bluuebunny/crossref_metadata_2025 huggingface dataset:
Treatment Bundle Improves Outcomes in the Management of Candidemia at Large Urban Academic Medical Center
Authors: Cook Gregory , Advani Shreena , Rab Saira , Kandiah Sheetal , Patel Manish , Wong Jordan
Published: October 2017

Background

A candidemia treatment bundle (CTB) may increase adherence to guideline recommended candidemia management and improve patient outcomes. The purpose of this study was to evaluate the impact of a best practice alert (BPA) and order-set on optimizing compliance with all CTB components and patient outcomes.

Methods

A single center, pre-/post-intervention study was completed at Grady Health System from August 2015 to August 2017. Post-CTB intervention began August 2016. The CTB included a BPA that fires for blood cultures positive for any Candida species to treatment clinicians upon opening the patient’s electronic health record. The BPA included a linked order-set based on treatment recommendations including: infectious diseases (ID) and ophthalmology consultation, repeat blood cultures, empiric echinocandin therapy, early source control, antifungal de-escalation, intravenous to oral (IV to PO) switch, and duration of therapy. The primary outcome of the study was total adherence to the CTB. The secondary outcomes include adherence with the individual components of the CTB, 30-day mortality, and infection-related length of stay (LOS).

Results

Forty-five patients in the pre-group and 24 patients in the CTB group with candidemia were identified. Twenty-seven patients in the pre-group and 19 patients in the CTB group met inclusion criteria. Total adherence with the CTB occurred in one patient in the pre-group and threepatients in the CTB group (4% vs. 16%, P = 0.29). ID was consulted in 15 patients in the pre-group and 17 patients in the CTB group (56% vs. 89%, P = 0.02). Source control occurred in three and 11 patients, respectively (11% vs. 58% P < 0.01). The bundle components of empiric echinocandin use (81% vs. 100%, P = 0.07), ophthalmology consultation (81% vs. 95%, P = 0.37), and IV to PO switch (22% vs. 32%, P = 0.5) also improved in the CTB group. Repeat cultures and antifungal de-escalation were similar among groups. Thirty-day mortality decreased in the CTB group by 10% (26% vs. 16%, P = 0.48). Median iLOS decreased from 30 days in the pre-group to 17 days in the CTB group (P = 0.05).

Conclusion

The CTB, with a BPA and linked order-set, improved guideline recommended management of candidemia specifically increasing the rates of ID consultation and early source control. There were quantitative improvements in mortality and iLOS.

Disclosures

All authors: No reported disclosures.
Searching for Bacterial Pathogens in Pediatric Patients with Chronic Recurrent Multifocal Osteomyelitis Using 16S rRNA Quantitative Real-Time PCR
Authors: Searns Justin
Published: October 2017

Background

Chronic recurrent multifocal osteomyelitis (CRMO) is a rare auto-inflammatory disease in children that causes relapsing episodes of pain. Patients are treated with anti-inflammatory medications or immune-modulating agents. Increasing evidence suggests that CRMO is mediated by dysregulation of the interleukin-1 pathway, not a bacterial source. However, CRMO is often a diagnosis of exclusion, and patients occasionally receive antimicrobials for possible culture negative infectious osteomyelitis. Few prior studies have utilized molecular diagnostic techniques to identify bacterial pathogens in CRMO bone biopsies.

Methods

Musculoskeletal specimens sent for culture during routine clinical care were banked from patients admitted to Children’s Hospital Colorado from 6/2012 to 10/2016. On retrospective chart review, 28 specimens were collected from 16 patients ultimately diagnosed with CRMO. Specimens were processed and extracted prior to molecular testing. All samples underwent quantitative real-time PCR (qPCR) testing using bacterial load assays targeting the bacterial 16S rRNA gene.

Results

Mean age at time of sample collection was 9.2 years. CRMO diagnosis was made by clinical, pathologic, and radiographic findings. All patients had pathology findings consistent with CRMO including lymphoplasmacytic infiltrate, focal necrosis, and/or marrow fibrosis. All patients had MRI findings consistent with CRMO. No patient had bacteria identified on Gram stain; 2/28 samples (7%) had bacterial growth on culture (both were coagulase-negative staphylococcus, felt to be contaminant). None of the 28 specimens met the threshold of bacterial load on qPCR testing to necessitate bacterial sequencing. None of the 16 patients were treated with antimicrobials and there were no readmissions for clinical worsening.

Conclusion

CRMO patients did not have bacteria identified on universal bacterial 16S rRNA testing. This finding further supports that CRMO patients do not require antimicrobial therapy. Future steps to exclude infectious pathogens in CRMO could include next-generation DNA sequencing.

Disclosures

All authors: No reported disclosures.
Clinical Outcomes of Prosthetic Knee Joint Infection in a United States Tertiary Healthcare Center
Authors: Ayoade Folusakin , Todd John
Published: October 2017

Background

The 2013 IDSA prosthetic joint infection (PJI) guidelines identified some research gaps, some of which include what factors may predict PJI outcome. We therefore conducted a retrospective single-center study with the goal of addressing some of these gaps.

Objectives

1. Describe the incidence, pathogens, role of inflammatory markers, and treatment outcomes of knee PJI. 2. Identify correlations between joint aspiration (JA) and intraoperative (IO) cultures.

Methods

We retrospectively analyzed all adult knee PJI that were diagnosed and managed at our institution between 1/1/2005 and 12/31/2015. Statistical analysis was done using the paired t-test, Fisher exact and McNemar χ 2 tests as applicable.

Results

Forty-six subjects met the inclusion criteria and were analyzed. See table below.

The incidence rate of PJI for the study period was 5.4%.. Staph. aureus was the commonest pathogen accounting for 11(65%) JA and 13(40%) of IO cultures. Low virulence organisms [Staph. epidermidis n = 8 (25%) and Corynebacterium spp. n =1 (3%)] were only recovered from IO cultures. Gram-negative bacilli accounted for 5(30%) JA and 7(28%) IO cultures.. JA correlates well with IO cultures using paired sample correlations (t-test); (correlation 0.61, P = 0.027).. 97% of subjects had elevated ESR while 96% had elevated CRP.. Concerning outcome, there was no statistically significant difference between groups based on implant duration (P = 0.98), symptom onset (P = 0.23), pathogen type (P = 0.83), and treatment options (P = 0.39).

Conclusion

1. JA culture is a good predictor of IO culture in knee PJI. 2. Yield of low virulence organisms from JA culture is poor. 3. Elevated ESR and CRP can support diagnosis of knee PJI. 4. Implant duration, pathogen type, duration of symptoms and treatment type do not appear to affect outcome.

Disclosures

All authors: No reported disclosures.
Clinical and Epidemiological Aspects Related to Infection of Orthopedic Prostheses in Argentinean Children. A 10-Year Period Study
Authors: Vergara Lobo Carlos Mauricio , Ferolla Fausto M , Contreras Elen , Carballo Carolina , Yfran Walter , Pannunzio Eugenia , Anteliz Eliana , Reviriego Juan , Escalada Maria , Rositto Gabriel , Legarreta Carlos , Cazes Claudia I , Contrini María M , Lopez Eduardo L
Published: October 2017

Background

Management of orthopedic prostheses infections (PI) in children is a main challenge, not only for the complexity of the disease but also for the scarce of evidence in this field.

Objectives

To describe the burden of PI and to analyze clinical and epidemiological aspects in pediatric patients.

Methods

Retrospective study in a tertiary pediatric hospital. Clinical charts of patients <18 years who underwent surgery for bone and/or joint implantation at “R. Gutierrez” Children’s Hospital in Buenos Aires from January 2007 to December 2016 were reviewed, and all PI cases were analyzed. PI was defined as early (E) when presentation was within 3 months of prothesis implantation, delayed (D) when presenting between 3–24 months and late (L) if presenting beyond 2 years.

Results

811 surgeries performed; 89 PI detected: E(n = 63); D(n = 9), L(n = 17); 58% male; median(m) age: 13 years (range[r] 4–20); m hospital stay 30 days (r 6–180). Annual incidence: 11% (CI95%: 8.9–13.1) (Figure 1). Underlying conditions: scoliosis (58.4%), malignancy (16.8%). Clinical features are detailed in Figure 2. Bacterial isolation in 63 (70.8%) cases, 51(57.3%) with a single microorganism (Figure 3). Gram(+) bacteria were isolated in 58% of E PI, 86% of D PI and 49% of L PI. Gram(−) pathogens in 49% of E PI and in 38% of L PI. Three febrile PI (3,4%) had Gram(+) bacteremia, two of them L PI. No differences were seen in white blood cell count (WBC) and C-reactive protein(CRP) levels on admission in children with and without bacteremia, nor among the different types of PI; m WBC 9000/mm3 (r 3200–25550), m CRP 37 mg/l (r 1–270). WBC on admission in MRSA PI was significantly higher, P < 0,01. Duration of EV treatment was different according to type of microorganism (P 0.03), higher in PI by Gram(−). Forty-eight (53.9%) cases continued with trimethoprim-sulfamoxazole orally, without side effects requiring its discontinuation. Total treatment duration (m): 189 days (r 28–756). Eighty-two children (92.1%) underwent surgical toilette, 37 (45.1%) required more than one. Six (6.7%) presented relapse and eight (9%) reinfection.

Conclusion

· PI in children is a considerable burden, with high morbidity. · Incidence of bacteremia was low. · Results of the study could help to delineate preventive strategies and improve decision making in PI in children.

Disclosures

All authors No reported disclosures.
A data-driven approach to predict daily risk of Clostridium difficile infection at two large academic health centers
Authors: Makar Maggie , Oh Jeeheh , Fusco Christopher , Marchesani Joseph , McCaffrey Robert , Rao Krishna , Ryan Erin E , Washer Laraine , West Lauren R , Young Vincent B , Guttag John , Hooper David C , Shenoy Erica S , Wiens Jenna
Published: October 2017

Background

An estimated 293,300 healthcare-associated cases of Clostridium difficile infection (CDI) occur annually in the United States. Prior research on risk-prediction models for CDI have focused on a small number of risk factors with the goal of developing a model that works well across hospitals. We hypothesize that risk factors are, in part, hospital-specific. We applied a generalizable machine learning approach to discovering, or “learning”, hospital-specific risk-stratification models using electronic health record (EHR) data collected during the course of patient care from the Massachusetts General Hospital (MGH) and the University of Michigan Health System (UM).

Methods

We utilized EHR data from 115,958 adult inpatient admissions from 2012–2014 (MGH) and 258,050 adult inpatient admissions from 2010–2016 (UM) (Fig 1). We extracted patient demographics, admission details, patient history, and daily hospitalization details, resulting in 2,964 and 4,739 features in the MGH and UM models, respectively. We used L2 regularized logistic regression to learn the models and measured the discriminative performance of the models on a year of held-out data from each hospital.

Results

The MGH and UM models achieved AUROCs of 0.74 (CI: 0.73–0.75) and 0.77 (CI: 0.75–0.80), respectively. The relative importance of risk factors varied significantly across hospitals. In particular, in-hospital locations appeared in the set of top risk factors at one hospital and in the set of protective factors at the other. On average, both models were able to predict CDI five days in advance of clinical diagnosis (Fig 2).

Conclusion

We used EHR data to generate a daily estimate of the risk of CDI for each inpatient hospitalization. We applied a generalizable data-driven approach to existing data from two large institutions with different patient populations and different data formats and content. In contrast to approaches that focus on learning models that apply generally across hospitals, our proposed approach yields risk stratification models tailored to an institution’s EHR system and patient population. In turn, these hospital-specific models could allow for earlier and more accurate identification of high-risk patients.

Disclosures

All authors: No reported disclosures.
Painting the Gown Red: Using a Colored Paint Quality Improvement Process to Evaluate Healthcare Worker Personal Protective Equipment for Highly Pathogenic Infections
Authors: Eiras Daniel , Echeverri Andrea , Toale Kieran , Tennill Patricia , Evans Laura
Published: October 2017

Background

Personal protective equipment (PPE) and strict infection control techniques are the primary methods by which healthcare workers (HCW) can avoid exposure during the treatment of patients with highly pathogenic infections such as Ebola Virus Disease (EVD) or the Middle East Respiratory Syndrome coronavirus (MERS-CoV). There is currently no consensus for the types of PPE that are recommended to be worn by HCWs, nor is there a universal process for the donning and doffing of PPE.

Methods

HCWs from Bellevue Hospital participate in quarterly PPE trainings as part of the Special Pathogens Program (SPP), which consist of didactic sessions as well as an evaluation of donning and doffing techniques. A total of 50 HCWs completed the training curriculum in 2017. During the doffing process, PPE trainers applied corn start powder paint (Chameleon Colors; American Fork, UT) to the participants’ gloved hands between multiple steps of PPE removal. At the end of the process, the areas where paint was found on was documented including the outer surgical gown, the powered air purifying respirator (PAPR) helmet and shroud, the inner impermeable suit, the knee-high boots and boot covers, and the extended-cuff gloves.

Results

The areas of PPE that were most marked with paint were the lower shoulders and upper arms of the surgical gowns, the top sides of the PAPR shroud, the front upper chest area, and the center back of the inner impermeable suits. In a majority of cases no powder paint was noted on the knee-high boots. In a minority of cases, paint was observed on the inside upper chest area of the surgical gown. These paint markings were used to discuss potential breaches in PPE doffing technique in real-time, as well as identify areas to target in future PPE trainings.

Conclusion

The powdered paint quality improvement process for donning and doffing PPE is a method to evaluate the complex PPE dressing procedure. It is particularly useful given the fact that it is incumbent on each hospital or healthcare system to develop its own processes and procedures for PPE, as well as maintain readiness through periodic trainings. Powdered paint can identify vulnerabilities in their process as well as areas that require further education.

Disclosures

All authors: No reported disclosures.
Immunogenicity and Safety of an Adjuvanted Herpes Zoster Subunit Candidate Vaccine in Adults with Hematologic Malignancies: A Phase III, Randomized Clinical Trial
Authors: Oostvogels Lidia
Published: October 2017

Background

Hematologic malignancy (HM) patients receiving immunosuppressive cancer therapy (ICT) are at increased risk of herpes zoster (HZ). Currently, no HZ vaccine is indicated for immunocompromised patients. The HZ subunit vaccine candidate (HZ/su), containing recombinant varicella zoster virus glycoprotein E and AS01B Adjuvant System, showed >90% efficacy and an acceptable safety profile in immunocompetent adults in all age groups ≥50 years. Here we report HZ/su immunogenicity and safety in HM adults ≥18 years of age who completed or are undergoing ICT.

Methods

In this phase III, observer-blind, multicenter study (NCT01767467), participants were randomized 1:1 to receive HZ/su or placebo (2 doses, 1–2 months apart) ≥10 days pre- or post-ICT. Humoral and cell-mediated immunogenicity (CMI) were assessed. The co-primary immunogenicity objectives were to evaluate HZ/su vaccine response rate and compare the immune response to HZ/su and placebo in participants excluding those with non-Hodgkin B-cell lymphoma (NHBCL) or chronic lymphocytic leukemia (CLL) at 1 month post-dose 2 (M2). Solicited and unsolicited adverse events (AEs) were recorded for 7 and 30 days after each dose, respectively. Serious AEs (SAEs), disease-related events and potential immune-mediated diseases (pIMDs) were recorded throughout the study. Partial safety results up to 6 months post-dose 2 are shown (partially blinded, ongoing study).

Results

Of 562 participants (283 HZ/su 283; placebo 279), (mean age 57.3 [HZ/su 56.8; placebo 57.8] years), 415 were included in the according-to-protocol (ATP) cohort for humoral immunogenicity and 132 in the ATP sub-cohort for CMI. M2 immune responses were higher in the HZ/su group (Table 1). Both co-primary immunogenicity objectives were met (Figure 1). The most frequent local and general solicited AEs were pain and fatigue, reported by 48.2% and 47.8% of all participants (per-group data remain blinded). The frequency of unsolicited AEs, SAEs and pIMDs in the 2 groups was similar (Table 2).

Conclusion

HZ/su induced robust humoral and cellular immune responses at M2 in HM adults excluding NHBCL and CLL, who completed or are undergoing ICT. No safety concerns were observed up to 6 months post-dose 2.

Funding

GlaxoSmithKline Biologicals SA

Disclosures

L. Oostvogels, GSK group of companies: Employee and Shareholder, Salary and Shares
Mortality and Retention in Care of HIV-Infected Patients According to Year of Admission and Availability of Antiretroviral Drugs in the Chilean National AIDS Program: Fundacion Arriaran 1990–2015
Authors: Wolff Marcelo , Northland Rebeca , Lizana Danae , Cortes Claudia P
Published: October 2017

Background

The HIV epidemic reached Chile in the mid 1980s, as response a national AIDS commission was created, AIDS care centers were organized (Fundacion Arriaran [FA] was the first) and free antiretroviral therapy (ART) was later provided with progressive coverage, complexity and availability over the years

Objective. Quantify evolution of mortality, retention and abandonment (LTFU) over 25 years according to qualitatively different periods in the national program of access to ART, from no availability to full coverage with current drugs at FA center

Methods

Retrospective analysis of FA updated database of the 5080 adult patients admitted from 1990 to 2014, who were distributed in 4 groups: A: no ART availability (1990–92); B: mono/dual ART (1993–98); C: early modern ART (HAART) (1999–2007) and D: contemporary HAART (2008–14). Mortality, Retention and LTFU were evaluated at 1, 3, 5 and 10 year intervals from admission and at end of 2015. Mortality was included in period of occurrence; LTFU was permanent absence at center of > 6 months during studied period. Local IRB approved the study

Results

Main results shown in Table. Mortality varied from 40% to 2%, and 62% to 7% at 1 and 5 years, for groups A and D respectively; 72% to 16% at 10 years for groups A and C, respectively. Retention at 5 years were 28%, 32%, 72% and 77% for groups A, B, C and D respectively. LTFU was 10%, 17%, 12% and 10% at 5 years for same groups, respectively. At 12/2015 6%, 19%, 61% and 84% from groups A, B, C and D, respectively, remained retained in care

Conclusion

This study showed the marked reduction in mortality and increase in retention of HIV patients concomitant to expanded access to therapy although LTFU remains a problem.

Disclosures

All authors: No reported disclosures.
Lack of Clinically Relevant Effect of Bictegravir (BIC, B) on Metformin (MET) Pharmacokinetics (PK) and Pharmacodynamics (PD)
Authors: Custodio Joseph , West Steve , Yu Amanda , Martin Hal , Graham Hiba , Quirk Erin , Kearney Brian
Published: October 2017

Background

BIC is a novel integrase inhibitor coformulated with emtricitabine (F) and tenofovir alafenamide (TAF) for treatment of HIV. MET is first-line therapy in diabetic HIV patients. In vitro, BIC inhibits renal transporters OCT2 and MATE1, which affect MET disposition. This study evaluated the effect of BIC on the PK and PD of MET following coadministration with the B/F/TAF.

Methods

This was a Phase 1, blinded, placebo-controlled, crossover study in 32 healthy subjects randomized 1:1 to either B/F/TAF or placebo QD for 9 days followed by a 3-day washout. Following 4 days of B/F/TAF or placebo, subjects received 850 mg MET at 12 hours postdose of B/F/TAF or placebo, and 500 mg BID for 4 additional days. Plasma and urine PK of MET were assessed on the last treatment day (Days 9 and 21 for B/F/TAF or placebo). Oral glucose tolerance test was performed before (Days 5 and 17) and after MET (Days 9 and 21). MET PD endpoints including plasma glucose, active Glucagon-Like Peptide 1 (GLP-1) and lactate were assessed after glucose intake. Geometric mean ratios (GMR) and 90% confidence intervals (CIs) for MET PK were calculated for B/F/TAF vs. placebo. Comparisons of PD responses within treatments (before vs. after MET) and comparisons between treatments (B/F/TAF vs. placebo) were done via nonparametric Wilcoxon signed-rank test (P > 0.05 denotes non-significance).

Results

MET plasma AUCtau was increased 39% (%GMR [90% CI]: 139 [131, 148]) with B/F/TAF vs. placebo, with no change in median plasma t1/2 (B/F/TAF: 6.4 hours; placebo: 7.1 hours). MET renal clearance decreased 31% with B/F/TAF vs. placebo. Following MET administration, statistically significant reduction of plasma glucose, and increase of plasma active GLP-1 and lactate levels relative to baseline were observed (P < 0.001) confirming their utility as PD endpoints. Importantly, PD responses were not statistically different when MET was administered with B/F/TAF vs. placebo (p >0.05).

Conclusion

Inhibition of renal transporters OCT2/MATE1 by BIC led to a modest increase of MET plasma exposure upon coadministration with B/F/TAF; however, the PD characteristics of MET were not significantly affected by B/F/TAF relative to placebo. Based on these findings, prospective dose adjustment/restriction of MET is not required upon coadministration with B/F/TAF.

Disclosures

J. Custodio, Gilead Sciences: Employee and Shareholder, Salary; S. West, Gilead Sciences: Employee and Shareholder, Salary; A. Yu, Gilead Science: Employee, Salary; H. Martin, Gilead Sciences: Employee, Salary; H. Graham, Gilead Sciences: Employee and Shareholder, Salary; E. Quirk, Gilead: Employee and Shareholder, Salary; B. Kearney, Gilead: Employee and Shareholder, Salary
Clearance of ceftazidime-avibactam in an in vitro continuous venovenous hemodialysis model
Authors: Bunnell Kristen L , Wenzler Eric , Danziger Larry H , Rodvold Keith A
Published: October 2017

Background

Optimal dosing of ceftazidime-avibactam (C-A) in critically ill patients on continuous renal replacement therapy (CRRT) is unknown. The objective of this study was to evaluate the adsorption and transmembrane clearance (CLTM) of C-A in an in vitro continuous venovenous hemodialysis (CVVHD) model to guide dosing in the absence of clinical data.

Methods

CVVHD was simulated with bovine blood (200 mL/minute) on a Prismaflex dialysis unit with polysulfone (HF1400) and AN69 (M150) hemofilters at dialysate flow rates (Qd) of 2 and 4 L/hours. Pre-hemofilter plasma samples were collected at 0, 5, 10, 20, 30, 45, and 60 mins after C-A addition; postfilter and dialysate samples were collected at 10 and 45 mins for saturation coefficient (SA) calculation. Adsorption was determined by total drug recovery in dialysate and plasma after 120 mins of dialysis at 2 L/hours. CLTM was calculated as the product of SA and Qd (CLTM-SA) and by elimination rate constant (CLTM-ke) derived from the slope of log-linear concentration-time plots.

Results

Mean (± SD) SA and CLTM values for C-A from duplicate experiments are in Table 1. CLTM was not affected by filter type, and increased linearly with Qd when calculated by two different methods. Avibactam CLTM was higher than ceftazidime CLTM with each filter and rate. Adsorption affected 17.3% and 20.2% of C-A for HF1400 and AN69 filters, respectively.

Conclusion

Significant Qd- dependent clearance of C-A was observed in in vitro CVVHD. CLTM of ceftazidime was slightly higher than previous reports and may reflect the larger surface area of contemporary filters in this study. The more rapid clearance of avibactam, particularly at higher flow rates, suggests that dose adjustments should focus on ensuring adequate avibactam exposure during CVVHD.

Disclosures

L. H. Danziger, Allergan: Investigator, Research grant.
Mapping Pediatric Tetanus Cases in Central Pennsylvania and Analyzing Hospital Costs Associated with Treatment
Authors: Ahmed Bilaal , Beck Michael , Kumar Parvathi
Published: October 2017

Background

Pennsylvania is home to Amish and Mennonite communities with an estimated combined population of over 90,000 people. Under-immunization is common with vaccine preventable diseases, including tetanus, periodically presenting among children from these communities. Nearly 20% of nationally reported pediatric tetanus cases in the past 10 years were treated at our institution, the tertiary care center which serves these unique populations. We characterize demographics and costs of treating this rare, but largely preventable infection.

Methods

Chart review based on ICD-9 codes for tetanus infection in patients aged 0–17 years treated for clinically diagnosed tetanus infection between January 2006 and December 2015. Cost data were extracted from Horizon Business Insight software and analyzed in Microsoft Excel. Cases were mapped using UDS Mapper.

Results

Four cases of pediatric tetanus infection were identified with 100% occurring in unimmunized patients and 3 of 4 (75%) in Amish individuals. Treatment costs amounted to $121,170 with estimated payment of $80,664 resulting in a net loss to the hospital of $40,506 over the course of 10 years. Each case treated resulted in a median loss of $4,402 to the hospital.

Conclusion

The costs of treating this vaccine preventable disease for both hospitals and under-immunized Amish and Mennonite communities, who tend to pay out-of-pocket, should be emphasized in targeted outreach and education programs at the population level.

Disclosures

All authors: No reported disclosures.
Joint Consultation Clinic by Infectious Diseases Specialists and Podiatry team (ID-POD) Compliments the Care of Diabetic Patients with Foot Infections by Reducing Cost and Decreasing Outpatient Clinic Visits
Authors: Lingegowda Pushpalatha Bangalore , Ooi Say-Tat , Somani Jyoti , Law Chelsea , Yeo Boon Kiak
Published: October 2017

Background

Management of diabetic foot infections (DFI) is challenging and involves multidisciplinary teams to improve outcomes (1). Appropriate wound care of patients with DFI plays an important role in successfully curing infections and promote wound healing. In Singapore, Infectious Diseases (ID) specialists help in the management of DFI by recommending appropriate antibiotics for infected wounds while wound debridement are managed by Podiatrists (POD). When patients are hospitalized multidisciplinary teams including Vascular Surgery review patients. In the outpatient setting patients have multiple appointments including ID and Endocrinology etc. The time spent and costs incurred by patients for traveling to multiple appointments is considerable. A joint ID-POD clinic was initiated to reduce the cost and inconvenience for patients.

Methods

A joint weekly clinic was initiated in October’16 and the data was analyzed upto May’17. Finance was involved in deriving costs. The service costs for consultations payable by patients before and after the initiation of the joint clinic were compared.

Results

First 6 months experience of initiating the joint ID-POD clinic is reported. 35 unique patients had a total of 88 visits. 1/third of the patients had more than 2 visits to the joint clinic. For each visit to the joint clinic the patient paid 25% less compared with having separate clinics. The hospital lowered the service cost for the new clinic by 11%. This was done by minimizing the time involvement of the ID physician.

Conclusion

Joint ID-POD clinic for managing diabetic patients with foot infections revealed several advantages. Hospital outpatient visits for each patient decreased by 50% for those requiring care of both ID and POD, without compromising care. With the consolidation of care each individual patient had a cost savings of 25% for the joint consultation. This joint clinic while making it convenient for patients has revealed significant cost savings to patients especially for those requiring multiple visits. We recommend hospitals with high prevalence of Diabetes and Diabetic foot infections to consider joint ID-POD clinics to reduce hassle and increase saving for patients.

Disclosures

All authors: No reported disclosures.
Potentially Inappropriate Durations of Anti-Infective Therapy at Hospital Discharge Despite Inpatient Antimicrobial Stewardship
Authors: Fox Neal , Haines Lauren , Bull Rachel , Jenkins Zachary , Ballentine John , Burdette Steven , Pleiman Craig
Published: October 2017

Background

Excess durations of anti-infective therapy are a common problem that may lead to unintended consequences. Antimicrobial stewardship (AMS) is a growing field that largely focuses on inpatient anti-infective use. For this study, one site was an academic medical center whose AMS uses prospective auditing; the other was a community hospital with pharmacy-driven AMS. Little research has examined durations of anti-infective therapy at hospital discharge.

Methods

Patient charts were reviewed and 284 were included in the final analysis. Patients were excluded if discharged on non-oral anti-infectives or only agents for a non-study indication. Patients were included if they were discharged on oral anti-infective therapy for CAP, healthcare-associated pneumonia (HCAP), UTI, cellulitis, and superficial abscess. Evidence-based durations of therapy were utilized to determine the potential inappropriateness of anti-infective therapy. Guidelines from the study period were used. Total duration of therapy was derived from the combination of outpatient therapy plus inpatient therapy beginning with the first day of relevant coverage for the given indication. Descriptive statistics were utilized to compare durations of therapy. Chi-squared tests were utilized to examine differences in expected frequencies. All statistics were performed in SPSS v. 24.

Results

The average combined duration of therapy was 11.3 days. 190 patients (66.9%) were found to have a potentially inappropriate duration of oral anti-infective therapy at hospital discharge. Only 2 durations were too short. Figure 1 displays the distribution of excess days of therapy. Figure 2 shows the breakdown of potential inappropriateness of duration by diagnosis. Figure 3 displays the percentage of potentially inappropriate cases by site. There were no significant differences in the primary outcome between the sites.

Conclusion

CAP and cellulitis appear to be areas that are often overtreated. Discharge durations of therapy should be a focus of AMS teams. Many patients receive potentially inappropriate durations of therapy at discharge without any discernible benefit. Further research is needed in this area.

Disclosures

All authors: No reported disclosures.
Safety and Effectiveness of Outpatient Parenteral Antimicrobial Therapy (OPAT) in the Aged Population
Authors: Van Anglen Lucinda J , Mandel Richard M , Nathan Ramesh V , Krinsky Andrew H , Luu Quyen , Bacon Alfred E , Baker H Barry , Schroeder Claudia P , Couch Kimberly A
Published: October 2017

Background

The aged population (≥75 years) have multiple comorbidities and are at increased risk of adverse events associated with intravenous antimicrobial therapy. Hospitalization (hosp) occurs frequently. This group presents challenges for site of care and reimbursement, which may be met with provision of OPAT through a physician office infusion center (POIC). This setting allows treatment immediately following hosp or directly from the community, thus avoiding hosp. For the aged patient (pt) population, we evaluated safety and effectiveness of OPAT in a POIC.

Methods

Records from 13 POICs were queried for patients ≥75 years receiving OPAT courses from January to July 2016. Data included demographics, therapy, disease characteristics, effectiveness and safety. Effectiveness was assessed as completion of therapy and no unplanned hosp related to the underlying infection. Safety assessment included adverse drug reactions (ADRs), catheter complications (CC) and hosp admissions for causes other than those related to the underlying infection. Descriptive statistics and regression analyses were performed.

Results

There were 260 OPAT patient courses provided. Mean age was 81 ± 5 years, 64% male. 51% were treated directly from the community and 49% post hosp. The most common infections were bone and joint (32%), genitourinary (21%), skin and skin structure (20%) and respiratory (12%). OPAT met criteria for effectiveness in 95%, with 247/260 completing therapy and avoiding infection-related hosp. Antimicrobials most frequently used were vancomycin (n = 59), ceftriaxone (n = 43), cefepime (n = 35) and ertapenem (n = 32). Median length of OPAT was 14 days (range 1–79). OPAT was assessed as safe in 81% of patients (211/260). 49 patients reported ≥1 safety events including ADRs (40; 15%), CC (6; 2.3%), and hosp (17; 6.5%). 9 hosp patients completed OPAT following discharge. Most common ADRs were diarrhea (n = 9), fatigue (n = 9) and nausea (n = 8) with 4 hosp for serious ADRs. All CCs resolved and there were no mortalities. Significant risk factors associated with safety events were drug allergies (OR=2.47, CI=1.31–4.65, P = 0.005), ≥3 comorbidities (OR=3.92, CI=1.16–13.23, P = 0.027) and hypertension (OR=2.19, CI=1.04–4.64 P = 0.039).

Conclusion

Provision of OPAT through a POIC demonstrated to be exceptionally safe and effective in the aged population.

Disclosures

L. J. Van Anglen, Theravance: Scientific Advisor, Consulting fee R. V. Nathan, Merck: Speaker’s Bureau, Speaker honorarium Allergan: Speaker’s Bureau, Speaker honorarium The Medicines Company: Speaker’s Bureau, Speaker honorarium K. A. Couch, Merck: Speaker’s Bureau, Speaker honorarium Allergan: Speaker’s Bureau, Speaker honorarium
Pilot of a Home Telehealth Platform in a Pediatric OPAT Program
Authors: Vaz Louise , Wagner Tamara , Cochran Bryan , Lovgren Mark
Published: October 2017

Background

Patients discharged with outpatient parenteral or prolonged oral antibiotic (OPAT) require monitoring to ensure optimal clinical outcomes. Advances in technology have allowed novel approaches for clinical interactions. We sought to develop a new home telehealth platform for a subsection of pediatric OPAT patients.

Methods

We used an existing infrastructure developed by our hospital telemedicine program to pilot the electronic home visit. A process was established to create a virtual connection at a pre-designated time using a HIPPA-secured web-based platform. Clinic staff performed a pre-visit technology check. Electronic Medical Record (EMR) scheduling platforms were created and the parent was coached on how to download and execute the necessary software. A virtual clinic was established between provider and family. Documentation occurred in the EMR with specific language and modifier codes for billing accuracy identified by the telemedicine team. Patients were selected based on medical complexity and travel time greater than 2 hours to our institution.

Results

Two pediatric OPAT patients completed the pilot in Spring 2017 for treatment of 1) CLABSI with retained line and 2) chronic ulcer with osteomyelitis. Three visits between the OPAT ID provider, located in her office, and the patient, located at home, were successfully piloted with video and voice. A routine clinic visit was conducted with a parent-driven physical exam. A clinical note was documented in the EMR with specific telemedicine templates. This platform also allowed for multi-disciplinary visits with a hospitalist and home health nurse to address a central line related issue with ID provider present. Total time for each visit was under 20 minutes.

Conclusion

We were able to demonstrate feasibility and functionality of this novel platform to conduct a billable OPAT clinic visit in a patient’s home. Health system infrastructure was a necessary and vital component to execution of the virtual clinic. Specific patient groups may benefit from this provider-patient interface. The use of telemedicine in OPAT may serve as a new platform for improving provider efficiency, lowering health system costs, and achieving greater patient satisfaction.

Disclosures

All authors: No reported disclosures.
Classical Fever of Unknown Origin: Retrospective Study in Infectious Clinical Hospital №2
Authors: Lunchenkov Nikolay , Filippov Eugene , Prihodko Olga , Volchkova Elena
Published: October 2017

Background

Despite the recent advances in medicine, fever of unknown origin (FUO) remains a diagnostic and therapeutic challenge even to expert physicians. The etiological structure of FUO is determined by many factors, including the one where a person lived and where has been hospitalized. The aim of this study is to investigate the etiology and clinical characteristics of adult classical FUO with more diagnostics available and to analyze the factors for certain disease categories.

Methods

The clinical data were retrospectively analyzed from 80 patients with cFUO hospitalized at the Infectious Clinical Hospital №2 between October 2015 and October 2016 the patients who met the D.Durack criteria (1) An axillary temperature of >38.0 which corresponds oral temperature of >38.3; (2) illness duration is more than 3 weeks; (3) there is no definite diagnosis after three outpatient visits or 3 days in the hospital with intensive investigations; (4) the fever is not related to FUO of other groups: nosocomial FUO, FUO in patients with AIDS, neutropenia were included.

Results

Of the 80 FUO cases, 70 were positively diagnosed with a diagnosis rate of 87,5%. Infectious diseases were still the primary causes of FUO 63% (n = 50). Among them the most frequent diagnoses were bacterial infection of unspecified site 12.5% (n = 10), infective endocarditis 11% (n = 9), as well as pneumonia 7.5% (n = 6) and viral infections of unspecified site 7.5% (n=6). Connective tissue diseases and other noninfectious inflammatory diseases accounted for 17.5% of the FUO cases among which SLE and autoimmune thyroiditis were the most common etiologies and made up 5% (n = 4) and 3,75% (n = 3), respectively. Neoplasms were 8% (n = 6) in our sample. Also ten patients (12,5%) could not be confirmed until they were discharged from hospital.

Conclusion

Infectious diseases are the major causes of FUO, and the most common cause is bacterial infection of unspecified site. To determine the etiology was difficult due to the limited conditions of the clinical hospital. Infectious endocarditis was found on the second place. The most common causative agents of infective endocarditis were MRSA (3/9) и streptococcus viridans (4/9). The frequency of undiagnosed cases was increasing, but in most FUO cases the causes can be diagnosed eventually after careful analysis of clinical data.

Disclosures

All authors: No reported disclosures.
Clinical Characteristics of Diarrheal Illness with Enteropathogenic E. coli (EPEC) Diagnosed with FilmArray (BioFire Diagnostics, Salt Lake City, UT) Multiplex PCR (MPCR) Testing. Maria Georgen BS, Paul Schreckenberger, PhD, Paul O’Keefe MD. Loyola University Medical Center, Maywood, Illinois, USA
Authors: Georgen Maria
Published: October 2017

Background

EPEC is a known cause of diarrhea, predominately in children, which has not been identified with conventional stool culture in most medical centers. MPCR testing assesses stool samples in which DNA targets for 20 or more pathogens are tested with rapid turnaround. This method has become the standard for diagnostic testing in many clinical laboratories. MPCR testing has identified EPEC as among the most frequent pathogens in published studies.

Methods

We have completed a retrospective review of medical records of patients who tested positive for EPEC in our medical center.

Results

EPEC was found in 56 of 332 MPCR samples analyzed between February 1, 2016 and July 31, 2016. EPEC was the only pathogen in 25 while co-infecting pathogens were found in 31. Co-infections included other diarrhea-causing E. coli (ETEC, EAEC and EIEC but none with STEC) in 17, C. difficile in 7, viruses (astrovirus 3, sapovirus 2, norovirus 2, rotavirus 2), Campylobacter 3, Giardia 2, Salmonella 2, Pleisiomonas 1 and Yersinia 1.

Patients ages ranged from <1 to 100 with 37 over age 19. Half were female. 7/46 had received antibiotic prior to sample collection. 10 reported recent travel. 51/52 presented to the emergency department, urgent care centers or ambulatory clinics. Symptoms included fever in 15/54, nausea 16/54, vomiting 14/54 and abdominal pain in 17/56. Diarrhea was described as watery in 23/32 and bloody in only 3. Antibiotic treatment was prescribed for 6/24 with EPEC only and for 22/31 with coinfection. A follow-up encounter was documented for 24 patients with EPEC only: 13 resolved, 3 remained ill and 8 could not be assessed.

Conclusion

EPEC is frequently found in stools from persons with diarrhea when MPCR is employed. Symptoms cannot be attributed to EPEC alone when other pathogens are found, but our analysis does suggest that EPEC is a common cause of diarrheal illness in adults as well as children. Prospective studies on natural history and treatment are necessary.

Disclosures

All authors: No reported disclosures.
Pharmacological Therapies for Hepatorenal Syndrome
Authors: Nanda Arjun , Reddy Rewanth , Safraz Humaira , Salameh Habeeb , Singal Ashwani K.
Published: October 2017

Background:

Hepatorenal syndrome (HRS) is a serious complication of advanced chronic liver disease. Different pharmacological therapies have variable efficacy. We performed a systematic review and meta-analysis to compare the efficacy of various drugs in the treatment of HRS.

Study:

Randomized controlled trials comparing active drug with placebo or comparing 2 different drugs were included in this analysis. Primary study outcome was reversal of HRS. Secondary outcomes were HRS relapse and patient survival. Subgroup analysis was performed on patients with type 1 HRS.

Results:

Thirteen randomized controlled trial were eligible for analysis. Terlipressin plus albumin was more efficacious than placebo plus albumin (odds ratio=4.72; 95% confidence interval, 1.72-12.93; P=0.003) or midodrine plus albumin and octreotide (odds ratio=5.94; 95% confidence interval, 1.69-20.85; P=0.005), for HRS reversal. However, no significant difference was noted comparing terlipressin plus albumin versus noradrenaline plus albumin, octreotide plus albumin versus placebo plus albumin or noradrenaline plus albumin versus midodrine plus albumin and octreotide. None of the comparisons showed difference on HRS relapse or patient survival. Subgroup analysis revealed that terlipressin was more effective than placebo for type 1 HRS reversal, but no significant differences were noted between any other comparisons, and none of the comparisons showed difference on HRS relapse or patient survival.

Conclusions:

Intravenous infusion of terlipressin is the most effective medical therapy for reversing HRS. Intravenous infusion of noradrenaline is an acceptable alternative. Studies are needed as basis for developing pharmacological strategies to reduce relapse of HRS and improve patient survival.
Viral infections in solid organ transplant recipients: novel updates and a review of the classics
Authors: Haidar Ghady , Singh Nina
Published: October 2017

Purpose of review

To summarize new discoveries in viral pathogenesis and novel therapeutic and prophylactic strategies in organ transplant recipients.

Recent findings

For decades, prophylaxis of cytomegalovirus (CMV) has been the standard preventive strategy, but new clinical trials are expected to determine the advantages of preemptive therapy over prophylaxis. Novel anti-CMV agents, such as maribavir and letermovir, are being studied for the treatment of resistant/refractory CMV as alternatives to foscarnet and cidofovir. CMV immune monitoring may offer individualized management plans. Epstein–Barr virus infections in transplant recipients are difficult to prevent and treat, though recent data suggest possible merit to pretransplant rituximab among high-risk transplant recipients. We review the groundbreaking HIV-to-HIV organ transplant trials, which are expected to revolutionize the care of HIV-infected individuals. Finally, we review topical developments in human herpesvirus 8, Zika virus, RNA respiratory viruses, adenovirus, norovirus, and polyoma viruses in organ transplantation.

Ongoing trials to optimize CMV prophylaxis and treatment, and outcomes of HIV-to-HIV organ transplantation in the United States, have significant implications to optimize management of these viruses in transplant recipients. Assessment of new antivirals and antiviral strategies, such as adoptive immunotherapy, is warranted for refractory viral infections.
Advances in understanding and management of lymphoedema (cancer, primary)
Authors: Keeley Vaughan
Published: October 2017

Purpose of review

Despite being neglected both clinically and in research in the past, primary lymphoedema, and lymphoedema secondary to cancer treatment have been the subject of an increasing number of studies in recent years. This review will focus on new developments relevant to clinical practice.

Recent findings

The main themes covered by the review include the incidence and prevalence of lymphoedema, early detection and intervention in cancer-related lymphoedema, risk reduction for the development of cancer-related lymphoedema, surgical treatment, palliative care for lymphoedema in advanced cancer and developments in the genetics of primary lymphoedema.

Evidence suggests that lymphoedema is more common than has been previously recognized. It continues to be a significant problem for people following cancer treatment. Developments in the early detection and treatment of cancer-related lymphoedema should reduce the future impact for patients. Advice on how to reduce the risk of developing lymphoedema may need to be modified in light of recent research. New treatments such as surgical procedures are still in their infancy but the results seem encouraging for selected patients.