bluuebunny/crossref_metadata_2025 huggingface dataset:
Herpes–Zoster Infection in a Tertiary Hospital in Brazil
Authors: Antoniolli Luciana , Azambuja Aline , Rodrigues Camila , Borges Rafael , Goldani Luciano
Published: October 2017

Background

herpes zoster (HZ) is a common infection with potential complications requiring hospital care, especially for patients with multiple comorbities. However, there is little information on HZ from hospital registries.

Methods

we searched for hospital-based records of B02 code (ICD-10) between March 2000 and January 2017 at Hospital de Clínicas de Porto Alegre, a tertiary, university hospital in south Brazil. To avoid misclassifications, we considered clinical evaluation for the diagnosis of cutaneous HZ and postherpetic neuralgia (PHN), ophthalmological evaluation for ophthalmic HZ and the combination of clinical, radiologic and cerebrospinal fluid analysis for HZ meningo-encephalitis (ME). We analyzed conditions associated with immune dysregulation, complications, length of hospital stay, and mortality. Chi-square test and Kaplan-Meier estimator were used for statistical analyses. P < 0.05 was considered statistically significant.

Results

there were 847 records for this period, of which 801 were confirmed according to our criteria and included in the analysis. Most patients were women (n = 448; 60%), with an average of 48.8 years, standard deviation of 22.2. There were more diagnoses in the inpatients group (74.4%), and fewer in the emergency room (22.4%) and outpatient (3.3%). The median length of hospital stay was 7 days (2-10, P25-P75) when HZ was the main reason for admission. Most patients presented cutaneous HZ (n = 743, 92.8%). There were fewer cases of PHN (6.1%), ophthalmic HZ (7.6%) and ME (4.1%). Seventy percent had some kind of immune dysregulation; more frequently AIDS (31%), use of immunosuppressive agents (18.7%) and malignant disease (16.2%). We followed the subjects for a median of 28.2 (2.8-77.5) months. During this period, there were 105 (13.1%) deaths. Five were related to HZ ME. The 30-day overall mortality rate was 1.5%. There was no statistical difference in cumulative survival (graph 1, P = 0.05) or incidence of complicated forms for patients with or without immune dysregulation.

Conclusion

our sample was characterized by a majority of inpatient diagnoses. The 30-day mortality rate was lower than reported in similar studies, but there was a relevant impact of complicated forms in mortality and sequelae.

Disclosures

All authors: No reported disclosures.
Evaluating the Risk of Viral Myocarditis following Influenza Infection among Hospitalized Patients during 2014–2015 and 2015–2016 Influenza Seasons
Authors: Helou Elie , Datta Rupak , John Blessy , Martinello Richard , Malinis Maricar
Published: October 2017

Background

Myocarditis is a severe cardiovascular complication of influenza infection that is often fatal and underdiagnosed. We evaluated the epidemiology of influenza myocarditis (IM) among inpatients at one institution.

Methods

We performed a retrospective cohort study of inpatients harboring influenza virus by reverse transcription-polymerase chain reaction from respiratory specimens between 2014 and 2016. We collected demographic, treatment, strain-typing, and hospitalization data for all patients. Definitive IM was proven by histopathology or viral isolation from myocardial tissue. Probable and possible IM were based on CDC and predefined clinical criteria, respectively. We used the chi-squared test to compare characteristics between 2014–2015 and 2015–2016 influenza seasons and the subset of patients with cardiovascular complications.

Results

We identified 757 patients with influenza in 2014–2015 (n = 453) and 2015–2016 (n = 304). Baseline characteristics including gender, influenza type, and co-morbidities were similar between seasons except for more white and cardiovascular disease (P <0.005) in 2014–2015. Overall, five (0.7%) (2014–2015 = 4, 2015–2016 = 1) had probable IM. Median age was 65 years (range 29–87) and median length of stay was 4 days (range 4–15). All had EKG changes, one had increased heart size without effusion requiring ICU stay and intubation. Four received oseltamivir, and all survived.

Possible IM occurred in 39 patients (5%) based on new EKG changes (58%), troponin elevation (38%) and pericardial effusion (2%). These patients were older (median 81 years, range 29–91) with longer length-of-stay (median 8 days, range 1–41). Oseltamivir was given to 30/39 (77%). Death occurred in 5/23 patients with EKG changes and 3/15 with troponin elevation.

Conclusion

IM was rare during the past two influenza seasons with no attributable mortality at our institution. Eight-fold more patients with IM were detected using a priori criteria when compared with CDC criteria with substantially higher mortality. This may represent a high-risk subset for whom future studies are needed to improve IM diagnosis and prevent morbidity and mortality.

Disclosures

All authors: No reported disclosures.
WU Polyomavirus Associated with Severe Respiratory Failure in Children
Authors: Uda Kazuhiro , Shoji Kensuke , Wakai-Koyama Chitose , Miyairi Isao
Published: October 2017

Background

WU polyomavirus (WUPyV) is a relatively new virus associated with respiratory infections. However, its role is unclear in children with severe respiratory failure. We aimed to evaluate characteristics of severe respiratory failure associated with WUPyV in children.

Methods

We retrospectively reviewed the cases of respiratory tract infection at a tertiary children’s hospital in Tokyo between April 2010 and April 2017. We performed real-time polymerase chain reaction (PCR) for WUPyV using residual extracted nucleic acid samples taken from respiratory tract samples of pediatric patients, primarily with respiratory failure. We investigated the clinical characteristics of patients positive for WUPyV. Samples positive for WUPyV were evaluated for co-infection with fast-track diagnostic kit (FTD-2); a multiplex PCR capable of detecting 21 respiratory pathogens.

Results

WUPyV was detected in 14 among 318 samples obtained from respiratory tract infections. Median age was 34 months old and males were predominant (n = 11, 64%). Underlying disease was found in 11 (79%) cases, including five cases of preterm children and three immunocompromised patients. The most common clinical diagnosis was pneumonia (n = 13, 93%). Majority of the respiratory samples were endotracheal tube aspirates (n = 11, 79%) and the remaining were nasopharyngeal swabs. Co- infection was found in eight (57%) cases. WUPyV was the only pathogen detected in six cases, including two preterm children and one immunocompromised patient. Nine cases required mechanical ventilation, and two cases required extracorporeal membrane oxygenation (ECMO).

Conclusion

WUPyV was detected from children with severe respiratory failure due to pneumonia, independently or concurrently with other pathogens, especially in preterm and immunocompromised patients.

Disclosures

All authors: No reported disclosures.
Morbidity, and Short- and Intermediate-term Mortality, in Adults ≥60 Years Hospitalized with Respiratory Syncytial Virus Infection vs. Seasonal Influenza Virus Infection
Authors: Tseng Hung Fu , Sy Lina S , Ackerson Bradley , Fischetti Christine , Slezak Jeff , Luo Yi , Solano Zendi , Chen Songyue , Shinde Vivek
Published: October 2017

Background

There is increasing evidence that respiratory syncytial virus (RSV) infection can cause serious health problems among older adults, whether healthy and community-dwelling, or high-risk. In older adults, RSV infection can lead to complications that are similar to those resulting from seasonal influenza infection. The aim of this study was to compare the morbidity and mortality in older adults ≥60 years hospitalized with RSV disease vs. those hospitalized with seasonal influenza.

Methods

This cohort study included members of Kaiser Permanente Southern California aged ≥ 60 years who tested positive for RSV or influenza A/B by multiplex RT-PCR in clinical diagnostic testing during January 1, 2011 to June 30, 2015 and were hospitalized. For multiple eligible hospitalizations, only the first RSV hospitalization for the RSV cohort or first influenza A/B hospitalization for the influenza cohort was included. Electronic medical records for each hospitalized individual were used to extract necessary information, including baseline characteristics, symptoms, comorbidities, and outcomes.

Results

The study included 664 RSV (mean age 78.5 years, 39.5% male) and 1922 influenza A/B (mean age 77.5 years, 49.7% male) hospitalizations. There were 310 (46.7%) RSV patients and 501 (26.1%) influenza patients with a diagnosis of pneumonia. There were 119 RSV patients (17.9%) vs. 272 (14.2%) influenza patients that were admitted to the intensive care unit during hospitalization (mean stay 6.8 vs. 7.8 days). The short-term mortality rate during hospitalization and within 90 days of discharge was 5.6% (n = 37) and 7.4% (n = 49) in the RSV cohort vs. 4.4% (n = 85) and 6.7% (n = 129) in the influenza cohort. The intermediate-term mortality rate within 91–180 days of discharge was significantly different between the RSV and the influenza cohorts (4.4% vs. 2.5%).

Conclusion

RSV infection can lead to complications and severe outcomes that are similar to those of seasonal influenza in older adults. Effective prevention and treatment strategies such as vaccination and antivirals against RSV could potentially reduce the burden of RSV infection as well as complications from disease.

Disclosures

H. F. Tseng, Novavax: Grant Investigator, Research grant. L. S. Sy, Novavax: Collaborator, Research grant. C. Fischetti, Novavax: Collaborator, Research grant. J. Slezak, Novavax: Collaborator, Grant recipient. Y. Luo, Novavax: Collaborator, Grant recipient. Z. Solano, Novavax Inc.: Collaborator, My employer received research funds to conduct the study. S. Chen, Novavax: Collaborator, Research grant. V. Shinde, Novavax Inc.: Collaborator, My employer received research funds to conduct the study.
Haemophilus Influenzae Type B Invasive Disease in a Pediatric Hospital of Argentina
Authors: Yfran Eduardo Walter , Ferolla Fausto M , Carballo Carolina , Del Pont Maria Marco , Acosta Carolina , Pasinovich Marina Elisa , Lobo Carlos Mauricio Vergara , Cazes Claudia I , Praino Maria Laura , Campoverde Christian , Contrini María M , Lopez Eduardo L
Published: October 2017

Background

Since

The vaccination strategy is a three-dose primary series (at two,

Active surveillance is important to opportunely detect variations on these trends.

Methods

Cross-sectional study, including all hospitalized patients with Hib infection since 2012 to May 2017 at Hospital de Niños “Ricardo Gutiérrez” in Buenos Aires, Argentina.

Results

Twenty previously healthy children were admitted. Male/female ratio 1.8:1. Median age: 12 (range 45 days-114) months; 85% younger than 2 years and 35% younger than 6 months. Nine patients (45%) had complete vaccination schedule, with three or more doses of DTP-Hib-HBV vaccine. Hospitalization Hib infections by year in Table 1.

Clinical presentation: meningitis (14/20), pneumonia (6/20) and arthritis (5/20), osteomyelitis (1/20). All patients with meningitis, 25% of pneumonias and 50% of arthritis had positive blood cultures. Hib was isolated from blood in 17/20 cases, cerebrospinal fluid in 7/14, joint fluid in 3/5 and pleural fluid in 2/6. Median WBC: 12,400/mm3 (1,600–42,900) and median C-reactive protein level 111 mg/L (7–358). Median days of hospitalization was 13 (8–40). Nine patients required intensive care, four of them required mechanical ventilation. None patients died. Immunological studies ruled out immunodeficiency in 10 patients, although four continues under study.

Conclusion

(i) Burden of invasive Hib infections have increased over the last few years in our setting. (ii) Most of patient had adequate immunization schedule for age; (iii) Surveillance studies should be continued to confirm these preliminary results as well as to evaluate possible causes.

Disclosures

All authors: No reported disclosures.
Single-Dose Universal Hepatitis A Immunization in 1-Year-Old Infants in Argentina: High Prevalence of Protective Antibodies up to 11 Years Following Vaccination
Authors: Urueña Analia , González Jorge , Carrega Maria Eugenia Perez , Rearte Analía , Uboldi Andrea , Calli Rogelio , Cañero-Velasco María Cristina , Vizzotti Carla
Published: October 2017

Background

Single-dose Hepatitis A Virus (HAV) vaccination was implemented for all Argentinean children aged 12 months in 2005, instead of the standard two-dose schedule. Previous studies demonstrated a dramatic decline in HAV infection rates, fulminant hepatitis, and liver transplantation along with low viral circulation and high prevalence of protective antibody response 8 years following the intervention. This study assessed long-term seroprotection against HAV after vaccination with this novel scheme.

Methods

Children who received one dose of HAV vaccine at 1 year of age, at least nine years before enrollment, were included at three centers in Argentina between May 2015 and April 2016. Demographic and socio-economic characteristics of the child, mother and house were collected through a questionnaire after informed consent signature. Blood samples were tested for anti-HAV antibodies. Antibody titers ≥10 mIU/mL were considered seroprotective. Logistic regression analysis was done to evaluate associations between different variables and seroprotection.

Results

Of 1119 children included, 97.0% lived in urban areas, 92.7% had safe water access and 57.8% had sewers at home. Mean age was 10.7 years, and the mean post-vaccination interval was 9.7 years (Range: 9.0–11.3 years). Of the total, 87.6% had protective antibodies against HAV. Higher seroprotection rates were observed in Santa Fe compared with the global rate (91.9% vs. 87.6%; OR 1.94 (95% CI: 1.27–2.95); P = 0.002). In contrast, lowest rates resulted in San Justo, Buenos Aires (81.4% vs. 87.6% OR 0.45 (95% CI: 0.32–0.65); P <0.001). No association between socio-economic variables and seroprotection was found. Geometric mean concentration (GMC) of HAV Ab titers was 28.0 mIU/mL (95% CI: 26.8–29.3 mIU/mL).

Conclusion

Single-dose universal hepatitis A immunization in infants resulted in sustained immunologic protection up to 11 years in Argentina. Lower seroprevalence rates in San Justo have no clear reason and were not associated with an increase in HAV cases in that area. These findings, along with the low current disease burden confirm the success of the intervention.

Disclosures

All authors: No reported disclosures.
Cord Blood Antibody Seroprevalance Against Diphtheria, Pertussis, Measles, Mumps and Rubella among Term Healthy Indian Newborns
Authors: James Deepak , Lavanya Jula , Verma Sanjay , Rawat Amit , S Venkataseshan , Aggarwal Neelam
Published: October 2017

Background

The resurgence of vaccine preventable diseases in young infants is a matter of concern worldwide. The aim of our study was to determine the seroprevalance of protective antibodies against diphtheria, pertussis, measles, mumps and rubella antigens in cord blood among term Indian newborns, at birth.

Methods

Apparently healthy term newborns, delivered at a tertiary care hospital in Northern India, over two year period (Apr 15-March 17) were enrolled after taking informed written consent from their parents; and their cord blood sample was collected. Ethical clearance was obtained from Institute Ethics committee, before enrolling subjects. Cord blood samples were tested for antibodies using commercial ELISA kits IMMUNOLAB IgG.

Results

A total of 160 newborns (M:F = 86:74) were enrolled. In our study, antibodies (IgG) against diphtheria toxin (DT) were > 0.1 IU/mL in 44.4% (71/160), 0.01 to 0.1 IU/mL in 53.1% (85/160) and < 0.01 IU/mL in 2.5% (4/160). None of their mothers received Tdap vaccine in past. Antibodies (IgG) against pertussis toxin (PT) > 40 U/mL were seen in 41.2% (66/160). Out of these 66 children, 23 had titres > 100 U/mL. Total of 58.8% (94/160) children had antibodies < 40 U/mL. Out of these 94 children, 48 had titers < 20 U/mL.

Antibodies (IgG) against measles antigen were > 12 IU/mL in 88.8% (142/160). A total of 11.2 (18/160) had titers below 12 IU/mL. Out of these 18 children, 5 had titers < 6 IU/mL. Antibodies (IgG) against mumps antigen were > 12 IU/mL in 83.1% (133/160). A total of 16.9% (27/160) had titers below 12 IU/mL. Out of these 27 children, 12 had titers < 6 IU/mL. Antibodies (IgG) against rubella antigen were > 12 IU/mL in 83.7% (134/160). A total of 16.3% (26/160) had titers below 12 IU/mL. Out of these 26 children, 22 had titers < 6 IU/mL.

Conclusion

Only 44.4% of studied newborns were fully protected (> 0.1 IU/mL) against diphtheria, because of maternal antibodies. As correlates of protection for pertussis are not yet defined; those having anti-PT titers >100 IU/mL i.e., 14.3% (23/160) were most protected; while those having titers < 20 U/mL i.e., 30% (48/160) were least protected. Out of studied newborns, fully protected (>12 IU/mL) against measles, mumps and rubella were 88.8%, 83.1% and 83.7% respectively.

Acknowledgement. PGI Intramural research grant

Disclosures

All authors: No reported disclosures.
Varicella Vaccination Coverage among Adolescents Ages 13–17 Years, United States, National Immunization Survey, 2007–2014
Authors: Leung Jessica , Reagan-Steiner Sarah , Lopez Adriana S , Jeyarajah Jenny , Marin Mona
Published: October 2017

Background

Varicella is typically a self-limiting disease but it can be more severe in adolescents and adults. In 2007, 2-doses of varicella vaccine were routinely recommended for children, with a catch-up second dose for persons who received 1 prior dose.

Methods

We used 2007–2014 NIS-Teen data to examine trends in ≥2 dose varicella vaccination coverage and proportions of adolescents with/without evidence of immunity to varicella. Evidence of immunity included receipt of ≥2 doses of varicella vaccine or varicella disease history. Additionally, using 2014 data, we assessed characteristics of ≥2 dose varicella vaccination coverage: 1) factors associated with ≥2 dose vaccination, 2) timing of receipt of second dose and 3) missed opportunities for second dose vaccination among adolescents who had received 1 prior dose of varicella vaccine.

Results

During 2007–2014, the proportion of adolescents with ≥2 doses of varicella vaccine increased from 8.3% to 66.9% in 13–15 year olds, and from 3.6% to 56.7% in 16–17 year olds. The proportion of adolescents with evidence of varicella immunity also increased for both age groups, from 68.0% to 84.1% in 13–15 year olds and from 78.6% to 83.4% in 16–17 year olds. Among adolescents who received ≥2 doses of varicella vaccine by 2014, a higher proportion of 13–15 year olds received their second dose at 4–6 years compared with 16–17 year olds (13.4% vs. 3.2%). Factors significantly associated with lower ≥2 dose coverage included non-Hispanic White race/ethnicity; rural residence; living at >133% of the income-to-poverty ratio; no 11- to 12-year well-child visit; not receiving an adolescent vaccine; and residence in a state with no 2-dose immunization school entry requirement. Among the 2,478 adolescents who received only 1-dose of varicella vaccine, 77.1% (1,922) had at least 1 missed opportunity to receive their second dose; potentially 2-dose coverage could have increased from 79.5% to 94.8%.

Conclusion

The ≥2-dose varicella vaccination coverage and the proportion of adolescents with evidence of immunity to varicella increased during 2007 to 2014, though 16% lacked evidence of immunity in 2014. Though catch-up campaigns have succeeded, decreasing missed vaccination opportunities will help with further improvement.

Disclosures

All authors: No reported disclosures.
Use of a Precision Antibiotic Therapy (PAT) Prediction Model to Identify Multidrug-Resistant (MDR) Enterobacteriaceae
Authors: Varga Alexandra , Cressman Leigh , Lautenbach Ebbing , Cluzet Valerie , Tolomeo Pam , Bilker Warren , Hamilton Keith
Published: October 2017

Background

Emergence of multidrug-resistant (MDR) Enterobacteriaceae complicates the selection of empiric antibiotic therapy. Software called Precision Antibiotic Therapy (PAT) (Teqqa, LLC; Jackson, WY) operationalizes a predictive model using patient factors to make real-time, personalized predictions of antibiotic susceptibility for each antibiotic, allowing prescribers to choose empiric therapy for patients at risk for resistant infections. The purpose of this study was to determine the performance of PAT software in identifying MDR Enterobacteriaceaebloodstream infections (BSI) as well as to determine optimal thresholds of predicted antibiotic susceptibility to choose a broader-spectrum antibiotic.

Methods

We conducted a retrospective cohort study including 475 unique patients with BSIs caused by Enterobacteriaceaefrom January 1, 2016 through December 31, 2016. First-line antibiotic therapy for BSI was defined as cefepime, piperacillin-tazobactam, levofloxacin, or aztreonam. Susceptibilities predicted by PAT were compared with known susceptibilities determined by routine laboratory testing. PAT thresholds for broadening antibiotics were assessed when predicted susceptibilities were 80%, 85%, 90%, and 95% using receiver-operating characteristic (ROC) curves. Performance characteristics were calculated for each threshold. Brier score calculations were then used to compare the accuracy of PAT predictions using the optimized predicted susceptibility threshold, to that of aggregate institutional susceptibility data.

Results

ROC curve analysis demonstrated an area under the curve of 0.82 for the 95% threshold. The sensitivity for the PAT prediction utilizing the 95% threshold was 91.7% with a specificity of 74.3%. The Brier score for the 2016 antibiogram to determine antibiotic therapy was 0.085, whereas the Brier score using PAT software was 0.071, representing a 16% improvement in accuracy.

Conclusion

PAT software demonstrated excellent capability to discriminate between Enterobacteriaceae BSIs resistant and susceptible to first-line therapy. A predicted susceptibility threshold of 95% should be used to indicate a need for escalation of empiric antibiotic therapy using PAT.

Disclosures

All authors: No reported disclosures.
Opportunities in the Acute Care Setting for Infectious Diseases/Hospitalist Patient Co-Management
Authors: Gupta Siddhi , Bansal Amit , Newman Eric , Martin Stanley
Published: October 2017

Background

In an inpatient setting, Infectious Diseases (ID) physician care may lead to lower mortality rates and readmissions. When consultation is performed earlier in the admission, outcomes may even be better. The model of individual consultative care that relies on primary services calling specialists to give recommendations can lead to missed opportunities for optimal diagnostic testing and antimicrobial utilization. Having ID specialists involved in the care of the hospitalized patient from the time of admission creates a unique opportunity for timely intervention that could have long-ranging effects.

Methods

Patients admitted to four of the non-teaching hospitalist services at Geisinger Medical Center over two separate weeks included automatic ID evaluation within 24 hours of admission. The ID physician reviewed the chart and records of each admission to determine whether the patient was being treated for an infection. Any potential ID-related interventions identified upon initial evaluation were recorded by the ID physician. Patients were excluded if formal ID consultation was requested.

Results

A total of 85 patients were admitted during the study and 84 were included for review. Forty-five (53.6%) were admitted for a total of 48 infection-related reasons and another 17 (20.2%) were found to have incidental infection-related findings. Seven patients had requests for formal ID consultation placed (8.3%). Of the remaining primary ID diagnoses on admission, 33 were accurate by ID physician assessment (68.8%) and empiric therapy was appropriate in 29 (60.4%). Of the incidental infection-related diagnoses, 12 (70.5%) were considered accurate and empiric therapy was appropriate in 12 (70.5%). Among primary ID diagnoses, 60 diagnostic testing opportunities and 25 potential therapeutic improvements were identified (Figures).

Conclusion

Despite the limitations of relying on medical records alone, when done in real time, a large number of opportunities exist to optimize diagnostic testing and antimicrobial use in the acute care setting. As healthcare moves away from fee-for-service models to population health, the concept of an ID physician/hospitalist co-management model of inpatient care should be explored further.

Disclosures

All authors: No reported disclosures.
Implementation of a Centralized Infectious Diseases Telehealth (IDt) Service for 16 Small Community Hospitals
Authors: Vento Todd J , Gelman Stephanie S , Veillette John J , Adams Mary A , Repko Katherine A , Jones Peter S , Webb Brandon J , Dascomb Kristin K , Lopansri Bert K , Stenehjem Edward A
Published: October 2017

Background

The majority of U.S. small community hospitals (SCHs) lack access to infectious diseases (ID) subspecialists. Telehealth can extend ID expertise to such facilities. We describe lessons learned from implementing a new IDt program for 16 SCHs in the Intermountain Healthcare system in Utah and Idaho.

Methods

From October 1, 2016 to April 30, 2017, we implemented an IDt service comprised of: a 24-hour ID physician advice line; an inpatient ID consult service that provided chart review and documentation (e-consults) and daytime telemedicine consultation (TC) using encrypted, HIPAA-compliant, synchronous, 2-way audio-video connection; and an ID pharmacist-led antibiotic stewardship program. The IDt service included a medical director, operations officer, ID pharmacist, analyst, and rotating ID physicians, and was implemented in a step-wise manner at 16 SCHs. IDt requests were received through a dedicated phone line with duplicate transcription to a monitored email inbox or generated from daily antibiotic stewardship rounds.

Results

The physician advice line was operational for all 16 SCHs on October 1, 2016. 312 advice-only calls were fielded (92 per 1000 hospital-days covered) through April 30, 2017. Common infections requiring phone advice included: bloodstream (16%), genitourinary (13%), and musculoskeletal (12%). E-consult and TC services were operational at 11 SCHs by April 30, 2017 (hospital-days covered: 1074). The IDt service completed 104 eConsults, 163 TCs, and 1198 stewardship reviews. Mean time [minutes (range)] spent per case was 16 (5–30) for eConsults and 55 (30–120) for TCs [on-camera time: 25 (12–46)]. Common infections requiring e-consult or TC were: bloodstream (45%), musculoskeletal (16%), and skin/soft tissue (11%). 22 patients (14%) seen by TC were surveyed: 100% felt the service improved their care and was necessary at their SCH. 97% of surveyed SCH staff felt the IDt service improved patient care and 90% felt it was a necessary service (32% response from 98 providers, nurses, pharmacists).

Conclusion

A new IDt service was well utilized and received by SCH staff and patients, with bloodstream infections being the most common reason for consultation. Future steps include evaluation of the IDt effect on clinical outcomes, financial metrics, and staff education on common ID conditions.

Disclosures

All authors: No reported disclosures.
Stability of Anidulafungin in Concentrated Pharmaceutical Solution
Authors: Yap Chien , Ho Chi Lui , Lim Yin Shan , Yeoh Siang Fei
Published: October 2017

Background

Currently, the reconstitution instructions in the package insert indicate that 100 mg of anidulafungin powder is to be dissolved in 30 ml of sterile water for injection and this reconstituted solution is to be further mixed with 100 ml of either normal saline (NS) or dextrose 5% (w/v) (D5) to give a final infusion solution of concentration 0.77 mg/mL. The compatibility of the reconstituted solution with diluents other than NS or D5 has not been established and there is no literature to support the the use of a more concentrated infusion solution. Thus, the infusion solution prepared strictly according to the method described by the manufacturer may pose a problem clinically in patients who are indicated for treatment with anidulafungin but require fluid restriction. In order to meet the needs of the abovementioned patient populations in the clinical setting, it is imperative to establish the stability of suitable anidulafungin infusion solutions prepared in diluents that are appropriate to the patients but differ from that set forth by the manufacturer

Methods

After an initial validation of the HPLC-MS/MS method, the concentration of the anidulafungin solutions was determined over 48/72 hours. Other parameters assessed were pH, osmolality and particulate matter.

Results

100 mg of anidulafungin powder was soluble in 15 ml of sterile water and this reconstituted solution was stable for at least 24 hours at 25. Anidulafungin infusion solutions of concentration 2 mg/mL prepared using diluents like NS, D5, half normal saline (HNS) and NSD5 were stable for at least 72 hours at 25. If the diluent was HNSD5, the infusion solution of concentration 2 mg/mL was stable for at least 48 hours at 25. All of the anidulafungin solutions tested were of acceptable standard for an injection in terms of pH, osmolality and particulate matter

Conclusion

The method of preparation employed yielded anidulafungin solutions of suitable stability for clinical use and can be adopted should there be a need to differ from the manufacturer’s recommended preparation method. We may use these concentrated preparations for patient with central line like in ICU or OPAT setting

Disclosures

All authors: No reported disclosures.
Incidence of Acute Kidney Injury Among Intensive Care Unit Patients Receiving Vancomycin in Combination with Cefepime or Piperacillin–Tazobactam
Authors: Rutter W Cliff , Burgess David S
Published: October 2017

Background

Combination therapy with piperacillin-tazobactam (TZP) and vancomycin (VAN) has been associated with increased AKI incidence when compared with cefepime (FEP) and VAN. However, this was not seen in critically ill patients, we hypothesized that critically ill patients receiving TZP+VAN would have a higher AKI incidence compared with those receiving FEP+VAN.

Methods

Clinical and demographic data were collected from the University of Kentucky Center for Clinical and Translational Science Enterprise Data Trust. Adult patients were included if they received TZP+VAN or FEP+VAN for ≥ 48 hours in the ICU. Patients were excluded for initial CrCl < 30 mL/minute, receipt of other β-lactam agents, past medical history of CKD. AKI cases were identified via the RIFLE criteria. Variables were analyzed via appropriate statistical tests. Patients were propensity score matched on a 1:1 basis on variables that were significantly different at baseline or associated with AKI.

Results

Overall, 1871 patients were included in this study, with 1205 receiving TZP+VAN and 666 receiving FEP+VAN. At baseline, TZP+VAN patients were older (56 [45–65] vs. 52 [37–63] years; P < 0.00001). Vasopressor exposure was more common in the FEP+VAN group (32.6% vs. 27.0%, P = 0.01). AKI incidence was higher in the TZP+VAN group (31.8% vs. 18.0%, P < 0.00001). Following matching, 1282 patients were included with 641 patients in each group. The cohorts were similar in baseline AKI risk factors, except hypertension (TZP+VAN 59.4% vs. 53.4%, P = 0.03), and loop diuretic exposure (53.4% vs. 46.7%, P = 0.02). AKI was significantly more common in TZP+VAN patients (34.2% vs. 17.8%, P < 0.00001) and after controlling for remaining confounders, TZP+VAN had 2.51 times the odds of experiencing AKI than those in the FEP+VAN (95% CI 1.9–3.34). Other factors associated with increased odds of AKI included: increasing severity of illness, higher baseline renal function, exposure to calcineurin inhibitors, vasopressors, and loop diuretics, diagnosis of heart failure, and duration of antimicrobial therapy > 7 days.

Conclusion

TZP+VAN therapy is associated with significant increases in AKI in critically ill patients compared with those who received FEP+VAN independent of other AKI risk factors.

Disclosures

All authors: No reported disclosures.
Is There a Significant Difference in Acute Kidney Injury Incidence Among Patients Treated with Vancomycin Combined with Cefepime or Meropenem?
Authors: Rutter W Cliff , Burgess David S
Published: October 2017

Background

Acute kidney injuries (AKIs) are common among patients receiving concomitant vancomycin (VAN) and piperacillin-tazobactam, especially compared with cefepime (FEP) with vancomycin. It is unknown if there is a significant difference between therapeutic alternatives to piperacillin-tazobactam. We hypothesized that AKI rates would be similar in patients treated with FEP+VAN and meropenem (MEM)+VAN.

Methods

Demographic and clinical data were abstracted from the University of Kentucky Center for Clinical and Translational Sciences Enterprise Data Trust from 2008 through 2015. Patients were included if they received VAN and FEP or MEM in combination for ≥48 hours. Patients with baseline CKD and creatinine clearance <30 mL/minute were excluded. AKI was defined as meeting any of the Risk, Injury, Failure, Loss, End-stage (RIFLE) criteria. Basic descriptive statistics were performed in addition to bivariable and multivariable logistic regression for AKI.

Results

In total, 3662 patients were included in this study with 3366 patients receiving FEP+VAN and 296 receiving MEM+VAN. Demographic characteristics were evenly distributed among both groups, with the exception of Charlson comorbidity index (MEM+VAN 4 [2–6] vs. 3 [1–6], P = 0.0002), and exposure to aminoglycosides (MEM+VAN 18.2% vs. 13.2%, P = 0.02) and calcineurin inhibitors (MEM+VAN 6.1% vs. 2.7%, P = 0.002). AKI incidence was similar between group (MEM+VAN 12.8% vs. FEP+VAN 10.8%, P = 0.33). After multivariable logistic regression, there was no significant increase in AKI odds with MEM+VAN compared with FEP+VAN (adjusted odds ratio = 1.02; 95% CI 0.67–1.50). Factors associated with increased AKI odds included: male gender, increased baseline comorbidity, age >80, increased duration of antimicrobial therapy, hypotension, increased baseline renal function, and exposure to aminoglycosides, amphotericin B, non-steroidal anti-inflammatory drugs, loop diuretics, or vasopressors.

Conclusion

No difference in AKI incidence was found between patients treated with MEM+VAN or FEP+VAN. Other clinical factors, aside from AKI potential, should be considered when choosing between alternatives to piperacillin-tazobactam combined with vancomycin.

Disclosures

All authors: No reported disclosures.
Correlations Between Environmental Factors and Increasing Lyme Disease Incidence in Canada
Authors: Koffi Jues , Gasmi Salima
Published: October 2017

Background

Lyme disease (LD) is an emerging infectious disease in Canada due to northward expansion of the geographic range of Ixodes scapularis, the principal tick vector for the LD agent Borrelia burgdorferi, into central and eastern Canada. This study aims to i) summarize the surveillance data for LD cases reported in Canada between 2009 and 2015, ii) identify potential environmental risk factors and iii) develop an acarological risk indicator from passive surveillance for occurrence of human cases.

Methods

We described the distribution, trends, demographic and clinical characteristics of cases of the disease. Logistic regression models were used to identify risk factors for the occurrence of LD: 1) demographic (age and sex), and 2) environmental (type of forest cover, temperature and abundance of ticks). Passive surveillance data were used to develop an acarological indicator of at-risk areas for LD.

Results

The number of reported LD cases increased more than six-fold overall, from 144 cases in 2009 to 917 cases in 2015, mainly due to locally acquired infections. LD incidence in Nova Scotia has risen sharply since 2013 and was the highest in Canada over the study period. Children below 15 years and adults of the 55–74 age groups reported highest incidence. Significantly more men than women were infected and men had significantly more symptoms of late disseminated LD than women. Variability in clinical manifestations is observed between provinces, years, for children below 15 years and between age groups. The majority of cases were reported between April and November and there was an increase in risk areas. The abundance of Ixodes scapularis ticks collected on humans and deciduous forest cover were significantly associated with the occurrence of LD cases at the municipality scale. Passive surveillance provides a cost-effective alert tool for public health authorities to timely identify risk areas and target vulnerable populations and front-line health professionals by means of awareness campaigns.

Conclusion

These findings showed that LD continues to increase in Canada, both over time and geographically, underlining the need to implement better preventive strategies, early disease recognition and treatment and efficient surveillance systems.

Disclosures

All authors: No reported disclosures.
Patient Safety and Efficacy of Metronidazole 1 g Intravenous Every 24 Hours
Authors: Desai Alpa , Burdette Steven
Published: October 2017

Background

Metronidazole (MTZ) is an imidazole that is used to treat parasites and anaerobic infections. The traditional dose of 500 mg every 6 to 8 hours achieves adequate serum concentration to treat most anaerobic infections. MTZ has a concentration dependent bactericidal activity with a long half-life of 8 hours and also exhibits post-antibiotic effect. The literature lacks clinical data in regards to a once daily higher dose of IV MTZ.

Methods

A retrospective quality improvement project via electronic medical record review of 88 adults who received MTZ 1 gm IV daily at a single tertiary medical center, from April 2014 to October 2016. Inclusion criteria were patients >/=18 years who received MTZ 1 gm IV every daily for >/= 48 hours.

Results

Of the 88 patients who received 1 gm of MTZ, 66 met inclusion criteria. Mean age was 58 years (range 24 to 90 years). Indications for use are shown in Figure 1. Mean duration of therapy was 10 days (range 2 to 42 days). Twenty-nine (43.9%) received </= 6 days and 37 (56.1%) received >/= 7 days. Fourteen (21%) were discharged home on MTZ 1 gm IV daily for 4–6 weeks duration. One patient had a documented adverse reaction (severe nausea) while the other 65 tolerated well. No documented treatment failure was reported.

Conclusion

MTZ has been used in combination with other antimicrobial agents to treat polymicrobial infections. It is generally well tolerated when administered in dosages of <2gm per day. Pharmacodynamic studies have demonstrated activity for 12 to 24 hours after administration of 1 gm of MTZ. Our study showed no safety concerns with 1 gm daily dosing and no reported treatment failure. The limitation of our study includes lack of comparative cohort. The potential advantages of once daily dosing include optimized bacterial killing, minimization of drug administration, and reduction of the cost of antibiotics as well as the cost of administration. Our safety and quality improvement project support that MTZ 1 gm IV daily dose is potentially a safe, efficacious and cost effective alternative to three times dosing especially in hospitalized patients and may have role in OPAT.

Disclosures

All authors: No reported disclosures.
Risk Factors for Community Acquired Extended-Spectrum Β-lactamase (ESBL) Producing Enterobacteriaceae Urinary Tract Infections (UTIs)
Authors: Goyal Dheeraj , Dascomb Kristin , Jones Peter S , Lopansri Bert K
Published: October 2017

Background

Community-acquired extended-spectrum β-lactamase (ESBL) producing Enterobacteriaceae infections pose unique treatment challenges. Identifying risk factors associated with ESBL Enterobacteriaceae infections outside of prior colonization is important for empiric management in an era of antimicrobial stewardship.

Methods

We randomly selected 251 adult inpatients admitted to an Intermountain healthcare facility in Utah with an ESBL Enterobacteriaceae urinary tract infection (UTI) between January 1, 2001 and January 1, 2016. 1:1 matched controls had UTI at admission with Enterobacteriaceae but did not produce ESBL. UTI at admission was defined as urine culture positive for > 100,000 colony forming units per milliliter (cfu/mL) of Enterobacteriaceae and positive symptoms within 7 days prior or 2 days after admission. Repeated UTI was defined as more than 3 episodes of UTI within 12 months preceding index hospitalization. Cases with prior history of ESBL Enterobacteriaceae UTIs or another hospitalization three months preceding the index admission were excluded. Univariate and multiple logistic regression techniques were used to identify the risk factors associated with first episode of ESBL Enterobacteriaceae UTI at the time of hospitalization.

Results

In univariate analysis, history of repeated UTIs, neurogenic bladder, presence of a urinary catheter at time of admission, and prior exposure to outpatient antibiotics within past one month were found to be significantly associated with ESBL Enterobacteriaceae UTIs. When controlling for age differences, severity of illness and co-morbid conditions, history of repeated UTIs (adjusted odds ratio (AOR) 6.76, 95% confidence interval (CI) 3.60–13.41), presence of a urinary catheter at admission (AOR 2.75, 95% CI 1.25 – 6.24) and prior antibiotic exposure (AOR: 8.50, 95% CI: 3.09 – 30.13) remained significantly associated with development of new ESBL Enterobacteriaceae UTIs.

Conclusion

Patients in the community with urinary catheters, history of recurrent UTIs, or recent antimicrobial use can develop de novo ESBL Enterobacteriaceae UTIs.

Disclosures

All authors: No reported disclosures.
Why and Where We Choose to Treat Children with Intravenous Antibiotic for Febrile Urinary Tract Infection/Pyelonephritis
Authors: Scanlan Barry , Ibrahim Laila , Hopper Sandy , Babl Franz , Davidson Andrew , Bryant Penelope
Published: October 2017

Background

Febrile UTI/pyelonephritis is a common diagnosis for children presenting to the Emergency Department (ED). A Cochrane review of the management of pyelonephritis in children showed no difference between intravenous (IV) and oral antibiotics. Despite this, many children are treated with at least initial IV antibiotics. The reasons are often unclear and it is uncertain whether this is appropriate as the Cochrane review excluded children at the worse end of the clinical spectrum. Our aim was to determine why physicians made these decisions as a first step in determining whether this is necessary.

Methods

A prospective observational study of children presenting to the ED at the Royal Children’s Hospital with UTI/pyelonephritis from Oct 2016 – Apr 2017. Data collection included demographic, clinical features, microbiology, treatment and outcomes. ED physicians were asked to record reasons for prescribing IV antibiotics and for treating the patient in hospital vs. in hospital-in-the-home (HITH).

Results

170 children were included, 123 (72%) were treated with oral antibiotics, 43 (25%) IV and 4 (3%) intramuscular – these are now included in the IV group. In the IV group, 32 (19%) were admitted, 3 (2%) were transferred directly to HITH from ED and 13 had a single dose of IV antibiotics in ED and were discharged. A comparison of the clinically significant features between the two groups is outlined (Table 1). The commonest reasons cited for using IV antibiotics and for hospital admission vs. HITH is shown (fig 1 and 2).

Conclusion

This is the first study of decision-making for IV antibiotics and hospital admission for UTI/pyelonephritis in children. The fact that the reasons cited for IV antibiotics were often not evident on objective clinical data suggests that there may be overuse of IV antibiotics. We will present an assessment of appropriateness and suggest alternatives to the traditional IV and hospital admission route.

Disclosures

All authors: No reported disclosures.
Assessment of Reflex Urine Culture Criteria Changes and its Impact on Treatment of Asymptomatic Bacteriuria
Authors: Wold Kirre , Brock Jeff , Percival Kelly , Rearigh Lindsey , Vocelka Lucas , Afroze Aneesa
Published: October 2017

Background

Asymptomatic bacteriuria (ASB) is a common clinical condition identified by the presence of bacteria in the urine of a patient without signs and symptoms of a urinary tract infection (UTI). Treatment of ASB leads to unnecessary antimicrobial use and can cause more harm than benefit in many patients. This study is to determine the impact of more stringent criteria for urinalysis with culture if indicated (UAC), implemented in September 2016, on the treatment of asymptomatic bacteriuria.

Methods

A pre-post descriptive study of patients was conducted with an order placed for UAC in the Emergency Department (ED) or hospital. Data was collected retrospectively via chart reviews. The data on ASB patients from November 2015 to April 2016 was compared with the post-implementation period October 2016 to January 2017. The number of UAC orders and cultures were averaged for 6 months pre and post implementation of the criteria change.

Results

A total of 580 patient charts were assessed post-implementation of the UAC criteria change. A majority of the orders originated from the ED, (N = 430, 72.8%). ASB was treated inappropriately at a rate of 60.4% (N = 64/106) pre-implementation and a rate of 65% (N = 41/63) post implementation, P = 0.542. The total number of UAC ordered before and after implementation did not change, (N = 2852 pre-intervention vs N = 2825 post-intervention, P = 0.744), as seen in Figure 1. However, the number of reflexed urine cultures did significantly decrease post criteria change,  (N = 1056 pre-intervention vs. N = 603 post-intervention, P < 0.0001). In addition, the number of positive urine cultures also significantly decreased, (N = 378 pre-intervention vs. N = 289 post-intervention, P = 0.0447). The impact the criteria change had on patient care is the number of potential antibiotic courses saved by reflexing fewer urine cultures off the UAC. Based on the decrease in positive urine cultures, it is estimated 702 courses of inappropriate antibiotics for ASB could be saved per year (59/month).

Conclusion

More stringent criteria for reflex urine cultures significantly decreases the number of urine cultures performed, therefore decreasing the number of patients treated with ASB. Additional stewardship measures are necessary to reduce the treatment of ASB for patients who have cultures performed.

Disclosures

All authors: No reported disclosures.