bluuebunny/crossref_metadata_2025_split huggingface dataset:
2436. Real-world Evidence of Fecal Microbiota Transplant Use and Outcomes in Patients with Clostridioides difficile Infection
Authors: Nelson Winnie , Lau Merwin , Kloss Stefan , Grace Tucker Sarah , Stong Laura , Dahdal David N 
Published: October 2019

Abstract

Background
Clostridioides difficile infection (CDI) and recurrent CDI (rCDI) are associated with substantial economic burden, quality-of-life impairment, and increased morbidity and mortality. Fecal microbiota transplant (FMT) is an investigational, non-antibiotic approach to attempt to prevent recurrences in patients with multiple CDI. In controlled trials, efficacy rates of 62–76% have been reported with a single FMT, and up to 90% with multiple FMTs. This study evaluated real-world outcomes in patients with CDI, most of whom had a single FMT.

Methods
Data from the Optum® de-identified Integrated Claims-Clinical dataset were extracted for patients with a first-observed CDI diagnosis between 4/2011 and 3/2018 that occurred within ±7 days of initial CDI antibiotics. Each patient had a > = 4-year look-back period with no CDI claims prior to the index episode. rCDI was defined as a subsequent antibiotic prescription between 7 and 365 days after the prior CDI episode. The proportion of patients with rCDI, use of FMT, and recurrences after FMT were reported.

Results
Of the 98,895 patients included in the analysis, 71,189 (72.0%) had one CDI episode, 27,706 (28.0%) had > = 1 rCDI, and 10,233 (10.4%) had multiple rCDI. The mean age was 64.2 years (56% > = 65 years), and 61% were female. Medicare was used by 48% of patients, and commercial insurance was used by 32%. A total of 522 (0.5%) patients (mean age, 61.9 years) received a total of 541 FMT procedures. 36% of the FMT procedures occurred after the first observed CDI episode, 22% after the 1st rCDI, and 42% after the second and/or subsequent rCDI episode. Of those who received FMT, 71.4% (n = 373) of patients had no subsequent CDI events by 3/2018.

Conclusion
As an investigational procedure, only a very small proportion of patients with CDI were identified as undergoing FMT, and the timing of the procedure for some patients may not have aligned with current guidance. This study provides data on real-world efficacy outcomes after a single FMT, with an efficacy rate of 71.4%, which is consistent with rates reported in controlled trials. A small number of patients received more than one FMT procedure, potentially due to treatment failures. Further research is needed to examine potential improvements in efficacy with multiple FMTs.

Disclosures
All authors: No reported disclosures.
138. Prognosis Following Valve Replacement Surgery for Infective Endocarditis Among Persons Who Inject Drugs
Authors: Bullis Sean , Spiess Krystine , Kemper Alston W 
Published: October 2019

Abstract

Background
Infective endocarditis (IE) is a major cause of morbidity and mortality among persons who inject drugs (PWID) and rates have increased during the current opioid epidemic. Severe cases may require valve replacement surgery (VRS). These patients are typically younger with fewer comorbidities than those who undergo VRS for other indications. This study was designed to examine the prognosis for these cases.

Methods
The University of Vermont Medical Center is a 562-bed academic medical center. A retrospective cohort included all cases of IE among PWID who underwent VRS between November, 2009 and December, 2015. The cohort intentionally included surgeries performed prior to 2016 in order to provide sufficient follow-up time. Outcomes included survival, readmission, complications, adherence to follow-up, length of stay, rate of repeat VRS, microbiology, and recurrent bloodstream infections.

Results
The cohort included 31 patients. 80% were male and the median age was 31. The valves replaced or repaired included 18 aortic, 10 mitral, 9 tricuspid, and 1 pulmonic (7 patients had two valves involved). Organisms included Staphylococcus aureus (48%), Streptococcus spp. (22%), and Enterococcus (13%). The median length of stay for the index admission was 35 days. To date, at least 38% of the cohort has died. The median survival for those who died was 337 days (0–2,224). Adherence with initial outpatient follow-up visit was only 50%, with others either canceling or missing appointments. 39% followed up with infectious diseases and 39% with cardiothoracic surgery. 29% never followed up. The readmission rate was 51%, and 22% of the cohort was readmitted more than three times. 48% had a repeat bloodstream infection, 73% of which were with a different organism than the index infection. The rate of repeat VRS was 31%.

Conclusion
Our observational data reveal a high mortality rate with poor adherence to follow-up and a high rate of readmission among this rural cohort of PWID who have VRS for IE. The major limitation of this work is the passive follow-up from the medical record. The high mortality and morbidity of this disease suggests that more intensive, multispecialty post-operative care is needed for PWID who are treated surgically.

Disclosures
All authors: No reported disclosures.
2463. Increased Rates of Candida Bloodstream Infections Associated with Drug Use, United States 2012–2017
Authors: McCarthy Natalie , Baggs James , Hatfield Kelly M , Wolford Hannah , Vallabhaneni Snigdha , Reddy Sujan , Jackson Brendan R , Jernigan John A 
Published: October 2019

Abstract

Background
Opioid misuse is epidemic in the United States (US), and persons who inject drugs are at increased risk for serious bacterial and fungal infections, including Candida bloodstream infections. Historically, candidemia has occurred almost exclusively among patients with severe underlying illness and extensive healthcare exposure. We examined whether the opioid crisis may be having an impact on the epidemiology of candidemia in the United States.

Methods
Using data from 200 US hospitals reporting to the Premier Healthcare Database (PHD) between 2012–2017, we conducted a retrospective study among hospitalized persons ≥ 18 years. Candidemia was defined by any blood culture yielding Candida species. Drug use-associated (DUA)-candidemia hospitalizations were defined as hospitalizations having both candidemia and at least one ICD-9-CM or ICD-10-CM diagnostic code for recreational drug use; drugs were classified as opioids, cocaine, amphetamines, or other drugs (excluding cannabis, alcohol, and nicotine). We described the characteristics and annual trends of candidemia hospitalizations, stratified by drug use.

Results
Of 7,590 candidemia hospitalizations during 2012–2017, 679 (9%) were DUA-candidemia. During this time, the rate of DUA-candidemia increased from 3.6 to 9.1 per 100,000 hospitalizations, while the rate of non-DUA-candidemia decreased from 64.7 to 55.6 per 100,000 hospitalizations. Patients with DUA-candidemia were younger (median 40 vs. 64 years), had a longer lengths of stay (median 14 vs. 13 days), and had lower in-hospital mortality (12% vs. 26%). Among DUA-candidemia hospitalizations, opioids accounted for 78% of substances identified. Among patients aged 18–44 years, the proportion of candidemia hospitalizations associated with drug use more than tripled from 13% in 2012 to 44% in 2017 (Figure 1).

Conclusion
DUA-candidemia hospitalizations increased almost 3-fold during 2012–2017, with drug use identified in nearly half of candidemia patients ages 18–44 years in 2017. These data suggest that the opioid crisis is having an impact on the epidemiology of candidemia in the United States, especially among young adults, underscoring an additional negative consequence of the ongoing crisis.

Disclosures
All authors: No reported disclosures.
2464. Partnerships in the Field: Using Real-time Sequencing to Enhance Epidemiologic Investigation and Response to a Norovirus Outbreak
Authors: Lori Handy K , Graf Erin H , Brostowski Linda , Cunnigham Lindsay , Dougherty Caitlin , Molitoris Kayla , Townsend Sara , Smathers Sarah , Sammons Julia S 
Published: October 2019

Abstract

Background
Norovirus is a common cause of infectious gastroenteritis and frequently leads to hospital-based outbreaks of gastrointestinal (GI) illness. We utilized hospital-wide surveillance to detect outbreaks of GI illness among patients and healthcare workers (HCW). Real-time norovirus sequencing was applied to establish conclusive links between patient cases.

Methods
Patient cases of healthcare-associated GI illness were detected through house-wide microbiologic surveillance. HCW cases were defined as acute episodes of vomiting and/or diarrhea that began within 48 hours of the last shift. Outbreak procedures were implemented on a unit when 3 or more cases were identified within 48 hours. Traditional epidemiologic methods were used, including an epidemic curve and line listing, while instituting local control measures. De-identified clinical stool samples positive for norovirus from any hospital unit during the defined outbreak time period were analyzed. Sanger sequencing was performed using primer sets targeting the norovirus VP1 capsid and polymerase regions. Capillary electrophoresis was implemented on a 3500 Genetic Analyzer (Applied Biosystems) and analysis was performed via MEGA7.

Results
Epidemiologic surveillance identified a norovirus outbreak involving 11 patients on a single unit. Sequencing was performed on 20 norovirus positive stool samples, of which 13 shared 100% identity across both the VP1 and polymerase regions. Of these 13, 10 specimens were from patients epidemiologically linked to the outbreak; 3 specimens were from patients located on 2 geographically separate floors, not epidemiologically linked to the outbreak. Identification of cases outside of the outbreak unit prompted additional hospital-wide infection prevention interventions, including increased education and messaging, changes in hand hygiene practice, and prohibition of shared food for staff.

Conclusion
Real-time sequencing confirmed epidemiologically linked cases of norovirus during an outbreak and identified additional transmission events not detected by conventional epidemiologic methods. Partnership between hospital epidemiology and the laboratory identified the need for hospital-wide infection prevention measures to halt ongoing transmission.

Disclosures
All authors: No reported disclosures.
2465. Healthcare-Associated Pediatric Cutaneous Mucormycosis at Texas Children’s Hospital, 2012–2019
Authors: Foster Catherine , Revell Paula , Campbell Judith R , Marquez Lucila 
Published: October 2019

Abstract

Background
Cutaneous mucormycosis in children is a rare fungal infection which primarily occurs in patients with underlying medical conditions and is associated with significant morbidity. We describe characteristics of pediatric patients with healthcare-associated (HCA) cutaneous mucormycosis at Texas Children’s Hospital (TCH) and results of an outbreak investigation.

Methods
Patients at TCH were identified retrospectively through review of the TCH Microbiology Laboratory mycology culture reports from 1/1/2012–2/18/2019. Pediatric patients <21 years of age with cutaneous mucormycosis that developed during a hospitalization or was associated with a medical device were included. Demographic information was collected through review of the electronic medical record. Randomly amplified polymorphic DNA (RAPD) analysis were performed by the Fungus Testing Laboratory, University of Texas Health Science Center at San Antonio. This study was approved through the Baylor College of Medicine Institutional Review Board.

Results
We identified 12 patients with HCA cutaneous mucormycosis. The characteristics of these patients are detailed in the table. Six cases of Rhizopus infection occurred over a narrow 7 month period from March through September of 2017 prompting an outbreak investigation. Genotyping results revealed 4 molecular types from 5 available isolates suggesting that the isolates were not clonally related. Adhesive products were suspected as a potential source. Infection Control activities included site visits to the hospital supply warehouse and linen facility. Tape practices throughout the hospital were assessed through a nursing survey. Samples of adhesive products were cultured at an environmental microbiology laboratory and no Rhizopus spp. were isolated. A source was not identified.

Conclusion
Mucormycosis is a life-threatening infection in children. Providers should have a low threshold of suspicion for cutaneous mucormycosis in patients with underlying medical conditions (malignancies and extreme prematurity) that develop skin lesions near medical device dressings or securement sites.

Disclosures
All authors: No reported disclosures.
2483. Characteristics and Outcomes Over First 12 Months of a Two-Drug Regimen (Dolutegravir/Rilpivirine) for Treatment of HIV-1 in the United States
Authors: Pierone Gerald , Schulman Kathy , Fusco Jennifer S , Vannappagari Vani , Aboud Michael , Ragone Leigh , Fusco Gregory 
Published: October 2019

Abstract

Background
In 2017, the first complete antiretroviral regimen (ART) containing only two drugs, dolutegravir/rilpivirine (DTG/RPV), was approved for treatment of HIV-1 in virologically suppressed (<50 copies/mL) patients on a stable ART regimen for ≥6 months with no history of treatment failure/resistance to DTG or RPV. Our objective was to characterize early utilization/outcomes of DTG/RPV in a real-world population.

Methods
HIV-1+ individuals initiating DTG/RPV from January 1, 2018 to December 31, 2018 were identified in the OPERA Database. Outcomes were evaluated among the virologically suppressed subgroup who initiated in the first 6 months. Discontinuation (d/c) was defined as cessation of DTG/RPV. Virologic failure (VF) was defined as either 2 consecutive HIV viral loads (VL) ≥ 200 copies/mL OR 1 VL ≥200 copies/mL + d/c. Population was observed from DTG/RPV start (index) until the first of: (a) d/c, (b) death, or (c) study end (December 31, 2018). Demographic and clinical characteristics were described at index. Kaplan–Meier methods were used to describe d/c and VF.

Results
A total of 880 patients were prescribed DTG/RPV in the first 12 months; demographic and clinical characteristics are described in Figures 1 and 2. Most (76%) DTG/RPV users were virologically suppressed at initiation (n = 671). Among the 197 (22%) ART experienced, viremic initiators, a third had a baseline VL ≥ 50 but <200. Few patients were ART naïve (n = 12, 1%). Index VL was unavailable for 21 (5%) initiators. Comorbidity was prevalent: 59% had ≥1 endocrine disorders; 42% hypertension, and 33% mental disorders. For the virologically suppressed at initiation, with ≥6 months of follow-up (n = 340); median (IQR) days on DTG/RPV was 248 (204–299); 88% remained on DTG/RPV at study end. Among the 42 (12.4%) discontinued patients, 41% were virologically stable (<200 copies/mL) at d/c. Median (IQR) days to d/c was 58 (29–141) (Figure 3). Most patients (n = 288, 85%) had ≥ 1 VL during follow-up; 79% (n = 270) had ≥1 VL during the first 24 weeks. Among these, VF occurred in 1.5% patients. Median (IQR) time to VF was 5.1 (2.0–9.2) months (Figure 4).

Conclusion
While DTG/RPV initiators were primarily ART-experienced, virologically suppressed individuals older than 50 years of age challenged by significant comorbid conditions, the frequency of d/c or VF in the first 12 months was low.

Disclosures
All authors: No reported disclosures.
2522. Prescription Drug Use Among Women with HIV Who Are of Childbearing Potential
Authors: Abernethy Jane L , Binkley Amanda , Cimino Christo L , Koenig Helen , Short William R 
Published: October 2019

Abstract

Background
In the context of medication safety, women with HIV who are of childbearing potential represent a particular challenge given the prevalence of unplanned pregnancies. Despite this, significant gaps in the literature exist characterizing prescription drug use in this cohort. Our study describes medication use and identifies medications that are contraindicated during pregnancy in a cohort of women with HIV who are of childbearing age.

Methods
Women with HIV aged 18–45 years who presented to an academic medical center between January 2016 and December 2017 were included for analysis. Patients were excluded if they were prescribed any form of contraception, received permanent sterilization, or were post-menopausal. The number of individual medications prescribed in the electronic medical record during the study period were documented. Chronic medications, defined as those prescribed for longer than 3 months, were analyzed. Patients were identified as experiencing polypharmacy if prescribed 5 or more medications at one time. In addition, contraindicated medications were reviewed and documented.

Results
A total of 213 patients met inclusion criteria for review. Of these, 169 (79%) and 66 (31%) patients experienced polypharmacy when including and excluding antiretrovirals, respectively. When antiretrovirals were included the mean number of medications prescribed was 7.48 (SD = 3.87) and 3.92 (SD = 3.75) when excluded. Of the 213 patients included, 64 (30%) were prescribed medications contraindicated during pregnancy. The majority of contraindicated medications were angiotensin converting enzyme inhibitors, angiotensin receptor blockers, statins, and hydroxyzine. In this cohort of women of child bearing potential (WOCBP) only 60 patients (28%) had been prescribed prenatal vitamins.

Conclusion
In this cohort of WOCBP with HIV, polypharmacy was observed in the majority of women. In addition, a third of these women were prescribed medications that are contraindicated during pregnancy. Given the potential impact of contraindicated medications on the developing fetus, our data supports the importance of preconception counseling on this issue as well as understanding the potential safety implications for mother and the fetus.

Disclosures
All authors: No reported disclosures.
2523. Optimizing Disclosure of HIV Status to a Diverse Population of HIV-Positive Pediatric Patients at an Urban HIV Clinic in the Southeastern United States
Authors: Dantuluri Keerti , Carlucci James G , Howard Leigh M , Johnson David , Garguilo Kathryn , Wilson Greg 
Published: October 2019

Abstract

Background
Developmentally-appropriate disclosure of human immunodeficiency virus (HIV) status to children living with HIV (CLWH) is essential to achieve optimal health outcomes, but stigma and fear result in delaying disclosure into adolescence. The American Academy of Pediatrics recommends disclosure of HIV status to school-age children. The objective of this quality improvement (QI) project was to increase the proportion of CLWH > 10 years of age who are disclosed about their HIV status from 57% to 80% by 18 months.

Methods
The Institute for Healthcare Improvement’s Model for Improvement was utilized for this QI project. This model accelerates quality improvement by implementing Plan-Do-Study-Act (PDSA) cycles to determine whether changes lead to improvement. The target population included CLWH followed at an urban pediatric HIV clinic. The primary outcome measure was the proportion of children > 10 years of age who are disclosed about their HIV status. PDSA cycles included monthly clinic check-ins to discuss new disclosures, quarterly team meetings to discuss implementation of new changes to improve disclosure and modifying a note template to prompt providers to document disclosure status and plan for undisclosed patients. Our process measure was the proportion of undisclosed children who have a documented disclosure status/plan. Annotated run charts were used to track the data.

Results
Prior to our first PDSA cycle, 57% of CLWH > 10 years of age were disclosed to about their HIV status, and none of the undisclosed children had a disclosure status/plan documented in their medical record. The proportion of CLWH disclosed to about their HIV status increased to 66% since meeting with the team regularly to discuss disclosure status (figure). Four months after introduction of the modified note template, the proportion of CLWH with documentation of their disclosure status and plan increased to 54%.

Conclusion
Team awareness of the importance of disclosure and a modified clinic note template were associated with increases in the proportion of CLWH with age-appropriate HIV disclosure and documentation of disclosure status. Future interventions will include adapting methods of step-wise disclosure which have been proven effective in other settings.

Disclosures
All authors: No reported disclosures.
2563. The Impact of HCV Educational Training on HIV Providers’ Attitudes, Knowledge, and Uptake of Treatment Initiation in HCV/HIV Co-infected Patients
Authors: Lau Abby A , Sura Teena , Vasudeven Anupama , Chavez Claudia , Hansen Laura , Jain Mamta 
Published: October 2019

Abstract

Background
Few HIV clinics train HIV providers on initiation of HCV treatment for their coinfected patients. We sought to evaluate the changes in comfort levels, attitude and knowledge of HCV evaluation and treatment among providers over time and track the uptake of treatment initiation.

Methods
Our program was implemented in an urban, Ryan-White outpatient clinic in 2018. Providers were given initial didactics and completed a survey that assessed their level of comfort and knowledge with treating HCV. We developed pocket cards and flow charts to help providers navigate the HCV cascade to cure. Additional training one year later through presentations and case-based discussions was given and the same survey was conducted again. We evaluated the number of HCV evaluation visits in 2018 and prescriptions written for HCV treatment.

Results
The first survey was completed by 21 and the second by 20 out of 28 providers; 70% attended at least one of the trainings. After the initial training, 38% of providers felt “confident” about discussing liver disease progression which increased to 50% after the second training. Similarly, 48% of providers felt “somewhat comfortable” talking about HIV/HCV drug interactions which increased to 80%. 33% of providers noted they were “not comfortable” discussing drug interactions which decreased to 15%. Approximately 1/3 providers felt “confident” talking about HCV treatment in both surveys. About 20% of providers disagreed with treating HIV/HCV patients with active substance use and this did not change. The median knowledge score was 7 (IQR) (6–9) after the first survey and changed to 8(5–9) after the second. Between 2018–2019, 81 HCV evaluation visits were scheduled and 64 (80% Male, 53% Black, 39% uninsured, 23% Medicaid, 73% with history of substance use) were completed and 69% of patients were prescribed HCV treatment. Among all HIV providers, 89% completed a median of 1 (1–3) HCV evaluation visits, and 71% prescribed treatment a median of 1 (1–2).

Conclusion
Implementation of HCV training to all HIV providers requires continued education and resulted in the initiation of HCV evaluation and treatment amongst the large majority of HIV providers who had previously never treated HCV.

Disclosures
All authors: No reported disclosures.