bluuebunny/crossref_metadata_2025 huggingface dataset:
1644. Performance of Symptom-Based Case Definitions to Identify Influenza Virus Infection among Pregnant Women in Middle-Income Countries: Findings from the Pregnancy and Influenza Multinational Epidemiologic (PRIME) Study
Authors: Wesley Meredith G , Tinoco Yeny , Patel Archana , Suntarattiwong Piyarat , Hunt Danielle R , Soto Giselle , Sinthuwattanawibool Chalinthorn , Kittikraisak Wanitchaya , Arriola Carmen S , Hombroek Danielle , Mott Joshua , Kurhe Kunal , Bhargav Savita , Prakash Amber A , Florian Richard , Gonzales Oswaldo , Cabrera Santiago , Llajaruna Zumaeta Edwin , Brummer Tana , Malek Parker , Saha Siddhartha , Garg Shikha , Azziz-Baumgartner Eduardo , Thompson Mark G , Dawood Fatimah S
Published: October 2019

Background

The World Health Organization (WHO) recommends case definitions for influenza surveillance that are also used in public health research, though their performance has not been assessed in many risk groups, including pregnant women in whom influenza may manifest differently. Â We evaluated the performance of symptom-based case definitions to detect influenza in a cohort of pregnant women in India, Peru, and Thailand.

Methods

In 2017, we contacted 4774 pregnant women twice a week during the influenza season to identify illnesses with new or worsened cough, runny nose, sore throat, difficulty breathing or myalgia, and collected data on other symptoms and nasal swabs for influenza rRT–PCR testing. To identify symptom predictors of influenza, we used multivariable logistic regression with forward selection of symptoms significant in univariate analysis after controlling for country, chronic conditions, influenza vaccination, and time from symptom onset to swab collection. We calculated sensitivity and specificity of each symptom, WHO respiratory illness case definitions and a case definition based on significant predictors from the multivariable model.

Results

Of 2431 eligible illness episodes among 1,716 participants, 142 (5.8%) were positive for influenza. Among individual symptoms, runny nose was most sensitive and measured fever ≥ 38° Celsius was most specific (Figure 1). In a multivariable model, measured fever ≥ 38° Celsius [adjusted odds ratio = 3.8, 95% confidence interval [CI] = 2.0–7.2], cough [2.7, CI 1.6–4.7], chills [2.2, CI 1.2–3.8], and myalgia [1.2, CI 2.2, 5.3] were independently associated with influenza illness. A case definition based on these four (measured fever, cough, chills or myalgia), was 91%-sensitive and 37% specific. Sensitivity and specificity of case definitions varied (Figure 2).

Conclusion

While a case definition based on one or more of fever, chills, cough or myalgia is highly-sensitive and moderately specific among pregnant women, case definitions requiring measured or subjective fever may miss many influenza cases making them sub-optimal for studies of burden or vaccine efficacy. The intended use of case definitions should be considered when evaluating the tradeoff between sensitivity and specificity.

Disclosures

All authors: No reported disclosures.
1649. That’s Not Cricket! Outbreak of Legionella pneumophila (L. pneumophila) in a Community Cricket Club in the UK, 2018: Challenges in Legionella Control in This Setting
Authors: Wright Natalie , Fenelon Deborah , Fleeson Rachel , Coopey Diane , Hawker Jeremy , Tahir Mamoona
Published: October 2019

Background

Cricket clubs in the UK are frequently collocated with community venues which host a range of activities, often for vulnerable members of society, such as children and elderly people. In July 2018, two cases of local laboratory-confirmed Legionnaires’ disease were notified to Public Health England (PHE). The cases were found to be players in the same cricket team (via the enhanced Legionnaires’ disease surveillance system) and had multiple shared potential exposures during their incubation periods.

Methods

A three-pronged outbreak investigation was conducted, with epidemiological, microbiological, and environmental components. Case-finding and potential shared exposures were identified through completion and analysis of Legionella enhanced surveillance questionnaires. Following risk assessment, environmental samples were obtained from aerosolizing outlets at identified sites. Additionally, sputum and urine samples were obtained from cases. All samples were sent to the PHE reference laboratory for confirmation of species and sequence typing.

Results

All cases were confirmed as L. pneumophila serogroup 1. Only one case provided a sputum sample suitable for sequence typing, which yielded a partial result. This result was consistent with a strain of L. pneumophila found in abundance at numerous water outlets at a local cricket club epidemiologically linked to all cases. On the emergence of these findings, control measures were put in place to prevent further exposure to the pathogen including shot-dosing of the water systems and closure of aerosolizing outlets. However, eradication of the organism proved challenging.

Conclusion

This is the first known outbreak of L. pneumophila epidemiologically and microbiologically linked to a cricket club in the UK. Control of the outbreak was challenging for two reasons. Firstly, the nature of the setting as a community venue meant that there was a large number of people potentially exposed, many with characteristics putting them at increased risk of Legionnaires’ disease. Secondly, the cricket club was run by a committee of volunteers with limited expertise and financial resource. There was a resultant lack of clarity about who was ultimately responsible for Legionella risk management and the implementation of control measures.

Disclosures

All authors: No reported disclosures.
1655. Performance of Molecular and Serologic Tests for the Diagnosis of Scrub Typhus
Authors: Varghese George M , Kannan Kavitha , Abhilash Kundavaram , Nithyananth Alice , David Thambu , Sathyendra Sowmya , Hansdak Samuel , Iyyadurai Ramya , Prakash John
Published: October 2019

Background

Diagnosis of scrub typhus, caused by the bacterium Orientia tsutsugamushi, is challenging because of the overlap of its nonspecific symptoms with other infections coupled with the lack of sufficient data on the performance of diagnostic tests. Early diagnosis of scrub typhus is crucial to improve outcomes and this study evaluated the diagnostic performance of various tests.

Methods

Adult patients with acute febrile illness and manifestations suggestive of scrub typhus confirmed by positive PCR in the blood or eschar were characterized as cases. Patients with acute febrile illness and a confirmed alternate etiology such as culture-confirmed typhoid, smear/PCR positive for malaria, PCR/NS1 antigen positive for dengue, PCR positive for influenza, PCR/MAT positive for leptospirosis, PCR positive for spotted fever were characterized as controls with other infections. The healthy controls consisted of subjects from the same geographic region. We performed the following tests on blood samples for scrub typhus and calculated the sensitivity, specificity, positive predictive value, and negative predictive value: (1) Quantitative PCR using 47 kDa gene (qPCR); (2) Conventional PCR using 56kDa gene (cPCR); (3) Loop-mediated isothermal amplification assay (LAMP assay); (4) Immunofluorescence assay (IFA); (5) Enzyme-linked immunosorbent assay (ELISA); (6) Weil–Felix test (WF test); and (7) Immunochromatographic Rapid Diagnostic Test (RDT).

Results

Among the 302 participants, 152 had confirmed scrub typhus (cases) and 150 were controls. ELISA and RDT detecting IgM antibodies had excellent discriminative potential with sensitivities and specificities of 94%, 93% and 92%, 93%, respectively. False-positive IgM serology was observed with spotted fever and leptospirosis. The sensitivity and specificity of IFA were found to be 80% and 85%, respectively. qPCR exhibited excellent sensitivity (96%) and perfect specificity.

Conclusion

ELISA and RDT detecting IgM antibodies have excellent sensitivity and specificity while the sensitivity of IFA is suboptimal for the diagnosis of scrub typhus. Given its perfect specificity and superior sensitivity, qPCR is preferred for diagnostic confirmation in reference laboratories.

Disclosures

All authors: No reported disclosures.
1665. The Cascade of Care for the Strong Hearts Chagas Disease Screening and Treatment Program in East Boston, Massachusetts
Authors: Manne-Goehler Jen , Davis Jillian , Huanuco Juan , Gallegos Salazar Jaime , Salazar Alejandra , Camelo Ingrid Y , Collins Katherine , Sun Park Hong , Hochberg Natasha , Hamer Davidson , Barnett Elizabeth , Köhler Julia
Published: October 2019

Background

Over 300,000 people in the United States are infected with Trypanosoma cruzi, the parasite that causes Chagas disease. Less than 1% of those people have received antitrypanosomal therapy. We report findings of an ongoing project to address Chagas disease in East Boston, including the epidemiology and cascade of care for this disease.

Methods

Providers at the East Boston Neighborhood Health Center were offered continuing medical education sessions on Chagas disease by the Strong Hearts project. One-time screening for Chagas disease is recommended for all patients <50 years old who had lived in Mexico, South or Central America for ≥6 months at the provider’s discretion. Screening is performed by a commercial laboratory using the Hemagen ELISA; confirmatory testing is performed at CDC. Patients with confirmed positive serology are referred to the Center for Infectious Diseases (ID) at Boston Medical Center for evaluation and treatment. We compared the prevalence of Chagas disease by age, sex and national origin. We then used a conditional numerator and fixed denominator to construct the cascade of care, with the stages defined as referred to ID care, evaluation in ID, initiation of treatment and completion of antitrypanosomal therapy. We used chi-squared tests to compare proportions.

Results

From March 21, 2017 to April 17, 2019, 5,125 patients were screened. 50 (0.97%) were confirmed to have T. cruzi infection, among them 3 pregnant women. There were no differences in the prevalence of T. cruzi infection by sex (M = 22/1870 [1.18%], F = 28/3305 [0.85%], P = 0.245) but prevalence increased from 0/190 (0%) in those <20 years old to 11/1083 (1.02%) in 40–49 year olds (P = 0.001). The 3 infants of infected mothers were screened. The cascade of care for Strong Hearts is displayed in Figure 1.

Conclusion

Chagas disease prevalence in at-risk communities in Boston is substantial. 20% of patients with T. cruzi infection identified in this program have completed treatment to date. Most infected patients were referred for evaluation, but substantial drop-off occurred at each of the next 3 steps of the cascade. Confronting barriers at each of these steps is a crucial component of efforts to address this neglected disease.

Disclosures

All authors: No reported disclosures.
1678. Assessing Performance of Multiple Methods for Measurement of Body Temperature, Bangladesh
Authors: Martin Daniel W , Das Pritimoy , Friedman Michael , Rahman Mahmudur
Published: October 2019

Background

CDC and icddr,b are conducting an acute febrile illness (AFI) research project in four hospitals in Bangladesh. Enrolled subjects have measured fever of ≥100.4°F. To determine the most-sensitive temperature measurement method, we collected multiple measurements on patients with fever history between March and April 2019.

Methods

Patients were screened in outpatient departments of four hospitals in Bangladesh between March 7 and April 15, 2019. Screening used at least two of three methods: tympanic, oral, or axillary. Records were consolidated using Microsoft Excel and analyzed in R3.4.3. We examined the correlation between temperatures measured by different methods for each patient. For records with all three measures, we calculated the likelihood of meeting AFI inclusion criterion of ≥100.4°F (38°C) by measurement method.

Results

3,060 subjects were enrolled. The highest correlation among measurements was between axillary and oral (r = 0.882, 95% CI 0.868–0.895). The lowest correlation was between tympanic and oral (r = 0.71, 95% CI 0.69–0.73). Axillary and oral had the highest correlation in both children and adults (peds: 0.88, 95% CI 0.86–0.90; adult: 0.89, 95% CI 0.86–0.90). By site, the highest correlation was axillary to oral among children in Hospital 1 (r = 0.98, 95% CI 0.92–1.00), while the lowest was axillary to tympanic for adults in Hospital 3 (r = 0.71, 95% CI 0.65–0.77). 882 subjects (334 pediatric, 548 adult) were assessed using all three measurement methods. 313 (159 pediatric, 154 adult) met AFI inclusion criterion by at least one method. From 49% to 63% of subjects at any site met the criterion by two or three methods (table). Results in hospitals 1, 2 and 4 were similar and grouped for analysis. In every site, subjects were detected by oral who would not have been detected using axillary or tympanic. Only in Hospital 3, subjects were detected by tympanic alone. No subjects in any site met the criterion by axillary measurement alone.

Conclusion

Accurate measurement of body temperature is essential for AFI surveillance, but literature on methodology is limited. We demonstrate that multiple modes of measurement increased detection of febrile patients. The most sensitive combination was oral and tympanic. Axillary measurement did not improve detection.

Disclosures

All authors: No reported disclosures.
1680. Guillain Barré Syndrome in Arbovirus Outbreak in Veracruz, Mexico: The Follow-up to 3 Years of the Pandemic
Authors: Del Carpio-Orantes Luis , Salvador Sánchez-Díaz Jesús , Gabriela Peniche Moguel Karla , García-Méndez Sergio , Arnulfo Perfecto-Arroyo Miguel , Solis-Sánchez Ishar , del Pilar Mata-Miranda Maria , García-Lechuga Maricela , Patricia Moreno-Aldama Nancy , Rosario Contreras-Sánchez Edna , Isela Luna-Ceballos Rosa
Published: October 2019

Background

From the arrival of Zika to America in 2015, and the increase in cases of Guillain sweeten in South America apparently associated with acute viral infection, Mexico had its first contact in 2016, with an increase in the incidence of cases of the syndrome, initiating a protocol study to look for the causal association of the Zika virus syndrome

Methods

We conducted a descriptive, prospective, and longitudinal study in Veracruz, Mexico, where follow-up of cases of Guillain Barre Syndrome (GBS) occurred during 2016 to 2018. The central point of the study is to look for the etiological association of GBS with the presence of acute zika infection. Secondarily, other know neutropic agents, both viral and bacterial were searched. The diagnosis techniques used were PCR-RT (blood and urine) and IgM/IgG for Zika; serum PCR-RT and IgM/IgG for Dengue and Chikungunya; IgM/IgG for TORCH; PCR-RT in CSF for Herpes and Enterovirus; serological panel of Hepatitis B and C; PCR-RT in rectal swab for Campylobacter.

Results

A cohort of 39 patients has been formed over 3 years of study. 38 patients met the operational definition of a suspected case of Zika, of which only 2 cases were identified by PCR-RT in urine; During the search protocol for infectious agents, others were identified such as: Dengue, Chikungunya, Enterovirus, Herpes and Hepatitis B; however, the identification of Campylobacter was even more remarkable, also highlighting that only four patients had diarrhea.

Regarding the treatment, 37 patients received IVIG, 1 patient received plasmapheresis and 1 patient received both. The prognosis was good in 34 patients (basal Hugues from 4–5 to 2), 5 had poor functional prognosis and died.

Conclusion

The incidence of Zika as a cause of GBS is relatively low (5%), so the etiological association could not be demonstrated; other neurotropic viral agents were identified, however the presence of Campylobacter cases was more notable (asymptomatic campylobacteriosis).

Disclosures

All authors: No reported disclosures.
1720. Isolation and Characterization of Candida auris From an Active Surveillance System in Texas
Authors: Alam M Jahangir , Begum Khurshida , Endres Bradley T , McPherson Jacob , Costa Gabriela , Miranda Julie M , Garey Kevin W
Published: October 2019

Background

Candida auris is an emerging new multi-drug-resistant fungal pathogen spreading globally. C. auris is associated with outbreaks due to the bloodstream, ear, and wound infections with a high mortality rate (30 to 60%). As part of our multi-pathogen surveillance system, we began screening for C. auris to understand the ecology, sources, and epidemiology of this important pathogen from leftover stool samples collected from hospitalized patients.

Methods

Four hundred and seventeen stool samples were collected, enriched in brain heart infusion broth for 2–3 days at 37°C, and sub-cultured onto selective Candida agar plates. Agar plates were incubated at 37°C for another 2–3 days and suspected Candida colonies were stocked for DNA extraction, PCR identification, and whole-genome sequencing. PCR amplicons were sequenced to confirm the identification C. auris. Enrichment samples were also screened by PCR to directly detect C. auris. Minimum inhibitory concentration (MIC) of various anti-fungal drugs was determined by the micro-dilution method using a commercial MIC plate (Sensititre “YeastOne”).

Results

Three C. auris samples were identified by PCR (0.7%; 3/417) of which one was able to be cultured. The isolated strain was resistant to fluconazole, itraconazole, voriconazole, posaconazole, and caspofungin. WGS data analysis demonstrates our isolate has high similarity with the Pakistani strains.

Conclusion

We have detected C. auris from stool samples of hospitalized patients in Texas for the first time. WGS data indicate our isolate has high similarity with South Asian patient strains. Long-term surveillance of C. auris is essential to understand the infection or colonization sources and epidemiology of this newly emerging fungal pathogen.

Disclosures

All authors: No reported disclosures.
1737. Impact of Therapeutic Drug Monitoring (TDM) of Azole Prophylaxis in Lung Transplant Recipients on the Development of Positive Fungal Events
Authors: Shah Anooj , D’Agostino Carly , Cunningham Kathleen , Kane Clare , Ison Michael G , Schulte Jamie
Published: October 2019

Background

The utility and clinical impact of therapeutic drug monitoring (TDM) of prophylactic azole antifungals in lung transplant recipients is not well described. The objective of this study was to investigate the impact of TDM of azole prophylaxis in lung transplant recipients on the development of positive fungal events.

Methods

A retrospective analysis was performed on 47 lung transplant recipients between 2013 and 2018 at Northwestern Memorial Hospital. A positive fungal event was defined as fungal species on BAL culture and/or positive BAL Aspergillus galactomannan (GM) with an index value ≥1.0. Study groups were defined based on attainment of therapeutic trough levels after initiation of oral therapy (therapeutic if posaconazole level ≥0.7 μg/mL or voriconazole ≥1–5.5 μg/mL, subtherapeutic if ≥2 consecutive levels of posaconazole <0.7 μg/mL or voriconazole <1 μg/mL after initial dose increase).

Results

There were no differences in baseline characteristics (Figure 1). There were a total of 11 fungal events with 3 (12.0%) occurring in the therapeutic cohort and 8 (36.4%) in those subtherapeutic (P = 0.08). In the 5 patients with a positive GM, the mean index was 2.02 ± 0.95. 7/30 (23.3%) of patients on posaconazole had a fungal event, with 2/7 (28.6%) requiring treatment at the time of event. For patients on voriconazole, 4/17 (23.5%) had a fungal event, with 1/4 (25.0%) requiring treatment. Mean time to fungal event was 164.5 ± 8.9 days vs. 135.9 ± 13.7 days in the therapeutic and subtherapeutic group, respectively (P = 0.05).

All patients on posaconazole suspension who experienced a fungal event were subtherapeutic (3/3, 100%) compared with the majority of patients on posaconazole delayed release (DR) tablets who achieved therapeutic levels (17/22, 77.3%). Mean posaconazole trough level observed in the patients receiving DR tablet was 2.15 ± 0.95 μg/mL.

Conclusion

There was an association between two consecutive subtherapeutic azole prophylaxis levels and positive fungal events indicating a role for TDM in lung transplant recipients. Time to fungal event post-transplant was shorter in subtherapeutic patients. As anticipated, the use of posaconazole suspension resulted in subtherapeutic levels. This study presents an opportunity for further research of the impact of TDM on clinical outcomes to optimize patient care.

Disclosures

All authors: No reported disclosures.
1738. Incidence and Outcomes of Hospitalization with Invasive Fungal Infection Among Solid-Organ Transplant Recipients: A Population-Based Cohort Study
Authors: Naylor Kyla L , Ouédraogo Alexandra , Bota Sarah E , Husain Shahid , Paterson J Michael , Hosseini-Moghaddam Seyed M
Published: October 2019

Background

Invasive fungal infection (IFI) in solid-organ transplant (SOT) recipients is associated with significant morbidity and mortality. The long-term probability of post-transplant IFI is poorly understood.

Methods

We conducted a population-based cohort study using linked administrative healthcare databases from Ontario, Canada to determine the incidence rate, 1-, 5- and 10-year cumulative probability of IFI-related hospitalization, and 1-year post-IFI all-cause mortality in SOT recipients from 2002 to 2016. We also examined post-IFI death-censored graft failure in renal transplant patients.

Results

We included 9326 SOT recipients (median follow-up 5.35 years). Overall, the incidence of IFI was 8.3 per 1000 person-years (95% confidence interval [CI]: 7.5–9.1). The 1-year cumulative probability of IFI was 7.4% (95% CI: 5.8–9.3%), 5.4% (95% CI: 3.6–8.1%), 1.8% (95% CI: 1.3–2.5%), 1.2% (95% CI: 0.5–3.2%), and 1.1% (95% CI: 0.9–1.4%) for lung, heart, liver, kidney-pancreas, and kidney-only transplant recipients, respectively. Lung transplant recipients had both the highest incidence rate and the highest 10-year probability of IFI: 43.0 per 1,000 person-years (95% CI: 36.8–50.0) and 26.4% (95% CI: 22.4–30.9%), respectively. Lung transplantation was also associated with the highest 1-year cumulative probability of post-IFI all-cause mortality (40.2%,95% CI: 33.1–48.3%). Among kidney transplant recipients, the 1-year probability of death-censored graft failure after IFI was 9.8% (95% CI: 6.0–15.8%).

Conclusion

The 1-year cumulative probability of IFI varies widely among SOT recipients. Lung transplantation was associated with the highest incidence of IFI with considerable 1-year all-cause mortality. The findings of this study considerably improved our understanding of the long-term probability of post-transplant IFI.

Disclosures

All authors: No reported disclosures.
1746. Prevalence and Resistance Patterns of Cytomegalovirus Viremia in Immunocompromised Patients
Authors: Kim Edward , Asmar Basim , Thomas Ronald , Abdel-Haq Nahed M
Published: October 2019

Background

We noted a recent increase in the number of patients with CMV viremia among immunocompromised children at our institution. The study was undertaken to determine the prevalence of CMV viremia and to evaluate factors associated with the development of antiviral drug resistance.

Methods

A retrospective study of immunocompromised hosts 0–21 years of age who had CMV viremia (2007–2017). We collected demographic data as well as details of antiviral therapy and resistance testing.

Results

A total of 31 patients were identified including 10 (32%) during the last 2 years. The age range was 3 months to 20 years (median 12.6 years); 23 (74%) were male and 12 (39%) were African American. Among the 31 patients, 18 had hematopoietic stem cell transplantation, 5 had primary immunodeficiency (2 common variable immunodeficiency, 1 SCID, 1 Langerhans cell histiocytosis, 1 DiGeorge syndrome), 4 had malignancies receiving chemotherapy, 3 with heart transplantation and one 17 year old with newly diagnosed HIV infection who presented with CMV pneumonia and viremia. Antiviral resistance testing was performed on 7 CMV isolates: 5 due to persistent viremia (> 1 months) despite treatment, and 2 prior to starting antiviral therapy. CMV resistance was identified in 3 patients including 2 with CVID and one with Hodgkin’s disease status post bone marrow transplantation. The 2 CVID patients had other comorbidities including chronic diarrhea and malabsorption and were TPN dependent. Both were diagnosed with CMV colitis and one also had pneumonitis. One had received a prolonged oral valganciclovir course (> 1 year) prior to diagnosis of resistance and the other received long-term intermittent oral valganciclovir courses. The patient with Hodgkin’s disease received a prolonged IV ganciclovir course. All 3 tested positive for UL97 mutation and one had both UL97/UL54 gene mutations.

Conclusion

Most of our patients with CMV viremia were transplant patients. Antiviral drug resistance was detected among 3 of 31 (10%) of our patients during the study period. Two had malabsorption that may have resulted in sub-therapeutic blood levels. Treatment with oral valganciclovir should be avoided in patients with poor gut absorption because it may increase risk of drug resistance.

Disclosures

All authors: No reported disclosures.
1750. Epidemiology of Cytomegalovirus DNAemia in Pediatric Solid-Organ Transplant Patients
Authors: Valencia Deray Kristen , Hosek Kathleen , Moulton Elizabeth A , Munoz Flor M , Munoz Flor M , Demmler-Harrison Gail J , Bocchini Claire
Published: October 2019

Background

Despite the widespread use of prevention strategies, CMV remains a common opportunistic infection in SOTR. Contemporary data regarding CMV in pediatric SOTR is limited. We sought to determine the frequency of and risk factors for CMV infection and disease in a large single-center cohort of pediatric SOTR.

Methods

A retrospective cohort study of patients <22 yr of age who received lung, heart, liver, kidney, or multi-organ transplants at TCH between 2014 and 2018 was completed. Universal CMV prophylaxis was used based on risk status (Figure 1). Primary outcome was CMV DNAemia (plasma level ≥ 1,000 IU/mL). Associations with CMV DNAemia were measured using Fisher exact, Kruskal–Wallis, and multivariate logistic regression. Survival analysis and time to CMV infection were assessed using Kaplan–Meier plots.

Results

Among 465 SOTR, 57 (12%) had CMV DNAemia ≥ 1,000 IU/mL; this included 9/52 (17%) lung, 22/155 (14%) liver, 16/125 (13%) heart, 1/9 (11%) multi-organ, and 9/124 (7%) kidney recipients. 6 (10%) SOTR had early-onset CMV reactivation while on antiviral prophylaxis. Post-prophylaxis, 48 (85%) SOTR had CMV reactivation and 3 (5%) had primary infection. Median time to DNAemia > 1,000 IU/mL was 366 days post-transplant for lung, 115 for liver, 185 for heart, and 290 for kidney (P = 0.04), reflecting differences in prophylaxis strategies. High-risk CMV status (D+/R- for heart, liver, kidney and D+ and/or R+ for lung) was associated with CMV DNAemia (P < 0.01, Figure 2). DNAemia was not associated with age at transplantation, type of organ, or induction immunosuppression. There was no difference in survival during the study follow-up period (1 – 5 years) for SOTR with vs. without DNAemia. Overall, 18/465 (4%) SOTR had CMV disease: 2 (4%) lung, 3 (2%) liver, 5 (4%) heart, 1 (11%) multi-organ, and 7 (6%) kidney recipients. 16 had CMV syndrome and 2 had tissue-invasive disease. Median (range) maximum viral loads were 35,768 IU/mL (3,239–4,807,992) for SOTR with vs. 2,605 IU/mL (1,000–112,000) for SOTR without CMV disease (P < 0.01)

Conclusion

This large contemporary cohort of pediatric SOTR on universal prophylaxis demonstrates low overall rates of CMV DNAemia and CMV disease. High-risk CMV status remains associated with CMV DNAemia, suggesting that further interventions targeting this group may be warranted.

Disclosures

Flor M. Munoz, MD, Biocryst: Grant/Research Support; CDC: Research Grant; Moderna: Other Financial or Material Support, Safety Monitoring Board Member/Chair; NIH: Research Grant; Novavax: Research Grant; UP to Date: Author and Editor - Royalties, Other Financial or Material Support.
1775. A Community-wide Study to Evaluate the Accuracy of Self-testing for Influenza: Works in Progress
Authors: Thompson Matthew , Zigman Suchsland Monica L , Lyon Victoria , Kline Enos , Huang ShiChu , Chu Helen Y , Rieder Mark , Starita Lea , Bosua Jeris , Lutz Barry R
Published: October 2019

Background

Seasonal influenza (flu) occurs annually, causing disease with substantial morbidity and mortality. Currently, flu is suspected from clinical features, but requires a laboratory test to confirm infection. No influenza tests in the United States are approved for use outside of clinical settings. We aimed to determine the accuracy of influenza self-testing using an at-home, app-guided, lateral flow assay compared with a molecular reference standard conducted at a laboratory among adults self-reporting influenza-like illness (ILI).

Methods

This is an observational study of individuals with self-reported ILI throughout the continental 48 United States recruited from the Flu Near You platform, online marketing, and clinics in the Seattle area. Recruitment took place from March 4 to April 26, 2019. Participants were directed to an iPhone App that determined eligibility, consent, and responses to symptom questions and risk factors. Individuals were mailed a commercially available CLIA-waived influenza lateral flow test to conduct at home, guided by the app, and returned the used test along with a second nasal swab collected in viral transport media to the research team. Influenza testing was performed by RT–PCR on the second nasal swab, as well as the residual fluid from the RDT. Accuracy of home test result (read by the participant), as well as image capture of the lateral flow test strip, were compared with the lab-based reference standard.

Results

To date, 1127 at-home flu tests were mailed to participants and 711 (63.1%) samples returned to the lab. There were 17 flu-positive results from the rapid diagnostic test for a flu positivity rate of 2.4%. Testing using the reference standard is currently in progress. We will share diagnostic accuracy results once testing of the reference standard is completed. Of the kits returned, 353 (49.7%)had an error recorded, which included errors in return packaging, reference standard, rapid test tube sample, or rapid test strip errors.

Conclusion

Overall, findings from this study will determine the accuracy of an at-home rapid diagnostic test, and inform more widely research design for evaluating smartphone-enhanced home tests for pathogens. Many samples returned to the lab had a recorded error, suggesting at-home testing requires additional feasibility testing and refinement of the current methods used.

Disclosures

All authors: No reported disclosures.
1790. Single-Center Experience and Lessons Learnt from Management of Nipah Virus Outbreak in India
Authors: Kumar A S Anoop , T Sohanlal , Prasad Ganga , Gupta Manisha , Gopal Ajith
Published: October 2019

Background

Nipah virus (NiV) is re-emerging zoonotic RNA virus belonging to Paramyxoviridae family. Suspecting Nipah virus in a NiV naive tropical area is a challenge. NiV management is further confounded by acute presentation, high mortality, broad species tropism, multiple modes of transmission, difficulty to diagnose and lack of definitive treatment.

Methods

Recent NiV outbreak that lasted for approximately 1 month (2–29 May 2018) and resulted in 23 cases with a case-fatality rate of 91%. We present clinical summary and management of five cases managed at Baby Memorial Hospital, Kozhikode, India from May 17, 2018 to May 30, 2018 and were epidemiologically linked to the index case. All patients presented with initial nonspecific prodromal symptoms of fever, muscle pain, watery diarrhea. Median age was 53 years, four were males, median hospital stay was 3 days, median incubation period of was days. Further complications, included encephalitis with viral bronchopneumonia/acute respiratory distress syndrome (ARDS) in 100 %, patients, encephalitis with viral bronchopneumonia/ARDS with myocarditis in 60 %patients, despite attempted therapy with ribavirin all patients developed cardiorespiratory arrest and succumbed to the illness.

Results

Hematological Investigations showed normal TLC with a mean of 7,920 cells/ mm3, mild thrombocytopenia (mean 1,57,800) high Hb 16.12(SD1.10), ESR 19 mm/hr, DLC-N 82% high relative neutrophilic cytosis. Normal liver and renal function, Na+ 133 meq/L. CSF analysis showed high opening pressure, 100% lymphocytic pleocytosis, mean CSF sugar 118 mg/100mL, CSF protein 73.6. CT chest -bilateral airspace opacities and ground glassing. Brain FLAIR sequence showed nonspecific hyperintensities in white matter and brainstem correlating with vasculitic changes. Laboratory diagnosis of NiV was made by Real-Time RT–PCR on throat swab, blood, urine and cerebrospinal fluid by Manipal virus research center and National Institute of Virology. Pathological autopsy was done in 2 cases and found noncontributory.

Conclusion

We report clinical and public health management experience from one of the three hospitals managing the patients affected with NiV. Managing outbreaks of high infectivity requires persistent organized and committed healthcare interventions

Disclosures

All authors: No reported disclosures.
1792. Viral DNA Loads in Various Blood Components of Patients with EBV-Positive T/NK Cell Lymphoproliferative Diseases
Authors: Kawada Jun-ichi , Kamiya Yasuko , Sawada Akihisa , Iwatsuki Keiji , Izustu Koji , Torii Yuka , Kimura Hiroshi , Ito Yoshinori
Published: October 2019

Background

Epstein–Barr virus (EBV) is associated with T- and NK-cell lymphoproliferative disorders (EBV T/NK-LPD). For diagnosis of EBV T/NK-LPD, quantification of EBV DNA loads in peripheral blood by real-time PCR has been widely used. However, optimal blood components and cut-off values for diagnosis were not fully evaluated.

Methods

Fifty-nine patients with EBV T/NK-LPD including chronic active EBV infection (CAEBV), severe mosquito bite allergy, hydroa vacciniforme-like lymphoproliferative disorder (HV), and EBV- hemophagocytic lymphohistiocytosis (EBV-HLH) were enrolled. EBV DNA loads were compared among disease categories in each blood component from the same whole blood sample. The association between EBV DNA loads and disease activity were evaluated in CAEBV patients. Furthermore, the diagnostic cut-off value for EBV DNA loads in whole blood from CAEBV patients as compared with infectious mononucleosis patients was determined.

Results

EBV DNA loads in whole blood and peripheral blood mononuclear cells (PBMCs) were not significantly different among disease categories, whereas EBV DNA loads in plasma were significantly higher in EBV- HLH patients than in HV patients. EBV DNA loads in whole blood and PBMCs showed strong correlation (Figure 1). EBV DNA loads in plasma were significantly higher in CAEBV patients with active disease than in those with inactive disease (median: 104.5 IU/mL vs. 100.8 IU/mL, P < 0.001) (Figure 2). Diagnostic cut-off values for whole blood EBV DNA loads of CAEBV patients as compared with those of infectious mononucleosis was 104.2 ( = 15,800) IU/mL (Figure 3).

Conclusion

Measuring EBV DNA loads in whole blood can be considered as initial evaluation for diagnosis of EBV T/NK-LPD. EBV DNA loads in plasma are more closely related to disease activity of CAEBV than EBV DNA loads in whole blood and PBMCs.

Disclosures

All authors: No reported disclosures.
1981. Implementation of an Antifungal Stewardship Bundle Focused on Candidemia in an Indian Hospital
Authors: Moni Merlin , Menon Vidya , Sudhir Sangita , T.S. Dipu , Philip Jeslyn , James Jini , Singh Sanjeev , Zhou Shiwei , Patel Twisha S , Kaye Keith S , Patel Payal K
Published: October 2019

Background

In India, Candida bloodstream infections have a reported incidence of 1–12 per 1,000 admissions and a mortality rate of up to 60%. Antimicrobial stewardship programs (ASP) can improve quality of care and clinical outcomes. This study evaluates the impact of a comprehensive candidemia ASP bundle in a hospital in southern India with an established stewardship program.

Methods

A single-center, pre-post quasi-experimental study was conducted at a tertiary-care center in southern India to analyze the impact of an ASP care bundle for the management of adults with candidemia. During the intervention period (October 2017–December 2018), the ASP provided recommendations to providers in accordance with the 2016 IDSA Guidelines for the Management of Candidemia, which included the following bundle: (1) appropriate selection and dosing of antifungal therapy; (2) repeat blood cultures every 48 hours until clearance; (3) removal of central venous catheters and other potential removable foci of infection; (4) echocardiogram; (5) ophthalmologic evaluation; and (6) appropriate duration of therapy. The primary outcome was initiation of appropriate antifungal therapy. Additional clinical outcomes were also compared with a historical cohort.

Results

One hundred and four patients with candidemia were included: 52 in the pre-intervention and 52 in the post-intervention group. Overall, baseline demographics were similar between the two groups (Table 1). Candida tropicalis (26.9%) and Candida parapsilosis (29.8%) were the most common causes of candidemia in the cohort. Following intervention, administration of appropriate antifungal therapy improved by 40.4% (28.8% pre vs. 69.2% post, P < 0.01). Average time to effective treatment initiation following culture positivity decreased from 57.6 hours to 12 hours in the post-intervention group (P < 0.01). Thirty-day all-cause mortality was similar between the two groups (34.6% 38.4%, P = 0.84).

Conclusion

Implementation of a comprehensive candidemia care bundle by the ASP significantly improved the use and timing of initiation of appropriate antifungal therapy.

Disclosures

All authors: No reported disclosures.
2001. Assessment of Real-world Effectiveness of a Rapid Blood Culture Diagnostic Panel at a Veterans Affairs Medical Center
Authors: Chiasson Jordan , Cutrell James B , Cutrell James B , Tomasz Jodlowski , Smith Winter , Kouma Marcus
Published: October 2019

Background

Rapid blood culture diagnostics can improve patient outcomes, particularly when paired with robust interventions such as 24/7 stewardship coverage. We sought to determine the clinical impact of a rapid blood culture identification (BCID) panel (BioFire® FilmArray Multiplex PCR) in an established antimicrobial stewardship program (ASP). In addition to clinician education, BCID results were reviewed by the ASP team during weekday business hours, for an average of 2 hours daily based on availability.

Methods

Data on demographics, blood cultures, antimicrobial use, length of stay and mortality were collected on inpatients at the VA North Texas Health Care System with at least one positive blood culture for bacterial or yeast isolates from March 2017 to June 2017 (pre-BCID) and from March 2018 to June 2018 (post-BCID). The primary outcome was a composite of time to optimal therapy from blood culture collection, defined as escalation, de-escalation, discontinuation, or optimization of antimicrobials retrospectively adjudicated based on final culture results. Secondary outcomes included time to effective therapy, total days of therapy (DOT), length of stay, and 30-day mortality and readmission rates.

Results

195 patients were screened with 130 patients included in the study. No significant differences in baseline characteristics were observed between groups (Table 1). Sixty-one patients were included in the pre-BCID arm and 69 in the post-BCID arm. Median time to optimal therapy was 82.9 hours (IQR; 12.8–99.8) in the pre-BCID arm and 33.9 hours (IQR; 11.2–64.8) in the post-BCID arm (P = 0.005) (Table 2). No significant change in 30-day mortality or 30-day readmission rates was noted. Vancomycin DOT was 4 days (IQR; 2–5) and 3 days (IQR; 1–4) (P = 0.024), and piperacillin–tazobactam DOT was 4 (IQR; 0–5) and 2 (IQR; 0–4) (P = 0.043), in the pre-BCID and post-BCID groups, respectively (Figure 1).

Conclusion

Introduction of BCID into the daily workflow of our ASP resulted in a significant reduction in time to optimal therapy for bloodstream infections. DOT for select broad-spectrum antibiotics were also significantly reduced. This study highlights the potential benefit of rapid diagnostics without negative impact to patient care even in settings without resources for 24/7 ASP review.

Disclosures

All authors: No reported disclosures.
2006. Evaluation of Rapid Blood Culture Identification with Antimicrobial Stewardship Treatment Recommendations at a Community Health System in Patients with Gram-negative Bacteremia: Adequacy, Adherence, and Outcomes
Authors: Deja Erin , Frens Jeremy J
Published: October 2019

Background

Sepsis mortality is greatly affected by the timely receipt of appropriate antibiotics. FilmArray Blood Culture Identification (BCID) is used at Cone Health to identify organisms in blood cultures within one to 2 hours after growth detected. The Cone Health antimicrobial stewardship (AMS) team has created treatment recommendations for each organism and resistance mechanism identifiable by BCID. Results and antibiotic recommendations are communicated in real time to providers by clinical pharmacists. The purpose of this evaluation was to validate the adequacy of antibiotics recommended by the BCID treatment algorithm for Gram-negative rods (GNR); assess proper implementation of the BCID notification procedure; and evaluate its effect on AMS.

Methods

Patients with GNR BCID results in January and April 2018 were retrospectively identified. Information collected for each patient included: demographics, location, organism, admission antibiotics, pharmacist compliance with BCID procedure, recommendation acceptance rate, organism susceptibility, changes to antibiotics post-BCID and final cultures, extended-spectrum β-lactamase (ESBL) incidence, length of antibiotic therapy, and patient outcome.

Results

A total of 101 patients were evaluated. The BCID treatment algorithm recommendations covered 97% of identified organisms (Figures 1–4). Resistant isolates were ESBL producers. Pharmacist antibiotic recommendations matched the treatment algorithm 66% of the time. Providers accepted 90% of pharmacist recommendations. Twenty-two percent of antibiotics were not de-escalated after BCID results without identifiable reason.

Conclusion

The BCID treatment algorithm provided adequate coverage for nearly all identified organisms, except ESBLs. However, patients with ESBL organisms all survived to hospital discharge. Pharmacists are following the BCID protocol in a majority of cases. One-third of recommendations deviated from the algorithm but only 17% did not have documented reasoning. Providers are very receptive to pharmacist input, with only 8% of recommendations rejected without documented reasoning. Finally, nearly a quarter of empiric antibiotics were not de-escalated despite organism identification, which represents opportunity for improvement.

Disclosures

All authors: No reported disclosures.
2008. Outcomes of Patients with Positive Procalcitonin Levels Who Do Not Receive Continued Antibiotics
Authors: George Jamie , Kale-Pradhan Pramodini , Johnson Leonard B
Published: October 2019

Background

Procalcitonin (PCT) is a biomarker used to direct continued use of antibiotic therapy in patients with sepsis and community-acquired pneumonia. There is a lack of data on outcomes of patients with a positive PCT who do not receive continued antibiotics. We compared outcomes in patients with positive PCT levels who received antibiotics <24 hours to those who received ≥ 24 hours.

Methods

A single-center, retrospective study to compare outcomes of adult patients with positive PCT (>0.25 μg/L) levels based on antibiotic duration. A report of hospitalized patients from January to June 2018 was generated and screened for inclusion criteria. Data collection included demographics, microbiologic data, Charlson Weighted Index of Comorbidity (CWIC), ICU admission, length-of-stay (LOS), and in-hospital mortality. Continuous and categorical variables were analyzed using Student’s t-test and Chi-square, respectively.

Results

443 of 998 patients met the inclusion criteria. 113 patients (25.5%) received <24 hours of antibiotics (Group 1) and 330 patients (74.5%) received ≥ 24 hours (Group 2). Group 1 had a higher CWIC, lower mean PCT and were less likely to have positive cultures (see table). Mean LOS was significantly different between the groups. ICU admission and mortality were not found to be different between the groups. While Group 1 had higher rates of noninfectious causes of mortality and Group 2 had higher rates of infectious, the differences were not significant. Among patients who died in-hospital, 47.6% vs. 63.2% had acute or chronic renal failure in Group 1 vs. Group 2, respectively.

Conclusion

Patients with elevated PCT levels are a heterogenous group. There was no overall difference in mortality between the two groups indicating that the interpretation of positive PCT results was overall appropriate in this study. Clinicians need to consider noninfectious causes of elevated PCT when evaluating patients.

Disclosures

All authors: No reported disclosures.
2019. Multicentric Antimicrobial Point Prevalence Survey in Four Tertiary Care Hospitals in Southern India
Authors: Prakash Shilpa , Wilson Arun , Warrier Anup R , Babu Rachana , Joy Sonya , Rathish Balram
Published: October 2019

Background

Antibiotic consumption data are scarce in the subcontinent. Defined Daily Doses (Doses) and Days of Therapy (DOT)-based metrics both have inherent disadvantages limiting their application in resource-limited settings primarily in terms of resource hours.. Point Prevalence Study (PPS) offers an offer an initial feasible step for describing antimicrobial use and identifying targets to reduce inappropriate use. Aim of the present study was to use PPS to identify quantitative and qualitative aspects of antimicrobial consumption.

Methods

A cross-sectional hospital-based PPS was conducted in 4 tertiary care hospitals—Aster Medcity (Kochi, Kerala), Aster MIMS (Calicut, Kerala), Aster Ramesh (Guntur, Andhra Pradesh), and Aster CMI (Bengaluru, Karnataka)—based on a standardized format derived from the GLOBAL-PPS initiative and WHO resources.

Results

The total number of patients surveyed was 944.42.7% patients had a standing antibiotic order, out of which 19.80%patients were receiving reserve antimicrobials (WHO classification). 76.23% of prescriptions were used empirically, 16.08% were used as prophylaxis meanwhile 7.67% had a culture-based indication. The overall DOT (per 1000 patient-days) for all antimicrobials in the 4 centers were 86.54, 64.19, 93.71 and 85.93 respectively with a cumulative mean DOT of 82.59. Reserve antimicrobials DOT were 26.28, 14.83, 28.08 and 19.61, respectively, with a mean of 22.2. The most common class of antimicrobial prescribed was β lactam -β lactamase inhibitors (BL/BLI) 27.3% while Carbapenems (8.16%) was the most common amongst reserve antimicrobials. Out of all the prescriptions only 7.67% had indications documented. Documented errors of dosing were seen in 8 patients. Adherence to monitoring for ADE was done in 92.57%.

Conclusion

The study reveals antibiotic use in almost 40% of patients under survey with a DOT of 82.59 per 1000 patient-days. Improving empirical use of antimicrobials, BL/BLI focused intervention and improved documentation has been identified as potential areas for intervention based on this study.The study also highlights the scope of PPS as an effective tool in resource-limited setting to define and refine antimicrobial use and contribute toward antimicrobial stewardship as well as other activities aimed reducing antimicrobial resistance across a range of settings.

Disclosures

All authors: No reported disclosures.