bluuebunny/crossref_metadata_2025_split huggingface dataset:
112. Physiological Signature of Bloodstream Infection in Critically Ill Patients
Authors: Zimmet Alex , Clark Matthew , Gadrey Shrirang M , Bell Taison , Randall Moorman J , Moore Christopher 
Published: October 2019

Abstract

Background
Bloodstream infection (BSI) is associated with high mortality rates in critically ill patients but is difficult to identify clinically. This uncertainty results in frequent blood culture testing, which exposes patients to additional costs and the potential harms of unnecessary antibiotics. Accordingly, we aimed to identify signatures in physiological data from critically ill adults that characterize BSI.

Methods
We reviewed all blood culture, vital sign, laboratory, and cardiorespiratory monitoring (CRM) data from patients admitted to the medical and surgical/trauma ICUs at the University of Virginia Medical Center from February 2011 to June 2015. Blood culture results were categorized as positive, negative, or contaminant. For the BSI population, we included data obtained within 12 hours before or 24 hours after the acquisition of a positive blood culture. The control population included data greater than 12 hours before or 24 hours after the acquisition of a positive blood culture, and all data from patients without BSI. We used multivariable logistic regression to identify the physiological characteristics of BSI.

Results
We analyzed 9,955 ICU admissions with 144 patient-years of vital sign and CRM data (1.3M hourly measurements). The average age was 59 years; the population was mostly Caucasian (81%) and male (56%). There were 5,671 (57%) admissions with ≥1 blood culture, and 744 (7%) had a BSI. The in-hospital mortality rate for patients with BSI was 28% vs. 12% for all others. The physiological signature of BSI was characterized by abnormalities in 12 parameters (Figure 1)—e.g., BSI was more likely in patients with a higher pulse and lower platelets. Several associations were nonlinear—e.g., temperature and WBC had U-shaped relationships with BSI. The internally validated C-statistic was 0.77.

Conclusion
Statistical modeling revealed a clinically sensible physiological signature of BSI that could assist with bedside decisions regarding the utility of blood culture testing in critically ill adults.

Disclosures
All authors: No reported disclosures.
2193. Factors Impacting the Duration of Antimicrobial Therapy for Community-Acquired Pneumonia
Authors: Sandhu Avnish , Goldman Erin , Polistico Jordan , Polistico Sarah , Oudeif Ahmed , Aranha Anil , Murray Kyle P , Zhao Jing , Mynatt Ryan , Pogue Jason M , Dhar Sorabh 
Published: October 2019

Abstract

Background
Pneumonia is a common cause of infection associated with hospitalization. Treatment durations for community-acquired pneumonia (CAP) often exceed guideline recommended durations of 5–7 days without a clear explanation. The objective of this study was to determine factors that may lead to durations exceeding this recommendation.

Methods
A retrospective chart review of 89 patients admitted to the Detroit Medical Center (DMC) for the treatment of pneumonia was conducted. Demographics, clinical signs and symptoms, antibiotic data, pneumonia severity score (CURB 65), risk factors for resistance, microbiology results, and outcomes were recorded and analyzed for factors associated with increased durations of antibiotics. Average durations of antibiotics and durations of antibiotics greater that 7 days were assessed for each risk factor.

Results
Average durations of antibiotics was 9 days (SD 3.8) for the cohort, and 55 (61%) received durations of > 7 days. Average durations of antibiotics for risk factors are shown in Table 1. Factors associated with durations of antibiotics longer than 7 days are shown in Table 2. There was a trend toward longer average durations of antibiotics for persons with risk factors for resistance [Drug Resistance in Pneumonia (DRIP) score ≥ 4 (increased duration of antibiotics by 1.7 days, P = 0.07] and those with a positive legionella antigen [increased durations of antibiotics by 6.6 days, P = 0.07].

Conclusion
Specific risk factors could not be associated with increased durations of antibiotics, although there was a trend toward longer durations for persons with markers for resistance and positive legionella testing. Efforts to reduce durations of antibiotics must target global clinician antibiotic prescribing patterns and not specific risk factors.

Disclosures
All authors: No reported disclosures.
2198. Weak Interobserver Reliability in the Clinical Diagnosis of Pneumonia Among Infectious Disease Trained Physicians
Authors: Sheffield Virginia , Dickson Robert , Chanderraj Rishi 
Published: October 2019

Abstract

Background
Pneumonia remains a common global cause of death. Varied definitions of pneumonia rely on clinical features, imaging, and microbiological data. The Center for Diseases Control/National Healthcare Surveillance Network (CDC/NHSN) definition is used to study population-level trends. Prior studies have revealed discordance in components of the definition, yet reliability of overall clinical diagnosis has not been evaluated, nor has it been compared with the surveillance definitions. This study was designed to determine the overall concordance in the diagnosis of pneumonia by Infectious Diseases (ID) clinicians and the agreement between this and the surveillance definition. We then set out to determine which clinical features were weighted most heavily in provider decision-making.

Methods
Using an iterative approach with input from ID and Pulmonary Medicine physicians, we designed and refined an adjudication tool for diagnosis of pneumonia that consolidates clinical features, laboratory data, and imaging. Cases were analyzed by strict CDC/NHSN surveillance criteria and adjudicated independently by ID-trained physicians based on overall clinical opinion. Kappa coefficient (κ) was used to determine diagnostic reliability, and a random forest model was used to identify clinical factors most heavily weighted by physicians.

Results
Twenty-eight cases were adjudicated by three ID-trained physicians. Overall, interrater agreement was low (κ = 0.438). In comparing providers’ clinical adjudication with CDC/NHSN criteria, agreement was even worse (κ range 0.125 to 0.378). Among specific clinical features, positive culture growth strongly informed clinician diagnosis of pneumonia, while chest imaging did not play a significant role.

Conclusion
Overall agreement in the clinical diagnosis of pneumonia is poor, even among ID-trained physicians. Culture results more strongly inform clinician decision-making than does chest imaging. The surveillance definition used by the CDC/NHSN has only weak agreement with in-practice clinical assessment. These results underscore the need for more precise diagnostic tools in cases of suspected pneumonia.

Disclosures
All authors: No reported disclosures.
113. Understanding the Changes in Infective Endocarditis Admission in Pennsylvania During the Opioid Crisis
Authors: Meisner Jessica A , Anesi Judith A , Anesi Judith A , Chen Xinwei , Grande Dave 
Published: October 2019

Abstract

Background
Nationwide, there has been a rise in cases of infective endocarditis (IE) correlating with the rise of the opioid crisis. Pennsylvania (PA) has the third highest rate of drug overdose deaths in the country, with Allegheny and Philadelphia counties having the highest rates in the country. With this study, we evaluated how IE has changed in the face of the opioid crisis with respect to the population impacted and associated healthcare utilization in PA.

Methods
We performed a retrospective cohort study of all adults admitted to an acute care hospital in PA between January 2013 and March 2017 with a diagnosis of IE. Patients were identified through the Pennsylvania Health Care Cost Containment Council (PHC4) via billing codes. Exposed patients were those with drug use-associated IE (DU-IE); the unexposed group was those with non-DU-IE. We determined the number of admissions and geographical distribution of IE and DU-IE in the state. We then assessed for differences in hepatitis C (HCV) and HIV serostatus, length of stay (LOS), insurance status, total hospital charges, and rates of valve surgery between the two groups.

Results
There were 17,224 admissions for IE in PA during the study period, of which 11.2% were DU-IE. In Allegheny and Philadelphia counties, 14.4% and 20.5% were from DU-IE, respectively. DU-IE cases increased from 6% in 2013 to 17% in 2017, P < 0.001. We found several significant differences between the DU-IE and non-DU-IE groups: DU-IE group was younger (median 33 vs. 69 years old, P < 0.001); the LOS was longer in the DU-IE group (10 vs. 7 days, P < 0.001); the percentage of patients leaving Against Medical Advice was higher in DU-IE group (15.7% vs. to 1.1%, P < 0.001); a higher proportion of the DU-IE group were HCV and HIV seropositive (27.1% vs. 3.3% for HCV, 2.4% vs. 0.74% for HIV, P < 0.001). See figures for complete results.

Conclusion
Pennsylvania had an increase in the number of IE cases over the last 4 years, driven by the opioid crisis, with Philadelphia and Alleghany counties being the most impacted areas. While this study is limited by the use of claims data, it demonstrates the downstream effects of the opioid crisis on the patient population at risk and the healthcare system due to longer and costlier hospital stays. This study supports the need for innovative and integrative care models to support them.

Disclosures
All authors: No reported disclosures.
2211. Impact of Early Fiberoptic Bronchoscopy on Microbiological Diagnostic Rate and Clinical Outcomes of Pneumonia in Acute Leukemia Patients
Authors: Sakurai Aki , Bala-Hampton Justin E , Mulanovich Victor E , Wierda William G , Cortes Jorge E , Adachi Javier 
Published: October 2019

Abstract

Background
Fiberoptic bronchoscopy with BAL (FOB) remains the cornerstone in the diagnosis of pneumonia in immunocompromised patients; however, there is no uniform agreement on the best timing for FOB, and its impact on microbiological diagnostic rate and clinical outcome has not been established.

Methods
Retrospective study (October 2017–December 2017, July 2018–January 2019) at MD Anderson Cancer Center. The medical records of adult patients with AML, MDS or ALL who developed pneumonia (CAP, HCAP, HAP excluding VAP) and underwent FOB were reviewed. By definition, patients who underwent FOB within 48 hours after the diagnosis of pneumonia were categorized as early FOB group. We compared demographic, clinical, microbiological data, and outcomes between two groups. Data were analyzed via χ 2, Fisher’s exact and Wilcoxon rank-sum test and logistic regression.

Results
Of 140 patients included, 33 patients (24%) had early FOB and 107 patients (76%) had late FOB. There was no significant difference between two groups in demographic features, radiological findings, ANC and pneumonia severity index. Microbiological diagnostic rate of FOB did not differ between early FOB and late FOB: identification of pathogenic microorganisms (33.3% vs. 36.5%, p = 0.837), bacteria (6.1% vs. 13.1%, P = 0.36), fungi (18.2% vs. 12.2%, P = 0.39) and respiratory virus (12.1% vs. 16.8%, P = 0.6), respectively (Figures 1 and 2). On univariate analysis, the duration of intravenous antibacterial therapy was shorter in early FOB, with a median duration of 8.5 days (IQR 6.5–12) in early FOB and 11 days (IQR 8–18) in late FOB (P = 0.0047) (Figure 3). Multivariable logistic regression analysis showed that late FOB (OR 3.26, 95% CI 1.41 to 7.53, P = 0.0057) and negative bacterial culture on FOB (OR 3.06, 95% CI 1.01 to 9.22, P = 0.048) were significantly associated with longer duration of intravenous antibacterial therapy (≥10 days). There was no significant difference in ICU admission, 30-day and 60-day mortality and re-admission rate.

Conclusion
Early FOB was associated with shorter duration of intravenous antibacterial therapy for pneumonia in acute leukemia patients, which has an important impact on both optimization of antimicrobial therapy for patients and improvement of antimicrobial stewardship.

Disclosures
All authors: No reported disclosures.
2218. Feasibility of Automated Prediction of Drug Resistance in Pneumonia in the Veteran Population.
Authors: Christensen Matthew A , Jones Barbara E , Babbel Danielle , Sutton Jesse D , Spivak Emily S , Haroldsen Candace , Stevens Vanessa W , Jones Makoto M , Samore Matthew H 
Published: October 2019

Abstract

Background
To enhance antimicrobial decision-making in community-onset pneumonia, several manually calculable clinical scores have been proposed to predict drug-resistant organisms (DRPs), most commonly methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa. The Drug Resistance in Pneumonia (DRIP) score includes 10 features that can be calculated by providers at the bedside but is potentially automatically extractable from an electronic health record (EHR). We aimed to explore the feasibility of calculating an automated “eDRIP” score from the EHR in the Veteran’s Affairs (VA) population.

Methods
We extracted patient characteristics, features relevant to the DRIP score, and detection of DRPs among all inpatient admissions for pneumonia between August 29, 2010 and July 31, 2013 at VA hospitals nationwide using EHR data from the VA corporate data warehouse. We calculated an eDRIP score for each admission. We compared the prevalence of each electronically extracted feature to that reported in a separate study of manually extracted factors performed at the Salt Lake City VA by Babbel et al, and to the original DRIP score validation cohort from Webb et al.

Results
Among 101,462 pneumonia admissions across 114 VA hospitals, 4% had a DRP detected on culture, 25% had an eDRIP ≥ 4, and 50% received broad-spectrum antibiotics. The Salt Lake City VA demonstrated slightly lower prevalence of eDRIP factors than the national population (table). Within the Salt Lake City VA, the EHR cohort and manually extracted Babbel cohort demonstrated similar prevalence of detected DRP’s, DRIP ≥ 4, and 8 of 10 features involved in the DRIP score (table). The eDRIP identified fewer hospitalizations with poor functional status and residence in long-term facilities.

Conclusion
In a large population of veterans admitted for community-onset pneumonia, automated extraction of an eDRIP score from the EHR was promising, though in need of revision. While some extracted features had similar prevalence to manual review, others differed by a factor of 10 or more, which may reflect issues with data extraction. Further work is needed to optimize feature extraction and compare electronic to manual DRIP scores to determine its utility within the VA population.

Disclosures
All authors: No reported disclosures.
2220. Comparative Incidence and Burden of Respiratory Viruses Associated with Hospitalization in Adults
Authors: Sieling William , Oberhardt Matthew , Zachariah Philip , Vargas Celibell , Barrett Angela , Phillips Matthew R , Finelli Lyn , Saiman Lisa 
Published: October 2019

Abstract

Background
The population-based incidence and burden of community-onset non-influenza respiratory viruses associated with hospitalization in adults has not been systematically assessed.

Methods
On admission, patients with respiratory symptoms are tested for respiratory viruses by multiplex polymerase chain reaction (BioFire FilmArray Respiratory Panel) as per standard of care at our university teaching hospital (1160 beds). A retrospective study was performed to identify adults who had influenza, parainfluenza virus (PIV), respiratory syncytial virus (RSV), human metapneumovirus (hMPV), or adenovirus (AV) detected within 3 days of admission from October 2017 to October 2018. To calculate population-based incidence per 100,000 persons (using 2010 US Census data), the number of cases was adjusted by the hospital’s percent market share for zip codes as determined by New York State’s all payer data reporting system. To improve the incidence estimate’s reliability, only cases living in zip codes for which the hospital had ≥ 60% market share were included. We compared median length of stay (LOS), ICU admission, and in-hospital mortality associated with each virus.

Results
Influenza A (H3) had the highest overall incidence followed by Influenza B and RSV. For each virus, the highest incidence was observed in adults ≥ 65 years old (figure). Overall, 12.9% of cases were hospitalized in the ICU and 4.7% died during hospitalization (table). AV, hMPV, and RSV were associated with the longest LOS. AV, PIV, and RSV were associated with the largest proportion of ICU admissions and deaths.

Conclusion
While Influenza A (H3) and Influenza B were associated with the highest population-based incidence, non-influenza respiratory viruses caused substantial morbidity in older adults. Compared with influenza viruses, AV, PIV, and RSV were associated with greater severity determined by ICU admissions and death.

Disclosures
All authors: No reported disclosures.
2222. Impact of Empiric Aminoglycoside Usage on Outcomes in Bacterial Pneumonia
Authors: Albin Owen , Patel Twisha S , Henig Oryan , Valley Thomas , Pogue Jason M , Petty Lindsay A , Mills John , Brancaccio Adamo , Kaye Keith S 
Published: October 2019

Abstract

Background
Although aminoglycosides are recommended as part of empiric combination therapy in selected patients with healthcare-associated pneumonia, their efficacy and safety remains unclear. The objectives of this study were to evaluate the impact of empiric aminoglycoside treatment on microbiologic cure, recurrent pneumonia and death, and acute kidney injury (AKI) among hospitalized patients treated for pneumonia who were clinically cured.

Methods
This was a nested cohort study including 441 hospitalized subjects with confirmed bacterial pneumonia who achieved clinical cure. All subjects had positive respiratory cultures at the beginning of therapy and also had cultures obtained at the time of antibiotic completion. Subjects with the same pathogen present at both the beginning of and at the end of treatment were categorized as microbiologic failure and all others were categorized as microbiologic cure. Serum creatinine was measured at both the beginning and end of therapy, with an absolute increase in serum creatinine of 0.5 mg/L or greater defined as AKI. Composite outcomes of 30- and 90-day recurrent pneumonia or death following the clinical cure of the index pneumonia were captured. Patients who received empiric aminoglycoside therapy were compared with patients who did not receive aminoglycoside therapy.

Results
Of 441 included subjects, 14.5% (N = 64) received aminoglycoside therapy and 85.5% (N = 377) did not. The mean age was 54.7 years, with 70.5% male and 78.2% white. Characteristics of the two groups (including Charlson Comorbidity Indices and APACHE II scores) were similar. Rates of microbiologic cure, death/recurrent pneumonia at 30- and 90-days and AKI and were similar in both groups (table). In subgroup analyses restricted to different pathogen groups these associations remained unchanged.

Conclusion
Among hospitalized patients with pneumonia who were clinically cured, empiric aminoglycoside therapy was not associated with an increased likelihood of microbiologic cure, death or recurrent pneumonia or AKI.

Disclosures
All authors: No reported disclosures.
2226. Impact of Prior and Concomitant Antibacterial Therapy on Outcomes in the ASPECT-NP Randomized, Controlled Trial of Ceftolozane/Tazobactam (C/T) vs. Meropenem (MEM) in Patients with Ventilated Nosocomial Pneumonia (NP)
Authors: Wunderink Richard G , Bruno Christopher , Martin-Loeches Ignacio , Kollef Marin , Timsit Jean-Francois , Yu Brian , Huntington Jennifer A , Li Linping , Jensen Erin , Wolf Dominik , Butterton Joan R , Rhee Elizabeth G 
Published: October 2019

Abstract

Background
NP is a frequent healthcare-acquired infection associated with high mortality; rising resistance rates among causative Gram-negative pathogens require new treatment options. In the randomized, controlled, double-blind, phase 3 ASPECT-NP trial, C/T (at double the initially approved dose) was noninferior to MEM for ventilated NP in both primary and key secondary endpoints. Here we evaluate the impact of prior and concomitant Gram-negative antibacterial therapy on outcomes in that trial.

Methods
Mechanically ventilated patients with ventilator-associated or hospital-acquired pneumonia were randomized 1:1 to 3 g C/T or 1 g MEM, both by 1-h IV infusion every 8 hours for 8–14 days. Patients could receive ≤24 hours of active antibacterial therapy within ≤72 hours prior to first dose; longer durations were permitted in case of prior treatment failure (i.e., signs and/or symptoms of the current episode of ventilated NP persisted/worsened despite ≥48 hours of treatment). At sites with MEM-resistant Pseudomonas aeruginosa rates ≥15%, patients could optionally receive up to 72 h of adjunctive empiric aminoglycoside (amikacin was recommended) until study drug susceptibility was confirmed. Primary and key secondary endpoints, respectively, were 28-d all-cause mortality and clinical response at test of cure (TOC; 7–14 days after the end of therapy) in the intent to treat (ITT) population (all randomized patients).

Results
In the C/T arm, 285/362 (79%) ITT patients received prior systemic Gram-negative therapy and 103/362 (28%) received adjunctive aminoglycoside, compared with 288/364 (79%) and 112/364 (31%) patients, respectively, in the MEM arm. In the microbiologic ITT population, causative pathogens in patients failing prior therapy at the time of enrollment (C/T 15%, MEM 11%) were mainly Klebsiella spp (33%), P. aeruginosa (17%), Escherichia coli (14%), and Acinetobacter baumannii (8%). Mortality and cure rates were comparable between C/T and MEM regardless of receipt of prior systemic or adjunctive Gram-negative therapy (table).

Conclusion
Prior and adjunctive Gram-negative antibacterial therapy did not affect the relative efficacy of C/T (at the 3-g dose) vs. MEM in these high-risk patients with Gram-negative ventilated NP.

Disclosures
All authors: No reported disclosures.