bluuebunny/crossref_metadata_2025 huggingface dataset:
903. Resensitization to β-Lactams in Enterococci Depends on Penicillin-Binding Protein (PBP) Mislocalization and Is Mediated by a Single Protein That Modulates Cell Membrane (CM) Adaptation to Daptomycin (DAP)
Authors: Khan Ayesha , Nguyen April , Panesso Diana , Vitrac Heidi , Miller William R , Tran Truc T , Shamoo Yousif , Arthur Michel , Arias Cesar A
Published: October 2019

Background

DAP disrupts bacterial CM by binding to septal anionic phospholipids (APLs). LiaX, an effector of the LiaFSR stress system, modulates DAP-R by diverting APLs away from the septum. Enterococci are intrinsically resistant to β-lactams due to the presence of PBPs (e.g., PBP5) with low affinity to these drugs. However, emergence of DAP-R leads to increased susceptibility to β-lactams, a phenomenon designated as the see-saw effect. Here, we dissect the molecular mechanism of this phenomenon.

Methods

We studied a clinical strain pair of DAP-S (S613) and DAP-R (R712) E. faecalis strains recovered from a patient before and after DAP therapy. We generated deletions of liaX and PBPs (ponA and pbp5) in DAP-susceptible (DAP-S) E. faecalis OG1RF and JH2-2. APLs and membrane structures were visualized with NAO and/or FM4-64. PBPs and LiaX localization were evaluated with bocillin-FL or immunofluorescence. PBP transcripts and PBP5 protein levels were measured by qRT-PCR or immunoblotting, respectively. β-Lactam binding affinity of PBPs was assessed by SDS-PAGE of bocillin-FL stained membranes and a LiaX–PBP5 interaction was evaluated by the bacterial two-hybrid (BACTH) system. MICs were determined via E-test.

Results

Deletion of liaX led to DAP-R and redistribution of APL microdomains (nonseptal foci with CM aberrations; Figure 1A) in all strains, with a marked decrease in ceftriaxone (CRO) MICs. Only PBP5 was essential for β-lactam resistance but not for DAP-R. DAP-R was associated with mislocalization of PBPs to the sites of CM aberrations (Figure 2). Notably, LiaX and PBP5 were localized to the septum in DAP-S strains but redistributed away from septal areas upon development of DAP-R (Figure 3). An interaction of LiaX and PBP5 was confirmed by the BACTH system. Mislocalized PBPs, most notably PonA and PBP5, had increased affinity for β-lactams in all DAP-R strains. The increased affinity of PBPs to β-lactams was not associated with increased transcripts or PBP5 levels.

Conclusion

LiaX regulates CM adaptation and cell wall synthesis via membrane remodeling and direct interactions with key PBPs. Changes in LiaX that cause DAP-R results in mislocalization of PBPs to nonseptal areas and likely increases access of β-lactam to the active site, explaining the see-saw effect.

Disclosures

All Authors: No reported Disclosures.
1831. Machine Learning Approaches to Predicting Resistance in Pseudomonas aeruginosa
Authors: Greenberg David E , Kim Jiwoong , Zhan Xiaowei , Shelburne Samuel A , Shelburne Samuel A , Aitken Samuel L , Aitken Samuel L
Published: October 2019

Background

Multi-drug-resistant (MDR) P. aeruginosa (PA) infections continue to cause significant morbidity and mortality in various patient groups including those with malignancies. Predicting antimicrobial resistance (AMR) from whole-genome sequencing data if done rapidly, could aid in providing optimal care to patients.

Methods

To better understand the connections between DNA variation and phenotypic AMR in PA, we developed a new algorithm, variant mapping and prediction of antibiotic resistance (VAMPr), to build association and machine learning prediction models of AMR based on publicly available whole-genome sequencing and antibiotic susceptibility testing (AST) data. A validation cohort of contemporary PA bloodstream isolates was sequenced and AST was performed. Accuracy of predicting AMR for various PA–drug combinations was calculated.

Results

VAMPr was built from 3,393 bacterial isolates (83 PA isolates included) from 9 species that contained AST data for 29 antibiotics. 14,615 variant genotypes were identified within the dataset and 93 association and prediction models were built. 120 PA bloodstream isolates from cancer patients were included for analysis in the validation cohort. ~15% of isolates were carbapenem resistant and ~20% were quinolone resistant. For drug-isolate combinations where >100 isolates were available, machine-learning prediction accuracies ranged from 75.6% (PA and ceftazidime; 90/119 correctly predicted) to 98.1% (PA and amikacin; 105/107 correctly predicted). Machine learning accurately identified known variants that strongly predicted resistance to various antibiotic classes. Examples included specific gyrA mutations (T83I; P < 0.00001) and quinolone resistance.

Conclusion

Machine learning predicted AMR in P. aeruginosa across a number of antibiotics with high accuracy. Given the genomic heterogeneity of PA, increased genomic data for this pathogen will aid in further improving prediction accuracy across all antibiotic classes.

Disclosures

Samuel L. Aitken, PharmD, Melinta Therapeutoics: Grant/Research Support, Research Grant; Merck, Sharpe, and Dohme: Advisory Board; Shionogi: Advisory Board
1948. Impact of @WuidQ, a Free Open-access Medical Education Twitter Resource, on Infectious Disease Learning and Teaching
Authors: Escota Gerome V , George Ige , Abdoler Emily
Published: October 2019

Background

Free open-access medical education (FOAMed) is increasingly used as a web-based platform for learning/teaching, with Twitter emerging as a leading medium. However, FOAMed resources in infectious disease (ID) are limited. @WuidQ is the first FOAMed Twitter resource to provide review of ID through board-style, multiple-choice questions (MCQs). We describe its creation and impact to date.

Methods

Two ID faculties created MCQs, vetting them based on accuracy and clarity. MCQs were posted a few times weekly using Twitter’s poll function, with answers tweeted as “threads” linked to the MCQ (Figure 1). We reviewed followers’ profiles to determine their demographics. We also used Twitter metrics to assess participation, including the average number of poll voters, impression (number of tweet views), engagement (number of retweets, clicks), and engagement rate (engagement divided by impression). In order to gauge follower satisfaction, we posted an anonymous online survey that included both close-ended questions utilizing Likert scale and open-ended questions.

Results

Over its first 9 months, @WuidQ reached 1,339 followers (56% based in the United States, 47% healthcare professionals, 13% students/trainees) (Table 1). During this time, it earned 582,400 impressions and had a 3.1% mean engagement rate. We posted 103 MCQs, with a mean of 143 (range 70–316) poll voters per MCQ. Forty-five followers completed the survey; of whom, 49% were ID doctors, 22% were ID fellows, and 11% were medical residents. The vast majority of respondents were between 25 and 44 years of age. Almost all agreed that @WuidQ is engaging and accessible (Figure 2). The majority of respondents who were taking exams agreed that @WuidQ helped them with test preparation. Of those who indicated teaching was a relevant practice, 80% said it helped them teach ID. Lack of time to read and learners’ short attention span were the most common learning barriers addressed by @WuidQ (Figure 4).

Conclusion

@WuidQ is an effective Twitter resource for ID education, filling a gap in FOAMed resources for ID. It has a global reach and caters to learners/teachers across a spectrum of training levels. Given its success, more work is warranted to understand practices for engaging learners and teachers in FOAMed for ID.

Disclosures

All Authors: No reported Disclosures.
1950. Intentional Interprofessional Experiential Education in an HIV/Infectious Diseases Clinic
Authors: Ann Justo Julie , Derrick Caroline , Baliko Beverly , Blake Elizabeth W , Brandon Bookstaver P , Crawford Kimberly , Custer Sabra S , Dunn Brianne L , Grubbs James , Harrison Adrena , Phaup Tricia , Ray Donna D , Reitmeier Melissa C , Sanasi Kamla , Shah Ansal , Ahuja Divya
Published: October 2019

Background

Experiential education opportunities, such as interprofessional practice, are currently limited in HIV care. This intentional interprofessional experiential education (IPEE) offering aimed to improve healthcare student attitudes, perceptions, and skills regarding interprofessional practice and HIV care.

Methods

An interprofessional team of faculty and clinicians designed a 2-week rotation, with each offering consisting of 6–9 students from 4 professions (medicine, nursing, pharmacy, social work). This intentional IPEE was delivered at a single ambulatory care infectious diseases clinic in Columbia, SC. It included time in clinic with providers from varying professions, didactic lectures, a peer health advocate session, and a team capstone project (i.e., simulated, then actual student team visit with an HIV-infected patient, plus note documentation/team presentation). Twelve offerings occurred from October 2016 to February 2019. Anonymous pre- and post-IPEE surveys were provided to each student at baseline and directly after to assess attitudes, perceptions, and skills regarding interprofessional practice and HIV care. Wilcoxon signed-rank tests were used to compare pre- vs. post-survey items. Multivariable logistic regression was used to evaluate predictors for interest in HIV as a specialty.

Results

Of 87 students, 84 (97%) completed both surveys (21 medicine, 25 nursing, 19 pharmacy, 19 social work). Attitudes toward healthcare teams significantly improved in 7/11 items (all P-values ≤ 0.019), teamwork perceptions improved in 5/8 items (P ≤ 0.017), and self-perceived team skills improved in all 6 items (P < 0.001). Students rated provider time in clinic as most valuable (mean 4.6, median 5 on 5-point Likert scale). Following the IPEE, the proportion of students interested in HIV care increased from 53% to 67% (P = 0.07). After adjusting for program year and profession, interest in HIV at baseline was a significant predictor of interest in HIV post-IPEE (aOR 8.2, 95% CI 2.6–25.5).

Conclusion

Short-term, intentional IPEE can positively impact student attitudes, perceptions, and skills regarding interprofessional practice and HIV care. Clinical educators should incorporate intentional HIV IPEE in healthcare curricula.

Disclosures

All Authors: No reported Disclosures.
2846. Perirectal Samples for Analysis of the Gut Microbiota as a Predictive Tool for Multi-drug-Resistant Organism (MDRO) Acquisition in Nursing Facility (NF) Patients
Authors: Wang Joyce , Cassone Marco , Gibson Kristen , Lansing Bonnie , Mody Lona , Snitkin Evan , Rao Krishna
Published: October 2019

Background

Most research examining the association between gut microbiota disruption and MDRO acquisition has been done in acute care settings. Obtaining stool samples in older NF adults is challenging. We hypothesized that perirectal samples can be used as a proxy of the gut microbiota. This prospective cohort study investigated the association between perirectal swab-derived gut microbiota features in newly admitted NF patients and the acquisition of vancomycin-resistant Enterococcus and/or resistant Gram-negative bacteria (rGNB) within 14 days.

Methods

Patients were recruited at 6 MI NFs from September 2016 to October 2018 as part of a larger NIH-funded trial. Colonization status was determined by culture swabs collected from multiple body sites at enrollment, d7, and d14. Our analysis focused on patients with no MDRO at baseline, a perirectal swab collected at baseline, and at least one follow-up visit. The V4 region of the 16S rRNA gene was sequenced from samples and processed with the mothur bioinformatics pipeline. Sequences typically associated with the skin microbiota were removed. The primary outcome was any MDRO acquisition. Exposures of interest included patient and microbiota characteristics. The Microbiome Health Index (MHI) was used to assess microbiota health. An MHI of 0 indicates a balanced abundance between taxa associated with protection and dysbiosis; an MHI above/below 0 suggests better/poorer health, respectively (Figure 1).

Results

Among 60 eligible patients (Table 1), 18 (30%) acquired MDROs within 14 days of enrollment (3 VRE, 13 rGNB, 2 both). The baseline microbiota features differed significantly in those who acquired a new MDRO. Of the major 8 phyla found across samples, patients who acquired an MDRO were depleted in the number of phyla present (4.4 ± 1.1 vs. 5 ± 1.1; P = 0.08) (Figure 2). The log-transformed relative abundance of Enterococcus was enriched in patients who acquired an MDRO (−0.7 ± 3.41) compared with those who did not (−4.2 ± 4.8; P < 0.01) (Figure 3). An MHI below 0 was predictive of MDRO acquisition after adjusting for catheter use within 30 days before baseline (adjusted OR 4.9; 95% CI 1.1–21.1).

Conclusion

Microbiota metrics calculated from perirectal samples are predictive of MDRO acquisition. The clinical utility of perirectal samples warrants further assessment.

Disclosures

All Authors: No reported Disclosures.
2891. Trends in Inpatient Antibiotic Use in US Hospitals, 2012–2017
Authors: Baggs James , Kazakova Sophia , Hatfield Kelly M , Reddy Sujan , Srinivasan Arjun , Hicks Lauri , Neuhauser Melinda M , Jernigan John A
Published: October 2019

Background

The National Action Plan for Combating Antibiotic-resistant Bacteria calls for monitoring inpatient antibiotic use to inform stewardship efforts. We estimated national trends in inpatient antibiotic usage from 2012 to 2017 in a large cohort of US hospitals.

Methods

We utilized the Premier Healthcare Database, containing detailed administrative records available by census region, including inpatient drug utilization data based on billing records, for all patients discharged from a convenience sample of over 700 US hospitals annually, approximately 20% of US inpatient discharges. We retrospectively estimated days of therapy (DOT)/1,000 patient-days (PDs) by year overall and by antibiotic class. To examine trends over time, we created multivariable models adjusting for hospital-specific location of antibiotic use (ICU vs. other) and hospital-specific summary measures including average patient age, average co-morbidity score, case mix index, number of hospital beds, teaching status, urban/rural location, US census division, proportion of discharges with a surgical diagnosis-related code, and proportion of PDs with an infectious disease primary ICD-9/10-CM discharge code. Estimates and models were weighted to be nationally representative using projected weights from the database.

Results

58% of patients had at least one antibiotic DOT, and the overall DOT for all hospitals was 810 DOT/1,000 PDs (interquartile range 701 to 913 DOT/1,000 PDs). Glycopeptides and third-/fourth-generation cephalosporins were the most common antibiotic classes (Figure 1). Overall antibiotic DOT did not change significantly over time, P = 0.9133. However, class-specific DOT varied with large decreases in fluoroquinolones from 2012 to 2017 (55% decrease, P < 0.0001), and large increases in third-/fourth-generation cephalosporins and tetracyclines (32% and 49% increase, respectively, P < 0.0001) (Figure 2). Overall antibiotic DOT significantly varied among US census divisions (Figure 3).

Conclusion

Estimated overall inpatient antibiotic DOT did not change in US hospitals from 2012 to 2017, but there were significant class-specific changes. The large decrease in fluoroquinolone use may reflect increased awareness of adverse events.

Disclosures

All Authors: No reported Disclosures.
2895. Threats to Successful Elimination of Viral Hepatitis: Results from the Nationwide Treatment as Prevention for Hepatitis C (TraP HepC) Program in Iceland
Authors: Gottfredsson Magnus , Runarsdottir Valgerdur , Love Thorvardur J , Fridriksdottir Ragnheidur H , Sigurdardottir Bryndis , Johannsson Birgir , Bjornsson Einar S , Bergmann Ottar M , Love Arthur , Sigmundsdottir Gudrun , Tyrfingsson Thorarinn , Olafsson Sigurdur
Published: October 2019

Background

The main driver of the Hepatitis C virus (HCV) epidemic in most western countries is injection drug use (IDU) among people who inject drugs (PWID). Iceland has provided unrestricted access to direct-acting antiviral agents (DAA) to all HCV-infected patients in the country covered by national health insurance, by a program entitled Treatment as Prevention for Hepatitis C (TraP HepC) from 2016 and is on track to become among the first to achieve the WHO goals of eliminating HCV as a public health threat.

Methods

We analyzed data regarding testing for HCV, incidence of IDU, prevalence of HCV viremia among PWID, drug use in the community and trends in homelessness prior to and during the first 24 months of TraP HepC to monitor outcomes and identify new or persistent challenges.

Results

Intensity of nationwide testing for HCV increased by 22% in 2016, 60% in 2017, and 81% in 2018 compared with previous years (P < 0.001). During 2016–2018 the incidence of new injection drug use, as surveyed among those admitted for addiction treatment increased by 48%. The total number of PWID admitted annually with HCV viremia however remained relatively stable during the entire period (2010–2018). The prevalence of HCV viremia among people recently injecting drugs admitted for addiction treatment however dropped from 48.7% to 16.2% in 2017, and to 10.2% in 2018 (P < 0.001). Analysis of data regarding stimulant use, as measured by drug levels in wastewater shows an almost threefold increase of amphetamine and an eightfold increase in cocaine levels during 2016–2018 compared with 2015. Concurrently, the number of homeless has doubled. Two years into TraP HepC > 80% of the estimated total HCV-infected population were started on their first course of DAAs. By intention to treat analysis, the cure rate was 92.4% among patients without history of IDU in the past 6 months, compared with 82.9% among active IDU (P = 0.0006); those with history of recent IDU were more likely to discontinue (P < 0.0001). Homelessness carried the highest relative risk (RR) of treatment failure (RR = 2.4, P = 0.008), mostly due to discontinuation.

Conclusion

Iceland is on track to eliminate HCV, but challenges such as increasing drug use in the community and homelessness need to continuously monitored and addressed; they may jeopardize the success of elimination efforts.

Disclosures

All Authors: No reported Disclosures.
2901. Measles in the United States During the Postelimination Era, 2017–2019
Authors: Gastanaduy Paul , Lee Adria D , Redd Susan B , Clemmons Nakia S , Patel Manisha , Patel Manisha
Published: October 2019

Background

Measles, a vaccine-preventable viral illness that can cause serious complications, was declared eliminated from the United States in 2000 because of a successful measles vaccination program. Recent years have seen an increase in the number of measles cases and outbreaks. We summarized measles epidemiology in the United States during 2017–2019.

Methods

We reviewed US national surveillance data on confirmed measles cases reported to the Centers for Disease Control and Prevention during January 1, 2017–April 26, 2019. We describe the demographic characteristics, vaccination status, and disease epidemiology of measles cases.

Results

During 2017–April 2019, 1,196 measles cases were reported in 37 US States and Washington DC, including 146 (12%) importations from 37 countries; 108 (74%) of importations were US residents returning from travel abroad, of which 60 (56%) were unvaccinated and 31 (29%) had unknown vaccinations status. Among 1,148 cases who were US-residents, the highest incidence of measles was among infants and children aged 6–11 and 12–15 months (112 cases [19 cases/million person-years] and 106 cases [27 cases/million person-years], respectively). Among US-resident cases, 846 (74%) were unvaccinated and 163 (14%) had unknown vaccination status; 777 (68%) were considered to have preventable measles (i.e., were eligible for vaccination but unvaccinated). Among the 1,196 cases, 85 were single cases, and the remaining 1,111 represented 19 two-case chains and 34 outbreaks of 3 or more cases linked epidemiologically; the median outbreak size and duration was 6 cases (range, 3 to 452 cases) and 19.5 days (range, 5 to 205 days). A total of 934 (78%) of the 1196 cases and 13 (38%) of the 34 outbreaks occurred in under-immunized close-knit communities; eight outbreaks are ongoing.

Conclusion

Outbreaks of measles in the United States result from recurring measles introductions and subsequent measles spread, especially in under-immunized close-knit communities. To sustain measles elimination, it will be necessary to maintain timely routine high coverage with MMR vaccine, improve implementation of pretravel recommendations to minimize importations, and close immunity gaps in communities of US residents who remain unvaccinated.

Disclosures

All Authors: No reported Disclosures.
1142. Implementation and Impact of a Tracheitis Diagnosis and Management Guideline in a Pediatric Intensive Care Unit
Authors: Iacono Denise , Tanweer Ammara , Sweberg Todd , Hagmann Stefan , Chua Vincent , DeCelie-Germana Joan , Tsirilakis Kalliopi
Published: October 2019

Background

Ventilator-associated tracheitis (VAT) is a common intensive-care unit entity considered in febrile patients with endotracheal intubation or with tracheostomy. Prospective-Audit-And-Feedback activities had identified an overall increased and high inter-provider-variability in the use of antibiotics for VAT. By developing a VAT-specific guideline, we intended primarily to decrease the amount of respiratory fluid cultures (RFCx) submitted, and secondly decrease the overall antibiotic use (AU) in the PICU, while not increasing the incidence of ventilator-associated events (VAE).

Methods

A multidisciplinary team developed a guideline for patients with fever or change in baseline respiratory support with endotracheal intubation or with tracheostomy who had no radiographic evidence of pneumonia consisting of three parts: A) When to send an RFCx, B) Diagnosis of VAT, C) Antibiotic management of VAT: A) To obtain a RFCx, patient needed to have an abnormal white cell count (WBC) ( <5 K/uL or >14.5 K/uL) AND purulent or increased amount of endotracheal secretions PLUS either abnormal body temperature (T <36°C or ≥38.3°C) or change in baseline respiratory support. B) A diagnosis of VAT is allowed if RFCx shows Gram stain with ≥+3 WBC AND ≥+3 bacteria. C) Empiric antibiotic treatment with antipseudomonal activity (informed by previous RFCx if exist) to be started after RFCx have been obtained. Reassessment and possible modification at 48H based on final RFCx results. Duration of AU to be limited to 5 days. Guideline education was completed at multiple PICU meetings from September 2017 through June 2018. Manual audits were used to analyze adherence to the guideline. Data on RFCx order utilization, ventilator days, and AU from January 2017 to December 2018 were analyzed.

Results

Since the initiation of the guideline, we observed a downward trend of RFCx orders (Fig1.A) with an average decrease of 19% after guideline implementation. The overall AU (Fig1.B) in PICU decreased by an average of 24% while the incidence of VAE has remained stable.

Conclusion

Efforts to standardize diagnosis and treatment of VAT in patients with endotracheal intubation or tracheostomy resulted in a decreased number of RFCx, and reduced overall AU without increasing the risk of VAE.

Disclosures

All authors: No reported disclosures.
1147. Improving Accessibility and Antibiotic Prescribing with an Enhanced Digital Antibiogram
Authors: Yarahuan Julia K , Hunter Brandon , Nadar Devin , Gujral Nitin , Fine Andrew M , Flett Kelly
Published: October 2019

Background

Institutional antibiograms play a key role in antimicrobial stewardship and may provide a venue for clinical decision support. Our institution recently transitioned our paper antibiogram to an enhanced digital antibiogram with antibiotic recommendations for common pediatric infections. The objectives of this study were (1) to improve the accessibility of our institutional antibiogram through a digital platform and (2) to improve trainee confidence when selecting empiric antibiotics by integrating clinical decision support.

Methods

The digital antibiogram was developed and evaluated at a tertiary children’s hospital. The tool was developed iteratively over one year by our innovation and digital health accelerator with recommendations for empiric antibiotic selection provided by experts in pediatric infectious diseases (see Figure 1 for example). Usability pilot testing was performed with a group of ordering providers and the tool was released internally in October 2018. A paired pre- and post- implementation survey evaluated residents’ perceptions of the accessibility of the paper vs. digital antibiogram and their confidence when selecting empiric antibiotics. Data were analyzed by Fisher exact test.

Results

During the 3 months after release, the digital antibiogram was accessed 1014 times with similar proportions of views for susceptibility data, dosing, and empiric antibiotic recommendations. Of the 31 pediatric residents who responded to both pre- and post- implementation surveys, only 59% had access to a copy of the paper antibiogram. Following release of the digital antibiogram, residents referred to antibiotic susceptibilities more frequently (P < 0.05, Figure 2) and were more frequently more confident when selecting the correct antibiotic dose (P < 0.01, Figure 3). See Figure 4 for dosing recommendation example.

Conclusion

Providing antibiotic susceptibility and dosing recommendations digitally improved accessibility and resident confidence during antibiotic prescribing. Our digital tool provides a successful platform for displaying the antibiotic data and recommendations that enable appropriate antibiotic use.

Disclosures

All authors: No reported disclosures.
1179. Rates and Causative Pathogens of Device-Associated Bloodstream and Urinary Tract Infections Attributed to Solid-Organ Transplant Units, 2015–2017
Authors: Chea Nora , Zhou Liang , Magill Shelley , Guh Alice , Edwards Jonathan R , Epstein Lauren , Sapiano Matthew
Published: October 2019

Background

Due to complex invasive medical procedures and compromised immunity, solid-organ transplant (SOT) patients are at high risk for infections. However, whether SOT patients are at higher risk than other hospitalized patients for selected healthcare-associated infections (HAI), such as central line-associated bloodstream infections (CLABSI) or catheter-associated urinary tract infections (CAUTI), or for infections with antimicrobial-resistant (AR) pathogens, is not well described. We analyzed data reported to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) from inpatient SOT units and compared CLABSI and CAUTI rates and AR in hospitals with both SOT and non-SOT units.

Methods

We analyzed 2015–2017 CLABSI and CAUTI data reported to NHSN from hospitals with adult or pediatric inpatient SOT units. We calculated CLABSI and CAUTI incidence rates per 1,000 central-line days (CLD) and urinary catheter days (UCD), respectively, and compared rates, pathogen distributions, and AR among events attributed to three unit types: (1) SOT units; (2) adult, pediatric, and neonatal critical care units; and (3) adult and pediatric medical, surgical, and combined medical-surgical wards. We compared proportions using χ 2 tests and determined statistical significance at P ≤ 0.05.

Results

CLABSI and CAUTI rates in SOT units were lower than rates in critical care units, but higher than rates in wards (table). Although the most common CLABSI and CAUTI pathogens were similar in all three unit types, the prevalence of individual pathogens differed (figure). Among CLABSI pathogens, Enterococcus faecium, Escherichia coli, and Klebsiella pneumoniae or oxytoca were significantly more prevalent in SOT compared with critical care units. Vancomycin resistance among CLABSI E. faecium was significantly lower (71.4% vs. 87.5%) and fluoroquinolone resistance among CAUTI E. coli was significantly higher (49.3% vs. 32.5%) in SOT compared with critical care units.

Conclusion

SOT units have lower CLABSI and CAUTI rates compared with critical care units. Differences in pathogens and AR among device-associated HAIs in SOT units should be considered when implementing infection prevention and treatment policies.

Disclosures

All authors: No reported disclosures.
1189. Effectiveness of Multimodal Intervention Strategies to Improve Hand Hygiene Compliance at an Academic Medical Center
Authors: Navalkele Bhagyashri D , Tate Myrtle , Dunaway Jeff , Fletcher Sheila , Inman Barbara , Hankins Phillip , Hung Leroy , Guy Rachel , Parham Jason
Published: October 2019

Background

Since the early 19th century, hand hygiene (HH) has been recognized as the most important factor in preventing healthcare-associated infections (HAI). Still, improving HH compliance is a major hurdle for most healthcare facilities. Our study objective was to evaluate effectiveness of bundled intervention tools in increasing hand hygiene (HH) compliance.

Methods

The study was performed at the University of Mississippi Medical Center located in Jackson, MS. A multidisciplinary HH team was established in January 2016. Team members included infection prevention, nurse managers, physician, resident, housekeeping, process engineers, and ancillary staff. Hand hygiene compliance was determined based on room entry and exit observations. Intervention strategies were based on Joint Commission Center’s Targeted Solutions Tool (TST) to identify barriers in HH compliance, standardization of data collection, covert observer training and Just-in-time training of providers. Other strategies implemented included education and feedback, rewards and recognition, and system change measures during the 3-year study period (timeline in Table 1). Hand hygiene compliance was calculated based on number of compliance opportunities/total number of observations. One-way Analysis of Variance (ANOVA) was performed to analyze HH data. We did not assess the concomitant reduction in HAI rates as simultaneous HAI prevention strategies confounded analysis.

Results

Based on total 95,491 observations performed (January 2016- December 2018), there was a statistically significant improvement in HH compliance during the study period from 66.5% in 2016 to 73% in 2017 and 79.5% in 2018 (P = 0.04).

Conclusion

At our institution, we observed a 56% improvement in hand hygiene compliance over 36-months timeframe. Multidisciplinary team involvement and multimodal intervention strategies play crucial role in improvement and sustainment of HH compliance.

Disclosures

All authors: No reported disclosures.
1205. Healthcare Personnel Knowledge, Attitudes, and Beliefs Towards Infection Prevention and Control Measures for Protection from Respiratory Infections
Authors: Bessesen Mary T , Radonovich Lewis , Rattigan Susan M , Cummings Derek , Rodriguez-Barradas Maria C , Simberkoff Michael , Gibert Cynthia L , Nyquist Ann-Christine , Price Connie S , Gorse Geoffrey , Gaydos Charlotte A , Perl Trish M , Perl Trish M
Published: October 2019

Background

Healthcare personnel (HCP) knowledge and attitudes toward Infection Prevention and Control (IPC) measures are important determinants of practices that can protect them from acquisition of infectious diseases from patients. We aimed to describe HCP knowledge and attitudes concerning IPC measures over time in the context of a clinical trial.

Methods

ResPECT was a multi-center, multi-season cluster randomized clinical trial designed to compare the effectiveness of medical masks (MM) and N95 respirators (N95) for preventing acute respiratory illnesses in HCP employed in outpatient clinical settings. At the beginning of each respiratory virus season, participants completed a survey instrument to measure IPC knowledge. At the beginning and end of each season participants completed a survey to assess attitudes and beliefs about IPC measures, especially MM and N95.

Results

A pre-study and post-study survey pair was available for 88.1% of participant seasons. There were no significant differences in demographic variables or job assignment between survey respondents and nonrespondents for each participant season. Participants correctly identified 59.8% to 63.4% of IPC measures that should be used by HCP when exposed to patients with symptoms of acute respiratory illness, or at high risk of infection. There was modest improvement in the knowledge score over time among providers who participated for multiple years in the study. In the first pre-study survey of IPC attitudes and beliefs, 88.5% and 87.9% of participants identified at least one reason to avoid using either MM and N95, respectively (Figure 1). At the post-season survey, the proportion of participants reporting a reason to avoid MM fell to 39.6% (IRR for pre- vs. post-season 0.15, 95% CI 0.13–0.17) and 53.6% reported a reason to avoid N95 (IRR 0.57, 95% CI 0.51–0.66).

Conclusion

HCPknowledge of IPC precautions was poor, suggesting a need for better IPC education and accountability in the outpatient setting. When given incentives to comply with processes toward which they had negative attitudes at baseline, HCP realized that medical masks and N95 respirators were comfortable enough to wear for patient encounters and interfered with their work processes less than expected.

Disclosures

Trish M. Perl, MD; MSc, 7–11: Advisory Board; medimmune: Research Grant.
1210. Investigating a Staphylococcus aureus Outbreak in a Clinical Intensive Care Unit: What Is the Role of the Mobile Phones?
Authors: Espinoza Evelyn Patricia Sanchez , Neto Lauro Viera Perdigão , dos Santos Sania Alves , Risek Camila , Franco Maria Renata Gomes , Martins Roberta C R , Pereira Gaspar C O , Guimaraes Thais , Boszczowski Icaro , Rossi Flavia , Pinheiro Freire Maristela , Sara Shafferman Levin Anna , Costa Silvia F
Published: October 2019

Background

Staphylococcus aureus (Sa) outbreaks are serious infections that if not controlled in time can be life-threating. The aim of this study was to describe the investigation and control of a Sa outbreak in an intensive care unit including analysis of MP.

Methods

During a microbiological research of MP conducted in December 2018 in a clinical intensive care unit (ICU) of a tertiary university hospital two patients had an MRSA infection. Since this unit had not reported MRSA infections during the last year it was recognized as an outbreak. The CDC criteria was applied to define MRSA colonization and infection. Hand hygiene (HH) adhesion in this unit was 47%,it has 9 beds and 30 Healthcare professionals (HP). Nasal Swab (NS) of all the HPs and of the patients in the same unit as well. HP’s MP were also analyzed. The samples were subjected to MALDI-TOF (Biomerieux), phenotypical tests, PCR for detection of gene coA and mecA, pulsed-field gel electrophoresis (PFGE), and whole-genome sequence to access resistance, virulence profile and sequence type. Feedback of microbiology results, reinforcement of hand hygiene and MP cleaning was discussed with the unit staff.

Results

A total of 34 samples were collected, 25 were Sa, 13 NS of all HPs and patients, 7 from the MPs and 3 from HPs hands. During the time of the outbreak 5 patients were in the unit.

Patients with infection by MRSA (n = 2), had Methicillin-susceptible Sa in their NSs. Another patient that from the same unit had a MRSA in the NS that when submitted to PFGE was seen to be closely related with the MRSA that originated the outbreak. The patients isolates were assigned to different STs and they had more virulent and resistance genes in comparison with two samples of MPs. The Sa recovered from the MPs belonged to the same ST, same resistance gene and same virulent genes. Figure 1, Table1. Since the feedback to the unit no cases of MRSA have been reported in the last 4 months.

Conclusion

The outbreak was controlled using simply measures (feedback, reinforcement of HH and MP cleaning). The ST398 from the MP has already been described in outbreaks in literature. It seems that MP can be a reservoir for Sa There was more than one Sa lineage in the ICU. Our findings highlighted the need of rethinking the MP cleaning policy in our hospital.

Disclosures

All authors: No reported disclosures.
1264. Characterization of HIV-Positive Patients with Low-Level Viremia in a Community HIV Clinic Between 2014 and 2018
Authors: Sanchez Eduardo , Borgman Jody , Joffe Aviva , Holdsworth Catherine
Published: October 2019

Background

Low-level viremia (LLV) has been defined as an HIV RNA level detectable by newer generation viral load quantification assays but that is ≤200 copies/mL.Contributing factors may include intermittent low-level releases of virus from existing reservoirs, random laboratory variation and decreased ART adherence.

Methods

This retrospective chart review aimed to characterize patients who developed LLV in a community HIV clinic between 2014 and 2018. LLV was defined as two consecutive detectable HIV RNA measurements ≤200 copies/mL. Possible factors that could be associated with viral rebound (VR), defined as an HIV RNA >200 copies/mL, were evaluated by using multivariate logistic regression.

Results

Of a total of 666 patients, 111 met criteria for LLV. Seventy-seven were male and 34 were female. The majority were African American (85.6%) with Hispanic and white accounting for 5.4% each. Fifty-five percent were heterosexual and 31.5% were men that have sex with men. Analyzing CD4 counts at the moment or just prior to the development of LLV, 42 of them (37.8%) had a CD4 between 501 and 800 cells/mm3, 25 (22.5%) between 200 and 500 cells/mm3 and only 3.6% had CD4 counts <200 cells/mm3. The majority (60.3%) were on integrase inhibitors (INSTI). Of the 111 patients, only 59 of them had at least 1-year follow-up post LLV. Those who were followed for less than 12 months post-LLV were not included in the statistical analysis to try and find potential factors associated with VR post LLV. Twelve (20.3%) of the 59 developed VR. HIV RNA levels between 51 and 100 copies/mL and 101 and 200 copies/mL were associated with higher odds of VR (OR 3.77 95% CI 0.37–38.77, 3.09 95% CI 0.27–35.88, respectively). Patients with STIs, heterosexuals and those on INSTI were also associated with higher odds of VR (OR 1.48 95% CI 0.12–18.5, 3.13 95% CI 0.75–13.03 and 1.61 95% CI 0.35–7.38, respectively). These results did not achieve statistical significance.

Conclusion

This community HIV clinic has a low prevalence of LLV. Most of the patients did not develop VR. Although some clinical factors were found to be associated with viral rebound in patients with LLV, the associations did not achieve statistical significance. LLV is a phenomenon that requires further research, specifically regarding predictors of VR, particularly now in the INSTI era.

Disclosures

All authors: No reported disclosures.
1304. Pharmacist Impact on HIV Management in a Psychiatric Patient Population
Authors: Margulis Alice , Uhlyar Stepan , Chin-Beckford Nafeesa , Salazar Veronica , DeRonde Kailynn , Abbo Lilian , Vega Ana D
Published: October 2019

Background

Patients with mental illnesses are more than four times more likely to have human immunodeficiency virus (HIV) compared with the general population. HIV management can be especially challenging in these patients due to potential substance abuse, drug interactions, and nonadherence. The purpose of this study was to determine the impact of pharmacist management of antiretroviral (ARV) therapy in a psychiatric patient population.

Methods

This is an institutional review board-approved, single-center, retrospective study of patients admitted to a psychiatric hospital with an order for one or more ARV medication(s) between October 2016 and March 2017 (no pharmacist involvement), October 2017 and March 2018 (partial pharmacist involvement), and November 2018 and January 2019 (consistent pharmacist involvement). Patients were excluded if less than 18 years of age, pregnant, incarcerated, or taking ARV medication(s) for a non-HIV indication. The primary outcome was difference in appropriateness of ARV therapy prior to and during pharmacist involvement. Secondary outcomes were appropriateness of opportunistic infection (OI) prophylaxis and laboratory testing.

Results

A total of 37 patients were included per group. A greater number of appropriate ARV regimens were initiated with partial pharmacist involvement compared with no pharmacist involvement (62% vs. 32%, P = 0.0096), as well as with consistent pharmacist involvement compared with partial pharmacist involvement (84% vs. 62%, P = 0.0327). There was a trend toward increased HIV viral load draws with partial vs. no pharmacist involvement (54% vs. 43%, P = 0.24) and additionally with consistent vs. partial pharmacist involvement (62% vs. 54%, P = 0.32). With consistent pharmacist involvement, more patients had a resulted CD4 cell count (65%) than with both partial and no pharmacist involvement (57%). Of the patients requiring OI prophylaxis, appropriate prophylaxis was initiated in more patients with consistent pharmacist involvement (57%) than with partial pharmacist involvement (50%) or no pharmacist involvement (11%).

Conclusion

Pharmacist involvement in HIV management in a psychiatric patient population increased appropriateness of ARV therapy, laboratory testing, and OI prophylaxis.

Disclosures

All authors: No reported disclosures.
1323. Clinic-Level Factors Associated with Antiretroviral Prescription Rates
Authors: Hayes Craig P , D’Aquila Erica , Bertolino Daniel , Abraham Bisrat K
Published: October 2019

Background

Despite overall high antiretroviral (ARV) prescription (Rx) rates for the treatment of HIV in New York City (NYC), clinic-level Rx rates can vary greatly by clinic. Previous literature suggests reasons for deferring ARV Rx include patient readiness or comorbidities and provider biases. We investigated the impact of these and other factors on clinic-level ARV Rx rates within NYC.

Methods

Data were obtained from the 2016 HIV Clinic Survey which contained questions related to clinic capacity and other clinic and patient characteristics. Multivariate linear regression models were developed from literature sourced variables and manual stepwise selection. These models were evaluated for predictive strength based on their respective root mean square error (RMSE) and adjusted R-squared (AR2) values.

Results

Among the 104 HIV primary care clinics, representing the care of 49,654 people living with HIV (PLWH), ARV Rx rates ranged from 41.4% to 100.0% (IQR: 92.1%-99.6%). An increase in clinic-level ARV Rx rates was found to be significantly associated with an increase in clinic-level viral load suppression rates. In the stepwise multiple linear regression model (Table 1), decreases in ARV Rx rates were associated with several factors: (1) care delivered at three specific healthcare networks; (2) infrequently seeing patients with excessive alcohol use; (3) a high proportion of PLWH ages 24 and below; (4) a low proportion of the clinic population that were PLWH; (5) a low proportion of Hispanic/Latino patients; (6) and a high number of other medical services available on-site (P < 0.05). This model was found to have a 20.4% reduction in the RMSE and a 335.4% increase in the AR2 value when compared with the literature sourced model (Table 1), indicating greater predictive accuracy and greater explanation of the variability in clinic-level ARV rates.

Conclusion

ARV Rx rates were better predicted by the model adjusting for clinic-level factors previously unreported in the literature including network affiliations, the number of medical services provided, and the proportion of PLWH seen at the clinic. Given the role of ARVs in clinical outcomes, it is important to further explore and address how these clinic-level factors may support or obstruct the prescribing of ARVs in order to support the care of PLWH.

Disclosures

All authors: No reported disclosures.
1327. Correlates of Need for Ancillary Service Referrals Among Persons Receiving HIV Care in New York City: Findings From the Medical Monitoring Project
Authors: Navejas Michael , Raj Singh Shavvy , Huang Jamie , Udeagu Chi-Chi N
Published: October 2019

Background

Retention of people with HIV (PWH) in HIV care is essential for optimal health outcomes. Unmet needs for ancillary services, such as housing, food, transportation, or mental health services may pose barriers to sustained retention in HIV care.

Methods

A representative sample of people with HIV (PWH) aged ≥18 years and receiving HIV care in NYC between 2015 and 2016 was interviewed for the Medical Monitoring Project (MMP). Questions attempted to identify needs for ancillary services among participants. We explored correlates of expressed needs for ancillary services in the 12 months prior to the interview date.

Results

Of 654 PWH interviewed, 650 (99%) were current with HIV care. Of these, 323 (50%) expressed a need for ancillary services. Among the 323 PWH expressing needs, 209 (65%) were males, 163 (50%) were non-Hispanic blacks, 118 (37%) were Hispanic, and 111 (35%) were individuals identifying as gay (26%) or lesbian (9%).The median age was 50 [interquartile range (IQR) 40–58 years]. In the multivariate model, non-Hispanic blacks (OR: 2.5; 95% CI: 1.4, 4.6) and Hispanics (OR: 2.5; 95% CI: 1.4, 4.7) had higher odds than whites of expressing current needs for ancillary services. A higher need for ancillary services was expressed by PWH that were virally suppressed vs. not suppressed (OR: 1.7; 95% CI: 1.0, 3.0) and those with a history of injection drug use vs. those without (OR 2.2; 95% CI: 1.3, 3.7).

Conclusion

Half of the PWH in our sample expressed a current need for ancillary services despite being actively engaged in HIV. Providers should routinely screen their patients, especially non-Hispanic black and Hispanic patients and persons with substance use history, for unmet needs and proactively link them to social service providers in order to promote overall well-being and retention in HIV care.

Disclosures

All authors: No reported disclosures.