bluuebunny/crossref_metadata_2025_split huggingface dataset:
80. Opioid Analgesics Are Associated with Increased Clostridioides difficile Infection Risk in a National Cohort of Veterans
Authors: Young Eric H , Lalani Falak S , Reveles Kelly R 
Published: October 2019

Abstract

Background
Clostridioides difficile infection (CDI) is the leading cause of healthcare-associated diarrhea. Several drugs are known to increase CDI risk, although the association between opioids and CDI risk has not been clearly established. Opioid analgesics have gastrointestinal antimotility and immunomodulatory effects, which may predispose patients to infection. The purpose of this study was to determine the association between opioid use and CDI risk.

Methods
This was a retrospective case–control study that utilized inpatient and outpatient data from the national United States Veterans Health Administration (VHA). CDI patients included those age 18 to 89 years with an ICD-9-CM code for CDI (008.45), a positive stool test, and active CDI therapy between October 1, 2002 and September 30, 2014. A control cohort of VHA patients was created by randomly sampling patients without a CDI ICD-9-CM code during the study period and matched to CDI patients by visit setting and fiscal year. Opioid use was defined as at least one prescription for morphine, hydromorphone, hydrocodone, and/or codeine in the 90 days prior to study inclusion. The χ 2 test was used to compare the proportion of patients who received an opioid in the CDI and control groups. Opioid risk factors for CDI were analyzed using a multivariable logistic regression model that included 33 covariates.

Results
A total of 85,451 patients were included in this study (26,149 CDI patients and 59,302 controls). Overall, 50.1% and 30.1% of patients were prescribed an opioid in the CDI and cohort group, respectively. Overall, opioids were associated with significantly increased CDI risk (OR 1.92, 95% CI 1.86–2.00) and was even greater for >1 opioid (OR 2.40; 95% CI 2.25–2.55). Opioids with the strongest association with CDI risk include morphine (OR 2.04, 95% CI 1.95–2.13), followed by hydromorphone (OR 1.74, 95% CI 1.63–1.87), codeine (OR 1.56, 95% CI 1.44–1.70), and hydrocodone (OR 1.14; 95% CI 1.09–1.19).

Conclusion
In a national cohort of veterans, patients with recent opioid analgesic use had an increased risk of developing CDI compared with a control group. Opioid analgesics with greater immunomodulatory and constipating effects were associated with increased risk compared with other opioids.

Disclosures
All Authors: No reported Disclosures.
85. Use of Dual Statistical Process Control Charts for Early Detection of Surgical Site Infection Outbreaks at a Community Hospital Network
Authors: Baker Arthur W , Nehls Nicole , Ilieş Iulian , Benneyan James C , Anderson Deverick J 
Published: October 2019

Abstract

Background
We recently showed that the empirical use of a combination of 2 moving average (MA) statistical process control (SPC) charts was highly sensitive and specific for detecting potentially important increases in surgical site infection (SSI) rates. We performed this follow-up study to examine the performance of these same SPC charts when applied to known SSI outbreaks.

Methods
We retrospectively applied 2 MA SPC charts to all 30 SSI outbreaks investigated from 2007 to 2015 in a network of over 50 community hospitals. These outbreaks were detected via routine SSI surveillance activities that occurred in the network. We reviewed prior outbreak investigation documentation to determine the estimated time of outbreak onset and time of traditional surveillance outbreak detection. The first SPC chart utilized procedure-specific, composite SSI data from the hospital network for its baseline; the baseline for the second chart was calculated from SSI data from the outbreak hospital undergoing analysis. Both charts used rolling baseline windows but varied in baseline window size, rolling baseline lag, and MA window size. SPC chart outbreak detection occurred when either chart had a data point above the upper control limit of 1 standard deviation. Time of SPC detection was compared with both time of outbreak onset and time of traditional surveillance detection.

Results
With the dual chart approach, SPC detected all 30 outbreaks, including detection of 25 outbreaks (83%) prior to their estimated onset (Figure 1). SPC detection occurred a median of 16 months (interquartile range, 12–21 months) prior to the date of traditional outbreak detection, which never occurred prior to outbreak onset. Both individual SPC charts exhibited at least 90% sensitivity in outbreak detection, but the dual chart approach showed superior sensitivity and speed of detection (Figure 2).

Conclusion
A strategy that employed optimized, dual MA SPC charts retrospectively detected all SSI outbreaks that occurred over 9 years in a network of community hospitals. SPC outbreak detection occurred earlier than traditional surveillance detection. These optimized SPC charts merit prospective study to evaluate their ability to promote early detection of SSI clusters in real-world scenarios.

Disclosures
All Authors: No reported Disclosures.
86. Ventilator-Associated Pneumonia in Trauma Intensive Care Unit, a Dilemma in Quality Metrics
Authors: Karnatak Rajendra , Schlitzkus Lisa , Hinkle Lauren , Lyden Elizabeth , Cawcutt Kelly , Cawcutt Kelly 
Published: October 2019

Abstract

Background
Ventilator-associated pneumonia (VAP) definition remains controversial. Ventilator-associated event (VAE) and probable/possible VAPs are reported to the National Healthcare Network (NHSN). In trauma patients, VAPs are also reported to the Trauma Quality Improvement Project (TQIP) utilizing the National Trauma Data Bank (NTDB)’s definition.

Methods
We reviewed all VAPs reported to NHSN and TQIP in trauma patients at the University of Nebraska Medical Center between January 1, 2015 and June 30, 2018. The primary objective was to determine the discordance rates between NHSN and NTDB definitions. VAPs identified by both NHSN+NTDB considered concordant; if identified by only one definition, considered discordant. Secondary objectives were mortality, intensive care unit (ICU) length of stay (LOS), and ventilator (vent) days. Fisher’s exact test and the Kruskal–Wallis test were used where appropriate; P < 0.05 = statistical significance.

Results
In total, 998 patients had 5,624 days of vent support during the study period. One hundred and one patients were diagnosed with VAP. The median age was 43 years (range 2–92), median vent days were 14 days (range 3–128), and median ICU LOS was 16 days (range 6–47). Of the 101 patients, 28 (27%) met VAP definition by NHSN and 88 (87%) by NTDB. Of the 101 patients, 15 (15%) were concordant and 85 (85%) were discordant. Cumulative all-cause mortality was 23/101 (23%). Composite analysis showed mortality 5/15 (33%) in concordant group, 3/13 (23%) in NHSN group, and 15/73 (20%) in NTDB group (P = 0.52). Median vent days between concordant, NHSN, and NTDB groups were 14 days, 16 days, and 14 days, respectively (P = 0.71). Median ICU LOS was 17 days in concordant, 21 days in NHSN, and 14 days in NTDB group (P = 0.094). Similarly, comparison of NHSN VAE with NTDB VAP definition showed 67/101 (66%) were discordant. There was no statistically significant difference in mortality between concordant (NHSN VAE+NDTB VAP) 9/34 (26%), NHSN VAE 3/13 (23%), and NTDB VAP 11/54 (20%) (P = 0.84).

Conclusion
Our study showed very high discordant (85%) reporting of VAP to different agencies. No difference in mortality, ICU LOS, and vent days was noted. The high discordance of reported VAPs results in inconsistency in quality metrics and hinders initiatives to decrease VAPs depending on which definition is followed. Improved standardization is needed.

Disclosures
All Authors: No reported Disclosures.
89. Efficacy and Tolerability of Voriconazole (VOR) vs. Isavuconazole (ISA) Prophylaxis (px) in Preventing Invasive Fungal Infections (IFI) in Lung Transplant Recipients (LTR)
Authors: Samanta Palash , Marini Rachel V , McCreary Erin K , Shields Ryan K , Falcione Bonnie A , Alex Viehman J , Sacha Lauren , Rivosecchi Ryan , Jeong Kwak Eun , Silveira Fernanda P , Clarke Lloyd , Clancy Cornelius J , Nguyen Minh-Hong 
Published: October 2019

Abstract

Background
IFI is a significant complication following lung transplant (LT). VOR was universal antifungal px in our LT program from 2004 to October 2015, at which time px was changed to ISA. We compared the efficacy and tolerability of VOR vs. ISA px in LTR.

Methods
We reviewed all LTR from September 2013 to February 2018 who received VOR or ISA Px. The standard duration of px was 3 or 4 months following basiliximab and alemtuzumab induction, respectively. All patients were followed for ≥1 years post-Tx. IFI was defined by revised EORTC/MSG criteria.

Results
In total, 310 LTR were included, 149 and 161 of whom received ISA and VOR px, respectively. There was no difference in demographics, underlying diseases, single vs. double LT, or induction therapy (alemtuzumab vs. basiliximab) between the 2 groups. At 1-year after LT, 9% (14) and 8% (13) of patients in ISA and VOR groups developed IFI, respectively (P = 0.5). 5% (7) and 3% (5) of patients developed breakthrough (BT) IFI during ISA and VOR px, respectively (P = 0.6; Figure 1, P = 0.4, Kaplan-–Meier). ISA BT included pneumonia (PNA, 2), endobronchial IFI (2), mediastinitis (1), chest wall IFI (1), and candidemia (1). ISA BT patients were infected with Aspergillus fumigatus (3; 2 with ISA MIC = 0.5 µg/mL, 1 MIC = 1 µg/mL), black mould (1), and yeasts (3; 2 C. glabrata, 1 C. albicans). VOR BT IFI included PNA (2), endobronchial IFI (1), empyema (1), and chest wall IFI (1). VOR BT IFIs were due to A. ustus, A. niger, A. lentulus, black mould, and Rhizopus spp (1 each). All Aspergillus VOR BT isolates exhibited VOR MIC ≥2 µg/mL. Patients with IFI were more likely to have positive pre-LT respiratory fungal culture (P = 0.01) and grade ≥3 ischemic reperfusion injury (IRI) post-LT (P = 0.01). VOR and ISA were prematurely discontinued in 53% (85) and 14% (21) of patients due to adverse events, respectively (P < 0.0001). Hepatotoxicity was more common with VOR (22%, 35) than ISA (5%, 7) (P < 0.0001). IFI was an independent risk factor for death at 1 year (Figure 2, P < 0.0001, Kaplan–Meier).

Conclusion
ISA was as effective as VOR in preventing IFI in LTR, and significantly better tolerated. Pre-LT fungal culture positivity and grade ≥3 IRI post-LT were risk factors for the development of IFI. IFI within 1-year post-LT had a significant impact on mortality

Disclosures
Fernanda P. Silveira, MD, MS, FIDSA, Ansun: Grant/Research Support; Qiagen: Grant/Research Support; Shire: Grant/Research Support; Whiscon: Grant/Research Support.
91. Differential Impact of Cytomegalovirus (CMV) Donor (D) Serostatus on Rates and Kinetics of CMV Viremia among CMV Seropositive Recipients (R+) of Ex vivo T-cell Depleted (TCD) and Unmodified (CONV) Hematopoietic Cell Transplants (HCT)
Authors: Stern Anat , Su Yiqi , Fang Jiaqi , Perales Miguel , Maloy Molly , Giralt Sergio , Papanicolaou Genovefa 
Published: October 2019

Abstract

Background
In unmodified (CONV) HCT, CMV donor seropositivity (D+) conveys partial protection against CMV disease mediated by the transfer of donor CMV T-cell immunity through the allograft. Ex vivo T-cell depletion by CD34 selection affords a stringent depletion of donor T cells, thus transfer of donor T-cell immunity to CMV would be negligible. We evaluate the impact of CMV D serostatus on rates and kinetics of CMV viremia by Day (D)100 post-HCT in a contemporary cohort of CONV and TCD recipients from a single center.

Methods
A retrospective cohort study of R+ adult recipients of first peripheral blood or marrow HCT for hematologic malignancies (excluding multiple myeloma) from June 2010 to December 2017 at MSKCC. Routine CMV monitoring by a quantitative PCR assay occurred weekly from D14 through D100. Patients were treated preemptively. CMV viral burden was assessed as the time-averaged area under the viremia curve over 100 days from HCT (AAUC) calculated as the sum of the area of trapezoids of AUC viral loads divided by the number of weeks of follow-up viremia. The median AAUC for all patients with CMV reactivation (AAUC50) was used to classify patients as CMV controllers (AAUC ≤ AAUC50) or noncontrollers (AAUC >AAUC50).

Results
Of 509 R+, 290 (57%) patients received CONV and 219 (43%) TCD HCT; from 300 (59%) D+ and 209 (41%) D− donors. In CONV, CMV viremia occurred with similar frequency in D+ (65%) and D− (62%), P = 0.6. In contrast, in TCD, CMV viremia occurred more frequently in D+ compared with D− (83% vs. 71%, P = 0.03). Among CONV, D+ was associated with lower CMV burden (median AAUC) compared with D− (0.791 vs. 1.13, respectively, P = 0.0004). In contrast, in TCD, AAUC was similar between D− and D+ (1.19 vs. 1.35; P = 0.86). Among CONV with CMV viremia, D− were more likely to be noncontrollers compared with D+ (56% vs. 31%, respectively, P = 0.001). In contrast, among TCD with CMV viremia the proportion of noncontrollers was similar between D− and D+ (61% vs. 60%, respectively; P = 1).

Conclusion
Donor CMV serostatus has a differential effect on rates and kinetics of CMV viremia in R+ TCD and CONV HCT recipients. D+ is associated with less CMV viremia and less CMV burden in CONV but not in TCD. Our findings, if confirmed, have implications for donor selection algorithms.

Disclosures
All Authors: No reported Disclosures.
93. Trends in the Laboratory Detection of Rotavirus Before and After Implementation of Routine Rotavirus Vaccination: the United States, 2000–2018
Authors: Hallowell Benjamin D , Parashar Umesh D , Curns Aaron , DeGroote Nicholas , Tate Jacqueline 
Published: October 2019

Abstract

Background
Before the introduction of rotavirus vaccine in the United States in 2006, rotavirus infection was the leading cause of severe gastroenteritis among US children.

Methods
To evaluate the long-term impact of rotavirus vaccination on disease burden in the United States, CDC analyzed national laboratory testing data for rotavirus from laboratories participating in CDC’s National Respiratory and Enteric Viruses Surveillance System (NREVSS) during the pre- (2000–2006) and post-vaccine (2007–2018) periods.

Results
Nationally, the median annual percentage of positive rotavirus tests declined from 25.6% (range: 25.2–29.4%) in the pre-vaccine era to 6.1% (range: 2.6–11.1%) in the post-vaccine period. When comparing the pre- and post-vaccine era, the annual peak in rotavirus positivity declined from a median of 43.1% (range: 43.8–56.3%) to a median 14.0% (range: 4.8–27.3%) while the season duration was reduced from a median of 26 weeks (range: 23–27 weeks) to 9 weeks (range: 0–18 weeks). In the post-vaccine period, a biennial pattern emerged with alternating years of low and high rotavirus activity.

Conclusion
The implementation of rotavirus vaccine has dramatically reduced the disease burden and altered seasonal patterns of rotavirus in the United States; these changes have been sustained over 11 post-vaccine introduction seasons.

Disclosures
All Authors: No reported Disclosures.
94. Pneumonia Severity Scores Poorly Predict Severe Outcomes Among Adults Hospitalized with Influenza
Authors: Doyle Joshua , Garg Shikha , O’Halloran Alissa , Beacham Lauren , Cummings Charisse N , Herlihy Rachel , Yousey-Hindes Kim , Anderson Evan J , Monroe Maya , Kim Sue , Lynfield Ruth , Irizarry Lourdes , Spina Nancy , Bennett Nancy M , Hill Mary , Reed Carrie , Schaffner William , Talbot Keipp , Self Wesley , Williams Derek 
Published: October 2019

Abstract

Background
Influenza can lead to severe outcomes among adults hospitalized with influenza, and causes substantial annual morbidity and mortality. We evaluated the performance of validated pneumonia severity indices in predicting severe influenza-associated outcomes.

Methods
We conducted a multicenter study within CDC’s Influenza Hospitalization Surveillance Network (FluSurv-NET) which included adults (≥ 18 years) hospitalized with laboratory-confirmed influenza during the 2017–18 influenza season. Medical charts were abstracted to obtain data on vital signs and laboratory values at admission on a stratified random sample of cases at a subset of hospitals at 11 network sites. Estimates were weighted to reflect the probability of selection. Cases were assigned to low- and high-risk groups based on the CURB-65 (‘Confusion, Urea, Respiratory rate, Blood pressure, Age ≥65’) index (high-risk cutoff = score ≥ 3), and the Pneumonia Severity Index (PSI) (high-risk cutoff = category V). We calculated area under receiver operating characteristic curves (AUROC), sensitivity, and specificity to estimate the performance of each index in predicting severe outcome categories: (1) intensive care unit (ICU) admission, 2) noninvasive mechanical ventilation (NIMV), (3) mechanical ventilation (MV), vasopressors, extracorporeal membrane oxygenation (ECMO) and (4) death.

Results
Among 27,523 adults hospitalized with influenza, 8665 (31%) were sampled for inclusion in this analysis; median age was 70 years and 92% had ≥ 1 chronic condition. A total of 1,366 (16%) were classified as high-risk by CURB-65 and 1,249 (14%) by PSI. Both indices had low discrimination for severe outcomes; the AUROC for CURB-65 ranged from 0.55 for ICU admission to 0.65 for death, and for PSI ranged from 0.58 for ICU admission to 0.73 for death. Risk status by CURB-65 was less sensitive than PSI in predicting MV, vasopressor, or ECMO usage as well as death (figure). The specificity of CURB-65 and PSI was similar against all outcomes (figure).

Conclusion
The CURB-65 and PSI indices performed poorly in predicting severe outcomes other than death; PSI had the best discrimination overall. Alternative approaches are needed to predict severe influenza-related outcomes and optimize clinical care.

Disclosures
All Authors: No reported Disclosures.
95. Impact of Influenza-Like Illnesses on Academic and Work Performance on a College Campus
Authors: Emanuels Anne , Brandstetter Elisabeth , Newman Kira L , Wolf Caitlin , Logue Jennifer , Englund Janet A , Boeckh Michael , Chu Helen Y 
Published: October 2019

Abstract

Background
Influenza-like illnesses are estimated to cause 500,000 hospitalizations and 50,000 deaths each year in the United States. The high-contact environment of a college campus makes students, faculty, and staff especially prone to respiratory illness, but the impact of these illnesses on academic and work performance is not well understood.

Methods
Between January 14 and April 3, 2019, the Seattle Flu Study enrolled participants with respiratory symptoms throughout the Seattle metropolitan area, including the University of Washington’s main campus. Individuals with at least two self-reported respiratory symptoms in the previous 7 days were eligible to enroll. Participants completed a questionnaire with questions about their medical history, current illness episode, and other behavioral characteristics; a corresponding mid-nasal swab was also collected. Influenza-like illness (ILI) was defined as self-reported fever with a cough and/or sore throat. Laboratory results are pending. Logistic regression was used to assess the association between ILI and work and academic outcomes, including missing class, missing work, performing poorly on an assignment or examination, and experiencing high interference on daily life.

Results
A total of 497 participants enrolled at the University of Washington. Participants had a median age of 22, and 61% were female. Of those with self-reported ILI, 27% reported smoking, 22% had traveled out of state, and 14% had traveled internationally in the month before enrollment. These characteristics did not differ between those with ILI and those with non-ILI. Having symptoms of ILI was associated with reports of missing work (OR 2.9; 95% CI: 1.9, 4.5), missing class (OR 3.4; 95% CI: 2.3, 5.2), performing poorly on assignments and exams (OR 1.8; 95% CI: 1.2, 2.6), and having high interference with daily life (OR 6.0; 95% CI: 3.8, 9.5) as compared with individuals with a non-ILI illness. These impacts were strongest during January and February.

Conclusion
A high prevalence of ILI was observed on campus. These symptoms were found to have a substantial impact on academic and occupational productivity. This demonstrates the need for greater illness prevention efforts on college campuses during influenza season.

Disclosures
All Authors: No reported Disclosures.
837. Prior Hospitalizations Among Cases of Community-Associated Clostridioides difficile Infection—10 US States, 2014–2015
Authors: Hatfield Kelly M , Baggs James , Winston Lisa Gail , Parker Erin , Johnston Helen , Brousseau Geoff , Olson Danyel M , Fridkin Scott , Wilson Lucy , Perlmuter Rebecca , Holzbauer Stacy , Phipps Erin C , Hancock Emily B , Dumyati Ghinwa , Ocampo Valerie , Kainer Marion A , Korhonen Lauren C , Jernigan John A , McDonald L Clifford , Guh Alice 
Published: October 2019

Abstract

Background
Despite overall progress in preventing Clostridioides difficile Infection (CDI), community-associated (CA) infections have been steadily increasing. Although the incubation period of CDI is thought to be relatively short, gastrointestinal microbial disruption from remote healthcare exposures (e.g., inpatient antibiotic use) may be associated with CA-CDI. To assess this potential association, we linked CA-CDI infections identified through CDC’s Emerging Infections Program (EIP) to Medicare claims data to describe prior healthcare utilization.

Methods
We defined an EIP CA-CDI case as a positive C. difficile test collected in 2014–2015 from an outpatient or inpatient within 3 days of hospital admission, provided there was no positive test in the prior 8 weeks and no admission to a healthcare facility in the prior 12 weeks. We linked EIP CA-CDI cases aged ≥65 years to a Medicare beneficiary using unique combinations of birthdate, sex, and zip code. Cases were included if they maintained continuous fee-for-service coverage for 1 year prior to the event date. To calculate exposure odds ratios for previous hospitalizations, each case was matched to 5 control beneficiaries on age, sex, and county of residence. We used logistic regression to calculate adjusted matched odds ratios (amOR) that controlled for chronic conditions.

Results
We successfully linked 2,287/3,367 (68%) EIP CA-CDI cases. Of these, 1,236 cases met inclusion criteria; the median age was 77 years and 63% were female. We identified 69 (5.6%) cases with misclassification of prior healthcare exposures, most of whom (48, 70%) were hospitalized in the 12 weeks prior to their event. Among the 1,167 true CA-CDI cases, 33% were hospitalized in the prior 12 weeks to 1 year. The median number of weeks from prior hospitalization to CDI was 27 (IQR 18–38, Figure 1). Cases had a higher risk of hospitalization than matched controls in the prior 3–6 months (amOR: 2.33, 95% CI: 1.87, 2.90) and 6–12 months (amOR: 1.43 95% CI: 1.18, 1.74).

Conclusion
Remote hospitalization in the previous year was a significant risk factor for CA-CDI, especially in the 3–6 months prior to CA-CDI. Long-lasting prevention strategies implemented at hospital discharge and enhanced inpatient antibiotic stewardship may prevent CA-CDI among older adults.

Disclosures
All Authors: No reported Disclosures.