bluuebunny/crossref_metadata_2025_split huggingface dataset:
2322. Etiology, Severity of Illness, and Risk Factors for Patients Hospitalized with Acute Gastroenteritis from Multi-Site Veteran’s Affairs (VA) Surveillance, 2016–2018: Results from SUPERNOVA
Authors: Cardemil Cristina , Balachandran Neha , Kambhampati Anita , Grytdal Scott , Rodriguez-Barradas Maria C , Vargas Blanca , Beenhouwer David , Evangelista Karen , Marconi Vincent , Meagley Kathryn , Brown Sheldon T , Perea Adrienne , Lucero-Obusan Cynthia , Holodniy Mark , Browne Hannah , Gautam Rashi , Bowen Michael , Vinje Jan , Parashar Umesh D , Hall Aron 
Published: October 2019

Abstract

Background
The severity of acute gastroenteritis (AGE) in adult populations and the relative contribution of specific pathogens is not well characterized. In 2016, we implemented a multisite AGE surveillance platform in 4 VA hospitals (Atlanta, Bronx, Houston and Los Angeles), collectively serving > 320,000 patients annually.

Methods
Inpatient AGE cases and age- and time-matched non-AGE controls were identified through prospective screening of admissions using standardized case definitions. Stool samples were tested for 22 pathogens using the FilmArray® Gastrointestinal Panel. Medical conditions were analyzed as risk factors for AGE by multivariate logistic regression.

Results
From July 2016 to June 2018, 731 cases and 399 controls were enrolled. Risk factors for AGE cases included HIV-positive status (adjusted odds ratio [aOR] 4.6; 95% confidence interval [CI] 1.6–12.9; P < 0.01), severe kidney disease (aOR 4.5; 95% CI 2.0–9.8; P < 0.01), and immunosuppressive therapy (aOR 4.0; 95% CI 1.2–13.3]; P = 0.02). Clostridioides difficile and norovirus were the most commonly detected pathogens in cases (18% and 5%, respectively); detection of these pathogens in cases was significantly higher than detection in controls (8% and 2%, respectively; P < 0.01 for both). The median duration of hospital stay was longer for C. difficile compared with norovirus cases (5 vs. 3 days; P < 0.01), and cases with both pathogens had intensive care unit (ICU) stays (C. difficile: 18%; norovirus: 8%; P = 0.2). Fourteen deaths occurred among AGE cases; 2 were associated with C. difficile and 1 with norovirus; the remainder did not have a clear etiology or pathogen detected. C. difficile and norovirus were detected year-round with a fall and winter predominance; C. difficile prevalence was highest in October, while norovirus prevalence was six times higher in December than in summer months.

Conclusion
This surveillance platform captured cases of severe AGE, including ICU stays and deaths, among hospitalized US Veterans. C. difficile and norovirus were leading pathogens in AGE cases. These findings can help guide appropriate clinical management of AGE patients and inform public health efforts to quantify and address the associated burden of disease through targeted interventions.

Disclosures
All authors: No reported disclosures.
2330. Acute Flaccid Myelitis Recovery: Filling in the Gaps and Assessing Likelihood for Independent Living
Authors: Downey Quick Rachel , Murphey Donald , Fernandez Mariosl , Russo Susan , Hauger Sarmistha Bhaduri 
Published: October 2019

Abstract

Background
Reports of Acute Flaccid Myelitis (AFM) typically describe outcomes according to full recovery of strength and function. Full recovery rates remain low (20–30%), but most children with AFM show some degree of improvement. Data are lacking describing the ability of children with AFM to perform activities of daily living (ADL) needed to eventually live as independent adults.

Methods
This is telephone survey-based study of parents with children diagnosed with AFM in 2018 at a free-standing children’s hospital in Central Texas. The survey assesses the level of functional independence in areas of eating, bathing, dressing, toileting, and mobility. Cases diagnosed in 2018 were surveyed at 6 months from diagnosis.

Results
Four cases were diagnosed with AFM during the 2018 season. All four patients with AFM who were called to answer the survey consented to participation. Figure 1 shows degree of residual weakness and recovery in each area of ADL for all 4 patients. Despite residual weakness in half of the cases, three of the four cases had either no deficit or mild functional deficit in all areas of ADLs. One case continues to require moderate assistance in 4 areas of ADLS. Of note, this case was also the only case in the 2018 season with identified enterovirus D68 at our institution. None reported total deficit in any ADL.

Conclusion
In this sample significant functional deficits were seen in one of the four cases. This child continues to develop adaptive skills using stronger extremities to compensate for flaccid weakness. While the hope is always for full recovery, it is important to give parents a realistic picture of partial recovery and likelihood of independence. Given the success of the survey locally, we plan to expand the study to the Texas AFM Collaborative and prospectively survey cases diagnosed in 2018 every 6 months for a period of 2 years.

Disclosures
All authors: No reported disclosures.
2334. Saliva Screening for Congenital Cytomegalovirus Infection in the Neonatal Intensive Care Unit: Beware!
Authors: Medoro Alexandra , Shimamura Masako , Hanlon Cory T , Kaptsan Irina , Malhotra S , Findlen Ursula M , Hounam Gina , Adunka Oliver , Sanchez Pablo J 
Published: October 2019

Abstract

Background
Congenital cytomegalovirus (cCMV) infection is the most common cause of non-genetic sensorineural hearing loss in infancy. Screening of newborns for cCMV infection has been performed utilizing saliva due to ease of collection and high sensitivity. Positive saliva screens for CMV DNA by polymerase chain reaction (PCR) testing has been reported to occur secondary to breast milk feeding without signifying congenital infection. The NICUs of Nationwide Children’s Hospital recently began universal saliva screening of all admissions. We report 3 neonates whose saliva CMV screen was positive yet the urine CMV PCR test was negative in order to inform CMV screening strategies.

Methods
Retrospective review of the electronic health records of neonates admitted to the neonatal intensive unit (NICU) at Nationwide Children’s Hospital, Columbus, OH who had CMV detected by PCR from saliva specimens but not from urine. Pertinent demographic and clinical data were obtained.

Results
Three female neonates had a positive saliva CMV DNA PCR test but urine CMV PCR was negative. The first infant (gestational age [GA] 34 weeks, birth weight [BW]1790 Grams) was a monochorionic diamionic twin gestation and born vaginally with unknown duration of rupture of membranes (ROM). At 16 days of age, the infant had a positive saliva CMV PCR but a negative urine CMV PCR test. The infant received maternal milk. The twin’s CMV PCR tests of saliva and urine were negative. The second infant (GA 38 weeks, BW 2952 grams) was born vaginally after 9 hours of ROM. On the first day of age, the infant had a positive saliva CMV PCR test that was followed by a negative urine CMV PCR on the third day of age. The infant had not been breastfed. The third infant (GA 33 weeks, BW 1762 grams) was born by C-section delivery with ROM at delivery. Saliva CMV PCR screen was positive on the second day of age but urine PCR was negative twice (days 5 and 7). All 3 infants had no signs/symptoms of cCMV infection and passed the newborn hearing screen.

Conclusion
Testing of saliva for CMV DNA by PCR is not always confirmatory for cCMV infection as contamination of saliva specimens with CMV could result from exposure to maternal milk and possibly vaginal secretions. Definitive diagnosis of cCMV infection requires additional confirmatory testing preferably with urine.

Disclosures
All authors: No reported disclosures.
2337. Health Outcomes in Congenital Cytomegalovirus, a Systematized and Unbiased Approach in the Electronic Medical Record Era
Authors: Rochat Ryan H , Demmler-Harrison Gail J 
Published: October 2019

Abstract

Background
There is limited data on the indirect and non-medical costs associated with congenital cytomegalovirus (cCMV). Attempts to predict the economic impact of disease often rely on secondary analyses of large private databases, and may not capture the full spectrum of a disease. The granularity of billing codes in the Electronic Medical Record (EMR) make it possible to track health outcomes over time, however, with over 80,000 unique codes in ICD-10, selecting the appropriate codes requires specific content knowledge and can lead to bias in categorization. The Systematized Nomenclature of Medicine—Clinical Terms (SNOMED-CT)® provides physicians a tool to find specific ICD-10 on the basis of semantic terms. These terms can be used to build disease state-specific clusters of ICD-10 codes by which to study the economic impact of any disease, including this potentially devastating congenital infection.

Methods
Using a series of data parsing and processing scripts written in SAS V9.4 (Cary, NC), we extracted the diagnosis codes for 190 patients seen in our Congenital Cytomegalovirus Clinic at Texas Children’s Hospital in Houston, Texas. This data were consolidated into a relational database of clinical information. Through a second program we developed, clusters of ICD-10 codes were imputed from the SNOMED-CT® on the basis of semantic terms associated with cCMV (e.g., “hearing problem,” “developmental disability,” “neurological problem”).

Results
A total of 190 patients have been seen in our clinic with an ICD-10 diagnosis of CMV infection, 144 of these had cCMV, and 102 of these were born after 1/1/2008 (the inception date of our EMR). 60% of these patients were Caucasian (21% Hispanic), and 25% African American. 54 (53%) had hearing deficits, 17 (16%) had hearing aids, and 55 (54%) had developmental abnormalities. The average time (in years) to development of specific deficits are shown in Figure 1.

Conclusion
The spectrum of disease of cCMV is broad and has been well studied in the past. The EMR gives us the potential to further study this disease in finer detail and identify rates of disease progression by mining the ICD-10 codes associated with these patients throughout time. These results should prove invaluable for generating cost-models for the economic impact of cCMV.

Disclosures
All authors: No reported disclosures.
2341. Effectiveness of Interventions Targeting Stewardship of Clostridium difficile Testing
Authors: Sterling Stephanie , Sarah Hochman , Kappus Natalie , Reed Alexis , Kramer Preston 
Published: October 2019

Abstract

Background
Clostridium difficile infection (CDI) is the most common healthcare-associated infection. C. difficile PCR assays do not differentiate between colonization (seen in up to 21% of inpatients) and symptomatic disease, highlighting the importance of testing only symptomatic patients.

Methods
Interventions included system-wide implementation of C. difficile testing guidelines, face-to-face education of licensed providers, and Best Practice Alerts (BPAs) embedded in the electronic health record (EHR) C. difficile PCR order. The guidelines recommend testing only when ≥ 3 liquid bowel movements within a 24-hour period, without laxatives, oral contrast or new enteral feeds in the preceding 24 hours, and without recent C. difficile PCR test (negative ≤ 7 days or positive < 30 days). We reviewed 100 consecutive C. difficile PCR orders across two hospitals pre- and post-intervention to assess compliance with guidelines; performed weekly review of all C. difficile PCRs, all BPA responses and all hospital-onset CDI. Cost savings were calculated based on published estimates of CDI attributable costs.

Results
Hospital-onset CDI rates fell from 0.75 to 0.48 cases per 1000 patient-days, with an estimated costs savings of $259,555 per quarter and $1.04 million per year. There were no deaths due to CDI and no morbidity due to delayed CDI diagnosis. C. difficile PCR guideline compliance increased from 39% to 53%; orders decreased by 50% post-intervention. Receipt of laxatives and < 3 episodes of diarrhea were the most common reasons for guideline noncompliance. BPAs fired an average of 150 times/month. The most common trigger for BPA was laxative use. Providers canceled PCR orders in 40% of BPA events.

Conclusion
Interventions incorporating testing guidelines, face-to-face education, and EHR-embedded decision support resulted in fewer C. difficile PCRs orders, increased guideline compliance, lower rates of hospital-onset CDI and cost savings of $1 million per year without an increase in CDI-attributable death or morbidity.

Disclosures
All authors: No reported disclosures.
2345. Reduction in Testing and Change in Testing Algorithm Associated with Decrease in Number of Nosocomial Clostridium difficile Infections
Authors: Nichols Susan , Jordan Michelle D , Coogan Michael , Opera Jackie , Cook Paul P 
Published: October 2019

Abstract

Background
Previous data at our facility indicated 37% of patients with Clostridium difficile infection (CDI) were receiving at least one laxative at the time of testing, suggesting the possibility of false-positive results. Nucleic acid amplification testing (NAAT) does not distinguish between colonization and infection with C. difficile. We implemented two interventions to address these issues and evaluated our rates of nosocomial CDI before and after these changes.

Methods
This was a retrospective study of all positive test results for adult patients with nosocomial C. difficile from October 1, 2017 through March 31, 2019 at Vidant Medical Center, a 911-bed hospital. In June, 2018, we implemented a best practice advisory (BPA) in our electronic health record to recommend against testing for CDI in patients receiving laxatives. We reviewed the number of C. difficile tests ordered before and after initiating the BPA. In December, 2018, we removed NAAT and replaced it with a cell cytotoxicity assay (CCA) for specimens that were enzyme immunoassay (EIA) negative and glutamate dehydrogenase (GDH) positive. Antimicrobial use was measured in days of therapy (DOT) per 10,000 patient-days (PD). Mann–Whitney U test was used for continuous variables. Linear regression was used to monitor antimicrobial use.

Results
The number of C. difficile tests ordered per month decreased 19.5% after implementing the BPA (P < 0.0001). There was a 44% reduction in the number of EIA+/GDH+ specimens per month after the BPA intervention (P = 0.003). Following substitution of CCA for NAAT for EIA-/GDH+ specimens, there was a 61% reduction in the rate of nosocomial CDI (8.6 cases/10,000 PD to 3.3 cases/10,000 PD; P = 0.005). Total antimicrobial use was unchanged over the course of the study (673 to 677 DOT/10,000 PD). Carbapenem use decreased 56% (P = 0.009); cefepime use increased 85%(p = 0.002); quinolone and clindamycin use were unchanged.

Conclusion
Laxative use in hospitalized patients is common and likely contributes to a false elevation in the CDI rate by identifying carriers in addition to those who have true infection. Implementing a BPA to reduce inappropriate testing and changing our testing algorithm for Clostridium difficile by substituting CCA for NAAT has resulted in a lower rate of nosocomial CDI.

Disclosures
All authors: No reported disclosures.
2349. C. diff-erent results: Eliminating Inappropriate Stool PCR Tests Through an Interdisciplinary Infection Prevention and Mirobiology Collaboration
Authors: Farrell John J , Bowers Alex 
Published: October 2019

Abstract

Background
Diagnosis of Clostridium difficile infection (CDI) is based on symptoms and laboratory results. Distinguishing between CDI vs colonization or antibiotic-associated diarrhea is challenging. Widespread adoption of a highly sensitive real-time nucleic-acid amplification assay for toxin B DNA (Xpert CD assay, Cepheid) by US hospital-based microbiology labs has increased the challenge, resulting in overreporting of healthcare facility-onset CDI. Excess testing is inevitable in hospitals with EPIC electronic medical record (EMR) that incorporate best practice alerts (BPAs) prompting for C. difficile testing (CDT) when loose stools are charted by nursing staff.

Methods
Beginning October 1, 2018 microbiology and infection prevention (IP) staff at our 650 bed teaching hospital in central IL agreed to partner on a diagnostic stewardship effort to engage providers on potentially unnecessary or inappropriate CDTs. All stool samples sent to lab for CDT are held pending IP review. The IP review tool provides a guide for EMR review of contributing factors in diarrhea, including patient history, medications (e.g., laxatives, stool softeners), nutrition (e.g., tube feeds), symptoms (abdominal pain), and labs (e.g., serum creatinine, WBC count). Inappropriate CDT was defined as test of patients receiving pro-motility treatment, without signs of infection.

Results
Between October 1, 2018 and December 31, 2018, 383 CDT were ordered on inpatients. 196 were requested within 3 days of admission, and 187 were requested on beyond day 4. 56.6% (107/187) HO-CDTs were deemed inappropriate and canceled; 80 HO-CDT were deemed appropriate. 18.8% (15/80) of HO-CDTs were positive. Compared with October 1 - December 31, 2017, HO-CDI cases decreased by 66.7% (1.0 - 15/45) over the same period in 2018.

Conclusion
A 66.7% reduction in HO-CDI (vs. FY2017 cases) was seen in the first 3 months following adoption of a team-based (IPs, microbiology lab staff and MD director), CDT diagnostic stewardship intervention employing EMR review and patient provider engagement (RNs and MDs). Opportunities identified during the first 90 days of CDT stewardship: (a) Lack of provider awareness of pro-motility therapies; (b)inappropriate prompting for CDT generated by the EPIC EMR.

Disclosures
All authors: No reported disclosures.
2357. Toxin Detection Using Single Molecule Counting Technology: The Best of Both Worlds?
Authors: Perry Michael , Graham Lee , Parida Sweta , Katzenbach Phoebe , Luis Baptista Baeza Jose , Estis Joel , Sandlund Johanna , Anderson Bethan , Copsey Sarah , Scotford Selina , Morris Trefor 
Published: October 2019

Abstract

Background
Accurate diagnosis of CDI remains challenging as there is no standalone laboratory test with adequate clinical sensitivity and specificity. Thus, many clinical laboratories currently employ a multistep algorithm incorporating a sensitive screening test followed by a specific toxin test. An automated ultrasensitive toxin immunoassay (Singulex Clarity® C. difficile toxins A/B assay) has demonstrated excellent performance compared with cell cytotoxicity neutralization assay (CCNA). In this study, the Clarity assay was evaluated relative to glutamate dehydrogenase (GDH), toxin EIA, toxin B gene PCR, multistep algorithms, and C. difficile culture with ribotyping.

Methods
Residual clinical stool samples (n = 293) were collected from patients with suspected CDI. The samples were tested on-site with GDH (C. DIFF CHEK™-60), PCR (EntericBio realtime® C. difficile assay), a membrane-type toxin EIA (Tox A/B Quik Chek®), and culture and ribotyping. In total, 188 samples were tested with GDH and 239 samples were tested by PCR. All PCR-positive samples (n = 148) and prospectively tested GDH samples (n = 97) were tested with the toxin EIA. Culture and ribotyping information were available for 205 samples.

Results
Three of the samples tested gave no result using the Clarity assay and were excluded from the analysis. The Singulex Clarity C. difficile toxins A/B assay had high positive percent agreement (PPA) and low negative percent agreement (NPA) compared with toxin EIA and multistep algorithms ending with toxin EIA. The Clarity assay had high NPA and low PPA compared with PCR, GDH, and the multistep algorithm ending with PCR (figure). Less than 70% of the detected C. difficile PCR positive samples had toxins present. There was no difference in toxin concentration between the ribotypes.

Conclusion
The Clarity assay had strong PPA compared with toxin EIA and strong NPA compared with PCR. The low NPA and PPA compared with toxin EIA and PCR, respectively, may reflect the poor sensitivity of current toxin EIAs and low specificity of PCR. The Clarity assay detected 30 different ribotype strains, and less than 70% of samples (by PCR) or strains (by ribotyping) had toxins present. The Clarity assay may be considered for use as a standalone test for CDI diagnosis.

Disclosures
All authors: No reported disclosures.
2377. Social Determinants Impact Readmission Following Clostridioides difficile-Related Index Hospital Stay in Medicare Patients
Authors: Scaria Elizabeth , Powell Ryan , Birstler Jen , Alagoz Oguzhan , Shirley Daniel , Safdar Nasia 
Published: October 2019

Abstract

Background
Clostridioides difficile infection (CDI) is the leading cause of healthcare-associated diarrhea and recurs in up to 30% of patients, often requiring readmission. Socioeconomic factors, such as living in a disadvantaged neighborhood may impact readmission but have not been studied.

Methods
We examined the relationship between neighborhood disadvantage, as measured by the Singh validated area deprivation index (ADI), and 30-day all-cause readmission risk in patients with an index hospital stay with CDI. We analyzed a random 20% sample of national Medicare claims for patients’ initial index hospitalization with a CDI diagnosis in 2014 (n = 19,528) that included each patient’s neighborhood ADI national percentile. The most disadvantaged neighborhoods were categorized as those in the upper 35 percentile, while the least disadvantaged was defined as those in the bottom 65% of national ADI rankings. We evaluated the relationship between ADI percentile and 30-day readmission risk using multivariate logistic regression, controlling for key patient demographics, comorbidities, and hospital/stay characteristics.

Results
A total of 19,528 patients had an index stay with CDI, 4,899 were readmitted within 30 days. Patients from the most disadvantaged neighborhoods had a higher average rate of readmission compared with those living in the least disadvantaged neighborhoods (28% vs. 24% rate; unadjusted risk ratio = 1.16 [1.10, 1.21]). This relationship held after controlling for confounders. After adjustment, being a resident in the most disadvantaged neighborhoods was associated with a 10% increased risk of readmission (adjusted risk ratio = 1.10 [1.05, 1.16]), which was similar to the effect sizes associated with dual Medicaid-Medicare enrollment status (adjusted risk ratio = 1.09 [1.03, 1.15]) and renal failure (adjusted risk ratio = 1.14 [1.08, 1.21]).

Conclusion
Living in a disadvantaged neighborhood is associated with an increased 30-day readmission risk similar in magnitude to Medicaid status and renal failure in patients with index hospitalizations of CDI. Future studies should examine whether interventions such as post discharge support and care coordination for patients in disadvantaged neighborhoods may reduce readmissions in this patient population.

Disclosures
All authors: No reported disclosures.