bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessing the Risk of Nephrotoxicity Associated With Non-renally Adjusted Intravenous Polymyxin B Compared with Traditional Dosing
Authors: Maniara Bejoy , Doan Thien-Ly , Healy Lauren
Published: October 2017

Background

Prior data states that polymyxin B is renally cleared and thus required renal adjustments, however newer data suggests that polymyxin B undergoes non-renal clearance. With more aggressive dosing, potential for increased nephrotoxicity is of concern. This study aims to determine whether time to acute kidney injury (AKI) differs between renally adjusted and non-adjusted doses of intravenous (IV) polymyxin B. Secondary objectives aim to evaluate incidence of AKI, length of stay (LOS), adverse reactions, and potential role of ascorbic acid in decreasing nephrotoxicity.

Methods

This retrospective chart review compared time to AKI in patients receiving renally adjusted and non-adjusted IV polymyxin B between Jan 2012 and Nov 2016. This study included patients who are at least 18 years old, received IV polymyxin B, and have creatinine clearance below 80 mL/minute. Patients were excluded if they had AKI (RIFLE criteria), received renal replacement therapy, or are pregnant prior to receipt of IV polymyxin B. Fine and Gray’s model for competing risks was used to predict the cumulative incidence function of AKI. Descriptive statistics, two-sample t-test, and Chi-square test were used as appropriate.

Results

Of the 132 patients screened, 54 met inclusion criteria (23 in the renally adjusted vs. 31 in the non-adjusted group). There was no statistical association between dosing type and time to AKI (P = 0.13). Incidence of nephrotoxicity was higher in the renally adjusted vs. non-adjusted groups (21.7% vs. 6.5% respectively). Mortality was higher in the renally adjusted vs. non-adjusted groups (17.4% vs. 6.5% respectively). LOS was greater in the renally adjusted vs. non-adjusted groups (16 vs. 14 days respectively, P = 0.26). All patients in the study received concomitant nephrotoxic agents (e.g., vancomycin, aminoglycosides). Ascorbic acid use was infrequent but, in the 4 patients who did receive it, none developed AKI. No difference in neurotoxicity, respiratory arrest, Clostridium difficile infections was seen.

Conclusion

No significant association between IV polymyxin B dosing type and time to AKI was found. Incidence of AKI, LOS, and mortality was higher in the renally adjusted group compared with the non-adjusted group. Ascorbic acid may mitigate the nephrotoxic potential of IV polymyxin B, but further studies are needed.

Disclosures

All authors: No reported disclosures.
Zika Virus Epidemic in the Dominican Republic, 2016
Authors: Peña Farah , Pimentel Raquel , Khosla Shaveta , Mehta Supriya , Brito Maximo
Published: October 2017

Background

The first cases of Zika (ZIKV) in the Americas were reported in Easter Island, Chile in 2014. The epidemic spread to Brazil and Central America in 2015. We describe the extent and distribution of the countrywide ZIKV epidemic in the Dominican Republic.

Methods

The DR Ministry of Health (MoH) instituted active surveillance, monitoring and mandatory reporting of suspected cases of ZIKV in 2015 through the National System of Epidemiologic Surveillance (SINAVE). In the pre-epidemic period, the MoH conducted active search and blood testing of suspected cases in communities rumored to have cases of the disease. During the epidemic, the MoH conducted weekly monitoring of all cases of febrile exanthems, flaccid paralysis and meningitis, and also conducted rapid surveys in highly populated areas to identify local outbreaks. Data from SINAVE was exported and analyzed using SAS.

Results

A total of 5226 cases ZIKV were reported to the MoH from January 2016 to December 2016 (figure). Cases were 74% female, of whom 1275 (33%) were pregnant. Most of the cases (51%) were diagnosed in the age group of 20 to 39, and did not differ by gender. The majority (58%) of cases were reported from a metropolitan area. Almost all cases (82%) were treated in the outpatient setting, while 17% were hospitalized. Only 3 patients died and 95% had an uncomplicated course. There were 285 cases of Guillain BarrŽ Syndrome (GBS; Figure), with the epidemic curve showing a peak 2–4 weeks following the peak of the epidemic. Compared with patients with suspected ZIKV (n = 1054), those with GBS were more likely to be male (47% vs. 19%, P < 0.001), aged ≥40 years (53% vs. 19%, P < 0.001),, more likely to have complications (18% vs. 6%, P < 0.001) and comorbidity (2% vs. 0.2%, P = 0.04) Seventeen (6%) of confirmed GBS cases resulted in death.

Conclusion

The DR reported one of the largest ZIKV outbreaks in the Americas. The epidemic started early in 2016 and had all but subsided by May 2017. Although most cases had an uncomplicated course, incidence of GBS was high.

Disclosures

All authors: No reported disclosures.
Zika Virus Serologic Diagnosis by NS1 ELISA in Curacao
Authors: Manuel Samantha , Virginia-Cova Liane , Joseph Loubiela , Roggeveen Chris , Steingrover Radjin
Published: October 2017

Background

Zika virus (ZIKV) was introduced in the Caribbean island of Curacao in January 2016. A commercially available ZIKV IgM and IgG ELISA was evaluated on patients that were PCR-positive for ZIKV.

Methods

ZIKV infection was established by PCR in urine samples. Samples from PCR-positive patients were selected for validation of a ZIKV NS1 IgG and IgM ELISA. Patients with a follow-up sample ≥ 2 weeks after initial presentation were used to assess the sensitivity of the assay. Samples of 15 historical controls with serological evidence of Dengue, Chikungunya or an unrelated viral infection were included to establish specificity and cross-reactivity.

Results

Fourteen patients with positive ZIKV PCR diagnosis had repeated serum samples drawn ≥ 2 weeks after the initial sample. The combined results of these repeated IgM and IgG tests resulted in a sensitivity of 92%. One pregnant female showed no presence of IgG or IgM in any of the two samples. Testing of the panel of historical ZIKV-negative controls resulted in a specificity of 100% in both the quantitative and semi-quantitative setting of the ELISA. One patient with known high-titers of antibodies against Chikungunya virus in the respective panel displayed borderline reactive results for ZIKV IgG in both quantitative and semi-quantitative setting of the assay.

Conclusion

In this PCR-positive ZIKV cohort of patients, the newly available ZIKV NS1 ELISA displayed excellent performance characteristics. Cross-reactivity was indicated for Chikungunya in one case. No cross-reactivity was found for Dengue virus infection. One pregnant female showed no signs of developing anti-ZIKV IgM or IgG in this study. In the light of intrauterine pathogenesis, the lack of development of maternal IgG during ZIKV infection is a concern.

Disclosures

All authors: No reported disclosures.
Utilizing an Equitable and Multifaceted Zika Screening Tool to Identify At-Risk Individuals For Testing and Education: Successes, Challenges, and Lessons Learned in Harris County, Texas.
Authors: Haynie Aisha , Martinez Diana , Jin Sherry , Piper Tamisha , Reed Brian , Shah Umair A
Published: October 2017

Background

Harris County Public Health (HCPH) is the health department for Harris County, Texas jurisdiction, representing 2.3 million residents. Located in the nation’s Third most populous county, HCPH’s 13 wellness clinics and WIC centers provide services for over 100,000 patients annually.

Since late 2015, HCPH confirmed 46 individuals with Zika infection/disease, including two infants with microcephaly and congenital disease. Over two-thirds of these infections were in individuals of Hispanic origin, including all twelve infected pregnant women, two of whom were unaccompanied minors.

Due to Harris County’s geographic vulnerability to Zika, highly mobile residents, and HCPH’s largely low-income Hispanic and refugee clinic population, equitably screening and educating patients about Zika exposure is of paramount importance.

Methods

Using U.S. CDC guidelines, HCPH developed a multifaceted Zika Screening Tool (ZST) for use within clinics. Front desk staff, outreach workers, nursing staff, and clinical providers all participate in various portions of the education-based screening process. The ZST is updated as new CDC guidance becomes available.

Results

All pregnant and high-risk patients received Zika education. Forty-five patients, mostly pregnant females, were additionally referred for testing and further care.

Conclusion

HCPH’s ZST successfully identified high-risk patients for education and testing. This presentation will explore HCPH’s equity-based rationale for education-oriented screening, the ZST’s evolution over time, and describe ZST forms and their integration into the clinic visit. Successful implementation strategies, challenges, and lessons learned will also be discussed, along with the role of the ZST as an integral part of HCPH’s overall multidisciplinary Zika response effort.

Disclosures

All authors: No reported disclosures.
Are New Biomarkers Useful in the Diagnosis of Meningitis in Adults?
Authors: Aksoy Firdevs , Yilmaz Gürdal , Aydin Nurten Nur , Kaya Selcuk , Karahan Süleyman Caner , Koksal Iftihar
Published: October 2017

Background

Meningitis is infection of the central nervous system with high mortality and morbidity in adults. Markers for diagnostic purposes can therefore be useful guides in differential diagnosis. Procalcitonin (PCT), platelet distribution width (PDW) and red blood cell distribution width (RDW) can be easily calculated with automated blood systems, and have been regarded as biomarkers showing inflammation in infection-related diseases. The purpose of this study was to determine the diagnostic significance of these biomarkers in adult meningitis.

Methods

This study was a retrospective investigation. Diagnosis of meningitis was based on clinical findings and microbiological and biochemical investigations of CSF specimens. Patients’ white blood cell count (WBC), C-reactive protein (CRP), PDW, RDW and PCT levels at time of presentation were compared. P < 0.05 was regarded as statistically significant.

Results

137 patients were assessed. Ninety-five patients had acute bacterial meningitis (ABM), 17 had aseptic meningitis (AM) and 25 had chronic meningitis (CM). When patients were evaluated by age, AMB was more common in the elderly and AM in the young (P < 0.05). CRP and PCT levels at presentation were significantly higher in AM than in AM and CM (P < 0.05). WBC levels differed statistically significantly between ABM and CM (P < 0.05). PDW levels were significantly higher in AM then in CM (P < 0.05). RDW was statistically significantly higher in CM than in ABM and AM (P < 0.05). When ROC analysis was performed to differentiate ABM from the other forms (table). Correlation analysis between CSF biochemistry and biomarkers revealed that PCT was positively correlated with CRP, PDW and CSF protein and negatively correlated with CSF glucose.

Conclusion

Our results suggest that PCT and CRP have diagnostic characteristics in favor of ABM at differential diagnosis in cases in which LP is contraindicated and/or CSF examination cannot be performed immediately or the agent cannot be identified. WBC and RDW can be useful guides in differentiating ABM from CM, and PDW and RDW in differentiating CM from ABM and AM.

Disclosures

All authors: No reported disclosures.
Achieving Optimal Specialty Cerebrospinal Fluid (CSF) Testing: Are Electronic Medical Record Order Sets Helpful?
Authors: Abrantes-Figueiredo Jessica I , Bieluch Virginia M , Nailor Michael D
Published: October 2017

Background

Specialty PCR testing has become available for lumbar puncture to determine the cause of infectious meningitis and encephalitis. Testing with low pre-test probability may increase antimicrobial therapy while results are pending and create increased direct costs. We aim to describe the appropriateness of testing before and after the implementation of electronic medical record (EMR) order sets designed to reduce excessive testing of CSF by creating two lists of tests: (1) a routine panel for all patients and (2) a list of optional specialty tests designed to be utilized after the nucleated cells are resulted.

Methods

Retrospective study of adult patients undergoing lumbar puncture with suspicion for CNS infection pre-and post-implementation of EMR order sets from January 2016–March 2017. Consecutive patients with complete charts were reviewed from a tertiary care center. Data collected included demographics, co-morbid conditions, clinical presentation, and lumbar puncture results. The primary outcome of interest was the frequency of CSF specialty testing in patients with ≤ 10 nucleated cells/µL in the CSF.

Results

Two hundred patients had ≤ 10 nucleated cells/µL in the CSF (n = 108 in pre-EMR group; n = 92 in post-EMR group). Of these patients 74% and 48.9% had Herpes Simplex Virus (HSV) PCR testing done pre and post EMR changes (P < 0.05). Enterovirus PCR testing remained similar among both groups (37% pre-EMR order sets vs. 36.9% post-EMR order sets, P = 0.99). Lyme PCR testing decreased between pre- and post-groups (26.8% vs. 9.7%, P < 0.05). CSF Epstein-Barr virus PCR testing also dropped significantly from 26.9% to 7.6% (P < 0.05). All specialty PCR testing that was performed on patients with ≤ 10 nucleated cells/µL in the CSF were negative. Paradoxically, HSV antibody testing increased post-implementation of EMR order sets (21.7% vs. 0%, P <0.05). Total costs of tests on average decreased by $70.71 per patient post EMR changes.

Conclusion

In this cohort, CSF specialty testing was common but decreased after EMR changes. Laboratory stewardship can be improved with EMR changes but further education is needed to prevent unnecessary tests. Unwanted tests (HSV antibodies) may be increased as prescribers are unable to locate familiar tests.

Disclosures

M. D. Nailor, Astellas: Scientific Advisor and Speaker’s Bureau, Consulting fee and Speaker honorarium. Merck: Grant Investigator, Research grant.
The Etiologies and Clinical Characteristics of Patients Hospitalized with an Acute Febrile Illness and Central Nervous System Sydromes in Indonesia
Authors: Aman Abu Tholib , Gasem Muhammad Hussein , Tjitra Emiliana , Alisjahbana Bachti , Kosasih Herman , Merati Ketut Tuti , Arif Mansyur , Karyana Muhammad , Sudarmono Pratiwi , Suharto Suharto , Lisdawati Vivi , Neal Aaron , Siddiqui Sophia
Published: October 2017

Background

Acute febrile illness is a common reason for hospitalization in many developing countries, including Indonesia. While patients can often be categorized and managed based on clinical presentations, diagnostic capacity in these countries remains limited, leading to poor patient outcomes. For patients with central nervous system (CNS) infections, identifying the underlying etiologies is particularly important to prevent lifelong neurological complications and death.

Methods

As part of a study conducted at 8 top-referral hospitals across Indonesia from 2013 to 2016, 114 of 1,486 enrolled subjects presented with an acute fever and a CNS syndrome. To identify the etiologies and clinical manifestations of these infections, as well as the management of febrile patients at the hospitals, demographic and clinical data were collected at enrollment, and blood samples were collected for diagnostic testing at enrollment, once during days 14–28, and at 3 months after enrollment.

Results

Subject ages ranged from 1 to 63.2 years old (median of 4.9 years old), and underlying diseases were reported in 35 (30.7%) subjects. Standard-of-care, molecular, and serological testing identified pathogens in 56 (49.1%) cases, as detailed in the table. Of the 19 subjects who died, 18 presented with decreased consciousness and 5 were infected with Rickettsia typhi, which was clinically misdiagnosed in each case.

Conclusion

The findings from this study will improve the diagnosis and treatment of patients presenting with CNS syndromes in Indonesia. Additionally, the discovery of misdiagnosed, fatal etiologies highlights the general need for greater diagnostic testing capacity to aid clinicians and inform public health policy makers.

Disclosures

All authors: No reported disclosures.
Long-term Outcomes of Acute Aseptic Encephalitis In Adults - a Single Center Study
Authors: Kusulja Marija , Santini Marija , Papic Neven
Published: October 2017

Background

Encephalitis is a heterogeneous syndrome associated with significant mortality and neurophysiological sequelae. The etiology is identified in only 20–50% of cases, and long-term outcomes of survivors are underinvestigated, especially in patients with unknown etiology. The aim of this study was to describe long-term outcomes of patients with aseptic encephalitis of various etiologies.

Methods

The study population consisted of a retrospectively identified cohort of consecutive adult patients diagnosed with viral and etiologically undiagnosed encephalitis during a 24-month period (2014-2015) at the University Hospital for Infectious Diseases Zagreb, Croatia. Clinical, laboratory data and short-term outcomes were collected from medical records, and long-term outcomes were assessed by telephone interviews and quantified through modified Rankin scores (mRS).

Results

A total of 90 patients were identified (57.7% female; 51.5 ± 17.4 years). Viral etiology was identified in 20 (22.2%) patients: herpes simplex virus (HSV-1, 8.9%), varicella-zoster virus (VZV, 6.7%), Tick-borne encephalitis (TBE, 4.4%) and enteroviruses (2.2%). Postinfectious meningoencephalitis was suspected in 14 (15.6%) patients, and 56 (62.2%) had unknown etiology. Elevated CSF WBC was present in 77 patients (mean of 169.3 ± 279.4/mm3) and all but 6 had elevated CSF proteins (1.23 ± 0.88 g/L). Convulsions occurred more frequently in HSV-1 (37.5%) and in unknown etiology group (15.7%). GOS<3 was noted in 50% of HSV, 33% of VZV, 25% of TBE and 24% of unknown group patients during hospitalization. Mechanical ventilation was necessary in 17.1% of patients with unknown and 23.5% with viral etiology for the mean duration of 1.8 ± 6.7 and 3.2 ± 6.3 days, respectively. The mean length of stay was 23.2 ± 18.5 days. In-hospital mortality was 7.8%. Among 64 survivors who were available for follow-up interviews (mean follow-up of 28.6 ± 6.8 months), 73.1% with unknown and 90.9% with viral etiology had favorable outcomes (mRS 0–1); 4 (6.25%) had moderate (mRS 3) and 3 (4.6%) had severe neuropsychological deficits (mRS 4-5).

Conclusion

Although the etiology of aseptic encephalitis is often unknown, long-term outcomes are favorable in the majority of patients.

Disclosures

All authors: No reported disclosures.
Establishing Models of Herpes Simplex Virus Type 2 Superinfection of Herpes Simplex Virus Type 1 Seropositive Mice to Test The Efficacy of a Novel Vaccine
Authors: Ramsey Natalie , Jacobs William , Herold Betsy C
Published: October 2017

Background

Multiple subunit vaccines that elicit neutralizing antibodies (nAbs) against the immunodominant HSV-2 glycoproteins D and/or B (gD and gB) were advanced into the clinic after demonstrating protection against disease in animal models. However, although the vaccines elicited nAbs in seronegative and boosted nAb titers in HSV-1 seropositive (HSV-1+) participants, none prevented HSV-2 infection suggesting that nAbs alone are not sufficient. The results also indicate that current animal models are not predictive of clinical trial outcomes. We recently engineered a candidate single cycle vaccine strain deleted in gD (ΔgD-2) and showed that it elicits high titer non-neutralizing Abs that provide complete protection against HSV-1 or HSV-2. The Abs passively protect naïve mice and activate the Fc receptor to induce antibody-dependent cell mediated cytotoxicity (ADCC). We hypothesize that ΔgD-2 will protect HSV-1+ individuals from HSV-2 because it elicits a different type of immune response. To test this hypothesis, we established a model of HSV-2 superinfection in HSV-1+ mice.

Methods

We infected mice by corneal scarification with serial dilutions of a clinical strain of HSV-1 (Bx31.1) to identify a sublethal dose associated with seroconversion. We then superinfected mice on the skin with HSV-2 and monitored for disease. The presence of virus in dorsal root ganglia (DRG), the site of HSV latency, was determined by quantitative PCR.

Results

Corneal infection with 10^4 PFU of HSV-1 resulted in disease in 18/29 (62%) mice and 13/18 survived. Seroconversion was documented in 9/13 survivors. Surviving mice were superinfected 2 weeks post-recovery with HSV-2. All of the mice developed signs of disease, but only 2/9 who were HSV-1+ died compared with 4/4 seronegative mice (P = 0.02, Fisher exact test). HSV-2 DNA was detected in the DRG of 12/13 mice.

Conclusion

Sublethal HSV-1 corneal disease provides partial protection against HSV-2 superinfection and provides a model to test vaccine efficacy. We speculate that superinfection boosts preexisting nAb titers, a response consistent with immune repertoire freeze, but that ΔgD-2, because it elicits ADCC Abs, will overcome repertoire freeze and provide greater protection against HSV-2 superinfection.

Disclosures

W. Jacobs, X-vax: Grant Investigator, Research grant and Research support. B. C. Herold, X-vax: Grant Investigator, Research grant and Research support.
Study to Address Threats of Acute Respiratory Infections among Congregate Military Populations (ATARI)
Authors: Coles Christian , Chen Wei-Ju , Milzman Jacqueline Owens , Grigorenko Elena , Robinson Scott , Jones Carol , Moreno Nicole , Burgess Timothy , Malone Leslie
Published: October 2017

Background

More than 90% of active duty personnel receive influenza vaccinations yearly. Despite high coverage, influenza-like illnesses (ILI) remain a frequent cause of missed duty and hospitalizations, particularly in U.S. military recruits. More research is needed on the epidemiology and etiology of ILI to reduce the burden of respiratory infections in congregated military settings.

Methods

We conducted a prospective cohort study to assess ILI patterns among US Army recruits in a 9-week basic combat training course at Ft. Benning, GA. Demographic data, vaccination history, and information on recent illness were collected at enrollment in January 2017. Participants were divided into two platoons with staggered biweekly visit schedules. Visits occurred from reception through training, with nasal swabs and symptom surveys (all visits) and blood draws (weeks 8 and 9). Nasal specimens were used to detect clinical and colonizing pathogens using the Diatherix TEM-PCR Respiratory Panel.

Results

A total of 90 recruits were enrolled in the study. Twelve recruits were lost due to training attrition in the first week of the study. The participants were male and the mean age was 23 yo (SD 4.9). There were 10 (13%) cases of ILI reported among the 78 remaining participants, 6 in week 1, 3 in week 2 and 1 in week 9. The most frequently detected pathogens in the 10 symptomatic cases were coronavirus (5, 50%), rhinovirus (4, 40%), other enterovirus (3, 30%), and influenza A (2, 20%). Pathogen co-detections were common, 8 out 10 cases were associated with 2 pathogens, representing 7 unique combinations. While rhinovirus and coronavirus were most common among asymptomatic trainees, 10% had detectable influenza A. Detection of multiple pathogens was common in the first two weeks of training (50% among those who had viral detection). The study is still in progress.

Conclusion

Symptomatic ILI was associated with coronavirus, rhinovirus, and enterovirus, in addition to influenza in the early weeks of training. Coronavirus and rhinovirus also circulated widely among healthy recruits, along with influenza. The findings will inform ILI control strategies for congregated military trainees.

Disclosures

E. Grigorenko, Diatherix Laboratories: Employee, Salary.L. Malone, Diatherix Laboratories: Employee, Salary.
Human Coronavirus (HCoV) Infection Among Adults in Cleveland, Ohio: An Increasingly Recognized Respiratory Pathogen
Authors: Kanwar Anubhav , Selvaraju Suresh , Esper Frank
Published: October 2017

Background

Human Coronaviruses (CoV) have been long recognized as a common cause of respiratory tract disease including severe respiratory tract illness, yet there are few recent studies characterizing disease among adults in the United States. Here, we describe CoV infections and clinical characteristics among adults (>18 years) presenting with respiratory illness in Cleveland, Ohio.

Methods

Between February 1, 2016 and April 30, 2017, 2949 nasopharyngeal swab specimens were analyzed by NxTAG Respiratory Pathogen Panel in adults presenting with respiratory illness at MetroHealth Medical Center. Clinical data were collected on adults whose samples screened positive for CoV-HKU1, CoV-OC43, CoV-229E or CoV-NL63.

Results

Coronaviruses were detected in 192 (6.5%) adults including 105 (3.5%) OC43, 67 (2.3%) 229E, 13 (0.4%) HKU1 and 7 (0.2%) NL63. The majority of adults with coronavirus infection were females (66.2%) with a median age of 53 years. Common comorbidities included smoking (40.0%), asthma (38.0%), COPD (35.4%), and inhaled corticosteroid use (28.6%). Eighty-five (46.4%) required admission to the hospital. Common presenting symptoms included shortness of breath (42.7%) and cough (31.0%) whereas fever was uncommon (12.5%). Gastrointestinal symptoms were more common in HKU1 and NL63 infected adults. Seventy-three percent of coronavirus disease occurred between the months of January and March. Despite the recognition of coronavirus infection, 70 (36.5%) received antibiotics for their disease.

Conclusion

This study provides needed insight into clinical characteristics and severity associated with coronavirus infection in adults. Coronavirus infection should be considered in differential diagnosis of respiratory tract illness in adults including those that require hospitalization, have a history of smoking and have pulmonary comorbidities.

Disclosures

All authors: No reported disclosures.
Active Surveillance to Quantify the Burden of Norovirus in a U.S. Veterans Affairs (VA) Patient Population, Houston, 2015–2016
Authors: Kambhampati Anita , Vargas Blanca , Mushtaq Mahwish , Browne Hannah , Perregaux Sara , Grytdal Scott , Atmar Robert L , Vinje Jan , Parashar Umesh D , Hall Aron J , Cardemil Cristina V , Lopman Benjamin , Rodriguez-Barradas Maria C
Published: October 2017

Background

Norovirus is the leading cause of acute gastroenteritis (AGE) outbreaks in the United States; however, little data exist on the burden of endemic norovirus disease among adults. Robust estimates of the norovirus disease burden among US adults are needed to inform assessment of potential norovirus vaccines, which are currently in development.

Methods

We conducted active surveillance for AGE at the Michael E. DeBakey Veteran’s Affairs (VA) Medical Center, where approximately 104,000 unique patients were served in 2016. Cases were defined as veterans with symptoms of AGE (≥3 loose stools, ≥2 vomiting episodes, or ≥1 episodes of both loose stool and vomiting, within 24 hours) occurring in the previous 10 days, who presented to the emergency department or outpatient clinics (outpatients), or were admitted to the hospital (inpatients). Patients without AGE symptoms in the prior 14 days were enrolled as controls. Demographic data and illness characteristics were collected from enrolled subjects, and stool samples were collected and tested using the FilmArray gastrointestinal panel. Norovirus positives were confirmed by real-time RT-PCR and genotyped after sequencing of conventional PCR products.

Results

From November 1, 2015–November 30, 2016, 130 inpatient and 85 outpatient AGE cases, along with 20 inpatient and 37 outpatient controls, were enrolled and provided a stool specimen. Among cases, 201 (93%) were male, and 94 (44%) were ≥65 years; median duration of illness was 3 days (range, 1–10 days). Norovirus was detected in 12 (9%) inpatient and 15 (18%) outpatient cases; norovirus was not detected in any controls. Incidence of norovirus-associated hospitalization was 15/100,000 population, and was similar in hospitalized cases aged <65 years (14/100,000) and ≥65 years (15/100,000). Of 22 norovirus positive specimens genotyped, 13 (59%) were GII.4 Sydney.

Conclusion

This robust, active surveillance platform employed screening and enrollment of patients in a VA population meeting a standardized AGE case definition, as well as asymptomatic controls. Data from this study highlight the burden of norovirus in adults and importance of a norovirus vaccine.

Disclosures

R. L. Atmar, Takeda Vaccines, Inc.: Research Support, Research support. B. Lopman, HHS/NIH/NIAID: Grant Investigator, Grant recipient. Bill & Melinda Gates Foundation: Grant Investigator, Grant recipient.
Epidemiology and Clinical Outcomes of Respiratory Viral Infections at a Single Tertiary Centre in Alberta, Canada
Authors: Teale Alastair , Zapernick Lori , Taylor Geoffrey , Smith Stephanie
Published: October 2017

Background

Respiratory viral infections (RVI) are commonly seen in hospitalized patients. While many studies have examined outcomes with influenza, fewer studies have examined outcomes of community and hospital acquired infections of other respiratory viruses.

Methods

Data were prospectively collected from adult (age>17 years) inpatients with a positive result from respiratory viral multiplex panel testing during consecutive viral respiratory seasons from November 2014 to April 2017 at our facility. Ambulatory patients were excluded. Clinical outcomes including ICU admission requiring intubation, overall mortality and respiratory virus infection-related mortality was assessed at 30 days post infection.

Results

A total of 731 inpatients with positive results were identified. Influenza A was the most commonly detected virus (44%) followed by respiratory syncytial virus (RSV)(14%) and rhinovirus/enterovirus (13%). Rates of RSV and human metapneumovirus infections displayed significant yearly variability. There were no significant differences in rates of ICU admission requiring intubation (16.8% vs. 14.3% P = 0.35) between infections caused by influenza A and B and other respiratory viruses. In addition, mortality related to respiratory infections between these groups was also similar (5.7% Influenza vs. 4.5% non-Influenza P = 0.46). Ninety-five (15%) of identified patients had hospital acquired respiratory viral infections. Influenza A was the most commonly isolated hospital acquired infection (39%). Rates of ICU admission requiring intubation (22.6% vs. 14.6%, P = 0.06) and respiratory infection-related mortality (7.4% vs. 4.8%, P = 0.14) were higher in hospital acquired RVI but did not meet statistical significance. Less than half (45%) of all patients testing positive for influenza received antiviral treatment (oseltamivir). Respiratory infection-related mortality was not significantly different between those who were treated and those who were not treated (5.5% vs. 4.4%, P = 0.64).

Conclusion

While influenza remains the most common community and hospital acquired respiratory viral infection in inpatients at our facility, half of infections were attributed to other respiratory viruses and these resulted in similar rates of serious outcomes including ICU admission and mortality.

Disclosures

All authors: No reported disclosures.
Factors for Hospitalizations and Neurologic Complications in Zika Virus Infection in the Department of Veterans Affairs (VA)
Authors: Schirmer Patricia , Wendelboe Aaron , Lucero-Obusan Cynthia , Ryono Russell , Oda Gina , Winters Mark , Saavedra Sonia , Martinez Mirsonia , Holodniy Mark
Published: October 2017

Background

Zika virus (ZIKV) is an important flavivirus, but severity of infection is poorly described in adults. We investigated factors associated with hospitalization and neurologic complications as measures of severity.

Methods

ZIKV cases from December 1, 2015 to October 31, 2016 were identified from clinical samples tested in VA, state and commercial laboratories, and patients were followed until 3/31/2017. ZIKV positive patients (RT-PCR or screening IgM positive confirmed by a plaque-reduction neutralization test [PRNT] IgM positive for ZIKV alone or including dengue virus) were reviewed for demographic and clinical factors. Logistic regression analysis was performed to evaluate factors associated with 1) hospitalization and 2) neurologic complications in VA ZIKV positive patients.

Results

736 of 1,538 (48%) patients tested were ZIKV positive; 655 (89%) were male and 683 (93%) were diagnosed at the VA Caribbean Healthcare System (VACHCS). In total, 94 (13%) were hospitalized with 91 (12%) at VACHCS. 19 (3%) patients, all at VACHCS, died from any cause after ZIKV diagnosis. Hospitalization was more likely with increased age, co-morbidities, neurologic symptoms, thrombocytopenia, or preadmission glucocorticoid use, and less likely if rash was present (Table 1). Hospitalization, prior cerebrovascular disease and dementia were associated with neurologic complications.

Conclusion

Older Veterans with multiple comorbidities or presenting with neurologic symptoms were more likely to be hospitalized after ZIKV infection, and those with a prior history of cerebrovascular disease and dementia were at increased risk for neurological complications.

Disclosures

All authors: No reported disclosures.
Clinical and Laboratoy Characteristics of Parvovirus B19 Infection During 2013/2014 Outbreak in Zagreb, Croatia
Authors: Ajdukovic Mia , Pejic Lucija , Papic Neven , Vince Adriana
Published: October 2017

Background

Human Parvovirus B19 (HPV-B19) occurs worldwide and causes mild, acute exanthematous disease that occurs in a form of cyclic local epidemics. The aim of this study was to analyze clinical features and complication rates of acute HPV-B19 infection in different age groups.

Methods

We retrospectively reviewed the charts of 718 consecutive patients clinicaly diagnosed with acute HPV-B19 infection who visited outpatient department at the University Hospital for Infectious Diseases in Zagreb, Croatia during 2013–2014 outbreak. In 212 patients (of 298 tested) diagnosis was confirmed by positive IgM antibodies and/or HPV-B19 DNA in peripheral blood.

Results

Outbreak started in June 2013 and had a peak in April 2014, with highest prevalence in schoolchildren. There were no difference in clinical presentation or laboratory findings between clinicaly and serologicaly diagnosed patients. Biphasic presentation, fever, myalgia, arthralgia, headache and peripheral edema were more frequent in adults, but „slapped cheeks” was found predominantly in children. Complications were more common in adults, most commonly hematological disordes (mild anemia, thrombocytopenia and leukopenia), vasculitis, hepatitis and aseptic meningitis. There were no deaths in our cohort.

Conclusion

Parvovirus B19 infection has different clinical presentation, laboratory findings and complications in children and adults. Since the diversity of the clinical manifestations in adults may be misleading, the infection in adults should be suspected when disease is prevalent in children.

Disclosures

`All authors: No reported disclosures.
Human Papillomavirus (HPV) Knowledge, Vaccine Acceptability and Acceptability of Text Message Reminders for Vaccine Doses in Adolescents Presenting to an Urban Emergency Department (ED)
Authors: Allison Waridibo E , Rubin Ada , Levine Deborah
Published: October 2017

Background

HPV vaccination has been shown to reduce the incidence of high grade cervical abnormalities in girls under 18 years old and the incidence of genital warts in young men and women under 21 years old. HPV vaccine uptake in the US is low. The 2012 National Immunization Survey–Teen indicated that of girls and boys aged 13–17 years, 33.4% and 6.8% respectively had completed the three dose HPV vaccine. It has been suggested that opportunities for HPV vaccination in less traditional health care settings and using reminder and recall systems may improve HPV vaccine uptake.

Methods

Adolescents aged 13–18 years old were recruited prospectively from two pediatric EDs in New York City. Recruited patients took part in a researcher-administered questionnaire based on the validated Carolina HPV Attitudes and Beliefs Scale. Demographic information was also collected. Patients were recruited between 8 am and 8 pm and approached consecutively within 4-hour time blocks. Standard descriptive statistics were used to summarize response data.

Results

Between September 21, 2016 and May 31, 2017, 117 adolescents were interviewed (70 females, 47 males). 76 (65%) had never had their parent or anyone else talk to them about the HPV vaccine. 71 (61%) of adolescents knew the HPV vaccine was not for girls only. 83 (71%) thought that the HPV vaccine was safe. Only 10 (8.5%) of participants thought they were too young to get the vaccine. 35 (30%) answered “yes” when asked if they had ever had sex but only 14 (12%) thought that the HPV vaccine was only for people who are sexually active. 83 (71%) of adolescents would agree, if their parent agreed, to have the HPV vaccine in the ED on the day they were interviewed. 104 (89%) of interviewed adolescents had a mobile phone and 88 (75%) stated they would have no problem with receiving a text message reminder for a vaccine shot.

Conclusion

Adolescents find it acceptable to receive HPV vaccination in these EDs and text message reminders for subsequent vaccine doses. Exploration of initial HPV vaccination of unvaccinated adolescents in the ED, with follow up doses in more traditional clinic settings aided by text message reminders warrants further investigation. Though a challenging care environment, the ED should not be ignored as a potential site for public health interventions such as HPV vaccination in adolescents.

Disclosures

All authors: No reported disclosures.
Using Preventive Health Alerts in the Electronic Health Record Improves Testing Rates for Infants Perinatally-Exposed to Hepatitis C
Authors: Hojat Leila , Bhardwaj Amrita , Bar-Shain David , Greco Peter , Abughali Nazha
Published: October 2017

Background

Perinatal exposure to hepatitis C virus (HCV) is a major public health issue, as testing rates are poor and many infected patients remain unidentified. We sought to use the electronic health record (EHR) to improve testing rates among infants born to HCV-infected mothers in an urban, safety-net hospital system.

Methods

Our study population was identified using our EHR database (Hyperspace Epic 2014, EpicCare Systems, Verona, WI). Children were included in the study if they had perinatal HCV exposure, were between the ages of 18 months to 18 years, and had at least one encounter in primary or urgent care during the study period. Our study included retrospective (October 2011-Febrary 2015) and prospective (February 2015-May 2016) arms. Our EHR-based intervention, which we initiated in the prospective arm, linked the patient to a one-time HCV antibody test on or after the age of 18 months using a preventive health forecasting engine. The preventive health forecasting engine activated a point of care clinical advisory alert for all children with perinatal hepatitis C exposure. This alert was associated with an order for a HCV antibody test and would occur in all well child or urgent care encounters during the study period.

Results

5.6% (7/125) of the patients with perinatal HCV exposure had a HCV antibody test performed on or after 18 months of age during the retrospective arm. After initiation of our EHR-based intervention, this proportion significantly increased to 18.7% (28/150) (P <0.002; CI, 1.6 to 9.2; OR, 3.9).

Conclusion

Among patients with perinatal HCV exposure, using a point of care clinical advisory within the EHR significantly increased the rate of HCV antibody testing in accordance with American Academy of Pediatrics recommendations. However, a significant number of infants continue to not be appropriately tested. More EHR-based interventions combined with increased physician awareness of appropriate HCV testing in perinatally-exposed infants is imperative.

Disclosures

All authors: No reported disclosures.
2015–2016, Georgia Department of Public Health Districts, Evaluating Oral Health Services in Ryan White Part B Clinics
Authors: Rabold Elizabeth , Felzien Gregory , Coker Michael
Published: October 2017

Background

Poor dental health adversely affects overall health, and people living with HIV/AIDS (PLWHA) have a higher prevalence of dental disease than the general population. This study evaluated dental care access and utilization among PLWHA who receive services at Ryan White Part B (RWPB) Clinics in Georgia using three different measurement instruments.

Methods

Of the 19 Georgia Department of Health (GA-DPH) districts, HIV coordinators from all 16 districts that receive RWPB funding completed a web-based dental care needs assessment survey in October 2016, evaluating July 2015 to June 2016 (FY16). We compared findings to metrics obtained from two other sources: CAREWare, a national HIV electronic health system; and manual chart audits, performed using a weighted analysis of 32–42 clients per district. We analyzed the survey data and compared the three instruments descriptively.

Results

Of the 9,461 total active clients with HIV in the 16 DPH districts evaluated in the survey, 20% had at least one dental visit during FY16. All 16 districts had established relationships with dental providers. The average waiting period to see a dentist was <4 weeks in 13 (81%) of districts. Coordinators most frequently identified lack of transportation, health literacy, and high cost as important barriers to care. Though the overall average of clients with at least one dental visit during FY16 was similar between the survey, CAREWare, and audit data (20%, 16%, and 19%, respectively), the three instruments demonstrated notable variability within sites. Proportion of clients with dental visits across Georgia showed regional variation, with fewer visits reported centrally and more dental visits reported in the northeastern and southeastern areas.

Conclusion

Even though all DPH districts had access to dental providers with short waiting periods, PLWHA served by RWPB received limited dental services and faced many barriers to care during FY16. Three measurement tools demonstrated poor consistency between and across districts, highlighting the challenges in reporting and evaluating data in this population. By developing targeted quality improvement initiatives, GA-DPH will use these finding to improve annual dental visit rates, reduce barriers to care, and more accurately measure specific health outcomes for PLWHA.

Disclosures

All authors: No reported disclosures.
Outpatient Parenteral Antimicrobial Therapy (OPAT) Practices at a Veterans Affairs Hospital: Potential for Pharmacist Impact
Authors: Yang Catherine , Nguyen Nancy N , Chary Aarthi , Nakasone Trisha S
Published: October 2017

Background

The Infectious Diseases Society of America (IDSA) OPAT Practice Guidelines and Handbook recommend multidisciplinary team involvement as a key element to the success of OPAT. Studies have demonstrated that OPAT pharmacist oversight can improve monitoring of intravenous (IV) antibiotics and achieve clinical cure in 77% of patients. Pharmacists at the Veterans Affairs Palo Alto Health Care System are currently not routinely involved with the management of OPAT patients.

Methods

A retrospective analysis was performed to determine the rate of adherence to IDSA recommendations on antibiotic laboratory and clinical monitoring in veterans discharged with OPAT between July 1, 2015 and June 30, 2016. Secondary outcomes assessed were rates of clinical cure, treatment failure, readmission, and OPAT complications. Data was analyzed using descriptive statistics.

Results

Of 83 patients evaluated, 91 IV antibiotics were administered and 70 patients completed OPAT. The most common infections were osteomyelitis (n = 33, 40%), bacteremia (n = 13, 13%), and skin and soft-tissue infection (n = 9, 11%). Cephalosporins (n = 41, 45%) were most commonly used, followed by vancomycin (n = 18, 20%) and penicillins (n = 12, 13%). Appropriate monitoring of complete blood count, basic metabolic panel, and liver function occurred 45%, 45%, and 25% of the time, respectively, based on IDSA guidance. An increase in treatment failure was observed when less than 25% of weekly lab monitoring was conducted. Twenty-six patients (31%) met the IDSA recommendation for follow-up visits within 7–14 days of discharge and 51 patients (61%) received follow-up visits upon OPAT completion. Clinical cure was achieved in 52 patients (63%). There were more 90-day readmissions related to infection, adverse drug reactions, catheter-related complications, and C. difficile infections reported in the treatment failure group compared with the clinical cure group.

Conclusion

In most cases, IDSA recommendations on OPAT management were not appropriately followed and lack of monitoring was associated with treatment failure. Fewer patients achieved clinical cure compared with rates documented in the literature, strongly suggesting the need for an OPAT pharmacist to achieve optimal monitoring and follow-up.

Disclosures

All authors: No reported disclosures.
Early ID Outpatient Follow-up of OPAT Patients Reduces 30-day Readmission
Authors: Saini Ena , Ali Mohammad , Du Ping , Crook Tonya , Zurlo John
Published: October 2017

Background

Although weekly outpatient follow-up for patients discharged on outpatient parenteral antimicrobial therapy (OPAT) has been recommended, few practitioners follow this recommendation. No studies have examined the relationship between outpatient follow-up and patient outcomes for this population. We examined the association between outpatient ID follow-up and the risk for 30-day readmission for patients discharged on OPAT.

Methods

We conducted a retrospective cohort study using EMR data comprising 1102 OPAT patients treated between January 2012 and December 2014 at a major tertiary care medical center. We sought to determine whether ID outpatient follow-up was associated with a lower risk of 30-day readmission, after adjusting for patient demographics, infection diagnosis, outpatient antibiotics, and comorbidities (mainly diabetes mellitus, renal failure and immunosuppression).

Results

Of 1102 cases, 201 of 1102 (18%, 95 females, 106 males) were readmitted within 30 days, of whom 133 (66%) were re-admitted in the first 2 weeks post discharge. 837 (76%) were seen in ID outpatient follow-up within 30 days of discharge, of whom 396 (47%) were seen in first 2 weeks. By univariate analysis OPAT patients seen in ID outpatient follow-up within 2 weeks of discharge were less likely to get readmitted within 30 days of hospital discharge (OR: 0.6, CI: 0.4–0.9, P < 0.02). Patients with immunosuppression (OR: 1.9, 95% CI: 1.3–2.7, P < 0.0001) or discharged on 3 or more antimicrobials (OR: 2.1, 95% CI:1.4–3.2, P < 0.0001) were more likely to have 30-day readmission. By multivariate analysis patients seen in outpatient ID follow-up within 2 weeks (OR: 0.6, CI: 0.4–0.9, P < 0.006) or those receiving ceftriaxone alone (OR: 0.6, CI: 0.3–0.9, P < 0.015) were less likely to have 30-day readmission. Patients who were immunosuppressed (OR: 1.9, CI: 1.3–3.0, P < 0.003) or those discharged on 3 or more antimicrobials (OR: 2.1, CI: 1.4–3.2, P < 0.001) were more likely to have 30-day readmission.

Conclusion

Infectious disease outpatient follow-up within 2 weeks for patients discharged on OPAT reduces all-cause 30-day readmission. Early outpatient follow-up is especially important for patients who are immunosuppressed and those receiving multiple antibiotics.

Disclosures

All authors: No reported disclosures.