bluuebunny/crossref_metadata_2025 huggingface dataset:
98. A nationwide intervention to improve pneumococcal vaccination rate among immunocompromised individuals
Authors: David Shirley Shapiro Ben , Shamai-Lubovitz Orna , Mourad Vered , Goren Iris , Iunger Erica Cohen , Alcalay Tamar , Irony Angela , Greenfeld Shira , Adler Limor , Cahan Amos
Published: December 2022

Background

Immunocompromised individuals (ICI) are at high risk for infections, some of which are preventable by vaccines. The Israeli MOH recommends PCV13 and PPSV23 vaccines for ICI, but vaccine coverage is suboptimal. The aim of this study was to assess the effectiveness of a project to improve pneumococcal vaccination (PV) rate among ICI in outpatient settings.

Methods

An automated validated, population-based registry of patients with ICI was developed in an Israeli health organization, Maccabi Healthcare Services, serving over 2.5 million members. Included in the registry were patients aged 18 and above, receiving immunosuppressive therapy (IT); patients living with HIV (PLWH); solid organ and bone marrow transplant recipients (TR); patients with advanced kidney disease (AKD); and patients with asplenia. Based on the registry and the Israeli MOH vaccination guidelines, a nationwide quality improvement project aimed at improving PV was implemented which began in October 2019. As part of the project, ICI were waived the need for preapproval for PCV13. During an eligible patient visit, physicians and nurses were prompted with an EHR alert reminding them to consider providing pneumococcal vaccine. In addition, eligible patients were invited via their patient health record (both desktop and mobile) to vaccinate. Vaccination rates during pre- and post-intervention periods were compared using the Chi square test.

Results

A total of 32,297 ICI were identified. Of them, 22,721 were on IT, 1651 PLWH, 1829 were TR ,5267 had AKD, and 1920 were asplenic. During the period October 2019 to October 2021, PCV13 vaccination rates went up from 12% to 54.1% (p< 0.0001), and PPSV23 vaccination rate improved from 44.7% to 62.6% (P < 0.0001).

Conclusion

Using one of the first real-world automated registries for ICI and implementation of targeted automated patient and provider alerts, markedly improved pneumococcal vaccine uptake was observed in this vulnerable population. Similar interventions may be used to increase the adherence for other vaccines, including COVID-19 vaccines.

Disclosures

Shirley Shapiro Ben David, MD, pfizer: Grant/Research Support Limor Adler, MD, pfizer: Grant/Research Support.
2147. Multi-modal Quality Improvement Study to Reduce C. difficile Detection and Infections in Hospitalized Children
Authors: Cotter Jillian , Tong Suhong , Stokes Claire , Dominguez Samuel R
Published: December 2022

Background

Our institution identified rising rates of Clostridiodes difficile (C. difficile) results and infections, which coincided in part with the introduction of gastrointestinal panels (GIP) testing. We aimed to reduce the rate of positive C. difficile results and hospital-acquired infections (HAI) by 20%.

Methods

We engaged key stakeholders to identify key drivers, develop interventions, and evaluate outcomes through several plan-do-study-act cycles. We conducted a multi-modal intervention that involved 1) provider education, 2) C. difficile clinical pathway development, 3) improved preventative cleaning measures, and 4) electronic medical record (EMR)-based GIP changes including a) added option for GIP with or without C. difficile (run on same testing platform, but C. difficile results were suppressed if not ordered), and b) built in testing restrictions with optional approval process (Table 1). Our population included all hospitalized children (< 18 years old) who had a stool test performed at a large quaternary-care children’s hospital over 30 months (2018-2020). Our primary outcomes were 1) rate of C. difficile positive results and 2) C. difficile HAI rates (defined as a positive test and symptom onset on or after day three of admission; adjudicated in real-time as part of routine surveillance) per 10,000 patient-days (PDs). Our process measure was the rate of testing capable of detecting C. difficile per 10,000 PDs. As a balancing measure, we evaluated the proportion of suppressed results that were ultimately released based on judgement of a infectious disease specialist who monitored these results in real-time for 7 months.

Results

We identified 2,001 stool tests performed for 1,982 encounters (Table 2). After education and EMR-based changes, we found special cause variation with a 44% decrease in the rate of positive C. difficile results and 55% decrease in HAI rates (Figures 1,2). There was a 44% decrease in testing for C. difficile, and only 2% (2/89) of suppressed results were ultimately released based on expert monitoring. The majority of patients (76%) with suppressed C. difficile results had a coinfection or were < 1 old.

Conclusion

Education coupled with EMR-based testing changes resulted in an impactful and sustained decrease in C. difficile detection and HAI rates.

Disclosures

Samuel R. Dominguez, MD PhD, Biofire DIagnostics: Advisor/Consultant|Biofire DIagnostics: Grant/Research Support|DiaSorin Molecular: Advisor/Consultant|Karius: Advisor/Consultant|Pfizer: Grant/Research Support.
99. COVID-19 Vaccine related Attitudes and Beliefs among Black and/or Hispanic respondents in Brooklyn, NY: Lessons Learned
Authors: Parameswaran Lalitha , Mulligan Mark , Park Yangjin
Published: December 2022

Background

Vaccine hesitancy remains a significant barrier against COVID-19 vaccination uptake in Black/Hispanic population. The objectives of our study were to assess attitudes such as trust in the process of vaccine development, its approval and its stakeholders and mistrust due to racial discrimination to determine their relationship to vaccine receipt.

Methods

We collected close-ended survey responses in English/Spanish among participants self-identifying as Black/Hispanic in ambulatory clinics affiliated to NYU Langone Health across Brooklyn in June 2021. The survey consisted of demographic questions, and those assessing components outlined in objectives.

Results

A total of 156 participants answered the survey; majority being women (77%), < 50years old (62%), employed full time (51%), annual household income < $75,000 (75%). A vast majority reported trusting their healthcare providers (91%). Of the respondents, 67% (105) self-reported receiving the COVID-19 vaccination, which was higher than the prevailing rate at that time in this population in Brooklyn. Significant proportions of vaccinated group compared to unvaccinated group reported (Table1): understanding how vaccines worked overall (85% vs 53%); trusted their healthcare providers’ advice to get vaccinated (82% vs 50%); trusted the scientists who created and tested the vaccine (80% vs 48%); agreed that it was very important that the community gets vaccinated (82% vs 27%), and it was people’s responsibility to get vaccinated to stop the spread of virus in their community (96% vs 70%); agreed that confidence in the vaccine’s safety (86% vs 50%) and effectiveness (85% vs 52%) were very important. Unvaccinated group reported concerns about the side effects of vaccines, and greater doubt about adequacy of testing for safety and effectiveness of vaccine in their racial/ethnic group, and mistrust with government.

Conclusion

Despite higher self-reported COVID-19 vaccine uptake rate in Black/Hispanic study respondents in June 2021, significant mistrust and concerns about the vaccine remain. The effect of racial discrimination and mistrust can mitigated by greater trust in healthcare team, and future interventions can test this hypothesis in order to improve vaccine uptake in these populations.

Disclosures

All Authors: No reported disclosures.
2154. Comparing the Clinical Outcomes of Human Rhinovirus/Enterovirus to Influenza and Respiratory Syncytial Virus Among Children in an Outpatient Setting
Authors: Jones Milissa U , Montgomery Agnes S , Coskun Jennifer , Marcelo Raymundo , Raiciulescu Sorana
Published: December 2022

Background

Human Rhinovirus/Enterovirus (HRV/ENT) infections are common among children and their full clinical impact is still being studied. We aimed to compare the clinical outcomes of children with HRV/ENT infection to other common respiratory viruses in the outpatient setting.

Methods

We conducted a retrospective analysis of nasopharyngeal samples positive for HRV/ENT, Influenza A/B (FLU), or Respiratory Syncytial Virus (RSV) from patients ≤ 17 years, submitted for testing via Multiplex polymerase chain reaction, between 2016 and 2019. Samples positive for more than one virus or arising from the same patient within 3 months were excluded. Outcome measures within proximity to the positive result were assessed via chart review and were: days of symptoms; outpatient visits for respiratory symptoms; bacterial diagnosis; and hospital admission. Between the 3 viruses: multivariable linear regression was used to compare the number of days of symptoms; Kruskal-Wallis test was used to compare the number of outpatient visits; and multivariable logistic regression was used to compare bacterial diagnosis as well as hospitalization.

Results

There were 1359 positive samples analyzed; 746 HRV/ENT, 304 FLU, and 309 RSV. After controlling for comorbid conditions and age, children with FLU had 29% fewer days of respiratory symptoms prior to testing versus HRV/ENT [β -0.34; 95% CI -0.54,-0.15; p < 0.001] (Fig1A) and had fewer outpatient visits (median [M] = 1) for respiratory symptoms in proximity to a positive result versus HRV/ENT (M=2) or RSV (M= 2) (Fig 1B). After adjusting for age and comorbid conditions, children with FLU had ∼ 80% decreased odds of hospitalization versus children with HRV/ENT and those with RSV infection had 3 times the odds of bacterial infection than children with HRV/ENT (Fig 2).

Conclusion

We highlight the clinical significance of HRV/ENT in the outpatient setting. Children with HRV/ENT had more outpatient visits and higher odds of hospitalization as compared to those with FLU. Outcomes between HRV/ENT and RSV were similar, with the exception of bacterial infection. Clinicians should have a high level of vigilance when managing children with HRV/ENT infections given the potential for clinical outcomes similar to, and in some cases, worse than established pathogenic viruses.

Disclosures

All Authors: No reported disclosures.
100. Differences in influenza vaccination by gender identity and state-level gender equity policies: Data from the Behavioral Risk Factor Surveillance System, 2015-2019
Authors: Cox Sarah N , Fajans Mark A , Frivold Collrane J , Littman Alyson J , Balkus Jennifer E
Published: December 2022

Background

It is estimated that 1.4 million people identify as transgender and over 700,000 people identify as non-binary in the United States, many of whom face significant health disparities impacting health care access. Although previous studies have reported greater vaccine uptake in women compared to men, national-level estimates of influenza vaccine uptake among transgender and non-binary people are unknown. This study aims to characterize differences in influenza vaccination by gender identity and examine associations between vaccination status and state-based gender equality policies.

Methods

We used cross-sectional data from adults aged 18 and older who participated in the 2015-2019 United States Behavioral Risk Factors Surveillance System surveys. Weighted prevalence differences (PDs) and associated confidence intervals (CIs) of being unvaccinated against influenza by self-reported gender identity were estimated using generalized linear regression models. We identified state policies on gender identity (Figure 1) as a potential effect modifier a priori and assessed through stratification. Figure 1.U.S. states implementing the SOGI module in Behavioral Risk Factors Surveillance System between 2015-2019, classified as having restrictive versus protective policies on gender equality (N = 38)

Results

A total of 1,016,012 individuals met the inclusion criteria. Compared to cisgender women (unvaccinated prevalence=57.3%), the prevalence of being unvaccinated was significantly higher among cisgender men (64.4%; PD=7.0 per 100, 95% CI: 6.7-7.4), transgender women (65.4%; PD=8.1 per 100, 95% CI: 4.0-12.2), transgender men (64.6%; PD=7.3 per 100, 95% CI: 2.7-11.8), and non-binary individuals (64.6%; PD=7.2 per 100, 95% CI: 1.3-13.2). This pattern was similar among individuals living in protective states with more favorable gender-related policies compared to restrictive states with less favorable policies (Figure 2). Figure 2.Weighted prevalence of U.S. adults unvaccinated against influenza by gender identity, Behavioral Risk Factors Surveillance System, 2015-2019

Conclusion

Our results provide evidence of a disparity in influenza vaccine uptake by gender identity. To improve vaccine uptake among transgender and non-binary individuals, future research should focus on identifying barriers to and facilitators of vaccination by gender identity. These findings could be used to inform policies and public health interventions to improve vaccine uptake co-designed and implemented in partnership with the transgender and non-binary communities.

Disclosures

All Authors: No reported disclosures.
2169. Anti-anaerobic Antibiotic Use is Associated With Lower Rehospitalization Rate in Known and Suspected Pleural Empyema in Adults
Authors: Avner Benjamin S , Qiryaqoz Zeena , Mak Justin , Le James , Ginosyan Anush , Huffman Cuyler
Published: December 2022

Background

There is not a prevailing consensus on appropriate antibiotic choice, route, and duration in the treatment of bacterial pleural empyema after appropriate source control. Professional society guidelines identify a wide range of antibiotic durations, and generally recommend an antibiotic with broad-spectrum activity against anaerobes (e.g. clindamycin, metronidazole, carbapenem, or penicillin/beta-lactamase inhibitor combination), while noting the lack of comparative trials with which to guide recommendations.

Methods

We performed a hypothesis-generating retrospective chart review analysis of clinical outcomes in 355 adult inpatients who had pleural drainage, via either chest tube or surgical intervention, for known or suspected empyema. The aims of the investigation were to compare clinical outcomes with regard to 1) the use of antibiotics with broad activity against anaerobes, 2) total antibiotic duration, and 3) IV antibiotic duration. Mann-Whitney U test with Bonferroni multiplicity adjustment was used to compare outcomes with regard to these variables.

Results

A longer course of an anti-anaerobic antibiotic was associated with both lower 30-day readmission rates for empyema (11.9 ± 13.8 antibiotic days in non-readmission group, n = 321 vs 2.2 ± 2.7 days in readmission group, n = 17, p-value 0.003) and lower all-cause 30-day readmission (12.3 ± 14.1 in non-readmission group, n = 290 vs 6.1 ± 7.9 in readmission group, n = 49, p-value 0.003). Longer total antibiotic duration was associated with lower empyema-specific 30-day readmission rates (21.5 ± 20.1 vs 12.4 ± 8.2, p-value 0.010), with a non-significant trend towards lower all-cause 30-day readmission (22.1 ± 20.9 vs 15.0 ± 8.3). IV antibiotic duration was not associated with a difference in 30-day readmission (data not shown).

Conclusion

Our data support the premise that routine use of anti-anaerobic antibiotics is indicated in the treatment of pleural empyema. However, our study casts doubt on the benefits of extended IV rather than oral antibiotics in the treatment of empyema. This represents a target for future investigation with the aim of limiting complications associated with the excessive use of IV antibiotics.

Disclosures

All Authors: No reported disclosures.
2173. Co-Occurring Dysphagia and Frailty are Common and Associated with Increased Disease Severity in Older Adults Presenting with Community-Acquired Pneumonia
Authors: Pulia Michael , Robison Raele , Schwei Rebecca , Gustafson Sara , Broghammer Charles , Herrin Rachelle , Rogus-Pulia Nicole
Published: December 2022

Background

Impaired swallowing (dysphagia) and physical (frailty) function are associated with community-acquired pneumonia (CAP), however, neither are routinely screened for in patients with CAP. We sought to: 1) examine frailty and dysphagia screening profiles in a cohort of older adults with CAP; and 2) determine if these screening profiles differ across CAP severity levels.

Methods

Older adults (≥65) meeting diagnostic criteria for pneumonia are included as participants. During the index encounter, dysphagia (3-ounce water swallow) and frailty (FSQ;4 ≥3 = frailty) screeners are administered. Thirty days post-enrollment, a standardized clinical severity scale is used to document CAP severity (mild (ambulatory management); moderate-severe (hospitalization)). Statistical analysis included descriptives and cross tabulations.

Results

We enrolled 26 participants (13 female) with a mean age of 73 (SD: 7.1). Nine (34.6%) and 17 (65.4%) patients had mild and moderate-severe CAP severity, respectively. Twenty (76.9%) and 14 (53.8%) patients met screening criteria for dysphagia and frailty, respectively. Screening profiles included: no frailty or dysphagia (15.4%), frailty and no dysphagia (11.5%), no frailty but dysphagia (30.8%), frailty and dysphagia (42.3%). No frailty but dysphagia (44.4%) was the most common mild CAP severity profile. When CAP severity worsened (moderate-severe), co-occurring frailty and dysphagia was most prevalent (47.1%). Fig. 1.Combined dysphagia and frailty screening profiles for this cohort.Dysphagia only was highly prevalent (31%), however, the majority of individuals presented with co-occurring dysphagia and frailty (42%).Fig. 2.Screening profiles across CAP severity levels.No frailty/dysphagia (44.4%) was the most common mild CAP profile. Co-occurring frailty/dysphagia was most prevalent (47.1%) in mod-severe CAP.

Conclusion

In this cohort, standardized screenings for dysphagia and frailty revealed both were common and frequently co-occurred, particularly in the high acuity CAP group. These data suggest older adults with pneumonia may have underlying dysphagia and/or frailty that warrant further evaluation. These potential impairments should be considered in care pathways (e.g. antibiotic therapy and rehabilitation services consultation) to mitigate negative sequelae.

Disclosures

All Authors: No reported disclosures.
2178. Microbiological Diagnosis of Ventilator Associated Pneumonia Caused by Gram Negative Bacterias Resistant to Carbapenems Using a Fast Molecular Method.
Authors: Briones-Rugama Thomas , Marenco-Avilés Sunaya , Castillo-Cano Maikelyn A , Porras-Cortés Guillermo D
Published: December 2022

Background

Ventilator-associated pneumonia (VAP) is one of the most important healthcare-associated infections. The burden of VAP regard morbility and mortality is significant. Most of the etiological agents of VAP are Gam negative organisms and a proportion of them could be resistant to carbapenems. GeneXpert Carba-R is a molecular test originally designed to detect rectal colonization by microorganisms expressing resistance genes to carbapenems (NDM, KPC, VIM, IMP, OXA-48). The aim of this study was to determine how useful is to use GeneXpert Carba-R in clinical samples of aspirates of bronchial secretion in patients with VAP.

Methods

This is a prospective observational study in a sample of patients that developed VAP at the intensive care unit in Hospital Dr. Fernando Vélez Paiz (Managua, Nicaragua) between April 2021 and December 2021. The diagnostic criterias of the CDC for VAP were used. Samples of bronchoalveolar secretions were processed using GeneXpert Carba-R and by bacteriological conventional culture. The molecular method GeneXpert Carba-R was able to detect genes as NDM, KPC, VIM, OXA-48 and IMP. The presence of any of them was considered as microorganism resistant to carbapenems and the result was correlated with the final identification and susceptibility pattern obtained in the bacteriological culture using the system Vitek2.

Results

A total of 45 patients were recruited in the study. Twenty-seven patients (60%) had at least one gene of resistance detected by GeneXpert Carba-R. The most frequent gene detected was NDM (81%). The cultures identified Acinetobacter baumannii (36%), Klebsiella pneumoniae (27%), and Pseudomonas aeruginosa (23%). The sensitivity and the specificity of the GeneXpert Carba-R for the diagnosis of a organism resistant to carbapenems were 86.7% (CI95%: 71.1-95-8) and 93.3% (CI95%: 80.7%-100%) respectively. The risk factors to develope a VAP with an organism expressing a gene of resistance were diabetes mellitus, extended staying in ICU, SOFA score > 2 points, mechanical ventilation ≥ 8 days, and to have had septic shock at the admission.

Correlation between GeneXpert Carba-R and bacteriological culture for microbiological diagnosis of VAP caused by carbapenem-resistant bacterias.

Conclusion

To process GeneXpert Carba-R directly of bronchoalveolar secretions was useful in the diagnosis of VAP caused by microorganisms resistant to carbapenems. The most frequent gene detected was NDM.

Disclosures

All Authors: No reported disclosures.
2187. Validation of Local Risk Factors for Antibiotic-resistant Pathogens in Community-acquired Pneumonia at an Urban Community-based Medical Center
Authors: Zafonte Veronica B , Ramdhanie Lisa , Miele Andrew S , Cervellione Kelly L , Liu Emily A , Bagheri Farshad , Daya Andrew
Published: December 2022

Background

The 2019 ATS/IDSA community-acquired pneumonia (CAP) guidelines recommend to abandon the term healthcare-associated pneumonia (HCAP) and to base the use of broad-spectrum antibiotics on local epidemiology and risk factors. Jamaica, NY represents a unique population of ethnically diverse, largely immigrant patients. Several nursing homes, an international airport, along with a low socioeconomic status population feed into the hospital. The purpose of this study is to determine prevalent risk factors for drug-resistant pathogens (DRP) in CAP within an urban population. The secondary objective is to validate the Drug Resistance in Pneumonia (DRIP) score in this population.

Methods

A retrospective study was conducted on adults admitted from August 2018-December 2019 with a diagnosis of CAP, including aspiration pneumonia. Patients with a DRP respiratory culture (collected within 48 hours of admission) were selected, the next consecutively admitted patient with a non-resistant culture was included as a control.

Results

A total of 227 patients were included (114 in the DRP group and 113 in the control group). The DRP group had more patients with tracheostomies (30% vs 3%, p < .001) and chronic pulmonary disease (37% vs 16%, p < .001) (Table 1). Approximately 40% of the DRP patients were admitted from a long term care (LTC) facility compared to 8.8% in the control group (p < .001). Isolation of P. aeruginosa was not associated with LTC residence (Odds Ratio: 0.75) in our population (Table 2). All DRIP score components were associated with the isolation of DRP in our patient population, except for methicillin-resistant S. aureus (MRSA) colonization (Table 3). In our population 50% of the DRP had a DRIP score < 3. DRIP scores > 2, > 3 and > 4 had low negative predictive values (NPV) for the isolation of DRP in CAP (71.9%, 67.4% and 64.2%, respectively).

Conclusion

Demographic risk factors may exist for DRP in CAP, e.g. tracheostomy, pulmonary disease. Using a DRIP score cut off of > 4 missed 50% of the DRP in our study population. Despite a DRIP score > 4 having a specificity of 90.3%, with a NPV of 64.2% this scoring tool may underestimate the prevalence of DRP in our patient population. Based on our findings, institutions should consider local validation of the DRIP score prior to implementing use at their site.

Disclosures

All Authors: No reported disclosures.
2221. Use of PCR and MLST analysis to establish Treponema pallidum as the cause of a painful oral lesion
Authors: Velasquez Espiritu Maria Rosa , Wormser Gary P , Cafferky Kaitlin , Edmondson Diane , Norris Steven , Munzer Eric , Rizk Ciril-Christian , Gelman Irina , Lawler Jacqueline , Boss Heather , Keller Marina
Published: December 2022

Background

A syphilitic chancre is described classically as a single, indurated, and painless ulcer at the site of Treponema pallidum inoculation.

Methods

We present a 39-year-old heterosexual, monogamous, HIV-negative woman with a painful tongue lesion of one month’s duration. To exclude a malignancy, a biopsy was performed.

Results

Histopathology showed intense inflammatory reaction, and T. pallidum immunocytochemistry demonstrated a high density of spirochetes in the subepithelial connective tissue. Subsequent testing revealed a reactive anti-T. pallidum IgG EIA and an RPR titer of 1:8. PCR amplification and multi-locus sequence typing (MLST) confirmed that the visualized spirochetes were T. pallidum. This particular MLST strain pattern has been identified twice before and named ST-109; however, no clinical information is available.

Diagnosis and appropriate treatment were delayed since syphilis was not suspected initially. When the results became available, the patient was treated with 2.4 million units of benzathine penicillin given IM with complete resolution of the lesion. The male partner, who reported no symptoms, had a positive T. pallidum EIA with an RPR titer of 1:64 and was also treated with penicillin. Within four months, a woman from an adjacent town presented to urgent care with three perineal severely painful lesions, testing negative for HIV, Herpes Simplex Virus (HSV) by PCR of an ulcer swab, and chlamydia and gonorrhea on a urine sample by a NAAT. The anti-T. pallidum EIA was reactive, and the RPR titer was 1:4. The lesions resolved with IM penicillin treatment.

Conclusion

The observations reported here indicate that a subset of early syphilis cases may present with painful lesions. Despite the commonly held belief that syphilitic chancres are painless, several case series have reported tender lesions, single or multiple, without evidence of concurrent HSV infection to explain the pain. This is the first PCR and MLST sequencing analysis of a T. pallidum strain within a painful chancre. Given the rise in the number of cases of syphilis in the USA, it is essential that clinicians be aware of this atypical presentation. It remains to be determined whether such painful lesions are only associated with certain T. pallidum genotypes.

Disclosures

All Authors: No reported disclosures.
2223. A comparative analysis of the detection of UTI pathogens via culture method and the Open Array-nanofluidic real time PCR method
Authors: Upadhyay Pallavi , Surar Fahida , Kim Geun , Reddy Jay , Shakir Salika , Alexander Barbara D , Hanson Kimberly , Singh Vijay
Published: December 2022

Background

Urinary tract infections (UTI) are the second most prevalent microbial infection, impacting 150 million people globally every year. Traditionally, urine culture is considered the gold standard for UTI pathogen detection. However, molecular techniques, such as real time multiplex PCR tests targeting multiple pathogens, are becoming the alternative diagnostic tools for rapid detection of pathogens with the potential to provide quick diagnosis and enable targeted treatment. Due to the serious economic and healthcare utilization burden UTIs pose, early pathogen detection with a rapid turn-around-time to results has the potential to be instrumental for improving patient care and outcomes.

Methods

A total of 300 deidentified patient samples that were previously tested via urine culture (ARUP laboratories, Utah) were subjected to real time PCR molecular testing employing the nanofluidic Open Array ® platform (HealthTrackRX, Texas). Statistical analyses were performed using R version 3.6.0.

Results

Among 300 urine specimens studied, culture detected pathogens in 183 patient samples (61%), and 117 samples were deemed negative. Culture and PCR results demonstrated an overall agreement of 75.3% (n=226) with 59% positive (n=177) and 16.3% negative (n=49). Results for 24.7% samples (n=74) were discordant. A total of 2% (n=6) were culture positive and PCR negative, and 22.7% (n=68) were culture negative and PCR positive. Agreement between PCR and culture positive results was 0.97, 95%CI (0.94, 0.99) (177/183). Among the PCR positive samples (n=245), 32.7% were poly-microbial (n=80) and 67.3% were mono-microbial (n=165). In comparison, among culture positive samples (n=183), 33.3% (n=61) were polymicrobial and 65.6% (n=120) monomicrobial.

Conclusion

Our study demonstrates that multiplex real time PCR-based detection of UTI bacterial pathogens has positive agreement with the traditional urine culture method. PCR based testing has the potential to deliver quick pathogen identification to enable targeted treatment options and medication adjustments. Further studies will correlate semi-quantitative cfu/mL culture values with semi-quantitative copies/mL PCR values to further refine result reporting and test performance.

Disclosures

Pallavi Upadhyay, PhD, HealthTrackRx: Stocks/Bonds Fahida Surar, B.S., HealthTrackRx: Salaried Employee Geun Kim, M.S., HealthTrackRx: Salaried Employee Jay Reddy, PhD, HealthTrackRx: Stocks/Bonds Barbara D. Alexander, MD, Astellas: Advisor/Consultant|HealthtrackRx: Advisor/Consultant|HealthtrackRx: Grant/Research Support|Scynexis: Grant/Research Support|UpToDate: Advisor/Consultant Kimberly Hanson, MD, MHS, FIDSA, HealthTrackRx: Advisor/Consultant|HealthTrackRx: Clinical Advisory Board Member Vijay Singh, PhD, HealthTrackRx: Stocks/Bonds.
2241. Methenamine for the Prevention of Recurrent UTIs: A Desirability of Outcome Ranking (DOOR) analysis for the Alternative to Prophylactic Antibiotics for the Treatment of Recurrent Urinary Tract Infections in Women (ALTAR) Trial
Authors: Sherwood Kyla , Ikuta Kevin
Published: December 2022

Background

The Alternative to Prophylactic Antibiotics for the Treatment of Recurrent Urinary Tract Infections in Women (ALTAR) trial demonstrated that twice daily methenamine hippurate was non-inferior to daily low dose antibiotics for the prevention of recurrent UTIs. Non-inferiority trials are frequently misrepresented or misinterpreted by patients and clinicians, and often do not address which treatment approach is preferred. The Desirability of Outcome Ranking (DOOR) and Response Adjusted for Duration of Antibiotic Risk (RADAR) superiority methodology has been used as a secondary outcome in selected non-inferiority studies to incorporate antibiotic exposure and clinical outcomes. We applied DOOR/RADAR methodology to the ALTAR trial to evaluate the clinical superiority of methenamine hippurate as compared to antibiotic prophylaxis for the prevention of recurrent UTIs.

Methods

The first step in the DOOR/RADAR analysis was to generate categories to rank clinical outcomes. Using the data supplement of the ALTAR trial, categories were created by comparing the number of UTIs observed during the study period for the antibiotic versus methenamine groups. Participants were assigned a ranking using both clinical outcome and antibiotic use, with the principle that less antibiotic use is preferred as long as the same clinical outcome is achieved. The Mann-Whitney U test was then used to compare outcomes between these groups.

Results

The study included 205 patients, with 103 receiving methenamine and 102 receiving low dose antibiotics. The methenamine and antibiotic prophylaxis groups were divided into categories based on number of UTIs observed during study period (Table 1), with the density of the DOOR/RADAR outcomes displayed in Figure 1. Using the Mann-Whitney U test, the probability of a better DOOR score (i.e. more desirable outcome) for a randomly selected patient from the methenamine group compared to the antibiotic group was 58% (p-value 0.045).

Number of UTIs by Treatment Group Table 1.Number of UTIs observed during study period between groups receiving methenamine as compared to antibiotic prophylaxis. The most desirable outcome (*) and the least desirable outcome (**) are designated above.

Figure 1. The density of DOOR/RADAR outcomes of methenamine as compared to antibiotic prophylaxis group.

Conclusion

Applying the DOOR/RADAR analysis to the data from the ALTAR trial provides evidence to suggest that there is a higher probability for desirable outcomes in women who receive methenamine hippurate as compared to prophylactic antibiotics for the prevention of UTIs.

Disclosures

All Authors: No reported disclosures.
2246. Urine Culture Clinical Decision Support Menu for Reducing Inappropriate Lab Ordering
Authors: Stensgard Erik S , Drekonja Dimitri M , Masoud Bobbie
Published: December 2022

Background

Antibiotic treatment of asymptomatic bacteriuria (ASB) is unnecessary except in pregnant women or those undergoing invasive urologic procedures. Unnecessary treatment of ASB is an important driver of inappropriate antimicrobial use (IAU), leading to antimicrobial resistance, Clostridioides difficile infection, adverse drug events, and increased costs. Because ASB requires detection to be treated, unnecessary urine cultures (UC) are a key cause of IAU. Strong evidence supports not obtaining a UC from asymptomatic patients.

Methods

To reduce unnecessary UC orders at the Minneapolis Veterans Affairs Health Care System (MVAHCS), UC orders within the electronic health record (EHR) were redirected to a UC clinical decision support (CDS) menu (Figure 1). Selection of an indication from the defined list is required to place a UC order and provides tracking. UC order data was obtained from the Corporate Data Warehouse (CDW), the VA’s data program. Patient bed days were collected from a CDW dashboard developed by the Iowa City Veteran’s Affairs Health Care System. Data was visualized using Microsoft Power BITM platform. FIGURE 1.Urine culture clinical decision support menu. Urine culture orders are items numbered 10-26.

Results

The UC CDS menu was implemented at the MVAHCS in September 2020. UC orders from 16 months prior to implementation (9/1/2018 - 12/31/2019) was compared to orders 16 months after implementation (9/1/2020 - 12/31/2021). Data from 1/1/2020 - 8/31/2020 was not included due to atypical patient care patterns during the COVID-19 pandemic.4 The monthly number of UC orders after implementation significantly decreased from an average of 765 to 564, a 26.3% reduction (P < .001; 2-sided t-test) (Figure 2). The average patient bed days prior to and following implementation was not significantly different (Figure 3). Most UC orders came from the UC CDS menu (8103, 89.8%) compared to orders placed from other order menus or directly from the drug file (920, 10.2%). The most common indication selected was dysuria, frequency, and urgency (4050, 44.9%) followed by fever or sepsis (1230, 13.6%) then pre-operative urologic screening (1056, 11.7%) (Figure 4). FIGURE 2.Urine culture lab count before and after urine culture clinical decision support menu intervention.FIGURE 3.Patient bed days before and after urine culture clinical decision support menu intervention.FIGURE 4.Urine culture orders by indication. Non-intervention labs are listed as no indication/other order.

Conclusion

Implementation of a UC CDS menu within the MVAHCS EHR resulted in significantly fewer UC orders. Most UC orders had an appropriate indication suggesting the decrease was primarily due to preventing unnecessary UC orders.

Disclosures

All Authors: No reported disclosures.
110. Improving Pneumococcal Vaccination in Patients Treated with Tumor Necrosis Factor-alpha Inhibitors: A Multidisciplinary Education-Based Quality Improvement Project
Authors: Curtin John M , Custer Benjamin L , Norwood Monique , Ayalew Memar , Costello Varea H , Blyth Dana M
Published: December 2022

Background

In 2012, pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) were recommended for immunocompromised adults ≥19 years, but pneumococcal vaccination (PV) in these patients (pts) remains suboptimal. With a new PV (PCV20) allowing for simplified PV, we study rates of PV in pts on infliximab (INX) 1 year post-initiation of a pt and provider education-based quality improvement project aiming to increase PV in pts on Tumor Necrosis Factor-alpha inhibitors (TNF-αI).

Methods

Starting in 11/2020, pamphlets detailing PV indications were distributed to the Walter Reed National Military Medical Center infusion center and pharmacies to be given to pts prescribed/administered TNF-αI. Provider educational materials and pt pamphlets were given to services prescribing TNF-αI. Provider education was also offered to these services. Up to date (UTD) on PV was defined as receipt of PCV13 and PPSV23 (including additional PPSV23 dose ≥5 years post-initial PPSV23 if applicable). Ongoing INX (o-INX) was defined as INX initiation before 10/1/2020. Newly initiated INX (new-INX) was 10/1/2020-10/1/2021. One-year post implementation, we reviewed the PCV13 and PPSV23 immunization records of pts ≥19 years of age on INX from 1/1/21-12/31/21. This project was approved by the IRB under a non-research determination.

Results

111 pts prescribed INX between 1/1/21-12/31/21 met inclusion criteria (87 o-INX and 24 new-INX). Prior to the intervention, of 87 o-INX pts, 45 (52%), 45 (52%), and 18 (21%) pts had received PCV13, ≥1 PPSV23 dose, and were UTD on PV respectfully. Between 1/1/21-12/31/21, 14 o-INX pts had PV (1 PCV13 and PPSV23, 7 PCV13, and 6 PPSV23), with 7 newly UTD (10% of the 69 previously not UTD), totaling 25 (29%) o-INX pts UTD on PV (figure 1). Of 24 new-INX pts, only 12 (48%), 9 (36%), and 6 (24%) had had PCV13, PPSV23, and were UTD on PV as of 12/31/21. No services prescribing TNF-αI requested the offered PV educational talks.

Conclusion

Despite frequent healthcare in a system where vaccination has no out of pocket expense, guideline-concordant PV was low in this cohort. With new, simplified PV, next steps include updated pt and targeted provider education. However, with prior small gains using multidisciplinary education, additional efforts to remove PV barriers may be needed.

Disclosures

Benjamin L. Custer, MD, Beam Therapeutics: Stocks/Bonds|CRISPR Therapeutics: Stocks/Bonds|glaxo-smith-kline: Stocks/Bonds|Hologic: Stocks/Bonds|Moderna: Stocks/Bonds|Pfizer: Stocks/Bonds|Regeneron: Stocks/Bonds|sanofi: Stocks/Bonds|Vertex Pharmaceuticals: Stocks/Bonds.
LB1528B. Inhaled Fluticasone for Outpatient Treatment of Covid-19: A Decentralized, Placebo-controlled, Randomized, Platform Clinical Trial
Authors: Boulware David R
Published: December 2022

Background

The effectiveness of inhaled corticosteroids to shorten time to symptom resolution or prevent hospitalization or death among outpatients with mild-to-moderate coronavirus 2019 (Covid-19) is unclear.

Methods

ACTIV-6 is an ongoing, decentralized, double-blind, randomized, placebo-controlled platform trial testing repurposed medications in outpatients with confirmed SARS-CoV-2 infection. Non-hospitalized adults aged ≥ 30 years, experiencing ≥ 2 symptoms of acute infection for ≤ 7 days were randomized to inhaled fluticasone furoate 200 μg once daily for 14 days or placebo. The primary outcome was time to sustained recovery, defined as the third of 3 consecutive days without symptoms. Secondary outcomes included composites of hospitalization or death with or without urgent care or emergency department visit by day 28.

Results

Of those eligible for the fluticasone arm, 656 were randomized to and received inhaled fluticasone; 621 received concurrent placebo. There was no evidence of improvement in time to recovery with fluticasone compared with placebo (hazard ratio [HR] 1.01, 95% credible interval [CrI] 0.91–1.12; posterior probability for benefit [HR > 1]=0.56). Twenty-four participants (3.7%) in the fluticasone arm had urgent care or emergency department visits or were hospitalized compared with 13 (2.1%) in the pooled, concurrent placebo arm (HR 1.9, 95% CrI 0.8–3.5; posterior probability for benefit [HR< 1]=0.03). Three participants in each arm were hospitalized, and no deaths occurred. Adverse events were uncommon in both arms.

Conclusion

Treatment with inhaled fluticasone furoate for 14 days did not result in improved time to recovery among outpatients with Covid-19 in the United States during the delta and omicron variant surges.

Disclosures

All Authors: No reported disclosures.
LB1576. High Prevalence of Oral Treponema pallidum by PCR among US Adults with Early Syphilis
Authors: Dionne Jodie , Giacani Lorenzo , Romeis Emily , Boutwell Alexander , Newman Lori , Workowski Kimberly , Hook Edward
Published: December 2022

Background

Treponema pallidum (T. pallidum) is transmitted from person to person by direct contact with widespread dissemination early after acquisition. Current syphilis diagnostic testing is limited to darkfield microscopy from visible lesions and serologic antibody detection. T. pallidum molecular diagnostics are urgently needed.

Methods

As part of a multicenter US syphilis treatment trial that completed enrollment in March 2022 (NCT 3637660), we randomized 249 adults with early syphilis infection to 1 vs 3 weekly doses of benzathine penicillin G to compare treatment response at 6 months. In a small substudy (n=32) presented here, consenting participants at the University of Alabama at Birmingham (UAB) and Emory University had pre-treatment oral (buccal mucosa and posterior pharynx) and lesion swab samples collected. Following DNA extraction, T. pallidum burden in samples was quantified by targeting the tp0574 gene. Syphilis was staged by experienced providers according to physical examination and serology.

Results

Study participants were men (100%) and most were living with HIV (91%) with mean CD4 count 477 cells/mm3. Syphilis stage was categorized as primary in 6 (19%), secondary in 18 (56%) and early latent in 8 (25%). Oral swab qPCR positivity rates were 17% in primary disease, 44% in secondary disease, and 63% in early latent disease (see Figure). Lesion PCR positivity was similar in primary and secondary syphilis (40% and 38.5%). Mean treponemal burden was highest on oral swabs of participants with early latent syphilis (13,128,969) and lesion swabs of participants with secondary syphilis (2,033,309).

Conclusion

Among adult males, many living with HIV, data suggest a role for oral and lesion swabs for the molecular detection of T. pallidum. Widespread availability of PCR, the relative ease of oral specimen collection, and the opportunity to directly demonstrate T. pallidum in persons with early latent syphilis suggest the opportunity for PCR testing to enhance and refine syphilis diagnostic testing. The elevated proportion of positive oral samples and significant organism burden in secondary and early latent syphilis is consistent with potential for transmission.

Disclosures

All Authors: No reported disclosures.
LB1577. Outcomes of Pregnant Women Exposed to Sotrovimab for the Treatment of COVID-19 in the Omicron Predominant Era (PRESTO)
Authors: Tuan Jessica , Sharma Manas , Kayani Jehanzeb , Davis Matthew W , McManus Dayna , Topal Jeffrey E , Ogbuagu Onyema
Published: December 2022

Background

Sotrovimab, a monoclonal antibody with efficacy against SARS-CoV-2 including certain Omicron variants, has been used in treatment of mild-moderate COVID-19. Limited data exists regarding its use in pregnant women.

Methods

Electronic medical record review of pregnant COVID-19 patients treated with sotrovimab from 12/30/21-1/31/22 (Yale New Haven Health Hospital System [YNHHS]) was performed. Included were pregnant individuals ≥ 12 years, weighing ≥ 40 kg, with positive SARS-CoV-2 test (within 10 days). Those receiving care outside YNHHS or receiving other SARS-CoV-2 treatment were excluded. We assessed demographics, medical history, and Monoclonal Antibody Screening Score (MASS). Clinical outcomes assessed included emergency department (ED) visit < 24 hours, hospitalization, ICU admission, and/or death within 29 days of sotrovimab. Pregnancy and neonatal outcomes were assessed until 8/15/22.

Results

Among 22 subjects, median age was 32 years and body mass index was 27 kg/m2. Sixty-three percent were Caucasian, 9% Hispanic, 14% African-American, and 9% Asian. Nine percent had diabetes and sickle cell disease. Five percent had well-controlled HIV. Eighteen percent, 46%, and 36% received sotrovimab in trimester 1, 2, and 3, respectively. No infusion/allergic reactions occurred. MASS values were < 4. Only 12/22 (55%) received complete primary vaccination (46% mRNA-1273; 46% BNT162b2; 8% JNJ-78436735); none received a booster.

There were no ICU admissions nor deaths. One subject was hospitalized for post-partum pyelonephritis; another had an ED visit for post-partum vaginal bleeding. Median gestational age at birth was 38.9 weeks. Nine percent had premature labor and premature rupture of membranes, respectively. Median infant birth weight was 3220 g. One neonate required an ICU stay due to prenatally diagnosed omphalocele (before sotrovimab) in a mother with congenital defect history. There were no abortions, fetal loss, or other birth/neurodevelopmental defects.

Conclusion

Pregnant COVID-19 patients receiving sotrovimab at our center tolerated it well with good clinical outcomes. Pregnancy and neonatal complications did not appear sotrovimab-related. Though a limited sample, our data helps elucidate the safety and tolerability of sotrovimab in pregnant women.

Disclosures

All Authors: No reported disclosures.
LB1578. Fully Automated Real-Time PCR for Detection of Candida auris
Authors: Jiang Alice , Lin Mike , Barakat Nesreen , Clark Craig
Published: December 2022

Background

Candida auris is an emerging fungus that presents a serious global health threat. It is often multidrug-resistant and difficult to identify with standard laboratory methods. C. auris outbreaks have been associated with high mortality in healthcare settings. Rapid and accurate screening for C. auris is crucial for preventing transmission and directing treatment. This study evaluated a new fully automated, lab-developed real-time PCR assay for the detection of C. auris.

Methods

Nasal swabs collected with Aptima Multitest swabs were used as a representative clinical matrix to evaluate C. auris detection using the Open Access™ functionality on the Panther Fusion® instrument. It provided fully automated nucleic acid extraction, amplification, and detection workflow. The primers and probe are published sequences designed by CDC which target the internal transcribed spacer 2 (ITS2) region of the C. auris ribosomal RNA gene. Analytical studies evaluated assay sensitivity, specificity, and inclusivity. An internal control is also included to ensure assay validity.

Results

The limit of detection (≥ 95% detection rate) of the Candida auris real-time PCR assay is 5 CFU/mL for nasal swabs. Eleven C. auris strains from CDC clinical isolates were reactive for inclusivity study. No cross reactivity or interference was observed from 60 microorganisms of closely related yeast, bacteria and viruses typically present in skin and groin samples.

Conclusion

A fully automated and high throughput real-time PCR test for C. auris with internal control, utilizing primers and probe sequences published by CDC, demonstrated excellent sensitivity, specificity, and inclusivity. This lab developed test (LDT) provides a rapid, sensitive, and scalable method for detection of C. auris. The results are crucial for timely detection, transmission prevention and targeted treatment of the multidrug-resistant C. auris.

Disclosures

All Authors: No reported disclosures.