent” and 45 (11%) were “non-adherent” (Figure 1). In the “partially adherent” and “non-adherent” groups combined, exams were inappropriate in 179 notes (45.4%) and antibiotic choice was inappropriate in 94 notes (23.9%). Cefdinir was the most frequent inappropriate antibiotic (44/94, 46.8%) (Table 1). “Watchful waiting” occurred in only 7% (16/229) of eligible cases.

Figure 1. Breakdown of encounters by adherence type

Table 1. Cross-table of indicated and prescribed antibiotics

Conclusion

Our analysis of independent pediatric practices showed moderate adherence to the AAP guidelines for AOM. Substantial room exists for improvement in diagnosing and treating AOM in young children, especially regarding the potential for watchful waiting.

Disclosures

All Authors: No reported disclosures
1479. Incidence of Acute Otitis Media in Children in the United States before and after the introduction of Pneumococcal Conjugate Vaccines (PCV7 and PCV13) during 1998-2018
Authors: Hu Tianyan , Sarpong Eric , Song Yan , Done Nicolae , Orvis Eli , Signorovitch James , Petigara Tanaz
Published: January 2021

Background

Acute otitis media (AOM) leads to considerable healthcare resource utilization in children. Streptococcus pneumoniae is an important cause of AOM. Merck is developing V114, an investigational 15-valent PCV that contains PCV13 serotypes as well as 22F and 33F. To demonstrate the potential value of V114, it is important to estimate the remaining clinical burden associated with AOM. This study estimated AOM incidence rates (IRs) before and after the introduction of 7-valent and 13-valent pneumococcal conjugate vaccines (PCV7 and PCV13) in the US.

Methods

This was a retrospective observational study using IBM MarketScan® Commercial Claims and Encounters (CCAE) (1998-2018) and Multi-State Medicaid databases (2001-2018). AOM claims in children < 18 years old were identified using ICD9 codes 382.x and ICD10 codes H66.x and H67.x. An episode could comprise one or more AOM-related claims. A gap of at least 14 days between two AOM-related claims was required to define the start of a new episode. IRs were defined as the numbers of episodes per 1,000 person-years (PY). Annual IRs were stratified by age groups (< 2, 2-4, and 5-17), and reported separately for CCAE and Medicaid databases.

Results

AOM IRs declined over time among commercially and Medicaid-insured children in all age groups < 18 years old. In particular, among children < 2 years, AOM IRs declined from 1,111 in 1998 to 727/1,000 PY in 2018 in commercially plans and from 895 in 2001 to 656/1,000 PY in 2018 in Medicaid (Figure 1). In children 2-4 years, AOM IRs declined from 517 in 1998 to 400/1,000 PY in 2018 in commercial plans and from 385 in 2001 to 329/1,000 PY in 2018 in Medicaid (Figure 2). In children 5-17 years, AOM IRs declined from 112 in 1998 to 87/1,000 PY in 2018 in commercial plans and from 98 in 2001 to 87/1,000 in 2018 in Medicaid (Figure 3).

Figure 1. AOM incidence in commercially and Medicaid-insured children ages 0 - 1 years, episodes per 100,000 patient-years (1998 - 2018)

Figure 2. AOM incidence in commercially and Medicaid-insured children ages 2 - 4 years, episodes per 100,000 patient-years (1998 - 2018)

Figure 3. AOM incidence in commercially and Medicaid-insured children ages 5 - 17 years, episodes per 100,000 patient-years (1998 - 2018)

Conclusion

AOM IRs declined following the introduction of PCV7 and PCV13; however, disease burden remains substantial in younger children. The impact of future PCVs on AOM will depend on the proportion of AOM caused by S. pneumoniae and vaccine-type serotypes.

Disclosures

Tianyan Hu, PhD, Merck (Employee, Shareholder) Yan Song, PhD, Merck (Consultant) Nicolae Done, PhD, Merck & Co., Inc. (Consultant) Eli Orvis, BA, Merck (Consultant) James Signorovitch, PhD, Merck & Co., Inc. (Consultant) Tanaz Petigara, PhD, Merck & Co., Inc. (Employee, Shareholder)
1483. Maternal Tdap Vaccination During Pregnancy and Immune Response: A Comparison Between Infants Born to Mothers Primed with Acellular or Whole Cell Pertussis Vaccines
Authors: Havers Fiona , Skoff Tami , Rench Marcia , Epperson Monica , Schiffer Jarad , Hariri Susan , Swaim Laurie S , Baker Carol , Healy C Mary
Published: January 2021

Background

Acellular pertussis (aP) vaccines replaced whole cell pertussis (wP) vaccines for the recommended childhood primary series in the United States in 1997. As women primed with aP vaccines in childhood enter reproductive age, it is unknown how maternal aP-priming will impact pertussis protection conferred to infants through Tdap (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis) vaccination during pregnancy.

Methods

Infants born at term to women who had been vaccinated with Tdap at 27-36 weeks’ gestation and ≥ 14 days prior to delivery were included. Geometric mean concentrations (GMC) of pertussis-specific antibodies (measured in IU/mL) in umbilical cord blood of infants born to women born after 1997 (aP vaccine primed) were compared with those born to women born before 1992 (wP vaccine primed).

Results

253 and 506 neonates born to aP- and wP-primed women, respectively, were included. Compared with wP-primed women, aP-primed women were younger (19.3 v. 24.5 years), more likely to be Hispanic or non-Hispanic black and to have infants with lower birthweight (3264 v. 3392 grams, p< 0.01 for all). Gestation at Tdap receipt, gestational age at delivery, and interval between Tdap administration and delivery were not statistically different.

Antibodies against pertussis toxin (PT) and filamentous hemagglutinin (FHA) were significantly lower among neonates born to aP-primed versus wP-primed mothers (PT: 17.3 v. 36.4, GMC ratio 0.475 (0.408 – 0.552) (Figure); FHA: 104.6 v. 121.4, GMC ratio 0.861 (0.776 – 0.958)). No significant differences were observed between the aP and wP-primed groups for anti- fimbriae (FIM) or anti-pertactin (PRN) antibodies ((FIM: 469.6 v. 577.2, GMC ratio 0.81 (CI 0.65 – 1.01); PRN 338.8 v. 292.6, GMC ratio 1.16 (CI 0.99 – 1.35)).

Figure. Distribution of anti-PT antibody levels in cord blood in infants born to women who were primed with whole cell pertussis compared with acellular pertussis vaccines in childhood.*

Conclusion

The type of pertussis vaccine a woman received during childhood significantly impacted her response to Tdap vaccination during pregnancy; the largest reduction was in anti-PT antibodies thought to be most important in preventing severe infection in infants. These findings suggest that infants born to aP-primed women who received Tdap during pregnancy may have less passive protection against pertussis during the first months of life than those born to wP-primed women.

Disclosures

All Authors: No reported disclosures
1488. Relationship Between Culture Conversion and Clinical Outcomes in Patients With Mycobacterium abscessus (MAB) Lung Disease: A Systematic Literature Review
Authors: Flume Patrick A , Mange Kevin C , Jumadilova Zhanna , Cline Kristan B , Winthrop Kevin L
Published: January 2021

Background

Treatment of MAB lung disease is difficult, and currently there is no consensus on the best course of treatment. We examined the relationship between culture conversion and clinical outcomes among patients with MAB lung disease.

Methods

English-language MAB lung disease studies with ≥10 patients and reporting culture conversion and/or an outcome of interest (eg, changes in symptoms, lung function, quality of life, and/or radiography) were identified from Embase, PubMed, relevant congress abstracts, and the Cochrane Library (data cutoff, September 24, 2019) using the National Institute for Health and Clinical Excellence guidance for systematic literature reviews. Two independent reviewers screened 1,551 indexed records; relevant data were extracted and are reported as population-weighted means.

Results

No study directly correlated culture conversion with a change in symptoms. In 10 studies (N=869) reporting overall symptoms and culture conversion separately, 72.5% of patients (range 36%–96%) reported symptom improvement and 56.5% (range, 13%-99%) achieved culture conversion; a weak trend between symptomatic improvement and higher culture conversion rates (R2=0.36) was observed. Three additional studies (N=106) reported symptomatic improvement and culture conversion as a single measurement (49.6%, range, 25%-81%). Limited data indirectly correlated improvement in cough, dyspnea, hemoptysis, sputum production, and fatigue with culture conversion (1-2 studies each). Two studies directly correlated improved lung function (N=62) with culture conversion, and one study indirectly reported improved health-related quality of life (N=47) with culture conversion; no study reported radiology outcomes in relation to culture conversion.

Conclusion

This systematic literature review underscores the lack of data correlating clinical outcomes and culture conversion in patients with MAB lung disease. Limitations include a small number of studies, inconsistencies/non-reporting of methods, and poorly defined outcomes. Although indirect data indicate a weak correlation between symptom improvement and culture conversion, more evidence is needed to demonstrate a clinical outcome benefit associated with culture conversion.

Disclosures

Patrick A Flume, MD, Insmed Incorporated (Grant/Research Support, Scientific Research Study Investigator, Advisor or Review Panel member) Kevin C Mange, MD, MSCE, Insmed Incorporated (Employee) Zhanna Jumadilova, MD, Insmed Incorporated (Employee) Kristan B Cline, PhD, Insmed Incorporated (Employee) Kevin L Winthrop, MD, MPH, Insmed Incorporated (Consultant, Grant/Research Support)
1490. Serious Infections Caused by Carbapenem Susceptible and Carbapenem Resistant Acinetobacter baumannii-calcoaceticus Complex - A Retrospective Review
Authors: Rana Khurram , Wunderink Richard G , Tsuei Betty J , Rahav Galia , Kovalchuk Eugenii , Koksal Iftihar , Maloney Kathleen , Srinivasan Subasree
Published: January 2021

Background

Increasing resistance to available antibiotics, including carbapenems, is limiting effective treatment options for serious Acinetobacter baumannii-calcoaceticus (ABC) complex infections that are associated with high mortality. This multi-center retrospective analysis is to describe the natural history and outcomes of serious ABC infections.

Methods

This was a retrospective review of 125 cases of ABC infections from United States (US), Israel, Turkey and Russia. Baseline, microbiologic, treatment and outcomes data were collected from patients with hospital-acquired (HABP, n=23) or ventilator-associated bacterial pneumonia (VABP, n=26), bacteremia (n=36), urinary tract infections/acute pyelonephritis (n=16), and wound ABC infections (n=24) between 2017-2019.

Results

Fifty percent of cases reviewed were from the US. The median age of patients was 63 years (range 18-93), 46% were > 65 years old, 69% were male, 31% had renal failure, and 22% had septic shock. The most common co-morbidities observed were cardiac disease (41%), diabetes (32%) and moderate or severe renal disease (26%). Rates of resistance were observed as follows: ciprofloxacin 74%, ceftazidime 67%, amikacin 52% and colistin 0%. Carbapenem resistance (CR) was observed in 49% of patients. Most patients (73%) received combination therapy with 37% receiving at least 4 antibiotics. Carbapenems (40%) and penicillin/b-lactamase inhibitors (42%) were mostly used for treatment. Polymyxins were used in 18% of cases. Overall, the 28-day mortality was 34% and was highest in bacteremia (56%) and VABP (50%). CR appears to be a factor in mortality and other outcomes, as well as hospital days (table). In patients who received monotherapy, all 5 patients with CR infection died compared to 29% mortality in patients with carbapenem sensitive (CS) infection. Mortality was 70% in 20 cases when colistin was used for treatment.

Conclusion

Serious ABC infections are associated with substantial comorbidities and a high mortality rate despite treatment with combination therapy. CR appears to be a major factor in mortality. New antibiotics are urgently needed to treat serious ABC infections.

Disclosures

Khurram Rana, PharmD, Entasis Therapeutics (Employee) Galia Rahav, MD, AstraZeneca (Scientific Research Study Investigator) Kathleen Maloney, CCRP, Entasis Therapeutics (Employee) Subasree Srinivasan, MD MPH, Entasis therapeutics (Employee)
1491. Standard- vs. High-dose Trimethoprim-Sulfamethoxazole for Stenotrophomonas maltophilia pneumonia
Authors: Hall Brenton C , Ortwine Jessica , Wei Wenjing , Mang Norman , Prokesch Bonnie C , Pichlinski Elisa
Published: January 2021

Background

Stenotrophomonas maltophilia is a multidrug-resistant pathogen known to cause pneumonia with associated mortality rates up to 44%.1,2 Trimethoprim-sulfamethoxazole (TMP-SMX) is the drug of choice based on available clinical evidence and excellent in-vitro susceptibility rates.3 High-dose TMP-SMX strategies recommend between 15-20mg/kg/day of the TMP component, however this has been associated with increased adverse drug events (ADE).4,5 The optimal dosing strategy remains unclear and it is unknown whether lower doses of TMP-SMX would achieve similar outcomes.

Methods

Patients with positive respiratory cultures for S. maltophilia who received at least 72 hours of TMP-SMX therapy for hospital-acquired or ventilator-associated pneumonia from January 2010 to March 2020 were included. Doses were categorized as standard-dose (SD) TMP-SMX (< 15 mg/kg/day TMP) or high-dose (HD) TMP-SMX (≥ 15 mg/kg/day TMP) after adjusting for renal function. The primary outcome was clinical success, defined as the composite of resolution of signs/symptoms of pneumonia, in-hospital survival, and no escalation of care. Secondary outcomes included hospital length of stay (LOS), 30-day mortality, 30-day readmission, and ADE.

Results

Of the 44 patients meeting inclusion criteria for the study, 27 received SD and 17 received HD TMP-SMX therapy. Patients received 12 mg/kg/day (IQR 11-14) and 16 mg/kg/day (IQR 16-19) in the SD and HD groups, respectively. There was no difference in clinical success between the SD and HD group (41% vs 59%, p=0.24). Secondary outcomes were similar between both groups except for 30-day hospital readmission; the SD group had significantly lower readmission rates (6% vs 69%, p < 0.01). Rates of adverse events were not statistically different between the two groups.

Conclusion

This study provides evidence that SD TMP-SMX may achieve similar clinical efficacy to HD TMP-SMX. We found no significant difference in clinical success, LOS, 30-day mortality, or adverse events between groups. Although HD TMP-SMX is the current recommendation for S. maltophilia infections, concerns about tolerability and adverse effects suggest that further clinical and pharmacodynamic research is needed.

Disclosures

All Authors: No reported disclosures
1498. Etiology of Community-acquired Pneumonia in Adults: A Systematic Review
Authors: Shoar Saeed , Musher Daniel
Published: January 2021

Background

Background: Recent guidelines recommend immediate empiric antibiotic treatment for patients (pts) with community-acquired pneumonia (CAP). Concerns about treatment recommendations and antibiotic stewardship motivated a systematic literature review of the etiology of CAP.

Methods

We reviewed English-language literature using PRISMA guidelines. Data were stratified into diagnostic categories according to the microbiologic studies that were done (Table1).

Fig.1. Flowchart of systematic literature review and study selection

Table 1. Characteristics of studies reporting the etiology of community-acquired pneumonia

Results

146 articles with 82,674 CAP pts met criteria for inclusion; 63,938 (77.3%) were inpatients, 16,532 (20.0%) were in- or outpatients, and 2,204 (2.7%) were outpatients. Pneumococcus was the most common cause of CAP without regard to which microbiological techniques were used (33-50% of all cases). The proportion due to this organism declined with time, much more strikingly in the US than in Europe. Haemophilus influenzae was the second most common cause (7-16% of cases), followed by Staphylococcus aureus and Enterobacteriaceae each in 4–10%. Pseudomonas (0.8-4.5%) and Moraxella (1.2-3.5%) were less common; all other bacteria were isolated far less frequently. Mycoplasma caused 4-11% of CAP, Legionella 3-8%, Chlamydophila 2-7%, and Coxiella < 2%; some studies showed a much higher frequency of Mycoplasma. With routine use of viral PCR, a virus was identified in 30-40% of pts; bacterial/viral coinfection was found in 25-35% of these cases. In a separate study of CAP pts in whom viral PCR was positive, 40% had bacterial coinfection. Influenza viruses were identified in 6.2-13.7% of cases and rhinoviruses in 4.1-11.5%. RSV and human metapneumovirus were less common (0.4-4.7%), followed more distantly by other viruses. Even with the use of the most sophisticated diagnostic techniques, no etiologic agent for CAP was identified in > 50% of cases.

Trends of identification of S. pneumoniae and H. influenzae as the etiology of CAP (above); and the proportion of S. pneumoniae as the causes of CAP in different geographic regions (below).

Conclusion

Our results justify current guidelines for initial empiric antibiotic treatment of all pts with CAP. With pneumococcus and Haemophilus continuing to predominate, efforts at antibiotic stewardship might be enhanced by greater attention to routine use of sputum Gram stain and culture. Because viral/bacterial coinfection is relatively common, the identification of a virus by PCR does not, by itself, permit the non-use of an antibiotic.

Disclosures

All Authors: No reported disclosures
1499. Incidence of Community Acquired Pneumonia by Age and Comorbid Conditions in the Veterans Health Administration (VHA)
Authors: Bej Taissa A , Song Sunah , Wilson Brigid , Banks Richard , Briggs Janet , Jump Robin , Perez Federico
Published: January 2021

Background

Community acquired pneumonia (CAP) remains a major cause of morbidity and mortality. Risk factors for CAP are often grouped as moderate- (e.g., diabetes mellitus, chronic liver, lung, or heart disease) and high-risk (e.g., immunosuppressive) conditions, which in turn influences preventative strategies, notably pneumococcal vaccination. Here, we use the national VHA databases to assess the risk of CAP among adults, expanding on previous work by using administrative data to assess the incidence of CAP among people with > 1 moderate risk condition

Methods

We used the national VHA databases merged with claims summaries from the Centers for Medicare and Medicaid Services (CMS) to identify patients receiving clinical care in the VHA without clinical Medicare claims in 2016-2017. Within this population, we identified CAP cases defined by the presence of a diagnostic code for pneumonia, chest X-ray, and antibiotics as well as the absence of healthcare exposure or antibiotics in prior 90 days. We determined the total patient years at risk and calculated incidence rates by age group and by moderate- and high-risk comorbid conditions.

Results

We identified 37,348 CAP cases in 7.9 million person-years at risk and observed similar annual rates in 2016 and 2017 (468.9 and 472.2 cases/100,000 person-years, respectively). The prevalence of high-risk conditions and incidence of CAP increased with age whereas the prevalence of >1 moderate-risk condition peaked for ages 50-64 and 65-74 years (Table). The incidence of CAP among those with > 1 moderate-risk condition exceeded that of patients with high-risk conditions across all age strata (Figure).

Table

Figure

Conclusion

Age-adjusted analysis revealed that the greatest burden of CAP occurs in patients with > 1 moderate-risk condition, even compared to those with a high-risk condition. Our analysis of CAP based on national VHA data suggest that additional preventative health measures directed at individuals older than 50 years with > 1 moderate-risk condition may help to reduce the burden of CAP and limit its morbidity and mortality.

Disclosures

Robin Jump, MD, PhD, Accelerate (Grant/Research Support)Merck (Grant/Research Support)Pfizer (Grant/Research Support, Advisor or Review Panel member)Roche (Advisor or Review Panel member) Federico Perez, MD, MS, Accelerate (Research Grant or Support)Merck (Research Grant or Support)Pfizer (Research Grant or Support)
1501. Pragmatic Assessment of Influenza Vaccine Effectiveness in the DoD (PAIVED): Updates from Year 2 of multi-site trial
Authors: Richard Stephanie A , Burgess Timothy , Burgess Timothy , Collins Limone , Colombo Rhonda , Ganesan Anuradha , Geaney Casey , Hrncir David , Lalani Tahaniyat , Markelz Ana E , Maves Ryan C , McClenathan Bruce , Mende Katrin , Modi Jitendrakumar , Montgomery Jay R , Schofield Christina , Seshadri Srihari , Skerrett Catherine , Spooner Christina , Utz Gregory , Warkentien Tyler , Coles Christian L
Published: January 2021

Background

Despite nearly universal influenza vaccination for active duty military personnel, breakthrough influenza infections occur. We are reporting on the second year of the Pragmatic Assessment of Influenza Vaccine Effectiveness in the DoD (PAIVED), comparing three FDA-licensed influenza vaccine types (egg-based, cell -based, and recombinant) to assess differences in immunogenicity and effectiveness.

Methods

Participants in the second year of PAIVED were enrolled from Oct 2019 through Jan 2020 at 9 military facilities. Participants received weekly inquiries about influenza-like-illnesses (ILI) experienced in the past week, and if the participant reported having a cough or sore throat and a) muscle/body aches or fatigue and/or b) being feverish or having chills, they were scheduled for a clinic visit. During this visit, a blood sample and a nasal swab were collected, as well as information about symptom duration and severity. A second (convalescent) visit was conducted approximately 4 weeks later, which involved collecting additional information about the duration of symptoms and illness burden, as well as a second blood draw. Due to the COVID-19 pandemic, acute and convalescent visits were disrupted at most sites in March and April due to COVID-19 precautions.

Results

PAIVED year 2 enrolled 5,892 participants who completed demographic forms (Table 1). Among those who reported any ILIs, most reported one ILI (1,345), while 264 reported two ILIs, and 42 reported three ILIs. Nasal swabs were processed from 273 ILIs at four sites (Fig 1), and 14 cases of influenza were identified thus far. The median duration of ILIs was ten days, with a median of three days of limited activity, and two days with fever. Nine individuals were hospitalized.

Table 1. Demographic characteristics of individuals enrolled in PAIVED 2019/20

Figure 1. Lab results as of 5/15 (N=273 samples)

Conclusion

Over 25% of participants reported an ILI, and 5% of the nasal swabs that have been tested thus far have been positive for influenza. While most samples have not yet been analyzed, we have identified some breakthrough cases of influenza among vaccinated participants. Planned analyses include comparative vaccine effectiveness in order to inform future vaccine purchasing decisions.

Disclaimer

Disclosures

All Authors: No reported disclosures
1502. Psychological Stress and Anxiety among Parents of Children Younger than 5 Years Hospitalized with RSV
Authors: Ampofo Krow , Choi Yoonyoung , Heller Evan G , Platt-Koch Alexander G , Gesteland Per H , Adua Lazarus , Finelli Lyn
Published: January 2021

Background

Respiratory Syncytial Virus (RSV) is one of the most common causes of childhood lower respiratory tract infection (LRTI) worldwide. While financial burdens have been documented, there are few data on parental psychological stress associated with RSV hospitalizations. We evaluated the psychological stress and anxiety of parents whose children were hospitalized with RSV.

Methods

During the 2019-2020 RSV season, parents with children < 5 years of age hospitalized with laboratory-confirmed RSV LRTI at Primary Children’s and Riverton Hospitals in Salt Lake City, Utah, were surveyed in person, and online after discharge. As part of the survey, parents completed the State-Trait Anxiety Inventory for Adults (STAIAD) instrument (short form) and the parental stressor scale (PSS). We evaluated the difference in parental stress and anxiety reported during hospitalization and at 2-weeks post-discharge using a paired t-test.

Results

Among 284 Salt Lake County resident children < 5 years, and hospitalized with RSV LRTI, 75 (26%) and 57 (20%) parents completed both surveys on admission and at 2-weeks post-discharge respectively. In 11 of 20 STAIAD items gauging stress and anxiety, parents reported higher levels of stress and anxiety whilst their children were admitted compared to post-discharge (Table 1). Parents’ average score on several items associated with a “positive outlook,” e.g. I feel calm, significantly improved (p < 0.05) at 2-weeks post-discharge. Similarly, several items associated with a “negative outlook,” e.g. I am worried, significantly decreased (p < 0.05) at 2-weeks post-discharge (Table 1). For the PSS items, ≥ 50% of parents rated 15 out of 25 as being “very or extremely stressful”, including: feeling helpless about how to help my baby; my baby’s unusual or abnormal breathing; and when my baby seemed to be in pain (Table 2).

Estimates of Psychological Burden of RSV lower respiratory tract infection (LRTI) Hospitalization of Children <5 Years of Age on Parents: State-Trait Anxiety Inventory for Adults (STAIAD)

Estimates of Psychological Burden of RSV lower respiratory tract infection (LRTI) Hospitalization of Children <5 Years of Age on Parents: Parental Stressor Scale (PSS)

Conclusion

RSV LRTI hospitalization among children < 5 years of age, imposed a significant psychological stress and anxiety on parents, which generally persisted up to 2-weeks post-discharge. Prevention of RSV infection through vaccines and immunoprophylaxis will help ease parental psychological burden associated with RSV hospitalization.

Disclosures

Krow Ampofo, MBChB, Merck (Grant/Research Support) Yoonyoung Choi, PhD, MS, RPh, Merck (Employee) Lyn Finelli, DrPH, MS, Merck & Co Inc, (Employee)
1503. Risk Factors for Contracting Infection with SARS-CoV-2: a Prospective Case-control Study
Authors: Shoar Saeed , Khavandi Siamak , Tabibzadeh Elsa , Vaez Aydin , Oskouei Ali Khabbazi , Maleki Armin Nehzati , Shoar Nasrin
Published: January 2021

Background

As the COVID-19 pandemic has exhausted the healthcare system and economic infrastructures, controlling measures are directed toward population-based strategies including individual’s hygiene and safe socializing. We conducted this study to identify individual’s factors at the population level which are associated with the risk of infection with SARS-CoV-2 in a middle-to-low income country.

Methods

A prospective case-control study was conducted to compare the demographics, socioeconomics, and individual’s behavior between patients with COVID-19 and randomly selected healthy controls from the same population referring to a general hospital in northwest Iran.

Results

Data of 250 patients with a positive RT-PCR test for COVID-19 was compared with 250 healthy controls between March 1st and May 15th (Table1). Higher education, better socioeconomic status, having access to the internet or following relevant news, having an obsession for cleanliness especially regular hands washing with alcohol-based disinfectants, wearing masks in public especially those with an N-95 filter, complying with stay-home orders, and receiving the flu shot over the past season were protective against contracting COVID-19. On the contrary, cigarette smoking or opium consumption, a history of recent travel, having an individual with infection with SARS-CoV-2 within the household, and recent hospitalization were associated with COVID-19.

Table1. Comparison of individual’s factors between COVID-19 positive and negative patients

Conclusion

Individuals’ characteristics at a family or public level can guide healthcare authorities and lawmakers in their ongoing endeavors toward controlling the COVID-19 pandemics, especially in low-to-middle income regions.

Disclosures

All Authors: No reported disclosures
1508. Hospitalizations and Emergency Department Visits for Respiratory Syncytial Virus Among Infants Aged < 1 year in the United States: An Analysis of Nationwide Inpatient and Emergency Room Data
Authors: Suh Mina , Jiang Xiaohui , Movva Naimisha , Frysek Joh , Bylsma Lauren , Rizzo Christopher , Nelson Christopher
Published: January 2021

Background

Respiratory syncytial virus (RSV) is a common cause of illness and hospitalization for infants and children globally. The objective of this study was to characterize the burden of RSV and all-cause bronchiolitis (ACB) inpatient hospitalizations and emergency room department (ED) visits in U.S. infants aged < 1 year with the most recent years of data available.

Figure 1. RSV and ACB hospitalizations among US infants <1 year old (NIS 2016)

Figure 2. ED visits due to RSV and ACB among US infants < 1 year old (NEDS 2016)

Methods

The National (Nationwide) Inpatient Sample (NIS) and the Nationwide Emergency Department Sample (NEDS), which are large national publicly available all-payer databases in the U.S., were used to estimate the burden of RSV in 2016 based on ICD-9 and 10 codes. The proportions of hospitalizations or ED visits due to RSV in infants aged < 1 year were quantified. Due to the potential of missing RSV encounters based on coding practices, ACB was also evaluated. Based on availability of variables and data recency, 2011 NIS data were used to describe RSV burden by age in months. Sensitivity analyses were conducted with NIS and NEDS data from other years (2011-2015).

Results

A clear seasonal pattern was observed for RSV hospitalizations and RSV ED visits with a peak in December-February and a trough in June-August in 2016. During the RSV season and peak months, RSV was a leading cause of hospitalization (12065/45490=27% in Jan and 12050/45080=27% in Feb) and ED visits (26423/316709=8% in Jan and 24721/306397=8% in Feb)) among U.S. infants under 1 year of age. Similar patterns were seen for ACB in 2016 (38% hospitalization and 17-18% ED visits in Jan and Feb) and for RSV and ACB in the other years. For the inpatient setting in 2011, RSV hospitalizations were the highest among the youngest patients (except those aged <1 month) and decreased with age during the RSV season and peak months.

Conclusion

These results show that during the RSV season, RSV and ACB were a leading cause of hospitalization and ED visit among US infants under 1 year of age. Current policy does not support routine RSV testing of clinical lower respiratory tract infections (LRTIs) among infants. In that context, as an approximation of RSV LRTI visits in each setting, ACB can be considered an upper bound and RSV can be considered a lower bound of the true proportion of hospital encounters associated with RSV in these settings..

Disclosures

Mina Suh, MPH, International Health, EpidStrategies (Employee) Xiaohui Jiang, MS, EpidStrategies (Employee)
1509. Impact of Respiratory Viral Infection on Outcomes of Congenital Heart Repair Surgery
Authors: Srivastava Namun , Kuriakose Emy , Sowinski Heather , Khuon Daliya
Published: January 2021

Background

Respiratory viral infections are common in the pediatric population and can range from mild to life-threatening. Given the risk factors that accompany these infections, some pediatric cardiothoracic surgeons in the United States avoid performing surgery for patients with congenital heart disease when there is a possibility of concurrent viral respiratory illness. Studies in this patient population have been limited either by small study populations, or a study focus that is too narrow. The impact of respiratory infections on patient outcomes based on previous literature is also unclear.

Methods

This retrospective chart review study aimed to compare outcomes after congenital heart repair surgery in patients with positive respiratory viral testing to those with negative testing over a five-year period, to determine if there are significant differences related to post-operative hospital course or morbidity.

Patient Inclusion Flowchart

Results

This study included 120 patients, of whom 43 tested positive for respiratory viruses and 77 tested negative. Patients were additionally divided based on the presence or absence of symptoms of respiratory infection, with 79 patients demonstrating respiratory symptoms and 41 who did not. Results demonstrate that negative respiratory viral testing is associated with a significant increase in post-operative ICU LOS (p = 0.01), hospital LOS (p < 0.01), and duration of post-operative respiratory support (p < 0.01), compared to positive testing. Additionally, an absence of respiratory symptoms at the time of testing was associated with a significant increase in post-operative ICU LOS (p = 0.01) and hospital LOS (p < 0.01), compared to patients who were symptomatic.

Outcomes by Positive vs. Negative FilmArray

Outcomes by Symptomatic vs. Asymptomatic

Conclusion

These results suggest that negative respiratory viral testing or lack of respiratory infectious symptoms should not be a reassuring factor in patients scheduled for repair of congenital heart disease, and positive testing does not appear to result in worse outcomes after surgery. Based on this data, we would recommend that respiratory viral testing should not be a routine component of preoperative planning for patients scheduled to undergo congenital heart repair surgery, which would reduce the burdens of unnecessary testing and delays in definitive heart repair.

Disclosures

All Authors: No reported disclosures