bluuebunny/crossref_metadata_2025_split huggingface dataset:
191. oral versus Intravenous Antibiotic Treatment in Skin and Soft Tissue Infections as a Consequence of Intravenous Drug Use: A Retrospective Study to Demonstrate Noninferiority
Authors: Andrzejewski Aryn M , Viehman J Alex 
Published: January 2021

Abstract

Background
Skin and soft tissue infections (SSTIs) are among the most prevalent infectious complications of intravenous drug use (IVDU). Given its polymicrobial nature, studies focusing on SSTIs in the general population may not be generalizable this group. We completed a retrospective chart review to better characterize the safety and efficacy of oral versus intravenous (IV) antibiotics for the treatment SSTIs in IVDU.

Methods
We reviewed patients admitted with bacterial SSTIs and IVDU from January 01, 2012 to December 31, 2019 based on ICD-10 codes. SSTIs complicated by bacteremia, endocarditis, bone or joint involvement on index admission were excluded. Patients who received &lt; 48 hours of IV antibiotics were considered oral therapy, otherwise they were considered IV therapy. Patient comorbidities, incision and drainage (I&D) status, substance use, microbiology and antimicrobial data were reviewed.

Results
Of 231 eligible patients, 84 received oral therapy. There was no statistical difference in patient characteristics between the two therapy groups. Streptococcus anginosus group were the most common organisms found (33%) followed by Staphylococcus aureus (31%). There was no statistical difference between rates of readmission (p=0.87), recurrent primary site infection (p=1.00), repeat debridement (p=0.08) or occurrence of deep-seated infections within 90 days of treatment completion. No morality was observed. The oral group had shorter length of stay (3 vs. 5 days, p &lt; 0.001) and shorter total duration of antibiotics (10 vs. 13 days, p &lt; 0.001). Overall, 90% of those with abscess underwent I&D, which did not differ between therapy groups. Time to I&D was shorter (0 vs. 1 day, p=0.005) in the oral group. Patients who did not receive and I&D were more likely to be readmitted within 90 days (p=0.025).

Conclusion
In SSTIs related to IVDU, oral antibiotic therapy was noninferior to IV in terms of mortality, readmission, and deep-seated infection rates within 90 days of treatment completion and had a decreased length of stay and total treatment duration. A delay in I&D led to increased length of stay and lack of I&D increased readmission rate. Therefore, a prompt I&D may allow a safe and effective early transition to oral therapy in SSTIs related to IVDU.

Disclosures
All Authors: No reported disclosures
193. quality Improvement Initiative for Non-purulent Cellulitis Management in Urgent care setting: provider-level Performance Feedback
Authors: Reddy Laya , Goicoechea Miguel , Kozak Thomas , Bagsic Samantha 
Published: January 2021

Abstract

Background
Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a common cause of skin and soft-tissue infections (SSTIs). This has resulted in an 88% increase in MRSA-directed antibiotic use in emergency departments. However, the majority of cellulitis presents as non-purulent due to Group A streptococci. An unintended consequence is that many with non-purulent cellulitis receive sub-optimal antibiotics and unnecessary diagnostics. Clinical guidelines at our institution recommend beta-lactam antibiotics and discourage empiric MRSA coverage for non-purulent cellulitis. The aim of this study is to use an audit-feedback intervention to optimize urgent care providers management of mild/moderate non-purulent cellulitis.

Methods
We identified all consecutive patients presenting to our urgent care with a diagnosis of lower extremity non-purulent cellulitis using ICD coding. We conducted a prospective pre and post-intervention study from 10/2018-3/2019 and 11/2019-4/2020 respectively. Intervention included review of practice guidelines with providers and feedback from pre-intervention phase. To assess individual practitioners’ prescribing habits, a comprehensive scoring system focused on empiric antibiotic selection, antibiotic duration, and diagnostics was combined with patient demographics. Scores classified non-purulent SSTI treatment as follows: 0–2 = good, 2.5–5 = fair, and &gt;5.5 = poor (Figure 1).
Figure 1: Provider Cellulitis Management Scoring Sheet

Results
There was statistically significant provider score improvement in the post-intervention phase with greater percentage of good cases (40% to 69%) and no poor cases (Figure 2). For IV antibiotics for mild and moderate cellulitis, there was decreased use of overly broad antibiotics (Figure 3). Antibiotic duration of greater than 7 days decreased from 68% to 52%. Combination antibiotic therapy decreased from 12% to 4%. There was also a statistically significant decrease in use of wound cultures but no change in ultrasound use.
Figure 2: Overall Provider Scores

Figure 3: IV Antibiotic Use

Conclusion
Audit-feedback intervention was effective for improving antibiotic usage and decreasing treatment duration. Providing physicians with data on their practice patterns relative to those of their peers and clinical practice guidelines can improve management of non-purulent cellulitis.

Disclosures
All Authors: No reported disclosures
194. Combinatorial Polyfunctionality Analysis of Antigen-specific T-cell Subsets (COMPASS) as a Predictor for Clinically Significant CMV Infection in the Letermovir Era
Authors: Zamora Danniel , Duke Elizabeth , Xie Hu , Edmison Bradley , Akoto Brenda , Kiener Richard , Stevens-Ayers Terry , Wagner Ralf , Mielcarek Marco , Schiffer Joshua , De Rosa Stephen , Boeckh Michael 
Published: January 2021

Abstract

Background
Increased CMV reactivation is observed following discontinuation of letermovir prophylaxis after hematopoietic cellular transplantation (HCT) and decreased CMV-specific polyfunctional T-cell immunity has been proposed as a possible mechanism (BBMT 2020;26:S68). COMPASS is a novel analytical tool that integrates polyfunctional T-cell cytokine responses into a single score value (Nat Biotechnol 2015;33:610). We employed COMPASS for the first time in the HCT setting to determine if CMV-specific immunodeficiency is associated with late CMV events in a prospective cohort of allogeneic HCT recipients receiving either letermovir or preemptive therapy.

Methods
Peripheral blood mononuclear cells were collected 3 months post-HCT and assessed with a 13-color intracellular cytokine staining (ICS) assay that includes 5 functional markers. Intermediate early-1 (IE-1) antigen and phosphoprotein 65 (pp65) were used to stimulate polyfunctional T-cell responses that were defined using COMPASS generated polyfunctionality scores (PFS). CMV DNAemia was monitored by weekly plasma PCR and patients who reactivated were treated with preemptive therapy per institutional standards. Cumulative incidence of clinically significant CMV infection (cs-CMV; ≥500 IU/mL or CMV disease) by day 270 was assessed. Univariable and multivariable Cox regression were used to estimate the association of polyfunctional T-cell responses (upper quartile versus lower 3 quartiles) with cs-CMV infection by day 270 post-HCT.

Results
56 letermovir recipients and 93 preemptive controls were evaluated. Time to first clinically significant CMV (cs-CMV) infection after HCT and among day 100 survivors in both groups is shown in Figure 1. COMPASS PFS at 3 months were significantly lower in letermovir recipients (Figure 2). After adjusting for CMV infection before day 100, CD4 and CD8 PFS to IE-1 and pp65 below the upper quartile were associated with higher risk of late cs-CMV infection, with IE-1 CD8 PFS reaching statistical significance (Figure 3).

Conclusion
Our findings demonstrate that COMPASS is a valuable tool to evaluate multiple, T-cell cytokine responses to CMV in HCT recipients. COMPASS appears to be useful to identify patients at risk for late cs-CMV infection.

Disclosures
Elizabeth Duke, MD, Merck (Grant/Research Support) Michael Boeckh, MD PhD, AlloVir (Consultant)EvrysBio (Advisor or Review Panel member, Other Financial or Material Support, share options)Gilead (Consultant, Grant/Research Support)GSK (Consultant)Helocyte (Advisor or Review Panel member, Shareholder)Lophius (Grant/Research Support)Merck (Consultant, Grant/Research Support)SymBio (Consultant)VirBio (Consultant, Grant/Research Support)
197. Dengue Virus Infection Among Renal Transplant Recipients in Singapore: A 15-year Single Center Retrospective Review
Authors: Xuan Sophie Tan Seine , Ho Quan Yao , Thangaraju Sobhana , Tan Thuan Tong , Kee Terence , Shimin Jasmine Chung 
Published: January 2021

Abstract

Background
Dengue is a mosquito-borne viral infection endemic in Singapore. Its clinical course in the immunocompetent host is well characterised but its impact in renal transplantation is not well described. We aim to characterise the clinical presentation and outcomes of dengue virus infection in renal transplant recipients treated at a tertiary center in Singapore.

Methods
We conducted a 15 year retrospective review of dengue in renal transplant patients treated at Singapore General Hospital between January 2005 to October 2019. The diagnosis of dengue was made if there were a compatible clinical syndrome and a positive dengue diagnostic assay, either Dengue NS1 antigen, IgM or PCR.

Results
Thirty-two renal transplant patients were diagnosed with dengue, 18 (56.3%) were deceased donor recipients. The median age at time of diagnosis was 53 [IQR 42,61] years; 16 (50%) were males. The median time to diagnosis of dengue was 95.5 [IQR 15.0,95.5] months from transplant; and the median duration of clinical illness was 7 [IQR 5,7] days. The most common clinical symptoms were fever (84.4%), myalgia (40.6%), gastrointestinal symptoms (37.5%) and headache (25.0%). Based on the WHO 2009 dengue classification, 20 (62.5%) had dengue without warning signs, 9 (28.1%) had dengue with warning signs, and 3 (9.4%) had severe dengue; 19 (59.3%) had graft dysfunction and 1 (3.1%) required dialysis. Of the patients who had graft dysfunction, 18 (94.7%) had recovery of graft function at time of dengue resolution. Dengue mortality rate was 3.1%. There were 2 possible cases of donor derived dengue infections, occurring within 2 weeks of deceased donor transplantation.

Conclusion
Dengue in renal transplant is usually community acquired; donor derived infections are uncommon. The clinical presentation of dengue is similar to the immunocompetent host, however graft dysfunction is common and fluid management in this population is important. Severe dengue is less common.

Disclosures
All Authors: No reported disclosures
314. A Retrospective Review of Dalbavancin Utilization at an Academic Medical Center
Authors: Napoli Emma , Badwal Jasmin K , Kirkpatrick Emily R , Pinilla Ruth Serrano , Wang Chen-Pin , Javeri Heta 
Published: January 2021

Abstract

Background
Dalbavancin is a novel long-acting lipoglycopeptide with increasing utilization for management of bone and joint infections as a two-dose regimen. The purpose of this study is to describe the patient characteristics, evaluate clinical outcomes, and calculate inpatient hospital days saved with use of dalbavancin as outpatient parenteral antimicrobial therapy (OPAT).

Methods
A retrospective review of patients treated with dalbavancin at University Hospital was conducted from Aug 2019- March 2020. Patients ≥ 17 yrs of age with plan to receive at least 1 dose of dalbavancin were included. All patients were initially evaluated by, and had clinic follow up with, an infectious disease physician. Information on baseline demographics, infection characteristics, treatments, and outcomes were recorded from the EMR.

Results
42 patients met the study criteria. 62% were males with a median age of 49 yrs. 67% of patients had diabetes and 12% had a documented history of intravenous drug use. The most common indication was osteomyelitis (71%). S. aureus was the most commonly isolated organism in monomicrobial infections (MRSA 24%, MSSA 9.5%) and often a component of polymicrobial infections (33%). 90.5% of patients were adherent to their prescribed therapy; 1 patient missed both doses and 3 only received 1 of their recommended doses. Adverse effects were mild and noted in only 4 patients. 24 patients (57%) received concomitant antibiotics. 45% of patients achieved a cure with another 12% were classified as improved but requiring further antibiotics. 31% (N=13) had failure of therapy of which, 69% (N=9) did not achieve prior source control. 5 patients were lost to follow up. Our health system saved 160 inpatient days through dalbavancin use.

Conclusion
Dalbavancin treatment had a high adherence rate with minimal adverse effects and achieved a positive outcome in 57% of patients. Of patients that failed, the majority did not have appropriate source control. Dalbavancin use has the potential to save inpatient days while offering a more convenient option for treatment. However, further studies should be conducted to evaluate its efficacy in comparison to standard of care therapy at our institution.

Disclosures
All Authors: No reported disclosures
325. Invasive and Non-Invasive Osteomyelitis Caused by Group B Streptococcus Infection Among Veterans
Authors: Bej Taissa A , Wilson Brigid , Banks Richard , Briggs Janet , Song Sunah , Perez Federico , Jump Robin 
Published: January 2021

Abstract

Background
Epidemiological studies that assess invasive Group B Streptococcus (GBS) infections may not capture cases of osteomyelitis diagnosed using non-invasive cultures in combination with imaging, laboratory tests, and clinical assessment. Here, we compare GBS osteomyelitis among individuals diagnosed using invasive and non-invasive cultures.

Methods
Using the Veterans Health Administration corporate data warehouse, we studied a national retrospective cohort review of Veterans diagnosed with GBS osteomyelitis between 2008 – 2017. Invasive cases were defined as an International Classification of Disease (ICD) code for osteomyelitis accompanied by a blood or bone culture positive for GBS within 2 weeks. Non-invasive cases were defined as an ICD code for osteomyelitis and a non-invasive culture positive for GBS from a concordant site within 2 weeks. We compared demographics, comorbid conditions, mortality, and time to below- or above-knee amputation among patients with invasive and non-invasive GBS osteomyelitis.

Results
We identified 1167 cases of invasive osteomyelitis among 1077 patients and 692 cases of non-invasive osteomyelitis among 644 patients. Most patients were male (98%) with an average age of 63.2 years (± standard deviation (SD) 10.1 years). The Charlson Comorbidity Index (CCI) was similar among patients with invasive and non-invasive disease (3.85 ± SD 2.3 and 3.83 ± SD2.4, respectively). Among those with lower extremity osteomyelitis, 11% of invasive cases had an amputation at 30 days while 2% of non-invasive cases had an amputation in the same time frame (Figure 1). Mortality was similar among those with invasive and non-invasive GBS osteomyelitis at 30-days (1% and 1%, respectively) and at 1-year (11% and 9%, respectively) (Figure 2).
Figure 1: Time to Amputation

Figure 2: Survival

Conclusion
Over 1/3 of the cases of osteomyelitis caused by GBS do not meet the case definition for invasive disease. Whether diagnosed using invasive or non-invasive microbiological cultures, survival outcomes for people with GBS osteomyelitis were similar. These findings suggest that non-invasive GBS osteomyelitis is as clinically important as invasive GBS osteomyelitis and that the rates of GBS osteomyelitis may be higher than previously reported.

Disclosures
Federico Perez, MD, MS, Accelerate (Research Grant or Support)Merck (Research Grant or Support)Pfizer (Research Grant or Support) Robin Jump, MD, PhD, Accelerate (Grant/Research Support)Merck (Grant/Research Support)Pfizer (Grant/Research Support, Advisor or Review Panel member)Roche (Advisor or Review Panel member)
328. Outcomes in Spinal Cord Injury Patients with Stage 3 and 4 Pressure Injuries at a Veterans’ Affairs Hospital
Authors: Koh Shannon J , Van Beest Dominique , Kargel Jennifer , Wang Jijia , Bedimo Roger , Cutrell James B , Tan Wei-Han 
Published: January 2021

Abstract

Background
Pressure injuries (PI) and the complication of PI-related osteomyelitis (PIrOM), are a significant source of morbidity and mortality in spinal cord injury (SCI) patients. This study describes the epidemiology, healthcare utilization, and outcomes of SCI patients with PI at a large Veterans’ Affairs (VA) hospital.

Methods
We retrospectively reviewed all SCI patients with stage 3 or 4 PI in the pelvic area admitted to the VA North Texas SCI unit from 1/1/2013 to 12/31/2018. We abstracted demographic, diagnostic testing, treatment, and outcomes data from PI-related admissions for wound care from the electronic medical record. A composite definition categorizing the diagnosis of PIrOM was created (table 1). Two-sample t test and Fisher’s exact test were used to compare variables between flap patients (FP, those who received at least one flap surgery) and non-flap patients (NFP, those without any flap surgery).
Table 1. Composite Definition for Pressure Injury-related Osteomyelitis

Results
A total of 78 patients, accounting for 113 hospitalizations, and 138 unique PI, were identified (table 2). Patients had a mean age of 59 years at index admission and male predominance (97%). Of the 138 PI, 49% were ischial and 88% were stage 4. There were 27 FP and 51 NFP. The mean Charlson Comorbidity Index was 4.9 overall and significantly higher in the NFP vs. FP (5.2 vs. 4.3, p=0.05). Diagnostics included at least one imaging study in 76% (n=86) of hospitalizations and a bone biopsy in 45% (n=51). Bone biopsy cultures were commonly polymicrobial (47%, n=24), with anaerobes, Staphylococcus aureus, and Streptococcus species being the most predominant organisms. A diagnosis of definite, probable, or possible PIrOM was made in 14%, 16%, and 41% of hospitalizations, respectively (table 3). Healthcare utilization was high, with a mean length of antibiotic therapy of 54 days and mean length of stay of 122 days per hospitalization. The rates of healed PI overall at discharge and at 1 year were 27% and 39%, and 12% and 40% in the NFP group. The 1-year mortality for NFP was 22%, while all FP were alive at one year.
Table 2. Demographics and Comorbidities in SCI Patients with Stage 3 and 4 Pressure Injury

Table 3. Healthcare Utilization, Osteomyelitis Classification, and Outcomes in PI-related Hospitalizations

Conclusion
Despite significantly high healthcare utilization, VA SCI patients with stage 3 and 4 PI had very poor wound outcomes and high mortality, particularly in NFP. Evidence-based, high value care paradigms are needed for this population and disease state.

Disclosures
Roger Bedimo, MD, Gilead Sciences (Consultant)Merck & Co. (Advisor or Review Panel member)ViiV Healthcare (Advisor or Review Panel member, Research Grant or Support)
330. Risk Factors for Acute Kidney Injury after the Use of Antibiotic Loaded Bone Cement in Orthopedic Surgery – a Retrospective Case-control Study
Authors: Schulz Lucas , Georgieva Darina , Haleem Ambar 
Published: January 2021

Abstract

Background
As the number of joint replacement surgeries continues to rise, so does the number of joint infections. Many patients end up needing the implantation of antibiotic loaded bone cement (ALBC) to treat their infection. The use of localized high dose vancomycin, tobramycin, and gentamicin may be linked to acute kidney injury (AKI) in certain patients. Our hypothesis is that patients who developed AKI after receiving a joint spacer had a predisposition to AKI due to other comorbidities, high antibiotic doses in ALBC, immunosuppression, or the use of other nephrotoxic drugs pre-op. These patients may need close monitoring of their renal function and serum antibiotic levels after surgery.

Methods
We performed a chart review of 428 patients who underwent an orthopedic surgery that involved insertion of ALBC at our institution between 2015 and 2018. We excluded patients under age 18, those who had antibiotic irrigation only, trauma patients, non-arthroplasty surgeries (such as fractures and debridement of deep wounds), and patients with missing data for 30 days after the surgery. We identified 57 patients who fit our inclusion criteria and received a bone cement spacer or beads to treat an infection of the hip, knee, shoulder, or ankle. We matched patients who had AKI to 2 patients who did not have AKI. Matching was based on age (± 5 years), joint operated on, and antibiotics used.

Results
15 patients showed an elevated serum creatinine level of over 1.2 within 30 days of surgery. 86.7% of these patients were male, their average age was 64.1 ± 6.2 years old, 40% had hip surgery, 46.7% knee surgery, 6.7% ankle, and 6.7% shoulder. All received vancomycin and tobramycin in Palacos bone cement. Compared to their case-control matches, these patients had more frequent use of immunosuppressive medication, a history of malignancy, a history of previous kidney disease, and obesity. The use of combined intravenous vancomycin and piperacillin-tazobactam post-operatively may also be linked to higher rates of AKI.

Conclusion
Immunosuppression, obesity, male gender, and history of kidney injury and cancer are factors associated with AKI after ALBC spacer implantation. Further analysis and study are needed to identify potential causation between ALBC use and AKI.

Disclosures
All Authors: No reported disclosures
331. Septic arthritis: when is the joint clean enough?
Authors: Young Heather , Aragon Deborah , Miller Whitney , Iams Dane , Mauffrey Cyril 
Published: January 2021

Abstract

Background
Septic arthritis is an orthopedic emergency that requires debridement. Previous authors reported that patients with inflammatory arthropathy, diabetes, infection with S. aureus, involvement of a large joint, and synovial fluid WBC &gt;85,000 are associated with &gt;1 debridements. The purpose of this study was to determine factors associated with 1 vs &gt;1 debridements.

Methods
This is a retrospective cohort of adult patients hospitalized at Denver Health Medical Center with large joint septic arthritis between 7/1/2012 and 4/13/20. Patients with implanted orthopedic material, osteomyelitis, and recurrent septic arthritis were excluded. Septic arthritis was defined as a patient presenting with acute arthritis and positive culture OR negative culture and no other etiology. Both electronic capture and manual chart review were performed. Descriptive statistics were used to characterize the population. Statistical analyses included bivariate and multivariate analyses.

Results
Forty-four cases were included (26 knee [59.1%], 4 hip [9.1%], 6 elbow [13.6%], and 8 shoulder [18.2%]. The median age was 55.7 years (41.3–64.1], and 79.5% were male. The most common organisms were S. aureus (n=20, 45.5%) and beta-hemolytic Streptococcus (n=10, 22.7%). Three patients had no surgical debridement, 21 had 1 debridement, and 20 had &gt;1 debridements.
As compared to those who had 1 debridement, those with &gt;1 debridements were more likely to be male (95% vs 61.9%, p=0.02) and to have a higher synovial fluid leukocyte count (102,761 vs 49,154, p=0.001), CRP at admission (162.5 vs 97.7, p=0.039), and WBC the day prior to debridement (13.4 vs 9.8, p=0.007). Intra-operative purulence trended to association with &gt;1 debridements. Pre- to post-operative changes in opiate use, temperature, and ability to work with physical therapy were not associated with 1 vs &gt;1 debridements. Both higher synovial fluid leukocyte counts and CRP value at admission were independently associated with &gt;1 debridements (OR 2.31, p=0.015; OR 1.01, p=0.036 respectively).

Conclusion
Patients with higher synovial fluid leukocytes and CRP at admission were more likely to have &gt;1 debridements. Additional studies with functional outcome scores are necessary to determine if &gt;1 debridements are associated with better clinical outcomes.

Disclosures
All Authors: No reported disclosures