bluuebunny/crossref_metadata_2025_split huggingface dataset:
2259. Predictors of Empiric Carbapenem Therapy in Complicated Intra-Abdominal Infections in the United States, 2013–2017: A Retrospective Cohort Study
Authors: Zilberberg Marya , Nathanson Brian , Lawrence Kenneth , Johnson Colby , Ditch Kristen , Olesky Melanie , Shorr Andrew F 
Published: October 2019

Abstract

Background
Complicated intra-abdominal infections (cIAI) remain an important cause for hospitalization. Evidence-based guidelines recommend reserving broad-spectrum antibiotic coverage for high-risk cases in order to reduce overuse of certain antibiotic classes, particularly in the face of emerging carbapanem resistance. We examined the factors associated with use of empiric carbapenem treatment (ECT) among hospitalized patients with cIAI.

Methods
We performed a multicenter retrospective cohort study in the Premier database of approximately 180 hospitals, 2013–2017. Using an ICD-9/10 based algorithm including a requirement for a laparotomy/laparoscopy, we identified all adult patients hospitalized with cIAI and included those with a positive blood or abdominal culture. We derived and tested a multivariable logistic regression model to examine predictors of ECT.

Results
Among 321,317 hospitalized patients with cIAI, 4,453 (1.4%) were culture-positive, 1,185 (26.6%) of whom received ECT. Among those given ECT, >50% (682) had no risk factors for resistance, and in only 120 (10.1%) was an organism resistant to a third-generation cephalosporin (C3R extended spectrum β-lactamase [ESBL] phenotype) isolated. The top 5 variables associated with ECT use were: pre-cIAI anti-fungal therapy (OR 2.57, 95% CI 1.91, 3.45) urgent (vs. emergent) admission (OR 1.56, 95% CI 1.21, 2.01), corticosteroids (OR 1.50, 95% CI 1.13, 1.99), ICU admission (OR 1.46, 95% CI 1.17, 1.82), and presence of sepsis/septic shock (OR 1.43, 95% CI 1.18, 1.74). The model had a moderately good fit (c-statistic = 0.683; 95% CI (0.665, 0.700), Hosmer-Lemeshow P value = 0.411).

Conclusion
Among patients hospitalized with a cIAI, 26.6% received ECT despite >50% lacking risk factors for resistance, and an only 10% prevalence of C3R in this cohort. This suggests that there remains an opportunity for carbapanem-sparing strategies. Further stratification of the risk for resistance is needed among patients with markers of high illness severity, such as those identified in our model.

Disclosures
All authors: No reported disclosures.
2326. Enterovirus-Associated Acute Flaccid Myelitis. Argentina′s Nationwide Surveillance of Acute Flaccid Paralysis 2016–2018
Authors: Pasinovich Marina , Neyro Silvina , del Valle Juárez María , Katz Nathalia , Rancaño Carolina , López Yunes Marcela , Lucconi Verónica , Rapaport Solana , Iglesias Martina , Stecher Daniel , Elbert Gabriela , Lema Cristina , Freire Cecilia , Biscayart Cristián 
Published: October 2019

Abstract

Background
Acute flaccid paralysis (AFP) surveillance is carried out in Argentina in the frame of the Polio Eradication Program. Acute flaccid myelitis (AFM) is a type of AFP and can be detected in the frame of AFP surveillance. Although many case series of AFM associated to enterovirus (EV) were released since 2014 in many countries, there were no notifications of this entity from Argentina until 2016.

Methods
Descriptive-observational study. AFP cases reported to the National Surveillance System (NSS) between 2016 and 2018 were included.

Results
From January 1, 2016 to December 31, 2018, 610 cases of AFP in children under 15 years old were registered (207 in 2016, 205 in 2017 and 198 in 2018). In 2016, from epidemiological weeks (EWs) 14 to 28, 23 cases of AFM were notified (median age 36 months; range: 3 months to 13 years). No special clustering was observed, and the number of AFM cases did not correlate with an increase in the annual rate of AFP notifications. Main prodromal were respiratory symptoms in 21 cases (91.3%) and fever in 18 (78.2%). One or two limbs were affected in 65%; in 35% mechanical ventilation was required. More than 90% had sequelae at discharge. Stool (ST), nasopharyngeal aspirate (NPA) and cerebrospinal fluid (CSF) samples were processed at the Regional Reference Laboratory facilities. RT nested PCR was employed. All detections are shown in Table 1. To note, In 12 cases (53%), EV D68 was detected (11, out of 16 NPA and 3, out of 11 ST samples). As for 2017, only one case of AFM was detected. Attempt of viral detection was unsuccessful. In 2018, 3 cases of AFM were detected, one EV C105, one Coxsackie B and one case without viral detection.

Conclusion
The occurrence of AFM cases in Argentina since 2016 is similar to the findings in other countries. An association with EV D68 is apparent, notwithstanding the finding of other EV, finding that further points to the causal association between EV D68 and AFM. As NPA is the sample of choice for AFM diagnosis, from 2019 the work-out of every case of AFP includes this sample as mandatory when AFM is suspected. Given the severity and the high rate of permanent sequelae, a high sensitivity of the health team must be sustained to keep with adequate surveillance, which allows prompt outbreak detection of other agents that can cause AFP in the last phase of polio eradication.

Disclosures
All authors: No reported disclosures.
2363. Implementation of a Multi-Step Diagnostic Algorithm for C. difficile Infection
Authors: Walker Morgan , Mitchell Miranda , Mellor Britney , Buras Suzanne , Young Monica , O’Neal Catherine S 
Published: October 2019

Abstract

Background
The diagnosis of C. difficile infection (CDI) in the hospital is challenging asymptomatic colonization rates vary between 3% and 26%. Guidelines recommend multistep testing for CDI diagnosis. On July 1, 2018 a two-step testing algorithm was implemented at our institution. Positive nucleic acid amplification test (NAAT) results reflexed to a toxin enzyme immunoassay (EIA) test. The EIA test result was then used for NHSN reporting; however, both test results were visible to the clinician. Updated guidance on the interpretation of the test and treatment of CDI was released to the medical staff in July. We compared the incidence of CDI lab ID events per 1000 patient-days and the rate of C. difficile antibiotic starts before and after the implementation of the testing algorithm.

Methods
A retrospective observational study was performed at an 800 bed regional medical center. CDI lab ID events between January 1 and December 31, 2018 were reviewed. Antibiotic initiation of intravenous (IV) and oral (PO) metronidazole and PO vancomycin was collected for all hospitalized patients diagnosed with C. difficile. The incidence of hospital onset (HO) and community-onset (CO) lab ID events as well as the rate of antibiotic starts were compared before and after implementation of the algorithm using a two-sided z test for proportions with an alpha of 0.05.

Results
The incidence of HO and CO lab ID events per 1000 patient-days decreased significantly from 0.56 to 0.16 (P < 0.0001) and 1.18 to 0.3 (P < 0.0001) after implementation of the testing algorithm (Figure 1). The CDI SIR decreased from 0.729 to 0.322, (P = 0.0048). The rate of antibiotic starts per 1,000 patient-days for IV and PO Metronidazole decreased significantly from 1.1 to 0.45 (P < 0.0001) and 0.86 to 0.35 (P < 0.0001), respectively. PO Vancomycinstarts decreased from 1.51 to 1.23 (P = 0.11) (Table 1).

Conclusion
A two-step algorithm for diagnosing CDI decreases the overall number of HO and CO C. difficile lab ID events and decreases overall antimicrobial use for CDI.

Disclosures
All authors: No reported disclosures.
2364. Surprising Prescribing: Treatment Practices following Addition of Toxin Testing to an Existing Molecular Test for Clostridioides difficile
Authors: Miller Ryan , Morillas Jose A , Fraser Thomas G , Brizendine Kyle D 
Published: October 2019

Abstract

Background
Diagnosis of Clostridioides difficile infection (CDI) is problematic. Adding toxin enzyme immunoassay (EIA) to molecular tests may differentiate disease from colonization and reduce treatment. Detailed descriptions of prescribing patterns following the introduction of EIA testing are not well characterized, particularly in PCR+/ EIA− patients.

Methods
In June 2018, Cleveland Clinic added EIA testing to PCR+ specimens. We conducted a retrospective cohort study on all adult inpatients who were PCR+/ EIA- from June–December 2018. Patients were placed into 3 groups for comparison: (1) complete treatment (guideline concordant); (2) incomplete treatment; and (3) no treatment. Associations with prescribing complete treatment were determined.

Results
We identified 240 patients (Figure 1). Mean age was 60 years, and 122 (51%) were female. Baseline conditions included many high severity comorbidities (Figure 2). 38 (16%) had history of prior CDI. 110/ 240 (46%) patients were receiving concomitant systemic antibiotics. 173 (72%) patients received complete CDI treatment, 41 (17%) incomplete treatment, and 26 (11%) none. 158/ 173 (91%) were prescribed vancomycin amounting to 2,107 days of therapy, averaging 13 PO vancomycin days each. Hematologic malignancy (P = 0.03) and leukocytosis > 15,000/ mm3 (P = 0.04) were significantly associated with complete treatment whereas Infectious Disease (I.D.) consultation was associated with not prescribing complete treatment (P = 0.001). Prior CDI was also associated with not prescribing complete treatment but did not reach statistical significance due to small sample with prior CDI (P = 0.09). There was no association with concomitant systemic antibiotic use or use in the past 1 month.

Conclusion
In the first 6 months after adding toxin EIA to an existing molecular test for CD, 89% of PCR+/ EIA− patients were prescribed some treatment. Hematologic malignancy and leukocytosis were associated with treatment. I.D. consultation was associated with not prescribing treatment. Although we suspect a learning curve with the 2-step approach to testing, it appears the challenge of optimizing testing and management remains. Improved understanding of the clinical significance of a sensitive test on a non-sterile specimen is required.

Disclosures
All authors: No reported disclosures.
133. The Changing Phenotypes and Genotypes of Invasive Pneumococcal Isolates From Children in Shenzhen During 2013–2017
Authors: Bao Yanmin , Zheng Yuejie 
Published: October 2019

Abstract

Background
The phenotypes and genotypes of Streptococcus pneumoniae (Spn.) isolated from children with invasive pneumococcal diseases (IPDs) were changed in these years. The purpose of this study was to monitor this mutation trends before the introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) in China.

Methods
Strains were isolated from children less than 14 years old between January 2013 and May 2017 in Shenzhen Children’s Hospital. Serotypes, antibiotic resistance, and genotypes of these isolates were determined using capsular swelling, E-test, and multi-locus sequence typing, respectively.

Results
A total of 94 Spn. strains were isolated, which belonged to 15 serotypes. The five most prevalent serotypes were 19F (25.5%), 19A (19%), 14 (17%), 23F (7.5%), and 6B (9.6%). The other two serotypes (19C and 15) were non-vaccine types. We found 42 sequence types (STs) for these isolates. The most abundant STs were ST271 (24.4%), ST876 (17%), and ST320 (10.6%), mainly related to 19F, 14, and 19A, respectively. The potential coverage of PCV13 was 87.2%. Among non-meningitis isolates, the resistance rates to penicillin and ceftriaxone were 0% and 2%. However, the meningitis isolates showed universal resistance to penicillin (80%) and ceftriaxone (20%). Most of these isolates (95.7%) were resistant to erythromycin, and 66 (70.2%) strains carried the ermB gene and 24 (25.5%) strains carried both the ermB and mefA/E genes. Serotype 19A showed the highest minimum inhibitory concentration (MIC) for penicillin than the other serotypes, but no significant difference in penicillin MIC among the three main STs (ST271, ST320, and ST876).

Conclusion
The phenotypes and genotypes of invasive pneumococcal isolates from children in Shenzhen have changed with the passage of time. Compared with PCV7, PCV13 can more effectively protect Chinese children from IPDs. To some extent, these changes are possibly related to the usage of antibiotics and vaccines.

Disclosures
All authors: No reported disclosures.
2443. Impact of Antimicrobial Stewardship on the Incidence of Carbapenem-Resistant Pseudomonas aeruginosa: A Nonlinear Time-Series Analysis Approach to Identify Carpapenem Thresholds
Authors: Meschiari Marianna , María Lòpez-Lozano José , Beyaert Arielle , Nebot Cesar , Orlando Gabriella , Bedini Andrea , Sarti Mario , Mussini Cristina 
Published: October 2019

Abstract

Background
To estimate the impact of antimicrobials stewardship in the temporary evolution of the Density Incidence of Pseudomonas aeruginosa resistant to carbapenems (DI_PaCRE).

Methods
In Modena Policlinico, a tertiary care hospital, from September 2014, universal rectal screening and antibiotic stewardship (ABS) focusing on carbapenem sparing strategy were introduced. We used the statistical approach already described (A nonlinear time-series analysis approach to identify thresholds in associations between population antibiotic use and rates of resistance. López-Lozano JM, et al. Nat Microbiol. 2019 Apr 8. doi: 10.1038/s41564-019–0410-0) in order to adjust a non-linear model (Multivariate Adaptive Regression Splines) looking for the identification and estimation of thresholds in the influence of the use of Carbapenems on the DI_PaCRE.

Results
We identified a threshold at 5.65 DDD/100 bed-days of Carbapenems (CarbUse). Indeed, above this threshold, for every increase of one DDD/100 bed-days, the DI_PaCRE increased by 0.15 new cases by 1000 bed-days. On the basis of our analyses, considering a typical course of 7 days of treatment, an average CarbUse of 6.5 DDD/100 bed-days in 2012 and 2013, for an average of 15000 monthly bed-days, means around 139 treated patients. In order to avoid the emergence of resistance, the threshold was equivalent to a maximum number of 121 patients to be treated. Below this threshold, i.e in 2018, CarbUse including 66 patients treated did not select antimicrobial resistance.

Conclusion
PaCRE could be controlled by reducing the use of carbapenems below minimum thresholds of 6.5 DDD/100 bed-days. In order to avoid the onset of resistance to carbapenems in Pseudomonas aeruginosa, less than 121 patients per month should receive this class of drug. This finding could provide innovative approach to guide antimicrobial stewardship strategy focused on limit the spread of PaCRE in hospital populations.

Disclosures
All authors: No reported disclosures.
2452. Outbreak of Candidemia Associated With a Contaminated Intravenous (IV) Anesthetic in an Adult Intensive Care Unit (ICU) in San Luis Potosí, México.
Authors: Portales-Castillo Carlos , Araujo-Meléndez Javier , Torres-González Pedro , Mancilla-González Mariana 
Published: October 2019

Abstract

Background
In June 2018, an unusual number of candidemia-associated sepsis cases were diagnosed in sedated patients hospitalized in the 12-bed adult ICU of a teaching hospital in Mexico. The pre-outbreak candidemia rate had been calculated at 0.66 cases/100 ICU admissions for the previous 3 years.

Methods
We performed a case–control and microbiological study designed to trace the source of the outbreak. Case definition included adult patients with systemic inflammatory response syndrome and Candida species isolated on BC (blood cultures). The rest of the patients in the ICU within the study period (6/12/2018–6/22/2018) were used as controls.

Results
A total of 5 cases and 19 controls were included in the study. Demographic and clinical characteristics were similar between groups, except for SOFA scores (Table 1). Differences in median SOFA scores between groups were statistically significant (7.5 in cases and 3 in controls (p = 0.02)). After review of common medications used between cases, propofol infusion use (5/5 in cases and 6/19 in controls) was calculated as the strongest risk factor for candidemia (OR 22.84 (p = 0.04)). In-use propofol infusions available at the time were stopped and sent for culture as were unopened vials stored in the pharmacy from the lot being used in the ICU. Intrinsical contamination with bacterial and fungal species related to the outbreak was identified (Table 3). Case fatality rate during the outbreak was 80% (4/5)

Conclusion
Lethal infections due to contaminated medications, including propofol, have been reported worldwide. Propofol is a potential source for infections given its lipophilic nature that promotes microbial growth. This likely remains an underecognized problem that deserves awareness for early recognition. Epidemiological surveillance in our hospital prompted our case–control study and the subsequent implementation of effective control measures including rapid notification to hospital and national authorities (COFEPRIS), elimination of the identified contaminated lot, and increased promotion of both hand hygiene and adequate IV medication handling techniques among staff.

Disclosures
All authors: No reported disclosures.
2466. What’s Lurking in the Drain? Serial transmission of NDM-1Klebsiella pneumoniae to patients admitted 9 months apart to the same ICU room
Authors: Smith Becky A , Mathers Amy , Kotay Shireen , Parikh Hardik , Barry Katie E , Seidelman Jessica , Addison Rachel , Huslage Kirk , Hnat Amy , Sova Christopher , Lewis Sarah S 
Published: October 2019

Abstract

Background
We evaluated the role of an in-room sink in NDM-1 K. pneumoniae (NDMKP) transmission.

Methods
In October 2017, Infection Prevention (IP) initiated weekly point prevalence rectal screening cultures in 4 ICUs. In 3/2018, IP launched an epidemiologic and environmental investigation following identification of a patient with NDMKP rectal colonization. Environmental samples including swabs of biofilm from drains and water from p-traps were obtained from the in-room sink. Illumina whole-genome sequencing (WGS) was performed on all NDMKP patient and environmental isolates. Single nucleotide variants (SNVs) were identified against the reference Klebsiella pneumoniae strain MLST15 (NZ_CP022127), and isolates within 150 SNVs of each other were considered to be genomically related.

Results
Two patients were identified with NDMKP infection or colonization between July 2017 and March 2018. The index patient had prolonged hospitalization and developed NDMKP bacteremia on hospital day (HD) 30. Approximately 9 months later, the second patient was admitted to the same ICU room that had been occupied by the index patient for 13 days and was identified to have NDMKP rectal colonization on HD 5. Environmental samples from the in-room sink of the ICU room grew NDMKP. WGS demonstrated relatedness between NDMKP isolates from the 2 patients (112 SNV), the index patient and the sink (52 SNV), and the second patient and the sink (80 SNV). The in-room sink was replaced in 4/18 and no further cases of NDMKP infection or colonization have been identified at DUH in over 12 months.

Conclusion
We report an NDM-1 K. pneumoniae transmission event possibly related to a contaminated in-room sink drain. Remarkably, 9 months elapsed between the index case and the second case, with no additional interim cases detected on weekly point-prevalence screening or clinical cultures. The long duration of time between and the index patient, secondary case, and sink culture may explain why WGS showed relatedness but not identical clones. Education around sink use, design, and more effective cleaning strategies are needed to mitigate environment-to-patient transmission of CRO.

Disclosures
All authors: No reported disclosures.
140. Trends of Infective Endocarditis at a Northern New England Academic Medical Center, From 2011 to 2017: A Case for Improved Methods to Reliably Identify Associated Substance Use
Authors: DesBiens Martha T , de Gijsel David , Chan Benjamin P , Talbot Elizabeth A , Conn Stephen , Laflamme David 
Published: October 2019

Abstract

Background
Infective endocarditis (IE) is a morbid and often lethal complication of injection drug use. There is an urgent need for accurate surveillance for IE related to substance use (SU) to support control strategies.

Methods
We conducted a retrospective comparative analysis of 3 datasets evaluating patients aged ≥16 years admitted to an academic medical center in New England with an ICD-9/10 discharge diagnosis of IE from April 2011 to December 2017. The 3 datasets included the hospital’s electronic medical record (EMR); the hospital’s Outpatient Parenteral Antibiotic Therapy (OPAT) program dataset; and the New Hampshire Uniform Hospital Discharge Data Set (UHDDS). We analyzed the number of admissions for IE per year, stratified by SU. We developed a SU composite measure by incorporating multiple sources of data from the EMR, and then verified accuracy of both the SU and IE diagnoses through manual chart review.

Results
The EMR documented 472 hospital admissions for IE, representing 385 unique patients. The median age was 56 years and 59% were men. Admissions increased 67%, from 56 in 2012 to 84 in 2017. SU was coded as a discharge diagnosis in 27% of these admissions; however, based on our composite measure of SU, 45% IE admissions were possibly associated with SU. The proportion of IE patients who had evidence of SU increased from 20% in 2011 to 49% in 2017 (P = 0.002). Patients with SU compared with those without were younger (40.5 vs. 65.2 years, P < 0.001) and more likely to be on Medicaid (59% vs. 8%, P < 0.001). They had higher average charges ($146,633 vs. $107,223, P = 0.002) and lengths of stay (19.1 vs. 13.4 days, P < 0.001). The UHDDS and EMR datasets identified a similar numbers of patients with a diagnosis of IE; however, manual chart review revealed that IE was over-coded in ~one-fifth of admissions.

Conclusion
The rate of IE in our hospital increased dramatically between 2011 and 2017, with a rising proportion associated with SU. Despite these trends, we found that discharge diagnosis coding alone substantially underestimated associated SU and overestimated IE disease burden. Our findings suggest public health administrative datasets, such as the UHDDS, can contribute to surveillance of IE disease burden with consideration of these important limitations, especially for assessing disease trends.

Disclosures
All authors: No reported disclosures.