bluuebunny/crossref_metadata_2025 huggingface dataset:
2252. Patient Preferences for Triazole Antifungals in the Treatment of Invasive Mold Infection: A Discrete Choice Experiment
Authors: Bhagat Hardik , Xu Yanqing , Spalding James , Song Yan , Zhao Jing , Zhou Mo , Fadli Ela , Yang Hongbo
Published: October 2019

Background

Invasive mold infections (IMIs) are an increasing cause of morbidity and mortality worldwide.1 Pharmacological differences among the currently available mold-active triazoles make treatment selection complex.1 To the best of our knowledge, this is the first study to assess patient preferences for mold-active triazoles in IMI treatment.

Methods

Patients were included if they were aged ≥ 18 years with investigator-confirmed invasive aspergillosis or invasive mucormycosis; had received voriconazole, isavuconazonium sulfate or posaconazole within ≤ 1 week previously; and were outpatients for ≥ 3 weeks. Participants were presented with 14 choice cards, each with two hypothetical treatments with varying levels of attributes, and asked to select their preferred treatment. Preference weights for attribute levels were analyzed using conditional logit regression and used to calculate the impact of changes in attribute levels on patient choices; relative attribute importance (RAI); and patient willingness to pay (WTP; monthly out-of-pocket cost) for an attribute improvement.

Results

Of 50 participants, 52% were female and the mean age was 47.3 years; 40%, 40%, and 28% had used posaconazole, voriconazole and isavuconazonium sulfate, respectively (Figure 1). Route of administration (27% RAI), treatment duration (22% RAI), and chance of symptom relief after treatment (20% RAI) were the most important attributes for patients (Figure 2). The odds ratios for patients choosing oral suspension or tablets/capsules over IV infusion were 5.6 and 4.5, respectively (P < 0.001) (Figure 3); patients were willing to pay an additional $205/month or $180/month out of pocket for these respective routes of administration over IV (Figure 4). The odds ratio for patients choosing a 30-day over a 90-day treatment were 4.1 (P < 0.001) (Figure 3); this decrease in duration was valued by patients at $168/month (Figure 4). For a 50% vs. 30% chance of symptom relief, the odds ratio was 3.5 (P < 0.001) (Figure 3) and WTP was $147.89/month (Figure 4).

Conclusion

Patients considered route of administration, treatment duration and chance of symptom relief to be the most important IMI treatment attributes among mold-active triazoles.

1Jenks JD et al. (2019) Med Mycol 57:S168–S178

Disclosures

All authors: No reported disclosures.
2259. Predictors of Empiric Carbapenem Therapy in Complicated Intra-Abdominal Infections in the United States, 2013–2017: A Retrospective Cohort Study
Authors: Zilberberg Marya , Nathanson Brian , Lawrence Kenneth , Johnson Colby , Ditch Kristen , Olesky Melanie , Shorr Andrew F
Published: October 2019

Background

Complicated intra-abdominal infections (cIAI) remain an important cause for hospitalization. Evidence-based guidelines recommend reserving broad-spectrum antibiotic coverage for high-risk cases in order to reduce overuse of certain antibiotic classes, particularly in the face of emerging carbapanem resistance. We examined the factors associated with use of empiric carbapenem treatment (ECT) among hospitalized patients with cIAI.

Methods

We performed a multicenter retrospective cohort study in the Premier database of approximately 180 hospitals, 2013–2017. Using an ICD-9/10 based algorithm including a requirement for a laparotomy/laparoscopy, we identified all adult patients hospitalized with cIAI and included those with a positive blood or abdominal culture. We derived and tested a multivariable logistic regression model to examine predictors of ECT.

Results

Among 321,317 hospitalized patients with cIAI, 4,453 (1.4%) were culture-positive, 1,185 (26.6%) of whom received ECT. Among those given ECT, >50% (682) had no risk factors for resistance, and in only 120 (10.1%) was an organism resistant to a third-generation cephalosporin (C3R extended spectrum β-lactamase [ESBL] phenotype) isolated. The top 5 variables associated with ECT use were: pre-cIAI anti-fungal therapy (OR 2.57, 95% CI 1.91, 3.45) urgent (vs. emergent) admission (OR 1.56, 95% CI 1.21, 2.01), corticosteroids (OR 1.50, 95% CI 1.13, 1.99), ICU admission (OR 1.46, 95% CI 1.17, 1.82), and presence of sepsis/septic shock (OR 1.43, 95% CI 1.18, 1.74). The model had a moderately good fit (c-statistic = 0.683; 95% CI (0.665, 0.700), Hosmer-Lemeshow P value = 0.411).

Conclusion

Among patients hospitalized with a cIAI, 26.6% received ECT despite >50% lacking risk factors for resistance, and an only 10% prevalence of C3R in this cohort. This suggests that there remains an opportunity for carbapanem-sparing strategies. Further stratification of the risk for resistance is needed among patients with markers of high illness severity, such as those identified in our model.

Disclosures

All authors: No reported disclosures.
2326. Enterovirus-Associated Acute Flaccid Myelitis. Argentina′s Nationwide Surveillance of Acute Flaccid Paralysis 2016–2018
Authors: Pasinovich Marina , Neyro Silvina , del Valle Juárez María , Katz Nathalia , Rancaño Carolina , López Yunes Marcela , Lucconi Verónica , Rapaport Solana , Iglesias Martina , Stecher Daniel , Elbert Gabriela , Lema Cristina , Freire Cecilia , Biscayart Cristián
Published: October 2019

Background

Acute flaccid paralysis (AFP) surveillance is carried out in Argentina in the frame of the Polio Eradication Program. Acute flaccid myelitis (AFM) is a type of AFP and can be detected in the frame of AFP surveillance. Although many case series of AFM associated to enterovirus (EV) were released since 2014 in many countries, there were no notifications of this entity from Argentina until 2016.

Methods

Descriptive-observational study. AFP cases reported to the National Surveillance System (NSS) between 2016 and 2018 were included.

Results

From January 1, 2016 to December 31, 2018, 610 cases of AFP in children under 15 years old were registered (207 in 2016, 205 in 2017 and 198 in 2018). In 2016, from epidemiological weeks (EWs) 14 to 28, 23 cases of AFM were notified (median age 36 months; range: 3 months to 13 years). No special clustering was observed, and the number of AFM cases did not correlate with an increase in the annual rate of AFP notifications. Main prodromal were respiratory symptoms in 21 cases (91.3%) and fever in 18 (78.2%). One or two limbs were affected in 65%; in 35% mechanical ventilation was required. More than 90% had sequelae at discharge. Stool (ST), nasopharyngeal aspirate (NPA) and cerebrospinal fluid (CSF) samples were processed at the Regional Reference Laboratory facilities. RT nested PCR was employed. All detections are shown in Table 1. To note, In 12 cases (53%), EV D68 was detected (11, out of 16 NPA and 3, out of 11 ST samples). As for 2017, only one case of AFM was detected. Attempt of viral detection was unsuccessful. In 2018, 3 cases of AFM were detected, one EV C105, one Coxsackie B and one case without viral detection.

Conclusion

The occurrence of AFM cases in Argentina since 2016 is similar to the findings in other countries. An association with EV D68 is apparent, notwithstanding the finding of other EV, finding that further points to the causal association between EV D68 and AFM. As NPA is the sample of choice for AFM diagnosis, from 2019 the work-out of every case of AFP includes this sample as mandatory when AFM is suspected. Given the severity and the high rate of permanent sequelae, a high sensitivity of the health team must be sustained to keep with adequate surveillance, which allows prompt outbreak detection of other agents that can cause AFP in the last phase of polio eradication.

Disclosures

All authors: No reported disclosures.
2363. Implementation of a Multi-Step Diagnostic Algorithm for C. difficile Infection
Authors: Walker Morgan , Mitchell Miranda , Mellor Britney , Buras Suzanne , Young Monica , O’Neal Catherine S
Published: October 2019

Background

The diagnosis of C. difficile infection (CDI) in the hospital is challenging asymptomatic colonization rates vary between 3% and 26%. Guidelines recommend multistep testing for CDI diagnosis. On July 1, 2018 a two-step testing algorithm was implemented at our institution. Positive nucleic acid amplification test (NAAT) results reflexed to a toxin enzyme immunoassay (EIA) test. The EIA test result was then used for NHSN reporting; however, both test results were visible to the clinician. Updated guidance on the interpretation of the test and treatment of CDI was released to the medical staff in July. We compared the incidence of CDI lab ID events per 1000 patient-days and the rate of C. difficile antibiotic starts before and after the implementation of the testing algorithm.

Methods

A retrospective observational study was performed at an 800 bed regional medical center. CDI lab ID events between January 1 and December 31, 2018 were reviewed. Antibiotic initiation of intravenous (IV) and oral (PO) metronidazole and PO vancomycin was collected for all hospitalized patients diagnosed with C. difficile. The incidence of hospital onset (HO) and community-onset (CO) lab ID events as well as the rate of antibiotic starts were compared before and after implementation of the algorithm using a two-sided z test for proportions with an alpha of 0.05.

Results

The incidence of HO and CO lab ID events per 1000 patient-days decreased significantly from 0.56 to 0.16 (P < 0.0001) and 1.18 to 0.3 (P < 0.0001) after implementation of the testing algorithm (Figure 1). The CDI SIR decreased from 0.729 to 0.322, (P = 0.0048). The rate of antibiotic starts per 1,000 patient-days for IV and PO Metronidazole decreased significantly from 1.1 to 0.45 (P < 0.0001) and 0.86 to 0.35 (P < 0.0001), respectively. PO Vancomycinstarts decreased from 1.51 to 1.23 (P = 0.11) (Table 1).

Conclusion

A two-step algorithm for diagnosing CDI decreases the overall number of HO and CO C. difficile lab ID events and decreases overall antimicrobial use for CDI.

Disclosures

All authors: No reported disclosures.
2364. Surprising Prescribing: Treatment Practices following Addition of Toxin Testing to an Existing Molecular Test for Clostridioides difficile
Authors: Miller Ryan , Morillas Jose A , Fraser Thomas G , Brizendine Kyle D
Published: October 2019

Background

Diagnosis of Clostridioides difficile infection (CDI) is problematic. Adding toxin enzyme immunoassay (EIA) to molecular tests may differentiate disease from colonization and reduce treatment. Detailed descriptions of prescribing patterns following the introduction of EIA testing are not well characterized, particularly in PCR+/ EIA− patients.

Methods

In June 2018, Cleveland Clinic added EIA testing to PCR+ specimens. We conducted a retrospective cohort study on all adult inpatients who were PCR+/ EIA- from June–December 2018. Patients were placed into 3 groups for comparison: (1) complete treatment (guideline concordant); (2) incomplete treatment; and (3) no treatment. Associations with prescribing complete treatment were determined.

Results

We identified 240 patients (Figure 1). Mean age was 60 years, and 122 (51%) were female. Baseline conditions included many high severity comorbidities (Figure 2). 38 (16%) had history of prior CDI. 110/ 240 (46%) patients were receiving concomitant systemic antibiotics. 173 (72%) patients received complete CDI treatment, 41 (17%) incomplete treatment, and 26 (11%) none. 158/ 173 (91%) were prescribed vancomycin amounting to 2,107 days of therapy, averaging 13 PO vancomycin days each. Hematologic malignancy (P = 0.03) and leukocytosis > 15,000/ mm3 (P = 0.04) were significantly associated with complete treatment whereas Infectious Disease (I.D.) consultation was associated with not prescribing complete treatment (P = 0.001). Prior CDI was also associated with not prescribing complete treatment but did not reach statistical significance due to small sample with prior CDI (P = 0.09). There was no association with concomitant systemic antibiotic use or use in the past 1 month.

Conclusion

In the first 6 months after adding toxin EIA to an existing molecular test for CD, 89% of PCR+/ EIA− patients were prescribed some treatment. Hematologic malignancy and leukocytosis were associated with treatment. I.D. consultation was associated with not prescribing treatment. Although we suspect a learning curve with the 2-step approach to testing, it appears the challenge of optimizing testing and management remains. Improved understanding of the clinical significance of a sensitive test on a non-sterile specimen is required.

Disclosures

All authors: No reported disclosures.
133. The Changing Phenotypes and Genotypes of Invasive Pneumococcal Isolates From Children in Shenzhen During 2013–2017
Authors: Bao Yanmin , Zheng Yuejie
Published: October 2019

Background

The phenotypes and genotypes of Streptococcus pneumoniae (Spn.) isolated from children with invasive pneumococcal diseases (IPDs) were changed in these years. The purpose of this study was to monitor this mutation trends before the introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) in China.

Methods

Strains were isolated from children less than 14 years old between January 2013 and May 2017 in Shenzhen Children’s Hospital. Serotypes, antibiotic resistance, and genotypes of these isolates were determined using capsular swelling, E-test, and multi-locus sequence typing, respectively.

Results

A total of 94 Spn. strains were isolated, which belonged to 15 serotypes. The five most prevalent serotypes were 19F (25.5%), 19A (19%), 14 (17%), 23F (7.5%), and 6B (9.6%). The other two serotypes (19C and 15) were non-vaccine types. We found 42 sequence types (STs) for these isolates. The most abundant STs were ST271 (24.4%), ST876 (17%), and ST320 (10.6%), mainly related to 19F, 14, and 19A, respectively. The potential coverage of PCV13 was 87.2%. Among non-meningitis isolates, the resistance rates to penicillin and ceftriaxone were 0% and 2%. However, the meningitis isolates showed universal resistance to penicillin (80%) and ceftriaxone (20%). Most of these isolates (95.7%) were resistant to erythromycin, and 66 (70.2%) strains carried the ermB gene and 24 (25.5%) strains carried both the ermB and mefA/E genes. Serotype 19A showed the highest minimum inhibitory concentration (MIC) for penicillin than the other serotypes, but no significant difference in penicillin MIC among the three main STs (ST271, ST320, and ST876).

Conclusion

The phenotypes and genotypes of invasive pneumococcal isolates from children in Shenzhen have changed with the passage of time. Compared with PCV7, PCV13 can more effectively protect Chinese children from IPDs. To some extent, these changes are possibly related to the usage of antibiotics and vaccines.

Disclosures

All authors: No reported disclosures.
2443. Impact of Antimicrobial Stewardship on the Incidence of Carbapenem-Resistant Pseudomonas aeruginosa: A Nonlinear Time-Series Analysis Approach to Identify Carpapenem Thresholds
Authors: Meschiari Marianna , María Lòpez-Lozano José , Beyaert Arielle , Nebot Cesar , Orlando Gabriella , Bedini Andrea , Sarti Mario , Mussini Cristina
Published: October 2019

Background

To estimate the impact of antimicrobials stewardship in the temporary evolution of the Density Incidence of Pseudomonas aeruginosa resistant to carbapenems (DI_PaCRE).

Methods

In Modena Policlinico, a tertiary care hospital, from September 2014, universal rectal screening and antibiotic stewardship (ABS) focusing on carbapenem sparing strategy were introduced. We used the statistical approach already described (A nonlinear time-series analysis approach to identify thresholds in associations between population antibiotic use and rates of resistance. López-Lozano JM, et al. Nat Microbiol. 2019 Apr 8. doi: 10.1038/s41564-019–0410-0) in order to adjust a non-linear model (Multivariate Adaptive Regression Splines) looking for the identification and estimation of thresholds in the influence of the use of Carbapenems on the DI_PaCRE.

Results

We identified a threshold at 5.65 DDD/100 bed-days of Carbapenems (CarbUse). Indeed, above this threshold, for every increase of one DDD/100 bed-days, the DI_PaCRE increased by 0.15 new cases by 1000 bed-days. On the basis of our analyses, considering a typical course of 7 days of treatment, an average CarbUse of 6.5 DDD/100 bed-days in 2012 and 2013, for an average of 15000 monthly bed-days, means around 139 treated patients. In order to avoid the emergence of resistance, the threshold was equivalent to a maximum number of 121 patients to be treated. Below this threshold, i.e in 2018, CarbUse including 66 patients treated did not select antimicrobial resistance.

Conclusion

PaCRE could be controlled by reducing the use of carbapenems below minimum thresholds of 6.5 DDD/100 bed-days. In order to avoid the onset of resistance to carbapenems in Pseudomonas aeruginosa, less than 121 patients per month should receive this class of drug. This finding could provide innovative approach to guide antimicrobial stewardship strategy focused on limit the spread of PaCRE in hospital populations.

Disclosures

All authors: No reported disclosures.
2452. Outbreak of Candidemia Associated With a Contaminated Intravenous (IV) Anesthetic in an Adult Intensive Care Unit (ICU) in San Luis Potosí, México.
Authors: Portales-Castillo Carlos , Araujo-Meléndez Javier , Torres-González Pedro , Mancilla-González Mariana
Published: October 2019

Background

In June 2018, an unusual number of candidemia-associated sepsis cases were diagnosed in sedated patients hospitalized in the 12-bed adult ICU of a teaching hospital in Mexico. The pre-outbreak candidemia rate had been calculated at 0.66 cases/100 ICU admissions for the previous 3 years.

Methods

We performed a case–control and microbiological study designed to trace the source of the outbreak. Case definition included adult patients with systemic inflammatory response syndrome and Candida species isolated on BC (blood cultures). The rest of the patients in the ICU within the study period (6/12/2018–6/22/2018) were used as controls.

Results

A total of 5 cases and 19 controls were included in the study. Demographic and clinical characteristics were similar between groups, except for SOFA scores (Table 1). Differences in median SOFA scores between groups were statistically significant (7.5 in cases and 3 in controls (p = 0.02)). After review of common medications used between cases, propofol infusion use (5/5 in cases and 6/19 in controls) was calculated as the strongest risk factor for candidemia (OR 22.84 (p = 0.04)). In-use propofol infusions available at the time were stopped and sent for culture as were unopened vials stored in the pharmacy from the lot being used in the ICU. Intrinsical contamination with bacterial and fungal species related to the outbreak was identified (Table 3). Case fatality rate during the outbreak was 80% (4/5)

Conclusion

Lethal infections due to contaminated medications, including propofol, have been reported worldwide. Propofol is a potential source for infections given its lipophilic nature that promotes microbial growth. This likely remains an underecognized problem that deserves awareness for early recognition. Epidemiological surveillance in our hospital prompted our case–control study and the subsequent implementation of effective control measures including rapid notification to hospital and national authorities (COFEPRIS), elimination of the identified contaminated lot, and increased promotion of both hand hygiene and adequate IV medication handling techniques among staff.

Disclosures

All authors: No reported disclosures.
2466. What’s Lurking in the Drain? Serial transmission of NDM-1Klebsiella pneumoniae to patients admitted 9 months apart to the same ICU room
Authors: Smith Becky A , Mathers Amy , Kotay Shireen , Parikh Hardik , Barry Katie E , Seidelman Jessica , Addison Rachel , Huslage Kirk , Hnat Amy , Sova Christopher , Lewis Sarah S
Published: October 2019

Background

We evaluated the role of an in-room sink in NDM-1 K. pneumoniae (NDMKP) transmission.

Methods

In October 2017, Infection Prevention (IP) initiated weekly point prevalence rectal screening cultures in 4 ICUs. In 3/2018, IP launched an epidemiologic and environmental investigation following identification of a patient with NDMKP rectal colonization. Environmental samples including swabs of biofilm from drains and water from p-traps were obtained from the in-room sink. Illumina whole-genome sequencing (WGS) was performed on all NDMKP patient and environmental isolates. Single nucleotide variants (SNVs) were identified against the reference Klebsiella pneumoniae strain MLST15 (NZ_CP022127), and isolates within 150 SNVs of each other were considered to be genomically related.

Results

Two patients were identified with NDMKP infection or colonization between July 2017 and March 2018. The index patient had prolonged hospitalization and developed NDMKP bacteremia on hospital day (HD) 30. Approximately 9 months later, the second patient was admitted to the same ICU room that had been occupied by the index patient for 13 days and was identified to have NDMKP rectal colonization on HD 5. Environmental samples from the in-room sink of the ICU room grew NDMKP. WGS demonstrated relatedness between NDMKP isolates from the 2 patients (112 SNV), the index patient and the sink (52 SNV), and the second patient and the sink (80 SNV). The in-room sink was replaced in 4/18 and no further cases of NDMKP infection or colonization have been identified at DUH in over 12 months.

Conclusion

We report an NDM-1 K. pneumoniae transmission event possibly related to a contaminated in-room sink drain. Remarkably, 9 months elapsed between the index case and the second case, with no additional interim cases detected on weekly point-prevalence screening or clinical cultures. The long duration of time between and the index patient, secondary case, and sink culture may explain why WGS showed relatedness but not identical clones. Education around sink use, design, and more effective cleaning strategies are needed to mitigate environment-to-patient transmission of CRO.

Disclosures

All authors: No reported disclosures.
140. Trends of Infective Endocarditis at a Northern New England Academic Medical Center, From 2011 to 2017: A Case for Improved Methods to Reliably Identify Associated Substance Use
Authors: DesBiens Martha T , de Gijsel David , Chan Benjamin P , Talbot Elizabeth A , Conn Stephen , Laflamme David
Published: October 2019

Background

Infective endocarditis (IE) is a morbid and often lethal complication of injection drug use. There is an urgent need for accurate surveillance for IE related to substance use (SU) to support control strategies.

Methods

We conducted a retrospective comparative analysis of 3 datasets evaluating patients aged ≥16 years admitted to an academic medical center in New England with an ICD-9/10 discharge diagnosis of IE from April 2011 to December 2017. The 3 datasets included the hospital’s electronic medical record (EMR); the hospital’s Outpatient Parenteral Antibiotic Therapy (OPAT) program dataset; and the New Hampshire Uniform Hospital Discharge Data Set (UHDDS). We analyzed the number of admissions for IE per year, stratified by SU. We developed a SU composite measure by incorporating multiple sources of data from the EMR, and then verified accuracy of both the SU and IE diagnoses through manual chart review.

Results

The EMR documented 472 hospital admissions for IE, representing 385 unique patients. The median age was 56 years and 59% were men. Admissions increased 67%, from 56 in 2012 to 84 in 2017. SU was coded as a discharge diagnosis in 27% of these admissions; however, based on our composite measure of SU, 45% IE admissions were possibly associated with SU. The proportion of IE patients who had evidence of SU increased from 20% in 2011 to 49% in 2017 (P = 0.002). Patients with SU compared with those without were younger (40.5 vs. 65.2 years, P < 0.001) and more likely to be on Medicaid (59% vs. 8%, P < 0.001). They had higher average charges ($146,633 vs. $107,223, P = 0.002) and lengths of stay (19.1 vs. 13.4 days, P < 0.001). The UHDDS and EMR datasets identified a similar numbers of patients with a diagnosis of IE; however, manual chart review revealed that IE was over-coded in ~one-fifth of admissions.

Conclusion

The rate of IE in our hospital increased dramatically between 2011 and 2017, with a rising proportion associated with SU. Despite these trends, we found that discharge diagnosis coding alone substantially underestimated associated SU and overestimated IE disease burden. Our findings suggest public health administrative datasets, such as the UHDDS, can contribute to surveillance of IE disease burden with consideration of these important limitations, especially for assessing disease trends.

Disclosures

All authors: No reported disclosures.
2479. Trends and Regional Differences in Extended Spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, 2012–2017
Authors: Wolford Hannah , Hatfield Kelly M , Olubajo Babatunde , Reddy Sujan , Jernigan John A , Baggs James
Published: October 2019

Background

Extended spectrum β-lactamase-producing Enterobacteriaceae (ESBLs) have been identified as a serious antibiotic-resistant threat. Studies have shown that ESBL infection rates were increasing through 2014. Our objective was to examine more recent ESBL trends and to evaluate differences across regions in the United States.

Methods

We measured the incidence of positive clinical cultures from inpatient encounters in a cohort of hospitals submitting data to the Premier Healthcare Database and Cerner Health Facts from 2012 through 2017. We included Escherichia coli and Klebsiella spp. cultures and defined ESBL as non-susceptibility to cefotaxime, ceftriaxone, ceftazidime, or cefepime. Cultures collected on days 1, 2, or 3 of hospitalization were considered community-onset (CO); cultures from day 4 or later were considered hospital onset (HO). We developed weights using a raking procedure to match the American Hospital Association distribution for acute care hospitals based on US census division, bed size category, teaching status, and urban/rural designation. We used weighted multivariable logistic regression adjusting for hospital characteristics to examine trends and regional differences in ESBL rates.

Results

In 2017, the estimated rate of ESBLs was 40.3 per 10,000 discharges for CO and 6.4 per 10,000 discharges for HO; 86% of all ESBLs were CO. The percent that were ESBLs among all included cultures increased for CO (8.2% in 2012 to 11.6% in 2017) and HO (13.1 to 16.8%) cultures. From 2012 – 2017, adjusted ESBL rates increased for CO (7.9% annually, P < 0.0001), while HO rates did not change significantly over time (P = 0.39, Figure 1). We found significant regional differences in the rates of ESBL (P < 0.0001) across US census divisions in 2017 (Figure 2). Estimated rates for 2017 varied 5-fold from 15.3 ESBLs per 10,000 discharges in the Northwest Central to 82.4 ESBLs in the Mid-Atlantic.

Conclusion

We estimated a 40% increase in the rate of CO-ESBLs among hospitalized patients from 2012 to 2017, but no increase in HO rates. ESBL rates varied greatly by region of the country and are estimated as much as 5× higher in some areas. A better understanding of factors contributing to community transmission and regional variation is necessary in order to inform ESBL prevention efforts.

Disclosures

All authors: No reported disclosures.
2494. Real-World Use of Ibalizumab in Physician Office Infusion Centers (POICs)
Authors: Prokesch Richard C , Schroeder Claudia P , Hardin Thomas C , Van Anglen Lucinda J
Published: October 2019

Background

Ibalizumab-uiyk (IBA) was recently approved for the treatment of multi-drug-resistant HIV-1 infection in patients (pts) failing other antiretroviral regimens. Clinical trial data demonstrated a decrease in HIV-1 viral load in 83% and 43% of patients (n = 40) receiving IBA for 2 and 25 weeks (weeks), respectively. Real-world post marketing data are needed. This pilot study reports the experience of IBA utilization in POICs.

Methods

Medical records of patients receiving intravenous IBA from approval through April 2019 were reviewed. Data collected include demographics, infection and treatment history, IBA regimen and adverse events. Plasma HIV-1 RNA viral load (log10 copies/mL) and CD4 count (cells/µL) were collected at baseline and as available during therapy. Based on available follow-up (FU) labs, response was assessed at 4–10 weeks (FU 1), 14–22 weeks (FU 2), and 24–37 weeks (FU 3).

Results

Nine patients (mean age: 48 ± 11 years, 67% male) from 7 POICs received IBA for a median duration of 33 weeks (range 4–43). Median length of HIV-1 diagnosis was 22 years (range 8–25). Resistance to ≥1 drug in at least 3 drug classes was reported in 56%. All patients received at least one concurrent anti-retroviral agent. IBA was initiated at 2000 mg followed by 800 mg every 2 weeks. All patients received infusions as scheduled (151 total infusions) except for one requiring a second loading dose. Baseline mean CD4 count and viral load were 49 cells/µL and 4.9 log10 copies/mL, respectively. Labs obtained at FU 1 indicated a decrease in viral load of at least 0.5 log10 copies/mL in 6/8 patients (75%); a mean reduction of 2.1 ± 1.8 log10 copies/mL (Table 1). Mean HIV-1 titers available for patients at FU 2 (n = 6) and FU 3 (n = 7) were 3.1 ± 2.0 and 3.2 ± 2.6 log10 copies/mL, respectively. Mean CD4 counts were 65 ± 57 cells/µL at FU 1, 96 ± 61 cells/µL at FU 2 and 88 ± 82 cells/µL at FU 3. Adverse events were reported in 8 patients (89%), most common itching/rash, diarrhea and abdominal pain. None resulted in discontinuation of IBA.

Conclusion

This study confirms the antiviral activity of IBA in patients with advanced HIV-1 infection in the real-world setting. We observed well-tolerated therapy with an early reduction in HIV-1 viral load of 75%, followed by a 43% reduction ≥24 weeks, consistent with the clinical trial.

Disclosures

All authors: No reported disclosures.
143. Opioid Use and Hospitalizations for Endocarditis, Osteomyelitis, and Central Nervous System Abscess among Adults — New York City, 2001–2014
Authors: Huang Chaorui , Lucero David , Paone Denise , Tuazon Ellenie , Daskalakis Demetre
Published: October 2019

Background

Along with a growing opioid epidemic nationwide, opioid users often have an increased risk of severe infectious diseases including endocarditis, osteomyelitis, and central nervous system (CNS) abscess. As the largest city in the United States, New York City (NYC) may serve as a study model for opioid use and infectious diseases. We investigated the association between opioid use and hospitalizations for endocarditis, osteomyelitis, and CNS abscess in NYC.

Methods

Data for NYC residents aged ≥18 years discharged from New York State hospitals during 2001–2014 were analyzed using a hospital discharge dataset. We defined a hospitalization for endocarditis, osteomyelitis, and CNS abscess as one with a principal or secondary diagnosis for these conditions within the discharge record. We identified opioid users by examining principal or secondary diagnoses for opioid use within the discharge record at the time of hospitalization for endocarditis, osteomyelitis, and CNS abscess. Log-binomial model was applied among all hospitalized patients using endocarditis, osteomyelitis, and CNS abscess as the outcome, adjusting for age, sex, race, and borough.

Results

During 2001–2014, there were 139,392 hospitalizations in total for endocarditis, osteomyelitis, or CNS abscess, of which 8,823 (6.3%) were among opioid users. There was an increased risk of hospitalization for endocarditis [RR: 2.6 (95% CI: 2.5–2.7)], osteomyelitis [RR: 1.1 (95% CI: 1.1–1.1)], and CNS abscesses [RR: 1.9 (95% CI: 1.8–2.1)] among hospitalized opioid users compared with hospitalized nonopioid users, adjusted by age, sex, race, and borough. Hospitalized opioid users had four times the risk for endocarditis hospitalization compared with hospitalized nonopioid users in the 18–44 year age group (RR: 4.2 [95% CI: 3.9–4.5]) (Table 1).

Conclusion

These results provide further evidence that opioid use is associated with an increased risk of endocarditis, osteomyelitis, and CNS abscess. Efforts to combat the opioid epidemic might lower the overall incidence of endocarditis, osteomyelitis, and CNS abscess.

Disclosures

All authors: No reported disclosures.
2513. The Effect of Treatment Supporter Interventions on ART Adherence in Eastern and Southern Africa: a systematic review and meta-analysis
Authors: Haddy Sallah Ya , Nyoni Thabani , Lipsey Kim
Published: October 2019

Background

Access to ART has significantly reduced morbidity and mortality and improved quality of life in people living with HIV (PLWH). Treatment supporter interventions (TSIs) utilize patient or facility selected individuals to increase optimal ART adherence through home visits, peer support and medication management. This aim of this meta-analysis is to evaluate the effectiveness of TSIs in improving optimal ART adherence among PLWH in SSA using process- and outcome-oriented measures.

Methods

We searched PubMed, EMBASE, SCOPUS, Web of Science (WOS), Cochrane Library, and ClinicalTrials.gov for randomized controlled trials or cohort studies comparing treatment supporter interventions to the standard of care conducted in Eastern and Southern Africa. The primary outcomes were ART adherence measured by pill counts and virologic suppression. Pooled risk ratios with 95% confidence intervals were calculated using random-effects models. Stratified analyses and meta-regression were conducted to determine the effect of study type and patient nomination of treatment supporters on ART adherence.

Results

Sixteen studies, 10 RCTs and 6 cohort studies, were selected for inclusion. Virologic suppression was reported in 14 studies with 12,457 individuals in TSIs and 23,592 receiving the standard of care. Optimal ART adherence was reported in 7 RCTs only (2,185 individuals in TSI and 1,545 receiving SOC). Optimal ART adherence was 7.6% higher in TSIs compared with SOC (pooled RR 1.076, 95% CI 1.005–1.151, p = 0.035). Heterogeneity of these studies was high (I2 = 91.1%). Virologic suppression was 5% higher in TSIs compared with the standard of care (pooled RR 1.05, 95% CI 1.019–1.081, P = 0.001). Meta-regression demonstrated that virologic suppression did not significantly vary by study type (b = −0.042, 95% CI −0.09–0.001, P = 0.057) and patient selection of the treatment supporter (b = 0.026, 95% CI −0.07–0.12, P = 0.554).

Conclusion

Optimal ART adherence is marginally higher in treatment supporter interventions compared with the standard of care. Patient-nominated supporters achieve similar rates of virologic suppression to facility-selected supporters, and could play a critical role in addressing disparities in health outcomes among PLWH.

Disclosures

All authors: No reported disclosures.
2530. TACO Tuesday as a Medical Education Tool
Authors: McCauley Melanie , Benson Constance , Wooten Darcy
Published: October 2019

Background

Novel strategies in medical education including the flipped classroom, test-enhanced learning, and gaming have proven to be effective for preclinical learners but little is known about their efficacy in post-graduate education. We implemented an educational tool in our Infectious Diseases (ID) Fellowship Training program called TACO (To Assess Cognitive Operations) Tuesday that utilizes aspects of the flipped classroom, test-enhanced learning, and gaming to improve ID fellow engagement, satisfaction, knowledge retention, and board examination preparation in association with a weekly ID core didactic curriculum.

Methods

One to three multiple choice clinical vignettes were emailed to ID fellows the day prior to their weekly didactic lecture. The first fellow to answer all questions correctly was the winner for the week. The correct answer choices along with detailed rationales were distributed to all fellows at the end of the week. After one year of using this educational tool, we surveyed fellows to evaluate its impact on their engagement with the weekly didactic sessions, self-perception of content retention, and sense of preparation for the ID board examination.

Results

We had a response rate of 82% with 9 of 11 fellows polled participating. Of those, two-thirds attempted to answer the multiple-choice questions prior to lecture and most (77%) reviewed the correct answer choices and rationales weekly. All participants felt the educational tool helped improve their engagement with the lectures and half felt it increased overall satisfaction with their educational experience. The majority felt the tool increased content retention and their level of preparation for the ID board examination. Implementation of this tool was associated with a higher mean IDSA in-training examination score compared with scores from the previous year (518 vs 469).

Conclusion

ID fellows found that an educational tool utilizing a flipped classroom, test-enhanced learning, and gaming in association with a weekly core didactic curriculum increased their engagement, satisfaction, knowledge retention, and board examination preparation. Future studies will investigate the impact of this tool on knowledge retention and ID board examination scores within our institution as well as across institutions.

Disclosures

All authors: No reported disclosures.
2553. Addressing Knowledge and Practice Gaps in HIV Management with Engaging Continuing Education
Authors: Robinson Katie , Frederick Jennifer , A. Esgro Robert , Heeg Marlene , Kays Michael B , Elion Richard
Published: October 2019

Background

Given the rapid evolution of HIV management guidelines and the emergence of new treatment paradigms, infectious disease specialists are challenged to stay current on the latest evidence-based care and how to tailor treatment to optimally meet an individual patient’s needs. To address identified knowledge and practice gaps regarding the care of patients with HIV, an engaging continuing education (CE) initiative was implemented, and the impact of the education on provider knowledge and practice was measured.

Methods

Vindico Medical Education partnered with Purdue University College of Pharmacy to deliver a highly engaging, 2.0-credit hour, CE initiative at ID week in October 2018. The symposium was comprised of multiple formats, including didactic presentations, case-based discussion, and the gamified segment, Wheel of HIV Knowledge. Coverage of the live program was posted to Healio.com, extending the reach of the education. Analysis of the impact of this education was achieved via pre- and post-test test assessment.

Results

357 healthcare providers participated in the live session, and 236 have accessed the web activity as of April 2019. The gamified and case-based segments of the live activity engaged on average 70% of learners and revealed insights into current practice patterns and persisting gaps in knowledge regarding the latest, evidence-based HIV care. Across the curriculum, there was a 46% relative increase in knowledge and competence. A total of 223 providers who see on average 15 patients per month with HIV completed the education, resulting in approximately 2,500 patients with HIV per month who are more likely to receive the latest evidence-based care. Moreover, 3 months following the education, 55% of providers reported implementing practice improvements, including applying the latest clinical guidelines and recommendations. Of those providers who implemented changes, 47% observed patient improvements such as improved adherence, satisfaction, and reduced viral loads.

Conclusion

In recent years of rapid advances for HIV management, providers are challenged to administer the latest evidence-based care. This study highlights the power of engaging CE to address persisting knowledge and practice gaps toward the delivery of enhanced care for patients with HIV.

Disclosures

All authors: No reported disclosures.
2554. A Standardized Medicine Resident Curriculum: Content Survey for an Infectious Diseases Rotation
Authors: Enriquez Matthew , Lio Jonathan , Pitrak David , Sherer Renslow
Published: October 2019

Background

There have been few studies performed or guidelines made to address which topics in Infectious Diseases (ID) should be essential for medicine residents to learn during their training for their future practice of clinical medicine. Furthermore, when residents rotate on ID specialty electives, rarely is there formalized, standardized instruction tailored to residents. Thus, the purpose of this project is to define which core topics in ID residents should focus on learning during their training as pertains to clinical practice rather than for simply passing Internal Medicine (IM) board exams, which many programs tend to instead use as a guide for teaching ID content.

Methods

An online survey was designed and distributed to the faculty of the University of Chicago Medicine (UChicago) IM and ID sections. The survey was 8 questions, one of which was to rank 28 topics in ID on a modified 5-point Likert scale (1 = “absolutely unimportant;” 5 = “absolutely essential”) with regards to importance for a resident to practice general medicine. A cutoff for inclusion was ≥ 4.0 (moderate importance) and ≥ 25% of the faculty ranking the topic as absolutely essential. Open-ended feedback was encouraged and evaluated via a semi-structured evaluation.

Results

The survey was distributed to the 88 attendings in the UChicago ID and general IM sections. The response rates were 85% (ID) and 44% (IM). Ten of the 28 topics were ranked ≥ 4.0 (moderate importance) and had ≥ 25% of the faculty designate the topic as absolutely essential (Figure 1). Open-ended feedback included to focus on value-based care, to include Infection Control, and to focus on areas not taught in other aspects of their residency curriculum such as in their outpatient rotations. A majority (61%) indicated that 2–5 hours of structured teaching (lectures, online modules, etc.) would be most appropriate during a 2-week ID specialty rotation.

Conclusion

This project defined the core topics in ID that medicine residents should focus on learning during their training. The next step will be a needs-assessment to survey baseline resident knowledge of the above topics. The ultimate the goal will be to design, deliver, and evaluate an ID curriculum that focuses on teaching this core content.

Disclosures

All authors: No reported disclosures.
2562. Implementation of Current Event Assignments to Engage Students and Enhance Public Health and Infectious Diseases Awareness in a Doctor of Pharmacy Program
Authors: Ernst Erika
Published: October 2019

Background

The Accreditation Council for Pharmacy Education standards for Doctor of Pharmacy (PharmD) programs include a required Public Health element. An ID-related current event assignment series was introduced into the PharmD ID Integrated Pharmacotherapy course in 2018.

Methods

Students were required to submit one ID-related current event weekly for 3 weeks and one reflection. A written summary and opinion about the article was submitted using the on-line course system. Instructions suggested they consider the public health implications of the article and how the article may impact practice (significance). They were asked to include any errors in reporting and could also include how they might respond to questions from patients or practitioners about the topic. For the reflection, students were asked to consider whether the assignments impacted their view of ID, public health and reporting to the public. In addition, they were asked if the assignments influenced how they stay informed for their patients. Suggestions for improvement and comments regarding whether the assignment should be retained for future classes were solicited. Student responses for each of 2 years were evaluated and summarized into themes.

Results

Overwhelmingly, students felt the current events were beneficial to their appreciation of ID-related topics and public health awareness. Students noted the open-ended nature of the assignment encouraged their own curiosity. Many said their first impression was that it would be difficult to find an article, and were surprised how easily they found articles and spent additional time researching topics of interest. Student stated the requirement to add an opinion enhanced their effort in finding, reading, researching and writing about the topic. Students suggested more time for sharing and discussing articles with the class. Most stated the assignments should be continued for future classes.

Conclusion

The addition of an open-ended, ID-related current event assignment provided PharmD students with exposure to public health-related issues. These assignments were positively received by students and served as a simple means to engage the students in self-directed learning of ID-related topics. It also enlightened students toward global public health issues and encouraged many to stay informed.

Disclosures

All authors: No reported disclosures.
2566. infection Dynamics of Pseudomonas aeruginosa Bloodstream Infections
Authors: Bachta Kelly E R , Allen Jonathan P , Hauser Alan R
Published: October 2019

Background

Pseudomonas aeruginosa (PA) is a critically important healthcare-associated pathogen responsible for a variety of infections including bloodstream infection (bacteremia), pneumonia, and urinary tract infection. PA bacteremia is a significant cause of morbidity and mortality, especially in immunocompromised patients; However, little is known about the in-host infection dynamics of PA bacteremia and the impact of individually infected patients on transmission in the healthcare environment.

Methods

We utilized animal modeling in conjunction with sequencing technology to dissect the infection dynamics of PA bloodstream infections. BALB/c mice were challenged intravenously with a human bacteremia isolate, PABL012. At various time points post infection, organs were harvested and the surviving PA enumerated. In parallel, PABL012 engineered to express the luciferase cassette was used to track PA in live mice over time using the IVIS imaging system. STAMP (sequence tag-based analysis of microbial populations) analysis was then applied to define the population dynamics of PA bloodstream infection.

Results

Bacterial enumeration and IVIS imaging revealed that systemically infected mice have a focus of bacterial expansion in their gallbladders (GB). Surprisingly, the same mice also shed PA in their gastrointestinal tract (GI), a phenomenon not previously appreciated following bloodstream infection. Finally, STAMP analysis revealed that (1) PA experiences a severe in vivo bottleneck when trafficking to the GB, (2) the population in the GB expands tremendously during infection and (3) this population is ultimately the source of excreted bacteria in the GI tract.

Conclusion

Our research, using murine models, provides the first evidence that the GB acts as a sanctuary site for PA replication following systemic infection and links replication with fecal excretion. Fecal excretion of PA from hospitalized patients is observed, but the direct link between acute infection, GI shedding, and transmission remains unclear. Our observations have significant implications on understanding how PA evades initial host clearance, the identity of protected expansion niches, and how PA might exit the human host in the healthcare environment facilitating a transmission event.

Disclosures

All authors: No reported disclosures.