bluuebunny/crossref_metadata_2025_split huggingface dataset:
1749. A Nationwide Survey of Cytomegalovirus Prevention Strategies in Kidney Transplant Recipients in a Resource-Limited Setting
Authors: Bruminhent Jackrapong , Bushyakanist Asalaysa , Kantachuvesiri Susarak , Kiertiburanakul Sasisopin 
Published: October 2019

Abstract

Background
Cytomegalovirus (CMV) causes morbidity in kidney transplant (KT) recipients. Strategies to prevent this infection in resource-limited settings have been unreliably implemented and under-explored. We investigated CMV prevention strategies utilized among transplant centers in Thailand.

Methods
A questionnaire on CMV prevention strategies for KT recipients was developed using a web-based electronic survey website (www.surveymonkey.com). The survey was delivered to 31 transplant centers in Thailand. One infectious disease physician (ID) and one nephrologist (NP) from each center were included.

Results
There were 43 respondents from 26 (84%) transplant centers including 26 (60%) IDs and 17 (40%) NPs. The majority worked in a public hospital setting (63%) and had encountered KT recipients for at least 2 years (74%). Forty-one (98%) physicians agreed on the necessity of CMV prevention. Of these, 34 (81%) physicians implemented prevention strategies for their patients. Interventions included preemptive approaches (47%), prophylaxis (44%), hybrid approaches (3%); surveillance after prophylaxis (3%), and CMV-specific immunity-guided approaches (3%). For CMV-seropositive KT recipients, use of preemption (84%) exceeded prophylaxis (12%). However, 81% of the former preferred targeted prophylaxis in patients receiving anti-thymocyte globulin therapy. Sixty-five and 93% of physicians started preemptive therapy when plasma CMV DNA loads reached 2,000 and 3,000 copies/mL (1,820 and 2,730 IU/mL), respectively. A significantly greater percentage of NPs initiated preemptive therapy at a plasma CMV level of 1,820 IU/mL compared with IDs (88% vs. 50%, [P = 0.02]). The most common barrier to prevention strategy implementation was financial inaccessibility of oral valganciclovir (67%) and quantitative CMV DNA testing (12%). The majority (81%) felt that a guideline would allow physicians to implement CMV prevention strategies for their patients.

Conclusion
Most physicians agreed on a need for preemptive approaches, although prophylaxis was targeted in those receiving intense immunosuppression. Guidelines and financial accessibility could improve CMV prevention strategy implementation in Thai KT recipients.

Disclosures
All authors: No reported disclosures.
1766. Osimertinib-Associated Progressive Multifocal Leucoencephalopathy
Authors: Gilotra Tarvinder S , Eranki Ambika P 
Published: October 2019

Abstract

Background
Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disease of white matter in the central nervous system (CNS) caused by reactivation of John Cunningham (JC) virus. Drug-induced PML is increasingly reported with the widely used biological immunosuppressant drugs and molecular targeted antineoplastic agents. Monoclonal antibodies were the pioneer drugs to be associated with PML including the prototypical natalizumab.

Methods
Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKI) have been rarely described in this context with few case reports of ibrutinib-associated PML. Osimertinib, a third-generation EGFR TKI, was recently FDA-approved for the first-line treatment of metastatic non-small-cell lung cancer (NSCLC), and to the best of our knowledge has never been associated with PML. We describe a case report of a rapidly progressive PML likely associated with osimertinib therapy.

Results
A 85-year-old female with history of NSCLC, on osimertinib, was admitted with progressively worsening left hemiparesis, facial palsy, unsteady gait, recurrent falls, and episodic confusion over a period of month. Brain magnetic resonance imaging revealed foci of non-enhancing increased T2 and fluid-attenuated inversion recovery (FLAIR) signal intensity in the periventricular and bilateral cerebral subcortical white matter. MRI cervical spine was unremarkable for acute enhancing lesions. Cerebrospinal fluid (CSF) was unremarkable for infectious etiology, oligoclonal bands, and cytology. The patient was readmitted 2 weeks later with worsening neurological deficits and new lesions in the bilateral middle cerebellar peduncles, pons, midbrain, and cerebral white matter. Positive CSF JC virus PCR lead to the final diagnosis of “probable” PML. Biopsy was deferred for high clinical suspicion of PML and procedural risks outweighing benefits. Osimertinib was likely contributing to PML in the absence of other immunosuppression.

Conclusion
Inhibition of tyrosine kinase-dependent pathways can potentially aid in the replication of JC virus per previously reported ibrutinib-associated PML. Clinicians should be aware of PML risk in patients on osimertinib and TKI therapy, especially those with positive serum JC virus serology.

Disclosures
All authors: No reported disclosures.
1791. Novel Metabolomics Approach for the Diagnosis of Respiratory Viruses Directly from Nasopharyngeal Specimens
Authors: Hogan Catherine , Le Anthony T , Mak Justin , Kumar. Sahoo Malaya , Cowan Tina , Pinksy Benjamin A 
Published: October 2019

Abstract

Background
Respiratory virus infections are important causes of morbidity and mortality among pediatric and adult patients. These viruses infect respiratory epithelial cells, where they may induce specific metabolite alterations. As a proof-of-concept, we investigate the novel use of liquid chromatography (LC) combined with quadrupole time-of-flight mass spectrometry (Q-TOF) for the study of host cell metabolite alterations to diagnose and differentiate respiratory viruses.

Methods
We studied nasopharyngeal swab samples positive for respiratory viruses by the eSensor Respiratory Viral Panel (GenMark Diagnostics, Carlsbad, CA). Banked, frozen samples (−80°C) stored in viral transport media were retrieved and thawed. Aliquots of 100 μL were centrifuged at 13.3 × g for 15 minutes, and the filtrate was analyzed by Agilent 6545 Quadrupole LC/Q-TOF (Agilent Technologies, Santa Clara, CA). Compounds were separated using a novel column arrangement based on hydrophobicity and charge using a quaternary solvent manager, followed by accurate mass analysis by LC/Q-TOF. Agilent Mass Profiler 3D principal component analysis was performed, and compound identification was completed using the METLIN metabolite database.

Results
A total of 235 specimens were tested by LC/Q-TOF, including 195 positive specimens [including adenovirus, coronavirus, influenza A H1N1 and H3N2, influenza B, human metapneumovirus, parainfluenza viruses 1, 2, 3, and 4, respiratory syncytial virus (RSV), and rhinovirus] as well as 40 negative clinical specimens. LC/Q-TOF primary component analysis (PCA) allowed preliminary identification of key metabolites that distinguished all virus-positive specimens compared with the negative group, and differentiated respiratory viruses from one another including between influenza A 2009 H1N1 and H3N2 subtypes (Figure 1).

Conclusion
Preliminary data from our LC/Q-TOF analysis show that respiratory viruses exhibit different host cell metabolomic profiles that allow viral differentiation to the species level, and for influenza A virus, the subtype level. This metabolomic approach has substantial potential for diagnostic applications in infectious diseases directly from patient samples, and may be eventually adapted for point-of-care testing.

Disclosures
All authors: No reported disclosures.
1982. A Diagnostic Stewardship Intervention for Clostridioides difficile: Impact of Stool Toxin Testing on Treatment of Adult Inpatients
Authors: Moss Jason , Forster Derek W , Arora Vaneet , Burgess David , Wallace Katie , Cotner Sarah , Burgess Donna R , Ribes Julie A , Suder Tigre , Myint Thein , VanHoose Jeremy , Jones C Randy 
Published: October 2019

Abstract

Background
Testing for Clostridioides difficile infection has been the subject of recent debate. Guidelines from the Infectious Diseases Society of America now support the addition of a stool toxin test to a positive nucleic acid amplification test (NAAT) as part of a multi-step testing algorithm. In November 2017, the University of Kentucky HealthCare system added stool toxin testing to any specimen positive for C. difficile by NAAT. This change was accompanied by face to face education with provider groups and clinical decision support in the form of interpretive verbiage added to the results that are reported into the electronic record. The objective of this study was to assess whether this diagnostic stewardship intervention made an impact on C. difficile treatment

Methods
We performed a retrospective review of adult patients admitted to UK HealthCare from November 1, 2017 through October 31, 2018 who tested positive by NAAT but negative by stool toxin test to determine whether or not they were treated. We also assessed treatment by service line to see whether there were treatment differences among these groups. A cost analysis was also performed.

Results
A total of 300 adult inpatients were positive for C. difficile by NAAT during the study period with 71% (213 patients) having a negative stool toxin test. Of those, 58% (123) were never started on C. difficile therapy and an additional 14% (30) had their therapy stopped after 48 hours. Only 28% (60) of these patients received a full course of therapy. Hospital medicine had the highest rate of non-treatment at 82%. Conversely, our solid-organ and bone marrow transplant services had the lowest rate of non-treatment at 31%. Overall, this approach was associated with an estimated 1470 oral vancomycin days avoided (5,880 doses) and a cost savings of $6,278.

Conclusion
The addition of stool toxin testing to NAAT combined with education and clinical decision support lead to a dramatic reduction of treatment for NAAT positive but toxin-negative patients. This form of diagnostic stewardship had a significant impact on therapy decisions and can be a powerful antimicrobial stewardship approach to decrease unnecessary treatment of C. difficile colonization.

Disclosures
All authors: No reported disclosures.
1984. A Multi-Disciplinary Team-based Quality Improvement Initiative to Reduce Clostridioides difficile Rates and Promote Antimicrobial Stewardship in Targeted Surgical Wards
Authors: Chang Amy , Smith Hurley , Sullivan Katrina , Meneses Joanne , Kirilcuk Natalie , Cooper-Sterling Jos , Kuo Jamie , Karam Amer , Schaffner Tammy , Mui Emily , Meng Lina , Deresinski Stan , Holubar Marisa 
Published: October 2019

Abstract

Background
At Stanford, two surgical wards, E3 and F3, were responsible for 1/5 of hospital-acquired Clostridioides difficile infection (HO CDI) cases in the fiscal year 2018 (FY2018). We used a quality improvement framework with a goal to reduce yearly HO CDI episodes by 1/2 on these wards.

Methods
A multidisciplinary quality improvement team was created with frontline nursing leaders and representatives from colorectal surgery, gynecology oncology, antimicrobial stewardship (ASP), infection prevention, and pharmacy. Coaching and instruction on quality improvement were provided as part of Stanford’s “Realizing Improvement through Team Empowerment” (RITE) program. Using A3 problem solving, root cause analysis identified key drivers, and interventions were performed. Cumulative HO CDI cases in FY2019 and weekly antibiotic days of therapy (DOT) on E3/F3 were monitored.

Results
Review of FY2018 HO CDI cases (n = 14) revealed the most common key driver as inappropriate antibiotic prescribing (8 cases, 57%). Multiple interventions were instituted (Figure 1). Three ASP interventions began February 2019: nursing questioned antibiotic choice/duration on daily interdisciplinary rounds (Figure 2), automatic infectious disease consultation for > 72 hours of piperacillin/tazobactam on gynecology/oncology patients, and twice-weekly rounds between ASP and a colorectal attending. Data from ASP/colorectal rounds from March 19, 2019 to April 16, 2019 showed means of 18.2 minutes taken for chart review and 4.4 minutes for discussion. 25 charts reviewed led to 16 (64%) ASP recommendations and 14/16 (87.5%) of recommendations accepted. Common interventions included: appropriate duration of antibiotics, clarification of the team’s planned duration, and review of microbiology data to narrow therapy. Mean DOT decreased from 35.28 to 21.61 (39%) since July 2018 (Figure 3). Patient volume and case mix index remained stable throughout, suggesting no impact on DOT. Though CDI cases did not decrease, interventions were in place for only 2 months (Figure 4).

Conclusion
While too early to determine its impact on HO CDI rates, a multi-disciplinary team approach utilizing A3 problem solving was successful in implementing effective ASP measures including nursing-led ASP and structured antibiotic timeouts.

Disclosures
All authors: No reported disclosures.
2003. Vancomycin Discontinuation Is Supported by-negative Nasal Methicillin-Resistant Staphylococcus aureus (MRSA) in Patients with Pneumonia
Authors: Pleasants Katherine A , Low Karly , Lucas Sara A , Kivlehan Audrey , Washburn Ronald G 
Published: October 2019

Abstract

Background
A negative nasal MRSA PCR test has a 98–99.6% sensitivity in confirming that MRSA is not the causative organism associated with pneumonia in hospitalized patients. Evidence supporting the clinical utility of nasal MRSA PCR testing in the Veteran patient population is limited, with no identified publications to date. The purpose of this project was to share outcomes associated with implementation of nasal MRSA PCR testing in the Veteran population to guide duration of vancomycin therapy.

Methods
This retrospective cohort quality initiative compared treatment of pneumonia that included vancomycin during a pre-Antimicrobial Stewardship Program (ASP) intervention phase (August 2013–February 2014) to an active ASP intervention phase (August 2017–March 2019). ASP intervention consisted of utilization of a negative nasal MRSA PCR as a rapid diagnostic test to support discontinuation of vancomycin prior to microbiologic culture results. Retrospective chart review evaluated vancomycin days of therapy (DOT), hospital length-of-stay (LOS), 30-day hospital readmission, and 30-day mortality. Patients admitted to the intensive care unit during the identified hospitalization were excluded.

Results
The average vancomycin DOT significantly declined by 1.08 days when comparing the pre-ASP intervention phase (N = 25) to the ASP-intervention phase (N = 47) (3.6 vs. 2.52 days, respectively; P = 0.0088). Mean hospital LOS decreased by 1.5 days (6.04 vs. 4.54 days, respectively, P = 0.0885). There was no significant difference in 30-day hospital readmission rate (12% vs. 8.5%) or 30-day mortality rate (12% vs. 10%).

Conclusion
Vancomycin DOT was reduced by 30% (1.08 days) and hospital LOS was reduced by 24.8% (1.5 days) in patients with pneumonia during a Vet. Affairs medical center’s utilization of negative nasal MRSA PCR testing to support vancomycin discontinuation. This project highlights the role of nasal MRSA PCR as a rapid diagnostic test to aid in diminishing empiric vancomycin usage and its associated toxicities.

Disclosures
All authors: No reported disclosures.
2004. Impact of Procalcitonin Roll-out Without Antimicrobial Stewardship Guidance in a Community Hospital Emergency Department
Authors: Mena Lora Alfredo J , Qasmieh Samah , Wenzler Eric , Borgetti Scott , Jhaveri Naman , Doyle Richard , Cortez Martin , Bleasdale Susan C 
Published: October 2019

Abstract

Background
Lower respiratory tract infections (LRTIs) are one of the most common infectious disease-related emergency department (ED) visits in the United States. The ID Society of America and the Agency for Healthcare Research and Quality support the use of procalcitonin (PCT) for antimicrobial stewardship (ASP) in LRTI. Though not widely available, awareness and access to PCT is rising. At our facility, PCT became available in February 2018. The aim of our study is to assess the impact of PCT at an urban community hospital and identify possible targets for ASP interventions.

Methods
Retrospective review of cases from February to August 2018. Cases from the ED were selected for review. Appropriateness of testing was assessed, defined as guideline-based use for cessation of antibiotics in uncomplicated LRTIs without critical illness or immunosuppression. Demographic variables and clinical characteristics, such as, diagnosis, antimicrobial use and PCT levels were obtained.

Results
PCT was ordered 268 times hospital-wide, of which 160 (60%) were in the ED. Ages ranged from 0–90, with an average of 47. Most cases were male (51%). Appropriate testing for LRTI occurred in 33 (29%) cases. Antimicrobials were used in 75% of cases with low (< 0.5) PCT levels (Figure 1). Length of stay (LOS) was higher in groups that received antimicrobials (Figure 2). Testing was not appropriate in 127 cases (71%), with upper respiratory (21%), soft-tissue (17%), genitourinary (15%) and abdominal (13%) infections as the most common reasons for testing. Other diagnosis included alcohol withdrawal, seizures and altered mental status. Cumulative cost of PCT testing was $24000, of which $19050 was not consistent with guidelines.

Conclusion
Clinicians routinely ordered PCT in the ED. Antimicrobials were used for LRTIs despite low PCT levels. This may have contributed to higher LOS and excess antimicrobial use. Unwarranted PCT testing had a cost of $19050. As PCT becomes widely available in hospitals across the United States, education and decision support by ASP to clinicians may be needed to enhance guideline-appropriate evidence-based use of PCT. Targeted ASP interventions in the ED may have cost savings by reducing excess testing, length of stay and improving antimicrobial use.

Disclosures
All authors: No reported disclosures.
2018. The Global Point Prevalence Survey of Antimicrobial Consumption and Resistance: Quantity and Quality of Antimicrobial Prescribing for Inpatients with Pneumonia in the Philippines in 2018
Authors: De los Reyes Mari Rose Aplasca , Hufano Maria Charmian M , Pauwels Ines , Versporten Ann , Goossens Herman 
Published: October 2019

Abstract

Background
Pneumonia is the most common indication for prescription of antibiotics in hospitals in the Philippines. We describe the quality and quantity of antibiotic prescribing for hospitalized pneumonia patients in the Philippines in 2018 (www.global-PPS.com).

Methods
A point prevalence survey was performed from September to December 2018 in 28 public and private hospitals in Luzon, Mindanao, and Visayas regions. Ward- and patient-level data were collected using a standardized methodology and entered through a web-based application. We analyzed all antibiotic (ATC J01) prescriptions for inpatients with pneumonia.

Results
Of all hospitalized patients, 16.2% (n = 1516) received one or more antibiotic (J01) for treatment of pneumonia, majority (78.3%) of which were for community-acquired pneumonia (CAP). In adults, the most commonly used antibiotics were azithromycin (19.5%), ceftriaxone (19.0%), and piperacillin/enzyme inhibitor (13.2%) for CAP and meropenem (19.8%), piperacillin/enzyme inhibitor (18.9%), and levofloxacin (8.6%) for healthcare-associated pneumonia (HAP). In neonates and children, cefuroxime was used most often (20.1%) for treatment of CAP, followed by ampicillin (16.7%) and amikacin (15.3%). Children and neonates with HAP were most commonly treated with amikacin (18.7%), meropenem (15.7%), and ampicillin (10.4%). Overall, 16.0% of all antibiotic prescriptions for pneumonia were based on microbiological results, 11.3% for CAP and 33.9% for HAP. Microbiology-based prescriptions were most commonly targeted at ESBL-producing Enterobacteriaceae (8.4%). Further analysis of quality indicators showed that up to 80.0% of all prescriptions for pneumonia were compliant to local guidelines and reason in notes was documented for 81.0% of prescriptions. However, the stop or review date of antibiotic treatment for pneumonia was less documented (27.8%).

Conclusion
Global-PPS data provided valuable insights into the quantity and quality of antibiotic prescribing for pneumonia inpatients. These results will be fedback to the Department of Health, medical societies, and hospitals for prioritization of targets and policies toward the improvement of the Philippine antimicrobial stewardship program.

Disclosures
All authors: No reported disclosures.
2050. Effect of a Stewardship Intervention on Post-Prescriptive Antibiotic Timeouts in Nursing Homes
Authors: Liao Chi-Yin , Ford James H , Nace David A , Crnich Christopher 
Published: October 2019

Abstract

Background
Antibiotic overuse and misuse is a common problem in nursing homes (NHs). Meaningful improvements in the quality of antibiotic prescribing in NHs may be improved through post-prescriptive interventions (antibiotic timeouts) focused on stopping, streamlining and/or shortening ongoing antibiotic treatments. A recently completed trial of a complex antibiotic stewardship intervention provided us with an opportunity to explore to what extent NH providers engaged in antibiotic timeouts at baseline and the effects of the intervention on these behaviors.

Methods
Data on antibiotic prescriptions in 11 NHs (6 intervention, 5 control) were collected for 12 months prior and 13 months after intervention introduction. We categorized antibiotic change events (ACEs) as: (1) changes in dose, frequency, or route for the same antibiotic, (2) change to another antibiotic with different spectrum, and (3) early discontinuation (stopped after 2 days or less). Modifications considered to be routine (e.g., Azithromycin dose reduction from 500 to 250 mg) were not considered a meaningful ACE. Frequency of ACEs both overall and by type were compared using a difference in difference (DID) approach.

Results
Of 2647 NH initiated antibiotic events, 376 (14.2%) were modified over the study period. The most common type of modification was a change in spectrum (n = 241, 64.1%) followed by early discontinuation of the antibiotic (n = 118, 31.4%). The difference in ACEs before and after the intervention as well as DID estimates are detailed in the Table.

Conclusion
The antibiotic stewardship intervention did not impact total ACEs but did appear to increase the frequency of discontinuation ACEs. An inability to capture data on shortening ACEs (e.g., reducing a treatment course from 14 to 7 days) was a limitation of this study. Additional research on how to foster more frequent and effective antibiotic timeouts in NHs is needed.

Disclosures
All authors: No reported disclosures.