bluuebunny/crossref_metadata_2025_split huggingface dataset:
1738. Incidence and Outcomes of Hospitalization with Invasive Fungal Infection Among Solid-Organ Transplant Recipients: A Population-Based Cohort Study
Authors: Naylor Kyla L , Ouédraogo Alexandra , Bota Sarah E , Husain Shahid , Paterson J Michael , Hosseini-Moghaddam Seyed M 
Published: October 2019

Abstract

Background
Invasive fungal infection (IFI) in solid-organ transplant (SOT) recipients is associated with significant morbidity and mortality. The long-term probability of post-transplant IFI is poorly understood.

Methods
We conducted a population-based cohort study using linked administrative healthcare databases from Ontario, Canada to determine the incidence rate, 1-, 5- and 10-year cumulative probability of IFI-related hospitalization, and 1-year post-IFI all-cause mortality in SOT recipients from 2002 to 2016. We also examined post-IFI death-censored graft failure in renal transplant patients.

Results
We included 9326 SOT recipients (median follow-up 5.35 years). Overall, the incidence of IFI was 8.3 per 1000 person-years (95% confidence interval [CI]: 7.5–9.1). The 1-year cumulative probability of IFI was 7.4% (95% CI: 5.8–9.3%), 5.4% (95% CI: 3.6–8.1%), 1.8% (95% CI: 1.3–2.5%), 1.2% (95% CI: 0.5–3.2%), and 1.1% (95% CI: 0.9–1.4%) for lung, heart, liver, kidney-pancreas, and kidney-only transplant recipients, respectively. Lung transplant recipients had both the highest incidence rate and the highest 10-year probability of IFI: 43.0 per 1,000 person-years (95% CI: 36.8–50.0) and 26.4% (95% CI: 22.4–30.9%), respectively. Lung transplantation was also associated with the highest 1-year cumulative probability of post-IFI all-cause mortality (40.2%,95% CI: 33.1–48.3%). Among kidney transplant recipients, the 1-year probability of death-censored graft failure after IFI was 9.8% (95% CI: 6.0–15.8%).

Conclusion
The 1-year cumulative probability of IFI varies widely among SOT recipients. Lung transplantation was associated with the highest incidence of IFI with considerable 1-year all-cause mortality. The findings of this study considerably improved our understanding of the long-term probability of post-transplant IFI.

Disclosures
All authors: No reported disclosures.
1746. Prevalence and Resistance Patterns of Cytomegalovirus Viremia in Immunocompromised Patients
Authors: Kim Edward , Asmar Basim , Thomas Ronald , Abdel-Haq Nahed M 
Published: October 2019

Abstract

Background
We noted a recent increase in the number of patients with CMV viremia among immunocompromised children at our institution. The study was undertaken to determine the prevalence of CMV viremia and to evaluate factors associated with the development of antiviral drug resistance.

Methods
A retrospective study of immunocompromised hosts 0–21 years of age who had CMV viremia (2007–2017). We collected demographic data as well as details of antiviral therapy and resistance testing.

Results
A total of 31 patients were identified including 10 (32%) during the last 2 years. The age range was 3 months to 20 years (median 12.6 years); 23 (74%) were male and 12 (39%) were African American. Among the 31 patients, 18 had hematopoietic stem cell transplantation, 5 had primary immunodeficiency (2 common variable immunodeficiency, 1 SCID, 1 Langerhans cell histiocytosis, 1 DiGeorge syndrome), 4 had malignancies receiving chemotherapy, 3 with heart transplantation and one 17 year old with newly diagnosed HIV infection who presented with CMV pneumonia and viremia. Antiviral resistance testing was performed on 7 CMV isolates: 5 due to persistent viremia (> 1 months) despite treatment, and 2 prior to starting antiviral therapy. CMV resistance was identified in 3 patients including 2 with CVID and one with Hodgkin’s disease status post bone marrow transplantation. The 2 CVID patients had other comorbidities including chronic diarrhea and malabsorption and were TPN dependent. Both were diagnosed with CMV colitis and one also had pneumonitis. One had received a prolonged oral valganciclovir course (> 1 year) prior to diagnosis of resistance and the other received long-term intermittent oral valganciclovir courses. The patient with Hodgkin’s disease received a prolonged IV ganciclovir course. All 3 tested positive for UL97 mutation and one had both UL97/UL54 gene mutations.

Conclusion
Most of our patients with CMV viremia were transplant patients. Antiviral drug resistance was detected among 3 of 31 (10%) of our patients during the study period. Two had malabsorption that may have resulted in sub-therapeutic blood levels. Treatment with oral valganciclovir should be avoided in patients with poor gut absorption because it may increase risk of drug resistance.

Disclosures
All authors: No reported disclosures.
1750. Epidemiology of Cytomegalovirus DNAemia in Pediatric Solid-Organ Transplant Patients
Authors: Valencia Deray Kristen , Hosek Kathleen , Moulton Elizabeth A , Munoz Flor M , Munoz Flor M , Demmler-Harrison Gail J , Bocchini Claire 
Published: October 2019

Abstract

Background
Despite the widespread use of prevention strategies, CMV remains a common opportunistic infection in SOTR. Contemporary data regarding CMV in pediatric SOTR is limited. We sought to determine the frequency of and risk factors for CMV infection and disease in a large single-center cohort of pediatric SOTR.

Methods
A retrospective cohort study of patients <22 yr of age who received lung, heart, liver, kidney, or multi-organ transplants at TCH between 2014 and 2018 was completed. Universal CMV prophylaxis was used based on risk status (Figure 1). Primary outcome was CMV DNAemia (plasma level ≥ 1,000 IU/mL). Associations with CMV DNAemia were measured using Fisher exact, Kruskal–Wallis, and multivariate logistic regression. Survival analysis and time to CMV infection were assessed using Kaplan–Meier plots.

Results
Among 465 SOTR, 57 (12%) had CMV DNAemia ≥ 1,000 IU/mL; this included 9/52 (17%) lung, 22/155 (14%) liver, 16/125 (13%) heart, 1/9 (11%) multi-organ, and 9/124 (7%) kidney recipients. 6 (10%) SOTR had early-onset CMV reactivation while on antiviral prophylaxis. Post-prophylaxis, 48 (85%) SOTR had CMV reactivation and 3 (5%) had primary infection. Median time to DNAemia > 1,000 IU/mL was 366 days post-transplant for lung, 115 for liver, 185 for heart, and 290 for kidney (P = 0.04), reflecting differences in prophylaxis strategies. High-risk CMV status (D+/R- for heart, liver, kidney and D+ and/or R+ for lung) was associated with CMV DNAemia (P < 0.01, Figure 2). DNAemia was not associated with age at transplantation, type of organ, or induction immunosuppression. There was no difference in survival during the study follow-up period (1 – 5 years) for SOTR with vs. without DNAemia. Overall, 18/465 (4%) SOTR had CMV disease: 2 (4%) lung, 3 (2%) liver, 5 (4%) heart, 1 (11%) multi-organ, and 7 (6%) kidney recipients. 16 had CMV syndrome and 2 had tissue-invasive disease. Median (range) maximum viral loads were 35,768 IU/mL (3,239–4,807,992) for SOTR with vs. 2,605 IU/mL (1,000–112,000) for SOTR without CMV disease (P < 0.01)

Conclusion
This large contemporary cohort of pediatric SOTR on universal prophylaxis demonstrates low overall rates of CMV DNAemia and CMV disease. High-risk CMV status remains associated with CMV DNAemia, suggesting that further interventions targeting this group may be warranted.

Disclosures
Flor M. Munoz, MD, Biocryst: Grant/Research Support; CDC: Research Grant; Moderna: Other Financial or Material Support, Safety Monitoring Board Member/Chair; NIH: Research Grant; Novavax: Research Grant; UP to Date: Author and Editor - Royalties, Other Financial or Material Support.
1775. A Community-wide Study to Evaluate the Accuracy of Self-testing for Influenza: Works in Progress
Authors: Thompson Matthew , Zigman Suchsland Monica L , Lyon Victoria , Kline Enos , Huang ShiChu , Chu Helen Y , Rieder Mark , Starita Lea , Bosua Jeris , Lutz Barry R 
Published: October 2019

Abstract

Background
Seasonal influenza (flu) occurs annually, causing disease with substantial morbidity and mortality. Currently, flu is suspected from clinical features, but requires a laboratory test to confirm infection. No influenza tests in the United States are approved for use outside of clinical settings. We aimed to determine the accuracy of influenza self-testing using an at-home, app-guided, lateral flow assay compared with a molecular reference standard conducted at a laboratory among adults self-reporting influenza-like illness (ILI).

Methods
This is an observational study of individuals with self-reported ILI throughout the continental 48 United States recruited from the Flu Near You platform, online marketing, and clinics in the Seattle area. Recruitment took place from March 4 to April 26, 2019. Participants were directed to an iPhone App that determined eligibility, consent, and responses to symptom questions and risk factors. Individuals were mailed a commercially available CLIA-waived influenza lateral flow test to conduct at home, guided by the app, and returned the used test along with a second nasal swab collected in viral transport media to the research team. Influenza testing was performed by RT–PCR on the second nasal swab, as well as the residual fluid from the RDT. Accuracy of home test result (read by the participant), as well as image capture of the lateral flow test strip, were compared with the lab-based reference standard.

Results
To date, 1127 at-home flu tests were mailed to participants and 711 (63.1%) samples returned to the lab. There were 17 flu-positive results from the rapid diagnostic test for a flu positivity rate of 2.4%. Testing using the reference standard is currently in progress. We will share diagnostic accuracy results once testing of the reference standard is completed. Of the kits returned, 353 (49.7%)had an error recorded, which included errors in return packaging, reference standard, rapid test tube sample, or rapid test strip errors.

Conclusion
Overall, findings from this study will determine the accuracy of an at-home rapid diagnostic test, and inform more widely research design for evaluating smartphone-enhanced home tests for pathogens. Many samples returned to the lab had a recorded error, suggesting at-home testing requires additional feasibility testing and refinement of the current methods used.

Disclosures
All authors: No reported disclosures.
1790. Single-Center Experience and Lessons Learnt from Management of Nipah Virus Outbreak in India
Authors: Kumar A S Anoop , T Sohanlal , Prasad Ganga , Gupta Manisha , Gopal Ajith 
Published: October 2019

Abstract

Background
Nipah virus (NiV) is re-emerging zoonotic RNA virus belonging to Paramyxoviridae family. Suspecting Nipah virus in a NiV naive tropical area is a challenge. NiV management is further confounded by acute presentation, high mortality, broad species tropism, multiple modes of transmission, difficulty to diagnose and lack of definitive treatment.

Methods
Recent NiV outbreak that lasted for approximately 1 month (2–29 May 2018) and resulted in 23 cases with a case-fatality rate of 91%. We present clinical summary and management of five cases managed at Baby Memorial Hospital, Kozhikode, India from May 17, 2018 to May 30, 2018 and were epidemiologically linked to the index case. All patients presented with initial nonspecific prodromal symptoms of fever, muscle pain, watery diarrhea. Median age was 53 years, four were males, median hospital stay was 3 days, median incubation period of was days. Further complications, included encephalitis with viral bronchopneumonia/acute respiratory distress syndrome (ARDS) in 100 %, patients, encephalitis with viral bronchopneumonia/ARDS with myocarditis in 60 %patients, despite attempted therapy with ribavirin all patients developed cardiorespiratory arrest and succumbed to the illness.

Results
Hematological Investigations showed normal TLC with a mean of 7,920 cells/ mm3, mild thrombocytopenia (mean 1,57,800) high Hb 16.12(SD1.10), ESR 19 mm/hr, DLC-N 82% high relative neutrophilic cytosis. Normal liver and renal function, Na+ 133 meq/L. CSF analysis showed high opening pressure, 100% lymphocytic pleocytosis, mean CSF sugar 118 mg/100mL, CSF protein 73.6. CT chest -bilateral airspace opacities and ground glassing. Brain FLAIR sequence showed nonspecific hyperintensities in white matter and brainstem correlating with vasculitic changes. Laboratory diagnosis of NiV was made by Real-Time RT–PCR on throat swab, blood, urine and cerebrospinal fluid by Manipal virus research center and National Institute of Virology. Pathological autopsy was done in 2 cases and found noncontributory.

Conclusion
We report clinical and public health management experience from one of the three hospitals managing the patients affected with NiV. Managing outbreaks of high infectivity requires persistent organized and committed healthcare interventions

Disclosures
All authors: No reported disclosures.
1792. Viral DNA Loads in Various Blood Components of Patients with EBV-Positive T/NK Cell Lymphoproliferative Diseases
Authors: Kawada Jun-ichi , Kamiya Yasuko , Sawada Akihisa , Iwatsuki Keiji , Izustu Koji , Torii Yuka , Kimura Hiroshi , Ito Yoshinori 
Published: October 2019

Abstract

Background
Epstein–Barr virus (EBV) is associated with T- and NK-cell lymphoproliferative disorders (EBV T/NK-LPD). For diagnosis of EBV T/NK-LPD, quantification of EBV DNA loads in peripheral blood by real-time PCR has been widely used. However, optimal blood components and cut-off values for diagnosis were not fully evaluated.

Methods
Fifty-nine patients with EBV T/NK-LPD including chronic active EBV infection (CAEBV), severe mosquito bite allergy, hydroa vacciniforme-like lymphoproliferative disorder (HV), and EBV- hemophagocytic lymphohistiocytosis (EBV-HLH) were enrolled. EBV DNA loads were compared among disease categories in each blood component from the same whole blood sample. The association between EBV DNA loads and disease activity were evaluated in CAEBV patients. Furthermore, the diagnostic cut-off value for EBV DNA loads in whole blood from CAEBV patients as compared with infectious mononucleosis patients was determined.

Results
EBV DNA loads in whole blood and peripheral blood mononuclear cells (PBMCs) were not significantly different among disease categories, whereas EBV DNA loads in plasma were significantly higher in EBV- HLH patients than in HV patients. EBV DNA loads in whole blood and PBMCs showed strong correlation (Figure 1). EBV DNA loads in plasma were significantly higher in CAEBV patients with active disease than in those with inactive disease (median: 104.5 IU/mL vs. 100.8 IU/mL, P < 0.001) (Figure 2). Diagnostic cut-off values for whole blood EBV DNA loads of CAEBV patients as compared with those of infectious mononucleosis was 104.2 ( = 15,800) IU/mL (Figure 3).

Conclusion
Measuring EBV DNA loads in whole blood can be considered as initial evaluation for diagnosis of EBV T/NK-LPD. EBV DNA loads in plasma are more closely related to disease activity of CAEBV than EBV DNA loads in whole blood and PBMCs.

Disclosures
All authors: No reported disclosures.
1981. Implementation of an Antifungal Stewardship Bundle Focused on Candidemia in an Indian Hospital
Authors: Moni Merlin , Menon Vidya , Sudhir Sangita , T.S. Dipu , Philip Jeslyn , James Jini , Singh Sanjeev , Zhou Shiwei , Patel Twisha S , Kaye Keith S , Patel Payal K 
Published: October 2019

Abstract

Background
In India, Candida bloodstream infections have a reported incidence of 1–12 per 1,000 admissions and a mortality rate of up to 60%. Antimicrobial stewardship programs (ASP) can improve quality of care and clinical outcomes. This study evaluates the impact of a comprehensive candidemia ASP bundle in a hospital in southern India with an established stewardship program.

Methods
A single-center, pre-post quasi-experimental study was conducted at a tertiary-care center in southern India to analyze the impact of an ASP care bundle for the management of adults with candidemia. During the intervention period (October 2017–December 2018), the ASP provided recommendations to providers in accordance with the 2016 IDSA Guidelines for the Management of Candidemia, which included the following bundle: (1) appropriate selection and dosing of antifungal therapy; (2) repeat blood cultures every 48 hours until clearance; (3) removal of central venous catheters and other potential removable foci of infection; (4) echocardiogram; (5) ophthalmologic evaluation; and (6) appropriate duration of therapy. The primary outcome was initiation of appropriate antifungal therapy. Additional clinical outcomes were also compared with a historical cohort.

Results
One hundred and four patients with candidemia were included: 52 in the pre-intervention and 52 in the post-intervention group. Overall, baseline demographics were similar between the two groups (Table 1). Candida tropicalis (26.9%) and Candida parapsilosis (29.8%) were the most common causes of candidemia in the cohort. Following intervention, administration of appropriate antifungal therapy improved by 40.4% (28.8% pre vs. 69.2% post, P < 0.01). Average time to effective treatment initiation following culture positivity decreased from 57.6 hours to 12 hours in the post-intervention group (P < 0.01). Thirty-day all-cause mortality was similar between the two groups (34.6% 38.4%, P = 0.84).

Conclusion
Implementation of a comprehensive candidemia care bundle by the ASP significantly improved the use and timing of initiation of appropriate antifungal therapy.

Disclosures
All authors: No reported disclosures.
2001. Assessment of Real-world Effectiveness of a Rapid Blood Culture Diagnostic Panel at a Veterans Affairs Medical Center
Authors: Chiasson Jordan , Cutrell James B , Cutrell James B , Tomasz Jodlowski , Smith Winter , Kouma Marcus 
Published: October 2019

Abstract

Background
Rapid blood culture diagnostics can improve patient outcomes, particularly when paired with robust interventions such as 24/7 stewardship coverage. We sought to determine the clinical impact of a rapid blood culture identification (BCID) panel (BioFire® FilmArray Multiplex PCR) in an established antimicrobial stewardship program (ASP). In addition to clinician education, BCID results were reviewed by the ASP team during weekday business hours, for an average of 2 hours daily based on availability.

Methods
Data on demographics, blood cultures, antimicrobial use, length of stay and mortality were collected on inpatients at the VA North Texas Health Care System with at least one positive blood culture for bacterial or yeast isolates from March 2017 to June 2017 (pre-BCID) and from March 2018 to June 2018 (post-BCID). The primary outcome was a composite of time to optimal therapy from blood culture collection, defined as escalation, de-escalation, discontinuation, or optimization of antimicrobials retrospectively adjudicated based on final culture results. Secondary outcomes included time to effective therapy, total days of therapy (DOT), length of stay, and 30-day mortality and readmission rates.

Results
195 patients were screened with 130 patients included in the study. No significant differences in baseline characteristics were observed between groups (Table 1). Sixty-one patients were included in the pre-BCID arm and 69 in the post-BCID arm. Median time to optimal therapy was 82.9 hours (IQR; 12.8–99.8) in the pre-BCID arm and 33.9 hours (IQR; 11.2–64.8) in the post-BCID arm (P = 0.005) (Table 2). No significant change in 30-day mortality or 30-day readmission rates was noted. Vancomycin DOT was 4 days (IQR; 2–5) and 3 days (IQR; 1–4) (P = 0.024), and piperacillin–tazobactam DOT was 4 (IQR; 0–5) and 2 (IQR; 0–4) (P = 0.043), in the pre-BCID and post-BCID groups, respectively (Figure 1).

Conclusion
Introduction of BCID into the daily workflow of our ASP resulted in a significant reduction in time to optimal therapy for bloodstream infections. DOT for select broad-spectrum antibiotics were also significantly reduced. This study highlights the potential benefit of rapid diagnostics without negative impact to patient care even in settings without resources for 24/7 ASP review.

Disclosures
All authors: No reported disclosures.
2006. Evaluation of Rapid Blood Culture Identification with Antimicrobial Stewardship Treatment Recommendations at a Community Health System in Patients with Gram-negative Bacteremia: Adequacy, Adherence, and Outcomes
Authors: Deja Erin , Frens Jeremy J 
Published: October 2019

Abstract

Background
Sepsis mortality is greatly affected by the timely receipt of appropriate antibiotics. FilmArray Blood Culture Identification (BCID) is used at Cone Health to identify organisms in blood cultures within one to 2 hours after growth detected. The Cone Health antimicrobial stewardship (AMS) team has created treatment recommendations for each organism and resistance mechanism identifiable by BCID. Results and antibiotic recommendations are communicated in real time to providers by clinical pharmacists. The purpose of this evaluation was to validate the adequacy of antibiotics recommended by the BCID treatment algorithm for Gram-negative rods (GNR); assess proper implementation of the BCID notification procedure; and evaluate its effect on AMS.

Methods
Patients with GNR BCID results in January and April 2018 were retrospectively identified. Information collected for each patient included: demographics, location, organism, admission antibiotics, pharmacist compliance with BCID procedure, recommendation acceptance rate, organism susceptibility, changes to antibiotics post-BCID and final cultures, extended-spectrum β-lactamase (ESBL) incidence, length of antibiotic therapy, and patient outcome.

Results
A total of 101 patients were evaluated. The BCID treatment algorithm recommendations covered 97% of identified organisms (Figures 1–4). Resistant isolates were ESBL producers. Pharmacist antibiotic recommendations matched the treatment algorithm 66% of the time. Providers accepted 90% of pharmacist recommendations. Twenty-two percent of antibiotics were not de-escalated after BCID results without identifiable reason.

Conclusion
The BCID treatment algorithm provided adequate coverage for nearly all identified organisms, except ESBLs. However, patients with ESBL organisms all survived to hospital discharge. Pharmacists are following the BCID protocol in a majority of cases. One-third of recommendations deviated from the algorithm but only 17% did not have documented reasoning. Providers are very receptive to pharmacist input, with only 8% of recommendations rejected without documented reasoning. Finally, nearly a quarter of empiric antibiotics were not de-escalated despite organism identification, which represents opportunity for improvement.

Disclosures
All authors: No reported disclosures.