bluuebunny/crossref_metadata_2025_split huggingface dataset:
2088. Cross-sectional Analysis of Administrative Structure and Practices for Hospital Antimicrobial Stewardship Programs (ASPs) in a Large Metropolitan City
Authors: Ha David , Lee Thomas , Gauthier Timothy , OYong Kelsey , McKinnell James 
Published: October 2019

Abstract

Background
Los Angeles (LA) County is large and diverse urban southern California county with a population of over 10 million and a multitude of hospitals. The state of California required hospitals to implement ASPs in July 2015. This collaborative with the LA County Department of Public Health sought to characterize administrative structure and practices of hospital ASPs in the county.

Methods
A survey of LA County hospital ASPs was conducted from November 2018 to April 2019. Initial telephone and email screenings were performed to confirm individuals’ involvement in hospital ASPs prior to survey participation.

Results
Overall, 40 of 87 (46%) hospitals responded. Of these, 90% (36/40) were private hospitals and 68% (27/40) were part of a multi-hospital network. All hospitals (40/40) reported an active ASP with 53% (21/40) established for 5 years or longer. Only 65% (26/40) reported meeting all seven CDC core elements of hospital ASPs and 85% (34/40) reported having an ASP committee. Of those with ASP committees, individuals who chaired or co-chaired the committee were predominantly ID physicians (33/34, 97%). Most held meetings quarterly (18/34, 53%). Committee member meeting attendance “all or most of the time” was highest for pharmacists (34/34, 100%) and ID physicians (33/34, 97%) and lowest for information technology (IT) personnel (9/34, 27%) and non-ID physicians (12/34, 35%). ASP committees reported to a mean of 2.4 other committees, most frequently to pharmacy and therapeutics (P&T) (32/34, 94%) and infection control (IC) (24/34, 71%). ASP committees received reports from a mean of 2.3 committees, most frequently from IC (22/34, 65%). Few ASP committees (<20%) reported to any of patient/medication safety, quality, sepsis, laboratory, risk management or nursing committees. Risk assessments and strategic planning were performed by only 35% (12/34) and 56% (19/34), respectively.

Conclusion
Our study demonstrates additional need in LA County hospital ASPs to meet CDC core measures as well as enhance ASP administrative structure. Notably, ASP committees appear to be siloed with P&T and IC with minimal reporting to other committees, do not frequently perform risk assessments or strategic planning, and have low meeting attendance by IT personnel and non-ID physicians.

Disclosures
All authors: No reported disclosures.
2090. Are Changes in Antimicrobial Use Associated with a Decline in Hospital Pathogen Rates in Veterans Affairs Medical Centers?
Authors: Jones Makoto M , Madaras-Kelly Karl , Stevens Vanessa W , Bostwick Doran , Lewis Julia , Roselle Gary , Glassman Peter A , Goetz Matthew B , Samore Matthew H , Rubin Michael , Kralovic Stephen 
Published: October 2019

Abstract

Background
The relationship between antimicrobial use and resistance is complex, making it difficult to understand and predict the impact of antimicrobial policies. Here, we examine trends of antimicrobial pressure and pathogen rates using novel metrics.

Methods
Data were extracted from 2007 through 2016. GEE-negative binomial regression modeled incident (within a year) hospital-onset (HO) pathogen rates, defined as the number of unique positive isolates between hospital day 3 and discharge, offset by patient-days at risk (eliminating the first 2 hospital days from the denominator, etc.). As predictors, we used pathogen-specific AM pressure metrics, summing the selection pressure of each AM regimen, given to a patient in a day, for and against the pathogen by each facility and year (e.g., if a regimen was 70% active by antibiogram then 0.7 was counted as selection against and 0.3 for the pathogen; different regimens would contribute differentially). We also adjusted by facility complexity index and pathogen admission prevalence.

Results
All HO-pathogen rates declined significantly after adjustment (raw rates in Figure 1), except Bacteroides. Admission prevalence trends were variable (Table 1 and Figure 2). Figure 3 demonstrates the trend of the log ratio of AM pressure for and against pathogens. Significant negative associations with AM pressure against 5 pathogens and for 1 were observed (Table 1).

Conclusion
There was a broad decrease in adjusted hospital pathogen rates. The negative association with selection pressure against pathogens suggests that (a) AM resistance among pathogens is decreasing, (b) it causes a decrease in infection rates, or (c) both. While residual confounding and endogeneity still exist, our findings highlight the possibility that new metrics might better predict AM effects, including potential protective effects of some patterns of AM use. It is also notable that the measured associations were not large enough nor AM pressure trends consistent enough to explain the decreases in HO-pathogen rates. This suggests that other factors not measured in this analysis, including infection prevention, likely played a large role in observed trends. Interpretation of these results should be nuanced; we are not advocating broad-spectrum AM use.

Disclosures
All authors: No reported disclosures.
2102. Does Monitoring Procalcitonin Levels in Septic and Septic Shock Patients Decrease the Use of Antibiotics and Predict Length of Hospital Stay?
Authors: Bilbe Sarah E , Azhar Ashaur , Brakta Fatima Z , Aymond Katherine N , Nsuami M Jacques , Figueroa Julio E 
Published: October 2019

Abstract

Background
Elevated levels of procalcitonin (PCT) reflect systemic inflammation associated with bacterial infection (BI). Compared with other acute-phase reactants, PCT levels more rapidly rise with BI and decline quickly as BI improves. A PCT protocol was implemented at University Medical Center New Orleans (UMCNO) in November 2017 that guided discontinuation of antimicrobial therapy in septic and septic shock patients if clinically improving with declining levels of PCT.

Methods
We performed a retrospective chart review of UMCNO patients 18+ years with a diagnosis of sepsis and a PCT level between January 1st, 2018 to July 31st, 2018 compared with those with sepsis and no PCT level. ICD-9/10 codes were used for diagnoses of sepsis and septic shock. The baseline characteristics including age, gender, body mass index, race and Charlston Comorbidity Index (CCI) data were collected. The primary objective was to compare the total days of antibiotic therapy (DOT) between the two groups. Secondary outcomes were broad-spectrum antibiotic DOT, patient length of stay (LOS), and all-cause 28-day mortality. SPSS was used for data analysis. P < 0.05 indicated statistical significance.

Results
There were 44 patients in the PCT group (PCTg) and 35 in the non-PCT group (nPCTg). The demographics are outlined in Table. The mean DOT was 6.25 days in PCTg and 10.74 days in nPCTg (P = 0.006). LOS was 7.5 days in PCTg and 14 in nPCTg (P = 0.006). The mean CCI was 2.4 in PCTg and 4 in nPCTg (P = 0.007). The all-cause 28-day mortality was 11% in PCTg and 23% in nPCTg (OR 0.4; 95% CI 0.128–1.466). On bivariate analysis, LOS was significantly associated with CCI (P < 0.05) and total DOT (P = 0.000). On multivariate analysis, LOS was only significantly associated with age (P = 0.015) and total DOT (P = 0.000) but not CCI (P = 0.811) nor PCTg (P = 0.250).

Conclusion
DOT was significantly shorter in the PCTg than in nPCTg. The LOS was 50% less in PCTg than in nPCTg; however, PCT monitoring did not contribute to LOS in multivariate analysis. Although the nPCTg were sicker, CCI did not correlate with LOS either. However, age and total DOT therapy remained positive predictors of LOS. Monitoring PCT levels decreased antibiotic use in septic patients. LOS, however, was not significantly affected by PCT monitoring.

Disclosures
All authors: No reported disclosures.
2115. Activity of a Long-Acting Echinocandin Rezafungin and Comparator Antifungal Agents Tested against Contemporary Invasive Fungal Isolates: SENTRY 2018
Authors: Pfaller Michael A , Carvalhaes Cecilia G , Messer Shawn A , Rhomberg Paul R , Castanheira Mariana 
Published: October 2019

Abstract

Background
Echinocandins are the first-line treatment of candidemia. We evaluated the activity of rezafungin (RZF), a novel long-acting echinocandin with front-loaded drug exposure and extensive distribution to sites of infection, and comparators using CLSI broth microdilution methods against 709 invasive fungal isolates collected worldwide during 2018.

Methods
Susceptibility (S) tests on 663 Candida spp. (6 species), 21 C. neoformans (CNEO), and 25 A. fumigatus (ASF) were conducted for RZF, anidulafungin (ANF), caspofungin (CSF), micafungin (MCF), and azoles. CLSI clinical breakpoint (CBP) and epidemiological cutoff value (ECV) interpretive criteria were applied. Isolates displaying echinocandin MIC>ECV were sequenced for fks hot spot (HS) mutations.

Results
RZF inhibited 99.7% of C. albicans (CA) isolates (MIC50/90, 0.015/0.06 mg/L), 100.0% of C. tropicalis (CT) (MIC50/90, 0.03/0.06 mg/L), 98.9% of C. glabrata (CG) (MIC50/90, 0.03/0.06 mg/L), 100.0% of C. krusei (CK) (MIC50/90, 0.015/0.12 mg/L), and 100.0% of C. dubliniensis (CD) (MIC50/90, 0.03/0.06 mg/L) at ≤0.12 mg/L. All (104/104 [100.0%]) C. parapsilosis (CP) isolates (MIC50/90,1/2 mg/L) were inhibited by RZF at ≤2 mg/L. Fluconazole resistance was detected among 9.0% of CG, 17.3% of CP, and 1.6% of CT. The activity of RZF against these 6 Candida spp. was similar to that of the other echinocandins, the vast majority of which were susceptible/wild type (WT) using CBP/ECV. A total of 5 isolates (3 CG, 1 CA, and 1 CT) displayed 1 or more non-WT or-resistant MIC values and were sequenced for fks HS mutations. Fluconazole and other azoles displayed good activity against CNEO whereas echinocandins including RZF displayed limited activity against CNEO isolates. Echinocandins displayed good activity against ASF, and RZF activity was similar to that of anidulafungin, caspofungin, and micafungin. All but 1 isolate (non-WT MIC for itraconazole, 2 mg/L) displayed WT MIC values for the mould-active azoles.

Conclusion
Rezafungin was as active as other echinocandins against common organisms recovered from invasive fungal infections. These in vitro data contribute to accumulating research demonstrating rezafungin potential for prevention and treatment of invasive fungal infection.

Disclosures
All authors: No reported disclosures.
2129. When Is Methicillin-resistant Staphylococcus aureus not Methicillin-resistant Staphylococcus aureus?
Authors: Gitman Melissa R , Obla Ajay , Van de Guchte Adriana , Sordillo Emilia Mia , Polanco Jose , Chung Marilyn , Oussenko Irina , Smith Melissa L , Altman Deena R , Van Bakel Harm 
Published: October 2019

Abstract

Background
As part of active surveillance in our NICU for methicillin-resistant Staphylococcus aureus (MRSA), two isolates representing modified S. aureus (MODSA), which are Methicillin resistant but lacking mecA or C were identified. Our current microbiology laboratory workflow for screening for MRSA involves plating isolates on chromoID agar (bioMérieux, Marcy-l’Etoile, France) as well as on sheep blood agar (SBA). Β hemolytic colonies on SBA that are catalase and coagulase positive are set up for confirmation and antimicrobial susceptibility testing on the Vitek 2 (bioMérieux, Marcy-l’Etoile, France).

Methods
These 2 isolates (from Baby 1 and Baby 2) tested positive for green colonies on the chromoagar plates. The Vitek 2 subsequently identified both these isolates as MRSA. However, for research purposes, all positive NICU MRSA isolates are tested via whole-genome sequencing (WGS). Both isolates were identified by WGS as methicillin-susceptible Staphylococcus aureus (MSSA). We subsequently went back and performed additional workup on these isolates. Isolates were plated on SBA and chromagar again and incubated for 24 hours. 2 colonies of different morphologies from the chromagar plates and 3 from the SBA were randomly selected and subcultured to chromagar and SBA for a total of 5 subcultures. Each of the subcultures was tested using staphaurex, mannitol salt agar and the Cepheid Xpert MRSA assay and all were confirmed to be Staphylococcus aureus.

Results
All 10 isolates tested negative by the Cepheid Xpert MRSA assay for MRSA. Phenotypic testing was set up again for all ten isolates using the vitek GP panel, as well as cefoxitin disk, and oxacillin E test using Mueller–Hinton agar supplemented with 2% NaCl as per CLSI methods. See table attached for results.

Conclusion
In conclusion, these two cases highlight the difficulty in identifying non-MecA, non-MecC-mediated MRSA isolates in the clinical microbiology laboratory. This is particularly important as more laboratories rely on testing for MecA by PCR for surveillance testing. These 2 cases were further complicated by heterogeneous sub-populations of Staphylococcus aureus. Failure to recognize these variant forms of MRSA can lead to difficulties in implementing appropriate therapy and infection control measures. Improved methodologies are needed.

Disclosures
All authors: No reported disclosures.
2135. Streptococcus pneumoniae DNA (lytA) Detection in Clinical Samples Sent for a Respiratory Viral Polymerase Chain Reaction: Is There Bacterial-Viral Association?
Authors: Roberts Matthew , Sadlon Tania , Higgins Geoff D 
Published: October 2019

Abstract

Background
Streptococcus pneumoniae (SPNEU) is a major cause of community-acquired pneumonia and frequently complicates respiratory viral infections. Clinical differentiation of viral and bacterial respiratory tract infection can be difficult, as can predicting which patients with respiratory viral infection will develop bacterial infection. A SPNEU polymerase chain reaction (PCR) to specific DNA region lytA may be able to determine which patients with viral infections may develop bacterial infection.

Methods
Stored nucleic acid extracts from clinical samples collected and tested for respiratory viral PCR (RVP) in 2015 and 2016 were tested for SPNEU lytA DNA using standard laboratory procedure. Analyses of demographic data, RVP and SPNEU PCR result were performed to determine relevant associations.

Results
1581 stored clinical RVP samples were tested for SPNEU DNA with PCR to lytA, 1550 of these had complete RVP panel results available for analysis. RVP samples from patients 0–5 years old were more likely to have a viral or bacterial pathogen detected than > 5 years old (78% vs. 45%, P < 0.001). Of 1,550 samples analyzed with SPNEU PCR, 19% were positive for SPNEU, this was more likely in those 0–5 years old than > 5 years old (50% vs. 10%, P < 0.0001). In 0–5 years old, SPNEU was more frequently detected when multiple pathogens were detected on RVP vs. those with no pathogen (63% vs. 43%, P = 0.031). In > 5 years old, compared with no pathogen samples, the presence of multiple pathogens, any single pathogen, influenza, rhinovirus and Bordetella pertussis were significantly associated with higher SPNEU positivity rates. Median SPNEU PCR DNA load was higher in multiple pathogen and single pathogen samples than in no pathogen RVP samples.

Conclusion
We have demonstrated an association between common respiratory pathogens and detection of SPNEU DNA via PCR. This association is strongest in samples with multiple RVP pathogens, suggesting additional nasopharyngeal inflammation may contribute to SPNEU presence in the nasopharynx. Previous data have focused on those 0–5 years old, we have demonstrated an SPNEU-viral association in those > 5 years old. This tool may be clinically useful to determine which individuals with viral respiratory tract infection will progress to bacterial pneumonia and warrants further investigation.

Disclosures
All authors: No reported disclosures.
2146. MALDI-TOF Mass Spectrometry Rapid Pathogen Identification and Outcomes of Patients with Bloodstream Infection: A Systematic Review and Meta-analysis
Authors: Hsieh Ronan , Mekary Rania , Li Raymund , Lin Chi-Yang , Weng Tzu-Hua , Hsu Wan-Ting , Li Guilin , Chang Chia-Na , Li Huayin , Liu Xiaoying , Lee Chien-Chang 
Published: October 2019

Abstract

Background
Several studies showed inconsistent results on the efficiency measures of the matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) technology and patients’ clinical outcomes. A meta-analysis was conducted to determine the effectiveness of MALDI-TOF MS-based bacteriology in improving the accuracy of microbiology report and clinical outcomes.

Methods
PubMed and EMBASE databases were searched from database inception through May 1, 2018 for pre–post and parallel comparative studies that evaluated the use of MALDI-TOF MS for identification of microorganism from blood culture. Pooled effect estimates were derived using the random-effects model. Univariate meta-regression on trial-level covariates was used to assess heterogeneity sources. Funnel plot, Begg’s and Egger’s tests were used to assess publication bias.

Results
Thirteen studies with 3,534 patients were meta-analyzed. Compared with conventional methods, MALDI-TOF MS was associated with 34% reduction in mortality (RR = 0.66; 95% CI: 0.54; 0.81; I2 = 27.6%; 9 studies); 5.3-hour reduction in time-to-effective antibiotic therapy (95% CI: -6.4; -4.3; I2 = 98.0%), 24.5-hour reduction in time to identify bacteria (95% CI: −25.7; −23.3; I2 = 91.0%); 0.9-day reduction in hospital stay (95% CI: −1.4; −0.3; I2 = 56.6%), and US$4100 saving in direct hospitalization cost (95% CI: $−8,200; $−113; I2 = 66.1%). No significant heterogeneity sources were found (all P-interaction from meta-regression > 0.05) and no statistical evidence for publication bias was found (all P > 0.05).

Conclusion
Rapid pathogen identification by MALDI-TOF MS with or without antibiotic stewardship was associated with reduced mortality, improved outcomes of bloodstream infection, and may be cost-effective among patients with bloodstream infection. Nevertheless, a multicenter randomized controlled trial is needed to confirm findings of these pre–post comparison studies.

Disclosures
All authors: No reported disclosures.
2153. Clinical Impact of Addition of Oropharynx MRSA PCR to Anterior Nares MRSA PCR for Patients Admitted with Pneumonia
Authors: Kessler Michael , Biswas Sandip , Choera Tsokyi , Chen Derrick , Lepak Alexander , Lepak Alexander 
Published: October 2019

Abstract

Background
Anterior nares (AN) MRSA PCR can help identify MRSA colonization as a risk factor for MRSA pneumonia and can be especially useful, given high NPV, in making treatment decisions when lower respiratory tract (LRT) cultures are lacking. Oropharynx (OP) MRSA carriage without AN colonization can occur suggesting the potential benefit of duel site screening, but doubles resource utilization. We evaluated concordance between the AN and OP sites and whether the addition of OP MRSA PCR testing provides clinical benefit.

Methods
MRSA PCR was performed using Xpert SA Nasal Complete (Cepheid; FDA-cleared and modified). Results were retrieved from January 2017 to July 2018 for adult in-patients who received both AN and OP testing within the same calendar day. Medical charts were reviewed for a clinical course, respiratory culture results, and effect of discordant PCR results.

Results
AN and OP MRSA PCRs were performed on 1,419 adult inpatients, concordance was 96.5% (n = 1370, see Table). In 38 of 49 discordant cases, PCR was used to evaluate the etiology of pneumonia. Of those, 22 (58%) had LRT culture results available within 48 h to direct therapy. We further evaluated the value of OP PCR by focusing on AN-/OP+ (n = 22) discordant results, of which 16 were used to evaluate pneumonia. LRT culture results were available in 7 (44%) of these cases. Three had isolation of MRSA; however, the remaining 4 were culture-negative but still received vancomycin for an average of 5 days. Of the 9 that were AN−, OP+, and without culture results, only 4 had clinical signs and symptoms consistent with MRSA pneumonia. OP MRSA PCR is $303.

Conclusion
OP and AN MRSA PCR screening are highly concordant in patients with pneumonia. 355 AN/OP PCRs (4/1419), at > $100,000 in additional healthcare costs, were needed to detect one potentially missed MRSA pneumonia compared with AN PCR only approach. Our results suggest addition of OP MRSA PCR: (1) has limited clinical utility for pneumonia evaluation as it is unlikely to be discordant with AN testing, which will not significantly alter the very high NPV and when discordant (AN-/OP+) has a <50% PPV, (2) is unlikely to be cost-effective, and (3) has unintended consequences such as overuse of MRSA therapy. Additionally, there is an opportunity to improve PCR ordering to include only those situations in which LRT cultures are lacking.

Disclosures
Alexander Lepak, MD, Paratek Pharmaceuticals: Research Grant; Tetraphase Pharmaceuticals: Research Grant.
2163. Clinical Impact of Inter-site Blood Culture Transport in a Canadian Tertiary Care Center
Authors: Carignan Alex , Dufour Kevin , Beauregard-Paultre Catherine , Martin Philippe 
Published: October 2019

Abstract

Background
The potential delays caused by transport of blood cultures to server laboratories might result in delayed issuance of results for patients with positive blood cultures. In this study, we aimed to determine the clinical impacts of inter-site transport of blood cultures.

Methods
We performed a retrospective cohort study involving cases with positive blood cultures (1 positive blood culture/species/patient/7 days; not deemed as a contaminant) at two sites of a Canadian tertiary care center between January 1, 2018 and December 31, 2018. Blood cultures from the affiliated site were transported to the laboratory of the primary server site. These two sites are located 8 km apart. The following outcomes were studied: the duration between blood culture sampling and issuance of the first report and the duration between blood culture sampling and administration of the first effective antibiotic.

Results
We observed 349 episodes of bacteremia, including 161 in the affiliated site (45.5%) and 193 in the primary server center (54.5%). Enterobacteriaceae (n = 151, 43%) and Staphylococcus aureus (n = 77, 22%) were the most commonly observed causative bacteria. Median duration for issuance of the first positive report was significantly shorter in the primary server hospital (32.4 h, interquartile range [IQR] 19.8–44.3) than in the affiliated center (37.9 h, IQR 24.1–46.5; P = 0.004). The median duration between blood culture sampling and administration of the first effective antibiotic was 2.7 h in the server site (IQR 0.75–15.2) and 2.3 h in the affiliated site (IQR 1–8.45) (P = 1.0). Receiving the first effective antibiotic after blood culture sampling required > 60 min in 8/189 patients (4.2%) in the affiliated site and 9/158 patients (5.7%) in the primary server site (P = 0.3). The 30-day mortality was 13.8% (26/189) and 8.9% (14/158) at the primary server site and affiliated site, respectively (P = 0.16).

Conclusion
Inter-site transport of blood cultures is associated with a significant delay in the issuance of positive blood culture reports. However, this delay does not cause any delay in administration of effective antibiotic therapy because of rapid recognition of sepsis in bacteremia patients. These results are reassuring in the context of increasing microbiology service centralization.

Disclosures
All authors: No reported disclosures.