bluuebunny/crossref_metadata_2025 huggingface dataset:
766. Everything Old is New Again-A Case Series of New World Leishmaniasis in African Children in Portland, Maine
Authors: Jubulis Jennifer , Goddard Amanda , Seiverling Elizabeth , Kimball Marc , McCarthy Carol A
Published: January 2021

Background

Leishmaniasis has many clinical manifestations and treatment regimens, dependent on species and host. Old world leishmaniasis is found primarily in Africa and Asia, and is associated with visceral disease, while new world disease, seen primarily in Latin America, is more commonly mucocutaneous. We present a case series of pediatric African patients with New World cutaneous leishmaniasis (NWCL).

Methods

Data extraction was performed via chart review, analyzing travel history, clinical presentation, diagnosis, and management in children with cutaneous leishmaniasis presenting to the pediatric infectious diseases clinic in Portland, ME. Biopsy specimens were sent to the federal CDC for identification by PCR and culture.

Results

Five cases of NWCL were diagnosed in pediatric patients in Maine from November 2018 through February 2020. Median age of patients was 10 years (range 1.5-15 years). Four cases (80%) occurred in children from Angola or Democratic Republic of Congo, arriving in Maine via Central/South America, with one case in a child from Rwanda who arrived in Maine via Texas. Three patients had multiple skin lesions and two had isolated facial lesions. Leishmaniasis was not initially suspected resulting in median time to diagnosis of 5 months (range 1-7 months). Four patients were initially treated with antibacterials for cellulitis and one was treated with griseofulvin. After no improvement, patients underwent biopsy with 2 patients diagnosed with L panamensis, 1 with L braziliensis, 1 with mixed infection (L panamensis and L mexicana), and 1 with Leishmania species only. One patient was managed with surgical excision, 3 with ketoconazole, and 1 was observed off therapy. Four patients were referred to otolaryngology. All continue to be followed in infectious disease clinic.

Conclusion

We present five cases of new world cutaneous leishmaniasis in African pediatric patients arriving to Maine through Latin America or Texas. Patients were diagnosed with cellulitis, tinea corporis or atopic dermatitis initially, underscoring importance of high index of suspicion in migrant patients. Detailed travel history and epidemiologic knowledge is essential to diagnosis, as patients may present with illness not congruent with country of origin. Optimal therapy remains unclear.

Disclosures

All Authors: No reported disclosures
768. Malaria in a Non-Endemic Setting: A Retrospective Review of Malaria Hospitalisations in Ireland over a Four Year Period
Authors: Moynan David , Reidy Niamh , O’Connell James , Reidy Paul , de Barra Eoghan
Published: January 2021

Background

With globalisation fuelling the fire for infectious diseases, it’s important for general physicians to be aware of the tropical infections presenting to hospitals. Malaria, with over 400,000 deaths annually worldwide, has an Irish notification rate of 1.2 per 100,000 of the population, the seventh highest incidence rate of imported malaria globally. This analysis aims to examine the demographics and outcomes of Irish patients with malaria over a four year period.

Methods

A retrospective analysis of all patients with malaria admitted to Irish hospitals between January 1st 2016 and December 31st 2019 was performed. Data was obtained from the National Quality Assurance Improvement System (NQAIS), a national electronic database that collates data from hospital admissions. This was analysed using STATA. Patient demographics, hospital length of stay and documented malaria subspecies are described.

Results

Between January 1st 2016 and December 31st 2019 there were 289 cases of malaria admitted to Irish hospitals, 13/289 (4.5%) requiring high dependency care. 197/289 (68%) were male. The mean age was 35 years (95% CI 33.3 – 37). 220/289 (76%) of all cases resulted from Plasmodium falciparum infection, 16/289 (5.5%) Plasmodium ovale, 11/289 (3.8%) Plasmodium vivax and 2/289 (0.7%) Plasmodium malariae, while 40/289 (13.8%) were unspecified. The median length of stay was 3 days (IQR 1-4 days) and 72/289 (25%) were admitted under an Infectious Diseases team, although this had no significant impact in length of stay (3.1 days versus 3.4 days, p=0.68). 117/289 (40%) were admitted in the months of August and September. There were no reported deaths.

Conclusion

This report gives a clinical context to the 2016 – 2019 NQAIS data, particularly with regards to inpatient length of stay, malaria species diagnosed and numbers requiring critical care. The majority of all cases in the four year period were P. falciparum, reflective of the dominant African region of exposure in most cases. Interestingly, 43% of all cases were from hospitals outside of the Dublin City catchment area, reflecting a diversification of travel and population demographics in Ireland. This highlights the importance of malaria awareness in all regions in Ireland, not simply the major urban centres.

Disclosures

All Authors: No reported disclosures
771. Prospective validation of the universal vital assessment (UVA) score to predict the in-hospital mortality of patients with acute illness admitted to a government district hospital in KwaZulu-Natal, South Africa
Authors: Ahmed Amiya A , Ladines-Lim Joseph B , Moore Christopher , Malinga Sipho , Moll Anthony , Eksteen Francois J , Shenoi Sheela
Published: January 2021

Background

Critical illness is a frequent cause of mortality in resource-limited settings. Improved triage on admission could improve mortality, but existing tools depend on variables that often are not available. We prospectively evaluated the universal vital assessment (UVA) score to predict mortality among patients admitted to a district hospital in rural, highly HIV-prevalent South Africa.

Figure 1. Receiver operator characteristic (ROC) curves for the UVA and qSOFA scoring tools.

Methods

In February-March 2020, adults admitted to the medical wards were enrolled, prior to interruption by covid19, and 30-day mortality assessed. Clinical parameters including temperature, heart and respiratory rates, systolic blood pressure, oxygen saturation, Glasgow Coma Scale score, and HIV status were collected within 24 hours of admission as part of routine care. Lower respiratory tract infections (LRTI) included pneumonia and suspected pulmonary tuberculosis. To evaluate the predictive ability of the UVA score, area under the receiver operating characteristic curve (aROC) and age-sex adjusted binary logistic regression models were generated, and compared to the sequential organ failure assessment (qSOFA).

Results

Sixty one patients were enrolled; outcomes were available for 56 patients. Patients had a mean age of 52 (SD+17), 51% were women, and 46% were HIV infected. The 30-day mortality was 16.1% (9/56) with infections and non-communicable diseases comprising 47% and 47% of admission diagnoses, respectively. The most common admitting diagnosis was LRTI (24.6%). The median (+IQR) UVA score was 2 (+3) accounting for 36% of participants. Medium-risk (2-4) and high-risk (>4) UVA groups were not associated with 30-day mortality, although the high-risk score trended towards significance (p=0.07). However, a UVA score > 3 was significantly associated with 30-day mortality, both alone and after adjusting for age and sex (aOR 6.2, 95% CI 1.2-33.1; p=0.03). The aROC (95% CI) for the UVA score was 0.74 (0.55 – 0.93), which performed better than qSOFA (aROC 0.59, 95% CI 0.37-0.81) and is shown in Figure 1.

Conclusion

In this resource-limited, HIV-prevalent setting, the UVA score predicted mortality better than the qSOFA score. A moderate-risk UVA score (>3) was predictive of 30-day mortality, though needs to be confirmed in larger studies.

Disclosures

All Authors: No reported disclosures
779. Clostridiodes difficile: Is it time for surveillance! Cost-benefit analysis
Authors: Yassin Mohamed , Donskey Curtis , Arbulu Ricardo , Dixon Heather , Smith Kenneth
Published: January 2021

Background

Clostridiodes difficile infection (CDI) has substantial morbidity, mortality and expense. Hospital surveillance to detect CD carriers could affect antibiotic use and determination of community-associated vs hospital-associated CDI.

Methods

A decision tree examined the cost-effectiveness of hospital CD surveillance compared to current practice (testing as indicated). Costs for CD testing, community-associated CDI and hospital-associated CDI came from US databases. CD carrier and infection probabilities came from literature and local data. Analyses examined potential benefits from 1) knowledge of CD carrier status affecting antibiotic use (healthcare perspective) and 2) avoiding penalties for hospital-acquired CDI (hospital perspective).

Results

From the healthcare perspective, if antibiotic use is unchanged by CD status, surveillance costs $39/patient than current practice with unchanged CDI risk. However, if knowing CD status changed antibiotic prescribing such that CDI risk decreased by 10% or 20%, then cost/CDI avoided becomes $15,519 and $3,822 respectively, with CD surveillance becoming cheaper and more effective current practice if CDI risk decreased ≥30%. From the hospital perspective, using published CDI incidence (2.7%) and a hospital-associated CDI penalty of $30,000, surveillance cost $336/patient less than current practice if patients colonized on admission were not considered hospital-associated CDI and $476/patient less with local data (incidence 4.2%).

Conclusion

Hospital CD surveillance is potentially a cost-effective or cost-saving strategy depending on perspective taken and clinical usage of these data. This strategy could be implemented hospital-wide or in high-risk populations. CD surveillance could be both cost-saving and decrease CDI risk if more appropriate antibiotic use results from its use.

Disclosures

All Authors: No reported disclosures
782. Clostridioides difficile environmental contamination in hospitalized patients with diarrhea: a pilot study
Authors: Warren Bobby G , Turner Nicholas A , Addison Rachel , Nelson Alicia , Marden Samantha , Gamez Isabella , Smith Becky A , Polage Christopher R , Weber David J , Weber David J , Rutala William , Sickbert-Bennett Emily , Anderson Deverick J
Published: January 2021

Background

The relative contribution of Clostridioides difficile colonization or infection in contamination of the hospital environment is poorly understood.

Methods

We performed a prospective cohort study of patients with diarrhea who were tested for C. difficile infection via PCR and enzyme immunoassay (EIA) to compare C. difficile environmental contamination by test result. Patients were stratified into one of three cohorts: PCR-, PCR+/EIA+ or PCR+/EIA-. Environmental microbiological samples were taken within 24 hours of C. difficile cultures and again for two successive days for a total of three days. Patients were excluded if they had C. difficile infection in the past 6-weeks. Microbiological samples of surfaces were obtained with pre-moistened cellulose sponges from three locations (bathroom, adjacent to bed, and care areas) and processed using the stomacher technique. Ribotyping was completed on a subset of stool and environmental samples to measure concordance of isolates. CFU and recovery rates between arms were compared with a global ANOVA followed by pairwise comparisons using a Bonferroni adjustment.

Results

We enrolled 41 patients between November 2019 and March 2020. 7 patients were PCR+/EIA+, 8 were PCR+/EIA- and 26 were PCR- (Table 1). A total of 347 individual and 116 room samples were obtained. PCR+/EIA+ patient rooms had a higher average room burden (435.6 CFU (95%CI: 178.0-694.0)) compared to PCR+/EIA- (83.5 (-9.1-175.0), p< 0.01) and PCR- rooms (17.1 (1.2-33.0), p< 0.01); PCR+/EIA- and PCR- rooms were similar (p=0.83). PCR+/EIA+ patient rooms had a higher recovery rate (61%) compared to PCR+/EIA- (36%, p=0.64), although not statistically significant, and PCR- rooms (16%, p< 0.01); PCR+/EIA- had a similar recovery rate to PCR- rooms (p=0.14) (Table 2). Of the rooms with both patient and environmental isolates, 79% of patient isolates had a concordant isolate recovered in the environment.

Table 1

Table 2

Conclusion

The amount of environmental contamination of PCR+/EIA+ patients was higher than both PCR+/EIA- and PCR- patients, however, the recovery rate of PCR+/EIA+ patients was similar to PCR+/EIA- patients. Subsequent larger trials are needed to expand on this pilot data to determine the difference, if any, between environmental contamination levels of these patient populations.

Disclosures

David J. Weber, MD, MPH, PDI (Consultant)
784. A Novel Method to Assess Virulence of Clostridioides difficile: Focus on C. difficile Ribotype 106
Authors: Almutairi Masaad , Garey Kevin W , Alnezary Faris S , Fallatah Saad , Gonzales-Luna Anne J , Alam M Jahangir , Begum Khurshida
Published: January 2021

Background

Clostridioides difficile ribotype (RT) 106 has emerged as one of the most commonly isolated strains in the USA and worldwide. However, studies investigating clinical outcomes associated with this strain are lacking. The purpose of this study was to compare disease severity, clinical cure, and recurrence rates associated with CDI caused by RT106 vs two other comparator strains.

Methods

This multicenter study (20 hospitals) assessed hospitalized patients infected with C. difficile RT106 compared to patients infected with a known hypervirulent strain (RT027) and a strain associated with less virulence (RT014-020). Electronic medical records were reviewed by investigators blinded to RT. Disease severity was calculated using the 2017 IDSA/SHEA guidelines, initial clinical cure was defined as resolution of symptoms by day 6 of treatment, and recurrence assessed 90-days after the initial positive toxin test. All isolates were ribotyped using PCR fluorescent ribotyping.

Results

A total of 380 patients with CDI aged 66 ± 17 years (Female: 59.5%; White: 70.5%) infected with RT 106 (115/380; 30.3%), RT027 (116/380; 30.5%), and RT014-020 (149/380; 39.2%) were included. Approximately half of the patients had severe CDI (47.6%). Disease severity was highest for RT027 (59.3%) followed by RT014-020 (45%), and RT106 (41.2%). Clinical cure rates were lowest for RT027 (74.8%) followed by RT106 (77.8%), and RT014-020 (85.5%). 90-day recurrence rates were highest for RT027 (20.7%) followed by RT106 (13.3%), and RT014-020 (8.7%). Compared to RT014-020, virulence increased with RT106 (OR:1.10; 95% CI: 0.67-1.8) and RT027 (OR: 2.0: 95% CI: 1.2-3.5) was noted.

Conclusion

Our novel analysis method established RT106 as a moderately virulent C. difficile strain vs. comparator ribotypes. This study presents a novel method for comparing clinical outcomes for emerging ribotypes.

Disclosures

Kevin W. Garey, PharmD, MS, FASHP, Merck & Co. (Grant/Research Support, Scientific Research Study Investigator)
786. Diagnostic stewardship of C difficile PCR testing with two step algorithm- A rural community hospital experience
Authors: Tirupathi Raghavendra , Freshman Ruth , Montoy Norma , Gross Melissa
Published: January 2021

Background

An estimated 15% of hospitalized patients are asymptomatic carriers of C. diff. Inappropriate testing can lead to over diagnosis, treatment, isolation & substantial financial penalties. Ours is a rural 310 bed hospital with nurse driven C. diff test ordering protocol. Due to inadvertent test ordering, we had an uptick in the HO-CDI incidence with rates as high as 0.94 per 1000 patient days in 2017. In order to streamline testing, we initiated an infection preventionist(IP) led diagnostic stewardship program which was implemented in two phases in 2017-2019

Methods

The phase 1 involved daily review by IPs regarding the legitimacy of PCR order for minimum 3 loose stools in 24 hours, use of laxatives, presence of symptoms.There were concerns nationally that then CDI risk adjustment model from NHSN in 2017 does not optimally account for the impact of specific CDI testing methods used by individual hospitals on CDI SIRs. Hence, in Jan 2018 NHSN’s MDRO/CDI Protocol stated “Results of the final test that are placed in the patient’s medical record should be used to determine whether event meets the CDI LabID defn”.This led to phase 2 in mar 2019 which involved two step testing which started with C diff PCR assay with positive test reflexed to the toxin A/B assay.

Results

During the first phase, and a full year of the protocol in 2018, the number of completed PCR tests decreased to 626 (compared to 940 PCR tests in 2016) with an 34% decrease. In the year following implementation of the Diagnostic Stewardship, HO CDI decreased from 60 in 2017 to 43 events in 2018 with a reduction of 28%. Subsequently, HO CDI further decreased in 2019 to 28 with a reduction of 35%. Since the start of the project in 2017, HO CDI have decreased 54% in total. The reduction in 314 C diff PCR tests in the first year[2017-2018] led to a savings of $8300 in lab supplies. No readmissions with C difficile infection documented within 30 days on patients who did not meet the criterion for testing. Significant decrease in the usage of C difficile antibiotics. After the start of the two step test, we have seen a precipitous drop in our HO-CDI rates to less than 0.3 per 1000 pt days by the end of 2019.

Quarterly comparison of HO CDI incidence for 2017-2020

HO CDI incidence before and following phase 1 and phase 2 interventions

C. difficile antibiotic use trends during intervention period

Conclusion

IP run diagnostic stewardship programs with two step tests are highly successful in streamlining testing and in discriminating infection from colonization

Disclosures

All Authors: No reported disclosures
789. Evaluation of Bezlotoxumab for Prevention of Recurrent Clostridioides difficile Infection in Patients at High Risk for Recurrence
Authors: Johnson Tanner M , Howard Amanda , Schwarz Kerry , Allen Lorna , Huang Misha , Bajrovic Valida , miller matthew
Published: January 2021

Background

Recurrent Clostridioides difficile infection (rCDI) within 180 days of the index episode is associated with a 33% increase in mortality and, to-date, few treatment options exist to prevent recurrent infection. Bezlotoxumab (BEZ) is a novel therapeutic option for the prevention of rCDI, yet limited data exist regarding its effectiveness in patients at high-risk for recurrence outside of controlled trials. This study aimed to compare BEZ to a historical standard of care (SoC) cohort for the prevention of rCDI in patients at high risk for recurrence.

Methods

A multi-center retrospective cohort study of patients within an academic health-system with one or more risk factors for rCDI. Patients received SoC with oral vancomycin (VAN) or fidaxomicin (FDX) from January 2015 to December 2017 or BEZ, in addition to oral SoC, from September 2017 to September 2019. The primary outcome was rCDI within 90 days of completion of oral VAN or FDX. Secondary outcomes included all-cause readmission, all-cause mortality, and safety events at 90 days.

Results

One-hundred twenty patients received BEZ in addition to SoC (n=47) or SoC alone (n=73). Mean (SD) age was 55 (16) years, mean (SD) number of lifetime CDI was 3 (2) episodes, and 30.8% of patients had severe CDI. Six (12.8%) patients in the BEZ cohort and thirty-one (42.5%) in the SoC cohort experienced rCDI at 90 days [OR (95% CI) = 0.20 (0.07-0.53), p=< 0.01]. Incidence of all-cause mortality (2.1% vs 5.5%, p=0.67) and all-cause readmission (42.6% vs 56.2%, p=0.20) within 90 days were not statistically different between groups. Patient body weight, timing of BEZ administration, CDI severity, nor prior receipt of fecal microbiota transplantation significantly affected BEZ effectiveness. BEZ was well tolerated with one infusion-related reaction. There were no heart failure exacerbations among BEZ recipients and two exacerbations identified from control group.

Conclusion

In patients with at least one risk factor for rCDI, BEZ in addition to SoC was associated with lower rates of recurrent infection than SoC alone and may be a reasonable adjunct therapy in high risk patient populations.

Disclosures

matthew miller, PharmD, Allergan (Speaker’s Bureau)Tetraphase (Speaker’s Bureau)
790. Evaluation of Connecticut Medical Providers Concordance with 2017 IDSA/SHEA Clostridioides difficile Treatment Guidelines in New Haven County, 2017-2019
Authors: Luc Casey M , Olson Danyel M , Banach David , Hadler James , Clogher Paula
Published: January 2021

Background

Treatment guidelines for Clostridioides difficile infection (CDI) were updated by the Infectious Disease Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) in 2017, notably for disease severity and antibiotic recommendations. Our objectives were to assess Connecticut medical providers’ concordance (2017-2019) with the 2017 update. The effect of guideline concordance on the risk of CDI recurrence was also assessed.

Methods

Using data from the Connecticut Emerging Infections Program’s CDI surveillance in New Haven County, severity and concordance were defined. For severity, white blood cell count and presence of megacolon and/or ileus were used. Concordant treatment was defined as receiving the recommended first-line antibiotic (vancomycin for adult patients, vancomycin or metronidazole for pediatric patients) for exactly 10 days. In univariate & multivariate analyses, significance was determined by a p-value of < 0.05.

Results

Of 1,216 cases, concordance increased from 10.0% in 2017 to 36.9% in 2019. Concordance with first-line antibiotic increased from 40.2% in 2017 to 80.8% in 2019. Concordance was highest for fulminant cases (62.2%). The recurrence rate was 11.2% and highest for non-severe cases and older cases but was not significantly associated with concordance.

Concordance with selected treatment criteria by year, 2017-2019

Conclusion

From 2017 through 2019, CDI treatment in New Haven County increasingly was concordant with the updated 2017 IDSA/SHEA guidelines, but still low overall in 2019. Although concordance with treatment did not affect recurrence risk, close attention should be paid by medical providers to non-severe cases and older cases as they are at an increased risk for recurrence.

Disclosures

All Authors: No reported disclosures
791. Evaluation of NSAID Exposure as a Risk Factor for Clostridium difficile infection: A Propensity-Score-Matched Case-Control Study
Authors: Ressler Adam M , Patel Alieysa , Rao Krishna
Published: January 2021

Background

Exposure to certain medications, particularly antibiotics and proton pump inhibitors, has been associated with increased risk for Clostridium difficile infection (CDI). Studies have suggested an increased risk for CDI associated with exposure to certain non-steroidal anti-inflammatory drugs (NSAIDs). We conducted a retrospective case-control study to evaluate the risk for CDI associated with NSAID use.

Methods

The population included 1338 patients tested for CDI from February–December 2016 at the University of Michigan. NSAID use within 30 days of CDI testing was determined by chart review. Both scheduled and as-needed NSAID use met the definition for exposure, but aspirin use alone did not. Additional clinical data such as comorbid disease and baseline laboratory parameters were extracted through electronic query. A random forest model imputed missing data. A propensity score for NSAID use was developed via logistic regression and included gender, back pain, baseline serum creatinine, osteoarthritis, rheumatoid arthritis, serum albumin, and use of anticoagulant or antiplatelet medications. Cases were matched 1:1 with C. difficile negative controls by propensity score, with a matching caliper of 0.2 x standard deviation of the logit of the score. The final study population consisted of 1256 cases and their matched controls, however 6 cases could not be matched to controls as none had scores within the matching caliper. Conditional logistic regression was used to compare cases to controls.

Results

NSAID use was similar between the two groups on unadjusted analyses. The adjusted, multivariable model demonstrates that non-aspirin NSAID use is not a significant risk factor for CDI (P =.816), after adjustment for comorbid disease burden, age, and history of prior CDI (Table). Older age and prior CDI were independent risk factors for CDI (Table).

Table Study population and modeling results

Conclusion

In this retrospective case-control study, non-aspirin NSAID use was not associated with an increased risk of CDI. To our knowledge, this is the first study of NSAID use as a risk factor for CDI that accounted for bias due to treatment assignment using a propensity score. Future studies should account for frequency or chronicity of NSAID use, which may affect the results.

Disclosures

Krishna Rao, MD, MS, Bio-K+ International, Inc. (Consultant)Merck and Co., Inc. (Research Grant or Support)Roche Molecular Systems, Inc. (Consultant)
792. Evaluation of Persistent Diarrhea and Recurrence Following Fecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection
Authors: Boton Noah , Ni Jiaqi , Mack Anthony , Eschenauer Gregory , Patel Twisha S , Kao John , Rao Krishna
Published: January 2021

Background

Patients treated for C. difficile infection (CDI) have high rates of recurrence. Fecal microbiota transplantation (FMT) is an effective therapy for patients with recurrent CDI. While highly successful, there are limited data to help clinicians predict which patients are more likely to have adverse outcomes following FMT. Here we aim to identify factors that are associated with recurrent CDI or persistent diarrhea following FMT for treatment of recurrent CDI.

Methods

At a large academic medical center, we conducted a retrospective cohort study of patients receiving their first FMT for recurrent CDI using product from a commercial stool bank. Patients were included if follow-up data on post-FMT outcomes were available. Through manual chart review, we collected information on patient demographics, comorbid disease burden, prior CDI, and antibiotic use prior to FMT. Outcomes included recurrent CDI and persistent diarrhea not from CDI, both within 90 days of FMT. Unadjusted and adjusted analyses via logistic regression were used to model the outcomes.

Results

This study included 81 subjects, of which 72 (89%) experienced no recurrence following FMT. In the multivariable model, the odds of recurrence decreased as BMI rose and with each 1-log increase in the duration of antibiotic therapy for CDI prior to FMT (Table). Among the 72 subjects not diagnosed with recurrent CDI following FMT, 26 (36%) experienced persistent diarrhea for which further work-up or therapy was recommended. History of irritable bowel syndrome (IBS) was the only predictor independently associated with persistent diarrhea while adjusting for age and number of prior CDI episodes (Table). IBS was also the most common etiology identified by the subjects’ clinical teams for persistent diarrhea following FMT.

Table. Multivariable models of adverse outcomes following FMT for CDI

Conclusion

We found FMT for CDI at our center to be effective in curing CDI without subsequent recurrence, at a level similar to what is seen from randomized controlled trials. Higher BMI and longer duration of antibiotic therapy for CDI prior to FMT may be protective against recurrence. Still, a significant proportion of patients experienced persistent non-C. difficile related diarrhea, and patients with a history of IBS were more likely to have persistent diarrhea after FMT.

Disclosures

Krishna Rao, MD, MS, Bio-K+ International, Inc. (Consultant)Merck and Co., Inc. (Research Grant or Support)Roche Molecular Systems, Inc. (Consultant)
796. Improving Clostridioides difficile Infection Treatment and Outcomes Using a Web-based Tool to Support a Care Coordination Intervention
Authors: McKoy J Nikki , Biondolillo Madeleine , House John A , Kunz Emily , Safo Stella
Published: January 2021

Background

Clostridioides difficile infection (CDI) is a highly burdensome disease, affecting 500,000 Americans each year. Despite extensive efforts to prevent and treat CDI, variability remains in the treatment guidelines, particularly as new medications are released. Treating CDI is particularly difficult, as approximately 25% of infected individuals experience recurrent CDI (rCDI).

Methods

We used a pre-post design to measure the impact of an intervention on rCDI, CDI readmission, and guideline-adherent treatment rates in adult patients who were admitted with or contracted CDI in the hospital. The intervention included the following:

• Web-based performance platform delivering education and care coordination support

• CDI care coordination for 8 weeks post-discharge (Figure 1)

• Education and tools for addressing CDI guidelines, workflow needs, and patient engagement

• Best practice sharing through peer-to-peer discussion calls

Patient Contacts

Results

Among the 77 patients consented in the Pre-Intervention period, 12 (15.6%) patients reported a recurrence of CDI, compared to 6 (15.4%) of the 39 Intervention patients who provided a response (P = 0.98). While a total of 55 patients were consented in the Intervention period, none reported a readmission for CDI, however 9 (11.7%) of Pre-Intervention patients reported a readmission for CDI (P = 0.03). There was a significant difference (P < 0.001) between the use of appropriate treatment, as defined by the 2018 SHEA/IDSA guidelines, between the Pre-Intervention and Intervention groups (55.8% vs. 94.3%).

Conclusion

A comprehensive multi-disciplinary team approach to preventing rCDI, including post-discharge care coordination, provides support to patients and caregivers. Future research is needed to evaluate how web-based tools, like those used in this study, could engage patients in the management of CDI and rCDI. Interventions aimed at improving the care of these patients may reduce recurrences and rehospitalizations.

Disclosures

All Authors: No reported disclosures
798. Metronidazole Exposure Prior to Clostridiodes difficile Infection (CDI) is a Risk Factor for Severe C. difficile Disease in Cancer Patients
Authors: Francisco Denise Marie A , Zhang Liangliang , Jiang Ying , Olvera Adilene , Guevara Eduardo Yepez , Garey Kevin W , Peterson Christine , Dillon Ryan J , Obi Engels N , Okhuysen Pablo C
Published: January 2021

Background

Antibiotic use is a risk factor for CDI. Few studies have correlated use of prior antibiotics with CDI severity in cancer patients. This study identified clinical and microbiology risk factors associated with severe CDI in patients with cancer. We hypothesized that previous antibiotic exposure and microbiome composition at time of CDI presentation, are risk factors for severe disease in cancer patients.

Methods

This non-interventional, prospective, single-center cohort study examined patients with cancer who had their first episode or first recurrence of CDI between Oct 27, 2016 and Jul 1, 2019. C. difficile was identified using nucleic acid amplification testing. Multivariate analysis was used to determine significant clinical risk factors for severe CDI as defined in the 2018 IDSA/SHEA guidelines. Alpha, and beta diversities were calculated to measure the average species diversity and the overall microbial composition. Differential abundance analysis and progressive permutation analysis were used to single out the significant microbial features that differed across CDI severity levels.

Results

Patient (n=200) demographics show mean age of 60 yrs., 53% female, majority White (76%) and non-Hispanic (85%). Prior 90 day metronidazole use (Odds Ratio OR 4.68 [1.47-14.91] p0.009) was a significant risk factor for severe CDI. Other factors included Horn’s Index > 2 (OR 7.75 [1.05-57.35] p0.045), Leukocytosis (OR 1.29 [1.16-1.43] p< 0.001), Neutropenia (OR 6.01 [1.34-26.89] p0.019) and Serum Creatinine >0.95 mg/dL (OR 25.30 [8.08-79.17] p< 0.001). Overall, there were no significant differences in alpha and beta diversity between severity levels. However, when identifying individual microbial features, the high presence of Bacteroides uniformis, Ruminococceae, Citrobacter koseri and Salmonella were associated with protection from severe CDI (p< 0.05).

Table 1 - Results of multivariate logistic regression analysis of factors associated with severe CDI

Figure 1. Microbiome features identified by progressive permutation analysis as seen in a volcano plot.

Conclusion

A number of risk factors for severe CDI were identified among this population, including prior 90 day metronidazole use. Also, increased relative abundance of Bacteroides uniformis, Ruminococceae, Citrobacter koseri and Salmonella were linked to protection from severe CDI. Reducing metronidazole use in patients with cancer may help prevent subsequent severe CDI.

Disclosures

Adilene Olvera, MPH MLS (ASCP), MERK (Grant/Research Support, Scientific Research Study Investigator) Kevin W. Garey, PharmD, MS, FASHP, Merck & Co. (Grant/Research Support, Scientific Research Study Investigator) Ryan J. Dillon, MSc, Merck & Co., Inc., (Employee) Engels N. Obi, PhD, Merck & Co. (Employee)
800. Oral Vancomycin Prophylaxis Against Clostridioides difficile in Patients Admitted to a Tertiary Academic Medical Center
Authors: Kopelman David B , Wright Sharon B , Gold Howard , Mehrotra Preeti , Mehrotra Preeti
Published: January 2021

Background

In an effort to more accurately diagnose Clostridioides difficile infection (CDI), many hospitals have switched to two-step testing algorithms that rely on nucleic acid amplification testing with reflex enzyme immunoassay for toxin. Additionally, oral vancomycin prophylaxis (OVP) against CDI is increasingly being used; initial studies focused on preventing recurrence in patients with a prior history of CDI, but OVP is also being studied in primary prevention. We hypothesized that following the implementation of two-step testing, clinicians may use OVP for prevention of a patient’s first episode of CDI based on knowledge of prior PCR+/Toxin- testing.

Methods

We performed a single-center, retrospective cohort study of patients admitted to Beth Israel Deaconess Medical Center. We identified patients who received oral vancomycin once daily or BID for the prevention of CDI following implementation of two-step testing. Patients who received oral vancomycin as part of a taper following acute infection were excluded. We categorized rationale for prophylaxis based on clinical documentation and collected details of patients’ CDI history, antibiotic exposure, and subsequent CDI testing during hospitalization.

Results

In the 12 months following implementation of two-step testing, there were 80 patients who received OVP during hospitalization (2 daily and 78 BID). The vast majority (73, 91.3%) had a history of CDI and received OVP for secondary prevention while receiving systemic antibiotics. There were only 3 patients (3.8%) without known clinical history of CDI whose clinicians documented prophylaxis based on previous PCR+/Toxin- testing. Patients on OVP received a mean of 4.1 systemic antibiotics during hospitalization. When continuing OVP for a finite period after discontinuation of systemic antibiotics, this was most commonly done for 2-7 days (16 of 26, 61.5%). 22 patients underwent stool testing for CDI while receiving OVP in the hospital and all resulted PCR-negative.

OVP Indication

OVP Duration

Conclusion

Following implementation of two-step testing for CDI, use of OVP for primary prevention based solely on knowledge of PCR+/Toxin- testing in patients without a history of CDI was rare. Acute CDI appears unlikely in patients actively receiving OVP.

Disclosures

All Authors: No reported disclosures
804. Use of a Trained Canine to Detect Clostridioides difficile in the Hospital Environment
Authors: Harrison Rachael M , Cook Paul P
Published: January 2021

Background

Clostridioides difficile infection (CDI) is the most common nosocomial infection in this country. The organism forms spores, which likely contribute to spread of infection in the hospital setting. Current guidelines call for special cleaning of rooms following discharge of patients who tested positive for CDI. There are currently no means to validate that cleaning has eradicated all of the spores. Canines (dogs) have been used to detect a variety of odors because of their superior olfactory abilities. A beagle was trained to detect the odor of C. difficile in the hospital setting.

Harley the Clostridium difficile sniffing canine.

Methods

C. difficile was grown at the microbiology department at Vidant Medical Center (VMC). Culture plates containing the organism were used by a professional trainer to train a two-year old female beagle dog. The canine was taught to sit when she identified the odor. The canine was given positive reinforcement with oral treats each time she identified the odor. Once the dog was proficient in identifying the organism, the trainer used clinical stool specimens that tested either positive or negative for C. difficile. Prior to coming into the hospital setting, the canine was able to identify positive stool samples with near 100% accuracy. The dog was brought to search rooms occupied or previously occupied by patients who had CDI. The study was approved by the Animal Use and Care Committee at East Carolina University and took place between October 2019 and March 2020 at VMC.

Results

The canine detected the presence of C. difficile in 51% of 47 rooms inhabited by patients currently being treated for CDI and in 46% of 28 rooms previously inhabited by patients that tested positive for CDI. In all positive rooms, the organism was detected on the bedrails. She did not detect C. difficile in any positive areas after they had been cleaned with bleach wipes.

Rooms found to be positive by canine.

Conclusion

Training a canine to detect C. difficile is an effective means of detecting the organism in the hospital environment. Use of a trained dog appears to be effective in validating the cleaning process of rooms that have been previously occupied by patients with CDI.

Disclosures

Paul P. Cook, MD, Contrafect (Grant/Research Support, Scientific Research Study Investigator)Gilead (Grant/Research Support, Scientific Research Study Investigator)Leonard-Meron (Grant/Research Support, Scientific Research Study Investigator)Lilly (Grant/Research Support, Scientific Research Study Investigator)
808. Evaluating the Incidence of Bacteriuria in Female Patients Before and After Implementation of External Catheter Devices
Authors: Noval Mandee , Leekha Surbhi , Bhatt Meghna , Armhazizer Michael , Celotto Abigale , Claeys Kimberly C
Published: January 2021

Background

Bacteriuria associated with indwelling urinary catheters is commonly linked to inappropriate antibiotic use in hospitals. The use of external catheter devices (ECD) has increased in recent years to reduce bacteriuria risk in women, based on data in male patients. Currently no studies have shown a similar benefit in the female population.

Methods

This was a quasi-experimental study among adult female ICU patients with urinary catheters (indwelling or external) between 12/2015 – 5/2017 (pre-ECD) and 12/2017 – 6/2019 (post-ECD). The primary outcome was the incidence of positive urine cultures pre- vs post-intervention. An a priori subgroup patient-level analysis evaluated positive urine cultures and antibiotic use pre- vs post-intervention in medical and surgical ICU patients who had a urinalysis ordered in the presence of an indwelling or external urinary catheter. Antibiotic use was considered appropriate when prescribed in the presence of a positive urine culture, clinical signs and symptoms of UTI, and a UTI order indication.

Results

There were 4,640 patient ICU encounters during the study period; 2,201 pre- vs 2,439 post-intervention. Mean age was 59.2 (SD 15.4) years, median Elixhauser Score was 6 (IQR 4, 7), and there were no significant differences between groups. In the overall cohort, there was a decrease in the monthly rate of indwelling urinary catheter use pre- versus post- intervention (Figure 1) of 182/1,000 vs 166/1,000 patient days, P = 0.03. There was also a decrease in rate of positive urine cultures from pre- to post- intervention (38/1,000 vs 28/1,000 patient days, P = 0.004). Antibiotic days of therapy (DOTs) for UTI indication was similar in the pre- versus post-intervention groups with 1.9/1000 vs. 1.8 DOT/1,000 patient days (P = 0.7). In the subgroup of 210 patients (73 pre- vs 137 post-intervention) who underwent urinalysis, there was also a decrease in the proportion of positive urine cultures from pre- to post-intervention (42.5% vs. 24.3%; P = 0.007). Of patient receiving antibiotics for UTI indication, appropriateness was numerically higher post-intervention (9.1% vs. 31.6%; P = 0.21).

Conclusion

The use of external urinary catheters may be beneficial in reducing bacteriuria and related antibiotic use among female ICU patients.

Disclosures

All Authors: No reported disclosures
LB-1. Efficacy and Safety of Oral Sulopenem Etzadroxil/Probenecid Versus Oral Ciprofloxacin in the Treatment of Uncomplicated Urinary Tract Infections (uUTI) in Adult Women: Results from the SURE-1 Trial
Authors: Dunne Michael W , Das Anita F , Zelasky Michael , Akinapelli Karthik , Boucher Helen , Aronin Steven I
Published: January 2021

Background

Sulopenem is a broad-spectrum IV and oral penem antibiotic being developed for the treatment of infections caused by multidrug-resistant bacteria.

Overall and Clinical Success in Patients with an Uncomplicated UTI at Test of Cure (TOC) and End of Treatment (EOT)

Methods

1,671 adult women with pyuria, bacteriuria, and signs and symptoms of uUTI were randomized to sulopenem etzadroxil/probenecid bid for 5 days or ciprofloxacin bid for 3 days. Two independent primary analyses, each with a separate alpha assigned, were incorporated into the design of the study with the primary endpoint being overall success (combined clinical and microbiologic success) at the Test of Cure (TOC) visit. In the micro-MITTR population (patients with baseline pathogen resistant to ciprofloxacin), sulopenem was compared for superiority over ciprofloxacin; in the micro-MITTS population (patients with baseline pathogen susceptible to ciprofloxacin), the two agents were compared for non-inferiority. Using a pre-specified hierarchical testing procedure (Westfall 2001), the primary efficacy endpoint was then to be further tested if either superiority or non-inferiority was declared in the MITTR or MITTS populations, respectively.

Results

In the micro-MITTR population, sulopenem demonstrated superiority to ciprofloxacin (p < 0.001). In the micro-MITTS population, sulopenem was not non-inferior to ciprofloxacin for the primary endpoint, driven primarily by the higher rate of asymptomatic bacteriuria post treatment in patients on sulopenem. In the combined analysis of all randomized patients with an organism identified at baseline (MITTR+MITTS), sulopenem was non-inferior to ciprofloxacin.

Treatment emergent adverse events occurred more frequently in sulopenem patients (all, 24.8% vs 13.9%; related, 17.0% vs 6.2%), accounted for by a higher incidence of self-limited diarrhea (12.4% vs 2.5%). Serious adverse events were similar on each regimen.

Conclusion

Sulopenem was superior to ciprofloxacin for the treatment of adult women with uUTI due to quinolone non-susceptible pathogens. Sulopenem was not non-inferior in the treatment of quinolone susceptible pathogens, driven by a lower rate of asymptomatic bacteriuria in patients receiving ciprofloxacin, but was non-inferior in the combined population of patients.

Disclosures

Michael W. Dunne, MD, Iterum Therapeutics (Employee, Shareholder) Anita F. Das, PhD, Iterum Therapeutics (Consultant) Michael Zelasky, BS, Iterum Therapeutics (Employee) Karthik Akinapelli, BS, Iterum Therapeutics (Employee) Steven I. Aronin, MD, Iterum Therapeutics (Employee)
LB-2. Relative Effectiveness of aIIV3 versus IIV4 and HD-IIV3 In Preventing Influenza-Related Medical Encounters in Adults ≥65 Years of Age at High Risk for Influenza Complications During the U.S. 2017–2018 and 2018–2019 Influenza Seasons
Authors: Fischer Lauren , O'Brien Dan , Vasey Joseph , Sylvester Gregg C , Mansi James A
Published: January 2021

Background

Individuals with health conditions have shown higher rates of influenza-related morbidity and mortality compared to healthy individuals and are often prioritized for influenza vaccination. However, vaccination with egg-derived standard quadrivalent inactivated influenza vaccines (IIV4) has shown to be less effective in adults ≥65 years of age largely due to immunosenecence. Two enhanced vaccines, the MF59®-adjuvanted trivalent inactivated influenza vaccine (aIIV3) and a high-dose trivalent inactivated influenza vaccine (HD-IIV3), were developed to provide adults ≥65 years with increased protection. The objective of this study was to determine the relative vaccine effectiveness (rVE) of aIIV3 versus IIV4 and HD-IIV3 in preventing influenza-related medical encounters in high-risk adults ≥65 years.

Methods

A retrospective cohort study was conducted among adults ≥65 years with ≥1 health condition with a record of receiving either aIIV3, IIV4 or HD-IIV3 in the 2017–18 or 2018–19 influenza seasons. Patient-level electronic medical records linked to pharmacy and medical claims were used to ascertain exposure, outcome and covariate information. The primary outcome was influenza-related medical encounters in primary care and hospital (ICD-10 codes J09*–J11*). Inverse probability of treatment weighting was used to obtain odds ratios (ORs) adjusted for age, sex, race, ethnicity, geographic region, comorbidities and week of vaccination for each health condition. rVE was determined using the formula (1-OR)*100 and reported with 95% confidence intervals (CI).

Results

Overall, 1,755,420 individuals with ≥1 health condition were included for analysis in the 2017–18 season and 2,055,012 individuals in the 2018–19 season. In both seasons, high-risk subjects who received aIIV3 had statistically significantly greater reduction in influenza-related medical encounters as compared to IIV4 (Table 1). Non-statistically significant estimates preclude definitive conclusions for comparisons with HD-IIV3.

Table 1. Adjusted relative vaccine effectiveness (rVE) of aIIV3 versus comparators in high-risk patients in the 2017–2018 and 2018–2019 influenza seasons in the U.S.

Conclusion

The results of this study support the use of aIIV3 in adults ≥65 years of age at high risk for influenza complications and provides further evidence supporting aIIV3 as an effective public health measure against influenza.

Disclosures

Lauren Fischer, M.A., Seqirus (Consultant) Dan O'Brien, BA, Seqirus (Consultant) Joseph Vasey, PhD, Seqirus (Consultant) Gregg C. Sylvester, MD, Seqirus (Employee) James A. Mansi, PhD, Seqirus (Employee)