bluuebunny/crossref_metadata_2025_split huggingface dataset:
2379. It’s Getting Complicated: Outcomes of Clostridiodes difficile PCR Positive/Toxin-Negative Patients
Authors: Morillas Jose A , Miller Ryan , Brizendine Kyle D , Fraser Thomas G 
Published: October 2019

Abstract

Background
The addition of toxin enzyme immunoassay to molecular tests creates challenges in the diagnosis and management of Clostridiodes difficile infection (CDI). In limited samples of PCR+/ toxin- patients, CDI-attributable complications are thought to be rare, even nonexistent. We aimed to characterize outcomes of a large PCR+/ toxin− cohort within 60 days of initial testing date.

Methods
We conducted a retrospective cohort study on all PCR+/toxin- adult inpatients from June–December 2018. Patients were placed into 3 groups to analyze outcomes: (1) complete treatment (guideline concordant); (2) incomplete treatment; and (3) no treatment. The primary outcome in group (1) was CDI-related complication, defined as megacolon, colectomy, or ICU care. For groups (2) and (3), clinical failure was defined as a composite of: need for repeat CDI testing or subsequent treatment.

Results
We identified 240 individuals (Figure 1). Mean age was 60 years, and 122 (51%) were female. 173 (72%) received complete treatment (85% vancomycin monotherapy), 41 (17%) incomplete treatment, and 26 (11%) none. Baseline conditions included high severity comorbidities (Figure 2). In the complete treatment group, 10/173 (5.8%) patients met criteria for fulminant colitis. 21/173 (12%) experienced CDI-attributable complications (2 megacolon, 1 colectomy, 18 ICU care). A significantly higher proportion of these patients had leukocytosis >15,000 (57 vs. 23%; P = 0.001), creatinine >1.5 (57 vs. 27%; P = 0.005), and were receiving concomitant proton pump inhibitors (65 vs. 43%; P = 0.05) and antibiotics (65 vs 44%; P = 0.05) compared with those without CDI-related complications. In patients who received incomplete treatment, there were 10 clinical failures (7 had repeat testing; 3 were administered complete treatment) compared with 4 in the no treatment group (Figure 3). Interestingly, 4/9 (44%) patients who had incomplete or no treatment and underwent repeat testing were found to be PCR+/ toxin+. There were 4 (1.7%) deaths related to CDI in the cohort. All occurred in the complete treatment group.

Conclusion
CDI-attributable complications and clinical failure occur in PCR+/toxin− patients. The challenge of distinguishing colonization from disease remains. Additional studies are needed to identify predictors of disease in PCR+/ toxin− patients.

Disclosures
All authors: No reported disclosures.
2393. Dimensions of Cumulative Antibiotic Exposure and Risk of Hospital Onset Clostridiodes Difficile
Authors: Song Jiyoun , Zachariah Philip , Cohen Bevin , Liu Jianfang , Larson Elaine 
Published: October 2019

Abstract

Background
The association between antibiotic exposure (AE) and healthcare-associated Clostridiodes difficile infection (HA-CDI) has been mostly quantified using cumulative AE as the predictor. However, patients receive similar durations of antibiotics in a variety of ways. We examine the relationship between HA-CDI and other dimensions of AE.

Methods
Retrospective cohort study was conducted with pediatric and adult inpatients at three New York City hospitals between 2011- 2016 who were prescribed at least one dose of antibiotic, excluding those used to treat CDI. Patient data were collected until the first diagnosis of HA-CDI (a positive CDI test > 3 days after admission), or alternatively at the end of the study period. Four dimensions of AE were calculated: 1) duration – cumulative total calendar days of antibiotics use, 2) discontinuity – the number of separate antibiotic courses that contributed to the duration (a course defined as antibiotics given over ≥ 2 consecutive calendar days separated by at least 24 hours), (3) antibiotic free days – days without antibiotic use, and (4) use of ‘high-risk’ antibiotics – use of antibiotics known for increasing C. difficile risk. We measured the association between each AE dimension and HA-CDI, mutually controlling for each dimension, in a multivariable logistic regression model adjusted for age, sex, comorbidities (e.g., malignancy, transplant status), length of hospitalization, and use of proton pump inhibitors (PPI).

Results
Of 227,967 hospitalized patients, 104,705 (45.9%) received antibiotics and 1,618 had HA-CDI. In regression analysis, adjusted for cumulative duration, discontinuous antibiotic therapy (OR = 2.02, 95% CI: 1.49–2.74, P < .0001) and high-risk antibiotics (OR = 1.639, 95% CI: 1.45–1.85, P < .0001) both increased HA-CDI risk. A longer antibiotic free interval between courses decreased HA-CDI risk (OR = 0.998, 95% CI: 0.997–0.998, P < .0001). In addition, both PPI use and being immunocompromised were significantly associated with HA-CDI.

Conclusion
Multiple dimensions of AE in addition to cumulative duration were collectively associated with CDI risk. This has implications for designing accurate CDI prediction models implementing antibiotic stewardship interventions.

Disclosures
All authors: No reported disclosures.
2412. Oral Vancomycin Prophylaxis Against Recurrent Clostridioides difficile Infection: Efficacy and Side-effects: Two Hospitals Experience
Authors: Zacharioudakis Ioannis , Zervou Fainareti , Dubrovskaya Yanina , Phillips Michael 
Published: October 2019

Abstract

Background
Clostridioides difficile is the most common hospital-acquired pathogen with an unchanged infection prevalence between 2011–2015. The data regarding the effectiveness of chemical prophylaxis to prevent recurrent C. difficile infection (CDI) are conflicting.

Methods
We conducted a retrospective study of hospitalized patients with CDI history in 2 New York academic hospitals over a 4.5-year period to determine the effectiveness of vancomycin prophylaxis for CDI prevention. The participating hospitals implemented an automated alert to providers recommending oral vancomycin 125 mg twice daily in patients with a history of CDI scheduled to receive any systemic antimicrobials for the duration of therapy and 5 days thereafter. Measured outcomes included the rate of breakthrough and recurrent CDI, defined as CDI during and in the one-month following prophylaxis, respectively. A self-controlled, before and after study design was employed to examine whether the use of oral vancomycin was associated with an increase in the prevalence of vancomycin-resistant Enterococcus species (VRE) both in absolute numbers and in comparison to vancomycin-sensitive Enterococcus species (VSE) in the period following vancomycin prophylaxis.

Results
264 patients were included in the final analysis. Breakthrough CDI was identified in 17 (6.4%; 95% CIs 3.8%–10.1%) and recurrent CDI in 22 (8.3%; 95% CIs 5.3%–12.3%) patients. Of the 102 patients with a history of CDI within the 3 months preceding the administration of prophylaxis 4 (3.9%, 95% CIs 1.1%-9.7%) had breakthrough CDI and 9 had recurrent disease (8.3%, 95% CIs 5.3%–12.3%). In the 3 months following vancomycin prophylaxis there was an increase in both the absolute number of VRE and the ratio of VRE to VSE isolates compared with the combined period of 1.5 months preceding and the 3–4.5 months following the administration of prophylaxis. The increase in the absolute number of VRE colonized patients remained in the extended period of 6 months following prophylaxis.

Conclusion
Prophylactic vancomycin is an effective strategy to prevent CDI recurrence, but is associated with an increase in VRE colonization in the immediate period after administration. The risk of VRE infection should lead to careful selection of patients at the highest risk for CDI recurrence.

Disclosures
All authors: No reported disclosures.
2423. Cost-effectiveness of core and emerging infection control interventions to reduce hospital-onset Clostridioides difficile infection: An agent-based simulation modeling approach
Authors: Alagoz Oguzhan , Barker Anna K , Scaria Elizabeth , Safdar Nasia 
Published: October 2019

Abstract

Background
Multiple infection control interventions have been recommended to reduce hospital-onset Clostridioides difficile infection (C. difficile; HO-CDI), including contact isolation, environmental disinfection, and hand hygiene. These interventions have differential effects on reducing HO-CDI that change for each hospital setting. In the context of today’s constrained resources, with trade-offs a necessary part of any prevention plan, infection control personnel need information regarding intervention cost-effectiveness that is tailored to their unique hospital setting.

Methods
We evaluated the cost-effectiveness of nine infection control interventions and eight multiple-intervention bundles using our group’s agent-based model of C. difficile transmission. This previously developed model represents a general 200-bed acute-care adult hospital. Effectiveness was measured from the hospital perspective in terms of both quality-adjusted life years (QALYs) and HO-CDIs.

Results
Six interventions reduced cost while increasing QALYs and averting HO-CDI, compared with baseline standard hospital practices: daily cleaning (saved an average of $407,854 and 36.8 QALYs annually in a 200-bed hospital), HCW hand hygiene ($181,767; 17.7 QALYs), patient hand hygiene ($25,700; 6.3 QALYs), terminal cleaning ($64,986; 12.8 QALYs), screening at admission ($9,083; 18.5 QALYs), and reducing patient transfers ($27,514; 3.1 QALYs). Adding patient hand hygiene to the HCW hand hygiene intervention was cost saving. When screening, HCW hand hygiene, and patient hand hygiene interventions were sequentially added to daily cleaning to form two, three, and four-pronged bundles, the incremental cost-effectiveness ratios for these additions were $26,588, $44,173, and $123,379 per QALY, respectively.

Conclusion
Using cost-effectiveness data, institutions may consider streamlining their infection control initiatives and prioritizing a smaller number of highly effective interventions. Our model could be used to evaluate the cost-effectiveness of existing core and emerging infection control interventions for specific hospital settings.

Disclosures
All authors: No reported disclosures.
2432. Durability Against Antibiotics After Response to Fecal Microbiota Transplantation in Recurrent Clostridioides difficile Infection
Authors: Saha Srishti , Tariq Raseen , Pardi Ryan , Pardi Darrell , Khanna Sahil 
Published: October 2019

Abstract

Background
Fecal microbiota transplantation (FMT) cures ~90% of patients with recurrent Clostridioides difficile infection (rCDI). Ongoing or repeated exposure to risk factors, especially antibiotics (a modifiable risk factor but often necessary), may lead to future CDI. However, it is not known if FMT provides durable protection against future CDI despite subsequent antibiotic exposure. We studied the long-term durability of FMT against antibiotic exposure post-FMT.

Methods
A retrospective cohort study of patients undergoing FMT via colonoscopy for rCDI from Sep 2012 - Jun 2018 was performed. Patients were followed up for 1 year after FMT; data regarding future CDI episodes (watery diarrhea with positive stool test after interim symptom resolution), healthcare exposure, systemic non-CDI antibiotics and acid blocker therapy were collected. Primary outcome was ‘durability’ of response to FMT (defined as no CDI within 1 year post-FMT). Descriptive statistics, Chi square test, Wilcoxon test and multivariate logistic regression were used as appropriate.

Results
The study included 460 patients; median age 57 years (range 18–94 years), 65.2% (300) female. Overall 31.6% (144) received antibiotics; median number of courses of antibiotics, 2 (range 1–7). Of those who received antibiotics, the incidence of future CDI was 24.3% (n = 34), compared with 9% (n = 28) of those who did not receive antibiotics (P < .001). Median time to first CDI episode post-FMT was 103 (range 5–338) days. Incremental antibiotic courses did not lead to increased risk of future CDI (comparing 1, 2 or ≥3 courses, p = .68). In patients with antibiotic exposure, age and risk factors were similar in patients with and without future CDI (Table 1). Amongst those without antibiotic exposure, inflammatory bowel disease (IBD) predicted future CDI (p = .02). After controlling for risk factors and comorbidities, antibiotic use (p = .004) and IBD (p = .02) independently increased risk of future CDI.

Conclusion
The majority of patients with rCDI have a durable response to FMT despite ongoing risk factors. These data suggest that three-fourth of patients who receive antibiotics after FMT do not develop future CDI. IBD and antibiotic exposure independently increase the risk of future CDI.

Disclosures
All authors: No reported disclosures.
2450. A data-driven model of the economic burden of healthcare-associated infections as impacted by use of comprehensive genomic analysis of bacteria
Authors: Wong Brian E , Carmona Juan J , Fortunato-habib Mary M , van Aggelen Helen C , Doty Alan J , Gross Brian D 
Published: October 2019

Abstract

Background
Each year, nearly 2 million patients contract and are affected by healthcare-associated infections (HAIs) in the United States alone, resulting in nearly 100K deaths. According to the Centers for Disease Control and Prevention (CDC), more patients die from HAIs in the United States per year than all breast and prostate cancer cases combined (National Vital Statistics Report, 2016). In addition to the mortality burden, the financial impact of HAIs within the hospital ecosystem is estimated to total between $28–45 billion. However, no economic model has demonstrated how early effective identification and mitigation of infection clusters can result in cost savings for hospitals until now.

Methods
As there is no publicly available data for infection cluster rates, we based our analysis on anonymized real-world retrospective data spanning 18 months (November 2016 to June 2018) from two US-based academic tertiary hospitals with a combined total of about 1,700 beds, then normalized to 800 beds. A cloud-computing platform (Philips IntelliSpace Epidemiology) was used for whole-genome sequence analysis and cluster identification. We determined that an average 800-bed facility would have an occurrence of 46 genetically related infectious clusters involving 2 or more patients (mean of 7.9, median of 3), affecting 180 patients in total.

Results
Given the average HAI treatment cost of $24,512 (average costs rescaled from literature to 2019 USD using PPI data), this represents a total cost of $4,412,160. If these clusters could have been limited to 2 patients, an additional 96 infections might have been prevented, representing a potentially avoidable economic burden of $2,353,152 for this 800-bed institution. Our data show that a 20% reduction in transmissions would drive a 3% overall reduction in HAIs, but results in savings of over $450,000.

Conclusion
Active, genomic-based surveillance can inform timely and precise preventative steps to help lower the size of infectious clusters. This health economic modeling shows that such measures can result in significant cost savings. As such, it recommends that prompt, dynamic detection of infectious clusters via genomics and active surveillance offers a relevant and timely strategy for cost savings within the healthcare ecosystem.

Disclosures
All authors: No reported disclosures.
2456. Stenotrophomonas maltophilia (SM) Pseudo-outbreak Associated with Bronchoscope
Authors: Eichenblat Siobhan , Campbell Eileen , Kester Shelley , Layell Jessica , Passaretti Catherine 
Published: October 2019

Abstract

Background
Stenotrophomonas maltophilia (SM) is a multi-drug-resistant Gram-negative organism that typically impacts patients with long hospital stays or severe immunocompromise. In Q4 2017, an increase in rates of SM from adult bronchoscopic alveolar lavage (BAL) specimens was detected.

Methods
The charts of all patients with SM from BAL specimens during the time frame in question were reviewed for commonalities, clinical symptoms and antibiotic treatment for Stenotrophomonas. Incidence rate ratios for the 21 months prior to, 3 months during and 15 months after the increase were compared using Fisher exact test.

Results
Quarter 4 2017 rates of SM isolated from BALs performed in patients >/ = 18 years of age increased significantly from baseline of 0.46 to 2.22 per 10,000 patient-days. Upon chart review 75% (12/16) of patients with SM during the increase had BALs performed with a specific bronchoscope. Q4 2017, 22 patients had a BAL performed with the scope in question with 16 sent for culture. 75% (12/16) of the BALs done with this scope during Q4 2017 grew SM. The scope was pulled from use once the association was identified. ATP and high-level disinfection records were reviewed with no failures noted. The scope was sent to an independent lab where boroscope evaluation showed epoxy lifting. Cultures from the scope were unrevealing. After the scope was removed from service, rates of SM from adult BALs dropped significantly back to 0.58 per 10,000 patient-days (Figure 1). Upon clinical review, SM was deemed clinically insignificant in all but 1 case, however, 8 of the 12 patients received antibiotic treatment for this pathogen. To date, none of the patients in question had subsequent cultures with SM. No adverse events due to antibiotic therapy have been noted 10 of the patient isolates were retrieved and sent for pulsed-field gel electrophoresis testing. All came back with identical PFGE patterns strongly suggesting a point source.

Conclusion
While the bronchoscope culture did not grow SM, the identical PFGE patterns in patients without evidence of active infection suggested a point source. Return of SM rates to baseline following removal of the scope from service strongly suggest a pseudo-outbreak resulting from a reusable bronchoscope.

Disclosures
All authors: No reported disclosures.
2469. A National Intervention to Improve Infection Prevention Efforts in Hospitals with High Rates of Clostridioides difficile infection, Central Line-Associated Bloodstream Infection, Catheter-Associated Urinary Tract Infection and/or Methicillin-Resistant Staphylococcus aureus
Authors: Patel Payal K , Meddings Jennifer , Calfee David P , Popovich Kyle , Rohde Jeff , Rolle Andrew J , Fowler Karen E , Ameling Jessica , Ratz David , Greene M Todd , Forman Jane , Chopra Vineet , Saint Sanjay 
Published: October 2019

Abstract

Background
To strengthen state collaborative efforts and reduce common healthcare-associated infections (HAIs) in short-stay and long-term acute care hospitals, the Centers for Disease Control and Prevention (CDC) launched “States Targeting Reduction in Infections via Engagement” (STRIVE) - a national quality improvement program.

Methods
STRIVE consisted of a multimodal intervention implemented from November 2016 to May 2018 (Figure 1). Hospitals with excess Clostridioides difficile infection (CDI) and a high burden of at least one of the following HAIs - central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI) or methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection were targeted. Monthly aggregate HAI and device utilization ratios - according to CDC National Healthcare Safety Network definitions - were measured during the pre vs. post-intervention periods. Thematic analysis of qualitative interviews with state partners was conducted to understand the influence of the intervention.

Results
Overall, 387 hospitals from 23 states and the District of Columbia participated. Changes in HAI rates and catheter utilization are illustrated in Figure 2. From pre- to post-intervention, substantial changes in HAI rates above temporal trends were not observed (CDI, 7.0 to 5.7 per 10000 patient-days; CLABSI, 0.88 to 0.80 per 1000 catheter days; CAUTI, 1.12 to 1.04 per 1000 catheter days; MRSA bloodstream infection, 0.075 to 0.071 per 1,000 patient-days) Similarly, catheter utilization did not differ substantially between the pre- and post-intervention periods (24.05 to 22.07 central line days per 100 patient-days; 21.46 to 19.83 urinary catheter days per 100 patient-days). Qualitative analysis of 17 interviews with state partners showed that relationships among state partners and hospitals were strengthened, potentially facilitating collaboration on future infection prevention efforts.

Conclusion
Though HAI reductions were observed during STRIVE, these reductions were consistent with temporal trends. Hospitals struggling with high HAI rates may require additional novel approaches.

Disclosures
All authors: No reported disclosures.
2473. Trends in Methicillin Resistance Rate of Staphylococcus aureus among Medical Facilities Participating in Japan Nosocomial Infections Surveillance (JANIS)
Authors: Suzuki Yuka , Horikoshi Masaki , Ikeda Ai , Matsuura Hiroaki , Noda Hiroyuki , Ikeda Satomi , Tsuzuki Shinya , Nishiura Hiroshi , Yamagishi Kazumasa , Yahara Koji , Shibayama Keigo , Matsunaga Nobuaki , Hayakawa Kayoko , Ohmagari Norio 
Published: October 2019

Abstract

Background
The medical fee revision in 2014 economically motivated hospitals to join surveillance programs, such as Japan Nosocomial Infections Surveillance (JANIS), and rapidly increased JANIS member hospitals. The characteristics of the newly joined hospitals might have affected the reported resistance rate trends regardless of the effect of the policy itself. We examined the effect of the hospitals joining JANIS after 2014 on the trends in methicillin resistance rate of S. aureus.

Methods
We analyzed annual trends in methicillin resistance rate of S. aureus among inpatients, using JANIS datasets of 2007 to 2016, and defined oxacillin- or cefoxitin-resistant S. aureus as methicillin resistant. The dataset consisted of a total of 7,105 hospitals and 2,740,750 S. aureus test results. Hospitals were divided into two groups; joining JANIS A) before 2014 (751 hospitals), B) in and after 2014 (781 hospitals). A probit model examined their characteristics, and a panel data analysis calculated the resistance rate trends adjusted for age and sex, including interaction terms of hospitals group and year. Finally, we divided patients into quintile age groups, and conducted the same analysis by sex.

Results
The methicillin resistance rate of S. aureus decreased from 59.4% (2007) to 48.6% (2016), and the decreasing trend kept significant through the study period but 2009 (mean annual decrease: 1.2%, P < 0.05). Inpatients of hospital B had higher age (β = 0.01, P < 0.001), and more male (β = 0.005, P < 0.05), but their resistance rate was not significantly higher (β = 0.05, p = 0.12) compared with hospital A. Age stratified analysis for all hospitals found the youngest group (younger than 35 years old) of both sex had steadily low resistance rates through the period, while the older groups had higher rates, but their rates decreased continuously.

Conclusion
The methicillin resistance rates of S. aureus decreased throughout 2007 to 2016 except 2009. The patients of the hospitals newly joining JANIS were higher in age, but the resistance rate of S. aureus was not statistically different from the hospitals having joined JANIS before 2014. Also, among JANIS member hospitals, older patients had higher resistance rates than younger patients, but their rates were continuously decreasing.

Disclosures
All authors: No reported disclosures.