bluuebunny/crossref_metadata_2025 huggingface dataset:
1265. Penicillin Allergy Delabeling: A Quality Improvement Project
Authors: Shah Ibrahim , Sheraz Sana , Ali Marriam
Published: November 2023

Background

15% of all hospitalized patients report a penicillin allergy, and greater than 90% of them are not truly allergic. Penicillin allergy labels are associated with worse clinical outcomes, increasing in-hospital mortality, and increasing hospital stays. Historically, penicillin allergies were delabeled by either allergists or infectious disease specialists. Pharmacy-led delabeling programs are emerging but are limited due to pharmacists not having provider status in all states. Also, after successful delabeling, a significant number of patients were relabeled for penicillin allergies on subsequent hospital visits.

Methods

We conducted an internal medicine resident-driven quality improvement project in a 350 bed community hospital. Fifty-six patients with a penicillin allergy label in the electronic medical record (EMR) were randomly selected from the inpatient service. If the patient had a non-allergic reaction or had prior exposure to penicillin without a reaction, they were directly delabeled. The remainder underwent risk stratification using the PENFAST scoring tool. Very low-risk and low-risk patients underwent an oral challenge after obtaining written consent. Following this, a hospital-wide pharmacist-triggered physician-driven delabelling protocol was established.

Results

We assessed 56 patients between 04/2022 and 09/2022. Thirty-eight patients were delabeled: 18 by direct delabeling and 20 via oral penicillin challenge. One patient who underwent the oral challenge had an adverse reaction (nausea and vomiting). Seven months later, we conducted a secondary survey to assess the durability of our delabeling. Thirteen percent of patients (n=5) had the penicillin allergy label re-added to their chart on subsequent hospital admissions.

Conclusion

Delabeling patients on the inpatient service is effective, carries little risk, and requires minimal resources. Additionally, it does not require specialist services. However, the durability of delabeling needs to be reinforced with a robust hospital delabeling protocol, continuous patient education, and EMR alerts to prevent allergy labels from being added back on subsequent visits.

Disclosures

All Authors: No reported disclosures
1266. Refining Antimicrobial Stewardship by De-escalating Vancomycin Using MRSA (Methicillin Resistant Staphylococcus aureus) Nasal Screening in a Community Hospital Setting
Authors: Shah Ruta , Sorell Caroline , Onussiet Monika
Published: November 2023

Background

Our institution has prioritized appropriate use of anti-Methicillin-resistant Staphylococcus aureus (MRSA) drugs such as vancomycin. The overuse of anti-MRSA drugs contributes to drug toxicities and development of resistant organisms such as vancomycin-resistant enterococcus (VRE). Recent studies show that MRSA nasal surveillance screening has a high negative predictive value of 96.5% in all types of pneumonia. At our community hospital a decentralized pharmacist-driven MRSA nares screening protocol was novel. We report the results of implementing a MRSA nares screening protocol for vancomycin de-escalation in pneumonia patients.

Methods

A decentralized pharmacist reviewed patients with a diagnosis of pneumonia and prescribed vancomycin. The pharmacist ensured that a culture-based MRSA nares screen was performed within 48 hours of admission, if not already ordered. If the nares screen returned negative and respiratory cultures did not grow MRSA at 48 hours, the decentralized pharmacist contacted the medical team to recommend discontinuing vancomycin. Reasons for exclusion included a positive respiratory culture for MRSA within the prior 7 days, septic shock, alternative site of MRSA infection, and greater than 48 hours of anti-MRSA therapy at time of swab collection.

Results

164 patients were reviewed by pharmacy between 6/16/22 and 4/25/23. 98% of MRSA nares screening had been performed within 48 hours of admission. MRSA screen was ordered by the decentralized pharmacist in 44% of patients. 89% of patients screened were negative for MRSA and reviewed for de-escalation of vancomycin. In 40% of patients, vancomycin was discontinued after recommendations by the decentralized pharmacist, with 95% of the recommendations accepted by the primary hospitalist physician. 37% of patients' vancomycin was discontinued by the attending physician. Overall, 77% of patients with negative MRSA nasal screen results were successfully de-escalated.

Conclusion

Our data highlights the effectiveness of close physician-pharmacy collaboration. Most nares cultures were negative for MRSA allowing for de-escalation of antibiotics. Pharmacist recommendations were accepted majority of the time. Given the data, we plan to apply this approach for other ongoing stewardship initiatives.

Disclosures

All Authors: No reported disclosures
1274. Long-term Sustainability of Improvements in Antibiotic Prescribing for Inpatient Skin and Soft Tissue Infections after Implementation of Local Treatment Guidelines
Authors: Voyer Kira , Shihadeh Katherine C , Cooper Margaret , Jenkins Timothy C
Published: November 2023

Background

Institutional guidelines for the management of inpatient skin and soft tissue infections (SSTIs) were implemented at an academic public safety-net hospital in 2009. This led to an immediate and marked decrease in unnecessary use of broad-spectrum antibiotics and durations of therapy. The objective of this study was to determine if these changes in prescribing have been sustained over time.

Methods

This was a retrospective review of patients hospitalized with cellulitis or abscess at Denver Health Medical Center between July 2016 and August 2022 (maintenance period). Case identification and data collection methods were identical to those used in a previous publication describing pre-intervention (January to December 2007) and intervention (July 2009 to July 2010) period data. The main outcomes were the proportion of patients exposed to an antibiotic with broad-spectrum gram-negative or antipseudomonal activity and the median duration of therapy.

Results

A total of 186 patients from the maintenance period were included for comparison with those from the pre-intervention (n = 169) and intervention (n = 175) periods. In the maintenance period, the median patient age was 41 years and 74% were male. The most common comorbid condition was injection drug use (27%). Overall clinical characteristics were similar between the three periods. The proportion of patients exposed to an antibiotic with broad gram-negative activity was 66% during the pre-intervention period, 33% during the intervention period, and 27% during the maintenance period. The proportion of patients exposed to an antibiotic with antipseudomonal activity was 28%, 18%, and 16% during the pre-intervention, intervention, and maintenance periods, respectively. The median total duration of therapy was 13 (IQR 10-15), 10 (IQR 9-12), and 8 (IQR 7-10) days in the pre-intervention, intervention, and maintenance periods, respectively.

Conclusion

Reductions in use of broad-spectrum antibiotics and durations of therapy for inpatients with SSTIs were sustained 12 years after implementation of a local treatment guideline. These findings add to the evidence that local guidelines are an effective antibiotic stewardship tool and demonstrate that resultant improvements in prescribing can be sustained over prolonged periods.

Disclosures

Timothy C. Jenkins, MD, Basilea: Clinical events adjudication committee
1284. Racial disparities in periprosthetic joint infections: A retrospective study
Authors: Davis Joshua B , Jamison Matthew P , Liimakka Adriana , Chen Antonia , Nelson Sandra B , Pinkney Jodian
Published: November 2023

Background

Total joint arthroplasty (TJA) is one of the most common surgical operations performed in the US. Periprosthetic joint infection (PJI) is a daunting complication of TJA and is associated with high morbidity. Previous studies have shown that racial disparities exist in postoperative complications of TJAs, including readmissions and mortality. However, it is unclear if such disparities also exist for PJI.

Methods

A single large hospital system database was used to identify all patients who underwent either primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) between January 2018 and December 2021. Patients were stratified by self-identified racial categories. PJI was defined by ICD-9/10 coding. We present descriptive data as frequencies and percentages for categorical variables and means and standard deviations for continuous variables. We used chi-square tests to estimate crude risk ratios (cRR) and 95% confidence intervals (CIs) for PJI by race.

Results

A total of 11,818 patients were included in the final analysis. The majority (96.6%) of patients identified as non-Black (Table 1). The mean age was 69.4 (±10.3) years for non-Black patients and 65.5 (±11.5) years for Black patients. Females represented the majority of non-Black and Black patients who underwent TJA (54.1% and 66.9%, respectively). The majority of TJAs were TKAs for both non-Black and Black patients (54.6% and 56.1%, respectively). The incidence of PJIs was 1.6% among non-Black patients compared to 3.3% among Black patients (cRR (95% CI): 1.99 (1.17 – 3.39); p=0.0112). The majority of PJIs occurred post TKA (Table 1).

Conclusion

Preliminary findings suggest that racial disparities exist in PJIs. These findings were not adjusted for possible confounding factors such as age, sex and comorbidities. Future studies are needed to determine if such disparities persist when other factors are considered.

Disclosures

Antonia Chen, MD, MBA, Adaptive Phage Therapeutics: Advisor/Consultant|Adaptive Phage Therapeutics: Grant/Research Support|Avanos: Advisor/Consultant|BICMD: Advisor/Consultant|Convatec: Advisor/Consultant|Elute: Grant/Research Support|Ethicon: Advisor/Consultant|GLG: Advisor/Consultant|Guidepoint: Advisor/Consultant|Heraeus: Advisor/Consultant|Hyalex: Stocks/Bonds|IlluminOss: Stocks/Bonds|Irrimax: Advisor/Consultant|Irrimax: Stocks/Bonds|Journal of Bone and Joint Surgery: Deputy Editor|Osteal Therapeutics: Advisor/Consultant|Osteal Therapeutics: Stocks/Bonds|Peptilogics: Advisor/Consultant|Peptilogics: Grant/Research Support|Pfizer: Advisor/Consultant|SLACK Incorporated: royalties|Smith and Nephew: Advisor/Consultant|Sonoran: Stocks/Bonds|Stryker: Advisor/Consultant|Taylor & Francis Group: Royalties|UpToDate: Royalties
1286. Evaluating Dalbavancin Suppression Therapy in Patients at High Risk for Recurrent Infections
Authors: Shaw Michael , Derrick Caroline , Pizzuti Morgan , Justo Julie Ann , Frens Jeremy J , Kufel Wesley D , de Lima Corvino Daniela , Krekel Tamara , Kabbani Salam , Brock Jeff , Derringer Jon , La Hoz Ricardo M , Kinn Patrick M , Diaz Beatriz , Brandon Bookstaver P , Antolí Ana Cristina
Published: November 2023

Background

Dalbavancin is a long-acting lipoglycopeptide used off-label in the treatment of deep-seated infections. An emerging potential niche for dalbavancin is chronic suppressive therapy in patients with retained sources. Limited data exists describing the use of DST. The purpose of this study is to evaluate the long-term safety, effectiveness, and optimal dosage regimens of dalbavancin suppression therapy (DST).

Methods

This was a multicenter, multinational, retrospective observational cohort study among adult patients who received as least 1 dose of suppressive dalbavancin between January 1, 2018 and March 31, 2023. The primary endpoint was the proportion of patients on DST who experienced treatment-emergent adverse events (TEAEs). Additional endpoints included assessment of clinical failure defined as hospitalization or microbiological recurrence due to index organism a and a detailed assessment of dosing regimens used.

Results

A total of 46 patients who received DST were assessed. Therapy was continued for an average of 6.8 months. The majority of patients (83%) had a retained prosthesis or device. Staphylococcal spp. was the most prevalent pathogen (47%) and the majority were monomicrobial. TEAEs were observed in 18 (39%) patients. Nephrotoxicity was the most common TEAE with 15 (33%) patients experiencing an AKI during DST. Only 1 TEAE (2.2%) was considered related to dalbavancin therapy TEAEs that led to the discontinuation or dosing modification of DST occurred in 1 (2.2%) patient. The most frequently used dosage scheme was 1500 mg IV every 2 weeks, followed by 1000 mg IV every 4 weeks. Eight patients (17%) were hospitalized or had microbiological recurrence due to the index organism, occurring an average of 7 months after starting DST.

Conclusion

DST was utilized for a variety of infections, most of which involved prostheses. Though TEAEs were observed in nearly 40% of patients, those resulting in discontinuation or dose modification were rare despite long-term follow-up. Majority of patients experienced clinical success at an average 7-month follow-up. Future prospective studies should assess pharmacokinetics of DST to determine the optimal dosage regimen.

Disclosures

Julie Ann Justo, PharmD, MS, FIDSA, BCPS, Gilead Sciences: Advisor/Consultant|Shionogi: Advisor/Consultant|Vaxart: Stocks/Bonds Wesley D. Kufel, Pharm.D., BCPS, BCIDP, AAHIVP, Merck & Co.: Grant/Research Support Tamara Krekel, PharmD, BCPS, BCIDP, AbbVie: Honoraria|Merck: Honoraria|Shionogi: Honoraria Ricardo M. La Hoz, MD, Takeda: Advisor/Consultant
1986. Switching to DOR/3TC/TDF Improves Renal Function and Decreases Lipid Levels in People Living With HIV: a Real-Life Multicentric Study
Authors: Micali Cristina , Russotto Ylenia , Doctor Medical , Francesco Pellicanò Giovanni , Panella Letizia , Albanese Antonio , Santoro Laura , Agata Sofia Sonia , Pantò Grazia , Coco Mariagiovanna , Guarneri Alessandro , Iacobello Carmelo , Paternò Raddusa Michele Salvatore , Ceccarelli Manuela , Marino Andrea , Maurizio Celesia Benedetto , Santi Cacopardo Bruno , Montineri Arturo , Frasca Chiara , Colpani Agnese , De Vito Andrea , Madeddu Giordano , Alibrandi Angela , Venanzi Rullo Emmanuele , Nunnari Giuseppe
Published: November 2023

Background

Pivotal studies on Doravirine (DOR) showed its high tolerability and effectiveness, even on resistant strains. Therefore, DOR and its single tablet combination treatment DOR/lamivudine (3TC)/tenofovir disoproxil fumarate (TDF) has been referred to as a cardiovascular-safe drug. However, data from real-life studies on safety and efficacy of DOR are lacking.

Methods

Retrospective multicenter cohort study, including 6 Italian HIV centers, evaluated adult treatment-experienced People Living With HIV (PLWH) who switched to DOR/3TC/TDF from June 2020 to June 2022. PLWH with known resistance mutations to DOR were excluded. Clinical and laboratory data were collected at the time of the switch and after 48 weeks.

Results

A total of 98 PLWH were switched to a DOR/3TC/TDF regimen, 75 (76.5%) male, with a median age of 52.41 years (IQR 42.95-58.79).

The main reason for switching to DOR/FTC/TDF regimens was proactive switch (33.3%). No differences were found between the two timepoints on plasma viral load (pVL) (p = 0.345), lymphocytes T CD4+ (CD4+) percentage (p = 0.994) and count (p = 0.611), and CD4+/lymphocytes T CD8+ (CD8+) ratio (p = 0.899), confirming the effectiveness of the drug combination. We also found a significant reduction in total (p < 0.001) and LDL (p = 0.025) cholesterol and triglycerides (p = 0.002). Importantly, we found that the estimated glomerular filtration rate (eGFR) calculated with CKD-EPI formula significantly improved despite the presence of TDF (p = 0.028).

Adverse events (AEs) were reported in 2 PLWHs and were characterized by the onset of a nodular rash in both arms and legs after 2 weeks of therapy in one PLWH, and by the onset of a progressive paresthesia in both extremities of arms after one week of treatment in the other PLWH. In both cases the treatment with DOR/3TC/TDF was interrupted.

Conclusion

The present real-life study showed that DOR/3TC/TDF significantly reduced lipid levels, surprisingly improving estimated renal function. The virological efficacy of DOR/3TC/TDF along with its immunological, metabolic and safety profile are key elements for a proactive management of the cardiovascular risk.

Disclosures

All Authors: No reported disclosures
1294. A Scientometric Study of the Top 100 Most Influential Papers on Septic Arthritis of Native Joints
Authors: Karaismailoglu Berna , Koroglu Ali Egemen , Celayir Arin , Karaismailoglu Bedri
Published: November 2023

Background

The rising popularity of bibliometric studies stems from their ability to determine the features of articles on particular topics. The objective of this study was to identify and evaluate the characteristics of the top 100 highly cited papers on septic arthritis of the native joints.

Methods

The study involved an analysis of the Web of Science database to identify the 100 most-cited articles related to septic arthritis. The characteristics of these articles, such as publication year, country of origin, journal, study type, and funding availability, were recorded and analyzed to identify any relationships or correlations with total citation count or citation density (i.e., citations per year). Additionally, software was used to create a visualization of the most frequently used keywords in the articles.

Results

The article with the highest citation count and density had 309 and 21.6, respectively. Out of the 100 selected papers, the majority (44 articles) were contributed by the United States. Case series studies were the most common type of research with 26 articles. Annals of the Rheumatic Diseases published the highest number of articles (8 in total). 15 studies were funded. The analysis revealed that the citation density of review articles was significantly higher than that of clinical and basic science studies (p< 0.001). The citation density was positively correlated with the publication year and number of contributing institutions, but negatively correlated with the level of evidence.

Figure 1

The map of keyword co-occurrence obtained by VOSviewer Version 1.6.16.

Figure 2

The correlation analysis between citation density and the publication year. A positive correlation was found indicating increased citation density in more recent papers. (Spearman’s Rho =0.655, p<0.001)

Figure 3

The correlation analysis between level of evidence and publication year. A negative correlation was found indicating that the recent papers have higher level of evidence. (Spearman’s Rho=-350, p=0.003)

Conclusion

The study found that the majority of highly cited papers related to septic arthritis have a low level of evidence, highlighting the need for higher quality research in this area. Furthermore, the analysis revealed a positive correlation between citation density and both publication year and number of institutions involved, indicating better citation performance for more recent articles and those with contributions from multiple institutions. There was a negative correlation between level of evidence and publication year, suggesting that study designs have improved over time.

Disclosures

All Authors: No reported disclosures
1297. Implementation of a Prosthetic Joint Infection Clinic in a Rural Setting
Authors: Lindsay John D , Lastinger Allison
Published: November 2023

Background

Nearly one million patients undergo hip or knee replacements in the United States every year This number is expected to double by 2030. The rate of prosthetic joint infection (PJI) ranges from 0.5 to 2% which translates to between 50,000 to 200,000 PJIs annually. Prosthetic joint infections have high rates of morbidity and mortality. These complex patients are best managed in a multidisciplinary clinic. In 2018, we implemented a specialized Ortho ID clinic where PJI patients are seen by their joint surgeon and ID physician in a single coordinated visit. In this study, we compared no-show rate, miles traveled to clinic, C diff rates, and other complication rates for PJI patients before and after the implementation of our Ortho ID clinic.

Methods

We performed a chart review of PJI patients treated at our institution, comparing a group of patients who were treated prior 2018 in the General ID clinic to a group of patients who were treated after 2018 in the Ortho ID clinic. We assessed no-show rates, cumulative distance driven and time spent driving (calculated using Google Maps), C. diff rate, and rates of side effects between the 2 groups.

Results

The combination clinic improved ID follow-up. Prior to the clinic, only 70% of PJI patients were followed by ID after hospital discharge compared to 100% after the clinic was founded. The no-show rate for PJI patients decreased from 18.2% pre-clinic to 6.9% post-clinic. The mean distance traveled pre-clinic was 226 miles compared to 192 miles post-clinic. The C diff rate decreased from 9.09% pre-clinic to 5.22% post-clinic. Rate of acute kidney injury decreased from 11.1% pre-clinic to 3.45% post-clinic.

Conclusion

Our Ortho ID Clinic’s biggest impact was improving ID follow-up for these complicated patients. Prior to the Clinic’s implementation, approximately 30% of PJI patients never followed up with ID after being discharged from the hospital. We saw positive outcomes with regards to reducing C diff rates and rates of acute kidney injury.

Disclosures

All Authors: No reported disclosures
1298. High Prescription Rate of Medications with Significant Rifampin Drug Interactions in Patients with Diabetic Foot Osteomyelitis: Should Rifabutin be Included in Clinical Trials for Adjunctive Therapy?
Authors: Mallarino-Haeger Christina , Watson Allison , Mahgoub Umnia , Francis Lily , Heydari Maryam , Choudhary Muaaz , Kempker Russell R , Schechter Marcos
Published: November 2023

Background

Diabetic foot osteomyelitis (DFO) is a leading cause of amputations. Rifamycins can penetrate osteoblasts and disrupt biofilm, making them ideal adjunctive antibiotics for DFO. A recent retrospective DFO study found that rifampin adjuvant therapy was associated with significantly higher amputation-free survival rate and randomized clinical trials to establish whether adjunctive rifampin therapy improves DFO outcomes are ongoing. Rifamycin use is complicated by drug-drug interactions (DDIs), primarily due to cytochrome P450 induction. However, rifabutin is a less potent and broad cytochrome P450 inducer versus rifampin. We evaluated DDI predicted rates of rifampin and rifabutin in a DFO cohort.

Methods

We conducted a retrospective cohort study of all patients hospitalized with DFO between 2017 and 2019 at Grady Memorial Hospital (Atlanta, GA). We queried discharge billing records using ICD-10 codes for DFO and performed a chart review to confirm the diagnosis. We used the Lexicomp DDI tool to determine the number of potential DDIs between all medications prescribed upon discharge and rifampin or rifabutin.

Results

There were a total of 530 hospital admissions among 330 unique patients for DFO of which 70% were male and 80% were Black. The mean hemoglobin A1c was 9.4%. Chronic kidney disease was present in 69% of patients. Among 239 DFO cases with a culture, S. aureus was identified in 79 (33%). Eighty-nine (27%) patients were prescribed medications with a class X (“avoid combination”) rifampin interaction versus 4 (1%) patients who were prescribed drugs with a rifabutin class X interaction. Two-hundred-and-forty (73%) patients had prescriptions for medications with a class D (“avoid combination”) rifampin interaction versus 15 (5%) with a class D rifabutin interaction. The most common medications with class X rifampin DDIs were proton pump inhibitors (20%) and directly acting oral anticoagulants (5.7%), while those for class D rifampin DDIs were atorvastatin (35%) and clopidogrel (12%).

Conclusion

A high percentage of patients with DFO were prescribed medications with significant rifampin DDIs compared with rifabutin, supporting the need to investigate rifabutin for adjunctive DFO therapy.

Disclosures

All Authors: No reported disclosures
1301. Assessing Safety and Clinical Outcomes of Outpatient Parenteral Antimicrobial Program in Veterans
Authors: Rich William , Epstein Lauren H , Oliver Nora T
Published: November 2023

Background

Outpatient parenteral antimicrobial therapy (OPAT) is administering intravenous antibiotics in the outpatient setting. Herein we wish to understand the Atlanta VAMC (AVAMC) home OPAT population, infection details, and risk factors for hospital readmission, adverse drug events (ADEs), and clinical failure.

Methods

Medical records of AVAMC veterans receiving home OPAT (not hemodialysis or infusion center) January 1, 2019 and June 30, 2022 were reviewed. Data collected included: demographic and co-morbidity data, OPAT indication/infection type, microbiological information, presence of surgical debridement, and antimicrobial selection and duration of therapy.

Outcomes included ADEs such as venous access events, laboratory abnormalities, and Clostridioides difficile infection. Other information include modification of OPAT plan (drug or duration), patient follow-up visit occurrence, re-hospitalization, and clinical resolution of infection. Univariate regression analyses were conducted on a subset of patients with musculoskeletal (MSK) infections (e.g. osteomyelitis, prosthetic joint infection).

Results

A total of 149 veterans were reviewed, with median age 66 years, 92% male, and 44% white race. Median CCI score was 5, and 80/149 (54%) patients had diabetes. The majority of infections were bone infections (30%), followed by diabetic foot osteomyelitis (24%). Methicillin-sensitive S. aureas was the predominant bacteria isolated (20%). See included table for full details.

In the full cohort, 100/149(68%) had clinical resolution at 6 months and 20/149 (13%) had ADE during therapy. Rehospitalization occurred in 29 (20%) pts. Diabetes was associated with increased risk of failure -- Risk Ratio (RR) 1.68 (95% CI 1.01-2.77). Patients with clinic follow-up had a RR of 0.39 (95% CI: 0.21-0.73) for rehospitalization versus pts without follow-up.

For pts with diabetes in the MSK group (N=97), risk of failure was 1.50x higher than those without diabetes (95% CI: 0.67-3.34).The RR for rehospitalization was 0.23 (95% CI: 0.06-0.82) for patients who received follow-up compared to patients who did not receive follow-up.

AVAMC OPAT population demographic data, N = 149

Conclusion

The AVAMC OPAT cohort is an older group with largely MSK-related infections and MSSA. Few ADEs occurred, and clinical failure remained high.

Disclosures

All Authors: No reported disclosures
1306. Lower Treatment Failure Rates in Patients with Non-Staphylococcal Prosthetic Joint Infections (PJI) Treated with Debridement and Implant Retention (DAIR) Receiving Chronic Antibiotic Suppression (CAS)
Authors: Sekar Poorani , Merchant James , Alexander Bruce , Miell Kelly , Beck Brice , Nair Rajeshwari , Suh Daniel , Richards Christopher , Puig-Asensio Mireia , Pugely Andrew , Walhof Julia , Dukes Kimberly , Schweizer Marin
Published: November 2023

Background

PJI occurs in 0.5-2% of Joint Arthroplasty. Patients with acute non-Staphylococcal PJI who undergo DAIR are treated with 6 weeks of antimicrobials after which CAS may be considered. We aimed to compare the incidence of treatment failure between people who received CAS and those who did not.

Methods

This is a retrospective cohort study of patients admitted to Veterans Affairs (VA) hospitals from 2003-2017 with a non-Staphylococcal PJI, underwent DAIR and received 6 weeks of antimicrobial treatment (Table 1). CAS was defined as at least 30 days of oral antibiotics after 6 weeks of antimicrobial treatment. Duration of CAS was categorized as short (1-3 months), moderate (3-6 months) and long ( >6 months) (Fig 1). Patients were followed for 5 years. Treatment failure was defined as microbiologically confirmed recurrent PJI, additional debridement or re-operation at the same site. Cause-specific Kaplan-Meier curves were used to compare treatment failure rates between those who did and did not receive CAS, censoring on death.

Results

Among 468 patients with non-staphylococcal PJI who underwent DAIR, 208 (44.4%) received CAS. Patients with Enterococcus PJI were statistically more likely to receive CAS. K-M curves showed patients on CAS had a higher estimated failure free survival probability at 5 years when compared to those who did not get CAS (66% vs. 55%, p< 0.01) (Fig 2). When antibiotic use was considered as a time-dependent covariate, CAS was associated with a decreased hazard of treatment failure (hazard ratio (HR): .47 (95% confidence interval [CI]: 0.29, 0.76). After statistically adjusting for surgical site, severity of illness, and alcohol abuse, a short duration of CAS was significantly associated with decreased treatment failure (HR=0.24; 95% CI: 0.11, 0.52). There was no significant association between moderate or long duration of CAS and treatment failure (Table 2)

Table 2

Conclusion

A short duration of CAS may be beneficial among patients with non-Staphylococcal PJI who underwent DAIR. However, there was not a statistically significant association between longer duration of CAS use and treatment failure. Thus, the risks and benefits of long-term antibiotics should be weighed when aiming to prevent recurrence of PJI.

Disclosures

Mireia Puig-Asensio, MD, GILEAD: Honoraria Andrew Pugely, MD, MBA, Globus Medical: Advisor/Consultant|Globus Medical: Grant/Research Support|Globus Medical: IP royalties|Medtronic: Advisor/Consultant|Medtronic: Grant/Research Support|RDB Bioinformatics: Grant/Research Support|United Healthcare: Advisor/Consultant
1307. Vaso-occlusive Crisis is Associated with Subsequent Osteomyelitis in Pediatric Sickle Cell Disease
Authors: Shapiro Kate , Wolf Joshua , Jesudas Rohith , Winer Jeffrey C , Arnold Sandra
Published: November 2023

Background

Children with sickle cell disease (SCD) commonly develop microvascular infarcts of bone known as vaso-occlusive crisis (VOC) and are also at high risk of osteomyelitis (OM). VOC and OM can be challenging to distinguish due to overlapping clinical features. VOC might predispose to OM, or an initial misdiagnosis of OM as VOC might lead to delayed diagnosis of OM. This study aimed to test whether VOC was associated with subsequent development of OM in children with SCD.

Methods

A retrospective Pediatric Health Information System (PHIS) database study (2010-2021) was performed. ICD-code data related to common diagnoses in pediatric patients with SCD were extracted. The rate of VOC within 30 and 180 days preceding episodes of OM was compared to the rate preceding acute chest syndrome (ACS), another common diagnosis in children with SCD but unlikely to be anatomically related to OM. Odds ratios (OR) were used to evaluate the association between these diagnoses.

Results

Of 22,818 PHIS participants with SCD, 13,699; 450; and 7,327 had ≥ 1 episode of VOC, OM and ACS, respectively. The distribution of OM diagnoses was similar across pre-specified age groups (0-4, 5-12, and 13-18 years). The odds ratio of VOC preceding a diagnosis of OM vs. ACS was 2.15 within 30 days (95% CI: 1.82-2.54; p= 3.68 x 10-18), and within 180 days was 1.39 (95% CI: 1.20-1.62; p=2.04 x 10-5).

VOC Preceding Osteomyelitis vs. Acute Chest Syndrome

Conclusion

VOC was significantly more common in the days preceding a diagnosis of OM than of ACS. The strength of association was stronger within 30 days prior to OM than 180 days. These results suggest possible misdiagnosis of OM since VOC might delay OM diagnosis in some cases, that recurrent VOC might be misdiagnosed as OM, or that VOC can directly contribute to risk of OM in some cases. Limitations of this study include possible incomplete adjustment for unmeasured variables which could confound the analysis. More research is needed to confirm and evaluate the mechanism behind this association. Understanding the relationship could lead to improved screening and treatment of both VOC and OM.

Disclosures

Joshua Wolf, MBBS, PhD, Karius Inc.: Grant/Research Support|Merck Inc.: Participation in industry-sponsored research Sandra Arnold, MD, Contrafect: Grant/Research Support|Enanta: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support
1318. Clinical Characteristics of Patients with Patent Foramen Ovale and Pyogenic Brain Abscess
Authors: Chesdachai Supavit , Tabaja Hussam , Yetmar Zachary A , Enzler Mark , Reeder Guy S , DeSimone Daniel C , Baddour Larry M , Abu Saleh Omar M , Corsini Campioli Cristina G
Published: November 2023

Background

Patent foramen ovale (PFO) can be identified in about 20-25% of the adult population and may result in variable degrees of left-to-right and right-to-left intracardiac shunting. The association between PFO and pyogenic brain abscess remains poorly understood. The current study aimed to compare the clinical characteristics and outcomes of pyogenic brain abscess in patients with and without PFO.

Methods

All adults with pyogenic brain abscess seen at Mayo Clinic from 1/1/2009-12/31/2021 who underwent either transesophageal echocardiography (TEE) or transthoracic echocardiography (TTE) with agitated saline shunt (bubble) study were included.

Results

A total of 222 patients developed pyogenic brain abscess during the study period; 148 (66.7%) patients were excluded due to unknown PFO status. Among 74 remaining patients, PFO was detected in 30 (40.5%) patients; 25 by TEE and 5 by TTE with bubble study (Figure 1). The prevalence of cryptogenic brain abscess (unable to identify the source of abscess) was significantly higher in patients with PFO as compared to those without PFO (53.3% versus 18.2%, p=0.002). Patients with PFO had a larger abscess size (25 mm [IQR 15.8-37.5] versus 15.5 mm [IQR 10.0-28.0], p=0.038). However, multiple abscesses were more common in the group without PFO (43.2% versus 20.0%, p=0.038). Additionally, patients with PFO had less documented bloodstream infection. There were no differences between other clinical characteristics and one-year, all-cause mortality between two groups.

Conclusion

These findings provide critical insights into the likely association between PFO and cryptogenic brain abscess; additional investigation is warranted.

Disclosures

Larry M. Baddour, MD, Boston Scientific: Advisor/Consultant|Roivant Sciences: Advisor/Consultant
1326. Comparison of Positive BioFire® FilmArray® Meningitis Encephalitis (ME) Panels, CSF cultures, CSF Parameters and Inpatient Mortality Among Patients with Bacterial and Fungal Meningitis
Authors: Myint Thein , Castillo Marice Ruiz Conejo , Soria Jaime , Arora Vaneet , Ribes Julie
Published: November 2023

Background

The aim of this study was to evaluate the performance of the BioFire® FilmArray® Meningitis Encephalitis panel (MEP) for the detection of bacterial and fungal pathogens compared with cerebrospinal fluid (CSF) cultures and other parameters to determine the predicted value of a positive result (PPV).

Methods

This study is a retrospective chart review of patients with positive MEP from 10/2016–9/2022 at the University of Kentucky. Results of the MEP, culture, cellularity, protein, and glucose were collected using an electronic medical record search. Chart review was performed to collect demographic data, presentation, and test indication if a bacteria or fungus was identified. MEP was considered true positive (TP) if it was confirmed by CSF culture. It was classified a likely TP based on a positive CSF Gram stain, blood culture, other CSF findings consistent with clinical meningitis. It was considered false positive (FP) if the MEP was discordant with CSF and clinical findings. Statistical analysis was performed.

Results

Of the 11,969 panels tested, 132 (1.1%) were positive for bacterial or fungal pathogens. Seventeen positive repeats were excluded. Clinical characteristics, outcomes, and CSF findings for 115 patients with positive MEP for bacterial and fungal organisms are shown in Table 1. Results were summarized as TP, likely TP or FP by the pathogen detected (Table 2). The majority of results [106(92.2%)] were classified as TP or likely TP whereas 9 (7.8%) were classified as FP. 28/37 (75.7%) of patients with negative CSF cultures received at least one day of antibiotics prior to lumbar puncture. One third of the FP results were S. agalactiae. FP were statistically different from those classified as positive for cellularity, glucose and protein (Table 3).Table 1.Clinical Characteristics, Outcomes, and CSF Findings of Patients with BioFire® FilmArray® ME panels Positive for Bacterial and Fungal OrganismsTable 2:Clinical Correlation of Positive BioFire® FilmArray® Meningitis Encephalitis Panel (MEP) for Bacterial and Fungal Organisms and CSF Parameters

Conclusion

The PPV of MEP ranged from 78.6-100% based on an organism. Three-quarters of negative CSF cultures were likely from a prior antibiotic exposure. FP MEP were most common for S. agalactiae. Interestingly, 27.4% (29/106) cases (excluding the FP) would not have had a pathogen definitively identified if MEP was not used. The positive CSF and blood culture rates were higher for cryptococcal meningitis. The median CSF cell count and protein were the highest among patients with S. pneumoniae meningitis. Inpatient mortality was uncommon.

Table 4. Clinical Characteristics and Outcome of Patients with False Positive Biofire® ME Panel with Negative CSF Gram Stain and Cultures

Disclosures

All Authors: No reported disclosures
1327. The Diagnosis of Subarachnoid Neurocysticercosis Is Often Delayed And Other Findings of a Multicenter Retrospective in the USA
Authors: Guzmán Janitzio J , Herrick Jesica A , Hatlen Timothy , Weatherhead Jill E , Clark Eva , Serpa Jose , Chow Felicia , Allyn Paul R , Wald-Dickler Noah , Rodriguez Jorge M , Bowman Natalie M , Cervantes-Arslanian Anna , Coyle Christina , White A Clinton Clinton , Amusu Senate , Martin Dannae , Duffey Megan M , Larsen Travis , Welford Elliott M , Jenks Jeffrey D , Cowell Anne , Henao Martínez Andrés F , Franco-Paredes Carlos , Mathisen Glenn , Lichtenberger Paola , Bouzigard Rory , Castellino Laila M , O’Connell Elise M
Published: November 2023

Background

Subarachnoid (racemose) neurocysticercosis (SANCC) is an uncommon but severe form of Taenia solium infection. There is limited evidence to guide clinical management of these patients.

Methods

We performed a multicenter retrospective chart review of 15 U.S. sites. A total of 69 subjects with racemose disease were entered.

Results

The most common region of exposure was Mexico (67%) followed by Central America (24%). Median age was 43 years (range 15-76) and 71% were male. Common symptoms at the time of index admission were headache (80%), nausea/vomiting (46%), dizziness (44%), and blurry vision (33%). Cysts were intracranial in 64 (93%) subjects and exclusively intraspinal in 4. One patient had meningitis without visible cystic lesions. Incident admission magnetic resonance imaging (MRI) demonstrated ventriculomegaly in 41 (59%) and focal findings in 9 (13%) including ischemic infarct, subarachnoid hemorrhage, and/or arterial aneurysm. For 55 (80%), SANCC was first diagnosed during the index admission. Of these, 23 (42%) had prior medical visits and substantial delay in diagnosis (i.e. previously seen with hydrocephalus [27%], stroke [5.5%], and/or meningitis [11%], missed diagnostic radiologic features [4%], or inadequate imaging [5.5%]). Of the 69 subjects, 54% underwent a neurosurgical procedure during index admission (cyst removal n=16, EVD/shunt/ventriculostomy n=24). At the time of discharge, 6 (8.6%) patients were not given albendazole and/or praziquantel due to cost or availability. Six months following discharge, < 10% of follow up MRIs demonstrated cyst resolution. Planned treatment course of < 4 weeks at discharge compared to >4 weeks was associated with increased risk for new cyst development on follow up imaging at a median of 3.8 years following discharge (range 2.6 months-8 years). Those with a delayed diagnosis received a significantly longer duration of corticosteroids (median 8 weeks) than those without a delay (median 5 weeks, p=0.047).

Conclusion

The diagnosis of SANCC is often missed, and most patients require neurosurgical intervention. Antiparasitic therapy is suboptimal, especially with regimens developed for parenchymal NCC.

Disclosures

Jeffrey D. Jenks, MD, MPH, Astellas: Grant/Research Support|F2G: Grant/Research Support|Pfizer: Grant/Research Support
1328. Human Parechovirus in Infants: A Case Series
Authors: Robles Tiffany , Gordji Roya , Downey Rachel , Hauger Sarmistha
Published: November 2023

Background

Human parechovirus (HPeV) is a common virus that causes a myriad of clinical presentations ranging from mild symptoms to severe disease. Signs of severe illness include sepsis, seizures, and meningoencephalitis as well as reports of abnormalities seen on brain imaging associated with neurodevelopmental or cognitive delay. Within the last year, there have been increased reports of severe HPeV in neonates.

Methods

This is a single-center, retrospective case series at a children's hospital in Central Texas. Inclusion criteria were patients from birth to 18 years with cerebrospinal (CSF) biofire positive for HPeV from 4/1/2016 to 2/28/2023. A comprehensive review of all CSF biofire tests in this interval was performed to identify the sample population.

Results

Seventeen children were identified and included in the study. Of these, 13 (76%) presented between 4/1/2022 to 6/30/2022. Laboratory findings included leukopenia in 87% of cases and unremarkable CSF in 94% of cases. Thirteen cases exhibited non-specific fussiness. Three infants had electroencephalogram (EEG) performed, for seizure-like activity or persistent fussiness, of which two had mild encephalopathy. While neither had CSF inflammation, brain magnetic resonance imaging (MRI) revealed areas of restricted diffusion. Repeat brain MRI 4 months from initial revealed resolution of restricted diffusion in both; one had sequelae of moderate volume loss.Figure 1:HPeV Frequency

Depicts the number of CSF biofire tests that resulted positive for HPeV by year. There were no cases in 2021 or in 2023 through 2/28/2023. A notable increase in frequency of HPeV is seen in 2022.Figure 2:Age at Presentation in Days

Depicts the age at presentation of each patient who tested positive for HPeV in CSF. The mean age at presentation was 26 days.Figure 3:White Blood Count of Patients with CSF Positive HPeV

Depicts the white blood count (WBC) of patients with positive HPeV on CSF biofire. Of note, two cases of positive HPeV were not included given WBC was not collected. The mean WBC was 6.2.

Conclusion

Our data parallel national trends of increased incidence of HPeV identified in 2022, with a cluster of 13 cases within a 3 month period. Cases were primarily neonates. The majority had non-specific fussiness, but there were cases of extensive neurologic involvement. CSF cell counts were relatively unremarkable, even in patients with encephalopathy. Generalized leukopenia was a common finding, thus may be an indicator of HPeV infection. Importantly, of the two infants with encephalopathy and changes on neuroimaging, one had imaging that remained persistently abnormal and clinically had mild delays in gross and fine motor functioning.

Disclosures

All Authors: No reported disclosures
1329. Clinical Profile and Outcomes of Adults with Meningitis: A Prospective Observational Study from India
Authors: Sukhadiya Pankaj , Gopalakrishnan Maya , Bohra Gopal Krishana , Shukla Kamlakant , Garg M K
Published: November 2023

Background

Meningitis is a highly fatal disease, causing 33,337 deaths/year in India, > 50% of survivors develop sequelae -hearing loss, seizures, and cognitive impairment. Prior studies have been limited to pediatric populations or specific etiology. We explored the clinical profile, outcomes, and mortality risk factors in adult meningitis.Table 1:Previous studies on the prevalence and outcomes of meningitis in India

Methods

Clinically suspected meningitis defined as 2 of 3 features- fever, headache, and focal/global central nervous system (CNS) dysfunction presenting to our centre were included from Mar 21-Sept 22, after consent and ethics approval. Patients were classified as acute/subacute based on the duration of illness of ≤ or > 5 days. Clinical details, Glasgow coma scale (GCS), cerebrospinal fluid parameters, and brain imaging were recorded. Modified Rankin Scale score (mRSS) was calculated at admission, discharge, and at 1 month. Multivariable regression analysis was done to identify mortality and morbidity risk factors.

Results

Of 209 patients enrolled, 154 were diagnosed with meningitis, (57% acute 43% subacute) with viral (40%), tubercular (TBM) (36%), bacterial (12%), and others (12%). Mean age was 48.2 ± 20.5y, male: female ratio 1.6, 24% had the classical triad of fever, headache, and neck stiffness. Abnormal brain imaging was reported in 77%- MRI (97.5%) and CT (60%). Mortality was 29% (n=44) and 30% within TBM. Medical Research Council grade was distributed as grade 3(48%), grade 2 (32%) and grade 1(20%) in TBM. At admission, 44% had mRSS 4 (highest). The highest score at discharge and 1 month were 1 (25%) and 0 (32%) respectively. 105 patients developed complications, 70% CNS, 4% only extra CNS and 26% both; most common being drug induced hepatitis in TBM (n=29). Multivariable regression showed GCS ≤ 10, focal neurological deficits, sepsis at admission, thrombocytopenia (≤ 1,00,000/uL) and HsCRP ≥ 45 mg/dL, were significant mortality predictors, whereas low GCS at presentation predicted morbidity.Figure 1:Frequency of etiology in meningitis patients (n=154)Figure 2:MRS Score at admission, on discharge and at 1 month follow up in meningitis patients (n=154)Table 2:Multivariable analysis: Mortality predictors in meningitis patients (n=154). OR - Odds Ratio CI - Confidence Interval

Conclusion

This is the first Indian study to explore the clinical profile and outcomes in adult meningitis. Viral meningitis was most frequent, while TBM had most fatalities. Our study shows that meningitis mortality is high even at tertiary care facilities in India. This highlights the need for reliable point of care diagnostics and better therapeutics.Table 3:Mortality in enrolled patients with meningitis (n=154)Table 4:Frequency of complications within different meningitis etiologies (n=154)

Disclosures

All Authors: No reported disclosures