bluuebunny/crossref_metadata_2025_split huggingface dataset:
1403. Infectious Causes of Acute Meningitis Among Thai Adults: A University Hospital Setting
Authors: Aimbudlop Kittipat , Kiertiburanakul Sasisopin 
Published: October 2019

Abstract

Background
Acute meningitis is a medical emergency which needs immediate assessment and treatment. Knowing the epidemiology of acute meningitis may guide the physician for promptly empirical therapy as well as minimize morbidity and mortality. In Thailand, there are few studies regarding acute meningitis in adults and most of them have not been updated. We aimed to determine etiology, clinical manifestations, cerebrospinal fluid (CSF) findings and outcomes of patients with acute meningitis.

Methods
A retrospective cohort study was conducted among adult (age >15 years) patients with acute meningitis who were treated at Ramathibodi Hospital between 2013 and 2017. The list of the patients was retrieved from the hospital database using the International Classification of Diseases, 10th revision (ICD-10) codes. Comparisons of clinical presentations and laboratory investigations between patients with bacterial meningitis and those with non-bacterial meningitis were analyzed.

Results
A total of 89 patients were included. Of all, 48 (53.9%) patients were men and median age (interquartile range; IQR) was 49 (32.1–63.8) years. The most common coexisting condition was HIV infection (30%), receiving prednisolone (16.9%), and diabetes mellitus (15.7%). Causes of acute meningitis were Cryptococcus neoformans (37%), bacteria (31.5%), Mycobacterium tuberculosis (27%), and virus (4.5%). Common clinical presentations were fever (74%), headache (70.8%), and confusion (31.5%). Older age, higher proportion of patients with diabetes, lower proportion of HIV infection, higher median white blood cells (WBCs) in complete blood count (CBC), lower median platelet, higher median aspartate aminotransaminase, higher median alkaline phosphatase, higher median WBCs, and polymorphonuclear neutrophils (PMNs) percentage in CSF were found in patients with acute bacterial meningitis. By multivariate logistic regression, predicting factors of acute bacterial meningitis were WBCs in CBC (OR 1.02 per 100 cells/mm3 increased; 95% CI 1.01–1.04, P = 0.001), WBCs in CSF (OR 1.04 per 10 cells/mm3 increased; 95% CI 1.01–1.07, P = 0.012) and PMNs percentage in CSF (OR 1.21 per 5% increased; 95% CI 1.07–1.37, P = 0.002). Overall, the median (IQR) duration of hospitalization was 23 (11–29) days. A total of 26 (29%) patients had a complication, such as septic shock, hydrocephalus, seizure, and brain edema. The mortality rate was 7.9%.

Conclusion
In this setting, the most common cause of acute meningitis in adults is cryptococcosis. In addition, tuberculosis is not uncommon. Awareness of update epidemiology may guide the physicians to initiate appropriate antimicrobial therapy.

Disclosures
All authors: No reported disclosures.
1407. Potential Impact of the Biofire® Film Array Meningitis and Encephalitis (ME) Panel in Reducing Repeat Lumbar Punctures in Patients with Meningitis and Encephalitis
Authors: Aguilera Elizabeth A , Simar Shelby , Wootton Susan H , Hasbun Rodrigo 
Published: October 2019

Abstract

Background
The Biofire® FilmArray Meningitis Encephalitis (FAME) is a multiplex polymerase chain reaction (PCR) test can rapidly detect up to 14 pathogens that cause meningitis and encephalitis. The impact on preventing repeat lumbar punctures to obtain more diagnostic studies is currently unknown.

Methods
Patients admitted to Memorial Hermann Hospital (MHH) between July 2018-February 2019 with community-acquired symptoms of meningitis or encephalitis, CSF with white blood cell count >5 cells/mm3, and with leftover CSF at the MHH microbiology laboratory were eligible for the study. Testing FAME was performed after discharge for specimens that had not been centrifuged, had a volume of ≥200 μL, were appropriately stored, and were collected by lumbar puncture (LP) for evaluation of suspected meningitis/encephalitis.

Results
Of 1,382 CSF specimens screened, 70 (5.0%) met the criteria and were tested with FAME. The majority was adults (72.8%), non-Caucasian (68.6%), male (60%), immunocompetent (75.7%) and had a meningitis presentation (75.7%). Mean age was 36.9 years (1 mo-89 years). The mean duration between CSF collection and any PCR result done in the hospital was 60 hours. Fifteen patients (21.4%) required 25 repeat LPs [13 (86.6%) for additional testing (7 (53.8%) pediatric patients) and 2 (13.3%) for cryptococcal meningitis assessment]. The FAME could have prevented repeat LPs in 86.6% of patients. Five of the 13 repeat LP (38.4%) FA ME showed a pathogen [VZV (2), HSV 1 (1), HHSV-6 (1), Neisseria meningitidis (1)]. Of 46 tests with negative FA ME, acyclovir therapy was started in 22 (47.8%) with a mean of 6 doses dispensed. 38 (26.6%) patients were discharged with an unknown etiology of whom FA ME was positive in 8 (21%) [HSV2 (37.5%), VZV (25%), Enterovirus (25%) and HSV1 (12.5%)]. PCR was ordered in the hospital for only 4 (50%) of these patients.

Conclusion
The FAME identified an etiology in 21% of patients with meningitis and encephalitis symptoms discharged with an unknown etiology. A total of 18.5% of patients required a repeat LP for additional testing. FAME testing offers an avenue for reducing the burden of repeat LPs and duration of unnecessary anti-infective therapy while increasing diagnostic yield.

Disclosures
All authors: No reported disclosures.
1412. Spontaneous Intramedullary Abscess from Streptococcus anginosus Group: A Case Report and a Review of the Literature
Authors: Patterson Monica M , Aleissa Muneerah , Dionne Brandon , Pearson Jeffrey , Yawetz Sigal , Manne-Goehler Jennifer 
Published: October 2019

Abstract

Background
Intramedullary abscess of the spinal cord (IASC) symptoms are often nonspecific with the diagnosis rarely considered on the initial differential. This can delay surgical management and may lead to permanent neurological deficits or mortality. Additionally, many organisms are implicated in IASC, leading to uncertainty in empiric antimicrobial therapy.

Methods
This case report follows a patient with IASC due to Streptococcus anginosus group (SAG). We also review a 25-case meta-analysis of IASC and 5 cases of SAG IASC.

Results
A 65-year-old woman with an unremarkable past medical history presented with 2 weeks of neck pain and paresthesias. She was afebrile with no systemic signs of infection or abnormal laboratory markers. MRI revealed an 8mm lesion at C4-C5 with edema C1-T1 and she received high-dose steroids for suspected malignancy. Follow-up MRI 4 days later revealed rapid progression of the lesion to 14mm, consistent with an infectious process (Figure 1). The patient received empiric therapy with ceftriaxone, vancomycin, and metronidazole. She underwent a C2-C7 laminectomy with midline myelotomy for evacuation of the abscess. Due to clinical and radiographic progression she required a second surgical wash-out 4 days later. Her intraoperative cultures grew SAG and her regimen was changed to penicillin and vancomycin. Her course was complicated by eosinophilia requiring meropenem and later linezolid to complete a 6-week course, during which she improved clinically and neurologically. Our review demonstrated that 40% of cases presented with fever. The majority of cases were idiopathic with the organisms known in 70% of cases. Surgery and IV antibiotics were used in 83% of cases and one case required a second surgery. A wide range of antibiotic regimens were reported with no consensus on how to best preserve neurological function.

Conclusion
This case highlights the complexities in diagnosing and managing IASC. We suspect that due to the protected nature of the intramedullary space, the infection may not trigger constitutional symptoms or a systemic inflammatory response. In patients who present with significant neurological deficits, MRI may reveal IASC and this should prompt immediate initiation of antibiotics that penetrate the blood–brain barrier and surgical intervention.

Disclosures
All authors: No reported disclosures.
1426. Outcomes of Additional Instrumentation in Elderly Patients with Pyogenic Vertebral Osteomyelitis and Previous Spinal Instrumentation
Authors: Kim Tae-Hwan , Kim Jihye 
Published: October 2019

Abstract

Background
In patients with pyogenic vertebral osteomyelitis (PVO) and previous instrumentation requiring surgical treatment, a decision must be made between a less invasive non-instrumented surgery, including retaining the previous instrumentation, or a more invasive additional instrumented surgery involving the complete removal of the infected tissue and firm re-stabilization.

Methods
A retrospective cohort study (case–control study) was planned to evaluate the clinical outcomes of using additional instrumentation in patients with PVO and previous instrumentation. Patients were divided into two groups (instrumented or non-instrumented) according to the presence or absence of additional instrumentation. The baseline characteristics, infection profile, and treatment outcomes were compared between the two groups, and a multivariate logistic regression analysis was performed to identify the risk factors for infection recurrence.

Results
A total of 187 postoperative patients with PVO and previous spinal instrumentation were included. There were no significant differences in the baseline characteristics except the presence of a titanium cage. Surgery for additional instrumentation in patients with PVO and previous instrumentation showed similar rates of infection recurrence and mortality compared with non-instrumented surgery despite a larger number of involved vertebral levels and greater incidence of epidural abscesses (Table 1). However, instrumented patients with PVO and previous instrumentation who experienced infection recurrence had worse clinical outcomes than those of the non-instrumented patients with PVO (Table 2). Severe medical comorbidities, the presence of a psoas abscess (Figures 1 and 2), and methicillin-resistant Staphylococcus aureus infection were associated with a higher risk of infection recurrence.

Conclusion
Surgery for additional instrumentation in patients with PVO and previous instrumentation showed similar rates of infection recurrence and mortality to those who underwent non-instrumented surgery despite a larger number of involved vertebral levels and an increased frequency of epidural abscesses.

Disclosures
All authors: No reported disclosures.
1431. Comparison of Treatment Outcomes with Definitive Antibiotic Therapy and Empiric Antibiotic Therapy in Osteomyelitis
Authors: Holzum Dorothy , Pearson Christopher D , Moenster Ryan P , Linneman Travis W , McMahan Jonathan 
Published: October 2019

Abstract

Background
Definitive therapy for osteomyelitis (OM) is thought to be superior to empiric antimicrobial therapy; however, identifying causative pathogens is difficult.

Methods
This retrospective cohort study included patients treated with either definitive or empiric antimicrobial therapy for OM at VA St. Louis HCS between 1 January 2010 and 1 January 2018. Definitive antibiotic therapy was defined as a regimen tailored to susceptibilities of an organism(s) cultured from bone or deep tissue. The primary outcome was treatment failure, defined as a need for unplanned surgical intervention or re-initiation of antibiotic therapy for OM of the same anatomical site within 6-months after initial therapy was discontinued. Secondary outcomes included the incidence of acute kidney injury (AKI), Clostridium difficile-associated diarrhea (CDAD), and thrombocytopenia. Surgical intervention as part of initial therapy, presence of peripheral vascular disease (PVD), creatinine clearance < 50 mL/minute at initiation of therapy, receiving antibiotics at an extended care facility, age > 60 years, and receiving definitive antibiotics were included in a univariate analysis with variables with a P < 0.2 included in a multivariate logistic regression.

Results
There were 301 patients included; 179 in the definitive therapy group and 122 in the empiric therapy group. Baseline characteristics were similar among groups; however, more patients receiving definitive therapy had a bone biopsy compared with those treated with empiric therapy (58.1% (104/179) vs. 36.8% (45/122); P < 0.05). 33 percent (60/179) of patient treated with definitive therapy failed compared with 45% (55/122) treated with empiric therapy (P = 0.109). No significant differences were observed in secondary outcomes; however non-CDAD diarrhea occurred more in the empiric therapy group than definitive therapy group (3.9% (7/179) vs. 8.2% (10/122); P > 0.05). Receiving definitive therapy (OR 1.43, CI 0.89–2.313; P = 0.138) and presence of PVD (OR 1.34; CI 0.823–2.197; P = 0.238) were included in the multivariate logistic regression, but neither were independently associated with failure.

Conclusion
Definitive antibiotic therapy was not associated with a significant decrease in treatment failure.

Disclosures
All authors: No reported disclosures.
1437. Safety and Effectiveness of a Laboratory Intervention to Reduce Antibiotic Consumption in Patients with Asymptomatic Bacteriuria
Authors: Mozafarihashjin Mohammad , Maze Dit Mieusement Lorraine , McGeer Allison , McCreight Liz , Van Horne Liz , So Jannice , Shrivastava Ananya , Khan Nadeem , Wong Louis , Leis Jerome A 
Published: October 2019

Abstract

Background
Antibiotic (AB) therapy for asymptomatic bacteriuria (ASB) persists despite evidence of lack of benefit. In 2012, our hospital piloted an intervention to stop routinely reporting positive midstream urine (MSU) from inpatients since the majority of patients were asymptomatic. Following the pilot, we moved to rejecting all MSU unless a telephone request was received. We undertook the present study to establish the safety and assess the long-term impact of this change.

Methods
From November 2013 to April 2019, when MSU were received from surgical wards (two surgical wards added in May 2015) and medical wards (from August 2017) in our hospital, a message was posted noting that ASB should not be treated and a call to the lab was required to initiate specimen processing. Patients were interviewed, and charts were reviewed within 24h of specimen receipt and 4d later to identify urinary tract symptoms/infection (UTS/UTI) and systemic infection. Primary outcome was serious adverse events (AEs). Secondary outcomes were: rate of MSU submitted, impact on lab workload, AB use.

Results
1,678 episodes with submitted MSU were included; 995/1,678 (60%) MSU cultures were not processed. Of 683 processed, 482 (71%) were negative. 1,111/1,678 (66%) patients were asymptomatic when MSU was ordered. 1,393/1,678 (83%) had negative culture (N = 482) or completed d4 follow-up (N = 911). No symptomatic UTI/sepsis/systemic infection occurred; the only AE identified were 4 patients with prolonged UTS which might have been prevented by MSU processing (4/911; 0.4% patients with AE). Rates of MSU submitted remained stable at 12 per 1,000 patient-days, P = 0.59 (Figure 1). Proportion of processed MSU decreased from 16/22, 73% in 2013 to 67/137, 49% in 2019 (Figure 2; P = 0.002). Overall, microbiology workload decreased by 5 person-days/year (fewer MSU processed, but staff needed to respond to telephone calls). 275/1,678 (16%) patients received AB for presumed UTI; 221 (80%) treated empirically, 54 (20%) in response to positive MSU. Of 69 patients with ASB whose MSU was processed and positive, 32 (46%) were prescribed antibiotics. Assuming that 21% of rejected MSU from asymptomatic patients would have been positive, AB therapy for ASB was avoided in 66 patients.

Conclusion
Rejecting MSU specimens does not result in harm, and reduces lab workload and AB therapy for ASB.

Disclosures
All authors: No reported disclosures.
1439. Reducing the Number of Urine Cultures Performed Through Stringent Urinalysis Reflex Criteria
Authors: Abu Sitta Emad , Keegan Ann , Cole Kelli , Byrd Heather , Blomquist Thomas , Suleyman Geehan 
Published: October 2019

Abstract

Background
Almost half of urine cultures (UCs) obtained are in asymptomatic patients, which may lead to misdiagnosis of urinary tract infection (UTI) and unnecessary treatment. To decrease misdiagnosis of UTI, changes were made to the order entry and urine culture process at our institution in April 2018. This included removal of a standalone UC from the electronic order entry system and development of a more stringent criterian for urinalysis with reflex culture (UAC). We evaluated the impact of these ordering changes on the total number of UCs performed.

Methods
This was a pre-post retrospective study comparing the hospital UAC rate per 1,000 patient-days and ED UAC rate per 1,000 visits in the pre-intervention period from April 2017 to March 2018 to the intervention period from May 2018 to March 2019 in a 319-bed teaching hospital in northwest Ohio. In April 2018, urine microscopy and UAC were the only available options. Furthermore, UC would only be performed if the following criteria were met: 10 white blood cells (WBC)/HFP. Standalone UC was available for the following patients who were excluded: immunosuppressed patients, pregnant women and patients undergoing invasive urologic procedures. These changes were accompanied by provider education, and providers were given the option to override UAC rules by calling the microbiology lab within 24 hours to request UC.

Results
After incorporating these changes, we observed an increase in the use of UAC compared with UC-only in both the ED (80% pre-vs. 94% post-implementation) and inpatient setting (59% pre-vs. 92% post-implementation). This was accompanied by a reduction in the overall UCs performed in both the ED (49.17 per 1,000 visits to 23.53 per 1,000 visits [P < 0.001]) and inpatient units (23.31 per 1,000 patient-days to 9.31 per 1,000 patient-days [P < 0.001]). Chart review of cases where providers overrode UAC criteria and requested UC have demonstrated no false negatives to date; cultures either had no growth or were consistent with contamination by polymicrobial urogenital flora.

Conclusion
Restricted access to standalone UC, implementation of UAC with more stringent criteria and provider education reduced the number of urine cultures performed without sacrificing sensitivity for detecting UTI and potential antimicrobial use.

Disclosures
All authors: No reported disclosures.
1441. Comparison of Cefpodoxime vs. Oral Cefuroxime for Urinary Tract Infections at a Large Academic Medical Center
Authors: Bao Hongkai , Dubrovskaya Yanina , (Polly) Jen Shin-Pung , Jie (Cindy) Chen Xian , Siegfried Justin , Papadopoulos John 
Published: October 2019

Abstract

Background
Cefpodoxime (CPD) and cefuroxime (CFX) are both oral cephalosporins indicated for urinary tract infection (UTI) treatment. CPD may have unfavorable pharmacokinetics (PK) given the lesser degree of renal excretion and urine concentration vs. CFX and risk of collateral damage. The objective of this study was to compare the efficacy and safety of these two agents for UTI treatment.

Methods
We conducted a retrospective evaluation among adult patients who received CPD or oral CFX for ≥48 hours for UTI treatment between January 2013 and July 2018. The primary outcome was the rate of subsequent UTI within 90 days following therapy. Safety outcomes included the rate of Clostridium difficile infection (CDI) and development of isolates resistant to third-generation cephalosporins (TGC) within 90 days. We also examined missed opportunities for antibiotic de-escalation in culture-positive patients.

Results
Of 747 patients assessed for study inclusion, 295 patients met eligibility criteria (CPD n = 165, CFX n = 130). Median age was 72 years (IQR 55–84) and 71% were female. More patients in the CPD vs. CFX group had pyelonephritis (29% vs. 11%, P = 0.0005) and were treated in the emergency department (42% vs. 16%, P = 0.0005). Escherichia coli was most commonly isolated (n = 139), followed by Klebsiella spp. The rate of subsequent UTI for CPD vs. CFX was 18% vs. 16%, P = 0.647 at median of 25 vs. 32 days, P = 0.399. CDI rate was 1% vs. 2%, P = 0.324 and resistance to TGC was detected in 4% vs. 1%, P = 0.068 for CPD vs. CFX, respectively. Missed opportunities to de-escalate antibiotics based on cultures were found in one-third of patients. After adjusting for multiple factors in multivariate analysis, genitourinary abnormality (Odds Ratio [OR] 2.2, 95% CI 1.10–4.29, P = 0.026) and prior history of UTI within 180 days (OR 2.2, 95% CI 1.08–4.398, P = 0.03), but not the choice of oral cephalosporin, were the only independent predictors of subsequent UTI.

Conclusion
Despite less favorable urinary PK of CPD compared with CFX, in this patient cohort, no differences in efficacy or safety between the two agents for UTI treatment were found. These findings warrant further exploration. Stewardship strategies for de-escalation from higher generation cephalosporins to narrow-spectrum antibiotics based on susceptibilities should be implemented.

Disclosures
All authors: No reported disclosures.
1443. N-Acetyl Cysteine Coadministration in Prevention of Amphotericin--Induced Electrolytes Imbalances in Children
Authors: Arikan Kamile , Kara Ates , Karadag-Oncel Eda 
Published: October 2019

Abstract

Background
Amphotericin B (AmB) can cause electrolyte abnormalities, including hypokalemia, hypomagnesemia, hypernatremia, and metabolic acidosis; and most important, acute renal failure.

Methods
We conducted a randomized prospective cohort study from March 2012 to February 2018 at Hacettepe University Ihsan Doğramacı Children Hospital to children receiving AmB.

Results
A total of 87 patients including 37 patients with NAC and 50 patients without NAC received liposomal amphotericin B during the study period.Serum creatinine, blood urea nitrogen, phosphorus were not different statistically in both groups during the study period. Serum sodium, potassium, calcium, phosphorus, magnesium values taken on third day of AmB treatment were not statistically different in both groups. Mean serum magnesium value was higher in NAC received group on the seventh day of AmB treatment; 1.97 ± 0.33 and 1.69 ± 0.46, respectively, it was statistically significant (P = 0.025). Mean serum magnesium value was also statistically significantly higher in NAC received group on the 14th day of treatment; 1.93 ± 0.20 and 1.72 ± 0.247, respectively, in both groups (P = 0.01). Mean serum sodium values on the 14th day of AmB treatment were also statistically different between 2 groups; 136.7 ± 3.7 and 140.04 ± 5.1, respectively (P = 0.005). Serum sodium values on the 14th day of AmB treatment was in more normal limits in NAC received group. Serum alanine aminotransferase level was significantly lower in NAC received group (P = 0.02). Serum aspartate aminotransferase level was significantly lower in NAC received group (P = 0.007). Nineteen of 37 (51.4%) patients who received NAC concomitantly with AmB and 44 of 50 patients (88%) who received AmB without NAC supplemented with potassium due to hypokalemia (P < 0.001). Two of NAC received 37 patients (5.4%) and 10 of NAC not received 50 patients (20%) died. Mortality was found 2.3 times more in NAC not-received group.

Conclusion
Co-treatment with oral NAC once daily in children during AmB treatment course was significantly effective in preventing or ameliorating different features of its nephrotoxicity including hypokalemia, hypomagnesemia, and renal potassium as well as magnesium wasting

Disclosures
All authors: No reported disclosures.