bluuebunny/crossref_metadata_2025 huggingface dataset:
806. 2013–2015 Nationwide Tuberculosis Contact Investigation in Childcare Centers and Schools in Korea
Authors: Suh Woosuck , Kim Jong-Hyun , Hwang Ji Hyen , Lee Sodam , Lee Kang-Hee , Park Misun
Published: November 2018

Background

The Republic of Korea has the highest incidence rate of tuberculosis (TB) among members of the OECD, reported as 78.8/100,000 population in 2016. In response, a state-run intensive contact investigation for TB is being conducted. More effective TB control requires an epidemiologic emphasis on the diagnosis and treatment of latent TB infections in children and adolescents, compared with other age groups. Here we present an analysis of data from the childcare center and school contact investigation by the Korea Centers for Disease Control and Prevention (CDC) in 2013–2015.

Methods

Data collected from index patients included age, sex, occupation, disease status, results of AFB smear/culture, and chest x-ray. Data collected from contacts included age, sex, results of serial tuberculin skin test (TST), and chest x-ray. Congregate settings included childcare centers, kindergartens, elementary and secondary schools, and age groups were stratified as follows: 0–4 years, 5–12 years, and 13–18 years. TSTs were considered positive if induration ≥10 mm on the first test (TST1) or demonstrated an increase ≥6 mm over the induration of TST1 on repeat testing after 8 weeks (TST2).

Results

Of the 197,801 subjects with data collected, 173,998 were eligible and included in our analysis. TST1 results were available for 159,346 (91.6%) and when results were positive, induration was 10–14 mm in 7.6% and ≥15 mm in 1.5%. TST2 results were available for 119,797 (82.7%) of the 144,904 with negative TST1, and conversion rate was 9.0%. Altogether considering TST1 and TST2, 17.3% contacts had latent TB infections. Positive rates of TST significantly decreased with age: 20.3% in 0–4 years, 18.8% in 5–12 years, 17.1% in 13–18 years.

Conclusion

In this 3-year school-setting contact investigation, 17.3% contacts were diagnosed with latent TB infection, as demonstrated by TST reactions. Positive rates of TST significantly but mildly decreased with age.

Disclosures

All authors: No reported disclosures.
807. A Risk-Stratified Approach to Healthcare-Associated Tuberculosis Exposures Following the “Stone in the Pond” Principle
Authors: Pepe Dana E , Aniskiewicz Michael , Paci George , Sullivan Linda , Dembry Louise-Marie , Martinello Richard , Advani Sonali
Published: November 2018

Background

Large-scale tuberculosis (TB) exposure investigations cause anxiety to healthcare personnel (HCP) and patients, in addition to being resource and time intensive. TB contact tracing in England and Singapore follow the “stone in the pond” principle. We propose a similar risk-stratified approach to TB exposure investigations in an area of low incidence.

Methods

This retrospective study was conducted at a 1,541 bed academic medical center in New Haven, CT between January 14 and 11, 2017. Microbiology records, patient charts, and infection prevention databases were reviewed to find TB exposures. A scoring system adapted from CDC’s “Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosis” was developed to predict infectivity (two points for laryngeal TB, one point each for: cavitary TB, ≥1 positive respiratory acid fast bacilli smear or Xpert MTB/RIF, multi-drug-resistant (MDR) TB, foreign-born status, immunocompromised status, cough/hemoptysis, or procedure associated with positive TB culture). Using the “stone in the pond” principle, contacts were graded based on the type of exposure (Figure 1). Based on high, medium, and low risk, our new risk-stratified approach was applied to contact tracing.

Results

During the study period, 17 of 29 patients with pulmonary TB led to exposures. A subset of seven TB patients with complete exposure data was selected for further analysis. The original exposure investigations led to contact tracing of 586 HCP and 72 patients. No active or latent TB cases were identified among these exposed contacts. Using our scoring system, these seven patients were categorized into three high, two medium, and two low infectivity risk groups. On applying our new risk-stratified approach, contact tracing could be reduced by 42% and 84% for medium and low-risk exposures, respectively, by excluding these HCP groups from investigation (Figure 2).

Conclusion

We recommend a risk-stratified approach to healthcare-associated TB exposure investigations similar to the “stone in the pond” principle, based on index patient’s infectivity risk and type of exposure. This has potential to optimize resources and possibly reduce anxiety in medium and low-risk TB exposures in an area of low TB incidence.

Disclosures

All authors: No reported disclosures.
808. Perinatal Depression Among HIV- and TB-Infected and Uninfected Women in an Urban Slum in India: Prevalence and Associated Birth Outcomes
Authors: Grossman Tracy , Mathad Jyoti S
Published: November 2018

Background

In low- and middle-income countries, depression during pregnancy is three times more common than in the United States and is more common than postpartum depression. There have been few studies on the prevalence of antepartum and postpartum depression in India. The objective of this study was to describe the prevalence of antepartum and postpartum depression among HIV-infected and uninfected pregnant women in an urban slum in India, and to evaluate associated pregnancy and birth outcomes.

Methods

This study was a longitudinal cohort study of HIV-infected and HIV-uninfected pregnant women at Sassoon General Hospital in Pune, India. Enrolled women answer questions about sociodemographics and medical history, including obstetric history. The PHQ-9 depression scale is administered during pregnancy and at 6 months postpartum.

Results

Of the 189 pregnant women enrolled, 113 (60 %) exhibited at least one symptom of depression on the PHQ-9 scale with 23 (12%) women having moderate or severe depression. However, significantly fewer postpartum women had evidence of depression (60% antepartum vs. 26% postpartum, P < 0.001). Of the 77 women who had a postpartum visit, 20 (26%) also had symptoms of depression prior to delivery, but only 2 (10%) had more severe depression scores while 18 (90%) had improved scores. Thirty (39%) women with antepartum depression had resolution of symptoms postpartum and no women developed incident depression in the postpartum period. There was a trend toward increased rates of antenatal depression among HIV-infected vs. uninfected women (69% vs. 57%, P = 0.13). Both depressed and nondepressed pregnant women experienced low rates of intrauterine fetal demise, intrapartum hypertension, and preterm delivery. However, women with depression had 3-fold higher incidence of intrauterine growth restriction on prenatal ultrasound (4.4% vs. 1.5%).

Conclusion

We found that the majority of pregnant women in our population experience some form of depression during pregnancy. Most women with antepartum depression experienced improvement in their mood postpartum, which contrasts with patterns of perinatal depression in developed countries. We are planning qualitative studies to understand the social contributors for antepartum depression in India, and to identify potential solutions.

Disclosures

All authors: No reported disclosures.
813. Combination of N-Acetyl-Cysteine With Clarithromycin Against Mycobacterium avium Infection
Authors: Shiozawa Ayako , Kajiwara Chiaki , Ishii Yoshikazu , Tateda Kazuhiro
Published: November 2018

Background

N-Acetyl-cysteine (NAC) is widely used in patients with chronic pulmonary diseases. In previous studies, its antimicrobacterial and antimycobacterial effects have been reported. Among its effect in Mycobacteria, it has been mainly studied in Mycobacterium tuberculosis. Here, we examined whether NAC has antibiotic activity against M. avium.

Methods

The antimycobacterial effect of NAC was assessed in JCM 15430 M. avium strain infected A-549 (human lung epithelial cells) and MH-S (mouse alveolar macrophages). These cells were infected with M. avium at multiplicity of infection of 10 for 1 hours, washed and then cultivated for 5 days. Bacterial uptake was evaluated at 0 days and 5 days of cultivation. For the NAC treatment group, 5% FBS medium with 10 mM NAC was used as culture medium. We also tested its effect in combination with clarithromycin in vivo. BALB/c mice were infected intranasally with M. avium, and were given NAC (400 mg/kg) or clarithromycin (100 mg/kg) or both by gavage daily for 6 days. On day 7 of infection, lungs were harvested and CFU, cytokines and antimicrobial peptides were measured.

Results

NAC treatment of M. avium-infected A-549 and MH-S resulted in a significant reduction of mycobacterial loads (P = 0.014 and P = 0.014). In vivo, NAC treatment resulted in a significant reduction of mycobacterial loads in the lungs of M. avium-infected mice (P = 0.007). When in combination with clarithromycin, we also had an additional reduction (vs. clarithromycin monotherapy; P = 0.001). Several antimicrobial peptides significantly increased when treated with NAC and clarithromycin combination therapy.

Conclusion

NAC exhibits potent anti-mycobacterial effects and may limit M. avium infection. In addition with clarithromycin, it showed an additive effect in reduction of mycobacterial loads. Interestingly, in our study, several antimicrobial peptides increased significantly which may be one of the possibility on how NAC is involved in antimycobacterial effects. These results indicate that NAC may be an additional option in treating M. avium-infected patients in future, along with its classical drug regimens containing clarithromycin.

Disclosures

All authors: No reported disclosures.
985. Safety of Guidelines Recommending LAIV for Routine Use in Children and Adolescents With Asthma
Authors: Nordin James , Vazquez-Benitez Gabriela , Olsen Avalow , Kuckler Leslie , Kharbanda Elyse
Published: November 2018

Background

Asthma is the most common chronic medical condition in children. Prior observational studies of live attenuated influenza vaccine (LAIV) safety in asthmatic children have been limited due to confounding by indication, with LAIV restricted to patients with mild asthma. To minimize bias, we evaluated safety of LAIV in children with asthma using a natural experiment in which two medical groups, within a single health system, serving similar populations, differed in vaccination guidelines. Prior to 2010 both groups recommended inactivated influenza vaccine (IIV). Starting in 2010, one group recommended LAIV for children with asthma.

Methods

Asthmatic children age 2–18 years with visits to two large medical groups in the upper Midwest from 2007 to 2015 were identified and classified by severity and control using validated algorithms. Primary outcomes were lower respiratory events (LRE) occurring within 21 and 42 days after influenza immunization. Multiple records per subject were included when children received influenza vaccines in more than one season. The analysis was intention to treat with each medical group’s subjects analyzed as a group. A pre-/post-ratio of ratios (ROR) approach was used to estimate the LAIV guideline impact using a generalized linear model with a Poisson distribution, accounting for multiple records per subject and adjusting for age and asthma classification. Analyses were for the overall population, and stratified by age group: 2–4 and 5–18 years.

Results

A total of 7,959 observations from 4,824 unique asthmatic children were analyzed, with 1,896 from the IIV guideline and 6,061 from the LAIV guideline medical groups. Postimplementation, 67% received LAIV. Age and asthma classification adjusted ROR showed no increase in LREs using the LAIV guideline: overall ROR (95% CI): 0.79 (0.46–1.37) for LRE 21 days and 0.82 (0.56–1.20) for 42 days; age 2–4: 1.07 (0.40–2.83) for 21 days and 1.0 (0.53–1.90) for 42 days; and age 5–18: 0.72 (0.37–1.41) for 21 days and 0.75 (0.46–1.21) for 42 days.

Conclusion

A guideline recommending LAIV rather than IIV for asthmatic children did not result in more LREs following vaccination in children age 2–18. Guidelines for influenza vaccination in asthmatic children should be based on effectiveness studies.

Disclosures

All authors: No reported disclosures.
991. Randomized Trial of High Dose, Adjuvanted, and Standard Inactivated Influenza Vaccine Immune Response Against Egg- and Cell-Propagated Vaccine Strains in Older Adults, 2016–2017 Season
Authors: McLean Huong , Levine Min , King Jennifer , Spencer Sarah , Flannery Brendan , Belongia Edward
Published: November 2018

Background

High dose (HD-IIV), standard dose (SD-IIV), and MF-59 adjuvanted (aIIV) influenza vaccines are licensed for adults ≥65 years old, but there is no preferential recommendation for a specific product. These vaccines are manufactured using egg-adapted high growth reassortant viruses. Recent data suggest that antibodies generated by egg-adapted A(H3N2) viruses may contribute to reduced vaccine effectiveness. We report results from the first year of a 2-year randomized trial of vaccine immunogenicity, including response to A(H3N2) vaccine strains propagated in egg (H3N2-egg) and cell culture (H3N2-cell).

Methods

Adults 65–74 years old were randomized to receive 2016–2017 trivalent inactivated influenza vaccines: SD-IIV (n = 60), HD-IIV (n = 59), and aIIV (n = 60). Pre- and post-vaccination sera were analyzed by microneutralization assays (MN) to egg- and cell-propagated A(H3N2) vaccine virus, A/Hong Kong/4801/2014 and tested by hemagglutination inhibition (HI) assays to A/California/7/2009 A(H1N1)pdm09-like and B/Brisbane/60/2008-like viruses. Endpoints were postvaccination geometric mean titer (GMT), mean fold rise (MFR), and seroconversion. Respiratory swabs from adults with acute respiratory illness during the season were tested by RT-PCR to identify vaccine failures.

Results

Prevaccination MN and HI titers were similar across study arms. There were no differences across study arms in postvaccination MN GMT, seroconversion, and MFR against H3N2-egg and H3N2-cell (figure). However, response was lower against H3N2-cell than H3N2-egg. HI MFR for H1N1pdm09 and B/Brisbane were significantly higher in HD-IIV than SD-IIV and aIIV recipients (figure). Eight participants had PCR-confirmed A(H3N2) infection: 1/60 (2%) SD-IIV, 4/57 (7%) HD-IIV, and 3/60 (5%) aIIV recipients. Postvaccination H3N2-cell MN GMT was 15 and 63, respectively for A(H3N2) cases and noncases. Among the eight A(H3N2) cases, postvaccination MN titers were ≥1:40 against H3N2-egg for 6 cases vs. 0 cases against H3N2-cell.

Conclusion

Postvaccination MN titers against H3N2 egg- and cell-propagated vaccine viruses were similar across study arms, although antibody response was lower to H3N2-cell. HD-IIV generated greater antibody response against A(H1N1)pdm09 and B compared with SD-IIV or aIIV.

Disclosures

All authors: No reported disclosures.
995. Effectiveness of Influenza Vaccine for Prevention of Influenza-Associated Hospitalizations Among High-Risk Adults in the United States, 2015–2016
Authors: Alyanak Elif , Gaglani Manjusha , Martin Emily T , Monto Arnold S , Middleton Don , Silveira Fernanda P , Zimmerman Richard , Talbot H Keipp , Ferdinands Jill M
Published: November 2018

Background

Individuals with cardiopulmonary and other chronic conditions are at increased risk for severe complications of influenza. Few studies have examined influenza vaccine effectiveness (VE) in high-risk groups. We evaluated VE against influenza-associated hospitalization among adults with specific high-risk conditions.

Methods

Adults hospitalized with acute respiratory illness (ARI) during the 2015–2016 influenza season were enrolled at eight hospitals participating in the US Hospitalized Adult Influenza Vaccine Effectiveness Network (HAIVEN) study. Respiratory specimens were tested for influenza by reverse transcription PCR. Measures of illness severity, underlying health status, and vaccination were obtained from medical records and enrollment interviews. The presence of high-risk conditions was determined from clinical codes assigned to prior year medical encounters. We estimated VE using a test-negative design as (1 − adjusted odds ratio), comparing odds of PCR-confirmed influenza among vaccinated patients vs. unvaccinated controls. Multivariate logistic regression was adjusted for age, sex, and other factors, stratifying by chronic conditions.

Results

Of 1,467 adults hospitalized with ARI, 236 (16%) had PCR-confirmed influenza; 180 (78%) were A(H1N1)pdm09. In all, 1,358 (93%) had ≥1 high-risk medical condition, and 1,026 (70%) had ≥3 conditions. Cardiovascular (n = 835), metabolic (including diabetes) (n = 773) and lung conditions (n = 692) were most common (figure). Patients with ≥1 high-risk conditions were more likely to be vaccinated (70%) vs. patients not at high risk (31%, P < 0.001). Among all patients, VE against any influenza-associated hospitalization was 50% (95% CI: 31–63). VE was similarly high among patients with neurologic (VE = 64%, 95% CI: 26–83), metabolic (VE = 55%, 95% CI: 30–71), and cardiovascular (VE = 53%, 95% CI: 27–69) conditions, though lower for patients with immunosuppression and malignancy (VE = 20%, 95% CI: −42–54).

Conclusion

Vaccination significantly reduced risk of influenza hospitalization among adults with the most prevalent high-risk cardiovascular, metabolic, and lung conditions. Results support the benefit of vaccinating adults with existing specific chronic conditions.

Disclosures

H. K. Talbot, sanofi pasteur: Investigator, Research grant. Gilead: Investigator, Research grant. MedImmune: Investigator, Research grant. Vaxinnate: Safety Board, none. Seqirus: Safety Board, none.
998. Missclassification of Community and Hospital Onset Bloodstream Infections Using Laboratory-Identified Events
Authors: Khatib Riad , Sharma Mamta , Fakih Mohamad G , Riederer Kathleen , Johnson Leonard
Published: November 2018

Background

Laboratory-identified bloodstream infections (LAB-ID-BSI) are classified as community onset (CO) if blood culture (BC) is collected within 3 days after facility admission and hospital onset if ≥4 days. This classification is often based on a computer-generated subtraction of the day of admission from day of onset. This method may miss recent prior hospitalizations at the same or different facilities.

Methods

We reviewed BC results (January 1, 2010–December 31, 2016), selected patients with BSI and defined the place of onset as CO (day 0–3) and HO (≥4 days) of admission based on LABID-BSI. All patients with CO were further evaluated to determine whether they were recently hospitalized. The source and microbiology of patients with hospitalization within 14 days of the onset of BSI was compared with HO and CO without prior admission within 6 months.

Results

We encountered 5,179 BSI episodes, 3866 (74.6%) were CO. Prior hospitalization in any hospital within 1–14 and 15–180 days of onset was documented in 659 (17.0%) and 1,465 (37.9%), respectively. Source of bacteremia and type of organisms in patients with prior hospitalization within 1–14 days were closer to HO than patients without prior hospitalization with higher frequency of Intravenous catheters (IVC), polymicrobial bacteremia, and candidemia (table).

Conclusion

Using Lab-ID events to classify BSI, one in six patients may risk being misclassified as CO. This underestimates BSI related to hospital setting. Onset classification should be based on thorough historical information and not a computer-generated subtraction of admission and Lab event dates.

Infective endocarditis; soft tissue/bone; pneumonia; abdomen; unknown/miscellaneous; polymicrobial. Gram-positive; Gram-negative; anaerobes; Candida spp. a: P < 0.01; chi square test.

Disclosures

All authors: No reported disclosures.
1002. Epidemiology of Pneumococcal Bacteremia in a Large Tertiary Center
Authors: Asis Aristotle , Gutierrez-Asis Esmeralda , Hassoun Ali
Published: November 2018

Background

Streptococcus pneumoniae remains an important cause of bacteremia in the United States with high morbidity and mortality despite readily available treatment and vaccines. Increased incidence of bacteremia observed during 2017–2018 season.

Methods

Retrospective chart review of patients admitted with pneumococcal bacteremia over the last two winter seasons. Demographics, laboratory data, ICU stay, need for ventilation or pressor, comorbidities, and mortality were collected.

Results

Fifty-three patients enrolled. 62% admitted during 2017–2018. Sixty-six percent white, 60% male, mean BMI 27 (38% had normal BMI). Mean age was 55 years (1–93) (57% > 61). Mean hospital length of stay was 7.8 days (1–30). More than 40% required ICU stay. The use of NPPV, vasopressors, and mechanical ventilation were 6%, 15%, and 17%, respectively. Most common presentation: dyspnea 30% and fever 18%. Smoking history (55%). Eighty percent of these patients had pneumonia. Resistance to penicillin 9% and intermediate susceptibility 6%. Resistance to erythromycin 44% and trimethoprim-sulfamethoxazole 12% which increased during winter 2017 (52% and 12%) compared with winter 2016 (30% and 10%). Only 2% of patients with pneumonia had positive sputum culture for pneumococcus and 62% had positive serum pneumococcal antigen with bacteremia. Positive co-detection of bacterial or viral targets in sputum using Multiplex PCR did not correlate with mortality and hospital stay but they were more likely needed ICU stay, use of vasopressor and mechanical ventilation. 43% of empiric therapy was as recommended by IDSA guidelines. Comparing 2016 vs. 2017 seasons, mortality (15% vs. 6%), hospital stay (9 days vs. 7 days), use of NPPV (5% vs. 6%) mechanical ventilation (15% vs. 18%) and vasopressor (5% vs. 21%). No correlation between influenza infection and bacteremia. Overall 6-month mortality and re-admission rate was 9% and 2%, respectively. Mortality was higher in overweight patients (60% vs. 20%), non-smokers (40% vs. 20%), coronary artery disease (40%) and congestive heart failure (40%).

Conclusion

Pneumococcal bacteremia cause significant morbidity and mortality, we observed less mortality and hospital stay, but more use of NPPV, mechanical ventilation, and vasopressor during 2017–2018 season which had widespread influenza like activity.

Disclosures

All authors: No reported disclosures.
1008. Cluster Analysis to Define Distinct Clinical Phenotypes Among Septic Patients With Bloodstream Infections
Authors: Guillamet M Cristina Vazquez , Bernauer Michael , Micek Scott , Kollef Marin
Published: November 2018

Background

Prior attempts at identifying outcome determinants associated with bloodstream infection have employed a priori determined classification schemes based on readily identifiable microbiology, infection site, and patient characteristics. We hypothesized that even amongst this heterogeneous population, clinically relevant groupings can be described that transcend old a priori classifications.

Methods

Cluster analysis was applied to variables from three domains: patient characteristics, acuity of illness/clinical presentation, and infection characteristics.

Results

Among 3,715 patients with bloodstream infections from Barnes-Jewish Hospital (2008 to 2015), the most stable cluster arrangement occurred with the formation of four clusters. This clustering arrangement resulted in an approximately uniform distribution of the population: Clusters One (21.5%), Two (27.9%), Three (28.7%), and Four (21.9%). Staphylococcus aureus distributed primarily to Clusters Three (40%) and Four (25%), while Enterobacteriaceae were divided predominantly into Clusters Two (34%), Three (30%), and Four (22%). Nonfermenting Gram-negative bacilli grouped mainly in Clusters Four and Two (30% and 31%). More than half of the pneumonia cases occurred in Cluster Four. Clusters One and Two contained 33% and 31%, respectively, of the individuals receiving inappropriate antibiotic administration. Mortality was greatest for Cluster Four (33.8%, 27.4%, 19.2%, 44.6%; P < 0.001), while Cluster One patients were most likely to be discharged to a nursing home.

Conclusion

Our results support the potential for machine learning methods to identify homogenous groupings in infectious diseases that transcend old a priori classifications. These methods may allow new clinical phenotypes to be identified potentially improving the severity staging and treatment of complex infectious diseases.

Disclosures

All authors: No reported disclosures.
1009. Venous 1: A Prospective Multicenter Cohort Study of Enterococcal Bacteremia
Authors: Contreras German , Munita Jose M , Reyes Katherine C , Sahasrabhojane Pranoti , Misikir Helina , Garza Heather , Zervos Marcus J , Aitken Samuel L , Shelburne Samuel A , Arias Cesar
Published: November 2018

Background

Enterococci often cause hospital-associated bloodstream infections in critically ill and immunocompromised patients. Prospective studies to assess the clinical impact of enterococcal bacteremia (EB) are lacking. We conducted a prospective study to investigate the clinical and microbiological factors associated with mortality in EB.

Methods

Adults with EB were prospectively followed in three US tertiary hospitals from September 2016 to March 2018. Individuals with EB for whom follow-up blood culture data within 7 days of index culture were available were included. Microbiologic failure (MF) was defined as clearance of bacteremia ≥4 days after the first blood culture. The main outcome was hospital mortality.

Results

A total of 282 patients were included with 69 (24%) infected with vancomycin-resistant enterococci (VRE). The majority of patients were male (60%) with a median age of 63 years. Median length of hospitalization for VRE patients was longer (25 d) than non-VRE (13 days, P < 0.001). E. faecium corresponded to 77% of VRE isolates, whereas E. faecalis comprised 72% of non-VRE. The average time to first blood culture was 16 days for VRE vs. 4 days for non-VRE (P < 0.001). Patients with VRE were more likely to have hematological malignancy or bone marrow transplant (P < 0.003), whereas patients infected non-VRE were more likely to have solid tumors (P = 0.02). The most common antibiotic used was daptomycin as monotherapy for both VRE and non-VRE with a median dose of 8 mg/kg for both groups. Overall mortality was 25% (43% vs. 20% in VRE vs. non-VRE patients, respectively; P < 0.0001). Factors significantly associated with mortality in univariate analyses included ICU admission, prolonged hospitalization, hematological malignancy, use of immunosuppressive therapy, hemodialysis, neutropenia (<500 cell/mL), Pitt bacteremia score >3, infection with VRE and MF. ICU admission (RR 3.3; 95% CI 1.7–7.5, neutropenia (RR 4.1; 95% CI 1.3–12.9), Pitt bacteremia score >3 (RR 6.8; 95% CI 2.6–18.0), MF (RR 4.7; 95% CI 2.2–10.3) and infection with VRE (RR 4.1; 95% CI 1.1–16.6) remained significantly associated with mortality in multivariate analyses.

Conclusion

The presence of VRE in EB and MF are associated with increased mortality. EB represent a major burden of disease in hospital settings.

Disclosures

C. Arias, Merck & Co., Inc.: Grant Investigator, Research support. MeMed: Grant Investigator, Research support. Allergan: Grant Investigator, Research support.
1012. Group B Streptococcus Bacteremia in Non-Pregnant Adults in a Tertiary Care Hospital Between 2008 and 2017 in Korea
Authors: Lee Jeong Eun , Lee Sun Hee , Lee Shinwon , Kim Kye-Hyung , Lee Soon Ok , Sim YongKi
Published: November 2018

Background

Group B streptococcus (GBS) has emerged as an important cause of invasive infection in nonpregnant adults. This study aimed to describe the clinical characteristics and risk factors associated with GBS bacteremia in nonpregnant adult patients in Korea.

Methods

Our retrospective study reviews the hospital records of nonpregnant adults, aged ≥18 years, with GBS bacteremia who attended the Pusan National University Hospital between January 1, 2008 and December 31, 2017. The presence of underlying diseases, such as cardiovascular diseases, diabetes mellitus, malignancy, liver disease and/or alcohol abuse and renal disease, as well as possible portals of entry of infection, was analyzed.

Results

During the period of 10 years, there were 79 patients with GBS bacteremia. In 47 episodes (59.5%), patients were aged 60 years or older and 43 (54.4%) episodes occurred in females. Their mean age was 61 years (range, 19–91 years) and 70 patients (88.6%) had underlying diseases. Cardiovascular diseases (n = 35, 44.3%) were the most common underlying conditions, and diabetes mellitus (n = 27, 34.2%) and nonhematologic malignancy (n = 27, 34.2%) were second. Genitourinary cancer composed nearly half of nonhematologic malignancy (n = 13, 48.1%). The other comorbid conditions were liver disease and/or alcohol abuse (n = 14, 17.7%), renal disease (n = 13, 16.5%) and hematologic malignancy (n = 7, 8.9%). The most common clinical syndrome was primary bacteremia (n = 31, 39.2%). The others were bone and joint infection (n = 15, 19.0%), urinary tract infection (n = 12, 15.2%), skin and soft-tissue infection (n = 7, 8.9%), infective endocarditis (n = 4, 5.1%), peritonitis (n = 4, 5.1%), and meningitis (n = 2, 2.5%). The overall mortality rate was 13.9%, all patients had at least one underlying disease. The mortality rate of primary bacteremia was significantly higher than those of bacteremia with focus (29.0% vs. 4.2%, respectively; P = 0.002). Hematologic malignancy, liver disease, and/or alcohol abuse and renal disease were significantly associated with the primary bacteremia.

Conclusion

GBS bacteremia is a significant problem in nonpregnant patients, especially primary bacteremia resulted in a high rate of mortality (29%). Hematologic malignancy, liver disease, and/or alcohol abuse and renal disease were significantly related to primary bacteremia occurrence.

Disclosures

All authors: No reported disclosures.
1014. Microbiology and Outcome of Bloodstream Infections in Children With Intestinal Failure
Authors: Seddik Talal , Maldonado Yvonne , Nespor Colleen , Kerner John , Gans Hayley
Published: November 2018

Background

Children with intestinal failure (IF) represent 20% of bloodstream infection (BSI) pediatric hospitalizations. We studied the microbiology and associated outcomes of this population.

Methods

Retrospective cohort study of children ≤18 years with IF dependent on parenteral nutrition (PN), with ≥1 BSI from January 2007 to December 2016. Organisms causing BSI were divided into skin or GI bacteria and fungi based on human habitat and kingdom. The impact of ethanol lock therapy (ELT) and clinical diagnosis of small intestine bacterial overgrowth (SIBO) on the type of these organisms was evaluated. Antimicrobial utilization and outcome measures for BSI were collected.

Results

There were 254 BSIs in 54 children resulting from GI bacteria (58%), skin bacteria (39%), and fungi (16%) with 11% containing >1 group. The proportion of skin bacteria was significantly higher on ELT (27% off vs. 45% on ELT; P = 0.003), while the proportion of GI bacteria was lower (67% off vs. 52% on ELT; P = 0.018). Significantly more fungal BSIs were seen in older children: mean age 4.2 years (95% CI: 2.9–5.5) vs. 2.7 years (95% CI: 2.3–3) with other organisms; P = 0.014. Fungal BSIs were more common with SIBO (18% vs. 5% with and without SIBO; P = 0.013). Twenty-eight organisms were resistant to ceftazidime, and five to cefepime. Hospitalization days totaled 2,432 (median 8 days), with 21 pediatric critical care admissions totaling 156 days. There were six deaths, none related to BSI, 18/54 children were weaned off PN, and four had liver and intestinal transplants. Median course of antimicrobial therapy was 14 days.

Conclusion

The majority BSIs in children resulted from GI bacteria, suggesting intestinal translocation; these infections were not less common in older children despite increased intestinal mass, signifying continued translocation. BSI with GI organisms was not more common in children with SIBO despite increased intestinal bacterial load, possibly due to antibiotic suppressive therapy, which instead lead to more fungal BSIs. Prevention of BSI by ELT was less effective for skin bacteria which may require different regimens or strategies. BSI causes frequent and prolonged hospitalizations including need for intensive care, but deaths are rare.

Disclosures

All authors: No reported disclosures.
1021. Repeat Infective Endocarditis (rIE) in Persons Who Inject Drugs (PWID)
Authors: Huang Glen , Barnes Erin , Peacock James
Published: November 2018

Background

Injection drug use (IDU) is a major risk factor for infective endocarditis (IE). Rates of IE have recently increased in the US concurrent with the opioid crisis. Although IDU-related IE is well described, few data exist on repeat IE (rIE) in persons who inject drugs (PWID).

Methods

Patients ≥18 years old seen at Wake Forest Baptist Medical Center from 2004–2017 with an ICD-9 or -10 diagnosis of IE who met Duke criteria for IE and who self-reported IDU in the 3 months prior to admission were identified. The subset of PWID who developed rIE, defined as another episode of IE at least 10 weeks after the diagnosis of the first episode, was then reviewed.

Results

Of the 94 PWID with IE, 22 (23.4%) experienced rIE (19 re-infections, three relapses). All patients were Caucasian, 50% were male, and 68.2% lived in rural areas; the median age was 30. All 22 patients resumed IDU after their first episode of IE. The mean duration from completion of antibiotics for the prior IE episode to admission with rIE was 257.5 days; the episode of rIE occurred within 1 year in 17 patients (77.3%). On repeat admission, those with rIE had a Pitt bacteremia score of 3.0 and an APACHE II score of 13.1. Fever and bacteremia persisted for an average of 5.6 days and 2.6 days, respectively. S. aureus was the cause of rIE in 54.5% of patients and the tricuspid valve (TV) was involved in 77.3% of cases. Valve surgery occurred in 22.7% of patients. Mean length of stay was 25.3 days and mean duration of antibiotic therapy was 32.1 days. Seven patients (31.8%) died during the rIE hospitalization and another died within 12 months after discharge resulting in a 1-year mortality of 36.3%. Compared with their first episode of IE, rIE patients had higher admission Pitt bacteremia (3.0 vs. 1.5, P = 0.07) and APACHE II scores (13.1 vs. 9.5, P = 0.18), fewer S. aureus infections (54.5% vs. 95.4%, P = 0.01), similar TV involvement (77.3% vs. 72.7%, P = 1), and less frequent surgery (22.7% vs. 59.1%, P = 0.06).

Conclusion

rIE is common in PWID with most episodes occurring within 1 year of the initial episode. Reinfection is more frequent than relapse. The microbiology of rIE is more varied than first episode IE in PWID with S. aureus being less frequently isolated. Illness severity is high, hospitalizations are prolonged, and 1-year mortality is significant. More effective strategies for preventing rIE in PWID are needed.

Disclosures

J. Peacock, Pfizer: Shareholder, Owns common stock in Pfizer which was inherited and held in a trust.
1023. A Controlled-Release Prescription Oral Opioid Can Prolong S. aureus Survival in Injection Drug Preparation Equipment and Potentially Increase Bacteremia Risk
Authors: Kasper Katherine , Manoharan Iswarya , Glockler-Lauf Dresden , Ball Laura , Hallam Brian , Koivu Sharon , McCormick John , Silverman Michael
Published: November 2018

Background

S. aureus is the most common pathogen associated with injection drug use-associated endocarditis (IDUaIE). Our center has a high incidence of IDUaIE and the opiate of choice in our population is hydromorphone-controlled release (HCR), a prescribed oral opiate widely used in Canada and Europe. The complex technique for preparation for injection provides multiple opportunities for contamination of the solution and the controlled-release preparation contains several excipients (carbohydrates, protein, and iron), which could enhance Staphylococcal survival. A large amount of drug remains in the injection drug preparation equipment (IDPE) after each use and therefore, used IDPE is saved by people who inject drugs (PWID) for subsequent reuse by adding more water and then injecting the solution intravenously.

Methods

Used IDPE was collected from active PWID, rinsed with sterile water, aspirated into a syringe in a technique which mimicked reuse of equipment by PWID, and then plated on Mannitol salt agar (MSA). Bacterial isolates from local bacteremic PWID were used to test the survival of S. aureus (MRSA and MSSA) and S. pyogenes on unused IDPE with HCR or hydromorphone immediate release (HIR). The solutions were aspirated using techniques similar to that of local PWID and then plated on MSA and Blood agar.

Results

A total of 109 used IDPE samples were collected between March 2017 and March 2018. S. aureus was detected in 15/94 (16%) IDPE samples that had been used for injection of HMC (seven MRSA, seven MSSA, and two borderline resistant [one sample contained both MRSA and MSSA]), but 0/15 (0%) samples used for hydromorphone immediate release (HIR). HCR, but not HM, was associated with greater survival of MSSA and MRSA (but not S. pyogenes) in solutions of the drug when compared with sterile water vehicle control (Figure 1). There was a 2-log reduction in the number of viable S. aureus when IDPE containing HCR solutions spiked with MRSA or MSSA were heated with a cigarette lighter until bubbling (<10 seconds).

Conclusion

IDPE that has been used in the preparation of HCR is frequently contaminated with S. aureus; and in vitro HCR, but not HM, prolongs the survival of MRSA and MSSA. Heating IDPE may be an effective harm-reduction strategy to reduce bacterial complications of injection of HCR.

Disclosures

All authors: No reported disclosures.
1027. Outpatient Parenteral Antimicrobial Therapy (OPAT) in Injection Drug Users (IDUs): Is It Safe?
Authors: Rizvi Hira , Baratz Nathalie , Hadid Hind , Bardossy Ana C , Herc Erica , Misikir Helina , Chen Anne , Markowitz Norman , Zervos Marcus J
Published: November 2018

Background

OPAT is widely implemented in the United States. However, there are concerns surrounding discharge of IDU with a peripherally inserted central catheter (PICC). The objective of this study was to evaluate the characteristics and treatment outcomes of IDUs discharged on OPAT.

Methods

This is a retrospective observational study conducted on patients discharged from an Infectious Diseases unit at a quaternary academic healthcare center in Detroit. Charts of all IDUs discharged on OPAT between 2011 and 2017 were reviewed. Current or former IDU were discharged on OPAT if they met the following criteria: self-reported history of IDU, stable living conditions, controlled psychiatric illness (if present), and willingness to sign a discharge agreement to refrain from using the PICC as a route for illicit drugs. Patients were categorized based on clinic follow-up vs. no clinic follow-up. Outcomes evaluated were: cured (completed treatment and symptom free for 1 month after completion), improved (symptoms were improved but there was no confirmation of treatment completion); and relapsed (readmitted within 30 days for the same infection or sequela). Outcomes of patients with no clinic follow-up were based on chart review of subsequent emergency department visits or admissions.

Results

Patient characteristics are shown in Table 1. Of the 61 patients evaluated, 33 (54.1%) attended clinic follow-up and 28 (45.9%) did not. Outcomes based on clinic follow-up are shown in Table 2. Of the 18 patients who were cured, 16 attended clinic follow-up vs. two who did not.

Conclusion

This study demonstrates that some IDUs can be discharged safely on OPAT. Patients with clinic follow-up had improved outcomes compared with those who did not. Further studies are needed to look at other predictors of outcome in this patient population.

Disclosures

All authors: No reported disclosures.
1030. Risk Predictive Model for Candida Endocarditis in Patients with Candidemia: A 12-year Experience in a Single Tertiary Care Hospital
Authors: Foong Kap Sum , Kronen Ryan , Salazar Ana S , Hsueh Kevin , Lin Charlotte , Powderly William , Spec Andrej
Published: November 2018

Background

Candida endocarditis (CE) is a rare but an invasive infection associated with a high mortality rate. The current understanding of this infection is poorly defined from case reports, case series and small cohorts. This study aimed to assess the risk factors for CE in patients with candida bloodstream infections (CBSI).

Methods

We conducted a retrospective analysis of all hospitalized patients diagnosed with CBSI at a large tertiary care hospital between 2002 and 2015. Data included demographics, comorbidities, laboratory parameters, and outcomes. Univariate and multivariable logistic regression analyses were used to build the predictive model.

Results

Of 1,873 cases of CBSI, 47 patients were identified to have CE. The most commonly isolated species were C. albicans (59.6%) followed by C. parapsilosis (16.2%). On univariate analysis, preexisting valvular disease (7.95, 95% CI [3.16, 20.02]) was associated with a higher risk of CE (P < 0.05). Factors such as isolation of C. glabrata (0.17, 95% CI [0.04, 0.68]), hematologic malignancy (0.09, 95% CI [0.01, 0.68]), and total parenteral nutrition (TPN) (0.40, 95% CI [0.17, 0.95]) were all associated with a lower risk of CE. In multivariable modeling, the factors of valvular disease (5.05, 95% CI [1.77, 14.43]), isolation of C. glabrata (0.19, 95% CI [0.05, 0.80]), hematologic malignancy (0.09, 95% CI [0.01, 0.66]), and total parenteral feeding (0.43, 95% CI [0.17, 1.09]) remained significant. The final model had a C-statistic of 0.82. The crude 90-day mortality for CE was 48.9%, similar to the overall CBSI mortality of 42.1%.

Conclusion

In a population of patients with CBSI, previous valvular disease was the only factor associated with a greater risk of development of CE. Use of TPN, hematologic malignancy, and isolation of C. glabrata were protective factors. A predictive model may reduce the need for expensive and sometimes invasive diagnostic imaging such as trans-esophageal echocardiography, as a subset of patients may be at low enough risk for CE not to warrant them.

Disclosures

All authors: No reported disclosures.
1031. Nationwide Temporal Trends of Candidemia Incidence Over 18 Years Within the Veteran Health Administration System
Authors: Suzuki Hiroyuki , Perencevich Eli , Diekema Daniel , Livorsi Daniel , Schweizer Marin , Nair Rajeshwari , Ohl Michael , Richardson Kelly , Beck Brice , Alexander Bruce , Goto Michihiko
Published: November 2018

Background

Bloodstream infection due to Candida spp. is common and associated with significant mortality and morbidity. Previous population-based studies in 2000s and early 2010s have suggested that the incidence of candidemia might be increasing, presumably due to widespread use of central lines and broad-spectrum antibiotics. However, recent trends of candidemia incidence have not been not well described.

Methods

We conducted a retrospective cohort study of all veterans cared for in the Veterans Health Administration (VHA) system from January 2000 to December 2017 to determine the incidence of candidemia. All patients who had positive blood cultures were identified using data available in the electronic medical record data warehouse, and the number of unique patients for each month was calculated. Patient-days was used as a denominator, and the incidence rate was expressed as the number of unique patients with candidemia per patient-days for each month. Temporal trends were analyzed by joinpoint regression models to identify statistically significant changes in trend.

Results

Over the study period, 31,370 positive blood cultures for Candida spp. from 15,763 unique patients were identified. The mean monthly incidence rate was 22.5 per 100,000 patient-days (IQR: 15.6–28.4). Incidence rates were increasing in the early 2000s and relatively stable in the mid-2000s, followed by a sustained decline (figure). Joinpoint regression analysis revealed there were two statistically significant changes in slope, one in September 2003 (95% CI: 2/2002–1/2005) and another in 6/2007 (95% CI: 4/2006–3/2009).

Conclusion

In the VHA system, there were significant changes in temporal trends of candidemia incidence rates over 18 years, including a substantial increase in the early 2000s followed by a sustained decline in later years. The incidence rates during 2016–2017 were nearly one-third of their peak in the mid-2000s. Possible explanations for the sustained decline include prevention efforts for healthcare-associated infections, such as central-line associated bloodstream infections. Further study is needed to investigate etiologies of these changes in temporal trends to identify potential effective prevention for candidemia.

Disclosures

M. Ohl, Gilead Sciences, Inc.: Grant Investigator, Research grant
1032. A Case Series of Clostridium septicum Aortitis
Authors: Lehman Bethany , Miller Ryan , Keller George , Richter Sandra S , Rehm Susan J
Published: November 2018

Background

Clostridium septicum is an anaerobic, motile, spore forming, toxin-producing Gram-positive bacillus (GPB) that has been associated with colon and hematologic malignancies. Despite the low incidence of infection, it is a virulent organism leading to rapidly progressive gas gangrene. Only 51 cases of C. septicum related aortic aneurysms have been reported. 100% mortality is reported in patients without surgical intervention vs. 79% undergoing surgery. The primary aim of this study was to determine the incidence and clinical outcomes of patients treated at our institution with C. septicum aortitis.

Methods

In this IRB-approved retrospective case series, we reviewed our microbiology laboratory’s blood and tissue cultures from January 2005 to 2018 to identify cases of C. septicum infection. All patients >18 years of age who had positive cultures were reviewed to provide radiographic or histopathologic correlation.

Results

Among 50 patients with C. septicum in blood and tissue cultures, seven patients were identified with aortitis. Underlying malignancy was found in four cases and included colon cancer (three cases) and prostate cancer (one case). The most common location for infection was the infrarenal aorta (four cases). Previous vascular surgery had been performed in three cases. Five of the seven patients underwent surgical repair with pathology revealing GPB in three patients and acute inflammation in the other two patients. C. septicum grew in tissue cultures from these patients. Four of the seven patients (all of whom underwent surgery) had positive blood cultures. The two patients that did not undergo surgery died which is consistent with the 100% mortality described in the literature. All patients were treated with β-lactam therapy. The median duration among the five who completed treatment was 7.5 weeks. Among the five patients who underwent surgery, two are alive (one at 1 year and another at 5 months postoperatively), two died within the first year after surgery, and one patient was lost to follow-up.

Conclusion

A small percentage of patients with C. septicum aortitis survived over 1 year. Earlier recognition and emergent surgery with appropriate antimicrobial therapy are needed to improve the outcome of patients diagnosed with this rare infection.

Disclosures

S. S. Richter, bioMerieux: Grant Investigator, Research grant. BD Diagnostics: Grant Investigator, Research grant. Roche: Grant Investigator, Research grant. Hologic: Grant Investigator, Research grant. Diasorin: Grant Investigator, Research grant. Accelerate: Grant Investigator, Research grant. Biofire: Grant Investigator, Research grant.