bluuebunny/crossref_metadata_2025 huggingface dataset:
1137. Implementation of Universal Screening for Strongyloidiasis Among Solid-Organ and Hematopoietic Stem Cell Transplantation Candidates in a Non-endemic Area
Authors: Kottkamp Angelica , Mehta Sapna
Published: November 2018

Background

Strongyloidiasis can lead to hyperinfection and dissemination after transplantation with significant morbidity and mortality. Treatment for Strongyloidiasis prior to transplantation can reduce the risk of disseminated infection. Targeted screening based on travel history and country of origin incompletely identifies at-risk patients. Data on universal screening prior to solid-organ (SOT) or hematopoietic stem cell transplantation (HSCT) are limited. We implemented universal serology-based screening for strongyloides at our transplant center, located in a metropolitan non-ndemic area.

Methods

We identified patients screened with serum Strongyloides IgG by ELISA during pre-transplant evaluation for SOT or HSCT from August 1, 2017 to April 25, 2018. We reviewed adherence to the screening recommendation by program type and the medical record of seropositive patients for country of origin, history of eosinophilia (>500 cell/μL), Gram-negative bacteremia, ova and parasite (O&P) examination and treatment.

Results

A total of 812 patients were evaluated for transplant during the study period: 484 for kidney, 152 for liver, 12 for liver/kidney transplant, 40 for heart, 24 for lung, and 100 for HSCT. 201 (24.7%) of the 812 patients were screened for Strongyloides; 107 (17%) evaluated for abdominal transplant, 32 (50%) for thoracic transplant, and 62 (60%) for HSCT. Seventeen (8.4%) of 201 patients screened tested positive: nine evaluated for kidney transplant, four for heart, one for liver, and three for HSCT. Nine of 17 patients (53%) were treated with Ivermectin or referred to Infectious Diseases clinic prior to our review. Ten (59%) seropositive patients were from the United States and 70% had no documented travel to endemic areas; six patients were from countries other than the United States; and one from Puerto Rico. Two patients with Strongyloidiasis had eosinophilia, one had history of Klebsiella pneumoniae bacteremia and one had stool O&P examination. Screening was higher when using an electronic order set (57% vs. 17%).

Conclusion

Universal screening for Strongyloidiasis identified individuals with latent infection who did not have epidemiological or clinical findings suggestive of Strongyloidiasis. Screening for Strongyloidiasis was higher in transplant programs that incorporated the recommendation into an electronic order set.

Disclosures

All authors: No reported disclosures.
1139. Novel Formulation SUBA-Itraconazole Prophylaxis in Patients With Hematological Malignancy or Undergoing Allogeneic Stem Cell Transplantation: Follow-up Survival Data
Authors: Lindsay Julian , Sandaradura Indy , Wong Kelly , Arthur Chris , Stevenson William , Kerridge Ian , Fay Keith , Coyle Luke , Greenwood Matthew
Published: November 2018

Background

Despite the advantageous spectrum of activity of itraconazole, it is rarely used as a prophylactic agent due to limited bioavailability and intolerance of the conventional formulation. After the development of a novel formulation SUBA-itraconazole® (SUper BioAvailability), we undertook a study to assess therapeutic levels, safety, tolerability, and IFI rates of this novel formulation when compared with the conventional itraconazole liquid in patients undergoing allogeneic hematopoietic stem cell transplantation or in hematological malignancy patients.

Methods

Following a single-centre, prospective study of SUBA–itraconazole 200 mg BID vs. conventional liquid itraconazole 200 mg BID, the SUBA–itraconazole group was assessed 1-year postallogeneic stem cell transplant for incidence of IFI and survival.

Results

A total of 57 patients (29 SUBA–itraconazole and 30 liquid-itraconazole) were assessed. Therapeutic concentrations were achieved significantly more quickly in the SUBA–itraconazole group; median of 6 days vs. 14 (P < 0.0001). At day 10, therapeutic concentrations were achieved in 69% of the SUBA–itraconazole group vs. 21% (P < 0.0001). The mean trough serum concentrations at steady state of SUBA–itraconazole were significantly higher, with less interpatient variability (1,577 ng/mL, CV 35%) vs. (1,218 ng/mL, CV 60%) (P < 0.001). There were 2 (7.5%) treatment failures in the SUBA–itraconazole group, both due to cessation of therapy for mucositis, compared with 7 (23.3%) treatment failures in the liquid-itraconazole group, due to subtherapeutic levels (five), mucositis (one), and gastrointestinal intolerance (one) (P = 0.096). There was one confirmed IFI in the SUBA–itraconazole treatment failure group defined by a blood culture that yielded yeast; however, this was after the cessation of SUBA–itraconazole for mucositis. No other probable/possible IFIs were observed. After 1 year postallogeneic stem cell transplant in the SUBA–itraconazole group, there were two deaths (10%) due to disease progression and no further IFIs were reported.

Conclusion

The use of the SUBA–itraconazole formulation was a safe and effective prophylactic agent. It was associated with more rapid attainment of therapeutic levels with less interpatient variability when compared with conventional liquid itraconazole.

Disclosures

J. Lindsay, Mayne Pharma: Consultant, Consulting fee.
1145. Sparring With Spores: Ultrasounds as a Vector for Pathogen Transmission in the Intensive Care Unit
Authors: John Amrita , Kapoor Aanchal , Mana Thriveen Sankar Chittoor , Jencson Annette , Cadnum Jennifer , Deshpande Abhishek , Donskey Curtis J
Published: November 2018

Background

Portable equipment that is shared among patients can be a potential source of pathogen dissemination. In busy healthcare settings, cleaning of shared medical equipment may be suboptimal. In addition, equipment such as ultrasound probe heads present a challenge because sporicidal cleaning solutions such as bleach cannot be used.

Methods

We conducted a culture survey of ultrasounds in 15 intensive care units (ICUs) at a large tertiary care referral center, including medical, surgical, neurology, cardiology, and cardiovascular ICUs. Multiple high-touch surfaces on different types of ultrasound equipment used in the ICUs were swabbed to assess for the presence of Clostridium difficile and antibiotic-resistant Gram-negative bacilli. To assess cleaning, a fluorescent marker visible only under UV light was placed on high-touch surfaces on each of the cultured ultrasounds and a black light was used determine if the marker was removed after 24 hours and again after 1 week.

Results

Of 15 ultrasounds cultured, 7% were contaminated with C. difficile spores and 7% were contaminated with Gram-negative bacilli. Based on fluorescent marker removal, only 20% of the ultrasounds were cleaned within 24 hours and only 31% were cleaned within 1 week. Ultrasounds with touchscreens were cleaned more frequently than those with no touchscreen. For equipment with a combination of touchscreen features and knobs, the touchscreens were cleaned more often than the knobs which often had residual marker even after 7 days.

Conclusion

Ultrasound equipment can be a vector for transmission of C. difficile and other pathogens in critical care settings. In our facility, cleaning of ultrasound equipment was suboptimal, particularly for ultrasounds that did not have a touchscreen interface. Since ultrasounds are being employed in critical care settings with increasing frequency, there is a need for improved methods for cleaning and disinfection.

Disclosures

A. Deshpande, 3M: Investigator, Research grant. Clorox: Investigator, Research grant. STERIS: Investigator, Research grant.
1149. Environmental Disinfection With Photocatalyst as an Adjunctive Measure to Control Multidrug-Resistant Organisms Transmission: A Prospective Cohort Study in High Incidence Setting
Authors: Kim Min Hyung , Jeong Su Jin , Lee Seong Gyu , Kim Ki Sook , Heo Yoon Ji , Oh Ji Eun
Published: November 2018

Background

Hand hygiene and isolation precaution are often difficult to sustain, requiring additional measure to control multidrug-resistant organisms (MDRO) transmission. It was suggested that continuously antimicrobial surfaces could offer superior control of surface bioburden.Thus, we sought to decide the efficacy of photocatalyst antimicrobial coating in reducing MDRO acquisition in high incidence setting.

Methods

At an institute where used to have high incidence rate of methicillin-resistant Staphylococcus aureus (MRSA), we performed prospective cohort study involving patients hospitalized in medical intensive care unit. Five months of preintervention (where routine infection control measures were maintained) data were compared with 5 months of postintervention (after titanium dioxide-based photocatalyst were coated on high touch surfaces) data. The acquisition rate of MDROs and the rates of hospital acquired blood stream infection (BSI), pneumonia, urinary tract infection (UTI), and Clostridium difficile-associated disease (CDAD) were compared using Cox proportional hazards regression analysis.

Results

A total of 621 patients were included. There was significant decrease in MRSA acquisition rate after photocatalyst antimicrobial coating. (hazard ratio, 0.37; 95% CI, 0.14–0.99; P = 0.04.) However, acquisition rates of vancomycin-resistant Enterococcus spp. and multidrug-resistant Acinetobacter baunmannii had not significantly decreased. The hazard of acquiring hospital acquired pneumonia during intervention period compared with baseline period was 0.46 (95% CI, 0.23–0.94; P = 0.03). There were not significant reduction in hospital acquired BSI, UTI, and CDAD, after photocatalyst antimicrobial coating.

Conclusion

MRSA acquisition rate and hospital acquired pneumonia were significantly reduced after photocatalyst antimicrobial coating. This study provides evidence that photocatalyst antimicrobial disinfection can be an adjunctive measure to control MRSA acquisition in high incidence setting.

Disclosures

All authors: No reported disclosures.
1150. Cleaning High Touch Surfaces of Patients’ Rooms: Make It Easier, and It Simply Gets Cleaner
Authors: Martin Emily T , Dadon Mor , Lazarovitch Tsilia , Saadon Hodaya , Maya Tal , Jaffe Katie , Moscovich Sharon , Zaidenstein Ronit , Marchaim Dror
Published: November 2018

Background

The healthcare environment has been established as a reservoir for human pathogens and specifically multidrug-resistant organisms (MDRO). High touch surfaces and fomites in a patient’s room mediate transmission between infected and uninfected patients and personnel. Efforts to reduce hospital-associated infections due to MDROs often focus on room cleaning; however, adherence to and thoroughness of cleaning pose significant challenges.

Methods

A crossover trial was implemented in January 2016 (for 15 months) at Assaf Harofeh Medical Center (Israel) in four identical medical units. Single-use wipes (Clinell®; universal wipes and sporicidal wipes for rooms of patients with C. difficile), were compared with common practices which consisted of reusable cloths and bleach (1,000–5,000 ppm). Six-month cleaning and intervention periods were used on units in alternating sequences, separated by washout periods. Cleaning was monitored twice a week (bedrail, bedside table, clinical binder, call button, and lamp switch), by a fluorescent marker system (Clinell®). Comparisons used GEE with clustering for room. Staff were surveyed on intervention feasibility, acceptability, and satisfaction.

Results

Complete cleaning in all five test locations was found in 23% of 400 total assessments and was more common in the intervention group (34% vs. 12%; OR = 3.7; P < 0.001). Cleaning adherence was highest for the bed rail (71%) and lowest for the call button (38%). The use of wipes had the largest effect on adherence for the light switch (59% vs. 26%; OR = 4.2; P < 0.001). Intervention timing was not associated with overall adherence (P = 0.10). 94% of staff reported overall satisfaction of “very good” or “excellent,” and 90% of staff reported that use of the wipes shortened the cleaning process.

Conclusion

The use of cleaning wipes resulted in greater adherence to room cleaning and the method was reported to be acceptable to staff. Future aims of this large study (over 10,000 patients were enrolled and data collection not yet completed) are to determine the impact of this intervention on rates of hospital-acquired infections, MDRO acquisitions, and mortality.

Disclosures

E. T. Martin, Clinell: Grant Investigator, Research grant. D. Marchaim, Clinell: Grant Investigator, Grant recipient.
1156. Observation of Stethoscope Sanitation Practices in an Emergency Department Setting
Authors: Vasudevan Rajiv , Mojaver Sean , Chang Kay-Won , Maisel Alan , Sedighi Romteen , Chowdhury Punam
Published: November 2018

Background

Nosocomial infections pose significant risk to patients and hygienic standards may be easily overlooked, especially in fast-paced emergency department settings. Studies have shown that stethoscopes can harbor pathogens, which can be transferred to patients when proper sanitary measures are not taken. Survey-based studies have mostly assessed stethoscope hygiene, but they may not accurately represent cleaning practice. This study aimed to accurately assess cleaning practice through observation of stethoscope cleaning and hand hygiene among medical providers in an emergency department setting.

Methods

Four hundred twenty-six provider–patient encounters were observed in the emergency department of the VA San Diego Healthcare System. The frequency and methods of stethoscope and hand hygiene practices were anonymously observed and recorded. Stethoscope hygiene was recorded during and after each encounter if cleaning took place for at least 15 seconds. Hand hygiene data were also gathered before and after each encounter. Data analysis was performed to determine the frequency of these practices.

Results

Of 426 encounters, 115 involved the use of a personal stethoscope. In 15 of 115 encounters (13.0%), the provider placed a glove over the stethoscope before patient contact. Following patient interaction, 13 of 115 encounters (11.3%) involved stethoscope hygiene with an alcohol swab. Stethoscope hygiene with water and hand towel before patient interaction was observed in 5 of 115 encounters (4.3%). Hand sanitizer use or hand washing was observed in 213 of 426 encounters (50.0%) before patient interaction. Gloves were also used prior to patient interaction in 206 of 426 (48.4%) encounters, some overlapping with those who used hand sanitizer or washed their hands. Hand sanitizer or hand washing was used in 332 of 426 encounters (77.9%) after patient interaction.

Conclusion

Only 11.3% of encounters involving the use of a personal stethoscope had stethoscope sanitation with an alcohol swab. In 4.3% post-encounters, there was an attempt to clean stethoscopes with water and towel. Rates of appropriate hand hygiene were also lower than expected. Stethoscope and hand hygiene standards need to be raised to reduce infection risk and further studies need to be conducted to set guidelines for adequate stethoscope sanitation.

Disclosures

All authors: No reported disclosures.
1160. Infrequency of Respirator Change Following Annual Respiratory Fit Testing at an Academic Medical Center
Authors: Chuang Tzu-Ying , Thomas Tania , Garrison Vickie , Schuch Jonathon , Kozower Benjamin , Eby Joshua
Published: November 2018

Background

The Occupational Safety and Health Administration (OSHA) of the Department of Labor requires that healthcare employers perform annual respiratory fit testing (RFT) for respiratory protection of employees with patient exposure. The annual cost of RFT in the United States is greater than $8 million and each fit test requires approximately 20 minutes. Due to the high resource expenditure for RFT, we sought to identify factors associated with changing respirators.

Methods

During annual RFT at the University of Virginia, employees complete a questionnaire about interval clinical changes since the last RFT. Questions are based on publications indicating that certain characteristics are associated with respirator change, including: have you had dental surgery, surgery on your face, or trauma; has your weight changed by >10%; have you been or are you currently pregnant; do you recall your mask type; do you want to change masks. Answers to these questions from May 2016 through March of 2018 were compiled and analyzed by Chi-square test using Excel and R. P-value of <0.05 was considered significant.

Results

A total of 4,278 employees completed questions at least once during the time period, with 29 requiring respirator change after RFT. Requesting a mask change, and 10% weight change were significantly associated with respirator change. Pregnancy and facial trauma were not significantly associated with respirator change. Of those who changed respirator, nine reported no change in weight, no facial trauma, and no pregnancy.

Conclusion

The infrequency of respirator change suggests that limiting RFT to those most likely to change their respirator may hold more value than screening all employees annually; however, questions included in this evaluation did not identify all employees who would require respirator change. We are continuing evaluation of predictors of respirator changes and association with tuberculin skin test conversion to improve efficiency of RFT.

Disclosures

All authors: No reported disclosures.
1164. County-Level Geographic Distribution of Extended-Spectrum Cephalosporin-Resistant Enterobacteriaceae Across Outpatient Settings of the Veterans Health Administration, 2000–2017
Authors: Goto Michihiko , Nair Rajeshwari , Livorsi Daniel , Schweizer Marin , Ohl Michael , Richardson Kelly , Beck Brice , Alexander Bruce , Perencevich Eli
Published: November 2018

Background

Extended-spectrum cephalosporin resistance (ESCR) among Enterobacteriaceae has emerged globally over the last two decades, with increased prevalence in the community. Data from European countries and healthcare-associated isolates in the United States have demonstrated substantial geographic variability in the prevalence of ESCR, but community-onset isolates in the United States have been less studied. We aimed to describe geographic distribution and spread of ESCR among outpatient settings across the Veterans Health Administration (VHA) over 18 years.

Methods

We analyzed a retrospective cohort of all patients who had any positive clinical culture specimen for ESCR Enterobacteriaceae collected in an outpatient setting; ESCR was defined by phenotypic nonsusceptibility to at least one extended-spectrum cephalosporin agent or detection of an extended-spectrum β-lactamase. Patient-level data were grouped by county of residence, and the total number of unique patients who received care within VHA for each county was used as a denominator. We aggregated data by time terciles (2000–2005, 2006–2011, and 2012–2017), and overall and county-level incidence rates were calculated as the number of unique patients in each year with ESCR Enterobacteriaceae per person-year.

Results

During the study period, there were 1,980,095 positive cultures for Enterobacteriaceae from 870,797 unique patients across outpatient settings of VHA, from a total of 107,404,504 person-years. Among those, 136,185 cultures (6.9%) from 75,500 unique patients (8.7%) were ESCR. The overall incidence rate was 9.0 cases per 10,000 person-years, which increased from 6.3 per 10,000 person-years in 2000 to 14.6 per 10,000 person-years in 2017. County-level incidence rates ranged widely but increased overall (interquartile range [IQR] in 2000–2005: 0–6.7; 2006–2011: 0–9.1; 2012–2017: 3.1–14.3 per 10,000 person-years), with some geographic clustering (figure).

Conclusion

This study demonstrates that there has been geographic variation both in incidence rates and trends of ESCR Enterobacteriaceae in outpatient settings of VHA, which suggests the importance of tailoring local antibiotic-prescribing guidelines incorporating geographic variability in epidemiology.

Disclosures

M. Ohl, Gilead Sciences, Inc.: Grant Investigator, Research grant.
LB9. Rising High Rate of Invasive Group A Streptococcus Infections Among Persons Experiencing Homelessness in San Francisco, 2010–2017
Authors: Scheuer Tara , Libby Tanya , Van Beneden Chris , Watt James , Reingold Arthur , Apostol Mirasol , Vugia Duc
Published: November 2018

Background

Rates of invasive group A Streptococcus (iGAS) disease in the United States have risen since 2014; reasons remain unclear. Outbreaks of iGAS infection among persons experiencing homelessness (PEH) and persons who inject drugs in Europe, Canada, and the United States have been described. Using active, population-based surveillance data from California’s Emerging Infections Program, we describe incidence trends and characteristics of iGAS infection among PEH and persons not experiencing homelessness (PNEH) in San Francisco (SF) County during 2010–2017.

Methods

We defined an iGAS case as infection with GAS isolated from a normally sterile site (e.g., blood) in an SF resident. We calculated annual iGAS disease incidence rates (cases per 100,000 population) for PEH and PNEH using denominators from SF’s Department of Homelessness and Supportive Housing and the State of California Department of Finance. Demographic, clinical, and exposure characteristics of PEH and PNEH were compared by chi-square or t-test.

Results

We identified 673 iGAS cases in SF during 2010–2017. Among these, 34% (229/673) were among PEH. Annual iGAS incidence among PEH rose from ~300 (2010–2014) to 547 (95% CI: 379–714) per 100,000 in 2017 (P < 0.001, Cochran-Armitage trend test); rates peaked at 758 (95% CI: 561–955) in 2016. Annual iGAS incidence in PNEH rose from a mean of 5 in 2010–2013 to 9.3 (95% CI: 7.3–11.4) per 100,000 in 2017 (P < 0.001). Annual iGAS incidence in PEH was 42–72 times that in PNEH. PEH with iGAS infections were significantly younger and more likely to be male, white, and uninsured or enrolled in Medicaid (P < 0.05 for each) compared with PNEH with iGAS disease. Case fatality ratios, ICU admission, infection type, and length of hospital stay did not differ significantly. Smoking, current injection drug use, current alcohol abuse, and AIDS diagnosis were significantly more common among PEH with iGAS. Obesity, diabetes, and cancer were significantly more common among PNEH with iGAS.

Conclusion

In San Francisco, iGAS rates among both PEH and PNEH have risen significantly. Incidence of iGAS is strikingly higher in PEH than in PNEH and exposures differed between PEH and PNEH with iGAS. This information could inform development of disease control and prevention strategies.

Disclosures

All authors: No reported disclosures.
LB11. Rapid Rise in Decreased Susceptibility to Azithromycin among Shigella Isolates in the United States: A Look at National Surveillance Data, 2011–2017
Authors: Friedman Cindy , Plumb Ian , Reynolds Jared , Chen Jessica , Tagg Kaitlin , Caidi Hayat , Watkins Louise Francois , Karp Beth
Published: November 2018

Background

Shigella spp. cause ~500,000 illnesses in the United States annually. Antibiotics are recommended for immunocompromised patients and shorten the duration of illness, thus limiting spread. First-line treatments include ciprofloxacin (CIP) and azithromycin (AZM). CIP resistance is a growing problem in the United States; decreased susceptibility to AZM (DSA) has been reported globally, particularly among men who have sex with men (MSM). We reviewed National Antimicrobial Resistance Monitoring System (NARMS) data to determine DSA trends among Shigella isolates in the United States.

Methods

Health departments nationwide forward every 20th Shigella isolate to CDC NARMS for antimicrobial susceptibility testing using broth microdilution. We defined CIP resistance using CLSI clinical breakpoints and DSA using epidemiological cutoff values where available. We performed whole genome sequencing on isolates from 2016 and screened the sequences for resistance determinants using ResFinder 3.0.

Results

To date, we have tested 3,044 Shigella isolates collected during 2011–2017. Overall, 264 isolates (9%) had DSA, increasing from 3% in 2011 to 23% in 2017; 41 (16%) were also CIP resistant. The odds of DSA increased by 1.5 (95% confidence interval [CI] 1.4–1.6) annually. DSA was more common among adult males (OR 21.2, CI 14.9–30.3), in isolates from the West census region (OR 2.4, CI 1.8–3.2), and in S. flexneri (OR 8.2, CI 6.3–10.7). Of 543 sequenced isolates, 52 (10%) had DSA; of these, 31 (60%) contained both mph(A) and erm(B) genes, 17 (33%) contained mph(A) only, and 4 (8%) had no identified macrolide-resistance mechanism.

Conclusions

In 2017, nearly 1 in 4 Shigella isolates tested had DSA, a 7-fold increase since 2011. This rapid rise in DSA parallels that seen in other countries, where resistance to other clinically relevant drugs is high and macrolides are no longer useful as empiric treatment. The increased risk of DSA in adult males is consistent with previous reports of DSA Shigella in MSM. The resistance genes observed are typically plasmid-mediated and can be transferred to other bacteria. Public health strategies to mitigate the spread of resistant Shigella should include antibiotic stewardship and novel approaches for sexually transmitted infection prevention in MSM.

Disclosures

All authors: No reported disclosures.
LB18. An Enveloped Virus-like Particle (eVLP) Cytomegalovirus (CMV) Vaccine Is Immunogenic and Safe: Results of a First-in-Humans Study
Authors: Gantt Soren , Quach Caroline , Anderson David E , Diaz-Mitoma Francisco , Langley Joanne
Published: November 2018

Background

CMV is the most common cause of congenital infection and may result in permanent neurodevelopmental injury including vision and hearing loss. A vaccine to prevent transmission of CMV during pregnancy or to immunocompromised persons is a public health priority. Neutralizing antibodies (nAb) to the CMV envelope glycoprotein B (gB) in natural infection are thought to confer protection, but some vaccine candidates based on this protein alone have been insufficiently immunogenic. In this FiH dose-ranging, controlled, observer-blinded study the safety and immunogenicity of an eVLP expressing the ectodomain of gB fused to transmembrane and cytoplasmic domains of the vesicular stomatitis virus G protein (gB-G) was evaluated.

Method

Healthy CMV-seronegative 18–40 year olds at three sites in Canada (Vancouver, Montreal, Halifax) were randomized to one of four dose formulations (0.5 µg, 1 µg, or 2 µg gB content with Alum) or 1 µg gB without Alum, or placebo given on days 0, 56, and 168. Outcome measures were solicited and unsolicited adverse events (AE), severe AE, gB binding antibody titers and avidity assessment, and nAb to CMV infection of fibroblast and epithelial cells. A Data Safety Monitoring Board was in place.

Result

Among 128 participants, the most common solicited local and general AEs were pain and headache, respectively. No SAEs or withdrawals occurred. A dose-dependent boosting of nAb titers was observed after doses 2 and 3, with the highest titers in the Alum-adjuvanted 2.0 µg dose recipients. Fibroblast cell nAb were seen in 100% of 2.0 µg dose recipients, and epithelial cell nAb in 31%. Epithelial cell nAb was correlated with higher geometric mean gB binding titers, and there was a correlation between fibroblast and epithelial cell nAb titers.

Conclusion

An eVLP CMV vaccine was immunogenic at very low doses in healthy seronegative adults and no safety signals were seen. Alum adjuvantation increased immunogenicity as did higher antigen content and multiple doses. This phase 1 trial supports further development of this eVLP CMV vaccine candidate.

ClinicalTrials.gov NCT02826798

Disclosures

S. Gantt, VBI Vaccines: Investigator, No direct financial benefit—company provided institutional support for clinical trial. C. Quach, VBI Vaccines: Investigator, No direct financial benefit—company provided institutional support for clinical trial. D. E. Anderson, VBI Vaccines: Employee and Shareholder, Salary. F. Diaz-Mitoma, VBI Vaccines: Consultant and Shareholder, Salary. J. Langley, VBI Vaccines: Investigator, No direct financial benefit—company provided institutional support for clinical trial.
LB20. Impact of School-Located Influenza Vaccination on Vaccination Coverage, School Absenteeism, and Influenza Hospitalization
Authors: Benjamin-Chung Jade
Published: November 2018

Background

School-located influenza vaccination programs aim to increase influenza vaccination coverage and produce indirect effects by interrupting influenza transmission. We evaluated the impact of a program that delivered the inactivated influenza vaccine in 2016–2017 to elementary schools in a large, diverse urban school district in Oakland, California on vaccination coverage, school absenteeism, and influenza hospitalization.

Methods

We conducted a prospective cohort study and used pre-program data from the California Department of Education on school characteristics to identify a control school district with similar characteristics to the program district. We measured parent recall of student influenza vaccination in surveys in 2017 in 44 schools per district (N = 6,070). We obtained absence data from school districts and influenza hospitalization data for district catchment areas prior to and during the program. We used generalized linear models to estimate difference-in-differences (DIDs) in absence rates during influenza season adjusting for month, race, and grade to account for differences in pre-program rates. Standard errors accounted for school clusters. For influenza hospitalization, we estimated cumulative incidence rates using census data to obtain the population size and risk ratios (RR) using modified Poisson regression.

Results

Vaccination coverage was 56.7% in control schools and 63.9% in program schools (difference = 7.2%; 95% CI 3.6%, 10.8%). 24% of students in program schools were vaccinated at school. Absences per 100 days were 5.40 vs. 6.68 in program vs. control sites for all absences and 3.01 vs. 3.60 for illness-related absences; DIDs were statistically significant for illness absences. Among all ages, the risk ratio for influenza hospitalization in program vs. control districts was 0.65 (95% CI 0.55, 0.78) among all ages and 0.71 for adults 65 or older (95% CI 0.57, 0.89). Hospitalization was too rare among elementary aged students to estimate RRs in that group.

Conclusion

Elementary school-located influenza vaccination increased influenza vaccination and decreased school absence and influenza hospitalization. There was an indirect effect on hospitalization in the elderly and nonelementary aged groups.

Disclosures

All authors: No reported disclosures.
LB21. Preemptive Therapy (PET) vs. Prophylaxis for Prevention of Cytomegalovirus (CMV) Disease in High-Risk Donor Seropositive/Recipient Seronegative (D+R−) Liver Transplant Recipients (LTR): A NIH-Sponsored, Randomized, Controlled, Multicenter Trial
Authors: Singh Nina , Winston Drew , Razonable Raymund R , Lyon III G Marshall , Silveira Fernanda P , Wagener Marilyn , Limaye Ajit P
Published: November 2018

Background

Current guidelines preferentially recommend valganciclovir (VGCV) prophylaxis over PET in most D+R− organ transplant populations, but adequately powered direct comparative clinical trials are lacking.

Methods

D+R− LTR were randomly assigned (1:1, stratified by site and T-cell depleting induction) to receive either PET (weekly plasma CMV DNAemia at central laboratory for 100 days, with VGCV 900 mg bid for DNAemia at any level, until two consecutive negative weekly tests) or prophy (VGCV 900 mg qd for 100 days). The primary outcome was CMV disease by 12 months as adjudicated by an independent, blinded, endpoint committee in ITT population. Secondary outcomes were opportunistic infections (OIs) (invasive fungal and bacterial), neutropenia (ANC < 1000/µL), acute rejection, graft loss, and mortality assessed at12 months.

Results

From October 2012 to June 2017, 205 patients were randomized at six centers; 100 to PET, 105 to prophy. The incidence of CMV disease was 9% (9/100) in PET and 19% (20/105) in prophy (P = 0.039) with majority of difference due to post-prophylaxis disease: 6% in PET vs. 17% in prophy (P = 0.027). CMV disease included syndrome in 55% (16/29) and end-organ in 45% (13/29), with similar proportions in two groups. Secondary outcomes were not different for PET and prophy groups: OIs (19% vs. 21%), neutropenia (34% vs.. 28%), acute rejection (27% vs. 27%), graft loss (2% vs. 2%), and mortality (10% vs. 6%), respectively, P > 0.05 for all comparisons. Mortality at last follow-up (median 3.2 years) was not different for PET vs. prophy (14% vs. 18%, P = 0.43).

Conclusions

PET significantly reduced the incidence of CMV disease compared with prophy in D+R- LTR, and was associated with similar other clinical outcomes. Current guidelines should be revised to recommend PET over prophylaxis in this setting, and similar trials conducted in other D+R− transplant populations. (Funded by NIAID; ClinicalTrials.gov# NCT01552369.)

Disclosures

D. Winston, Merck: Investigator, Research support. Chimerix: Investigator, Research support. Shire: Investigator, Research support. Gilead: Investigator, Research support. Oxford Immunotech: Investigator, Research support. G. M. Lyon III, Shire: Investigator, institutional research support. Hookipa: Investigator, institutional research support. Merck: Investigator, institutional research support. F. P. Silveira, Shire: contracted clinical research, site investigator. A. P. Limaye, Merk: Consultant and Investigator, Consulting fee and Research grant. Astellas Pharma Inc.: Consultant and Investigator, Consulting fee. Helocyte Inc.: Consultant, Consulting fee.
Technique Tip: Platysma-flap Approach to the Clavicle
Authors: Gallusser Nicolas , Goetti Patrick , Moor Beat K.
Published: November 2018

The surgical treatment of a displaced fracture of the clavicular shaft generally consists in an open reduction and plate fixation. The most common complications of the classic direct “transplatysma” approach are hardware related. These consist of simple hardware irritations requiring secondary plate removal but also feared wound healing problems ranging from dehiscence to superficial and deep wound infections. In the present article, we describe the so-called “platysma-flap” approach in which the platysma muscle is entirely preserved and distally raised as a flap. This modified exposure allows to cover the osteosynthesis with a viable, well perfused soft tissue envelope and is a safe alternative to the standard “transplatysma” approach.
Nomogram-based prediction of cervical dysplasia persistence/recurrence
Authors: Bogani Giorgio , Tagliabue Elena , Ferla Stefano , Martinelli Fabio , Ditto Antonino , Chiappa Valentina , Leone Roberti Maggiore Umberto , Taverna Francesca , Lombardo Claudia , Lorusso Domenica , Raspagliesi Francesco
Published: November 2018

The widespread introduction of screening methods allow to identify cervical dysplasia before having invasive cancer. The risk of developing cervical dysplasia persistence/ recurrence following conization represent a major health issue. Although several studies tried to identify predictors for cervical dysplasia persistence/recurrence, no previous study has been conducted to develop a risk calculator. The current study aimed to identify predictors of cervical dysplasia persistence/recurrence among women undergoing primary conization. We aimed to build nomograms estimating the risk of developing cervical dysplasia recurrence. Data of consecutive women with diagnosis of high-risk human papillomavirus (HPV) undergoing conization were retrospectively evaluated (1503 patients). The risk of developing cervical dysplasia persistence/recurrence was assessed with Kaplan–Meier and Cox’s hazard models. Additionally, two nomograms were built to estimate likelihood of cervical dysplasia recurrence: the first based on baseline and operative parameters and the second focusing on type-specific HPV detected. The performance of the above nomograms was assessed using concordance index. A total of 1503 patients were analyzed. After a mean (SD) follow-up of 48.6 ( ± 17.5) months, 84 (5.6%) patients required secondary conization. By multivariate analysis, HIV infection [hazard ratio (HR): 7.78; 95% confidence interval (CI): 2.77–21.81; P < 0.001], positive margins (HR: 26.2; 95% CI: 14.1–48.71; P < 0.001) and persistence of HPV (HR: 6.82; 95% CI: 4.15–11.21; P < 0.001) correlated with cervical intraepithelial neoplasia 2+ persistence/recurrence. The importance of those variables was corroborated by our first nomogram. The second nomogram suggested the impact of type-specific HPV infection in predicting cervical dysplasia persistence/ recurrence. HPV16, HPV18, HPV33, HPV35 and HPV45 were the HPV types most commonly associated with cervical dysplasia persistence/recurrence. The concordance index was greater than 0.70 for both nomograms, thus suggesting the reproducibility of our models. We developed the first two nomograms predicting this risk. The findings of this study require external validation. Once validated our data might be useful to plan a tailored postoperative surveillance of women receiving primary conization.
Oral 17β-estradiol/progesterone (TX-001HR) and quality of life in postmenopausal women with vasomotor symptoms
Authors: Simon James A. , Kaunitz Andrew M. , Kroll Robin , Graham Shelli , Bernick Brian , Mirkin Sebastian
Published: November 2018

Objective:

The aim of the study was to describe the effects of TX-001HR (17β-estradiol [E2] and natural progesterone [P4] in a single oral capsule) on menopause-specific quality of life in women with moderate to severe vasomotor symptoms (VMS).

Methods:

The REPLENISH study (NCT01942668) was a phase 3, randomized, double-blind, placebo-controlled, multicenter trial which evaluated four E2/P4 doses in postmenopausal women with VMS and a uterus. Women with moderate to severe hot flushes (≥7/d or ≥50/wk) were included in a VMS substudy. Participants self-administered the Menopause-Specific Quality of Life (MENQOL) questionnaire. Baseline changes in MENQOL overall and domains were determined as well as correlations between changes in MENQOL scores and VMS frequency or severity.

Results:

In the VMS substudy, women treated with E2/P4 had significantly greater improvements from baseline in their MENQOL overall score at week 12, and months 6 and 12, compared with placebo (all, P < 0.05, except the lowest E2/P4 dose at months 6 and 12). Improvements from baseline for the MENQOL vasomotor domain score were significantly greater with TX-001HR doses versus placebo at all time points (all, P < 0.01). Changes in MENQOL vasomotor scores moderately correlated with changes in VMS frequency (r = 0.56, P < 0.0001) and severity (r = 0.55, P < 0.0001).

Conclusion:

In the REPLENISH trial, women with moderate to severe VMS treated with most E2/P4 doses reported significant improvements in quality of life from baseline to 12 weeks compared with placebo, which were maintained up to 12 months. TX-001HR, if approved, may provide the first oral hormone therapy formulation in a single capsule containing E2 and P4 for the treatment of VMS in postmenopausal women with a uterus.
Comparative Study of Performance using Five Different Gamma-ray Spectrometers for Thyroid Monitoring under Nuclear Emergency Situations
Authors: Hosoda Masahiro , Iwaoka Kazuki , Tokonami Shinji , Tamakuma Yuki , Shiroma Yoshitaka , Fukuhara Takahiro , Imajyo Yusuke , Taniguchi Jun , Akata Naofumi , Osanai Minoru , Tsujiguchi Takakiyo , Yamaguchi Masaru , Kashiwakura Ikuo
Published: November 2018

A performance test was carried out using five different gamma-ray spectrometers applicable to thyroid monitoring. The energy resolution and efficiency for 7.6-cm × 7.6-cm NaI(Tl), 5.1-cm × 5.1-cm CeBr3, 3.8-cm × 3.8-cm SrI2(Eu), and 2.5-cm × 2.5-cm SrI2(Eu) gamma-ray scintillation spectrometers and a CdTe gamma-ray semiconductor spectrometer were evaluated using the Oak Ridge Institute for Nuclear Studies thyroid-neck phantom with a mock 131I source for prompt thyroid monitoring after a nuclear emergency. The respective energy resolutions of the full-energy peak for ~0.360 MeV of 3.8-cm × 3.8-cm SrI2(Eu) and 2.5-cm × 2.5-cm SrI2(Eu) scintillation spectrometers were 4.2% and 4.3%, and these values were very close to the value obtained by the CdTe semiconductor spectrometer. The efficiencies of four of the gamma-ray spectrometers were compared based on the efficiency of the 7.6-cm × 7.6-cm NaI(Tl) scintillation spectrometer at 0 cm from the phantom surface, and these values were ~70% for 5.1-cm × 5.1-cm CeBr3, ~30% for 3.8-cm × 3.8-cm SrI2(Eu), 10% for 2.5-cm × 2.5-cm SrI2(Eu) and 2% for 1-cm2 × 0.1-cm CdTe. Furthermore, the detection limits at various dose rates for the four gamma-ray scintillation spectrometers were evaluated using the method based on International Organization for Standardization publication ISO 11929:2010.
Thrombosis in the portal venous system caused by hypereosinophilic syndrome
Authors: Lin Jinfeng , Huang Xiaoying , Zhou Weihua , Zhang Suyan , Sun Weiwei , Wang Yadong , Ren Ke , Tian Lijun , Xu Junxian , Cao Zhilong , Pu Zunguo , Han Xudong
Published: November 2018

Rationale:

Extensive thrombosis in the portal venous system caused by hypereosinophilic syndrome (HES) is rare, and there is no consensus on anticoagulant and thrombolytic treatments for arteriovenous thrombosis caused by HES.

Patient concerns:

The clinical data of a patient with extensive thrombosis in his portal venous system (superior mesenteric, splenic, hepatic, and portal veins), renal artery thrombosis, and mesenteric thrombosis caused by HES with secondary gastrointestinal bleeding and intestinal necrosis were retrospectively analyzed. Before admission, his eosinophil count increased to 7.47 × 109/L, and HES had been confirmed via bone marrow cytology. The patient experienced fever, cough, abdominal pain, massive hematemesis, and hematochezia that developed in succession. Abdominal computed tomography showed portal vein and superior mesenteric vein thromboses.

Diagnosis:

Hypereosinophilic syndrome; extensive thrombosis in the portal venous system; acute eosinophil-associated pneumonia; gastrointestinal bleeding; intestinal necrosis.

Interventions:

The patient was first treated with methylprednisolone, plasma exchange/hemofiltration, and single or combined use of unfractionated heparin and argatroban for anticoagulation. He was also administered alteplase and urokinase, successively, for thrombolytic treatment. Once the thromboses finally disappeared, the patient underwent surgery to excise a necrotic intestinal canal.

Outcomes:

The thromboses disappeared with these treatments, and the patient recovered after the necrotic intestinal canal was excised.

Lessons:

The clinical manifestations of HES are complex and varied, and this condition can cause severe and extensive arteriovenous thrombosis. Anticoagulation therapy and thrombolysis are necessary interventions, and appear to be safe and effective.
Prospective Study of Pulmonary Embolism Presenting as Syncope
Authors: Pop Calin , Ianos Raluca , Matei Claudia , Mercea Delia , Todea Bogdan , Dicu Daniela , Tarus Mariana , Filip Dan , Kozma Gabriela , Cotoraci Coralia , Petris Antoniu , Tint Diana
Published: November 2018

Background:

Syncope represents a common condition among the general population. It is also a frequent complaint of patients in the emergency department (ED). Pulmonary embolism (PE) considers a differential diagnosis, particularly in a case of syncope without chest pain.

Study Question:

What is the prevalence of PE among patients who presented an episode of syncope to the ED and among those hospitalized for syncope in a tertiary care hospital?

Study Design:

From January 2012 to December 2017, we conducted a prospective observational study among adult patients presenting themselves to the ED consecutively or admitted for syncope.

Measures and Outcomes:

Syncope and PE were defined by professional guidelines. PE was ruled out in patients who had a low pretest clinical probability, as per Wells score and a negative D-dimer assay. In other patients, computed tomography pulmonary angiography was performed.

Results:

Seventeen thousand eight-two patients (mean age 71.3 ± 13.24 years) visited the ED for syncope. PE was detected in 45 patients (mean age 65.75 ± 9.45 years): 4 with low risk, 26 with intermediate risk, and 15 with high risk. The prevalence of PE in those hospitalized with syncope was 11.47%, which is 45 of 392 (confidence interval 95% 8.48–15.04), and was 2.52%, 45 of 1782 (confidence interval 95% 1.8–3.3), in patients presenting with syncope to the ED. The location of the embolus was bilateral in 24 patients (53.33%), in a main pulmonary artery in 10 (22.22%), in a lobar artery in 10 (22.22%), and in a segmental artery in 1 (2.22%).

Conclusions:

The occurrence of syncope, if not explained otherwise, should alert one to consider PE as a differential diagnosis. PE rate, presenting as syncope, is the highest in patients with large thrombi, which is responsible for bilateral or proximal obstruction in a main or lobar pulmonary artery.
Health Equity Demands Health Literacy
Authors: Dreisinger Naomi , Nahn Jeffrey
Published: November 2018

The ability of the patient or the parent, in pediatrics, to read, understand, and act upon health information is termed health literacy. Health literacy has been shown to be of primary importance when determining a patient's ability to achieve optimal health. As physicians, we often fail to recognize the enormous obstacles facing our patients. In the pediatric emergency department (PED), communication is complicated. Physicians must be able to effectively relay information to the patient's caregiver while still not forgetting to provide developmentally appropriate instructions to the child. Individuals who do not have a good understanding of what is needed to properly care for themselves or their children are at a disadvantage, and it is therefore the responsibility of the pediatric provider to do all they can to identify gaps in health literacy. As providers, we need to always be questioning as to whether we properly conveyed the information to our patients. Teaching which results in good understanding is the ultimate goal when treating and releasing our patients in the pediatric emergency department. Matching the method of delivery of information and education to the family's health literacy will help the care team deliver effective information so that it is applied at home hopefully preventing a rapid revisit.
Things Are Not Always What They Seem
Authors: Vukovic Adam A. , Poole Meifawn D. , Hoehn Erin F. , Caldwell Alicia K. , Schondelmeyer Amanda C.
Published: November 2018

We describe 2 cases of child maltreatment who presented as common pediatric conditions: preseptal cellulitis and gastroenteritis. The first case is an 8-year-old girl who presented with progressive right eye pain, swelling, and discharge. She was initially treated for preseptal cellulitis, but eye cultures ultimately grew Neisseria gonorrhoeae. Further investigation revealed sexual abuse by a male family member. The second case is a 2-year-old previously healthy girl who presented with 6 hours of emesis, lethargy, and abdominal pain. Initially attributed to viral gastroenteritis, her serum blood urea nitrogen and creatinine were above what was expected for her clinical course, and she later developed signs of peritonitis. She was ultimately found to have a large bladder wall defect secondary to inflicted blunt abdominal trauma. These cases are presented to emphasize the need for pediatricians to consider child abuse even when patients present with common pediatric complaints.