bluuebunny/crossref_metadata_2025_split huggingface dataset:
1137. What Do We Know? Teaching Medical Students to Deal with Uncertainty as a Pandemic Unfolds
Authors: Bauer Margaret E , Trujillo Daniel , Brown Cameron , Gomez Martiza , Davidson Darrell , Relich Ryan F , Allen Bradley L 
Published: January 2021

Abstract

Background
The global COVID-19 pandemic has had a major impact on medical student education. As the pandemic spread nationwide, numerous universities shut down with only days’ notice, and medical students were removed from all patient care settings and restricted from campuses. Yet, the need and curiosity of these future physicians to understand this new disease was great, including how to interpret and integrate rapidly evolving information on the underlying viral and immune mechanisms, pathophysiology, and epidemiology. Time students spent away from patient care settings presented an opportunity to rapidly develop and deliver new curriculum covering SARS-CoV-2 and COVID-19.

Methods
A team of students and faculty at Indiana University developed a Fundamentals of COVID-19 course that included up-to-date information on the virology, immunology, and pathophysiology of COVID-19. The course was delivered online, with both synchronous and asynchronous activities. Virology and immunology of the coronavirus family, including current knowledge to-date of SARS-CoV-2, were delivered using a series of readings and brief videos, followed by a small group exercise that required students to choose and present to their peers a paper from the scientific literature on COVID-19. A similar approach was used to deliver content about the pathophysiology of COVID-19. To place the COVID-19 experience in context of other pandemics, students researched and educated their small group cohort on another historical pandemic.

Results
To measure course effectiveness, we administered a pre-course survey gauging students’ self-confidence in their knowledge of these topics; the same survey was administered after completion of the course. Surveys from 645 (89% of enrolled) 3rd and 4th year medical students who completed both surveys were analyzed. Results showed that the course elicited a 57% increase (p&lt; 0.001) in students’ confidence in their knowledge of COVID-19 virology and immunology and a 64% increase (p&lt; 0.001) in knowledge of the pathophysiology.

Conclusion
Data showed that the asynchronous content and group activities were successful in engaging and educating the students on foundational knowledge of COVID-19 and were an effective approach to rapidly evolving information when faced with a novel disease.

Disclosures
All Authors: No reported disclosures
88. A Behavioral Economic Approach to C. difficile Testing Stewardship
Authors: Drees Marci , Winiarz Michael , Zhang Zugui , Dressler Robert , Eppes Stephen C 
Published: January 2021

Abstract

Background
To decrease inappropriate testing for C. difficile patients, we first employed an alert, followed by a hard stop (based on lack of documented diarrhea or laxative use), that could be overridden only by calling the laboratory. We describe a behavioral economic approach to test overrides that decreased the burden on both clinicians and laboratory staff without encouraging unnecessary testing.

Methods
Our 2-hospital, &gt; 1200-bed community-based academic healthcare system has performed PCR-only C. diff testing since January 2015. We implemented our initial laxative alert, which did not prohibit testing, in March 2015. In April 2017, we launched a “hard-stop” alert that cancelled orders without documented diarrhea or recent laxative use. The provider could override by calling the laboratory and documenting the laboratorian’s name in the order; no further justification was required, but entries were intermittently monitored. In August 2019, we allowed clinicians to document their clinical justification instead of making this additional call, while emphasizing that rationales would be monitored for validity (Fig 1). We measured number of C. diff tests completed/month, overrides, and CDI standardized infection ratios (SIRs). We performed time-series analysis to account for each of these test ordering changes.
Figure 1: Image of C. diff alert

Results
At baseline, we observed a mean of 448 (SD, ±25) C. diff orders per month. The initial laxative alert led to a sustained decrease in monthly C. diff orders by 17% (p &lt; 0.001; Fig 2). Another sustained decrease in monthly C. diff orders of an additional 29% (p&lt; 0.001) occurred after the “hard stop” alert. Overall, C. diff orders decreased by 40% (3.5% per month). After introduction of the clinical justification documentation, to date we have not observed significant trends in C. diff override rates. The CDI SIR decreased from 0.9 (95% CI, 0.77- 1.04) in 2016 to 0.52 (0.42–0.64) in 2019.
Figure 2: Interrupted time series analysis

Conclusion
An iterative process to improve C. diff testing stewardship resulted in sustained improvements in C. diff ordering and hospital onset CDI cases. Behavioral economic approaches emphasizing the importance of clinical reasoning allowed us to reduce burden on clinicians and laboratory staff without increasing inappropriate testing.

Disclosures
All Authors: No reported disclosures
1152. Characteristics of Patients with Invasive Infections Caused by Trichosporon asahii
Authors: Kim Jinyeong , Kim Min Jae , Chong Yong Pil , Kim Sung-Han , Choi Sang-Ho , Lee Sang-Oh , Woo Jun Hee , Kim Yang Soo , Jung Jiwon 
Published: January 2021

Abstract

Background
Trichosporon asahii is main species for invasive infection by genus Trichosporon. There has been few data regarding the incidence, clinical characteristics, and treatment outcomes of T. asahii colonization and invasive infection.

Methods
We retrospectively reviewed the microbiological records of patients whose culture results were positive for T. asahii, from a tertiary hospital in South Korea between January 2009 and July 2018. Invasive disease was defined according to the consensus statement of the Invasive Fungal Infections Cooperative Group of the European Organization for Research and Treatment of Cancer and the Mycoses Study Group (EORTC-MSG).

Results
During the study period, a total of 259 clinical T. asahii isolates (137 urine, 55 respiratory specimen, 26 blood, 16 surgical site drainage, 9 tissue biopsy, 9 open discharge, 3 toe/nail, 2 pleural fluid and 2 stool) were collected from 102 patients. Of the 102 patients, 18 (18%) had invasive infection: fungemia (12 [67%]), complicated skin and soft tissue infection (3 [17%]), pneumonia with or without empyema (2 [11%]), and complicated intra-abdominal infection (1 [5%]). Invasive infection was associated with hematologic malignancy (33% vs. 7%, P=0.006), end stage renal disease requiring dialysis (28% vs. 7%, P=0.02), indwelling central venous catheter (94% vs. 54%, P =0.001), and prior antifungal agent use (50% vs. 18%, P=0.01). Invasive group had significantly higher in-hospital mortality than non-invasive group (61% vs. 27%, P = 0.006).
Characteristics of 102 patients with invasive and non-invasive Trichosporon asahii disease

Conclusion
Invasive infection was associated with hematologic malignancy, end stage renal disease, indwelling of central venous catheter, and prior antifungal agent use, and high mortality up to 60%. Those with above risk factors should be monitored for development of invasive T. asahii infection.

Disclosures
All Authors: No reported disclosures
1154. Characterizing fungemic outcomes among adult inpatients at a community teaching hospital: a retrospective cohort study
Authors: Staicu Mary L , Laguio-Vila Maryrose R , Uzoma Joy , VanSice Ryan 
Published: January 2021

Abstract

Background
Fungemia is among the highest causes of mortality and length of stay (LOS) within the inpatient setting. We aim to characterize outcomes in adult inpatients with fungemia at our institution.

Methods
Adult inpatients with at least one positive blood culture with yeast between January 1st, 2017 and December 31st, 2018 were retrospectively identified via an electronic health record report. Outcome measurements were stratified into three categories: demographic, infectious, and antifungal-related.

Results
Forty-five patients were identified for review. The mean age was 62 years (SD 16.8) while the prevalence of fungemia among men and women was comparable (48.9 versus 51.1%). Diabetes (24.4%) and past malignancy (22.2%) were among the top comorbidities. One in five patients received total parenteral nutrition at the time of positive blood culture results. Central lines were present in 66.7% of patients and were implicated as the source of infection in the majority of cases (31%). Intensive care unit (ICU) admission, 30-day mortality, and 30-day hospital readmission occurred in 66.7%, 24.4%, and 26.7% of patients, respectively. The median time to culture positivity and time to antifungal therapy after positive culture results were 42.5 (IQR 36.5 - 63) and 6.5 hours (IQR 2.75 - 12.5), respectively. Candida albicans was found to be the primary fungal pathogen identified among cases reviewed, isolated in 53.3% of patients. ID consultation occurred in 86.7% of cases. Caspofungin was the predominant empiric antifungal agent prescribed (50.8%). Median total duration of therapy was 14 days (IQR 11.5 - 19).

Conclusion
This analysis successfully identified key high-risk areas of attention in the clinical management of adult inpatients with fungemia at our institution. Central lines and ICU admission were predominant characteristics identified, suggesting the complexity of the management of these patients. Although 30-day mortality and readmission rates were found to mirror current national averages for this population, further risk-assessment of these outcomes would be appropriate to evaluate in a larger study cohort.

Disclosures
All Authors: No reported disclosures
1156. Clinical and epidemiological features and outcomes of Blastomycosis in a tertiary hospital in Kentucky
Authors: Cari Evelyn Villacorta , Leedy Nicole , Ribes Julie A , Soria Jaime , Myint Thein 
Published: January 2021

Abstract

Background
Blastomycosis is an endemic dimorphic fungal infection caused by Blastomyces dermatitidis. The risk factors associated with severe presentation are not well defined.

Methods
Retrospective study of patients treated for blastomycosis at the University of Kentucky Hospital from 2004-2019. Statistical analyses were performed with STATA version 12.0 (College Station, Texas). Logistic regression was used to identify variables associated with severe infections.

Results
Among 82 patients, median age was 48 years old (range: 16 - 89); 66 (80.5%) were male and 71 (92.2%) were white, 25/77 (32.4%) were obese, 24 (29.2%) were diabetic, 21 (25.6%) had COPD, 26 (31.7%) had at least one immunosuppressive condition. The median duration of illness was 86 (3-365) days. 37 (45.1%) had cough and 35 (42.6%) had dyspnea 19 (23.1%) patients were treated in the ICU, 42 (51.3%) in non-ICU inpatient wards, and 21 (25.6%) in an outpatient setting. Cultures were obtained in 69 cases, 59 (85.5%) reported as positive, KOH stain positive in 30/61 (49.1%). Histopathology was positive in 48/66 (72.7%) samples. Urine Histoplasma or Blastomyces antigen was positive in 41/58 (70.6%), and Serum Histoplasma or Blastomyces antigen was positive in 22/34 (64.7%). Among 64 (78.0%) patients with pulmonary blastomycosis, acute and chronic pneumonia were 16 (25.0%) and 12 (18.7%) cases respectively, and nodular lung lesions were reported in 36 (56.2%). Initial antifungal treatment was amphotericin B liposomal in 38/80 (47.5%), overall mortality was 11 (13.4%). A multivariable analysis was performed to find predictors of severe blastomycosis infection, no association was seen with factors as male sex (IRR 1.96; 95%CI 0.84 – 4.55), and was confirmed that significant independent associated risk factors for severe infection were age older than 50 (IRR 3.5; 95%CI 1.42-8.83), obesity (IRR 3.1; 95% CI 1.41-6.87), diabetes (IRR 2.5; 95% CI 1.16-5.50), leukocytosis (IRR 1.03; 95%CI 1.00-1.07) and anemia (IRR 3.0; 95% CI 1.55-5.85).

Conclusion
Pulmonary Blastomycosis is the most common presentation. Culture and histopathology are more sensitive than antigen assay. Independent factors associated to severe disease were older age, obesity, diabetes, and anemia at admission.

Disclosures
All Authors: No reported disclosures
1159. Echinocandins Dosing in Obese Patients: A Systematic Review
Authors: Alsowaida Yazed S , Pharm B S , Almulhim Abdulaziz S , Kalbasi Alireza 
Published: January 2021

Abstract

Background
Echinocandins are a milestone in antifungal chemotherapy given their fungicidal properties with improved toxicity profiles compared to other antifungal agents. Echinocandins are used in the empiric treatment of invasive candidiasis and aspergillosis in critically ill, neutropenic, and transplant patients. There is emerging evidence that obese patients treated with echinocandins antifungal agents have lower plasma serum concentration and faster clearance. The objective of this review was to systematically evaluate the available evidence for echinocandins dosing in obese patients.

Methods
A systematic review of PubMed, Embase, Cochrane library from inception until June 8, 2020 was conducted by 2 authors. Studies with data for micafungin, anidulafungin, or caspofungin in obese patients’ exposure [body mass index (BMI) 30 or greater] were included. Studies for patients on renal replacement therapies, extracorporeal membrane oxygenation support, and language other than English were excluded.

Results
Twenty-five studies met the inclusion criteria; micafungin (n=10), caspofungin (n=8), and anidulafungin (n=7). In micafungin, the correlation between obesity and increasing systemic clearance and reduced exposure was reported. Some studies reported even lower systemic exposure with morbid obesity, BMI greater than 40. The evidence was also consistent with anidulafungin, two studies revealed that body weight had inverse correlation with anidulafungin exposure. Anidulafungin exposure was about 30% lower in obese patients. Furthermore, caspofungin exposure was also reduced in obese patient as demonstrated in several studies.

Conclusion
Adequate antifungal exposure is a key in success treatment, and there are several factors that can influence exposure of echinocandin antifungal agents. There is consistent evidence revealing lower echinocandins exposure in obese patient. Research is needed to determine outcomes of fungal infections of obese patients, and perhaps the need for dose adjustment in obese patient population.

Disclosures
All Authors: No reported disclosures
1171. Lower Mortality with Adjuvant Corticosteroid Therapy in non-HIV Infected Patients with pneumocystis jirovecii pneumonia: A Single US Cohort Study and a Proposed Novel Mechanism of Corticosteroids
Authors: Mundo William , Franco-Paredes Carlos , Johnson Steven C , Shapiro Leland , Henao-Martinez Andres 
Published: January 2021

Abstract

Background
Pneumocystis jirovecii pneumonia (PJP) remains a cause of mortality in HIV-negative patients. The clinical benefit of adjuvant corticosteroids given at the time of PJP antimicrobial therapy in these patients is uncertain. This study aimed to determine if corticosteroids reduced mortality in a cohort of HIV-negative PJP patients, and to propose a novel mechanism explaining corticosteroid benefit in patients regardless of HIV status.

Methods
We examined a retrospective case series of patients diagnosed with PJP at the University of Colorado Hospital between 1995-2019. Data were collected in 71 PJP-infected patients. Twenty-eight patients were HIV-negative, and 43 were infected with HIV. We performed bivariate and forward, stepwise multivariable logistic regressions to identify predictors of mortality.

Results
Underlying conditions in HIV-negative patients were hematologic malignancies (28.6%), autoimmune disorders (25.9%), or solid organ transplantation (10.7%). Compared to HIV-positive patients, HIV-negative patients had higher rates and duration of mechanical ventilation and ICU stay. Survival was significantly increased in HIV-negative patients receiving adjunct corticosteroids, with 100% mortality in patients not receiving corticosteroids vs 60% mortality in patients receiving corticosteroids (p=0.034). In an adjusted multivariable model, corticosteroids were associated with lower mortality (OR 13.5, 95% CI: 1.1-158.5, p= 0.039) regardless of HIV status. In a novel model of adjunct corticosteroid benefit, we propose corticosteroids reduce immune-mediated lysis of Pneumocystis organisms that curtails the surfactant-disabling effect of PJP internal contents.
Table 1. Multivariable Analysis of Predictors of Mortality in patients with PJP

Figure 1. Mortality differences by HIV status and use of steroids in PJP

Conclusion
We found substantial mortality among HIV-negative patients with PJP and adjunct corticosteroid use was associated with decreased mortality. Adjunct corticosteroid mortality-lowering effect is best explained by suppressing pneumocystis lysis. This reduces surfactant disruption resulting from pneumocystis internal substances.
Figure 2. Proposed mechanism of action for benefits of adjunct exogenous corticosteroid therapy during PJP

Disclosures
All Authors: No reported disclosures
91. Implementing Criteria to Reduce Blood Cultures Ordering: A Pre- and Post-Intervention Retrospective Study in a Critical Access Hospital
Authors: Mahatanan Rattanaporn , Gomez Gina , Olsen Bridget , Henderson Racheal 
Published: January 2021

Abstract

Background
Blood culture utilization has been performed widely. Typically, clinicians order blood cultures in patients whom bacteremia is suspected. Our previous study showed that 35% of blood cultures performed in May 2019 could have been prevented since they did not meet the certain criteria. This study sought to examine the outcomes after education intervention by implementing criteria of blood culture ordering whether it could reduce unnecessary blood cultures.

Methods
Electronic medical records of adult patients who had blood cultures done during pre-and post-study period were reviewed. Demographic data, clinical presentation, vital signs, location, quantities and sites of blood cultures were obtained. The measurement of qSOFA, SIRS and severe sepsis criteria were collected on the presentation. There were some clinical prediction rules for blood stream infection described in the previous studies. For this study, we use the criteria of at least 2 SIRS and/or at least one of the qSOFA criteria or severe sepsis to be a minimum indication for ordering blood cultures. The follow-up study was done after 6 weeks of educational intervention with implementation of criteria. Chi-square was used to compare the differences between two groups.

Results
There were a total of 165 patients included in our study (112 in pre- and 53 in post-intervention group). There were a total of 18 patients with positive blood cultures (12/112;10.71% in pre-intervention gr. vs 6/53;11.32% in post-intervention gr., p=0.91). Six out of 18 (33%) were deemed to be contaminated (3/12;25% vs 3/6;50%, p=0.29). Gram positive cocci were the most common organisms of the true positive blood cultures (10/12;83%). Of 165 patients, 78 (47%) had at least one of qSOFA (47/112;41% vs 31/53;58%, p=0.05), 18 (11%) had met severe sepsis criteria (9/112;8% vs 9/53;17%, p=0.09). There were 47 (28%) patients who had less than 2 criteria of SIRS and did not meet either criteria of qSOFA or severe sepsis (39/112; 35% vs 8/53; 15%, chi 6.87, p&lt; 0.01). There was no true bacteremia in this group of patients.

Conclusion
Our study found that implementation of criteria for blood cultures successfully reduces the unnecessary blood cultures orders approximately 20% without missing true bacteremia in suspected patients.

Disclosures
All Authors: No reported disclosures
1174. Phase 2 STRIVE Clinical Trial of Rezafungin for Treatment of Candidemia and/or Invasive Candidiasis Demonstrates Consistent Trough Concentrations Across Diverse Patient Populations
Authors: Flanagan Shawn , Rubino Christopher M , Sandison Taylor 
Published: January 2021

Abstract

Background
Rezafungin is a novel echinocandin antifungal in development for treatment as well as prevention (prophylaxis) of invasive fungal infections. STRIVE (NCT02734862) is a global, randomized, double-blind, placebo-controlled, Phase 2 trial evaluating safety and efficacy of IV rezafungin once weekly (QWk) for treatment of candidemia and/or invasive candidiasis compared with standard-of-care (IV caspofungin once daily with optional oral stepdown). Here we report pharmacokinetic (PK) data from the completed STRIVE trial analyzed by patient demographics at baseline.

Methods
Rezafungin Day 8 trough (Cmin) concentrations from patients treated with rezafungin were summarized categorically by race (black or white), sex (male or female), and geographic region (North America [NA], or Europe [EU]), or plotted versus continuous variables of age, body weight, body mass index (BMI), and body surface area (BSA). As the first dose of rezafungin was 400 mg for all rezafungin-treated patients, data from both dose groups (Group 1: 400 mg QWk; Group 2: 400 mg in Week 1 followed by 200 mg QWk) were combined in this analysis.

Results
Rezafungin mean Cmin (SD) values were 1.8 (0.7) and 2.3 (1.2) in black and white patients, 1.9 (1.0) and 2.6 (1.2) in males and females, and 1.9 (0.6) and 2.4 (1.3) in patients from NA and EU. There were small differences in point estimates between the groups, but there was a great deal of overlap and the differences are not expected to be clinically meaningful (Figure). Similarly, no trends in Cmin values were observed across a range of ages (20-80 years), weights (~40-155 kg), BMI (~15-65 kg/m2), and BSA (~1.4-2.4 m2).
Figure

Conclusion
No meaningful differences in rezafungin Cmin values were observed in patients grouped by sex, race, or geographic region, or across a wide range of patient factors, including age and body weight and size. These findings indicate that a single rezafungin dose regimen can be expected to provide consistent PK across diverse patient populations.

Disclosures
Shawn Flanagan, PhD, Cidara Therapeutics, Inc. (Employee, Shareholder) Christopher M. Rubino, PharMD, Institute for Clinical Pharmacodynamics, Inc. (Employee)Spero Therapeutics (Grant/Research Support) Taylor Sandison, MD, MPH, Cidara Therapeutics, Inc. (Employee, Shareholder)