bluuebunny/crossref_metadata_2025 huggingface dataset:
117. Hospitalized Burn Patients with Fever and Leukocytosis: Blood Culture or Not?
Authors: Luo Ruihong , Janoian Paul
Published: October 2019

Background

Fever and leukocytosis are very common in patients with burn injury. Many patients had to do blood cultures frequently during their hospitalization given the concern of bacteremia. We opt to utilize the clinical characters of the patients to evaluate the risk for bacteremia and avoid unnecessary blood culture.

Methods

The adult patients (≥18 years) with burn injury were selected from the Nationwide Inpatient Sample database (2005–2014). Using ICD-9 codes, we further identified bacteremia, total body surface area (TBSA) of burn, inhalation injury, pneumonia, urinary tract infection, wound infection, escharotomy, placement of central venous line, indwelling urinary catheter, gastrostomy tube (G-tube), intubation, and total parenteral nutrition (TPN). The risk factors for bacteremia were evaluated by Logistic regression. A risk-adjusted model to predict the occurrence of bacteremia was developed by discriminant analysis.

Results

In total, 241,323 hospitalized patients with burn injury were identified. The incidence of bacteremia was 1.1% (n = 2,634). Comparing with the patients without bacteremia, those with bacteremia were older (51.1 vs. 46.7 year old, P < 0.001), had more severe burn injury (50.7% vs. 12% with burn TBSA over 20%, P < 0.001) and comorbidities (22.7% vs. 14.9% with Charlson index ≥2, P < 0.001), higher in-hospital mortality (5.6% vs. 3.7%, P < 0.001), longer hospital stay (26 vs. 5 days, P < 0.001) and more hospital charges ($206,028 vs. $30,339, P < 0.001). When the age, sex, race, and Charlson index of the patients were adjusted by Logistic regression, it was found that the factors of inhalation injury (OR = 1.25, 95% CI 1.03–1.51), intubation (OR = 1.62, 95% CI 1.44–1.82), TPN (OR = 1.56, 95% CI 1.16–2.11), placement of central venous line (OR = 1.86, 95% 1.57–2.01), and G-tube (OR = 2.04, 95% CI 1.60–2.60) were associated with increased risk for bacteremia. A risk-adjusted model composed of the patient’s age, Charlson index, burn TBSA, inhalation injury, intubation, TPN, placement of central venous line, and G-tube could predict the occurrence of bacteremia with an accurate rate of 85.4% (Table 1).

Conclusion

The risk factors and risk-adjusted model for bacteremia may assist to decide whether a blood culture is needed in the hospitalized burn patients.

Disclosures

All authors: No reported disclosures.
2244. Clinical Outcomes with Extended Infusion (EI) vs. Intermittent Infusion (II) of Cefepime (FEP), Piperacillin/Tazobactam (TZP), and Meropenem (MEM) in Patients with Gram-Negative (GN) Bacteremia
Authors: Tran Kieu-Nhi , Mynatt Ryan , Kaye Keith S , Pogue Jason M
Published: October 2019

Background

The increase in drug-resistant pathogens has prompted interest in dosing of β-lactams (BLs) via EI. Available data on this practice are conflicting, rarely assess non-critically ill patients or low MIC pathogens, and do not focus on outcomes other than clinical cure or mortality. Further assessment of this practice is warranted.

Methods

This is a retrospective cohort study of adult patients who received FEP, TZP, or MEM for GN bacteremia via INI or EI from 2010 to 2018. Patients were included if the pathogen was susceptible to the target BL and they received study drug within 24 hours of bacteremia onset and continued it for ≥ 48 hours. Patients were excluded if they had a mixed infection or received > 48 hours of combination therapy. Patients were matched 1:1 based on study drug utilized, sepsis severity, ICU status, bacteremia source, and causative pathogen. Outcomes assessed included time to clinical stabilization as well as treatment failure, mortality, length of stay (LOS), and recurrence.

Results

268 patients (134 matched patients in each group) were included. Median (IQR) age of the cohort was 64 (55–77) years, and 57% were male. Common comorbidities were diabetes (35%) and CKD (26%), and the median (IQR) Charlson Comorbidity Index (CCI) was 3 (1–4). 40% of the population presented with severe sepsis or septic shock, and 42% were in the ICU at infection onset. Baseline characteristics were similar between the two groups except patients receiving EI were older (65.5 (58–78) vs. 61.5 (52–73); P = 0.006 and had higher median CCI (3 (2–4) vs. 2 (1–3); P < 0.001,) while patients in the II group had a higher mean weight (85.5 ± 27.8 vs. 78.8 ± 19.2, P = 0.02.) The most common organisms isolated were E. coli(41%), K. pneumoniae (18%), and P. aeruginosa (13%), and the most common source of infection was the urine (51%). Outcomes are listed in Table 1. EI was associated with decreases in time to defervescence, WBC normalization, and SIRS resolution. Furthermore, EI was associated with a lower incidence of treatment failure and recurrence as well as decreases in LOS and ICU-LOS. There was no difference in mortality.

Conclusion

The findings of this analysis highlight the role of EI in BL therapy as an important stewardship strategy to optimize clinical outcomes in all patients with GN bacteremia.

Disclosures

All authors: No reported disclosures.
2268. Clinical Implications of Azole-Resistant vs. Azole-Susceptible Invasive Aspergillosis in Hematological Malignancy (CLARITY): A Multicenter Study
Authors: Seidel Danila , Cornely Oliver , Arenz Dorothee , Meis Jacques , Vehreschild Jörg , Salmanton-Garcia Jon , Zarrouk Marouan , Falces Romero Iker , Racil Zdenek , Lagrou Katrien , Maertens Johan , Reséndiz Sharpe Agustìn , Blennow Ola , Lass-Flörl Cornelia , Legovic Yohann , Ostojic Alen , Desoubeaux Guillaume , Alakel Nael , Schalk Enrico , Bergeron-Lafaurie Anne , Steinmann Jörg , Buchheidt Dieter , Stanzani Marta , Klimko Nikolai , Prattes Jürgen , Melchers Willem , Vehreschild Maria , Verweij Paul
Published: October 2019

Background

In recent years, survival of patients with invasive aspergillosis (IA) has improved mainly due to availability of extended spectrum triazoles. These advances are jeopardized by the emergence of azole resistance in Aspergillus fumigatus, the most common causative pathogen of IA. Despite several studies suggesting high probability of azole treatment failure in patients with azole-resistant isolates, the clinical implications of azole-resistant IA compared with azole-susceptible IA remain unclear.

Methods

In patients with hematological malignancies, cases of proven or probable IA (EORTC/MSG 2008) caused by A. fumigatus are registered. Retrospective data are documented, comprising demographics, diagnosis, treatment, response and outcome. Participating sites provided susceptibility results or isolates. Provided isolates were analyzed in a central laboratory.

Results

Since January 2018, 51 sites in 15 countries worldwide enrolled 154 cases diagnosed with IA between 2010 and 2019, of which 23 (14.9%) had azole-resistant IA. Of 44 cases, the respective clinical fungal isolate was analyzed in the central laboratory. A mixed fungal infection was reported for 34 patients (22.1%), 1 (2.9%) in the azole-resistant group; most were related to non-fumigatus Aspergillus species (n = 12, 35.3%) and non-Aspergillus molds (n = 10, 29.4). Most patients were male (n = 98, 63.6%); 19 (82.6%) in the azole-resistant group, 79 (60.3%) in the azole-susceptible group. Age was documented in categories instead of the exact age. Median age group was 50–69 years in both groups (ranging from 7–11 to 70–89 years for azole-resistant cases, 1–12 months to 70–89 years for azole-susceptible cases). Underlying disease and survival are shown in the table.

Conclusion

A worldwide network of investigators contributes to the CLARITY registry study. Completion of recruitment and subsequent data analysis are planned for 2019. Further sites may be added if azole-resistant cases are encountered.

Disclosures

All authors: No reported disclosures.
2269. Clinical Outcomes in Patients with Carbapenem-Non-Susceptible, β-Lactam-Susceptible Pseudomonas aeruginosa Infections
Authors: Gavaghan Victoria M , Lee Michelle , Butler David , Biagi Mark , Santarossa Maressa , Harrington Amanda , Albarillo Fritzie S , Wenzler Eric
Published: October 2019

Background

Pseudomonas aeruginosa (PsAr) isolates harboring OprD mutations often present phenotypically as carbapenem nonsusceptible but susceptible to antipseudomonal β-lactams (APBLs). It is unknown whether this unique genotype–phenotype combination affects the clinical outcomes of patients infected with these pathogens. The objective of this study was to compare clinical outcomes of patients treated with APBLs for pneumonia and/or bacteremia caused by PsAr bearing this unique carbapenem nonsusceptible, β-lactam susceptible phenotype (Carba-NS) to those retaining susceptibility to both carbapenems and APBLs (Carba-S).

Methods

Retrospective multicenter cohort of adult in-patients who received effective APBL for PsAr pneumonia and/or bacteremia from January 2012 to November 2018. Baseline characteristics, treatment information, and clinical outcomes were obtained from the electronic medical record. The primary outcome was 14-day mortality. Secondary outcomes included 30-day mortality, 30-day infection recurrence, and infection-related length of stay (IR-LOS). IR-LOS was defined as the time from index culture to antibiotic discontinuation or hospital discharge, whichever was sooner. Descriptive statistics were analyzed using SPSS.

Results

387 patients were evaluated; 60 Carba-S and 21 Carba-NS were included. The primary reason for exclusion was ineffective empiric therapy. Select demographics and clinical outcomes are displayed in Table 1. Compared with the Carba-S group, Carba-NS patients were younger, had better renal function, increased incidence of pneumonia, more severely ill, and higher rate of empiric ceftazidime use. Despite these differences at baseline there were no significant differences in empiric APBL treatment patterns, 14- or 30-day mortality, or recurrence at 30 days between the groups. Carba-NS patients had lower rate of oral step down therapy and a significantly longer LOS and IR-LOS.

Conclusion

In this cohort of patients who received appropriate and timely APBL therapy, the Carba-NS phenotype was not associated with increased rates of 14-day mortality, 30-day mortality, or 30-day infection recurrence. These data suggest that APBLs may be effective therapeutic options against this phenotype. Further research is warranted to confirm these findings.

Disclosures

All authors: No reported disclosures.
2276. Clinical Epidemiology of the Carbapenem-Resistant Enterobacteriaceae (CRE) Epidemic in Colombia: A Multicenter Prospective Study
Authors: Valderrama-Beltrán Sandra Liliana , Komarow Lauren , Salcedo Soraya , Mora Laura , Marin Adriana , Ordonez Diaz Karen M , Cristancho Quintero Edilberto , Elena Ariza Beatriz , Cortes Gloria , la Hoz Alejandro De , Oñate José , Yasmín Venté Elsa , Mendez Viviana , Figueroa Jairo , Osorio Luz , Moreno Carlos , Reyes Jinnethe , Dulcey Luis , Christian Pallares , Chambers Henry , Chambers Henry , Fowler Vance G , Evans Scott R , Kreiswirth Barry , Virginia Villegas Maria , Bonomo Robert A , van Duin David , Arias Cesar A
Published: October 2019

Background

The CRE epidemic in Colombia is amplified by horizontal transmission of mobile genetic elements encoding KPC among Enterobacteriaeae and clonal expansion of K. pneumoniae clonal group (CG) 258, making the country hyperendemic for CRE. However, the clinical impact of CRE infections has not been comprehensively assessed.

Methods

In the framework of a prospective study assessing the clinical epidemiology of CRE (CRACKLE II), we report the results of the first 246 patients enrolled in 5 Colombian hospitals (from July 2017 to November 2018). Clinical variables, outcomes at 90 days post-hospitalization and susceptibility patterns were collected. Resistance to carbapenems was defined per CDC guidelines. Infection was defined with standardized criteria. All isolates which did not meet these criteria were considered colonization

Results

The majority of patients were men (66%); median age was 62 years [IQR 37–73]); 67% were admitted from home and 33% were hospital transfers. The mean Charlson Comorbidity Index and Pitt Bacteremia scores were 2 (SD = 2) and 3 (SD = 3), respectively. Most patients (60%; n = 148) were considered to be infected. The most frequent source of culture was urine (36%), followed by blood (30%) and wound secretions (13%). A respiratory source was found in the minority (6%) of patients. Species of CRE are summarized in Table 1 with the majority being K. pneumoniae. The best in vitro activity against CRE was found for fosfomycin (80% susceptible (47/59)), tigecycline (75% (67/89)), colistin (70% (35/50)) and amikacin (67% (148/220)). From 234 patients with available information at 90 days of follow-up, 13% were readmitted after discharge. Mortality at 30 and 90 days after a positive culture was 31% and 35%, respectively.

Conclusion

K. pneumoniae are the main drivers of the CRE epidemic in Colombia isolated mainly from non-respiratory sources. Non-susceptibility to last resource antibiotics (tigecycline, colistin and fosfomycin) is substantial among the Colombian isolates leaving few therapeutic options, a finding that correlates with high mortality. Our findings indicate that introduction of novel therapeutics in Colombia is urgently needed with a rampant epidemic of CRE causing high burden of disease.

Disclosures

All authors: No reported disclosures.
2287. Real-world Use of Tedizolid Phosphate: A Case Series of Long-Term Tolerability
Authors: Morrisette Taylor , Da Silva Beatriz , Mueller Scott W , Damioli Laura , Krsak Martin , Fish Douglas N , Miller Matthew A
Published: October 2019

Background

Tedizolid is an oxazolidinone antibiotic with broad-spectrum Gram-positive activity approved for the treatment of skin and skin structure infections with a 6-day course. Oxazolidinone antibiotics represent appealing options for prolonged antimicrobial therapy due to their available oral formulations with excellent bioavailability and potent in vitro activity against various multidrug-resistant Gram-positive organisms, Mycobacterium spp., and Nocardia spp. Although tedizolid and linezolid offer a similar clinical spectrum based on antimicrobial activity alone, long-term use of linezolid is often limited by serious adverse effects. Preliminary assessments have suggested better tolerability with tedizolid; however, these are limited by shorter exposure duration. The objective of this study was to evaluate the long-term safety and tolerability of tedizolid.

Methods

Retrospective cohort of adult patients receiving tedizolid for ≥ 28 days, with baseline complete blood cell (CBC) indices available, and CBC indices drawn ≥ 14 days into tedizolid course. The primary objective was to evaluate the long-term tolerability of tedizolid.

Results

13 patients met inclusion criteria: median age 61 years (IQR, 51–64 years), 69% male, 85% Caucasian. The majority of patients utilized tedizolid for suppression (85%), and the median duration of tedizolid was 113 days (IQR, 71–204 days). There were no differences in CBC indices when comparing baseline to last laboratory draw throughout tedizolid exposure: platelets (baseline: 203 x 109/L (IQR, 186–283 x 109/L) vs. last: 196 x 109/L (IQR, 161–303 x 109/L; p = 0.65), hemoglobin (baseline: 9.8 g/dL (IQR, 8.8–11.1 g/dL) vs. last: 11.7 g/dL (IQR, 11.0–13.1 g/dL; p = 0.10), and white blood cells (baseline: 6.2 x 109/L (IQR, 5.6–7.6 x 109/L) vs. last: 6.5 x 109/L (IQR, 6.3–7.3 x 109/L; p = 0.45). The final laboratory draws were obtained a median of 78 days (IQR, 44–119 days) into therapy. No patients experienced peripheral neuropathy, optic neuritis/visual changes, or serotonin syndrome during treatment/suppression with tedizolid during the period evaluated.

Conclusion

Long-term therapy with tedizolid appears to be well-tolerated. Treatment and suppression with tedizolid seems to be a safe alternative to linezolid.

Disclosures

All authors: No reported disclosures.
2296. Hypoglycemia Risk with Antibiotics: An Epidemiologic Surveillance Study of the FDA Adverse Event Reporting System (FAERS)
Authors: Kennedy Kaitlin E , Teng Chengwen , Patek Taylor M , Frei Christopher R
Published: October 2019

Background

In July of 2018, the FDA published a drug safety warning for the potential risk of developing hypoglycemia with fluoroquinolones. Some studies have evaluated the potential risk of developing hypoglycemia with linezolid and tigecycline. A few case reports have also been published that report hypoglycemia from cefditoren, doxycycline, and trimethoprim-sulfamethoxazole use. Since data comparing various antibiotics and the risk of developing hypoglycemia is limited, the objective of this study was to evaluate the association between hypoglycemia and antibiotics using the FDA Adverse Event Reporting Systems (FAERS).

Methods

FAERS reports from January 1, 2004 to December 31, 2017 were included in the study. The Medical Dictionary for Regulatory Activities (MedDRA) was used to identify cases of hypoglycemia. Reporting odds ratios (RORs) and corresponding 95% confidence intervals (95% CI) for the association between antibiotics and hypoglycemia were calculated. An association was considered to be statistically significant when the lower limit of the 95% CI was greater than 1.0.

Results

A total of 2,334,959 reports (including 18,466 hypoglycemia reports) were considered, after inclusion criteria were applied. Cefditoren had the greatest proportion of hypoglycemia reports, representing 10% of all cefditoren reports. Statistically significant hypoglycemia RORs (95% CI) for antibiotics were: cefditoren 14.03 (8.93–22.03), tigecycline 3.32 (1.95–5.65), clarithromycin 2.41 (1.89–3.08), ertapenem 2.07 (1.14–3.75), moxifloxacin 2.06 (1.59–2.65), levofloxacin 1.66 (1.37–2.01), linezolid 1.54 (1.07–2.20).

Conclusion

Cefditoren, tigecycline, clarithromycin, ertapenem, moxifloxacin, levofloxacin, and linezolid were all significantly associated with hypoglycemia. The ertapenem association had not been reported in prior literature. Levofloxacin and moxifloxacin were the only fluoroquinolones significantly associated with hypoglycemia, even though the FDA drug safety warning was issued for all fluoroquinolones. Doxycycline and trimethoprim-sulfamethoxazole were not significantly associated with hypoglycemia, even though case reports have reported hypoglycemia with doxycycline and trimethoprim-sulfamethoxazole.

Disclosures

All authors: No reported disclosures.
2298. Infections in Patients Receiving TVEC Therapy
Authors: Robilotti Elizabeth , Kamboj Mini
Published: October 2019

Background

Oncolytic viral immunotherapy is an emerging cancer treatment, but the infectious complications are not well described outside of clinical trials. Genetically engineered replication competent herpes simplex virus (HSV-1), commercially known as IMLGYIC® (AmGen) or talimogene laherparepvec (TVEC) was the first FDA approved agent in this class and is used for the local intralesional treatment (of unresectable melanoma. TVEC is derived from a wild-type(WT) strain of HSV-1 (JS—1), which is modified to attenuate off-target effects and promote selective proliferation within cancer cells. Despite these changes local and systemic infection with HSV have been reported from trials and is the subject of an FDA mandated post-marketing review. Here we review the infectious complications of the first cohort of patients treated at our institution post-FDA approval.

Methods

Demographic and clinical information for 52 adult patients treated for unresectable melanoma with TVEC following FDA approval in 2015 was extracted from the EMR for the period October 1, 2015–June 30, 2018. EMR and microbiologic data were reviewed for evidence of local site reaction and disseminated infection.

Results

No cases of disseminated HSV infection were identified during the study period. Of cutaneous reactions, none were documented as greater than severity grade 2, based on standard adverse event reporting criteria. 3 (50%) grade 1–2 cutaneous reactions were deemed probable or definitely related to TVEC and described as pruritis or rash. 12 (23%) patients had any microbiologically confirmed infection identified following TVEC therapy; 6 were bacterial (3 UTI, 1BSI, 2 wound). 8 episodes of viral infections occurred (5 respiratory and 3 GI). A single patient was noted to have localized HSV dermal lesions more than one year after the final TVEC.

Conclusion

No local or disseminated HSV infections were encountered in the study cohort. Bacterial skin and soft-tissue infection were uncommon. Most other infections were unrelated to TVEC therapy. Real-world review of the use of an HSV-derived oncolytic viral vector therapy mimics reported infectious complications from clinical trials.

Disclosures

All authors: No reported disclosures.
2308. Comparison of Clinical Characteristics Between Laboratory-Confirmed Positive and Negative Patients with Severe Fever with Thrombocytopenia Syndrome
Authors: Oh Suhyun , Rae You Jeong , Taek Heo Sang , Jo Sujin
Published: October 2019

Background

Severe fever with thrombocytopenia syndrome (SFTS) is a tick-borne emerging infectious disease caused by SFTS virus (SFTSV). Mortality of SFTS estimated to be 21.8% in South Korea, and this disease is difficult differential diagnosis. Here, we analyzed clinical characteristics between SFTS positive group (SPG) and negative group (SNG) in a primary clinical setting.

Methods

In this prospective observational study, data were collected on patients with SFTS test performed at the single teaching hospital, in South Korea, between April 2013 and December 2018. The association between each demographic, climatic, clinical, and laboratory variable was assessed. All SFTS was confirmed at the KCDC by detecting the M segment gene of SFTSV RNA using reverse transcription-polymerase chain reaction (RT–PCR), and were confirmed at our laboratory by S segment gene of SFTSV RNA using RT–PCR about patient’s family member and those with close contact.

Results

Of the 199 patients in the study periods, 61 (31%) were SPG and 138 (69%) were SNG. Mean age was 55.1 ± 20.3 years, and 103 (52%) patients were male. In SPG, the comorbidity score and history of tick bite were significantly higher compared with SNG. SPG and SNG were prevalent in summer and autumn, respectively (60.7% vs. 45.7%, P < 0.05). SPG was associated with mean outdoor temperature, humidity and rainfall compared with SNG (22.9°Cvs. 18.9 ℃; 78.8% vs. 70.6%; 12.6 mm vs. 8.5 mm, all P < 0.01). Dizziness, poor oral intake, nausea, and diarrhea were common in SPG. In laboratory findings, white blood cell counts, absolute neutrophil count, and C-reactive protein were significantly lower in SPG. Lymphocyte fraction, activated partial thromboplastin time, and creatinine phosphokinase were significantly higher in SPG. Case fatality of the SPG and SNG were 9.8% and 1.0%, respectively. In multivariate analysis, mean outdoor temperature, humidity, dizziness, and low CRP were predictive factors in SPG.

Conclusion

Early prediction of SFTS diagnosis is important because this emerging zoonotic disease was a high fatality in endemic areas. When a physician wants to do SFTS test, they would consider according to this predictive variable for differentiating SFTS in primary care settings.

Disclosures

All authors: No reported disclosures.
2319. Clinical Predictors of Influenza and Hospitalization of Children with Influenza in an Emergent Care Setting
Authors: Rao Suchitra , Lamb Molly , Moss Angela , Yanni Emad , Bekkat-Berkani Rafik , Schuind Anne , Innis Bruce , Asturias Edwin J
Published: October 2019

Background

Objective measures utilizing early vital sign data show promise in predicting more severe outcomes among adults with influenza, but data are sparse in children. The objectives of this study were to determine the value of vital signs in predicting influenza infection or hospitalization due to influenza infection among children evaluated in an emergency department (ED) or urgent care (UC) setting in Colorado.

Methods

We evaluated vital signs obtained from a prospective cohort study of children aged 6 months to 8 years of age with influenza like illness evaluated at an ED/UC site in Aurora, CO from 2016–2018, and who underwent influenza testing by PCR. We collected the first set of vital signs, peak heart rate and temperature, and converted heart rate (HR) and respiratory rate (RR) to z-scores by age. HR z scores were further adjusted for temperature. Bivariable analyses for each vital sign as a predictor of influenza-related hospitalization and influenza infection as main outcomes were conducted. Predictors with P < 0.2 were entered into a multivariable logistic regression model to determine odds ratios (OR) and 95% CI; model performance was assessed using the Brier score and discriminative ability with the C statistic.

Results

Among 1478 children, 411 were positive for influenza, of which 28 were hospitalized. In multivariable analyses, among children with influenza infection, lower initial oxygen saturation (OR 0.87, 95% CI 0.78–0.98, P = 0.026) and higher adjusted respiratory rate (OR 2.09, 95% CI 1.21–3.61, P = 0.0085) were significant predictors of hospitalization (Figure 1). Among children with ILI, higher peak temperature (OR 1.46, 95% CI 1.30–1.63, P < 0.0001), lower adjusted peak heart rate (OR 0.79, 95% CI 0.69–0.90, P = 0.0005), higher initial oxygen saturation (OR 1.07, 95% CI 1.03–1.12 P = 0.002) and lower adjusted respiratory rate (OR 0.74, 95% CI 0.64–0.87, P = 0.0002) were significant predictors for having PCR-confirmed influenza. However, this model had poor calibration and discriminatory ability.

Conclusion

Higher respiratory rate adjusted for age and lower initial oxygen saturation were significant predictors of hospitalization among young children with PCR-confirmed influenza, but were not reliable discriminators of having influenza infection.

Disclosures

All authors: No reported disclosures.
2329. Incidences and Characteristics of Influenza Among Pregnant Women in Middle-Income Countries: Preliminary Results of the Pregnancy and Influenza Multinational Epidemiologic (PRIME) Study
Authors: Dawood Fatimah S , Tinoco Yeny , Suntarratiwong Piyarat , Patel Archana , Hunt Danielle R , Kittikraisak Wanitchaya , Soto Giselle , Das Prabir Kumar , Wesley Meredith G , Hombroek Danielle , Florian Richard , Gonzales Oswaldo , Kurhe Kunal , Cabrera Santiago , Llajaruna Zumaeta Edwin , Prakash Amber A , Sinthuwattanawibool Chalinthorn , Mott Joshua , Brummer Tana , Malek Parker , Saha Siddhartha , Chang Howard , Lindstrom Stephen , Arriola Carmen S , Garg Shikha , Mundhada Shailendra G , Deshmukh Madhavi , Klungthong Chonticha , Thompson Mark G , Azziz-Baumgartner Eduardo
Published: October 2019

Background

The World Health Organization recommends influenza vaccination for pregnant women. However, few data exist on influenza incidence and clinical course among pregnant women in middle-income countries where influenza vaccine use during pregnancy is often limited. We conducted a prospective cohort study of pregnant women to estimate incidences of influenza in Lima, Peru; Bangkok, Thailand; and Nagpur, India.

Methods

Prior to and early in the 2017 and 2018 influenza seasons, we enrolled pregnant women aged > 18 years with expected delivery dates > 8 weeks after the start of the season. We contacted women twice weekly until end of pregnancy to identify illnesses with myalgia, cough, runny nose, sore throat, or difficulty breathing and collected nasal swabs from symptomatic women for influenza real-time reverse transcription polymerase chain reaction testing. Using 2017 cohort data, we calculated crude incidences per 10,000 pregnancy-months during influenza season by site and trimester and overall incidence weighted for population of women of childbearing age in each country.

Results

We enrolled 4774 women with a median age of 26 years (interquartile range [IQR] 23–31) and gestational age of 20 weeks (IQR 15–24); 15% received influenza vaccine. Local influenza seasons spanned 4.5–8 months. Overall, 143 participants (3%) had influenza (113 (79%) influenza A and 30 (21%) influenza B). Weighted influenza incidence was 88.7/10,000 pregnancy-months (95% CI 68.6–114.8), though incidences varied up to two-fold by site (Figure 1). Incidences did not differ by pregnancy trimester (Figure 2). Among the 143 influenza episodes, the median duration was 7 days (IQR 5–10), 30% involved fever or chills, 43% disrupted daily activities, 47% prompted medical attention, 4% were associated with hospitalization, and < 1% were treated with antiviral medications.

Conclusion

Overall, pregnant women had an average risk of influenza of 0.9% per month of pregnancy spent in the influenza season with almost half of illnesses disrupting daily activities and prompting medical attention. Influenza-associated hospitalization was infrequent. These findings provide valuable inputs to estimate illnesses averted by vaccine programs and evaluate their cost–benefit among pregnant women in middle-income countries.

Disclosures

All authors: No reported disclosures.
2331. Seroprevalence of Cytomegalovirus in Pregnant Women and Birth Prevalence of Congenital Cytomegalovirus Infection in Henan Province, China
Authors: Huang Yue , Li Tingdong , Song Qiaoqiao , Man Tengfei , Wang Han , Guo Xiaoyi , Yu Huan , Adam Cui Yadong , Wu Ting , Marks Morgan , Fu Tong-Ming , Ge Shengxiang , Xia Ningshao , Zhang Jun
Published: October 2019

Background

Congenital cytomegalovirus infection (cCMVi) is the leading viral cause of birth defects and developmental disabilities in newborns. The epidemiology of cCMVi in settings with high cytomegalovirus (CMV) seroprevalence, such as China, is not well studied. This study sought to describe maternal CMV seroprevalence and cCMVi prevalence at birth in Henan Province, China.

Methods

A multicenter prospective cohort study was conducted in three counties of Henan Province in China from June 2015 through May 2018. Pregnant women were enrolled early in pregnancy and followed up through delivery. Serum specimens were collected at enrollment for CMV immunoglobulin G serological testing. Saliva and urine specimens were collected in newborns within 72 hours after birth and tested with real-time polymerase chain reaction for CMV DNA. cCMVi was defined as CMV DNA positive in the infants’ urine or saliva specimens.

Results

A total of 6327 pregnant women underwent CMV serological testing and 6062 were CMV seropositive (95.8%). The maternal age was 26.8 ± 4.3 (mean ± SD) years. There were 49 (0.7%) newborns identified with cCMVi among 6705 newborns screened. Lower maternal education level (middle school or lower), younger maternal age (<25 years) and twin-pregnancy were associated with higher cCMVi prevalence (P = 0.04, 0.016, and 0.001, respectively).

Conclusion

Despite a high maternal CMV seroprevalence in this large cohort study from China, the birth prevalence of cCMVi is similar to other studies in settings of high and medium CMV seroprevalence. In settings of high maternal CMV seroprevalence, additional research is needed to ascertain the relative contribution of non-primary CMV infections during pregnancy to congenital transmission.

Disclosures

All authors: No reported disclosures.
2333. Influenza-Related Neurologic Complications in Hospitalized Children with Underlying Neurologic Disorders
Authors: Frankl Sarah , Coffin Susan E , Swami Sanjeev , McGuire Jennifer
Published: October 2019

Background

Children with underlying neurological and neuromuscular conditions are considered “high risk” for developing severe infection due to influenza. Prior reports highlighted this population’s increased risk for respiratory failure. Little is known about neurological complications experienced by children with pre-existing neurologic disorders (PNDs) when infected with influenza.

Methods

Retrospective cohort study of children 0.5–18.0 years old hospitalized at a tertiary care pediatric hospital between August 2010 and June 2017 with laboratory-confirmed influenza. Eligible children were identified by electronic medical record query for influenza assay CPT codes with positive results during an admission; cases were confirmed by chart review. Demographics and clinical data were abstracted.

Results

A total of 1217 immune competent children (median age 5.5 [IQR 2.2–9.8] years) were hospitalized with laboratory-confirmed influenza during the study period. About 28% (341/1217) had at least one PND, including epilepsy (n = 105), developmental delay or intellectual disability (n = 234), neurogenetic or metabolic disorders (n = 77), neuromuscular disorders (n = 22) and others (n = 253). Compared with previously healthy peers, these children were more often admitted to the intensive care unit (31% vs. 16%, P < 0.001), had a longer length of stay (3 vs. 2 days, P < 0.001), and had a higher incidence of neurologic complications (23% vs. 6%, P < 0.001). Seizures (18% vs. 4%, P < 0.001) and encephalopathy (8% vs. 2%, P < 0.001) in particular were more common in children with PNDs, but other neurologic complications occurred in comparable proportions (3% vs. 1%, P = 0.088). Only 49% of the overall cohort had documented annual influenza vaccine; coverage was slightly better for children with PNDs than those without (55% vs. 48%, P = 0.017). The odds of having a neurologic complication in children with documented vaccination was nearly half that of other children when adjusted for age, influenza strain, and any PND (adjusted OR 0.64, 95% CI 0.44–0.94, P = 0.021).

Conclusion

The excess risk of neurological complications in children with PNDs highlights the importance of vaccinating this population. Additional consideration should be given to post-exposure prophylaxis for children with PNDs who have not received vaccine.

Disclosures

All authors: No reported disclosures.
2336. Adherence to Follow-up and CMV Testing in Infants Who Failed Newborn Hearing Screens: Evaluation of New Protocol to Ensure Follow-up and Testing
Authors: Penton Manuel , Herzog Aaron , Pan Jun , Manopla Charles , Otto Caitlin , Kohlhoff Stephan
Published: October 2019

Background

CMV is the most common non-hereditary cause of sensorineural hearing loss (SNHL) in children in the United States. SNHL may be the only presenting symptom in otherwise asymptomatic infants. Several states are making CMV testing mandatory for newborn infants who have a hearing deficit. Testing should be performed before 21 days of life to diagnose congenital CMV infection and provide effective therapy. However, the results of a retrospective 1 year audit of all newborn patients in the nursery of University Hospital of Brooklyn (UHB) who failed their hearing screen found that none were tested for CMV and approximately half failed to follow-up with audiology. Therefor we developed a new protocol to ensure testing and follow-up.

Methods

Under the new protocol, newborns who fail an initial and repeat hearing screen are tested for CMV in urine by culture and the audiology appointment is scheduled before discharge. Patients are tracked by a pediatric infectious disease fellow to ensure adherence to protocol.

Results

The pre-intervention audit conducted from November 1, 2017 to October 31, 2018 found 37/923 (4%) infants failed their hearing screening tests. Although 34/37 (92%) of these children had audiology appointments made before discharge, only 19 (56%) actually attended. Two (11%) children failed an otoacoustic emissions hearing test. One infant also went on to fail an auditory brainstem response test; both were lost to follow-up. None of these infants was tested for CMV. The new protocol was initiated November 1, 2018, 11/372 (3%) infants failed initial and repeat hearing screening tests. All 11 (100%) of these children had audiology appointments made before discharge, of which 9 (82%) attended. 2 (18%) of these children failed the otoacoustic emissions hearing test at that visit, 1 infant was lost to follow-up; 9 infants who failed hearing test were tested for CMV; 1 (9%) was positive.

Conclusion

Although it has only been in place for 5 months, the new protocol has increased adherence to audiology appointments. CMV testing has increased from 0% to 82% and 1 patient has tested positive for congenital CMV infection. The ongoing success of this protocol could facilitate timely and appropriate treatment of CMV with valgancyclovir.

Disclosures

All authors: No reported disclosures.
2343. How Smart Is the Chart? Accuracy of the Medical Record in Documenting Diarrhea in Patients Tested for Clostridium difficile Infection
Authors: Pora Gavriella , Karen Ng Wong Y , Jury Lucy , Donskey Curtis
Published: October 2019

Background

Inappropriate testing for Clostridium difficile infection (CDI) may result in diagnosis of CDI in asymptomatic carriers with diarrhea due to other causes such as laxatives. Current guidelines suggest that periodic chart review may be useful to assess the appropriateness of CDI testing, but it is not known how accurate the medical record is in documenting diarrhea.

Methods

We conducted a prospective cohort study of 80 patients tested for CDI to determine the accuracy of diarrhea documentation in the medical record in comparison to patient interviews and to assess the appropriateness of testing.

Results

Thirty-five of 80 (44%) CDI tests were deemed inappropriate because patients either did not have clinically significant diarrhea (i.e., 3 or more unformed stools per day) or had an alternative explanation for diarrhea. Seventy-four of 80 (93%) patients stated they had diarrhea, but only 53 (66%) had clinically significant diarrhea based on symptom review. Physician and/or nursing notes documented diarrhea in 67 of 80 (84%) patients, but the number of bowel movements and the consistency of stool were documented for only 36 (45%) and 41 (51%) patients.

Conclusion

In our facility, inappropriate CDI testing was common and the accuracy of the medical record in documenting diarrhea was suboptimal. Education of patients and providers may be beneficial in improving the accuracy of diarrhea documentation and the appropriateness of testing.

Disclosures

All authors: No reported disclosures.
2344. Evaluation of a Best Practice Alert (BPA) to Reduce Inappropriate Testing for Clostridium difficile Infection (CDI) Within a Multi-Hospital System
Authors: Dare Ryan K , Bewley Claire E , Novack Amanda J , Heiles Jared M , Chin Larissa K
Published: October 2019

Background

Hospital-acquired CDI contribute to significant morbidity, mortality, and cost burden in hospitalized patients. Clinical practice guidelines recommend strict testing criteria when employing nucleic acid amplification testing alone as to not test asymptomatic carriers. A BPA within the electronic medical record (EMR) may assist with this screening.

Methods

At our 9-hospital system, we created a BPA to help identify patients who may not meet criteria for CDI testing. Initial BPA (January 2018) asked if patient had 3 or more stools (yes/no) and if laxatives were administered in the last 48 hours (yes/no). An expanded BPA was updated to pull medication administration records for use of laxatives in the prior 48 hours (August 2018) and notified providers of recent C. difficile testing in the past 7 days (January 2019). C. difficile orders from March 2017 (historical), March 2018 (intervention 1), and March 2019 (intervention 2) were evaluated to assess impact of these interventions.

Results

C. difficile testing during 30,621 (historical), 31,299 (intervention 1), and 31,960 (intervention 2) patient-days were evaluated. Rates of C. difficile orders and infections are reported in the table. Ratio of positive C. difficile specimens to tested specimens were similar between the historical arm (51 of 402; 12.7%) and both intervention 1 (42 of 271; 15.5%) and intervention 2 (45 of 316; 14.2%) arms (P = 0.3 and P = 0.5, respectively). Intervention 1 and intervention 2 arms were similar in all metrics. Statistical analysis was performed using Stata, v.14.2.

Conclusion

Implementation of a decision support tool to assist with C. difficile testing significantly decreased order rates in both the initial and expanded BPA intervention arms. Compared with historical rates, incidence of CDI decreased in both intervention arms though these were not statistically significant. Similarly, ratio of positive specimens to specimens tested increased in both intervention arms, though not significant, indicating a trend toward improved patient selection. To improve appropriate CDI testing, further oversight and/or education is needed to accompany implementation of an EMR decision support tool, such as BPAs.

Disclosures

All authors: No reported disclosures.
2348. Incorporating Electronic Medical Record Hard Stops to Reduce Inappropriate Clostridioides difficile Testing at an Academic Medical Center: A Quality Improvement Study
Authors: Lakshmi Seetha , Atrubin Kimberly , Myers Andrew , Teter Jonathan , Jariwala Ripal , Zeitler Kristen , Haubner Laura , Ashmeade Terri , Balakrishnan Maya
Published: October 2019

Background

Clostridioides difficile is the most common pathogen causing healthcare-associated infections. This study highlights the multi-disciplinary efforts to reduce C. difficile infections (CDI) at a large, tertiary care teaching facility.

Methods

A quality improvement study was performed between March 2017 and April 2018, using six Plan-Do-Study-Act cycles that included transmission prevention, diagnostic stewardship, education, and antimicrobial stewardship. Process measures included hand hygiene, isolation precautions, low-level disinfection compliance, number of tests ordered, lab cancelation of tests, and compliance with the Electronic Medical Record (EMR) hard stop for patients with laxative use, and negative C.difficile test in the past 7 days.

Results

A total of 2,046 C. difficile tests were ordered during the initiative. Of the 124 patients with a positive C. difficile LabID event, 50% were male with a median age of 65 years (range: 11–92 years). A 53% reduction in C. difficile LabID events (7.5 to 4 events per 10,000 patient-days, P < 0.001), with a pronounced decrease between cycle 4 and 5 (5.4 to 2.9 events per 10,000 patient-days, P < 0.001) was achieved. The largest decrease in C. difficile lab tests ordered was seen after implementation of the EMR hard-stop (cycle 5), with fewer than 0.5 LabID events per 1,000 patient-days for each subsequent month after EMR hard-stop implementation. Frequent reasons for physician phone calls to Infection prevention department was related to chronic use of lactulose in patients with cirrhosis (30%) and unexplained diarrhea (70%). Based on provider feedback, EMR changes were made to remove lactulose from the hard-stop and offer infectious disease consultation upfront. There was 99% compliance with electronic medical record hard stop. There was a nonsignificant increase in lab cancelations due to inappropriate stool specimens over time (1.9% to 3.1% from cycle 1 to 6, P = 0.28) A 55% reduction in hospital-onset CDI surveillance events (from 6.9 to 3.2 per 10,000 patient-days, P < 0.001) was noted.

Conclusion

A multi-disciplinary Quality Improvement initiative is a successful strategy in reducing CDI events, with the largest decrease seen with introduction of EMR hard stops.

Disclosures

All authors: No reported disclosures.
2353. Easy Does It: Decreasing and Sustained Hospital-Onset (HO) CDI Lab-ID Event Incidence Through a Series of Interventions
Authors: Lee Rachael A , Walker Jeremey , Freeze Elizabeth , Khalid Rashida , Camins Bernard
Published: October 2019

Background

Clostridioides difficile infection (CDI) Laboratory (Lab) identified (ID) events are reportable to CMS through the CDC’s NHSN. Prevention of transmission has been the main component of interventions; however, avoiding false-positive laboratory diagnoses can also lead to decreased incidence.

Methods

A retrospective analysis of HO-CDI Lab-ID events was conducted to evaluate the results of a series of interventions at the University of Alabama Hospital, a 1150-bed tertiary care center in Birmingham, AL. The study period was from the first quarter of 2013 (1Q 2013) until 1Q of 2019. Interventions were implemented in sequential order were: (i) CDI prevention bundle education (3Q 2014); (ii) two-step laboratory testing algorithm (2Q 2015); (iii) selective enhanced environmental disinfection on oncology units (2Q 2016); (iv) diagnostic stewardship by reminding providers to reconsider testing if the patient received a laxative within 48 hours (4Q 2016).

Results

At the beginning of the study period, the HO CDI Lab ID Event SIR was 0.96. The standard infection ratio (SIR) over the time period is shown in Figure 1. We observed a slight decrease in HO-CDI Lab ID event SIR after implementation of the CDI prevention bundle (0.96 vs. 0.77). A change in the diagnostic testing from PCR-based to a two-step algorithm (EIA testing for GDH and Toxin confirmed by PCR) resulted in a slight increase although not statistically significant (0.77 vs. 0.83). A downward trend was observed when selective enhanced terminal disinfection with hydrogen peroxide vapor was performed on all oncology patient rooms vacated by patients with CDI (0.83 vs. 0.72). The largest and sustained impact was observed after implementation of a computer-assisted diagnostic stewardship in which providers were reminded if the patient was administered any stool softener or laxative within 48 hours of the order for CDI testing (0.72 vs. 0.32). The institutions SIR value became significant in 2Q 2016 (P = 0.0014) and significance was maintained since that time. The difference between expected and observe HO-CDI Lab ID events is demonstrated in Figure 2.

Conclusion

Through a series of interventions, we observed a decrease in HO-CDI event rates. Diagnostic stewardship with academic detailing resulted in the most impactful and sustained improvement.

Disclosures

All authors: No reported disclosures.