bluuebunny/crossref_metadata_2025 huggingface dataset:
532. Establishing a SARS-CoV-2 Monoclonal Antibody Infusion Clinic: Early Trends in Outcomes and Disparities
Authors: Hare Allison J , Rivera McPhaul Judith M , Cargan Patrick , Tebas Pablo , Degnan Kathleen , Baron Jillian T , Hamilton Keith W
Published: December 2021

Background

SARS-CoV-2 monoclonal antibodies (SMA) have demonstrated efficacy in treatment of early, mild to moderate COVID-19 in patients at high risk for progression to severe COVID-19. We created an SMA infusion clinic at a large, urban academic medical center using both internal and community-based referral mechanisms to promote the equitable distribution of treatment.

Methods

Data were analyzed from clinic referrals from December 13, 2020 through April 20, 2021. Patient demographics, census-based area deprivation index (ADI) scores (scale of 1-10, with 1 representing least socioeconomic deprivation and 10 representing most), and relevant comorbidities were collected. Outcomes included days of symptoms until referral, patient receipt of SMA therapy after referral, adverse events, and ER visits and hospitalizations within 14 days of SMA administration. Association between demographic factors and relevant outcomes were determined using chi-square or Wilcoxon rank-sum tests as appropriate.

Results

47/433 (11%) referred patients were ineligible based on inclusion and exclusion criteria. Of eligible patients, 310/386 (80%) received treatment; patients who did not receive treatment either declined (93%), could not be contacted (5%), no-showed (1%), or were admitted for hypoxia (1%). Of treated patients, only 3 (1%) had adverse reactions. Within 14 days of SMA administration, 28 (9%) patients visited the ER or were admitted for COVID-19. Black patients had a longer median duration of symptoms prior to referral compared to White patients (5 vs. 3 days, p < 0.01) (Figure 1). White patients were more likely to receive SMA after referral compared to Black patients (88% vs. 64%, p < 0.01), as were patients with ADI score 1-5 compared to those with ADI score 6-10 (88% vs. 70%, p < 0.01) (Figures 2 and 3). Black patients who received SMA had a higher rate of ER visits or admissions than White patients, although the difference was not statistically significant (14% vs. 7%, p = 0.10).

Figure 1. Bar graph displaying number of patients per race (White, Black, or Other) by duration of symptoms prior to referral.

Figure 2. Bar graph displaying number of patients who did and did not receive SMA by race

Figure 3. Bar graph displaying number of patients who did and did not receive SMA by ADI.

Conclusion

Rate of adverse reactions and COVID-related ER visits or admissions were low in patients who received SMA. Despite efforts to promote the equitable distribution of treatment through multiple referral mechanisms, racial and socioeconomic disparities still exist.

Disclosures

All Authors: No reported disclosures
538. The Role of N-acetylcysteine on Post Covid-19 Pulmonary Fibrosis
Authors: Demot Bernard , Hizon Kristin Ivan Mark
Published: December 2021

Background

Covid 19 have long lasting complications, from myalgia, body weakness to life debilitating strokes, and pulmonary fibrosis. Several mechanisms had been described but mostly viral or autoimmune which causes damages which leads to Acute respiratory distress syndrome. There is no approved treatment as of this time. Antifibrotic drugs use had been limited due to hepatoxicity, on top of Covid 19 hepatopathy. This study aims to describe the role of N-acetylcysteine on Post COVID 19 pulmonary fibrosis as an alternative treatment.

Methods

Patients are admitted at Baguio General Hospital and Medical Center at the COVID wards. Patients are COVID confirmed by RT PCR nasopharyngeal swab. Patient who are classified as severe were given Dexamethasone, Enoxaparin and Remdesivir for 5-10 days. Patients who are not weaned off from O2 support underwent Chest CT scan. Patients with Extensive Fibrosis were then consented to undergo High Dose IV Infusion of N-acetylcysteine. (150mg/kg in 1st hour, 50mg/kg next 4 hours and 100mg/kg last 20 hours). Repeat Chest CT Scan was done.

Results

Peripheral Bilateral Ground Glass Opacities and Pulmonary Consolidation was seen on pre-treatment CT Scans. Repeat CT scans showed significant regression of Ground Glass Opacities and Pulmonary Consolidation.

CT SCAN pre and post treatment

Conclusion

High dose N-acetylcysteine showed promising results on Post COVID 19 Pulmonary Fibrosis.

Disclosures

All Authors: No reported disclosures
566. Impact of a Culturally Sensitive Multilingual Community Outreach Model on COVID-19 Vaccinations at an Urban Safety-net Community Hospital
Authors: Mena Lora Alfredo J , Echeverria Stephanie L , Li Ella , Morales Miguel , Esquiliano Rita , Schultz Genessa , Sifuentes James , Spencer Sherrie , Takhsh Eden , Lavani Romeen
Published: December 2021

Background

The United States (US) is one of the most affected countries by the COVID-19 pandemic. A disproportionate burden of COVID-19 deaths is seen in Black, Asian, and Latinx groups. COVID-19 vaccines are the primary mitigation strategy to reduce morbidity and mortality. However, vaccine hesitancy is high in these communities due to factors such as low health literacy, language barriers, and other health inequities. Our objective was to implement a culturally sensitive, multi-lingual, community outreach model to promote vaccine education and facilitate vaccine administration.

Methods

Community healthcare workers or “promotoras” were deployed to high traffic areas such as supermarkets, laundromats, churches, and commercial hubs from February-May 2021. The promotoras provided culturally sensitive vaccine counseling to individuals in their preferred language and facilitated vaccine appointments at our hospital. Our data was compared with publicly available data from other facilities organized by ZIP codes defined by the Department of Public Health as low, medium, or high-vulnerability to COVID-19.

Results

A total of 109 outreach workers were hired, of which 67% (73) were Latinx, 27% (29) Black and 6% (7) Asian. Overall, 8,806 individual encounters led to 6,149 scheduled appointments and 3,192 completed first doses (Figure 1). A total of 14,636 individuals were vaccinated. Average age was 45.5 (range 12-98). Preferred language was 54% Spanish, 38% English, and 8% Chinese. Ethnicity was mostly Hispanic (66%) with race mostly white (54%) (Figure 2). High and medium-risk ZIP codes represented 69.4% of vaccinations at our facility (Figure 3).

Figure 1. Education encounters and appointments made by community outreach workers and associated vaccinations.

Figure 2. Racial distribution of vaccinated individuals at our facility

Figure 3. Comparative vaccinations by zip codes from hospitals in our area.

Conclusion

We successfully implemented a culturally sensitive community outreach model which resulted in higher vaccination rates from at risk ZIP codes when compared to other hospitals. Promotoras encouraged vaccination in native languages, thereby increasing vaccine awareness and appointment faciliation. Barriers to vaccine access remain in these vulnerable communities. This model educated the community via its own members and may help reduce barriers, increase vaccine awareness and vaccination rates.

Disclosures

All Authors: No reported disclosures
605. Rates of Patient Satisfaction with Home-Based Outpatient Antimicrobial Therapy (OPAT)
Authors: Garst Ryan , Haines Danell J , Sullivan Connie
Published: December 2021

Background

The use of home-based outpatient parenteral antimicrobial therapy (OPAT) is well established. Studies by the National Home Infusion Foundation (NHIF) show that 1.4 million patients receive OPAT each year.1 With patient satisfaction a priority, NHIF developed, validated, and reliability tested the Uniform Patient Satisfaction Survey for Home Infusion Providers in 2017.2 Medicare patients are the fasting growing segment in the US and account for a disproportionate share of health care usage. Determining older patient satisfaction is imperative because patients who are more satisfied are more compliant with treatment3 and tend to return for continued care.4 Accordingly, the purpose of this study was to determine the level of home-based OPAT patient satisfaction and if a significant difference (p = ≤ .05) exists between the 0-64 and 65+ age groups.

Methods

2019 and 2020 OPAT survey data (n=5,559) was used in this study. Top box percent, typically used in health care patient satisfaction, was calculated for each survey question. Data was summarized using 7 composite categories formed from the 22 survey questions. Differences (p = ≤ .05) between the age groups was also calculated.

Results

Mean patient age was 64.31 (SD=14.78), 54.99% were 65+ years old, and 58.85% were male. OPAT patients gave high marks to their home infusion service (Table 1). The highest top box % for the composite scores was “Patient instructions” which averaged 98.91%. The most common healthcare satisfaction question “I was satisfied with the overall quality of the services provided” showed significant difference between the age groups (p = .002) with the 0-64 groups being more satisfied than the 65+ (Exhibit 1).

Table 1. OPAT Patient Satisfaction Survey Composite Scores: Percent of Patients Selecting Top-Box Score (n= 5,559)

Exhibit 1. Level (%) of Agreement to “I was satisfied with the overall quality of the services provided” by Age Group (n = 5,559)

Conclusion

Analysis of each survey question shows the 65+ patients are less satisfied than younger patients on the following: being informed of side effects, explanation of financial responsibilities, and the helpfulness of the billing staff. Even though the scores are high for both age groups, additional research needs to be conducted to determine why scores for the 65+ age group are lower, and changes needed for improvement. Knowing the level of OPAT patient satisfaction will benefit infectious disease physicians, providers, prescribers, payers, and regulators as they evaluate how to expand home-based services.

Disclosures

All Authors: No reported disclosures
616. Predicting Misdiagnoses of Infectious Disease in Emergency Department Visits
Authors: Chapman Alec B , Peterson Kelly , Widanagamaachchi Wathsala , Jones Makoto M
Published: December 2021

Background

Diagnostic error leads to delays of care and mistaken therapeutic decisions that can cascade in a downward spiral. Thus, it is important to make accurate diagnostic decisions early on in the clinical care process, such as in the emergency department (ED). Clinical data from the Electronic Health Record (EHR) could identify cases where an initial diagnosis appears unusual in context. This capability could be developed into a quality measure for feedback. To that end, we trained a multiclass machine learning classifier to predict infectious disease diagnoses following an ED visit.

Methods

To train and evaluate our classifier, we sampled ED visits between December 31, 2016, and December 31, 2019, from Veterans Affairs (VA) Corporate Data Warehouse (CDW). Data elements used for prediction included lab orders and results, medication orders, radiology procedures, and vital signs. A multiclass XGBoost classifier was trained to predict one of five infectious disease classes for each ED visit based on the clinical variables extracted from CDW. Our model was trained on an enriched sample of 916,562 ED visits and evaluated on a non-enriched blind testing set of 356,549 visits. We compared our model against an ensemble of univariate Logistic Regression models as a baseline. Our model was trained to predict for an ED visit one of five infectious disease classes or “No Infection”. Labels were assigned to each ED visit based on ICD-9/10-CM diagnosis codes used elsewhere and other structured EHR data associated with a patient between 24 hours prior to an ED visit and 48 hours after.

Results

Classifier performance varied across each of the five disease classes (Table 1). The classifier achieved the highest F1 and AUC for UTI, the lowest F1 for Sepsis, and the lowest AUC for URI. We compared the average precision, recall and F1 scores of the multiclass XGBoost with the ensemble of Logistic Regression models (Table 2). XGBoost achieved higher scores in all three metrics.

Table 1. Classification performance

XGBoost testing set performance in each disease class, visits with no labels, and macro average. The infectious disease classes with the highest score in each metric are shown in bold.

Table 2. Baseline comparison

Macro average scores for XGBoost and baseline classifiers.

Conclusion

We trained a model to predict infectious disease diagnoses in the Emergency Department setting. Future work will further explore this technique and combine our supervised classifier with additional signs of medical error such as increased mortality or anomalous treatment patterns in order to study medical misdiagnosis.

Disclosures

All Authors: No reported disclosures
627. CURE ID as a Tool for Curating and Analyzing Drugs Used in COVID-19 Clinical Trials
Authors: Charles Reema , Paul Parvesh , Stone Heather , Gorobet Serghei , Nhundu Belinda , Borkowski Katarzyna M , Duggal Mili , Tirupathi Raghavendra
Published: December 2021

Background

CURE ID is an internet-based data repository (https://cure.ncats.io/explore) developed collaboratively by FDA and NCATS/NIH. It is designed to capture real-world clinical outcome data to advance drug repurposing and to inform future clinical trials for infectious diseases with high unmet medical need. It also serves as a repository of clinical trials automatically pulled from https://www.clinicaltrials.gov into the CURE ID platform, where they were then manually curated, with the intention of keeping the infectious diseases community updated on the various clinical trials underway. The current study is a descriptive analysis of various therapeutics in clinical trials against COVID-19 on the CURE ID platform.

Methods

Using clinicaltrials.gov we selected those trials addressing therapeutics for COVID-19 and reviewed the drugs used, the current status of the trials, and the phases of development.

Results

As of May 2021, we identified 2,154 clinical trials and 933 drugs from clinicaltrials.gov that met the inclusion criteria. Hydroxychloroquine (n=251) was the most commonly investigated agent, followed by convalescent plasma (n=147), azithromycin (n=98), ivermectin (n=68), mesenchymal Stem Cells (n=63), tocilizumab (n=58), remdesivir (n=53) and favipiravir (n=51). At the time of our analysis, the majority (45%) of the clinical trials were in the recruiting phase, 12% were in the active phase, and 13% of the studies were completed. The majority (31%) of trials were in phase two, followed by phase three (21%) and phase one (10%). The vast majority of the agents were repurposed (92%), while only 8% of the agents were new molecular entities. Remdesivir was the only drug approved for marketing for treatment of certain patients with COVID-19 at the time of our analysis.

Conclusion

Several repurposed and novel drugs are being investigated to treat COVID-19 in clinical trials. CURE ID provides a broad view of the various drugs being researched and serves to keep the scientific community informed. Such a platform may help prevent duplication of efforts and help the scientific community with more coordinated research efforts and larger platform trials that can robustly answer scientific questions during a pandemic.

Disclosures

All Authors: No reported disclosures
631. Economic Analysis of Imipenem/Cilastatin/Relebactam Compared to Piperacillin/Tazobactam for Treating Hospital-Acquired and Ventilator-Associated Bacterial Pneumonia
Authors: Naik Jaesh , Massello Matthew , Ralph Lewis , Dillon Ryan J , Yang Joe
Published: December 2021

Background

Hospital-acquired and ventilator-associated bacterial pneumonia (HABP/VABP) is associated with high rates of morbidity and mortality; this is often worse among patients who experience a delay in receiving appropriate therapy. Initial treatment choice and early adjustment occurs prior to pathogen susceptibility results and may be based on suspicion of a resistant infection and/or clinical deterioration. This study assesses the cost effectiveness of Imipenem/cilastatin/relebactam (IMI/REL) in an early adjustment prescribing scenario compared to PIP/TAZ for patients with high risk of resistant infection from a US perspective.

Methods

Although early adjustment data was not directly available, pathogen susceptibility data derived from 2017-19 Study for Monitoring Antimicrobial Resistance Trends (SMART) surveillance program was applied to estimate patients who may have clinical worsening, likely due to a resistant infection. The efficacy and safety data for IMI/REL and PIP/TAZ were informed by the modified intent-to-treat population of a phase III trial (RESTORE-IMI 2). Our analysis comprised a decision tree (reflecting hospitalization period) followed by a yearly Markov model (capturing lifetime impact). The decision tree captured short-term outcomes (clinical cure, all-cause mortality, and hospital resource use). The Markov model translated short term outcomes into quality-adjusted life years (QALYs). Results were expressed as an incremental cost-effectiveness ratio (ICER). Sensitivity analyses were conducted to test the robustness of model results.

Results

Compared with PIP/TAZ, IMI/REL in the early adjustment setting was associated with increased costs (&10,087 per patient) but a higher cure (+7%) and lower mortality (-3%) rate. The resulting ICER (&12,173/QALY) falls well below typical US willingness to pay thresholds. Model drivers were the SMART-based susceptibility profiles and RESTORE-IMI 2 response and mortality rates.

Conclusion

Our results suggest that IMI/REL, used as an early adjustment option, could be considered cost effective for patients with worsening HABP/VABP in a US setting, when compared against PIP/TAZ.

Disclosures

Jaesh Naik, MSc, BresMed Health Solutions (Employee) Lewis Ralph, MSc, Bresmed (Employee) Ryan J. Dillon, MSc, Merck & Co. Inc., (Employee, Shareholder) Joe Yang, Ph.D., Merck & Co (Employee)
640. Development of a Laboratory Verification Protocol for Concurrent Detection of Bacterial, Fungal, and Antimicrobial Resistance Genes in a Multiplex Syndromic Joint Infection Panel
Authors: Cronin Monica , Fadgen Taylor K , Ogden Lisa , Green Jeremy P , Thatcher Stephanie A , Young Rebecca C , Hoelcle Brandon
Published: December 2021

Background

Verification is a critical component of implementing a diagnostic test in a clinical lab and can be time consuming and costly. A verification protocol and organism panel were developed in collaboration with ZeptoMetrix®, LLC to verify all analyte detections for the BioFire® Joint Infection (JI) Panel*. The BioFire JI Panel detects 31 pathogens and 8 antimicrobial resistance (AMR) genes associated with joint infections from synovial fluid specimens.

Methods

A protocol was developed using prototype NATtrol™ controls from ZeptoMetrix®, synovial fluid, and the BioFire® FilmArray® 2.0 and the BioFire® FilmArray® Torch Systems. Control materials were tested in the presence of synovial fluid from pooled human donors. The 32 targets required for all analyte detections were divided into 5 pools of 6-7 analytes and then tested over multiple days on several systems.

Results

Preliminary outcomes were good with a cumulative positive detection rate of 100% (310/310) and expected negative detections of 99.3% (1182/1190) from 50 prototype BioFire JI Panel test runs. AMRs were correctly identified in 50/50 (100%) replicates when a correlated bacterium was present. Unexpected detections of Streptococcus spp. (7/50) and Staphylococcus lugdunensis (1/50) were likely due to contaminants in the synovial fluid; Streptococcus spp. was confirmed by testing the synovial fluid in isolation.

Conclusion

Efficient performance verification may be achieved by combining 32 organisms/8 AMR into 5 pools and can be completed with 20 test runs in 4 days. The pooling scheme provides multiple positive/negative detections per analyte and accurately detects AMR. The protocol and controls serve as a useful tool for providing reliable detections of targets over multiple days, operators and systems and offers a flexible solution for supporting verification needs.

*The BioFire® Joint Infection Panel is currently pending US FDA De Novo review. This product has not been evaluated by other global regulatory agencies for in vitro diagnostic use.

Not available for sale. Panel menu subject to change.

Disclosures

Monica Cronin, MS, BioFire Diagnostics, LLC (Employee) Taylor K. Fadgen, Bachelor of Science, BioFire Diagnostics, LLC (Employee) Lisa Ogden, BS, BioFire Diagnostics, LLC (Employee) Jeremy P. Green, BS, BioFire Diagnostics, LLC (Employee, Shareholder) Stephanie A. Thatcher, MS, BioFire Diagnostics (Employee) Rebecca C. Young, MS, BioFire Diagnostics, LLC (Employee) Brandon Hoelcle, BS, ZeptoMetrix, LLC (Employee)
648. Rapid, Non-invasive Detection of Cryptic Tularemia Using a Plasma-Based Microbial Cell-Free DNA Next-Generation Sequencing Test
Authors: Malik Salma , Paul Vishesh , Damodaran Thara , Prabakhar Deepa , Khan Amir , Ahmad Sharjeel
Published: December 2021

Background

Francisella tularensis causes severe infections and is a Category A potential bioterrorism agent but its microbiological diagnosis can be challenging. The diagnosis of tularemia is limited by non-specific protean clinical symptoms that overlap with other infectious syndromes, the fastidious nature of Francisella tularensis, along with insensitivity and poor specificity of serology. Rapid, non-invasive diagnosis of tularemia by microbial cell-free DNA (mcfDNA) next-generation sequencing (NGS) of plasma offers a means to overcome these limitations.

Methods

The Karius Test™ (KT) detects and quantifies mcfDNA in molecules/µL (MPM) from >1400 organisms in plasma (performed at the CLIA certified/CAP accredited Karius laboratory). KT detections of Francisella tularensis were compiled from three medical centers with clinical review by healthcare providers.

Results

KT detected Francisella tularensis in four patients. All were adult males in whom the diagnosis was unexpected. The most common symptoms were fever and chest pain. White blood cell count neutrophilic predominance and abnormal chest X-ray findings were found in three cases. A broad infectious disease work-up was performed with the initiation of broad spectrum empiric antibiotics in all cases. KT was the first test to identify Francisella tularensis as the microbiological diagnosis with a time to diagnosis of 2.25 days (avg) +/- 0.5 from sample collection (one day from sample receipt in all cases), enabling narrowed, targeted antibiotic treatment. Francisella tularensis mcfDNA concentration was 1772 MPM (avg) +/- 1914. KT was the only test to establish the diagnosis in two cases; tularemia serologies were confirmatory in two cases, one of which had confirmatory culture from lymph node biopsy. Three patients were diagnosed with the pneumonic form of the illness and one with a visceral glandular form. Possible epidemiological exposures were identified in all cases.

Conclusion

KT enabled rapid, non-invasive, plasma-based diagnosis of diverse clinical manifestations of invasive tularemia against a competing broad infectious and non-infectious differential diagnosis. Timely diagnosis enabled targeted narrowing of antibiotic therapy and successful treatment of pneumonic and glandular forms of the infection.

Disclosures

All Authors: No reported disclosures
671. Initial Impression of Explify Respiratory Testing: Is It an Effective Diagnostic Tool?
Authors: Donkin Joshua D , Polega James , Bhugra Mudita , de Sanctis Jorgelina , Hassouna Habiba
Published: December 2021

Background

Respiratory infections are a common cause of hospital admissions resulting in significant morbidity and mortality. Isolating specific pathogens from the respiratory tract is a diagnostic challenge. Traditional testing modalities are prone to contamination, time consuming, and have low sensitivity. Next generation genetic sequencing technology has made possible the development of a number of hypothesis free, fast, and highly accurate genome-based identification tests. In this study, we aim at assessing the initial use and performance of one of these tests, the Explify Respiratory panel, at a large quaternary hospital in west Michigan.

Methods

We performed retrospective analysis on 16 patients with suspected lower respiratory infections. Subjects were chosen for inclusion in the analysis based on the suspicion of pulmonary infection without an identified pathogen. The patient population included 5 immunocompromised patients, 3 with hematologic malignancy, 4 with solid tumor malignancy, and 2 transplant recipients.

Results

The test resulted in: lack of identified organism (5 patients), identification of non-pathogenic organisms (6 patients), and identification of organisms that were either identified by other traditional testing or did not impact provider’s therapeutic plan (5 patients). The results of Explify testing in all 16 patients did not have a clinical impact on patient care or treatment plan.

Conclusion

Explify testing seemed to be an appealing cost-effective tool that could replace other available testing modalities such as culture, other sequencing tests, and serological testing with faster turn-around time and less cost. However, it failed to demonstrate any benefit to clinicians in identifying respiratory pathogens while resulting in added cost burden to the patient. Moreover, it resulted in clinical delays of further investigation while awaiting the results. It remains unclear if the lack of clinical impact results from the extensive interventions and treatments that patients receive prior to Explify testing or from the poor sensitivity and performance of the test.This study emphasizes the importance of continuous evaluation of new diagnostic testing before widespread implementation to improve patient care and minimize cost burden.

Disclosures

All Authors: No reported disclosures
672. Diagnosis of Rocky Mountain Spotted Fever Using Plasma Metagenomic Next-Generation Sequencing
Authors: Chiang Leslie , Ramchandar Nanda , Coufal Nicole , Farnaes Lauge , Foley Jennifer
Published: December 2021

Background

Rocky mountain spotted fever (RMSF), caused by Rickettsia rickettsii, incurs significant morbidity and mortality, especially in children. Early in the course of illness, standard diagnostic tests are of limited sensitivity, and diagnosis is often based on clinical symptoms and local epidemiology. The diagnosis can be missed in areas where RMSF is not endemic, and a delay in initiation of therapy may lead to poor clinical outcomes. Plasma metagenomic next-generation sequencing (mNGS), with turnaround times approaching 48 hours, may be a useful adjunctive tool in the diagnosis of RMSF.

Methods

We describe four children hospitalized with RMSF between January 1, 2017 to May 15, 2021 at a tertiary children’s hospital in southern California. All had plasma mNGS and rickettsial serologic testing as part of clinical care.

Results

mNGS detected Rickettsia rickettsii in all 4 patients. Only 2 subjects had positive serologic testing initially and required repeat testing in the convalescent stage to confirm RMSF. The mean turnaround time for mNGS was 2.75 days, which was comparable to serologic testing. Antibiotic therapy was changed in three subjects as a result of the plasma mNGS result.

Conclusion

Plasma mNGS may be a useful diagnostic modality early in the disease course of RMSF.

Disclosures

Lauge Farnaes, MD, PhD, Cardea Bio (Advisor or Review Panel member)IDbyDNA (Employee)
691. Infective Endocarditis with an Indication for Cardiac Surgery in a Tertiary Care Educational Hospital: Does Cardiac Surgery Improve Outcomes?
Authors: Akyol Deniz , Quliyeva Gunel , özcem Selin Bardak , kayıkçıoğlu Meral , Yamazhan Tansu , Ulusoy Sercan , Sipahi Hilal , Taşbakan Meltem , Sipahi Oğuz Reşat
Published: December 2021

Background

In this retrospective cohort study, it was aimed to compare the clinical characteristics and outcomes of IE cases without and with an indication for cardiac surgery in terms of whether they have been operated or not, in a tertiary-care educational hospital.

Methods

Patients that were followed up for definite IE (diagnosed according to modified Duke criteria between March 2007 and November 2020) with an indication for cardiac surgery according to European Society of Cardiology Guidelines, comprised the study group. Subjects were evaluated in terms of whether these cases have been operated or not, demographic features, underlying diseases, risk factors, clinical and laboratory findings, therapy responses, complications, and mortality. The timing of surgery is defined as emergency; surgery performed within 24 hours, urgent; within a few days, elective; after at least one-two weeks of antibiotic therapy. Statistical analysis was performed via Chi square and Student T tests and a p value < 0.05 was considered significant.

Results

A total of 90 patients with an indication for surgery, 33.3% patients in underwent surgery, 66.6% patients in not underwent surgery group fulfilled the study criteria. The most frequently seen complaints in patients were fever (91.1%), cold-shiver (56.6%), weight-loss (27.7%), dyspnea (25.5%), and tachycardia (20%). Heart murmur was detected during cardiac auscultation of 44 patients. Mean blood leukocyte count, C-reactive protein and erythrocyte sedimentation rate were 12324 ± 6558/mm3 (1408-30330), 11.46 ± 8.38 mg/dl (0.18-34.6) and 61.43 ± 33.4 mm/h (2-130), respectively. There was no significant difference between two groups in terms of cardiac/non-cardiac risk factors, age, gender, etiologic agents, laboratory findings, septic embolisms and complaints (Table 1). In total IE with an indication for surgery mortality was 27.7%. Mortality rate was significantly less and heart murmur was significantly higher in cases who underwent surgery than those did not undergo surgery (p: 0.0447).

Table 1. Comparison of basic characteristics of patients in the two operated / unoperated cohorts.

Conclusion

These data support the importance of the guidelines’ criteria for cardiac surgery in the management of IE. Assuming that only 1/3 of the surgery needing cases received surgery, more interventions are needed to decrease the barriers against surgery.

Disclosures

All Authors: No reported disclosures
698. Contemporary Clinical Epidemiology of Pediatric Shigella and Campylobacter Infections in Houston, TX, 2019 and 2020
Authors: tabarani christy , Flores Anthony R , Flores Anthony R , Arias Cesar A , Wanger Audrey
Published: December 2021

Background

Infections due to Gram-negative, diarrheal pathogens are a significant cause of morbidity in children. Clinical features of pediatric Shigella and Campylobacter infections in urban cities in the United States are not well described.

Methods

We used a retrospective chart review of records (0-18 years of age) from a network of hospitals in Houston, TX. Only patients with Shigella spp. or Campylobacter spp. isolated from clinical samples in 2019 and 2020 were included. Demographic, clinical, and microbiological data were extracted from the medical record.

Results

We identified a total of 59 and 16 pediatric patients with Shigella spp. and Campylobacter spp. infections, respectively. Hospital admission occurred in 27.1% (16/59) of Shigella and 25% (4/16) of Campylobacter. Length of stay ranged between 1 and 2 days for both pathogens (Table 1). Of cases with available clinical data, Shigella infections were more likely to report fever during their illness compared to Campylobacter (80% versus 45.4%) (Table 2). Seizures were observed in 4 Shigella infected patients. No episodes of Shigella or Campylobacter bacteremia were identified. Among patients with an identified exposure, daycare attendance and contact with individuals experiencing similar symptoms were most common (Table 2). The vast majority of Shigella species were S. sonnei (96.6%) and all Campylobacter were C. jejuni (Table 3). Resistance to trimethoprim-sulfamethoxazole (TMP-SMX) was common (40/55, 72.7%) among Shigella isolates tested. No resistance to fluoroquinolones or third generation cephalosporins in any of the Shigella spp. isolates was observed. Susceptibility testing was not performed in Campylobacter due to lack of isolates. The most frequent antibiotic used was azithromycin (in 73.3% and 75% of patients with Shigella and Campylobacter, respectively). Major complications included urinary tract infection (n=1), rectal prolapse (n=1) and splenomegaly (n=1).

Conclusion

Infections due to Shigella and Campylobacter were a significant burden among pediatric patients between 2019 and 2020 in Houston, TX. The observed high frequency of resistance to TMP-SMX and emergence of multi-drug resistant Shigella in other countries warrants continued surveillance.

Disclosures

Anthony R. Flores, MD, MPH, PhD, Nothing to disclose Cesar A. Arias, M.D., MSc, Ph.D., FIDSA, Entasis Therapeutics (Grant/Research Support)MeMed Diagnostics (Grant/Research Support)Merk (Grant/Research Support)
713. Coccidioidal Meningitis Among Children: A Case Series and Single Center Experience In Central California
Authors: Naeem Fouzia , Giglio Linda , Sharma Julia , Clerkin Patricia , Laningham Frederick , McCarty James
Published: December 2021

Background

Coccidioidal meningitis is a severe form of coccidioidomycosis associated with significant morbidity and mortality. Published literature in the pediatric population is limited, particularly on coccidioidal meningitis. Here we describe a large case series of pediatric coccidioidal meningitis followed at a tertiary care center in an endemic region.

Methods

We performed a retrospective case review of patients ≤21 years old followed at our facility with a diagnosis of coccidioidal meningitis from January 1, 2000, to December 31, 2018.

Results

Overall, 30 patients were identified during the study period. The median age was 10.8 years (IQR: 4.6-15). The majority of patients were previously healthy (93%) and all required hospitalization. Fever (90%), headache (70%), vomiting (53%), and fatigue (57%) were the most common clinical manifestations. More than one-third (40%) had concurrent pulmonary disease. Only 20 patients (67%) had initial Coccidioides complement fixation (CF) titers >=1:16. The majority had extra-axial brain involvement (60%) and seven (23%) had associated spinal canal disease. Over two-third required shunt placement (70%) and almost half of them (43%) underwent revision. Neurological complications including paresis/paralysis, stroke, neuropathy, seizures, and cognitive delay were observed in 20% of patients. Two-thirds (73%) of patients received fluconazole as the initial drug. However, 37% of those had fluconazole failure, requiring alternative treatment. Due to refractory disease, two patients required a novel triazole, isavuconazole, while adjunctive therapy with steroids and interferon-gamma (IFNγ) was used in 20% of patients. Most cases (83%) stabilized, 13% experienced relapses and/or progressive disease, and 3% were fatal.

Conclusion

Pediatric coccidioidal meningitis is an uncommon and sometimes devastating complication of disseminated coccidioidomycosis. Many patients present with relatively low CF titers, and communicating hydrocephalus and long term neurologic complications are common. Fluconazole treatment failures are common, and management remains difficult despite recent advances in therapy. Most patients do well once the disease is stabilized and require lifelong therapy. Newer therapeutic agents are needed.

Disclosures

All Authors: No reported disclosures
730. Ocular Involvement Associated with Rickettsial Infection
Authors: Hammami Fatma , Koubaa Makram , Chakroun Amal , Rekik Khaoula , Marrakchi Chakib , Smaoui Fatma , Jemaa Mounir Ben
Published: December 2021

Background

Rickettsiosis, a re-emerging disease, is characterized with a myriad clinical symptoms and various manifestations. Ocular involvement is often misdiagnosed since it’s rarely symptomatic. It especially involves the posterior segment. We aimed to study the clinical, laboratory and therapeutic features of ocular involvement associated with rickettsial infection.

Methods

We encountered a retrospective study including all patients hospitalized for rickettsial infection with ocular involvement in the infectious disease department between 2007 and 2020. The diagnosis was confirmed based on serology (seroconversion) and/or positive polymerase chain reaction for Rickettsia in skin biopsy.

Results

A total of 24 patients were included with a mean age of 40±12 years. There were 13 women (54.2%). Sixteen patients sought medical care during the warm months, from June to October (66.6%). The revealing clinical signs were febrile maculopapular skin rash (79.2%), cephalalgia (54.2%) and arthralgia (33.3%). Five patients had visual loss (20.8%). Physical examination revealed conjunctival hyperemia (37.5%) and pathognomonic eschar (29.1%). Laboratory investigations revealed elevated liver enzymes (79.1%), thrombocytopenia (75%) and cholestasis (58.3%). Ocular involvement was unilateral in 14 cases (58.3%). Retinitis was the most common manifestation (70.8%), followed by anterior uveitis (20.8%). Retinal fluorescein angiography, performed in ten cases (41.6%), confirmed retinitis in 8 cases (80%). Both retinal vasculitis and papillary hyperfluorescence were noted in two cases (20%). Patients received doxycycline in 21 cases (87.5%) and fluoroquinolones in three cases (12.5%). The median duration of treatment was 7[6-15] days. The disease evolution was favourable in all cases (100%). No ocular sequelae were noted. Complications were noted in two cases (8.2%) represented by thrombophlebitis (one case) and recurrent seizures (one case).

Conclusion

Systematic fundus examination should be performed in front of suspected rickettsiosis, even in the absence of ocular symptoms and signs. It provides clinical clues to promptly diagnose and treat rickettsiosis.

Disclosures

All Authors: No reported disclosures
749. A Nurse-Driven Protocol for Early Detection of Clostridiodes difficile Infections
Authors: Beckman Shannon , Chia Jonathan , Stibbe Bethany , Rykse Monica , Wang Michael S
Published: December 2021

Background

Clostridiodes difficile infections (CDI) are a significant cause of hospital acquired infections, resulting in significant morbidity and mortality. Early detection of CDI has been shown to reduce the spread of CDI within the hospital. As nurses are frequently at the patient’s bedside, we proposed to empower the nursing staff to assess, collect stool samples, and order C. difficile testing.

Methods

Rates of CDI were measured by our Infection Control Department. Hospital-onset CDI (HO-CDI) was defined as a positive C. difficile PCR assay after 3 days of admission, defined as a stay of at least 3 midnights. Community-onset CDI (CO-CDI) was defined as any case that was diagnosed in the Emergency Department or inpatient ward < 3 days of hospitalization based on stool testing as above. Nursing was instructed and empowered to assess, collect stool specimens, and place an order for C. difficile testing, based on the criteria of ≥3 loose or watery stools over 24 hours. Nursing was also educated to not order a test if patients had received stool softeners, enemas, or laxatives within 24 hours. The protocol was initiated in February 2019.

Results

Rates of HO-CDI increased during the intervention period, rising from 2.6 cases/10000 patient days and peaking at 17.7 cases/10000 patient days (average 6.7 vs. 12.1 monthly cases per 10,000 patient days. Rates of CO-CDI did not significantly change (12.4 vs. 11.5 monthly cases per 10000 patient days). Due to concerns of inappropriate testing, which included testing after laxatives, enemas, or sending specimens despite < 3 stools over 24 hours, the protocol was discontinued in June 2019. Although the HO-CDI rate remained elevated over the next month, the rate subsequently decreased over the next several months (12.1 vs. 8.0 cases per 10000 patient days). Overall testing also increased over the study period (148.3 vs. 169.9 cases/per 10000 patient days).Figure 1 - Clostridiodes difficile rates

Figure 2 - CDI testing rates

Conclusion

A nursing driven protocol resulted in increased HO-CDI and overall CDI rates suggesting that the intervention may have been a factor in increasing the frequency of HO-CDI diagnoses, although the possibility of misdiagnosis of colonization for true CDI cannot be excluded. Further education of nursing staff may be a potential intervention in improving appropriate CDI testing.

Disclosures

All Authors: No reported disclosures
750. Retrospective Evaluation of the Three-Step EIA/PCR Algorithm as a Cost-Effective Method for Detection and Treatment of Clostridium Difficile Infection
Authors: Kulla Bakri , Haggerty patrick
Published: December 2021

Background

Clostridium difficile infection (CDI) is the primary cause of infectious diarrhea in the United States. With an estimated 453,000-500,000 burden cases that are associated with 15,000-30,000 deaths annually in the United States. Because of its prevalence, there is a projected 3.2-4.8 billion dollar annual cost for inpatient care related to CDI. For these reasons, accurate and timely detection of CDI is crucial to reduce the morbidity, mortality, and medical costs.

Methods

This is a retrospective cohort study. Adult patients, aged 18 through 80 years, admitted between 9/1/2016 and 9/30/2017, who presented with diarrhea and received a CDI algorithm test. To assess bivariate associations between true positive and indeterminate positive groups, categorical variables were compared using Chi-Square or Fisher’s exact tests when appropriate, and continuous variables were analyzed using independent samples t-tests.

Results

The study included 1031 stool samples, of which 853 (82.7%) were CDI negative and 178 (17.3%) were CDI positive. Of the full sample, 265 (25.7%) were GDH (+), 94 (9.1%) were toxin (+), and 84 (8.1%) were PCR (+).

In order to examine patient-level variables, the first positive from each patient was included to ensure independence of data points, resulting in 830 unique tests and patients. The true positive rate of this sub-sample was 9.4% (n = 78) and indeterminate positive rate was 8.7% (n = 72).

An important findings of the study is that of the patients who were GDH (+)/toxin (-), 87 (50.9%) were PCR (-) and 84 (49.1%) were PCR (+).Table 1

Conclusion

The study found that of the patients who are GDH (+) and Toxin (-), the PCR test serves as a proxy for the CDI test. In addition, we demonstrated that whether the patient was true positive by the GDH/Toxin test or indeterminate positive, the outcomes were the same. The only difference was the antibiotic selections for treatment. Performing PCR tests as a part of three-step algorithm prevented nearly half of discrepant patients from being unnecessarily treated with antibiotics and placed on enteric precaution, thereby extending their hospital stay. Finally, by preventing unnecessary antibiotic use, isolation and hospital length of stay, it is proposed that the three-step algorithm effectively reduces hospital cost.

Disclosures

All Authors: No reported disclosures
766. Readmissions of Hospitalized Patients with Clostridioides difficile Infection (CDI) for Recurrent CDI Is Common
Authors: Drwiega Emily N , Danziger Larry H , Johnson Stuart , Skinner Andrew M
Published: December 2021

Background

Hospital acquired infections (HAI) and hospital readmissions are of particular focus by Centers for Medicare and Medicaid Services. Clostridioides difficile infection (CDI) is an HAI notorious for causing recurrent illness and potentially resulting in re-hospitalizations. The purpose of our study was to identify the frequency of follow-up appointments in patients with CDI and determine the rate of re-hospitalization for recurrent CDI (rCDI).

Methods

This was a single-center, retrospective, chart review at a tertiary medical center. Through the electronic medical record, we queried all hospitalized patients with a positive stool test for C. difficile (GI panel PCR, FilmArray, Biofire, or C. difficile PCR, Xpert CD assay, Cepheid) with or without an ICD-10 code Enterocolitis due to C. difficile (A04.7, A04.71, A04.72) from January 2018 through April 2018. Demographic and clinical data at the time of diagnosis and up to 90 days after were collected from patient records.

Results

One-hundred and eighty-five patient episodes were evaluated. Of these, 147 (79.5%) were primary CDI, 13 (7.0%) were rCDI, and 25 (13.5%) were determined to be colonization. Twenty-two (11.9%) patients from the total cohort attended a follow-up appointment for CDI within 30 days, most often with a primary care provider or infectious disease physician. Twenty-three (12.4%) patients, 18 of whom were hospitalized for primary CDI episodes, developed a recurrent episode within 90 days of their initial CDI episode. Of these 23 patients with rCDI, 10 (43.5%) patients were re-hospitalized for their rCDI. Only 4 (17.4%) patients with rCDI had a follow-up appointment after their primary episode and among the 10 patients re-hospitalized for rCDI, only 2 (20.0%) patient had been seen for follow up for their previous CDI episode.

Conclusion

In our study, few patients had a follow-up appointment for CDI. Also, more than one third of the patients who had rCDI had to be re-hospitalized for the recurrent episode. Our study highlights a concern that the majority of patients re-hospitalized with rCDI did not have a follow-up appointment within 30 days of their initial diagnosis. Further study is necessary to determine if a dedicated follow-up appointment for CDI would result in decreased re-hospitalizations associated with rCDI.

Disclosures

Stuart Johnson, MD, Acurx Pharmaceuticals (Advisor or Review Panel member)Bio-K+ (Advisor or Review Panel member)Ferring Pharmaceutical (Advisor or Review Panel member)