bluuebunny/crossref_metadata_2025 huggingface dataset:
Co-circulation of Influenza A and B During the 2016–2017 Influenza Season at Rush University Medical Center
Authors: Simms Andrew , Gonzalez Hemil , Moore Nicholas M , Chapman Leslie A , Lolans Karen , Trenholme Gordon M
Published: October 2017

Background

Two strains of influenza B virus, B/Yamagata and B/Victoria, co-circulate in the USA, typically appearing in late March. This year, influenza B virus (FluB) co-circulated consistently with influenza A virus (FluA). We hypothesized that this could be explained by an increased use of influenza trivalent vaccine, which lacks the B/Yamagata strain, over the quadrivalent vaccine.

Methods

We performed a retrospective, observational cohort study of patients with laboratory-diagnosed influenza from October 2016 through April 2017. Age, comorbidity categories, pregnancy status, symptoms, The presence of opacity on chest film, ICU admission, death, and receipt of oseltamivir were reviewed for 256 patients. A subset of FluB specimens were subtyped for lineage using RT–PCR.

Results

Influenza was detected in 495 (10.4%) of 4,754 samples collected, including 305 FluA and 190 FluB. The H3 strain represented 97% of FluA cases. FluB subtypes were: 70, B/Victoria; 21, B/Yamagata; and 41, not subtyped. Chart review was conducted for 124 randomly selected FluA and 132 sequential FluB patients. Median age of patients with FluA was 44 compared with 27 with FluB (P < 0.001). Forty-three (34.7%) FluA patients had heart disease compared with 21 (15.9%) FluB patients (P < 0.001). Otherwise, there were no differences in comorbidities, pregnancy status, clinical symptoms, or infectious complications between FluA vs. FluB patients. Ninety-three (75%) FluA patients and 78 (59.1%) FluB patients received oseltamivir. ICU admission occurred in 15 (12.1%) FluA and 9 (6.8%) FluB patients (OR 1.414; 95% CI 0.83-2.4). Seventy-seven (30%) patients received flu vaccine, 39 with FluA, and 38 with FluB; 97 (37.9%) were not vaccinated and 82 (32%) were missing data. Of those vaccinated, 6 patients received trivalent vaccine, and 71 received quadrivalent. Only 24 patients with B/Victoria and 7 patients with B/Yamagata were vaccinated.

Conclusion

The proportion of infected patients who had received vaccination was low, limiting our ability to detect the effect of the trivalent vaccine on the incidence of infection with B/Yamagata. In contrast to conventional thought, when compared with influenza B, influenza A (predominantly H3N2) did not appear to disproportionally affect those with most medical comorbidities, and was not disproportionately associated with our identified clinical complications.

Disclosures

All authors: No reported disclosures.
Influenza Vaccination and Treatment with Antiviral Agents Among Hospitalized Adults in the 2014–2015 and 2015–2016 Influenza Seasons
Authors: E Segaloff Hannah , Petrie Joshua G , Malosh Ryan E , Cheng Caroline K , Ferdinands Jill M , Lamerato Lois , Lauring Adam S , Monto Arnold S , Martin Emily T
Published: October 2017

Background

Vaccination and treatment with neuraminidase inhibitors can reduce incidence and severity of influenza. Observational studies suggest antiviral treatment reduces influenza symptom duration and severe outcomes among hospitalized patients. The interaction of the effects of vaccination and antiviral treatment against severe influenza has not been established.

Methods

We used data from a test-negative influenza vaccine effectiveness study. The parent study enrolled adults admitted to two hospitals in Michigan with an acute respiratory illness of ≤10 days duration during the 2014–2015 and 2015–2016 influenza seasons. Respiratory swabs from enrolled patients were tested for influenza by RT-PCR; influenza-positive individuals were included in this analysis. We evaluated predictors of vaccination and antiviral treatment using logistic regression. We also assessed the association between antiviral treatment and hospital length of stay (LOS) using linear regression models stratified by vaccination status.

Results

We included 200 individuals in the analysis; 103 (51.5%) were vaccinated and 135 (67.5%) were treated with antivirals. Significant predictors of vaccination included age ≥65, white race, a Charlson comorbidity index (CCI) score ≥3, study site, and increased past-year health care visits. Antiviral treatment varied by study site and was more common in the 2015–2016 season and among those aged 18–49. Vaccination was not associated with antiviral treatment or with time from illness onset to treatment. Antiviral treatment was associated with reduced LOS (percent change in LOS: −23.6% (−39.2%, −4.1%), P = 0.02) among vaccinated participants but not among unvaccinated participants (21.1% (−10.9%, 64.8%), P = 0.22) after adjustment for sex, age, influenza subtype, site, CCI, frailty, and past-year health care contacts. When an interaction term was used in lieu of stratification the interaction was significant (P = 0.01). This difference in antiviral effectiveness by vaccination status held across age groups, but was most dramatic for those aged 18–49.

Conclusion

Vaccinated individuals were more likely than unvaccinated individuals to benefit from antiviral treatment. This finding warrants confirmation in other populations.

Disclosures

A. S. Monto, sanofi pasteur: Grant Investigator, Research grant. Novartis: Consultant, Consulting fee. Protein Sciences: Consultant, Consulting fee. E. T. Martin, Pfizer: Scientific Advisor, Research grant. Merck: Scientific Advisor, Research grant. Multiparty Group For Advice on Science: Scientific Advisor, Research grant.
Norovirus, Astrovirus, and Sapovirus in a Tertiary Care Research Hospital
Authors: Daniel-Wayman Shelby , Fahle Gary , Palmore Tara , Green Kim , Prevots D Rebecca
Published: October 2017

Background

Norovirus, astrovirus, and sapovirus are known to cause acute gastroenteritis and are associated with chronic viral excretion in stool among immunocompromised patients. Because molecular tools for their detection only recently became widely available, the prevalence and chronic excretion of these viruses has not been well defined. We describe features of these viral infections among patients receiving care at the Clinical Center of the National Institutes of Health.

Methods

We identified patients with a positive BioFire FilmArray® gastrointestinal panel result for norovirus, astrovirus, or sapovirus from September 15, 2015 through November 30, 2016. We reviewed patient medical records to abstract clinical and microbiologic information. Chronic excretion was defined as more than one positive test for a given virus with more than 30 days between tests.

Results

Of 932 samples tested, 102 (11%) samples from 48 patients tested positive for norovirus, 15 (2%) samples from 11 patients tested positive for sapovirus, and 16 (2%) samples from 7 patients tested positive for astrovirus. One of these patients had a sample that tested positive for both sapovirus and norovirus, and one tested positive for astrovirus and sapovirus at separate points during the study period. Of the 48 patients with norovirus, 16 (33%) had evidence of chronic excretion, with a median duration of 189 days (range 72–372). Of these 16, 14 were known or suspected to be immunodeficient, and 4 had hematologic malignancies. Of 7 patients with astrovirus, 1 (14%) had evidence of chronic excretion (132 days). This patient had a hematologic malignancy and was taking immunosuppressive medication. No patients with sapovirus had evidence of chronic excretion. Overall, 20 (31%) patients additionally tested positive for another gastrointestinal pathogen, most commonly enteropathogenic E. coli and C. difficile.

Conclusion

Norovirus remains common in this immunocompromised patient population, and both sapovirus and astrovirus are present. Additional follow-up in this and other cohorts with new molecular tools will enable more complete description of the prevalence, excretion duration, and clinical features of infection with these enteric viruses.

This research was supported by the Intramural Research Program of the NIH, NIAID, and the NIH CC.

Disclosures

All authors: No reported disclosures.
Incidence of Norovirus-Associated Acute Gastroenteritis in Four Veteran’s Affairs Medical Center Populations in the United States, 2011–2015
Authors: Grytdal Scott , Browne Hannah , Collins Nikail , Vargas Blanca , Rodriguez-Barradas Maria , Beenhouwer David , Brown Sheldon , Lucero-Obusan Cynthia , Holodniy Mark , Kambhampati Anita , Parashar Umesh D , Vinje Jan , Lopman Benjamin , Hall Aron , Cardemil Cristina
Published: October 2017

Background

In the USA, norovirus is an important cause of epidemic acute gastroenteritis (AGE) as well as a leading cause of pediatric AGE. However, the burden of sporadic norovirus disease in US adults has not been well-documented. Our objective was to estimate the incidence of outpatient visits and hospitalizations for community-acquired norovirus AGE at four Veterans Affairs Medical Centers (VAMCs) and their associated outpatient clinics in Atlanta, GA; Bronx, New York; Houston, TX; and Los Angeles, CA.

Methods

From November 2011 to September 2015, stool specimens collected for clinician-requested diagnostic testing within 7 days of AGE symptom onset and with reported vomiting or diarrhea were tested for norovirus by real-time RT-PCR and positive samples were genotyped by Sanger sequencing. Incidence of norovirus-associated outpatient visits and hospitalizations were calculated by multiplying the prevalence of norovirus among tested specimens by AGE-coded outpatient encounters and inpatient discharges, and dividing by the unique patients served at each VAMC.

Results

1,620 stool specimens were tested from all 4 sites. Seven percent of outpatient (n = 795) samples (annual range: 3%–10%; range by site: 3%–10%) and 6% of (n = 825) samples from hospitalized patients tested positive for norovirus (annual range: 3%–8%; range by site: 3%–10%). Forty-four percent of norovirus-positive specimens were typed as GII.4 Sydney. Seventy-four percent of norovirus-positive specimens were collected between November and April. From 2011 to 2015, outpatient norovirus incidence was 250/100,000 population (annual range: 129 to 426/100,000; range by site: 87 to 428/100,000), and the incidence of norovirus hospitalizations was 28/100,000 population (annual range: 19 to 39/100,000; range by site: 14 to 57/100,000). By age group and setting, the highest incidence was observed among 45- to 64-year-old outpatients (370/100,000 population), and 85+-year-old inpatients (63/100,000 population).

Conclusion

This study provides estimates of the incidence of norovirus AGE outpatient visits and hospitalizations across multiple years among a geographically distributed VA population, highlighting the substantial burden of norovirus in US adults.

Disclosures

All authors: No reported disclosures.
Severe Fever with Thrombocytopenia Syndrome Virus Infection Associated with Hemophagocytic Lymphohistiocytosis as Poor Prognostic Factor
Authors: Park Sunmin , Kim Juwon , Kim Hyo Youl , Uh Young , Kim Young Keun
Published: October 2017

Background

Severe fever with thrombocytopenia (SFTS) is an emerging infectious disease caused by a novel bunyavirus designated SFTS virus (SFTSV) with a high fatality rate. Hemophagocytic lymphohistiocytosis (HLH) is an immune-mediated life-threatening disease triggered by infections, neoplasms and noninfectious inflammatory diseases. A few HLH associated with SFTSV were reported. According to the diagnostic criteria of HLH, 11 patients with SFTS were reviewed.

Methods

During last 2 years (2015–2016), 11 SFTS patients were diagnosed at the Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, South Korea. Clinical features were analyzed using diagnostic criteria of 2004-HLH trial. We described if the prognosis of SFTSV-infected patients was associated with clinical features of HLH.

Results

Of 11 patients, four patients were fulfillled the diagnostic criteria of 2004-HLH trial (five of eight criteria). Two patients were fulfilled the four criteria. Five patients were fulfilled three or less criteria. Three of six patients who fulfilled four or more criteria were died. There was no mortality in five patients who fulfilled three or less criteria. Hemophagocytosis in bone marrow (BM) was observed in all six patients who were taken BM study.

Conclusion

In SFTS, HLH was severe clinical feature and it might be associated with poor prognosis.

Disclosures

All authors: No reported disclosures.
No Viral Spreading After Rotavirus Vaccination in NICU
Authors: Hiramatsu Hiroyuki , Suzuki Ryota , Yamada Shigeki , Ihira Masaru , Nagatani Arisa , Miyata Masafumi , Miura Hiroki , Hattori Fumihiko , Sugata Ken , Taniguchi Koki , Nishimura Naoko , Ozaki Takao , Yoshikawa Tetsushi
Published: October 2017

Background

Preterm and low birth weight infants are considered to be high risk for severe rotavirus gastroenteritis. However, it has been demonstrated that many infants are ineligible for receiving rotavirus vaccine due to over the age limitation within the neonatal intensive care unit (NICU). We sought to elucidate the safety of rotavirus (RV) vaccination in NICU by assessing vaccine virus transmission from vaccine recipients in NICU.

Methods

This study was designed as the prospective study conducted at the NICU of Fujita Health University hospital and Konan Kosei Hospital. This study was approved by the ethical committee in our university. Premature age-eligible infants were recruited to administer rotavirus vaccine. Stool samples were serially collected from unvaccinated infants (UVI) and vaccinated infants (VI) who received either the pentavalent rotavirus vaccine (RV5) or monovalent rotavirus vaccine (RV1). During October 10, 2014 and December 25, 2015, 19 VIs and 49 UVIs were enrolled in this study. Contact precaution was carried out in NICU. All stool samples were analyzed by real-time RT-PCR for detection of RV5, RV1, and wild-type strain’s genomes.

Results

Total of 676 stool samples (89 samples collected from the 9 RV5 vaccinated infants, 110 samples collected from the 10 RV1 vaccinated infants, and 477 samples collected from the 49 UVIs) were analyzed in this study. Nineteen VIs received with first dose of vaccine demonstrated persistent shedding of rotavirus vaccine genome during 1–8 days after the first dose of the vaccine. Meanwhile, in comparison to VIs received with first dose of vaccine, the detection of viral genome in stool samples decreased gradually in there VIs after second dose of vaccine. In contrast to the VI, no vaccine genome was detected in any of the stool samples collected from the UVIs.

Conclusion

This study suggests that RV vaccine may be safe for administration of preterm and low birth weight infants in NICU. Accordingly, the contact precaution measures may play an important role in prevention of vaccine virus transmission between VIs and UVIs.

Disclosures

All authors: No reported disclosures.
M Protein-Deficient Respiratory Syncytial Virus (RSV) Vaccine Protects Infant Baboons Against RSV Challenge
Authors: Welliver Robert C , Oomens Antonius , Wolf Roman , Papin James , Ivanov Vadim , Preno Alisha , Staats Rachel , Piedra Pedro , Yu Zhongxin
Published: October 2017

Background

RSV bronchiolitis is the most common cause of hospitalization of infants in the US, and may lead to the development of long-term airway disease. Inactivated vaccines may lead to enhanced disease, while replicating vaccines have caused unacceptable degrees of illness, and may revert back to wild type. We developed an RSV vaccine lacking the gene for the M protein (Mnull RSV). The M protein is responsible for reassembly of the virus after it infects cells and expresses its proteins. Infant baboons vaccinated intranasally (IN) with Mnull RSV develop serum neutralizing antibody (NA) responses, but the virus does not replicate.

Methods

2-week-old baboons (n = 12) were primed IN with 107 vaccine units of Mnull RSV or a control preparation, and a similar booster dose was given 4 weeks later. Mnull RSV vaccination did not cause tachypnea, airway inflammation or other signs of illness when compared with sham-vaccinated controls. Two weeks after boosting, all infants were challenged intratracheally with human RSV A2. We continuously monitored respiratory rates and levels of overall activity. On various days following challenge, we obtained BAL fluids for leukocyte counts and degree of virus replication, and evaluated alveolar-arterial oxygen gradients (A-a O2).

Results

Vaccinated animals (vs. unvaccinated controls) had lower respiratory rates (P = 0.0014), improved A-a O2 (P = 0.0063) and reduced viral replication (P = 0.0014). Activity scores were higher in vaccine recipients than in unvaccinated animals. Vaccine recipients also were primed for earlier serum and secretory neutralizing antibody responses, and greater airway lymphocyte responses. Airway lymphocyte numbers (but not antibody responses) were associated with lower respiratory rates and reduced viral replication (P < 0.01).

Conclusion

Vaccination intranasally with Mnull RSV protected infant baboons against an RSV challenge without causing respiratory disease or enhanced illness, and is a promising candidate for use in human infants. Lymphocyte responses to vaccination may play an equal or greater role in protection against RSV infection than antibody responses.

Disclosures

All authors: No reported disclosures.
Reported History of Measles and Long-term Impact on Antibody to Tetanus in Children 6–59 Months of Age Receiving DTP in the Democratic Republic of Congo
Authors: Ashbaugh Hayley , Cherry James D , Gerber Sue , Higgins Stephen G , Gadoth Adva , Alfonso Vivian H , Mukadi Patrick , Hoff Nicole , Doshi Reena , Rimoin Anne W
Published: October 2017

Background

Recent studies suggest a measles-induced immune amnesia that could have long-term immunosuppressive effects via preferential depletion of memory B and T CD150+ lymphocytes.

Methods

We examined the association between past measles and tetanus antibody levels among children participating in the 2013–2014 Democratic Republic of Congo (DRC) Demographic and Health Survey (DHS). Our sample consisted of 833 children aged 6–59 months whose mothers were selected for interview. Mothers reported (via recall) history of measles within the lifetime of the child. Classification of children who previously had measles was completed using maternal recall and measles immunoglobulin G (IgG) serostatus obtained via dried blood spot (DBS) analysis. A multiplex chemiluminescent immunoassay platform was used to obtain serologic results and Assay Score (AS) was calculated as a ratio to a positive control included in each run. Tetanus serostatus was categorized as being above or below the sample median serology AS value. Tetanus vaccination status was obtained via dated vaccination card and limited to children receiving the complete 3-dose vaccination series.

Results

The median AS for tetanus serology among the entire sample of 833 children was 0.085, while children with history of measles had a median AS of 0.053 (N = 41) and children with no history of measles had a median AS of 0.088 (N = 792), chi-square P-value < 0.05. A random intercept logistic regression model was used to examine the association between previous measles disease and odds of having below median levels of tetanus antibody. Controlling for potential confounding variables, the odds of a child with past history of measles having less than the median level of tetanus antibody was 3.86 (95% CI: 1.70, 8.78) among children fully vaccinated for tetanus.

Conclusion

The results suggest that, among children 6–59 months in DRC, measles may have a long-term impact on levels of pre-existing, vaccine-induced immunity to tetanus. These findings suggest the need for laboratory studies examining measles’ impact on pre-existing, vaccine-induced immunity and underscore the need for continued evaluation and improvement of DRC’s measles vaccination program.

Disclosures

All authors: No reported disclosures.
Trends in the Burden and Seasonality of Rotavirus in the United States, 2000–2016
Authors: Aliabadi Negar , Haynes Amber , Tate Jacqueline , Parashar Umesh D , Curns Aaron T
Published: October 2017

Background

Before implementation of rotavirus vaccination in 2006, rotavirus caused 55,000-70,000 hospitalizations and 410,000 clinic visits annually in US children. This report examines the long-term impact of vaccine introduction on rotavirus detection and seasonality through comparison of pre (2000–2006) and post (2007–2016) vaccine seasons through the National Respiratory and Enteric Virus Surveillance System (NREVSS).

Methods

NREVSS is a passive laboratory system collecting results of weekly total and rotavirus-positive stool specimens. Seasons are defined as July through June. To characterize changes in rotavirus detection, total and positive specimens for each post vaccine season from 11 continuously reporting (≥26 weeks per season) laboratories were compared with median values for 2000–2006. Data from 20 participating laboratories were used to determine changes in season characteristics. ArcGIS software was used to document the annual geographic trend across the United States between 2000 and 2015. For season 2015–2016, data are available through April and are not included in the ArcGIS analysis.

Results

Nationally, there was a 53–93% reduction in rotavirus positivity in the post vaccine period as compared with the median in 2000–2006. Trends in rotavirus positivity declined steeply after vaccine introduction in 2006, and have remained low compared with the pre-vaccine period, with alternating years of lower and greater activity (figure). All regions had similar reductions in positive tests. ArcGIS data indicate that peak seasonal activity was largely restricted to January-April for each pre-vaccine year. In the 2006–2007 season, peak activity occurred during January-April, for 2007–2008, this shifted to March-April, for 2008–2009, the peak activity nationwide occurred at all months of the year from the reporting laboratories. This diffuse activity occurred for all subsequent years, save 2009–2010 and 2012–2013, where peak seasonal activity was again confined to January-April.

Conclusion

Rotavirus vaccine substantially and sustainably reduced the burden and changed the epidemiology of rotavirus in US children. The biennial pattern observed may be explained by accumulating unvaccinated children over two successive seasons resulting in stronger rotavirus seasons every alternate year.

Disclosures

All authors: No reported disclosures.
Perception of Japanese Physicians about Human Papillomavirus Vaccine
Authors: Katsuta Tomohiro , Moser Charlotte , Offit Paul , Feemster Kristen
Published: October 2017

Background

Current vaccination coverage of Human Papillomavirus vaccine (HPVV) in Japan is less than 1% because the Ministry of Health, Labour and Welfare (MHLW) suspended its proactive recommendations for HPVV in 2013 after some reports of possible adverse events following immunization. We evaluated the perception of Japanese physicians about HPVV in order to consider the appropriate countermeasure to improve HPVV coverage in Japan.

Methods

We conducted a cross-sectional study using a postal questionnaire targeting 330 Japanese physicians (78 pediatricians, 225 internists and 27 obstetricians-gynecologists (OB-GYNs)) in Kawasaki, Japan in 2016. The questionnaire comprised questions about education frequency, physicians’ perception and recommendation behavior related to adolescent vaccines (HPVV, diphtheria tetanus toxoid (DT) and inactivated influenza vaccine (IIV)).

Results

Valid responses were obtained from 148 (44.9%) physicians (pediatricians 80.8%, internists 31.6% and OB-GYNs 51.9%). Very few (8.0%) of physicians provided HPVV during the past month. Only 21.3% of physicians educated aggressively about HPVV, which was significantly less frequently than DT (61.7%) and IIV (88.6%). Similarly, 53.1% of physicians recommended HPVV aggressively, which was significantly less frequently than DT (83.1%) and IIV (80.3%). We found no significant differences in the frequency of HPVV education or recommendation by pediatricians, internists and OB/GYNs (22.4% vs. 16.9% vs. 35.7% and 54.8% vs. 47.9% vs. 71.5%, respectively). However, 90.0% of physicians answered that if MHLW were to reinstate its HPVV recommendation, they would more aggressively recommend HPVV for adolescents.

Conclusion

Although Japanese physicians were cautious about HPVV and infrequently provided education or made a recommendation for HPVV compared with other adolescent vaccines, our survey suggested such a passive attitude could be improved by the MHLW resuming its proactive recommendation in Japan.

Disclosures

All authors: No reported disclosures.
Fixed vs. Free-text Documentation of Indication for Antibiotic Orders
Authors: Javaid Waleed , Cavanaugh Shaelyn , Lupone Christina , Stewart Telisa , Fazili Tasaduq , White Benjamin
Published: October 2017

Background

Requiring indications for antimicrobial orders can allow stewardship programs to evaluate adherence to guidelines and assess outcomes. We extracted indication data from our institution’s EPIC system and found that in a 29-month time frame there were 12,218 uniquely entered indications. Only 136 of these were standardized drop-down (fixed) menu options; the rest were entered manually (free-text). Enormous variation in these uniquely typed entries emphasizes the value and necessity of fixed indication options to allow for better evaluation of stewardship program outcomes.

Methods

We evaluated the 718 most commonly used indications accounting for a total of 113,741 unique antibiotic orders for 42,665 patients. We excluded indications used for less than 36 orders during the study period. We analyzed the characteristics of these orders to identify opportunities for improvement in indication documentation and developed a new list of less than 200 indications that could account for nearly all of the various indications entered.

Results

66,404 (58%) orders were placed using fixed options available in the menu (Figure 1). 32,427 (29%) orders were placed with no indication listed. The remaining 14,910 (13%) orders were documented with free-text indications. Within these manual entries, 59% were identical or nearly identical to an option that was available in the drop down menu. 37% of free-text indications could not be appropriately placed with an option available in the menu. For example, the menu contained a fixed option for “Severe C. difficile infection” forcing all non-severe cases to be entered as varied free-text alternatives (Figures 2 and 3).

Conclusion

In our sample, use of fixed menu options was high but robust evaluation of proper antimicrobial use was substantially limited by failure to document indication and free-text entry by providers. Free-text entry and blank fields can be used as quality metrics, with high use indicating poor quality. We recommend that standard comprehensive indication lists are developed, providers are encouraged and empowered to utilize menu options consistently, and computerized order systems are programmed to prevent orders from being placed without an indication listed.

Disclosures

All authors: No reported disclosures.
Antibiotic Prescription Patterns for Acute Diarrhea in a Hospital in Shanghai in 2016: A Cross-sectional Study
Authors: Hu Yanhong , Wang Shanjuan , Hua Sunying , Willcox Merlin , Moore Michael , Little Paul
Published: October 2017

Background

Unnecessary antibiotic use increases the risk for antibiotic resistance. The rates of antibiotic use for upper respiratory infections are high in hospitals in China. Although most guidelines advise against the use of antibiotics for acute diarrhea, little is known about antibiotic use practices for acute diarrhea in China.

Methods

A retrospective prescription review from a Shanghai hospital outpatient electronic health records system was conducted from 1 January 2016 to 30 December 2016. Records were included for adult patients. The microbial resistance seasonal data in 2016 were extracted. Chi-squared and multivariable logistic regression and adjusted odd ratio (aOR) were used to assess the relationships between demographic characteristics and antibiotic prescribing.

Results

In total, there were 16,565 prescriptions, 16,060 prescriptions were included in the final analysis after excluding the follow up visits. There were 12,131 (76%) prescriptions with antibiotics prescribed. 5505 (45%) of the antibiotics prescribed were injectable. Of the antibiotics prescribed, levofloxacin was the most frequent (85%), followed by various cephalosporins (14%). Of the cephalosporin prescriptions, third-generation products were the most common (97%). Treatment with oral rehydration salts (ORS) was prescribed 34 (0.2%) times, probiotics were prescribed 3414 (21%) times and smectite was prescribed 2209 (14%) times. Multivariable regression analysis showed that those more likely to receive antibiotics were age 31–50 aOR 1.3 (1.1–1.4), P < 0.001, evaluated in the late evening (11pm to 7am) aOR 2.6 (2.2–2.9) P < 0.001, in the early evening (6pm-11pm) aOR 2.0 (1.8–2.2) P < 0.001, in the summer (June-August) aOR 1.7 (1.5–1.9) P < 0.001. At the same time, the Gram-positive and Gram-negative resistance rates to levofloxacin exceeded 40%, including 50% of E. coliisolates.

Conclusion

High rates of antibiotic use were observed for acute diarrhea in this hospital. Given the inappropriateness of antibiotics for acute diarrhea and the nonsensical high rates of of intravenous levofloxacin use and the concurrent high rates of the levofloxacin resistance, a more effective antibiotic stewardship program is needed to improve patient outcomes, reduce costs, reinforce policy and address the underlying causes of antibiotic abuse.

Disclosures

All authors: No reported disclosures.
Changing Pattern of Antibiotics Usage Among Hospitalized Patients of a Tertiary Hospital in South Korea: 2004–2013
Authors: Kim Bongyoung , Hwang Hyeonjun , Lee Myoung-Jae , Kim Jieun , Pai Hyunjoo
Published: October 2017

Background

This study was performed to evaluate the changing pattern of antibiotics usage among hospitalized patients of tertiary hospital in South Korea.

Methods

Total antibiotics prescription record of hospitalized patients from 2004 to 2013 were collected at a tertiary university hospitals. The antibiotics is defined as class J01 from anatomical therapeutic chemical classification system (ATC). The consumption of each class of antibiotic was converted to defined daily dose (DDD)/1,000 patient-days by using ATC of World Health Organization.

Results

Over the 10-year study period, the annual consumption of systemic antibiotics ranged from 815.10 to 1047.96. The proportion of broad-spectrum antibiotics and non-broad-spectrum antibiotics use are as follows: 45.4% (417.55/920.69) vs.. 54.6% (503.15/920.69), respectively. A 16.9% of decrease in total antibiotics consumption was observed in 2013 compared with 2004 (1000.69 in 2004 vs.. 831.46 in 2013). The decrease rate of non-broad spectrum antibiotics usage was 39.3% during the study period (607.21 in 2004 vs. 368.88 in 2013). In contrast, a stepwise increase in consumption of broad-spectrum antibiotics was observed (14.9% of increase; 393.48 in 2004 vs. 462.58 in 2013). Among broad-spectrum antibiotics, a significant decrease trend was observed for third-generation cephaloporins (P < 0.001). In contrast, a significant increase trend was observed for β-lactam/lactamase (P < 0.001). The monthly overall consumption trend of fluoroquinolones and glycopeptides remained stable (P = 0.061; P = 0.107, respectively). In addition, there were significant decrease trends for consumption of non-broad-spectrum antibiotics, including first generation cephalosporins (P = 0.019) and aminoglycosides (P = 0.004). However, the consumption of second generation cephalosporins, imidazole and penicillins showed a stable trend (P = 0.175; P = 320; P = 0.234, respectively).

Conclusion

A total antibiotics consumption showed significantly decrease trend from 2004 to 2013. In contrast, a stepwise increase in consumption of broad-spectrum antibiotics was observed in the tertiary hospital in South Korea.

Disclosures

All authors: No reported disclosures.
Comparison of Outcomes in Outpatient Parenteral Antimicrobial Therapy (OPAT) Patients Receiving Vancomycin vs. Non-Vancomycin Anti-MRSA Therapy
Authors: Stoneking Carolyn , Moenster Ryan P , Linneman Travis W
Published: October 2017

Background

This evaluation set out to determine whether vancomycin therapy was associated with higher rates of clinical failure compared with non-vancomycin anti-methicillin-resistant Staphylococcus aureus therapy (NVAMT) in outpatient parenteral antimicrobial therapy (OPAT).

Methods

This was a retrospective, single center cohort study including patients who received ≥7 days of OPAT with vancomycin, ceftaroline, or daptomycin from January 1, 2009 through March 31, 2016 at the VA Saint Louis Healthcare System. The primary outcome was clinical failure, defined as a composite of acute kidney injury (AKI), creatinine phosphokinase elevations ≥ 500 units/L, adverse drug events necessitating a change in therapy, readmission due to recurrence of infection, or reinitiation of antibiotics after discontinuation. Secondary outcomes were the individual components of the composite primary outcome. Multivariate logistic regression was used to evaluate independent risk factors for clinical failure. Factors evaluated for inclusion in the multivariate model were age >65 at initiation, creatinine clearance >50 mL/minute, length of therapy >28 days, concomitant antibiotic therapy, comorbid disease states, and vancomycin therapy.

Results

A total of 125 patients were included in the analysis – 72 receiving vancomycin and 53 receiving NVAMT. Baseline characteristics between groups were similar, except patients in the NVAMT group had a greater mean serum creatinine and a higher rate of CKD at baseline; 1.53 vs 1.23 (P = 0.032) and 35.9% vs. 19.4% (P = 0.04) respectively. Forty-three percent (31/72) of patients receiving vancomycin achieved clinical failure compared with 54.7% (29/53) of NVAMT patients (P = 0.197). Of the secondary outcomes analyzed, only readmission due to recurrence was significant between groups (vancomycin vs. NVAMT) – 13.8% vs. 30.2% (P = 0.026). In the univariate model only the choice of vancomycin met pre-defined criteria (P < 0.2) for inclusion in the multivariate model. In the multivariate analysis the choice of vancomycin was not found to be significant (0.71 (95% CI 0.33–1.52), P = 0.37).

Conclusion

Vancomycin was not associated with an increased risk of clinical failure when compared with NVAMT in patients receiving OPAT.

Disclosures

All authors: No reported disclosures.
Patient Self-Referral to Infectious Diseases Clinic: You Don’t Always Get What You Want, But Hopefully What You Need
Authors: Holman Katherine , Wolske Eric , Nance Demeatrice , Olender Jeff , Englund Kristin , Gordon Steven
Published: October 2017

Background

Patients call into the departments at the Cleveland Clinic Foundation (CCF) to request appointments directly for all specialties. The Infectious Diseases (ID) department chose to evaluate these self-referred patients being seen in our clinic due to (1) limited outpatient clinic appointment availability and (2) patients’ perception of need may not align with the subspecialty care provided.

Methods

In spring 2016, all self-referred patients requesting an outpatient ID evaluation were screened by the ID Access Plus program. Patients were called by administrative staff with a request for records from a licensed practitioner, and when received, were reviewed within 72 hours of receipt by a staff ID physician. Requests were either (1) accepted for appointment, (2) declined, or (3) referred to a more appropriate department within the CCF system. Patients who were declined appointments were informed by an administrator via telephone call. All patients were also informed of the ability for urgent referrals to be accepted with an MD to MD discussion.

Results

During a 12-month period a total of 1000 referrals were processed through the ID Access Plus program: 25% were declined for appointments; 45% were tabled as requested records were not received; and 30% had appointments scheduled. The most common patient reported reasons for self-referral to ID clinic were “Lyme disease” (10%) and “parasites” (4%). The “no-show” rate for scheduled self-referred patients was <5%. The median wait period for a new patient ID appointment in the department declined from over 40 days to < 10 days.

Conclusion

A system of prescreening patients self-referred to ID, requiring a review of medical records by ID clinicians, resulted in improved access for patients.

Disclosures

All authors: No reported disclosures.
Follow-up Appointment Adherence of Outpatient Parenteral Antimicrobial Therapy (OPAT) Patients
Authors: Lall Ambika , Hu Angela , Allison Geneve
Published: October 2017

Background

Outpatient parenteral antibiotic therapy (OPAT) is a safe and effective care delivery system that allows patients to receive intravenous (IV) antibiotic therapy outside of the hospital. OPAT patients require frequent follow-up appointments for clinical and laboratory monitoring of common adverse outcomes of any IV antibiotic administration such as line infections, adverse drug events, and reinfection. Despite the known importance of clinical monitoring, patient factors that influence adherence to OPAT appointments are unknown. The objective of this study was to identify factors that influence adherence to OPAT appointments, in order to improve the OPAT program and make adherence easier for patients if possible.

Methods

80 patients undergoing OPAT between December 2014 and January 2016 were interviewed via telephone regarding the following: reasons for not showing up to appointments, when the first follow up appointment was scheduled, whether they received appointment reminders, transit time, and whether they had to make special arrangements to attend their appointments.

Results

Adherence to follow-up appointments was high (83.8%). 52.5% of initial follow-up appointments were made while patients were still in the hospital. 92% of patients received at least one reminder in the form of a letter (32%), call to cell phone (21%), call to landline (22%), email (17%), or other (1%). Participants mostly cited either transportation (23.4%) or other (30.4%), specifically not feeling well, and work as the reason for missing an appointment.

Conclusion

The majority of patients attended all appointments, and of those, almost all received an appointment reminder, suggesting this is an important factor contributing to appointment adherence. These data reveal some of the barriers some patients face. Future studies can examine whether decreased appointment adherence leads to worse clinical outcomes.

Disclosures

G. Allison, Merck: Grant Investigator and Speaker’s Bureau, Grant recipient and Salary
Risk Factors for Readmission in Patients with Outpatient Parenteral Antimicrobial Therapy
Authors: Huang Victoria , Lerner Polina , Ruhe Jorg , Fedorenko Marianna
Published: October 2017

Background

Outpatient parenteral antimicrobial therapy (OPAT) is a practical and effective way of delivering antimicrobial therapy, but may be associated with significant risk for hospital readmission. This study aimed to elucidate risk factors related to 30-day readmissions in patients who were discharged with OPAT at Mount Sinai Beth Israel (MSBI).

Methods

This IRB approved retrospective cohort study included patients who were at least 18 years or older, admitted to MSBI from August 2015 to March 2016, and discharged to receive OPAT. Subjects were identified using the vascular access team’s monthly reports of peripherally inserted central catheter (PICC) and midline insertion; there was no standardized OPAT program at MSBI. Patients with intravenous antibiotics prescribed for chronic suppression or planned readmission within 30 days were excluded. Information on baseline demographic, clinical, and treatment parameters were collected. The main outcome was readmission to the hospital within 30 days from previous hospital discharge. Univariate and logistic regression analyses were performed to determine predictors of 30-day readmission.

Results

There were a total of 200 patients included in the analysis; the median age was 60 years, 66% were male, and the median Charlson score was 2. Diabetes, peripheral vascular disease, and chronic obstructive pulmonary disease were the most common comorbidities. A total of 155 (78%) patients received a PICC line; the remainder was discharged with a midline. The most common medications prescribed for OPAT included cephalosporins (41%), vancomycin (31%), carbapenems (23%), and penicillins (16%). A total of 42 patients (21%) were readmitted within 30 days after previous discharge. Independent predictors of readmission on logistic regression analyses were (P < 0.05): discharge to a skilled nursing facility or subacute rehabilitation center, diabetes without end-organ damage, and PICC line usage.

Conclusion

Readmissions are common in patients discharged with OPAT. Recognizing predictors of readmission may help determine strategies to optimize care.

Disclosures

All authors: No reported disclosures.
Characterization of Readmissions Among Patients Enrolled in an Outpatient Parenteral Antimicrobial Therapy (OPAT) Program Over a 2-Year Period at UNC Medical Center
Authors: Nwankwo Onyeka , Eichholz Anh , Chundi Vahini , Kinlaw Alan , Medlin Tenesha , Fletcher Lisa , Kufel Wesley , Farel Claire , Marx Ashley
Published: October 2017

Background

The UNC Medical Center OPAT program was started in 2015 to provide multidisciplinary management of medically complex patients referred by the infectious diseases (ID) inpatient services and discharged on parenteral antimicrobials. A primary aim of the program is to avert avoidable readmissions during OPAT therapy through protocolized laboratory monitoring, case review and streamlined access to ID urgent care services.

Methods

We abstracted electronic health records for the first 250 patients enrolled in the OPAT program. 223 patients with sufficient recorded data for entire OPAT course were included. All-cause readmission events during OPAT therapy were collected, and cause for readmission was adjudicated by a multidisciplinary committee.

Results

Of the 223 patients, 62% were male with median age 53 years (20–88). 39 (17%) experienced a readmission (Table 1). Most readmissions occurred among patients not seen in our OPAT urgent care for the admitting complaint. 57 patients (26%) experienced at least one adverse drug reaction (ADR), e.g., laboratory abnormality, rash, or diarrhea; 7 of these required readmission. ADR was the most common reason for ID urgent care visit. Almost half of readmissions were unrelated to OPAT therapy or OPAT-related diagnosis. Less than 10% of OPAT patients utilized ID urgent care services; none of these visits resulted in readmission.

Conclusion

Our OPAT program represents a medically complex cohort that may be at higher risk of readmission at baseline. The availability of providers and pharmacists for urgent care services is effective in avoiding readmission for OPAT-related causes. Future interventions to address common causes of readmission include expanded access to urgent care servvices and close interval follow-up after discharge for particularly high-risk patients.

Disclosures

All authors: No reported disclosures.
Experience with High Dose Once-daily Vancomycin for Patients with Skin and Soft-tissue infections in an Ambulatory Setting
Authors: Wong Maggie , Chapman Michael G , Malhotra Sangita , Mirzanejad Yazdan , Deans Gregory D
Published: October 2017

Background

Intravenous (IV) vancomycin is commonly used to treat MRSA (methicillin-resistant Staphylococcus aureus) infections and is typically dosed at 15 mg/kg every 12 hours. Pharmacokinetic studies, animal models, and limited human study suggest that once-daily high dose (30 mg/kg) vancomycin is similar in efficacy for certain types of infection in the hospital setting, but there is little evidence for its use in outpatient antibiotic therapy (OPAT).

We have used a high dose vancomycin regimen for MRSA skin and soft-tissue infections (SSTI) since 2011. We describe our experience with this regimen in an ambulatory setting supervised by Infectious Diseases (ID) physicians and evaluate its efficacy and safety.

Methods

This retrospective observational study included patients treated with vancomycin for SSTI from Jan 1, 2014 to July 31, 2015. Exclusion criteria included noncompliance with treatment. Patients with initial renal impairment were also excluded as they would be given 15 mg/kg vancomycin daily. Patient demographics, response to vancomycin, duration of therapy, readmission to emergency department (ER), and side effects experienced by patients were collected. A successful outcome was defined as no further requirement for IV vancomycin on the last day of therapy with either oral step down therapy or no further antibiotic.

Results

407 charts were reviewed and 208 patients qualified for inclusion. The mean age of included patients was 38 years. Of the 208 patients, 31% were people who inject drugs, 39% had preceding SSTI in the 12 months prior, and 48% had been on antibiotics in the previous 8 weeks. Incision and drainage was done in 50% of the patients. There were 135 positive wound cultures, of which 58% grew MRSA. The average duration of treatment was 4.7 days.

A successful outcome was achieved in 162 patients (79%). Side effects including red man syndrome and phlebitis were seen in 19 patients (9.3%). 42 patients (20.5%) were readmitted to ER within 30 days of initial referral, and 18 of those were related to the original infections.

Conclusion

High dose (30 mg/kg) once-daily vancomycin for SSTI was effective and safe when used for select patients under the supervision of ID physicians in an ambulatory setting.

Disclosures

All authors: No reported disclosures.