bluuebunny/crossref_metadata_2025 huggingface dataset:
694 DRUG INDUCED KIDNEY INFARCTION: A CASE REPORT
Authors: Amati Francesca , Santoro Daniela , Ciccone Marco Matteo
Published: December 2022

Isotretinoin (ISO) is a synthetic analog of vitamin A. Notwithstanding the well-known long-term efficacy in the treatment of severe resistant cystic acne, ISO induces several side effects too. Dyslipidemia, increased liver enzymes, as well as reduction of biotidinase have been already reported [1]. Homocysteine (HCY), a sulfur-containing amino acid, is recycled into methionine by a transmethylation reaction requiring folate and vitamin B12. Given that during ISO treatment elevated liver enzymes (SGOT, SGPT) are often observed, it has been hypothesized that iatrogenic liver dysfunction could affect cystathionine-b-synthase, an enzyme involved in HCY metabolism, [2]. Several studies have highlighted that elevated plasma HCY concentrations are associated with an increased risk of premature occlusive vascular disease.

We hereby report a case of drug-induced kidney infarction after ISO therapy.

A previously healthy 18-year-old male, on therapy with 40 mg/die isotretinoin for acne, was admitted to the Emergency Unit for abdominal pain, nausea and vomiting and dyspnea. A trans-thoracic echocardiogram showed dilated and hypocontractile left ventricle. During the hospitalization he had a total body CT that showed the presence of an ischemic lesion on left kidney without other pathological findings. He started therapy with 12 IU/kg UFH as soon as a surgical emergency was excluded. Subsequently, he underwent a coronary angiogram that resulted unremarkable. Cardiac MRI showed extensive delayed gadolinium late enhancement with intramural linear pattern.

In the hypothesis of drug-induced vasculitis, an extensive serological testing was performed. Elevation of serum liver enzymes (SGOT, SGPT), CRP, LDH was found. Mutations on MTHFR gene and Leiden Factor were not detected, neither alteration in coagulation parameters. Finally the dosage of plasmatic HCY resulted over the range of normality and ISO was discontinued. The patient was discharged on optimized medical therapy for heart failure. He is currently managed as outpatient.

HCY levels could be found elevated in patients with ischemic events during ISO treatment. Given the widespread use of this drug for acne, it could be reasonable to dose HCY in patients with suspected liver dysfunction. Physicians should be aware of this scenario and should act swiftly to avoid uneventful outcomes.

[1] Schulpis KH et al. Elevated plasma homocysteine levels in patients on isotretinoin therapy for cystic acne. Int J Dermatol. 2001 Jan;40(1):33-6.

[2] Polat M, et al. Plasma homocysteine level is elevated in patients on isotretinoin therapy for cystic acne: a prospective controlled study. J Dermatolog Treat. 2008;19(4):229-32.
1004 AN UNUSUAL, UNAVOIDABLE BUT SUCCESSFUL MANAGEMENT OF TYPE A AORTIC DISSECTION. A CASE REPORT
Authors: Lepre Veronica , De Biasio Marzia , Imazio Massimo , Sinagra Gianfranco
Published: December 2022

Background

Cardiac tamponade complicates 18,7% of patients with type A aortic dissection and is associated with dramatically worse outcome and a nearly doubling of in-hospital mortality. Immediate surgical repair with intra-operative pericardial drainage is the treatment of choice. Nevertheless, the management of unstable patients who cannot undergo cardiac surgery in short time is controversial.

Case report

Here we present a case report of an 82-year woman with type A aortic dissection complicated by cardiac tamponade. The patient alerted the emergency system because of a sudden epigastric pain. On her arrival to the hospital, her systolic blood pressure was 50 mmHg; despite intravenous fluids and inotropic support, she remained hypotensive. Transthoracic echocardiography revealed an intimal flap involving ascending aorta and aortic arch, and a hemodynamically significant pericardial effusion. Immediate surgical repair was not possible due to the lack of available operating rooms. To stabilize the patient, percutaneous pericardiocentesis from apical approach was attempted, unsuccessfully. A second attempt of percutaneous pericardiocentesis was made from substernal approach, with removal of just 150 cc of pericardial fluid and insertion of a pigtail drainage catheter. Thanks to this procedure systolic blood pressure raised up to 100 mmHg and the patient was stabilized. A CT Angiography scan was performed, showing an aortic dissection extending from the aortic valvular plane to the origin of the right iliac artery. The patient maintained hemodynamical stability until surgical intervention, which started four hours later her arrival. The patient underwent substitution of ascending aorta, aortic hemiarch, non-coronary sinus and aortic valve. There were no complications related to the pericardial drainage and in 34th post-operative day she was discharged in good condition.

Conclusion

Percutaneous pericardiocentesis should be considered in unstable patients with type A dissection complicated by cardiac tamponade who cannot await surgical treatment, providing that very small amount of pericardial fluid is removed, in order to maintain systolic blood pressure around 90 mmHg.
Hidradenitis Suppurativa Reddit Support Group: Finding New Meaning in Social Media During the COVID-19 Pandemic
Authors: Yesantharao Lekha V , Suresh Rachana , Lerman Sheera F , Cox Carrie , Caffrey Julie
Published: December 2022

Hidradenitis suppurativa (HS) can significantly impact quality of life. Reddit allows users with common interests, like HS, to form a community and share information. This has become increasingly important with pandemic-related social isolation. We administered a survey from May 2021 to July 2021 to characterize patients with HS use of Reddit and social media more broadly before and during the COVID-19 pandemic. An analysis of a popular HS support page on Reddit from January 2019 to August 2021 was also conducted, analyzing subscribers over time. The rate of subscriber increase was higher before the pandemic. Of 42 patients contacted, 20 patients enrolled (90% female, mean age of 32.4 years) and 18 of the 20 fully completed the survey that was administered. Participants were stratified into two groups: online support group users (n = 8) and nonusers (n = 12). There were no differences in sex, age, education level, antidepressant usage, and overall social media usage between these groups. However, there was a difference in Hurley staging, with more than four times as many users reporting a Hurley III staging compared to nonusers (p = .003). Nonusers ranked the following as desired features of a social media group more frequently than current users: bandaging/dressing boils, living with HS, medical advice from professionals, causes of HS, and diet (P = .047, P = .043, P = .043, P = .047, and P = .013, respectively). This study demonstrates that online support group use is associated with HS of higher clinical severity. Based on the needs/expectations identified in this study, recommendations can be made to providers to help fill any lacunae in clinical care.
Investigation of Anxiety and Depression Predictors in Burn Patients Hospitalized at Velayat Hospital, a Newly Established Burn Center
Authors: Farzan Ramyar , Hossein-Nezhadi Mitra , Toloei Mohammad , Rimaz Siamak , Ezani Fazel , Jafaryparvar Zakiyeh
Published: December 2022

Burns are a leading cause of global mortality and disability. Burns have the mental, psychological and physical impact on the sufferers. Burn patients need special care, both physical and mental, and majority of them are suffering from symptom of difficulty, such as depression, anxiety, post-traumatic stress disorder, and isolation. Finding the predictors of post-burn anxiety and depression can accelerate the treatment and recovery process and maintain the mental health of the patients. The present study investigated the depression and anxiety predictors in burn patients admitted to a medical facility in northern Iran. The present study is a descriptive-analytical study with a cross-sectional methodology on all the burn patients (n = 611) admitted to the Velayat Subspecialty Burn and Reconstructive Surgery Center, Rasht, Iran during 2013–2019. The study tools included the demographic and clinical questionnaire and the Symptom Checklist-90-Revised (SCL-90-R) for anxiety and depression. Data were collected using interviews. Data analysis was performed using the SPSS version 19 and the statistical tests of Chi-square and logistic regression test. The present study included 611 patients, with 61% males and 39% females. The mean age of the participants was 38.86 ± 18.39, while most participants were in the age group of 20–40 years. The most common cause of admission was burning by flames (36.7%), and most patients had third-degree burns (67%). Five hundred forty three patients showed mental symptoms, of which 343 (52.6%) had anxiety disorder symptoms, and 309 (47.4%) had symptoms suggestive of depression. The independent predictors of depression were found to be the gender (OR = 0.253), age group (OR = 0.706), and the degree of burn (OR = 0.406), while the independent predictors of anxiety disorder included the gender (OR = 1.669), age group (OR = 1.58), the classified burn area (OR = 0.653), marital status (OR = 0.532), and education level (OR = 0.773). It is important to identify predictors of depression and anxiety after burn. The predictors can serve as indicators that these patients may benefit from mental health evaluations and treatment.
Dynamic Nonparametric Clustering of Multivariate Panel Data
Authors: Custodio João Igor , Schaumburg Julia , Lucas André , Schwaab Bernd
Published: December 2022

We introduce a new dynamic clustering method for multivariate panel data characterized by time-variation in cluster locations and shapes, cluster compositions, and possibly the number of clusters. To avoid overly frequent cluster switching (flickering), we extend standard cross-sectional clustering techniques with a penalty that shrinks observations toward the current center of their previous cluster assignment. This links consecutive cross-sections in the panel together, substantially reduces flickering, and enhances the economic interpretability of the outcome. We choose the shrinkage parameter in a data-driven way and study its misclassification properties theoretically as well as in several challenging simulation settings. The method is illustrated using a multivariate panel of four accounting ratios for 28 large European insurance firms between 2010 and 2020.
Update on Enrollment of Older Adults Onto National Cancer Institute National Clinical Trials Network Trials
Authors: Mishkin Grace E , Denicoff Andrea M , Best Ana F , Little Richard F
Published: December 2022

Background

Older adults are a large and growing proportion of cancer cases in the United States, but concerns persist about whether older adults are adequately represented in the cancer clinical trials that test new options for treatment and cancer care.

Methods

This paper describes adult patient enrollments by age group to the National Cancer Institute’s National Clinical Trials Network (NCTN) from 2016 to 2021, compares patient enrollment by age with the estimated incident cancer population across cancer types, and explores possible associations between patient age and patient race, ethnicity, and sex.

Results

This analysis found that patients aged 18 to 69 years were overrepresented in NCTN trials, whereas patients aged 70 years and older were underrepresented compared with the estimated incident cancer population. Underrepresentation of older patients was seen across cancer types. Older patients who enrolled to NCTN trials were more likely to be non-Hispanic White than the estimated incident cancer population.

Conclusions

Compared with earlier analyses, NCTN trials are enrolling greater proportions of older adults, primarily driven by higher enrollment among patients aged 65 to 74 years. There is still significant room for improvement, however, especially among patients aged 75 years and older. Additionally, patient demographics should not be viewed in isolation: older Hispanic patients, for instance, were particularly underrepresented among patients enrolled to NCTN trials. The intersection between trial enrollment and age, race, and ethnicity warrants further study so that more targeted enrollment enhancement efforts can be developed that enhance trial diversity across demographic groups.
Shaping a Climate of Arrival: National and Local Media Representations of Refugees’ Arrival Infrastructures in the Netherlands
Authors: Kox Mieke , van Liempt Ilse , Smits Anna
Published: December 2022

Negative media representations such as framing refugees as criminals may increase concerns among the general audience about the arrival of asylum seekers. At the same time, these media representations may also create anxiety among the refugees themselves and negatively impact on their sense of belonging. In this article, we explicitly focus on media representations of arrival infrastructures for refugees and how these representations shape their climate of arrival. We zoom in on the regulatory-administrative dimension consisting of all formal structures involved in the arrival of refugees, the everyday practical dimension that refers to infrastructuring practices outside the regulatory-administrative framework related to refugees, as well as the normative-discursive dimension that consists of ideas and debates around arrival and arrival infrastructures. By taking arrival infrastructures as our centre of attention, we move beyond a refugee-centred approach. This allows us to uncover the different layers of the climate of arrival brought to light by national and local media representations as well as to nuance the rather uniform and dominant image of refugees in the media. Our findings show the responsibility of media to represent a more diverse image of refugees as well as the need for migration and media scholars to move beyond a sole focus on how refugees are represented in the media.
738. Outcomes of Ceftriaxone Versus Antistaphylococcal Penicillins or Cefazolin for Definitive Therapy of Methicillin-susceptible Staphylococcus aureus Bacteremia
Authors: Khodadadi Ryan B , Yetmar Zachary A , Go John R , Chesdachai Supavit , Razi Samrah , Abu Saleh Omar M
Published: December 2022

Background

Methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia requires weeks of IV antimicrobial therapy for treatment with antistaphylococcal penicillins (ASP) and first-generation cephalosporins being mainstays of therapy. While effective, use of these agents in the outpatient setting requires frequent dosing along with close toxicity monitoring through the duration of therapy. Ceftriaxone is an appealing alternative given daily dosing and tolerability, but efficacy in this setting remains uncertain. We sought to review outcomes of patients who received ceftriaxone versus an ASP and first-generation cephalosporins for definitive therapy of MSSA bacteremia.

Methods

Following IRB approval, we reviewed medical records of a retrospective adult cohort diagnosed with MSSA bacteremia treated with ceftriaxone, cefazolin, or an ASP between January 2018 and December 2019 at Mayo Clinic campuses. Treatment was defined as the antibiotic used in the outpatient setting. The primary outcome was 90-day treatment failure, defined as a composite of mortality and microbiologic relapse. Secondary outcomes were 30-day treatment failure and individual components of treatment failure. Multivariable Cox regression analysis was performed to analyze for an association between ceftriaxone use and the primary outcome after adjusting for factors that may also impact outcomes. Kaplan-Meier curves were compared utilizing a log-rank test for survival between groups.

Results

A total of 223 patients with the accompanying characteristics met study criteria (Table 1). Thirty-seven received ceftriaxone (16.5%) and 186 (83.4%) were treated with cefazolin or an ASP. Ninety and 30-day treatment failure were higher in those treated with ceftriaxone (27%, 8.1%) compared to cefazolin or an ASP (8.6%, 3.8%). Multivariable analysis for risk of 90-day treatment failure revealed a hazard ratio of 2.91 for ceftriaxone (Table 2) and a significant difference in event-free survival for those treated with ceftriaxone compared to cefazolin or an ASP (Figure 1).

Conclusion

Patients receiving definitive therapy with ceftriaxone for MSSA bacteremia experienced a higher rate of 90 and 30-day treatment failure and a lower rate of event-free survival as compared to those treated with cefazolin or an ASP.

Disclosures

All Authors: No reported disclosures.
751. Decoding a Decade: Temporal Trends of MIC Distribution of Antifungals Against Cryptococcus species From a Reference Laboratory
Authors: Ordaya Eloy E , Abu Saleh Omar M , Vergidis Paschalis , Deml Sharon , Wengenack Nancy , Fida Madiha
Published: December 2022

Background

There are not established clinical breakpoints (CBP) for antifungals against Cryptococcus species; However, the analysis of their MICs using epidemiological cut-off values (ECVs) can help to distinguish wild-type (WT) isolates from non-WT strains that may harbor intrinsic or acquired resistance to antifungals. Herein, we analyze the MIC distribution of antifungals against Cryptococcus spp. isolated over the last decade at our reference laboratory.

Methods

We conducted a retrospective evaluation of antifungals MICs for Cryptococcus neoformans and Cryptococcus gattii complex isolates from various sources that were processed at the Mayo Clinic Laboratory from November 18, 2011 to June 7, 2021. Antifungal susceptibility testing was performed by the Clinical & Laboratory Standards Institute (CLSI) standards (CLSI M59-ED3:2020). We used recommended ECVs to define if the isolates were WT or non-WT, and described the change in the percentage of WT isolates over time.

Results

During the study period, C. neoformans was isolated from 632 samples collected from 533 patients. Sample sources included cultures from blood (n=301), cerebrospinal fluid (n=230), respiratory (n=71), and other sources (n=30). The overall percentage of WT isolates for amphotericin B (AMB), 5-flucytosine, and fluconazole were 77%, 98% and 91% respectively with no significant difference based on various sources (Table). We noticed an overall increase in MICs for AMB, with 100% WT isolates in 2011 compared to 79% in 2021. No such increase was seen for fluconazole or 5-Flucytosine (Figure). Irrespective of the source or the year of isolation, WT strains for itraconazole, voriconazole, and posaconazole were consistently > 93%. C. gattii was isolated from 16 samples, and 94% were WT strains for AMB and 100% for the other antifungals.

CLSI, Clinical and Laboratory Standard Institute; CSF, cerebrospinal fluid; ECVs, epidemiologic cut-off values.

AMB, amphotericin B; FLU, fluconazole; 5FC, 5-flucytosine.

Conclusion

In the last decade, we have observed an overall increase in MICs of AMB for C. neoformans. The number of WT strains for other antifungals was high and not significantly changed during the study frame. Further studies are needed to identify the clinical implications of these findings.

Disclosures

Paschalis Vergidis, MD, AbbVie: DSMB|Cidara: Grant/Research Support|Scynexis: Grant/Research Support.
755. Predictors of Mortality in Invasive Mold Infections Among Patients with Hematologic Malignancies and Hematopoietic Stem Cell Transplant Recipients
Authors: Gupta Aanchal , Ranganath Nischal , Mendoza Maria A , Diseases Infectious , Deml Sharon , Wengenack Nancy , Vergidis Paschalis
Published: December 2022

Background

Invasive Mold Infections (IMI) cause significant morbidity and mortality, particularly in patients with hematologic malignancies (HM) and hematopoietic stem cell transplant (HSCT) recipients. Although the risk has significantly decreased with the use of triazole agents as primary prophylaxis, breakthrough infections still occur. Risk factors for IMI have been well-described. Limited data exist on factors predicting mortality.

Methods

We identified cases using the Cancer registry and Microbiology data at Mayo Clinic Minnesota from 11/19/2011–8/6/2021 and Mayo Clinic Arizona and Florida from 09/13/2017–11/19/2021. We conducted a retrospective review to identify cases of proven/probable IMI per EORTC/MSG criteria. Patients who received at least 7 days of anti-mold prophylaxis were considered having breakthrough infection (Br-IMI). Survival function was estimated using the Kaplan-Meier method. We evaluated predictors of mortality using Cox regression analysis.

Results

401 cases of IMI were included (80.2% aspergillosis, 10.2% fusariosis, 8.4% mucormycosis, 1.2% scedosporiosis). 189 patients had proven/probable and 212 had possible disease. 12-week mortality for the entire cohort was 33%. There were 87 cases of Br-IMI (21.6%) on mold-active prophylaxis (posaconazole n=54, voriconazole n=26, isavuconazole n=5, itraconazole n=1, liposomal amphotericin B n=1).

A comparison between patients not receiving prophylaxis and those with Br-IMI is shown in Table 1. Higher proportion of patients with Br-IMI had prolonged neutropenia/lymphopenia and graft-versus-host disease involving the gastrointestinal tract or lungs. Positive Aspergillus galactomannan (index ≥ 1.0) was seen more in patients who were not on mold-active prophylaxis. Mortality was 31.5% in patients not receiving prophylaxis and 41.3% with Br-IMI (Figure 1). In multivariate analysis, age, prolonged neutropenia, active HM, Br-IMI and HSCT were associated with increased mortality (Table 2).

Conclusion

In this cohort, the rate of Br-IMI was significant despite the use of primary prophylaxis (mainly posaconazole). Mortality was higher in patients with Br-IMI compared to those not receiving mold-active prophylaxis. Therefore, clinicians should remain alert to the possibility of Br-IMI.

Disclosures

Paschalis Vergidis, MD, AbbVie: DSMB|Cidara: Grant/Research Support|Scynexis: Grant/Research Support.
783. Lung Transplantation for COVID-19-Associated Lung Injury (CALI): An International Registry
Authors: Alamri Maha M , Osborn Rebecca , Girgis Reda , Marschalk Nicholas , Rivosecchi Ryan , Ison Michael G , Weder Max , Aslam Saima
Published: December 2022

Background

SARS-CoV-2 can result in a range of infections from asymptomatic disease to progressive COVID-19 and death. In some pts with CALI, lung transplantation (LTx) may be lifesaving. Up to 10% of LTx in the US is currently for pts with CALI. Understanding the characteristics and outcomes of these pts is critical.

Methods

A open-access electronic registry was established to collect de-identified data from pts who have undergone LTx for CALI from centers globally. The study was IRB approved at Northwestern with a wavier for consent (no PHI is collected sites could submit data about pre-Tx, peri-Tx and post-Tx course). Follow-up for 1-yr post-LTx was collected.

Results

To date, 89 pts with complete day 30 post-LTx data have been entered into the registry. Pt demographics and pre-Tx status are shown in Table 1. 3 pts required oxygen prior to COVID-19. Most sites required neg PCR tests prior to listing (11 (12.4%) required no - PCRs, 11 (12.4%) required 1 and 61 (68.5%) required 2). LTx occurred 137 days post-infection and none developed COVID-19 in the first 30 d; 4 were given monoclonal antibodies post-tx. Post-tx ICU LOS averaged 24.5 d with total post-tx hospitalization of 37.6 d (See Table 2). Most experienced infectious and non-infectious morbidity. Most (47.8%) required an additional 30 days of rehab. 2 pts died within 30 days due to sepsis and anoxia. 5 died between day 30 and 90 and an additional 12 died between day 90 and 365.

Conclusion

The contribution of cases to this international registry is ongoing. While outcomes of LTx for CALI are generally good, patients experience prolonged post-transplant hospitalization, rehabilitation and significant morbidity and infections are common.

Disclosures

Michael G. Ison, MD MS, GlaxoSmithKline: Advisor/Consultant|GlaxoSmithKline: Grant/Research Support Saima Aslam, MD, Armata: Grant/Research Support|BioMx: Advisor/Consultant|Contrafect: Grant/Research Support|Gilead: Honoraria|Merck: Honoraria|Phico: Advisor/Consultant.
787. Predictors of Co-infection with Multidrug Resistant Organisms among Hospitalized Patients with COVID-19: An Exploratory Analysis
Authors: Zhang Yue , Li Haojia , Jones Barbara E , Rubin Michael , Haroldsen Candace , Willson Tina M , Effiong Atim , Cole Jessica , Khader Karim
Published: December 2022

Background

Bacterial co-infection has been reported with COVID-19, but risk factors for bacterial co-infection remain unclear due to limited large scale studies. We seek to identify predictive factors associated with risk of co-infection with multidrug-resistant organisms for patients hospitalized at Veterans Affairs (VA) hospitals with COVID-19.

Methods

This retrospective cohort study included Veterans admitted to VA hospitals from March 1, 2020 through May 31, 2022 with a confirmed positive COVID-19 test within the previous 14 days and up to 2 days after admission. Outcomes of interest were hospital-onset co-infection (HOI, > 2 calendar days after admission) and community-onset co-infection (COI, within 2 calendar days of admission). Potential risk factors included both patient- (e.g. vital sign, medication use) and facility-level covariates (e.g. bed size, antibiotic use rate). We compared the covariate distributions for patients with and without HOI and COI. Our analytical approaches included variance inflation factors to detect the presence of multicollinearity among these factors, and Least Absolute Shrinkage and Selection Operator to identify the subset of factors associated with HOI and COI. We conducted a two-stage analysis, first performing feature selection among the individual-level risk factors followed by identification of facility-level risk factors. Optimal models were identified using 10-fold cross validation.

Results

By July 2021, 33,383 patients were admitted to VA with positive COVID-19 test. We found that medications for ventilator induction (OR with 95% CI: 2.9 (2.2, 3.9)), norepinephrine (OR with 95% CI: 1.6 (1.2, 2.2)) and antimicrobial therapies for gram-positive infections (OR with 95% CI: 4.5 (3.6, 5.6)) [Table 1] were associated with the increased risk of HOI and patients in facilities with high C difficile infection rates were more likely to have COI detected (OR with 95% CI: 1.14 (1.11, 1.18)) [Table 2]. Homeless Veterans had higher risk of developing an HOI (OR with 95% CI: 1.5 (1.1, 2.0)), but not a COI.

Conclusion

Risk factors for HOI and COI in COVID-19 were distinct, with specific classes of medications and antibiotics as well as patient factors resulting in increased risk for HOI. Further work is needed to better understand the risk factors for COI.

Disclosures

Karim Khader, PhD, BioFire Diagnostics: Grant/Research Support.
873. Comparison of Antibiotic and Antiviral Use before and after Deployment of Rapid Influenza Testing in the Emergency Department
Authors: Wesolowski Alec , Clifton Jennifer D , Miller Jessica , Shields Maureen
Published: December 2022

Background

Influenza shares common symptoms with bacterial pneumonia, resulting in inappropriate prescribing of antibiotics that may lead to increased risk of adverse reactions, antimicrobial resistance, and healthcare costs. Rapid influenza polymerase chain reaction (PCR) tests have reduced turnaround times compared to multiplex PCR respiratory panels allowing for earlier diagnosis, which may improve antimicrobial stewardship outcomes in the emergency department (ED). This study aims to compare antibiotic and antiviral use before and after deployment of a rapid influenza PCR in the ED.

Methods

This single-center, retrospective, cohort study included pediatric and adult patients discharged from the ED with a positive influenza test with either the multiplex PCR respiratory panel (January 2017 – July 2019) or rapid PCR (July 2019 – February 2020). The primary endpoint was antibiotic use pre- and post-implementation of the rapid influenza PCR in the ED. Secondary endpoints included antiviral use, duration of antimicrobial therapy, test turnaround time, ED length of stay, 30-day readmission, and adverse events. A multivariable regression model evaluated patient factors associated with antimicrobial prescribing.

Results

A total of 620 positive influenza results were identified with 280 patients (multiplex PCR = 33; rapid PCR = 247) meeting inclusion criteria. Patients were less likely to be prescribed antibiotics (39.4% vs 8.9%, OR 0.15, 95% CI 0.067–0.34) and more likely to be prescribed antivirals (24.2% vs 61.1%, OR 4.92, 95% CI 2.13–11.34) with the rapid influenza PCR. Rapid influenza PCR significantly reduced ED length of stay (4.9 vs 3.4 hours, p < 0.01) and test turnaround time (27 hours vs 3.5 hours, p < 0.01). Patients at high risk for complications associated with influenza were more likely to be prescribed antiviral therapy (25% vs 77.7%, OR 5.27, 95% CI 3.02–9.17). Based on the regression analysis conducted, asthma, (OR 3.5, 95% CI 1.48–8.26), immunosuppression (OR 9.6, 95% CI 1.18–78.2), and age less than 5 years old (OR 3.1, 95% CI 1.80–5.45) are predictors of antiviral prescribing.

Conclusion

Implementation of a rapid influenza PCR in the ED reduced antibiotic use and optimized antiviral therapy for patients at higher risk of influenza with complications.

Disclosures

All Authors: No reported disclosures.
879. Intravenous to Oral Antibiotic Switch in Patients Hospitalized with Community-Acquired Pneumonia
Authors: Deshpande Abhishek , Guo Ning , Imrey Peter B , Rothberg Michael
Published: December 2022

Background

Community-acquired pneumonia (CAP) is a leading cause of hospital admissions and antimicrobial use worldwide. The ATS/IDSA guidelines recommend switching antimicrobials to per-oral once patients are clinically stable. Using a large national inpatient database, we assessed switch therapy practices across hospitals and their associations with outcomes in patients hospitalized with CAP.

Methods

We included adult patients admitted with CAP and initially treated with intravenous (IV) antibiotics at 642 US hospitals from 2010–2015. Switching was defined as discontinuation of IV antibiotics and starting oral antibiotics without delay. Patients switched on or before hospital day 3 were considered early switchers. We conducted subgroup analysis restricted to patients initially treated with either 3rd generation cephalosporin/macrolide or quinolone monotherapy, indicating non-severe inpatient CAP. In a propensity-adjusted analysis, we compared length-of-stay (LOS), in-hospital 14-day mortality, late deterioration (ICU transfer), hospital costs, total antibiotic days, and C.difficile infection between early switchers and others. We also compared adjusted outcomes across hospital switching rate quartiles.

Results

Of 378,041 CAP patients, 116,118 (31%) were switched to oral antibiotics before discharge, and 21,784 (6%) were switched early. Hospital rates of early switching ranged from 3%-47%. Figure 1 summarizes the estimated effects of early switching among patients initially treated with cephalosporins/macrolide or quinolone monotherapy. Figure 2 shows the switch rate for patients within each hospital quartile, stratified by predicted mortality. Within each quartile, patients at higher predicted risk for mortality were less likely to be switched.

Conclusion

In this large multihospital cohort, most patients were not switched to oral antibiotics before discharge and < 6% were switched early. Early switching was not associated with worse outcomes and was positively associated with shorter LOS and total days on antibiotics. Patients at hospitals in the top quartile of early switch rates did not suffer worse outcomes and had shorter LOS and total antibiotic duration. Our findings suggest clinicians could switch more patients early without compromising outcomes.

Disclosures

Abhishek Deshpande, MD, PhD, Clorox: Grant/Research Support|Merck & Co., Inc., Kenilworth, NJ, USA: Advisor/Consultant|Merck & Co., Inc., Kenilworth, NJ, USA: Stocks/Bonds|Seres Therapeutics: Grant/Research Support.
1520. Mind the Clap: Reported Disseminated Gonococcal Infections in the United States, 2020–2022
Authors: Quilter Laura A , Tang Eric C , Johnson Kelly A , Jacobson Kathleen , Ridpath Alison , Cohen Stephanie , Rajagopalan Shobita , Munoz Monica D , Holderman Justin L , Kent James B , Bachmann Laura H , Bernstein Kyle
Published: December 2022

Background

Disseminated gonococcal infections (DGI) are estimated to occur in 0.5% to 3% of untreated Neisseria gonorrhoeae (GC) infections; however, surveillance and population-based studies to estimate DGI burden and describe recent DGI epidemiology and clinical manifestations are limited. In response to increased reports of DGI cases and clusters in the U.S., the Centers for Disease Control and Prevention (CDC) developed a surveillance system in 2020. We analyzed data captured by the initial two years of surveillance.

Methods

During 1/1/2020–3/31/2022, U.S. state/local health jurisdictions reported DGI cases to CDC utilizing a standardized case report form that collects demographic, sociobehavioral, and clinical information. A confirmed case was defined as isolation or detection of GC from a disseminated site of infection by culture or nucleic acid amplification test (NAAT); a probable case was defined as clinical manifestations of DGI and isolation or detection of GC from a mucosal site by culture or NAAT.

Results

In total, 274 DGI cases were reported to CDC from 13 U.S. states (65.7% from California): 215 (78.5%) confirmed cases and 59 (21.5%) probable cases. Among DGI cases, 51.1% were cisgender male, 33.2% were ≥ 45 years old, and 26.6% reported methamphetamine use in the past 12 months. Most patients (87.6%) did not have documented underlying immunosuppression or predisposing medical conditions. Among patients with DGI, 85.8% were hospitalized, 41.2% underwent related surgeries, and 2.2% died. Among confirmed cases, the most common disseminated sites of infection were synovial fluid (50.2%) and blood (45.1%). Among 184 (67.2%) patients with DGI who were tested for GC at a mucosal site, 115 (62.5%) were diagnosed with a mucosal GC infection (69.6% urogenital, 27.0% pharyngeal, 12.2% rectal); however, 85.5% of those not diagnosed with mucosal GC were only tested at urogenital sites. Only 89 patients (32.5%) reported mucosal symptoms present at the time of or within the month prior to DGI presentation.

Conclusion

Health care providers should maintain a high degree of suspicion for patients presenting with DGI symptoms given the potential for significant associated morbidity and the low proportion of patients who present with concurrent GC mucosal symptoms.

Disclosures

Alison Ridpath, MD, MPH, 3M company: Stocks/Bonds|Abbott Laboratories: Stocks/Bonds|Abbvie Inc.: Stocks/Bonds|Allogene Theraputics: Stocks/Bonds|Amarin Corperation PLC: Stocks/Bonds|infinity Pharmaceutical Companies: Stocks/Bonds|IQVIA Holdings Inc: Stocks/Bonds|Johnson and Johnson: Stocks/Bonds|Medtronic: Stocks/Bonds|pfizer: Stocks/Bonds|Thermo Fisher Scientific: Stocks/Bonds.
1572. Impact of a Multicenter Fluoroquinolone Stewardship Collaboration on Prescribing Trends over Five Years
Authors: Olson Kelsey , Blackburn Laura , Feltman Judy
Published: December 2022

Background

Fluoroquinolone (FQ) use is generally discouraged in uncomplicated infections when alternative therapies exist. Antimicrobial stewardship programs use diverse strategies to encourage appropriate prescribing of antibiotics, and FQ stewardship is often a priority due to the known toxicity risks. This study aimed to evaluate how the coordinated implementation of several stewardship strategies impacted FQ prescribing at eight community hospitals.

Methods

This retrospective, observational study includes data from January 2017 to January 2022. In 2018, the facility clinical pharmacy programs established formal clinical metrics to be tracked and reported on a regular basis. One such metric tracked FQ prescribing in urinary tract infections (UTI), and this metric has remained active since 2018. In early 2019, the health-system implemented a clinical decision support alert in the electronic health record, which requires acknowledgement of a risk/benefit assessment upon FQ order entry. In late 2019, some facilities began suppressing automated susceptibility results for FQ on cultures, due to technological limitations with new minimum inhibitory concentration breakpoints. Using a clinical surveillance system, a report was generated to assess the year-over-year changes in FQ days of therapy (DOT) per 1000 patient days at each facility.

Results

An 83% reduction in FQ use was observed over five years (737 DOT/1000 patient days vs. 125 DOT/1000 patient days), with facility-level reductions ranging from 62% to 96%. The smallest decrease in FQ use (18%) occurred from 2017–2018, before any system-wide FQ stewardship initiatives were adopted. A larger decrease in FQ use (33%) was seen from 2018–2019, after introducing the formal FQ UTI metric. The biggest decrease in FQ use (50%) occurred from 2019–2020, when the FQ alert and susceptibility suppression strategies were implemented alongside the existing UTI metric. An additional 39% decrease in FQ use was seen from 2020–2022, when no additional FQ interventions were implemented.

Conclusion

Substantial decreases in FQ prescribing were observed when multiple FQ stewardship strategies were utilized. The decreases were sustained over several years across multiple hospitals.

Disclosures

All Authors: No reported disclosures.
1185. Taking care of migrants: The approach to eosinophilia
Authors: Kladias Michael , Berto Moreano Cesar G , Mahmood Sumaita , Friedman Lianna , Coyle Christina
Published: December 2022

Background

Eosinophilia in immigrant patients is a common finding in the outpatient setting. While screening guidelines for refugee populations exist, there are no guidelines to the approach to eosinophilia in immigrants. Etiologic diagnosis and laboratory investigation in migrant patients requires attention to the epidemiological risk factors. Serodiagnosis is an important tool in the diagnosis of chronic parasitic diseases affecting migrant patients.

Methods

We describe the demographic, laboratory and diagnosis characteristics of migrant patients with eosinophilia (absolute eosinophil count ≥ 500 cells/mm3) who were referred to the Tropical Medicine clinic of Jacobi Medical Center, New York.

Results

A total of 104 cases of eosinophilia were seen. Most individuals were female (54.8%) and born in The Caribbean (27.9%), followed by Asia (23.1%) and Central America (15.4%). The mean age of the patients was 50.7 ± 14.4 years and the median time from migration was 18 years [IQR 6-28 years]. The mean of the peak of eosinophils in the past 3 months was 1300 ± 600 cel/mm3. Serology for Strongyloides was positive in 24 patients (23.1%). The proportion of seroprevalence for Strongyloides by country was higher in Central America (7 patients; 43.8%), Africa (3 patients; 37.5%) and The Caribbean (8 patients; 27.6%). Patients with bathroom and plumbing outdoors were more likely to be seropositive for Strongyloides (p=0.04). Chagas serology was positive in 6 out of 10 patients tested and Schistosoma antibodies were positive in 3 out of 8 patients tested. Of note, both results were only tested in patients with epidemiological risk factors.

Conclusion

Strongyloidiasis was common in our migrant population. Individuals without water supply and bathroom inside the house were more likely to have a positive serology. Many of these patients can develop disseminated infection if receiving corticosteroids. Screening in at-risk asymptomatic patients allows to identify and treat this latent disease and avoid potential morbidity and mortality. Patients were also screened for other latent parasitic infections based on epidemiology risk factors that do not result in eosinophilia such as Chagas disease and schistosomiasis. Further studies are needed to help inform guidelines on screening immigrant populations.

Disclosures

All Authors: No reported disclosures.
1191. Comparison of High Touch Surface Bioburden Associated with the Use of Disinfectants With and Without Continuously Active Disinfection Properties in Ambulatory Care Settings
Authors: Torres Heidi M , Marino Jamie , Simon Matthew , Singh Harjot K , Westblade Lars , Calfee David P
Published: December 2022

Background

Microbial contamination of high-touch surfaces (HTS) in health care settings contributes to pathogen transmission. HTS quickly become re-contaminated after disinfection. A quaternary ammonium (QA) and isopropyl alcohol (IPA)-based disinfectant (Sani-24®) with reported continuously active disinfection (CAD) properties for up to 24 hours has been associated with reduced microbial buildup on HTS over time in in vitro studies and inpatient healthcare settings. The performance of this product in ambulatory care settings has not been reported.

Methods

HTS bioburden associated with use of QA-IPA with CAD (Sani-24®) was compared to that of a QA-IPA disinfectant without CAD (Super Sani-Cloth®) in an urgent care center (UCC) and outpatient clinic (OPC). Surfaces/rooms were assigned 1:1 to the disinfectants. Study team used pre-saturated wipes to disinfect designated HTS (stretcher/exam table, stretcher rail, armrest, doorknob, counter, light switch) at the beginning of each sampling period. In the UCC, unit staff performed subsequent disinfection per routine protocols. In the OPC, unit staff used the study-assigned disinfectant for disinfection between patients. HTS were sampled at 0, 4-6, 8-12, and 24 hours using Eswabs soaked in neutralizing broth. Microbial burden was quantified after 48 hours of incubation. Average CFU/cm² were compared using T-tests and proportion of samples with < 2.5 CFU/cm², a microbiologic standard for environmental surfaces, were compared by chi-square test.

Results

66 UCC HTS (33 per disinfectant) and 70 OPC HTS (35 per disinfectant) were included. There were no statistically significant differences in average CFU/cm² on individual HTS (Figure 1) or average CFU/cm² on all HTS combined between the disinfectants. There were also no significant differences in the proportion of surfaces with < 2.5 CFU/cm² (Figure 2) between the disinfectants.

Conclusion

No differences were observed in the HTS bioburden in ambulatory settings over 24 hours following disinfection using products with and without CAD. These findings differ from those of studies in other settings, perhaps due to frequent disinfection, less extensive recontamination, or Hawthorne effect in these ambulatory settings. Further study in other ambulatory care settings is warranted.

Disclosures

Harjot K. Singh, MD, clinical care options: Advisor/Consultant|MJSciences/HCP Live: Advisor/Consultant|NYC Health and Hospitals: Advisor/Consultant Lars Westblade, PhD, Accelerate Diagnostics, Inc.: Grant/Research Support|BioFire Diagnostics, LLC: Grant/Research Support|Hardy Diagnostics: Grant/Research Support|Roche Molecular Systems, Inc.: Advisor/Consultant|Roche Molecular Systems, Inc.: Grant/Research Support|Shionogi, Inc.: Advisor/Consultant|Talis Biomedical: Advisor/Consultant.
1208. Polymorphic Locus SerMT1 for Sequence-based Typing of Serratia marcescens
Authors: Edlind Tom
Published: December 2022

Background

Outbreaks of pathogenic agents within healthcare facilities may have sporadic or nosocomial sources. Effective intervention requires distinguishing between these sources, which in turn requires epidemiological investigation in conjunction with typing of pathogen isolates. For the latter, established methods range from ribotyping and pulse-field gel electrophoresis to multilocus sequence typing and whole genome sequencing. Due to technical complexities and costs associated with these methods, however, typing is rarely pursued. Polymorphic locus sequence typing (PLST) addresses these issue by employing conventional PCR and Sanger sequencing; the key to PLST is its focus on a tandem repeat-containing locus exhibiting maximal variation due to combinations of single nucleotide polymorphisms and insertions/deletions. Serratia marcescens has been implicated in numerous nosocomial outbreaks, and relatedly has the ability to colonize the hospital environment (e.g., sinks), although few studies have definitively established an outbreak-environment link.

Methods

To extend PLST to S. marcescens, tandem repeats were bioinformatically identified in the genome sequence of strain WW4 (accession CP003959) and used with flanking sequences as queries in BLASTN searches of the GenBank nr/nt Serratia genome database including 97 S. marcescens strains. One locus designated SerMT1 (bp 243212-244195) was present in all strains and exhibited high variability associated with 6-16 copies of a PVVEPE-encoding repeat within signal recognition particle receptor gene ftsY.

Results

SerMT1 was downloaded from all 97 strains, aligned using Clustal Omega, and phylogenetically analyzed using DNA parsimony. This analysis resolved 91 total alleles and yielded an impressively high Simpson’s Diversity Index of 0.998. Six clusters of 2 to 4 strains shared SerMT1 sequence; their epidemiologic relatedness was supported by their GenBank annotations (e.g., UMH-10 and UMH-11 isolated the same month at the same facility).

Conclusion

SerMT1 PLST provides an affordable, user-friendly new tool for epidemiologic investigation of S. marcescens outbreaks.

Disclosures

Tom Edlind, PhD, MicrobiType LLC: Ownership Interest.
1211. Assessing the Applicability of Enhanced Barrier Precautions among Adult Hospitalized Patients
Authors: Makhija Jinal , Lin Michael Y
Published: December 2022

Background

In nursing homes, the CDC has endorsed an interim approach for containment of multidrug-resistant organisms called Enhanced Barrier Precautions (EBP). With an EBP approach, residents with either indwelling medical devices or chronic wounds are considered at risk for multidrug-resistant organisms; therefore, healthcare personnel are to use gown and gloves for care activities that are considered high risk for organism transmission (e.g., dressing or bathing a patient), while lower risk activities are excluded. EBP guidance currently does not apply to acute care hospitals; we aimed to assess what proportion of hospitalized patients would qualify for an EBP prevention approach.

Methods

We performed rolling single day point prevalence surveys for all adult inpatient units at Rush University Medical Center, Chicago, IL in March-April 2022. Using electronic chart review, we recorded patient unit location, multidrug-resistant organism colonization status, Contact Precautions status, presence of indwelling medical devices, and presence of wounds (pressure ulcer of stage ≥2, or open surgical wound). Patients with any indwelling device or wound qualified for EBP. We also assessed alternate definitions of EBP (device-only or wound-only). Prevalence differences were analyzed using the Chi-squared test.

Results

We assessed 353 hospitalized patients (characteristics, Table 1). Among all patients, 18% (n = 65) were in Contact Precautions, primarily for the indication of multidrug-resistant organism or C. difficile control. Under an EBP approach, a higher proportion (52%, n = 184, P = .005) would qualify. Under alternate EBP definitions, 49% (n = 172) would qualify under a device-only criterion, and 9% (n = 32) would under a wound-only criterion. Comparing intensive care unit (ICU) vs non-ICU patients, Contact Precautions rates were similar, but EBP rates would be higher in ICU patients than non-ICU patients, driven by device use (Table 2).

Conclusion

An EBP infection control approach would impact a substantially larger proportion of hospitalized patients, compared to traditional indications for Contact Precautions. To improve feasibility of an EBP approach among hospitalized patients, further refinements to the qualifying criteria are likely needed.

Disclosures

All Authors: No reported disclosures.