bluuebunny/crossref_metadata_2025 huggingface dataset:
1069. Predictive Factors for Metastatic Infection in Patients With Bacteremia Caused by Staphylococcus aureus
Authors: Shimizu Akihiro , Horino Tetsuya , Hosaka Yumiko , Hoshina Tokio , Nakaharai Kazuhiko , Lee Kwangyeol , Miyajima Makiko , Nakazawa Yasushi , Yoshida Masaki , Yoshida Hiroshi , Hori Seiji
Published: November 2018

Background

Metastatic infections, such as infective endocarditis and pyogenic spondylitis, are very serious complications of Staphylococcus aureus bacteremia (SAB), because failure to identify metastatic infections may cause poor prognosis. The aim of the present study is to determine the predictive factors for metastatic infections of SAB.

Methods

This retrospective cohort study was conducted among patients with bacteremia due to S. aureus (including both methicillin-sensitive S. aureus and methicillin-resistant S. aureus: MSSA and MRSA) in The Jikei University Kashiwa Hospital. The study population comprised 125 adult patients with SAB between January 2014 and December 2017. Patients, that died or transferred within 3 months after the initial positive blood culture, were excluded, because metastatic infection was defined as deep-seated infection detected within 3 months after the initial positive blood culture. We analyzed several factors, including demographics, comorbidities, community acquisition, primary site of infection, persistent fever and laboratory data such as c-reactive protein (CRP) levels after treatment.

Results

Seventy-four patients met inclusion criteria of this study. The most common primary site of bacteremia was catheter-related [24 (32.4%) of 74]. Metastatic infection occurred in 22 (29.7%) of 74 patients, and spondylitis was most common, following psoas abscess. Of these, 11 infections (50% of 22) were community acquired. We did not find any significant differences in demographics and comorbidities, except central venous catheter-associated bloodstream infection, which was associated with low rate of metastatic infection. By multivariate analysis, the predictive factors associated with the development of metastatic infection were community onset of infection (OR 11.6; 95% CI 2.98–45.1; P < 0.001), persistent fever over 72 hours (OR 6.7; 95% CI 2.12–21.8; P = 0.001), and higher CRP levels (>3 mg/dL) lasting 2 weeks after the administration of appropriate antibiotics (OR 7.47; 95% CI 2.39–23.3; P < 0.001).

Conclusion

This study demonstrated that additional diagnostic tests to identify metastatic infection should be performed, especially in the patients with community-acquired SAB, persistent fever or persistently high CRP levels after the administration of appropriate antibiotics.

Disclosures

All authors: No reported disclosures.
1074. Management and Outcomes of Infective Endocarditis Due to Nutritionally Variant Streptococci
Authors: Fida Madiha , Mansoor Tarab , Saleh Omar Abu , Hamdi Ahmed , Desimone Daniel C , Wilson Walter R , Steckelberg James , Baddour Larry M , Sohail M Rizwan
Published: November 2018

Background

Nutritionally variant streptococci (NVS) are an infrequent cause of infective endocarditis (IE) and management recommendations are based on weak levels of evidence largely derived from case reports, small case series, and animal models of experimental endocarditis. Moreover, taxonomic changes have led to some confusion in designation of these organisms.

Methods

We retrospectively collected and analyzed data from 33 patients with NVS IE from 1970 to 2017. Only patients who met modified Duke Criteria for IE were included.

Results

Mean patient age was 55 years and 61% were males. The most common comorbidities included diabetes mellitus (12%), malignancy (3%), heart failure (16%), coronary artery disease (25%), and chronic liver disease (9%). Predisposing valve abnormalities included rheumatic heart disease (11%), bicuspid aortic valve (22%), transplant valvulopathy (3%), mitral valve prolapse (3%), and congenital heart disease (11%). Cultures were reported as NVS (70%), Granulicatella species (18%) and Abiotrophia species (12%). Echocardiogram findings included vegetations (67%), new regurgitation (55%), perivalvular abscess (3%), mitral valve prolapse (3%), and ruptured mitral valve chordae (3%). Both prosthetic (26%) and native valve IE (74%) was seen, and the valves involved were aortic (37%), mitral (50%) and both aortic and mitral (13%). Complications were seen in 27% of patients, including heart failure (17%), splenic infarct (11%), stroke (8%), mycotic aneurysm (3%), and glomerulonephritis (2%). In vitro susceptibility to penicillin, ceftriaxone, and vancomycin was 88%, 80%, and 100%, respectively. The majority (77%) of patients were treated with a combination of β-lactam and aminoglycoside. Median duration of treatment was 33 days. Surgery was performed in 50% of patients with no significant difference in survival between those who were treated with combined medical/surgical treatment and those treated with medical therapy alone. Overall survival at 1, 4, and 10 years was 93%, 83%, and 66%, respectively.

Conclusion

IE due to NVS is a rare entity and is associated with a high rate of serious complications and may involve multiple valves. Long-term, two-thirds of the patients survived more than 10 years.

Disclosures

All authors: No reported disclosures.
1076. What Is the Positivity Delay of Blood Cultures in Infective Endocarditis?
Authors: Issa Nahema , Peuchant Olivia , Lecomte Raphael , Machelart Irene , Greib Carine , Wirth Gaetane , Camou Fabrice
Published: November 2018

Background

Blood culture is a key test for the positive diagnosis of infective endocarditis (IE). In order to detect certain so-called fastidious bacteria and to avoid the absence of documentation, it is customary to repeat the blood cultures (at least three series) and to keep them for 21 days. However, objective data regarding the positivity delay of blood cultures in case of infective endocarditis are lacking.

Methods

To determine the time to positivity of blood cultures during IE, all patients with documented IE by bacterial blood culture and presented to the Endocarditis team of our center were prospectively included. The study was conducted in a university hospital between 2013 and 2017.

Results

During the study, 441 patients with IE were hospitalized and 401 IE had a bacteriological documentation (91%), including 380 by blood cultures. In 21 cases, the bacteriological documentation was made by serological tests or specific PCR assays. Information on positivity delay was available for 237 patients (135 IE on native valve and 102 on prosthetic valve) and 183 of them (77%) had 4 aero-anaerobic series or more blood cultures. Of the 988 series sampled, 978 (99%) were positive. The main documented bacteria were staphylococci (41%), streptococci (32%), and enterococci (21%). The median time to positivity of the first blood culture was 11.4 hours [interquartile = 7.3 hours–16.7 hours] and the maximum delay was 93 hours. There was no difference in positivity delay between the 123 community acquired IE and the 114 healthcare-associated IE: 11.2 hours vs. 11.4 hours. The median growth time was 9.9 hours for S. aureus vs. 18 hours for coagulase negative staphylococci, 11 hours for enterococci and 10.4 hours for streptococci. In the case of IE complicated by extracardiac emboli, the median positivity delay was 9.7 hours in the case of S. aureus vs. 12.3 hours for the other bacteria.

Conclusion

In case of IE, our study shows that the median time positivity of the first blood culture is about 11 hours and no blood culture becomes positive beyond the fourth day. Slow-growing bacteria are identified by other diagnostic methods. We can, therefore, wonder about the need to multiply and conserve blood cultures beyond a week to document IE.

Disclosures

All authors: No reported disclosures.
1077. Heart Transplantation as Salvage Treatment for Intractable Infective Endocarditis
Authors: Tattevin Pierre , Muñoz Patricia , Moreno Asuncion , Hékimian Guillaume , Delahaye François , Duval Xavier , Castel María Ángeles , Hasse Barbara , Jamarillo Natalia , Vincelj Josip , Wray Dannah , Mestres Carlos , Miro Jose
Published: November 2018

Background

Infective endocarditis (IE) remains a severe disease with contemporary in-hospital mortality rates of 20%. Although valvular replacement is performed in 50% of patients during the acute phase, heart transplantation remains the last resort in selected patients with extensive perivalvular lesions or end-stage cardiac failure.

Methods

Cases were identified through the International Collaboration on Endocarditis (ICE) network. All patients who underwent heart transplantation during the acute phase of IE, with at least three months follow-up, were enrolled. Data were extracted from medical charts on a standardized questionnaire. Only patients who fulfilled Duke criteria for definite IE were enrolled.

Results

Between 1991 and 2017, 19 patients (6 women, 13 men), with a median age of 52 years (interquartile range, 41–61) underwent heart transplantation for IE refractory to optimized medical treatment and/or other cardiac surgery in Spain (n = 9), France (n = 6), and Colombia, Croatia, Switzerland, and the United States (one patient each). IE affected prosthetic (n = 10), native valves (n = 9), primarily aortic (56%), and mitral (28%). Pathogens were oral streptococci (n = 7), Staphylococcus aureus (n = 5, including two methicillin-resistant), Enterococcus faecalis (n = 2), and Mycoplasma hominis, Haemophilus para-influenzae, Candida albicans (one patient each). Two cases were not documented. Main cardiac lesions were vegetations (n = 17), severe regurgitation (n = 15), peri-annular abscesses (n = 9), prosthetic valve desinsertion (n = 4), and intra-cardiac fistula (n = 1). Seventeen patients underwent cardiac surgery at least once before transplantation, and four patients were on circulatory assistance (left ventricular assist-device, or extra-corporeal membrane oxygenation, two patients each). Median delay between first cardiac surgery and transplantation was 28 days (IQR, 18–71). Six patients died (32%), including four during the first month post-transplant. Thirteen patients survived, with a median follow-up of 44 months post-transplantation (IQR, 13–88).

Conclusion

Heart transplantation may be considered as salvage treatment in highly selected patients with intractable infective endocarditis.

Disclosures

All authors: No reported disclosures.
1079. When Does a Trans-Esophageal Echocardiogram (TEE) Change Management of Staphylococcus aureus Bacteremia (SAB)?
Authors: Lam John , Robinson Stephen , Gregson Daniel , Somayaji Ranjani , Conly John , Welikovitch Lisa , Parkins Michael
Published: November 2018

Background

The recognition of infective endocarditis (IE) as a serious complication of SAB has led to a low threshold for echocardiography, extended treatment (eTx) with anti-staphylococcal agents (anti-SA), and even surgery. However, indications for eTx outside of IE are numerous. We sought to determine the frequency in which findings from a TEE changed clinical SAB management.

Methods

Adults with SAB within the Calgary Health Zone between 2012 and 2014 were included if both a transthoracic echocardiogram (TTE) and TEE were performed within 7 days of each other. Patients potentially benefiting from eTx courses were a priori defined as having ≥1 of; (1) metastatic phenomena, (2) complicated SAB (defined as community acquired (CA), persistent fever/bacteremia at ≥48 hours), (3) intracardiac devices, and/or (4) Duke criteria defined IE (separately evaluated using TTE or TEE). Patient demographics, treatment (including changes to anti-SA duration and surgical indications), and clinical outcomes were extracted and evaluated.

Results

Of 961 SAB episodes, 179 (18% MRSA) met inclusion criteria (median 3.0 days, IQR 1.9–5.1 between TTE and TEE). Within the cohort 29% (n = 51) had metastatic phenomena (intracranial; 9% [n = 16], vertebral; 8% [n = 14]; empyema; 6% [n = 11]). Complicated bacteremia was present in 89% (n = 159), while 13% (n = 23) had intravascular hardware (39% pacemakers, 65% valve prostheses). IE was diagnosed in 22% (n = 40) of SAB episodes, with TTE identifying 58% of vegetations (n = 23) and TEE identifying an additional 30% (n = 15). Of the cohort, 89% (n = 160), 37% (n = 67), 4% (n = 7) of SAB had ≥1, 2, and 3 nonechocardiographic indications for eTx, respectively. Only one patient met criteria for eTx solely based on IE diagnosed from concordant TTE and TEE. Actual duration of therapy did not differ in SAB episodes that had ≥1 a priori eTx criteria but had a negative TEE relative to those who had a positive TEE (36.7 days, IQR 23.4–48.6 vs. 43.8 days, IQR 33.3–49.5, P = 0.17). Of the 15 episodes of TEE-only evident IE, 14 were CA, 12 had prolonged BSI, and nine embolic phenomena. Only 11 patients in the cohort required cardiac surgery, none were identified exclusively by TEE.

Conclusion

Routine performance of TEE may not be required in all SAB as many patients have alternate indications for eTx with anti-SA regardless of TEE findings.

Disclosures

All authors: No reported disclosures.
1081. Antimicrobial Activity of Dalbavancin Tested Against Gram-Positive Organisms Isolated From Patients With Infective Endocarditis in United States and European Medical Centers
Authors: Sader Helio S , Mendes Rodrigo E , Pfaller Michael A , Flamm Robert K
Published: November 2018

Background

The management of endocarditis requires aggressive and prolonged antimicrobial treatment. Dalbavancin (DALBA) has demonstrated potent in vitro activity against Gram-positive (GP) organisms commonly responsible for endocarditis and is being evaluated for treatment of complicated bacteremia and infective endocarditis.

Methods

A total of 626 GP organisms were collected from patients with a diagnosis of bacterial endocarditis in the United States (n = 222) and Europe (n = 404) from 2007 to 2017 via the SENTRY Antimicrobial Surveillance Program and were tested for susceptibility (S) against DALBA and comparators by CLSI broth microdilution.

Results

The most common organisms were S. aureus (48.4%), E. faecalis (EF; 19.6%), and viridans group streptococci (VGS; 12.5%). DALBA and daptomycin (DAPTO) showed complete activity (100.0%S) against S. aureus, but DALBA MICs were 4- to 8-fold lower (table). Linezolid (LZD) and teicoplanin were also active against all SA; whereas vancomycin (VAN) and trimethoprim–sulfamethoxazole were active against 99.7% of isolates. Ceftaroline (CPT) exhibited potent activity against methicillin-susceptible S. aureus (MSSA; MIC90, 0.25 mg/L; 100.0%S) and inhibited 78.4% of methicillin-resistant S. aureus (MRSA) isolates at ≤1 mg/L. All EF isolates were S to ampicillin, DAPTO, and LZD, whereas 97.6% (120/123) of isolates were S to DALBA (MIC90, 0.06 mg/L) and 96.7%S to VAN (MIC90, 2 mg/L). Against EF, DALBA MIC values were 16- to 32-fold lower than DAPTO and VAN. All VGS and coagulase-negative staphylococcal (CoNS) isolates were S to DALBA, DAPTO, VAN, and LZD, and the highest CPT MICs were 0.5 mg/L for VGS and 4 mg/L for CoNS (93.5% inhibited at ≤1 mg/L). Against E. faecium (EFM), 65.7% of isolates were inhibited at ≤0.25 mg/L of DALBA and 62.9% were VAN-S. All EFM were S to DAPTO and LNZ. β-Hemolytic streptococci (BHS) was S to most antimicrobial agents, and only 66.7% of S. pneumoniae (SPN) isolates were PEN-S at ≤0.06 mg/L.

Conclusion

DALBA exhibited potent in vitro activity against a large collection of GP isolates recovered from patients with endocarditis in the United States and Europe medical centers. These results support further investigations to determine the role of DALBA in the treatment of infective endocarditis.

Disclosures

H. S. Sader, Allergan: Research Contractor, Research support. R. E. Mendes, Allergan: Research Contractor, Research support. M. A. Pfaller, Allergan: Research Contractor, Research support. R. K. Flamm, Allergan: Research Contractor, Research support.
1083. Long-Term Prognosis of 448 Infectious Endocarditis Followed by an Endocarditis Team
Authors: Camou Fabrice , Greib Carine , Machelart Irène , Dijos Marina , Cornolle Claire , Barandon Laurent , Peuchant Olivia , Wirth Gaetane , Issa Nahema
Published: November 2018

Background

The management of infective endocarditis (IE) by an expert medico-surgical team through multidisciplinary consultation meetings is now recommended. While it seems clear that it can improve the short-term prognosis of patients, long-term data are still scarce.

Methods

All patients hospitalized between 2013 and 2017 in the three teaching hospitals of our center with an IE treated by the multidisciplinary team were followed prospectively at 1, 3, 6, and 12 months. The main objective was to determine the 1-year mortality of the entire cohort treated by the team.

Results

During the study, 493 patients had a certain or possible IE and the outcome at 1 year was known for 448 of them (4 lost to follow-up and 41 followed for less than 1 year): 254 had native valve IE (57%) and 194 had prosthetic valve IE (43%). The median age of IE patients was 69.3 years (155 patients were over 75 years old) and 329 (73%) were men. Healthcare-associated IE (HAIE) accounted for 47% of cases. A microorganism was isolated in 92% of cases (S. aureus = 24%), 252 patients (56%) had an embolic events and 68 (15%) had heart failure. The Charlson Median Comorbidity Index (ICC) was 5.0. Two hundred sixteen patients (48%) underwent surgery. The mortality rates at 1 month, 3 months, 6 months, and 1 year were, respectively, 14.1%, 19.0%, 23.2%, and 27.7%. The ICC at inclusion of patients who died at 1 year was 6.0 vs. 4.0 for survivors. Mortality at 1 year was significantly higher in case of HAIE (33% vs. 23%), documented S. aureus IE (39% vs. 24%), exclusive medical treatment (40% vs. 15%), and heart failure (43% vs. 25%).

Conclusion

While the management of IE by an endocarditis team seems to improve the short-term prognosis of IE, 1-year mortality remains high as patients are increasingly older and have severe comorbidities. Our study confirms that early prognostic factors remain in the long term and that the prognosis is better in community-acquired IE with surgery.

Disclosures

All authors: No reported disclosures.
1092. Tuning Down Clostridioides difficile PCR Sensitivity Reduces Treatment for C. difficile Infection in Toxin-Negative Patients With No Increase in Adverse Outcomes
Authors: Hitchcock Matthew , Holubar Marisa , Tompkins Lucy , Banaei Niaz
Published: November 2018

Background

Studies have shown that toxin detection identifies those who require treatment for C. difficile infection (CDI) and free toxin can be predicted with high negative predictive value from PCR cycle threshold (CT). CT-toxin was introduced at our institution in two phases: from October 2016 to October 2017, CT-toxin was reported with the PCR result (split reporting) and CDI therapy was discouraged if CT-toxin was negative (PCR+/CTtox−). Interim analysis showed that CDI treatment had no effect on outcomes in these CTtox− patients, so starting November 2017, only CT-toxin was reported. Outcomes in PCR+/CTtox− patients treated during split reporting and untreated during the toxin-only period are detailed here.

Methods

Patients tested from October 2016 to February. 2018 with a positive Xpert tcdB PCR (Cepheid, Sunnyvale, CA) and CTtox− result were included. Clinical data were collected by retrospective chart review in the split reporting period and prospective review in the toxin-only period and analyzed using SPSS at α = 0.01.

Results

Of 186 unique PCR+/CTtox- patients during split reporting, 99 (53%) were treated, compared with 6 (12%, n = 51) in the toxin-only period (P < 0.001). In comparing treated patients during split reporting to untreated patients during toxin-only reporting (n = 45), there were no significant differences in age, sex, prior antibiotic use, CDI in the previous 6 months, Charlson Comorbidity Index, patient location, immune status, or data at testing, including WBC count, creatinine, albumin, and stools/day. There were no cases of fulminant CDI in either group and no difference in outcomes (table).

Conclusion

Reporting of CT-toxin alone significantly reduced treatment for CDI compared with split reporting in CTtox− patients with no increase in adverse outcomes in short-term follow-up. Further study is needed to confirm these findings in a larger cohort.

Disclosures

All authors: No reported disclosures.
1097. Is Early Bisphosphonate Treatment Safe or Effective for Pyogenic Vertebral Osteomyelitis With Osteoporosis?
Authors: Kim Jihye , Kim Tae-Hwan
Published: November 2018

Background

Patients with pyogenic vertebral osteomyelitis (PVO) are expected to have increased risk of bone loss. Therefore, early bisphosphonate therapy would be clinically effective for PVO patients with osteoporosis.

Methods

A retrospective case review was performed on PVO patients with osteoporosis. PVO patients were divided into three groups: group A (initiation of bisphosphonate within 6 weeks after PVO diagnosis); group B (initiation of bisphosphonate between 6 weeks and 3 months after PVO diagnosis), and group C (no treatment for osteoporosis). Cox proportional hazard model was used to evaluate long-term effectiveness and safety of bisphosphonate in PVO patients, and event of interests included surgical treatment, recurrence of infection, subsequent fracture of adjacent vertebral bodies, and death.

Results

A total of 360 PVO patients with osteoporosis were investigated for the four events of interest. Group A PVO patients had significantly lower hazard ratios for undergoing later (more than 6 weeks after diagnosis) surgery than group C PVO patients (P = 0.014 for model 1 and 2) (Figure 1) despite similar occurrences of overall surgery. Significant difference was also observed in the occurrence of subsequent fractures at adjacent vertebral bodies (P = 0.001 for model 1 and P = 0.002 for model 2), and group A and B PVO patients had significantly lower hazard ratios for subsequent fracture than group C PVO patients (Figure 2). There were no significant differences in the hazard ratios of recurrence and death among the three groups.

Conclusion

Early bisphosphonate treatment in PVO patients with osteoporosis was associated with significantly lower occurrence of subsequent vertebral fracture at adjacent vertebral bodies, and lower occurrence of later surgery.

Disclosures

All authors: No reported disclosures.
1100. Characterization of Enteropathogenic Escherichia coli (EPEC) in Cancer Patients With Diarrhea
Authors: Okhuysen Pablo , Olvera Adilene , Carlin Lily
Published: November 2018

Background

Biofire FilmArray multiplexed nucleic acid amplification tests (NAAT) for bacterial diarrhea include probes specific for EPEC. However, the platform does not differentiate typical EPEC (tEPEC, defined as carrying eaeA and bfp) which have strong epidemiologic associations with diarrhea from atypical EPEC (aEPEC, carrying eaeA but not bfp) for which there is a weaker association. Nevertheless, emerging data suggest that aEPEC subsets carrying efa1/lifA which encodes for adherence factor 1/lymphocyte inhibitory factor A, are associated with diarrhea. The role of EPEC and its subtypes as agents of bacterial diarrhea have not been well defined in immunosuppressed and cancer patients.

Methods

We characterized EPEC subtypes in stools from healthy individuals with no diarrhea (HI, N = 21), cancer patients with diarrhea and negative NAAT (DN, N = 25) and patients with diarrhea positive NAAT for EPEC (DP, N = 54). EPEC isolated from stool cultures were tested for eaeA and bfp, stx and other E. coli pathotypes. We estimated the number of fecal EPEC using a qPCR for eaeA, efa1/lifA that detected 5.6 × 101 to 5 × 107 cfu/mg of stool.

Results

Demographic characteristics and underlying malignancy were similar between DN and DP groups. DP were more likely to have diarrhea on admission than DN [46/52 (88%) vs. 13/25 (52%), P < 0.01]. Stool cultures confirmed EPEC in 24/52 (60%) DP of which 23/24 (96%) were aEPEC. Fecal qPCR for eaeA confirmed EPEC in 43/52 (83%) of DP, 0/25 DN and in 3/21 (14%) of HI (P < 0.001). DP excreted a higher number of EPEC cfu/mg of stool than HI (median 168 vs. 1.18 cfu/mg, P < 0.001) and only DP excreted EPEC efa1/lifA (+) [14/52 DP (27%) vs. 0/25 DN and 0/21 HI; P < 0.001]. When compared with DP EPEC efa1/lifA (-), DP EPEC efa1/lifA (+) had a longer median duration of illness (3 days vs. 1 days, P < 0.05); more likely to be hematopoietic stem cell transplant recipients [7/14 (50%) vs. 7/38 (18%), P < 0.05] and had a higher EPEC eaeA fecal burden (median 3885 vs. 84 cfu/mg, P < 0.05). Co-infections with other pathogens were equally represented in efa1/lifA (−) and efa1/lifA (+) DP subgroups [8/14 (57%) vs. 21/38 (55%) P = NS].

Conclusion

Most EPEC in cancer patients with diarrhea are aEPEC acquired in the community and when carrying efa1/lifA (+), are associated with more severe disease.

Disclosures

All authors: No reported disclosures.
1108. Diagnostic Yield of the BioFire FilmArray Gastrointestinal Panel in Hospitalized Children at an Academic Children’s Center
Authors: Madigan Theresa , Rajapakse Nipunie , Patel Robin
Published: November 2018

Background

The BioFire FilmArray Gastrointestinal Panel (BioFire Diagnostics) (GIP) is a multiplex stool PCR test that detects 22 organisms. Studies in adults suggest that the diagnostic yield of the GIP in hospitalized patients is low. The utility of the GIP among hospitalized pediatric patients and indications for diagnostic stewardship of this test are not well described.

Methods

We conducted a retrospective chart review of hospitalized pediatric patients who had a GIP ordered between October 2015 and October 2017. Demographic, clinical, and laboratory information was extracted from the medical record. Statistical analysis was completed using JMP Pro 13.0.0 (SAS Institute Inc.).

Results

Over the 2-year study period, 193 GIPs were obtained on 155 individual pediatric patients. The mean patient age was 8 years and 59% were male. Forty-four percent of patients were immunocompromised and 21% had inflammatory bowel disease. The pediatric infectious disease (PID) team was consulted in 15% of patients at the time the test was ordered. The overall positivity rate of the GIP for one or more pathogens was 42% (Figure 1), with 76% of GIPs positive for one, 23% for two, and 1% for three pathogens. No parasitic infections were diagnosed. The GIP was more likely to be positive if GI symptom onset was prior to admission (48% vs. 24%, P = 0.004), if GI symptoms had been present for < 2 weeks vs. ≥2 weeks (52% vs. 20%, P = 0.0001), and if GI symptoms were the primary reason for the hospital admission (50% vs. 32%, P = 0.012). Only Clostridioides difficile or viral pathogens were detected in patients whose symptoms began in the hospital (Figure 2). Among patients with a positive test, 40% received treatment targeted at one or more of the detected pathogens (Figure 1). Enteropathogenic E.coli (EPEC) and Enteroaggregative E.coli (EAEC) were never treated (Figure 3).

Conclusion

The GIP was positive for one or more pathogens in 42% of hospitalized children for whom the test was ordered, and led to specific therapy in 40% of those with a positive test. EPEC and EAEC were not treated. The diagnostic yield of the GIP was higher if GI symptoms were present for <2 weeks, began before hospitalization, and were the primary reason for admission. The GIP was frequently obtained without guidance from the PID team.

Disclosures

R. Patel, CD Diagnostics, BioFire, Curetis, Merck, Hutchison Biofilm Medical Solutions, Accelerate Diagnostics, Allergan, and The Medicines Company: Grant Investigator, Research grant – monies paid to Mayo Clinic. Curetis, Specific Technologies, Selux Dx, GenMark Diagnostics, PathoQuest and Genentech: Consultant and Scientific Advisor, Consulting fee – monies paid to Mayo Clinic. ASM and IDSA: Travel reimbursement and editor’s stipends, Travel reimbursement and editor’s stipends. NBME, Up-to-Date and the Infectious Diseases Board Review Course: Varies, Honoraria. Mayo Clinic: Employee, Salary.
1109. Factors Impacting the Decision to Order Stool Diagnostic Testing in Patients With Acute Gastroenteritis Among Primary Care Providers
Authors: O’Leary Sean , Allison Mandy , Cardemil Cristina V , Hurley Laura , Crane Lori , Brtnikova Michaela , Beaty Brenda , Hall Aron J , Pierre Jeanette St , Ivey Kathryn , Lindley Megan C , Kempe Allison
Published: November 2018

Background

Diagnostic options for stool pathogens are evolving and expanding rapidly. The majority of acute gastroenteritis (AGE) patients seeking medical care are seen by primary care providers (PCPs), and stool testing may not be performed as AGE is generally self-limited. Little is known about how PCPs decide for which patients to order testing. Our objective was to describe among PCPs factors affecting the decision of whether to order stool diagnostic testing for pathogen detection in patients with AGE symptoms in the outpatient setting.

Methods

A national survey was conducted from January to March 2018 among primary care pediatricians (Peds), family physicians (FP), and internists (GIM).

Results

The response rate was 50% (689/1,383; Peds 59% [275/466], FP 49% [226/461], GIM 41% [188/456]). Factors most often reported as greatly increasing the likelihood of testing that did not differ significantly between specialties included patient history of travel to a high-risk area (75% Peds, 71% FP, 72% GIM), immunocompromised patient (Peds 67%, FP 60%, GIM 69%), and clinical suspicion of a pathogen that can be treated with antibiotics or antiparasitics (Peds 63%, FP 56%, GIM 65%). Factors with significant differences between specialties that were most often reported as greatly increasing likelihood of testing included presence of blood in stool (Peds 76%, FP 58%, GIM 48%, P < 0.0001), history of recent antibiotic use (Peds 31%, FP 66%, GIM 72%, P < 0.0001), history of recent hospitalization (Peds 29%, FP 61%, GIM 64%, P < 0.0001), consideration of inpatient admission (Peds 36%, FP 57%, GIM 56%, P < 0.0001), and fever ≥38.5 C (Peds 13%, FP 27%, GIM 40%, P < 0.0001). Factors most often reported as greatly decreasing the likelihood of testing included presence of vomiting without diarrhea (Peds 49%, FP 43%, GIM 50%) and presence of vomiting and diarrhea together (Peds 12%, FP 7%, GIM 9%).

Conclusion

Physicians rely on a variety of factors when considering diagnostic testing for stool pathogens in AGE, with recent travel, caring for an immunocompromised patient, and antibiotic/antiparasitic treatment decisions often reported as increasing the likelihood of testing. Consideration of the clinical presentation and most common AGE pathogens by age group may be driving some of the differences between specialties.

Disclosures

All authors: No reported disclosures.
1115. Use of a Fluoroquinolone (FQ) vs. a Non-Fluoroquinolone (Non-FQ)-Based Antibiotic Regimen in the Treatment of Acute, Uncomplicated Diverticulitis
Authors: Mourani Jessyca , Postelnick Michael , Martin David
Published: November 2018

Background

The management of acute, uncomplicated diverticulitis (DVT) remains based on expert consensus rather than on evidence from randomized clinical trials. The most common antibiotic (AB) regimen used in this patient population is metronidazole plus a fluoroquinolone (FQ). Non-FQ options, including B-lactam and non B-lactam regimens are available. Since there is a lack of clinical data comparing outcomes between these regimens, it remains uncertain whether patients presenting with acute, uncomplicated DVT require a FQ-based regimen. Increasing rates of FQ resistance and awareness of collateral damage have raised concern about whether this class should remain a first-line option.

Methods

This retrospective cohort study was conducted utilizing electronic health records to identify patients 18 years of age or older with acute, uncomplicated DVT, defined by ICD 10 codes. Patients included had CT confirmed DVT and were started on a guideline recommended AB regimen. Data points collected included length of stay, 30-day readmission due to DVT, time to conversion from IV to PO AB, progression to surgery, and discharge AB regimen. The primary objective is to evaluate differences in length of stay and 30 day re-admission rates. The secondary objectives are to evaluate time from intravenous (IV) to oral (PO) AB, progression to surgery, and discharge AB between the two groups.

Results

136 patients were evaluated, 71 FQ and 65 non-FQ. Length of stay was 4 days (1–18) in the FQ group vs. 5 days (1–19) in the non-FQ group (P = 0.236). 11% of patients in the FQ group vs. 9% of patients in the non-FQ group had a DVT related 30 day readmission (P = 0.451). 22% of patients in the FQ group vs. 23% of patients in the non-FQ group progressed to GI surgery during the admission. Time from IV to PO conversion of AB was 34.2 hours (0–63) in the FQ group vs. 48.4 hours (0–81) hours in the non-FQ group. Lastly, 63 of the 71 patients who were started on a FQ were discharged on an oral FQ vs. Forty patients of the 65 patients started on a non-FQ were discharged on an oral FQ

Conclusion

In the treatment of acute, uncomplicated DVT outcomes including length of stay, 30-day readmission, time from IV to PO AB, and progression to surgery were comparable in patients receiving treatment with a FQ based AB regimen vs. a non-FQ based regimen.

Disclosures

D. Martin, GlaxoSmithKline: Independent Contractor, Salary

Syneos Health: Employee, Salary.
1120. Clostridium difficile Infection Risk Factors, Severity, and Outcomes in Patients Infected with NAP1/027 Strain in a Non-Epidemic Setting
Authors: Nahar Julie
Published: November 2018

Background

Evidence surrounding outcomes with the North American pulsed-field gel electrophoresis type 1 (NAP1) Clostridium difficile (CDI) strain remains conflicting. We compared risk factors, severity of illness, and mortality of patients infected with NAP1 strain compared with patients with non-NAP1 strains in our multihospital health system.

Methods

This is a retrospective case–control analysis of patients admitted to one of five hospitals (one academic and four community hospitals) and diagnosed with CDI from April 2014 through July 2017. CDI definition included three or more stools per day with positive stool sample polymerase chain reaction (PCR) testing for C. difficile.

Results

A total of 490 patients met inclusion, of which 155 had the NAP1 strain and 335 patients were infected with non-NAP1 strains. More patients with NAP1 were older, female, had CHF, and presented from a healthcare facility as opposed to from the community (all P < 0.05). No difference in 90-day antibiotic class use was found. NAP1 patients had increased ICU admission (12.3 vs. 6.0%, P = 0.016), a shorter length of stay (10.8 vs. 13.4 days, P = 0.037), abnormal CT findings (P < 0.023), and trend toward more ID consults (P = 0.067). Per IDSA classification, 61.9% in the NAP1 CDI group had severe CDI as opposed to 49.6% in the non-NAP1 study group. (P ≤ 0.038). There was no observed difference in inpatient mortality (7.7 vs. 5.7%, P = 0.381).

Conclusion

CDI caused by NAP1 strain did result in increased severity but did not result in increased mortality compared with CDI caused by non-NAP1 strains. Evidence continues to mount that while the NAP1 strain may affect severity, its effect on mortality remains in question.

Disclosures

All authors: No reported disclosures.
1126. Three Cases of Neutropenic Enterocolitis Following Midostaurin Administration
Authors: Carroll Ryan , Nichols Courtney , Awadh Hesham , Visweshwar Haresh , Evans Derek , Willenburg Kara
Published: November 2018

Background

Neutropenic enterocolitis is a life-threatening inflammation of the colon with a mortality rate above 50% primarily seen in neutropenic patients on cytotoxic chemotherapy. The following cases illustrate three patients with this condition following midostaurin administration after standard induction chemotherapy with daunorubicin/idrarubicin and cytarabine for acute myeloid leukemia (AML). Midostaurin is a multitargeted FMS-Like Tyrosine kinase 3 (FLT3) receptor inhibitor used in AML treatment after induction chemotherapy.

Methods

Review of records of three patients seen by the infectious disease service.

Results

In these cases, patients were diagnosed with AML with FLT3 mutation. All three were admitted and started on standard induction chemotherapy. Midostaurin was started on chemotherapy day 8 at which time all patients were neutropenic. The patients developed fevers, abdominal pain, and diarrhea within 36 hours of starting midostaurin and had abdominal CT findings consistent with neutropenic enterocolitis. For two patients, midostaurin was discontinued and symptoms improved upon discontinuation. One patient completed the course of midostaurin with symptom resolution after its completion. Of note, all were started on appropriate prophylactic antibiotics at chemotherapy initiation and were started on broad-spectrum antibiotics at onset of fevers and abdominal symptoms. Appropriate evaluation was also done for each patient to rule out other causes of abdominal symptoms, including testing for Clostridium difficile colitis.

Conclusion

These cases are significant because they illustrate individuals treated with standard induction chemotherapy for AML and started on midostaurin while neutropenic who began reporting symptoms of neutropenic enterocolitis within 36 hours of receiving midostaurin. This shows a possible increased toxicity when midostaurin is given after induction chemotherapy in the setting of neutropenia. Stone et al. showed increased intestinal symptoms with midostaurin, but no cases of neutropenic enterocolitis have been reported. With increased midostaurin use in the past year, further studies are warranted to establish and raise awareness of a possible direct association between midostaurin and gastrointestinal toxicity.

Disclosures

All authors: No reported disclosures.
1130. Low Risk of Pneumocystis jiroveci Pneumonia in Patients With Waldenstrom’s Macroglobulinemia on Ibrutinib
Authors: Kusztos Amanda E , Cheng Matthew P , Gustine Joshua N , Dubeau Toni E , Woolley Ann E , Hammond Sarah P , Baden Lindsey R , Castillo Jorge J , Issa Nicolas C
Published: November 2018

Background

Ibrutinib is a Bruton’s tyrosine kinase inhibitor that is FDA approved for the treatment of chronic lymphocytic leukemia (CLL), mantle cell lymphoma, marginal zone lymphoma, and Waldenstrom’s macroglobulinemia (WM). Fungal infections including Pneumocystis jiroveci pneumonia (PCP) are increasingly reported in patients with CLL and lymphoma on ibrutinib possibly due to the off-target effect of ibrutinib on the adaptive immune system. Whether this increased risk is due to the effect of ibrutinib alone or in combination with immune dysregulation due to underlying malignancy is unknown. The purpose of this study was to assess the incidence of PCP in patients with WM on ibrutinib therapy.

Methods

A retrospective cohort study was performed of all patients with WM who initiated ibrutinib monotherapy at Dana-Farber Cancer Institute between July 1, 2015 and January 30, 2018. Baseline characteristics, laboratory parameters, previous and concomitant malignancy treatment regimens, and antimicrobial medications were collected by chart review. Patients were followed until April 1, 2018 for the development of PCP.

Results

There were a total of 106 patients with WM on ibrutinib during the study period. Sixty-one (58%) were male, and the median age at initiation of ibrutinib was 69 years (range 43 – 89). Forty-six patients (43%) received prior therapy for WM, with a median of two previous treatment courses (range 1–6). Fourteen patients (13%) were on PCP prophylaxis for a combined duration of 8 person-years. No cohort patient developed PCP during the study period, which included 146 person-years of ibrutinib exposure. Three patients (3%) died due to disease progression (n = 2) and E. coli sepsis (n = 1).

Conclusion

Patients with WM on ibrutinib monotherapy appear to have a different infectious risk profile than patients with CLL or lymphoma and do not have a high risk of developing PCP. These data suggest that PCP prophylaxis is likely not beneficial for patients with WM on ibrutinib.

Disclosures

M. P. Cheng, Royal College of Physicians and Surgeons of Canada: Member, Salary. S. P. Hammond, Merck: Investigator, Research support. J. J. Castillo, Pharmacyclics: Consultant and Grant Investigator, Consulting fee and Research grant. N. C. Issa, GSK: Investigator, Research grant. Merck: Investigator, Research grant. Akros Pharma: Consultant, Consulting fee.
1131. Characteristics and Risk Factors for Mortality in Hematologic Patients with Invasive Non-Aspergillus Mold Infections: A Single-Center 7-Year Cohort Study
Authors: Lee Hyeon-Jeong , Lee Dong-Gun , Cho Sung-Yeon
Published: November 2018

Background

Since anti-mold active azole prophylaxis has become a standard approach for patients with high-risk hematologic diseases, the epidemiology of invasive fungal infections (IFIs) has shifted toward non-Aspergillus molds in recent years. The aim of this study was to identify the epidemiology and characteristics of non-Aspergillus invasive mold infections (NAIMIs) in the real-world.

Methods

Proven/probable NAIMIs developed in patients with hematologic diseases were reviewed from January 2011 to January 2018 at the Catholic Blood and Marrow Transplantation Center.

Results

There were 662 patients with proven/probable IMIs, of which 40 patients (41 isolates) were diagnosed with NAIMIs. The incidence of NAIMIs showed an increasing trend since 2013 when posaconazole prophylaxis was approved in Korea [correlation coefficient (r) = 0.735, P = 0.265]. Mucormycosis (n = 24, 58.5%) was the most common, followed by Fusarium (n = 7, 17.1%), Alternaria (n = 2), Scopulariopsis (n = 2), Scedosporium (n = 2), Paecilomyces (n = 1), Coprinus (n = 1), Chaetomium (n = 1), and Schizophyllum (n = 1). Twenty-eight patients were under neutropenia upon diagnosis of NAIMI and 35.0% were allogeneic stem cell transplantation recipients. The most common sites of NAIMI were the lungs (60.0%), followed by the paranasal sinus (17.5%) and disseminated infections (12.5%). There were 35.5% breakthrough IMI cases. In addition, there were 42.5% mixed or concurrent IFIs and 77.5% had coexisting bacterial or viral infections. The overall mortality at 6 and 12 weeks was 32.5% and 42.5%, respectively. The mortality rates for mucormycosis and nonmucormycosis at 6 weeks were 21.7% and 47.1%, respectively. Breakthrough IFIs [adjusted hazards ratio (HR) = 4.83, P = 0.018] and surgical treatment [HR = 0.09, P = 0.003] were independently associated with 6-week mortality.

Conclusion

NAIMIs showed an increasing trend, mixed/concurrent IFIs were substantial, and coexisting bacterial or viral infections were found in more than two-thirds of patients. Breakthrough IFIs and surgical treatment have significant impact on mortality. More meticulous approaches to diagnosis and treatment strategies of NAIMIs are needed.

Disclosures

All authors: No reported disclosures.
1132. Pneumocystis Infection in Children: National Trends and Characteristics in the United States, 1997–2012
Authors: Inagaki Kengo , Blackshear Chad , Hobbs Charlotte V
Published: November 2018

Background

Although epidemiology of immunocompromising condition in children has evolved over time, updated epidemiology of pediatric pneumocystis infection in the United States is not available.

Methods

We performed a retrospective analysis using the Kids’ Inpatient Database, a nationally representative sample of US pediatric hospital discharges collected in 1997, 2000, 2003, 2006, 2009, and 2012. Pneumocystis cases were identified using International Classification of Diseases, Ninth Revision, Clinical Modification code 136.3 among children aged 0–18 years. Demographic data of cases with and without mortality were compared.

Results

We identified 1,902 (standard error, SE: 95) pneumocystis cases during the study period. The pneumocystis hospitalization rate decreased from 7.5 (SE: 0.91) to 2.7 (SE: 0.31) per a million US children from 1997 to 2012 (63.2% decrease). Cases with human immunodeficiency virus (HIV) infection decreased from 285 (SE: 56) cases in 1997 to 29 (SE: 7) cases in 2012, although non-HIV-associated cases remained relatively stable. After 2009, HIV was the third common underlying disorder after hematologic malignancy and primary immunodeficiency. All-cause in-hospital mortality was 11.7% (SE: 1.3%) and was particularly high among cases with hematopoietic stem cell transplant (HSCT) (32.4% [SE: 7.1%]) (P < 0.001).

Conclusion

Pneumocystis infection in children showed a marked decrease from 1997 to 2012 in the United States, largely driven by the reduction in HIV-associated cases. Non-HIV illnesses including hematologic malignancy and primary immunodeficiency became prominent underlying conditions over time. HSCT-associated cases had particularly high mortality. Non-HIV conditions should be the target for primary and secondary prevention in reducing the disease burden.

Disclosures

All authors: No reported disclosures.
1135. Strongyloides Stercolaris Serology in Transplant Patients: To Test or Not?
Authors: Rivera Karla Rivera , Shah Tulsi , Garcia-Diaz Julia , Hand Jonathan
Published: November 2018

Background

Strongyloides stercoralis is an intestinal nematode endemic to the tropics, subtropics, and to a limited extent the United States and Europe. The global estimates of strongyloidiasis are reported to range from 3 to 100 million infected worldwide; however, the true US prevalence is unclear. The seroprevalence of infection in solid-organ transplant candidates and recipients in the New Orleans, Louisiana region is also unknown. The purpose of this study was to identify the prevalence of Strongyloides seropositivity within transplant candidates at Ochsner Medical Center (OMC).

Methods

Patients were identified using EPIC-CLARITY with ICD-9 and ICD-10 codes for any solid-organ transplant at OMC from July 2012 to December 2016. Inclusion criteria were age 18 or older, patients evaluated for solid-organ transplant, and Strongyloides IgG testing. Patients were excluded if they had other immunocompromising conditions or exposures including but not limited to steroids, TNF-alpha, or biologic agent use. The primary outcome was the overall prevalence rate of strongyloidiasis at OMC. Secondary outcome was the comparison of prevalence between January 1, 2012 to July 31, 2016 (when testing was ordered based on risk stratification) vs. August 1, 2016 to December 31, 2016 (when routine testing was implemented).

Results

We analyzed a total of 1,047 patients which had 1,128 tests ordered for Strongyloides. Of those, 985 were unique patients (62 patients had multiple serological tests resulting in 81 repeat tests). During July 1, 2012 to July 31, 2016 testing yielded a total of 822 tests. From August 1, 2016 to December 31, 2016 testing yielded 306 tests.

Overall, 43/1,128 (3.8%) tests were positive for Strongyloides. The remaining 1,085/1,128 (96.2%) tested negative. For our secondary outcome, we found that testing based on risk stratification yielded 22/822 (2.7%) positives while testing for all patients we had 21/306 (6.9%) positives.

Conclusion

Our data suggest that testing based on risk stratification yielded a lower prevalence rate as compared with generalized testing, underestimating the true incidence of disease (2.7% vs. 6.9%). Testing all patients being evaluated for transplantation will capture a greater number of patients with positive serology.

Disclosures

J. Garcia-Diaz, Astellas Pharma: Speaker’s Bureau, Speaker honorarium.