bluuebunny/crossref_metadata_2025 huggingface dataset:
183. Management of Left Ventricular Assist Device Infections at a Large Academic Medical Center
Authors: Green Bliss , Roshdy Danya , Revollo Jane , Gajurel Kiran , CyrilleSuperville Nicole , Skipper Eric
Published: December 2021

Background

Left ventricular assist device infections (LVADIs) contribute significantly to morbidity and mortality. The lack of evidenced-based treatment recommendations results in substantial variability in clinical practice. The purpose of this study was to evaluate the management of LVADIs at our institution to better assess practice patterns and standardize treatment decisions.

Methods

This was a retrospective study including adults diagnosed with an initial LVADI from January 1, 2013 to July 1, 2019. Exclusion criteria included concomitant non-LVADI, patients with other mechanical circulatory systems, or pregnancy. Pertinent patient, LVAD, infection, management, and clinical outcome data was collected and described with descriptive statistics.

Results

A total of 49 patients were included, 37 of which had at least one recurrence, resulting in 57 recurrent and 106 total LVADIs. The majority of LVADIs were driveline infections (DLIs) (92%). There was an increase in the incidence of deep DLIs (35% vs. 10%) and bloodstream infections (26% vs. 4%) amongst recurrent vs. initial LVADIs. Staphylococcus aureus (51%) and nosocomial gram-negatives (20%) were the most common causative pathogens. Surgical interventions were common (55%). LVADIs treated predominately with oral antibiotics (54%) or IV antibiotics (46%) received a median duration of therapy of 31 and 35 days, respectively. Antibiotic regimens included anti-methicillin-resistant S.aureus coverage and anti-pseudomonal coverage in 49% and 22% of total cases, respectively. Suppressive antibiotics were commonly prescribed (54%). LVADI-related readmission (69%) and recurrence (76%) within one year of initial LVADI was frequent. Recurrent LVADI occurred regardless of receiving suppressive therapy in 60% of total recurrent cases.

Conclusion

This study offers unique insight into initial vs. recurrent LVADIs as well as infection characteristics and clinical outcomes at a large academic medical center. Future studies with additional focus on risk factors for recurrence would be beneficial for drawing conclusions on the efficacy of current practices and shaping future treatment guidelines.

Disclosures

All Authors: No reported disclosures
184. Staphylococcus aureus Bacteremia Management and Outcomes Following Infectious Disease Consult Over Time at a Tertiary Care Center in Canada
Authors: McAllister Mark , Chen Justin , Smith Stephanie , King Arienne , Dingle Tanis C , Mansour Sarah
Published: December 2021

Background

Staphylococcus aureus bacteremia (SAB) is associated with high morbidity and mortality. Infectious disease consultation (IDC) is associated with increased adherence to guideline management and improved patient outcomes. We describe the IDC rate over time and impact of IDC on the management and outcomes of patients with SAB.

Methods

This retrospective chart review includes adult patients (≥ 18 years) hospitalized at the University of Alberta Hospital, Edmonton, Canada who had at least 1 blood culture growing Staphylococcus aureus during two time periods (A: Jan 2010 to Dec 2012; B: Jan to Oct 2020). Patients who died or were made palliative within 48hrs following bacteremia were excluded. Descriptive statistics were used to compare appropriateness of SAB management and outcomes in patients receiving IDC and those who did not (NIDC).

Results

325 patients in period A and 129 in period B were included. Baseline demographics were similar. IDC rate increased from 63% to 88% (p< 0.001) between the study periods. IDC was associated with increased odds of receiving an echocardiogram (OR=3.56, 95% CI 2.22 – 5.57; OR=20.4, 95% 4.13 – 110.6, p< 0.001) and appropriate duration of antimicrobial therapy (OR=6.74, 95% 3.93 – 11.54; OR=43.2, 95% 5.72 – 529.5, p< 0.001) between study periods. Mean length of stay decreased in patients receiving IDC (44.8 vs 28.1 days, p=0.005) and increased in NIDC patients (19.9 vs 28.7 days, p=0.216). IDC was associated with lower 30-day mortality in period A (OR=3.53, 95% 1.95 – 6.36), however this association was not observed in period B (OR=1.43, 95% 0.40 – 5.56). There was a trend towards decreased odds of mortality in patients receiving early IDC (≤2 days from bacteremia, n=65) compared to late IDC (≥3 days from bacteremia, n=45) (OR=2.59, 95% 0.95 – 7.10, p=0.077).

Conclusion

Our centre’s IDC rate for SAB increased over time without specific intervention. IDC increased the odds of appropriate SAB management and was associated with decreased length of stay in period B. IDC was associated with lower 30-day mortality in period A and trended towards lower mortality in period B. Specifically, early IDC decreased odds of 30-day mortality compared to late IDC. These results suggest that routine early IDC be part of SAB management.

Disclosures

All Authors: No reported disclosures
186. Evaluating Clinical Outcomes for Treatment of Staphylococcal Bloodstream Infection in Patients with Febrile Neutropenia
Authors: Aleissa Muneerah M , Gonzalez-Bocco Isabel H , Kubiak David W , Zekery-Saad Sara , Signorelli Jessie , Hammond Sarah P , Manne-Goehler Jennifer , Marty Francisco M
Published: December 2021

Background

Staphylococcus aureus bloodstream infections (BSIs) in patients with febrile neutropenia (FN) is associated with a mortality rate of up to 49%. For documented infections in patients with FN, guidelines recommend narrowing therapy once susceptibilities result and fever has resolved. Although anti-staphylococcal beta-lactams are the mainstay of treatment for Methicillin-Susceptible and Penicillin-Susceptible Staphylococcus aureus (MSSA and PSSA) BSIs, some clinicians opt to continue broad antibiotics against Pseudomonas during FN. Studies evaluating treatment modalities and outcomes of MSSA and PSSA BSI in patients with FN are lacking.

Methods

We conducted a retrospective cohort study of adult patients with MSSA or PSSA BSI who received antibiotics for the treatment of FN (absolute neutrophil count < 500 cells/L and temperature > 100.4F) at Brigham and Women’s Hospital and Dana-Farber Cancer Institute from 1/2010 to 4/2021. Patients who received < 72-h of antibiotics were excluded. The primary outcome was composite clinical failure (60-day all-cause mortality and/or 60-day BSI recurrence). Other outcomes included inpatient mortality, 60-day readmission, 60-day infection outcomes, incidence of acute kidney injury and hepatotoxicity. Data was analyzed using Chi-Square test or Fisher’s Exact test.

Results

Among 108 patients who met our criteria, 58% were male, median age was 57 years (IQR 44, 66), 94% had a hematologic malignancy, 4% had a solid tumor, and 2% had both. A total of 41 (38%) received combination therapy with broad spectrum and anti-staphylococcal beta-lactam, 48 (44%) received broad spectrum beta-lactam followed by anti-staphylococcal beta-lactam after neutrophil recovery, and 19 (18%) were narrowed to an anti-staphylococcal beta-lactam prior to resolution of neutropenia. Clinical failure was similar across all treatment arms (34% for combination therapy, 25% for broad spectrum beta-lactam, and 37% for anti-staphylococcal beta-lactam) (Table).

Table. Outcomes

Conclusion

De-escalation to an anti-staphylococcal beta-lactam prior to neutrophil recovery in FN patients with MSSA or PSSA BSIs did not result in significantly higher clinical failures. Further prospective studies are needed to support antimicrobial stewardship initiatives in oncology patients.

Disclosures

All Authors: No reported disclosures
187. Vancomycin Plus Ceftaroline Salvage Therapy for Persistent Methicillin-Resistant Staphylococcus aureus Bacteremia
Authors: Kufel Wesley D , Parsels Katie A , Steele Jeffrey , Seabury Robert , Paolino Kristopher M , Thomas Stephen J
Published: December 2021

Background

The preferred antibiotic salvage regimen for persistent methicillin-resistant Staphylococcus aureus bacteremia (pMRSAB) is unclear. Vancomycin plus ceftaroline (V/C) has demonstrated potent in vitro synergistic activity against MRSA; however, clinical data is limited. Thus, we sought to evaluate V/C salvage therapy for pMRSAB.

Methods

This was a single-center, retrospective cohort study of patients with MRSAB who received V/C salvage therapy between 1/1/2016-3/10/2021. Adult patients were included if blood cultures (BC) were positive for MRSA for ≥ 72 hours, received anti-MRSA monotherapy initially, and subsequently received V/C ≥ 24 hours. Patients were excluded if they received other anti-MRSA antibiotics within 72 hours of V/C initiation. The primary outcome was time to BC clearance following V/C initiation. Secondary outcomes included 90-day all-cause mortality, microbiological cure, 90-day MRSAB recurrence, and length of stay (LOS). Microbiological cure was defined as BC clearance.

Results

Of 178 patients identified, 20 were evaluated after inclusion and exclusion criteria were applied. Mean (SD) age and Pitt Bacteremia score were 38.5 (14.5) years and 4.2 (3.1), respectively. Most patients were male (70%), intravenous drug users (65%), and admitted to the intensive care unit (65%). The most common source was intravenous drug use (55%) and the majority had infective endocarditis (70%). All patients received infectious disease consultation and median (IQR) vancomycin AUC:MIC was 527 (454, 611). Source control, if possible, was obtained in most patients (55%). Median (IQR) time to bloodstream clearance from first positive BC and from when ceftaroline was initiated was 9.7 (8.4, 10.2) and 2.4 (1.5, 3.1) days, respectively. 90-day all-cause mortality, microbiological cure, and 90-day MRSAB recurrence occurred in 35%, 95%, and 5% of patients, respectively. Median (IQR) LOS was 25 (14.5, 32.0) days.

Conclusion

To our knowledge, this is the largest cohort to evaluate V/C for pMRSAB. Patients were medically complex; however, median time to MRSAB clearance following ceftaroline initiation was < 2.5 days and microbiological cure was obtained in nearly all patients. V/C may represent a potential salvage regimen for pMRSAB.

Disclosures

Wesley D. Kufel, PharmD, Melinta (Research Grant or Support)Merck (Research Grant or Support)Theratechnologies, Inc. (Advisor or Review Panel member) Jeffrey Steele, Pharm.D., Paratek Pharmaceuticals (Advisor or Review Panel member)
188. Outcomes After Implementing the OPTIONS-DC Multidisciplinary Care Conference for Patients with Substance Use Disorders and Severe Bacterial Infections
Authors: Schneider Brenton J , Streifel Amber C , Varley Cara D , Conte Michael , Sikka Monica K
Published: December 2021

Background

Hospitalizations for patients with severe bacterial infections (SBI) and substance use disorders (SUDs) are increasing. To address the unique treatment challenges for these patients and balance appropriate medical therapy with patient goals, we implemented the OPTIONS-DC, a structured multidisciplinary discharge planning conference. All patients with SBI and SUD at our institution qualify for an OPTIONS-DC.

Methods

We performed a retrospective case-control study to evaluate differences and describe outcomes in patients who received an OPTIONS-DC compared to those who did not. Admissions were included if the patient was diagnosed with a SUD, a SBI requiring at least 2 weeks of antibiotics, consultation by infectious diseases and addiction medicine, and who were admitted between February 2018 and March 2020 (following implementation of OPTIONS-DC conferences). Patients were excluded for infected prosthetic material, pregnancy, or non-bacterial infection.

Results

173 admissions qualified for inclusion and 73 had at least one OPTIONS-DC. Unstable housing and psychiatric disease were common (table 1). Opioid and methamphetamine use disorders were most common and almost all SUDs were severe. Patients who received an OPTIONS-DC had less medical comorbidities, less unstable housing, and were more likely to have an opioid use disorder, use more than one substance, start MAT while inpatient, and have vertebral osteomyelitis or epidural abscess (table 2). Patients who had a conference had similar proportions of unexpected discharges (13.7% vs 17%), but a higher proportion of treatment completion (83.6% vs 69%), more days of antibiotic therapy remaining after discharge (13.9 vs 9.8 days), were more likely to discharge to an outpatient setting with family or medical support (30% vs 9%), and more likely to complete their antibiotic course with a long-acting injectable (27.4% vs 9%)(table 3).

Conclusion

Not all eligible patients received an OPTIONS-DC and there were significant differences in substances used, housing status and type of infections between those groups. Descriptive data suggest that OPTIONS-DC may reduce the duration of inpatient antibiotic treatment and increase likelihood of completion of antibiotic therapy, however this requires further study.

Disclosures

Amber C. Streifel, PharmD, BCPS, Melinta (Advisor or Review Panel member) Monica K. Sikka, MD, FG2 (Scientific Research Study Investigator)
189. Bacteremia among COVID-19 and Non-Covid-19 Patients Admitted in the ICU
Authors: chra paraskeui , Gavrielatou Evdokia , Temperikidis prodromos , Tsimaras Michalis , magira eleni
Published: December 2021

Background

The aim of this work were to investigate the rate and aetiology of bloodstream infection collected from COVID and non-COVID patients admitted in the ICU

Methods

A retrospective cohort study was conducted on PCR Covid-19 positive patients admitted in the ICU from 20th March to 30th April 2020. Corresponding data from the same period in 2019 collected of all consecutive patients admitted in the same ICU were retrospectively reviewed for the presence of microbiologically documented bloodstream infections at least 8 hours after admission. All patients in the cohort study were on mechanical ventilation, or at some point during their ICU admission required mechanical ventilation.

Results

We identified a total of 19 (38%) BSIs in the COVID-19 group and 10 (12%) BSI in the non-COVID-19 group (p=0,8). COVID-19 patients had an increased probability to develop ICU-BSI, at a median of 8 days of ICU admission as opposed to 6 in the non-COVID-19 group. Patients were comparable in terms of age, and APACHE II score. Out of 19 BSI CoVID-19 patients, 14 (73%) were male vs 5 (50%) in the non-CoVID-19 BSI patients (p=0.0007). Of all BSI-CoVID-19 patients, 7 cases (37%), 3 (16%), and 3(16%) had underlying diseases such as hypertension, diabetes, and obesity vs 1(9%), 0(0%), and 0 (0%) in the BSI-non CoVID-19 patients statistically significant at p=0.004, p=0.05, and p=0.05, respectively. ICU-acquired BSIs were mostly due to multi-drug-resistant pathogens. Clinical outcomes were statistically significantly different between patients with CoVid-19 BSI 7(37% ) and 2(20%)in BSI- non-CoVID-19 pneumonia (p=0.02).

Conclusion

Our findings emphasize that although the incidence of BSI in CoVID-19 positive ICU admitted patients slightly increased their impact on overall outcome was significantly worse. Consequently, it is important to pay attention to bacterial superinfections in critical patients positive for COVID-19.

Disclosures

All Authors: No reported disclosures
190. Outcomes of Early Ceftaroline-based Combination Therapy for Methicillin-resistant Staphylococcus aureus Bacteremia
Authors: Dolan Mackenzie , Shah Megan , Platts-Mills James A , Elliott Zachary , Madden Gregory , Eby Joshua
Published: December 2021

Background

Monotherapy with vancomycin (VAN) or daptomycin (DAP) remains the guideline-driven standard of care for methicillin-resistant Staphylococcus aureus bacteremia (MRSA-B) despite concerns regarding efficacy. While combination therapy is often utilized as salvage treatment for persistent MRSA-B, growing data suggest a potential benefit of combination therapy with ceftaroline as initial therapy for MRSA-B. In light of these data, we updated practice guidance at our institution for management of MRSA-B in March 2020 to favor initial combination therapy with ceftaroline. Herein, we present an assessment of outcomes of patients with MRSA-B initiated on early combination therapy.

Methods

This was a single-center, retrospective, cohort study of adult patients admitted to the University of Virginia with MRSA-B between July 1, 2018 and February 28, 2021. Patients were considered to have received combination therapy if they received VAN or DAP plus ceftaroline (CPT) within 5 days of index blood culture, and monotherapy if during that period they received VAN and/or DAP alone. The primary outcome was a composite of persistent bacteremia, 30-day all-cause mortality, and 30-day bacteremia recurrence. Time to microbiological cure and safety outcomes were also assessed. A propensity score-weighted logistic regression was conducted. A post-hoc analysis of the primary composite outcome was performed in which patients were only deemed to have received combination therapy if it was started within 72 hours.

Results

Of 94 patients included, 57 received monotherapy (55 VAN, 2 DAP) and 37 received combination therapy with CPT (30 VAN, 7 DAP). There was no difference between groups for the primary composite outcome in the primary analysis (OR 2.7, 95% CI 0.95-7.72) or the post-hoc analysis (OR 2.37, 95% CI 0.68-8.22). Time to microbiological cure was not different between groups (mean difference 1.47, 95% CI 0.20-2.74). Safety outcomes were similar.

Conclusion

In this retrospective study, there was no clear benefit or harm of early initiation of combination therapy for MRSA-B. Additional study of initial combination therapy with ceftaroline is warranted given the small number of subjects in the study presented.

Disclosures

All Authors: No reported disclosures
191. Oral Antibiotic Step-Down Therapy for Non-Staphylococcal Gram-Positive Bloodstream Infections
Authors: Gandhi Kelvin , Wrzesinski Magdalena , Bunnell Kristen , Long Ashley , Hutzley Vanessa , Hamilton Rachel , Sundsbak John , Gibble Allison
Published: December 2021

Background

Bloodstream infections are traditionally treated with intravenous (IV) antimicrobial therapy, which may increase length of stay and healthcare costs. The purpose of this study is to evaluate if oral antibiotic step-down therapy for non-staphylococcal gram-positive bloodstream infections (GP-BSIs) is non-inferior to IV antibiotics.

Methods

This single-center, retrospective cohort study included patients with a non-Staphylococcus aureus, non-Staphylococcus lugdunensis GP-BSI from January 2017 to December 2019. Patients were excluded if they fit any of the following criteria: organism identified as contaminant, polymicrobial BSI, recurrent BSI within the past 90 days, or receipt of an effective antibiotic for a duration longer than what is indicated for BSI treatment. Patients were categorized into those who received an IV antibiotic for the total duration of therapy and those who received an oral step-down antibiotic for at least one-third of the treatment course. The primary composite outcome was the incidence of 90-day clinical failure consisting of 90-day all-cause mortality, change in therapy due to inadequate clinical response, and 90-day BSI recurrence. The secondary outcomes included the individual components of the primary composite outcome, line-related complications, and hospital length of stay. Bivariate analysis was conducted to assess for predictors of 90-day clinical failure.

Results

A total of 308 patients were included (oral group, n=94; IV group, n=214). Pitt Bacteremia Scores were low overall, but higher in the IV group (0 vs 1, p=0.045). The oral group had a higher proportion of GP-BSI caused by streptococcal species (76% vs 61%, p< 0.001). The oral group had a lower incidence of 90-day clinical failure and was found to be noninferior to the IV group (9% vs 14%; mean difference -5%, 90% CI -12.7 to 2.6). The IV group had a longer hospital length of stay (4 vs 6 days, p< 0.001), however there were no other significant differences in secondary outcomes. Bivariate analysis found no significant predictors of 90-day clinical failure.

Conclusion

Oral antibiotic step-down therapy was found to be non-inferior to IV antibiotic therapy, and thus may be an alternative option for the treatment of non-staphylococcal GP-BSIs.

Disclosures

All Authors: No reported disclosures
193. Evaluation of Severity Scores in Patients with Methicillin-Susceptible Staphylococcus aureus Bloodstream Infections
Authors: Craig Alexandra , Wagner Jamie , Barber Katie
Published: December 2021

Background

Staphylococcus aureus bloodstream infections (BSIs) are associated with increased morbidity, mortality, and healthcare costs. Severity of illness scores help stratify critically ill patients and assist providers in making decisions. The quick Pitt (qPitt) score is a reliable predictor of mortality in patients with Gram-negative BSIs (AUROC 0.85); however, limited data exist for using the qPitt in methicillin-susceptible S. aureus (MSSA) BSIs.

Methods

This retrospective cohort evaluated patients with MSSA BSIs. The primary outcome was the discrimination of the qPitt in predicting hospital mortality compared to the Pitt bacteremia score (PBS). Secondary outcomes were clinical failure and the predictive discrimination of the qPitt score in comparison to other severity scoring modalities. Categorical data were analyzed using chi-square test or Fisher’s exact test. Continuous data were analyzed using Student’s t-test or Mann-Whitney U. Predictive discrimination was determined by the area under receiver operating characteristic curve.

Results

One hundred patients were included with the mean age of 52 years (p=0.84) and a BMI of 30 kg/m2. Males were predominant (70%). Mortality occurred in 13 patients who had more ICU admissions (92% vs. 37%; p< 0.01) and longer ICU LOS (10 vs. 5 days; p=0.03) despite similar baseline comorbidities. Time to definitive therapy was longer in the mortality group than non-mortality group (28 vs. 23 hours; p=0.79) though antimicrobial use did not differ. As outlined in Figure 1, the mortality group had higher severity of illness scores. The qPitt had a ROC of 0.83, indicating high discrimination. Overall, qPitt was found to be similarly predictive than PBS, equally as predictive as qSOFA, and more predictive than SIRS and APACHE II (Figure 1). Clinical failure occurred in 23% of patients; 54% of the mortality group experienced persistent BSI vs. 11% in the non-mortality group (p< 0.01), and 3% of the non-mortality group had recurrent infection (p=1.00).

Conclusion

Compared to previous studies on Gram-negative BSIs, the qPitt performed similarly in MSSA BSIs. The qPitt can be considered for use in predicting mortality for patients with MSSA BSIs; however, further studies are needed to confirm these results.

Disclosures

All Authors: No reported disclosures
194. Antimicrobial Susceptibility Data of Staphylococcus lugdunensis After the Implementation of Rapid Molecular Blood Culture Diagnostics (Verigene® Gram-Positive Blood Culture Nucleic Acid Test)
Authors: Constance Kristin , Hunt Alauna , Karimaghaei Sam , Chijioke Juliet , Chavez Violeta , Wanger Audrey , Masayuki Nigo
Published: December 2021

Background

S. lugdunensis is a coagulase negative staphylococci (CoNS) demonstrating high level pathogenicity. In contrast to other CoNS, S. lugdunensis (SL) remains susceptible to most antibiotics. Prior to the implementation of Verigene®, SL was identified by provider request only. We sought to describe the susceptibility data of SL isolated from blood culture after the implementation of multiplex PCR, as well as to determine the correlation of the mecA gene provided by Verigene® and oxacillin resistance.

Methods

Retrospective review of all blood culture isolates positive for SL from two major hospital systems, Memorial Hermann Hospital System (14 hospitals) and HarrisHealth System (two acute care hospitals) identified on Verigene® PCR. Multiple isolates detected from the same patients were excluded from this analysis. Memorial Hermann utilized Microscan®, and HarrisHealth utilized BD Phoenix® for susceptibility testing.

Results

Between 2017 – 2021, 157 patients were identified with SL positive blood cultures. Of them, 141 isolates had susceptibility data collected, which is summarized in table 1. Resistance rates were highest amongst clindamycin 97/141 (68.8 %) susceptible, erythromycin 98/141 (69.5%) susceptible, and oxacillin 120/141 (85.1%) susceptible. 127/141 (90.1%) of isolates were tested for mecA on Verigene®. 13 of 21 oxacillin resistant isolates were from pure culture, of these isolates, none had mecA detected.

Conclusion

In our study, clindamycin and erythromycin demonstrated similar susceptibility compared to prior studies in the literature, however oxacillin susceptibility rate was lower than expected at 85.1%, compared to 95.3% in a prior large-scale United States based study in 2017. Absence of mecA gene detection on multiplex PCR did not correlate with oxacillin susceptibility suggesting that oxacillin susceptibility cannot be accurately predicted by the use of multiplex PCR systems, such as Verigene®, as demonstrated in Table 2. Our study also suggested that increased prevalence of oxacillin resistant SL isolates may be emerging.

Disclosures

All Authors: No reported disclosures
197. A Predictive Model for the Prompt Identification of Suspected Sepsis Patients with High Death Risk
Authors: Vrandecic Erika , Oliveira Joel T , Couto Bráulio R G M
Published: December 2021

Background

How to improve the high mortality rate of sepsis? The prompt identification of at-risk patients, and the interdisciplinary sepsis treatment protocol implementation are interventions that can reverse such unacceptable outcome. The objective of our study is to summarize main results of the protocol for the management of sepsis and septic shock, implemented at Biocor Instituto, a general hospital in Belo Horizonte, a 3,000,000 inhabitants city from Brazil.

Methods

Prospective cohort study of patients with sepsis, evaluated between May/2018-Apr/2020. Univariate and multivariate analysis by logistic regression to identify risk factors for hospital death.

Results

Over 28 months, 220 patients were included in sepsis protocol: 121 hospital deaths, a crude mortality = 121/220 = 55% (95%C.I. = [48%;62%]). 136 patients (62%) came from the emergency room. In 97 cases (44%) it was possible to isolate 111 microorganisms, with a predominance of Klebsiella, E.coli, and S.aureus. 75% of the cases (165) had definition of APACHE, with the absolute majority of these (88%) having APACHE between 25 and 40. Most patients (52%) received antibiotic (ATB) in 15 minutes and only 4% received ATB after 60 minutes of waiting time. In 198 patients (90%) it was possible to identify the focus of sepsis, with a predominance of pulmonary (47%), urinary (21%) and abdominal (15%). Hospital mortality varied from 30 to 62%, when the focus was pulmonary (p-value = 0.045). In univariate analysis (Figure 1), pulmonary sepsis, creatinine, lactate, and APACHE were significantly associated with hospital death. The time for ATB administration was typically close to 20 minutes, and time to receive the therapeutic antibiotic were not associated with the patient’s death. By using the logistic model (Figure 2) to assign cases of predicted hospital death for probabilities >= 0.5 and controls for probabilities < 0.5, the prediction model had a sensitivity of 0.68 (0.59–0.76), a specificity of 0.58 (0.48–0.67), an area under the curve of the receiver operating characteristic curve of 0.75 (0.68–0.82). There was no significant difference between observed versus expected mortality by APACHE (Figure 3).

Figure 1. Univariate analysis to identify risk factors for hospital death.

Figure 2. Logistic model for predicting hospital death.

Figure 3. Observed X Expected/severity-adjusted mortality (APACHE).

Conclusion

The logistic model developed uses only creatinine and lactate data to predict suspected sepsis patients with high death risk.

Disclosures

All Authors: No reported disclosures
199. Prospective Observational Cohort Of Transition to Oral Antibiotics in Persons Who Inject Drugs with Invasive Infections
Authors: Lewis Sophia , Marks Laura , Stephen Liang , Nolan Nathan , Durkin Michael
Published: December 2021

Background

Persons who inject drugs (PWID) are at increased risk of invasive bacterial infections. Increasing data supports the efficacy of transition to oral antibiotic therapy to complete treatment of invasive bacterial infections including osteomyelitis and endocarditis. The aim of this study is to evaluate the impact of transition to oral antibiotics on a prospective observational cohort of PWID.

Methods

We prospectively analyzed PWID admitted 2/2020 - 2/2021 at Barnes-Jewish Hospital in St. Louis with osteomyelitis, endocarditis, epidural abscesses or septic arthritis. All patients were offered multidisciplinary support during their inpatient hospitalization including addiction medicine consultation and medications for opioid use disorder, if appropriate. Health coaches and case managers met with patients during their hospitalization and followed patients for up to 90 days after discharge. Patients were offered the option of transition to oral antibiotics if they were not able to complete recommended IV antibiotics. Patients discharged on oral antibiotics were offered post-discharge infectious diseases follow-up. Antibiotic adherence was documented by health coaches through phone out-reach. We collected data on demographics, comorbidities, microbiologic data, antibiotic selection, mortality and readmission rates. We compared 90-day readmission rates between PWID who completed IV antibiotics inpatient and those who discharged early with oral antibiotics.

Results

Of 166 PWID, 61 completed IV antibiotics inpatient (37%) while 105 were discharged with oral antibiotics (63%). Causative pathogens were not significantly different between inpatient IV vs oral antibiotics; MSSA (34.4% vs 35.2%, p= 0.92), MRSA (34.4% vs. 28.6%, p=0.43), or streptococcal species (26.6% vs. 24.8%, p=0.85). Of patients discharged on oral antibiotics 7.6% had documented non-adherence to therapy, 23% had unknown adherence and 67% had documented adherence. There was no significant difference in all-cause 90-day readmission rates (p=0.819) (Figure 1).

All-cause readmissions by antibiotic strategy

Conclusion

Oral antibiotic regimens provided similar efficacy to IV antibiotics in our prospective cohort analysis of PWID.

Disclosures

All Authors: No reported disclosures
202. The Impact and Safety of Discontinuing Routine Surveillance Blood Culture Monitoring in Allogeneic Hematopoietic Cell Transplant Recipients
Authors: Garner Will , Oleksiuk Louise-Marie , Malek Elisa , Reinecke Kristen , Dorritie Kathleen , Im Annie , Ito Sawa , Rothenberger Scott , Agha Mounzer , Haidar Ghady
Published: December 2021

Background

Bloodstream infections (BSI) cause significant morbidity and mortality after hematopoietic cell transplant recipients (HCT). Surveillance blood cultures (SBC) are commonly used to decrease the risk of developing BSI but prior data suggest limited clinical utility. At our center, SBC monitoring was discontinued on 12/1/2019. This is a single center study evaluating the impact and safety of discontinuing routine SBC monitoring.

Methods

Retrospective review of allogeneic hematopoietic cell transplant recipients (HCTR) seen before (12/1/2017 – 11/30/2019) and after (12/1/2019 - 12/1/2020) discontinuation of SBC. We evaluated utility of SBC and the impact of discontinuation of SBC on admissions, mortality, and other variables.

Results

One hundred thirty-six and 133 HCTR were followed before and after discontinuation of SBC, respectively. Median (range) ages were 58 (22-73) and 56 (19-73); 60 (44%) and 59 (44%) were female, respectively. The most common cancer was acute myelogenous leukemia (71 (52%) and 61 (46%)); 87 (64%) and 77 (58%) had graft-versus-host disease respectively. Pre-intervention, 1946 SBCs were drawn; 81/1946 (4.2%) were positive. Post-intervention, 29 SBC were drawn; 1/29 (3.4%) were positive. Of the 82 positive SBCs, 63 (77%) were skin flora, and 9 (11%) were gram negative rods. No cultures grew Staphylococcus aureus or fungi. Fifty-one (63%) of the positive SBC resulted in an admission; median (range) length of stay (LOS) was 3 days (1-11). Following discontinuation of SBC, median monthly blood culture-related admissions decreased from 3 (0-6) to 1 (0-3) shown in Figure 1. In the pre-intervention period, there were 2 BSI-related deaths, and 0 following cessation of SBCs.

Figure 1. Monthly Hospital Admissions for Positive Outpatient Blood Cultures

Conclusion

SBCs were infrequently positive and often resulted in unnecessary antibiotic use, admission, and clinical interventions. After SBC monitoring was discontinued, there was a decrease in hospital admissions and health care utilization for positive blood cultures drawn in the outpatient setting. This intervention did not negatively impact clinical outcomes, including BSI-related mortality. Discontinuation of SBC appears to be safe and results in a reduction in healthcare utilization. Centers performing SBC should consider eliminating this practice.

Disclosures

Ghady Haidar, MD, Karuys (Grant/Research Support)
203. Gardnerella vaginalis Bacteremia in Male Patients: A Case Series and Review of the Literature
Authors: Akamine Christine , Tavakoli-Tabasi Shahriar , Chou Andrew , Musher Daniel M
Published: December 2021

Background

Introduction: Gardnerella vaginalis is a colonizer of the female genitourinary tract and can cause serious morbidity as a pathogen. It is an uncommon cause of infection in men and bacteremia with this organism is rare. We describe two cases of G. vaginalis bacteremia in male patients. A literature search was performed for cases of G. vaginalis bacteremia in men. A total of 13 patients were identified and discussed.

Methods

Case 1: A 52-year-old man with diabetes and prior nephrolithiasis presented for dysuria, hematuria, and left sided flank pain. He was febrile and tachycardic with mild left costovertebral angle tenderness, leukocytosis and acute kidney injury. Urinalysis revealed pyuria. Computed tomography of the abdomen and pelvis showed pyelonephritis and a small calculus of the proximal left ureter. He was treated with ceftriaxone and then piperacillin-tazobactam. Aerobic culture of the urine yielded < 10,000 cfu/mL of mixed gram-positive flora. Blood cultures yielded G. vaginalis after 48 hours. He was treated with ciprofloxacin 500 mg orally twice daily for 7 total days and clinically recovered. Case 2: A 61-year-old man with alcohol use disorder and gout, presented with altered mental status. He had leukocytosis and acute kidney injury and was treated with vancomycin and cefepime with clinical improvement. Admission blood cultures demonstrated G. vaginalis in the anaerobic bottle of 1 of 2 cultures, reported 96 hours after collection. Urine culture was negative. The patient was treated with amoxicillin-clavulanate on discharge to complete a 14-day course with clinical resolution.

Results

see above

Gram stain of G. vaginalis on blood culture

Conclusion

Discussion: G. vaginalis is a facultative anaerobic gram-positive pleomorphic rod, which can be gram variable due to poor staining of the thin peptidoglycan cell wall. Isolation and identification are often delayed. Bacteremia in men is rare but nearly all have originated in the genitourinary tract. The most severe cases of G. vaginalis bacteremia implicate endocarditis, urethral stricture and an empyema as the sources. Collection of blood cultures and speciation are often delayed, ranging from 48 hours to 7 days. Selection and duration of treatment have ranged widely in previously reported cases, likely due to the lack of guidance regarding effective treatment.

Disclosures

Andrew Chou, MD, bluebird bio (Shareholder)
204. Clinical Outcomes with Ceftaroline Monotherapy versus Daptomycin-Ceftaroline Combination Therapy in the Treatment of Methicillin-Resistant Staphylococcus aureus Bacteremia
Authors: Andonie Gabriela , Hand Elizabeth O , Reveles Kelly R , Traugott Kristi A
Published: December 2021

Background

Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is associated with poor outcomes and increased mortality. Daptomycin (DAP) and ceftaroline (CPT) in combination has been explored as a potential treatment option and showed improved outcomes compared to vancomycin/standard therapy. CPT monotherapy has been evaluated as salvage therapy for MRSA bacteremia but, to our knowledge, not as a comparator to DAP-CPT combination therapy. The purpose of this study is to compare the clinical outcomes of DAP and CPT combination therapy to CPT monotherapy in the setting of MRSA bacteremia.

Methods

A retrospective chart review of adult patients (≥ 18 years of age) admitted to University Health from January 2017 to December 2020 with a diagnosis of MRSA bacteremia was performed. Patients received either CPT monotherapy or DAP-CPT combination therapy for a minimum of 48 hours during their course of therapy.

Results

Thirty-two patients met inclusion criteria and were evaluated. Primary source of infection was pulmonary in the CPT monotherapy group (n=7/24; 29.2%) and osteomyelitis in the DAP-CPT combination group (n= 4/8; 50.0%). Median duration of bacteremia was 8 days and 9 days in the CPT monotherapy and DAP-CPT combination group, respectively. Microbiological cure was achieved in 95.8% (n=23/24) of patients in the CPT monotherapy and 100% (n=8/8) of patients in the DAP-CPT combination group. Bacteremia relapse (30 day, p=0.62; 60 day, p=0.63), readmission rates (30 day, p=0.62; 60 day, p=0.63), and mortality rates (30 day, p=0.70; 90 day, p=0.85) were similar in both groups. There was no statistically significant difference in safety parameters, including incidence of acute kidney injury (p=1.00) and creatine kinase elevations (p=1.00). Bone marrow suppression after at least 72 hours of therapy, including anemia, leukopenia, and thrombocytopenia, was also not statistically significant between groups.

Conclusion

This study was unable to find a statistically significant difference in clinical outcomes between patients receiving CPT monotherapy or DAP-CPT combination therapy. A large prospective, randomized controlled trial to assess CPT monotherapy and DAP-CPT combination therapy for the treatment of persistent MRSA bacteremia is warranted.

Disclosures

All Authors: No reported disclosures
206. Clinical and Molecular Characteristics of Community-associated Staphylococcus aureus Bacteremia in Injection and Non-injection Drug Users at a New York City Medical Center
Authors: Shoucri Sherif , Gomez-Simmonds Angela , Lankarani Amir , Shi Qiuhu , Lowy Franklin D , Uhlemann Anne-Catrin
Published: December 2021

Background

The opioid epidemic has resulted in a dramatic resurgence of bacterial infections, most notably those due to Staphylococcus aureus (SA). We compared the demographic, clinical, and molecular factors of injection drug users (IDUs) and non-IDUs with SA bacteremia.

Methods

Patients with SA bacteremia were identified through a query of the electronic medical record EMR from January 2018 to December 2019 at a New York City medical center. All cases of community-associated (CA) SA bacteremia among adults with a history of active injection drug use were evaluated. Patients with positive SA blood cultures ≤ 72 hours of admission were considered CA. IDUs were identified with keyword searches and were deemed active if they had a history of use in the 12 months prior to admission. A randomly selected group of non-IDUs with CA SA bacteremia was used for comparison at a 4:1 ratio. Available SA isolates underwent Illumina whole genome sequencing (WGS). Using SRST2 multilocus sequence types (MLST), antimicrobial resistance genes and putative virulence factors were extracted.

Results

From January 2018 to December 2019, 669 patients with SA bacteremia were identified. 29 patients were active IDUs. Compared to 112 randomly selected non-IDUs, IDUs were significantly younger and more likely to be unstably housed (Table 1). Rates of MRSA were similar in IDUs (31%) and non-IDUs (32.1%). Endocarditis (44.8% vs 11.6%) and abscesses (27.6% vs 8.9%) were diagnosed more frequently in IDUs than non-IDUs. A positive hepatitis C antibody was strongly associated with SA bacteremia in IDUs (62.1% vs 6.3%, p< 0.001). WGS demonstrated comparable proportions of sequence types across IDUs and non-IDUs. ST8 accounted for the majority of infections in both groups (Table 2). MRSA bacteremia due to ST8 occurred in a higher proportion of IDUs (7/29, 24.1%) than non-IDUs (14/112, 12.5%).

Conclusion

IDUs with CA SA bacteremia have unique demographic and clinical features that differentiate them from non-IDUs. Endocarditis rates in IDUs are of particular concern. Use of these risk factors could allow hospitals to rapidly identify IDUs and offer them necessary medical and social services. WGS revealed a majority of MRSA bacteremia was due to one sequence type in IDUs (ST8). Further analysis of virulence genes in this cohort are ongoing.

Disclosures

Franklin D. Lowy, MD, GlaxoSmithKline (Advisor or Review Panel member)UpToDate (Other Financial or Material Support, Topic Writer and Editor) Anne-Catrin Uhlemann, MD, PhD, Merck (Grant/Research Support)
207. Ineffective Initial Antibiotics for Enteric Bacteremia: Does Every Hour Count with Rapid Diagnostics and Stewardship Intervention?
Authors: Box Maggie , Bagsic Samantha , Saiki Shaina
Published: December 2021

Background

It has been a long-standing practice to administer broad-spectrum antibiotics early for sepsis as each hour delay is associated with increase in mortality. With increasing rates of antibiotic resistance fueled by unnecessary use of antibiotics, it is delicate to balance the benefits vs consequences of empiric carbapenem therapy. With rapid molecular blood culture diagnostics available, identification of extended-spectrum beta-lactamase (ESBL) producing bacteremia can occur within hours and therapy optimized with active stewardship intervention. With rapid diagnostics, does each hour of ineffective antibiotic therapy really count?

Methods

This multicenter, retrospective, cohort study compared adult inpatients with E. coli bacteremia from a urinary source who received initial effective (EA) vs ineffective antibiotics (IA). The primary outcome was clinical treatment success at day 4. Secondary endpoints included length of stay (LOS), infection-related mortality, incidence of C. difficile infection (CDI), and subgroup analysis of outcomes by ESBL (CTX-M type) vs non-ESBL. Associations with endpoints were assessed using Fisher’s Exact tests using R v. 4.0.3.

Results

Clinical treatment success at day 4 was higher in the EA (n = 488) vs IA (n = 119) groups (93.7% vs 86.6%, p = 0.01) and median LOS was shorter (5 [IQR 4-6] vs 5 [IQR 5-7] days, p < 0.01). There were no differences in infection-related mortality (3.1% vs 3.4%, p = 0.8), 30-day mortality (2.5% vs 2.5%, p > 0.9), or incidence of CDI (1.8% vs 0%, p = 0.3) in the EA vs IA groups, respectively. For patients on IA < 24 h vs > 24 h, there was no difference in clinical improvement at day 4 (86.7% vs 90.5%, p > 0.9) nor 30-day mortality (2.4% vs 4.8%, p = 0.4). Clinical treatment success at day 4 was higher among non-CTX-M (n = 476) vs CTX-M (n = 131) patients (93.9% vs 86.3%, p = 0.01) even among those that received initial EA (94.5% vs 83.3%, p = 0.02). Median LOS was also shorter in CTX-M vs non CTX-M (5 [IQR 4-6] vs 5 [IQR 4-8] days, p < 0.01).

Conclusion

There was no mortality difference among patients receiving initial EA vs IA for E. coli bacteremia with rapid molecular blood culture diagnostics with active stewardship. Therapy for patients on IE is rapidly corrected and stewardship programs can use this intervention to promote judicious use of carbapenems.

Disclosures

All Authors: No reported disclosures
208. Comparison of Bloodstream Infections in Hospitalized Patients Before and During the COVID-19 Surge in a Community Hospital in the South Bronx: An Observational Study
Authors: Afzal Afsheen , Gomez Edgar , Guttierrez Victor Perez , Mon Aye Myat , Sarmiento Carolina Moreira , Khalid Amna , Polishchuk svetlana , Al-Khateeb Mohannad Al-Khateeb , Yankulova Boyana , Yusuf Mubarak , De Castro Yinelka Silverio , Pillai Anjana , Venugopal Usha , Feinstein Addi , LaFortune Alexander , Sittler Daniel , Hennessey Karen , Menon Vidya
Published: December 2021

Background

There is a paucity of data of bloodstream infections (BSI) before and during the COVID-19 pandemic. The aim of our study was to compare the incidence and characteristics of blood stream infections (BSI) in hospitalized patients before and during the surge of COVID-19 pandemic in a community hospital in South Bronx.

Methods

This is a retrospective observational comparative study of adult hospitalized patients with BSI admitted before (Jan 1-Feb 28, 2020) and during COVID-19 surge (Mar 1- May 1,2020). The incidence of BSI, patient demographics, clinical and microbiological characteristics of infections including treatment and outcomes were compared.

Results

Of the 155 patients with BSI, 64 were before COVID and 91 were during the COVID surge (Table 1). Incidence of BSI was 5.84 before COVID and 6.57 during surge (p = 0.004). Majority of patients during COVID period had ARDS (39.6%), required mechanical ventilation (57%), inotropic support (46.2%), therapeutic anticoagulation (24.2%), proning (22%), rectal tube (28.6%), Tocilizumab (9.9%), and steroids (30.8%) in comparison to pre-COVID (Table 2). Days of antibiotic therapy prior to BSI was 5 days before COVID and 7 during COVID. Mortality was higher among patients with BSI admitted during COVID surge (41.8% vs. 14.1% p < 0.0001). Of 185 BSI events, 71 were Pre-COVID and 114 during surge. Primary BSI were predominant (72%) before COVID contrary to secondary BSI (46%) (CLABSI) during COVID. Time from admission to positive culture was 2.5 days during COVID compared to 0.9 pre-COVID. Majority of BSI during COVID period were monomicrobial (93%) and hospital acquired (50%) (p=0.001). Enterococcus (20.2%), E.coli (13.2%), and MSSA (12.3%) were predominant microbes causing BSI during COVID vs. MRSA (15.5%), Streptococci (15.5%), and S. pneumoniae (14.1%) before COVID (Figure 1). In multivariate logistic regression, Enterococcal coinfection was associated with COVID positivity (OR 2.685, p = 0.038), mechanical ventilation (OR 8.739, p = 0.002), and presence of COPD/Asthma (OR 2.823, p = 0.035).

Comparison of Microorganisms Isolated in the BSI

X-axis represents the total number of BSI events whereas the number at the end of each bar represents the percentage

Conclusion

Higher incidence of secondary BSI (CLABSI) due to Enterococcus spp. was observed during the surge of COVID-19 infection in the South Bronx. Breakdown of infection control measures during the COVID-19 pandemic could have been contributory.

Disclosures

All Authors: No reported disclosures