bluuebunny/crossref_metadata_2025_split huggingface dataset:
137. Impact of Rapid Susceptibility Testing on Outcomes in Patients with Bacteremia
Authors: Megherea Oxana , Patel Ruchi , Lake Patrick , Bicking Keri , Sebti Rani 
Published: October 2019

Abstract

Background
Early organism identification via rapid diagnostics has been shown to reduce time to effective antimicrobial therapy and improve patient outcomes in patients with bacteremia, but antimicrobial susceptibility testing is still required to optimize therapy. The objective of this study was to determine the impact of an institution-specific rapid susceptibility testing method on outcomes in patients with bacteremia.

Methods
This was a retrospective pre- and post-intervention study of 100 adult patients with bacteremia. Patients were excluded if they had polymicrobial infection, fungemia, blood cultures collected at outside hospitals, or if they expired prior to susceptibility results. Patients were identified through a report containing positive blood cultures from October 2017 to February 2018 (pre-intervention [PrI]) and October 2018 to February 2019 (post-intervention [PoI]). The primary endpoint was the rate of clinical failure (a composite of 28-day mortality or bacteremia persisting greater than 6 days). Secondary endpoints included microbiologic outcomes, time to effective and optimal therapy, length of stay (LOS) and therapy adjustments.

Results
Baseline characteristics were similar between groups; a third of the patients were immunosuppressed (Table 1). The most common sources of infection were urinary and intra-abdominal, and the most common organisms identified were E.coli and Klebsiella spp. No significant difference in the rate of clinical failure was identified between PrI and PoI (24% vs. 18%, P = 0.6242) (Table 2). In the PoI, the time to identification, susceptibility results, and effective therapy was significantly shorter with similar time to optimal therapy and LOS. In the PoI, antimicrobial stewardship program (ASP) interventions were made significantly sooner after susceptibility results.

Conclusion
In this small, retrospective, single-center study, the implementation of a rapid susceptibility testing method was associated with reduced time to susceptibility results and more rapid interventions by the ASP, but no difference in the rate of clinical failure or time to optimal therapy was identified.

Disclosures
All authors: No reported disclosures.
2451. Hospital-acquired Legionella Pneumonia Outbreak at an Academic Medical Center. A Case–control Study of Risk Factors
Authors: Kessler Michael , Osman Fay , Pop-Vicas Aurora E , Safdar Nasia 
Published: October 2019

Abstract

Background
An outbreak of hospital-acquired Legionella pneumonia, associated with potable water contamination, occurred at our university hospital in November of 2018, despite a longstanding copper-silver ionization system. We conducted a case–control study to examine risk factors for Legionella pneumonia.

Methods
We matched controls to cases by dates of admission, hospital ward, and admitting service, in a 4:1 ratio. We reviewed patient charts for potential risk factors and exposures, and summarized demographic information using descriptive analyses. Univariate and multiple logistic regression analyses were also performed. We used pulsed-field gel electrophoresis for molecular typing of isolates from patient respiratory samples and hospital water samples.

Results
We identified 13 cases of nosocomial legionella pneumonia over a one-month period (Figure 1), with 8 males, 5 females, and a mean age of 63 years. The average time to diagnosis was 19 days following admission. Six patients were transplant recipients – two had solid organ, and six had bone marrow transplant. Urinary Legionella antigen was positive in all cases. Table 1 shows predictors for Legionella pneumonia in univariate analyses. Current smoking (OR = 7.5, 95% CI [1.11 – 50.84], p = 0.03], pre-admission steroid prescription (OR = 6.5, 95% CI [1.65 – 26.20], p = 0.008], documentation of shower (OR = 6.2, 95% CI [1.54 – 25.82], p = 0.01], and number of showers prior to hyper-chlorination (OR = 1.45, 95% CI [1.03 – 2.04], p = 0.03] were significant risk factors on univariate analysis. The multiple regression model was also significant (P < 0.001) with all of the above-identified predictors (Table 2). Molecular typing found Legionella strains from patient respiratory samples and water samples to be identical. Multiple interventions, including restriction of showering, hyper-chlorination, and optimization of water flow through the copper-silver ionization system were implemented, and were successful in mitigating the outbreak.

Conclusion
We found showering to be a modifiable risk factor for Legionella pneumonia in this outbreak. Interventions to reduce this risk might include point of use filters in showers in high-risk populations.

Disclosures
All authors: No reported disclosures.
2462. Public Health Response to Contain the First Outbreak of New Delhi Metallo-β-Lactamase-Producing Klebsiella pneumoniae in Minnesota
Authors: VonBank Brittany , O’Malley Sean , Snippes Vagnone Paula , Ellen Bennett Mary , Hale Tammy , Walters Jacy , Lynfield Ruth 
Published: October 2019

Abstract

Background
Carbapenem-resistant Enterobacteriaceae (CRE) producing the New Delhi-metallo-β-lactamase (NDM) carbapenemase are uncommon in the United States but are a serious threat for untreatable antibiotic-resistant infections. In Minnesota (MN), NDM-CRE is typically associated with receipt of healthcare abroad. We describe the public health response to contain the first outbreak of NDM-CRE in MN.

Methods
CRE is reportable, with isolate submission to the MN Department of Health (MDH) for MALDI-TOF identification, phenotypic carbapenemase production testing, and PCR for carbapenemase genes. On December 24, 2018, MDH identified a case of NDM-K. pneumoniae in a long-term care facility (LTCF) without travel. MDH initiated an investigation. We defined a case as having NDM-K. pneumoniae matching the outbreak PFGE pattern from a clinical or surveillance culture. Cases were identified through surveillance, point prevalence survey (PPS) rectal swab colonization testing, and PFGE at MDH. MDH collected a healthcare exposure history for all cases. A containment response occurred in any facility where a case received healthcare in the 30 days prior.

Results
Nine cases of clonal NDM-K. pneumoniae with specimen collection dates between December 24, 2018 and March 26, 2019 were identified; 8 were residents of LTCF A and 1 was a roommate in LTCF B of a former LTCF A resident. PPS testing of 260 healthcare contacts occurred in 6 facilities, including LTCF A, LTCF B, and 4 acute care hospitals (ACH) that accepted LTCF A transfers; 7/9 cases were identified through PPS and 2/9 cases were identified through CRE surveillance. One case from LTCF A was identified in an ACH, but PPS did not identify transmission in ACHs. MDH conducted on-site infection control assessments in 2 LTCFs, identified numerous infection control (IC) lapses at LTCF A, and provided telephone IC consultation to 4 ACHs.

Conclusion
Surveillance and PPS uncovered an outbreak of NDM CRE in 2 LTCFs. Patient transfers led to a regional public health response lasting several months that included IC consultation and additional PPS. Intervention to coordinate containment responses among interconnected healthcare facilities is critical to containing the spread of novel resistance mechanisms in the United States.

Disclosures
All authors: No reported disclosures.
2471. Review of Methicillin-Resistant Staphylococcus aureus, Clostridium difficile and Acquired Bloodstream Infections Across all United Kingdom Intensive Care Units following Implementation of a Statutory National Infection Control Campaign.
Authors: Batra Rahul , Edgeworth Jonathan , Wulff Jerome , Harrison David 
Published: October 2019

Abstract

Background
Methicillin-Resistant Staphylococcus aureus (MRSA) and C. difficile infection have reduced across the UK National Health Service in the last decade following implementation of an infection control campaign. The national impact on hospital-acquired infections in the ICU however has not been comprehensively documented.

Methods
Data on MRSA, C. difficile, vancomycin-resistant Enterococcus (VRE) and ICU-acquired bloodstream infection (UABSIs) were analyzed from 1,189,142 consecutive patients from 2007 to 2016 recorded prospectively and standardized by highly trained assessors. Initial coverage was 139 ICUs increasing to 275 ICUs representing 100% of general, adult UK ICUs.

Results
ICU MRSA and C. difficile admissions and acquisitions per 1000 patients decreased between 2007 and 2012 (MRSA admissions 38.8 to 13.1; acquisitions 25.4 to 4.1; C. difficile admissions 10.6 to 4.2; acquisitions 11.1 to 3.5), whereas VRE admissions and acquisitions increased from 1.9 to 5.3 and 1.5 to 5.9, respectively. There were 13,114 UABSIs in 1.8% patients staying >48 hours. UABSIs fell from 7.3 (95% CI 6.9–7.6) to 1.6 (95% CI 1.5–1.7)/1,000 bed-days between 2007 and 2012. Adjusting for patient admission and ICU factors the IRR was 0.21 (95% CI 0.19–0.23, P < 0.001) from 2007 to 2016. Reductions in UABSIs were seen for all main organisms excluding VRE with greatest reductions for MRSA (97%), Pseudomonas aeruginosa (80%), S. aureus (77%) and Candida spp. (71%) but lower reductions for E. coli (54%) and Klebsiella (42%).

Conclusion
Large decreases in ICU-acquired infections occurred across the UK ICU network between 2007 and 2012 linked with the first few years of the national infection control campaign, but rates have been static since. Further reductions in ICU will likely require a new intervention framework.

Disclosures
All authors: No reported disclosures.
2495. Pharmacokinetics of Cabotegravir (CAB) and Rilpivirine (RPV) Long-Acting (LA) Injectables in HIV-infected Individuals through 48 Weeks in the FLAIR and ATLAS Phase 3 Studies
Authors: Patel Parul , Ford Susan L , Crauwels Herta , Han Kelong , Rossenu Stefaan , Neyens Martine , Griffith Sandy , Hudson Krischan J , Margolis David , Baker Mark , Williams Peter , Spreen William 
Published: October 2019

Abstract

Background
Monthly injectable CAB LA + RPV LA was noninferior to daily oral 3-drug antiretroviral therapy in HIV-1 virologically suppressed adults. CAB and RPV pharmacokinetics (PK) were assessed during the 48 Week maintenance period of the ATLAS and FLAIR Phase 3 studies.

Methods
Patients received oral CAB 30 mg + RPV 25 mg once daily for 4 weeks to assess individual tolerability prior to intramuscular (IM) injections of CAB LA 600 mg + RPV LA 900 mg followed by CAB LA 400 mg + RPV LA 600 mg every 4 weeks. Plasma CAB and RPV concentrations were measured pre-and post-dose at select visits using validated analytical methods.

Results
Baseline demographics for the pooled randomized ATLAS and FLAIR population (n = 591, LA arms) were: median age 38 years, 27% female, 18% African American, median BMI 25 kg/m2 (range: 15 – 51). CAB and RPV plasma concentrations at select visits are summarized in the table. After initial IM doses, mean CAB and RPV troughs were well above their respective in vitro PA-IC90 values (CAB, 0.166 μg/mL; RPV 12 ng/mL). At Week 48, mean CAB troughs were 17x PA-IC90 and between oral CAB 10–30 mg exposures. Similarly, mean RPV troughs were 7x PA-IC90 and remained within the exposure range following oral RPV 25 mg once daily. 80% of RPV steady-state was achieved by Week 48 and 100% for CAB by Week 44. Initial CAB concentrations in females and those with BMI ≥30 kg/m2 were lower due to slower absorption but this difference resolved by Week 48. For RPV, there was no absorption difference by gender or BMI.

Conclusion
CAB and RPV PK were consistent between studies achieving therapeutic concentrations within the first dosing interval that steadily increased over time through Week 48, for both males and females and irrespective of BMI. CAB LA + RPV LA provided compatible PK profiles following monthly IM dosing in a diverse patient population through 48 weeks.

Disclosures
All authors: No reported disclosures.
2510. Systematic Literature Review of Multiclass Resistance in Heavily Treatment Experienced Persons with HIV
Authors: Mauskopf Josephine , Fernandez Maria M , Ghosn Jade , Sax Paul , Priest Julie , Garris Cindy , Clark Andrew 
Published: October 2019

Abstract

Background
Because of progress in antiretroviral therapy (ART), fewer people with HIV experience virologic failure with multiclass resistance. We sought to estimate the prevalence of multiclass resistance since the introduction of INSTI-based regimens using a systematic literature review.

Methods
A systematic literature search using PubMed, Embase, and the Cochrane Library was conducted of articles published since 2008, the year when INSTI-based regimens for treatment-experienced people with HIV became widely used. Bibliographies of existing literature reviews, websites of European and International organizations reporting data on HIV and AIDS, and abstracts presented from 2016–2018 at conferences were searched to identify additional relevant studies. Using predefined criteria, two reviewers independently reviewed studies reporting multiclass (three-class or greater) resistance in persons with HIV infection who are treatment experienced and were either perinatally infected or infected as adults. Studies from Western Europe, Australia, Canada and the United States (US) using any type of resistance definitions and resistance tests were included.

Results
A total of 441 unique articles were identified, 343 were excluded during level 1 screening and 98 articles were included for full-text review. A total of 34 articles (11 US studies, 3 from Canada, 1 from Australia, and 19 from Western European countries.) met the inclusion criteria and were included in data extraction analysis. Over the past decade, a modest decrease in the prevalence of three-class (NNRTI, NRTI, PI) resistance was observed in studies from the United States and Canada, ranging from 8.3% in 2009 to 6.7% in 2014 (Figure 1). Western European countries and Australia showed similar trends. The prevalence of 4-class resistance (including INSTIs) with virologic failure in the current treatment era is low, less than 2% (Figure 2).

Conclusion
The prevalence of multiclass resistance has decreased over the past decade, with three-class resistance continuing to decline and four-class resistance rare. Although the population with treatment failure and no viable options for a suppressive regimen is currently small, this group of people with HIV are in urgent need of novel treatment options.

Disclosures
All authors: No reported disclosures.
2543. Implementation of a Fellow-Driven Β-Lactam Allergy De-Labeling Initiative on an Inpatient ID Consult Service
Authors: Mulliken Jennifer S , Bystritsky Rachel , Anstey Karen , Otani Iris M , Doernberg Sarah B 
Published: October 2019

Abstract

Background
Approximately 10% of patients in the US report a penicillin (PCN) allergy, but more than 90% can safely receive β-lactam (BL) antibiotics. Having a reported BL allergy (BLA) is associated with increased length of stay, cost of care, adverse events, and mortality. As part of our institutional quality improvement incentive program for graduate medical trainees, the Infectious Diseases (ID) and Allergy/Immunology (AI) fellows implemented a protocol-driven approach to BLA evaluation. We sought to evaluate the success of this implementation.

Methods
This is a pre–post investigation of our BLA protocol. As an initial pilot phase prior to house-wide deployment, the ID and AI services implemented a BLA guideline incorporating thorough history-taking, graded challenge, and focused penicillin skin testing for patients on the ID consult service. All patients seen by the ID consult service from July 1, 2018 through June 30, 2019 with a documented BLA were included (baseline period April 1, 2018 through June 30, 2018). The primary endpoint was the proportion of patients meeting any one of the following: receipt of a BL, inpatient or outpatient referral to AI, or removal of BLA from the medical record by the time of discharge. Data were tracked quarterly and fed back to ID and AI fellows electronically. The Chi-square test was used to compare pre-post outcomes.

Results
Over the first three quarters, 258 patients with BLA were evaluated by the ID consult service. Our baseline compliance was 65%, which increased to an average of 81% over the subsequent three quarters (P = 0.003). Among patients with BLA seen by the ID consult service during the intervention, 177 (69%) received a BL, 37 (14%) underwent inpatient AI evaluation, 11 (4%) received discharge referrals to AI, and 126 (49%) had their BLA removed. Several patients met more than one primary endpoint.

Conclusion
Implementation of a protocol-driven BLA guideline by ID and AI fellows was feasible and led to an increase in the number of patients either receiving BLs in the hospital or undergoing timely evaluation or removal of BLA. In conclusion, the implementation of a β-lactam allergy de-labeling initiative is an effective way to empower trainees to incorporate BLA de-labeling into their practice.

Disclosures
All authors: No reported disclosures.
2555. Relationship-Based Communication to Enhance ACGME Infectious Disease Fellowship Competencies
Authors: Howell Alan C , Howell Martha , Cooper Stacy 
Published: October 2019

Abstract

Background
Relationship Centered Communication (RCC) acknowledges the physician’s expertise as well as the patient’s perspective.1 Clinician empathy also serves to improve patients’ ability to cope with chronic diseases.2 Furthermore, effective communication aids with diagnosis and improves treatment adherence.3 Hence, the need to teach and assess competence in Interpersonal Communication - Communicates effectively with patients, caregivers and interprofessional teams milestones. Created in conjunction with the Academy of Communication in Healthcare, RCC training for faculty is encouraged by our organization. Having attended the inter-professional workshop, ID faculty collaborated with the training program to afford the fellows the same opportunity to learn RCC skills.

Methods
Faculty have reported limited opportunities to observe/assess their learners. Trainees report infrequent and nonspecific feedback regarding areas for improvement.4 Given these challenges, the ID fellows began a multi-step plan to hone new communication skills after attending the RCC workshop. Activities included both real and simulated encounters as well as didactic presentations. Each scenario built upon the previous one providing continuity of care. Upon completing both outpatient and inpatient encounters, the fellow joined the debriefing team (standardized patient, Program Director and RCC coach) to discuss areas of competence as well as opportunities for improvement. The fellows were also evaluated by faculty in actual patient encounters in addition to choosing a RCC skill to highlight during didactic conference.

Results
Activities provided fellows RCC teaching opportunities, interaction with a standardized patient and learn how the interaction was perceived from the patient’s perspective. Ability to practice in a safe simulation environment, access to coaching and real-time assessment was reported as valuable for all parties. The RCC training afforded both parties the ability to give and receive specific/objective feedback for a competency usually perceived as subjective.

Conclusion
Varied activities urged the fellows to establish consistent communications habits. The program generated a framework for sustainability of skills and objective assessment.

Disclosures
All authors: No reported disclosures.
2564. What Predicts Journal Publication Tier and Audience Engagement in the Infectious Diseases Literature? A Review of 146 Publications
Authors: Cortes-Penfield Nicolas W , Salemi Jason 
Published: October 2019

Abstract

Background
As part of an online medical education project (www.idjournal.club), we surveilled the infectious diseases (ID) literature, selecting subsets of what we deemed the most clinically impactful articles on a monthly basis using a prespecified search algorithm. We used this resource to perform a broad overview of articles published in the field and examine factors associated with publication in higher tier journals and higher rates of public and ID community engagement.

Methods
We examined articles reviewed on www.idjournal.club between June and September 2018. For each article, we recorded the publishing journal, subfield of ID, study type, nation and degree of the lead author, and sample size, and we assigned the paper up to three topic keywords. Our outcomes of interest were the publishing journal’s Scimago Journal Rank (SJR), a surrogate for journal tier, and the article’s Altmetric score, a surrogate for audience engagement.

Results
Of 146 articles included in the analysis, the most common study types were retrospective observational (n = 47), randomized controlled trial (n = 23), in vitro (n = 20), and prospective observational (n = 19). The median sample size was 238; median sample sizes were higher for randomized controlled trials (n = 400) and lower for in vitro and pharmacokinetic/pharmacokinetic studies (n = 53 and n = 44). Lead authors were based in the United States in 38% of cases and in North America or Europe in 86% of cases. Physicians accounted for 65% of lead authors, PhDs 23%, and PharmDs 10%. The most commonly referenced pathogens were HIV, MDR Gram-negative bacteria, S. aureus, and C. difficile; the most commonly referenced disease states were bacteremia, sexually transmitted infection, respiratory tract infection, and UTI. The mean SJR was 3.5 (SD 3.1) and the mean Altmetric score was 54.5 (SD 143). SJR and Altmetric score were associated with study type, sample size, and key topics; Altmetric score was also associated with publishing journal. In multivariate analysis, SJR was associated with study type and sample size, and Altmetric score was associated with ID subfield, journal, and sample size.

Conclusion
We present a descriptive overview of the ID literature and identify article factors associated with journal tier and audience engagement after publication.

Disclosures
All authors: No reported disclosures.