bluuebunny/crossref_metadata_2025 huggingface dataset:
651. Implementing a Multiplex-PCR Test for the Diagnosis of Acute Gastroenteritis in Hospitalized Children, Are All Enteric Viruses the Same?
Authors: Danino Dana , Hazan Guy , Mahajna Rufaida , Khalde Firas , Farraj Lama , Shemer-Avni Yonat , Greenberg David , Hershkovitz Eli , Givon-Lavi Noga , Faingelernt Yaniv
Published: November 2023

Background

Multiplex-PCR for the diagnosis of acute gastroenteritis (AGE) has allowed for rapid detection of multiple pathogens simultaneously but poses challenges in distinguishing between shedding and disease-causing pathogens. We aimed to evaluate the epidemiology of viral AGE and compare clinical characteristics among the 5 most common viruses.

Methods

SUMC is the only hospital in southern Israel serves a population of ∼97,500 children < 5 years. Rotavirus vaccine was added to the national immunization program in 2010 and vaccine coverage (3 doses) reached 70% in 2 years. All rectal swabs for multiplex-PCR targeting; rotavirus, norovirus, adenovirus 40,41, astrovirus and sapovirus collected from diarrheic children < 5 years, December 2017 - March 2022, were included. Detection of the same virus within 2 months was considered a single episode. The clinical analysis included all episodes with single-virus detection and negative stool bacterial PCR (Figure 1).

Results

Of the 5,151 rectal swabs collected, 1,934 (37.5%) were positive for at least one virus, with 245 (12.6%) showing multiple virus detection. Norovirus and rotavirus were the most prevalent (Figure 1). No clear seasonality was observed for AGE viruses in 2018-19. However, during the 2nd year of the COVID-19 pandemic, an unusual surge in warm months was observed, first attributed to rotavirus and later to norovirus (Figure 2). Of the single-virus AGE episodes with negative bacterial PCR, 34.6% and 5.9% presented with mucus and bloody stool, respectively, and 29.3% were treated with antibiotics. No significant differences in rotavirus vaccination rates were found between rotavirus and other viruses. Children infected with astrovirus and sapovirus had higher rates of hospital-acquired AGE and immunodeficiency (P< 0.05) (Table), while children with rotavirus had higher dehydration severity and metabolic acidosis (P< 0.05) (Figure 3).

Conclusion

37.5% of all rectal swabs from diarrheic hospitalized children < 5 years were positive for enteric virus, 12.6% with multiple detection. Rotavirus remained significant and the most severe despite vaccination efforts. Our findings highlight the importance of continuous surveillance in the context of multiplex PCR testing for accurate management and future prevention methods.

Disclosures

Dana Danino, Dr. MD, Pfizer: Grant/Research Support David Greenberg, Professor MD, GSK: Advisor/Consultant|GSK: Honoraria|MSD: Advisor/Consultant|MSD: Grant/Research Support|MSD: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Honoraria
657. Impact of Oral Vancomycin Duration on Clostridioides difficile Recurrence in Patients Requiring Concurrent Systemic Antibiotics
Authors: Marsh Kassandra , Kwiatkowski Diana , Dubrovskaya Yanina , Katz Alyson , Papadopoulos John , So Jonathan , Major Vincent J , Sommer Philip , Hochman Sarah , Arnouk Serena
Published: November 2023

Background

IDSA guidelines for the treatment (TX) of Clostridioides difficile infection (CDI) do not provide specific guidance for total duration of oral vancomycin (VAN) TX in patients requiring prolonged concomitant systemic antibiotics (cABX), as limited evidence exists.

Methods

This was a retrospective study of adult patients with an initial episode of CDI from 2017 to 2022 at NYU Langone Health. Patients were included if they received CDI TX with oral VAN (without fidaxomicin or oral metronidazole) and > 72 hours of cABX (categorized as high, medium or low CDI risk). Prescribing of VAN TX was described as standard duration (SD; ≤ 14 days) vs prolonged duration (PD; > 14 days). The primary outcome was CDI recurrence within 8 weeks of TX completion. Secondary outcomes included risk factors for recurrence, and VAN-resistant Enterococci (VRE) isolation and all-cause mortality at 6 months.

Results

After screening 1,350 patients, 218 were included (PD n=140, SD n=78). The median age was 65 years (IQR 54-72), the median Charlson comorbidity index was 4 (2-6), 52% were immunocompromised, 32% required intensive care unit admission, and 66% received high-risk ABX with no differences between groups for any baseline characteristic. Non-severe, severe, and fulminant CDI occurred in 39%, 36%, and 25%, respectively. Patients who received PD had significantly more carbapenem use (37% vs 21%, p=0.011), a longer duration of ABX overlap with VAN TX (11 [7-16] vs 8 [6-11] days, p< 0.001), and more infectious disease consultation (69% vs 54%, p=0.023). After ABX completion, 147 (67%) patients continued VAN TX for a median of 7 (5-10) days, and 30 (14%) patients continued VAN prophylaxis for a median of 6 (5-14) days. Recurrence occurred in 20 (9%) patients, isolation of VRE in 14 (6%), and mortality in 21 (10%), with no statistical differences between SD and PD arms. Stopping VAN prior to completion of ABX was identified as a risk factor for recurrence on univariate analysis (OR 4.25, 95%CI 1.214-14.880, p=0.037).

Conclusion

Our findings suggest that in this high-risk cohort, continuation of VAN after completion of systemic antibiotics may decrease risk of recurrence. Prospective studies are needed to determine optimal VAN TX durations and alternative strategies to reduce CDI recurrence in patients who require cABX.

Disclosures

All Authors: No reported disclosures
663. Epidemiology and outcomes of recurrent C. difficile infection among hematopoietic cell transplant recipients
Authors: Sanchez Eduardo , Krantz Elizabeth M , Pergam Steven A , Liu Catherine , Tverdek Frank P , Escobar Zahra
Published: November 2023

Background

Recent updates in Clostridioides difficile infection (CDI) treatment guidelines among hematopoietic cell transplant (HCT) recipients recommend fidaxomicin as first line therapy as it reduces the risk of recurrent CDI. We aimed to characterize HCT recipients with CDI and describe their clinical outcomes, including incidence of recurrent CDI.

Methods

This retrospective cohort study included patients ≥18 years old who underwent HCT at Fred Hutchinson Cancer Center from January 2012 to December 2021 and were diagnosed with CDI between day -7 and day +100 relative to HCT (Figure 1). Chart review was conducted to capture demographic, clinical and outcome data, including data on episodes of recurrent CDI. Recurrent CDI was defined as a new episode of symptoms consistent with CDI and a positive CDI test within 12 weeks after completing primary treatment. We computed the cumulative incidence of recurrent CDI, with treatment completion for the initial CDI as time zero and death before recurrent CDI as a competing risk.

Results

Of 3479 HCT recipients, 416 (12%) patients had CDI at a median of 5 days from HCT (Table 1). The most common underlying malignancies were acute leukemia and multiple myeloma; 248 (59%) patients received an allogeneic HCT. All but one patient were treated with metronidazole or oral vancomycin. Within 14 days of CDI, 38 (32%) patients of 119 diagnosed as outpatients required hospitalization and 3 (0.7%) of 410 not in the intensive care unit (ICU) required ICU level of care (Table 2); 10 (2%) died within 30 days of CDI diagnosis. Of 381 patients eligible for analysis of CDI recurrence, 30 patients had recurrent CDI at a median of 57 days (range, 1, 93) follow-up, for a cumulative incidence of 10% at 12 weeks (95% confidence interval, 7%, 14%, Figure 2). In the 14 days after CDI recurrence, 2 (10%) of 21 had a new hospital admission; none died within 30 days.

Conclusion

The majority of HCT recipients in our cohort developed CDI early posttransplant; serious complications and deaths were uncommon. The incidence of recurrent CDI was low and may not warrant use of fidaxomicin for all initial CDI episodes in this population. Further work identifying HCT subgroups at higher risk of recurrent CDI may help to target fidaxomicin use to those most likely to benefit.

Disclosures

Steven A. Pergam, MD, MPH, Cidara: Investigator in clinical trials|F2G: Investigator in clinical trials|Global Life Technologies: Grant/Research Support|Symbio: Investigator in clinical trials Catherine Liu, MD, Pfizer: Site Investigator|SNIPR BIOME: Advisor/Consultant
665. Duration of Spontaneous Bacterial Peritonitis Prophylaxis in Acute Variceal Hemorrhage Patients
Authors: Tedeschi Carissa M , Hoff Abigail , Scherrer Nicole , Shigle Amanda , Burwell Sheena
Published: November 2023

Background

To prevent spontaneous bacterial peritonitis (SBP), re-bleeding, mortality, and long hospital stays in patients with acute variceal hemorrhage, the American Association for the Study of Liver Diseases recommends up to 7 days of ceftriaxone, with guidance to consider discontinuing when hemorrhage resolves and vasoactive drugs are stopped. Due to the ambiguous recommendation, practices vary surrounding duration of SBP prophylaxis. To our knowledge, no study has been completed on the duration of SBP prophylaxis within our current standard of care.

Methods

This was a retrospective, non-inferiority trial of adult patients receiving an octreotide infusion with confirmed variceal hemorrhage diagnosed via esophagogastroduodenoscopy at WVU Hospitals from 1/1/2020 - 12/31/2022. Medical records were reviewed to include demographic information, antibiotic selection, and duration of therapy for SBP prophylaxis, in addition to outcome measures such as infection, re-bleeding, length of stay, and mortality. Patients who received 5 or fewer days (shorter group) of prophylactic antibiotics were compared to those who received more than 5 days (longer group).

Results

84 patients were included: 39 patients in the shorter group, and 45 patients in the longer group. There was no statistically significant difference found between the shorter and longer groups in terms of demographic information. The primary outcome was development of infection. Four (10.3%) patients in the shorter group developed infection, and three (6.7%) patients in the longer group developed infection. The number of patients gathered met power for a 20% non-inferiority margin. There was no statistically significant difference found in any of the secondary outcomes.

Results

Primary and Secondary Outcomes

Conclusion

We can conclude that shorter durations of SBP prophylaxis are non-inferior to longer durations for preventing infections. In general, decreasing the duration of antibiotics to only what is necessary allows for preventing the development of resistance and fewer secondary infections. Additional studies are needed to confirm the results and impact guideline recommendations.

Disclosures

All Authors: No reported disclosures
693. Clinical and Economic Outcomes Associated with Fidaxomicin in Comparison to Vancomycin, Metronidazole, and FMT: a Systematic Literature Review
Authors: Li Qinghua , Obi Engels N , Marciniak Anne , Newman Rebecca
Published: November 2023

Background

Clostridioides difficile causes Clostridioides difficile infection (CDI), of which there are estimated half a million cases in the United States (US) each year. Fidaxomicin, vancomycin, and metronidazole are commonly used for the treatment of CDI, and fidaxomicin is recommended by clinical guidelines as the preferred treatment for patients with initial and recurrent CDI.

The aim of this systematic literature review was to explore the clinical and economic outcomes associated with the use of fidaxomicin with or without comparison to vancomycin, metronidazole, or fecal microbiota transplantation (FMT).

Methods

The Embase, Medline, EconLit, and Evidence Based Medicine (EBM) Reviews databases were searched from 1st January 2012 to 6th December 2022. Identified publications were assessed and extracted by two independent reviewers.

Results

Overall, 82 publications were included. In studies with ≥50 patients, ≥90 days post-treatment, clinical cure rate was 68–97% for fidaxomicin (N=12) and 66–92% for vancomycin (N=5), recurrence rate was 0–36% for fidaxomicin (N=19) and 17–29% for vancomycin (N=7), and all-cause mortality rate was 0–23% with fidaxomicin (N=4) and 4–39% with vancomycin (N=3). No relevant clinical outcomes were identified with metronidazole or FMT. There were limited healthcare resource use data. In studies with ≥50 patients (N=3), median hospital stay with fidaxomicin was 5.6–19.0 days.

Of 20 publications reporting cost-effectiveness, fidaxomicin was cost-effective compared to vancomycin in twelve, metronidazole in four, and FMT in one, as first-line treatment for non-severe CDI and in populations at high risk of recurrence. Six of 20 studies reported vancomycin or FMT as more cost-effective than fidaxomicin. Six of seven publications including patients aged ≥60 years, with cancer, renal impairment, or concomitant antibiotics found fidaxomicin cost-effective compared to vancomycin. Six publications stated that the high acquisition cost of fidaxomicin was offset by reduced recurrence and associated HCRU.

Conclusion

Fidaxomicin was clinically effective compared to vancomycin. Fidaxomicin is often reported as cost-effective compared to vancomycin, consistently within high-risk subpopulations.

Disclosures

Qinghua Li, PhD, Merck & Co Inc: Employee Engels N. Obi, PhD, Merck & Co Inc: Employee Anne Marciniak, MD, PhD, MPhil, MSc, Abbvie: Stocks/Bonds|Amgen: Stocks/Bonds|Pfizer: Stocks/Bonds
696. Effectiveness of Oral Vancomycin as Prophylaxis against Clostridioides difficile Infection in Hematopoietic Stem Cell Transplant Patients
Authors: Reitmeyer Kelly M , Rana Brijesh , Awad David A , Huang Esther , Park Jiyeon J , Yassin Arsheena , Mills John P , Azim Ahmed Abdul , Bhatt Pinki , Narayanan Navaneeth
Published: November 2023

Background

Patients receiving hematopoietic stem cell transplants (HSCT) are at increased risk for Clostridioides difficile infection (CDI) due to decreased immune function, frequent exposure to broad-spectrum antibiotics and chemotherapy, prolonged hospitalizations, and alteration in gut microbiome. The purpose of this study was to assess the effectiveness of oral vancomycin prophylaxis (OVP) for CDI in all patients admitted for HSCT.

Methods

This was a single-center, retrospective, cohort study conducted at a tertiary care academic medical center in New Jersey. Medical records of patients admitted between June 2019 to August 2022 to undergo an allogeneic or autologous HSCT were reviewed. Universal OVP from admission to discharge for HSCT patients began December 2019. Patients ≥ 18 years at the time of admission for the HSCT were included. Patients who were admitted less than 72 hours or who were being treated for an active CDI prior to HSCT were excluded. The primary endpoint was the incidence of in-hospital CDI. Secondary endpoints included incidence of vancomycin-resistant enterococci (VRE) bloodstream infections, VRE isolated from any clinical culture, gram-negative bloodstream infections, hospital survival, and hospital length of stay. Exploratory endpoints including one-year survival, relapse, and incidence of graft-versus-host disease were also collected. Confounding by relevant covariates were assessed and controlled for in a multivariable regression model.

Results

A total of 132 HSCT patients were included. There was one case (1/68, 1.47%) of CDI in the prophylaxis group compared to six CDI cases (6/64, 9.38%) in the no prophylaxis group (P=0.057). There were no significant (P>0.05) between-group differences of incidence of gram-negative bloodstream infections, hospital survival, and length of stay. There were zero clinical cultures positive for VRE in either group.

Conclusion

In-hospital incidence of CDI in HSCT patients was decreased with the use of OVP but did not meet statistical significance. Randomized controlled trials are needed in this high-risk patient population to assess the efficacy and long-term risks of OVP for CDI.

Disclosures

Pinki Bhatt, MD, Sanofi: Grant/Research Support Navaneeth Narayanan, PharmD, MPH, BCIDP, Astellas: Honoraria|Beckman Coulter: Honoraria|Merck: Grant/Research Support|Shionogi: Grant/Research Support
701. Predicting hospital-associated Clostridioides difficile infection risk in hospitalized patients using routinely-collected electronic health record data
Authors: Ray Michael J , Strnad Luke , Furuno Jon P , Lofgren Eric , Gerber Jeffrey S , McGregor Jessina C
Published: November 2023

Background

Antibiotic therapy is a known risk factor for Clostridioides difficile infection (CDI), though the risk varies by agent. The antibiotic spectrum index (ASI) captures information on spectrum of antibiotic activity and days of therapy (DOT). We evaluated ASI and other routinely collected clinical data as predictors of hospital-associated (HA) CDI.

Methods

We developed and tested a model to predict HA-CDI in a cohort of adult inpatient encounters at a 576-bed academic medical center in Portland, OR. We excluded patients with recurrent or community-acquired CDI. We used encounter data from 2/2018 – 2/2020 to train and validate our model. Using a randomly-selected two-thirds of our data, we trained our logistic regression model using a stepwise variable selection process. We used the remaining one-third of our data to validate our model. Finally, we applied the model to the 3/2020 – 3/2021 period to test the model’s ability to predict HA-CDI. We generated receiver operating characteristic (ROC) curves and calculated area under the curve (AUC) to evaluate model discrimination. Finally, we compared observed and predicted HA-CDI counts by decile using the Hosmer-Lemeshow test.

Results

The training sample included 84 HA-CDI cases among 23622 encounters. The final model included ASI per DOT, time at-risk (days), patient age, number of hospitalized days in the 8 weeks prior, and inpatient receipt of a proton pump inhibitor or H2 receptor antagonist. When applied to the validation set (44 cases/11807 encounters), the model achieved an AUC of 0.79 (95% Confidence Interval: 0.71, 0.86) When applied to the test period (35 cases/12341 encounters), the AUC was 0.73 (0.66, 0.81). According to the Hosmer-Lemeshow test, our model fit the data reasonably well (p=0.2; Figure 1). Using ASI in the model achieved a significantly better prediction than DOT (Figure 2).

Conclusion

Using a combination of ASI and data that is routinely-collected for clinical practice, we were able to reasonably predict HA-CDI in our hospital using a small number of variables easy-to-obtain variables. The antibiotic spectrum index could be a valuable tool in predicting individual-level HA-CDI risk, though further work is required to test and implement a CDI risk score in a prospective environment.

Disclosures

All Authors: No reported disclosures
708. Three Stages of Laboratory Stewardship in Improving Appropriate Clostridiodes Difficile Testing
Authors: Beckman Shannon , Zimmerman Gretchen , Raza Khateeb , Ballard Samuel , Vijayam Naveen , Stibbe Bethany , Rykse Monica , Brown Joe , Klein Theresa , Skinner Andrew M , Wang Michael S
Published: November 2023

Background

Clostridioides difficile infections are a frequent cause of nosocomial infections and a large financial burden to the health care system. Molecular diagnostics such as PCR may frequently detect colonized patients and lead to overdiagnosis. Using the electronic medical record (EMR) system, we implemented multiple interventions to improve testing stewardship.

Methods

Over the span of 3 years, our Infection Control (IC) team implemented 3 separate testing interventions: in July 2019, a hard stop was implemented, requiring providers to document >3 loose or watery stools and no laxative use within 48 hours. In July 2020, Stage 2 was implemented, requiring an infectious diseases (ID) physician to electronically approve a CDI test for all tests after 3 midnights. In April 2022, Stage 3 was implemented, changing the testing protocol to an algorithmic approach, with positive C. difficile PCR reflexing to a toxin immunoassay with regular surveillance by IC practitioners to ensure compliance.

Results

From 2019 to 2022, our CDI testing interventions resulted in a reduction of C. difficile tests completed from 21.22 tests/1000 patient days (PD) to 6.95 tests/1000 PD (p< 0.01). The median number of tests completed in persons admitted for ≤ 3 days decreased from 63 (Interquartile Range (IQR):61 – 67) to 28 (IQR:26-35), p< 0.01. The median number of tests completed in persons admitted for > 3 days decreased from 34 (IQR:31 – 35) to 9 (IQR:7-10), p< 0.01. and the median, decrease of 27.8% (36 to 26), and increase of 7.69% (26 to 28), p < 0.01, respectively. The PCR percent positivity remained constant after the 1st intervention (15.3% vs. 14.4%, p=NS) but there was a slight increase in the test percent positivity between intervention 1 and 2 (19.2%, p=.08). After the 3rd intervention, the PCR percent positivity was 20.2% (80/316). However, the majority of these were PCR positive/toxin negative (74% vs 26%, p< 0.01).

Conclusion

3 stages of EMR-based interventions, including testing indications, ID physician review, and 2-tiered testing plus IC review, were effective in reducing CDI tests. These interventions led to an upward trend in percent positivity indicating that persons appropriate for testing were not adversely impacted, but further study is necessary to determine the long-term impacts on patient outcomes.

Disclosures

Andrew M. Skinner, MD, Academy for Continued Healthcare Learning: Honoraria|American Society of Healthcare Pharmacists: Honoraria|Ferring Pharmaceuticals: Honoraria|MJH Life Sciences: Honoraria
711. High Prevalence of Positive Cell Cytotoxicity Neutralization Assay in Symptomatic and Asymptomatic Pediatric Oncologic Patients
Authors: Zhang David , Oram Ronda , Landry Meghan , Kumar Madan , Cherny Katie , Hillerbrand Addison , Kociolek Larry K , Davila Nathalia , Galvan Mariel , Knopoff Karyssa , Ansari Rasheed
Published: November 2023

Background

Clostridium difficile infection (CDI) is the most common cause of nosocomial diarrhea in the United States. This burden is more prevalent and severe in the oncologic population and is associated with greater morbidity and mortality. Diagnostic modalities are limited, and misdiagnosis is high with resultant mismanaged care – inappropriate antibiotics, and potentially missed opportunities for appropriate targeted care towards graft-versus-host disease or other etiologies. To date, no large-scale evaluations have been performed to characterize the incidence of true disease in this population or to help delineate predictive markers for true infections (cell cytotoxicity neutralization assay (CCNA) positivity).

Methods

This is a multi-center, prospective stool banking study from January 2020 to date enrolling pediatric patients with an oncologic diagnosis admitted at Advocate Children’s Hospital and Comer Children’s Hospital. Stool was collected weekly along with relevant clinical histories and symptomology. Isolates of C. difficile were cultured and CCNA performed. Stool was also collected during episodes of PCR diagnosed CDI.

Results

65 unique subjects were enrolled over 183 admissions. 11 samples from 10 patients were thought to represent CDI with PCR positivity noted. Five of these specimens were confirmed as CCNA positive while the remainder did not have active toxin presence. Bristol type 4 stools or > 3 stools in 24 hours were significant factors for modeling CCNA positivity, but not for modeling PCR positivity. Notably 26 stool specimens were CCNA positive, and 21 did not have PCR tests done. Among all CCNA positive specimens, no significant difference was noted in symptomatology or antibiotic use.

Conclusion

Differentiating true CDI can be challenging. However, even in patients with high risk of alternative GI pathology, the frequency of stooling and stool characteristics can be used. Although considered the gold standard for assessment of disease, CCNA positivity in this population was noted in patients who were not evaluated for disease by their primary providers. Underdiagnosis is possible, but potentially less likely given the absence of clinically significant differentiation in symptoms. Host factors predisposing to disease are likely present.

Disclosures

Larry K. Kociolek, MD, MSCI, Merck: Grant/Research Support
717. Antimicrobial Resistance of Gram-Negative Bacteria in Respiratory Isolates from an Intensive Care Unit in Guatemala
Authors: Erdmenger Diego , Rodriguez Luis , Ochoa Fernando , Alfaro Andres , Portillo Carolina , de Leon Izabel , Valenzuela Laura
Published: November 2023

Background

Antimicrobial resistance (AMR) among Gram-negative bacteria (GNB) is a growing concern in public health, particularly in ICU settings. Over the past few decades, there has been a significant increase in ESBL and carbapenem resistance in Latin America, which has resulted in higher mortality rates and increased healthcare costs.

One way to understand local bacterial resistance profiles is to examine respiratory isolates, which can serve as a proxy for resistance observed in the clinical setting. It is critical for clinicians to be aware of these profiles in order to make informed decisions about treatment options.

Methods

A retrospective study was conducted on all respiratory isolates from the ICU of a third-level national hospital over a 6-month period. All respiratory isolates were analyzed for to identify microorganisms and their AMR to selected antibiotics, including Ceftriaxone (CRO), Ceftazidime (CAZ), Cefepime (CEF) and carbapenems.

Results

A total of 500 isolates were obtained during the study period, resulting in the isolation of 988 microorganisms. GNB represented 92.3% (n=912) of these isolates. Pseudomonas spp was the most common GNB identified (28.07%), followed by Acinetobacter (26.97%) and Klebsiella spp (20.94%).

Stenotrophomona isolates were excluded from the analysis as resistance profiling for this organism is not routinely performed in the institution, leaving a total of 868 isolates for AMR analysis.

A total of 527 GNB isolates (60.78%) were identified as resistant to both 3rd generation cephalosporines and CEF. Strains with this resistance pattern were considered highly suggestive of ESBL production. Moreover, 66.78% (n=579) of GNB’s analyzed evidenced resistance to carbapenems, with 13.61% (n=118) of strains having been identified as carbapenemase-producing bacteria.

Some GNB exhibited alarming levels of resistance as evidenced in table 1.Table 1.Resistance of selected GNBPercentage of bacterial strains from respiratory isolates resistant to selected antibiotics.

Conclusion

The high level or resistance observed in GNB from respiratory isolates in this study is concordant with other data from Latin America. While the prevalence of GNB in respiratory isolates does not necessarily correlates with clinical infection rates, the high level of resistance found may be an indicator of the AMR epidemiology of infections in this ICU.

Disclosures

All Authors: No reported disclosures
736. Risk Factors and Outcomes Associated with Daptomycin-nonsusceptible Enterococcus Bloodstream Infections
Authors: Failla Andrew J , Suleyman Geehan
Published: November 2023

Background

Enterococcus spp. are a common cause of nosocomial bloodstream infections (BSIs) with increasing resistance to currently available antibiotics and high mortality. Although the emergence of daptomycin-nonsusceptible Enterococcus (DNSE) has been reported, risk factors and outcomes associated with acquisition of daptomycin (DAP) resistance are not well characterized.

Methods

Retrospective cohort study of patients with enterococcal BSIs at Henry Ford Health in Southeast Michigan from 2014 to 2022. Cases included patients with DNSE; patients with persistent daptomycin (DAP)-susceptible Enterococcus (DSE) bacteremia ( > 2 days of positive blood cultures) were used as controls. Outcomes included 30-day readmission and mortality.

Results

24 cases and 24 controls were included; median age was 67 years (IQR 59-72), 28 (58.3%) were male and 26 (54%) white. All patients were exposed to antibiotics within 90 days with no difference in DAP use between the two groups (8% vs 21%, p=0.220). The majority (90%) had prior hospitalization within the year, 44% were immune suppressed and 42% had end-stage renal disease. Hepatitis C virus (HCV) (17% vs 0, 0.037) and prior VRE (42% vs 21%, p < 0.001) were more prevalent among cases. Indwelling urinary catheter (IUC) use was more common in cases (83% vs 54%, p=0.029), but there was no difference in central venous catheter use (75% vs 58%, p=0.221). Most common source of infection was intra-abdominal in both groups (54% vs 75%, p=0.188). Although not statistically significant, need for intensive care unit admission was higher (75% vs 50%, p=0.074) and length of stay was longer (54 vs 32 days, p=0.063) in cases compared to controls; treatment duration was significantly longer in controls (23 vs 16 days, p=0.04). There was no significant difference in readmission (12.5% vs 25%, p=0.267) or mortality (58% vs 46%, p=0.386) between the two groups.

Table 1

DNSE patient demographics, risk factors and outcomes

Conclusion

DNSE is an emerging pathogen associated with HCV, prior VRE and IUC use in our cohort; however, prior daptomycin exposure was not a significant risk factor for DNSE. Despite the high mortality, there was no difference in outcome between the two groups. Mechanism of DNSE in patients without prior DAP exposure should be explored to prevent potential spread of resistance.

Disclosures

All Authors: No reported disclosures
754. Utilization of Internal Special Program Review to Institute Change in an Academic ID Fellowship
Authors: Carey Adrienne , Pender Melissa , Cariello Paloma F
Published: November 2023

Background

Fellowship accreditation is crucial to ensure adequate clinical education for physicians in training, yet there is limited data on use of accreditation survey results for program quality improvement. The Accreditation Council for Graduate Medical Education (ACGME) administers annual surveys to trainees and core faculty to monitor education and identify potential non-compliance with ACGME accreditation standards. Our purpose is to describe the creation of an internal program review process for program improvement based on results of nationally implemented accreditation surveys.

Methods

We collected data from standardized ACGME survey responses administered to core faculty and fellows at our academic Infectious Diseases fellowship program. The identification of areas scoring lower than 20% in comparison with national average prompted creation of a Special Program Review (SPR) committee comprised of a program director, a program coordinator, and a trainee from programs outside of the program under review. This committee met separately with core faculty, trainees, and program leadership to compile an assessment of each survey component and opportunities for improvement. This review process of survey results was completed annually from 2020-2022.

Results

Between 2020-2022, surveys were completed by 100% of fellows (7/7 or 8/8) and up to 92% of core faculty (11/12). Key findings raised concerns involving clinical education, faculty supervision, patient safety, and teamwork. Actions taken in response to the SPR included the creation of: an updated backup and weekend coverage system, new didactic curricula, a morbidity and mortality conference, documentation limits, informal fellow/faculty dinners, opt out counseling, and a division culture committee.

Conclusion

A non-punitive internal review process mimicking accreditation standards is valuable for program assessment and improvement as means to identify areas of risk for accreditation issues at a national level. This review process is generalizable, as all accredited programs complete the survey annually. The quality improvement interventions taken will differ depending on survey findings and areas to be addressed.

Disclosures

All Authors: No reported disclosures
778. PrEParing Medical Students For Their Transition to Residency: The Benefit of Early Education on HIV Prevention
Authors: Pavia Jonathan E , Hornak Joseph P
Published: November 2023

Background

Pre-exposure prophylaxis (PrEP) is a cornerstone of broad efforts to end the HIV epidemic, but uptake by primary care providers (PCP) has been demonstrated as suboptimal. Knowledge gaps have been linked to decreased PrEP uptake among PCPs. This report demonstrates the effectiveness of early career PrEP education aimed at the graduating 4th year medical student (MS4) as they transition to residency.

Methods

Anonymous, online, optional, pre- and post-intervention surveys were administered to MS4s at our institution to assess awareness, knowledge, and perceived comfort around prescribing PrEP as future resident physicians. Students attended a comprehensive, interactive, case-based lecture (“intervention”) about HIV prevention, with particular focus around PrEP availability, identification of potential candidates, and patient monitoring. Results from the two surveys were measured and compared. Fisher's exact test was used for nominal statistics.

Results

Thirty-one pre-intervention and 19 post-intervention surveys were completed. At baseline, a majority of respondents were aware of PrEP (94%), but a minority were comfortable prescribing PrEP (39%). Prior knowledge regarding PrEP (67%) and concerns for cost (16%) were the two highest reported factors contributing to perceived comfort with prescribing PrEP. Post-intervention, MS4s reported significantly increased comfort prescribing PrEP (100% vs. 39%, P = < 0.0001) and no significant decrease in attributing knowledge as a barrier to providing PrEP (52% vs. 67%, P = 0.37). Participants reported very high satisfaction in the material presented during the lecture (100%).

Conclusion

These results indicate the benefit of early career education on the topic of HIV PrEP aimed at senior medical students. If efforts to significantly reduce HIV transmission are to be successful, PrEP use must be greatly expanded across medical disciplines including primary care, pediatrics, infectious diseases, women’s health, and others. Bolstering PrEP education within medical school curricula may assist with accomplishing these goals. Further research should explore other modalities for delivering HIV prevention education to medical students.

Disclosures

All Authors: No reported disclosures
786. Online CME Improves Adoption of Clinical Practice related to Incorporating long-acting Injectables into HIV Clinics
Authors: Thorpe Sara , Blatherwick Donald , Uravich Maria B
Published: November 2023

Background

Recently, the first long-acting injectable (LAI) for the treatment of HIV was approved by the FDA. Although this advancement in therapeutics offers many potential advantages, including eliminating the needs for daily medications, the successful uptake into clinical settings will require navigating systems-level challenges such as clinic or hospital infrastructure. This study examined whether online continuing medical education (CME) focused on evidence-based best for incorporating long-acting injectables into clinical care would result in the adoption of new clinical practices.

Methods

Performance in the real world was assessed 30-60 days post-education for learners in the target audience(s). Email invitations were sent for the first 3 months of learners. Each respondent reported for each possible practice whether they were implementing for the first time or had modified it due to education, they were already doing it prior to education; or they were not doing it before or after education. They also indicated barriers they experience at least “some” of the time for each practice. The activity posted on 4/15/2022. Data was collection ended on 2/1/2023.

Results

There were a total of 39 learners consisting of PCPs, OB/GYNS, Nurses and NPs. Analysis showed that 80% of learners made a practice change or had practices reinforced due to education. Top 3 practice changes included:• 59% of learners are now educating eligible patients about the availability of LAI ART• 57% are staying abreast of current data from clinical trials, evaluating LAI ART for HIV• 56% are implementing LAI ART in clinical practice

Survey results evidence persistent barriers to incorporating long-acting injectables into HIV Clinics. Top barriers included:• 38% Lack understanding of guidance about patient eligibility• 24% Lack knowledge of about best practices for getting started with LAI ART15% lack expertise in counseling patients on LAI ART

Conclusion

The clinical practice changes identified in this assessment provide compelling evidence that participation in online CME/CE prompts adoption of changes in practice related to incorporating LAI ART in the care of people with HIV. Future education is needed to address the barriers identified in this assessment.

Disclosures

All Authors: No reported disclosures
787. Next Steps: Teaching Future Generations an Interdisciplinary Approach to Diabetic Foot Ulcer Care
Authors: Parikh Shalvi B , LaMantia Jamie N , Brennan Meghan B , Tischendorf Jessica S
Published: November 2023

Background

Interdisciplinary care of diabetic foot ulcers (DFUs) is associated with nearly 40% reduction in major (above ankle) amputations. We developed a curriculum emphasizing interprofessional collaboration (IPC) between Infectious Disease (ID) fellows and Podiatry residents in the care of veterans with DFUs.

Methods

The curriculum was delivered in two one-hour in-person sessions. The first session provided background on principles of IPC and perspective sharing of other professions through case discussions. The second session, co-facilitated by an ID physician and a podiatrist, allowed ID fellows and podiatry residents to work through DFU cases. We used a quasi-experimental design (Figure 1) and a multipronged assessment designed by applying Miller's pyramid (Figure 2). We used a modified Jefferson Scale of Attitudes toward IPC (Likert scale 1-5, 5 = strongly positive) to measure fellow attitudes, with items subcategorized by themes of shared learning and diversity & ethics. Fellows reported on the frequency of communication with the primary and podiatry team weekly, and charts of veterans with DFUs were reviewed for documentation of ID-specific content (organism and antibiotic plan), as well as non-ID specific plans (glycemic control, vascular status, and biomechanical considerations). Two-sided t-test was used to compare pre-post performance.

Results

Five ID fellows participated. Post-session evaluations suggest the curriculum was viewed favorably. Fellows had strongly positive baseline attitudes toward IPC. Attitudes toward shared learning improved (4.13 vs 4.44, p < 0.01), but diversity & ethics did not (4.86 vs 4.82, p = 0.61). Hospitalizations of seven veterans with DFUs were analyzed pre-intervention and four analyzed post-intervention. ID-specific content and communication with the primary team remained 100% over the study period. Non-ID-specific content documentation remained low (20% vs 11%, p = 0.30). Frequency of communication with podiatry did not change significantly (57% vs 25%, p = 0.35).

Conclusion

Interdisciplinary didactic sessions were well-received and may improve attitudes toward shared learning, but likely need to be augmented with interprofessional clinical experiences to achieve practice improvements in the care of veterans with DFUs.

Disclosures

All Authors: No reported disclosures
788. Social media as a powerful tool for expanding infectious disease-related medical knowledge: A Twitter account perspective
Authors: Torres Mario A , Zuckerman Richard A , Mazurkiewicz Rebecca
Published: November 2023

Background

The influence of social media on medical education has been demonstrated by multiple meta-analyses, highlighting the important role of this medium in the medical community. Within the realm of available platforms, Twitter plays a major role. The goal of this project was to create an account to propagate medical content and attract learners to the field of Infectious Disease.

Methods

In 2021 @theIDtrivia was founded, an account dedicated to sharing Infectious Disease-related content, creating trivia (Figure 1-A) and “board-style” questions based on the American Board of Internal Medicine Infectious Disease Certification Exam Blueprint. After posting questions in a poll-type format, users have 3-7 days to select an answer before the correct one is posted along with an infographic (Figure 1-B). All tweets and infographics are well-researched, and the references are shared with links embedded with the intent of developing a reliable social media resource.

Results

The first tweet was posted on September 2021, and the account had just one follower at the time. Over the next 18 months, 881 tweets have been posted and the account has gained over 7500 followers (Graph 1-A) - 35% are active accounts from the United States (Figure 2). The number of impressions (times a user is served a tweet in their timeline or search results, Graph 1-B) has increased concomitantly with engagement with the account (total number of times a user interacts with a tweet, including retweets, replies, likes). Based on responses, people at multiple stages of their careers, practitioners of other areas such as pharmacy and microbiology, and institutional accounts from different parts of the world have actively engaged with the content of @theIDtrivia.

Conclusion

We have shown that infectious disease-based trivia via social media engages a wide and varied population interested in exchanging knowledge and ideas. While this is positive in and of itself, one limitation is that we are unable to show that those who follow the account and/or participate in its content, feel that it results in improved test performance or in clinical practice. This opens an opportunity for continued exploration of the role of social media in medical education and how it can be integrated into clinical decision-making.

Disclosures

All Authors: No reported disclosures
813. Characteristics and Outcomes of Hospitalized Patients with Newly Diagnosed Histoplasmosis
Authors: Dalton Liam , Miceli Marisa H
Published: November 2023

Background

Histoplasmosis (histo), is the most common cause of hospitalization and death among the endemic mycoses in the US. Clinical presentation varies from asymptomatic to severe, disseminated illness indistinguishable from other infections, which may result in misdiagnosis. Physicians must remain vigilant for histo given the potentially devastating consequences of disseminated infection. We sought to determine the characteristics and outcomes of admitted patients (pt) newly diagnosed with histo at our institution.

Methods

We performed a retrospective evaluation of hospitalized adult pt newly diagnosed with histo via culture, histopathology, or antigen testing (Ag) at the University of Michigan from 1/1/2015-12/31/2022. Demographic, clinical, treatment, & outcome data were collected. We compared the characteristics and outcomes of immunocompromised (IC) pt with those of non-immunocompromised (NIC) pt.

Results

62 pt were included, 51 IC (76%) & 16 NIC (24%). The IC group included pt with solid organ transplants (19), autoimmune disorders treated with immunosuppressive drugs (22), hematologic (4) or solid malignancies & AIDS (1 each). Mean age of IC was 46.13+17.4 yr vs 58.1+16.4 yr among NIC, p=0.02; 74% IC were men vs 80% NIC. Mean BMI in IC pt was 26.8+6.2 vs 24.1+5.2 among NIC, p=0.13. Disseminated histo was more common in IC pt (74.5% vs 46.7%, p=0.048). ICU admission occurred in 46.8% IC vs 40% NIC, p=0.75. All-cause 6-month (m) mortality was 24%: 25.5% IC vs 20% NIC; 3 pt died before diagnosis was made (2 IC; 1 NIC). The initial treatment for most IC pt was amphotericin B (76.6%, p< 0.01). Fifty-two pt were diagnosed using Ag testing (40 IC; 12 NIC); Ag titers above the limit of quantification occurred in 15 IC pt; 14 had disseminated disease. Histo was diagnosed year-round in our pt cohort, but the most pt presented in winter (39%; p=0.02). December was the m with the most cases (27.4%, p< 0.001). There was no statistical difference in diagnostic seasonality between hospitalized IC & NIC pt.

Conclusion

Hospitalized IC pt diagnosed with histo were younger and more frequently had disseminated disease than NIC pt, but morbidity and mortality did not differ. Unlike other reports, at our institution, the most pt with histo were diagnosed during the winter months.

Disclosures

Marisa H. Miceli, MD, Astellas: Advisor/Consultant|F2G: Grant/Research Support|Scynexis: Advisor/Consultant|Scynexis: Grant/Research Support
816. Fatal Coccidioidomycosis Cases in an Endemic Area
Authors: D’Assumpcao Carlos M , Kooner Lovedip , Dhillon Amritpal , Valdez Michael , Kuran Rasha , Johnson Royce H , Heidari Arash
Published: November 2023

Background

While a majority of Coccidioides infections are asymptomatic, it is estimated that 1% develop severe disease and can be fatal. Prior retrospective reviews that attempt to identify risk factors for fatal disease have been limited to public health data hampered by reporting challenges and accuracies. Morbidity review of fatal cases identified by clinical criteria rather than ICD-9/ICD-10 reporting may improve accuracy of conclusions.

Methods

At an academic center in an endemic area, medical records from three sequential electronic medical record systems were reviewed from approximately January 2000 to January 2023. Patients with coccidioidomycosis were identified by microbiological, pathological, serological, or skin testing criteria. Deaths were determined by in hospital records, insurance reporting, review of death certificate if available, or public record. Demographics, clinical course, outcomes and causes of death are compared. Incomplete medical records to make comparison were excluded. Retrospective root cause analysis was performed.

Results

To date, at least 50 patients met clinical criteria for having coccidioidomycosis at one point in their life and died. ICD coding was wrong in about half of the cases. Data integrity has been a challenge when extracting data across three electronic medical record systems. New risk factors found by root cause analysis not previously identified.

Conclusion

Patients were found to have died either with coccidioidomycosis or from coccidioidomycosis. ICD coding was inconsistent. Precise and accurate description of coccidioidomycosis staging is important when trying to determine risk factors for fatal disease.

Disclosures

All Authors: No reported disclosures