bluuebunny/crossref_metadata_2025 huggingface dataset:
1199. Epidemiology of Carbapenem-Resistant Klebsiella pneumoniae: A Comparative Study Between Facilities in the United States and the Dominican Republic
Authors: Mena Lora Alfredo J , Fermin Rita Rojas , Guzman Anel , Borgetti Scott , Bleasdale Susan C
Published: November 2018

Background

The prevalence of multi-drug-resistant organisms (MDRO) is on the rise globally. MDRO infections carry high morbidity and mortality. There is a paucity of data on Carbapenem-resistant Klebsiella pneumoniae (CRKp) in the Dominican Republic (DR). Evaluating CRKp in various settings will provide data on contrasting epidemiologic risk factors. We evaluated the epidemiology of CKRp in three contrasting settings, a 495-bed urban academic center (AC), a 151-bed urban community hospital (CH) and a 200 bed teaching hospital in the DR (DRH).

Methods

We performed a retrospective cohort study of patients with CRKp cultures from 2014 to 2016 from AC, CH and DRH. A comparative evaluation of the epidemiology of CRKp between the cohorts was performed. Demographics, co-morbid conditions, antibiotic sensitivity, and outcomes were compared between hospital cohorts.

Results

Cohort AC had 64 patients, compared with eight from CH and eight from DRH. AC (59%) and CH (62%) cohorts included more men than the DRH cohort (25%). Average age was 62, 66, and 51, respectively. History of MDRO, antibiotic use in the past 6 months and hospitalization within the past year were common risk factors (Figure 1). Diabetes and end-stage renal disease were common comorbidities at all facilities (Figure 2). Charleston Comorbidity Index (CCI) score was highest at AC (6.6) and DRH (6.4) compared with CH (4). Mortality was highest in DRH (63%, 6/8) and AC (11%, 7/64) while CH had no deaths. Urine was the most common source at AC (67%) and CH (75%) while blood was most common at DRH (62.5%). CRKp isolates were susceptible to colistin at varying rates (AC=85%, CH = 63%, DRH = 80%).

Conclusion

Prior antibiotic use and hospitalization were common risk factors in all settings. Mortality and CCI scores for CRKp was highest at AC and DRH, which are tertiary referral centers. CH had less overall mortality and higher rates of colistin resistance. Further studies are needed to understand these risk factors. Strengthening antimicrobial stewardship and infection control practices in the United States and abroad may help curb the spread of resistance in different clinical settings.

Disclosures

All authors: No reported disclosures.
1200. Molecular Epidemiology of Cephalosporinases and Extended Spectrum β-Lactamases (ESBLs) in Proteus mirabilis Isolates From Croatia: Following the Spread of Resistance Determinants Between Long-Term Care Facilities and the Community
Authors: Mestrovic Tomislav , Lukic-Grlic Amarela , Bogdan Maja , Bandic-Pavlovic Daniela , Cavric Gordana , Drenjancevic Domagoj , Sreter Katherina Bernardette , Bencic Ana , Sardelic Sanda , Bedenic Branka
Published: November 2018

Background

Previous studies on P. mirabilis strains isolated from Croatian healthcare institutions revealed the predominance of TEM-52 extended spectrum β-lactamase (ESBL), as well as the emergence of plasmid AmpC β-lactamases. Our aim was to molecularly characterize cefalosporinases in P. mirabilis isolates from long-term care facilities (LTCFs) and to compare their resistance profile and dynamics with community isolates.

Methods

From a total of 3,321 P. mirabilis isolates collected from two LCTFs and from outpatients between 2015 and 2017, 1.23% of them were resistant to third generation of cephalosporins. Antimicrobial sensitivity was tested by broth microdilution method. ESBLs and plasmid-mediated AmpC β-lactamases were detected with phenotypic inhibitor-based tests and polymerase chain reaction (PCR). Antibiotic resistance dissemination and genetic context of bla genes were interrogated by conjugal mating and PCR mapping, respectively. Plasmids were characterized by conjugation and transformation experiments, as well as PCR-based replicon typing.

Results

High-level of resistance to amoxicillin, co-amoxiclav, first, second and third generation of cephalosporins was found in all isolates. Three isolates tested positive in inhibitor-based test with clavulanic acid, and 38 both in Hodge test and combined disk test with phenylboronic acid, indicating the production of ESBLs and plasmid-mediated AmpC β-lactamases, respectively. Two ESBL-positive organisms yielded amplicons with primers for CTX-M β-lactamase of group 1 and one for TEM. All AmpC-positive organisms were identified by PCR as CMY (with an additional TEM). Insert sequence ISEcp-1 was found upstream of blaCMYi blaCTX-M genes. CTX-M positive strains harbored IncK plasmid, whereas AmpC-positive strains were negative for known plasmid types. This is also a first description of P. mirabilis harboring CTX-M-15 β-lactamase in Croatia.

Conclusion

Our study showed the persistence of CMY β-lactamases in one LTCF, but also the dissemination of characteristic resistance determinants to another LTCF and the community. Similar to some other studies, there was a clear trend of cephalosporinase dynamic switch from TEM variants to CMY and CTX-M, with impending consequences for treatment decisions.

Disclosures

All authors: No reported disclosures.
1210. Staphylococcal Acute Post-Operative Prosthetic Joint Infection (PJI) Treated With “DAIR” (Debridement and Implant Retention) and Impact of Rifampin: A Retrospective Cohort Study in France
Authors: Becker Agathe , Triffault-Fillit Claire , Forestier Emmanuel , Lesens Olivier , Boyer Bertrand , Descamps Stéphane , Chidiac Christian , Lustig Sébastien , Montbarbon Eric , Batailler Cécile , Cazorla Celine , Ferry Tristan
Published: November 2018

Background

Staphylococci are the most frequent bacteria in PJI. In patients with acute PJI (i.e., <1 month following the implantation), DAIR with exchange of removal components followed by a combination of antibiotics including rifampin (RMP) (particularly RMP + fluoroquinolone) are recommended. Unfortunately, some patients could not receive RMP due to drug–drug interaction or stopped it due to an adverse event. Finally, it is unclear whether the dose and the duration of RMP influenced the prognosis.

Methods

Retrospective cohort study in four hospitals including patients with staphylococcal acute post-operative PJI treated with DAIR in 2011–2016. Univariate and multivariate Cox analysis and Kaplan–Meier curves were used to determine the risk factors for treatment failure.

Results

Seventy-nine patients were included (median age: 71 years [IQR 53–89]; 55 men [69.6%]; median ASA score: 2 [IQR 2–3]). Cultures revealed 65 (82%) S. aureus and 15 (19%) coagulase negative staphylococci infections, including 14 methicillin-resistant strains (18%). Among all isolates, only two (3%) were resistant to RMP and 16 (20%) were resistant to fluoroquinolone. The median duration of antimicrobial therapy was 92 days (IQR 31–152). Only 59 patients received RMP (75%), and 35 (44%) the combination RMP + fluoroquinolone. Median duration of RMP was 57 days (IQR 16–86) and median dose 14.6 mg/kg/d (IQR 13–17). Forty patients (51%) received RMP in the first 2 weeks and 43 patients (54%) received at least 2 weeks of RMP. Six patients (8%) developed an adverse event leading to RMP interruption. During a median follow-up of 443 days (IQR 220–791), 21 patients (27%) experienced a treatment failure including 12 persistence of the initial pathogen (57%) and nine superinfections (43%). An ASA score >2 (OR 2.8; 95% CI 1.26–6.15), the use of RMP (OR 0.4; 95% CI 0.71–0.95) and the duration of RMP treatment (OR 0.83; 95% CI 0.75–0.92 per week of treatment) were significant determinants of the outcome (but not methicillin-resistance). Receiving >2 weeks of RMP prevented the failure, but an introduction during the first 2 weeks did not influence the outcome.

Conclusion

In patients with staphylococcal acute PJI, the use of RMP and its duration strongly influenced the prognosis. As 25% of patients could not receive RMP, new drugs with anti-biofilm activity are required.

Disclosures

All authors: No reported disclosures.
1213. Evaluation of an Alcohol-Based Antiseptic for Nasal Decolonization of Methicillin-Resistant Staphylococcus aureus (MRSA)
Authors: Kanwar Anubhav , Cadnum Jennifer L , Mana Thriveen Sankar Chittoor , Gestrich Scott , Jencson Annette , Donskey Curtis J
Published: November 2018

Background

Due to concerns for emergence of mupirocin resistance, there is an interest in use of topical antiseptics for nasal decolonization of Staphylococcus aureus. Alcohol-based nasal antiseptics have recently been developed as an alternative to mupirocin, but there is limited data on efficacy, particularly among patients where the burden of carriage is often high.

Methods

We evaluated the effectiveness of a one-time application of a commercial alcohol-based nasal sanitizer for reduction in nasal methicillin-resistant Staphylococcus aureus (MRSA) in MRSA-colonized patients. Patients received either a single dose or triple dose over 3 minutes; the triple dose is recommended for preoperative dosing. Swabs were used for quantitative culture of MRSA from the anterior nares and vestibule prior to and 10 minutes, 2 hours, and 6 hours after application. For a subset of patients, cultures for MRSA were collected from hands, clothing, groin, and chest/axilla.

Results

Of 34 MRSA carriers enrolled, 27 (79%) had MRSA detected in nares, 32 (94%) were male, and the mean age was 65. Of the 27 carriers positive for nasal MRSA, 15 (56%) received a single alcohol dose and 12 (44%) received a triple dose over 3 minutes. As shown in the figure, the single and triple dose applications significantly reduced MRSA concentrations at 2 hours post-treatment when the initial burden was low (i.e., <2 log10colonies per swab), but there was no significant reduction at 6 hours; there was no significant reduction with either dose when the initial burden was high (≥2 log10colonies per swab).

Conclusion

A single application of an alcohol nasal sanitizer significantly reduced nasal MRSA at 2 hours post-application when the initial burden of colonization was low, but not when a high burden of carriage was present. Additional studies are needed to determine whether higher alcohol doses or repeated applications might result in improved efficacy.

Disclosures

All authors: No reported disclosures.
1214. High Frequency of Genes Encoding Resistance to Heavy Metals in Methicillin-Resistant Staphylococcus aureus (MRSA) Endemic Lineages From South America
Authors: Diaz Lorena , Solano Juan , Rios Rafael , Carvajal Lina P , Munita Jose M , Rincon Sandra , Arias Cesar , Reyes Jinnethe
Published: November 2018

Background

MRSA-USA300 is a community-associated clone that has spread worldwide, becoming the most successful clone in the USA. Since 2005, the MRSA-USA300 Latin-American Variant (USA300-LV) has disseminated in community and hospitals in Northern South America. Phylogenetic analysis revealed that USA300-LV is not derived from the USA300 (NA-USA300) but rather, the two clones diverged from a common ancestor. During their evolution, NA-USA300 strains incorporated the ACME element and USA300-LV acquired a copper and mercury resistance mobile element designated COMER. Interestingly, contamination by heavy metals in South American has been recently highlighted and could be driving the selection of resistant genetic lineages. We investigated the frequency of merA, merB, and copB in genomes of clinical isolates of S. aureus from Latin America (LA).

Methods

The presence of merA/merB and copB encoding mercury and copper resistance, respectively, were investigated in 515 S. aureus sequenced genomes recovered from bacteremic patients in hospitals from nine Latin American hospitals trough BLAST searches.

Results

The prevalence of merAB in S. aureus was 35% (181 out of 515 genomes). Interestingly, among 181 merAB-positive S. aureus, 174 were MRSA (96%). Moreover, 71%, 60%, 59%, and 51% of MRSA genomes from Peru, Ecuador, Colombia, and Venezuela, respectively, harbored mercury resistance genes. Similarly, 65%, 60%, and 22% of MRSA genomes from Ecuador, Colombia, and Venezuela, contained the copB gene. Among 174 MRSA harboring merAB, ST8 and ST5 were the most predominant lineages in (43% and 45% of genomes, respectively). In contrast, among 95 MRSA carrying copB, ST8 was the most frequent lineage (96% of isolates). MRSA from countries with high prevalence of mercury genes showed association with ST5 and ST8. 88% of Colombian and 87% of Ecuadorian MRSA harboring merAB belonged to ST8 lineage, whereas ST5 was predominant in 88% of Peruvian MRSA. In Venezuela, ST5 and ST8 were found in 44% and 33%, respectively, of MRSA positive for merAB.

Conclusion

High levels of mercury in rivers of Colombia, Ecuador and Peru has been reported. Thus, the prevalence of heavy metal resistance genes in MRSA clinical isolates suggest an adaptation of endemic genotypes to heavy metal contamination caused by activities like metal mining.

Disclosures

J. M. Munita, Pfizer: Grant Investigator, Research grant. C. Arias, Merck & Co., Inc.: Grant Investigator, Research support. MeMed: Grant Investigator, Research support. Allergan: Grant Investigator, Research support.
1218. Retapamulin as a Potential Decolonizing Agent: Activity against Mupirocin-Resistant Strains From Pediatric Patients With Methicillin-Resistant Staphylococcus aureus Infection
Authors: Patel Ami , Lighter-Fisher Jennifer , Fulmer Yi , Copin Richard , Ratner Adam , Shopsin Bo
Published: November 2018

Background

Controlling methicillin-resistant Staphylococcus aureus (MRSA) colonization is a common strategy to prevent transmission and recurrent infection. Standard decolonization regimens include nasal application of mupirocin ointment; however, increasing rates of mupirocin-resistance (Mup-R) have been noted globally. At our institution there has been an increase in community-acquired MRSA (CA-MRSA) infections among children living in Brooklyn, New York. A genotypic geographic cluster of an outbreak clone of the CA-MRSA strain USA 300 with a high rate (>85%) of mupirocin resistance, mediated by the plasmid borne mupA gene, was identified prompting investigation into an alternative decolonizing agent. We sought to investigate retapamulin, a topical pleuromutilin antibiotic, which has been shown to be effective against S. aureus with in vitro and in vivo activity against MRSA and a low propensity to develop resistance.

Methods

Broth microdilution was used to determine the minimum inhibitory concentrations (MIC) of retapamulin against 53 Mup-R MRSA isolates collected from pediatric patients (aged 9 months–17 years) presenting to our institution over an 18 month period with clinical MRSA infection. Susceptibility defined as ≤0.5 mg/L susceptible (EUCAST). Whole genome sequence data were analyzed for the presence of rplC and cfr gene mutations known to confer resistance to retapamulin.

Results

All 53 isolates were susceptible to retapamulin. 49/53 (92%) strains were inhibited at MIC 0.25 mg/L, 2/53 (4%) at MIC 0.125 mg/L, and 2/53 (4%) at MIC 0.5 mg/L. DNA sequence analysis showed that one isolate had a first-step mutation in the rplC gene, but it was not associated with reduced phenotypic susceptibility to retapamulin, as the MIC of that isolate was 0.25 mg/L.

Conclusion

Retapamulin demonstrated excellent in vitro activity against a genotypic cluster of Mup-R isolates from pediatric patients presenting to our institution with MRSA infection. These data suggest that retapamulin may be a promising alternative decolonization therapy for MRSA and a viable option to prevent the spread of mupirocin-resistant MRSA clones. Further research includes an ongoing randomized, placebo-controlled trial testing the in vivo efficacy of retapamulin as a nasal and perirectal decolonizing agent in children.

Disclosures

A. Patel, Aqua Pharmaceuticals: Investigator inititiated grant, Research grant. J. Lighter-Fisher, Aqua Pharmaceuticals: Investigator Initiated Grant, Research grant.
1219. Increasing Methicillin Resistance of Staphylococcus lugdunensis in a Tertiary Care Community Hospital in Japan
Authors: Ichikawa Takahiro , Kodama Fumihiro
Published: November 2018

Background

Staphylococcus lugdunensis, a coagulase-negative staphylococcus, has virulence and pathogenicity similar to that of Staphylococcus aureus. Methicillin resistance and presence of mecA gene are not common in S. lugdunensis in many parts of the world. Recently, higher prevalence of methicillin-resistant S. lugdunensis is reported from Taiwan and Japan. We describe the change in methicillin resistance of S. lugdunensis in a tertiary care community hospital in Sapporo, Japan.

Methods

We performed a retrospective study of S. lugdunensis, isolated from inpatients and outpatients at our hospital from 2008 to 2017. Rate of methicillin resistance of the first 5 years from 2008 to 2012, and that of the second 5 years from 2013 to 2017 were compared. Risk factors of methicillin resistance were also evaluated. Phenotypic detection of methicillin resistance was identified using broth microdilution by VITEK two system (bioMérieux).

Results

A total of 369 cases of S. lugdunensis were detected during the study period. Of all cases, 228 (61.8%) were men, and 177 (48.0%) were hospitalized. Twenty-one isolates (5.7%) were positive in blood culture, 216 (58.5%) were positive in cultures of skin and soft tissue. Methicillin-resistant strains were found in 43 (31.6%) of 136 isolates from 2008 to 2012, and in 108 (46.4%) of 233 from 2013 to 2017 (OR 1.87; 95% CI 1.20–2.91; P = 0.006). Of patients with methicillin-resistant S. lugdunensis, 105 cases (69.5%) were hospitalized (P < 0.001).

Conclusion

In our hospital, methicillin-resistant S. lugdunensis is increasing over the 10 years. Further research is needed to assess trend of methicillin resistance of S. lugdunensis in other healthcare facilities and countries.

Disclosures

All authors: No reported disclosures.
1223. Increasing Incidence of Methicillin-Resistant Staphylococcus aureus in Greenland
Authors: Kjerulf Anne , Holt Jette , Jensen Anne Birgitte , Poulsen Peter , Petersen Andreas
Published: November 2018

Background

The first case of methicillin-resistant Staphylococcus aureus (MRSA) in Greenland was diagnosed in 2000 and led to the first guideline on screening and treatment for MRSA. Up to 2015 there were only 13 patients with MRSA but since then a nearly 4-fold increase in incidence has been seen. The objectives of this study were to analyze the reasons for this increase.

Methods

MRSA data were collected from the laboratory surveillance database at Dronning Ingrids Hospital, typing results from the Reference Laboratory for Antimicrobial Resistance and Staphylococci at SSI, and the patient records.

Results

From 2000 to 2017, 48 patients (15 children and 33 adults) have been diagnosed with MRSA. Thirty patients were colonized with MRSA, predominantly in the nose and throat. Eighteen patients had infections: conjunctivitis, middle ear infections, wounds, skin abscesses, mastitis, surgical site infections, for example.

The increase since 2015 was mainly due to three large outbreaks in three different cities: Aasiaat in 2014/2015 (seven persons with MRSA; three children and four adults), the capital Nuuk in 2016 (six persons with MRSA; two children and four adults) and Tasiilaq in 2017 (13 persons with MRSA; three children and ten adults). The first two outbreaks were community-acquired with transmission in families and the last one was community-acquired or community-onset hospital acquired. Each outbreak was caused by a specific MRSA-type: t902 CC22 in Aasiaat (unknown epidemiology), t3979 CC5 in Nuuk (probably from Australia), and t304 CC6 in Tasiilaq (probably from Denmark).

MRSA was mainly imported from Denmark or abroad due to admission to hospital or due to traveling to high-endemic countries like Australia, but in some cases the epidemiology was unknown. Transmission occurred mainly in families with close contact.

Conclusion

The increasing number of patients with MRSA in Greenland can be explained by factors such as import from Denmark or abroad due to admission to hospital or traveling, and transmission in Greenland. An ongoing surveillance, compliance to screening procedures (especially patients admitted to hospitals abroad) and guidelines for infection prevention and control are necessary in order to combat MRSA in Greenland in the future.

Disclosures

All authors: No reported disclosures.
1230. Epidemiology and Risk Factors for Recurrent Invasive Methicillin-Resistant Staphylococcus aureus Infection: nine US States, 2006–2013
Authors: Kracalik Ian , Jackson Kelly , Nadle Joelle , Bamberg Wendy , Petit Susan , Ray Susan M , Lynfield Ruth , Harrison Lee H , Townes John M , Dumyati Ghinwa , Schaffner William , Lake Jason , See Isaac
Published: November 2018

Background

Methicillin-resistant Staphylococcus aureus (MRSA) causes >70,000 invasive infections annually in the United States, and recurrent infections pose a major clinical challenge. We examined risk factors for recurrent MRSA infections.

Methods

We identified patients with an initial invasive MRSA infection (isolation from a normally sterile body site) from 2006 to 2013, through active, population-based surveillance in selected counties in nine states through the Emerging Infections Program. Recurrence was defined as invasive MRSA isolation >30 days after initial isolation. We used logistic regression with backwards selection to evaluate adjusted odds ratios (aOR) associated with recurrence within 180 days, prior healthcare exposures, and initial infection type, controlling for patient demographics and comorbidities.

Results

Among 24,478 patients with invasive MRSA, 3,976 (16%) experienced a recurrence, including 61% (2,438) within 180 days. Risk factors for recurrence were: injection drug use (IDU) (aOR; 1.38, 95% confidence interval [CI]: 1.15–1.65), central venous catheters (aOR; 1.35, 95% CI: 1.22–1.51), dialysis (aOR; 2.00, 95% CI: 1.74–2.31), and history of MRSA colonization (aOR; 1.35, 95% CI: 1.22–1.51) (figure). Recurrence was more likely for bloodstream infections (BSI) without another infection (aOR; 2.08, 95% CI: 1.74–2.48), endocarditis (aOR; 1.46, 95% CI: 1.16–1.55), and bone/joint infections (aOR; 1.38, 95% CI: 1.20–1.59), and less likely for pneumonia (aOR: 0.75, 95% CI: 0.64–0.89), compared with other initial infection types. When assessed separately, the presence of a secondary BSI with another infection increased the odds of recurrence over that infection without a BSI (aOR: 1.96, 95% CI: 1.68–2.30).

Conclusion

Approximately one in six persons with invasive MRSA infection had recurrence. We identified potential opportunities to prevent recurrence through infection control (e.g., management and early removal of central catheters). Other possible areas for preventing recurrence include improving the management of patients with BSI and bone/joint infections (including both during and after antibiotic treatment) and mitigating risk of infection from IDU.

Disclosures

All authors: No reported disclosures.
1235. Transmission of Genetically Related, Multidrug Resistant, and Invasive Vancomycin-Resistant Enterococci (VRE) Between Patients and Rooms on the Stem Cell Transplant (SCT) and Leukemia (LKM) Units
Authors: El Haddad Lynn , Hanson Blake , Arias Cesar , Otero Glen , Harb Cynthia , Ghantoji Shashank S , Stibich Marc , Chemaly Roy F
Published: November 2018

Background

VRE are a major cause of morbidity and mortality in immunocompromised patients. Tracking the dissemination of VRE strains is crucial to understand the dynamics of infections, emergence, and spread of VRE in the hospital setting.

Methods

Whole-genome sequencing (WGS) and phylogenetic analyses were performed to identify dominant VRE strains and potential transmission networks between patients and their rooms on the leukemia (LKM) and the stem cell transplant (SCT) units, located on two consecutive floors. We included 35 VRE-positive rectal swabs from SCT and LKM patients, and 55 environmental swabs from the patients’ main rooms and bathrooms. Sequence types, drug resistance genes, virulence genes, and patients’ outcomes were also determined.

Results

We identified VRE strains with newly described sequence types (ST) such as ST736, ST494, and ST772 which were isolated from both floors. One VRE genetic lineage belonged to ST494 (only previously isolated in Peru and was the only VanB-type strain). All other strains harbored the vanA gene. We observed highly genetically related strains transmitted between distinct rooms, floors, and time periods within the hospital in a period of 1 month (figure). Of five VRE bacteremia events, three strains were lacking the pili operon fms14-17-13 (ST203) and the remaining two were resistant to daptomycin (ST736, ST664) (figure). Of 10 patients harboring daptomycin-resistant strains, only 3 (30%) were exposed to daptomycin within 18 months before strain recovery.

Conclusion

Our findings confirmed horizontal transfer of highly related genetic lineages of multidrug resistant and invasive VRE strains between SCT and LKM patients and their room environment. New STs were identified and some correlated with bacteremia events. The use of a routine real-time WGS can characterize VRE strains and identify potential reservoirs of transmission in the healthcare setting in order to design interventions to prevent and control the spread of opportunistic and highly resistant organisms.

Disclosures

C. Arias, Merck & Co., Inc.: Grant Investigator, Research support. MeMed: Grant Investigator, Research support. Allergan: Grant Investigator, Research support. M. Stibich, Xenex Services: Employee, Salary. R. F. Chemaly, Xenex Services: Consultant and Grant Investigator, Research grant.
1237. New York State Outpatient Regional Antibiogram for Urinary Pathogens: Have We Reached a Post Antibiotic Era for the Treatment of UTIs?
Authors: Rank Elliot , Lodise Thomas P , Avery Lisa , Bankert Eve , Dobson Erica , Dumyati Ghinwa , Hassett Stephen , Keller Marina , Lubowski Theresa , Pearsall Matthew , Carreno Joseph
Published: November 2018

Background

Outpatient prescribing for acute uncomplicated cystitis is a significant driver of antimicrobial use. Empiric therapy should be based on local susceptibility data. However, there is limited guidance on regional susceptibility trends in outpatient settings. This study describes the epidemiology and prevalence of antimicrobial resistance in uropathogens in New York State outpatient settings to help inform empiric treatment decisions.

Methods

Retrospective analysis of positive urine cultures sent to Quest Diagnostics in 2016 from outpatient settings. Cultures that grew ≥105 CFU/mL were included from 17 NYS counties. Bacterial identification and antimicrobial sensitivities were determined on the Vitek-2 using CLSI M-100 S-25 breakpoints. Data were summarized as proportions and stratified by age (<17, 18–64, ≥65) and sex.

Results

Over 78,000 isolates were included (Table 1). The most prevalent isolates were Escherichia coli (65.2%), Enterococcus spp. (11.9%), and Klebsiella pneumoniae (9.9%). E. coli was highly susceptible to nitrofurantoin (NTF, 97.2%) and cefazolin (CFZ, 89.9%) and less susceptible to trimethoprim–sulfamethoxazole (TMP-SMX, 72.9%) and ciprofloxacin (CIP, 78.0%). Enterococcus spp. was highly susceptible to NTF (99.0%) and ampicillin (99.8%). K. pneumoniae was highly susceptible to TMP-SMX (90.0%) and CIP (95.2%) and markedly less susceptible to NTF (42.0%). E. coli was more prevalent in females (69.7% vs. 39.6%, P < 0.001). Enterococcus was more prevalent in males (39.6% vs. 10.1%, P < 0.001). The prevalence of K. pneumoniae was similar in men and women (9.6% vs. 10.1%, P = 0.08). Resistance was more prevalent in males (NTF: 6.3% vs. 4.2%; TMP-SMX: 26.3% vs. 22.7%; CIP: 35% vs. 17.3%) and for adults ≥65 (NTF: 6.2% vs. 3.6%; TMP-SMX: 25.1% vs. 22.1%; CIP: 30.0% vs. 14.0%) P < 0.001 for all comparisons.

Conclusion

NTF appears to be the best empiric choice for outpatient treatment of acute uncomplicated cystitis in New York State. TMP-SMX and ciprofloxacin should be avoided empirically. These data also highlight the necessity to obtain uropathogen sensitivity data to confirm empiric therapy or make appropriate adjustments in the outpatient setting.

Table 1. Summary of Antimicrobial Susceptibilities

Disclosures

T. P. Lodise Jr., Motif BioSciences: Board Member, Consulting fee.
1239. Frequently Identified Infection Control Gaps in Outpatient Hemodialysis Centers
Authors: Tyner Kate , Nailon Regina , Drake Margaret , Fitzgerald Teresa , Beach Sue , Lyden Elizabeth , Rupp Mark E , Schwedhelm Michelle , Tierney Maureen , Ashraf Muhammad Salman
Published: November 2018

Background

Little is known about infection control (IC) practice gaps in outpatient hemodialysis centers (OHDC). Hence, we examined the frequency of IC gaps and the factors associated with them.

Methods

The Nebraska (NE) Infection Control Assessment and Promotion Program (ICAP) in collaboration with NE Department of Health and Human Services conducted on-site visits to assess infection prevention and control programs (IPCP) in 15 OHDC between June 2016 and March 2018. The CDC Infection Prevention and Control Assessment Tool for Hemodialysis Facilities was used for IPCP evaluation. A total of 124 questions, 76 of which represented best practice recommendations (BPR) were analyzed in 10 IC domains. Gap frequencies were calculated for each BPR. Fisher’s exact test was used to study the association of the identified gaps with typical patient census of the facilities and chain affiliation (CA).

Results

Of the 15 OHDC, seven were large centers (typically following >50 patients) and 11 were part of national chains. Important IC gaps exist in all OHDC. A median of 64 (range 57–70) of 76 BPR were being followed by OHDC or were nonapplicable to them. The IC Program and Infrastructure domain had the highest frequency of IC gaps (Figure 1). Figure 2 describes the top 5 IC gaps. Smaller OHDC (sODHC) and those without CA performed better in a few areas. For example, a higher proportion of sODHC had work exclusion policies that encourage reporting of illness without any penalty when compared with larger OHDC (75% vs. 0, P = 0.01). Similarly, a higher proportion of sOHDC provided space and encouraged persons with symptoms of respiratory infection to sit as far away from others as possible in nonclinical areas (63% vs. 0, P < 0.05). None of the nonchain OHDC had shared computer charting terminals when compared with 64% of OHDC with CA (P = 0.08) and a majority of nonchain OHDC provided space and encouraged persons to maintain distance with others when having respiratory symptoms as opposed to a minority of OHDC with CA (75% vs. 18%, 0.08).

Conclusion

Important IC gaps exist in OHDC and require mitigation. Informing OHDC of existing IC gaps may help in BPR implementation. Larger scale studies should focus on identifying factors promoting certain BPR implementation in smaller and nonchain OHDC.

Disclosures

All authors: No reported disclosures.
1245. Infection Prevention and Control (IP&C) and Antibiotic Stewardship (AS) Practices in Pediatric Long-Term Care Facilities
Authors: Johnson Candace L , Hill-Ricciuti Alexandra , Saiman Lisa
Published: November 2018

Background

In November 2017, the Centers for Medicare and Medicaid (CMS) implemented a requirement for long-term care facilities (LTCFs) to incorporate AS into their IP&C programs. The purpose of this study was to describe baseline IP&C and AS practices in pediatric LTCFs.

Methods

We modified a survey from the CDC to assess IP&C in pediatric LTCFs. The internet-based survey was distributed to the 41 pLTCFs in the Pediatric Complex Care Association from May to June 2017. The 67-question survey included questions to assess IP&C domains and infrastructure such as written policies, hand and respiratory hygiene (HH), personal protective equipment (PPE) use, environmental cleaning, and AS practices. Responses to questions were summarized using frequencies and analyzed using χ2 or Fisher’s exact tests, as appropriate. The characteristics of sites with ≥90% compliance with the CMS rule, as assessed by 14 relevant survey questions, were compared with those of sites with <90% compliance.

Results

Overall, 25 (61%) facilities nationwide completed the survey. All sites reported having written IP&C policies and most had a person responsible for IP&C (96%); fewer reported reviewing/updating these policies annually (72%). Few sites provided feedback to staff on HH adherence (44%), PPE use (40%), and cleaning/disinfection procedures (44%). Few had written policies on antibiotic prescribing (48%) or provided prescribers with feedback about their prescribing practices (40%). Sites with ≥90% compliance with the CMS rule were more likely to report providing prescribers with feedback (70% vs. 20%, P = 0.03), to have provided AS training to clinical (60% vs. 0%, P < 0.01) and nursing staff (70% vs. 7%, P < 0.01) in the past 12 months, and to provide feedback regarding HH (70% vs. 27%, P = 0.05).

Conclusion

While most facilities had implemented some IP&C and AS strategies pertaining to the CMS rule before its enforcement, this survey identified several gaps, especially pertaining to staff feedback for IP&C practices and antibiotic prescribing. Facilities should develop feedback strategies and regularly reinforce the importance of IP&C at employment and during regular trainings.

Disclosures

All authors: No reported disclosures.
1260. Decreasing Hospital Acquired Blood Stream Infections Through Self-Investigation by Hospital Wards
Authors: Shitrit Pnina , Chowers Michal , Gerber Beatriz , Lederman Hanni , Maram Mira
Published: November 2018

Background

Data on the incidence of hospital-wide acquired bloodstream infection (BSI) and the best ways to reduce it are lacking. Our aim was to increase hospital-wide awareness and decrease incidence of hospital-acquired (HA)-BSI through self-investigation.

Methods

Meir Medical Center is a 740-bed hospital. Beginning in January 2016, reports of HA-BSI events were sent daily to the wards with requests to investigate the source of infection, and preventability using a structured questionnaire. The infection control staff gave immediate feedback to the wards regarding their investigation. A summary of the results was sent to all wards and to hospital management quarterly. Interrupted time series analysis was used to compare the monthly rate of HA-BSI before and after the intervention. We estimated the number of cases prevented by the intervention by applying the HA-BSI rate in 2015 to the number of admissions in 2016–2017 and comparing the observed number of cases to the expected if the rate had not changed.

Results

In 2016, 64% of HA-BSI underwent investigation by the wards; this increased to 78% in 2017. As illustrated in the figure, before the intervention, the HA-BSI rate per 1,000 admissions increased by 0.11 per month (not significant P = 0.15). In the first month of the intervention, the HA-BSI rate decreased significantly by 0.43 (P = 0.04, 95% CI: −0.84 to −0.02). The HA-BSI rate continued to decrease (relative to the pre-intervention period) by 0.045 per month (P = 0.05, 95% CI: −0.09 to 0.00). During these 3 years, there was no significant change in the rate of community-acquired BSI (8.46, 8,88, 8,58, P for trend = 0.83) or in the rate of blood cultures drawn. During the intervention, the rate of HA-BSI decreased in both ICU units and in non-ICU wards. The number of HA-BSI caused by Enterobacteriaceae decreased from 170 in 2015 to 116 in 2017. S. aureus decreased from 51 to 30 and Candida from 11 to 0. The most common sources of BSI were urinary tract infection (31.4%) and central line associated BSI (16.4%). All-cause 30-day mortality for patients with HA-BSI was 30%. We estimated that in 2016–2017, 200 cases of HA-BSI and 60 deaths were prevented.

Conclusion

Increase awareness to HA BSI through self-investigation by the wards led to hospital-wide significant reduction in HA-BSI.

Disclosures

M. Chowers, GSK: Grant Investigator, Research grant
1261. Utility of a Multiplex Molecular Gastrointestinal Panel in Rapid Identification and Control of a Norovirus Outbreak in a Pediatric Tertiary Care Center
Authors: Comeau Jeannette L , Ivany Allana M , Romeo Terry , Maxwell Bridget S , Nymark Natalie , MacKinnon Belinda , Doon Erin , Mailman Tim
Published: November 2018

Background

Norovirus is one of the most common viral pathogens implicated in gastroenteritis outbreaks in community and healthcare settings. The virus’ short incubation period and high attack rate allow its rapid spread through inpatient wards to patients (Patients), staff and visitors. Early identification and appropriate implementation of infection prevention and control measures is essential to interrupt transmission.

Methods

The IWK Health Centre is a 250-bed tertiary care Pediatric and Women’s hospital serving the Maritime Provinces, Canada. We describe a norovirus outbreak in our Pediatric Medical Unit, a 24-bed, single room ward with individual bathrooms for patients and families. Hospital-acquired norovirus definition: Patients admitted ≥48 hours with lab-confirmed norovirus AND ≥ 1 of: (1) acute onset diarrhea (no noninfectious cause) or (2) ≥2 of: nausea, vomiting, abdominal pain, fever, or headache. In 2017 the FilmArray Gastrointestinal (GI) Panel was introduced in the Clinical Microbiology Laboratory as part of a prospective post-implementation study. Since then, stool samples sent for viral, bacterial, or parasitic testing are evaluated by PCR. The panel tests for 22 GI analytes, including five viruses, with a 2-hour turnaround time. Previously, in-house stool viral testing was limited to adeno- and rotavirus antigen. Patient characteristics were collected and analyzed for this study.

Results

Patients 1, 2, and 3 had new onset diarrhea and emesis; Pt 1 on day 0, and Patients 2 and 3 on day 1. Patient 3’s parents (likely source) had had diarrhea and emesis on days 3 and 2, and used the ward kitchen. Two care-givers of Patient 2, and 1 medical resident developed diarrhea and emesis over days 0 to 2. The outbreak was declared over on day 7. Patients 1, 2, and 3 all tested positive for norovirus in stool on day 1. On days 2–3, six other patients with diarrhea tested norovirus negative. All symptomatic patients were immediately placed on contact precautions, room/ward cleaning frequency increased and proper hand hygiene was reinforced. Common areas (playroom/kitchen) were closed until the outbreak was over. All patients with loose stool were tested during the outbreak.

Conclusion

FilmArrayGI panel enabled same-day identification of norovirus in this single-ward outbreak and permitted real-time identification of the termination of the outbreak.

Disclosures

All authors: No reported disclosures.
1262. Investigation and Mitigation of a Multi-Species Outbreak of Invasive Fungal Infections on Two Oncology Wards
Authors: Huslage Kirk , Stiegel Matthew , Lobaugh-Jin Erica , Hnat Amy , Strittholt Nancy , Lewis Sarah S , Baker Arthur W , Thomann Wayne R , Smith Becky
Published: November 2018

Background

We investigated an increase in hospital-acquired invasive fungal infections (HA-IFI) among patients admitted to adjacent hematopoietic stem cell transplant (HSCT) and hematologic malignancy (HM) wards in the setting of a large construction project adjacent to the hospital.

Methods

We defined cases of HA-IFI as HSCT or HM patients who met criteria for probable or proven IFI with suspected inpatient acquisition. We hypothesized that outside construction increased internal particle/spore counts despite preconstruction prevention efforts. The environmental investigation included an evaluation of storage/distribution of supplies, air handler inspections, air particulate counts, and bioaerosol sampling of airborne fungal spores.

Results

From October 2017 to January 2018, 11 cases of probable/proven HA-IFI occurred (Figure 1). Infections caused by multiple pathogens (Figure 2) ranged from pneumonia and sinusitis to disseminated disease. Bioaerosol sampling and particulate counts were taken from unit corridors and rooms on both wards. Fungal species identified via bioaerosol sampling were primarily Penicillium and Cladosporium species, with rare Aspergillus identified. Geometric mean particulate counts of 1 μm aerodynamic size were reduced by 88% and 75% on the HM and HSCT wards, respectively (Figure 3). Interventions on these units occurred from January to February 2018 and included: limiting the frequency of outdoor air exchanges on air handler units, reinforcing seals around entrance doors, adjusting room pressurizations to be positive or neutral on HM ward (HSCT ward is already a positive pressure environment), eliminating cardboard associated with supplies, and requiring N95 respirators for HSCT patients when off unit. After implementing these environmental control measures, we have not identified additional cases of HA-IFI on these wards.

Conclusion

We describe a multispecies outbreak of IFI in HM and HSCT patients potentially associated with new building construction that occurred despite implementation of multiple pre-construction control efforts. A multifaceted strategy to improve air quality and protect patients on and off high-risk units was needed to mitigate the outbreak.

Disclosures

All authors: No reported disclosures.
1263. Managing an Influenza Outbreak Which Spilled Over to an Acute Care Hospital from a Behavioral Health Unit
Authors: Clay Colleen M , Girio-Herrera Leonardo , Younus Faheem
Published: November 2018

Background

Behavioral health units (BHU) have been implicated in influenza outbreaks due to group activities, low availability of alcohol-based hand gels and unique host factors. We describe the management of an unusual influenza outbreak, which started in the BHU and then spilled over to the acute care hospital (ACH).

Methods

University of Maryland Harford Memorial Hospital is a 95-bed ACH with a 14-bed closed-door adult BHU located on the fifth floor. Two cases each of hospital-acquired influenza were identified in our BHU during 2016 and 2017. In January 2018, however, hospital-acquired influenza cases in the BHU spilled over to the adjacent ACH to cause an outbreak. A case was defined as a patient with fever of >100.4°F, presence of influenza-like illness, and a positive influenza test >72 hours after admission. Outbreak control measures included twice daily fever screening, enhanced droplet precautions, visitor restrictions, discontinuing community activities, enforcing hand hygiene at all hospital entrances, and hospital-wide chemoprophylaxis with oseltamivir.

Results

On January 15, 2018, the index patient developed influenza in the BHU followed by a second case in BHU 4-days later. Over the next 10 days, five more patients on the third and fourth floors of ACH tested positive. Attack rate was 3% and average length of stay was 8.9 days. Chemoprophylaxis with oseltamivir 75 mg orally once a day was given to 71% of all eligible hospitalized patients for a week (at a cost of $17,000). All seven patients yielded influenza A, subtype H3N2 and were successfully treated with oseltamivir 75 mg orally twice a day for 7 days. The outbreak lasted 11 days. Figure 1 shows the epidemiologic curve.

Conclusion

Special attention should be paid to influenza prevention in the BHUs due to the risk of spillover effect to sicker patients in the adjacent ACH. A short, 7-day course of hospital-wide oseltamivir chemoprophylaxis, in addition to promptly implementing the infection prevention measures was effective in controlling the outbreak.

Disclosures

All authors: No reported disclosures.
1264. Healthcare-Acquired Influenza in Critical Ill Patients
Authors: Gutierrez Valentina , Cerda Jaime , Corre Nicole Le , Medina Rafael , Ferres Marcela
Published: November 2018

Background

Healthcare-associated infections (HAIs) increases morbidity and mortality. During 2014, at Hospital Clínico Red de Salud UC CHRISTUS (RS-UCCH), was estimated that 15% of viral respiratory infections were acquired during hospitalization, and influenza was the main etiologic agent. The aim of this study was to obtain clinical characterization of HAIs due to influenza virus in patients hospitalized in critical care units (CCU) and special care units (chronic patients who need hospitalized nurse care).

Methods

Descriptive study of CCU and special care patients with hospital acquired influenza during 2014–2017. HAI due to influenza was defined as: symptoms onset and/or positive influenza PCR ≥48 hours after hospital admission, without previous respiratory symptoms or with negative PCR.

Results

22 patients with median age of 74 years old were identified, only three pediatric cases. The average time of acquired influenza was at 13th day of hospitalization. In 77% Influenza A was the only agent detected and 27% had respiratory co-infection. Thirteen (59%) were previously hospitalized in CCU, but only 2 (15%) due to respiratory problems. Nineteen patients (86%) presented comorbidity such as arterial hypertension (59%), chronic kidney disease (18%), and immunosuppression (18%). Half of them had a decompensation, mainly respiratory, associated to influenza infection. The observed lethality was 18%. Among all the influenza HAI, 59% occurred in unvaccinated patients, although 46% of them met criteria for vaccination recommendation.

Conclusion

HAI due to influenza occurred in chronic, older, and unvaccinated patients. Education about HAIs and continuing high vaccination coverage must be a priority.

Disclosures

All authors: No reported disclosures.
1275. Will an App-Optimized HIV Self-testing Strategy Work for South Africans? Results From a Large Cohort Study
Authors: Pai Nitika Pant , Esmail Ali , Marathe Gayatri , Oelofse Suzette , Pretorius Marietjie , Smallwood Megan , Daher Jana , Janssen Ricky , Saha-Chaudhuri Paramita , Engel Nora , Dheda Keertan
Published: November 2018

Background

HIV self-testing (HIVST) offers a potential for expanded test access; challenges remain in operationalizing rapid personalized linkages and referrals to care. We investigated if an app-optimized personalized HIVST strategy improved referrals, detected new infections and expedited linkages to care and treatment.

Methods

In an ongoing cohort study (n = 2,000) based in South Africa, from November 2016 to January 2018, to participants presenting to self-test at community township based clinics, we offered a choice of the following strategies: (a) unsupervised HIVST; (b) supervised HIVST. We also observed participants opting for conventional HIV testing (ConvHT) in geographically separated clinics. We observed outcomes (i.e., linkage initiation, referrals, disease detection) and compared it between the two (HIVST vs. ConvHT) for the same duration.

Results

Of 2,000 participants, 1,000 participants were on HIVST, 599 (59.9%) chose unsupervised HIVST, 401 (40.1%) on supervised HIVST; compared with 1,000 participants on ConvHT. Participants in HIVST vs. ConvHT were comparable young (mean age 27.7 [SD = 9.0] vs. 29.5 [SD = 8.4]); female (64.0% vs. 74.7%); poor monthly income <3,000 RAND ($253 USD) (79.9% vs. 76.4%). With HIV ST (vs. ConvHT), many more referrals (17.4% [15.1–19.9] vs. 2.6% [1.7–3.8]; RR 6.69 [95% CI: 4.47–10.01]), and many new infections (86 (8.6% (6.9–10.5)) vs. 57 (5.7% (4.3–7.3)); Odds Ratio 1.55 [95% CI 1.1–2.2]) were noted. Break up: 45 infections in supervised HIVST 45 (52.3%); 41 infections in unsupervised HIVST (47.6%)]. Preference for HIVST was at 91.6%. With an app-optimized HIVST strategy, linkages to care were operationalized within a day in all participants (99.7% (HIVST) vs. 99.2% (ConvHT); RR 1.005 [95% CI: 0.99–1.01]); 99.8% supervised HIVST, 99.7% unsupervised HIVST.

Conclusion

Our app-optimized HIVST strategy successfully increased test referrals, detected new infections, and operationalized linkages within a day. This innovative, patient preferred strategy holds promise for a global scale up in digitally literate populations worldwide.

Disclosures

All authors: No reported disclosures.