bluuebunny/crossref_metadata_2025 huggingface dataset:
1065. Evaluation of a Staphylococcus aureus Bacteremia Treatment Checklist
Authors: Soukup Hailey , Holt Jessica
Published: November 2018

Background

Staphylococcus aureus bacteremia (SAB) is associated with high morbidity and mortality. Appropriate management involves repeat blood cultures, echocardiography, drug selection/route, and duration of therapy. Multiple studies have demonstrated improved outcomes in patients who are managed by infectious disease (ID) physicians compared with non-ID physicians; however, not all sites have access to an ID provider. To improve management of SAB, a checklist was developed and approved for use in a large healthcare system in August 2015.

Methods

A retrospective review was conducted on 400 randomly selected patients with SAB, 200 pre- and 200 post-implementation of a four-part management checklist. The primary outcome was overall adherence to the checklist, which included: repeat blood cultures, echocardiography, correct antibiotic/route selection, and appropriate antibiotic duration. Secondary outcomes included adherence when an ID physician was not consulted, adherence to the four components individually, and appropriate imaging.

Results

Adherence to the four part bundle remained stable from 2015 to 2017, with overall adherence rates of 80% and 79%, respectively. From 2015 to 2017, patients without repeat blood cultures (7% vs. 2%, respectively) and inappropriate inpatient antibiotic selection (6% vs. 3%, respectively) improved. Outpatient prescribing (11% vs. 11%), lack of imaging (11% vs. 9%), and antibiotic duration (15% vs. 15%) were consistent from 2015 to 2017, respectively. In 2017, 13 patients were discharged on oral antibiotics and were deemed inappropriate per the study criteria, although 12 of these patients were on appropriate antibiotics while inpatient. Infectious diseases providers were consulted on 96% of cases in 2017, an increase from 90% in 2015.

Conclusion

Adherence to an evidence based treatment bundle remains consistent with a previous analysis, despite an increase in cases with an ID provider consulted. Repeating blood cultures and inpatient prescribing improved over the interval. Focus areas for improvement include imaging, outpatient prescribing, and duration of therapy.

Disclosures

All authors: No reported disclosures.
1088. Ultrasensitive Detection of C. difficile Toxins in Stool Using Single Molecule Counting Technology: A Multicenter Study for Evaluation of Clinical Performance
Authors: Young Stephen , Mills Ray , Griego-Fullbright Christen , Wagner Aaron , Herding Emily , Nordberg Vickie , Friedland Emily , Bartolome Amelita , Almazan Anna , Tam Stanley , Biscocho Sheryl , Abusali Salina , Sandlund Johanna , Estis Joel , Bishop Jeffrey , Hansen Glen
Published: November 2018

Background

Commercially available tests for Clostridium difficile infection (CDI) make test selection by the laboratory difficult due to the following unsatisfactory characteristics: long turnaround time, poor sensitivity, and/or poor specificity. The Singulex Clarity® C. diff toxins A/B assay (in development) is a rapid and automated immunoassay for the detection of C. difficile toxins A and B in stool, with analytical limits of detection for toxins A and B at 2.0 and 0.7 pg/mL, respectively. In this multicenter study, the clinical performance of the Singulex Clarity C. diff toxins A/B assay was compared with standalone PCR, a multistep algorithm with enzyme immunoassay (EIA) and PCR, and cell cytotoxicity neutralization assay (CCNA).

Methods

Fresh samples from 267 subjects with suspected CDI were tested at two sites (Minneapolis Medical Research Foundation and TriCore Reference Laboratories) with the Singulex Clarity assay, PCR (Xpert®C. difficile), and EIA (C. Diff Quik Chek Complete®) for GDH and toxin testing. The performance of the assays and multistep algorithms were evaluated against CCNA (Microbiology Specialists, Inc.).

Results

The overall CDI prevalence was 15.7%. The Singulex Clarity C. diff toxins A/B assay had 90.5% sensitivity and 96.0% specificity, with a 98.2% negative predictive value when compared with CCNA, and the Clarity assay’s AuROC was 0.9534. PCR had 90.5% sensitivity and 91.1% specificity. Compared with CCNA, the toxin EIA had 47.6% sensitivity and 100% specificity. Testing with a multistep algorithm using EIA with discordant results reflexed to PCR resulted in 85.7% sensitivity and 94.7% specificity.

Conclusion

The ultrasensitive Singulex Clarity C. diff toxins A/B assay is equivalent to the sensitivity of PCR while providing higher specificity. Compared with a multistep algorithm, the Clarity assay provides higher sensitivity and specificity while providing faster time-to-result in a simpler-to-understand, one-step reporting structure, allowing for a standalone, single-step solution for detection of C. difficile toxins in patients with suspected CDI.

Disclosures

E. Friedland, Singulex, Inc.: Employee, Salary. A. Bartolome, Singulex, Inc.: Employee, Salary. A. Almazan, Singulex, Inc.: Employee, Salary. S. Tam, Singulex, Inc.: Employee, Salary. S. Biscocho, Singulex, Inc.: Employee, Salary. S. Abusali, Singulex, Inc.: Employee, Salary. J. Sandlund, Singulex, Inc.: Employee, Salary. J. Estis, Singulex, Inc.: Employee, Salary. J. Bishop, Singulex, Inc.: Employee, Salary.
1090. Patient Outcomes With Prevented vs. Negative Clostridium difficile Tests Using Computerized Clinical Decision Support (CCDS)
Authors: Madden Gregory , Enfield Kyle , Sifri Costi
Published: November 2018

Background

Overtesting and overdiagnosis of Clostridium difficile infection (CDI) are increasingly recognized as potentially avoidable causes for unnecessary treatment and cost. Reducing inappropriate testing through diagnostic stewardship may improve C. difficile test utilization. However, the safety of these interventions is not well understood, despite the potential risk for missed or delayed diagnosis. A computerized clinical decision support (CCDS) tool was implemented at a 619-bed tertiary care hospital as part of a multifaceted effort to reduce inappropriate C. difficile testing. The intervention was associated with reductions in tests (41%) and hospital-onset CDI events (31%). We sought to examine patient outcomes associated with the intervention.

Methods

The CCDS was designed to identify patients with a prevented test if a provider initiated the CCDS and aborted the order. Outcomes of patients with either a prevented or negative nucleic acid amplification test (NAAT) were compared retrospectively. A logistic regression model was created to evaluate the association between a prevented test attempt and serious adverse events. Patients with a subsequent positive result within 7 days of the initial trigger and those treated with CDI-effective antibiotics underwent chart review.

Results

Multivariate analysis of 637 cases (490 negative, 147 prevented) showed that a prevented test was not associated with the primary composite outcome (inpatient mortality or ICU-transfer) compared with a negative test (adjusted odds ratio, 0.912; 95% CI 0.513–1.571). Prevented tests were associated with shorter length of stay and similar rates of CDI-related complications. Eleven (7.5%) had a subsequent positive CDI, four within 30 minutes of the prevented test, suggesting nonsignificant delay in testing. Of the remaining seven patients, case review confirmed that five did not meet testing criteria while two met testing criteria at the time of the prevented test. No serious adverse events attributable to delayed CDI diagnoses or unjustified CDI treatment were identified by individual case review.

Conclusion

CCDS-based diagnostic stewardship for CDI may be both a safe and effective means to reduce inappropriate testing.

Disclosures

All authors: No reported disclosures.
1096. Effect of Diarrheal Illness During Pregnancy on Adverse Birth Outcomes in Nepal
Authors: Newman Kira , Gustafson Katie , Englund Janet , Katz Joanne , Magaret Amalia , Khatry Subarna , Shreshtha Laxman , Leclerq Steven C , Tielsch James , Steinhoff Mark C , Chu Helen
Published: November 2018

Background

Adverse birth outcomes, including low birthweight (LBW), small-for-gestational-age (SGA) and preterm birth, contribute to 60–80% of infant mortality worldwide. Little published data exist on the association between diarrhea during pregnancy and adverse birth outcomes. We sought to identify whether diarrhea during pregnancy was associated with adverse birth outcomes.

Methods

We used data from a community-based, prospective randomized trial of maternal influenza immunization of pregnant women and their infants conducted in rural Nepal from 2011 to 2014. Illness episodes were defined as at least three watery bowel movements per day for one or more days with 7 diarrhea-free days between episodes. Diarrheal illnesses were identified through longitudinal household-based weekly symptom surveillance. The c2 test, two-sample t-test, and log-binomial regression were performed to evaluate baseline characteristics and the association between diarrhea during pregnancy and adverse birth outcomes.

Results

Of 3,682 women in the study, 527 (14.3%) experienced one or more episodes of diarrhea during pregnancy. Diarrhea incidence was not seasonal. Women with diarrhea had a median of one episode of diarrhea (interquartile range (IQR) 1–2 episodes) and two cumulative days of diarrhea (IQR 1–3 days). Of women with diarrhea, 16.1% (85) sought medical care. Mean maternal age, parity, biomass cook stove use, home latrine, water source, caste, and smoking did not differ in pregnant women with and without diarrhea. In crude and adjusted analyses, women with diarrhea during pregnancy were significantly more likely to have SGA infants (42.6% vs. 36.8%; adjusted risk ratio=1.20, 95% CI 1.06–1.36, P = 0.005). LBW and preterm birth incidence did not significantly differ between women with diarrhea during pregnancy and those without. There was no significant association between seeking medical care for diarrhea and birth outcomes.

Conclusion

Diarrheal illness during pregnancy was associated with a significantly higher risk of SGA infants in this rural South Asian population. Interventions to reduce the burden of diarrheal illness during pregnancy may have an impact on SGA births in resource-limited settings.

Disclosures

All authors: No reported disclosures.
1102. Food Insecurity and Reported History of Cholera in Haitian Households: An Analysis of the 2012 Demographic and Health Survey (DHS)
Authors: Richterman Aaron , Franke Molly F , Ivers Louise C
Published: November 2018

Background

Food insecurity is defined as a lack of consistent access to food in adequate quantity or quality. Both cholera and food insecurity tend to occur in impoverished communities where poor access to food, inadequate sanitation, and an unsafe water supply often coexist. The relationship between the two, however, has not been previously studied.

Methods

We performed a secondary analysis of household-level data from the 2012 Demographic and Health Survey in Haiti, a nationally and subnationally representative cross-sectional household survey conducted every 5 years. We used multivariable logistic regression to evaluate the relationship between household food insecurity (as measured by the Household Hunger Scale) and (1) reported history of cholera since 2010 by any person in the household and (2) reported death by any person in the household from cholera. We used survey commands to apply sampling probability weights and account for clustering and stratification in sample design. We performed a complete case analysis because there were no missing data on household food insecurity or cholera and <1% for the other covariates of interest.

Results

There were 13,181 households in the survey, 2,104 of which reported at least one household member with history of cholera. Both moderate hunger in the household [adjusted odds ratio (AOR) 1.47, 95% confidence interval (CI) 1.27–1.71; P < 0.0001] and severe hunger in the household (AOR 1.71, 95% CI 1.42–2.05; P < 0.0001) were significantly associated with reported history of cholera in the household after controlling for urban setting, household size, wealth index, water source, time to water source, latrine, and housing materials. Severe hunger in the household (AOR 2.81, 95% CI 1.58–5.00; P = 0.0005), but not moderate hunger in the household, was independently associated with reported death from cholera in the household.

Conclusion

This is the first study to identify an independent relationship between household food insecurity and reported history of cholera and death from cholera. The directionality of this relationship is uncertain and should be further explored in future prospective research.

Disclosures

All authors: No reported disclosures.
1104. Deployment-Associated Infectious Gastroenteritis and Associations With Irritable Bowel Syndrome, Post-Traumatic Stress Disorder, and Combat Stress: A Retrospective Cohort Study Among Deployed United States Military Personnel
Authors: Dunbar Christopher R , Riddle Mark S , Clarkson Kristen , Gutierrez Ramiro L , Alcala Ashley , Byrd Angelique , Porter Chad K
Published: November 2018

Background

Previous studies have shown an association between post-traumatic stress disorder (PTSD) and the development of irritable bowel syndrome (IBS) in deployed service members. Deployment places soldiers at risk for chemical, physical, psychological, and infectious stressors. Acute stress can alter the gastrointestinal barrier leading to gut barrier dysfunction, which is an independent risk factor for infectious gastroenteritis (IGE). We sought to assess if there was an association between IBS and PTSD in military deployed in support of recent and ongoing military operations.

Methods

We conducted a retrospective cohort study of United States service members who participated in a combat deployment to the Middle East from 2001 to 2013 with no prior Axis I disorders or PTSD diagnoses based on data from the Defense Medical Surveillance System. Univariate and multivariate logistic regression models were used to assess the differential risk of PTSD following a combat deployment among those with and without a predeployment diagnosis of IBS. These models were controlled for confounders/covariates of interest (IGE, age, duration of deployment, sex, race, marital status, education level, military rank, branch of service, number of deployments).

Results

Among the 3825 subjects, those who developed IGE had a 34% (P = 0.02) increased risk of PTSD compared with those with no IGE during deployment. Additionally, those with IBS predeployment had a 40% (P = 0.001) increased risk of PTSD upon return from deployment compared with those without IBS predeployment. Duration of deployment was significantly (P < 0.0001) associated with PTSD with an increasing risk with increasing duration of deployment.

Conclusion

IGE and IBS were significantly associated with PTSD further supporting previous studies describing their association. Baseline chronic dysbiosis and acute stress-related microbiota perturbations may lead to short- and long-term resilience and performance deficits in our soldiers that may compromise mission capabilities and decrease the quality of life in returning soldiers. Further understanding the potential interactions between the gut–brain–microbiome may have immediate and long-term impacts on improving warfighter health and performance.

Disclosures

All authors: No reported disclosures.
1105. Vibriocidal Titer Variation and Likelihood of Protection in Children Compared With Adults in a Cholera Endemic Area
Authors: Ritter Alaina , Chowdhury Fahima , Becker Rachel , Bhuiyan Taufiq , Khan Ashraful , Ryan Edward T , Calderwood Stephen B , LaRocque Regina , Harris Jason , Qadri Firdausi , Weil Ana
Published: November 2018

Background

Vibrio cholerae, the causative agent of cholera, is responsible for significant morbidity and mortality worldwide. Children less than 5 years old have the highest disease burden of cholera in endemic areas. While children develop serum vibriocidal antibody responses to cholera vaccines, they derive less protection from vaccination compared with adults. The aim of our study was to determine whether the vibriocidal immune responses to V. cholerae infection are equally accurate as markers of protection in all age groups.

Methods

Cholera patients and their household contacts, who are known to be at high risk of V. cholerae infection, were enrolled between 2001 and 2017 in Dhaka, Bangladesh. Baseline vibriocidal titers were measured at the time of enrollment of household contacts, and participants were followed prospectively for development of V. cholerae infection.

Results

We studied 50 contacts < 5 years old (“young children”), 228 contacts 5–16 years old (“older children”), and 548 contacts > 16 years old (“adults”). The baseline serum vibriocidal titer was higher in contacts who remained uninfected from all age groups than in contacts who developed cholera during the follow-up period (young children: P = 0.0092; older children: P = 0.0003, adults: P = 0.0012).

Conclusion

We found that higher vibriocidal antibody titers were associated with protection against V. cholerae infection across all three age categories. These findings may help increase our understanding of the protective immune response against V. cholerae infection and have importance for future vaccine development strategies.

Acknowledgments: This research was supported by Massachusetts General Hospital training grant T32AI007061.

Disclosures

All authors: No reported disclosures.
1106. Infectious Etiologies of Acute Gastroenteritis in Children during the First 100 Days Post-Allogeneic Hematopoietic Cell Transplant
Authors: Schuster Jennifer , Johnston Samantha , Piya Bhinnata , Dulek Daniel , Wikswo Mary E , Browne Hannah , Vinje Jan , Payne Daniel C , Azimi Parvin H , Selvarangan Rangaraj , Halasa Natasha B , Englund Janet
Published: November 2018

Background

Acute gastroenteritis (AGE) is a frequent sequela in children undergoing hematopoietic cell transplant (HCT). Although rotavirus and norovirus have been implicated as important causes of AGE, the frequency of other pathogens is unknown. Little data exist on longitudinal prevalence of infectious AGE in HCT.

Methods

From February 2015 to May 2016, subjects <18 years undergoing allogeneic HCT were enrolled at four CDC-NVSN sites: Oakland, Kansas City, Seattle, and Nashville. Stool samples were collected at enrollment, weekly until discharge or day 100 (whichever occurred earliest), during re-admissions within the first 100 days, and day 100. AGE was defined as unexplained ≥3 episodes diarrhea and/or ≥1 episode vomiting/24 hours. Specimens were tested using Luminex xTAG Gastrointestinal Pathogen Panel (Austin, TX) and real-time PCR for adenovirus, astrovirus, norovirus, and sapovirus.

Results

Thirty-one patients were enrolled at four sites (Seattle: 13, Kansas City: 8, Oakland: 6, Nashville: (4) with median age 5 (IQR 3–10) years. Two hundred sixteen samples were obtained with median 7 samples/subject. During the first 100 days, 29 (94%) subjects met the AGE definition. Thirty-six single pathogen detections occurred in 16 (52%) subjects. Clostridium difficile was the most frequent pathogen (Figure 1), with 14 detections in nine patients, all ≥3 years; 50% of detections were asymptomatic. Seven (50%) detections occurred at HCT onset and none received targeted C. difficile therapy. Sapovirus was detected nine times in four patients, with seven (78%) detections associated with AGE symptoms. Rotavirus was detected nine times, during five symptomatic episodes, in three patients. Adenovirus was detected four times in three patients and all were symptomatic.

Conclusion

We longitudinally characterized the etiology of infectious AGE in children undergoing HCT. Despite the majority of patients meeting the definition for AGE, only half had a pathogen detected, suggesting that differentiating infectious vs. noninfectious AGE (e.g., medication induced) in this population is difficult. Although all subjects with adenovirus and most with sapovirus were symptomatic, asymptomatic C. difficile detection was common. Interestingly, norovirus was not detected. Further investigation of AGE is warranted in this population.

Disclosures

All authors: No reported disclosures.
1110. A multicenter Evaluation of Outcomes Associated With Oral Vancomycin Dose in Patients With Clostridium difficile Infection
Authors: Bidell Monique , Novak Gregory , Singh Gurkirat , Bratek Benjamin , Duru Odirichukwu , Mitchell Colby , O’Donnell J Nicholas
Published: November 2018

Background

Clostridium difficile infection (CDI) is a significant cause of morbidity and mortality. IDSA guidelines recommend oral vancomycin (VAN) for the treatment of CDI, although doses used in practice vary substantially. The purpose of this study was to determine differences in outcomes between patients treated with high dose (HD; ≥250 mg four times daily [QID]) vs. standard dose (SD; 125 mg QID) VAN for CDI.

Methods

This multicenter study evaluated patients at two hospitals in Albany, NY diagnosed with CDI and treated with oral VAN between January 2013 and August 2017. Hospitalized patients were included if: age ≥18 years, positive C. difficile toxin polymerase chain reaction (PCR), symptomatic infection (e.g., new onset or increased frequency of loose stools), and received ≥48 hours of VAN QID. Patients were excluded if: received ≥48 hours of metronidazole prior to VAN initiation, VAN per rectum, required surgical intervention ≤48 hours from PCR, had a history of fecal microbiota transplant, received ≥1 dose of fidaxomicin or tigecycline prior to or within 48 hours from PCR, or died ≤48 hours from PCR. The primary outcome was 90-day CDI recurrence; secondary outcomes included 30-day all-cause mortality and 90-day readmission. Variables with a P-value <0.2 in univariate analysis were evaluated in multivariate (MV) analyses.

Results

Four hundred fifty-eight patients were included (site 1: 270; site 2: 188). Two hundred twenty-four patients received SD VAN (48.9%); 234 received HD VAN [250 mg QID: 199 (43.5%); 500 mg QID: 35 (7.6%)]. Baseline demographics were similar between groups. Patients treated with HD were more likely to present with colitis (19.2 vs. 29.5%, P = 0.01) and have higher infection severity based on IDSA (P < 0.01), Zar (P < 0.01), and American College of Gastroenterology (P < 0.02) criteria. Modified APACHE II scores were similar between SD and HD groups (median: 12.2 vs. 12.9, P = 0.17). MV analysis identified no difference in 90-day recurrence with HD (OR 1.65, P = 0.13) after controlling for solid tumor cancers, immunosuppression, and IDSA severity. Similarly, no significant differences between SD and HD were observed for 30-day mortality and 90-day readmission.

Conclusion

No differences in recurrence, mortality, or readmission were identified between SD and HD oral VAN for the treatment of CDI, though HD VAN patients primarily received 250 mg QID.

Disclosures

All authors: No reported disclosures.
1127. Genomic Analysis of Biofilm-Forming Enteroinvasive E. coli Emergent Pathogen
Authors: Gomez-Duarte Oscar , Guerra Julio , Ko Ricky
Published: November 2018

Background

Enteroinvasive Escherichia coli (EIEC) are involved in dysenteric diarrhea among children in low- and middle-income countries. EIEC strains isolated in Colombia, South America were shown to form biofilms and to be invasive in vitro. The O96:H19 serotypes and biofilm formation (BF) are not common phenotypes among EIEC, and the role they may play in diarrhea is at present unknown. The main goal of this study was to identify virulence and BF genes from EIEC genomic data. We hypothesize that EIEC O96:H19 strain 52.1 originated from horizontal transfer of a Shigella-like virulence plasmid into a non-EIEC pathogenic E coli strain.

Methods

WGS was performed on the BF-EIEC 52.1 strain using NextGen Illumina and Pacific Biosciences (PacBio) platforms. Publically available genomes from other EIEC O96H19 and Shigella genomes previously published were analyzed using online available software and databases including NCBI, BLAST, Mauve, among others. This analysis was tailored to identify virulence factors from the virulence factor database (VFDB). BLASTn was used to determine identity and query coverage of genes encoding the Shigella virulence factors. EIEC and Shigella genomes were analyzed on a multiple genome alignment software (Mauve) to verify results from BLASTn and to determine pseudogenes.

Results

The genome of EIEC O96:H19 strain 52.1 was 5,193,449 bp in size, containing 5,050 coding DNA sequences (CDSs). O96:H19 strain 52.1 carries three plasmids, the invasion plasmid (pINV) contains all type 3 secretion system (TTSS) and TTSS effectors genes previously described for Shigella and EIEC O96:H19 CFSAN029787 Italian strain. Non-TTSS virulence genes were also identified, including: long polar fimbrial gene (IpfA), enterotoxin (senB), and antibiotic resistance genes.

Conclusion

The EIEC O96:H19 strain 52.1 genome carries TTSS genes within a virulence plasmid, protein effector genes, and enterotoxin genes known to be associated with EIEC virulence. The EIEC O96:H19 stain 52.1 is an emergent diarrheagenic pathogen likely derived from an E. coli O96:H19 strain that acquired a Shigella-like virulence plasmid by horizontal transfer.

Disclosures

All authors: No reported disclosures.
1136. Universal Prophylaxis for Prevention of Invasive Aspergillus in Lung Transplant Recipients
Authors: Guenette Alexis , Gonzalez A Adrian , Emtiazjoo Amir
Published: November 2018

Background

Invasive aspergillosis (IA) is a significant complication status post lung transplantation with an incidence of 6% to 16%. Because early diagnosis of IA in lung transplant is hampered by the lack of specific clinical signs and by the low sensitivity of culture-based diagnostic methods, the efficacy of bronchoalveolar lavage galactomannan (BAL GM) for early diagnosis is explored in this study.

Methods

A retrospective analysis was performed on 45 consecutive lung transplant recipients between January 2015 and February 2016 at UF Health Shands Hospital. All patients were placed on prophylactic itraconazole post-transplant. Surveillance bronchoscopies were performed at 2 weeks, 1 month, 3 months, 6 months, 9 months, and 12 months post-transplant. During each bronchoscopy, bacterial, fungal, and acid-fast bacterial cultures along with BAL GM [an optical density (OD) index of ≥0.5 considered positive] were obtained. If BAL GM ≥1.0, the patient was switched to voriconazole for further treatment. CT Chest was also evaluated. If BAL GM remained ≤1.0 at the 6 month interval, then prophylaxis was complete. IA was defined using the EORTC/MSG criteria for invasive fungal disease (i.e., patient classified as either having proven, probable or possible IA).

Results

There was a total of 225 observations from the 45 patients. Two patients (4.4%) had proven IA with a mean GM of 4.153 (SE, 0.629) and seven patients (15%) had probable IA with a mean of 2.169 (SE, 0.409). There was no correlation of cold ischemic time (P = 0.88), primary graft dysfunction (PGD, P = 0.38), presence of Candida species (P =0.048) or non-tuberculous mycobacteria (NTM) in bronchoalveolar lavage (P = 0.044), and viral pneumonitis (P = 0.047) with a positive BAL GM. All nine patients with GM >1 were switched to voriconazole from itraconazole which resulted in negative GM levels on follow-up bronchoscopy.

Conclusion

Our data suggest that the implementation of universal antifungal prophylaxis with itraconazole may not be efficacious in preventing IA in lung transplant recipients. On the other hand, surveillance with BAL GM is a strategy that can lead to early detection of IA in patients during the first year after lung transplantation.

Disclosures

All authors: No reported disclosures.
1146. Effectiveness of Ultraviolet Irradiation on Candida auris: A Laboratory Study
Authors: Garmon Gennifer , Navarathna Dhammika , Coppin John , Williams Marjory , Jinadatha Chetan
Published: November 2018

Background

Candida auris is a multidrug-resistant yeast which persists on healthcare surfaces for prolonged periods of time and is an emerging pathogen in hospitals. It has been linked to healthcare-associated infection (HAI) through surface transmission. Mobile ultraviolet (UV) light emitting devices from mercury sources have been shown to be effective in reducing C. auris bioburden but require prolonged exposure. In this study, we demonstrate the efficacy of an UV emitting device used in our hospital for terminal disinfection on C. auris.

Methods

Two C. auris strains (AR-381-CAU-01 and CAU-02) isolates obtained from Centers for Disease Prevention and Control (CDC) were used along with a Candida albicans (C. albicans) strain. An organism load of 10 μL containing 106 colony forming unit (CFU) was spread on a 20-mm diameter stainless steel coupon and exposed to the UV source from a pulsed xenon device at 5 feet distance and 4 feet height for 5, 10, and 30 minutes. Killing efficacy in terms of log reduction was calculated in comparison to untreated control coupons.

Results

Mean CFU log10 reduction for C. albicans, CAU-01, and CAU-02 was 0.547, 1.051, and 0.952 at 5 minutes; 1.412, 1.975, and 1.879 at 10 minutes; and 2.639, 3.971, and 4.145 at 30 minutes, respectively. Figure 1 describes the mean log10 reduction as well as the minimum and maximum log reduction by isolates.

Conclusion

Our study demonstrates the UV from a pulsed xenon device is effective in reducing the C. auris on stainless steel coupons. Similar to previously published data on reduction of C. auris by other UV sources, extended exposure is required to achieve a higher log reduction of C. auris. We did not have any C. auris clinical infections to assess efficacy of UV on HAI reduction.

Disclosures

C. Jinadatha, Xenex Healthcare Service: Grant Investigator, Research grant.
1148. Reduction of Blood Culture Contamination Rates by an Altered Sampling Protocol: Single-Center, Prospective, Randomized, Controlled, Open-Label Trial
Authors: Strahilevitz Jacob , Svinik Or , Lalezari Alon , Tel-Zur Odaya , Sinvani Shlomo , Al-Dayem Yasmin Sa’id Abed , Moses Allon , Cohen Matan , Oster Yonatan
Published: November 2018

Background

Contaminated blood cultures remain a challenge for patients, physicians, and microbiology laboratories, often leading to unnecessary antibiotic treatment. One approach to reduce contamination is to avoid culturing the initial blood sample that can contain a contaminated plug of skin from the needle stick. Initial specimen diversion technique (ISDT) was associated with decreased rate of blood culture contamination, when applied by trained phlebotomists, using either sterile vacuum blood collection tubes or a designated device. The aim of this study was to test ISDT in real-life, using externally nonsterile regular vacuum sample tubes for the diversion, by any medical personnel taking blood cultures.

Methods

Adults from whom the treating physician planned to take blood cultures and additional blood chemistry tests, in the same venous puncture, were eligible and were randomly assigned to intervention or control arms. The hospital’s standard procedure for blood drawing was maintained, except that in the intervention arm, blood was aspirated to a green-capped tube, which was used for regular biochemistry tests, prior to the blood culture.

Results

Four hundred twenty-three blood cultures were obtained from 404 patients. Of 404 (11.1%) of the blood cultures, 45 yielded microbial growth, with 31 (7.7%) regarded as true pathogens and 14 (3.5%) as contaminants. Detection of true bloodstream infection was similar by the two methods, 16/181 (8.83%) with the ISDT, and 15/223 (6.72%) using the standard method. The ISDT was associated with a significantly less isolation of presumed contaminants compared with the standard method, 2/165 (1.2%) vs. 12/208 (5.76%), P = 0.02.

Conclusion

ISDT, by any medical personnel, through altered order of test tube vs. blood culture sampling significantly reduced contamination of blood cultures without loss of diverted blood.

Disclosures

All authors: No reported disclosures.
1157. Optimal Isolation Periods Based on Time Interval to Elimination of Scabies After Topical Agent in the Real Clinical Practice
Authors: Park Jebyung , Park Se Yoon , Han Jaijun , Lee So Young , Kim Gil Eun , Jeong Yeon Su , Kim Jin Hwa , Lee Eunyoung , Lee Eun Jung , Yu Shi Nae , Kim Tark , Jeon Min Hyok , Choo Eun Ju , Kim Tae Hyong
Published: November 2018

Background

Scabies reemerged globally as the ninth of most highly prevalent skin diseases from 1990 to 2010. Existing topical agents, like permethrine and lindane are highly effective showing 95% or more therapeutic response. Patient isolation is only recommended for one day after treating with topical agents. However, there is little evidence-based recommendation on optimal isolation period after treatment in healthcare settings to prevent secondary infection.

Methods

All patients who were diagnosed from 2008 to 2017 with scabies at a referral university hospital in Seoul, Republic of Korea were analyzed. We investigated the time interval between symptom onset and diagnosis of scabies. The period from the application of topical agents and clinical resolution was also analyzed.

Results

A total of 23 patients were diagnosed with scabies. There was no crusted scabies such as Norwegian scabies. Seventy percent of these patients were referred from long-term care facilities. Median number of treatment was three times per patient (Interquartile range [IQR], 2–3). Time interval between the onset of symptoms and the diagnosis of scabies was median 4 days (IQR, 2–14). Median isolation period was 13 days (IQR, 8–15). Dermatologist confirmed successful treatment of 16 patients, the median time until confirmation was 15 days (IQR, 8–17). Three patients discontinued isolation before dermatologist’s confirmation. After re-evaluation by a dermatologist, one of the three was re-isolated due to persistent scabies infestation.

Conclusion

Scabicides are highly efficacious, but repeated microscopic examination for confirming elimination is strongly recommended. Optimal isolation period should be individualized based on the repeated dermatologic examination.

Disclosures

All authors: No reported disclosures.
1162. Epidemiology of Carbapenem-Resistant Pseudomonas aeruginosa Identified Through the Emerging Infections Program (EIP), United States, 2016–2017
Authors: Grass Julian , Bulens Sandra , Bamberg Wendy , Janelle Sarah J , Stendel Patrick , Jacob Jesse T , Bower Chris , Sukumaran Stephen , Wilson Lucy E , Vaeth Elisabeth , Li Linda , Lynfield Ruth , Vagnone Paula Snippes , Dobbins Ginette , Phipps Erin C , Hancock Emily B , Dumyati Ghinwa , Tsay Rebecca , Pierce Rebecca , Cassidy P Maureen , West Nicole , Kainer Marion A , Muleta Daniel , Mounsey Jacquelyn , Campbell Davina , Stanton Richard , Karlsson Maria S , Walters Maroya Spalding
Published: November 2018

Background

Pseudomonas aeruginosa is intrinsically resistant to many commonly used antimicrobials and carbapenems are often required to treat infections. We describe the epidemiology and crude incidence of carbapenem-resistant P. aeruginosa(CRPA) in the EIP catchment area.

Methods

From August 1, 2016 through July 31, 2017, we conducted laboratory- and population-based surveillance for CRPA in selected metropolitan areas in Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee. We defined an incident case as the first isolate of P. aeruginosa-resistant to imipenem, meropenem, or doripenem from the lower respiratory tract, urine, wounds, or normally sterile sites identified from a resident of the EIP catchment area in a 30-day period. Patient charts were reviewed. A random sample of isolates was screened at CDC for carbapenemases using the modified carbapenem inactivation method (mCIM) and real-time PCR.

Results

During the 12-month period, we identified 3,042 incident cases among 2,154 patients. The crude incidence rate was 21.2 (95% CI, 20.4–21.9) per 100,000 persons and varied by site (range: 7.7 in Oregon to 31.1 in Maryland). The median age of patients was 64 years (range: <1–101) and 41.2% were female. Nearly all (97.1%) had at least one underlying condition and 10.2% had cystic fibrosis (CF); 17.8% of cases were from CF patients. For most cases, isolates were from the lower respiratory tract (49.2%) or urine (35.3%) and occurred in patients with recent hospitalization (87.2%) or indwelling devices (70.3%); 8.7% died. At the clinical laboratory, 84.7% of isolates were susceptible to an aminoglycoside and 66.4% to ceftazidime or cefepime. Among the 391 isolates tested, nine (2.3%) were mCIM-positive; one had a carbapenemase detected by PCR (blaVIM-4).

Conclusion

The burden of CRPA varied by EIP site. Most cases occurred in persons with healthcare exposures and underlying conditions. The majority of isolates were susceptible to at least one first-line antimicrobial. Carbapenemase producers were rare; a more specific phenotypic definition would greatly facilitate surveillance for these isolates.

Disclosures

All authors: No reported disclosures.
LB13. Candida auris in NYC: A Health System’s Experience Treating the Emerging Drug-Resistant Yeast
Authors: Mazo Dana , Gottlieb Lindsey , Schaefer Sarah , Alexander Kinta , Ehni Jordan , Javaid Waleed , Patel Gopi , Aberg Judith , Lorin Scott
Published: November 2018

Background

Candida auris is emerging multidrug-resistant yeast that can cause serious infections with published mortality rates as high as 60%. It was first recognized in 2009 and has been reported in over a dozen countries. The current United States outbreak was identified in 2016 with New York City (NYC) as the epicenter. The aim of this evaluation was to describe the clinical infections and outcomes with C. auris in a large health system in NYC.

Methods

Cases were identified from clinical specimens collected December 2015–June 2018 from the Mount Sinai Hospital Clinical Microbiology Laboratory, the central laboratory for the Mount Sinai Health System, which encompasses seven hospitals across NYC. All C. auris isolates were confirmed by the New York State Department of Health Wadsworth Center. Medical charts were reviewed. A case was included if C. auris grew from a sterile body site, an antifungal treatment was initiated or the patient expired before the yeast was identified on Gram stain.

Results

Twenty-nine possible cases were identified with 23 meeting the case definition. These cases included 19 bloodstream infections (BSI), two intra-abdominal abscesses, one skin soft tissue infection, and one otitis externa. Using the MIC breakpoints recommended by the Centers for Disease Control and Prevention, 100% of isolates tested were susceptible to caspofungin, 29% were susceptible to amphotericin B, and 17% were susceptible to fluconazole. Nineteen patients received antifungal treatment, 13 with caspofungin monotherapy and four with sequential therapy of caspofungin followed by an azole (three with fluconazole, one with posaconazole). Fifteen (65%) patients expired within 90 days of the positive culture. Fourteen of the deaths were in candidemic patients, despite that eight (57%) of these patients had documented microbiologic clearance after appropriate therapy. The 90-day mortality rate was 74% for BSI.

Conclusions

This case series is the largest reported in the United States. Candidemia was the most common site of infection and had a very high 90-day mortality rate, despite sterilization of the blood. These findings highlight the significant morbidity and mortality associated with C. auris and the need to focus efforts on rapid diagnostics and infection prevention.

Disclosures

All authors: No reported disclosures.
LB15. Vaccine Effectiveness of Flucelvax Relative to Inactivated Influenza Vaccine During the 2017–18 Influenza Season in Northern California
Authors: Klein Nicola P , Fireman Bruce , Goddard Kristin , Zerbo Ousseny , Asher Jason , Zhou James , King James , Lewis Ned
Published: November 2018

Background

In June 2018, the CDC reported that influenza vaccine effectiveness (VE) against A(H3N2) influenza virus for the 2017–2018 season was ~24%. This lower than expected VE was hypothesized to be partially related to genetic changes arising in the vaccine virus during passage in eggs. Flucelvax™ (Seqirus) is a cell culture-based inactivated influenza vaccine (ccIIV) which is not manufactured in eggs. We investigated whether the VE of ccIIV against influenza A differed from that of egg-based IIV (ebIIV) during the 2017–2018 influenza season.

Methods

The study included all Kaiser Permanente Northern California members aged 4–64 years. We identified all individuals who were positive for influenza by polymerase chain reaction (PCR). This cohort analysis estimated the relative VE of ccIIV vs. ebIIV by comparing the ccIIV vaccinees vs. the ebIIV vaccinees with respect to the risk of PCR-confirmed influenza. We separately estimated the absolute VE of ccIIV and ebIIV by comparing each group of vaccinees with unvaccinated individuals. We used Cox regression with a calendar timeline, stratified by birth year, and adjusted for facility, race, years of membership, prior season influenza vaccine, co-morbidities, and number of inpatient admits in the prior year. We calculated VE as 1 − hazard ratio (HR).

Results

Of the 3,015,891 members aged 4–64 years, 1,017,314 were vaccinated. Of these, 932,874 (91.7%) received ebIIV and 84,440 (8.3%) received ccIIV. Most ebIIV (86.2%) was trivalent. Comparing ccIIV with ebIIV, the adjusted relative VE against influenza A was 6.8% (95% CI: 11.2, 21.9; P = 0.43). The adjusted absolute VE vs. unvaccinated of ccIIV was 30.2% (95% CI: 17.1, 41.3; P < 0.0001) and of ebIIV was 17.9% (95% CI: 12.1, 23.3; P < 0.0001).

Conclusion

Both cell-culture and egg-based IIV vaccines showed relatively low effectiveness during the 2017–2018 influenza season in which A(H3N2) predominated. The findings of this study show there was no significant difference in the effectiveness of cell-culture IIV compared with egg-based IIVs. Improvements in influenza vaccines will require ongoing monitoring of vaccine effectiveness.

Disclosures

N. P. Klein, GSK: Investigator, Research support. Sanofi Pasteur: Investigator, Research support. Merck: Investigator, Research support. Pfizer: Investigator, Research support. Protein Science: Investigator, Research support. MedImmune: Investigator, Research support. Dynavax: Investigator, Research support.
The Effect of Body Weight Support on Energy Expenditure in an Individual With High-Level Lower Extremity Amputation
Authors: Miller Carol A , Hayes Dawn M , Brooks Bailey E , Sloan Katie Y , Sloan Phillip G
Published: November 2018

Background

High-level lower extremity amputation (HLLEA) has significant impact on an individual's ability to ambulate and maintain cardiovascular fitness for extended periods of time.

Objective

The purpose of this study was to evaluate whether body weight support (BWS) would improve energy efficiency in an individual with HLLEA to achieve appropriate target cardiovascular intensity for aerobic training.

Design

This was an exploratory single-subject study.

Methods

The participant was a 45-year-old woman, 4.5 years after left hip disarticulation secondary to necrotizing fasciitis with resultant organ failure and cardiomyopathy. She was wearing a well-fitted prosthesis and had a goal of ambulating in the community with less fatigue. Vital signs and expiratory gases were recorded, and oxygen uptake efficiency slope was calculated during treadmill walking at 0%, 20%, and 40% unweighting. An age-matched control completed 0% unweighting baseline testing.

Results

Under all conditions of treadmill walking, the participant's heart rate, blood pressure, and rate of perceived exertion consistently increased as speed and time increased. The participant's oxygen uptake efficiency slope was most efficient at 20% unweighting, and the economy of movement improved as the percentage of BWS increased, bringing values closer to the age-matched control. The participant reported only minimal pain immediately following 20% unweighting.

Limitations

The primary limitation of this study is generalizability of findings because of minimal information for comparing the effects of BWS on aerobic capacity in individuals with HLLEA. Additionally, the percentages of unweighting using BWS were extrapolated based on corollary preexisting research; thus, there were no set parameters defined for this specific population.

Conclusions

BWS allowed the participant to work more efficiently, which suggests that if used during an intervention, BWS might enable individuals with HLLEA to achieve recommended levels of training for aerobic conditioning. In future studies, it is recommended that 20% BWS be used at a speed that results in moderate-intensity exercise for individuals with HLLEA as determined by 50% to 70% of maximum heart rate for 20 to 30 minutes.
Weight-related quality of life and temperament as predictors and moderators of outcomes among treatment-seeking, low-income, ethnically diverse children with obesity
Authors: Frerichs Leah , Smith Natalie R , Lyden Jessica , Gaskin Kiah , Skinner Asheley , Armstrong Sarah
Published: November 2018

Within any childhood obesity treatment program, some children have better outcomes than others. Little is known about predictors or moderators of more positive outcomes. We aimed to identify whether child temperament and weight-related quality of life predict or moderate childhood obesity treatment outcomes at 6 months. From 2015 to 2016, children (n = 97) ages 5–11 years old with obesity were randomized to a clinic–community (Bull City Fit) or a clinic-only treatment program. Linear regression was used to explore whether dimensions of child temperament and weight-related quality of life predicted or moderated 6-month anthropometric and physical activity outcomes. Children who had more social avoidance due to their weight at baseline had significantly better improvements in body fat percent in the clinic–community model compared with the clinic-only model at 6 months. Across programs, better baseline social quality of life predicted greater increases in waist circumference; conversely, better physical quality of life predicted a decrease in percent of the 95th percentile. Also, children with longer attention spans had greater increases in physical activity. Our findings suggest that children who have social avoidance due to their weight may benefit most from comprehensive clinic–community treatment. Weight-related quality of life may influence outcomes across all treatments, and practitioners need to carefully counsel children experiencing weight negatively.