bluuebunny/crossref_metadata_2025 huggingface dataset:
1178. Cardiac Device Infection: Do We Follow the Guidelines?
Authors: Nagarakanti Sandhya , Bishburg Eliahu , Bapat Anita
Published: October 2019

Background

Cardiovascular implantable electronic device (CIED) such as pacemaker (PPM) and automated implantable cardiac defibrillator (AICD) are commonly utilized in clinical practice. Definitions of device infection (DI) and guidelines for the work up and device extraction (DE) have been published by the American Heart Association and the Infectious Disease Society of America. Our objective was to evaluate whether the work up of DI as recommended was followed, and whether the device was extracted according to guidelines.

Methods

A retrospective review in a 680-bed tertiary care hospital. Adult patients (patients) >18 years. who were diagnosed as having a DI and had the device extracted between 2008 and 2017 were included. Data were collected on demographics, device duration, blood culture (BC), echocardiogram utilization, lead cultures (LC) and device pocket cultures, appropriateness of extraction as per guidelines.

Results

Ninety-five patients were included. Mean age 68 years (range 23–90). 67 (70%) were male. Devices included: AICD in 75 (79%), PPM in 20(21%). CIED was present <1 year prior to infection in 24(24%). Compliance with guidelines recommendation to draw blood cultures, obtain an echocardiogram and send lead cultures and device pocket cultures were seen in 100%, 90.5% and 49.4% and 67.7%, respectively. Criteria for extraction was met in 65/95 (69%); reason for extraction was a pocket infection in 16/65(24.6%), bacteremia in 49/65 (75%), infective endocarditis in 38/65(58%). Thirty (31.5%) had device extracted without meeting guidelines recommendation, in 17 a diagnosis of pocket infection but without microbiological criteria or clinical diagnosis. In 9 patients lead vegetations were seen but no cultures to support extraction. Mortality was seen in 4 patients, one during the extraction procedure.

Conclusion

In our institution, 1/3 of the patients diagnosed with DI had no indication for DE. Guidelines recommendation for CIED extraction should be followed as extraction could be associated with significant complications. In this study, overall compliance with guidelines work up recommendations were not consistently followed, especially LC and device pocket cultures.

Disclosures

All authors: No reported disclosures.
1185. Impact of Utilizing Drug Resistance in Pneumonia (DRIP) Score on Management of Pneumonia
Authors: Sandhu Avnish , Goldman Erin , Polistico Jordan , Polistico Sarah , Oudeif Ahmed , Aranha Anil , Murray Kyle P , Zhao Jing , Mynatt Ryan , Pogue Jason M , Dhar Sorabh
Published: October 2019

Background

Pneumonia is a leading cause of infection-related admissions and death. It is imperative that appropriate antibiotic therapy is selected. Traditional scoring systems for identifying at-risk persons for drug-resistant pathogens– i.e., Healthcare-associated pneumonia (HCAP), have been inaccurate and often lead to inappropriate antibiotic selection. A novel pneumonia scoring system –“Drug Resistance in Pneumonia (DRIP)” was implemented at the Detroit Medical Center (DMC) in January 2018. The objective of this study was to evaluate the effectiveness of the DRIP score in reducing the use of broad-spectrum antibiotics and the impact on key outcomes in patients treated for pneumonia.

Methods

A retrospective chart review of 89 patients admitted to the DMC for treatment of pneumonia was conducted—45 patients prior to and 44 patients post-implementation of the DRIP score. Basic demographics, signs and symptoms, antibiotics data, pneumonia severity score (CURB – 65), Charlson co-morbidity score, and outcome measures were compared. DRIP scores and HCAP risk factors were calculated for all patients. The definitions of broad-spectrum antibiotics (BSA) were consistent with DMC guidelines for the treatment of pneumonia (antibiotics targeting nosocomial Gram-negative organisms and/or methicillin-resistant Staphylococcus aureus).

Results

Demographics are shown in Table 1. 18 (40%) of the pre-implementation cohort had risk factors for resistance (HCAP risk factors) compared with 14 (32%) in the post. Conversely, 15 (33%) of the pre-implementation cohort had risk factors for resistance (DRIP ≥4) compared with 8 (18%) in the post-implementation period (Table 2). A difference in BSA prescribing was seen in patients previously characterized as having a high risk of resistance (HCAP) but with DRIP score <4 [5/7 (72%) vs.1/7 (16%) (Table 2)]. BSA use was 24 (53%) in the pre-implementation cohort and 12 (27%) in post-implementation cohort, P = 0.03. Durations of antibiotics were 8.3 days vs. 9.8 days respectively, P = 0.04. Readmission with pneumonia at 30 days was 3 (7.5%) for both groups.

Conclusion

The implementation of a novel DRIP scoring system resulted in improved prescribing patterns and a significant reduction of broad-spectrum antibiotics by 26% as compared with traditional HCAP score.

Disclosures

All authors: No reported disclosures.
1188. Calibrating a Product Use Metric for Hand Hygiene Compliance
Authors: Shelly Mark A
Published: October 2019

Background

Measuring hand hygiene (HH) by soap and alcohol hand rub product use is a relatively inexpensive and comprehensive way to estimate hand hygiene episodes per unit of patient care. Translating this number to compliance requires a reliable target for full compliance. Published data on this are few. The our objective of this study was to calibrate estimates of HH targeted performance across diverse inpatient medical unit types based on actual product use data.

Methods

Retrospective review of monthly product use and patient volumes in 8 diverse hospitals in central Pennsylvania from 2017 through March 2019.

Results

Over 27 months we calculated 98.2 million HH episodes. Months with no dispenser changes recorded were dropped from consideration, as were months with extraordinarily high replacement counts secondary to remodeling or product expiration. To further correct for variations within and between units, the median and 95th percentile are used. Medians represent observed compliance between 60 and 85% (see table). Given the month to month product use variation, using a 3-month reporting window is appropriate to keep this estimate to ±10%. Using these values for full compliance, the 3-month average rarely exceeds the maximum of 100%.

Conclusion

The product use values recorded here exceed published targets in half of the observed months. By adjusting the target for full compliance to the 95th percentile for the unit type, hand hygiene feedback by patient care area can more accurately estimate actual performance. As compliance improves further, recalibration will again be required.

Disclosures

All authors: No reported disclosures.
1196. Is the Weekend Staff Really to Blame? Challenges in Isolation Compliance at an Academic Tertiary Care Center
Authors: Bassett Sonia , Boston Kelley M , Ostrosky-Zeichner Luis
Published: October 2019

Background

Transmission-based isolation precautions are implemented in an effort to decrease the risk of transmission of pathogens. Weekend staff are perceived to have lower compliance.

Methods

Visual observation of healthcare worker (HCW) compliance with an institutional isolation precautions practices was done at an academic tertiary care center. In the first quarter of 2019, observations were completed for 894 patients who required contact, droplet or airborne isolation precautions. Observations included patients with infection or colonization with multi-drug-resistant organisms (MDRO) or highly transmissible infections. Observations focused on availability of appropriate supplies, compliance with infection control practices, and documentation. Audits were performed on workdays and weekends, and results were communicated to unit leadership via email. Comparison of proportions was calculated using the normal approximation in Minitab18.

Results

Compliance with the different elements of the audit can be seen in Table 1. HCW compliance with the use of personal protective equipment and hand hygiene on exit from the room had the lowest compliance and was statistically lower on weekends than on weekdays, and compliance was significantly lower than all other categories for both weekday and weekend measurements. Fifty-seven percent of all patients had missed compliance on one or more elements. There was not a statistically significant variation in practice between weekends and weekdays in overall compliance.

Conclusion

There is opportunity for improvement in all compliance on isolation practices facility-wide, and elements that require changes in behavior had the lowest compliance, and were lower on weekend shifts. We did not find other differences in performance for weekend staff vs. weekday staff. Educational measures should focus on all individual staff across all shifts.

Disclosures

All authors: No reported disclosures.
1202. It’s a Confidence Scheme—Transmission-based Precautions in the Ambulatory Setting
Authors: McQuaide Colleen , Romano Carrie , Swartz Michelle , Schaffzin Joshua K
Published: October 2019

Background

Following consistent transmission-based precautions (TBP) beyond the inpatient ward can be challenging. Specifically, ensuring patients are removed when eligible can prevent overuse of TBP and PPE and counter the negative connotations of TBP/Isolation. We sought to enhance providers’ ability to provide TBP for indicated patients only.

Methods

We initiated an iterative process to identify patients eligible for TBP discontinuation based on hospital policy. Staff huddle at the start of each clinic to identify patients needing TBP. An electronic medical record (EMR) report was generated and reviewed by an Infection Preventionist (IP) 3 days in advance of a clinic session to identify and remove eligible patients from TBP. When TBP discontinuation required clinical criteria not available in the EMR, clinic staff were notified and asked to collect the information from families so a decision could be made.

Results

Following 6 weeks of review for 5 services, over 30 patients were removed from TBP prior to their visit. IP review entails approximately 20 minutes three times per week. Clinic staff reported greater confidence with enforcing TBP for patients. Specifically, they could trust the list generated the day of clinic, and they understood following TBP was in accordance with policy.

Conclusion

Verifying the need for TBP in ambulatory patients is not labor intensive. Enhancing the accuracy of lists of patients requiring TBP increases provider confidence in communicating with families and preventing transmission. Increased confidence may empower providers to better utilize TBP appropriately, leading to less waste and dissatisfaction.

Disclosures

All authors: No reported disclosures.
1203. Epidemiology of Respiratory Viruses in Influenza-Vaccinated Healthcare Workers During an H1N1-Dominant Season
Authors: Wohrley Julie , Collison Maggie , Marrs Rachel , Marchese Ed , Beavis Kathleen , Bartlett Allison , Wilson Patrick , Cobey Sarah , Landon Emily
Published: October 2019

Background

Respiratory pathogens are an important cause of morbidity and mortality in hospitalized patients and nosocomial spread of such pathogens is known to occur. However, little is known about the epidemiology of respiratory viruses in healthcare workers (HCW).

Methods

Between December 28, 2018 and April 26, 2019 enrolled HCW completed a weekly symptom diary, including presence or absence of respiratory symptoms, flu exposure history and whether they received medical attention. Vaccination and flu infection history were collected on enrollment. Participants self-collected flocked nasopharyngeal (NP) swabs every other week and if they reported any symptom on the weekly diary. These were tested using a multiplex PCR platform (Biofire, Salt Lake City, UT) with targets for 14 respiratory viruses. Symptomatic HCW with influenza or respiratory syncytial virus (RSV) were notified and followed policy regarding work restriction.

Results

66 HCWs provided baseline data and 57 continued data submission (9 withdrew). The active participants included 13 nurses (22.8%), 7 advanced practice providers (12.3%), 18 physicians (31.6%), and 19 other (33.3%). Participants received quadrivalent inactivated flu vaccine this season (2 self-reported/unknown type). Compliance was 89.8% (749 of 834) with weekly diary completion and 83.3% (378/454) for biweekly NP swabs. Thirty-nine unique participants reported symptoms on weekly diaries 100 times and submitted 88 total “symptomatic” NP swabs (88% compliance). Of these, 16 swabs revealed any pathogen (18.2%) and 3 had influenza H3N2 (18.8%) (only one reported fever). Other pathogens identified are detailed in Figure 1. 12 of the 366 asymptomatic swabs were positive for respiratory viruses (23.3%, see Figure 1). No participant had asymptomatic influenza.

Conclusion

Pauci-symptomatic influenza has been previously described by our group and others and is noted even in this small cohort. While asymptomatic flu was not found, there were several cases of other asymptomatic respiratory viruses in HCW. Analysis of the impact on patients is still underway from this cohort but the initial data suggest that patients are at risk of contracting healthcare-acquired respiratory infection even from health care providers.

Disclosures

All authors: No reported disclosures,
1215. Ultraviolet-C (UV-C) Monitoring Made Ridiculously Simple: UV-C Dose Indicators for Convenient Measurement of UV-C Dosing
Authors: Cadnum Jennifer , Jencson Annette , Redmond Sarah , Sankar Chittoor Mana Thriveen , Donskey Curtis
Published: October 2019

Background

Ultraviolet-C (UV-C) light is increasingly used as an adjunct to standard cleaning in healthcare facilities. However, most facilities do not have a means to measure UV-C to determine whether effective doses are being delivered. We tested the efficacy of 2 easy-to-use colorimetric indicators for monitoring UV-C dosing in comparison to log reductions in pathogens.

Methods

In a laboratory setting, we exposed methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile spores on steel disk carriers with or without an organic load (5% fetal calf serum) to UV-C for varying times resulting in fluence exposures ranging from 10,000 to 100,000 µJ/cm2. The UV-C indicators were placed adjacent to the carriers. Log reductions were calculated in comparison to untreated controls and the change in color of the indicators was correlated with dose and log reductions.

Results

The UV-C doses required to achieve a 3-log reduction in MRSA and C. difficile were 10,000 and 46,000 µJ/cm2, respectively. For both indicators, there was a visible color change from baseline at 10,000 µJ/cm2 and a definite final color change by 46,000 µJ/cm2 (Figure 1). Organic load had only a modest impact on UV-C efficacy. The indicators required only a few seconds to place and were easy to read (Figure 2).

Conclusion

UV-C doses of 10,000 and 46,000 µJ/cm2 were required to achieve 3 log reductions of MRSA and C. difficile spores, respectively. The colorimetric indicators provide an easy means to monitor UV-C dosing.

Disclosures

All authors: No reported disclosures.
1239. Efficacy of Preoperative Chlorhexidine Gluconate and Mupirocin in the Prevention of Orthopedic Surgical Site Infections
Authors: Kahler Gabrielle , Ing Michael
Published: October 2019

Background

Surgical site infections (SSIs) affect 1–5% of patients undergoing surgical procedures in the United States each year and have a mortality rate of up to 75%. We sought to assess the efficacy of a bundled preoperative decolonization treatment protocol to prevent SSIs in hip, knee, or spine procedures.

Methods

A retrospective chart review was conducted for 2224 adult patients undergoing spine, knee, or hip procedures performed at the JL Pettis Memorial VAMC from October 1, 2010 to December 31, 2018. NHSN/CDC criteria were utilized. The study included spine surgeries with or without new hardware, but only hip and knee surgeries with new hardware. Procedures with an infection present at the time of surgery (PATOS) were excluded. A pre-operative methicillin-resistant Staphylococcus aureus (MRSA) nares screen was performed. Patients treated were given mupirocin (MPN) to apply to their nares and 4% chlorhexidine gluconate (CHG) to wash all skin prior to the procedure. Patients undergoing emergent procedures received CHG without MPN. The intention to treat model and chi-square test were utilized. The primary endpoints were the infection rates in both the untreated and treated groups. Secondary endpoints included the MRSA screening result, SSI class, causative organism(s), and the surgical site.

Results

A total of 2,112 procedures were included in the study. Thirty-three (1.56%) procedures met NHSN/CDC criteria for SSI. Of the 1,754 (83.0%) procedures given decolonization treatment with MPN and/or CHG, 22 (1.25%) developed an SSI. Of the 358 procedures not receiving treatment, 11 (3.07%) developed an SSI.

Conclusion

Patients given decolonization treatment had a lower infection rate compared with those who were not treated (1.25% vs. 3.07%, P = 0.0115). Even though the decrease in infection rates were most significant for hip procedures, the overall trend favored the use of a preoperative decolonization treatment protocol for all of the orthopedic procedures studied (Table 1). Current barriers include patient compliance and correct use of decolonization agents, which may affect the actual efficacy of decolonization treatment. A possible confounder was the known increased risk of SSIs in emergent procedures.

Disclosures

All authors: No reported disclosures.
1243. Continuous vs. Intermittent Intraoperative Infusion of Cefazolin on Surgical Site Infections (SSIs) and Acute Kidney Injury in Patients Undergoing Cardiac Procedures
Authors: Tichy Michael , Seidelman Jessica , Lewis Sarah S , Drew Richard H , Drew Richard H , Sarubbi Christina
Published: October 2019

Background

Continuous infusion cefazolin (CI) has been investigated as a means to optimize antibiotic exposure for prophylaxis against SSI, notably in patients undergoing cardiac procedures involving cardiac bypass (CPB). However, data are limited on its impact on late SSIs and adverse events. In 6/16, the Duke University Hospital (DUH) Antimicrobial Stewardship Team implemented a program to promote CI. We compared the incidence of culture-confirmed SSIs through postoperative day 90 (POD90) between patients receiving either intermittent infusion cefazolin (INT) or CI intraoperatively. We also compared the rate of acute kidney injury (AKI) between groups.

Methods

This retrospective quasi-experimental design included adult and pediatric patients undergoing cardiac surgery at DUH between March 2014 and August 2018 and receiving intraoperative cefazolin (alone or in combination with other antibiotics). Patients were categorized as CI (having received at least 1 intraoperative CI infusion) or INT. Culture-confirmed SSIs utilizing NHSN definitions were recorded and a relative risk (RR) determined. AKI was defined as a ≥0.3 mg/dL rise in serum creatinine within 2 days postoperatively.

Results

A total of 2,172 unique surgical procedures (from 2,143 unique patients) were included. Comparisons of groups are summarized in Table 1. Rates of SSIs were 1.1% and 1.6% in the CI and INT groups, respectively (RR [95% confidence interval] for CI 0.73, [0.35, 1.52]). AKI was reported in 12.9% and 17.4% of patients, respectively.

Conclusion

We were unable to detect a difference in late SSIs between intraoperative CI and INT cefazolin. Differences observed between AKI between groups requires further investigation, but likely impacted by confounders, including pre-existing renal dysfunction.

Disclosures

All authors: No reported disclosures.
1246. Outcomes of Extended Spectrum β-Lactamases Producing Enterobacteriaceae Colonization among Patients Underwent Abdominal Surgery
Authors: Apisarnthanarak Anucha , Condo Sumalee , Mingmalairak Chatchai , Mahawongkajit Prasit , Juntong Jatupong , Limpavitayaporn Palin , Sriussadaporn Ekkapak , Tongyoo Assanee , Mundy Linda
Published: October 2019

Background

To evaluate the outcomes of surgical patients colonized with extended-spectrum β-lactamases (ESBL) producing enterobacteriaceae (EN).

Methods

A prospective cohort study was performed from February 1, 2016 to April 1, 2019. All patients who underwent abdominal surgical procedures were enrolled. Enrolled surgical patients were screened for ESBL EN colonization by rectal swab culture 1 day before and 5 days after surgery. Data collection included clinical characteristics, risk of SSIs, previous hospitalization, and type of surgical procedure, antibiotic prophylaxis and duration, ASA risk class, and 28-day postoperative outcomes, inclusive of SSIs and associated microbiological data.

Results

Among 360 prospectively enrolled patients, 204 (56%) were male; the abdominal surgical types included 234 (65%) clean-contaminated, 90 (25%) contaminated, and 36 (10%) dirty cases. Pre-op,129 patients (36%) had ESBL EN colonization. Surgical prophylaxis included second-generation cephalosporins (N = 224, 62%), third-generation cephalosporins (N = 92, 25%), and carbapenems (N = 44, 12%). Post-operative SSIs were identified in 51 patients (14.1%) [superficial SSIs (N = 41) and intra-abdominal SSIs (N = 10)] By multivariate analysis, ESBL EN colonization (aOR = 2.4; 95% CI = 1.19–19.91) and dirty abdominal wound classification (aOR = 3.6; 95% CI = 1.94–16.99) were independent risk factors for SSIs. Culture detection of SSI pathogens differed for superficial vs. intra-abdominal SSIs. Pathogens associated with superficial SSIs included Staphylococcus aureus (10/41;24%), Streptococcus spp. (5/41; 12%), Pseudomonas aeruginosa (6/41; 15%) and non-ESBL EN (16/41;39%). In contrast, all 10 cases of intra-abdominal SSIs were attributed to ESBL EN.

Conclusion

Enteric colonization with ESBL EN was an independent predictor of intra-abdominal SSIs due to ESBL EN, while superficial SSIs were associated with a variety of non-ESBL pathogens. Our study support the need for awareness of the SSI risks associated with ESBL EN. Additionally, the findings support current surgical prophylactic guideline for the use of non-carbapenem among ESBL EN colonizer undergoing abdominal surgery.

Disclosures

All authors: No reported disclosures.
1247. Multicenter Study on Risk Factors for Surgical Site Infection After Exploratory Laparotomy
Authors: Rodrigues Túlio Alves Jeangregório , Fernandes de Oliveira Guilherme , Dias Júlia G C , Campos Laís Souza , Rodrigues Letícia , Correa Paulo Roberto Alvim , Soier Rute Rodrigues , Starling Carlos E F , Couto Bráulio R G M
Published: October 2019

Background

Exploratory laparotomy surgery is abdominal operations not involving the gastrointestinal tract or biliary system. The objective of our study is to answer three questions: (a) What is the risk of surgical site infection (SSI) after exploratory abdominal surgery? (b) What is the impact of SSI in the hospital length of stay and hospital mortality? (c) What are risk factors for SSI after exploratory abdominal surgery?

Methods

A retrospective cohort study assessed meningitis and risk factors in patients undergoing exploratory laparotomy between January 2013 and December 2017 from 12 hospitals at Belo Horizonte, Brazil. Data were gathered by standardized methods defined by the National Healthcare Safety Network (NHSN)/CDC procedure-associated protocols for routine SSI surveillance. 26 preoperative and operative categorical and continuous variables were evaluated by univariate and multivariate analysis (logistic regression). Outcome variables: Surgical site infection (SSI), hospital death, hospital length of stay. Variables were analyzed using Epi Info and applying statistical two-tailed test hypothesis with significance level of 5%.

Results

A sample of 6,591 patients submitted to exploratory laparotomy was analyzed (SSI risk = 4.3%): Hospital length of stay in noninfected patients (days): mean = 16, median = 6, std. dev. = 30; hospital stay in infected patients: mean = 32, median = 22, std. dev. = 30 (P < 0.001). The mortality rate in patients without infection was 14% while hospital death of infected patients was 20% (P = 0.009). Main risk factors for SSI: ügeneral anesthesia (SSI = 4.9%, relative risk – RR = 2.8, P < 0.001); preoperative hospital length of stay more than 4 days (SSI=3.9%, RR=1.8, P = 0.003); wound class contaminated or dirty (SSI = 5.4%, RR = 1.5, P = 0.002); duration of procedure higher than 3 hours (SSI = 7.1%, RR = 2.1, P < 0.001); after trauma laparotomy (SSI = 7.8%, RR = 1.9, P = 0.001).

Conclusion

We identified patients at high risk of surgical site infection after exploratory laparotomy: trauma patients from contaminated or dirty wound surgery, submitted to a procedure with general anesthesia that last more than 3 hours have 13% SSI. Patients without any of these four risk factors have only 1.2% SSI.

Disclosures

All authors: No reported disclosures.
1248. 30-Day Colon Surgical Site Infections: Using NSQIP to Cross Check NHSN
Authors: Strollo Stephanie L , Neelakanta Anupama , Reinke Caroline , Barringer Michael , Passaretti Catherine
Published: October 2019

Background

While infection prevention (IP) programs utilize National Health Safety Network (NHSN) definitions, surgical site infection (SSI) case-finding methods may vary between facilities based on resources and availability/type of healthcare-associated infection (HAI) electronic surveillance tracking software. Furthermore, surgeons may receive SSI data from other databases such as National Surgery Quality Improvement Project (NSQIP) which has slightly different definitions and case finding methodologies. Our goal was to compare colon SSIs across our health system found by IP using NHSN definitions to those obtained utilizing NSQIP case finding methodology and definitions.

Methods

Between January 2018 and September 2018 across 8 acute care facilities ranging in size from 100 to 898 beds, HAI electronic surveillance tracking triggered IP and infectious diseases (ID) trained physician review for NHSN SSI criteria if a patient was either readmitted or had a positive culture within 30 days of colon surgery. SSI results were compared with NSQIP SSI data which reviews all charts and conducts post-discharge surveillance during active surveillance periods. All discrepant cases were reviewed by an infection preventionist, an ID physician and surgery physician champion. Cases were classified as discrepant due to different case inclusion criteria, different case finding or clinical misclassification.

Results

69 cases were reviewed. Both databases called 11 cases (16%) an SSI initially. NSQIP identified 35 cases that were not detected by IP surveillance. Of the 35 NSQIP detected SSI, 17 (49%) were felt to meet NHSN SSI criteria after review (7 organ space, 10 superficial). Majority (76%) were discordant due to case finding issues (diagnosed as outpatient, same hospital course with no cultures to flag for review). Two infections were missed because of human error. Once the SSIs were entered into NHSN, only one facility had an increase in the SIR which impacted interpretation of SSI performance (from 0.949 up to 1.423). NHSN identified 23 cases that were not identified in the NSQIP database. There were 8 organ space infections and 8 superficial site infections.

Conclusion

Without 100% surveillance, SSIs may be missed. Not all missed infections were superficial. Opportunities were found for both NHSN and NSQIP.

Disclosures

All authors: No reported disclosures.
1250. Don’t Turn Your Back on Fusion Surgical Site Infections (SSIs)
Authors: Mclain Jessica , Bender Sarah , Santana Brandy , Brown Sidonne , Kuhl Ann , Layell Jessica , Passaretti Catherine
Published: October 2019

Background

Spinal fusion surgical site infections (SSI) increase morbidity, length of stay, readmissions and cost compared with those who do not develop an SSI. Initiatives aimed at improving spinal fusion care and reducing SSI are essential.

Methods

In a large metropolitan teaching hospital that performs 1,352 fusions annually, a multidisciplinary team consisting of infection prevention (IP), neurosurgeons, a performance improvement specialist, administration, and postoperative nursing staff was convened to discuss fusion SSI prevention best practices. The SSI prevention team focused on improving chlorhexidine (CHG) bathing compliance in preoperative areas and appropriate alcohol containing skin preparation compliance, developing a postoperative power plan, implementing CHG bathing postoperatively and standardizing postoperative wound care. Compliance with CHG bathing and alcohol containing skin prep was monitored, dressing audits were completed and compliance with all process measures was fed back to the stakeholders. Rates of fusion SSI pre-intervention (January 2017 thru June 2018) were compared with postintervention (July thru December 2018)

Results

From July 2018 to December 2018, compliance with CHG bathing in the preoperative area increased from 81% to 92% and compliance with the use of alcohol containing skin preparation agent improved from 83% to 94%. Postoperative daily CHG bath x 10 days was implemented January 2018 with 72% compliance. With the efforts of the multidisciplinary team, Fusion SSI decreased from 1.43 to 0.75 per 100 fusion surgeries (Risk Ratio 0.52, 95% CI 0.18 -1.27, p-value 0.17) pre vs. post-intervention. This correlated to a Standardized Infection Ratio (SIR) decrease from 1.43 to 0.73. There was a concomitant trend toward decreased observed: expected (O: E) 30-day readmission (1.05 pre vs. 0.98 post) during the same time frame.

Conclusion

An interdisciplinary team developed spinal fusion bundle consisting of CHG bathing pre and postoperatively, alcohol containing skin preparation agent, and standardized postoperative dressing care resulted in a trend toward decreased fusion SSIs. Further data are needed to determine whether the improvement in process measures and outcomes is sustainable and significant.

Disclosures

All authors: No reported disclosures.
1253. Sex-on-Premise Venue (SOPV) Attendance Among Men Who Have Sex with Men (MSM) in Lima, Perú: Results From a Cross-Sectional Web-Based Survey
Authors: Lankowski Alexander , Sanchez Hugo , Hidalgo Jose , Cabello Robinson , Duerr Ann
Published: October 2019

Background

In Perú, where the HIV epidemic is concentrated among men who have sex with men (MSM), incidence has not changed appreciably over the last decade despite the rapid scale-up of free antiretroviral treatment (ART). New strategies for delivering effective HIV testing and prevention services to at-risk populations are greatly needed. Because most adult MSM in Perú live at home with family where it may be difficult to bring new sex partners, sex-on-premise venues (SOPVs)—such as saunas, sex clubs, and hourly hotels—might represent opportune sites at which to offer targeted HIV testing and prevention interventions.

Methods

From November 26, 2018 through April 15, 2019 we conducted a cross-sectional web-based survey using REDCap to assess the prevalence of SOPV attendance and associated sexual risk behaviors among MSM in Lima, Perú. SOPVs were defined as saunas, sex clubs, adult movie theaters, hotels, or bars/discos known to permit sex. We recruited participants by disseminating an anonymous survey link through local gay social media networks, with no monetary incentive to complete the survey. We asked participants how/where they met any sex partners from the prior 3 months, where they went for sex, and about HIV-associated sexual risk factors, including self-reported HIV status. We used the Pearson chi-squared test and Student’s t-test to assess whether the frequency of sexual risk behaviors differed based on SOPV attendance.

Results

Among n = 324 cis-gender MSM completing the survey, 16% identified as bisexual. Median age was 30 years, 62% lived at home with family, 50% had a university education or higher, and 29% reported being HIV+. 65% of respondents reported attending an SOPV to meet a partner and/or have sex in the prior 3 months. SOPV attendees were significantly more likely to report transactional sex, group sex, sex under the influence of alcohol, popper use, and have a higher number of sex partners (table).

Conclusion

SOPV attendance is common among MSM in Lima and associated with higher levels of several sexual behavioral risk factors. In light of this, SOPVs warrant further consideration as potential sites of outreach to offer HIV testing and prevention interventions designed to reach MSM at high risk for HIV infection.

Disclosures

All authors: No reported disclosures.
1255. Comparison in AIDS-Related Mortality Between African Americans and Whites with Human Immunodeficiency Virus During the HAART Era
Authors: Cihlar Jennifer , Fichtenbaum Carl
Published: October 2019

Background

Higher death rates have been reported in African American (AA) compared with non-Hispanic whites with HIV infection. However, there are no published studies of attributable mortality by racial and ethnic groups. We evaluated differences in attributable mortality between AA and whites.

Methods

We conducted a retrospective review of all persons with HIV infection who received care at the University of Cincinnati Medical Center whose deaths were between 1996 and 2017. We abstracted chart data using a standard data tool and identified all deaths reported to the social security national database. Probable cause of death was assigned using the EuroSida CoDe methodology. Primary endpoint was to compare AIDS vs. non-AIDS-related deaths between AA and whites.

Results

Initial analysis of 588 deaths are reported through 2007 (44% AA and 53% white). The median age at the time of HIV diagnosis was 37 years for AA patients and 36 years for white patients, while median age at the time of death was 43 years for AA and 42 years for whites (P = ns). 16.9% of AA were women, 2.6% were transgender; 10.3% of whites were women and 1% were transgender (P < 0.02). Risk factors for HIV acquisition included: MSM, 61.3% of whites vs. 46.0% AA; heterosexual contact, 11.7% of whites vs. 13.4% for AA; and injection drug use 16.9% white vs. 18.3% AA (P < 0.0001). African Americans had both lower median CD4 counts at the time of diagnosis and within 3–6 months prior to death (167 and 68 cells/mm3, respectively) as compared with whites (214 and 103 cells/mm3, respectively) (P < 0.0001 for both). There was no statistical significance of having AIDS at entry into the practice between AA and whites (P = 0.79). AIDS-related deaths accounted for a larger percentage of overall deaths within white patients (51%) compared with AA patients (40%) (P = 0.03).

Conclusion

Our data show that while a greater percent of AIDS-related deaths were found in whites vs. AA in the early HAART era, AA patients typically have lower CD4 counts at the time of diagnosis and within 3–6 months prior to death. Future analyses will examine specific attributable mortality, HIV viremia and changes in causes of death over later HAART era. Understanding factors associated with mortality may inform care models to prevent or delay future deaths.

Disclosures

All authors: No reported disclosures.
1258. The Pregnancy Factor: Differences in the Prevalence of Depression Among Pregnant and Nonpregnant Sub-Saharan African Women Living with HIV
Authors: Jones Milissa U , Esber Allahna L , Reed Domonique , Kiweewa Francis , Maswai Jonah , Owuoth John , Bahemana Emmanuel , Iroezindu Michael , Crowell Trevor A , Polyak Christina , Ake Julie A , Hickey Patrick
Published: October 2019

Background

In Sub-Saharan African (SSA) women living with HIV, pregnancy creates unique stressors that may induce or exacerbate depression. We described the prevalence of depression during the perinatal period among women living with HIV that became pregnant (P-WLWH) as compared with those that did not (NP-WLWH).

Methods

We analyzed data from WLWH, age < 45 years, across 11 HIV clinics in Kenya, Nigeria, Uganda, and Tanzania, within the African Cohort Study (AFRICOS). Depression screening was performed via the Center for Epidemiological Studies-Depression (CESD) scale at enrollment and every 6 months in the study. For these analyses, the CESD score was assessed during three periods in time. For P-WLWH, these periods were: (1) enrollment, (2) during pregnancy and (3) the study visit following delivery. For NP-WLWH, three sequential evaluations were analyzed, with visit 1 being enrollment. We compared the prevalence of depression between groups at each period using χ 2 analysis and calculated adjusted odds ratios (OR) using logistic regression for variables associated with positive depression screening (CESD score ≥16).

Results

There were 764 WLWH selected for analysis, including 164 P-WLWH and 600 NP-WLWH. At enrollment, P-WLWH tended to be younger than NP-WLWH (mean age=30 vs. 34, P < 0.01). Neither group differed significantly with respect to marital status, employment, education, viral load, or duration of HIV. The crude prevalence of depression during periods 1 thru 3 for P-WLWH and NP-WLWH was: 20% (in both groups, P = 0.99), 10% and 13% (P = 0.26), and 4% and 10% (P = 0.01), respectively (figure). P-WLWH had 74% lower odds [OR = 0.26 [0.09–0.75], P = 0.01] of positive depression screening during period 3 than NP-WLWH, when controlling for age, marital status, educational level, viral load, and duration of HIV.

Conclusion

Surprisingly, our analyses demonstrate P-WLWH were less likely to have positive screening for depression following their pregnancies. These findings may highlight the strength of comprehensive maternal health initiatives in SSA. Additionally, these women will be followed further longitudinally to evaluate patterns of depression in the months following pregnancy.

Disclosures

All authors: No reported disclosures.
1274. The PrEP Care Continuum Among an Uninsured Patient Population
Authors: Jones Trahern Wallace , De La Cruz Cinthya N , Spivak Adam , Keeshin Susana
Published: October 2019

Background

Despite the clear preventive benefits of HIV Pre-Exposure Prophylaxis (PrEP), uptake among populations at highest risk of HIV acquisition has been limited by lack of health insurance and access to care. In March 2018 we opened a free PrEP clinic for those without insurance. We provide HIV prevention services, following the CDC guidelines, with PrEP case manager navigation, medical management, and medication for at-risk individuals free of charge.

Methods

Half-day clinics were organized on a twice-monthly basis with supervision provided by two infectious disease specialists and several other licensed providers/fellows, with supporting case managers and medical assistants. Medical students were enlisted to help organize and manage patient visits. All patient visits were preceded by discussion with case managers to document insurance status, followed by a sexual history and general physical examination by medical students and supervisory licensed providers. We performed all laboratory testing, diagnostics, and follow-up visits per CDC guidelines.

Results

From March 2018 to 2019, 193 self-identified at-risk patients scheduled an appointment; 157 unique patients were seen and all deemed eligible for PrEP per CDC guidelines. Of those eligible for PrEP, 140 (89%) received a prescription and started emtricitabine/tenofovir and 115 (73%) remain in care with ≥2 visits completed. Of the 25 no longer in care at our clinic, 6 have insurance or Medicaid (2 continue to be seen in our insured PrEP Clinic), 1 reports no HIV risk factors, and 1 is over-income for pharmacy patient assistance. Patients enrolled in clinic are largely male (145, 92%); 74% age ≤ 34, a disproportionate fraction belonging to a minority racial/ethnic group (67, 43%), with a majority Latinx (60, 38%). A total of 48 STI cases were identified, mostly rectal chlamydia, rectal and pharyngeal gonorrhea 39 (81%), and 9 (19%) cases of syphilis, and no new HIV or HCV infections. At the first visit, 17% of our patients have an STI and at subsequent visits 22% have a new STI.

Conclusion

Implementation of a free PrEP clinic for uninsured patients is a feasible and effective strategy to reach key populations at risk for HIV. STI rates are high in our population and increased after starting PrEP.

Disclosures

All authors: No reported disclosures.
1277. Retention Among Adolescents with Mental Health Diagnoses on Pre-Exposure Prophylaxis (RAMP) Study
Authors: Mayer Christopher M , Siddiqui Ramail D , Ellen Adams Mary , Strauss Brooke , Mathur Aneesh , Tristram Debra A , Santos Roberto P
Published: October 2019

Background

The CDC reported in 2017 that 21% of new HIV diagnoses were composed of persons 13–24 years old. New York State (NYS) is addressing this with the Ending the Epidemic initiative, started in 2014, which emphasized pre-exposure prophylaxis (PrEP) for persons at risk of acquiring HIV. Though PrEP can effectively prevent HIV transmission, NYS minors were only granted capacity to accept PrEP in 2017. The Adolescent Medicine Trials Network found clinicians had varying perceptions on whether mental health diagnoses (MHD) were a barrier to adolescent PrEP utilization. This study aims to test the hypothesis that patients with MHD do not differ in PrEP retention length when compared with adolescents without MHD.

Methods

This is a retrospective single-center study analyzing self-reported visit data for adolescent enrolled on PrEP (n = 27) in the Capital District, NY. MHD were confirmed with clinician notes and retention to PrEP was defined as attending appointments. Between-group differences were compared using Fisher’s Exact Test (FET). Kaplan–Meier curves were compared using the log-rank test.

Results

Of the 27 adolescents enrolled on PrEP between Sep 2015-March 2019, most self-identified as males (93%), MSM (85%), white (74%), and 13 (48%) had a MH diagnosis. Anxiety was the most common MHD (69%), followed by depression (38%). The mean age was 20.3 years (16–24). The average PrEP retention for patients with and without MHD were 262±136 and 292±138 days, respectively (P = 0.575). For patients with MHD, follow-up at 1-month, 3-months and 1-year was 10 (77%), 8 (62%), and 5 (39%), respectively. For patients without MHD, follow-up at 1-month, 3-months, and 1-year was 11 (79%), 10 (71%), 5 (36%), respectively. Follow-up between adolescents with and without MHD was compared at 1-month (P = 0.086, FET), 3-months (P = 0.695, FET), and 1-year (P = 1.0, FET). Adolescents’ retention on PrEP was depicted on Kaplan–Meier curves (Figure 1). Log-rank test indicated that PrEP retention is not significantly associated with MHD (χ2(1) = 0.1, P = 0.727).

Conclusion

Adolescents with and without MHD did not significantly differ in PrEP retention outcomes. The RAMP study elucidates a potentially incorrect provider bias regarding PrEP retention and MHD. Future investigation should be done prospectively with larger sample size.

Disclosures

All authors: No reported disclosures.
1283. Attitudes and Practices Regarding HIV Post-Exposure Prophylaxis
Authors: Sherrerd-Smith William , O’Connell Katie , Gill Shanedeep , Kisteneff Alice , Derber Catherine , Salts Laila , Lo Bruce
Published: October 2019

Background

Research suggests nonoccupational Post Exposure Prophylaxis (nPEP) is underprescribed when indicated in the Emergency Department (ED). This study is an assessment of ED providers’ attitudes and practices regarding administration of HIV nPEP.

Methods

This was an anonymous survey based on literature review and modified Delphi technique. We approached 153 ED providers at work over a 4-month period from 5 hospital-based and 2 freestanding EDs with an annual census between 35,000 and 75,000 patients. The EDs are a combination of urban, suburban, and rural EDs. There were 152 completed surveys: 80 attendings, 27 residents, and 44 physician assistants.

Results

The majority of surveyed providers (133/149, 89.3%) believe it is their responsibility as an emergency provider to provide HIV nPEP in the emergency department (Figure 1). Although 91% (138/151) and 87% (132/151) of respondents are willing to prescribe nPEP to a patient in the ED for IV drug use and unprotected sex, respectively, only 40% (61/152) of participants felt they could confidently prescribe the appropriate regimen. Ultimately, only 25% (37/151) of participants prescribed nPEP in the last year. Number of years in practice, age, and gender did not result in a significant difference in nPEP administration. Respondents noted time (27%), access to follow-up care (26%), cost to patients (23%), patients’ perceived interest in HIV counseling (15%), and concern for ongoing risky behaviors (9%) as barriers to prescribing nPEP (Figure 2). 64% (95/149) of respondents feel that it is their responsibility as an ED provider to refer patients at risk of nonoccupational exposures for risk-reduction counseling.

Conclusion

This study identified an opportunity for HIV prevention in the emergency department. The majority of participants had not prescribed nPEP in the past 12 months. Although most were willing to prescribe nPEP and felt it was their responsibility, the majority of participants were not confident in prescribing it. Future interventions to increase the use of nPEP in the ED should target provider education, cost, access to follow-up care and counseling.

Disclosures

All authors: No reported disclosures.
1288. Bone Safety Outcomes with F/TAF vs. F/TDF for PrEP in the DISCOVER Trial
Authors: Wohl David , Ruane Peter , Hosek Sybil , Creticos Catherine , Morris Sheldon , Phoenix John , Ramgopal Moti , Brinson Cynthia , Tremblay Cecile , Carter Christoph C , Wong Pamela , Brainard Diana M , McCallister Scott , Das Moupali , Thompson Melanie A
Published: October 2019

Background

In the DISCOVER PrEP trial, emtricitabine/tenofovir alafenamide (F/TAF) was noninferior to emtricitabine/tenofovir disoproxil fumarate (F/TDF) for HIV prevention. Here we report the bone safety outcomes of F/TAF and F/TDF.

Methods

Men who have sex with men (MSM) and transgender women (TGW) at risk of HIV were randomized 1:1 to receive blinded F/TDF or F/TAF, taken once daily. Those on PrEP with F/TDF were eligible to enroll. Bone densitometry (DXA) of the hip and spine were performed in a subset of participants (BMD subset). Fracture events were compared in all study participants. Week 48 data are presented.

Results

5387 participants were enrolled in the main study, with 383 included in the BMD subset. In the BMD subset, the median age was 37 (IQR 29, 46); 0.8% were TGW, 9.4% were black, and 20.6% were Hispanic or Latinx. Fifty-three BMD subset participants were on baseline F/TDF PrEP at enrollment, 26 of whom were randomized to F/TAF. F/TAF was associated with more favorable changes in hip and spine BMD compared with F/TDF (Table 1); these differences were similar when participants on baseline PrEP were excluded. Participants age <35 on F/TAF gained BMD, whereas those on F/TDF lost BMD (Table 1). BMD decreases of ≥3% were less frequent in the F/TAF group than the F/TDF group at the hip (3.8% vs. 18.4%, P < 0.001) and spine (10.1% vs. 26.9%, P < 0.001). Osteopenia was more frequently diagnosed in the spine in participants on F/TDF compared with F/TAF (Figure 1, P = 0.007); but not in the hip. Fracture event frequency was the same (53 [2.0%] per group, P = 1.00). One pathological fracture was reported in the F/TAF group compared with two in the F/TDF group (P = 0.57). In participants on baseline F/TDF PrEP, those randomized to F/TAF had significantly improved hip BMD compared with baseline (median percent change 1.13 [IQR −0.86, 3.47], P = 0.027), while spine BMD was unchanged.

Conclusion

Through 48 weeks, DXA subset participants taking F/TAF for PrEP had significantly less change in BMD than those taking F/TDF, and were less likely to develop spine osteopenia. The incidence of fracture was similar, and pathological fractures were rare. F/TAF for PrEP is effective and has a superior bone safety profile compared with F/TDF.

Disclosures

All authors: No reported disclosures.