bluuebunny/crossref_metadata_2025 huggingface dataset:
1248. Implementing Infection Prevention and Control with Antimicrobial Stewardship in a Tertiary Care Hospital in India: An Interprofessional Education and Collaborative Practice Approach
Authors: Dr Raksha K , Anand Kukkamalla , Prakash Peralam Yegneswaran
Published: November 2023

Background

Infection Prevention & Control (IPC) along with Antimicrobial Resistance (AMR) has complex problems, it requires distinctive disciplinary efforts. There are few data concerning the facilitators and barriers in India. Interprofessional practice and education (IPE & IPP) initiatives amongst various stakeholders is one amongst them. Current approaches to IPC & AMR are fragmented and unidisciplinary, more like ''An Elephant and the Blind Men'. Hence the need of this structured study.

Methods

We conducted a prospective interventional study for one year with an interprofessional team. After institutional ethical committee clearance, an Antimicrobial Stewardship team was formed which devised training modules validated by Delphi technique /& ADDIE (Analyze, Design, Develop, Implement & Evaluate) approach by the Infection Control Committee and external resource persons. Simulated sessions, case based discussions, patient education videos & pamphlets, online interactive classrooms, ward & laboratory rounds were instituted for all doctors, staff nurses, laboratory technicians, pharmacists, and patients. Key quality indicators for antimicrobials prescription & consumption was defined and monitored. High end antimicrobial policy was implemented. Checklists & surveillance forms were put in use. Feedback surveys and audits were conducted to assess the effectiveness of these interventions.

Results

We observed a statistically significant increase in compliance to hand hygiene, health care associated infections (HAI) monitoring, reporting of needle stick injury, adherence to isolation protocols, and antibiotic policy (P value< 0.001) across all units. Maximum compliance to antibiotic policy was observed in medical intensive care units, least in nephrology & neonatal intensive care. Pre-test & post-test questionnaires were used for assessment. An improvement of ∼78 % in the knowledge domain was seen after the sessions. Key quality indicators for HAIs showed statistically significant improvement (P value< 0.001).

Conclusion

A multimodal interprofessional approach aids the training aspect of IPC & AMSP. Such structured programs in the curriculum addresses the silent pandemic of health care associated infections and antimicrobial resistance.

Disclosures

All Authors: No reported disclosures
1251. Strengthening Antimicrobial Stewardship Programs through Public Health Support
Authors: Kriengkauykiat Jane , Mitsunaga Tisha , Epson Erin
Published: November 2023

Background

Antimicrobial stewardship programs (ASP) improve patient outcomes and reduce resistance and Clostridioides difficile infections. The California Department of Public Health (CDPH) Healthcare-Associated Infections (HAI) Program developed an Honor Roll to recognize and promote ASP and offers consultation service to hospitals seeking to strengthen their ASP. We evaluated the service and compared ASP who sought consultation (consult) versus those who did not (non-consult).

Methods

We included ASP applying for Honor Roll between Sep 2020 to Mar 2022. Each hospital ASP completed a standardized application and provided documentation for Bronze, Silver, or Gold designations. Criteria increases as designation increases; details are on the Honor Roll website (www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/Honor_Roll.aspx). ASP may apply for upgrade within one year of designation. Consultation was initial review of ASP; mentorship was ongoing support beyond initial review. We reviewed consultation and mentorship meetings for themes in type(s) of support provided. For ASP that applied for upgrades, we compared consult to non-consult, including facility characteristics, and receipt of upgrade.

Results

There were 168 ASP (176 hospitals) Honor Roll enrollees (44% of California hospitals): 29 consults with 13 receiving mentorship, and 139 non-consult. Community hospital was the majority facility type which was similar between consult, 16/29 (55%), and non-consults, 80/139 (58%). The proportion of community hospitals ≤250 beds was higher for consult 13/29 (45%) vs non-consult 52/139 (37%). Thirty ASP applied for upgrades: 13/13 (100%) consults received upgrades vs 10/17 (59%) non-consults. Among non-consults, 4 received no upgrades and 3 received a lower designation (i.e., applied for Gold, received Silver). Among consults, 15/29 (52%) required support in strengthening their program, 10/29 (30%) application assistance, and 4/29 (14%) metrics or tracking. Approximately 7% of both consults and non-consults were in lower population- dense areas (< 1000 population/square mile).

Conclusion

Public health can support facilities improve their ASP through technical assistance and consultation; ASP in smaller facilities might require additional support.

Disclosures

All Authors: No reported disclosures
1258. Consulting Colleagues: Increasing Role of Advanced Practice Providers in Inpatient ID Consultation
Authors: Perez Reinaldo , Yarrington Michael E , Deri Connor R , Smith Michael J , Hayes Jillian E , Wrenn Rebekah , Moehring Rebekah W
Published: November 2023

Background

Advanced practice providers (APPs) have taken on increasing roles as primary team members in acute care hospitals. Little is known about variable consulting practices across provider types. Here we describe longitudinal trends in infectious diseases (ID) consultation by attributed provider type in 3 hospitals.

Methods

We performed a retrospective time series analysis of ID consultation from July 2015 to June 2022 to investigate the changes in requesting provider type at 3 hospitals: a major university hospital and 2 community hospitals. ID consultation rates were based upon new consult orders placed into the electronic health record (EHR). Provider type was categorized by type of ordering clinician: physicians, trainees (residents, fellows and medical students), and APPs (nurse practitioners, physician assistants, and nurse anesthetists). We evaluated the number of ID consult orders over time to assess quarterly rate trends. Then, we calculated the percent of ID consults attributed to each provider group. We used multinomial logistic regression to measure changes in ID consults across the clinician groups over time using physicians as the referent.

Results

We observed an overall increase in rate of ID consultation per 1000 days present by 35% (Table 1, Figure 1). Each hospital had a distinct baseline care model, though all 3 showed increased consultation by APPs (Figure 2, Table 2). This shift was largest at the university hospital, and was a statistically significant increase relative to attending physicians. Trainee proportion of consultation was stable at community hospitals and decreased at the university hospital.

Figure 2. Percent of ID Consults Ordered by Provider Type and Hospital, July 2015 – June 2022

Conclusion

Hospitals had differing baseline patterns of ID consultation attributed to provider groups, but all experienced increases in consults attributed to APPs and increased ID consultation rates over time. Hospital staffing models aiming to increase use of APPs must consider consultation rates as a potential effect and support infectious diseases services accordingly. As research showing the benefits of ID consultations expands and consultation increases, ID providers will need to continue to optimize their interprofessional collaboration.

Disclosures

Michael J. Smith, M.D., M.S.C.E, Merck: Grant/Research Support|Pfizer: Grant/Research Support Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties
1983. Clinical outcomes of people living with HIV and cirrhosis: a clinical cohort study
Authors: Arant Elizabeth C , Gay Cynthia L , Davy-Mendez Thibaut , Moon Andrew M
Published: November 2023

Background

People with HIV (PWH) are aging, with an increasing prevalence of cirrhosis from causes such as viral hepatitis, non-alcoholic fatty liver disease (NAFLD) and alcohol-associated liver disease (ALD). It is hypothesized that HIV could accelerate the progress of liver disease, but the characteristics and outcomes of PWH with cirrhosis are not well-known. We characterized patient characteristics and longitudinal outcomes of PWH with cirrhosis in a clinical setting.

Methods

This was a retrospective cohort study including PWH ≥18 years old with cirrhosis in HIV care in the UNC Center for AIDS Research HIV Clinical Cohort between 2014 and 2022. We estimated incidence rates (IR) of hospitalization, hepatocellular carcinoma (HCC), and death. In a subgroup of PWH with incident cirrhosis, we estimated 3-year cumulative incidence (CI) of first decompensation event and death from Kaplan Meier curves.

Results

The 114 PWH with cirrhosis were mostly male (78%), Black (53%), aged 50-59 (44%), and 38% had Medicare. A third (32%) had injection drug use (IDU) as the mode of HIV transmission, and almost all were virally suppressed (91%). Hepatitis C virus infection was the most common cirrhosis etiology (62%), followed by ALD (24%). Unadjusted IR per 100 person-years was 27.0% (95% CI 20.2-36.1) for hospitalization, 1.8% (95% CI 1.1-3.1) for HCC, and 3.8% (95% CI 2.6-5.6) for death. Among 69 PWH with incident cirrhosis, the 3-year CI was 38.0 (95% CI 32.0-44.0) for decompensation and 10.9 (95% CI 7.0-14.9) for death (Fig. 1). Three participants (2.6%) were referred for liver transplantation during the study period, however none received a transplant.

Figure 1

Conclusion

PWH with cirrhosis in this cohort had high rates of adverse health outcomes, with hospitalization and death rates that are higher than those reported among PWH overall. Despite being engaged in HIV care, over a third of PWH experienced decompensation within 3 years, indicating a need for earlier consideration for liver transplantation. Analyses are ongoing to compare clinical outcomes by cirrhosis etiology and severity at diagnosis.

Disclosures

Andrew M. Moon, MD, MPH, TARGET RWE: Advisor/Consultant
1261. Prospective Audit and Feedback Approach Differs between Antimicrobial Stewardship Professions
Authors: Ausman Sara , Mara Kristin , Brown Caitlin , Epps Kevin L , Kooda Kirstin , Mendez Julio C , Rivera (O'Connor) Christina G
Published: November 2023

Background

Implementing effective antimicrobial stewardship interventions is an important component of antimicrobial stewardship programs. Recently, stewardship research has shown that clinician characteristics may have an impact on antimicrobial stewardship intervention methods and acceptance rates.

Methods

A multisite health system antimicrobial stewardship prospective audit and feedback program interventions performed by stewardship staff using a standardized electronic medical record (EMR) tool were compared by stewardship clinician profession (pharmacist, physician, or advanced practice provider, APP) from 7/1/2017 to 6/30/2022. Outcomes assessed were intervention rates, communication methods, and intervention acceptance by patient age and intensive care unit (ICU) status of patient. Generalized estimating equations utilizing logistic regression were used to assess for associations between staff. Associations were assessed both univariately and after adjusting for other factors.

Results

Of 69,503 prospective audit and feedback EMR based rules, there were 14,699 rules associated with an intervention. The majority of rules were reviewed by pharmacists (90.7%) followed by physician (9.2%) and APP (< 1%). Of 9,034 interventions with an outcome documented, 7326 (85.5%) pharmacist interventions were accepted and 360 (77.3%) physician interventions were accepted (adjusted p=0.047).  Pharmacists intervened by direct action (ie, adjust a medication order) in 6.6% of interventions; whereas, physicians did so rarely (0.4%). Pharmacists were more likely to use synchronous communication than physicians in the adjusted model (pharmacist vs. physician: 63.8% vs 52.5%; p=0.004). Patients in the ICU had a significantly lower intervention acceptance rate (non-ICU vs. ICU: 86.6% vs. 78.0%; adjusted OR 0.57 [95% CI 0.46-0.70], p< 0.001).Table 1.Intervention Rate by Baseline Demographics of Stewardship Clinicians and Patients.

*% are reported as row % **Multivariable model was also adjusted for day of week and time of day APP-Advanced practice provider; ICU-intensive care unitTable 2.Intervention Acceptance.

*% are reported as row % **Multivariable model was also adjusted for day of week and time of day APP-Advanced practice provider; ICU-intensive care unit

Conclusion

Antimicrobial stewardship pharmacists and physicians are both effective at prospective audit and feedback but used different intervention styles. Advanced practice providers were vastly underrepresented. Patients in the ICU may benefit from tailored ASP efforts.

Disclosures

Sara Ausman, PharmD, Gilead: Honoraria Caitlin Brown, PharmD, Alexion: Grant/Research Support|Trevena: Advisor/Consultant Christina G. Rivera (O'Connor), Pharm.D, Gilead Sciences: Advisor/Consultant|Gilead Sciences: Board Member|Gilead Sciences: Grant/Research Support|Gilead Sciences: Honoraria
1263. The Experience of an Antimicrobial Stewardship Program at a Tertiary Referral Hospital in a Low/Middle Income Country
Authors: Abdallah Tamara , Haddad Nisrine , Rizk Nesrine , Zeenny Rony , Kanj Souha S
Published: November 2023

Background

Antimicrobial Stewardship Programs (ASP) play a crucial role in optimizing antimicrobial utilization and limiting the use of broad-spectrum antibiotics, to reduce antimicrobial resistance. During the COVID-19 pandemic, there was a noticeable increase in antimicrobial consumption globally. The ASP at the American University of Beirut Medical Center (AUBMC) began formal operations in January 2019. In this study, our aim is to evaluate the activities of the ASP -since implementation and during the pandemic- at our institution, a tertiary referral hospital in Beirut.

Methods

The ASP team performed handshake stewardship rounds and daily reviews of antimicrobial use. It provided educational activities in a multi-disciplinary approach in addition to implementing a carbapenem sparing strategy and ongoing monitoring of antibiotic consumption. This study is a retrospective review of those activities. We compiled the ASP recommendations from January 2019 until December 2021. Data collected included the number of ASP recommendations and their sub-categories in addition to acceptance rates.

Results

We recorded a total of 9922 recommendations during this three-year period. Recommendations aiming at reducing antimicrobial consumption were the most common (42%), and included: duration of therapy, de-escalation, and duplicate coverage (Figure 1). Rates of acceptance of these recommendations were 88%, 92% and 95% in 2019, 2020 and 2021 respectively. The number of recommendations increased during the pandemic and coincided with COVID-19 surges in Lebanon (figure 2). There was also an increase in the acceptance rate of recommendations to reduce antibiotic consumption (Figure 3) over this period.Figure 1.Distribution of ASP Interventions per sub-CategoryFigure 2.Number of ASP Recommendations pre- and During COVID-19Figure 3.ASP recommendations to Reduce Antibiotic Consumption and Acceptance Rate

Conclusion

Despite the challenges imposed by the pandemic and the involvement of the ASP in the COVID-19 response, the team maintained its efforts and involvement to mitigate antibiotic misuse. The results are encouraging and attest to the important role of ASP in driving culture change regarding the judicious use of antimicrobials even during a pandemic.

Disclosures

Souha S Kanj, MD, Gilead: Advisor/Consultant|Menarini: Advisor/Consultant|MSD: Advisor/Consultant|Pfizer: Advisor/Consultant
1276. Mechanical, Microbiological, and Inflammatory Factors May Impact 1-Year Revision Rates after Arthroplasty Resection for Periprosthetic Joint Infection
Authors: Aljadani Rawabi , Kremers Hilal Maradit , Carvour Martha
Published: November 2023

Background

Periprosthetic joint infection (PJI) is often managed using a combination of medical and surgical treatments, including irrigation and debridement or joint resection, spacer placement, and then revision to reimplant the arthroplasty components. The timing between surgical stages may vary, and little information exists about the clinical and microbiological factors impacting these temporal relationships.

Methods

A single center cohort study was conducted. The cohort included all cases of PJI for which resection was performed at the University of Iowa Health Care (UIHCs) between January 1, 2009, and December 31, 2016. Using a 1-year follow-up period, we constructed Kaplan-Meier estimates of the time to revision after resection—overall and then stratified by joint location (knee vs. hip), organism identification (known vs unknown), and C-reactive protein level (CRP >10 mg/L vs. CRP ≤10 mg/L). We then used Cox proportional hazard modeling to identify factors associated with revision within 1 year.

Results

Among a total of 109 cases of prosthetic joint resections (n = 67 knee, n = 42 hip), 56.9% underwent revision surgery during the follow-up period (n = 46 knee, n= 16 hip). Most revisions occurred between 2.5 and 3.0 months after resection. Knee arthroplasties were significantly more likely to undergo revision during the study period (hazard ratio, HR = 2.53, 95% confidence interval, CI: 1.38, 4.94) compared to hip arthroplasties. Identification of one or more organism involved in the PJI was also associated with revision during the study window (HR = 3.56, 95% CI: 1.94, 6.47), whereas elevated CRP was associated with lower rates of revision during the study period (HR = 0.21, 95% CI: 0.09, 0.46 for CRP >10 mg/L compared to CRP ≤10 mg/L).

Figure 1. Kaplan-Meier curves for revision within 1-year after resection for the (A) cohort overall and then stratified by (B) joint location (hip vs knee), (C) organism identification (known vs unknown), and (D) C-reactive protein level (CRP >10 mg/L vs. CRP ≤10 mg/L).

Conclusion

For patients with surgically managed PJIs, joint location, organism identification, and lower CRP level were all associated with revision procedures within 1-year after resection. These findings may reflect mechanical and microbiological factors influencing the decision to proceed with revision. The variable length between stages—and thus, the variable time during which a spacer is retained—may be important to measure in future observational and clinical studies examining PJI outcomes.

Disclosures

All Authors: No reported disclosures
1288. Rapidly evolving Lyme epidemiology in central Ohio creates challenges in prompt diagnosis and management of Lyme arthritis
Authors: Erdem Guliz , Watson Joshua R , Barson William J
Published: November 2023

Background

Institutional practices regarding care for septic arthritis (SA) patients varies. To streamline the care of SA patients we established a clinical pathway with two care delivery expectations: % of patients on appropriate antibiotics and % of patients with time to diagnostic joint fluid aspiration < 24 hours after admission.

Key driver diagram

Lyme and non-Lyme bacterial arthritis patients since 2020

Methods

Quality improvement initiative aimed to streamline the care and key drivers were established (Figure 1). Interventions included development management algorithm, consensus building among infectious diseases physicians. The pre-study baseline period was January 1, 2020 to May 31, 2021, and the study period was from June 1, 2021, to March 1, 2023. Control charts were used to assess the interventions.

Results

Of the 97 patients admitted during the baseline and study period 42 patients were diagnosed with non-Lyme associated SA, 39 had Lyme arthritis, 16 had reactive arthritis. Significant increase in Lyme arthritis patients were observed since 2021 (Figure2) coinciding with reported geographic expansion of ticks in Ohio attributed to climate change. Length of hospitalization for Lyme arthritis (median: 2.35 days, IQR 1.29) was shorter than non-Lyme associated SA (median: 3 days, IQ 1.48). 18 (42.9%) of non-Lyme SA patients and 10 (25.6%) of Lyme arthritis patients underwent surgical washouts. 27 (69 %) of Lyme arthritis patients were initially treated with anti-staphylococcal antimicrobial agents. Lyme serologies took 1-3 days to result causing delays in diagnosis and management. 7 (18%) of patients were discharged home on no antibiotics or with antibiotics not appropriate for Lyme arthritis.

Conclusion

Our streamlined approach led to timely and appropriate diagnostic and therapeutic approach in non-Lyme associated SA patients. Rapidly evolving Lyme epidemiology in central Ohio created challenges in prompt diagnosis and management of Lyme arthritis patients.

Disclosures

All Authors: No reported disclosures
1299. Clinical Characteristics of Native Vertebral Osteomyelitis in Patients with a History of Acupuncture
Authors: Moon Soo-youn , Lim Kyoung Ree , Son Jun Seong
Published: November 2023

Background

Considering that vertebral osteomyelitis (VO) can occur via various routes. It can be predicted that clinical characteristics may vary depending on the way of infection or risk factors of the disease. In this study, the clinical characteristics, causative pathogens, clinical features, and prognosis of the native VO in patients with a history of acupuncture were compared with those without a history of acupuncture.

Methods

This retrospective study was conducted at a university-affiliated hospital in Seoul, from May 2006 to February 2021. The patients of age 18 or older with native VO were enrolled. Data on demography, clinical presentation, treatment, causative organisms, and clinical outcomes were collected via electronic medical records.

Results

A total of 100 patients with VO were reviewed, among which 34 patients had a history of acupuncture before the diagnosis of VO. The frequency of Gram-positive cocci (GPC) was significantly higher in the acupuncture group than in the non-acupuncture group (p=0.016). Abscess was observed more frequently in the acupuncture group than in the non-acupuncture group (p=0.01). Patients with abscesses underwent surgical treatment more often than those without (p=0.021). There was no difference in clinical outcomes between the two groups, including mortality, neurologic sequelae, and recurrent after one year.

Conclusion

This study suggests that confirming a history of acupuncture may help predict the pathogen or clinical characteristics of the disease. If the patient has a history of acupuncture, GPC can be considered the causative organism. The presence of abscesses may lead to surgical treatment more frequently.

Disclosures

All Authors: No reported disclosures
1305. Current Management of Osteoarticular Infections by Infectious Diseases Physicians: Results of an Emerging Infections Network (EIN) Survey
Authors: Cortes-Penfield Nicolas W , Beekmann Susan E , Polgreen Philip M , Ryan Keenan L , Sekar Poorani
Published: November 2023

Background

Osteoarticular infections (OAI) have been commonly treated with prolonged intravenous (IV) antimicrobials. The Oral versus Intravenous Antibiotics for Bone and Joint Infection (OVIVA) trial demonstrated that oral (PO) antibiotic therapy was noninferior to IV antibiotics in the treatment of OAIs. We surveyed Infectious disease (ID) physicians to see how often they used PO antibiotics in the treatment of OAIs and the barriers to using PO antibiotics.

Methods

An EIN survey was sent to 1475 ID physicians. The survey had 9 questions pertaining to antibiotic prescribing patterns in the treatment of OAIs. The questions were mostly multiple choice, Yes/No questions with an area provided for free text. Definitive oral antibiotic therapy was defined as switching to PO antibiotics within 2 weeks of starting antibiotics.

Results

There were 413 respondents who treated OAIs and responded to the survey. A plurality of respondents 150/413 (36%) switched from IV to PO antibiotics after 4 weeks of IV therapy. 129/413 (31%) switched to oral antibiotics as definitive treatment (Fig 1). PO antibiotics were used as definitive therapy most often for diabetic foot osteomyelitis and native joint septic arthritis (Fig 2). Trimethoprim-sulfamethoxazole was most often used as definitive therapy for Staphylococcus aureus infections followed by doxycycline/minocycline. Amoxicillin/ cefadroxil/ cephalexin was used for treatment of streptococcal infections and fluoroquinolones were used as definitive treatment for infections caused by Gram-negative organisms. The most common reasons for not transitioning to PO antibiotics included non-susceptible pathogen, comorbidities preventing therapeutic drug levels and concern about adherence

For the following infections, how often do you use oral antibiotics as definitive therapy?

Conclusion

A sizeable portion of ID physicians utilize PO antibiotics for the management of OAIs, although significant practice variation exists regarding the timing of IV to PO switch.

Disclosures

Philip M. Polgreen, MD, Eli Lilly: Case adjudication for a clinical trial Keenan L. Ryan, PharmD, PhC, PharmCon: Honoraria
1308. Exploration of Infectious Disease Specialist Attitudes on Utilizing Oral Antimicrobials for the Treatment of Bone and Joint Infections
Authors: Wolfe Katy , Funaro Jason , Seidelman Jessica , Dicks Kristen , Yarrington Michael E , Shroba Jenny
Published: November 2023

Background

Despite recent literature supporting non-inferiority of oral therapy, many patients are treated with traditional extended intravenous (IV) antimicrobial courses. The objective of this study was to evaluate the attitudes of infectious disease (ID) specialists on utilizing oral antimicrobials (PO-A) for the treatment of bone and joint infections (BJI).

Methods

This was a multicenter clinician survey study of ID specialists from 1/10/23 – 1/31/23, regarding their attitude towards using PO-A for the treatment of BJIs. Survey respondents were presented with statements and rank order questions and asked to indicate their level of agreeance using a 5-point Likert scale. The primary outcome was agreement with the phrase ‘I am willing to prescribe PO-A for treatment of BJIs’. Secondary outcomes included patient case and ID specialist characteristics associated with willingness to prescribe PO-A. Study utilized descriptive statistics and univariate tests.

Results

A total of 216 surveys were distributed to ID specialists of which 65 recorded responses with 50 complete responses (30% overall response rate and 23% completion rate). Of the 50 complete surveys, the majority of respondents (60%) indicated they prescribe PO-A in ≤25% of their patient-case load as definitive treatment of BJIs. A total of 41/50 respondents (82%) indicated strong agreement with comfortability prescribing and dosing PO-A for BJIs (Table 1) and were most willing to prescribe PO-A ( >70%) in patients with diabetic foot infection (Table 2). ID specialists’ willingness to prescribe PO-A for treatment of BJIs significantly correlated with their current clinical practice. Respondents who disagreed with the statement ‘I am willing to prescribe PO-A’ currently prescribe PO-A in less than 25% of their BJI patients compared to respondents who agreed (37% prescribe PO-A 26-50% of their patients with 35% of those who strongly agree prescribe PO-A it in >50% of their BJI patients (p=0.004). The most common concern (62%) when prescribing PO-A for BJIs is the identified pathogen may not be susceptible to the preferred antibiotic (Table 3).

Conclusion

The findings of this survey suggest that most ID specialists in this sample are comfortable prescribing PO-A for treatment of BJIs and was significantly related to current practice.

Disclosures

Jessica Seidelman, MD, MPH, Uptodate: content editor for pelvic osteomyelitis page Kristen Dicks, MD, UpToDate: Advisor/Consultant
1319. Microbiology and Epidemiology of Pediatric Ventriculoperitoneal Shunt Infections
Authors: Claunch Kevin M , Adams Daniel , Deperrior Sarah , Rajnik Michael
Published: November 2023

Background

Infections complicate approximately 10% of ventriculoperitoneal (VP) shunts in children, with considerable associated morbidity and mortality. Recent guidelines for empiric treatment of VP shunt infections recommend use of vancomycin combined with an anti-pseudomonal beta-lactam, but are based on low-quality evidence. We aimed to further characterize and update the microbiology of pediatric VP shunt infections using the U.S. Military Health System database.

Methods

Department of Defense beneficiaries less than 22 years-of-age admitted for VP shunt infection between Oct 1, 2008 and Sep 30, 2019 were included. VP shunt infection was defined using a combination of ICD-9-CM and ICD-10-CM codes, CPT codes for removal or replacement of a shunt (Table 1), and positive cultures from a normally sterile site (cerebrospinal fluid, blood, catheter tip, and peritoneum). Demographic data on age, sex, and year of admission were collected for each patient, as was microbiologic data including organism and specimen source.

Results

There were 32 qualifying admissions among 30 patients for VP shunt infection over the 10-year study period, with no discernable year-to-year trend identified. Half of all VP shunt infections occurred in patients less than 12 months of age (Table 2). Sixty-one unique positive cultures were identified among the 30 patients, 38 (62%) from CSF samples, and the remaining 23 (38%) from blood, peritoneum, and catheter tips (Figure 1). Coagulase-negative Staphylococcus (28%), Staphylococcus aureus (15%), and Enterococcus spp. (10%) were the leading causative pathogens (Figure 2). Enteric gram-negative rods accounted for 21% of positive cultures. Pseudomonas spp. were rarely isolated (3%), however, strict anaerobic pathogens made up 8% of positive cultures.

Conclusion

Empiric antibiotic treatment of VP shunt infections in children should cover gram-positive cocci and enteric gram-negative rods but need not cover Pseudomonas spp. Existing guidelines do not recommend anaerobic coverage, however, these data indicate empiric anaerobic coverage is prudent, especially when an intra-abdominal VP shunt infection is suspected.

Disclosures

All Authors: No reported disclosures
1334. Amino Acid Sequence Diversity of HIV-1 Viral Proteins Tat and Vpr in South African People Living with HIV: Implications for Neurocognitive Function
Authors: Williams Monray E
Published: November 2023

Background

The transactivator of transcription (Tat) and Viral protein R (Vpr) of HIV-1 have functional roles in the neuropathophysiology of HIV-associated neurocognitive disorders (HAND). Pre-clinical studies have identified specific amino acid substitutions, including Tat T24K, C31S, R57S and Vpr H45Y, A55T and R77Q, as crucial influencers of the neurovirulence of HIV-1 subtype C infection. However, there is limited clinical data on the amino acid sequence diversity of Tat and Vpr, particularly in South African people living with HIV (PLWH).

Methods

In this study, amino acid sequence diversity in Tat and Vpr was investigated in n = 70 treatment-naïve South African PLWH. RNA was extracted from plasma, reverse transcribed and DNA was prepared for PCR analysis. The Tat exon 1/Vpr (HXB2 position 4900–6351) was amplified using primer pair Vif-1/ CATH-4R. PCR products were sequenced by BigDye Terminator v.3.1 Cycle Sequencing Ready Reaction Kit and analysed on the ABI Prism 3130xl automated DNA sequencer. Bioinformatic analyses were applied to identify key amino acids in Tat and Vpr.

Results

Tat sequence data were available for n = 53 participants and Vpr sequence data was available for n = 63 participants. The most common amino acid at position 24 of Tat was K (37%), followed by N (28%) and P (9%). At position 31, S was the most common amino acid (66%), followed by C (11%). At position 57, the most common amino acid was S (53%), followed by R (9%) and A (8%). Regarding Vpr, the most common amino acid at position 45 was Y (53%), followed by H (33%). At position 55 of Vpr, T was the most common amino acid (70%), followed by A (19%). At position 77 of Vpr, Q was the most common amino acid (84%), followed by R (6%) and H (5%).

Conclusion

Our understanding of the impact of HIV-1 sequence variation on neurovirulence primarily stems from preclinical studies and research conducted on participants with subtype B. However, this study presents evidence of sequence variations in Tat and Vpr among South African PLWH, who are predominantly infected with subtype C. The predominant amino acids observed in Tat and Vpr of the investigated participants are known to be linked to lower neurovirulence. These findings may help elucidate the differing neurocognitive outcomes observed when comparing PLWH with subtypes B and C.

Disclosures

All Authors: No reported disclosures
1347. Do Class 3 Semaphorins Play a Role in COVID-19 Outcomes in Patients with Non-alcoholic Fatty Liver Disease?
Authors: Vargovic Martina , Gjurasin Branimir , Samadan Lara , Vince Adriana , Papic Neven
Published: November 2023

Background

Class 3 semaphorins are newly recognized regulators of T-lymphocyte differentiation, neutrophil migration, and the production of inflammatory cytokines, with a possible role in controlling COVID-19 “cytokine storm”. While non-alcoholic fatty liver disease (NAFLD) is associated with COVID-19 severity and outcomes, immunological mechanisms remain unclear. Since NAFLD is associated with semaphorin pathway dysregulation, this study aimed to determine the possible association of serum semaphorin concentrations with the severity of COVID-19 in patients with NAFLD.

Methods

This was a secondary analysis of the prospective observational study (CovidFAT) that recruited patients with severe COVID-19 during the delta wave of the pandemic. Upon admission, patients were screened for NAFLD, routine clinical and laboratory data were collected, and serum semaphorin -3A, -3C and -3F concentrations were analyzed by ELISA. Sixty SARS-CoV2 negative, age and sex-matched healthcare workers (30 with NAFLD) were included as controls.

Results

Eighty patients (44 males (55%); mean age of 58±12 years) with COVID-19 were included. Of them, 42 had NAFLD. There were no differences in age, sex, comorbidities, duration of symptoms, and disease severity at admission, except for BMI which was higher in the NAFLD group (32±8 vs 27±3 kg/m2). Patients with NAFLD had significantly higher CRP (123±70 vs 97±60 mg/L), IL-6 (92±59 vs 45±38 pg/mL), neutrophile-lymphocyte ratio (11±14 vs 6.5±2.6) and GGT (93±78 vs 54±47 IU/L). Patients with COVID-19 had significantly higher serum concentrations of SEMA3C and SEMA3F and lower of SEMA3A than healthy controls, as presented in Figure 1. Patients with COVID-19 and NAFLD had significantly higher SEMA3C and SEMA3F serum concentrations than patients without NAFLD. In ROC analysis, SEMA3A and SEMA3F showed good accuracy for differentiating moderate from severe/critical COVID-19 (AUC 0.75, CI95% 0.66-0.85 and 0.74, CI95% 0.54-0.84, respectively).

Serum semaphorin concentrations measured in healthy controls and patients with COVID-19. Shown are means with standard deviations and p-values (ANOVA test).

Conclusion

NAFLD is associated with distinct semaphorin profiles in COVID-19, possibly associated with disease severity and adverse outcomes.

Disclosures

All Authors: No reported disclosures
1379. Evaluation of Cardiovascular Disease Risk among People Living with HIV in Lebanon
Authors: Helou Remie El , Zaidan Mariam , Wehbe Saliba , Rizk Nesrine
Published: November 2023

Background

Since the introduction of antiretroviral therapy (ART), People Living with HIV (PLHIV) have become more prone to developing chronic illnesses, such as cardiovascular diseases (CVD), than to suffer from AIDS related conditions. The global burden of CVD associated with HIV has tripled over the last two decades, especially in low/middle income countries. Scarce data exist on the prevalence of CVD and CVD risk factors among PLHIV in the Middle East and North Africa (MENA) region. Therefore, we aim to examine the prevalence of CVD risk factors and calculate the CV risk in a cohort of PLHIV in Lebanon.

Methods

This is a retrospective chart review conducted between 2018 and 2023 at an HIV clinic in a tertiary care center in Lebanon. The study population includes adult subjects receiving ART and with at least 6 months of undetectable viral loads. Data included demographics, laboratory values, HIV-specific data, and review of traditional CVD risk factors. Atherosclerotic Cardiovascular Disease (ASCVD) risk score was calculated using the American College of Cardiology Risk Estimator Plus, to estimate patients’ 10-year risk for developing ASCVD. Descriptive statistics were implemented to summarize the cohort’s characteristics and the prevalence of CVD risk factors.

Results

A total of 85 HIV-infected subjects were included in the analysis. Subjects’ characteristics are summarized in table 1. The majority were males (89.4%), and the mean age was 43.31±12.28 years. The prevalence of smoking, alcohol consumption, and illicit drug use was 70.6%, 54.1%, and 20%, respectively. The mean BMI was 26.1±5 kg/m². Additionally, 20.2 % of subjects had dyslipidemia, 6% had diabetes, and 15.5% had hypertension. The mean current CD4 cell count was 687.83 ±356 cells/ml. The cohort had a mean ASCVD risk score of 8.8%, higher than that of age-matched population (mean ASCVD risk score of US firefighters aged 40-44 years is 1.8%).

Conclusion

This study shows the prevalence of traditional CVD risk factors among PLHIV receiving effective ART in Lebanon. The cohort mean ASCVD risk score indicates an intermediate risk for developing CVD over the next decade. in the MENA region, we need larger studies to inform on the prevalence of CVD among PLHIV, and to develop guidelines to mitigate the risk.

Disclosures

All Authors: No reported disclosures
1392. An observational study to test efficacy of oral fluconazole in pediatric cases of Cutaneous Leishmaniasis
Authors: Mitra Debdeep
Published: November 2023

Background

Cutaneous Leishmaniasis(CL) is the commonest form of Leishmaniasis with a worldwide incidence of about 0.7 to 1.2 million cases per year and 90% of these cases are in Asia, the Middle East, South America, and North Africa. Pentavalent antimony medications are still the most effective treatments for leishmaniasis, however, due of the severe side effects and the need for parenteral administration, other therapies, such as oral medicines for cutaneous leishmaniasis, have been sought. Given the extended duration of the illness and the disfiguring impact of unhealed skin lesions, a well-tolerated oral medication would be beneficial. In vitro, certain azole antifungal medications exhibit cidal action against leishmania. Fluconazole, a triazole antifungal drug available for oral administration, has clinical efficacy against leishmania but very limited data is available to support this.

Methods

To test the efficacy of oral fluconazole in CL in children we treated 14 Indian patients of age less than 12 years with once daily doses of fluconazole for four weeks. Patients less than 12 years old with clinically and smear positive confirmed cases were included in the study. Immuno-compromised patients were excluded.

Results

In the majority of patients, a parasitological smear was used to confirm the diagnosis, and in a few cases, histological testing was used. 10 patients were male, and mean values (SE:Standard error) at study entry were: age, 7(2) years; weight, 20 (3) kg; duration of illness, 2·4 (0·4) months. All children were prescribed fluconazole dispersible tablet at the dose of 3-5 mg/kg body weight to adjust doses in multiple of 50 mg of dispersible tablet daily. No drug discontinuation or any case drop out was noted as the drug was well tolerated and there was good noticeable clinical response. Intermittent nausea and occasional diarrhea was the most common side effect (7% of cases). Clinical cure was noted with complete clearance of skin lesions in all 14 cases and no appearance of any new lesions was observed over next 3 months. The average treatment response time was 43 days

Conclusion

There are very limited studies on the use of fluconazole in pediatric CL in endemic areas and this study suggests a very safe and effective treatment option.

Disclosures

All Authors: No reported disclosures
1396. Performance of a Telemedicine Travel Clinic
Authors: Pomeranz Adam , Zohar Iris , Caliari Gabriele , Orbach Nili , Mizrachi Yulia , Mimon Hadar , Ben-David Debby , Maor Yasmin
Published: November 2023

Background

International travel has become easier and more accessible, with increasing numbers of people embarking trips to diverse destinations worldwide. This trend is accompanied by elderly individuals and families venturing to remote locations, as well as digital nomads. As a result, there is a growing demand for pre-travel medical consultations, which current medical resources in Israel are not able to meet. To address this, we launched a telemedicine-based travel clinic that aims to improve accessibility for Israeli residents.

Methods

The digital clinic is located within a 700-bed medical center in central Israel and offers telemedicine consultations scheduled online. After the appointment, customers receive recommendations and prescriptions via email. They can then make an appointment to receive vaccinations at our on-site in person clinic or at other travel clinics in Israel. From February 1st to March 31st, 2023, we analyzed all cases that receive a digital consultation. Data included demographics, travel destinations, vaccination recommendations, and attendance to the in-person vaccination clinic.

Results

239 customers received a telemedicine consultation. Mean age was 33±17 years, 122 (51.0%) were females, 40 (16.7%) were minors. 18.4%44 () resided outside the pooling area of the hospital. Of these, 81.8%36 () lived in central Israel but had closer clinics to their place of residency requiring personal attendance, 18.2%8 () lived in the North or South of Israel (figure 1). Travel destinations are presented in figure 2. 219 (91.6%) customers received a recommendation for at least one vaccine. 53.0%116 () attended or scheduled an appointment to the vaccine clinic. 103 (47.0%) did not schedule an appointment despite having a recommendation to receive vaccines.

Conclusion

About 50% of patients did not attend or schedule an appointment to the in-person clinic to receive the recommended vaccines. Personal attendance decreased as the residence distance from the hospital increased ( >30 Km), suggesting that customers found closer clinics for vaccination. The telemedicine-based travel clinic simplified pre-travel medical consultations and for 10% of clients who did not need to get vaccines enabled them not to attend the hospital in person.

Disclosures

Yasmin Maor, MD, Astra Zeneca: Advisor/Consultant|Astra Zeneca: Honoraria|Gilead: Honoraria|GSK: Honoraria|kamada: Honoraria|Medison: Honoraria|MSD: Advisor/Consultant|MSD: Honoraria|Pfizer: Grant/Research Support|Pfizer: Honoraria
1997. Risk Factors and Outcomes of Mycobacterium abscessus Complex (MABC) Acquisition after Lung Transplantation
Authors: Nick Sophie E , Yarrington Michael E , Reynolds John M , Anderson Deverick J , Baker Arthur W
Published: November 2023

Background

Lung transplant recipients are at increased risk of MABC acquisition. The objective of this study was to analyze risk factors and outcomes of early post-transplant MABC acquisition.

Methods

We conducted a single center retrospective case-control study of patients who underwent lung transplant from 1/1/2012 – 12/31/2021. Cases were patients with de novo MABC acquisition within 90 days post-transplant. Controls had no positive MABC cultures and were matched 1:3 with cases based on age and transplant date. Recipient demographics, pre-/peri-operative characteristics, and outcomes for 1-year post-transplant were analyzed.

Conditional logistic regression was used to determine independent risk factors for MABC acquisition. The reference model included all variables with a P value ≤ 0.2 in univariate analysis after accounting for collinearity and epidemiologic plausibility. Confounding variables and variables with an adjusted P value ≤ 0.05 were included in the final model.

Results

79 cases and 237 controls were identified out of 1,145 lung transplants. The median time to MABC isolation was 33 days (IQR 11 – 59) after transplant. The first positive culture was pulmonary for 70 (89%) cases; 59 (75%) cases were treated with antibiotics targeting MABC.

Univariate analysis found cases were more likely than controls to have CMV mismatch (D+/R-), bilateral transplant, higher end-match allocation score, increased ventilator time pre- and post-transplant, and days in the hospital before MABC index date (Table 1). IPF diagnosis and receipt of azithromycin were protective. Multivariable analysis showed only post-transplant ventilation for ≥ 2 days was independently associated with MABC (Table 2).

Compared to controls, cases required more days of hospitalization after the MABC index date (28 vs. 12 days; p=0.01) and had decreased 1-year post-transplant survival (78% vs. 89%; p=0.02) (Figure 1). When stratified by subspecies, 1-year survival was 69% for M. abscessus and 89% for M. massiliense (p=0.10).

Table 1.

Lung transplant recipient characteristics

Table 2.

Conditional logistic regression model constructed via backward elimination to determine independent predictors and confounders of MABC acquisition

Figure 1.

Kaplan-Meier survival curve comparing cases and controls for 1-year after transplant

Conclusion

In this large case-control study, post-transplant ventilator duration was associated with MABC acquisition, which in turn was associated with increased hospital days and mortality. Further studies are needed to determine the best strategies for MABC prevention and surveillance.

Disclosures

Arthur W. Baker, MD, MPH, Insmed: Grant/Research Support|Medincell: Advisor/Consultant