bluuebunny/crossref_metadata_2025 huggingface dataset:
1427. Treatment of Children with Acute Hematogenous Osteomyelitis and Staphylococcus aureus Bacteremia: Impact of Severity of Illness on Antimicrobial Therapy
Authors: Copley Lawson Ashley , Sanchez Maria J , Sue Paul K , Patel Karisma , Lindsay Eduardo A , Tareen Naureen G , Jo Chanhee
Published: October 2019

Background

There is limited evidence-based guidance for the treatment of children with acute hematogenous osteomyelitis (AHO) and concurrent Staphylococcus aureus bacteremia (SAB). Current guidelines emphasize the need for parenteral antibiotics in the setting of SAB, but optimal duration of parenteral therapy in this setting remains unclear. We examined the utility of a Severity of Illness (SOI) score to provide guidance for antimicrobial use in this setting.

Methods

We retrospectively studied children with AHO from 2009–2017, employing a clinical practice algorithm and previously validated SOI to assess the incidence and treatment implications of SAB in AHO. Data collected included demographics, antimicrobial therapy, and response to treatment. Cohorts were categorized according to SOI as follows: mild (0–3); moderate (4–7); and severe (8–10), and compared utilizing one-way ANOVA and Kruskal–Wallis tests for continuous variables, and chi-square test for categorical data.

Results

Among 466 children diagnosed with AHO, 274 (58.5%) were culture positive for Staphylococcus aureus, with SAB noted in 209 (44.8%) individuals. Among children with SAB, 72, 81, and 56 children had SOI scores classified as mild, moderate, and severe, respectively. There were 41 of 72 (57.7%) children with mild illness who were managed with clindamycin alone, clindamycin followed by β-lactam, or β-lactam alone, compared with 36 of 81 (44.4%) with moderate illness, and 3 of 56 (5.4%) with severe illness. Median parenteral antibiotic durations per SOI cohort were 4.7 days, 10.4 days, and 24.7 days, respectively. Greater SOI was associated with longer hospitalization, prolonged bacteremia, more surgeries, increased vancomycin use, greater number of antibiotic combinations, and longer total duration of antibiotics.

Conclusion

Treatment of AHO with SAB should be tailored to the severity of illness in the affected child. A “one size fits all” approach may expose children to unnecessarily prolonged parenteral antibiotic courses, as well as suboptimal and potentially toxic regimens. Our study demonstrates the utility of an SOI to help guide antibiotic decisions in the setting of AHO with SAB. Additional studies are needed to further delineate optimal parenteral antibiotic durations in AHO with SAB.

Disclosures

All authors: No reported disclosures.
1469. Effect of Treatment Duration on Outcomes in Septic Patients Admitted for Urinary Tract Infections from Extended Care Facilities
Authors: Jongekrijg Annelise , George Jamie , Kale-Pradhan Pramodini , Johnson Leonard B
Published: October 2019

Background

Adults in extended care facilities (ECFs) are at an increased risk of urinary tract infections (UTIs) with sepsis and there are little data on effective antibiotic duration. The purpose of this project was to assess the impact of inpatient antibiotic duration on clinical outcomes in these patients.

Methods

A single-center, retrospective study of adult, ECF, septic UTI patients from 5/1/16 to 4/30/18 were included. In-hospital mortality, 30-day readmission rate, and length-of-stay (LOS) were compared based on the effective antibiotic duration of short- and long-term therapies (≤ 5 and > 5 days, respectively). Pregnant and asymptomatic bacteriuria patients were excluded. Demographics, Charlson Weighted Index of Comorbidity (CWIC), presence of indwelling catheter, SIRS criteria, microbiologic results and antibiotic regimen were collected. Continuous variables were analyzed using Student’s t-test and categorical variables with Chi-square test.

Results

105 of 1,158 ECF patients met the inclusion criteria. 38 patients received ≤ 5 days of effective antibiotic therapy, and 67 received > 5 days. Baseline demographics were similar, except the ≤ 5 days group were older and less likely to have fever (see table). In-hospital mortality was 18.4% in the short-term antibiotic group and 6.0% in the long-term group. Overall 30-day readmission was not significantly different. LOS was significantly greater in the > 5 day overall and non-bacteremia group.

Conclusion

Duration of antibiotics (≤ 5 and > 5 days) did not significantly affect 30-day readmission and in-hospital mortality; however, LOS was significantly longer in the > 5 days group. Further studies are needed to confirm these findings.

Disclosures

All authors: No reported disclosures.
1478. Efficacy and Safety of a Booster Dose of the MenACWY-TT Vaccine Administered 10 Years After Primary Vaccination with MenACWY-TT or MenACWY-PS
Authors: Quiambao Beatriz , Peyrani Paula , Webber Chris , Van Der Wielen Marie , Bianco Veronique , Perez John L , Cutler Mark W , Li Ping
Published: October 2019

Background

The quadrivalent meningococcal ACWY polysaccharide tetanus toxoid conjugate vaccine (MenACWY-TT; Nimenrix) is licensed in various countries to prevent disease caused by meningococcal serogroups A, C, W, and Y. In a previous study (NCT00464815), subjects aged 11‒17 years received a primary dose of MenACWY-TT or a quadrivalent polysaccharide vaccine (MenACWY-PS). Here, we report the long-term antibody persistence of the primary dose and the immunogenicity and safety of a booster dose given 10 years after primary vaccination of subjects.

Methods

Participants were enrolled from the Philippines and received a booster dose of MenACWY-TT at 10 years postvaccination. Antibody persistence 10 years postprimary vaccination and immunogenicity 1 month after the booster dose were evaluated by serum bactericidal activity assays using rabbit complement (rSBA) to assess the percentages of subjects with titers ≥1:8 and ≥1:128 and geometric mean titers (GMTs) for each serogroup. Safety was assessed for the booster dose.

Results

Of 229 subjects enrolled in this extension study, 169 and 58 subjects in the MenACWY-TT and MenACWY-PS groups, respectively, completed the booster phase. The percentages of primary MenACWY-TT recipients with prebooster rSBA titers ≥ 1:8 and ≥ 1:128 at year 10 ranged from 71.6%‒90.7% and 64.8%‒85.2% for all serogroups, respectively, compared with 43.1%‒82.4% and 25.5%‒76.5% of primary MenACWY-PS recipients; rSBA GMTs for all serogroups were higher in the MenACWY-TT group than in the MenACWY-PS group at year 10. For the MenACWY-TT and MenACWY-PS groups, respectively, the MenACWY-TT booster dose elicited rSBA titers ≥1:8 in 100% and ≥98.0% of subjects (figure); 100% and ≥96.1% of all subjects had titers ≥1:128. For all serogroups, rSBA GMTs at 1 month after the booster dose were higher than before the booster dose. No new safety signals were observed during the booster phase.

Conclusion

Functional antibody responses elicited by MenACWY-TT persisted 10 years after primary vaccination; the booster dose was well tolerated and elicited robust immune responses.

ClinicalTrials.gov: NCT03189745, EudraCT # 2013-001512-29. Funded by Pfizer.

Disclosures

All authors: No reported disclosures.
1487. Recent Resurgence of Salmonellosis-Related Mortality in the United States, 1990–2015
Authors: Panchal Palak , Sorvillo Frank , Dworkin Mark S
Published: October 2019

Background

Non-typhoidal salmonellosis is one of the most common causes of foodborne illness in the United States. The objective of this study was to update the epidemiology of salmonellosis-related mortality in the United States by examining multiple-cause-of-death data (MCOD).

Methods

MCOD data from the National Center for Health Statistics (NCHS) for the years 1990–2015 were analyzed. Mortality rates and 95% confidence intervals (CI) were calculated for age, sex, race/ethnicity, year, and state. Poisson regression models were used to examine temporal trends. Logistic regression was used to determine whether selected comorbid conditions were associated with salmonellosis-related deaths.

Results

Overall, 1,987 salmonellosis-related deaths (3.17%) were identified as an underlying and/or associated cause of death. The average annual age-adjusted mortality rate was 0.027 per 100,000 person-years. Salmonellosis mortality rates were higher among males with an age-adjusted rate ratio (RR) of 1.89 (95% CI, 1.79–2.01) compared with females. Mortality rates were higher among non-Hispanic Blacks and Asian/Pacific Islanders with an age-adjusted RR of 2.46 (95% CI, 2.19–2.77) and 2.06 (95% CI, 1.67–2.55) compared with Whites, respectively. The highest number of salmonellosis deaths were reported among the 75–84 year age group (n = 467; 24% of all cases). A significant decrease in trend was observed in age-adjusted salmonellosis mortality rates from 1990 to 2015. Since 2006, a significant increase of 66% in mortality rates was observed. Among selected comorbid conditions, HIV, acute renal failure, cancers affecting bone marrow, and diseases of the digestive system were associated with salmonellosis deaths with odds ratios of 11.51 (95% CI 8.78–15.10), 3.09 (95% CI, 2.01 = 4.75), 2.81 (95% CI, 1.67–4.74), and 2.82 (95% CI, 2.34–3.40), respectively.

Conclusion

Salmonellosis is an underlying and/or associated cause of death, especially among those with immune senescence and suppression. Despite a substantial decline in mortality rates, since 2006 rates have increased, a concerning trend. If rates continue to increase, an evaluation of Salmonella prevention efforts will be warranted.

Disclosures

All authors: No reported disclosures.
1603. Observation of Treatment Outcomes During an Outbreak of Multidrug-Resistant Shigella sonnei Infections in a Retirement Community—Vermont, 2018
Authors: Gharpure Radhika , Francois Watkins Louise , Francois Watkins Louise , Fialkowski Veronica , Collins Jennifer P , Strysko Jonathan , Marsh Zachary A , Tagg Kaitlin A , Meservey Elizabeth H , Adediran Azizat , Schroeder Morgan N , Wadhwa Ashutosh , Fullerton Kathleen E , Friedman Cindy R , Friedman Cindy R
Published: October 2019

Background

In 2018, CDC and the Vermont Department of Health investigated an outbreak of multidrug-resistant Shigella sonnei infections in a retirement community. Most Shigella infections are self-limited, but antibiotics are indicated for severe illness and sometimes to limit transmission. The Clinical and Laboratory Standards Institute has not yet established breakpoints for azithromycin, so laboratories cannot report resistance. Although breakpoints exist for ciprofloxacin, isolates with one fluoroquinolone resistance mechanism typically have minimum inhibitory concentrations within the susceptible range (≤ 0.25 µg/mL).

Methods

We reviewed charts for treatment outcomes of outbreak patients to evaluate clinical and microbiologic response. We defined clinical failure as ≥ 3 loose stools per day for ≥ 1 day after completion of antibiotics and microbiologic failure as a positive stool culture after completion of antibiotics. We used broth microdilution to perform antimicrobial susceptibility testing, and whole-genome sequencing to identify resistance mechanisms.

Results

Among the 24 patients with culture-confirmed Shigella infection, 4 were hospitalized and 2 died. All isolates were multidrug-resistant (Table 1) and harbored mechanisms for resistance to ampicillin, ceftriaxone, trimethoprim-sulfamethoxazole, azithromycin, and ciprofloxacin. Fifteen patients received one course of ciprofloxacin, 5 received multiple courses of antibiotics, and 4 received no antibiotics. Overall, 6 patients had treatment failure (Table 2); all 4 patients who received azithromycin had subsequent clinical failure and 2 also had microbiologic failure. Two patients had failure after ciprofloxacin (1 clinical, 1 microbiologic).

Conclusion

This outbreak of highly resistant shigellosis highlights the importance of comprehensive susceptibility testing and systematic outcome studies. Evidence of treatment failure after azithromycin suggests that an appropriate clinical breakpoint is needed to inform clinical decision-making. Ciprofloxacin treatment failures were observed in patients with a susceptible strain harboring a resistance mechanism, warranting further investigation.

Disclosures

All authors: No reported disclosures.
1609. Using a Novel Rapid Test to Investigate a Multistate Outbreak of Coccidioidomycosis Among US Residents Returning From Mission Trips in Baja California, Mexico, June–July, 2018
Authors: Toda Mitsuru , Caceres Diego H , Gonzalez Francisco J , Pomeroy Mary , Bergeron Genevieve , Wilson Eliza , Franklin Patrick , Kresl Laura , Lunquest Kristy , Raybern Chelsea , Ratner Adam J , Chiller Tom M , Jackson Brendan R , Lindsley Mark , McCotter Orion
Published: October 2019

Background

In August 2018, New York City health authorities notified CDC of two students with pneumonia and rash following mission trips to Mexico. Send-out Coccidioides serology tests took 7 days for results to return. Both students and five additional travelers from four states were diagnosed with coccidioidomycosis. A seroepidemiologic survey implicated soil-disturbing activities at a single site as a likely source. Given the time to diagnosis observed, we examined the use of a novel one-hour lateral flow assay (LFA).

Methods

We interviewed and collected sera from people who traveled with seven case-patients during June‒July 2018 and performed LFA, enzyme immunoassay (EIA), and immunodiffusion (ID). We asked travelers about exposures and symptoms and compared test results with reports of ≥1 coccidioidomycosis symptom(s) within 6 weeks of travel.

Results

Of 133 travelers, we interviewed 108 (81%) and collected sera from 75 (56%). Majority were male teenagers. One-third (34%, 37/108) reported symptoms, and of those, 43% (16/37) sought healthcare. Four were hospitalized, including one in intensive care, for a median of 7 days (range 3–12). Only six (6%) had previously heard of coccidioidomycosis. One-third (32%, 24/75) tested LFA positive, 10 (13%, 10/75) EIA positive, and eight (11%, 8/75) ID positive. Seventy-one percent (17/24) with positive LFA reported symptoms, compared with 83% (10/12) with positive EIA, 100% with positive ID (8/8), and 31% (16/51) with negative LFA. Of 51 travelers with negative LFA, we observed one positive EIA and no positive ID.

Conclusion

In this outbreak that resulted in a high attack rate and prolonged hospitalizations, the rapid one-hour LFA appeared as a useful screening tool compared with send-out testing, which took at least 7 days to return. The proportion of symptomatic LFA-positive travelers was nearly as high as for those with positive EIA, and we observed agreement with EIA and ID-negative results. Whether 12 people with positive LFA but negative EIA and ID truly had infection is unclear. Further evaluation to examine sensitivity and specificity of LFA are needed. Additionally, greater education is needed for groups traveling to coccidioidomycosis-endemic areas.

Disclosures

All authors: No reported disclosures.
1742. Kinetics of CMV Viremia with Letermovir Prophylaxis in the First 100 Days post Hematopoietic Cell Transplantation (HCT): A Single-center Experience
Authors: Zavras Phaedon D , Stern Anat , Su Yiqi , Fang Jiaqi , Giralt Sergio , Perales Miguel , Maloy Molly , Seo Susan K , Papanicolaou Genovefa
Published: October 2019

Background

Letermovir (LTV) is approved for the prevention of CMV infection in CMV seropositive (R+) HCT recipients. Low rates of CMV breakthrough viremia have been reported with LTV prophylaxis. We studied the kinetics of CMV reactivation up to day (D) +100 in patients (patients) receiving LTV prophylaxis and compared them to historical controls not receiving LTV.

Methods

Retrospective cohort study of CMV R+ recipients of peripheral blood or marrow allografts at MSKCC during 2017–2018. Routine LTV prophylaxis was implemented in MSKCC in December 2017. Patients were categorized based on LTV prophylaxis to LTV group (LTV prophylaxis) and no LTV group [managed with preemptive therapy (PET)]. Routine CMV monitoring was performed weekly by a qPCR assay in plasma from D +14 through D +100. CMV viremia was defined as any detectable CMV viral load (VL). Clinically significant CMV viremia (csCMV) was defined as any CMV VL treated preemptively. CMV end-organ disease (EOD) was assessed by standard criteria. LTV resistance was tested at Viracor-Eurofins Laboratories after May 2018.

Results

Of 193 R+ HCT, 98 (50.8%) were in the LTV and 95 (49.2%) in the no LTV group. CMV viremia occurred in 43 (43.9%) patients in LTV and 63 (66.3%) in no LTV (Figure 1). CMV viremia occurred earlier in LTV compared with no LTV (median, 19 vs. 26 days post HCT, respectively, P = 0.009). The duration of CMV viremia was shorter in LTV compared with no LTV (median 16 days vs. 35 days, respectively; P < 0.0001). The peak CMV VL was lower in LTV compared with no LTV (median, 137 IU/mL vs. 578 IU/mL, respectively); P < 0.0001. Rates of csCMV viremia were significantly lower in LTV compared with no LTV (5.1% vs. 54%, respectively); P < 0.0001 (Figure 2). LTV group received a total of 134 PET-days and no LTV group received 2,160 PET-days by D +100. No patient in LTV developed CMV EOD, while two patients in no LTV developed CMV duodenitis. LTV resistance was documented in 2 patients (2% of the LTV group). Overall survival by D +100 was similar between LTV and no LTV groups.

Conclusion

Implementation of LTV prophylaxis significantly reduced rates of csCMV infection and resulted in 93.8% reduction in total PET days. Among patients with csCMV viremia, LTV group had a shorter duration of viremia and lower peak CMV VL compared with no LTV.

Disclosures

All authors: No reported disclosures.
1754. Pre-Transplant Vaccination Rates in Solid-Organ Transplant Recipients
Authors: Friedman Daniel , Belga Sara , Burton Catherine , Preiksaitis Jutta , Kabbani Dima
Published: October 2019

Background

Recipients of solid-organ transplants (SOT) are at increased risk of vaccine-preventable illnesses. Because of the immunosuppression administered following SOT, live vaccines are generally contraindicated post-SOT, and response to inactivated vaccines may be suboptimal. National and international guidelines recommend optimizing immunizations prior to SOT. We analyzed rates of vaccination for SOT candidates in a cohort of adult kidney and liver transplant recipients.

Methods

A retrospective chart review of adult kidney, kidney/pancreas (KP) and liver transplant recipients was conducted between 2014 and 2016. We calculated the rates of vaccinations of the following vaccines: pneumococcus, meningococcus, Hepatitis A and B, Haemophilus influenzae type B, measles, mumps, rubella, polio, tetanus, diphtheria and pertussis.

Results

300 patients were included (147 kidney, 14 KP, 139 liver). Liver recipients were older (mean age 53 vs. 50; P = 0.028) and less likely to have had a previous transplant (5.8% vs. 21.1%; P < 0.001) or a living donor (15.8% vs. 32.3%, P = 0.01). Liver recipients were more likely to have been vaccinated against hepatitis A (106 [53.9%] vs. 28 [17.4%]; P < 0.001). Kidney and KP recipients were more likely to have received at least 1 dose of hepatitis B vaccine (138 [85.7%] vs. 91 [65.5%]; P < 0.001) or at least 1 dose of any of the pneumococcal vaccines (PSV23 94 [67.6%] vs. 92 [57.1%]; P = 0.062; PCV13 130 [80.7%] vs. 93 [66.9%]; P = 0.006; pneumococcal vaccine not clarified 47 [29.2%] vs. 14 [10.1%]; P < 0.001). No difference was observed with regards to other vaccines (Table 1). Being a kidney transplant recipient increased the odds of getting at least 1 dose of hepatitis B, tetanus/diphtheria/acellular pertussis (Tdap), measles, and pneumococcal vaccine (OR = 1.75, 95% CI [1.063–2.864]; P = 0.028)

Conclusion

In our cohort, kidney transplant recipients were more likely to have received pre-transplant vaccination. Despite the availability of local and international guidelines, vaccination in SOT candidates remains suboptimal and further study of barriers to implementation of these guidelines is warranted to inform future quality improvement initiatives.

Disclosures

All authors: No reported disclosures.
1755. Assessment of Vaccine Rates in Solid-Organ Transplant Recipients and Identification of factors Associated with Completion of Vaccination
Authors: Parraga Acosta Tommy J , Hanna Zachary W , Daering Nicholas J , Vahia Amit T , Alangaden George J
Published: October 2019

Background

Vaccine administration is an essential component of pre and post-transplant care. Although Society guidelines for vaccination of solid-organ transplant recipients (SOT) are published, rates of vaccination remain low and potential factors influencing these rates are not well identified.

Methods

A retrospective review of electronic medical records (EMR) was done for all adult SOT patients who underwent transplantation from January 2015 to December 2016 at Henry Ford Hospital, Detroit, MI. Sociodemographic data, comorbidities, and vaccination status at 1-year post-SOT for influenza, pneumococcus, hepatitis A and B, Tdap, and Td vaccines were assessed from EMR and the Michigan Care Improvement Registry. Data were analyzed using SAS 9.4 software, univariate analysis was done with Chi-square test, t-test, and multivariate analysis with logistic regression.

Results

530 patients underwent SOT during the study period. Characteristics of the study population are shown (Table 1). The median age was 59, mean Charlson Comorbidity Index was 5.25, 58.3% had smoking history. At 1-year post SOT, 88.7% had received ≥1 vaccine(s), whereas 11.3% received no vaccines. Most patients received vaccines before SOT. Influenza (69.4%) and pneumococcal (69.3%) vaccines were the most administered (Table 2). On univariate analysis, pre-SOT visits with a primary care provider (PCP), transplant team or PCP based at our institution were significantly associated with vaccination (Table 3). On multivariate analysis, PCP based at our institution (odds ratio [OR], 2.03 [95% confidence interval {CI}, [1.06–3.88], P = 0.033) and pre-SOT PCP visits (OR 1.47, [95% CI 1.11–1.96], P = 0.008) were significantly associated with vaccine uptake. Smoking history negatively impacted vaccine uptake (Table 4). Patients who had received the influenza vaccine(s) were significantly associated with increased uptake of other vaccines (P < 0.0001).

Conclusion

Despite guidelines, vaccination rates in SOT patients remain low at our institution. Factors associated with improved vaccination were institution-based PCP, pre-SOT PCP visits and receipt of influenza vaccines. A multidisciplinary approach is required for the optimization of vaccination rates in the SOT population.

Disclosures

All authors: No reported disclosures.
1758. Epidemiology of Invasive Mycoplasma and Ureaplasma Infections Early after Lung Transplantation
Authors: Baker Arthur W , Messina Julia A , Maziarz Eileen K , Saullo Jennifer , Miller Rachel , Miller Rachel , Wolfe Cameron R , Arif Sana , Reynolds John M , Perfect John R , Alexander Barbara D
Published: October 2019

Background

Mycoplasma and Ureaplasma species can cause invasive infections early after lung transplant that are difficult to diagnose and associated with substantial morbidity, including hyperammonemia syndrome. Data on the epidemiology and clinical outcomes of these infections are needed to inform clinical management and screening protocols for donors and recipients.

Methods

We retrospectively collected clinical data on all patients who underwent lung transplantation at our hospital from January 1, 2010 to April 15, 2019 and subsequently had positive cultures or PCR studies for M. hominis or Ureaplasma spp. Patients with positive studies from only the genitourinary tract were excluded. We analyzed donor and recipient clinical characteristics, treatment courses, and outcomes for up to 2 years after transplant.

Results

Of 1055 total lung transplant recipients, 20 (1.9%) patients developed invasive infection with M. hominis or Ureaplasma spp. M. hominis caused the first 10 infections (2010–2016), and Ureaplasma spp. caused 10 subsequent infections (2017–2019). Date of first positive culture or PCR study occurred a median of only 19 days after transplant (range, 4–90 days). Median donor age was 31 years (range, 18–45 years), and chest imaging for 16 (80%) donors revealed airspace disease compatible with aspiration. Infection outside of the respiratory tract was confirmed for 13 (65%) recipients, including 8 patients with M. hominis empyemas (Figure 1). Ten (50%) patients developed altered mental status that was temporally associated with infection; 8 (80%) of these patients had elevated serum ammonia levels, including 3 patients with M. hominis infection. Median duration of therapy was 6 weeks (IQR, 4–9 weeks), consisting of combination antimicrobial regimens for nearly all patients. Additional postoperative complications were common, and 11 (55%) patients died within 1 year after transplant (median, 117 days; IQR, 65–255 days) (Figure 2).

Conclusion

Ureaplasma and M. hominis infections occurred early after lung transplant and were associated with substantial morbidity and mortality. Transplant clinicians should have low thresholds for performing specific diagnostic testing for these organisms. Protocols for donor and recipient screening and management need to be developed.

Disclosures

Rachel Miller, MD, Synexis: Research Grant.
1768. Dengue Virus Infection in Solid-Organ Transplant Recipients: Case Series and Literature Review
Authors: Rosso Fernando , Sanz Ana M , Parra-Lara Luis Gabriel , Moncada Pablo A , Vélez Juan D , Caicedo Luis A
Published: October 2019

Background

Dengue fever is the most prevalent arbovirus among humans, its incidence has increased since the re-emergence, and Colombia is a hyperendemic country for this infection. The number of solid-organ transplant (SOT) recipients, at risk of acquiring dengue virus infection, is constantly increasing, and there are few data regarding the clinical course and outcomes of dengue infection among this population. The aim of this study was to describe dengue virus infection in SOT recipients in Cali, Colombia.

Methods

We present a case series of SOT recipients with dengue virus infection, diagnosed by World Health Organization criteria and a positive NS1 and/or IgM dengue antibodies, which were attended at the FVL from 2001 to 2018. Furthermore, we performed a literature review regarding dengue infection in SOT recipients.

Results

A total of 20 patients were included: 17 kidney and 3 liver recipients. The median age was 50.5 years (IQR = 31–63.5), 65% were female. The median time from transplant to dengue was 27.6 months (IQR = 3.82–59.12), and 3 patients had the infection in the first month after the transplant. The most common symptoms were fever (95%), myalgia, headache, and abdominal pain. Warning signs were present in 75% of patients, thrombocytopenia and hemorrhagic manifestations were present in 30% and 15%, respectively. 35% of patients were classified as severe dengue, and 45% were managed at the intensive care unit. Regarding laboratory findings, six patients had transaminases elevation more than three times the upper limit and 7 had serum creatinine elevation, which returned to normal levels. All patients were discharged and none of them had alterations in the graft function. To date, there are approximately 180 reported cases of dengue in SOT recipients (Table 2).

Conclusion

Dengue represents a threat among SOT recipients. Unlike other reports, all patients in this series had a full recovery after the infection, suggesting that timely and effective management of patients and the access to high complexity services could prevent fatal cases.

Disclosures

All authors: No reported disclosures.
1772. Factors that Influence Viral Load in Patients Infected with Influenza Over Multiple Seasons
Authors: Shaw-Saliba Katy , Hsieh Yu-Hsiang , Rothman Richard E
Published: October 2019

Background

The factors that influence influenza viral load are poorly understood, but may have important implications for viral transmission and disease severity. We explored the relationship between patient and virus factors on influenza viral load across 4 consecutive influenza seasons.

Methods

Adult influenza-positive patients presenting to emergency departments in Baltimore, MD and Taipei, Taiwan between 2014 and 2018 were consented and enrolled. Nasopharyngeal (NP) samples and detailed paired data on symptom duration, demographics, and vaccination were collected. Viral load was inferred using the cycle threshold (Ct) values from quantitative real-time RT–PCR assays for 299 samples and influenza subtype was determined. Bivariate and multivariate analyses were conducted.

Results

Viral load was impacted by both patient and virus characteristics. Older age and shorter duration of symptoms was associated with a higher viral load (age: Ct difference -0.04, P = 0.022. symptoms: each increasing day, Ct difference +1.02, P < 0.001). Seasonal variability was observed, with the highest viral load associated with the 2014–2015 predominant H3N2 subtype (Ct 21.69, P < 0.001), where there was also a vaccine mismatch. Across seasons, H1N1 was associated with a lower viral load than H3N2 (Ct value + 2.66, P < 0.001). There was not association between gender and immunosuppression on viral load.

Conclusion

Our study demonstrates that both host and virus factors that can affect Ct values and inferred viral loads. As anticipated, higher viral load, were found to be associated with older age and shorter duration of symptoms; interestingly infection with the H3N2 subtype, traditionally associated with more severe disease was also associated with higher viral loads. Future-focused studies are required to better characterize these relationships, and directly evaluate relevance to both transmission and disease severity.

Disclosures

All authors: No reported disclosures.
1773. Development and Evaluation of an Automated Adenovirus Quantitative Assay Using the Luminex ARIES® System
Authors: Wu Fann , Shi Jun , Desai Shailesh , Green Daniel A , Whittier Susan
Published: October 2019

Background

The quantification of circulating human adenovirus (HAdV) DNA is the recommended diagnostic method to predict disseminated disease. Most current HAdV quantitative assays are manually performed and lack the flexibility needed to provide rapid answers when required.The purpose of this study was to evaluate the application of MultiCode® HAdV PCR assay for use with the Luminex ARIES® system (Luminex Corporation, Austin, TX) as an automated and random access test for the quantitative detection of HAdV DNA in plasma.

Methods

Analytical performance characteristics including assay limit of detection/quantitation (LoD/LoQ), accuracy, and inter-, intra-reproducibility were studied using commercial panels (Exact Diagnostics, Fort Worth, TX). Assay specificity was determined usingHAdV reference strains obtained from the American Type Culture Collection (Manassas, VA) and plasma spiked with related Herpes viruses and pathogens commonly found in the blood. Assay accuracy was verified with analysis of 30 plasma samples spiked with different concentrations of control material that covered the full range of HAdV DNA levels. We also prospectively analyzed 180 plasma samples collected from 102 patients. DNA from all samples were extracted, amplified and detected on a single automated Luminex ARIES® system.

Results

The assay has a wide linear range from 2.55 to 9.4 log10 HAdV DNA copies/mL (coefficient of determination; R2 = 0.995) with a detection limit of 1.82 log10 (95% positivity rate), and a limit of quantification of 2.55 log10 copies/mL. The assay detected HAdV DNA from Adenovirus groups A-F, although slight shifts in Tm peaks were observed. Inter- and intra-assay reproducibility was evaluated using 6 panels of commercial standards, producing variation coefficients of 5% and 2%, respectively. Assay accuracy results reflected a good correlation with a mean difference of 0.10 log10 copies/mL. The results of the prospective study showed 6/102 (5.8%) patients had HAdV viremia, including 4 (3.9%) patients with a viral load ≥4 log10/mL, which might necessitate therapy.

Conclusion

The HAdV quantitative assay using the Luminex ARIES® system provides excellent performance for routine testing with the additional advantage of random access capabilities for urgent testing to identify patients at risk for disseminated disease.

Disclosures

All authors: No reported disclosures.
1983. Adherence vs. Non-adherence: Clinical Outcomes of an Antimicrobial Stewardship Directed Treatment Protocol for Clostridioides difficile Infection
Authors: Begnoche Brendan , Chen Victor , Saraiya Nidhi , Guo Yi
Published: October 2019

Background

The 2018 Infectious Diseases Society of America (IDSA) C. difficile infection (CDI) treatment guideline no longer recommends metronidazole as first-line therapy in adults, instead recommending vancomycin or fidaxomicin. At our 1500-bed academic medical center, a new CDI treatment protocol was initiated by the antimicrobial stewardship program (ASP) to guide treatment based on disease severity and risk factors for recurrence. In this study, we compared the clinical cure rate and 30-day recurrence rate in patients who are adherent and non-adherent to our institutional CDI treatment protocol.

Methods

Patients with CDI between September-December 2018 were identified using electronic health record (EHR) reports. A retrospective chart review was conducted to collect the following information: baseline demographics, white blood cell count, CDI severity, and risk factors, etc. Outcome measures included clinical cure rate, 30-day recurrence rate, and global cure rate, stratified by whether treatment was adherent or non-adherent to institutional protocol. Student’s t-test was used for continuous variables. Fisher exact test or Chi-square test was used for categorical variables.

Results

A total of 188 patients (adherent group n = 100; non-adherent group n = 88) were included. Patient demographics and baseline risk factors did not differ between groups. Clinical cure rate was higher in adherent group (P < 0.05), while no significant differences were observed in recurrence and global cure rates between the two groups (Figure 1). The overall protocol adherence rate was 53%. The most common reasons for non-adherence are inappropriate vancomycin dose for fulminant CDI (69%) and insufficient duration of treatment (27%).

Conclusion

An ASP directed new CDI treatment protocol was successfully implemented at our institution. Patients treated according to our institutional protocol resulted in a higher overall cure rate than those non-adherent. Global cure and 30-day recurrence rates were similar. An overall protocol adherence rate of 53% is consistent with previously published literature. Future direction to develop an EHR order set with targeted recommendations is anticipated to further improve adherence and clinical outcomes.

Disclosures

All authors: No reported disclosures.
1996. Enteric Multiplex PCR Testing: Antimicrobial Stewardship Friend or Foe
Authors: Ellen Acree Mary , McElvania Erin , Charnot-Katsikas Angella , Beavis Kathleen , Matushek Scott , Pettit Natasha N
Published: October 2019

Background

There are advantages and challenges associated with enteric multiplex PCR testing. Fast turnaround time can lead to prompt pathogen identification and antibiotic initiation, decreased length of stay and decreased time in isolation. Challenges include identification of multiple organisms, carrier state detection, and detection of organisms with uncertain pathogenic potential, which can lead to unnecessary antibiotic use.

Methods

Two institutions transitioned from stool culture to stool PCR testing for identification of diarrheal pathogens. On February 1, 2016, Center 1 employed the BioFire® FilmArray® GI Panel, which detects 22 organisms and includes targets of unclear clinical significance. Center 2 implemented the BD MAX™ Enteric Bacterial Panel on 3/6/2019, which reports 4 bacterial known pathogens. Fluoroquinolone (FQ) and third-generation cephalosporin (TGC) prescribing in response to positive PCR testing was assessed over a 1 month period. Antibiotics were counted when prescribed within 72 hours of the collection date.

Results

At Center 1, 332 GI PCR panels were ordered, 94 (28.3%) were positive and 15 (16%) were treated; 4 received an FQ (26%), and 11 (73%) received a TGC. Center 1 organisms included 44 Clostridioides difficile, 27 Norovirus, 8 Enteropathogenic E. coli, 7 Sapovirus, 4 Campylobacter species, 2 Giardia lamblia, 2 Rotavirus, 1 Shigella/Enteroinvasive E. coli and 1 Salmonella species. Of 642 PCR tests ordered at Center 2, 16 (2.5%) were positive and 11 (69%) were treated; 10 (91%) received a FQ, and 1 (9%) received a TGC. Center 2 organisms included 8 non-typhoidal Salmonella species, 5 Aeromonas species, 2 Shigella sonnei and 1 Salmonella typhi.

Conclusion

Implementation of an enteric multiplex PCR test with targets of uncertain clinical significance is more likely to yield an abnormal result than a PCR test with only known pathogens. However, careful interpretation of results can avoid unnecessary antimicrobial use. Antimicrobial stewardship teams should work in tandem with microbiology laboratories to implement enteric multiplex PCR tests and monitor the impact on antibiotic use. Larger studies are needed to definitively assess the impact of the GI panel on antimicrobial prescribing within the context of patient comorbidities and institutional practices.

Disclosures

All authors: No reported disclosures.
2029. Prevalence of Antibiotic Use and Administration among Hospitalized Adult Patients at a Tertiary Care Hospital in Kilimanjaro, Tanzania
Authors: Lyamuya Furaha , Muro Florida , Sheng Tianchen , Mallya Rose , Uronu Tabitha S , Minde Rehema M , Anderson Deverick J , Woods Chris W , Mmbaga Blandina T , Tillekeratne L Gayani
Published: October 2019

Background

Antimicrobial stewardship programs (ASPs) have been shown to improve the appropriate use of antimicrobials, especially in high-income countries. However, ASPs are relatively less well implemented in low-or-middle income countries. To improve the effectiveness of ASPs in these settings, it is important to determine the core actions and targets for improving antimicrobial use. We sought to describe the prevalence and patterns of antibiotic use at a tertiary care hospital in Tanzania.

Methods

Consecutive patients admitted to an adult medical ward at a tertiary care hospital, Kilimanjaro Christian Medical Centre, in Moshi, Tanzania were enrolled from June 2018 to March 2019. The medical record was reviewed for data regarding the type of antibiotics prescribed, indications for use, and microbiologic testing ordered.

Results

A total of 1103 patients were enrolled during the study period. The majority of patients were males (663, 60.1%), with the median age being 54 years (IQR 39–70). About one-third (390, 35.4%) of the admitted patients received antimicrobials during hospitalization, with pneumonia being the leading indication for antimicrobial use (158, 40.5%). The most commonly used antibiotics included ceftriaxone in 285 (73.1%), metronidazole in 155 (39.7%), and amoxicillin/ ampicillin in 46 (11.8%) patients. The median duration of antimicrobial use was 5 days (IQR 3–7). Few patients on antimicrobials (27, 6.9%) had culture results, of which half (15, 55.6%) were positive for an organism and a minority (8, 29.6%) were susceptible to the antibiotics being used. Overall, mortality in the cohort was 22.7% and the median duration of hospitalization was 5 days (IQR 3–8).

Conclusion

Antibiotics were used in a substantial proportion of admitted patients. However, in most cases, treatment was empirical with limited use of culture results. Future ASP efforts can target the improved use of microbiologic cultures to target antimicrobial use.

Disclosures

All authors: No reported disclosures.
2038. Antimicrobial Stewardship (AS) Recognition, Confidence, and Organizational Factors: Multi-center Survey of Bedside Nurses
Authors: Monsees Elizabeth , Monsees Elizabeth , Goldman Jennifer , Popejoy Lori
Published: October 2019

Background

There is no literature on practices nurses associated with AS processes and how patient safety culture influences nursing AS understanding and confidence.

Methods

This cross-sectional study used an investigator-developed survey with optional comments to describe how bedside nurses recognize and perceive their confidence performing nursing activities that support AS processes and the potential role of organization culture as an AS engagement factor. 9 hospitals ranging in size from 42 to 562 beds participated. Composite scores for practice, confidence, and safety were calculated and correlated. ANOVA with Tukey HSD post-hoc tests and non-parametric (Kruskal–Wallis) tests with Bonferroni adjusted P-values for multiple comparisons were used to evaluate differences by clinical unit and years of clinical experience.

Results

A total of 558 inpatient nurses participated (response rate 13%). A significant positive association was identified between nurses’ beliefs about nursing practices that contribute to the antibiotic stewardship process and their perceived confidence to perform rs = 0.454, P < 0.001. Nurses ≤5 years of experience were significantly less confident than those with >15 years of experience in: (a) assessing for a history of an adverse drug reaction (P = 0.049, P = 0.023), (b) reviewing preliminary microbiology results and comparing susceptibilities (P = 0.011, P < 0.001), and (c) notifying a provider of a wrong antibiotic dose (P = 0.011, P = 0.017). Medical/surgical nurses (P = 0.003 recognized that taking an allergy history contributes to the stewardship process significantly more than ICU respondents and were more confident, in assuring that cultures are obtained prior to antibiotic administration (P = 0.038). Free text comments indicated: organizational factors (n = 50), knowledge gap (n = 35) and poor communication (n = 11) impeded AS engagement.

Conclusion

This is the largest multi-site study on nursing stewardship practice that includes organizational culture as a factor influencing behavior to steward. The results identify interprofessional collaboration is needed to improve organizational factors so nurses can serve as powerful AS collaborators in this important patient safety effort.

Disclosures

All authors: No reported disclosures.
2043. The “Resistance Calculator”: Refining Empiric Practices of Antimicrobials Prescription in the Era of Widespread Resistance
Authors: Zilberman-Itskovich Shani , Strul Nathan , Chedid Khalil , Shorbaje Akram , Lazarovitch Tsilia , Zohar Yarden , Razin Hadas , Low Amitai , Strulovici Ariela , Katz David , Dhar Sorabh , Milton Parsons Leo , Ramos-Mercado Abdiel , Zaidenstein Ronit , Martin Emily T , Marchaim Dror
Published: October 2019

Background

In the era of widespread resistance, there are two events in the course of a hospitalized septic patient where the majority of empiric prescription errors occur: (1) infections upon admission (UA) due to multi-drug-resistant organisms (MDRO) and (2) nosocomial infections due to extensively drug-resistant organisms (XDRO). These errors seriously impact patient outcomes and the ecological burden of resistance. Our objective was to develop a tool, to calculate the probability of MDRO UA, and nosocomial XDRO infections, in order to reduce delays in initiating appropriate therapy to the “right population,” i.e., with “resistant pathogens,” while avoiding overuse of broader (frequently more toxicת less efficacious) therapeutics to the “wrong population,” i.e., with “susceptible pathogens.”

Methods

Retrospective case–control analyses were conducted for septic adults at Shamir Medical Center, Israel (2016). Logistic regression was used to develop models of risk factors. All parameters incorporated into the models were readily accessible at the point of care. The performances of the development cohorts, and on 8 other validation cohorts, were assessed by the area under the receiver operating characteristic curve (ROC AUC). A web calculator (mobile modifiable) was generated.

Results

A total of 4,199 patients were enrolled: 2,472 with sepsis UA, and 1,727 with nosocomial sepsis. The “MDR UA score” included 10 parameters and with a cutoff of ≥22 points, had a ROC AUC of 0.85 (sensitivity 86%, NPV 98%). The “Nosocomial XDR score” included 7 parameters and with a cutoff of ≥36 points, had a ROC AUC of 0.88 (sensitivity 90%, NPV 96%). The median ROC AUC was 0.75 among the validation cohorts of the “MDR UA score,” and 0.66 among the “Nosocomial XDR score.” A free web tool was generated: https://assafharofe.azurewebsites.net/.

Conclusion

A simple electronic calculator was generated to aid in bedside empiric prescription practices. The tool is composed of two scores to assist in common scenarios where the majority of errors occur. Prospective interventional investigations, should trial the performances of this tool in improving patient outcomes and the ecological burden in the facility.

Disclosures

All authors: No reported disclosures.
2046. A Qualitative Study on Perceived Barriers and Facilitators of Implementing an Antimicrobial Stewardship Intervention in the Management of Urinary Tract Infections in a Long-Term Care Setting
Authors: Chan April , O’Donnell Denis , Kaasa Benjamin , Mathers Annalise , Paraschiv Nicoleta , Goldstein Mark L , Brazil Kevin , Papaioannou Alexandra , Dolovich Lisa
Published: October 2019

Background

50% of antibiotic courses in long-term care facilities (LTCFs) are unnecessary, leading to increased risk of harm such as Clostridiodes difficile infection and antibiotic-resistant organisms. Antimicrobial stewardship (AS) interventions play an important role in optimizing antibiotic use. Most studies addressing strategies to improve antibiotic prescribing in LTCFs showed modest and unsustained results. We aimed to identify facilitators, barriers and strategies in implementing a urinary tract infection (UTI)-focused AS intervention at an LTCF in Toronto.

Methods

A qualitative approach using conventional content analysis was used. Through purposeful sampling, we recruited different LTCF healthcare providers and administrators at Kensington Gardens. Interviewees attended focus groups or one-on-one interviews. Data were collected using a semi-structured interview guide. Data were analyzed inductively using a codebook modified in an iterative analytic process. Barriers and facilitators with potential strategies were summarized and mapped using the COM-B (capability, opportunity, motivation and behavior) model (Mitchie et al.) and emerging themes identified.

Results

Sixteen participants were interviewed. The most common barriers were family pressure, lack of access and test result delay while the barrier themes were lack of access, inadequate communication, lack of time and lack of knowledge of both HCPs and resident’s families. These can be addressed by the most common facilitators and facilitator themes, which included good communication between healthcare professionals (HCPs), education for HCPs and families and collaboration between HCPs. Most barriers and facilitators were mapped to the opportunities domain of the COM-B model.

Conclusion

Strategies for improved UTI-focused antimicrobial stewardship intervention in LTC setting should focus on increasing opportunities and innovative formats for education, communication and collaboration among HCPs and with families although barriers and facilitators in all aspects of the COM-B model were identified.

Disclosures

All authors: No reported disclosures.