bluuebunny/crossref_metadata_2025 huggingface dataset:
The COMBS Survey - II. Distinguishing the metal-poor bulge from the halo interlopers
Authors: Lucey Madeline , Hawkins Keith , Ness Melissa , Debattista Victor P , Luna Alice , Asplund Martin , Bensby Thomas , Casagrande Luca , Feltzing Sofia , Freeman Kenneth C , Kobayashi Chiaki , Marino Anna F
Published: January 2021

The metal-poor stars in the bulge are important relics of the Milky Way’s formation history, as simulations predict that they are some of the oldest stars in the Galaxy. In order to determine if they are truly ancient stars, we must understand their origins. Currently, it is unclear if the metal-poor stars in the bulge ([Fe/H] < −1 dex) are merely halo interlopers, a unique accreted population, part of the boxy/peanut-shaped bulge, or a classical bulge population. In this work, we use spectra from the VLT/FLAMES spectrograph to obtain metallicity estimates using the Ca-II triplet of 473 bulge stars (187 of which have [Fe/H] < −1 dex), targeted using SkyMapper photometry. We also use Gaia DR2 data to infer the Galactic positions and velocities along with orbital properties for 523 stars. We employ a probabilistic orbit analysis and find that about half of our sample has a >50 per cent probability of being bound to the bulge, and half are halo interlopers. We also see that the occurrence rate of halo interlopers increases steadily with decreasing metallicity across the full range of our sample (−3 < [Fe/H] < 0.5). Our examination of the kinematics of the confined compared to the unbound stars indicates the metal-poor bulge comprises at least two populations; those confined to the boxy/peanut bulge and halo stars passing through the inner galaxy. We conclude that an orbital analysis approach, as we have employed, is important to understand the composite nature of the metal-poor stars in the inner region.
3. Phase 3 Pivotal Evaluation of 20-valent Pneumococcal Conjugate Vaccine (PCV20) Safety, Tolerability, and Immunologic Noninferiority in Participants 18 Years and Older
Authors: Essink Brandon , Sabharwal Charu , Xu Xia , Sundaraiyer Vani , Peng Yahong , Moyer Lisa , Pride Michael W , Scully Ingrid L , Jansen Kathrin U , Gruber William C , Scott Daniel , Watson Wendy
Published: January 2021

Background

PCV20 contains the 13-valent pneumococcal conjugate vaccine (PCV13) components, and 7 additional conjugates (for serotypes 8, 10A, 11A, 12F, 15B, 22F, and 33F), extending pneumococcal serotype coverage. Key data from the pivotal Phase 3 evaluation of PCV20 in adults are presented.

Methods

Adults naïve to pneumococcal vaccination were enrolled into 3 age cohorts (≥60, 50–59, and 18–49 years of age). Participants ≥60 years received either PCV20 and saline 1 month later, or PCV13 and 23-valent pneumococcal polysaccharide (PPSV23) 1 month later (1:1 randomization, double blind). Participants 50–59 and 18–49 years received either a dose of PCV20 or PCV13 (3:1 randomization, double blind). Tolerability, safety and immunogenicity (opsonophagocytic activity [OPA] responses) were assessed.

Results

3889 participants received vaccine. 1507 and 1490 participants ≥60 years received PCV20 or control respectively. All 20 vaccine serotypes induced robust responses and OPA geometric mean titers (GMTs) to all 13 matched serotypes were noninferior to PCV13. In addition, the OPA GMTs to 6 of the 7 additional serotypes 1 month after PCV20 were noninferior compared to the same serotypes in PPSV23. The OPA GMT of serotype 8 missed noninferiority by a very narrow margin (2-sided 95% lower bound of GMT ratio [20vPnC/PPSV23] was 0.49, with noninferiority criterion of >0.5); this is unlikely to be clinically significant given the high geometric mean fold rise of OPA titers after PCV20 (22-fold above baseline). GMTs after PCV20 in each of the younger age cohorts (18–49 years, 50–59 years) were noninferior to adults 60–64 years. The tolerability and safety profile of PCV20 was similar to PCV13.

Conclusion

Based on the robust immune responses and comparability to licensed pneumococcal vaccines, as well as bridging to the younger age group, these data support that PCV20 will be protective against pneumococcal disease due to the 20 serotypes in adults.

Disclosures

Charu Sabharwal, MD, MPH, Pfizer (Employee, Shareholder) Xia Xu, PhD, Pfizer (Employee, Shareholder) Vani Sundaraiyer, PhD, MS, Pfizer (Independent Contractor) Yahong Peng, PhD, Pfizer (Employee, Shareholder) Lisa Moyer, BS, Pfizer (Employee, Shareholder) Michael W. Pride, PhD, Pfizer (Employee, Shareholder) Ingrid L. Scully, PhD, Pfizer Inc (Employee, Shareholder) Kathrin U. Jansen, PhD, Pfizer (Employee, Shareholder) William C. Gruber, MD, Pfizer (Employee, Shareholder) Daniel Scott, MD, Pfizer (Employee, Shareholder) Wendy Watson, MD, Pfizer (Employee, Shareholder)
12. Evaluation of Rapid Phenotypic Testing for KPC Carbapenemase Producing klebsiella Pneumoniae Directly from Positive Blood Cultures by Use of “Hot Chocolate” Plates
Authors: Lawandi Alexander , Leite Gleice C , Lefebvre Brigitte , Longtin Jean , Lee Todd C
Published: January 2021

Background

Invasive infections with Carbapenemase Producing Enterobacterales are associated with considerable morbidity and mortality, in part due to the risk of inappropriate empiric therapy. Consequently, the rapid identification of carbapenem resistance is crucial to the management of these infections. We sought to evaluate possible reductions in turnaround time to identification of this resistance in blood cultures growing these organisms by applying rapid phenotypic test kits to growth from “hot chocolate” plates.

Methods

30 blood cultures, spiked with carbapenem resistant Klebsiella pneumoniae isolates or susceptible controls, were inoculated onto chocolate agars that had pre-warmed at 37°C. These plates were incubated at 37ºC for 3.5 hours. The resulting minimal growth was then identified using MALDI-TOF and underwent rapid phenotypic testing using three commercially available products (β-lacta and β-carba, from Bio-Rad, Marnes-la-Coquette, France, and Carba-NP, from bioMérieux, Durham, NC). The time to identification of carbapenem resistance using this method was then compared to that of the conventional laboratory workup.

Results

The identification was 100% accurate to the species level using MALDI-TOF paired to the 3.5 hour growth on the “hot choocolate” plates. The β-lacta kit identified resistance to 3rd generation cephalosporins for all ESBL and carbapenemase producing Klebsiella pneumoniae isolates, while the β-carba and Carba-NP kits identified carbapenem resistance only in the carbapenemase producers. The sensitivity of all assays was 100% (95% CI 0.87–1.0) and the specificity of carbapenemase detection was 100% (97.5% one-sided CI 0.4–1.0). The corresponding sensitivities and specificities of direct disc diffusion for ertapenem resistance detection were 88.5% (95% CI 0.70–0.98) and 100% (95%CI 0.40–1.0) respectively. The turnaround time for the rapid kits coupled to the “hot chocolate” plates was 4.25 to 5.1 hours as compared to 16 hours for the conventional workup.

Conclusion

Rapid phenotypic tests performed after inoculation of “hot chocolate” plates are highly sensitive for the presence of carbapenemase production and can be incorporated into the laboratory workflow for Klebisella pneumoniae with important reductions in turnaround time.

Disclosures

All Authors: No reported disclosures
22. Patient Satisfaction Remains Unchanged Following Implementation of an Antibiotic Stewardship Intervention in Primary Care
Authors: Hostetler Zachary , Hamilton Keith W , Cressman Leigh , Todman McWelling H , Lautenbach Ebbing , Dutcher Lauren
Published: January 2021

Background

Inappropriate prescription of antibiotics for respiratory tract infections (RTIs) in ambulatory care settings is common, increasing the risk of adverse health outcomes. Behavioral and educational interventions targeting primary care providers (PCPs) have shown promise in reducing inappropriate antibiotic prescribing for RTIs. While one perceived barrier to such interventions is the concern that these adversely impact patient satisfaction, few data exist in this area. Here, we examine whether a recent PCP-targeted intervention that significantly reduced antibiotic prescribing for RTIs was associated with a change in patient satisfaction.

Methods

The PCP-targeted intervention involved monthly education sessions and peer benchmarking reports delivered to 31 clinics within an academic health system, and was previously shown to reduce antibiotic prescribing. Here, we performed a retrospective, secondary analysis of Press Ganey (PG) surveys associated with the outpatient encounters in the pre- and post-intervention periods. We evaluated the impact on patient perceptions of PCPs based on provider exposure to the intervention using a mixed effects logistic regression model.

Results

There were 17,416 out of 197,744 encounters (8.8%) with associated PG surveys for the study time period (July 2016 to September 2018). In the multivariate model, patient satisfaction with PCPs was most strongly associated with patient-level characteristics (age, race, health status, education status) and survey-level characteristics (survey response time, patient’s usual provider) (Figure 1). Satisfaction with PCPs did not change following delivery of the provider-based intervention even after adjusting for patient- and survey-level characteristics [adjusted odds ratio (95% CI): 1.005 (0.928, 1.087)]. However, a small increase in satisfaction associated with receiving antibiotics during the entire study period was seen [adjusted odds ratio (95% CI): 1.146 (1.06, 1.244)].

Figure 1: Association of a provider-targeted intervention as well as patient, provider, and practice characteristics with patient satisfaction in a multivariable mixed effects logistic regression model

Conclusion

Patient perceptions of PCPs remain unchanged following the delivery of a behavioral and educational intervention to primary care providers that resulted in observable decreases in antibiotic prescribing practices for RTIs.

Disclosures

All Authors: No reported disclosures
29. Rapid Restoration of Bile Acid Compositions After Treatment with Investigational Microbiota-based Therapeutic RBX2660 for Recurrent clostrioides Difficile Infection
Authors: Ferdyan Nicky , Papazyan Romeo , Walsh Dana , Klein Sarah , Qi Steve , Blount Ken , Srinivasan Karthik , Fuchs Bryan
Published: January 2021

Background

Recurrent Clostrioides difficile infection (rCDI) is a public health threat associated with intestinal microbiome disruption (dysbiosis), which is postulated to increase CDI recurrence risk via disruption of bile acid(BA)-mediated resistance to C. difficile colonization. RBX2660 is an investigational microbiota-based therapeutic in clinical development for reducing rCDI recurrence. Herein, we assessed BA composition among participants in a Phase 2 trial of RBX2660 for rCDI.

Methods

In a double-blinded trial (PUNCH CD2), rCDI participants were randomized to receive RBX2660 or placebo. Primary efficacy was defined as absence of CDI recurrence at 8 weeks after the last study treatment. Participants were asked to provide stool samples before (baseline) and up to 24 months after treatment. A liquid chromatography tandem mass spectrometry method was developed to extract and quantify 36 BAs from a total of 167 participant stool samples from 47 participants. Participant-matched samples at baseline and 1, 4, and 8 weeks were compared with a linear mixed effects model.

Results

Primary BAs predominated at baseline but were significantly reduced (p< .02) as early as 1 week after treatment and remained so to 24 months. Concurrently, secondary BAs, most notably deoxycholic acid (DCA) and lithocholic acid (LCA), were significantly increased (p< .01) after treatment and remained so throughout. Moreover, increases in DCA and LCA were associated with treatment response (p=.05 and p< .01, respectively), recognizing the limited sample size of treatment failures. Observed BA changes coincided with changes in taxonomic compositions—a shift from Gammaproteobacteria and Bacilli predominance before treatment to Clostridia and Bacteroidia predominance after treatment.

Figure 1: BA restoration of successfully-treated participants

Conclusion

In a trial of RBX2660 for rCDI, participant BA compositions significantly changed from before to after treatment, remained so for at least two years, and correlated with treatment outcome. The resulting predominance of secondary BAs coincided with microbiome compositional changes. Because secondary BA are thought to repress C. difficile colonization, these changes may partly explain how RBX2660 reduced CDI recurrence. Continued evaluation of RBX2660 for rCDI is underway.

Disclosures

Romeo Papazyan, PhD, Ferring Pharmaceuticals (Employee) Dana Walsh, PhD, Rebiotix Inc. (Employee) Steve Qi, PhD, Ferring Pharmaceuticals (Employee) Ken Blount, PhD, Rebiotix Inc. (Employee) Karthik Srinivasan, PhD, Ferring Pharmaceuticals (Employee) Bryan Fuchs, PhD, Ferring Pharmaceuticals (Employee)
30. Antimicrobial Resistance Genes Are Reduced Following Administration of Investigational Microbiota-based Therapeutic RBX7455 to Individuals with Recurrent clostrioides Difficile Infection
Authors: Walsh Dana , Gonzalez Carlos , Shannon Bill , Blount Ken
Published: January 2021

Background

Antimicrobial resistance (AMR) is a challenge in individuals at risk for recurrent Clostrioides difficile infection (rCDI). Recognizing that AMR bacteria colonize the intestinal microbiota, therapeutic approaches that decolonize the gut of AMR bacteria would be valuable. Herein, we assessed the microbial resistome before and after treatment with RBX7455—a room temperature-stable, orally-administered investigational microbiota-based therapeutic—in a Phase 1 trial for reducing CDI recurrence.

Methods

This investigator-sponsored trial enrolled 30 rCDI patients in 3 open-label treatment groups (n=10 per group): 1) Four RBX7455 capsules BID for 4 days, 2) Four RBX7455 capsules BID for 2 days, 3) Two RBX7455 capsules BID for 2 days. RBX7455 administration began 48 hours after finishing CDI antibiotics. Participants were asked to submit stool samples at baseline, 1, 7, 28 and 56 days after treatment. These were extracted and sequenced using a shallow shotgun method. Relative taxonomic abundances at the class level and the presence of AMR genes were determined for 148 participant samples and 11 product samples using 90% K-mer sequence coverage based on the MEGARes database.

Results

Ninety percent of participants met the primary endpoint of no CDI recurrence through 8 weeks after treatment, and participant microbiome compositions became more similar to RBX7455 after treatment. The total AMR counts per participant decreased from before to after treatment (p< .05, mixed effects model), with the pattern of AMRs identified (resistome) becoming more like the RBX7455 resistome (Figure 1). Most notably, AMRs associated with multi-drug, fluoroquinolone, and betalactam resistance decreased from before to after treatment. There was no significant difference among the groups with respect to clinical response or changes in microbiome composition and AMR content.

Figure 1 Average total and per-class AMR gene counts in participant samples before and after RBX7455 treatment.

Conclusion

In a Phase 1 trial of RBX7455 for rCDI, AMR gene content decreased after treatment. This underscores the potential of microbiota-based therapies for decolonizing AMR bacteria from the gut microbiota. Continued clinical evaluation of RBX7455 is underway.

Disclosures

Dana Walsh, PhD, Rebiotix Inc. (Employee) Carlos Gonzalez, MS, BioRankings, LLC (Employee) Bill Shannon, PhD MBA, BioRankings, LLC (Employee) Ken Blount, PhD, Rebiotix Inc. (Employee)
43. The Capsule and Beyond: Genetic Determinants of Pediatric streptococcus Pneumoniae empyema
Authors: Pershing Nicole L , Kapusta Aurelie , Nielsen Shannon , Crandall Hillary , Korgenski Kent , Byington Carrie L , Ampofo Krow , Blascke Anne
Published: January 2021

Background

Streptococcus pneumoniae is the most common cause of pneumonia in children, including empyema, a severe complication with increasing incidence in the post-pneumococcal vaccine era. Only a subset of > 90 serotypes cause empyema. Virulence determinants of empyema remain largely unknown.

Methods

We performed Illumina sequencing of invasive Pneumococcal isolates from pediatric patients at Primary Children’s Hospital (Salt Lake City, UT) isolated between 1996–2018, de novo genome assembly (SPADES), annotation (PROKKA), serotyping (Quelling and SeroBA), and pan-genome assembly (ROARY). SCOARY and pyseer were used for microbial GWAS. Maximum likelihood phylogeny was calculated using RAxML/Gubbins.

Results

366 pneumococcal isolates were analyzed from 39 serotypes and multiple phenotypes including pneumonia (n=76), empyema (n=63), CNS infection (n=54), and isolated bacteremia (n=79). Serotypes and empyema phenotype clustered roughly by phylogeny. Most analyzed empyema isolates after 2010 were serotype 3 (19/25); prior to PCV-13 introduction serotypes 1 (8/38), 7F (7/38), and 19A (11/38) were more highly represented. Genes implicated in capsule synthesis, transposases, and metabolism were statistically correlated with the empyema phenotype.

Conclusion

Specific capsular or metabolic genes may confer optimal fitness for pleural disease. Further characterization of these genetic associations is needed and will inform future treatment and prevention.

Disclosures

Carrie L. Byington, MD, BioFire (Other Financial or Material Support, Royalties for Intellectual Property)IDbyDNA (Advisor or Review Panel member) Krow Ampofo, MBChB, Merck (Grant/Research Support)
13. Uncommon rash and neurological symptoms related to Shingrix
Authors: Yadava sanjay K , Mahapatra Rahul
Published: January 2021

Background

Shingrix is a non-live recombinant vaccine approved by the Food and Drug Administration (FDA) in 2017 to prevent shingles and postherpetic neuralgia in immunocompetent adults age 50 years and older. A myriads of local and systemic reactions due to the vaccine have been reported, but diffuse erythematous maculopapular rash and neurological symptoms have not yet been reported in English literature.

Methods

Using Google and PubMed, we searched for relevant case reports and journal articles describing adverse effects related to shingrix vaccination.

Results

A 54-year female without significant past medical history presented with diffuse erythematous maculopapular rash, itching and a feeling of weakness in both legs. Her symptoms started with itching and erythematous macular rash at the site of shingles shot followed by headache, myalgia, and malaise which did not improved much with Benadryl. Next day, she felt numbness and weakness in both legs. On the third day, she awoke with diffuse red rash on the face, trunk, lower extremities, fewer lesions on upper extremities. Her review of systems was negative except as mentioned. on examination, she was found to have diffuse erythematous maculopapular itchy rash as shown in Fig 1, but no sensory, motor, cranial never or cerebellar signs. Infectious disease was consulted who recommended IV acyclovir considering early varicella with given morphology. The morphology of lesions did not change over a period of times and VZV PCR of lesions came negative hence acyclovir was discontinued after three days. Her symptoms and rash improved over the hospital stay with supportive treatment and was discharged home on day fifth of admission.

Fig. 1A, Rash over face

Fig. 1B, Rash over right thigh

Conclusion

The safety of shingrix was evaluated by the pool data from eight clinical trials of more than 10,000 participants. Among the study population, 9.4% had local injection-site reactions including pain, redness, and swelling and 10.8% had systemic events including myalgia, fatigue, headache, shivering, fever, and gastrointestinal symptoms. The nature and duration of rash described in our patient has not been reported in english literature including these clinical trials. Noticing new reactions with broad use of new vaccine is conceivable.

Disclosures

All Authors: No reported disclosures
27. Hepatitis B Virus Screening and Vaccination in Patients with HIV: A Survey of Physicians’ Current Clinical Practices
Authors: Hastie Elizabeth , Wooten Darcy
Published: January 2021

Background

Hepatitis B virus (HBV) and HIV co-infection is associated with high morbidity and mortality, but data and guidelines vary in terms of the best vaccination, re-vaccination, and monitoring practices. The purpose of this study was to evaluate the current HBV monitoring and vaccination practices of physicians who care for patients living with HIV.

Methods

A Web-based survey was distributed to the University of California San Diego (UCSD) Infectious Diseases division via the UCSD ID listserv, Infectious Disease Society of America (IDSA) members via the IDea Exchange listserv, and to ID and HIV social network members via Twitter and Facebook. The survey consisted of demographic questions followed by two sets of case-based questions. The case questions focused on type, timing, and dosage of HBV vaccination administration among people living with HIV, HBV monitoring post-vaccination, and clinical approach to patients with isolated hepatitis B core antibody.

Results

A total of 67 clinicians from 24 states completed the survey (Table 1). Most (55%) provide care for more than 20 patients living with HIV per month. The majority of participants (82%) would not defer HBV vaccination until HIV virologic suppression. Almost half of participants (43%) indicated they would use Heplisav-B over older HBV vaccine formulations (Energix-B or Recombivax-HB) for initial vaccination of susceptible patients. The majority (88%) would repeat a vaccination series if the patient does not seroconvert; 23% would repeat with a standard dose series of Energix-B or Recombivax-HB, 24% with a double dose series of Energix-B or Recombivax-HB, and 45% would repeat with Heplisav-B. Approach to management of a patient living with HIV with isolated hepatitis B core antibody was varied. The majority would check a HBV DNA level (42%), while 25% would initiate a vaccination series and 24% would not pursue further intervention (Table 2).

Table 1: Clinician Demographics

Table 2: HBV Vaccination Practices of Physicians Caring for People Living with HIV

Conclusion

This study provides insight into current HBV vaccination and monitoring practices of physicians who care for patients with HIV. The results revealed varied practice preferences and opportunities for improvement through standardization. Additional research is needed to elucidate the impact these various practices have on patient outcomes and healthcare expenditure.

Disclosures

All Authors: No reported disclosures
31. Influenza Vaccination During Pregnancy: A Descriptive Cross-sectional Survey of the Knowledge, Beliefs, and Attitudes of Mexican Gynecologists and Family Physicians
Authors: Lopatynsky-Reyes Erika Z , Costa-Clemens Sue Ann , Chacon-Cruz Enrique , Greenberg Michael
Published: January 2021

Background

Influenza in pregnancy is associated with elevated morbidity and mortality. Influenza vaccines are both safe and effective in pregnancy, supporting routine use in this population. Even though influenza vaccination in Mexico is recommended for pregnant women, there are no publications of influenza vaccine coverage in pregnancy.

This is the first Latin American survey done only in physicians aiming to assess the knowledge, beliefs, and attitudes that Mexican Obstetrics-Gynecologists (OBG) and Family Physicians (FP) have towards influenza and influenza immunization during pregnancy.

Methods

A cross-sectional survey was conducted, both paper-based and online. The questionnaire was composed of 35 questions, which addressed general knowledge of influenza, recommendations for vaccination during pregnancy, and beliefs and attitudes concerning the acceptability of the vaccine in pregnant women.

Results

A total of 206 completed surveys were available, 98 (47.6%) from OBG, 108 (52.4%) from FP. Regarding current practicing medical institutions, 76 (37%), 69 (34%), 31 (14.5%), 30 (14.5%) reported working for the Mexican Institute of Social Security, Private Sector, Secretariat of Health, or a combination of all respectively, representing an estimated 2,472 daily pregnancy consultations.

About a quarter (26.2%) reported not having a notion that influenza is more severe among pregnant women. More than half (51.5%) ignored the potential side effects of influenza infection on the fetus. The majority (56.8%) did not know when vaccination during pregnancy should occur.

Pregnancy as a risk factor for developing influenza complications was known only in 48.1%. Also, 46.1 % believed that vaccination only confers protection to the mother, but not to the fetus. Nevertheless, 96.1% considered that immunization against influenza during pregnancy is a safe and effective preventive intervention.

A results’ summary is shown in Figure-1.

Conclusion

Based on this survey, current knowledge of OBG and FP for influenza morbidity and mortality during pregnancy, and the importance of influenza vaccination in pregnant women, is poor.

Mandatory recommendations to educate medical providers regarding influenza vaccination during pregnancy in Mexico are necessary, even as imperative for CME credits.

Disclosures

All Authors: No reported disclosures
38. Strategies to Improve HPV Vaccination Rates Among Eligible Undergraduates and Graduate Students at Johns Hopkins University
Authors: Gentile John P , Kessler Roanna , Auwaerter Paul , Auwaerter Paul
Published: January 2021

Background

Completed Poster Presentation

Methods

Results

Study period (8/15/2018 – 5/31/2019) was compared to prior year as a historical control (8/15/2017 – 5/31/2018). During the study, 888 HPV vaccines were administered vs. 504 in the control period (76.1 % increase). The difference between # of vaccines given during these 2 years was statistically significant at p< 0.01. The increase was particularly notable among male students: 383 vaccinations vs. 120 (219.2% increase). About half of the students who completed the EMR form saw the marketing materials on campus: 1,579 out of 3,228 responses. Of the marketing materials, the greatest number of students noticed the yard signs (596). The most frequently cited reason that providers did not give the HPV vaccine during their visit was that the patient already completed the HPV vaccine series (1,603).

Conclusion

A well-coordinated campaign with extensive awareness efforts and focused clinical interventions can dramatically impact the number of HPV vaccinations on college campuses.

Disclosures

Paul Auwaerter, Collidion (Consultant)DiaSorin (Consultant)Johnson and Johnson (Shareholder)MicroB-Plex (Research Grant or Support)Shionogi (Consultant)
39. Survey of Hepatitis B Vaccination Rates in Adult Patients with Diabetes at a Large Internal Medicine/Geriatrics Clinic
Authors: Rivard Kaitlyn , Ohtola Jennifer A , Pallotta Andrea , Jolly Stacey E , Rehm Susan J
Published: January 2021

Background

The Advisory Committee on Immunization Practices (ACIP) recommends immunization with hepatitis B vaccine (HBV) for diabetic adults aged 19–59 years and advises HBV at the discretion of the treating clinician for those 60 years or older. Current HBV rates are suboptimal. In one 2015 survey, only 24.4% of diabetic adults aged 19–59 years were immunized.

Methods

This is a single center, retrospective cohort of patients seen in an internal medicine/geriatrics clinic at Cleveland Clinic Main Campus between January 1, 2017 and December 31, 2017. Patients included were at least 19 years of age and had a diagnosis of diabetes mellitus (type I or type II) as determined by ICD-10 code. Patients with acute or chronic hepatitis B infection were excluded from the primary analysis. Data collected included demographics, HBV status, pneumococcal vaccination status, and risk factors for hepatitis B virus infection (chronic liver disease, end stage renal disease (ESRD)). Primary objective evaluated rate of HBV, defined as documented completion of 3-dose series or positive qualitative anti-HBs. Descriptive statistics included number (percentage) or mean + standard deviation.

Results

A total of 3104 patients, aged 65 + 1.5 years, male (50.2%) or white (72.6%) with Type II diabetes (88.9%) were enrolled. Of these, 171 (5.5%) received one dose of HBV, with 62 (2.0%) completing the immunization series. There were 806 (26%) patients with hepatitis B screening, of those 10 (0.3%) and 177 (5.7%) were HbsAg positive or anti-HBs seropositive, respectively. Overall, 221 (7.1%) patients received the 3-dose series or were anti-HBs positive. In comparison, 1719 (55.4%) patients received at least one dose of either pneumococcal vaccine. Comorbid liver disease or ESRD yielded higher rates of HBV immunity (3-dose series completion or anti-HBs positive) at 28.8% (46/160) and 57.8% (52/90) respectively.

Conclusion

We found low HBV rates for adults with diabetes despite ACIP recommendations, indicating that efforts are needed to improve vaccination coverage. Patients were more likely to have received immunization if comorbid conditions were present that conferred a higher risk of hepatitis B acquisition, however rates were still suboptimal.

Disclosures

All Authors: No reported disclosures
53. Effect of rapid identification of bloodstream isolates on antibiotic management using a pharmacist-based treatment algorithm
Authors: Marshall Marybeth , Harriott Melphine , Johnson Leonard B
Published: January 2021

Background

The use of rapid molecular diagnostic testing to identify microorganisms and resistance markers has great potential to optimize medical care and assist with antimicrobial stewardship. We implemented the Verigene bloodstream infection testing panel along with a pharmacy notification system to clinicians and assessed efficacy of the system.

Methods

In November 2019, we implemented the Verigene gram positive and negative panels for patients with positive blood cultures. Our antimicrobial stewardship committee developed a recommended treatment algorithm for pharmacists to use when notified of Verigene results. The first positive bottle per patient and per admission was tested. Subsequent positive bottles were not tested on the Verigene unless a different morphology was noted on the gram stain. A gram stain was performed on all positive cultures and this result was called to the patient’s nurse (if inpatient) and the covering physician was notified of the result. After the Verigene result was available, an assigned pharmacist was notified of these results (organism identification and resistance markers if identified). Pharmacists notified covering physicians of the test results and the recommended antibiotic management. Pharmacists documented the frequency that the test result changed the antibiotic management, including escalation, de-escalation or no change in therapy. The data from the first six months was summarized.

Results

From 11/19/19-5/18/20, a total of 575 test results were called into the pharmacist (average 3.2/day). Among these, 165 (28.7%) were considered likely contaminants, 106 had no change in therapy and 59 had antibiotic de-escalation. Among the remaining 410 patients, 156 had de-escalation, 53 had escalation, 30 were not on any antibiotics and appropriate antibiotics were started. Overall, antibiotic management changed in 298/575 (51.8%) of isolates run by Verigene in our institution including 215 (37.4%) de-escalations. The most frequent antibiotics that were stopped included vancomycin (142) and cefepime (53).

Conclusion

Our pharmacist-based algorithm for notification and treatment recommendation based on Verigene results was highly successful in optimizing antibiotic management and improving antimicrobial stewardship in our institution.

Disclosures

All Authors: No reported disclosures
810. Resistance to the Minocycline-Rifampin-Chlorhexidine (MRCH) combination does not emerge in biofilms of Tetracycline and Rifampin resistant bacteria grown on MRCH catheters depleted below antimicrobially effective concentrations
Authors: Gerges Bahgat , Rosenblatt Joel , Truong Y-Lan , Reitzel Ruth , Hachem Ray Y , Raad Issam I , Raad Issam I
Published: January 2021

Background

Central Line Associated Bloodstream Infections (CLABSIs) remain a significant medical problem for critically ill cancer patients who required catheters for extended durations. Minocycline (M) -Rifampin (R) loaded catheters have shown the greatest impact on reducing CLABSIs; however, there is a risk for developing antibiotic resistant organisms when exposed to catheters whose concentration becomes depleted below antimicrobially effective levels due to extended indwells. Chlorhexidine (CH) and M-R combination catheters (MRCH) have been proposed as a next generation catheter with improved performance. Here we studied whether bacteria that were Tetracycline and Rifampin resistant became resistant to MRCH when allowed to form biofilms on MRCH catheters depleted below antimicrobially effective MRCH concentrations.

Methods

Minimum inhibitory concentrations (MICs) of Tetracycline and/or Rifampin resistant stock isolates were measured by standard microbroth dilution methods. MRCH catheters were depleted to below antimicrobially effective concentrations by soaking in serum for 6 weeks. The resistant bacteria were then allowed to form biofilm for 24 hrs on the depleted catheters in broth. Following 24 hour incubation the adherent (breakthrough) bacteria were removed by sonication and MICs were remeasured. The same organisms grown on non-antimicrobial catheters were used as controls.

Results

MICs (ug/mL) of the organisms against each agent and the combination are tabulated below:

MICs (ug/mL) of the organisms against each agent and the combination

Conclusion

The M and R resistant bacteria did not develop in vitro resistance to the MRCH combination after forming biofilms on MRCH catheters depleted below antimicrobially effective concentrations.

Disclosures

Joel Rosenblatt, PhD, Cook Medical (Shareholder, Other Financial or Material Support, Inventor of the MRCH catheter technology which is owned by the University of Texas MD Anderson Cancer Center and has been licensed to Cook Medical)Novel Anti-Infective Technologies (Shareholder, Other Financial or Material Support, Inventor of the MRCH catheter technology which is owned by the University of Texas MD Anderson Cancer Center and has been licensed to Cook Medical) Issam I. Raad, MD, Citius (Other Financial or Material Support, Ownership interest)Cook Medical (Grant/Research Support)Inventive Protocol (Other Financial or Material Support, Ownership interest)Novel Anti-Infective Technologies (Shareholder, Other Financial or Material Support, Ownership interest)
56. Ertapenem Utilization: “CRE”ating Solutions for Improving Hospital Stay and Stewardship
Authors: Willner Debra M , Bengualid Victoria , Bisono-Garcia Bismarck , Berger Judith
Published: January 2021

Background

Ertapenem, a carbapenem offers advantages over other carbapenems. It is administered daily and can therefore facilitate home infusion discharges, it has a narrower spectrum of activity which could reduce resistance, and is more cost effective than meropenem. Our objectives were to determine whether ertapenem utilization decreased hospital length of stay and whether use had an impact on future meropenem resistance.

Methods

This was a retrospective chart review of ertapenem over 2 years for the following infections: urinary tract, skin and soft tissue (SSTI), and osteomyelitis. Evaluated pathogens, duration of inpatient therapy, discharged antimicrobials, length of discharged therapy, and positive cultures up to 90 days post treatment. Analyzed length of stay, and calculated the hospital days that were saved by discharging patients on ertapenem.

Results

70 patients were analyzed, with indications and pathogens listed in Figure 1. Patients were initially placed on empiric therapies pending culture results. On average, patients received 2.9 days of empiric meropenem. Once cultures finalized, patients were switched to ertapenem. On average, patients received 6 days of inpatient ertapenem prior to discharge. 37 patients were discharged with ertapenem, totaling 937 days of discharged therapy. Of the 36 patients readmitted within 90 days, 20 had pathogens identified, of which 4 were meropenem-resistant (Figure 2).

Infections, Pathogens, and Treatment Duration

Conclusion

In this pilot stewardship initiative, switching to and discharging patients on ertapenem saved 937 hospital days over the 2 years evaluated, with the greatest days of therapy saved in osteomyelitis and SSTIs. There were a total of 422 days of inpatient ertapenem, mostly in the SSTI and cystitis indications. Of the 20 pathogens identified on readmission, 4 (20%) were meropenem-resistant. All were Acinetobacter baumanii-often carbapenem-resistant; none of the cultures were the same pathogen as the originally identified, but this warrants further investigation. The indication associated with least days of therapy saved and the highest days of inpatient ertapenem was cystitis. 53% of the patients were discharged with ertapenem; future direction involved identifying barriers for speedy discharge across all indications.

Disclosures

All Authors: No reported disclosures
827. Does Patient Location (Rural or Urban) influence risk factors and incidence rate for 30-day readmission after gram positive pneumonia?
Authors: Kunnumpurath Anthony , Mehta Neal , Khan Shoaib , Kamoga Gilbert-roy
Published: January 2021

Background

In the US, pneumonia is the most common cause of a hospital admission. Prior analysis has shown that nearly one in six patients will have an all-cause 30-day readmission. Given the disparities in access to healthcare between rural and urban settings, we sought to see if patient location influenced the incidence rate for 30-day readmission after treatment for Gram Positive Pneumonia.

Methods

We utilized Agency of Healthcare Research and Quality’s (AHRQ) 2014 Nationwide Readmission Database to identify index admissions with a principal diagnosis of Gram Positive Pneumonia (ICD-9 codes 482.3, 482.31, 482.32, and 482.39 for streptococcus and 482.40, 482.41, 482.42, and 482.49 for staphylococcus). The 2013 NCHS Urban-Rural Classification System was used to classify if originating from an urban or rural location. Applicable admissions were all adults (age >= 18) from January 1 to November 30, 2014. Patients who died during index admission and those with missing covariates were excluded. All-cause readmissions within 30-days of an index admission were analyzed. Predictors for readmission were determined using a multivariable logistic regression model.

Results

A total of 8,130 patients met criteria for inclusion of which 1,631 (20.06%) were readmitted (all-cause) within 30-days. There was no statistically significant difference in readmission between patients from a rural (18.7%) or urban (20.4%) location. The statistically significant predictors for readmission for patients from a rural location were those admitted on a weekend (OR: 1.41, CI: 1.04-1.90), discharged to short term hospital (OR: 2.70, CI: 1.18-6.19) or AMA (OR: 6.53, CI: 1.46-29.10), and those with a LOS between 7 and 14 days (OR: 1.48, CI: 1.10-2.00). For patients from an urban location, statistically significant predictors were those admitted on a weekend (OR: 1.17, CI 1.02-1.34), discharged AMA (OR: 2.89, CI: 1.74-4.78), LOS between 7 and 14 days (OR: 1.19, CI: 1.03-1.37) and those with CKD (OR: 1.20, CI: 1.03-1.39).

Conclusion

The risk factors for readmission after Gram Positive Pneumonia for patients from a rural and urban location are similar. More research is needed to develop interventions for those who are at risk for readmission after Pneumonia to reduce future morbidity and mortality.

Disclosures

All Authors: No reported disclosures
851. Compliance with Guidelines for Management of Staphylococcus aureus Bacteremia and its Effect on Mortality
Authors: Travez Robert D , Eagleston Anjuli , Brandt Dominique , Blatt Stephen
Published: January 2021

Background

In the US, Staphylococcus aureus Bacteremia (SAB) occurs in about 19.7 /100,000 people. A recent increase in methicillin-resistant Staphylococcus aureus (MRSA) bacteremia infections rate and mortality has led to more infectious diseases (ID) consultations. We assessed if an infectious diseases consultation within 7 days of initial blood culture results was associated to greater compliance with Infectious Diseases Society of America (IDSA) guidelines for managing Staphylococcus aureus bacteremia and a decrease in all-cause mortality and relapse within 90 days.

Methods

A retrospective cohort of patients admitted to two community hospitals from January 2014 to June 2016 with a positive blood culture for methicillin-susceptible S. aureus (MSSA), MRSA, or coagulase-negative Staphylococcus were included in the study. I. Patients were excluded if they were immunocompromised, had a polymicrobial blood stream infection, died within first 48 hours of admission, left against medical advice during treatment or participated in another study requiring an alternative treatment strategy.

Results

A total of 331 patients were included in the analysis. A significantly higher proportion of patients with complicated SAB had an ID consult (61% vs. 17.5%, p< .0001) and for uncomplicated SAB the reverse was true (39% vs 79%, P< .0001). An ID consult was associated with increased compliance with IDSA guidelines (75% vs. 5%, p< .0001). Patients with an ID consult had a significantly higher duration of antibiotic treatment [30(14-42) vs. 5(1.5-12), p< .0001], an earlier start of treatment in number of days [0(0-7) vs. 0(0-12), p=0.036] and a lower mortality within 90 days of blood culture (61% vs. 17.5%, p< .0001). Logistic regression model showed than an ID consult reduced 90-day mortality by 69%, OR 0.313[CI 95 %(0.313-0.154), p=0.001] and transesophageal echography by 78%, OR 0.228[CI 95 %(0.228-0.052), p=0.05].

Population characteristics and outcomes

Conclusion

ID consultation in the setting of SAB has been shown to increase compliance with IDSA guidelines and reduce 90-day mortality.

Disclosures

All Authors: No reported disclosures
859. Remote Video Auditing (RVA) To Assess Personal Protective Equipment (PPE) Compliance In Rooms With Clostridioides difficile Patients
Authors: Khatri Akshay M , Khameraj Aradhana , Franklin Tony , Malhotra Prashant , Farber Bruce
Published: January 2021

Background

Nosocomial Clostridioides difficile (Cdiff) outbreaks can be prevented by PPE use and hand hygiene (HH) by healthcare providers (HCPs). A rise in Cdiff cases in our oncology unit prompted the use of novel educational and monitoring measures for infection control. Remote video auditing (RVA), a new technique to ensure isolation adherence, is more objective and reliable than standard direct observation. In this study, we used RVA to assess HCP compliance with PPE in Cdiff patient (pt) rooms (rms) and other rms in the same unit.

Methods

A prospective observational study (supported by the Karen Brown research fund) was conducted over 8 months. RVA involved video recording of HCP encounters at entry/exit from Cdiff pt rms and other rms in the same unit. Adherence to PPE (gowns/gloves), HH and PPE doffing sequence was reviewed by independent trained observers using a uniform protocol. Data was captured from electronic records and infection prevention data (using NHSN criteria). Data from 2 time periods [P1 (July 2019-Oct 2019), P2 (Nov 2019-Feb 2020)] and historical controls (HC) were compared for significance using students t-test.

Results

We compared PPE/HH rates in 5685 encounters in all rms in the unit to PPE/HH rates from HC and surprisingly saw lower compliance rates during the study (Table 1). We also analyzed 507 encounters in Cdiff rms (Table 2). An increased compliance with PPE (but not HH) was noted at rm entry in P2 as compared to P1, but it was not statistically significant (Table 2). There was significantly increased compliance with PPE/HH and proper doffing when exiting a pt rm in P2 as compared to P1 (Table 2). Cdiff cases per patient day decreased from P1 to P2 (0.003 to 0.001). We believe the discordant findings were due to Hawthorne effect (change in behaviors due to the awareness of being observed) and the well-known inherent unreliability of direct observation methods used for monitoring HC.

Table 1: Comparison of PPE compliance rates (use of gowns, gloves, and mask) and hand hygiene for the entire unit, between the entire study period and historical control rates

Table 2: Comparison of PPE compliance rates (use of gowns, gloves, and mask), proper doffing sequence and hand hygiene at entry and exit at a Cdiff patient’s room, between two time periods [#: Doffing was recorded by RVA only at time of exit from Cdiff rooms]

Conclusion

RVA is a more reliable and less labor-intensive assessing adherence to isolation precautions than direct observation. RVA recorded increased PPE compliance over time (particularly at exit from isolation rms), resulting in reduced Cdiff infections. Thus, RVA, by ensuring strict isolation precautions, may be better than direct observation in preventing communicable infections like Cdiff.

Disclosures

All Authors: No reported disclosures
863. Outcomes of Healthcare-Associated Respiratory Viral Infections in a Pediatric Hospital: A Historical Cohort Study
Authors: Most Zachary , Jackson Patricia , Sebert Michael , Perl Trish M , Perl Trish M
Published: January 2021

Background

Healthcare-associated respiratory viral infections (HARVI) occur frequently at pediatric hospitals. The spectrum and attributable outcomes of these infections are unknown.

Methods

Using a matched historical cohort design, HARVI cases identified between July 2013 and June 2018 at a large pediatric referral hospital in Dallas, Texas were defined as patients who tested positive for one of eight respiratory viruses during their hospitalization, had new respiratory symptoms develop during hospitalization, and had symptom onset on a hospitalization day that was greater than the maximum incubation period for the specific respiratory virus. Controls were matched 1:1 for index time, meaning that the control had a hospital length of stay that was at least as long as the length of stay in the matched case prior to viral testing. Controls were also matched for year and month of infection as well as hospital unit and/or age. The primary outcome was additional length of stay following infection or index time. Additional outcomes included transfer to intensive care, need for intubation, hospital charges, and all cause in-hospital mortality.

Results

Over the 5-year study period, 317 definite HARVI were identified (0.62 per 1,000 admitted patient days), and only 287 (91%) had a matched control to be included in analysis. Among these cases and matched controls, the median time to index time was 19 days (IQR 10-39 days). The most common causative viruses where rhinovirus/enterovirus (188, 65.5%), RSV (30, 10.5%), parainfluenza virus (28, 9.8%), and seasonal coronaviruses (27, 9.4%). Fewer cases than controls were in an intensive care unit at index time (101 [35.2%] vs. 156 [54.4%]) The mean additional length of stay following index time was shorter in cases than controls (35.2 days vs. 48.1 days, difference = -12.9 days, 95% CI -20.95 to -4.82 days).

Conclusion

Hospital length of stay for cases with HARVI was not longer than for those without HARVI. Possible explanations include confounding and selection bias. Further studies with carefully selected controls are needed.

Disclosures

All Authors: No reported disclosures