bluuebunny/crossref_metadata_2025 huggingface dataset:
1379. Comparison of Inpatient Tuberculosis Screening Methods and Their Effect on Patient Duration in Airborne Isolation
Authors: Katherine. Theoktisto Mary , Ford Delvina , Khan Omar , Reveles Kelly R , Cadena Jose
Published: October 2019

Background

Tuberculosis (TB) remains a significant public health concern, and exposure in healthcare settings is prevalent. Current guidelines recommend testing for TB by acid-fast bacilli (AFB) smear microscopy with 3 sputum samples and/or using nucleic acid amplification test (NAAT), and mycobacterium culture. The purpose of this project is to compare how different TB diagnostic tests affect the duration of stay in respiratory isolation.

Methods

This study was conducted at the Veteran Affairs South Texas hospital, which includes a total of 437 beds. Data were collected retrospectively from medical records. Eligibility included patients admitted to the hospital and placed in airborne isolation for TB screening and diagnosis, had 3 sputum samples collected 8 hours apart and/or had 2 PCR MTB/RIF. Patients were excluded if they had TB or were not undergoing evaluation for TB. Three time periods analyzed included, 3 AFB sputum samples analyzed in-house from December 2012 to January 2014 (Group A), 3 AFB sputum samples analyzed at outside facility during 2013 to 2014 as well as 2 months in 2012 (Group B), and 2 MTB PCR/RIF in house during 2017 and 2018 (Group C). Duration of isolation was compared between groups using the Kruskal–Wallis test. A total number of 815 patients were screened, leaving 105 patients for analysis after exclusion. There were 49 patients analyzed from Group A, 28 from Group B, and 28 from Group C.

Results

Crude analysis of the data showed numerical differences in the total number of days and hours in isolation between the 3 groups. The average (mean) days in isolation were 4.2 for Group A, 7.4 for Group B, and 5.5 for Group C. There was no statistically significant difference in either days or hours of airborne precautions by “rule out” method. Days of isolation in airborne precautions (median IQR) was 4 for all groups (P = 0.3313). Likewise, hours of airborne precautions had a median IQR of 96 for all groups P = 0.4347.

Conclusion

Although there was no statistical significance between the groups, crude analysis did show a numerical difference in the mean total airborne days and hours. Lack of statistical difference may be due to low number of patients, timing of order placement for in-house PCR, and longer than expected stay in airborne precautions.

Disclosures

All authors: No reported disclosures.
1380. Safety of Repurposed Drugs for Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis: An Analysis of Adverse Events Reported in the Literature
Authors: Stone Heather , Duggal Mili , Sacks Leonard , Ghosh Mayurika
Published: October 2019

Background

Multi and extensively drug-resistant (MDR and XDR) tuberculosis (TB) remains a treatment challenge due to drug adverse events (AEs) and long regimens. Our aim was to identify AEs which resulted from repurposing drugs for MDR and XDR-TB.

Methods

A PubMed search for case reports of repurposed drugs for MDR and XDR-TB from January 1, 2014 to October 23, 2018 identified 130 patients (78 MDR, 52 XDR) in 91 articles. There were 31 extrapulmonary, 81 pulmonary TB cases, and 18 with both. Drugs were regarded as repurposed if they were either not approved for TB by the FDA, or they were approved for TB but were used in novel populations, novel combinations, or nonstandard doses. Drug labels were reviewed for AEs.

Results

Linezolid (n = 65) and moxifloxacin (n = 48) were the most commonly repurposed drugs. The following were also frequently used: clofazimine (n = 47), levofloxacin (n = 45), amikacin (n = 43), amoxicillin-clavulanate (n = 40), kanamycin (n = 36), carbapenems (n = 22), and clarithromycin (n = 17). Of the drugs that are approved for TB, the following were repurposed in a novel population, dose, or combination: cycloserine (n = 20), bedaquiline (n = 13), capreomycin (n = 4), ethambutol (n = 3), and isoniazid (n = 3). Treatments were discontinued due to AEs in 41 patients. There were no discontinuations for amoxicillin-clavulanate and levofloxacin. Extended drug exposure is a unique treatment feature for MDR and XDR-TB, which often requires ~2 years of treatment. Approximately 87% of treatment discontinuations due to AEs occurred after >1 month of exposure. AEs leading to treatment discontinuation after > 6 months of drug exposure were seen in 15 cases, of which 12 were due to linezolid and cycloserine. Peripheral and optic neuropathy was the most common AE reported (linezolid n = 12, cycloserine n = 1). Most AEs were labeled events.

Conclusion

Several antimicrobials are being repurposed to treat MDR and XDR-TB. There were no AEs reported after prolonged use that was not described in drug labels. Physicians should review information in labeling if prescribing drugs in this manner. There is a need for comparative safety data for repurposed drugs assessed through clinical trials.

Disclosures

All authors: No reported disclosures.
1381. M.genavense in the ART Era: From Persistent Disseminated Disease to Severe Disease
Authors: Manion Maura , Lynn Niamh , Pei Luxin , Hammoud Dima , Laidlaw Elizabeth , Roby Gregg , Metzger Dorinda , Mejia Yolanda , Lisco Andrea , Bergin Colm , Sereti Irini
Published: October 2019

Background

Mycobacterium genavense is an opportunistic pathogen in HIV patients that is difficult to culture and difficult to manage clinically. Here we describe three cases of HIV patients with Mycobacterium genavense with courses representing the spectrum of M.genavense presentations in the current ART era complicated by differing divergent immune responses.

Methods

Two patients were in a longitudinal study at NIAID enrolling patients with HIV and suspected IRIS (PANDORA) (NCT02147405) and one was seen at St. James’s hospital in Dublin. Frozen peripheral blood mononuclear cells were collected at the time of presentation and were used for in vitro stimulation with irradiated M. genavenese in cases 1 and 2 to detect production of cytokines by CD4 T cells.

Results

Pt 1: 27-year old male with M. genavense presenting as diarrhea, abdominal pain, skin nodules, hepatosplenomegaly, and lymphadenopathy (LAN) that persisted on one year of anti-mycobacterial therapy and ART. No CD4 T-cell cytokine response to M. genevense genavense was detected (Fig 1). He received interferon-g and optimization of his antimycobacterial regimen with improvement of symptoms and decreased pathogen burden on repeated biopsies. Pt 2: 55-year old female with M. genavense IRIS manifesting as fevers and abdominal pain that persisted for 10 months on ART (CD4 109 cells/µmL) requiring intermittent corticosteroid use complicated by adrenal insufficiency. She had evidence of CD4 T-cell response to M. genavense in vitro and improved with optimization of her anti-mycobacterial and corticosteroid regimen. Pt 3: 39-year-old male with M. genavense IRIS presenting as fevers, LAN, pleuritic chest pain, and abdominal pain on ART (CD4 19 c/mµL) persisting despite immunologic response to ARV therapy (CD4 recovery to 419 c/mL), appropriate anti-mycobacterial therapy and corticosteroids. He required 4 doses of infliximab (5 mg/kg IV) that facilitated tapering of prednisone.

Conclusion

The clinical presentation of Mycobacterium genavense in HIV patients in the ARV era range from disseminated disease with poor immune reconstitution to persistent or severe IRIS requiring immune suppression. Effective clinical outcomes relied on appropriate anti-mycobacterial and either immune-boosting or immune-suppressive therapies.

Disclosures

All authors: No reported disclosures.
1402. Long-Term Mortality and Epilepsy in Patients After Brain Abscess: A Nationwide Population-based Matched Cohort Study
Authors: Bodilsen Jacob , Dalager-Pedersen Michael , van de Beek Diederik , Brouwer Matthijs C , Nielsen Henrik
Published: October 2019

Background

The long-term outcome of brain abscess is unclear.

Methods

We used medical registries to conduct a nationwide population-based matched cohort study to examine the long-term risks of mortality and new-onset epilepsy in patients hospitalized with brain abscess in Denmark from 1982 through 2016. Comparison cohorts from the same population individually matched on age, sex, and residence were identified, as were siblings of all study participants (Figure 1). We computed cumulative incidences and hazard rate ratios (HRRs) for mortality and new-onset epilepsy among brain abscess patients, comparison cohorts and siblings. Population and appendicitis controls had similar characteristics and prognosis why only comparisons between brain abscess patients and population controls are detailed here.

Results

We identified 1,384 brain abscess patients with a median follow-up time of 5.9 years (IQR 1.1–14.2). The 1-year, 2–5 year, and 6–30-year mortality of patients after brain abscess was 21%, 16% and 27% when compared with 1%, 6% and 20% for matched population controls (Figure 2). Cox regression analyses adjusted for Charlson comorbidity index score showed 1-year, 2–5 year, and 6- to 30-year HRRs of 17.5 (95% CI 13.9–22.2), 2.61 (95% CI 2.16–3.16) and 1.94 (95% CI 1.62–2.31). The mortality in brain abscess patients compared with population controls was significantly increased regardless of sex or age group except among subjects 80 years or older, and in both previously healthy individuals and immuno-compromised persons. Among the 30-day survivors of brain abscess (median follow-up 7.6 years [IQR 2.2–15.5]), new-onset epilepsy occurred in 32% compared with 2% in matched population controls. Cause-specific Cox regression analysis adjusted for stroke, head trauma, alcohol abuse, and cancer showed 1-year, 2–5-year, and 6–30-year HRRs for new-onset epilepsy of 155 (95% CI 78.8–304), 37.7 (95% CI 23.0–59.9), and 8.93 (95% CI 5.62–14.2) (Figure 3). Comparisons between sibling cohorts suggested no substantial effect of family-related factors on the long-term risk of death or epilepsy after brain abscess (Figure 4).

Conclusion

Brain abscess is associated with an increased long-term risk of mortality and new-onset epilepsy for several years after the acute infection.

Disclosures

All authors: No reported disclosures.
1403. Infectious Causes of Acute Meningitis Among Thai Adults: A University Hospital Setting
Authors: Aimbudlop Kittipat , Kiertiburanakul Sasisopin
Published: October 2019

Background

Acute meningitis is a medical emergency which needs immediate assessment and treatment. Knowing the epidemiology of acute meningitis may guide the physician for promptly empirical therapy as well as minimize morbidity and mortality. In Thailand, there are few studies regarding acute meningitis in adults and most of them have not been updated. We aimed to determine etiology, clinical manifestations, cerebrospinal fluid (CSF) findings and outcomes of patients with acute meningitis.

Methods

A retrospective cohort study was conducted among adult (age >15 years) patients with acute meningitis who were treated at Ramathibodi Hospital between 2013 and 2017. The list of the patients was retrieved from the hospital database using the International Classification of Diseases, 10th revision (ICD-10) codes. Comparisons of clinical presentations and laboratory investigations between patients with bacterial meningitis and those with non-bacterial meningitis were analyzed.

Results

A total of 89 patients were included. Of all, 48 (53.9%) patients were men and median age (interquartile range; IQR) was 49 (32.1–63.8) years. The most common coexisting condition was HIV infection (30%), receiving prednisolone (16.9%), and diabetes mellitus (15.7%). Causes of acute meningitis were Cryptococcus neoformans (37%), bacteria (31.5%), Mycobacterium tuberculosis (27%), and virus (4.5%). Common clinical presentations were fever (74%), headache (70.8%), and confusion (31.5%). Older age, higher proportion of patients with diabetes, lower proportion of HIV infection, higher median white blood cells (WBCs) in complete blood count (CBC), lower median platelet, higher median aspartate aminotransaminase, higher median alkaline phosphatase, higher median WBCs, and polymorphonuclear neutrophils (PMNs) percentage in CSF were found in patients with acute bacterial meningitis. By multivariate logistic regression, predicting factors of acute bacterial meningitis were WBCs in CBC (OR 1.02 per 100 cells/mm3 increased; 95% CI 1.01–1.04, P = 0.001), WBCs in CSF (OR 1.04 per 10 cells/mm3 increased; 95% CI 1.01–1.07, P = 0.012) and PMNs percentage in CSF (OR 1.21 per 5% increased; 95% CI 1.07–1.37, P = 0.002). Overall, the median (IQR) duration of hospitalization was 23 (11–29) days. A total of 26 (29%) patients had a complication, such as septic shock, hydrocephalus, seizure, and brain edema. The mortality rate was 7.9%.

Conclusion

In this setting, the most common cause of acute meningitis in adults is cryptococcosis. In addition, tuberculosis is not uncommon. Awareness of update epidemiology may guide the physicians to initiate appropriate antimicrobial therapy.

Disclosures

All authors: No reported disclosures.
1407. Potential Impact of the Biofire® Film Array Meningitis and Encephalitis (ME) Panel in Reducing Repeat Lumbar Punctures in Patients with Meningitis and Encephalitis
Authors: Aguilera Elizabeth A , Simar Shelby , Wootton Susan H , Hasbun Rodrigo
Published: October 2019

Background

The Biofire® FilmArray Meningitis Encephalitis (FAME) is a multiplex polymerase chain reaction (PCR) test can rapidly detect up to 14 pathogens that cause meningitis and encephalitis. The impact on preventing repeat lumbar punctures to obtain more diagnostic studies is currently unknown.

Methods

Patients admitted to Memorial Hermann Hospital (MHH) between July 2018-February 2019 with community-acquired symptoms of meningitis or encephalitis, CSF with white blood cell count >5 cells/mm3, and with leftover CSF at the MHH microbiology laboratory were eligible for the study. Testing FAME was performed after discharge for specimens that had not been centrifuged, had a volume of ≥200 μL, were appropriately stored, and were collected by lumbar puncture (LP) for evaluation of suspected meningitis/encephalitis.

Results

Of 1,382 CSF specimens screened, 70 (5.0%) met the criteria and were tested with FAME. The majority was adults (72.8%), non-Caucasian (68.6%), male (60%), immunocompetent (75.7%) and had a meningitis presentation (75.7%). Mean age was 36.9 years (1 mo-89 years). The mean duration between CSF collection and any PCR result done in the hospital was 60 hours. Fifteen patients (21.4%) required 25 repeat LPs [13 (86.6%) for additional testing (7 (53.8%) pediatric patients) and 2 (13.3%) for cryptococcal meningitis assessment]. The FAME could have prevented repeat LPs in 86.6% of patients. Five of the 13 repeat LP (38.4%) FA ME showed a pathogen [VZV (2), HSV 1 (1), HHSV-6 (1), Neisseria meningitidis (1)]. Of 46 tests with negative FA ME, acyclovir therapy was started in 22 (47.8%) with a mean of 6 doses dispensed. 38 (26.6%) patients were discharged with an unknown etiology of whom FA ME was positive in 8 (21%) [HSV2 (37.5%), VZV (25%), Enterovirus (25%) and HSV1 (12.5%)]. PCR was ordered in the hospital for only 4 (50%) of these patients.

Conclusion

The FAME identified an etiology in 21% of patients with meningitis and encephalitis symptoms discharged with an unknown etiology. A total of 18.5% of patients required a repeat LP for additional testing. FAME testing offers an avenue for reducing the burden of repeat LPs and duration of unnecessary anti-infective therapy while increasing diagnostic yield.

Disclosures

All authors: No reported disclosures.
1412. Spontaneous Intramedullary Abscess from Streptococcus anginosus Group: A Case Report and a Review of the Literature
Authors: Patterson Monica M , Aleissa Muneerah , Dionne Brandon , Pearson Jeffrey , Yawetz Sigal , Manne-Goehler Jennifer
Published: October 2019

Background

Intramedullary abscess of the spinal cord (IASC) symptoms are often nonspecific with the diagnosis rarely considered on the initial differential. This can delay surgical management and may lead to permanent neurological deficits or mortality. Additionally, many organisms are implicated in IASC, leading to uncertainty in empiric antimicrobial therapy.

Methods

This case report follows a patient with IASC due to Streptococcus anginosus group (SAG). We also review a 25-case meta-analysis of IASC and 5 cases of SAG IASC.

Results

A 65-year-old woman with an unremarkable past medical history presented with 2 weeks of neck pain and paresthesias. She was afebrile with no systemic signs of infection or abnormal laboratory markers. MRI revealed an 8mm lesion at C4-C5 with edema C1-T1 and she received high-dose steroids for suspected malignancy. Follow-up MRI 4 days later revealed rapid progression of the lesion to 14mm, consistent with an infectious process (Figure 1). The patient received empiric therapy with ceftriaxone, vancomycin, and metronidazole. She underwent a C2-C7 laminectomy with midline myelotomy for evacuation of the abscess. Due to clinical and radiographic progression she required a second surgical wash-out 4 days later. Her intraoperative cultures grew SAG and her regimen was changed to penicillin and vancomycin. Her course was complicated by eosinophilia requiring meropenem and later linezolid to complete a 6-week course, during which she improved clinically and neurologically. Our review demonstrated that 40% of cases presented with fever. The majority of cases were idiopathic with the organisms known in 70% of cases. Surgery and IV antibiotics were used in 83% of cases and one case required a second surgery. A wide range of antibiotic regimens were reported with no consensus on how to best preserve neurological function.

Conclusion

This case highlights the complexities in diagnosing and managing IASC. We suspect that due to the protected nature of the intramedullary space, the infection may not trigger constitutional symptoms or a systemic inflammatory response. In patients who present with significant neurological deficits, MRI may reveal IASC and this should prompt immediate initiation of antibiotics that penetrate the blood–brain barrier and surgical intervention.

Disclosures

All authors: No reported disclosures.
1426. Outcomes of Additional Instrumentation in Elderly Patients with Pyogenic Vertebral Osteomyelitis and Previous Spinal Instrumentation
Authors: Kim Tae-Hwan , Kim Jihye
Published: October 2019

Background

In patients with pyogenic vertebral osteomyelitis (PVO) and previous instrumentation requiring surgical treatment, a decision must be made between a less invasive non-instrumented surgery, including retaining the previous instrumentation, or a more invasive additional instrumented surgery involving the complete removal of the infected tissue and firm re-stabilization.

Methods

A retrospective cohort study (case–control study) was planned to evaluate the clinical outcomes of using additional instrumentation in patients with PVO and previous instrumentation. Patients were divided into two groups (instrumented or non-instrumented) according to the presence or absence of additional instrumentation. The baseline characteristics, infection profile, and treatment outcomes were compared between the two groups, and a multivariate logistic regression analysis was performed to identify the risk factors for infection recurrence.

Results

A total of 187 postoperative patients with PVO and previous spinal instrumentation were included. There were no significant differences in the baseline characteristics except the presence of a titanium cage. Surgery for additional instrumentation in patients with PVO and previous instrumentation showed similar rates of infection recurrence and mortality compared with non-instrumented surgery despite a larger number of involved vertebral levels and greater incidence of epidural abscesses (Table 1). However, instrumented patients with PVO and previous instrumentation who experienced infection recurrence had worse clinical outcomes than those of the non-instrumented patients with PVO (Table 2). Severe medical comorbidities, the presence of a psoas abscess (Figures 1 and 2), and methicillin-resistant Staphylococcus aureus infection were associated with a higher risk of infection recurrence.

Conclusion

Surgery for additional instrumentation in patients with PVO and previous instrumentation showed similar rates of infection recurrence and mortality to those who underwent non-instrumented surgery despite a larger number of involved vertebral levels and an increased frequency of epidural abscesses.

Disclosures

All authors: No reported disclosures.
1431. Comparison of Treatment Outcomes with Definitive Antibiotic Therapy and Empiric Antibiotic Therapy in Osteomyelitis
Authors: Holzum Dorothy , Pearson Christopher D , Moenster Ryan P , Linneman Travis W , McMahan Jonathan
Published: October 2019

Background

Definitive therapy for osteomyelitis (OM) is thought to be superior to empiric antimicrobial therapy; however, identifying causative pathogens is difficult.

Methods

This retrospective cohort study included patients treated with either definitive or empiric antimicrobial therapy for OM at VA St. Louis HCS between 1 January 2010 and 1 January 2018. Definitive antibiotic therapy was defined as a regimen tailored to susceptibilities of an organism(s) cultured from bone or deep tissue. The primary outcome was treatment failure, defined as a need for unplanned surgical intervention or re-initiation of antibiotic therapy for OM of the same anatomical site within 6-months after initial therapy was discontinued. Secondary outcomes included the incidence of acute kidney injury (AKI), Clostridium difficile-associated diarrhea (CDAD), and thrombocytopenia. Surgical intervention as part of initial therapy, presence of peripheral vascular disease (PVD), creatinine clearance < 50 mL/minute at initiation of therapy, receiving antibiotics at an extended care facility, age > 60 years, and receiving definitive antibiotics were included in a univariate analysis with variables with a P < 0.2 included in a multivariate logistic regression.

Results

There were 301 patients included; 179 in the definitive therapy group and 122 in the empiric therapy group. Baseline characteristics were similar among groups; however, more patients receiving definitive therapy had a bone biopsy compared with those treated with empiric therapy (58.1% (104/179) vs. 36.8% (45/122); P < 0.05). 33 percent (60/179) of patient treated with definitive therapy failed compared with 45% (55/122) treated with empiric therapy (P = 0.109). No significant differences were observed in secondary outcomes; however non-CDAD diarrhea occurred more in the empiric therapy group than definitive therapy group (3.9% (7/179) vs. 8.2% (10/122); P > 0.05). Receiving definitive therapy (OR 1.43, CI 0.89–2.313; P = 0.138) and presence of PVD (OR 1.34; CI 0.823–2.197; P = 0.238) were included in the multivariate logistic regression, but neither were independently associated with failure.

Conclusion

Definitive antibiotic therapy was not associated with a significant decrease in treatment failure.

Disclosures

All authors: No reported disclosures.
1437. Safety and Effectiveness of a Laboratory Intervention to Reduce Antibiotic Consumption in Patients with Asymptomatic Bacteriuria
Authors: Mozafarihashjin Mohammad , Maze Dit Mieusement Lorraine , McGeer Allison , McCreight Liz , Van Horne Liz , So Jannice , Shrivastava Ananya , Khan Nadeem , Wong Louis , Leis Jerome A
Published: October 2019

Background

Antibiotic (AB) therapy for asymptomatic bacteriuria (ASB) persists despite evidence of lack of benefit. In 2012, our hospital piloted an intervention to stop routinely reporting positive midstream urine (MSU) from inpatients since the majority of patients were asymptomatic. Following the pilot, we moved to rejecting all MSU unless a telephone request was received. We undertook the present study to establish the safety and assess the long-term impact of this change.

Methods

From November 2013 to April 2019, when MSU were received from surgical wards (two surgical wards added in May 2015) and medical wards (from August 2017) in our hospital, a message was posted noting that ASB should not be treated and a call to the lab was required to initiate specimen processing. Patients were interviewed, and charts were reviewed within 24h of specimen receipt and 4d later to identify urinary tract symptoms/infection (UTS/UTI) and systemic infection. Primary outcome was serious adverse events (AEs). Secondary outcomes were: rate of MSU submitted, impact on lab workload, AB use.

Results

1,678 episodes with submitted MSU were included; 995/1,678 (60%) MSU cultures were not processed. Of 683 processed, 482 (71%) were negative. 1,111/1,678 (66%) patients were asymptomatic when MSU was ordered. 1,393/1,678 (83%) had negative culture (N = 482) or completed d4 follow-up (N = 911). No symptomatic UTI/sepsis/systemic infection occurred; the only AE identified were 4 patients with prolonged UTS which might have been prevented by MSU processing (4/911; 0.4% patients with AE). Rates of MSU submitted remained stable at 12 per 1,000 patient-days, P = 0.59 (Figure 1). Proportion of processed MSU decreased from 16/22, 73% in 2013 to 67/137, 49% in 2019 (Figure 2; P = 0.002). Overall, microbiology workload decreased by 5 person-days/year (fewer MSU processed, but staff needed to respond to telephone calls). 275/1,678 (16%) patients received AB for presumed UTI; 221 (80%) treated empirically, 54 (20%) in response to positive MSU. Of 69 patients with ASB whose MSU was processed and positive, 32 (46%) were prescribed antibiotics. Assuming that 21% of rejected MSU from asymptomatic patients would have been positive, AB therapy for ASB was avoided in 66 patients.

Conclusion

Rejecting MSU specimens does not result in harm, and reduces lab workload and AB therapy for ASB.

Disclosures

All authors: No reported disclosures.
1439. Reducing the Number of Urine Cultures Performed Through Stringent Urinalysis Reflex Criteria
Authors: Abu Sitta Emad , Keegan Ann , Cole Kelli , Byrd Heather , Blomquist Thomas , Suleyman Geehan
Published: October 2019

Background

Almost half of urine cultures (UCs) obtained are in asymptomatic patients, which may lead to misdiagnosis of urinary tract infection (UTI) and unnecessary treatment. To decrease misdiagnosis of UTI, changes were made to the order entry and urine culture process at our institution in April 2018. This included removal of a standalone UC from the electronic order entry system and development of a more stringent criterian for urinalysis with reflex culture (UAC). We evaluated the impact of these ordering changes on the total number of UCs performed.

Methods

This was a pre-post retrospective study comparing the hospital UAC rate per 1,000 patient-days and ED UAC rate per 1,000 visits in the pre-intervention period from April 2017 to March 2018 to the intervention period from May 2018 to March 2019 in a 319-bed teaching hospital in northwest Ohio. In April 2018, urine microscopy and UAC were the only available options. Furthermore, UC would only be performed if the following criteria were met: 10 white blood cells (WBC)/HFP. Standalone UC was available for the following patients who were excluded: immunosuppressed patients, pregnant women and patients undergoing invasive urologic procedures. These changes were accompanied by provider education, and providers were given the option to override UAC rules by calling the microbiology lab within 24 hours to request UC.

Results

After incorporating these changes, we observed an increase in the use of UAC compared with UC-only in both the ED (80% pre-vs. 94% post-implementation) and inpatient setting (59% pre-vs. 92% post-implementation). This was accompanied by a reduction in the overall UCs performed in both the ED (49.17 per 1,000 visits to 23.53 per 1,000 visits [P < 0.001]) and inpatient units (23.31 per 1,000 patient-days to 9.31 per 1,000 patient-days [P < 0.001]). Chart review of cases where providers overrode UAC criteria and requested UC have demonstrated no false negatives to date; cultures either had no growth or were consistent with contamination by polymicrobial urogenital flora.

Conclusion

Restricted access to standalone UC, implementation of UAC with more stringent criteria and provider education reduced the number of urine cultures performed without sacrificing sensitivity for detecting UTI and potential antimicrobial use.

Disclosures

All authors: No reported disclosures.
1441. Comparison of Cefpodoxime vs. Oral Cefuroxime for Urinary Tract Infections at a Large Academic Medical Center
Authors: Bao Hongkai , Dubrovskaya Yanina , (Polly) Jen Shin-Pung , Jie (Cindy) Chen Xian , Siegfried Justin , Papadopoulos John
Published: October 2019

Background

Cefpodoxime (CPD) and cefuroxime (CFX) are both oral cephalosporins indicated for urinary tract infection (UTI) treatment. CPD may have unfavorable pharmacokinetics (PK) given the lesser degree of renal excretion and urine concentration vs. CFX and risk of collateral damage. The objective of this study was to compare the efficacy and safety of these two agents for UTI treatment.

Methods

We conducted a retrospective evaluation among adult patients who received CPD or oral CFX for ≥48 hours for UTI treatment between January 2013 and July 2018. The primary outcome was the rate of subsequent UTI within 90 days following therapy. Safety outcomes included the rate of Clostridium difficile infection (CDI) and development of isolates resistant to third-generation cephalosporins (TGC) within 90 days. We also examined missed opportunities for antibiotic de-escalation in culture-positive patients.

Results

Of 747 patients assessed for study inclusion, 295 patients met eligibility criteria (CPD n = 165, CFX n = 130). Median age was 72 years (IQR 55–84) and 71% were female. More patients in the CPD vs. CFX group had pyelonephritis (29% vs. 11%, P = 0.0005) and were treated in the emergency department (42% vs. 16%, P = 0.0005). Escherichia coli was most commonly isolated (n = 139), followed by Klebsiella spp. The rate of subsequent UTI for CPD vs. CFX was 18% vs. 16%, P = 0.647 at median of 25 vs. 32 days, P = 0.399. CDI rate was 1% vs. 2%, P = 0.324 and resistance to TGC was detected in 4% vs. 1%, P = 0.068 for CPD vs. CFX, respectively. Missed opportunities to de-escalate antibiotics based on cultures were found in one-third of patients. After adjusting for multiple factors in multivariate analysis, genitourinary abnormality (Odds Ratio [OR] 2.2, 95% CI 1.10–4.29, P = 0.026) and prior history of UTI within 180 days (OR 2.2, 95% CI 1.08–4.398, P = 0.03), but not the choice of oral cephalosporin, were the only independent predictors of subsequent UTI.

Conclusion

Despite less favorable urinary PK of CPD compared with CFX, in this patient cohort, no differences in efficacy or safety between the two agents for UTI treatment were found. These findings warrant further exploration. Stewardship strategies for de-escalation from higher generation cephalosporins to narrow-spectrum antibiotics based on susceptibilities should be implemented.

Disclosures

All authors: No reported disclosures.
1443. N-Acetyl Cysteine Coadministration in Prevention of Amphotericin--Induced Electrolytes Imbalances in Children
Authors: Arikan Kamile , Kara Ates , Karadag-Oncel Eda
Published: October 2019

Background

Amphotericin B (AmB) can cause electrolyte abnormalities, including hypokalemia, hypomagnesemia, hypernatremia, and metabolic acidosis; and most important, acute renal failure.

Methods

We conducted a randomized prospective cohort study from March 2012 to February 2018 at Hacettepe University Ihsan Doğramacı Children Hospital to children receiving AmB.

Results

A total of 87 patients including 37 patients with NAC and 50 patients without NAC received liposomal amphotericin B during the study period.Serum creatinine, blood urea nitrogen, phosphorus were not different statistically in both groups during the study period. Serum sodium, potassium, calcium, phosphorus, magnesium values taken on third day of AmB treatment were not statistically different in both groups. Mean serum magnesium value was higher in NAC received group on the seventh day of AmB treatment; 1.97 ± 0.33 and 1.69 ± 0.46, respectively, it was statistically significant (P = 0.025). Mean serum magnesium value was also statistically significantly higher in NAC received group on the 14th day of treatment; 1.93 ± 0.20 and 1.72 ± 0.247, respectively, in both groups (P = 0.01). Mean serum sodium values on the 14th day of AmB treatment were also statistically different between 2 groups; 136.7 ± 3.7 and 140.04 ± 5.1, respectively (P = 0.005). Serum sodium values on the 14th day of AmB treatment was in more normal limits in NAC received group. Serum alanine aminotransferase level was significantly lower in NAC received group (P = 0.02). Serum aspartate aminotransferase level was significantly lower in NAC received group (P = 0.007). Nineteen of 37 (51.4%) patients who received NAC concomitantly with AmB and 44 of 50 patients (88%) who received AmB without NAC supplemented with potassium due to hypokalemia (P < 0.001). Two of NAC received 37 patients (5.4%) and 10 of NAC not received 50 patients (20%) died. Mortality was found 2.3 times more in NAC not-received group.

Conclusion

Co-treatment with oral NAC once daily in children during AmB treatment course was significantly effective in preventing or ameliorating different features of its nephrotoxicity including hypokalemia, hypomagnesemia, and renal potassium as well as magnesium wasting

Disclosures

All authors: No reported disclosures.
1468. Determination of Antibiotic Susceptibilities in Aerococcus urinae Urinary Isolates
Authors: Krishnan Anish , Nadeau Lynn
Published: October 2019

Background

Aerococcus urinae is a Gram-positive organism, initially identified in 1992. It is known to cause urinary tract infections (UTIs), bacteremia, and endocarditis in humans. There is limited data regarding the susceptibility of A. urinae to first-line antimicrobials indicated for the treatment of UTIs. In 2016, A. urinae was isolated in 125 urine samples processed by the Integrated Hospital Laboratories Service, which services four hospitals in Southwestern Ontario, Canada. The unfamiliarity with this organism and the lack of local antimicrobial susceptibility rates presents a challenge for clinicians and often results in the unnecessary use of broad-spectrum antibiotics. The primary objective of this study was to establish the susceptibility rate of A. urinae urinary isolates to cefazolin, ampicillin, nitrofurantoin, fosfomycin, and ciprofloxacin. The secondary objective was to identify demographic characteristics associated with A. urinae bacteriuria in our patient population.

Methods

Urinary samples received by the laboratory from October 2017 to June 2018 underwent routine identification as per physician orders. Samples that grew A. urinae were included in this study and subjected to susceptibility testing. Susceptibility testing was conducted via disk diffusion and results were interpreted based on published breakpoints for zone diameters.

Results

A total of 72 isolates were included. Susceptibility rates for cefazolin, ampicillin, nitrofurantoin, fosfomycin, and ciprofloxacin were 100%, 99%, 99%, 96%, and 65%, respectively. The average age of patients was 79 years, 63.9% were female, 31.9% were recently hospitalized, and 44.4% were residents of a long-term care facility.

Conclusion

Cefazolin, ampicillin, nitrofurantoin, and fosfomycin demonstrated good in vitro activity against A. urinae. In contrast, ciprofloxacin demonstrated decreased activity against this organism. Currently recommended first-line agents for the management of uncomplicated UTIs could be utilized to treat this organism. Characteristics of patients with A. urinae bacteriuria are consistent with risk factors predisposing to UTIs.

Disclosures

All authors: No reported disclosures.
1472. Non-Carbapenems for Treating Community-Associated Urinary Tract Infection Caused by Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in Children
Authors: Joo Jung Hyun , Young Lee Shin
Published: October 2019

Background

Childhood urinary tract infection (UTI) may cause increased major morbidity and long-term clinical consequences. Extended-spectrum β-lactamase (ESBL) is produced by the members of the Enterobacteriaceae family, which are the primary infectious agents that cause UTI in children. Isolation of ESBL-producing Enterobacteriaceae (ESBL-E) typically occurred in healthcare facilities; however, the incidence of community-associated (CA) UTIs due to ESBL-E has increased worldwide. It has led to an increase in the use of carbapenems. In this study, we determine the characteristics of community-onset UTIs caused by ESBL-E in children to suggest non-carbapenem options for the treatment of childhood UTIs due to ESBL-E in order to preserve carbapenems.

Methods

A total of 2,157 isolates of ESBL-E were collected from children below 18 years old who were clinically certified UTI or urosepsis between January 2008 and August 2018 at tertiary university hospital in Korea. Their electronic medical records were retrospectively reviewed. Long-term healthcare facility stay within the preceding month and isolates recovered more than 72 hours after hospitalization were the criteria of healthcare-associated (HA) infection.

Results

The most common isolates were E. coli 1815 (84.2%) followed by K. pneumoniae 342 (15.8%). CA infection was detected in 1,513 of the 2157 ESBL-E (70.1%). The prevalence of CA ESBL-E infection increased significantly from 68 cases in 2008 to 325 cased in 2017. Antibiotic susceptibility test showed highest sensitivity to ertapenem, meropenem, and amikacin (>90%) followed by cefoxitin (82%), and piperacillin–tazobactam (TZP) (80.5%). CA E. coli showed higher sensitivity to amikacin and TZP compared with HA E coli. CA K. pneumoniae showed much higher sensitivity to TZP compared with HA K. pneumoniae. Of total ESBL-E, the antimicrobial resistance rate to aminoglycoside such as amikacin and gentamicin showed full sensitivity during the study period; furthermore, a rate of resistance to TZP has been decreasing over the years.

Conclusion

Identifying antibiotic susceptibility patterns of ESBL-E is a useful guide for treatment strategy of UTI. This study showed that there are non-carbapenem options for the treatment of CA ESBL UTI in children.

Disclosures

All authors: No reported disclosures.
1482. Microbiological Analysis from a Phase II Study Evaluating Gepotidacin (GSK2140944) in the Treatment of Uncomplicated Urinary Tract Infections
Authors: Scangarella-Oman Nicole , Hossain Mohammad , Tiemeyer Jr. Timothy , Perry Caroline R , Tiffany Courtney , Raychaudhuri Aparna , Dumont Etienne
Published: October 2019

Background

Gepotidacin (GEP), a first in class novel triazaacenaphthylene bacterial topoisomerase inhibitor, inhibits bacterial replication and has in vitro activity against key pathogens, including drug-resistant strains, associated with a range of infections.

Methods

This phase IIa single-center study evaluated the safety, tolerability, pharmacokinetics, and efficacy of oral GEP 1,500 mg BID for 5 days in female subjects with acute cystitis. Clean catch mid-stream urine specimens were obtained for quantitative culture by standard methods. Susceptibility testing by CLSI broth microdilution and gradient diffusion (fosfomycin only) was conducted. Inclusion in the microbiological intent-to-treat population (micro-ITT) required growth of a qualifying baseline uropathogen (≥ 105 CFU/mL). Microbiological success was defined as culture-confirmed eradication (no growth, <103 CFU/mL) of the qualifying baseline uropathogen.

Results

Of 22 participants, 8 (36%) had a baseline qualifying uropathogen (5 E. coli, 1 S. saprophyticus, 1 K. pneumoniae, and 1 C. koseri) and were included in the micro-ITT. GEP MICs against the 8 qualifying uropathogens ranged from 0.06 to 4 µg/mL. Two E. coli isolates were multidrug-resistant (defined as resistance to ≥3 antibiotic classes) due to resistance to ampicillin, trimethoprim-sulfamethoxazole and ciprofloxacin/levofloxacin or cefazolin. One additional E. coli isolate was ampicillin-resistant. Of the 8 participants in the micro-ITT, 7 (88%), and 6 (75%) were microbiological successes at the Test of Cure (TOC) and Follow-up Visits, respectively. The one microbiological failure at TOC (E. coli) was due to an unreportable (out of stability) urine specimen. For the 4 participants with available steady-state PK, qualifying Enterobacteriaceae uropathogens and who were microbiological successes at TOC, plasma fAUC24h/MICs ranged from 7 to 90.5 and urine AUC24h/MICs from 1292 to 121,698. The participant with the lowest plasma fAUC/MIC (7) and urine AUC24h/MIC (1292) had a K. pneumoniae with a gepotidacin MIC of 4 µg/mL.

Conclusion

This first report of microbiological efficacy in the treatment of acute cystitis supports further clinical study of GEP as a first-in-class, novel mechanism of action antibacterial.

Disclosures

All authors: No reported disclosures.
1485. Trends in Important-Resistant Gram-Negative (GN) and Gram-Positive (GP) Urine Bacterial Pathogens in Hospitalized Patients in the United States: A Multicenter Evaluation from 2013 to 2018
Authors: Lodise Thomas , Gelone Steven P , Yu Kalvin , Gupta Kalpana , Early Maureen , Ye Gang , Schranz Jennifer , Gupta Vikas
Published: October 2019

Background

The US CDC has identified a number of antibiotic-resistant (AR) bacteria as urgent or serious public health threats. This study sought to quantify the prevalence and incidence of extended-spectrum β-lactamase (ESBL) Enterobacteriaceae (ENT), Carbapenem-resistant ENT (CRE), P. aeruginosa (Carb NS-PsA), vancomycin-resistant enterococci (VRE), and methicillin-resistant S. aureus (MRSA) in the urine of adult hospitalized patients.

Methods

All hospitalized adult patients with a positive urine culture (first urine isolate of a species per 30-day period) were evaluated from over 400 US hospitals (2013–2018; BD Insights Research Database, Becton, Dickinson and Company). The following five groups of AR bacteria were examined: (1) ESBL ENT if ESBL-positive per commercial panels or intermediate/resistant (non-susceptible [NS]) to a third-generation cephalosporin; (2) CRE ENT if NS to imipenem (IPM), meropenem (MEM), doripenem (DOR) or ertapenem; (3) Carb-NS PsA if NS to IPM, MEM or DOR; (4) VRE if resistant to vancomycin; and (5) MRSA as resistant to methicillin/oxacillin. For each AR grouping, % NS and rates of NS per 100 admissions were calculated and trends were examined using Logistic regression and Poisson models.

Results

Across the 6-year study period, there were 24,558,856 admissions, accounting for 2,285,971 non-duplicate urine isolates; 1,016,642 were ENT, 87,450 were PSA, 203,231 were enterococci, and 41,979 were S. aureus. The % of NS for ESBL, CRE ENT, Carb-NS PsA, VRE, and MRSA were 12%, 0.9%, 13%, 19%, and 55%, respectively. The % of NS for ESBL increased from 2013 to 2018 (P < 0.001) whereas % NS for PsA and % MRSA decreased during the same time period (P < 0.001) (Figure 1). The rates of NS per 100 admissions for ESBL, CRE ENT, Carb-NS PsA, VRE, and MRSA were 0.44, 0.04, 0.05, 0.16, and 0.09, respectively. The annual NS rates per 100 admission trends for ESBL and CRE ENT were increasing (all P < 0.0001) while the trends for Carb-NS PsA, VRE, and MRSA were decreasing (all P < 0.0001).

Conclusion

While the percent of ESBL, CRE ENT, Carb-NS PsA, VRE, and MRSA have remained relatively constant over the past 6 years, there has been a notable increase in the rates of ESBL and CRE ENT per 100 admissions among adult hospitalized patients with positive urine cultures.

Disclosures

All authors: No reported disclosures.
1502. Risk Factors Associated to Aeromonas spp. Infection and Outcome at a Third-level Care Hospital in Mexico
Authors: López-Iñiguez Alvaro , Morado-Aramburo Oscar , Pérez-Gutiérrez Teresa , Peña-Puga Cecilia F , Aranza Marañon-Solorio Karen , Zamora-Tapia Irwin , Lambraño-Castillo Darwin , Maravilla-Franco Ernesto , Sifuentes-Osornio José , Ponce de Leon Alfredo
Published: October 2019

Background

Information regarding infections caused by Aeromonas spp. is limited. The aim of this study was to describe the clinical and epidemiologic characteristics of infections by Aeromonas spp. during a 7-year period at a tertiary care hospital in Mexico.

Methods

We analyzed a retrospective cohort of adults with Aeromonas spp. clinical isolates, between January 1, 2010 and August 31, 2017 from the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. We analyzed demographic, clinical, microbial characteristics and antimicrobial susceptibility test. Risk factors for bacteremia and mortality were identified with logistic regression; adjustment for possible confounder factors was carried out. Data were analyzed with IBM SPSS Statistics version 21. Statistical significance was defined as the value for P < 0.05.

Results

We identified 387 patients with an infection by Aeromonas spp.; the median age was 55 years and 52% were women. 94 (24.3%) patients had an autoimmune disease; 74 (19.1%) had a solid tumor (ST); 51 (13.2%) had chronic kidney disease (CKD); 43 (11.1%) had chronic liver disease (CLD); 37 (9.6%) had a hematologic malignancy (HM); 23 (5.9%) were solid-organ recipients and 20 (5.2%) HIV infected. 41.6% (n = 161) of the infections were healthcare related. Stools were the most frequent isolation site (n = 299, 77%), followed by blood cultures (n = 29, 7.4%) and abscess (n = 19, 4.9%). The most common species was A. veronii. Aminoglycosides, quinolones, carbapenems, and trimethoprim/sulfamethoxazole were the most active antibiotics in vitro. The variables associated with bacteremia were CLD OR 5.647; diabetes OR 2.376 and nosocomial acquisition OR 4.08. 30-day mortality was 5.7%, while global mortality was 10.3%. Mortality was associated with sex (male) OR 1.753; HM OR 2.741; ST OR 2.576; polymicrobial infection OR 2.445; ICU admission OR 5.175 and bacteremia OR 3.881.

Conclusion

Infections by Aeromonas spp. have increased and have a greater incidence among individuals with chronic diseases and immunosuppressive states in this setting. Mortality described in this cohort was minor than previously stated by other series.

Disclosures

All authors: No reported disclosures.