bluuebunny/crossref_metadata_2025_split huggingface dataset:
570. “I don’t know”: The Typical Response When Taking Pneumococcal Immunization Histories in Kidney Transplant Candidates
Authors: Ramakrishna Jahanavi M , Jarmi Tambi , Libertin Claudia R 
Published: January 2021

Abstract

Background
Vaccine-preventable diseases account for significant morbidity and mortality in the kidney transplant (KT) patient population. AST Guidelines support review and documentation of pneumococcal vaccines in KT candidate infectious disease (ID) evaluations. The objective of this study is to determine the number of KT candidates screened for prior pneumococcal immunizations and the frequency of vaccines ordered by providers when indicated at Mayo Clinic Florida’s (MCF) Transplant Center.

Methods
This study was an institution-based retrospective analysis of all KT candidates evaluated at MCF from December 2, 2019 – January 14, 2020. Data collection was obtained by electronic health record review. Outcomes included known history and documentation rates of prior pneumococcal vaccinations (both Prevnar 13 and Pneumovax 23) by infectious disease (ID) providers, as well as pneumococcal vaccine order frequency during ID pre-transplant evaluation when indicated. Data analysis was done using simple descriptive statistics.

Results
Sixty-one patients underwent KT evaluation during the study period. Among the 61 patients, 20 (32.8%) and 20 (32.8%) had a known prior history of receiving Prevnar 13 and Pneumovax 23 vaccinations, respectively. Vaccine history was unknown for Prevnar 13 and Pneumovax 23 in 39 (63.9%) patients. Vaccine status was not documented by ID providers in 2 (3.3%) patients. When appropriate, ID providers ordered Prevnar 13 and Pneumovax 23 in 38 (92.7%) and 41 (100%) patients, respectively. Orders included both electronic and written documentation to account for patients planning immunization elsewhere. Of the 38 patients advised to receive the Prevnar 13 vaccine, 17 (41.5%) patients were documented completing immunization. Pneumovax 23 order completion rates were not recorded since the study period only lasted six weeks due to closure by COVID-19.
Table 1. Pneumococcal Vaccine History Documentation Rates Obtained by Patient Recall or Records

Table 2. Pneumococcal Vaccine Order Rates at Pre-Kidney Transplant Consultations

Table 3. Prevnar 13 Order Completion Rate by Documentation

Conclusion
The data reflect a high number of patients who either do not recall or have documentation of prior pneumococcal vaccination available at time of KT ID evaluation. Providers documented history of pneumococcal vaccinations extremely well, ordering immunizations when necessary. This study highlights lack of portability of immunization histories in a given patient population and opportunity for improved care.

Disclosures
Claudia R. Libertin, MD, Pfizer, Inc. (Grant/Research Support, Research Grant or Support)
572. Antiviral Toxicities Among Pediatric Solid Organ Transplant Recipients
Authors: Downes Kevin J , Sharova Anna , Mitrou Marina , Hayes Molly , Galetaki Despoina , Gianchetti Lauren , Vella Laura A , Li Yun 
Published: January 2021

Abstract

Background
Ganciclovir (GCV) and valganciclovir (VGCV) are used for prophylaxis (PPX) and treatment for CMV in pediatric solid organ transplant (SOT) recipients, but the frequency and impact of toxicities from these medications are not well described.

Methods
Retrospective cohort study of children undergoing SOT at Children’s Hospital of Philadelphia from Jan 2012 - Jun 2018. EMR were reviewed to identify laboratory-based toxicities between 15 days and 1 year post-transplant; medication management within 14 days of toxicity onset was recorded. Toxicities were defined as GCV or VGCV-associated if a patient was on the antiviral at toxicity onset. We defined acute kidney injury (AKI) as ≥50% change in creatinine (Cr) from 30 days prior, leukopenia as WBC &lt; 3500/µL, neutropenia as ANC &lt; 1000/µL, and thrombocytopenia as &lt; 100K/µL. Incidence rates of toxicities on PPX and treatment were compared to rates during no antiviral using univariate Poisson regression.

Results
285 children received 299 SOTs: 108 liver, 91 kidney, 69 heart, 31 lung. Nearly half (46%) of toxicities during the first year after transplant occurred while on GCV or VGCV PPX or treatment, but their use accounted for only 23% of all follow-up time. Receipt of VGCV and GCV PPX and treatment were associated with significantly higher incidence rates of toxicities compared to no antiviral (Fig 1). Of 259 GCV or VGCV-associated toxicities, 44% (n=113) were leukopenia, 26% (66) neutropenia, 26% (66) AKI, and 6% (15) thrombocytopenia (Table 1). Most recipients of VGCV PPX (64%) sustained at least one toxicity while on PPX. AKI during VGCV PPX led to stopping/dose-adjusting of VGCV in 43% and of immunosuppression in 57% of cases. Neutropenia during VGCV PPX resulted in stopping/dose-adjusting of VGCV in 63%, of immunosuppression in 36%, and of TMPX/SMX PPX in 36% of cases. During VGCV PPX, 81% of AKI was stage II/III (≥100% change in Cr) and 65% of neutropenia was severe (&lt; 500/µL); 11% of both AKI (n=6) and neutropenia (n=7) during VGCV PPX resulted in hospitalization.
Figure 1. Incidence Rates of Toxicities from Day 15 through 1 Year After Transplant

Table 1. Antiviral Use and Toxicity 2 Weeks to 1 Year After Transplant

Conclusion
GCV and VGCV use was associated with significant renal and hematological toxicities in pediatric SOT recipients. While VGCV and GCV are effective at preventing CMV disease in pediatric SOT, clinicians should consider risk of toxicity when evaluating CMV prevention strategies.

Disclosures
Kevin J. Downes, MD, Merck, Inc. (Grant/Research Support)
573. Continuing Medical Education: Leveraging a Digital Tool to Help Improve CMV Management Strategies
Authors: Hurst Simi Thomas , Martorano James 
Published: January 2021

Abstract

Background
Increasing the risk for complications and negatively impacting patient health outcomes, an estimated 45% - 80% of HSCT patients experience CMV infection/reactivation, with mortality rates sometimes reaching as high as 60%.
Figure. Assessment of Educational Effectiveness

Methods
This study assessed the ability of digital education to improve the ability of ID specialists to make evidence-based recommendations for CMV management in HSCT recipients. A CME/ABIM MOC educational program featuring interactive discussion between two ID faculty was developed and launched on 12/12/19, on a website dedicated to continuous professional development. Educational effectiveness was assessed with a repeated-pairs pre-/post-assessment study design; each individual served as his/her own control. A chi-square test assessed changes pre- to post-assessment. P values &lt; 0.05 are statistically significant. Effect sizes were evaluated using Cramer’s V (&lt; 0.05 modest; 0.06–0.15 noticeable effect; 0.16–0.26 considerable effect; &gt; 0.26 extensive effect). Data for this matched-learner analysis were collected through 04/14/20.

Results
To date, 3315 HCPs (2891 physicians; 162 nurses/NPs) have participated in the activity. Data from the subset of ID specialists (n=190) who answered all pre-/post-assessment questions during the initial study period were analyzed. Following activity participation, significant improvements were observed in the proportion of ID specialists who answered all assessment questions correctly (8% pre vs 28% post; P &lt; .0001; V=.217). Improvements were also observed in several specific areas of assessment (Figure). Additionally, 65% of ID specialists indicated they planned to modify their patient assessment or treatment approach because of participating in the education.

Conclusion
Participation in this digital educational program significantly improved ID specialists’ ability to differentiate among therapeutic options when developing management strategies for HSCT recipients with CMV infection/reactivation. These findings highlight the potential for well-designed online education to positively impact physicians’ competence and confidence.

Disclosures
All Authors: No reported disclosures
575. Effectiveness of Short vs Long Course Perioperative Antibiotics in Lung Transplant Recipients with Donor Positive Respiratory Cultures
Authors: Groff Lindsey T , Reed Erica E , Coe Kelci E , El Boghdadly Zeinab , Keller Brian C , Whitson Bryan A , Burcham Pamela K 
Published: January 2021

Abstract

Background
Lung transplant recipients are at increased risk for infection in the early post-operative phase. Perioperative antibiotic (POA) practices are variable among transplant centers with sparse data regarding optimal antibiotic prophylaxis duration. This study aimed to evaluate the efficacy of short course (SC) (≤10 days) vs long course (LC) (≥11 days) POA in lung transplant patients.

Methods
This was a single-center, retrospective study of non-cystic fibrosis first time lung transplant recipients with donor positive cultures between Aug 2013 and Sept 2019. Patients who died within 14 days of transplant were excluded. Data collected included baseline characteristics, donor and recipient cultures, POA, and hospitalization details. The primary outcome was 30-day recipient freedom from donor-derived respiratory bacterial infection. Secondary outcomes included development of Clostridioides difficile infection (CDI), cumulative time on ventilator, post-op time to extubation, in-hospital all-cause mortality, and 30-day development of POA resistance. Descriptive statistics were used for analysis. Continuous variables were compared using the Wilcoxon rank sum test while categorical variables were compared using the chi-square or Fisher’s exact test. Statistical significance was defined as p&lt; 0.05.

Results
A total of 147 patients were included (58 SC vs 89 LC). Median POA duration in the SC group was 6.5 days vs 13 days in the LC group (p&lt; 0.0001). The primary outcome of 30-day freedom from donor-derived respiratory infection was present in 56 (97%) patients in the SC vs. 85 (96%) patients in the LC group (p= 1). There was no difference in development of CDI (p = 0.4), mortality (p = 1), or resistant organisms (p=0.28) while cumulative ventilator time and time to post-op extubation were longer in the LC group (p = 0.002 & 0.007, respectively). Methicillin-sensitive Staphylococcus aureus was the most common organism isolated from donors in the SC (23, 40%) and LC (48, 54%) groups.

Conclusion
Among lung transplant recipients with positive donor cultures, short course POA was as effective as long course in preventing donor-derived bacterial pneumonia. Further studies are needed to assess heterogeneity in POA practices and optimal duration among transplant centers.

Disclosures
Brian C. Keller, MD, PhD, CareDx, Inc. (Grant/Research Support) Bryan A. Whitson, MD, PhD, Abbott Laboratories (Consultant)TransMedics OCS (Other Financial or Material Support, Serves on the Clinical Events Committee)
577. Incidence and Outcomes of Positive Outpatient Surveillance Blood Cultures in Hematopoietic Stem Cell Transplant (HSCT) Patients with Graft Versus Host Disease (GvHD) On High Dose ≥ 0.5 mg/kg/day (HD) and Low Dose &lt; 0.5mg/kg/day (LD) Steroid Therapy
Authors: Perreault Sarah , Schiffer Molly , Zhao Jennifer , McManus Dayna , Foss Francine , Gowda Lohith , Isufi Iris , Seropian Stuart , Topal Jeffrey E 
Published: January 2021

Abstract

Background
Treatment of GvHD with steroids increases the risk of infection in HSCT patients due to additive immunosuppression and may delay the diagnosis of infection due to lack of symptoms. Outpatient surveillance blood cultures in HSCT with GvHD being treated with HD steroids has demonstrated a blood culture positivity rate of 3.5%. Currently, the utility of surveillance cultures in patients receiving LD steroid therapy is unknown. Our practice includes weekly outpatient surveillance cultures for all GvHD patients treated with steroids regardless of the dose. The primary endpoint of this study was to assess the incidence of positive surveillance blood cultures in GvHD patients receiving HD or LD steroids. Secondary endpoints included number of patients treated, hospitalization, 30 day mortality due to infection, and organisms isolated.

Methods
This was a single-center, retrospective review of GvHD patients at Yale New Haven Hospital between January 2013 and May 2019. Patients were excluded if: lack of signs or symptoms of GvHD, treatment with steroids for any indication other than GvHD, and active GvHD without central line. Cultures from patients receiving antibiotics for concurrent infection were also excluded.

Results
A total of 71 patients met criteria with 901 blood cultures. On HD, eight patients (14%) had 12 positive cultures (4%), and on LD, 16 patients (25%) had 22 positive cultures (4%) (p=0.15). Treatment occurred in six patients (75%) with four (24%) requiring hospitalization on HD, and 12 patients (75%) with 10 (83%) requiring hospitalization on LD (p=0.45). The median duration of steroid therapy was 93 and 236 days with a median dose of steroids of 1mg/kg/day and 0.15mg/kg/day, respectively. The number of positive cultures/1000 steroid days was 1.2 on HD and 0.5 on LD (RR 2.2). 30 day mortality was only noted in one patient (8%) on LD. The most common organism in both groups was Coagulase-negative staphylococci with all six cultures on HD classified as contaminants and 6/10 cultures requiring treatment on LD.

Conclusion
Although the relative risk of positive surveillance blood cultures in HD patients compared to LD was twofold higher, there were clinically significant infections identified in the LD group.

Disclosures
All Authors: No reported disclosures
581. Risks versus Benefits of Metronidazole Use for the Prevention of Acute GVHD in Allogeneic Stem Cell Transplant Recipients
Authors: Young Mary T , Monogue Marguerite , Patel Hetalkumari 
Published: January 2021

Abstract

Background
Currently, acute graft versus host disease (aGVHD) prophylaxis in hematopoietic stem cell transplants (HSCT) varies amongst different institutions. There is a lack of data supporting the use of metronidazole for aGVHD prophylaxis in HSCT. To further investigate if metronidazole has an effect on aGVHD, allogeneic HSCT recipients will be examined to determine if metronidazole post-transplantation decreases the incidence of aGVHD and the risks of adverse drug events (ADE) associated with this practice.

Methods
This retrospective study included 120 adult patients who received an allogeneic HSCT between January 1, 2010 to December 31, 2013. The primary endpoint is the incidence of aGVHD, defined as within 100 days post-transplant. Secondary endpoints include the rate of metronidazole discontinuation due to intolerance, frequency of metronidazole-related adverse effects, incidence of Clostridioides difficile infection, mortality, and overall survival.

Results
One hundred six patients met the inclusion criteria. The majority of patients received metronidazole (88 vs. 18). Less patients in the metronidazole arm developed aGHVD (51.1% vs 61.1%, p=0.44). In the subcategories of liver, skin, and gastrointestinal aGHVD, patients who received metronidazole developed less gastrointestinal aGVHD (26.1% vs 50.0%, p=0.045). Gastrointestinal ADEs were the most common metronidazole-related ADEs (19.3%, Table 1). There were no significant differences in the incidence of C. difficile infection, mortality, and overall survival between the two arms (Table 2).
Table 1. Adverse Drug Events and Discontinuation of Therapy

Table 2. Additional Secondary Outcomes

Conclusion
Despite a reduction in gastrointestinal aGVHD in the metronidazole arm, approximately one in four patients experienced an ADE to the medication, likely due to the prolonged use of the medication (33 days). The utilization of post-transplant cyclophosphamide for GVHD prophylaxis likely eliminates the need for metronidazole; however our findings suggest a benefit in preventing gastrointestinal aGVHD with metronidazole; albeit, caution is warranted given the high incidence of ADE associated with prolonged use.

Disclosures
All Authors: No reported disclosures
584. Ventricular assist device infections with Pseudomonas aeruginosa
Authors: Roberts Scott C , Nam Hannah H , Kumar Rebecca N , Zembower Teresa , Qi Chao , Malczynski Michael , Rich Jonathan D , Pawale Amit A , Harap Rebecca S , Stosor Valentina 
Published: January 2021

Abstract

Background
Infection is a leading cause of morbidity and mortality in ventricular assist device (VAD) recipients. Pseudomonas aeruginosa (PA) is the second most common organism implicated in VAD infections, occurring in 10–50% of infections. The epidemiology of VAD recipients with PA infection are poorly described.

Methods
We identified patients (pts) at Northwestern Memorial Hospital with a VAD-specific PA infection from January 1, 2012 to Dec 31, 2019. VADs included the Heartmate II, Heartmate 3, and Heartware HVAD devices. VAD-specific infections were defined according to the 2013 ISHLT Guidelines.

Results
Seventeen out of 91 (18.7%) VAD infections were due to PA. Infections of the driveline exit site (DLES) occurred most commonly (n=15, 88.2%), followed by pocket (n=2, 11.8%) and pump (n=2, 11.8%) infections. Median time to infection after VAD implantation was 295 days (IQR 154 – 440 days). Eight (47.1%) pt isolates were not fluoroquinolone (FQ) susceptible. Resistance to multiple antibiotic classes was observed in pts in whom serial cultures were obtained. Median antibiotic treatment was 107 days (IQR 55 – 183 days, maximum 775 days). Five (29.4%) pts received FQ monotherapy on initial diagnosis, 3 (60%) of whom required change to a different class for resistance. Surgical debridement and VAD exchange were performed in 5 (29.4%) and 3 (17.6%) pts respectively. Co-pathogens were identified in 9 (52.9%) pts, the most common being Staphylococcus aureus (n=2) and Enterococcus spp (n=2). A total of 5 (29.4%) pts went on to successful heart transplantation; one had recurrent PA infection at the prior DLES requiring prolonged antibiotics and removal of retained DL material. All cause 1-year mortality rate was 11.7% (n = 2), both of whom died from cerebrovascular accidents.

Conclusion
VAD-specific infections with PA occurred late after device implantation and required prolonged antibiotic courses. Antimicrobial resistance was high at diagnosis and worsened in pts on prolonged therapy. Morbidity and mortality in pts with PA VAD infections were high. The preponderance of DLES infections warrants further study and highlights the need for improvements in DLES care and infection prevention strategies.

Disclosures
All Authors: No reported disclosures
588. Implementation of a standardized OPAT SmartForm was associated with improved post-discharge outcomes
Authors: Certain Laura , Benefield Russell J , Thomas Frank O 
Published: January 2021

Abstract

Background
The outpatient parenteral antimicrobial therapy (OPAT) plan has frequently been omitted or incompletely communicated during transitions of care at our institution. Better communication of the OPAT plan at discharge has the potential to improve patient outcomes.

Methods
A standardized OPAT documentation tool (SmartForm) was developed in our electronic health record system for use by our inpatient Infectious Disease (ID) consult service. This intervention was part of an ongoing quality improvement project to improve communication of the OPAT plan at discharge. Outcomes were assessed prospectively during the post-intervention time period (11/18/2019 - 4/13/2020) and compared to the pre-intervention time period (10/14/2019 - 11/11/2019). Patients were included if discharged on IV antibiotics with follow up by a University of Utah Health ID provider. Patients discharged to long-term acute care facilities were excluded.

Results
Three hundred five patients were included: 231 in the post-intervention period and 74 in the pre-intervention period. Demographic characteristics were similar between time periods with the exception of older age (mean 60 vs 56 years), a greater percentage of patients receiving OPAT via an infusion center (19% vs 9%), and fewer patients receiving OPAT via home health (54% vs 64%) in the pre-intervention cohort. Documentation of an OPAT progress note occurred more frequently (94% vs 85%, p = 0.02) and patients were more likely to be enrolled in our OPAT program (77% vs 51%, p &lt; 0.0001) after implementation of the OPAT SmartForm. Outpatient laboratory monitoring occurred with similar frequency during the pre- and post-intervention time periods (85% vs 82% of expected laboratory encounters completed, p = 0.31). Sixty-day unplanned hospital readmissions were reduced after implementation of the SmartForm (22% vs 35%, p = 0.02). Multivariable logistic regression identified Charlson comorbidity index (OR 1.10, 95% CI: 1.02–1.18) and the pre-intervention time period (OR 1.78, 95% CI: 0.99–3.18) as variables independently associated with readmission.

Conclusion
Implementation of an OPAT SmartForm was associated with improved documentation of the OPAT plan, increased enrollment in the OPAT program, and reduction in hospital readmissions.

Disclosures
Russell J. Benefield, PharmD, Merck and Co (Grant/Research Support)Paratek Pharmaceuticals (Grant/Research Support)Rempex Pharmaceuticals (Grant/Research Support)
589. Use of Dalbavancin in Facilitating Discharge of High Risk Patients in Low Resource Settings
Authors: Milgrom Alexander 
Published: January 2021

Abstract

Background
Patients who inject intravenous drugs (PWID) can have devastating infections with poor outcomes while being burdensome to the healthcare system, both in terms of lack of payment and length of stay. These issues are only exacerbated in settings where addiction treatment resources such as medication assisted therapy (MAT) are limited. One potential method of alleviating some of this burden is with long acting glyco-lipopeptide antibiotics, such as dalbavancin, to reduce length of stay.

Methods
A retrospective evaluation of 10 PWID patients treated with dalbavancin to facilitate early discharge was performed at Prisma Health Richland hospital in 2019. Reduction in length of stay was calculated based on estimated length of stay typical for treatment of their clinical syndrome.

Results
Average length of stay was reduced by 22.4 days. 9 of the patients were seen inpatient, and one was evaluated outpatient. 4 patients (40%) had documented mental illness in their chart diagnoses, and 7 (70%) of patients were uninsured. 4 (40%) of patients had a history of leaving AMA, 2 (20%) were rehospitalized within 30 days, Of these 10 patients, only 1 patient who already had been following as an outpatient had appropriate follow-up with an Infectious Disease specialist after treatment.

Conclusion
Discussion
Long acting glyco-lipopeptide antibiotics can facilitate discharging patients from an inpatient setting where status as PWID cannot be managed in an outpatient setting. On average, a little over 3 weeks was saved in terms of hospital days, which is a significant savings for the hospital system. However, it remains unclear how much this benefits the patient as follow-up for this treatment was abysmal and thus it is difficult to assess for the clinical response. Further evaluation is required to the utility of such treatments, as well as the implementation of MAT and more widespread assistance for this vulnerable population.

Disclosures
All Authors: No reported disclosures