bluuebunny/crossref_metadata_2025 huggingface dataset:
The Use of Rifampin Therapy to Treat Diabetic Patients with Osteomyelitis of the Foot in the Veterans Health Administration: Patient Characteristics and Clinical Outcomes
Authors: Wilson Brigid , Saade Elie , Doros Gheorghe , Hermos John , Bessesen Mary , Bonomo Robert A
Published: October 2017

Background

Nearly 25% of Veterans Health Administration (VHA) patients are diagnosed with diabetes mellitus (DM). Among DM patients, the lifetime incidence of foot ulcers is 15%. Infection is a common complication of foot ulcers and 20–60% of infections result in diabetic foot osteomyelitis (DFO). Current treatment guidelines do not endorse any specific antibiotic agent for DFO, but small clinical trials suggest the addition of rifampin to antimicrobial regimens results in improved cure rates for osteomyelitis.

Methods

Using VHA databases, we identified index DFO cases from 2009 to 2013 and extracted patient and infection characteristics including demographics, comorbidities, chronic medications, antibiotic regimens, and microbiology data when present. We analyzed the subset of patients alive, without high-level amputation, and treated with antibiotics at 90 days after diagnosis. We summarized patient characteristics and compared a composite endpoint of amputation or death within 2 years of DFO diagnosis among those treated with rifampin to those not treated with rifampin.

Results

In total, 10,736 DFO cases met our criteria (Figure). Of these, 151 were considered treated with rifampin, based on 14 or more days of rifampin initiated within 90 days of diagnosis; 10,551 were unexposed to rifampin; and 34 were excluded for late or short treatment with rifampin. We observed significant differences between patients treated with and without rifampin (Table) and 44% of rifampin-treated patients were seen in 14 facilities.

Amputation or death at 2 years was observed in 44 (29%) of patients treated with rifampin and 4,007 (38%) of patients not treated with rifampin (P = 0.03).

Conclusion

Rifampin was rarely used in the treatment of DFO in the VHA and a few facilities accounted for a large proportion of rifampin-treated cases. We observed higher rates of amputation-free survival in patients treated with rifampin, but in the presence of notable confounders including age, comorbidities, and organism.

Disclosures

E. Saade, Steris: Grant Investigator, Grant recipient. Janssen: Grant Investigator, Research grant. Sequiris: Grant Investigator, Research grant. Pfizer: Grant Investigator, Research grant. R. A. Bonomo, Entasis: Grant Investigator, Research grant. Allecra: Grant Investigator, Research grant. Wockhardt: Grant Investigator, Research grant. Merck: Grant Investigator, Research grant. Roche: Grant Investigator, Research grant. GSK: Grant Investigator, Research grant. Allergan: Grant Investigator, Research grant. Shionogi: Grant Investigator, Research grant
The Detection Rates of Urogenital Chlamydia trachomatis and Neisseria gonorrhoeae in Chinese Population Applying for U.S. Immigration
Authors: Wu Jian , Chen Jiandong , Chen Chen , Zhu Yunfeng , Huang Yongxin , Liang Shaojun , Zeng Kui , He Hongtao
Published: October 2017

Background

Medical screening for gonorrhea is under the mandatory requirements of the Center for Disease Control and Prevention for aliens applying for U.S. immigration. Gonorrhea is frequently associated with Chlamydia trachomatis (CT) infection. There is limited data on the detection rates of urogenital CT and Neisseria gonorrhoeae (NG) in Chinese population.

Methods

Data on physical examinations of applicants in Guangdong International Travel Health Care Center, China were collected and retrospectively analyzed. The nucleic acids of urogenital CT and NG from urine specimens were detected by fluorescent probe PCR using cobas 4800 CT/NG Amplication Detection Kit (Roche Molecuar Systems, Inc.). The detection rates of CT and NG among the overall population were assessed. In addition, the detection rates of CT by age and gender were also evaluated.

Results

In total, 10,549 applicants underwent physical examinations from September 2016 to March 2017. Mean (SD) age was 41.4 (15.6) years, ranging from 15 to 90 years. The proportion of females (56.17%) was higher than that of males (43.83%). Of the 10,512 people who completed the detection of CT, 369 (3.51%) were CT-positive. The detection rate of CT was significantly higher in females (4.15%) than males (2.69%) (Table 1). The highest CT-positive rate was observed in the age group of 25–29 years (24/344, 6.98%) among males, while in a slightly younger age group of 20–24 years (34/524, 6.49%) among females (Figure 1). Of the 10,510 applicants who completed the detection of NG, 10 (0.10%) were NG positive. The detection rate of NG in males and females was 0.11 and 0.08%, respectively (Table 1).

Conclusion

Our study first reported the detection rates of urogenital CT (3.51%) and NG (0.10%) among Chinese applicants for U.S. immigration. The highest positive rate of CT was observed among young and middle-aged people, which should gain more attention.

Disclosures

All authors: No reported disclosures.
Macrolide Resistance in Mycoplasma genitalium in Singapore
Authors: Barkham Timothy , Tang Wen Ying , Mansoor Siti Aminah , Chio Martin Tze-Wei
Published: October 2017

Background

Mycoplasma genitalium was first reported as a cause of non-gonococcal urethritis in 1980. It has progressed from being an ‘emerging’ sexually transmitted infection (STI) to an accepted STI. Prevalence of infection has been reported as the Netherlands 4.5%, Sweden 6.3%, UK 1.2% and France 4%. M. genitalium has the smallest known bacterial genome and was the second bacterial genome fully sequenced. It has minimal requirements and is said to approach the minimum possible for a living cell. It is extremely fastidious; only a few strains have been cultured worldwide. Diagnosis relies on direct detection. It does not have a cell wall so it is not susceptible to antibiotics such as penicillins and cephalosporins. Therapy depends on fluoroquinolones and macrolides but resistance to macrolides has been widely reported: 13% France, 18% Sweden, 40% UK, Australia and Denmark, 100% Greenland, 30% Japan.

Methods

Ethics approval was granted. DNA extracts left over after routine clinical diagnostics at the Department of STI Control (DSC) Clinic, Kelantan Lane, Singapore were harvested. DNA had been extracted on a Cobas 4800 instrument (Roche) from urine and urethral swabs collected for testing for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). A 2-plex real-time PCR assay targeting the pdhD and mgpB genes was used to screen for M. genitalium. Samples were deemed positive if both targets were detected. If only one target was detected, the sample was retested; if reactive in either target upon retest, the sample was considered positive for M. genitalium. Positive DNA preps were then screened for macrolide resistance mutations after Sanger sequencing of the 23S rRNA gene.

Results

368 anonymised DNA elutes from 254 urines and 114 urethral swabs were collected between May and July 2016. One hundred eighty-four were CT/NG positive and 184 were CT/NG negative. Sixteen (4.3%) were positive for M. genitalium. Four (25%) of these 16 samples contained macrolide resistance associated mutations; A2058T (x2), A2058G (x1), and A2059G (x1).

Conclusion

M. genitalium was detected in 4.3% of samples. Macrolide resistance mutations were detected in 25%, similar to international rates. Some guidelines recommend testing for resistance to guide therapy and to perform a test of cure.

Disclosures

All authors: No reported disclosures.
Optimizing Screening for Sexually Transmitted Infections in Men Using Self-Collected Swabs — A Systematic Review
Authors: Yared Nicholas , Horvath Keith , Fashanu Oluwaseun , Zhao Ran , Baker Jason , Kulasingam Shalini
Published: October 2017

Background

Sexually transmitted infection (STI) rates are increasing in the US while funding for prevention and treatment programs has declined. Self-collection testing for STI detection in men may provide an acceptable, easy, rapid, and potentially cost-effective method for increasing diagnosis and treatment of STIs. The purpose of this study was to systematically review articles assessing self-collection of anal, oral, or genital tests among adult men for STI detection and/or human papillomavirus (HPV)-related dysplasia.

Methods

We searched for English-language articles involving self-collection tests for STI detection among men aged ≥ 18 years using the following databases: MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials. Three coders used a screening and data abstraction form to record each study’s design, participant demographics, intervention, and primary outcome. The self-collection devices, targeted micro-organisms, and self-collection acceptability measures were also recorded. All studies were double-coded to determine final inclusion in the review.

Results

Self-collection methods were highly sensitive and comparable to clinician-collection for detection of multiple STI pathogens but were of less adequate quality for anorectal cytology. Self-collection was highly acceptable.

Conclusion

Limitations of this systematic review include the fact that studies were small, heterogeneous, and used designs providing lower levels of evidence. Nevertheless, self-collection methods were shown to be a viable option for STI testing in adult men based on their high feasibility, acceptability, and validity. Implementation of self-collection procedures in STI testing venues should be performed to expand opportunities for STI detection and treatment.

Disclosures

All authors: No reported disclosures.
Alcohol Misuse and Associated Risk Factors Across a Shipboard Deployment Among Active Duty US Navy and Marine Corps Personnel
Authors: O’Malley Christopher , Harbertson Judith , Hale Braden , Shaffer Richard , Michael Nelson , Scott Paul
Published: October 2017

Background

Alcohol misuse rates are elevated in the US military. Relevant longitudinal data are rare in deployed shipboard personnel. We examined the prevalence of hazardous and dependent alcohol misuse at 3 months prior to (T1), during (T2), and 3 months following (T3) deployment among shipboard US Navy and Marine Corps personnel.

Methods

Data were collected from 11 local ships. Participants voluntarily completed anonymous surveys, including demographics, Alcohol Use Disorders Identification Test–Consumption (AUDIT–C), drug use, sexually transmitted infection (STI), and sexual risk behavior at T1, T2, and T3. Participants reporting age, gender, and ≥1 AUDIT-C response were included in the analysis. AUDIT-C scoring criteria were ≥3 for women and ≥4 for men (hazardous) and ≥8 (dependent). Data were analyzed using SAS software version 9.3. Proportions of alcohol misuse by time point were reported. Generalized regression model analyses assessed effects of main exposures after adjusting for demographic characteristics (statistical significance of P < 0.05). Generalized estimating equations were used when longitudinal data were included. Models included the longitudinal data’s interaction with time.

Results

Participants in the analyses were: T1 (n = 2,593), T2 (n = 2,010), and T3 (n = 1,556). For T1, T2, and T3, respectively, 38.9, 39.4, and 42.4% screened positive for hazardous and 14.6, 12, and 10.8% for dependent alcohol misuse. Among those aged <21 years, 43.9, 49.3, and 35.4% screened positive for alcohol misuse at T1, T2, and T3, respectively. Longitudinal analysis showed those who screened positive for alcohol misuse were more likely to report an STI diagnosis (OR 2.4; 95% CI 1.44–4.01), exchange or receive money or goods for sex (OR 3.2; 95% CI 2.01–4.94), and use prescription or non-prescription drugs before sex (OR 2.1; 95% CI 1.64–2.61) than those who did not screen positive, after adjusting for other variables.

Conclusion

Alcohol misuse was associated with STIs and sexual risk behaviors across deployment. Improved screening and intervention for individuals who misuse alcohol are needed among deploying shipboard personnel, which may result in a reduction of sexual risk-taking.

Disclosures

All authors: No reported disclosures.
Assessment of the Sexual Violence Situation in a Regional Hospital in Guatemala: The Need for a Multidisciplinary Clinic
Authors: Soto Blanca , Canet Miriam , Erdmenger Diego
Published: October 2017

Background

Sexual violence is a global health problem, in terms of age and sex, showing a significant negative impact on health. Incidence in Guatemala is among the highest of the region reaching an average of 23 cases reported daily nationally per statistics from the Ministry of Health in 2015.

Methods

Retrospective analysis of the database of all sexual violence cases reported from a secondary -level national hospital in Guatemala from January 2005 to September 2015 (period A) and in-depth analysis on demographic and epidemiological data along with information of the follow-up of cases between January 2012 and September 2015 (period B) was performed.

Results

Period A: 500 cases; female (96%; 481/500). Assault occurred between 16–20 years (34%; 163/481) 11–15 years (22.25%; 107/481), and 21–30 years (22.04%; 106/481). From all reported male cases, 73.68% (14/19) occurred under 15 years.

Period B: 154/217 (70.96%) cases included; female (95.45%; 147/154), mean age: 17.87 years. Assault occurred in public spaces (57.14%; 88/154) and victim’s home (29.87%; 46/154). Almost 13% of victims reported history of previous assault, 5.84% by the same aggressor. More than one aggressor participated in 36.37% of assaults. Physical violence was associated in 57.79% of cases. Most victims (92.76%; 141/152) consulted within 72 hours of the assault. HIV, VDRL, and Hepatitis B testing performed in 100, 52, and 33.77%, respectively, were negative.

Follow-up visits at 3, 6, and 12 months after the aggression were attended by 20.78% (30/154), 1.95% (3/154), and 1.95% (3/154) of victims, respectively. Psychology support was completed only in 18.18% (28/154). Emergency contraception was provided when indicated; pregnancy as result of the aggression was reported in nine cases (5.84%).

Conclusion

The study shows that young women were the most vulnerable group for sexual violence. There is a lack of multidisciplinary approach and follow-up. Interventions on infectious diseases screening have to be optimized to reduce the risk of ETS transmission. This evidence supports the need for a specialized clinic to ensure access to comprehensive health services for victims.

Disclosures

All authors: No reported disclosures.
Ocular syphilis: Case Series (2000–2015) from Two Tertiary Care Centers in Montreal
Authors: Vadboncoeur Julie , Rabia Yasmine , Aubin Marie-Josée , Labbé Annie-Claude , Jaworsky Laurence , Serhir Bouchra , Fortin Claude
Published: October 2017

Background

In the past 15 years, a recrudescence of syphilis was observed in Canada, along with a surge in ocular syphilis cases. Without treatment, ocular syphilis can have serious consequences potentially leading to blindness. Our goal was to describe the demographics, clinical presentations, proportion of co-infection with HIV, treatments and visual outcomes of ocular syphilis cases.

Methods

Patients with a confirmed positive syphilis serology between 2000 and 2015 were identified through the reference laboratory database. A retrospective chart review was performed for those who visited the ophthalmology clinic of Hôpital Maisonneuve-Rosemont or Hôpital Notre-Dame to identify ocular syphilis cases.

Results

Among the 119 patients (174 eyes) identified (2.5% of the population screened), 80% were male; of which 63% were MSM. Mean presenting logMAR visual acuity was 0.70 (20/100 Snellen) and unilateral ocular involvement occurred in 54%. Ocular manifestations included interstitial keratitis (24 eyes), anterior uveitis (37 eyes), intermediate uveitis (17 eyes), posterior uveitis (31 eyes), panuveitis (27 eyes), isolated optic nerve involvement (25 eyes), and others (12 eyes) including VI nerve palsy, scleritis, and episcleritis. Cerebrospinal fluid (CSF) examination was done in 65 (55%) patients. Of those, VDRL was positive in 14 (22%) patients; white blood cells and proteins were elevated in, respectively, 28 (43%) and 39 (60%) of patients. HIV status was unknown in 39 (33%) patients; among those whose serology were performed (or previous status was known), 38 (48%) were HIV infected. Intravenous aqueous penicillin G was administered in 69 (58%), intramuscular benzathine penicillin in 25 (21%) and other antibiotics, mainly due to allergy, in three (3%) patients. Treatment allowed a visual improvement of –0.22 logMAR (gain of five lines on Snellen chart) after a mean follow-up period of 19 months.

Conclusion

Syphilis can manifest with a widely diversified array of ocular presentations, especially uveitis and optic nerve involvement. Therefore it is primordial to keep this diagnosis in mind when facing high-risk patients with ocular symptoms. It is of utmost importance that clinicians improve rates of lumbar puncture, HIV screening and intraveinous penicillin treatment when managing ocular syphilis.

Disclosures

All authors: No reported disclosures.
External validation of predictive scores for mortality following Clostridium difficile infection
Authors: Beauregard-Paultre Catherine , Chakra Claire Nour Abou , Mcgeer Allison , Labbé Annie-Claude , Simor Andrew E , Gold Wayne , Muller Matthew P , Powis Jeff , Katz Kevin , Cadarette Suzanne , Pépin Jacques , Garneau Julian R , Valiquette Louis
Published: October 2017

Background

The burden of Clostridium difficile infection (CDI) has increased in the last decade, with more adverse outcomes and related mortality. Although many predictive scores were developed, few were validated and their performances were sub-optimal. We conducted an external validation study of predictive scores or models for mortality in CDI.

Methods

Published predictive tools were identified through a systematic review. We included those reporting at least an internal validation approach. A multicenter prospective cohort of 1380 adults with confirmed CDI enrolled in two Canadian provinces was used for external validation. Most cases were elderly (median age 71), had a healthcare facility-associated CDI (90%), and 52% were infected by NAP1/BI/027 strains. All-cause 30-day death occurred in 12% of patients. The performance of each scoring system was analyzed using individual primary outcomes.

Results

We identified two scores which performances (95% CI) are shown in the table. Both had low sensitivity and PPV, moderate specificity and NPV, and similar AUC/ROC (0.66 vs. 0.77 in the derivation cohort, and 0.69 vs. 0.75 respectively). One predictive model for 30 days all-cause mortality (Archbald-Pannone 2015, including Charlson score, WBC, BUN, diagnosis in ICU, and delirium*) was associated with only 5% increase in odds of death (crude OR = 1.05 (1.03–1.06)) with an AUC of 0.74 (0.7–0.8).

Conclusion

The predictive models of CDI mortality evaluated in our study have limitations in their methods and showed moderate performances in a validation cohort consisting of a majority of CDI caused by NAP1 strains. An accurate predictive tool is needed to guide clinicians in the management of CDI to prevent adverse outcomes.

Disclosures

J. Powis, Merck: Grant Investigator, Research grant; GSK: Grant Investigator, Research grant; Roche: Grant Investigator, Research grant; Synthetic Biologicals: Investigator, Research grant
Are Patients with Prior Clostridium difficile Infection (CDI) a Potential Source of Transmission during Hospital Admissions?
Authors: Gonzalez-Orta Melany , Saldana Carlos , Cadnum Jennifer , Donskey Curtis J
Published: October 2017

Background

Many patients with Clostridium difficile infection (CDI) continue to shed spores asymptomatically after completion of CDI therapy. However, the duration of shedding and the potential for transmission during subsequent healthcare exposures is unknown.

Methods

During a 6-month period, we collected perirectal, groin, and skin (chest/abdomen and hands) cultures for toxigenic C. difficile from patients with a prior history of CDI who were admitted to the hospital. We calculated the frequencies of perirectal and skin shedding of C. difficile at the time of admission, stratified by the time since the prior CDI diagnosis.

Results

Of 28 patients with a prior history of CDI enrolled in the study, 10 (36%) had positive perirectal cultures for toxigenic C. difficile upon admission, and 6 of 10 (60%) had positive skin cultures. The figure shows the percentages of CDI cases with positive perirectal, groin, or skin cultures, stratified by the time since the prior CDI diagnosis.

Conclusion

Patients with prior CDI often shed spores asymptomatically during hospital admissions. Further studies are needed to determine whether these carriers contribute significantly to transmission.

Disclosures

All authors: No reported disclosures.
Hospital-Nursing Home Transfer Patterns and Influence on Nursing Home Clostridium difficile Infection Rates
Authors: Campbell Lauren , Bush Kristen , Dumyati Ghinwa
Published: October 2017

Background

Little is known as to how hospital C. difficile infection (CDI) may impact nursing home (NH) CDI, or how patient transfers may modify this relationship. This study aims to examine a possible association between hospital and NH CDI rates, and whether NH CDI rates are influenced by patient transfers from hospital to NH.

Methods

Patient transfers among the 5 hospitals and 34 NHs in Monroe County, NY were identified from the Minimum Data Set (MDS) 3.0 and Medicare Provider Analysis and Review files for 2011–13, and aggregated to the NH level. NH and hospital CDI rates were obtained from Emerging Infections Program CDI population surveillance and National Healthcare Safety Network data, respectively. Multivariate negative binomial regression modeled the association between hospital CDI rate (weighted by hospital-to-NH transfers/overall transfers among hospitals and NHs) and NH CDI rate, controlling for NH covariates from NH Compare and the Online Survey, Certification, and Reporting files. Patient transfer networks between hospitals and NHs were constructed, and basic network analysis of transfer patterns was conducted to confirm contributing factors to NH CDI rates from the multivariate model.

Results

When weighted hospital CDI rate increased by 1%, NH CDI rate increased by 18% (P = 0.016). Antibiotic and feeding tube prevalence were associated with a 4% and 8% increase in NH CDI rate, respectively (P≤0.014). Network analysis confirmed multivariate results and detected hospital-NH pairs with high edge weights (number of transfers) where NHs receiving patients from hospitals with high CDI rates had higher CDI rates. Network clustering methods were used to identify 2 sub-networks within overall annual networks and clusters of hospital-NH pairs for targeted intervention.

Conclusion

Hospital CDI rate, adjusting for patient transfers, is associated with higher NH CDI rates in multivariate and network analyses, suggesting that NHs with a large inflow of patients from hospitals may need to implement stricter infection prevention practices to reduce transmission among residents. By identifying regional sub-networks, network analysis can also be used to actively manage facility CDI and prevent spread to other healthcare facilities.

Disclosures

All authors: No reported disclosures.
Risk factors for Clostridium difficile infection in C. difficile colonized ICU patients
Authors: Zhou Yuan , Lewis Larissa , McIntosh Michelle , Fang Ferric C , Pergamit Ronald , Dellit Timothy , Lynch John B
Published: October 2017

Background

Clostridium difficile is a major cause of healthcare-associated infections leading to significant morbidity and mortality; however, data-driven interventions to decrease C. difficile infections (CDI) are lacking due to an incomplete understanding of disease transmission and risk factors. Asymptomatic C. difficile carriers may be an important source of nosocomial transmission and disease but few studies have examined colonized patients who later develop CDI. We describe risk factors for the development of CDI in a critical care population screened for C. difficile colonization.

Methods

All patients admitted to our medical or trauma ICUs were screened for toxigenic C. difficile by PCR via rectal swab. Colonized patients were placed in contact enteric precautions for their entire hospitalization and monitored for signs and symptoms of CDI. Retrospective chart review assessed risk factors associated with development of CDI.

Results

868 rectal swabs were collected from 4/01/16 to 10/31/16. 40 patients were colonized with C. difficile on ICU admission and 20 developed symptomatic CDI (Table 1). Risk factors for CDI in colonized patients include enteral feeding and exposure to antibiotics (Table 2).

Conclusion

50% of C. difficile colonized ICU patients progressed to symptomatic CDI during their hospitalization. Antibiotic use was a significant risk factor for CDI. C. difficile carriers may be a particularly vulnerable population for CDI, warranting further investigation for early identification of colonized patients and strategies for infection prevention.

Disclosures

F. C. Fang, BioFire: Collaborator, Consultant and Scientific Advisor, Consulting fee, Research support and Speaker honorarium; Cepheid: Collaborator, Consultant and Scientific Advisor, Consulting fee, Educational grant, Research support and Speaker honorarium
Watch Out! Syphilis Is Back – Case Series of Four Cases of Ocular syphilis
Authors: Awadh Hesham , Visweshwar Haresh , Kilgore Jacob , Willenburg Kara
Published: October 2017

Background

Syphilis is an ulcerative sexually transmitted genital infection caused by Treponema pallidum, which is a member of the order Spirochaetales, family Spirochaetaceae, and genus Treponema. The incidence rate of Syphilis has been steadily rising since 2000; from 2.1 cases per 100,000 population to up to 7.5 cases per 100,000 population in 2014–2015 (the highest rate since 1994). In the state of West Virginia, we have witnessed an increase in the number of cases from 0.5 cases per 100,000 population in 2011, to 5.9 cases per 100,000 population in 2015. Systemic symptoms can include cardiovascular and neurological manifestations. We report to your attention four cases of syphilis mainly with neurological and ocular manifestations.

Methods

We report a series of four cases of neurosyphilis we encountered between 2013 and 2016. Main presentation of all four cases was ocular; primarily redness and photophobia. Diagnosis was confirmed by standard ophthalmological examination with positive initial rapid plasma regain titers (RPR) and fluorescent treponemal antibody absorption testing (FTA-ABS). The cerebrospinal fluid venereal disease research laboratory test (CSF-VDRL) was positive in two of the four cases (in which lumbar puncture was performed). Two of the four cases suffered from an overt immunodeficiency (HIV and laryngeal cancer on chemotherapy) and subjects of all four cases confessed to high-risk sexual behaviors. All four cases were managed with continuous infusions of Penicillin G potassium 24 million International Units for 14 days with variable response.

Results

Response to treatment was variable in that initial complete resolution was achieved in one patient (Case #3), another (Case #1) was retreated in 6 months due to rising RPR titers on follow-up with subsequent improvement. Two patients were lost to follow-up (Cases #2 and #4).

Conclusion

Sir William Osler reportedly said: “He who knows syphilis knows medicine”. The steady rise in the incidence of Syphilis warrants that health care providers consider such a diagnosis in the evaluation of suggestive neurological and ocular manifestations in predisposed patients. We also stress on the importance of follow-up to detect failure of initial treatment.

Disclosures

All authors: No reported disclosures.
Decrease of Hospital-Onset Clostridium difficile through Enhanced Electronic Decision Support
Authors: Donatoni Gina , Mikolajczak Anessa , Lewis Steven , Daniels Mark , Haviley Corinne , Postelnick Michael , Sutton Sarah
Published: October 2017

Background

Literature supports appropriate testing as a key factor affecting hospital onset (HO) Clostridium difficile (CDIF). It was recognized that our institution was a significant outlier in HO CDIF with a standardized infection ratio (SIR) of 2.567 in the second quarter of 2016 compared with a national SIR of 0.997. A February 2015 – April 2015 line list of CDIF LabID events were pulled from the National Healthcare Safety Network (NHSN) and medical records were reviewed for test appropriateness based on CDC/IDSA guidelines. Of these, 50% were related to inappropriate testing. Infection Prevention and Quality identified this as an opportunity for improvement and Executives dedicated resources to reduction efforts.

Methods

A report was created using our data warehouse to track specimens that were not collected within 24 hours of an order, as well as patients that had testing done in the previous 7 days. Physician and nurse education was completed on appropriate testing for CDIF, including symptoms and timely specimen collection. An enhanced order set was launched which embedded the testing algorithm into a series of cascading questions and best practice alerts (BPAs) which prompt the provider to reconsider ordering if the patient has less than 3 episodes of diarrhea in a 24 hour period, and/or has alternative explanations for diarrhea, including tube feedings and/or laxatives. Any CDIF test results from the past 30 days appear on the order screen to further guide physician ordering.

Results

Based on our NHSN data, HO CDIF cases were identified from October 2015 – September 2016, resulting in a peak (SIR) of 2.567. Since the interventions in November 2016, we have decreased our SIR to 0.356 in the first quarter of 2017. This shows a 50% overall decrease in HO CDIF. The data warehouse report showed 99% compliance of specimens collected within 24 hours of an order and only 5% of patients with an order in the past 7 days.

Conclusion

By implementing targeted education and a sophisticated order entry process that includes decision support, as well as recent results and treatments in the electronic medical record, CDIF cases are being appropriately ordered and collected, ensuring appropriate classification within NHSN and a decrease in overall SIR

Disclosures

All authors: No reported disclosures.
Similar Sexually Transmitted Infections Prevalence Despite Lower HIV Prevalence Among Transgender Women Compared with Men Who Have Sex With Men in Thai Community-Based Test and Treat Cohort
Authors: Hiransuthikul Akarin , Prawepray Nanthika , Pengpum Supab , Reankhomfu Ratchadej , Panpet Phubet , Mahachokchai Nopparat , Sumalu Saman , Brutat Pornpichit , Sungsing Thanthip , Janamuaysook Rena , Pengnonyang Supabhorn , Jantarapakde Jureeporn , Trachunthong Deondara , Na Nakorn Panus Rattakittvijun , Charoenying Sutinee , Phanuphak Praphan , Vannakit Ravipa , Phanuphak Nittaya
Published: October 2017

Background

Men who have sex with men (MSM) and transgender women (TG) are at increased risk for sexually transmitted infections (STIs). To understand potential different characteristics, we assessed gender-specific, demographic data, behavioral risks and prevalence of STIs.

Methods

Thai MSM and TG aged ≥18 years from six community-based organizations in Thailand were enrolled into the Test and Treat cohort during 2015–2016. Baseline demographic and behavior risk assessment and HIV/STIs testing were done. Blood for syphilis serology and pharyngeal and anal swab, and urine for gonorrhea and chlamydia nucleic acid amplification testing were collected. Logistic regression was used to determine factors associated with gender-specific STIs prevalence.

Results

From 1862 MSM and 787 TG enrolled, 874 (33%) had STI and 402 (15.2%) were HIV-positive. Compared with MSM, more TG were single (79.7% vs. 71.6%), had lower education (23.6% vs. 40% with diploma or higher), had lower income (35.7% vs. 42.6% gained >288 USD/month), had first sex at young age (20.1% vs. 12.8% at <15 years old), and reported >3 sexual partners in the past 6 months (32.9% vs. 24.6%) (all P < 0.001). The overall STIs prevalence was similar between both genders (31.5% vs. 33.6%, P = 0.29), but TG had lower HIV prevalence (8.9% vs. 17.8%, P < 0.001). TG had higher prevalence of pharyngeal and anal chlamydia (5.5% vs. 2.9%, P = 0.001 and 19.5% vs. 15.1%, P = 0.007, respectively), while syphilis prevalence was higher in MSM (9.9% vs. 3.6%, P < 0.001). Among HIV-positive participants, MSM had higher prevalence of HIV and syphilis coinfection (26.2% vs. 8.6%, P = 0.001). STIs prevalence among TG was associated with HIV-positive status (adjusted odd ratio [aOR] 2.74; 95% CI 1.52–4.95, P = 0.001), having multiple sexual partners or refused to answer (aOR 2.36; 95% CI 1.31–4.24, P = 0.004 and 2.33; 95% CI 1.24–4.37, P = 0.009, respectively) and unprotected sexual intercourse (aOR 1.66; 95% CI 1.02–2.69, P = 0.041).

Conclusion

Almost one-third of TG enrolled into the Test and Treat cohort had STI. TG had lower HIV prevalence but similar STIs prevalence compared with MSM, despite practicing riskier sexual behaviors. Our findings signified the importance of studying TG sexual networks in Thailand to better strategize sexual health programs.

Disclosures

All authors: No reported disclosures.
Electronic Hand Hygiene Monitoring: A Tool to Drive Improvement and Measure Impact
Authors: Knepper Bryan , Miller Amber , Reese Sara , Kurtz Jennifer , Stella Sarah , Young Heather
Published: October 2017

Background

Hand hygiene (HH) is a basic principle of infection control, yet national HH adherence rates are only 40%. Challenges to improving HH rates include finding effective ways to promote and sustain change and collecting unbiased observations to measure the success of interventions. Our institution implemented an electronic HH (eHH) monitoring system on select hospital units with the goal of using this technology to both improve and measure HH rates.

Methods

In Apr 2016, Denver Health installed the HillRom Hand Hygiene Compliance Solution in 4 inpatient units (2 adult wards, 1 intensive care unit, and 1 progressive care unit). Sensors were installed on all HH dispensers and at the thresholds of patient rooms on the units. Registered nurses and certified nursing assistants wear badges that track HH upon entry and exit from the room. Appropriate eHH was defined as the use of waterless hand sanitizer or soap within 60 seconds before or after entering or exiting a room. Baseline data was collected for 2 months; a series of interventions, including public recognition of top performers, private individualized feedback, and posters emphasizing social pressures, were undertaken beginning in June 2016 (Figure 1). Descriptive statistics, chi-squared tests, and interrupted time series analyses were used to analyze the data.

Results

The median number of total daily observations was 4083 (IQR 3801–4437). The mean eHH adherence rate in the baseline period (Apr/May 2016) was 46% (IQR 44%-49%) and increased to 76% (IQR 75%-78%) in Mar 2017. Over the study period, there was a significant decreasing trend in the proportion of nurses with eHH rates <50% (P < 0.0001, Figure 2) and a significant increasing trend in the proportion of nurses with eHH rates ≥80% on all units (P < 0.0001, Figure 3).

Conclusion

eHH provides thousands of objective observations per day. eHH rates improved over the study period both due to an increase in nurses with eHH ≥80% and a decrease in the proportion of nurses with eHH <50%.

Disclosures

All authors: No reported disclosures.
Monitoring Hand hygiene Compliance among Healthcare Workers at a Tertiary Care Center: Use of Secret Observers Is the Way Forward
Authors: Krishna Amar , Navalkele Bhagyashri , Pervaiz Amina , Kotecha Aditya , Maroof Shahram , Stern Dale , Robinson Katia , Kado Jenna , Flanagan Elaine , Hussain Syed , Chopra Teena
Published: October 2017

Background

Hand-hygiene (HH) is known to be the most effective way to reduce healthcare acquired conditions (HACs). Despite being a simple answer to the complex HAC issue, compliance with HH practice has been abysmal with reported compliance rate of 40% among healthcare workers (HCWs). In 2015, compliance rate with HH at Detroit Medical Center (DMC) was reported to be 100% when direct observers were used to monitor compliance. In order to confirm the previously reported compliance rates, this study used secret observers to audit HH compliance and provide performance feedback to HCWs.

Methods

A prospective observational study was conducted at DMC from June 2016 to December 2016. Hand hygiene committee was established comprising of Infection Prevention and Hospital leadership members. Trained medical residents were appointed as “secret observers” to provide accurate HH reporting. HH auditing was performed using the smartphone app “Speedy audits” to survey and capture the 5 moments of hand hygiene among HCWs. Compliance reports based on different professions, hospital sites, unit locations and auditors were generated using online web portal and analyzed to determine HH compliance rate.

Results

During the 7-month study period when secret observers were used, a total of 1229 HCWs were observed. Overall, the HH opportunity compliance rate was 31% (916 complied opportunities /2939 opportunities). Hand hygiene compliance rates drastically fell when secret observers were used (31% compared with 100% in 2015 using direct observers). Based on two major before and after patient contact indications, 1022 compliances were observed from 3343 opportunities (30.5% compliance rate). The other compliance rates were 44% before aseptic procedure, 35% after body fluid exposure and 20% after patient environment contact [Figure 1]. Based on profession, compliance rates were lowest among nurses (613/2058; 30%) and medical students (36/169; 21%) when compared with physicians (445/957; 46%).

Conclusion

Hand-hygiene monitoring by secret observers with use of smartphone app is a feasible and accurate way for tracking HH compliance. The advantage of generating profession-based and unit-based reports for feedback will help to promote HH awareness and improve adherence rates.

Disclosures

All authors: No reported disclosures.
What Psychological Theories of Behavior Change Can Teach Us about Improving Hand Hygiene Adherence: Do We Mean What We Say?
Authors: Corace Kimberly , Smith Jeffrey , MacDonald Tara , Fabrigar Leandre , Saedi Arezou , Quirk Jacquelyn , MacFarlane Sam , Valickis Debbie , Garber Gary
Published: October 2017

Background

Health care worker (HCW) hand hygiene is effective in reducing healthcare associated infections, yet hand hygiene rates are suboptimal. Psychological theories of behavior change can be used to improve and sustain hand hygiene adherence. While past research has examined HCW explicit attitudes towards hand hygiene (ie., self-reported attitudes), it is unclear if these explicit attitudes are consistent with implicit attitudes (ie., attitudes outside of one’s awareness). Understanding HCW explicit and implicit attitudes is important when designing effective interventions to improve hand hygiene rates. This study examined explicit attitudes towards HCW hand hygiene and compared these to implicit attitudes.

Methods

HCWs (N = 420) from 70 long-term care facilities in Ontario, Canada completed: (1) a survey tool based on psychological theories of behavior change to examine explicit attitudes towards hand hygiene, and (2) a computer administered implicit association test (IAT) and affect misattribution procedure (AMP) to evaluate implicit attitudes towards hand hygiene. Sociodemographics and self-reported hand hygiene adherence were measured. Factor analysis was performed to identify themes. Correlations were conducted between explicit and implicit measures.

Results

Factor analysis identified key explicit attitudes themes: (1) beliefs about consequences to self and others, (2) environmental resources, (3) time pressure and workload, and (4) social/professional role and identity. AMP and IAT results indicated that these procedures can be successfully applied to hand hygiene. While results suggested implicit positive attitudes towards hand hygiene, implicit test scores were neither correlated with explicit attitudes nor with self-reported hand hygiene adherence.

Conclusion

Explicit attitudes did not predict implicit attitudes. So, what we say is not always what we really think or do. Interventions have successfully targeted implicit attitudes to foster behavior change when targeting explicit attitudes alone did not work. This is yet to be explored in the hand hygiene arena, and is a key area for future research in order to guide the development of successful interventions to sustainably improve hand hygiene rates.

Disclosures

All authors: No reported disclosures.
Humoral and Cellular Immunogenicity of Zoster Vaccine within One Year after Herpes Zoster
Authors: Lee Eunyoung , Chun June Young , Song Kyoung-Ho , Choe Pyeong Gyun , Bang Ji Whan , Kim Eu Suk , Kim Hong Bin , Park Sang Won , Kim Nam Joong , Park Wan Beom , Oh Myoung-Don
Published: October 2017

Background

Herpes zoster vaccination is recommended to patients with a prior history of herpes zoster to prevent reactivation. However, the appropriate timing of vaccination is controversial. We compared immunogenicity of vaccine according to timing of vaccination after zoster illness.

Methods

In this prospective observational study, subjects were stratified into two groups by the vaccination timing since their zoster illness: 6–12 months (within-1 year group) vs. 1–5 years (after-1 year group). Blood samples were collected before and 6 weeks after vaccination of zoster vaccine live. Varicella-zoster virus (VZV)-specific IgG concentrations were measured by enzyme-linked immunosorbent assay. Interferon-gamma enzyme-linked immunosorbent spot (ELISPOT) assays were performed to assess VZV specific T-cell responses.

Results

A total of 59 patients (18 in the within-1 year group and 41 in the after-1 year group) were enrolled. Ages were not significantly different between groups. The baseline geometric mean titer (GMT) of VZV IgG was higher in the within-1 year group than in the after-1 year group (245.8 IU/mL vs. 124.9 IU/mL; P = 0.040). The geometric mean fold-rise (GMFR) of VZV IgG was lower in the within-1 year group than in the after-1 year group (1.42 vs. 2.46; P = 0.002). The GMT of spot forming cell (SFC) counts by ELISPOT at baseline and 6 weeks after vaccination were not significantly different between groups. The GMFRs of SFCs were also comparable.

Conclusion

Zoster vaccination within 1 year after zoster illness may have disadvantage in the aspect of humoral immune response (ClinicalTrials.gov number, NCT02704572).

Disclosures

All authors: No reported disclosures.
Immunogenicity and Safety of a Candidate Subunit Adjuvanted Herpes Zoster Vaccine (HZ/su) in Adults Post Renal Transplant: a Phase III Randomized Clinical Trial
Authors: Vink Peter
Published: October 2017

Background

The incidence rate of herpes zoster (HZ) in individuals with solid organ transplants (SOTs) is estimated as 8–9 times higher than the rate in the overall US population (3.2/1000 person-years). No vaccine is currently available to prevent HZ in immunocompromised individuals. GSK’s HZ/su candidate vaccine, containing varicella-zoster virus glycoprotein E (gE) and AS01B Adjuvant System, has shown >90% efficacy for HZ prevention in immunocompetent adults ≥50 years of age (YOA). We performed a study to determine immunogenicity and safety of HZ/su in adult renal transplant (RT) recipients (RTR) on chronic immunosuppressive therapy; RT was chosen as it can be representative of SOTs due to the nature of administered immunosuppressive therapies.

Methods

In this phase III, observer-blind, multicenter study (NCT02058589), RTRs ≥18 YOA were randomized 1:1 to receive 2 doses of HZ/su or placebo intramuscularly 1–2 months apart. gE-specific vaccine response rates (VRRs) and geometric means (GMs) were assessed for humoral and CD4+ cell-mediated immune (CMI) responses 1 month post dose 2 (M2). Solicited adverse events (AEs) were recorded for 7 days and unsolicited AEs and medically-attended AEs (MAEs) for 30 days after each dose. Solicited general and unsolicited AEs were also collected for 7 days prior to dose 1. Potential immune-mediated diseases (pIMDs) and serious AEs (SAEs) were recorded until 1 year post dose 2. Data from dose 1 through M2 is presented.

Results

At M2, 240 subjects (121 HZ/su; 119 placebo) were included in the humoral immunogenicity according-to-protocol (ATP) cohort. All immunogenicity success criteria were met at M2 (Table 1). VRRs for ATP humoral immune cohort and CMI sub-cohort (72 subjects: 36 HZ/su; 36 placebo) were higher in HZ/su groups. Humoral GM concentrations and CMI GM frequencies were significantly higher in HZ/su compared with placebo groups. The frequency of AEs was higher in HZ/su vs. placebo groups for solicited local AEs, but similar for solicited general AEs, unsolicited AEs, MAEs and SAEs. No pIMDs, vaccine-related SAEs or transplant rejections were reported (Table 2).

Conclusion

HZ/su was highly immunogenic in adults with RT at M2. No safety concerns were identified.

Funding

GlaxoSmithKline Biologicals SA

Disclosures

P. Vink, GSK group of companies: Employee, Salary and stock options and stock granted
Improved HIV markers and decreased emergencyroom usage and hospital admission with initiation of a pilot specialty pharmacy at a southeastern Ryan –White –funded clinic over a three year period
Authors: Ly Nguyen Minh , Condra Alton , Corbin-Johnson Della , Woodson Kay , Patel Manish , Colasanti Jonathan , Armstrong Wendy
Published: October 2017

Background

Specialty pharmacy (SP) provides timely medication delivery to patients and seeks to improve patient adherence through monthly pharmacist medication therapy management (MTM). Patients living with HIV/AIDS have both high cost medications and complex disease states and thus will benefit from SP. We report on the outcome of HIV therapy after 3 years of a pilot SP ina southern inner city RW funded clinic.

Methods

This is a single center retrospective chart review of patients at our clinic who were enrolled in the SP from 6/3/13–5/1/16 for at least 6 months. Baseline demographic characteristics and HIV markers (CD4, viral load) were collected. Outcomes of interest were: change in CD4 count, percent with viral suppression (VS), emergency room (ER) and hospital admission usage, as well as percent of scheduled providers’ appointment kept. Each individual had the same follow up time before and after SP initiation. Bivariate analysis compared outcomes preSP and during SP using Chi-square or Fisher exact tests for categorical and Wilcoxon rank-sum test for continuous variables.

Results

During the 3-year period, there were 212 individuals referred to SP, of which 170 participated in the program. There were 92(54%) men, 136(80%) black. The median age was 48.3 years (IQR: 28.5–56.3). The average duration of follow up pre and during SP was 22.1(IQR: 16.5–27) months. In terms of insurance, 69(40%) had Medicare, 22(13%) had Medicaid, 22(13%) had private insurance, 54(32%) received AIDS drug Assistance Program (ADAP), and 3(2%) had Ryan White. Patients resided an average distance from the clinic of 17.4(IQR: 8.8–25) miles. The respective outcomes before and during SP were: CD4: 350(IQR: 181–551) vs. 413(IQR: 263–611 cells/mL (P < 0.0001), VS in 78 ± 30% vs. 91 ± 20% (P < 0.0001). The proportion of patients with emergency room usage or hospital admissions was 68(40%) vs. 49(29%) (P = 0.036). There was no difference in the rate of kept providers’ appointment (66.6 %(IQR: 53.8–78.6%) vs. 63.8 %(50-77%) (P = 0.19). There was no reported death during the follow –up period.

Conclusion

This pilot SP program at the RW clinic showed statistically significant improvement of CD4 count and VS, as well as 40 % decrease in odds of using ER or hospital admission. Further studies are needed to determine whether SP is beneficial to people living with HIV/AIDS in other settings.

Disclosures

M. Patel, ViiV: Scientific Advisor, Consulting fee