bluuebunny/crossref_metadata_2025 huggingface dataset:
2327. 2018–2019 Seasonal Epidemiology of Infections Caused by Influenza Viruses and RSV in Ecuadorean Children Less than 5 Years of Age Residing at Opposite Extremes of Elevation
Authors: Jose Moubarak Marie , Bonville Cynthia A , Domachowske Joseph B , Suryadevara Manika , Salazar-Gomez Gloria M , Borbor-Cordova Mercy J , Sippy Rachel , Cueva-Aponte Cinthya , Ortiz-Prado Esteban , Hidalgo Ivan , Victoriano-Aguilar Guillermo , Pizarro-Fajardo Freddy
Published: October 2019

Background

The epidemiology of ambulatory acute respiratory tract infections (ARTI) caused by influenza viruses and respiratory syncytial virus (RSV) in young children is not well described in Ecuador. The seasonality of these infections vary across and within tropical countries experiencing different climates. Understanding trends that differ from one region to the next is needed to optimize implementation of effective preventive measures.

Methods

This 5-year prospective study compares the epidemiology of ARTI caused by influenza and RSV in children from Machala (6 m) and Quito (2,832 m), Ecuador. Children < 5 years presenting with ARTI for ≤7 days are eligible. Demographic and clinical data are gathered and a nasopharyngeal sample is collected for diagnostic testing using the Biofire FilmArray® respiratory panel platform that allows for the detection of 17 viruses.

Results

Between July 2018 and March 2019, we enrolled 446 subjects; 322 from Machala and 124 from Quito. Eighteen percent of the samples from Quito and 9% from Machala were positive for influenza viruses, while RSV accounted for 4% of the samples from Quito and 5% of those from Machala. The influenza B season at both elevations lasted 14 weeks, but started 5 weeks earlier in Machala (weeks 29–42 vs. weeks 34–47). Influenza B seasonal activity preceded influenza A at both sites. In Machala, the influenza A season began 6 weeks after the influenza B season (weeks 48–4), but overlapped with the influenza B season in Quito (weeks 45–2). In Machala, RSV was detected during the first week of surveillance (2018, week 29) but did not re-emerge to cause sustained activity until 2019, week 6. The RSV season began in Quito in 2018 during week 47, with sustained activity through the time of this report, 2019, week 12.

Conclusion

The 2018–2019 seasonal epidemiology of ARTI caused by influenza viruses and RSV differed between Ecuadorean children living close to sea level and those living at high elevation. Patterns of seasonal activity observed throughout the 5-year study period will facilitate decision-making regarding the optimal timing and duration for implementing existing and emerging prevention measures.

Disclosures

All authors: No reported disclosures.
2351. Rate and Consequences of Missed Clostridioides (Clostridium) difficile Infection Diagnosis from Non-disclosure of Clostridioides difficile Multiplex PCR Results. Two-Hospital Experience
Authors: Zacharioudakis Ioannis , Zervou Fainareti , Phillips Michael , Aguero-Rosenfeld Maria E
Published: October 2019

Background

It is common practice among microbiology laboratories in the United States to blind the BioFire FilmArray GI Panel results for Clostridioides (Clostridium) difficile (C. difficile) in fear of over-diagnosis of C. difficile infection (CDI).

Methods

We conducted a retrospective cohort study in 2 tertiary academic centers in New York to examine the rate of missed CDI diagnosis and the associated adverse outcomes from blinding the BioFire FilmArray GI Panel results for C. difficile. Of note, in one of the two included hospitals the list of daily positives is reviewed by an Infectious Diseases attending to determine whether cases have been tested for CDI and if not if they meet criteria for CDI. Adult patients with FilmArray GI Panel positive for C. difficile on admission to the hospital who lacked dedicated testing for C. difficile were included in the analysis and were stratified as possible, probable and definite cases of missed CDI diagnosis.

Results

Among the 144 adult patients with a FilmArray GI Panel test positive for C. difficile within 48 hours of hospital admission, 18 did not have a concurrent dedicated C. difficile testing. Eight patients were categorized as possible cases of missed CDI diagnosis, 5 as probable and 4 as definite, for a total of 17 cases of at least possibly missed CDI diagnosis. One case was considered to represent C. difficile colonization rather than infection for a rate of 6.9% of CDI over-diagnosis based on the FilmArray GI Panel results. Missed CDI diagnoses were associated with a delay in initiation of appropriate therapy, admission to the intensive care unit, hospital re-admission, colorectal surgery and death/discharge to hospice. Five out of 17 cases of missed CDI diagnosis (29.4%) lacked traditional risk factors for CDI.

Conclusion

In conclusion, the practice of concealing FilmArray GI Panel results for C. difficile may lead to a higher rate of missed CDI diagnosis than over-diagnosis and might need to be re-considered at least in patients with community-onset colitis of unknown etiology on presentation to the hospital.

Disclosures

All authors: No reported disclosures.
2376. Incidence of Clostridioides difficile Infection Among United States Medicare Advantage Enrollees
Authors: Heinrich Kirstin , Emir Birol , Ivanova Jasmina , Zhou Jingying , Yu Holly
Published: October 2019

Background

Clostridioides difficile infection (CDI) may be life-threatening, and individuals aged ≥ 65 years are at increased risk. CDI burden among Medicare fee-for-service enrollees and nursing home residents in the United States have been characterized previously. The present study aimed to describe the incidence of CDI among Medicare Advantage Enrollees (MAEs), who account for 34% of all Medicare beneficiaries with enrollment increasing annually since 2004.

Methods

De-identified claims data for this retrospective cohort study were collected from the Optum® Clinformatics® Data Mart and included MAEs aged ≥ 65 years with continuous enrollment for ≥ 1 year before January 1, 2016, followed through death or disenrollment. CDI incidence was defined using the International Classification of Diseases 9th Revision diagnosis code of 008.45 or 10th Revision code of A04.7 (other than admitting diagnosis) or by treatment with nontopical metronidazole, oral vancomycin, or fidaxomicin within 14 days of CDI test. Incident CDI cases were identified from January 1 to December 31, 2016, and required that no CDI occurred within the previous 60 days in 2016. Incidence in 2016 was calculated as CDI cases and CDI patients per 100,000 person-years (PY) of observation time.

Results

Of 2,542,341 MAEs analyzed, 15,201 patients (0.6%) experienced a total of 18,842 incident CDI episodes. Overall, incidence rates were 762.8 CDI cases and 616.5 CDI patients per 100,000 PY. Incidence increased with age (539.6, 847.3, and 1259.6 cases per 100,000 PY in patients aged 65‒74 years, 75‒84 years, and ≥ 85 years, respectively). Most episodes (50.9%) were community acquired; the remaining 37.7% and 11.4% of episodes were hospital acquired and indeterminate, respectively. CDI patients were more likely than non-CDI patients to be older (mean age, 78.3 vs. 76.1 years, P < 0.0001), be women (64.5% vs. 58.1%, P < 0.0001), or have comorbidities (mean Charlson comorbidity index score, 4.5 vs. 1.8, P < 0.0001).

Conclusion

CDI incidence rates in the Medicare Advantage population were similar to those reported previously in the Medicare fee-for-service population and nationally among adults aged ≥ 65 years. Data are consistent with a high CDI burden among older US adults.

Funding: Pfizer.

Disclosures

All authors: No reported disclosures.
2398. Effect of Eosinopenia and Binary Toxin on Clostridioides difficile Infection Clinical Outcomes
Authors: Carlson Travis J , Endres Bradley T , Le Pham Julie , Gonzales-Luna Anne J , Alnezary Faris S , Nebo Kimberly , Miranda Julie , Begum Khurshida , Alam M Jahangir , Garey Kevin W
Published: October 2019

Background

The ability of Clostridioides difficile to cause clinical disease in humans is dependent on toxin production. Significantly fewer eosinophils are seen in the peripheral blood of mice infected with a binary toxin positive (CDT+) C. difficile strain. Furthermore, the presence of CDT and eosinopenia have separately been associated with increased mortality in humans with C. difficile infection (CDI). We hypothesized that CDI due to a CDT+ C. difficile strain accompanied by peripheral eosinopenia would be associated with higher odds of inpatient mortality.

Methods

This multicenter, retrospective cohort study included all patients ≥ 18 years of age with toxigenic CDI in which specimen ribotype data were available as part of our ongoing surveillance study. The cohort was stratified by eosinophil count (0.0 cells/μL vs. > 0.0 cells/μL). The primary outcome was inpatient mortality. A logistic regression model was developed modeling inpatient mortality as a function of the available patient covariates. All P-values were from 2-sided tests, and results were deemed statistically significant at P < 0.05.

Results

A total of 688 patients from 13 institutions in six cities were included. Of those, 132 had a baseline eosinophil count of 0.0 cells/µL and 556 had a baseline eosinophil count > 0.0 cells/µL. While the odds of inpatient mortality were higher among patients with eosinopenia and those infected with a CDT+ ribotype, the combination of these variables remained an independent predictor of inpatient mortality after adjusting for CCI score, WBC count, and serum albumin level (OR, 7.84; 95% CI, 1.85–33.20; P = 0.005).

Conclusion

This is the first attempt to study the in vivo relationship between CDT presence, human immune response, and CDI clinical outcome. We identified an association between CDT presence with concomitant eosinopenia and worsened CDI outcomes. Healthcare facilities should consider identifying this important subset of patients at the time of CDI diagnosis. Future CDI drug development might benefit from targeting C. difficile properties that impair host immune response, which may in turn decrease adverse clinical outcomes associated with this disease.

Disclosures

All authors: No reported disclosures.
2406. Trends of Clostridioides difficile-Associated Diarrhea at a Tertiary Care Center in India
Authors: Khullar Swati , Chaudhry Rama , Agrawal Sonu , Kumar Lalit , Gupta Nitin , Wig Naveet , Ahuja Vineet
Published: October 2019

Background

Clostridioides difficile has been recognized as a significant cause of morbidity and mortality globally. Its infection can range from asymptomatic carriage to antibiotic-associated diarrhea and colitis. Reports of outbreak with the hypervirulent strain (N1/NAP1 Ribotype 027) has raised the concern on the magnitude and severity of C. difficile infections. This study aimed to determine the prevalence of C. difficile-associated diarrhea (CDAD) among the patients at a tertiary care hospital in India.

Methods

A retrospective analysis from January 2015-December 2018 was done to determine the trends of C. difficile infection. ELISA for detection of toxins A and B was performed on stool samples. A diagnosis of CDAD was made in all patients with stool samples positive for toxins A and B.

Results

Samples from 1311 patients were received from January 2015-December 2018 from patients with suspected nosocomial diarrhea. 9/1311 were culture positive for C. difficile, 7/9 were both culture and ELISA positive. A total of 74 patients were positive for ELISA for detection of toxins A and B. The prevalence of CDAD in the years 2015–2018 were as follows: 4.01% (10/249) in 2015, 10.03% (26/259) in 2016, 4.7% (21/446) in 2017 and 5.32% (19/357) in 2018, respectively. Malignancy was found to be the most common underlying pathological condition 15/69. Most common group of antibiotics used in these patients of CDAD were carbapenems 20/64. Amongst 82.6% (57/69) of the patients were hospitalized. Diarrhea was associated with fever in 40.5% (28/69) of the patients.

Conclusion

Our results show over all variable prevalence of CDAD over the years and was higher in the year 2016. Timely appropriate diagnosis, high index of suspicion in high-risk patients and proper implementation of antimicrobial stewardship programs may help in reducing morbidity and mortality in patients of CDAD.

Disclosures

All authors: No reported disclosures.
2408. Genotypic Corroboration of Epidemiologically Linked Clusters to Detect Outbreaks of C. difficile at a Tertiary Care Hospital
Authors: Bayoumi Nagla , McMillen Tracy , Aslam Anoshé , Kamboj Mini
Published: October 2019

Background

The Society for Healthcare Epidemiology of America (SHEA) recommends that surveillance for healthcare facility-onset C. difficile infections (HO CDI) be conducted to detect elevated rates or outbreaks of CDI and stratify data by hospital unit when possible to facilitate detection of clusters. At Memorical Sloan Kettering Cancer Center, strain typing of isolates using multi-locus sequence typing (MLST) is performed routinely and in real time to inform control efforts. Genotyping can conclusively establish or debunk transmission events based on routine surveillance. Management of C. difficile outbreaks is time and resource intensive.

Methods

A retrospective analysis was conducted to identify all nosocomial C. difficile cases between July 2013 and July 2018. Based on Memorial Sloan Kettering’s baseline surveillance data, a cluster of C. difficile was defined as three or more hospital-acquired cases (as defined by NHSN) on the same inpatient unit within a 7-day period. Data were analyzed to quantify the number of clusters observed and determine genetic relatedness among cases to detect an outbreak.

Results

A total of 1,116 HO CDI cases occurred during the 5-year time period. Annual nosocomial rates of CDI remained stable (P = 0.052). Eighty clusters were identified; 63 clusters had 3 cases within each cluster, 16 were each made up of 4 cases, and 1 cluster consisted of 5 cases. Two clusters had strain typing concordance amongst all 3 cases; strain type 42 and strain type 1. Among all the epidemiologically linked clusters over the 5-year period, only 2.5% were genetically linked suggestive of true outbreaks.

Conclusion

The majority of HO-CDI clusters detected on clinical surveillance are non-clonal. Genotyping should be routinely used to corroborate clusters identified on microbiological surveillance before costly outbreak control interventions are deployed.

Disclosures

All authors: No reported disclosures.
2422. Effectiveness of a Probiotic for Primary Prevention of Clostridium difficile Infection and Antibiotic-Associated Diarrhea among Hospitalized Patients Receiving Broad-Spectrum Antibiotics
Authors: Le Khanh-Linh , Young Heather , Jenkins Timothy C , Tapia Robert , Shihadeh Katherine C
Published: October 2019

Background

Prior to 2016, Denver Health Medical Center had a higher-than-expected rate of hospital onset Clostridium difficile infection (HO-CDI). A multifaceted CDI prevention plan was implemented, including the use of a probiotic as primary prevention for HO-CDI and antibiotic-associated diarrhea (AAD) in inpatients receiving broad-spectrum antibiotics. We aimed to study the effectiveness of probiotic use in this clinical context.

Methods

During the intervention, inpatient orders for a broad-spectrum antibiotic triggered a best practice advisory recommending once daily co-administration of 100 billion units of a probiotic containing Lactobacillus casei, L. rhamnosus, and L. acidophilus (BioK+ ®). To evaluate effectiveness and safety of this intervention, we performed a retrospective cohort study including adult inpatients who received > 24 hours of a broad-spectrum antibiotic between April 2016 and March 2018. The primary endpoint was the incidence of HO-CDI (> 3 days after admission) compared between patients who received antibiotics alone vs. antibiotics plus the probiotic. Secondary endpoints were the incidence of AAD, defined as a negative CDI test after antibiotic initiation, and the incidence of Lactobacillus species identified in clinical cultures.

Results

3,291 patients were included; 1,835 received antibiotics alone and 1,456 received antibiotics plus the probiotic. Baseline characteristics between groups were similar, except patients in the antibiotic alone group had a greater incidence of cirrhosis and proton-pump inhibitor use (16.1% vs 10.1%, P < 0.001; 39.1% vs 31.5%, P < 0.001). Length of stay and antibiotic days of therapy were longer in the antibiotic plus probiotic group [6 days (IQR, 3–11) vs 6 days (IQR, 4–12), P = 0.014; 4 days (IQR, 3–7) vs 5 days (IQR, 3–7), P < 0.001]. The incidence of HO-CDI (37, 2% vs 35, 2.4%; P = 0.450) and AAD (231, 12.6% vs 199, 13.7%; P = 0.362) were similar between groups. Lactobacillus was identified in at least one clinical culture from 0.2% (3/1835) and 0.3% (4/1456) of patients in the antibiotic alone group and antibiotic plus probiotic group, respectively (P = 0.497).

Conclusion

In hospitalized patients receiving broad-spectrum antibiotics, co-administration of a probiotic did not appear to reduce the incidence of HO-CDI or AAD.

Disclosures

All authors: No reported disclosures.
2436. Real-world Evidence of Fecal Microbiota Transplant Use and Outcomes in Patients with Clostridioides difficile Infection
Authors: Nelson Winnie , Lau Merwin , Kloss Stefan , Grace Tucker Sarah , Stong Laura , Dahdal David N
Published: October 2019

Background

Clostridioides difficile infection (CDI) and recurrent CDI (rCDI) are associated with substantial economic burden, quality-of-life impairment, and increased morbidity and mortality. Fecal microbiota transplant (FMT) is an investigational, non-antibiotic approach to attempt to prevent recurrences in patients with multiple CDI. In controlled trials, efficacy rates of 62–76% have been reported with a single FMT, and up to 90% with multiple FMTs. This study evaluated real-world outcomes in patients with CDI, most of whom had a single FMT.

Methods

Data from the Optum® de-identified Integrated Claims-Clinical dataset were extracted for patients with a first-observed CDI diagnosis between 4/2011 and 3/2018 that occurred within ±7 days of initial CDI antibiotics. Each patient had a > = 4-year look-back period with no CDI claims prior to the index episode. rCDI was defined as a subsequent antibiotic prescription between 7 and 365 days after the prior CDI episode. The proportion of patients with rCDI, use of FMT, and recurrences after FMT were reported.

Results

Of the 98,895 patients included in the analysis, 71,189 (72.0%) had one CDI episode, 27,706 (28.0%) had > = 1 rCDI, and 10,233 (10.4%) had multiple rCDI. The mean age was 64.2 years (56% > = 65 years), and 61% were female. Medicare was used by 48% of patients, and commercial insurance was used by 32%. A total of 522 (0.5%) patients (mean age, 61.9 years) received a total of 541 FMT procedures. 36% of the FMT procedures occurred after the first observed CDI episode, 22% after the 1st rCDI, and 42% after the second and/or subsequent rCDI episode. Of those who received FMT, 71.4% (n = 373) of patients had no subsequent CDI events by 3/2018.

Conclusion

As an investigational procedure, only a very small proportion of patients with CDI were identified as undergoing FMT, and the timing of the procedure for some patients may not have aligned with current guidance. This study provides data on real-world efficacy outcomes after a single FMT, with an efficacy rate of 71.4%, which is consistent with rates reported in controlled trials. A small number of patients received more than one FMT procedure, potentially due to treatment failures. Further research is needed to examine potential improvements in efficacy with multiple FMTs.

Disclosures

All authors: No reported disclosures.
138. Prognosis Following Valve Replacement Surgery for Infective Endocarditis Among Persons Who Inject Drugs
Authors: Bullis Sean , Spiess Krystine , Kemper Alston W
Published: October 2019

Background

Infective endocarditis (IE) is a major cause of morbidity and mortality among persons who inject drugs (PWID) and rates have increased during the current opioid epidemic. Severe cases may require valve replacement surgery (VRS). These patients are typically younger with fewer comorbidities than those who undergo VRS for other indications. This study was designed to examine the prognosis for these cases.

Methods

The University of Vermont Medical Center is a 562-bed academic medical center. A retrospective cohort included all cases of IE among PWID who underwent VRS between November, 2009 and December, 2015. The cohort intentionally included surgeries performed prior to 2016 in order to provide sufficient follow-up time. Outcomes included survival, readmission, complications, adherence to follow-up, length of stay, rate of repeat VRS, microbiology, and recurrent bloodstream infections.

Results

The cohort included 31 patients. 80% were male and the median age was 31. The valves replaced or repaired included 18 aortic, 10 mitral, 9 tricuspid, and 1 pulmonic (7 patients had two valves involved). Organisms included Staphylococcus aureus (48%), Streptococcus spp. (22%), and Enterococcus (13%). The median length of stay for the index admission was 35 days. To date, at least 38% of the cohort has died. The median survival for those who died was 337 days (0–2,224). Adherence with initial outpatient follow-up visit was only 50%, with others either canceling or missing appointments. 39% followed up with infectious diseases and 39% with cardiothoracic surgery. 29% never followed up. The readmission rate was 51%, and 22% of the cohort was readmitted more than three times. 48% had a repeat bloodstream infection, 73% of which were with a different organism than the index infection. The rate of repeat VRS was 31%.

Conclusion

Our observational data reveal a high mortality rate with poor adherence to follow-up and a high rate of readmission among this rural cohort of PWID who have VRS for IE. The major limitation of this work is the passive follow-up from the medical record. The high mortality and morbidity of this disease suggests that more intensive, multispecialty post-operative care is needed for PWID who are treated surgically.

Disclosures

All authors: No reported disclosures.
2463. Increased Rates of Candida Bloodstream Infections Associated with Drug Use, United States 2012–2017
Authors: McCarthy Natalie , Baggs James , Hatfield Kelly M , Wolford Hannah , Vallabhaneni Snigdha , Reddy Sujan , Jackson Brendan R , Jernigan John A
Published: October 2019

Background

Opioid misuse is epidemic in the United States (US), and persons who inject drugs are at increased risk for serious bacterial and fungal infections, including Candida bloodstream infections. Historically, candidemia has occurred almost exclusively among patients with severe underlying illness and extensive healthcare exposure. We examined whether the opioid crisis may be having an impact on the epidemiology of candidemia in the United States.

Methods

Using data from 200 US hospitals reporting to the Premier Healthcare Database (PHD) between 2012–2017, we conducted a retrospective study among hospitalized persons ≥ 18 years. Candidemia was defined by any blood culture yielding Candida species. Drug use-associated (DUA)-candidemia hospitalizations were defined as hospitalizations having both candidemia and at least one ICD-9-CM or ICD-10-CM diagnostic code for recreational drug use; drugs were classified as opioids, cocaine, amphetamines, or other drugs (excluding cannabis, alcohol, and nicotine). We described the characteristics and annual trends of candidemia hospitalizations, stratified by drug use.

Results

Of 7,590 candidemia hospitalizations during 2012–2017, 679 (9%) were DUA-candidemia. During this time, the rate of DUA-candidemia increased from 3.6 to 9.1 per 100,000 hospitalizations, while the rate of non-DUA-candidemia decreased from 64.7 to 55.6 per 100,000 hospitalizations. Patients with DUA-candidemia were younger (median 40 vs. 64 years), had a longer lengths of stay (median 14 vs. 13 days), and had lower in-hospital mortality (12% vs. 26%). Among DUA-candidemia hospitalizations, opioids accounted for 78% of substances identified. Among patients aged 18–44 years, the proportion of candidemia hospitalizations associated with drug use more than tripled from 13% in 2012 to 44% in 2017 (Figure 1).

Conclusion

DUA-candidemia hospitalizations increased almost 3-fold during 2012–2017, with drug use identified in nearly half of candidemia patients ages 18–44 years in 2017. These data suggest that the opioid crisis is having an impact on the epidemiology of candidemia in the United States, especially among young adults, underscoring an additional negative consequence of the ongoing crisis.

Disclosures

All authors: No reported disclosures.
2464. Partnerships in the Field: Using Real-time Sequencing to Enhance Epidemiologic Investigation and Response to a Norovirus Outbreak
Authors: Lori Handy K , Graf Erin H , Brostowski Linda , Cunnigham Lindsay , Dougherty Caitlin , Molitoris Kayla , Townsend Sara , Smathers Sarah , Sammons Julia S
Published: October 2019

Background

Norovirus is a common cause of infectious gastroenteritis and frequently leads to hospital-based outbreaks of gastrointestinal (GI) illness. We utilized hospital-wide surveillance to detect outbreaks of GI illness among patients and healthcare workers (HCW). Real-time norovirus sequencing was applied to establish conclusive links between patient cases.

Methods

Patient cases of healthcare-associated GI illness were detected through house-wide microbiologic surveillance. HCW cases were defined as acute episodes of vomiting and/or diarrhea that began within 48 hours of the last shift. Outbreak procedures were implemented on a unit when 3 or more cases were identified within 48 hours. Traditional epidemiologic methods were used, including an epidemic curve and line listing, while instituting local control measures. De-identified clinical stool samples positive for norovirus from any hospital unit during the defined outbreak time period were analyzed. Sanger sequencing was performed using primer sets targeting the norovirus VP1 capsid and polymerase regions. Capillary electrophoresis was implemented on a 3500 Genetic Analyzer (Applied Biosystems) and analysis was performed via MEGA7.

Results

Epidemiologic surveillance identified a norovirus outbreak involving 11 patients on a single unit. Sequencing was performed on 20 norovirus positive stool samples, of which 13 shared 100% identity across both the VP1 and polymerase regions. Of these 13, 10 specimens were from patients epidemiologically linked to the outbreak; 3 specimens were from patients located on 2 geographically separate floors, not epidemiologically linked to the outbreak. Identification of cases outside of the outbreak unit prompted additional hospital-wide infection prevention interventions, including increased education and messaging, changes in hand hygiene practice, and prohibition of shared food for staff.

Conclusion

Real-time sequencing confirmed epidemiologically linked cases of norovirus during an outbreak and identified additional transmission events not detected by conventional epidemiologic methods. Partnership between hospital epidemiology and the laboratory identified the need for hospital-wide infection prevention measures to halt ongoing transmission.

Disclosures

All authors: No reported disclosures.
2465. Healthcare-Associated Pediatric Cutaneous Mucormycosis at Texas Children’s Hospital, 2012–2019
Authors: Foster Catherine , Revell Paula , Campbell Judith R , Marquez Lucila
Published: October 2019

Background

Cutaneous mucormycosis in children is a rare fungal infection which primarily occurs in patients with underlying medical conditions and is associated with significant morbidity. We describe characteristics of pediatric patients with healthcare-associated (HCA) cutaneous mucormycosis at Texas Children’s Hospital (TCH) and results of an outbreak investigation.

Methods

Patients at TCH were identified retrospectively through review of the TCH Microbiology Laboratory mycology culture reports from 1/1/2012–2/18/2019. Pediatric patients <21 years of age with cutaneous mucormycosis that developed during a hospitalization or was associated with a medical device were included. Demographic information was collected through review of the electronic medical record. Randomly amplified polymorphic DNA (RAPD) analysis were performed by the Fungus Testing Laboratory, University of Texas Health Science Center at San Antonio. This study was approved through the Baylor College of Medicine Institutional Review Board.

Results

We identified 12 patients with HCA cutaneous mucormycosis. The characteristics of these patients are detailed in the table. Six cases of Rhizopus infection occurred over a narrow 7 month period from March through September of 2017 prompting an outbreak investigation. Genotyping results revealed 4 molecular types from 5 available isolates suggesting that the isolates were not clonally related. Adhesive products were suspected as a potential source. Infection Control activities included site visits to the hospital supply warehouse and linen facility. Tape practices throughout the hospital were assessed through a nursing survey. Samples of adhesive products were cultured at an environmental microbiology laboratory and no Rhizopus spp. were isolated. A source was not identified.

Conclusion

Mucormycosis is a life-threatening infection in children. Providers should have a low threshold of suspicion for cutaneous mucormycosis in patients with underlying medical conditions (malignancies and extreme prematurity) that develop skin lesions near medical device dressings or securement sites.

Disclosures

All authors: No reported disclosures.
2483. Characteristics and Outcomes Over First 12 Months of a Two-Drug Regimen (Dolutegravir/Rilpivirine) for Treatment of HIV-1 in the United States
Authors: Pierone Gerald , Schulman Kathy , Fusco Jennifer S , Vannappagari Vani , Aboud Michael , Ragone Leigh , Fusco Gregory
Published: October 2019

Background

In 2017, the first complete antiretroviral regimen (ART) containing only two drugs, dolutegravir/rilpivirine (DTG/RPV), was approved for treatment of HIV-1 in virologically suppressed (<50 copies/mL) patients on a stable ART regimen for ≥6 months with no history of treatment failure/resistance to DTG or RPV. Our objective was to characterize early utilization/outcomes of DTG/RPV in a real-world population.

Methods

HIV-1+ individuals initiating DTG/RPV from January 1, 2018 to December 31, 2018 were identified in the OPERA Database. Outcomes were evaluated among the virologically suppressed subgroup who initiated in the first 6 months. Discontinuation (d/c) was defined as cessation of DTG/RPV. Virologic failure (VF) was defined as either 2 consecutive HIV viral loads (VL) ≥ 200 copies/mL OR 1 VL ≥200 copies/mL + d/c. Population was observed from DTG/RPV start (index) until the first of: (a) d/c, (b) death, or (c) study end (December 31, 2018). Demographic and clinical characteristics were described at index. Kaplan–Meier methods were used to describe d/c and VF.

Results

A total of 880 patients were prescribed DTG/RPV in the first 12 months; demographic and clinical characteristics are described in Figures 1 and 2. Most (76%) DTG/RPV users were virologically suppressed at initiation (n = 671). Among the 197 (22%) ART experienced, viremic initiators, a third had a baseline VL ≥ 50 but <200. Few patients were ART naïve (n = 12, 1%). Index VL was unavailable for 21 (5%) initiators. Comorbidity was prevalent: 59% had ≥1 endocrine disorders; 42% hypertension, and 33% mental disorders. For the virologically suppressed at initiation, with ≥6 months of follow-up (n = 340); median (IQR) days on DTG/RPV was 248 (204–299); 88% remained on DTG/RPV at study end. Among the 42 (12.4%) discontinued patients, 41% were virologically stable (<200 copies/mL) at d/c. Median (IQR) days to d/c was 58 (29–141) (Figure 3). Most patients (n = 288, 85%) had ≥ 1 VL during follow-up; 79% (n = 270) had ≥1 VL during the first 24 weeks. Among these, VF occurred in 1.5% patients. Median (IQR) time to VF was 5.1 (2.0–9.2) months (Figure 4).

Conclusion

While DTG/RPV initiators were primarily ART-experienced, virologically suppressed individuals older than 50 years of age challenged by significant comorbid conditions, the frequency of d/c or VF in the first 12 months was low.

Disclosures

All authors: No reported disclosures.
2522. Prescription Drug Use Among Women with HIV Who Are of Childbearing Potential
Authors: Abernethy Jane L , Binkley Amanda , Cimino Christo L , Koenig Helen , Short William R
Published: October 2019

Background

In the context of medication safety, women with HIV who are of childbearing potential represent a particular challenge given the prevalence of unplanned pregnancies. Despite this, significant gaps in the literature exist characterizing prescription drug use in this cohort. Our study describes medication use and identifies medications that are contraindicated during pregnancy in a cohort of women with HIV who are of childbearing age.

Methods

Women with HIV aged 18–45 years who presented to an academic medical center between January 2016 and December 2017 were included for analysis. Patients were excluded if they were prescribed any form of contraception, received permanent sterilization, or were post-menopausal. The number of individual medications prescribed in the electronic medical record during the study period were documented. Chronic medications, defined as those prescribed for longer than 3 months, were analyzed. Patients were identified as experiencing polypharmacy if prescribed 5 or more medications at one time. In addition, contraindicated medications were reviewed and documented.

Results

A total of 213 patients met inclusion criteria for review. Of these, 169 (79%) and 66 (31%) patients experienced polypharmacy when including and excluding antiretrovirals, respectively. When antiretrovirals were included the mean number of medications prescribed was 7.48 (SD = 3.87) and 3.92 (SD = 3.75) when excluded. Of the 213 patients included, 64 (30%) were prescribed medications contraindicated during pregnancy. The majority of contraindicated medications were angiotensin converting enzyme inhibitors, angiotensin receptor blockers, statins, and hydroxyzine. In this cohort of women of child bearing potential (WOCBP) only 60 patients (28%) had been prescribed prenatal vitamins.

Conclusion

In this cohort of WOCBP with HIV, polypharmacy was observed in the majority of women. In addition, a third of these women were prescribed medications that are contraindicated during pregnancy. Given the potential impact of contraindicated medications on the developing fetus, our data supports the importance of preconception counseling on this issue as well as understanding the potential safety implications for mother and the fetus.

Disclosures

All authors: No reported disclosures.
2523. Optimizing Disclosure of HIV Status to a Diverse Population of HIV-Positive Pediatric Patients at an Urban HIV Clinic in the Southeastern United States
Authors: Dantuluri Keerti , Carlucci James G , Howard Leigh M , Johnson David , Garguilo Kathryn , Wilson Greg
Published: October 2019

Background

Developmentally-appropriate disclosure of human immunodeficiency virus (HIV) status to children living with HIV (CLWH) is essential to achieve optimal health outcomes, but stigma and fear result in delaying disclosure into adolescence. The American Academy of Pediatrics recommends disclosure of HIV status to school-age children. The objective of this quality improvement (QI) project was to increase the proportion of CLWH > 10 years of age who are disclosed about their HIV status from 57% to 80% by 18 months.

Methods

The Institute for Healthcare Improvement’s Model for Improvement was utilized for this QI project. This model accelerates quality improvement by implementing Plan-Do-Study-Act (PDSA) cycles to determine whether changes lead to improvement. The target population included CLWH followed at an urban pediatric HIV clinic. The primary outcome measure was the proportion of children > 10 years of age who are disclosed about their HIV status. PDSA cycles included monthly clinic check-ins to discuss new disclosures, quarterly team meetings to discuss implementation of new changes to improve disclosure and modifying a note template to prompt providers to document disclosure status and plan for undisclosed patients. Our process measure was the proportion of undisclosed children who have a documented disclosure status/plan. Annotated run charts were used to track the data.

Results

Prior to our first PDSA cycle, 57% of CLWH > 10 years of age were disclosed to about their HIV status, and none of the undisclosed children had a disclosure status/plan documented in their medical record. The proportion of CLWH disclosed to about their HIV status increased to 66% since meeting with the team regularly to discuss disclosure status (figure). Four months after introduction of the modified note template, the proportion of CLWH with documentation of their disclosure status and plan increased to 54%.

Conclusion

Team awareness of the importance of disclosure and a modified clinic note template were associated with increases in the proportion of CLWH with age-appropriate HIV disclosure and documentation of disclosure status. Future interventions will include adapting methods of step-wise disclosure which have been proven effective in other settings.

Disclosures

All authors: No reported disclosures.
2563. The Impact of HCV Educational Training on HIV Providers’ Attitudes, Knowledge, and Uptake of Treatment Initiation in HCV/HIV Co-infected Patients
Authors: Lau Abby A , Sura Teena , Vasudeven Anupama , Chavez Claudia , Hansen Laura , Jain Mamta
Published: October 2019

Background

Few HIV clinics train HIV providers on initiation of HCV treatment for their coinfected patients. We sought to evaluate the changes in comfort levels, attitude and knowledge of HCV evaluation and treatment among providers over time and track the uptake of treatment initiation.

Methods

Our program was implemented in an urban, Ryan-White outpatient clinic in 2018. Providers were given initial didactics and completed a survey that assessed their level of comfort and knowledge with treating HCV. We developed pocket cards and flow charts to help providers navigate the HCV cascade to cure. Additional training one year later through presentations and case-based discussions was given and the same survey was conducted again. We evaluated the number of HCV evaluation visits in 2018 and prescriptions written for HCV treatment.

Results

The first survey was completed by 21 and the second by 20 out of 28 providers; 70% attended at least one of the trainings. After the initial training, 38% of providers felt “confident” about discussing liver disease progression which increased to 50% after the second training. Similarly, 48% of providers felt “somewhat comfortable” talking about HIV/HCV drug interactions which increased to 80%. 33% of providers noted they were “not comfortable” discussing drug interactions which decreased to 15%. Approximately 1/3 providers felt “confident” talking about HCV treatment in both surveys. About 20% of providers disagreed with treating HIV/HCV patients with active substance use and this did not change. The median knowledge score was 7 (IQR) (6–9) after the first survey and changed to 8(5–9) after the second. Between 2018–2019, 81 HCV evaluation visits were scheduled and 64 (80% Male, 53% Black, 39% uninsured, 23% Medicaid, 73% with history of substance use) were completed and 69% of patients were prescribed HCV treatment. Among all HIV providers, 89% completed a median of 1 (1–3) HCV evaluation visits, and 71% prescribed treatment a median of 1 (1–2).

Conclusion

Implementation of HCV training to all HIV providers requires continued education and resulted in the initiation of HCV evaluation and treatment amongst the large majority of HIV providers who had previously never treated HCV.

Disclosures

All authors: No reported disclosures.
2624. Viral Pneumonia in Children: Facing the Challenge Using the Host Response
Authors: Mastboim Niv Samuel , Gottlieb Tanya , Srugo Isaac , Gervaix Alain , Paz Meital , Navon Roy , Boico Olga , Bamberger Ellen , Klein Adi , Stein Michal , Chistyakov Irina , Oved Kfir , Eden Eran , Shani Liran
Published: October 2019

Background

Diagnosing viral pneumonia in children is challenging. Chest radiographic imaging and clinical findings cannot reliably distinguish viral from bacterial pneumonia. Furthermore, pathogen-based diagnosis is limited by inaccessible site of infection and high asymptomatic detection rates. The objectives of this analysis were twofold: first, to establish pneumonia etiology by applying a rigorous expert panel process, and second, to evaluate whether a novel host-immune signature that integrates viral induced proteins TRAIL and IP-10 together with bacterial CRP, can accurately differentiate viral from bacterial pneumonia.

Methods

This analysis included 1025 febrile children enrolled in two multi-center clinical studies that evaluated the host-immune signature performance: ‘Curiosity’ study (Oved et al., PLoS One 2015) and ‘Pathfinder’ study (Srugo et al., Pediatrics 2017). Pneumonia etiology – viral or bacterial – was determined by a panel of 3 independent experts, after reviewing patients’ clinical, laboratory, microbiological, and radiological data. Only cases with majority panel assignment were included. The host-signature generated one of the three results: viral, equivocal or bacterial, based on predetermined cut-offs.

Results

A total of 709 children were eligible for analysis and had an expert panel etiology determination. Of them, 114 were diagnosed with pneumonia: 51 assigned viral and 63 assigned bacterial (Figure 1). The signature separated viral from bacterial pneumonia with a sensitivity of 94% (95% CI: 85%–99%) and specificity of 95% (85%–99%) with 14% equivocal test results. Out of the 51 children diagnosed with viral pneumonia by the expert panel, 40 (78%) were given antibiotics, and 43 (83%) underwent chest x-ray evaluation. The signature correctly classified 42 of these 51 viral children, indicating its potential to reduce antibiotic overuse rates by 4.4-fold (from 78% to 18%; P < 0.001) and chest x-ray examination by 4.8-fold (from 83% to 18%; P < 0.001).

Conclusion

The TRAIL/IP-10/CRP signature exhibits high accuracy for diagnosing viral pneumonia in children. The signature’s potential to safely decrease unnecessary antibiotics and chest radiographic imaging should be examined in future utility studies.

Disclosures

All authors: No reported disclosures.
2626. Rhinovirus in Children Presenting to the Emergency Department: Role of Viral Load in Disease Severity and Co-Infections
Authors: Waghmare Alpana , Strelitz Bonnie , Lacombe Kirsten , Perchetti Garrett , Nalla Arun , Rha Brian , Midgley Claire , Lively Joana Y , Klein Eileen J , Kuypers Jane , Englund Janet A
Published: October 2019

Background

Rhinovirus (RV) quantitation by reverse transcription-quantitative PCR is limited by variable amplification efficiency across genotypes. We used a precise viral quantitation method, reverse transcription-digital PCR (RT-dPCR), to characterize the role of viral load in clinical outcomes and in viral co-infections in children presenting to a tertiary hospital emergency department (ED).

Methods

Children < 18 years with respiratory symptoms for ≤ 14 days were enrolled from December 1, 2016 to December 31, 2018. Participants had nasal and throat specimens obtained and multiplex PCR testing with a commercial assay (FilmArray; bioMerieux). RV positive samples were quantified using RT-dPCR. Samples with sufficient viral load were sequenced at a 543 bp fragment of the RV VP4/VP2 region. RV species were assigned by comparison to RV sequences in GenBank using BLAST. Clinical data were collected into REDCap. T-tests were used to compare mean viral loads between groups.

Results

Of 1703 children enrolled in the ED, 697 were RV/enterovirus positive by FilmArray [median age 18 months (interquartile range 9–39 months)]. Of 590 subjects with viral load available, 276 (47%) were admitted to the hospital. Among RV mono-infections (N = 434), mean viral load did not differ between subjects admitted vs. discharged from the ED (7.03 log copies/mL for both, P = 0.97). Among admitted subjects with RV mono-infection, viral load also did not differ between subjects requiring supplemental oxygen vs. not (7.01 vs. 7.10 log copies/mL, P = 0.6). Subjects with viral co-infections had lower mean RV viral loads (6.31 log copies/mL) compared with those with RV only (7.03 log copies/mL; P < 0.001) (figure). Significantly different RV viral loads were seen with co-infections with respiratory syncytial virus (RSV), metapneumovirus (MPV) and parainfluenza (PIV), but not with influenza, adenovirus or coronavirus. In 525 sequenced samples (46% RV-A, 4% RV-B, 50% RV-C), viral load did not vary between RV viral species (P = 0.09).

Conclusion

Precise viral quantitation demonstrates children co-infected with RV and RSV, MPV or PIV have lower nasal viral loads than those with RV alone. Among RV mono-infections, RV viral load was not associated with admission or need for supplemental oxygen.

Disclosures

All authors: No reported disclosures.
2644. Evaluation of Clinical Course and Heath-Related Quality-of-Life Following Treatment with Oseltamivir, Laninamivir, and Baloxavir Marboxil in Adult Patients with Seasonal Influenza: Prospective Observational Study
Authors: Yoshino Yusuke , Misu Keita , Wakabayashi Yoshitaka , Ota Yasuo , Kitazawa Takatoshi
Published: October 2019

Background

Influenza is currently being treated in Japan with 4 types of neuraminidase inhibitors and the cap-dependent endonuclease inhibitor baloxavir marboxil. Among these, baloxavir marboxil is the newest agent and currently available in limited countries, while the clinical efficacy of this drug in the real world remains to be determined.

Methods

Adult patients with seasonal influenza during the 2018–2019 winter season, who received either oseltamivir (75 mg twice daily for 5 days), laninamivir (40 mg once), or baloxavir marboxil (40 or 80 mg once) at their physician’s discretion in one hospital, were enrolled. The course of the symptoms including fever were surveyed by questionnaire. Health-related quality-of-life (HRQOL) was also examined by using Short Form-8 before and 7 days after admission. The main study endpoints were the time to defervescence and the extent of improvement of HRQOL after treatment initiation. Welch’s t-test and Fisher exact test were used for statistical analysis.

Results

Forty-two patients (oseltamivir group; n = 12, laninamivir group; n = 16, baloxavir group; n = 14) could be followed up. There were no significant differences in clinical backgrounds of all groups. Although there were no significant differences between the oseltamivir and each other groups with the time of defervescence, the average time to defervescence in the baloxavir group was shorter than that in the oseltamivir group (average ± standard deviation; 1.57 ± 0.76 vs. 2.33 ± 1.23 days, P = 0.0853). There were significant differences between the baloxavir and laninamivir groups (2.50 ± 1.26 days, P = 0.0231). There were no significant differences between each group with respect to the change of HRQOL and the time of clearing of other symptoms.

Conclusion

Regarding the antipyretic effect, baloxavir marboxil is clinically superior to laninamivir. Although there was no significant difference between the baloxavir group and the oseltamivir group with respect to the time to defervescence, baloxiavir marboxil also might be clinically superior to oseltamivir because baloxavir marboxil has an advantage over oseltamivir with respect to medication adherence.

Disclosures

All authors: No reported disclosures.