bluuebunny/crossref_metadata_2025 huggingface dataset:
2440. Using a geospatially explicit agent-based model of a regional healthcare network to assess varied antibiotic risk on Clostridioides difficile infection incidence
Authors: Rhea Sarah , Jones Kasey , Bobashev Georgiy , Munoz Breda , Rineer James , Hilscher Rainer , DiBiase Lauren , Sickbert-Bennett Emily , Weber David J
Published: October 2019

Background

Different antibiotic classes are associated with different Clostridioides difficile infection (CDI) risk. The impact of varied antibiotic risk on CDI incidence can be explored using agent-based models (ABMs). ABMs can simulate complete systems (e.g., regional healthcare networks) comprised of discrete, unique agents (e.g., patients) which can be represented using a synthetic population, or model-generated representation of the population. We used an ABM of a North Carolina (NC) regional healthcare network to assess the impact of increasing antibiotic risk ratios (RRs) across network locations on healthcare-associated (HA) and community-associated (CA) CDI incidence.

Methods

The ABM describes CDI acquisition and patient movement across 14 network locations (i.e., nodes) (11 short-term acute care hospitals, 1 long-term acute care hospital, 1 nursing home, and the community). We used a sample of 2 million synthetic NC residents as ABM microdata. We updated agent states (i.e., location, antibiotic exposure, C. difficile colonization, CDI status) daily. We applied antibiotic RRs of 1, 5, 8.9 (original model RR), 15, and 20 to agents across the network to simulate varied risk corresponding to different antibiotic classes. We determined network HA-CDI and CA-CDI incidence and percent mean change for each RR.

Results

In this simulation study, HA-CDI incidence increased with increasing antibiotic risk, ranging from 11.3 to 81.4 HA-CDI cases/100,000 person-years for antibiotic RRs of 1 to 20, respectively. On average, the per unit increase in antibiotic RR was 33% for HA-CDI and 6% for CA-CDI (figure).

Conclusion

We used a geospatially explicit ABM to simulate increasing antibiotic risk, corresponding to different antibiotic classes, and to explore the impact on CDI incidence. The per unit increase in antibiotic risk was greater for HA-CDI than CA-CDI due to the higher probability of receiving antibiotics and higher concentration of agents with other CDI risk factors in the healthcare facilities of the ABM. These types of analyses, which demonstrate the interconnectedness of network healthcare facilities and the associated community served by the network, might help inform targeted antibiotic stewardship efforts in certain network locations.

Disclosures

All authors: No reported disclosures.
2441. Automated, Rapid Detection of Potential Healthcare-Acquired Infection Clusters Based on Microbiology And Patient Geotemporal Data
Authors: Kolde Raivo , Loving Joshua , Sharma Rohit , Carmona Juan J , Doty Alan J , Gross Brian D , van Aggelen Helen C
Published: October 2019

Background

Whole-genome sequencing (WGS) has shown promise in identifying transmissions of healthcare-associated infections (HAIs), but it may be costly to sequence all potential HAIs. By automatically identifying samples likely to be HAIs, WGS can be focused on specific samples. We describe an algorithm that quickly identifies potential HAI clusters by analyzing patient geotemporal and pathogen microbiology data. This approach systematically triages potential HAI investigations to aid infection control professionals (ICPs) in their workflow.

Methods

This novel algorithm within Philips IntelliSpace Epidemiology scores the potential of transmission for pairs of infections. Inputs include microbiology (MB) data (genus- or species-level identification and antimicrobial susceptibility test results) and geotemporal (GT) data (timing of sample collection and shared location stays). From the resulting pairwise scores, clusters of potential HAIs are identified. Leveraging 9 months (June, 2018 – March, 2019) of data from a 900-bed US hospital (i.e., 2825 samples, 1814 patients and 13 organisms—of which a subset of 404 samples had WGS performed concomitantly with MB studies), we evaluated the extent to which this algorithm captures genetically similar sample pairs.

Results

Pairwise scores enrich for genetically similar samples when considering MB data only (odds ratio: 17.3), GT only (odds ratio: 6.1) and a combination of both (odds ratio: 19.8), with highly significant P-values for all (P < 10−16). Considering MB only, 91% of samples group together in potential transmission clusters. With MB and GT data, this fraction drops to 24.6% (694 samples) forming 178 possible clusters, 173 of which contain fewer than ten samples each. The 5 larger clusters contain 40–64 samples each and span multiple units in the hospital.

Conclusion

The proposed system automatically suggests potential HAI clusters. By combining MB and GT data, the number of samples to review is reduced, enabling ICPs to focus their attention and sequencing efforts. By focusing on a targeted group of higher probability clusters, ICPs may be able to increase their efficiency and effectiveness in controlling the spread of HAIs—thus boosting potential for patient safety and amelioration of cost of care.

Disclosures

All authors: No reported disclosures.
2444. Infection Prevention in Home Healthcare: Results from a National Study of Home Health Agencies
Authors: Pogorzelska-Maziarz Monika , Shang Jingjing , Chastain Ashley , Stone Patricia
Published: October 2019

Background

As the population of older Americans with chronic conditions continues to grow, the role of home healthcare (HHC) services in improving care transitions between acute care and independent living has become a national priority. This has led to the development of value-based purchasing (VBP) initiatives, changes in the Centers for Medicare and Medicaid Services’ Home Health Conditions of Participation, and the Joint Commission’s national patient safety goals for HHC. We aimed to describe the infection prevention and control (IPC) infrastructure in US home health agencies (HHA).

Methods

From March to November 2018, we conducted in-depth, phone interviews with 41 staff from 13 HHAs across the United States, including administrators, IPC and quality improvement (QI) personnel, registered nurses and home health aides. In October 2018, we launched a nationwide survey to a random sample of 1,500 HHAs stratified by census region, ownership status and urban/rural location, and achieved a 40% response rate. Transcripts of the qualitative interviews were coded and themes were identified using content analysis. Survey data were analyzed using descriptive statistics.

Results

Themes from the interviews included: 1) Uniqueness of HHC setting, 2) Importance of staff and patient/caregiver education, (3) Care coordination challenges, and, (4) Keys to success and innovation. From the surveys, we found that, at the majority of HHAs, the staff member in charge of IPC had other responsibilities including QI (57%), clinical/administrative/managerial (49%), supervision of clinical services/patient coordination (48%), and education/training (45%). For those staff members in charge of IPC, over a third had received no specific IPC training, and only 5% were certified in IPC. For those staff who received training, the training was provided by external consultants (26%) or a professional society/health department (28%). Respondents cited the most challenging aspect of IPC as collecting/reporting infection data (24%), adherence to/monitoring bag technique (15%) and adequate staff coverage (13%).

Conclusion

This work represents a current snapshot of IPC infrastructure and challenges in US HHC agencies and identifies important barriers to IPC in these settings.

Disclosures

All authors: No reported disclosures.
2445. Risk for Readmission and Mortality Amongst LTACH Residents with New-Onset Healthcare-Associated Infections
Authors: Massey Kyle D , Murphy Melissa , Miano Todd , Binkley Shawn , Morgan Steven C , Jacob Jerry
Published: October 2019

Background

Long-term acute care hospitals (LTACH) provide cost-effective alternatives for stable patients requiring ICU-level care. LTACH patients are at increased risk for adverse outcomes including healthcare-associated infections (HAI). There is a paucity of data describing outcomes associated with HAIs in LTACH patients.

Methods

This was a single-center, retrospective study of LTACH patients over a 3 year period. Patients with an HAI (bloodstream [BSI], pneumonia [PNA], urinary tract [UTI], and Clostridioides difficile [CDI] infections) as defined by NHSN criteria were matched by length of stay (LOS) at the time of inclusion to unexposed patients. Follow-up was 30 days from the date of inclusion. The primary outcome was a composite of unplanned readmission to an acute care hospital or death at the LTACH. Secondary outcomes included all-cause mortality. Patients with HAIs were further evaluated to determine risk factors associated with readmission Antibiotics and cultured organisms were collected. Outcomes were analyzed using Cox proportional hazards model. Variables found to have a P < 0.1 on univariate analysis and those of clinical interest were included in the models.

Results

250 patients were included, 125 in each group. The distribution of HAIs was 40 BSI, 39 UTI, 26 PNA, and 20 CDI. The incidence of the primary outcome and mortality were 26.0% and 11.6% respectively. HAI was associated with increased risk of the primary outcome, but the effect varied over time: Risk increased seven-fold during the first 5 days (HR, 7.47 [95% CI, 2.86–19.42]) but was smaller and non-significant after day five (HR, 1.94 [95% CI, 0.85–4.43]). Mortality was not significantly different between groups (HR, 1.58 [95% CI, 0.74–3.38]). After adjustment, only hypotension (HR, 2.27 [95% CI 1.21–4.27]) and referral hospital LOS > 28 days (HR, 1.97 [95% CI 1.10–3.53]) were associated with readmission. 37% of cultured organisms were multi-drug-resistant. 17% of Enterobacteriaceae were carbapenem resistant. Empiric antibiotics failed to cover in 35% of infections.

Conclusion

HAI was associated with a significant increase in risk of readmission. Exploration of modifiable variables of infection, including hypotension and antibiotic selection, may help to reduce rates of readmission.

Disclosures

All authors: No reported disclosures.
2446. Longitudinal Results and Cost Savings Using a Bundle of C. difficile Infection Prevention Strategies in a Long-Term Care Facility
Authors: Olson Bridget A , Butera Michael L , Ship Noam
Published: October 2019

Background

Long-term care patients are at high risk of C. difficile infections (CDI) due to advanced age, high comorbid illness burden, and frequent antibiotic use. Primary infection prevention of CDI is challenging and not frequently studied. Following a period of high CDI incidence, the Long-Term Care facility at Sharp Coronado Hospital implemented a bundle of strategies.

Methods

Patient census, the incidence of CDI (primary and recurrent cases), transfers to acute care and length-of-stay were collected from Jul 2008 through December 2018. In the first phase, 2010, a bundle of CDI prevention strategies was initiated, including an Antimicrobial Stewardship Program (ASP), reduction of acid suppression, and L. acidophilus and S. boulardii probiotics with antibiotic use. From 2012, there was further refinement of the ASP and the probiotic was changed to capsules of a 3-species combination of Lactobacillus acidophilus CL1285, L. casei LBC80R and L. rhamnosus CLR2, 100 Billion CFU daily. In October 2016, a protocol was put in place delegating authority to pharmacists to add probiotics to all antibiotic courses. The average CDI rates were calculated and compared for each time period. The net cost of CDI was calculated from the number of CDI cases, hospital length-of-stay and probiotic purchases.

Results

The incidence of facility-onset CDI cases decreased significantly with each policy change from 7.6 cases/10,000 patient-days (2008–09), to 2.8 (2010–11, p = 0.028), to 0.91 (2012-Q3 2016, p = 0.0015) and to the present incidence 0.24 (Q4 2016–2018, p = 0.048). The annual cost of facility-onset CDI was $214k initially. The annual cost, including the purchase of probiotic, decreased to $161k with introduction of the bundle, to $57k in switching probiotics, and to $18k with initiation of a probiotic policy.

Conclusion

Implementing a bundle of concurrent infection prevention strategies resulted in a significant reduction in CDI incidence. Refinements to the bundle led to significant reductions in CDI incidence, along with switching the type of probiotic, and delegating ordering authority to pharmacists to ensure probiotic compliance. Cumulatively, there was a 95% decrease in CDI incidence at the Long-Term Care facility and meaningful cost savings with each refinement.

Disclosures

All authors: No reported disclosures.
2449. Early Detection of Candida auris is Essential to Control Spread: Four Effective Active Surveillance Strategies
Authors: Vallabhaneni Snigdha , Zahn Matthew , Epson Erin , ODonnell Kathleen , Horwich-Scholefield Sam , Brooks Richard , Vaeth Elisabeth , Blood Timothy , Shannon D J , Feaster Christine , Leung Vivian , Maloney Meghan , Forsberg Kaitlin , Kallen Alexander , Jackson Brendan R , Walters Maroya S
Published: October 2019

Background

C. auris has been identified from > 1600 US patients. Risk factors include high-acuity post-acute care admissions (e.g., long-term acute care hospitals (LTACHs)), hospitalization abroad, and carbapenemase-producing organism (CPO) colonization. Early detection of C. auris is key to controlling spread. We describe four active surveillance strategies that led to early C. auris identification.

Methods

Based on known risk factors, state health departments used active C. auris surveillance strategies: (1) species identification of yeast from urine cultures from LTACHs, (2) screening patients with a CPO and hospitalization abroad, (3) LTACH C. auris point prevalence surveys (PPS), or (4) admission screening in acute and long-term care settings.

Results

(1)A laboratory in Southern California serving 12 LTACHs began species identification for all Candida from urine cultures, which would have otherwise been discarded because they are assumed to be not clinically significant. Within 5 months, testing of 271 Candida urine isolates identified the region’s first C. auris case, prompting contact tracing and identification of additional cases and facilities. (2) When CPOs were identified in patients with recent hospitalizations outside of the United States, the Maryland Department of Health screened patients for C.auris colonization. Of four screened, one, who received care in Kenya, was C. auris colonized. (3) The Indiana State Department of Health implemented monthly PPS at an LTACH that frequently admits patients transferred from a high prevalence area. Of 38 patients screened, two were colonized. (4) The Connecticut Department of Public Health offers C. auris admission screening for patients who received inpatient care in high prevalence areas; of 12 screened, one C. auris colonized patient was found. Infection control assessments and implementation of infection control measures followed each detection.

Conclusion

Early detection of C. auris is important but is impacted by infrequent yeast species identification and a reservoir of asymptomatic colonized patients. Healthcare facilities and public health jurisdictions can consider adopting one or more of these strategies based on epidemiology and resource availability.

Disclosures

All authors: No reported disclosures.
2453. Prolonged Local Epidemic of an XDR P. aeruginosa Subclade of High-Risk Clonal Complex 298
Authors: Pincus Nathan B , Bachta Kelly E R , Ozer Egon A , Allen Jonathan P , Pura Olivia N , Marty Francisco M , Pandit Alisha , Mekalanos John J , Hauser Alan R
Published: October 2019

Background

Antimicrobial resistance (AMR) poses an increasing challenge to the treatment of the nosocomial pathogen Pseudomonas aeruginosa, with the majority of highly resistant infections caused by relatively few high-risk clones. We investigated the role of clonal complex 298 (CC298: ST298 and ST446) in multidrug-resistant (MDR) and extensively drug-resistant (XDR) infections at Northwestern Memorial Hospital (NMH).

Methods

We determined the AMR of 40 whole-genome sequenced CC298 isolates, including 30 from patients at NMH in Chicago (2000–2017), 7 from hospital environments (e.g., sinks) in Chicago (2017–2018), and 3 from patients at Brigham and Women’s Hospital (BWH) in Boston (2015–2016). We used phylogenetics to assess the population structure of these isolates and 38 additional publicly available CC298 genomes. We interrogated the genomes of NMH CC298 isolates to uncover drivers of AMR.

Results

NMH CC298 isolates showed high rates of AMR, with 76.7% (23/30) MDR and 46.7% (14/30) XDR. Phylogenetic analysis revealed that 21/23 MDR (13/14 XDR) isolates from NMH formed a subclade of ST298, termed ST298*, as of yet not seen elsewhere. A time-scaled phylogeny of ST298* indicates a last common ancestor in 1980 (mean 1980.8, 95% HPD interval 1973.3–1987.4), with XDR ST298* isolates seen between 2001 and 2017. Many ST298* isolates, including all XDR isolates, harbored a large plasmid with an AMR class 1 integron. This plasmid is part of a family of large Pseudomonas genus plasmids. By comparing a plasmid-cured strain to its parent, we show that the plasmid imparts resistance to gentamicin and piperacillin–tazobactam. In the parental strain we detect T83I GyrA and S87L ParC substitutions known to cause fluoroquinolone resistance, showing that mutational resistance also contributes to the high AMR of ST298*. Publicly available genomes and previous reports indicate that CC298 has caused infections worldwide with multiple instances of significant AMR.

Conclusion

The repeated isolation of XDR ST298* P. aeruginosa at NMH over 16 years raises concern for the ability of this strain to persist in the healthcare environment. With this local epidemic and additional reports of MDR CC298 isolates around the world, we argue that CC298 should be considered a high-risk clone.

Disclosures

All authors: No reported disclosures.
2455. Outbreak of carbapenemase-producing Enterobacteriaceae in cardiology units associated with contaminated water dispenser and sink drain in Korea
Authors: Jung Jiwon , Choi Hye-Suk , Lee Jeong-Young , Jee Hong Min , Hee Kwak Sun , Sung Heungsup , Kim Mi-Na , Kim Sung-Han
Published: October 2019

Background

There is a growing concern about the importance of hospital water environment for the transmission of carbapenemase-producing Enterobacteriaceae (CPE). Herein, we report a large outbreak in cardiology units involving intensive care units (ICU) and wards at a tertiary care hospital.

Methods

During a CPE outbreak between July and December 2018, contact tracing and environmental sampling were performed. For outbreak control, we performed education to healthcare workers, hand hygiene enforcement, active surveillance test, preemptive isolation, chlorhexidine bathing for CPE positive patients, and deep terminal cleaning including UV and hydrogen peroxide non-touch disinfection. Patients with CPE were isolated at a single room with dedicated staffs, contact precaution was implemented, and when case patients were located in multi-patient room, we performed surveillance culture for exposed patients in the room.

Results

A total of 87 patients with CPE infection or colonization were identified at two cardiology ICUs and three cardiology wards. CPE from the first two index patients were identified from sputum culture suspecting pneumonia, and the remaining 85 patients were identified to harbor CPE through surveillance culture (exposed patients n = 22, active surveillance test n = 63). Diverse organisms were identified; organisms with blakpc (n = 13), blaNDM-1 (n = 55), blaVIM or blaIMP (n = 12), blaOXA-48 (n = 3), and co-producing organisms (n = 4). We performed environmental culture; KPC-producing Escherichia coli was isolated from water dispenser in ICU and NDM-1 producing Citrobacter freundii and Enterobacter cloacae were isolated from sinks in the patient room. Outbreak ended after the removal of water dispenser and the replacement of sink drain with pouring bleach to the sink drain.

Conclusion

Water dispenser and sink drain were suspected for the possible reservoirs of CPE in this outbreak. Replacement of plumbing system and use of bleach for pouring to sink as well as the removal of water dispenser was needed to control outbreak. Investigation of water system is warranted for finding the source of CPE.

Disclosures

All authors: No reported disclosures.
2458. A comprehensive approach to ending an outbreak of rare OXA-72 producing carbapenem-resistant Acinetobacter baumannii at a Community Hospital, Kansas City, MO, 2018
Authors: McKinsey David S , Gasser Carolyn , McKinsey Joel P , Ditto Geri , Agard Alyssa , Zellmer Brianna , Poteete Carrie , Snippes Vagnone Paula , Dale Jennifer , Bos John , Hahn Rachael , Turabelidze George , Poiry Madison , Franklin Patrick , Vlachos Nick , McAllister Gillian A , Halpin Alison L , Glowicz Janet , Ham David , Epstein Lauren
Published: October 2019

Background

In 2018, an outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) containing a rare β-lactamase (OXA-72) was detected at Research Medical Center, a 511 bed community hospital in Kansas City, MO. We describe a coordinated effort among hospital infection control personnel and public health to control the outbreak.

Methods

We defined a case as isolation of OXA-72-producing CRAB from any clinical culture collected from a hospitalized patient during 2018. We assessed infection control practices, including adherence to transmission-based precautions and hand hygiene, environmental cleaning and patient transfers. After patients with CRAB were discharged, terminal cleaning was performed using bleach and environmental cultures were collected; rooms were closed to new patients until CRAB was not isolated. Whole-genome sequencing and bioinformatics analyses were performed.

Results

From January through October, CRAB was isolated from clinical cultures among 20 patients; 6 OXA-72-positive cases were identified during June and July. We found practices for cleaning and disinfection of shared medical equipment were not clearly delineated among nursing and environmental services staff and we ensured responsibilities were well defined. W restricted all patients with CRAB to certain medical units in order to limit the spread. In total, 248 environmental cultures were collected; 151 (61%) from inside patient rooms and 97 (39%) from shared medical equipment or surfaces outside patient rooms. Overall, Acintobacter baumannii was isolated from 39 (16%) environmental cultures (21 from inside rooms and 18 from outside rooms); 5 isolates were confirmed to contain OXA-72. Using WGS, we compared 6 clinical and 5 environmental OXA-72 CRAB isolates; all were determined to be genetically related (0–6 single nucleotide polymorphisms, 88.4% core genome) (figure). No additional cases were identified after these interventions.

Conclusion

We identified widespread CRAB environmental contamination, illustrating the challenges of eradicating CRAB from the hospital environment. We developed a comprehensive approach focusing on infection control, environmental cleaning and culturing, and patient movement to stop the outbreak.

Disclosures

All authors: No reported disclosures.
2467. Inferring Strain Type Attribution from Antibiotic Resistance Profiles among E. coli Causing Healthcare-Associated Infections in the United States, 2013–2017
Authors: Kourtis Athena P , Lutgring Joseph D , Sheriff Edward , Halpin Alison L , Rasheed James , Elkins Christopher , McDonald L Clifford
Published: October 2019

Background

E. coli is a leading cause of healthcare-associated infections; clonal group ST131, which has expanded worldwide with notable increased severity of infections, is commonly resistant to extended-spectrum cephalosporins (ESC) and fluoroquinolones (FQ). Herein, we relate ESC and FQ resistance profiles from CDC’s National Healthcare Safety Network (NHSN) with specific strain types from CDC laboratory surveillance collections.

Methods

NHSN isolate and antibiotic susceptibility testing data were collected from all E. coli associated with central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated events, or surgical site infections from 2013–2017. Resistance was scored as non-susceptibility to at least one drug per class [susceptible (S); resistant (R)]. ESC and FQ susceptibilities and multilocus sequence types (ST) using the Achtman 7 loci scheme were determined for a contemporaneous set of E. coli isolates collected through CDC laboratory surveillance.

Results

Of 96,672 E. coli infections reported to NHSN, 13% were ESC-R/FQ-R, 23% ESC-S/FQ-R, 4% ESC-R/FQ-S, and 60% were ESC-S/FQ-S. Among 105 ESC-R/FQ-R and 21 ESC-S/FQ-R laboratory isolates, the majority (67.6% and 52.4%, respectively) were ST131, whereas of 38 ESC-R/FQ-S and 53 ESC-S/FQ-S isolates, ST131 was a minority (18.4% and 7.5%, respectively). The odds of an isolate being ST131 were 10.5 if FQ-R (P < 0.001), 3.4 if ESC-R (P < 0.001), and 6.0 if ESC-R/FQ-R (P < 0.001). Using the national distribution of resistance combinations from NHSN, and assuming static ST-resistance distribution, we can infer that ST131 was responsible for 25.8% (95% CI, 23.9%-27.6%) of all E.coli healthcare-associated infections in the United States in 2013–2017.

Conclusion

Molecular inferences generated by applying laboratory data to resistance signature data in reportable datasets may make national E. coli ST burden estimates possible. Further characterization of resistance combinations with strain type, infection rates, and clinical outcomes may inform targeted prevention strategies at the local/regional level.

Disclosures

All authors: No reported disclosures.
2470. Readmission for Healthcare-Acquired Infections: Does Patient Disposition Matter?
Authors: Hoffman Geoffrey J , Min Lillian , Liu Haiyin , Marciniak Dan , Mody Lona
Published: October 2019

Background

Although common and preventable, healthcare-acquired infections (HAI) are associated with high risk for hospital readmission. This risk may increase when follow-up care is not provided. However, whether infection-related readmissions are more common in older adults discharged from the hospital to a skilled nursing facility (SNF) vs. home or home healthcare is unknown.

Methods

We used 2013–14 national discharge data and logistic regression models to retrospectively examine the relationship of discharge disposition (home, SNF, home healthcare) with unplanned readmission for the same HAI observed at the index admission, among Medicare beneficiaries 65, controlling for patient sociodemographics, comorbidity score, and length of stay during index hospitalization.

Results

Of 318,134 index admissions involving HAI treatment, 158,682 (50%) were discharged to a SNF, 76,523 (24%) to home, and 82,929 (26%) to home health. Overall, 7,867 (2.5%) of index admissions involving treatment for an HAI resulted in a linked HAI readmission. HAI readmissions were more common for Clostridium difficile infections (4.0%) and urinary tract infections (UTI, 2.3%) than for ventilator-acquired pneumonia (1.4%) or surgical site infections (1.1%) (P < 0.001). Being discharged home or to home healthcare, compared with a SNF, was associated with increased odds (OR: 1.63, P < 0.001 for each) of HAI readmission. This was equivalent to a 1.2% lower risk of a linked HAI readmission for those discharged to a SNF compared with home or home healthcare. This risk difference was observed to increase with greater patient comorbidity scores.

Conclusion

We conclude that Clostridium difficile and UTIs result in higher risk for readmission than other HAIs. Patients discharged to nursing facilities are protected from readmission. Further research into identifying modifiable mechanisms for HAI readmission, in order to improve post-hospital care of infection at home, is needed.

Disclosures

All authors: No reported disclosures.
2480. Communication During Patient Transfers: Describing Gaps in the Infectious Status Information Pipeline
Authors: Mayer Jeanmarie , Horth Roberta , Todd Madison , Gruninger Randon , Nakashima Allyn K
Published: October 2019

Background

Fragmented communication of patients’ infectious status across healthcare networks impact regional spread of multidrug-resistant organisms (MDRO). This study aimed to quantify gaps in communication of patient MDRO status across Utah healthcare facilities and to identify opportunities to improve.

Methods

This is a cross-sectional retrospective mixed-methods study of patient transfers from three purposively selected healthcare facilities: an acute care (ACF), long-term acute care (LTAC), and skilled-nursing facility (SNF). Patients with known MDRO transferred out of these facilities over the previous week were identified in bimonthly samples spanning 2 months. Infection preventionists and admission nurses from facilities receiving these patients were interviewed.

Results

Of 293 patients transferred to another facility, 13% (n = 38) had an active infection or colonization with an MDRO. These 38 patients were transferred to 26 healthcare facilities within the state (4 ACF, 3 LTAC, 19 SNF). Gram-negative organisms with resistance to a carbapenem accounted for 15.8% of those transferred with an MDRO. There was no documentation of the state infection control transfer form (ICTF) at the sending facility for 68.5% of MDRO patient transfers. Of 22 admitting nurses interviewed, 19 (86.4%) did not receive an ICTF, 6 (27.3%) received no communication regarding patients’ infectious status, and 11 (50%) had to contact the sending facility for additional information. Moreover, 18.2% of patients had not been put on appropriate precautions. Several nurses expressed confusion with MDRO definitions and lack of guidance regarding care of MDRO colonized patients. Among infection preventionists asked about general MDRO transfers (n = 26), 26.9% reported that communication on infectious status of MDRO patients was received in under 40% of incoming transfers. When asked about a planned statewide MDRO registry, 80.8% felt that such a system would be actively searched at their facility, and 96.2% felt that a system that pushes out alerts would be useful.

Conclusion

Given the widespread gaps in communication of infectious status of patients with MDROs transferred across the healthcare facilities sampled, efforts to standardize and improve MDRO communication in the region is warranted.

Disclosures

All authors: No reported disclosures.
2484. Patient Reported Outcomes After Switching to a 2-Drug Regimen of Dolutegravir + Rilpivirine: Week 148 Results from the Sword-1 and Sword-2 Studies
Authors: Oglesby Alan , Angelis Kostas , Punekar Yogesh , Chounta Vasiliki , Antela Antonio , Matthews Jessica , Kahl Lesley , Gartland Martin , Wynne Brian , Murray Miranda , Andre Van Wyk Jean
Published: October 2019

Background

The SWORD-1 and SWORD-2 studies previously demonstrated that high rates of virologic suppression were maintained for 148 weeks after switching virologically suppressed HIV-1 infected adults from their current 3- or 4-drug antiretroviral regimen (CAR) to the 2-drug regimen (2DR) of dolutegravir + rilpivirine on Day 1 (Early Switch (ES) DTG+RPV group). This abstract reports the pooled SWORD-1/2 results of patient reported outcomes (PRO) measures through Week 148.

Methods

HIV Treatment Satisfaction Questionnaire (HIVTSQ) and Symptom Distress Module (SDM) were secondary PRO endpoints in the SWORD trials. For HIVTSQ, high scores represent greater treatment satisfaction (range 0 to 60). SDM was assessed using the Symptom Bother Score with low values indicating less symptom bother (range 0 to 80). The EQ-5D-5L measure of general health status was assessed as an exploratory endpoint with maximum utility score of 1 to indicate perfect health. Change from Baseline in these endpoints was calculated for the ES subjects (over 148 weeks). Subjects randomized to CAR switched to DTG+RPV at Week 52 (Late Switch (LS) DTG+RPV group) and change from LS Baseline (i.e., last pre-switch assessment) was calculated (over 96 weeks).

Results

Low Symptom Bother (9.6 and 10.3) and high TSQ scores (54.4 and 54.3) were reported pre-switch in the ES and LS groups, respectively.

ES subjects reported modest improvements from Baseline in both symptom burden and overall treatment satisfaction in all visits through Week 148 (Figures 1 and 2). Among the LS group, there was little change in symptom burden but similar improvement in treatment satisfaction. Pre-switch health status was high in ES and LS groups (EQ-5D mean utility: 0.96 and 0.94, respectively) and remained stable in both groups at all time points.

Conclusion

High treatment satisfaction and low symptom burden that were observed in patients under CAR were maintained long term after switching to DTG+RPV. These results corroborate DTG+RPV as a well-tolerated 2DR alternative treatment option in patients currently suppressed on other 3/4-drug regimens without previous virologic failure.

Disclosures

All authors: No reported disclosures.
2485. Real-world Experience with Dolutegravir Plus Rilpivirine Two-Drug Regimen
Authors: Ward Douglas , Scheibel Steven F , Ramgopal Moti , Riedel David J , Garris Cindy , Oglesby Alan , Waller John E , Roberts Jenna , Mycock Katie L , Dhir Shelly , Bonnie Collins , Megan Dominguez , Mrus Joseph , Pike James
Published: October 2019

Background

Three-drug regimens (3DRs) have long been the mainstay of antiretroviral treatment (ART) for HIV. Dolutegravir-based two-drug regimens (DTG 2DRs) are now accepted alternatives to 3DRs, with the first 2DR single tablet regimen (STR), Juluca (DTG/rilpivirine [RPV]), FDA-approved in 2017. This study evaluated treatment patterns of DTG+RPV in clinical practice to understand use prior to availability of DTG/RPV STR.

Methods

A retrospective medical chart review was conducted across 10 US sites identified as using any DTG 2DRs. Eligible patients were adults initiated on DTG 2DR prior to July 31, 2017 and followed up to January 30, 2018. This analysis describes a subgroup who received DTG+RPV 2DR. Patient demographics, clinical characteristics and treatment history were abstracted from medical charts. Analyses were descriptive.

Results

From an overall sample of 278 DTG 2DR patients, 66 received DTG+RPV 2DR. In this DTG+RPV subgroup, mean age was 56 years, 79% were male and 68% were Caucasian. Most were treatment-experienced (97%), with an average 15.5 years of prior ART; 48% had received ≥ 4 prior regimens. The most common physician reported reasons for initiating DTG+RPV were avoidance of potential long-term toxicities (53%), toxicity/intolerance of ARVs (20%) and treatment simplification/streamlining (15%). Prior to initiation of DTG+RPV, 70% of patients were virologically suppressed (< 50 copies/mL); of those, 98% remained suppressed after switching to DTG+RPV. Of the 30% of patients with detectable viral load prior to DTG+RPV initiation, 60% achieved and maintained virologic suppression on DTG+RPV. Mean time on DTG+RPV was 1.6 years. Only 5 (8%) patients discontinued DTG+RPV by data cut-off, and one patient was lost to follow-up. Reasons for discontinuation were virologic failure (n = 2), treatment simplification/streamlining (n = 2) and toxicity/intolerance (n = 1). Physicians reported that most patients (91%) achieved the desired outcome from DTG+RPV use.

Conclusion

Prior to commercial availability of DTG/RPV STR in the United States, DTG+RPV was used primarily in treatment experienced patients, most commonly to avoid potential long-term toxicities. A high proportion of patients achieved the desired outcome and maintained virologic suppression while receiving DTG+RPV.

Disclosures

All authors: No reported disclosures.
2487. Low Rate of Virologic Failure in Antiretroviral Experienced Patients Prescribed Once Daily Raltegravir
Authors: Hsu Ricky , Schulman Kathy , Fusco Jennifer S , Marie Arduino Jean , Prajapati Girish , Fusco Gregory
Published: October 2019

Background

Raltegravir has been used to treat HIV infection for over a decade. In 2017, a 1200 mg, once-daily, formulation of raltegravir (RALQD) was approved. We sought to characterize the utilization and effectiveness of RALQD in ART-experienced, virologically suppressed, HIV+ adults in a real-world cohort of patients treated in the United States.

Methods

HIV+ adults, suppressed to <50 copies/mL at RALQD initiation (7/1/2017–December 31/2017), were identified in the OPERA® Observational Database, a collaboration following 100,000 people living with HIV through electronic medical records. Patients were followed until RALQD discontinuation, death, or study end (December 31/2018). Demographic and clinical characteristics were described at initiation. The primary study outcome was the incidence of virologic failure (VF), defined as 2 consecutive viral load (VL) test results > = 200 copies/mL or 1 VL ≥ 200 copies + RALQD discontinuation. Kaplan–Meier methods were used to describe VF.

Results

The study eligible population (n = 121) was older (median 54 years, IQR: 44, 61) than the overall ART experienced OPERA population (median 47 years, IQR: 35, 55), equally as likely to be male (84% vs. 83%), or African American (38%), but more likely to be Hispanic (23% vs. 20%) and receiving care in the southern United States (61% vs. 56%). RALQD initiators were also more likely to be heavily treatment experienced (≥3 lines ART) than the overall ART experienced OPERA population (57% vs 43%). They were also more likely to have at least one comorbid condition complicating their care (88% vs. 72%), most frequently hyperlipidemia (50%), hypertension (47%), anemia (26%), anxiety disorders (25%) and diabetes (22%). Half of all RALQD initiators had ≥3 comorbidities at the time of RALQD initiation. Two-thirds of RALQD initiators had baseline CD4 cell counts >500 cells/µL. Median (IQR) time on RALQD was 57 weeks (43–65); 89% of RALQD initiators had ≥1 VL test result during follow-up. Among these patients, VF occurred in 3 patients at a rate of 2.7 (0.9, 8.4) per 100 person years of observation. Figure 1 depicts Kaplan–Meier curves.

Conclusion

RALQD was found to be an effective treatment option in ART experienced patients who are virologically suppressed at initiation, and who often face challenges associated with managing comorbid conditions.

Disclosures

All authors: No reported disclosures.
2496. Qualitative Thematic Analysis of Social Media Data to Assess Perceptions of Daily Oral and Long-Acting Injectable Antiretroviral Treatment among People Living with HIV
Authors: Matza Louis S , Paulus Trena , Garris Cindy , Van de Velde Nicolas , Chounta Vasiliki , Deger Kristen A
Published: October 2019

Background

Current HIV treatment options consist of daily oral antiretroviral therapies (ART). A long-acting injectable HIV treatment is in development for monthly or every other month administration. Patient preferences for ART are important to understand and can impact retention in care, adherence and outcomes. The purpose of this study was to obtain and analyze patient perceptions of oral and injectable ART using a novel approach.

Methods

Qualitative thematic analysis was conducted to examine online discussion threads posted by people living with HIV (PLHIV) in POZ Community Forums from 2013 to 2018. Perceptions of ART were analyzed using keywords (e.g., dose, pill, daily, long-acting, injection, monthly, cabotegravir). Relevant threads were extracted, reviewed and coded using qualitative data analysis software (ATLAS.ti.8).

Results

Analyses identified 684 relevant discussion threads including 2,629 coded quotations posted by 568 PLHIV. Oral ART (2,517 quotations) was discussed more frequently than injectable ART (112). Positive statements on oral ART commonly mentioned the small number of pills (278), dose frequency (248), ease of scheduling (154), and ease-of-use (146). PLHIV also noted disadvantages of oral ART including negative emotional impact (179), difficulty with medication access (137), scheduling (131), and treatment adherence (128). Among the PLHIV discussing injectable ART, common positive comments focused on less frequent administration (34), emotional benefits of not taking a daily pill (7), potential benefits for adherence (6), overall convenience (6), and benefits for traveling (6). Some quotations (10) perceived the frequency of injections negatively, and others had negative perceptions of needles (8) or appointments required to receive injections (8).

Conclusion

ART was frequently discussed among PLHIV on this online forum. This innovative approach for obtaining and analyzing unsolicited comments revealed that while many PLHIV expressed positive views about their daily oral regimen, others perceived inconveniences and challenges. Among PLHIV who were aware of a possible long-acting injectable treatment, many viewed this potential new option as a convenient alternative with the potential to improve adherence.

Disclosures

All authors: No reported disclosures.
2505. Incidence of Transmitted Drug Resistance and Its Clinical Implications Between 1999 and 2018 in a Regional HIV Population
Authors: Lang Raynell , Krentz Hartmut B , Vu Quang , John Gill M
Published: October 2019

Background

Baseline genotype antiretroviral resistance testing (GART) were introduced to allow better selection of antiretroviral therapy (ART), minimizing the use of less effective drugs and risk for ongoing transmission of drug-resistant virus. However, the value of baseline GART has recently been questioned due to declining incidence of TDR in the setting of improved drug tolerability profiles and effectiveness. We aimed to evaluate the long-term clinical and economic impact of TDR using a well characterized, geographically defined cohort between 1999–2018.

Methods

In the Southern Alberta Cohort (SAC) database we identified all (ART naïve) HIV patients, ≥16 years of age, with a baseline GART. They were classified by presence or absence of TDR. Clinical and sociodemographic data were obtained from database and chart review. All statistical analysis was performed with Stata.

Results

During the study 745 GART tests were done on ART naïve patients. Baseline ART resistance was documented in 78 /745 patients. TDR was to the NNRTI class in 59 (75.6%), to NRTI in 12 (15.4%) and to the PI class in 7 (8.9%) patients. Two patients had two class resistance and none had INSTI resistance. There was a significant difference in cost per year of therapy comparing the TDR and control ($17,152/year vs. $15,362/year, P ≤ 0.001). Patients with TDR had greater pill burden with 20% being on BID/TID ART regimens compared with the controls of 13% (P = 0.003). No differences in incident ART adverse events (12.8% TDR vs. 13.3% no TDR), drug interactions (1.6% vs. 1.0%) or reasons to stop or change ARVs were seen between study groups. The duration of ART on any given drug class was similar between the two populations (P = 0.6694) as was status of viral suppression at one year 73% vs. 65%.

Conclusion

Presence of TDR at baseline had little immediate impact on ART initiation or tolerance, but by limiting choices negatively impacted pill burden and dosing as well as drug costs.

Disclosures

All authors: No reported disclosures.
2517. Oral Fecal Microbiota Transplantation Increases Gut Microbiome Diversity and Alters the Microbiome Distribution in People with HIV
Authors: Utay Netanya S , Monczor Ana , Somasunderam Anoma , Jiang Zhi-Dong , Alexander Ashley , Vigil Karen J , Lake Jordan , Hanson Blake , DuPont Herbert , Arduino Roberto
Published: October 2019

Background

Reduced microbiota diversity (dysbiosis) in people with HIV (PWH) can damage the intestinal barrier and increase microbial translocation, resulting in inflammation, a driver of morbidity and mortality. We hypothesized that fecal microbiota transplants (FMT) would reverse dysbiosis in PWH.

Methods

We administered 6 weekly oral doses of a novel lyophilized fecal microbiota product from 2 healthy donors to 6 men who have sex with men with HIV on suppressive ART. Shotgun sequencing on stool before, after 6 weekly FMT, and 20 weeks after the last FMT (Weeks 0, 6 and 26), and from donors, was performed to determine bacterial community profiles. Biomarkers were measured by Luminex assays and ELISAs. All comparisons used Wilcoxon matched-pairs signed rank test.

Results

Median age at Week 0 was 41 years, CD4+ T-cell count 504 cells/mm3, VL < 20 copies/mL. Mean α diversity by observed species index increased from Week 0 to 6 (61.2 to 70.2, P = 0.29; Figure 1) and decreased by Week 26 (70.2 to 52.2, P = 0.33) to be similar to the donors’ (63.5, P = 0.86). Microbiome distribution by principal component analysis shifted toward the donors’ distribution in most participants at Week 6 but shifted away by Week 26 (Figure 2). Biomarkers did not change significantly during the study. PID3, with HIV > 35 years, had chronic constipation that resolved with FMT with a large shift in distribution but recurred at Week 26. Fusobacterium gonidiaformans, Porphyromonas somerae, and Haemophilus parainfluenzae comprised 27% of his microbiome at Week 0 but 0.73% at Week 6; untyped Bacteroides comprised 35% at Week 6. I-FABP (6,899 to 2,736 pg/mL), sCD14 (1.67 to 1.31 μg/mL), IL-6 (1.51 to 1.13 pg/mL) and sTNFRII (11,659 to 8,300 pg/mL) levels decreased in PID3; Week 0 levels in PID3 were higher than in other recipients. No related serious adverse events occurred.

Conclusion

Weekly FMT resulted in increased intestinal microbiome α diversity and a shift in microbiome distribution in most participants. These changes did not persist after stopping FMT. PWH with long-term HIV and/or greater inflammation or gut damage may be most likely to benefit from FMT. The effects of recurrent FMT were transient, suggesting longer duration of treatment or intermittent FMT boosting may be required to maintain its benefits.

Disclosures

All authors: No reported disclosures.