bluuebunny/crossref_metadata_2025 huggingface dataset:
1712. Candida auris: A Case Series at a Large Tertiary Care Medical System
Authors: Yeturu Preethi , Harrington Amanda , Reid Gail
Published: October 2019

Background

Candida Auris has become one of the most feared pathogens globally in a relatively short period of time and, despite increased awareness, its incidence continues to rise. Recently there has been growing concern regarding drug resistance, difficulty in identification, as well as problems with eradication.

Methods

Loyola Medicine includes Loyola University Medical Center, a large tertiary care transplant center, and Gottlieb Memorial Hospital, a community-based medical center. Both hospitals have reported cases of Candida auris infection. We reviewed the microbiology laboratory data and clinical information of all positively identified cases over a 17-month period.

Results

Candida auris was isolated from 14 patients in cultures from blood, urine, wounds, and respiratory secretions. Matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS; Burker, Biotyper RUO) was used for identification in all of the cases and susceptibility testing was performed using microbroth dilution (Sensititre, YeastOne) for all isolates. 7/14 isolates (50%) were considered resistant to fluconazole; however, none were multi-drug resistant. All 14 isolates (100%) were considered susceptible to echinocandins. In addition, all patients were critically ill and had multiple comorbidities.

Conclusion

Candida auris is an emerging global health threat with increasing incidence of infection. Awareness of the pathogen, appropriate contact precautions, and laboratory methods of identification are necessary. Given increasing drug resistance, we recommend susceptibility testing on all isolates.

Disclosures

All authors: No reported disclosures.
1718. The Natural History of Chronic Pulmonary Coccidioidomycosis in the Pre-Antifungal Era
Authors: Freifeld Alana J , Bays Derek , Thompson George R , Reef Susan , Snyder Linda , Galgiani John N
Published: October 2019

Background

Prior studies to characterize pulmonary coccidioidomycosis (CM) have been limited by small samples. The historical VA-Armed forces CM patient group provides a unique cohort of patients not treated with conventional antifungals to better characterize and describe chronic pulmonary CM with an emphasis on chronic nodules and cavities.

Methods

A retrospective study of 374 VA-Armed forces non-disseminated CM patients diagnosed between 1955 and 1958 and followed to 1966. Patients had a pulmonary nodule or a pulmonary cavity secondary to CM. Basic demographic information, complement fixation serology, and details regarding the nodules and cavities were investigated.

Results

The studied population had a median age of 34 with 97% men and 84% white. Eighty percent had no underlying pulmonary disease and concurrent tuberculosis was the most common comorbid pulmonary condition (11%). Patients with cavities had a median complement fixation (CF) serology of 1:2 (interquartile range (IQR) negative 1:8). Patients with nodules had a median CF serology of negative (IQR negative 1:2). The median number of pulmonary nodules was 1 with a median size of 1–1.9 cm. Sixty-nine percent of the nodules had a sharp, well-defined border, while 10% had a calcified border. The median number of cavities was 1 with a median size of 3–3.9 cm. Forty-five percent of the cavity walls were thin, 31% were thick, and 19% were variable in size. Twenty-six percent of the cavities developed during acute infection with 46% developing without a prior history of primary infection. Twenty-nine percent of the cavities were stable in size, 20% increased in size, 5% disappeared, 4% ruptured, and 2% decreased in size.

Conclusion

This study helps further characterize chronic pulmonary nodules and cavities caused by CM. To the best of our knowledge, this is the largest study of the natural history of chronic CM pulmonary cavities and nodules providing valuable descriptive features.

Disclosures

All authors: No reported disclosures.
1729. Profiling Human Neutrophil Functional Responses From Solid-Organ and Stem Cell Transplant Recipients to Candida albicans
Authors: Barros Nicolas , Alexander Natalie , Viens Adam , Hopke Alex , Knooihuizen Sally , Scherer Allison , Dagher Zeina , Irimia Daniel , Mansour Michael
Published: October 2019

Background

Solid-organ (SOT) and stem cell transplant (SCT) recipients are at increased risk of invasive fungal disease despite normal neutrophil counts in peripheral blood. However, the neutrophils function against fungi has not been completely defined. In this study, we measure human neutrophil anti-candida activity in SOT and SCT recipients.

Methods

SOT and SCT patients were identified and consented from September 2018 until April 2019. Healthy control patients (HC) were identified at primary care clinics. EDTA-anticoagulated peripheral blood was obtained from healthy and transplant patients 2–4 months post-transplant. Neutrophils were isolated by negative selection. C. albicans was incubated for 2 hours with and without human neutrophils at multiplicity of infection (MOI) of 10, 5 and 1. Following neutrophil cell lysis, percent remaining live Candida was measured using a viability dye. In addition, growth inhibition of C. albicans by neutrophil swarming to C. albicans spotted onto glass slide arrays was also assessed by live cell imaging.

Results

22 SOT (15 kidneys, 7 livers), 20 SCT (allograft) and 22 HC were enrolled. Neutrophils from SCT and SOT had lower C. albicans killing percentages compared with HC at MOI 10 (HC: 47%, SOT: 29%, SCT 24% P = 0.0041); MOI 5 (HC: 72%, SOT: 35%, SCT 38% P < 0.0001) and MOI 1 (HC: 91%, SOT: 48%, SCT: 45% P < 0.0001). Neutrophil swarming and fungal control of C. albicans spots was significantly inhibited by neutrophils from SCT when compared with SOT and controls (P <0.0001). Analysis of medications, including tyrosine kinase inhibitor (TKI) use, did not demonstrate significant differences of a specific drug class when patient groups are compared (SCT vs. SOT).

Conclusion

Our study indicates that despite normal circulating numbers, neutrophils from SOT and SCT recipients are dysfunctional and show profoundly impaired anti-Candida activity. There were no medications or laboratory values that predicted functional neutrophil outcome. These data strongly support the use of functional neutrophil profiling to risk stratify those individuals at higher risk for invasive fungal infections.

Disclosures

All authors: No reported disclosures.
1734. Antifungal Prophylaxis in Allogeneic Hematopoietic Stem Cell Transplantation: A Single-Center Experience in Colombia
Authors: Estacio Mayra , Rosales Joaquin , Jaramillo Francisco , Sanz Ana-Maria , Vélez Juan D , Moncada Pablo A , Rosso Fernando
Published: October 2019

Background

Invasive fungal infections (IFI) are significant causes of morbidity and mortality among patients with hematopoietic stem cell transplantation (HSCT). Primary antifungal prophylaxis has lowered the IFI cases however there is no clear guidance regarding which mold active agent is most useful if mold-active prophylaxis. We aim to present the incidence of IFI in patients with allogeneic HSCT, and the impact of primary antifungal prophylaxis regimen.

Methods

Retrospective cohort study. We included patients older than 18 years, with allogeneic HSCT from Fundación Valle del Lili, between January 2008 and April 2017. The patients received antifungal prophylaxis with fluconazole, itraconazole, or posaconazole from conditioning day to +100 post-transplant day. The prophylactic antifungal agent was selected according to the initial diagnosis, transplant type, conditioning regimen and the risk of developing GVHD. All patients received myeloablative conditioning regimens and were hospitalized in laminar airflow rooms during their period with neutropenia. The cases were defined according to the EORTC/MSG Consensus Group. We analyzed patients with probable or confirmed IFI, in the first 120 post-transplant days.

Results

We enrolled a total of 101 patients who received HSCT over the course of the study. The median age was 32 (23–43). Posaconazole prophylaxis was used in 73%, fluconazole in 18% and itraconazole 10% of the patients. The IFI incidence was 3.9% (4 cases) and the median time from HSCT to the diagnosis of IFI was 60 days. The percentages of patients who experienced probable IFI in the itraconazole arm was 22% (2/9 patients) and in the fluconazole arm 11.1% (2/18), there was no infection in the posaconazole group (P = 0.001). Donor sources were HLA-matched sibling (42%), Haploidentical (48%), and cord blood (10%). The cumulative incidence of grade I–IV aGVHD was 63.4% and that of grade III–IV aGVHD was 37.5%.

Conclusion

In patients undergoing HSCT posaconazole prevented invasive fungal infections more effectively than did either fluconazole or itraconazole.

Disclosures

All authors: No reported disclosures.
1747. Impact of Inappropriately Low Cytomegalovirus (CMV) Prophylaxis Dosing on CMV Outcomes Among Lung Transplant (LT) Recipients
Authors: Watts Corey , Blumberg Emily , Lee James , Claridge Tamara , Crespo Maria , Anesi Judith A , Anesi Judith A
Published: October 2019

Background

Valganciclovir (VGCV) and ganciclovir (GCV) are commonly used to prevent CMV in at-risk lung transplant recipients (LTRs). Because renal function changes frequently in the post-transplant setting, antiviral under-dosing may occur. We sought to determine the frequency of GCV/VGCV under-dosing and its impact on CMV-related outcomes among LTRs.

Methods

We conducted a retrospective cohort study of all adult LTRs with a CMV seropositive donor (D+) between 2014 and 2016 at the Hospital of the University of Pennsylvania. Exposed patients were those with exposure to inappropriately low-dose GCV/VGCV. Unexposed patients were those whose antiviral dosing was consistently appropriate for their creatinine clearance. We employed a multivariable Cox proportional hazard analysis to determine the impact of low-dose prophylaxis on time to CMV infection post-transplant; prophylaxis dosing was incorporated as a time-varying covariate in this survival analysis.

Results

108 adults underwent CMV D+ LT during the study period. 46 (43%) experienced low prophylaxis dosing at some point during their prophylaxis course. 47 (43%) LTRs developed CMV viremia, of which 10 (9%) were still on prophylaxis. 20 (19%) LTRs developed CMV disease and 6 (6%) had ganciclovir-resistant CMV. In the multivariable Cox analysis, we found that there was not a significant association between exposure to any low-dose prophylaxis and the hazard of CMV infection (HR = 1.001, 95% CI 0.99–1.01, P = 0.75; Table 1), even among CMV seronegative recipients (D+/R−) (HR = 1.002, 95% CI 0.99–1.01, P = 0.68). When only those who received > 28 days of low-dose prophylaxis (N = 6, 6%) were evaluated, there was a trend toward an increased hazard of CMV infection (HR = 1.001, 95% CI 0.999–1.004, P = 0.18; Table 2).

Conclusion

CMV D+ LTR are frequently exposed to inappropriately low CMV prophylaxis dosing. This does not appear to significantly increase the risk for CMV infection, though prolonged subtherapeutic exposure merits further exploration as a risk factor for CMV outcomes in higher-risk patients.

Disclosures

All authors: No reported disclosures.
1748. Incidence of Cytomegalovirus Disease and Viral Replication Kinetics in Intermediate Risk Liver Transplant Recipients Managed According to a Preemtive Therapy Algortihm
Authors: Fernández Oscar , Cuellar-Rodríguez Jennifer , Sifuentes-Osornio Jose , García Ignacio , Belaunzarán Pablo
Published: October 2019

Background

Cytomegalovirus (CMV) is an important opportunistic pathogen in liver transplant recipients (LTR). Risk of invasive disease is determined by CMV donor/recipient (D/R) serostatus, immunosuppression, and use of antiviral prophylaxis. Viral replication kinetics that can predict the development of CMV disease in transplant recipients are a high maximal viral load (VL) and a fast replication velocity. At our institution LTR at intermediate risk for CMV disease (CMV D/R+) are managed following a preemptive therapy algorithm (the pre-established cutoff for treatment initiation is 4,000 IU/mL). The primary endpoint of this study was to determine the incidence of early CMV disease in CMV D/R+ LTR. Secondary endpoints were to calculate the period of maximal VL and viral kinetic parameters.

Methods

We performed a retrospective observational study of CMV D/R+ LTR. Patients were followed for 6 months after transplantation. We calculated the incidence of CMV disease. Viral kinetic parameters calculated were the VL duplication time (Td) and the basic reproductive number (R0). For the assessment of viral kinetics we used the maximal VL of 10 patients who had a VL determined within the previous week.

Results

Forty CMV D/R+ LTR were included. The median age was 52 years, 65% were women. The mean MELD score was 18, 83% of patients had decompensated cirrhosis. No patient developed CMV disease during the first 6 months after LT. Nineteen patients (47%) had CMV DNAemia, but only 8 (20%) required antiviral therapy. The highest VLs were observed during the second month after transplant. The median duplication time was 2.14 days. The median R0 was 1.46.

Conclusion

Although limited by our sample size, our algorithm appears useful for discriminating the patients who need antiviral treatment from those who will only have asymptomatic DNAemia. The study population VL, Td and R0 behave as described by other groups, which emphasizes the need for frequent monitoring. This is a challenge for CMV prevention in resource-limited countries.

Disclosures

All authors: No reported disclosures.
1759. Incidence of Hospitalizations and Emergency Department Visits for Herpes Zoster in Immunocompromised and Immunocompetent Adults in Ontario, Canada, 2002–2016
Authors: Buchan Sarah , Wang John , Wilson Sarah , Wormsbecker Anne E , Garber Gary , Daneman Nick , Deeks Shelley
Published: October 2019

Background

Adults with immunocompromising conditions are at increased risk of herpes zoster (HZ) infection and related complications. We aimed to assess the incidence of HZ seen in hospital or emergency department in immunocompromised populations and compare it to that of immunocompetent populations.

Methods

Using healthcare administrative data, we calculated incidence rates (IR) of HZ in Ontario, Canada between April 1, 2002 and August 31, 2016 in adults ≥18 years categorized as immunocompromised or immunocompetent. We repeated these analyses by type of immunocompromising condition and provided incidence rate ratios (IRR) comparing to immunocompetent adults. We also calculated IRs and IRRs of HZ complications by immunocompromised status.

Results

There were 120,654 incident cases of HZ seen in hospital or emergency department during the study period. Immunocompromised adults accounted for 13% of these cases despite representing only 3% of the population. The risk of HZ was higher for immunocompromised adults compared with immunocompetent (IRR = 2.8, 95% CI 2.8–2.9) and ranged across type of immunocompromising condition (from 2.4 [95% CI 2.3–2.5] in those with a solid tumor malignancy to 11.0 [95% CI 10.0–12.0] in those who had undergone a hematopoietic stem cell transplant). The risk of any HZ complication was also higher in immunocompromised adults (IRR = 3.5, 95% CI 3.4–3.6) and was highest for disseminated zoster (IRR = 31.5, 95% CI 26.3–37.5).

Conclusion

The risk of HZ and related complications was higher in immunocompromised populations compared with immunocompetent. Our findings underscore the high-risk nature of this population and the potential benefits that may be realized through HZ vaccination of this group.

Disclosures

All authors: No reported disclosures.
1765. BK Polyomavirus Reactivation Outcomes After Renal Transplantation in Association With Adherence to a Standardized BK Polyomavirus Screening Protocol: A Multi-Center Collaboration
Authors: Rogers Ralph , Chobanian Michael , Gilligan Hannah , Goyal Nitender , Rodig Nancy , Rossi Ana , Sabrina Tan Chen , Pavlakis Martha
Published: October 2019

Background

Reactivation of BK polyomavirus (BKPyV) due to immunosuppression after renal transplantation can lead to allograft nephropathy (BKAN) or even allograft loss. Many transplant centers implement screening protocols in an attempt to detect BKPyV reactivation before progression to BKAN, although the frequency and duration of screening vary widely among centers.

Methods

The New England BK Consortium (NEBKCON), a collaboration of 12 transplant centers in the northeastern United States, has adopted a standard BKPyV screening protocol (screening monthly for the first 6 months followed by screening every 3 months until 2 years after transplantation). Participating members implemented this screening protocol at their centers, and later measured adherence to the protocol as part of a NEBKCON quality improvement project. This study retrospectively analyzes BKPyV-specific outcomes in association with adherence to this protocol.

Results

Six centers reported data on 472 subjects who received a renal transplant between January 2016 and December 2017. Adherence to the screening protocol during the first 12 months (7.1–76.7%, mean 56.1%) and 24 months (2.9–52.5%, mean 36.8%) after transplant varied between centers. Rates of BKPyV viremia (3.6–28.2%, mean 20.6%) as well as BKAN (0–4.5%, mean 3.2%) also varied among centers. Adherence to the screening protocol was associated with a decrease in the magnitude of the initial viral load detected (3.29 vs. 3.74 log10 copies/mL, P = 0.065), but was not associated with peak viral load (3.95 vs. 4.14 log10 copies/mL, P = 0.47), viremia duration (179 vs. 196 days, P = 0.74), or incidence of BKAN among viremic subjects (15.3 vs. 16.0%, P = 0.91).

Conclusion

Even with a uniform screening protocol for BKPyV in place, adherence to this protocol varied widely among centers. More research is needed to determine patient-level and center-level barriers to adherence, as well as to determine optimal screening practices to further reduce the incidence of BKAN.

Disclosures

All authors: No reported disclosures.
1769. The Impact of Checkpoint Inhibitor Immunotherapy on Infections in Lung Cancer Patients
Authors: Malek Alexandre , Fares Johny , Khalil Melissa , Hachem Ray Y , Chaftari Anne-Marie , Jiang Ying , Kontoyiannis Dimitrios P , Fossella Frank , Chaftari Patrick , Mulanovich Victor E , Viola George , Raad Issam I
Published: October 2019

Background

Immune checkpoint inhibitors (ICI) therapy has ushered cancer treatment into a potentially curative era. However, infectious complications remain largely unknown and the few studies that described infectious complications associated with ICI had no comparative control groups. We assessed the rate of infections in patients with non-small cell lung cancer (NSCLC) treated with ICI plus conventional chemotherapy (CC) vs. CC alone.

Methods

We performed a comparative single-center retrospective cohort study of patients with NSCLC who received de novo treatment with either Pembrolizumab or Nivolumab, and/or Ipilimumab combined with CC including Pemetrexed and Carboplatin vs. patients treated with CC alone between August 2016 and January 2019. We excluded all patients who were switched from CC to ICI or vice-versa. We evaluated patients’ characteristics, treatment modality, immune-related adverse events (irAEs), and outcome. Infections were defined by clinical signs and symptoms, microbiologic documentation, and/or imaging studies.

Results

A group of 126 patients who received ICI concurrently with CC were compared with 126 patients who received CC alone (control group). Patients in the ICI group were more likely to have stage IV NSCLC compared with the control group (P < 0.0001). Pembrolizumab was most commonly used as a single ICI agent in 107 patients (85%), followed by Ipilimumab and Nivolumab as dual therapy (9%). Confirmed infections were identified in 20 (16%) patients in the ICI group and 18 (14%) in the control group (P = 0.7). The control group had a higher rate of multiple infections at different times compared with the ICI group (P = 0.014). However, there was no significant difference in the types of infections (bacterial, fungal or viral) that occurred between the two groups. The irAEs were reported in 14 (11%) patients, 13 of them received corticosteroids with a median duration of 32 days (range, 15–64 days). Out of these patients, three (21%) developed confirmed infections of which two were viral upper respiratory tract infections and one was a bacterial urinary tract infection.

Conclusion

Patients with NSCLC treated with the combination of Immune Checkpoint Inhibitors plus Conventional Chemotherapy have comparable risk of developing infections compared with those on Conventional Chemotherapy alone.

Disclosures

All authors: No reported disclosures.
1779. Comparison of Two Zika IgM Antibody Capture Enzyme-linked Immunosorbent Assays (MAC-ELISA) in Symptomatic Patients from Dominican Republic, 2016
Authors: Kiechle Frederick , Carlton Ronald , Freddo Angelica , Quezada Henry
Published: October 2019

Background

Zika virus (ZIKV) is a Flavivirus transmitted to humans by Aedes mosquitos. To assess the clinical presentation in 434 symptomatic patients (64 men, 370 women [65 pregnant; 305 nonpregnant]) during a ZIKV outbreak in the Dominican Republic (DR) in 2016, we evaluated clinical symptoms, ZIKV by qualitative detection of ZIKV RNA and ZIKV IgM by two MAC-ELISA assays, one from CDC and performed by the Florida Department of Health, Jacksonville, FL and one from InBios International Inc., Seattle, WA (Zika Virus Detect).

Methods

The Aptima ZIKV assay (Hologic, San Diego, CA) was used to detect ZIKV by transcription-mediated amplification RT–PCR in serum, plasma, or urine. Corresponding clinical symptomology reports were reviewed for all 434 patients. The results from the two MAC-ELISA assays were evaluated by linear regression analysis. The two MAC-ELISA assays were reported as optical density (OD) ratios from a sample with three different antigens (P/N ratio for CDC Zika MAC-ELISA and Zika Immune Status Ratio or ISR for InBios Zika Virus Detect MAC-ELISA).

Results

There was a biphasic increase in ZIKV detection in April and late May/June 2016 in the 434 symptomatic patients. All 434 had one or more of four symptoms including rash, fever, conjunctivitis, and arthralgia. Linear regression analysis (log scale) of results from subject samples tested on the two MAC-ELISAs (282 total) revealed a slope of 1.172, y-intercept of 0.1584 and R2 of 0.587. In 88 RT–PCR-negative patients, 48 (54.5%) were positive by both MAC-ELISAs; 27 (30.7%) were negative by both MAC-ELISAs and 13 (14.7%) had discrepant results with a sensitivity of 85% for the InBios MAC-ELISA. The InBios also detected IgM in 54.4% of samples that were positive for ZIKV by RT–PCR attributable to errors in determining the days post symptom onset.

Conclusion

In 2016 there was a biphasic spike of ZIKV-positive infections in 434 symptomatic men and women tested in DR. Both linear regression analysis and our comparative analysis in the ZIKV RT–PCR-positive and negative cohorts demonstrate that the InBios Zika Virus Detect MAC-ELISA provides diagnostic results comparable to the CDC Zika MAC-ELISA.

Disclosures

All authors: No reported disclosures.
1978. Statements about Antibiotic Side-Effects and Patient Desire for Unnecessary Antibiotics
Authors: Miller Benjamin , Carson Kathryn , Pathak Sujay , Keller Sara C
Published: October 2019

Background

Antibiotic resistance is a global health emergency fueled in part by non-indicated use of antibiotics. Current public education campaigns primarily focus on the risks of global antibiotic resistance or society-wide adverse impacts of antibiotic misuse. There has been little research into what messages have the greatest impact on patient requests for non-indicated antibiotics.

Methods

We administered a survey at a primary care clinic in August 2018. Participants rated 18 statements about potential harm from antibiotics on how that statement changed their likelihood to request antibiotics for an upper respiratory tract infection (URI) on an 11-point Likert scale. These included 8 statements about potential harm to the individual, 4 statements about potential harm to contacts of the individual, and 6 statements about resistance or the societal impact of antibiotic misuse. Before and after the survey, participants rated how likely they were to request antibiotics for a URI.

Results

Of 1150 adult patients in clinic over the 6 days of the survey, 250 completed the survey. Statements about potential harm to the individual decreased patient likelihood to request antibiotics more than statements about societal impacts of antibiotic misuse. (P < 0.001). Statements about potential harm to contacts of the patient also decreased patient likelihood to request antibiotics more than statements about resistance or societal impacts of antibiotic misuse (P < 0.001). Statements discussing antibiotic resistance were less likely to impact patient likelihood to request antibiotics than statements not mentioning antibiotic resistance (P < 0.001). All statements decreased patient likelihood to request antibiotics. Overall likelihood to request antibiotics decreased after the survey (from 5.3 pre- to 3.1 post-survey, P < 0.001).

Conclusion

Statements about how potential harm of antibiotics to the individual had a greater impact than statements about resistance or societal impact of antibiotics. Our results suggest that when dissuading patients from requesting non-indicated antibiotics, providers and public health campaigns focus on the potential harm of antibiotics to the individual patient rather than on antibiotic resistance or societal impacts.

Disclosures

All authors: No reported disclosures.
1986. Impact of Two-Step Testing on the Diagnosis and Management of Clostridium difficile in a Multi-Hospital Healthcare System
Authors: Davis Angelina , Parker Todd , Coluccio Julia , Mann Kimberly , Dodds Ashley Elizabeth , Yarrington Michael E , Moehring Rebekah W , Sexton Daniel J , Couk Jesse , Zurawski Christine
Published: October 2019

Background

Distinguishing active C. difficile infection (CDI) from asymptomatic colonization remains a significant challenge. A multi-step testing algorithm can improve the diagnostic accuracy of CDI and associated antibacterial prescribing. This study evaluated the impact of two-step testing on CDI rates and management in a multi-hospital community health system.

Methods

Two-step C. difficile testing (PCR for initial screening followed by EIA for toxin detection) was implemented in 6 acute care community hospitals in April 2018. EIA testing was automatically performed on all stool samples with a positive C. difficile PCR result. Prior to implementation, PCR alone was used to identify CDI. Messaging attached to the PCR laboratory report alerted prescribers of discrepant results (PCR +/EIA -). Anti-C. difficile therapy was at the discretion of the prescriber. We performed a retrospective cohort analysis over a 2-year period to evaluate the effect of two-step testing on system-wide hospital-onset CDI (HO-CDI) per 10,000 patient-days (PD) and anti-CDI antimicrobial use (AU) in days of therapy (DOT) per 1,000 PD. Segmented negative binomial regression with hospital clustering was used to estimate predicted HO-CDI rate for the baseline period between April 1, 2017 through March 31, 2018 and the post-intervention between May 1, 2018 through March 31, 2019. The implementation date at all sites in April 2018 was unknown; therefore, this month was removed from the analysis. Anti-CDI agents included fidaxomicin, metronidazole, and oral vancomycin, but may have included non-CDI indications for metronidazole.

Results

A total of 115 HO-CDI cases were identified; 91 (79%) before and 24 (21%) after. Prior to implementation of two-step testing, CDI rates declined at 4% per month (P = NS). The rate immediately dropped by 36% (P = 0.004) after two-step testing was implemented, but the trend did not significantly change (P = 0.52, Figure 1). Community-onset CDI rates also decreased during this time period. Combined facility-wide anti-CDI agent use was 824.87 before and 838.21 DOT/1,000 PD after and did not significantly change.

Conclusion

Use of a two-step approach for CDI testing reduced HO-CDI rates, but did not have a significant impact on anti-CDI antibiotic use in a multi-hospital community health system.

Disclosures

All authors: No reported disclosures.
1992. Initial Procalcitonin Level and Antibiotic Practice Patterns Among Patients with Acute Respiratory Infections
Authors: Costales Jessica K , Nomura Jim H , Joanie. Chung Wen-Ling , Ironside Kristen , Sim John J , Salama Paul
Published: October 2019

Background

The utility of procalcitonin (PCT)-guided algorithms to decrease antibiotic use has been extensively studied in clinical trials. The guidance that PCT provides as it translates into real-world practice is unclear. This study aims to describe real-world antibiotic prescribing practices in relation to PCT in patients admitted to our US-based health system with acute respiratory infections.

Methods

Retrospective cohort study of 1,606 adults admitted within our US health system from January 1, 2016 to December 31, 2018 with a primary diagnosis of acute upper or lower respiratory infection with at least one PCT measurement. Antibiotic practice patterns were evaluated using pharmacy analytic information and antibiotic status to note antibiotics given prior to and 36 hours after PCT result. Analysis of discordance with initial PCT level was defined as continuing or starting antibiotics after a low PCT level (PCT ≤0.25 μg/L) and withholding or discontinuing antibiotics after a high PCT level (PCT > 0.25 μg/L).

Results

Antibiotic prescription patterns after the result of initial PCT level are summarized in Table 1. Only 242 patients (15%) had more than one PCT-level checked. Overall, antibiotic discordance with initial PCT result was 45%; mostly attributed to continuing or starting antibiotics despite a low PCT level (77%). (Figure 1) There were 496 patients who were initially started and continued on antibiotics despite a low PCT result. Of this subgroup, only one patient had a serial PCT measured, and 12 were admitted for Chronic Obstructive Pulmonary Disease (COPD) exacerbation and continued on azithromycin/doxycycline after result of the low PCT.

Conclusion

Utilization of antibiotics went against well-studied PCT cutoffs 45% of the time, primarily driven by antibiotic use at low PCT levels. Only a small number were continued on azithromycin/doxycycline for anti-inflammatory effect in COPD exacerbations, indicating that most patients received antibiotics for presumed bacterial infection despite the high negative predictive value of PCT. This study illustrates PCT use in real-world practice did not significantly alter prescribing practices, potentially from lack of confidence or knowledge in interpreting PCT results and lack of serial measurements to aid in decision-making.

Disclosures

All authors: No reported disclosures.
2007. Impact of Combining Rapid Diagnostics with an Interpretation Guide on Vancomycin Usage for Contaminant Blood Cultures Growing Coagulase-Negative Staphylococci (CoNS)
Authors: Wu Simon , Watson Richard L , Graber Christopher J
Published: October 2019

Background

Contaminant blood cultures can lead to unnecessary antibiotic use, longer admissions and increased costs. Rapid diagnostics, like the BioFire® FilmArray® Blood Culture Identification (BCID) Panel, can potentially lessen these harms. BioFire BCID was implemented at VA Greater Los Angeles in 7/2017. When providers review BCID results, they are also directed to an interpretation guide developed by our antimicrobial stewardship program. This study aimed to determine the impact of BioFire BCID with this interpretation guide on unnecessary vancomycin use for contaminant blood cultures growing CoNS.

Methods

This was a retrospective cohort study on adult inpatients with contaminant blood cultures positive for CoNS. We evaluated cases before BCID (April 2016–July 2017) and after BCID (July 7/2017–December 2018) implementation. Cases with patients who died or were discharged prior to preliminary results, polymicrobial cultures, no empiric vancomycin use, or where vancomycin was indicated were excluded. We defined a “case” as anytime a provider concurrently ordered blood cultures and empiric antibiotics. Our primary outcome was the duration of unnecessary vancomycin. Secondary outcomes were time to discontinuation/modification of any empiric antibiotic, length of stay (LOS), LOS in ICU and 30-day mortality.

Results

A total of 99 cases were included (N = 45 pre-BCID; N = 54 post-BCID). Demographics between the 2 groups were largely similar except the post-BCID group had more patients with end-stage renal disease (ESRD) (14 vs. 4, P = 0.037) and more frequent infectious disease (ID) consultation (21 vs. 8, P = 0.027). The post-BCID group had shorter mean duration of unnecessary vancomycin (53.0 hours vs. 38.1 hours, P = 0.0029). After controlling for ESRD and ID involvement, the mean duration of unnecessary vancomycin was not significantly different between the 2 groups (P = 0.30 and P = 0.49, respectively). There was no difference in time to modification/discontinuation of any empiric antibiotic (44.6 hr vs. 35.0 hr, P = 0.36). There was no difference in mean LOS, mean LOS in ICU, or 30-day mortality.

Conclusion

Shorter duration of unnecessary vancomycin for CoNS bacteremia after BCID implementation and provision of an interpretation guide may have been driven in part by more frequent ID consultation.

Disclosures

All authors: No reported disclosures.
2012. Trends in Microbiological Culture Collection Across Veterans Affairs Medical Centers and Community Living Centers, 2010 to 2017
Authors: Appaneal Haley , Caffrey Aisling , Hughes Stephanie , Lopes Vrishali , Jump Robin L , LaPlante Kerry , Dosa David
Published: October 2019

Background

Microbiological cultures are critical in the diagnosis of infection, identification of pathogenic organisms, and tailoring antibiotic use. However, unnecessary collection of cultures, particularly from the urine, may lead to overuse of antibiotics. There have been no national studies to evaluate trends in the collection of cultures in acute and long-term care settings. Here we describe changes in the collection of cultures nationally across Veterans Affairs medical centers (VAMCs) and Community Living Centers (CLCs).

Methods

All positive and negative cultures collected from 2010 to 2017 among Veterans admitted to VAMCs or CLCs were included. Cultures were categorized by specimen source (urine, blood, skin and soft tissue, or lung). Joinpoint software was used for regression analyses of trends over time and to estimate annual average percent changes with 95% confidence intervals (CI).

Results

A total of 5,089,640 cultures from 158 VAMCS and 342,850 cultures from 146 CLCs were identified. The number of cultures collected for all culture types in VAMCs and CLCs decreased significantly. The number of cultures collected per admission decreased significantly by 5.5% annually among VAMCs (95% CI −7.0 to −4.0%) and by 8.4% annually among CLCs (95% CI −10.1 to −6.6%). The proportion of positive cultures decreased 1.6% annually among VAMCs (95% CI −2.3 to −0.9%) and remained stable among CLCs (-0.4% annually, 95% CI, −1.1 to 0.4%). The most common culture source among VAMCs was blood (36.2%), followed by urine (31.8%), and among CLCs was urine (56.9%), followed by blood (16.0%). Urine cultures decreased by 4.5% annually among VAMCs (95% CI −5.4 to −3.6%) and 7.0% annually among CLCs (95% CI −7.6 to −6.4%).

Conclusion

Our study demonstrates a significant reduction in the number of cultures collected over time. Positive cultures decreased significantly in VAMCs, possibly indicating fewer culture-positive infections.In both VAMCs and CLCs, decreases in cultures taken may represent an important reduction in the collection of unnecessary cultures nationally driven by increased awareness about over-testing and over-treatment of presumed infection, particularly urinary tract infections.

Disclosures

All authors: No reported disclosures.
2013. Blood Culture Contamination in the Emergency Department: A Risk Factor Analysis
Authors: Klucher Justin , Lakkad Mrinmayee , Painter Jacob , Dare Ryan K
Published: October 2019

Background

Blood cultures (BCx) guide treatment for hospitalized patients, yet contaminated BCx lead to clinical uncertainty, impacting care. The Clinical and Laboratory Standards Institute (CLSI) recommends contamination rates should be <3%, yet our Emergency Department (ED) rate is consistently above this benchmark. Reasons for this are unclear, thus it is imperative to investigate potential risk factors for BCx contamination.

Methods

We performed a retrospective case–control risk factor analysis of patients with BCx collected in our ED between 2014 and 2018. Contaminated BCx were identified by the microbiology laboratory per American Society of Microbiology recommendations. Demographics, comorbidities, and clinical characteristics were evaluated in patients with false-positive/contaminated BCx (cases) and patients with negative BCx (controls). Potential risk factors identified in univariate analysis were included in a logistic regression model. Unadjusted and adjusted analyses were performed using SAS 9.4.

Results

25,668 BCx from 13,782 patients were included in analysis. 20,907 BCx from 11,266 (82%) patients were negative, 2,856 BCx from 1,504 (11%) patients were true positives, and 1,905 BCx from 1,012 (7%) patients were contaminated. Yearly ED contamination rates ranged from 5.0–9.3%. Collector contamination rates varied, though 38 (19%), 75 (35%), and 7 (3%) of 209 collectors had a contamination rate <3%, ≥ 10%, and ≥ 20%, respectively. Significant patient-specific risk factors identified in univariate analysis are listed in the attached table along with adjusted analysis.

Conclusion

In our analysis, we identified that older age, African American race, higher BMI, COPD, paralysis, and presenting in septic shock independently increases risk of having a contaminated BCx. Difficulty obtaining venipuncture in patients with these risk factors, often requiring multiple collection attempts, likely leads to decreased sterile technique. It is imperative to have a process assuring sterile technique in these high-risk individuals to minimize consequences associated with having a false-positive BCx result in these high-risk patients. Additionally, variable collector contamination rates seen in this study highlight the necessity for frequent technique in-service training.

Disclosures

All authors: No reported disclosures.
2017. Age-specific Distribution of Antimicrobial Days of Therapy (DOT) Using National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB Japan): Comparison with Defined Daily Doses per 1,000 Inhabitants Per Day (DID)
Authors: Yamasaki Daisuke , Tanabe Masaki , Muraki Yuichi , Kusama Yoshiki , Ishikane Masahiro , Tanaka Chika , Ohmagari Norio
Published: October 2019

Background

Nationwide surveillance of antimicrobial use (AMU) is often assessed by defined daily doses per 1,000 inhabitants per day (DID) as a measurement unit. We previously reported the age-specific distribution of AMU using National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB Japan), which archives e-claim big data (Infection. 2018 46:207–214). The estimated AMU assessed by DID could be underestimated in patients with diminished renal function and in pediatric patients. Our objective was to analyze days of therapy (DOT) using NDB and to evaluate its utility by comparing with DID.

Methods

The DID value was calculated by the same method in our previous study.The DOT values was extracted from data in NDB and were standardized by a population and were described as per 1,000 inhabitant days (DOTID). The values of DID, DOTID and the ratios (DID/ DOTID), the indicator for reflecting the extent of daily dosage were compared between three groups stratified by age groups (younger than 15 years: children, 15–64 years old: productive age, and older than 64 years: elderly).

Results

The total DID (oral, parenteral) from 2013 to 2016 in three age groups was shown in the following table. The total DID (oral, parenteral) in three age groups in 2016 were 16.31, 0.27 in the children, 12.82, 0.39 in productive age, and 15.91, 2.13 in elderly, respectively. Similarly, the total DOTID (oral, parenteral) in three age groups in 2016 were 36.15, 1.20 in the children, 16.48, 0.80 in productive age, and 23.52, 3.62 in elderly, respectively. The total DID/DOTID (oral, parenteral) in three age groups in 2016 were 0.45, 0.23 in the children, 0.78, 0.49 in productive age, and 0.68, 0.59 in elderly, respectively. The gap between DID and DOTID in children was much larger than that of other age groups regardless of dosage form, suggesting that AMU assessed by DID could be underestimated, especially in children.The gap between DID and DOTID in elderly was comparable with that in productive age, suggesting that daily dosage in the elderly is similar to that in productive age.

Conclusion

These results demonstrated the utility of AMU surveillance using the DOTID as a tool and benchmark to assess the AMU, especially in children, and the ratio of DID to DOTID could be useful as an indicator for reflecting the extent of daily dosage.

Disclosures

All authors: No reported disclosures.
2020. Impact of Local Antimicrobial Stewardship Guidelines through a Cellphone App to Lower Hospital-acquired MDR Infections in a Private Hospital in Mexico City
Authors: Villanueva Reza Marco , Lanz-Zubiria Lorena , Rojas de Ita Israel , Castañeda-Méndez Paulo , Aleman Aguilar Esperanza , Aguilar-Zapata Daniel , Soto-Ramirez Luis E , Reyes Mar Javier , Lorena Cabrera Ruiz Maria
Published: October 2019

Background

Hospital-acquired multi-drug-resistant organisms (HA-MDRO) infections are associated with increased cost, length of stay, morbidity, and mortality. The prevalence of HA-MDRO has been increasing worldwide. We look to describe how the implementation of local guidelines as an app available for tablets or cellphones in our hospital in 2014 decrease the prevalence of HA-MDRO.

Methods

Local guidelines were implemented as an electronic application available and intended for hospital staff only. This app gives local patterns of resistance for bacteria with treatment recommendations alongside suggested antimicrobial drugs for empiric treatment. Descriptive statistics were performed.

Results

In 2013, before implementing the app, HA-MDRO were reported in 25% of hospital-acquired infection. After the introduction of the app, compliance in 2014 was 56.7% with HA-MDRO reported in 20%, 2015 use was 60.7% and HA-MDRO in 18%, 2016 compliance 68.7% and HA-MDRO in 16%, 2017 compliance in 73.7% and HA-MDRO in 14%, lastly in 2018 prevalence was 15% of HA-MDRO while use of local guidelines was 78.7%. Different type of infections (VAP, HAP, UTI, SSI, BSI) also decreased while following guidelines recommendations.

Conclusion

These programs are needed as a part of the healthcare program to control the HA-MDRO morbidity and complications. Simple friendly-user electronic applications such as the one implemented in our hospital led to higher compliance and lower hospital-acquired infections. Antimicrobial stewardship programs and local guidelines should be part of the standard of care of all hospitals.

Disclosures

All authors: No reported disclosures.
2028. A Survey of Antimicrobial Availability, Training, and Antimicrobial Recommendations by Staff in Pharmacies and Non-pharmacy Stores in the Dominican Republic
Authors: Mena Lora Alfredo J , Almonte Marcos , Jimenez Mariel , Rodriguez Abreu Julia , Rojas Fermin Rita , Bleasdale Susan C
Published: October 2019

Background

Antimicrobial resistance (AMR) is a rising global health challenge. Antimicrobial use (AU) is a key factor in the development of AMR, but knowledge gaps remain on AU and dispensation in low- and middle-income countries (LMICs). AU can be purchased without prescriptions in many LMICs and are available in pharmacies and non-pharmacy stores. We seek to describe the availability, training and AU recommendations in pharmacies and non-pharmacy stores in the Dominican Republic (DR).

Methods

We conducted a survey of pharmacies and non-pharmacy stores that dispense antimicrobials from March to April 2019 in randomly selected locations throughout metropolitan Santo Domingo. Data on the availability of antimicrobials and training on AU was obtained. Antimicrobial of choice for common symptoms such as dysuria, throat pain, diarrhea, fever, and cough were queried, and data tabulated. Availability of antimicrobials by phone and online delivery was assessed.

Results

A total of 35 stores were surveyed. Ten pharmacies and 15 nonpharmacy stores agreed to participate. Ten refused and were excluded. Fifty AU recommendations were given in pharmacies and 16 in non-pharmacy stores. The most common type of antimicrobial recommended were aminopenicillins (Figure 1). Staff received prior training on antimicrobials in 70% of pharmacies and 0% of non-pharmacy stores. Antimicrobial recommendations by symptom in pharmacies and non-pharmacy stores are seen in Figure 2 and 3. Antimicrobials are available for phone delivery in 100% of pharmacies and 90% of non-pharmacy stores. No antimicrobials were available via online delivery apps.

Conclusion

Antimicrobials are widely available in the DR without prescriptions and can be purchased in person or via phone delivery. Aminopenicillins are commonly prescribed and may contribute to high rates of ESBL in the DR. Pharmacy staff gave more specific symptom-based recommendations than non-pharmacy staff and commonly had prior training on antibiotic use. In LMICs with easy access to antimicrobials, frontline staff in pharmacies and non-pharmacy stores are gatekeepers for AU and may benefit from further education and training. Further studies on attitudes and perceptions related to antimicrobial use in the community are needed.

Disclosures

All authors: No reported disclosures.