bluuebunny/crossref_metadata_2025 huggingface dataset:
Emergency Department Visits During Outpatient Parenteral Antimicrobial Therapy: A Cohort Study
Authors: Kim So Lim , Everett Angela , Rehm Susan J , Gordon Steven , Shrestha Nabin
Published: October 2017

Background

Outpatient parenteral antimicrobial therapy (OPAT) carries risk of vascular access complications, antimicrobial adverse effects, and worsening of infection. Both OPAT-related and unrelated events may lead to emergency department (ED) visits. The purpose of this study was to describe adverse events that result in ED visits and risk factors associated with ED visits during OPAT.

Methods

OPAT courses between January 1, 2013 and December 31, 2016 at Cleveland Clinic were identified from the institution’s OPAT registry. ED visits within 30 days of OPAT initiation were reviewed. Reasons and potential risk factors for ED visits were sought in the medical record.

Results

Among 11,440 OPAT courses during the study period, 603 (5%) were associated with 1 or more ED visits within 30 days of OPAT initiation. Mean patient age was 58 years and 57% were males. 379 ED visits (49%) were OPAT-related; the most common visit reason was vascular access complication, which occurred in 211 (56%) of OPAT-related ED visits. The most common vascular access complications were occlusion and dislodgement, which occurred in 99 and 34 patients (47% and 16% of vascular access complications, respectively). In a multivariable logistic regression model, at least one prior ED visit in the preceding year (prior ED visit) was most strongly associated with one or more ED visits during an OPAT course (OR 2.96, 95% CI 2.38 – 3.71, p-value < 0.001). Other significant factors were younger age (p 0.01), female sex (p 0.01), home county residence (P < 0.001), and having a PICC (p 0.05). 549 ED visits (71%) resulted in discharge from the ED within 24 hours, 18 (2%) left against medical advice, 46 (6%) were observed up to 24 hours, and 150 ED visits (20%) led to hospital admission. Prior ED visit was not associated with hospital admission among patients who visited the ED during OPAT.

Conclusion

OPAT-related ED visits are most often due to vascular access complications, especially line occlusions. Patients with a prior ED visit in the preceding year have a 3-fold higher odds of at least one ED visit during OPAT compared with patients without a prior ED visit. A strategy of managing occlusions at home and a focus on patients with prior ED visits could potentially prevent a substantial proportion of OPAT-related ED visits.

Disclosures

All authors: No reported disclosures.
Outpatient Parenteral Antibiotic Therapy (OPAT) Serial Readmissions and High Utilizers: Drilling Down on Readmission Following Discharge on Intravenous Antibiotics
Authors: Andrews Mary-Margaret , Gallagher Megan , Gentry Mary
Published: October 2017

Background

OPAT discharges (d/c’s) are at high risk for hospital readmission. We observed that a subgroup of OPAT patients (patients) had multiple 30 day readmissions (30DRs) and wanted to define both global and global minus serial readmitter (SR) or high utilizer (HU) 30DR rates to improve the d/c process and resource utilization.

Methods

Our program tracks all d/c’s on IV antibiotics (excluding Cystic Fibrosis patients) and reviews unsuccessful d/c’s and 30DRs (to DHMC only). OPAT patients include those d/c to home or to facilities. We studied d/c’s from 2014 to 2016 and the 30DRs linked to those index d/c’s (through January 2017). 30DRs linked to non-OPAT d/c’s were not included. Around each index d/c, we quantified: LOS; ID diagnosis; d/c disposition; underlying disease; insurance status; # of 30DRs (emergent, urgent, and elective per current Medicare reporting; excluding deaths and against medical advice d/c’s); readmit cause. SRs were defined as having >2 30DRs following an index d/c; HUs were defined as having >4 OPAT d/c’s over a rolling 12-month period. We compared the entire d/c cohort with the subgroups of SRs and HUs. Statistical analysis was performed using SPC Excel.

Results

1189 unique patients had 1454 OPAT d/c’s and 267 unique 30DRs. The ALOS for all d/c’s was 10.1 days (range 0–113); 65.4% were d/c to home (54% to home infusion). Medicare patients comprised 52.3%. The average monthly 30DR rate was 20.4% (range 3.6% to 40.6%), compared with DHMC all cause 30DR rate of 10.5% (FY2016). 8 SRs had >2 30DRs (range 3–6) around 14 index d/c’s (0.9 % of total). 10 HUs had >4 d/c in 12 consecutive months, accounting for 54 d/c’s (3.7% of total). If SRs were excluded, the average 30DR rate fell to 19.0%; if HUs were excluded, the rate fell to 18.4%. Rates were not combined since 4 patients were both SRs and HUs. Underlying diseases of HUs included: cirrhosis, DM, IBD, cancer, renal transplant. HUs ID diagnoses included recurrent bacteremias from occult TIPS infection, IVC’s for TPN, UTIs and osteomyelitis.

Conclusion

OPAT patients have high 30DR rates that exceed overall and population specific 30DR rates in our hospital. By excluding SRs and HUs, 30DR rates may more closely typify an average OPAT experience and be a better program process measure. More understanding about drivers for OPAT d/c for SRs and HUs is needed.

Disclosures

All authors: No reported disclosures.
Impact of Obesity on Acute Kidney Injury Incidence Among Patients Treated with Piperacillin–Tazobactam and Vancomycin
Authors: Rutter W Cliff , Hall Ronald , Burgess David S
Published: October 2017

Background

Obesity is associated with worse patient outcomes in a variety of clinical scenarios. It is unclear from previous research if obesity is associated with increased acute kidney injury (AKI) among patients receiving concomitant piperacillin-tazobactam (TZP) and vancomycin (VAN).

Methods

Clinical and demographic data were collected from the University of Kentucky Center for Clinical and Translational Science Enterprise Data Trust. Patients who received TZP+VAN for at least 48 hours in combination were included. Patients with CKD, a baseline creatinine clearance (CrCl) < 30 mL/minute, CF, or missing height and weight information were excluded from analysis. AKI was defined using the Risk, Injury, Failure, Loss, End-stage (RIFLE) criteria. A weight cutoff point of 91 kg was determined by finding the most predictive bivariable logistic regression model with weights varying from 70 kg through 120 kg via minimization of the Akaike information criterion. Basic descriptive statistics were performed and bivariable and multivariable logistic regressions were performed.

Results

In total, 8125 patients were included in the final analysis. A total of 2452 (30.2%) of patients weighed ≥91 kg. Patients weighing less 91kg were less likely to receive concomitant nephrotoxins and had higher baseline CrCl (97.3 [70.1–128.1] mL/minute vs. 91.8 [68.1–116.5] mL/minute, <0.00001). Baseline severity of illness was similar between groups; however, diabetes (38.9% vs. 20.8%, P < 0.00001), hypertension (63.5% vs. 46.7%, P < 0.00001), and heart failure (14.8% vs. 12.5%, P = 0.007) were more common among the 91kg+ patients. Median daily VAN doses were less in the sub-91kg patients (2000 [1250–2500] mg vs. 3000 [2000–3500] mg, P < 0.00001); however, weight-based doses were lower in the ≥91kg group (25.5 [16.3–31.5] mg/kg/day vs 27.9 [18.7–34.2] mg/kg/day, P < 0.00001). AKI was more common in the patients weighing ≥91kg (23.8% vs. 17.8%, P < 0.00001; adjusted odds ratio 1.46 [95% CI 1.28–1.66]).

Conclusion

Obesity appears to increase the incidence of AKI among patients treated with TZP+VAN, independent of clinically important confounders, with an important breakpoint occurring at 91 kg.

Disclosures

R. Hall, Genentech: Scientific Advisor, Consulting fee Merck: Grant Investigator, Grant recipient
Safety and Efficacy of Telavancin at an Outpatient Parenteral Antibiotic Therapy (OPAT) Unit in New York City
Authors: Rodriguez George D , Polo Lorena , Urban Carl , Turett Glenn , Prasad Nishant , Warren Nathan , Tsapepas Demetra , Ghimire Rabindra , Segal-Maurer Sorana
Published: October 2017

Background

Telavancin is an intravenous (IV) lipoglycopeptide with concentration-dependent bactericidal activity against a broad spectrum of gram-positive organisms and is approved for the treatment of skin and skin structure infections and nosocomial pneumonia; however, post-marketing data is limited. At a hospital-based Outpatient Parenteral Antibiotic Therapy (OPAT) unit, telavancin is used to treat patients due to its convenient daily dosing, its lack of need for therapeutic drug monitoring and its potent in-vitro gram-positive activity. We sought to evaluate the safety and efficacy of telavancin in the OPAT setting.

Methods

We performed a two-year, IRB-approved, retrospective evaluation of all adult patients admitted to the OPAT unit treated with telavancin. Primary outcome was clinical success defined as completion of telavancin and documented clinical resolution. Secondary outcomes included time to initial clinical improvement, 30-day infection related readmission, frequency and time to acute kidney injury (AKI) per RIFLE criteria and incidence of adverse drug reactions (ADRs).

Results

A total of 43 patients were evaluated. Median age was 51 years, 56% were male, and 84% were admitted from the hospital. Baseline demographics differed between clinical failure and success in BMI (38.1 vs. 31 P = 0.168), rates of diabetes mellitus (47% vs. 25% P = 0.148) and chronic vascular insufficiency (33% vs. 11% P = 0.104). Clinical success was observed in 28/43 patients (Figure 1). Successfully treated patients were more likely to be treated for abscesses (21% vs. 0% P = 0.076) and dosed using actual body weight (79% vs. 60% P = 0.196). AKI occurred in 4.7% of all patients, at a median of 7 days after starting (Figure 2). ADRs occurred in 9 patients, of whom 7 led to discontinuation (Figure 3). No difference in time to clinical resolution and 30-day infection-related readmission was observed.

Conclusion

Our study shows real-life experience with telavancin in an OPAT setting, demonstrating tolerability, efficacy, and potential factors which may predispose one to clinical failure (BMI, vascular insufficiency, and dosing weight). Further investigation is warranted to better individualize patient selection and optimize dosing and management of ADRs.

Disclosures

All authors: No reported disclosures.
To Add or Not to Add: Would the Addition of Dalbavancin to Formulary Decrease Admissions for Acute Bacterial Skin and Skin Structure Infections (ABSSSI)?
Authors: Freshwater Dustin , Murphy Nina , Hecker Michelle T
Published: October 2017

Background

One of the major advantages of dalbavancin is that it may be administered as a single dose for the treatment of acute bacterial skin and skin structure infections (ABSSSI). Our objective was to determine the number (%) of patients with an ABSSSI diagnosis whose admission to a county hospital could have been avoided if dalbavancin was on formulary.

Methods

From November 2016 to April 2017, we reviewed encounters for adult patients seen in the emergency department or inpatient setting with a primary ABSSSI diagnosis. For those admitted, potential candidates for dalbavancin included those with ≥2 local signs/symptoms of ABSSSI AND ≥1 systemic sign of infection AND none of the exclusion criteria used in the DISCOVER 1 and 2 trials. Potential candidates were classified as qualifying for dalbavancin if they received IV antibiotics for ≥3 days but <14 days, had no Gram-negative or anaerobic organisms isolated, had no operative intervention nor ≥2 incision and drainage procedures, had a contraindication to linezolid, and did not require hospitalization for management of other comorbidities.

Results

Of 1203 patients with a primary diagnosis of ABSSSI, only 219 (18%) were admitted, of whom only 11 (5%) were classified as potential candidates for dalbavancin. The most common reasons admitted patients were excluded as potential candidates were not meeting signs and symptoms criteria (n = 147), age <18 years (n = 13), being admitted to the hospital for >14 days (n = 11), periorbital or joint cellulitis (n = 9), deep seated infection (n = 5), required admission for another reason (n = 5), and diabetic foot ulcer (n = 4). Of the 11 potential candidates, one qualified for dalbavancin based on our criteria.

Conclusion

At our hospital only a minority of patients with a primary diagnosis of ABSSSI were admitted and one ultimately met our criteria for dalbavancin use. Adding dalbavancin to our formulary would not have resulted in fewer admissions for patients with ABSSSI.

Disclosures

All authors: No reported disclosures.
Pharmacist-Directed Use of Dalbavancin in Acute Bacterial Skin and Skin Structure Infections to Reduce Hospital Length of Stay
Authors: Jones Bruce , Hersey Roby , Crosby Joseph , Bland Christopher
Published: October 2017

Background

Acute bacterial skin and skin structure infections (ABSSSI) are a rapidly increasing cause of hospitalization. Prolonged length of stay (LOS) increases the cost burden to health systems due to administration of parenteral antimicrobials. Dalbavancin is a lipoglycopeptide providing a full course of therapy with one dose and is indicated for the treatment of patients with ABSSSI and presents a unique opportunity for cost avoidance by decreasing inpatient LOS and shifting care to the outpatient setting. This study evaluated the practice of a pharmacist-directed model for discharging hospitalized patients with ABSSSI to receive intravenous dalbavancin at a hospital outpatient infusion center.

Methods

A quasi-experimental investigation of an ongoing, prospective process with open enrollment for patients discharged to receive single-dose dalbavancin therapy between March 2016 and March 2017. To be eligible, adult patients must have been admitted with an ABSSSI based upon inclusion and exclusion via International Classification of Diseases codes. Subjects were compared with a cohort of patients from March 2015 through March 2016 (comparator group) meeting the same criteria for inclusion and exclusion. The primary outcome is hospital LOS and secondary outcomes are cost-savings associated with a reduced LOS and hospital readmission within 30 days of discharge.

Results

Fifty-three patients were identified who received dalbavancin during the enrollment period, and 44 were included in the study. In the comparator group 1191 patients were identified of which 945 were included in the study. Hospital LOS (4.3 vs. 8.0, P < 0.001) and total direct cost per case ($7,863 vs. $2,989, P < 0.001) were statistically significantly decreased for the dalbavancin group compared with the comparator group. Readmission rates at 30 days were similar between the dalbavancin and comparator groups (11.4% vs. 8.6%, P = 0.34).

Conclusion

Patients discharged to an outpatient infusion center to receive dalbavancin had a decreased LOS and total direct cost per case in relation to the comparator group of standard of care. No statistically significant difference in readmission rates was observed. Early goal-directed discharge for the treatment of patients with ABSSSI is a safe and effective way to decrease LOS.

Disclosures

B. Jones, Allergan: Speaker’s Bureau, Speaker honorarium
Using Group-Based Trajectory Temperature Modeling to Predict Postoperative Infections after Total Knee Arthroplasty
Authors: Grant Jennifer , Mcnulty Moira C , Kinnard Krista , Nagin Daniel , Robicsek Ari , Bashyal Ravi , Padman Rema , Shah Nirav
Published: October 2017

Background

Fever is common in the postoperative setting and frequently physiologic. Despite this, roughly half of febrile patients undergo testing for infectious complications, of which only a few reveal infection. We analyzed whether temperature trajectories could help optimize postoperative (post-op) risk assessment in total knee arthroplasty (TKA) patients.

Methods

We included adult patients who underwent primary TKA between January 1, 2007–December 31, 2013 within NorthShore University HealthSystem. Patients were excluded if infection was suspected before/during surgery. Patient data were extracted from the Database Warehouse. A physician verified post-op complications by chart review. We performed group-based trajectory modeling (GBTM) with covariates: age, BMI, gender, co-morbid conditions and procedure time (STATA). We compared complications per group by χ2 test and evaluated associations with any post-op complication by multivariable (MV) logistic regression (SPSS).

Results

We identified 5495 independent patients, following three distinct temperature trajectories (Figure 1) – low (group 1), medium (group 2), high (group 3). Noninfectious complications were more likely than infectious complications, and complications were 5x more common in group 3 vs. group 1 (Table 1). In MV logistic regression, membership in group 3 was independently associated with developing a post-op complication, adjusting for age, presence of renal failure and presence of a cardiac arrhythmia (OR 4.4, 95% CI 3.2–6.0, P < 0.01).

Conclusion

GBTM may help identify TKA patients at increased risk of a post-op complication in real-time, thus helping clinicians avoid unnecessary testing and antibiotics in the post-op setting.

Disclosures

All authors: No reported disclosures.
Weighing in: Effect of BMI on Postoperative Fever and Complications in Patients Undergoing Three Distinct Surgeries
Authors: Bhaimia Eric , McNulty Moira C , Lahrman Frances , Parikh Ronak , Saeed Huma , Robicsek Ari , Padman Rema , Shah Nirav , Grant Jennifer
Published: October 2017

Background

Current trends estimate a 33% increase in obesity and 130% increase in severe obesity by the year 2030. It is unclear what the effect of obesity is on postoperative fevers, postoperative complications, and diagnostic workup rates.

Methods

We evaluated 5,330 patients undergoing knee arthroplasty, colectomy, or craniectomy from October 2009 to December 2014 at NorthShore University HealthSystem, in Illinois. Clinical data were extracted from the Enterprise Data Warehouse, including diagnostic testing and complications. Complications were also verified by physician chart review. Χ2 and Mann–Whitney U tests were used to analyze categorical and continuous variables.

Results

Obesity (BMI ≥ 35) was present in 1081 (23.4%) of knee arthroplasty, 38 (16.9%) of colectomy and 55 (12.6%) of craniectomy patients. There was no increase in complications by BMI in each individual surgery except for increased 30-day readmissions in craniectomy patients with BMI ≥ 35 (P = 0.032). Collectively, there was no difference in the relationship between BMI and rate of post-op complications (Table 1). However, patients with BMI ≥ 35 experienced more fevers (P = 0.002), underwent additional workup (0.011), and had higher workup costs (P < 0.001).

Conclusion

Patients with BMI ≥ 35 had more fevers, more workups and higher cost, but not higher complication rates during the index hospitalization after surgery. Awareness of the predisposition towards post-op fever in obese patients in the absence of complication may prevent costly and unnecessary testing. More work is still needed to understand the effect of obesity on more distant complication rates.

Disclosures

All authors: No reported disclosures.
Variation in Reporting of Penicillin Allergy and its Consequences: an Evaluation of 13 Hospitals
Authors: Daragjati Florian , Silver David , Guharoy Roy , Groves Clariecia , Sebastian Danielle , Fakih Mohamad
Published: October 2017

Background

Penicillin allergy is the most common antibiotic allergy noted within medical records, and its inaccurate reporting leads to increased use of alternative antibiotics that may be less effective, broader in spectrum, more toxic, and costly.

Methods

We retrospectively reviewed the reported allergies to penicillin in patients cared for at 13 hospitals within one health system over a 3 month period (June-August 2016). The data were abstracted from the electronic medical records on penicillin allergy status for both inpatient and outpatient visits. Hospitals were compared on their use of systemic antibiotics for inpatients. The proportions of total defined daily doses (DDD) for quinolones, aztreonam, carbapenems, cephalosporins, and penicillins were compared. Spearman’s rank and Pearson’s correlation were used to evaluate the strength of the relation between increased penicillin allergy reported and the use of the different antibiotic classes.

Results

23,290 of 169,912 (13.7%; range 8%–20%) patients from 13 hospitals were reported penicillin allergic. There was a strong correlation between the proportion of patients with penicillin allergy and quinolone use (rho=0.77; P = 0.002; Figure 1), cephalosporins excluding fourth-generation (r=0.70; P = 0.007; Figure 2), and a weaker correlation with carbapenem use (rho=0.52; P = 0.168) and aztreonam (r=0.53; P = 0.06). On the other hand, penicillins had a moderate negative correlation (r=-0.58; P = 0.036; Figure 3), and extended spectrum penicillins had a strong negative correlation (r=-0.72; P < 0.005). Fourth-generation cephalosporin use did not correlate with the penicillin allergy rate (rho=-0.03; P = 0.92).

Conclusion

Reported penicillin allergy varies between hospitals and higher reported allergy is associated with more quinolone and cephalosporin use, and less use of penicillin-based regimens. Adequate documentation of penicillin allergy may promote the choice of more optimal regimens when treating patients.

Disclosures

All authors: No reported disclosures.
The Utility of Repeat Blood Cultures for Bacteremic Urinary Tract Infections and Associated Durations of Therapy
Authors: Sayood Sena , Sutton Jesse , Baures Timothy , Spivak Emily
Published: October 2017

Background

Urinary tract infections (UTIs) are common among hospitalized patients with 10–40% of cases complicated by bacteremia. Recent literature suggests limited utility in repeating blood cultures for non-Staphylococcus aureus bacteremia; however, clinicians often repeat blood cultures to document clearance prior to selecting definitive therapy for bacteremias. Additionally, comparative data evaluating treatment duration for bacteremic UTIs are lacking and clinical practice guidelines do not address optimal duration for bacteremic UTIs. We aimed to evaluate local practice patterns and utility of repeat blood cultures and their influence on treatment durations for bacteremic UTIs.

Methods

We identified patients with bacteremia from a urinary source at the Salt Lake City Veterans Affairs (VA) hospital from a previously compiled cohort of inpatients with bacteremia from any source between November 2013 and October 2015. Demographic and clinical information including presence of comorbidities, source of infection, number of repeat blood cultures collected, repeat blood culture positivity, planned duration of antibiotic therapy and recurrent bacteremia with the same organism within 30 days of discharge were collected by manual chart review.

Results

Fifty-three bacteremic UTIs were included during the study period. Ninety-four percent of patients were male with a median age of 77. Repeat blood cultures were drawn in 77% (41/53) of cases; however, only 7% (3/41) of repeats were positive, all with Enterococcus faecalis. Median duration of therapy was 14 days (IQR 14, 15), with a longer mean duration in patients with repeat blood cultures as compared with not (15 vs.. 12 days, P = 0.03). Two patients had recurrent bacteremia with the same organism within 30 days; both with negative repeat blood cultures at the time of initial bacteremia and undetected metastatic complications.

Conclusion

Patients with bacteremic UTIs are at low risk of persistent bacteremia. Repeat blood cultures are of low utility, specifically with Gram-negative organisms, and may lead to prolonged durations of therapy. The impact of reducing repeat blood culture collection on outcomes, length of stay, and antibiotic durations warrants further evaluation.

Disclosures

All authors: No reported disclosures.
Urinary Tract Infections After Combat-related Genitourinary Trauma
Authors: Jackson Brendan , Liang Stephen Y , Kuhn Janis , Shaikh Faraz , Blyth Dana M , Whitman Timothy J , Petfield Joseph L , Carson Leigh , Tribble David R , McDonald Jay R
Published: October 2017

Background

Genitourinary (GU) trauma accounted for 5% of combat-related injuries sustained by U.S. military personnel during Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF). Incidence and risk factors for long-term infectious complications, including urinary tract infections (UTI), have not been described in this unique population.

Methods

Demographics, injury patterns, initial and long-term medical care, urologic complications, and infectious complications involving the urinary tract for enrollees within the Trauma Infectious Disease Outcomes Study (TIDOS) were collected from Department of Defense (DOD) and Department of Veterans Affairs (VA) data sources. Statistical analyses were conducted to identify candidate predictors for UTIs after GU trauma.

Results

Among the 530 TIDOS enrollees who entered VA care, 90 (17%) sustained GU trauma. Blast injury (93.3%), injury during dismounted operations (56.7%), and lower extremity amputation (56.7%) were common characteristics among those with GU trauma. Higher median injury severity scores (ISS) were associated with GU trauma vs. non-GU trauma [33 (IQR: 21–38) vs. 17 (IQR: 9–26), P < 0.001]. Of those with GU trauma, 21 (23.3%) had ≥1 UTI (range 1–9) during DOD-VA care. A total of 42 unique UTI episodes were identified, with 11 (26.2%) occurring during initial DOD care, 19 (45.2%) during subsequent DOD care after initial hospital discharge, and 12 (28.6%) during VA care. The median time to first UTI episode was 49 days (IQR: 40.5–171.8). Having an UTI was associated with bladder (P = 0.002) and posterior urethral injury (P = 0.002), pelvic fracture (P < 0.001), urinary catheterization (P = 0.001), and urologic complications, including urinary retention or incontinence (P = 0.001) and stricture (P = 0.007). Pseudomonas aeruginosa (61.5%) was commonly isolated in urine cultures obtained within 6 months of the initial injury.

Conclusion

UTIs are a common infectious complication after combat genitourinary trauma, particularly in the setting of severe injury and urologic sequelae. Episodes of UTIs typically occur early on after the initial injury while in DOD care; however, recurrent infections may continue well into long-term VA care.

Disclosures

All authors: No reported disclosures.
Antibiotic Bladder Irrigation in Preventing and Reducing Chronic Urinary Catheter-Related Urinary Tract Infections (UTI)
Authors: Harmon Christian , Hassoun Ali
Published: October 2017

Background

Recurrent UTI is a common complication of chronic urinary catheter use. We report our experience with the use of antibiotic bladder irrigation to reduce catheter associated UTI and systemic antibiotics use.

Methods

Retrospective chart review of patients treated with antibiotic bladder irrigation for recurrent UTI related to chronic urinary catheter (2013–2016). Data collected include demographic, co-morbidities, urological anomalies, symptoms, documented pathogens during episodes of infection, and irrigation medication used. Antibiotic regimen included: gentamicin, gentamicin alternated with piperacillin-tazobactam, or tobramycin once weekly. Parameters for successful therapy and alleviation of symptoms included complete relief of symptoms for six months and no systemic antibiotics use for six months post initiation of therapy, or reduced frequency of infections for one year post initiation of therapy.

Results

39 patients were enrolled, all were patients who had been referred to infectious disease physicians after persistence of symptoms despite multiple rounds of systemic antibiotics and had at least 6 episode of documented UTI despite following guideline for aseptic urinary catheter insertion and care. Mean age 66.5 y (range 27–92), 69% male. Most common urologic problem was neurogenic bladder in 48% and prostate or bladder surgery. 5 self-catheterize, 12 had suprapubic catheter and 22 had chronic indwelling catheter. Most common co-morbidities include: DM, BPH, paraplegia, spina bifida and multiple sclerosis. Most common presenting symptoms were abdominal pain 49% and fever 34%. Most common organisms were Escherichia coli 38%, Pseudomonas aeruginosa 23% and Enterococcus faecalis 18%. 67% used gentamicin bladder irrigation. 26 (66.67%) met the criteria for alleviation of symptoms and success with antibiotic irrigation therapy, and a further four featured improvement of frequency of symptoms despite not successfully meeting the study’s pre-set criteria for full improvement. Patient did not report any associated side effect.

Conclusion

Use of antibiotic bladder irrigation was successful in reducing symptom frequency and requirement of systemic antibiotics. Further Studies needed to assess the benefit of this mode of therapy.

Disclosures

All authors: No reported disclosures.
Impact of Culturing All Uncomplicated Urinary Tract Infections on the Estimated Prevalence Of Resistance in the Primary Care Setting
Authors: Tallman Gregory B , Elman Miriam R , Irwin Adriane N , Noble Brie N , Atkins Peter K , Ham YoungYoon , Waldrip Kallie , McGregor Jessina C
Published: October 2017

Background

Urine cultures to confirm a urinary tract infection (UTI) are not consistently collected in the primary care setting; thus estimates of the prevalence of resistance in uropathogens may be biased. As part of an ongoing study, microbiologic cultures were collected for all patients presenting with uncomplicated UTI at primary care clinics over a six-month period to assess the potential misclassification in frequency of resistance.

Methods

Data from an electronic health record repository were used to identify clinic encounters for women with a diagnosis code for unspecified UTI or cystitis from six primary care clinics between October 1, 2015 and February 28, 2017 in this cross-sectional study. Prior to August 22, 2016, urine microbiology cultures were collected at the discretion of the provider (usual care period), and from August 22, 2016 to February 28, 2017 urinary microbiology cultures were collected from all patients suspected of having uncomplicated UTI (full culturing period). Urinary microbiology culture and pharmacy data occurring within three days of the encounter were collected. Antibiotic susceptibility data was summarized for isolated Enterobacteriaceae. Frequency of susceptibility to trimethoprim-sulfamethoxazole (TMP-SMX), nitrofurantoin, and fluoroquinolones were compared between usual care vs. the full culturing periods using a chi-square test.

Results

We identified 131 urine microbiology cultures in the usual care period and 104 in the full culturing period with 61.1% and 55.8%, respectively, being positive cultures. Enterobacteriaceae were isolated from 85.0% of positive cultures in the usual care period and 86.2% in the full culturing period. Between the usual and full culturing periods, antibiotic susceptibility in the Enterobacteriaceae did not differ statistically for TMP-SMX (85.1% vs.. 88.0%; P = 0.65), nitrofurantoin (98.5% vs. 94.0%; P = 0.19), and fluoroquinolones (89.6% vs. 90.0%; P = 0.94).

Conclusion

Full culturing did not significantly change estimates of the prevalence of antibiotic resistance among Enterobacteriaceae isolated from urine samples. Current urine culturing practices provide adequate susceptibility information to inform empiric prescribing for women with uncomplicated UTIs.

Disclosures

J. C. McGregor, Merck & Co.: Grant Investigator, Research grant
Comparison of Inflammatory Markers Between Adult and Pediatric Brucellosis Patients
Authors: Tekin Recep , Aktar Fesih , Ayaz Celal
Published: October 2017

Background

Brucellosis is still endemic in many developing countries and frequently leads to misdiagnosis and treatment delays. Indirect inflammatory markers such as mean platelet volume (MPV), platelet distribution width (PDW), red cell distribution width (RDW), neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) have been identified as markers of inflammation. The present study aimed to evaluate and compare the levels of these markers for prognostic purposes, and to assess the correlation of C-reactive protein (CRP) with brucellosis in adults and children.

Methods

The study included 137 adults and 141 age- and gender-matched healthy controls, as well 71 children and 81 age- and gender-matched healthy controls. Hematological parameters and CRP were retrospectively recorded and compared between the adult and pediatric patients.

Results

The mean age of the adult patients (54% female) was 43.1 ± 15.4 years, whereas the mean age of the pediatric patients (50.7% male) was 9.5 ± 3.6 years. Significantly higher lymphocyte count, and lower neutrophil count, platelet count, RDW, MPV, NLR and PLR values were found in adult brucellosis patients compared with their healthy subjects, whereas higher lymphocyte count, PDW and lower neutrophil count, platelet count, MPV, NLR and PLR values were observed in pediatric brucellosis patients compared with the control subjects. Significantly higher neutrophil count (p=0.019) and NLR (p<0.001) were found in adult patients compared with the pediatric patients. Positive correlation was found between CRP and NLR (R2 = 0.052, P = 0.011), PLR (R2 = 0.061, P = 0.006) in adult patients.

Conclusion

Based on our findings, we consider that the use of complementary indirect markers such as MPV, NLR, PLR and RDW together with the CRP test – which is used concomitantly with serological diagnostic tests in situations where brucellosis is suspected – might be helpful in the diagnosis and follow-up of brucellosis, as well as in the evaluation of complications and response to therapy, in both adult and pediatric brucellosis patients.

Disclosures

All authors: No reported disclosures.
Serial Procalcitonin Levels Correlate with Microbial Etiology in Hospitalized Patients with Pneumonia
Authors: Ankomah Pierre , Mccluskey Suzanne , Abers Michael , Bearnot Benjamin , Patel Shreya , Schuetz Philipp , Chiappa Victor , Lewandrowski Kent , Vyas Jatin , Mansour Michael
Published: October 2017

Background

Procalcitonin (PCT) is a biomarker that is finding increasing diagnostic and prognostic utility in lower respiratory infections. It remains unclear, however, whether it can be helpful in predicting the bacterial etiology of pneumonia, with a view to informing antibiotic choice and duration. This study examines the relationship between serial PCT measurements and microbial etiology in patients hospitalized for pneumonia to determine whether changes in PCT levels provide discriminatory information on microbial etiology.

Methods

We performed a subgroup analysis of data from a prospective cohort study of 505 patients admitted to a tertiary care center with findings concerning for pneumonia. Microbial etiology of pneumonia was determined from high quality respiratory samples, blood cultures or other relevant diagnostic tests according to standard protocols. Procalcitonin levels were measured serially during the first four days of hospitalization. We compared procalcitonin levels between different bacterial etiologies over the first four days of admission, using the Mann–Whitney-U test to assess for statistical significance.

Results

Out of 505 patients, the diagnosis of pneumonia was adjudicated in 317, and bacterial etiology determined in 62 cases. The predominant pathogens were Staphylococcus aureus (N = 18), Streptococcus pneumoniae (N = 6), Pseudomonas aeruginosa (N = 11) and Haemophilus influenza (N = 5). Admission levels of PCT were lowest in Pseudomonas infections and highest in pneumococcal infections, though not reaching statistical significance. On hospital days two and three, pneumococcal procalcitonin levels were significantly higher than all other etiologies, but on day four, there was no statistically significant difference in PCT values for different microbial etiologies.

Conclusion

Serial procalcitonin levels during the early course of bacterial pneumonia reveal a difference between pneumococcal and other bacterial etiologies, and may have an adjunct role in guiding antibiotic choice and duration.

Disclosures

All authors: No reported disclosures.
BioFire FilmArray Decreases Infection Control Isolation Times by 4 days in ICU, BMT and Respiratory Wards
Authors: Wong Titus , Stefanovic Aleksandra , Locher Kerstin , Bryce Elizabeth , Grant Jennifer M , Connolly Eithne , Woznow Tracey , Charles Marthe , Hoang Linda Mn , Jassem Agatha , Roscoe Diane
Published: October 2017

Background

Novel, rapid, syndromic testing of patients presenting with respiratory infections has the potential to improve patient access and care by decreasing time to diagnosis. BioFire FilmArray (BioFire Diagnostics, bioMerieux) is a cartridge-based, multiplex PCR platform capable of detecting 17 viral and 3 bacterial targets in one hour. This study assessed the impact of implementing this technology on the duration of infection control isolation.

Methods

A randomized control trial in a 900-bed tertiary-care academic hospital was conducted between December 2016 and January 2017. Fifty consecutive samples of patients with respiratory infections on our ICU, BMT and Respiratory wards to received either BioFire FilmArray Respiratory Panel (BF) diagnostic testing or our routine diagnostic testing (RO) consisting of an influenza A/B/RSV PCR (in-house) followed by Luminex NxTag Respiratory Pathogen Panel that was batched at a reference lab. Five patient charts with missing data were excluded from analysis. Statistical analysis was completed using RStudio Version 1.0.136 – © 2009–2016 RStudio, Inc.

Results

Patients randomized to the BF arm remained on respiratory isolation precautions on average (42.3 ± 72.9 hours) over 100 hours less than patients randomized to the routine arm (151.3 ± 151.8 hours) (95% CI: 35.6–184.4 hours, P = 0.0052).

Conclusion

Implementing the BioFire FilmArray Respiratory Panel decreased infection control isolation time by approximately 4 days compared with routine testing; further study is warranted to determine the impact of this technology on patient outcomes and cost benefit.

Disclosures

T. Wong, bioMerieux: Investigator, Research grant A. Stefanovic, bioMerieux: Investigator, Research grant E. Bryce, bioMerieux: Investigator, Research grant J. M. Grant, bioMerieux: Investigator, Research grant D. Roscoe, bioMerieux: Investigator, Research grant
When to Order a Respiratory Viral Panel (RVP): Physician Use in Clinical Practice
Authors: Linn Alexandra , Wang Li , Silveira Fernanda P , Williams John V , Zimmerman Richard , Rinaldo Charles R , Michaels Marian
Published: October 2017

Background

Multiplex RVP assays are frequently offered at medical centers to screen for viruses using nucleic acid technology. The University of Pittsburgh Medical Center (UPMC) uses the Genmark eSensor RVP detecting 14 virus types/subtypes. This study evaluated how RVPs are used in a large medical center to better understand physician practices.

Methods

A 32 question, descriptive survey, created using the Qualtrics survey database, was sent via email to pediatric, emergency, internal, and family physicians at large academic hospitals in the UPMC network. The anonymous survey was sent 3 times between January 2017 and March 2017. Survey data were analyzed using the SPSS statistics software.

Results

543/1,265 (43%) survey responses were received; 492 were evaluable. 56% were female; 42% see children, 45% see adults, 13% see both; 16% see patients in the ED. Training levels included 51% residents/fellows and 49% attendings. Of doctors responding, 87% order RVPs. Most (85%) have changed treatment decisions based on a RVP result; 53% changed management ~50% of the time.

Conclusion

Physicians order RVPs most frequently if they believe the results will change treatment. RVPs are ordered more for young and elderly patients, and those with underlying immunosuppression or chronic illness. Cost does not limit physician ordering and most are unaware of it. Suspected influenza or specific virus is also considered.

Disclosures

J. V. Williams, Quidel: Scientific Advisor, Consulting fee GlaxoSmithKline: Scientific Advisor, Consulting fee R. Zimmerman, Sanofi: Grant Investigator, Grant recipient
Sensitivity and Specificity of the Quidel Sofia Influenza A+B FIA Rapid Influenza Detection Test in Long-Term Care Facilities
Authors: Temte Jonathan , Checovich Mary , Barlow Shari , Shult Peter , Reisdorf Erik , Haupt Thomas
Published: October 2017

Background

Influenza is a significant pathogen for long-term care facility (LTCF) residents. As part of a randomized controlled trial to assess early detection of influenza in LTCFs, we deployed rapid influenza detection tests (RIDTs) at intervention LTCFs. Our primary objectives for this interim analysis were to evaluate the sensitivity and specificity of the Quidel Sofia® Influenza A+B Fluorescent Immunoassay RIDT in a high-risk, nontraditional population, and to describe the virology of acute respiratory infections (ARI) in LTCF residents.

Methods

Personnel at LCTFs identified cases of ARI, collected nasal specimens, and ran RIDTs from 10/21/2016 to 4/28/2017. The residual nasal swab and leftover lysis buffer were placed into a viral transport medium tube and sent to the Wisconsin State Laboratory of Hygiene for confirmatory influenza RT-PCR testing. In addition, all specimens were tested for other viruses using the Luminex NxTAG® Respiratory Pathogen Panel. Sensitivity and specificity of the Sofia RIDT were calculated using RT-PCR results as the reference standard.

Results

Specimens were collected from 228 residents (mean age = 71.3 ± 22.4 years). The mean time from symptom onset to specimen collection was 1.4 ± 1.6 days (range: 0-7 days). Respiratory viruses were identified in 134/228 cases (58.8%); influenza viruses (A: 7.5% and B: 14.5%) were the most commonly detected virus by PCR, followed by rhinovirus/enterovirus (13.2%), RSV (11.0%) and coronaviruses (10.1%). The sensitivities of Sofia RIDT for influenza A and influenza B were 77.8% (95% CI: 52.4–93.6%) and 80.0% (95% CI: 61.4–92.3%), respectively, with specificities of 98.4% (95.3–99.7%) and 97.1% (93.4–99.1%), respectively. Overall performance assessment for influenza A or B yielded a sensitivity of 79.2% (65.0–89.5%) and specificity of 96.1% (91.7–98.6%). The estimated likelihood of discovering one of the first two influenza cases at a LTCF using this RIDT is estimated to be ≥95.7%.

Conclusion

Although a wide constellation of respiratory viruses cause ARIs within LTCF populations, influenza is very common. Early ARI recognition in residents, with testing shortly after symptom onset, likely contributed to high performance of the Sofia RIDT. Use of RIDTs allows early identification of influenza with high sensitivity and specificity in elderly LTCF residents.

Disclosures

J. Temte, Quidel: Investigator, Research support
Detection of Cytomegalovirus (CMV) in Saliva of Congenitally Infected Neonates
Authors: Wissel Mark , Demmler Gail , Gandaria Cindy , Cravens Stephanie , Berg Amy , Widen Ashley , Altrich Michelle , Kleiboeker Steve
Published: October 2017

Background

Congenital cytomegalovirus (cCMV) infection is a significant, but potentially under-recognized health threat. Approximately 1 of 150 neonates in the US is born with cCMV infection, with 20% exhibiting long-term health problems due to infection. Both targeted CMV testing of newborns with failed hearing screens and universal CMV screening of all newborns have been proposed as approaches to identify infected newborns early in life. Congenital CMV infection can be diagnosed by testing a newborn’s saliva, urine, or blood by CMV qPCR or culture. Dried blood spots for use in qPCR assays have been shown to be a minimally sensitive specimen. Of the three specimens that are recommended, only saliva is simple, noninvasive and easy to collect.

Methods

In this study, we have validated a real-time (TaqMan) PCR assay for use in testing saliva samples from neonates for the presence of CMV. In conjunction with compatible clinical findings, a CMV positive PCR result forms the basis for a clinical diagnosis. The assay was shown to be specific for CMV, with no cross-reactivity detected for other human herpesviruses or for other human viral pathogens. Since CMV shedding levels from cCMV cases are known to be above the analytical limit of detection for the assay, and samples are collected in a nonsterile environment in which incidental CMV shedding may be present from other neonatal or pediatric patients, the reporting cutoff for this assay was set at 1000 IU/mL. Following analytical validation of the assay, stored (-80°C) residual de-identified clinical saliva samples were tested. The comparator assay was CMV cell culture, and the clinical diagnosis was used to resolve discrepant results.

Results

A total of 9 saliva samples, collected at approx. 1 month of age (or earlier) were tested by both assays. Two samples were negative by both assays and 6 samples were positive by both assays. A single sample was positive by qPCR but negative by cell culture; the qPCR value for this sample was 15,100 IU/mL. This infant had two positive urine cultures, a positive saliva shell vial culture and was clinically confirmed to have cCMV infection.

Conclusion

This study suggests improved sensitivity of qPCR over CMV cell culture for identification of neonates congenitally infected with CMV.

Disclosures

M. Wissel, Viracor Eurofins Laboratories: Employee, Salary S. Cravens, Viracor Eurofins Laboratories: Employee, Salary A. Berg, Viracor Eurofins Laboratories: Employee, Salary A. Widen, Viracor Eurofins Laboratories: Employee, Salary M. Altrich, Viracor Eurofins Laboratories: Employee, Salary S. Kleiboeker, Viracor Eurofins Laboratories: Employee, Salary
CSF HSV PCR Testing in Adults and Children with Meningitis and Encephalitis
Authors: Parra Liliana , Hasbun Rodrigo , Salazar Lucrecia , Aguilera Elizabeth , Wootton Susan
Published: October 2017

Background

Herpes simplex virus (HSV) is a common treatable cause of meningitis and encephalitis. Delayed antiviral therapy is associated with worse clinical outcomes in HSV encephalitis.

Objectives

To determine the utilization of a cerebrospinal fluid (CSF) HSV polymerase chain reaction (PCR) and identify predictors for a positive HSV PCR result.

Methods

A retrospective review of 751 adults and children with meningitis and encephalitis at 9 hospitals in Houston TX from January 1 2005 to December 31 2010.

Results

Of 751 patients, 331 (44%) underwent CSF HSV PCR testing. Adults were more commonly tested than children (84% vs. 69%, P <0.0001). Additionally, patients with more comorbidities and clinical findings of encephalitis (e.g., altered mental status, focal neurological findings, seizures) were more commonly tested for HSV (P <0.001). Patients tested for HSV were also more likely to be evaluated for West Nile Virus, receive empiric acyclovir and have worse outcomes (P < 0.001). In total, 48 of 331 (14.5%) patients tested had a positive CSF HSV PCR. Predictors for a positive CSF HSV PCR on logistic regression analysis were stiff neck (odds ratio [OR], 2.181 [1.090–4.366]; P = 0.028, lymphocytic pleocytosis >50% lymphocytes (OR, 6.187 [1.412–27.11] P = 0.016, and CSF protein > 100mg/dl (OR, 3.279 [1.105–9.731] P = 0.032.

Conclusion

CSF HSV PCR is underutilized in community acquired meningitis and encephalitis and is done more frequently in adults and in those with an encephalitis presentation.

Disclosures

R. Hasbun, Biomeriaux: Consultant, Consulting fee Biofire: Speaker’s Bureau, Speaker honorarium Merck: Speaker’s Bureau, Speaker honorarium Pfizer: Speaker’s Bureau, Speaker honorarium Medicine’s Co: Speaker’s Bureau, Speaker honorarium