bluuebunny/crossref_metadata_2025_split huggingface dataset:
1490. Vancomycin 125 mg vs. 250 mg for the Treatment of Non-Severe and Severe Clostridium difficile Infections
Authors: Hsu Amy , Richardson Caitlin , Kuriyama Steve M 
Published: October 2019

Abstract

Background
Infectious Diseases Society of America (IDSA) guidelines recommend oral vancomycin 125 mg four times daily for 10 to 14 days for both non-severe and severe Clostridium difficile infections (CDI). Although 125 mg achieves sufficient fecal concentrations, doses of 250 mg are still commonly used in practice. There is limited data available comparing vancomycin 125 mg to higher doses. To the best of our knowledge, there are no studies that compare the effectiveness of vancomycin 125 mg vs. 250 mg in the treatment of CDI.

Methods
Single-center, retrospective cohort analysis of oral vancomycin 125 mg vs. 250 mg for the treatment of CDI between June 2018 and February 2019. Diagnosis of CDI involved symptomatic patients with positive Clostridium difficile toxin by either polymerase chain reaction or toxin enzyme immunoassay. We used IDSA guideline criteria of severe and non-severe to evaluate those who received a 10- or 14-day course of oral vancomycin. We excluded patients with concomitant metronidazole or fidaxomicin use, history of CDI in the past 8 weeks, fulminant CDI, or mortality prior to completion of therapy. The primary outcome was resolution of clinically significant diarrhea. Secondary outcomes included duration of loose stools, relapse of CDI within 30 days of diagnosis, and 30-day all-cause mortality.

Results
A total of 93 patients were included in the study, with 71 patients (76.3%) in the 125 mg group and 22 patients (23.7%) in the 250 mg group. Both groups were well matched with no significant differences at baseline or during treatment. Results showed no statistical difference in clinical resolution between the 125 mg and 250 mg groups, with 70 patients (98.6%) and 22 patients (100%) achieving clinical resolution, respectively (P = 1.00). Secondary outcomes revealed no statistical difference in duration of symptoms, relapse, or 30-day all-cause mortality.

Conclusion
There was no difference in clinical resolution of CDI between the vancomycin 125 mg and 250 mg groups. Furthermore, the dose of vancomycin did not have a significant effect on duration of symptoms, relapse, or 30-day all-cause mortality. Using the lower, guideline-recommended dose of vancomycin could potentially reduce patient exposure and provide cost-savings benefits without sacrificing efficacy.

Disclosures
All authors: No reported disclosures.
1492. Comparison of Acute Cholangitis in Patients With or Without Cancer
Authors: Sokal Aurélien , Chawki Sylvain , Nguyen Yann , Sauvanet Alain , Ponsot Philippe , Fantin Bruno , de Lastours Victoire 
Published: October 2019

Abstract

Background
Cancer-associated acute cholangitis (CAAC) are becoming more frequent and their characteristics may be changing with the evolution of cancer management. Our aim was to compare clinical, microbiological and outcome characteristics of CAAC to those of cancer-free acute cholangitis (CFAC).

Methods
All consecutive cases of acute cholangitis (AC) from November 2015 to March 2017 were collected retrospectively in a single tertiary care hospital in Clichy, France, specialized in gastroenterology. Hospital stays referred as AC by coding were screened. Patients fulfilling the 2018 Tokyo Guidelines diagnostic criteria for definite AC were included. Data were collected using a standardized form. CAAC were defined as AC that occurred in patients who had active cancer or history of cancer in the five previous years. CFAC were defined as AC in patient who no history of cancer, or in remission for more than 5 years. Comparison was made using Fisher or Student’s t-test. P < 0.05 was considered as significant.

Results
156 episodes of AC in 130 patients were analyzed. 101 had CAAC and 55 had CFAC. Age and sex did not differ (table 1), but CAAC had a higher Charlson’s comorbidity index (4.4 vs. 1.7, P < 0.0001). Despite similar clinical presentation, CAAC had more pronounced cholestasis (Gamma GT 659 vs. 391UI/L; Alkaline phosphatases 526 vs. 309 UI/L; P < 0.0001 for both) and C-reactive protein level (133 vs. 97mg/L, P = 0.008, Table 2). E. coli was more common in CFAC (72.4% vs. 54% of positive blood cultures, P = 0.004). In bile cultures, Enterococci and multi-drug-resistant Gram negatives tended to be more frequent in CAAC than in CFAC (63 vs. 17%, P = 0.07 and 9.1% vs. 4.1%, P = 0.33, Table 2), respectively. CAAC more frequently required drainage (86.1% of cases vs. 43.6% in CFAC (P < 0.0001), including radiological drainage (42.5% vs. 12.5%; P = 0.008) and with multiple sessions (28.7% vs. 8.3%, P < 0.0001, Table 3). Antibiotherapy duration did not differ between the two groups. Despite similar initial severity, only 51.5% of patients with CAAC were alive, without febrile recurrence or other biliary drainage at day 28, vs. 85.5% of patients with CFAC (P < 0.0001, Table 3).

Conclusion
Despite comparable initial clinical presentation, management is more complex and outcome less favorable in CAAC vs. CFAC.

Disclosures
All authors: No reported disclosures.
1494. Clinical Factors Associated with a Positive C. difficile PCR Test
Authors: Cushman Teresa , Barron Michelle , Arbet Jaron , Weber Rachel , Zhuang Yaxu , Jeffers Alexiss , Huang Misha 
Published: October 2019

Abstract

Background
C. difficile infection (CDI) remains a significant cause of morbidity and mortality. The most appropriate clinical scenario for CDI testing is unclear. The IDSA/SHEA guideline recommends testing patients with unexplained new-onset ≥3 stools in 24 hours. This study sought to evaluate clinical factors associated with a positive C. difficile PCR test.

Methods
We conducted a retrospective cohort study of adults (age >18 years old) admitted to the University of Colorado Hospital for whom a C. difficile PCR, either as a standalone test or part of the Biofire® Filmarray® Gastrointestinal Panel (GI Panel), was ordered between October 1, 2015 and August 31, 2017. Data collected included time since admission to test order, hospital length of stay, history of CDI, antibiotic use in the past 90 days, clinical presentation in the 24 hours preceding test order (fever, leukocytosis, number of stools), and laxative or antibiotic administration within 24 hours of test order. Multivariate logistic regression was used to evaluate the association of the above variables with having a positive C. difficile PCR test. If multiple tests were ordered during a single hospital encounter, only the first test was included in our analysis.

Results
3,070 tests were performed; of these, 72% were ordered in the first 72 hours of admission. Overall, 19% of tests were positive. After adjusting for clinical variables, patients with a prior history of C. difficile or who had received antibiotics in the past 24 hours were significantly more likely to have a positive test [OR 2.2 95% CI (1.54, 3.18) P < 0.0001] and [OR 16 95% CI (8.22, 31.41) P < 0.0001], respectively. Patients who used laxatives were significantly less likely to have a positive test [OR 0.75 95% CI (0.61, 0.91) P = 0.004]. The number of stools and presence of fever or leukocytosis were not significantly associated with a positive test.

Conclusion
Prior history of C. difficile and antibiotics use was highly associated with a positive C. difficile test, while laxatives use was associated with a negative test. The number of stools was not significantly associated with a positive C. difficile test, suggesting this may be less important clinical factor than previously believed; however, restricting testing in patients receiving laxatives is likely warranted.

Disclosures
All authors: No reported disclosures.
1496. Bezlotoxumab Administered at the End of a Suppressive Drug Regimen for Patients with Multiply Recurrent Clostridioides difficile Infection
Authors: Tan Xing , Danziger Larry H , Gerding Dale N 
Published: October 2019

Abstract

Background
Recurrent Clostridioides difficile infection (CDI) remains a public health burden, affecting as many as 35% of patients with primary CDI. Bezlotoxumab, a monoclonal anti-toxin B antibody, was the first FDA-approved agent indicated for the prevention of recurrent CDI, but real-world experience is limited, particularly in patients with multiple CDI recurrences.

Methods
We conducted a retrospective case study of patients with multiple CDI recurrences who failed prior treatments with pulsed and tapered vancomycin and fidaxomicin regimens. Six patients in a single CDI specialty outpatient clinic received a single iv infusion of bezlotoxumab at the end of a suppressive vancomycin or fidaxomicin treatment regimen. The suppressive treatment was stopped immediately after the bezlotoxumab infusion and the patients were followed closely for recurrent symptoms and need for additional CDI treatment.

Results
Four of 6 patients who received bezlotoxumab at the end of a suppressive treatment regimen did not require subsequent CDI treatment and have been followed for 2 weeks to 1.5 years to date. These four patients experienced a single, self-limited episode of diarrhea within 2 weeks of the infusion, and did not require subsequent CDI treatment. Two patients had recurrent symptoms and positive stool C. difficile tests one month after infusion and were re-started on CDI treatment. One of the patients had longstanding underlying irritable bowel syndrome and variable initial response to re-starting vancomycin. The other patient responded to re-starting fidaxomicin.

Conclusion
Bezlotoxumab at the end of a prolonged suppressive treatment regimen may be an effective therapeutic strategy in preventing recurrent CDI in complicated, multiply recurrent CDI patients.

Disclosures
All authors: No reported disclosures.
1501. Risk Factors for Clostridium difficile Infection in Patients Hospitalized with Community-Acquired Pneumonia
Authors: Deshpande Abhishek , Zilberberg Marya , Yu Pei-Chun , Imrey Peter , Rothberg Michael 
Published: October 2019

Abstract

Background
Patients with community-acquired pneumonia (CAP) are often prescribed broad-spectrum antibiotics, putting them at risk for developing Clostridium difficile infection (CDI). Previous studies of risk factors for CDI in this population have suffered from small sample sizes. We examined the risk factors for CDI in patients hospitalized with CAP using a large US database.

Methods
We included adult patients admitted with CAP 2010–2015 to 175 US hospitals participating in Premier and providing administrative and microbiological data. Patients were identified as having CAP if they had a diagnosis of pneumonia, a chest radiograph, and were treated with antimicrobials on day 1 and for ≥3 days. Incident CDI was identified with ICD-9 diagnosis code (not present on admission) and a positive laboratory test. We used descriptive statistics and mixed multiple logistic regression modeling to mutually adjust and evaluate risk factors previously suggested in the CDI literature.

Results
Among 148,417 inpatients with pneumonia treated with antibiotics, 789 (0.53%) developed CDI. The median age was 75 years, and 53% were female. Compared with patients with no CDI, those with CDI were older (75 vs. 72 years), had more comorbidities (5 vs. 3), and were more likely to be admitted from SNF (15.7% vs. 7.3%) or hospitalized in the past 3 months (11.8% vs. 7.1) (all comparisons P < 0.001). After multivariable adjustment, factors significantly associated with development of CDI included increasing age, admission from a skilled nursing facility, and receipt of piperacillin/tazobactam, aztreonam or intravenous vancomycin (Figure 1). Receipt of third-generation cephalosporins or fluoroquinolones was not an independent predictor of CDI.

Conclusion
In a large US inpatient sample hospitalized for pneumonia and treated with antimicrobials, only 0.53% of the patients developed CDI as defined by an ICD-9 code and positive laboratory test. Reducing the exposure to healthcare facilities and certain high-risk antibiotics may reduce the burden of CDI in patients with CAP.

Disclosures
All authors: No reported disclosures.
1506. Outcomes of Standardized Neonatal Cephalexin Dosing
Authors: Robertson Melena J , Tran Van , Nuibe Andrew M 
Published: October 2019

Abstract

Background
The optimal dosing of cephalexin in infants ≤90 days old is not well known. Our Antimicrobial Stewardship Program (ASP) standardized cephalexin dosing for inpatients ≥30 days old using available literature and released an antimicrobial dosing guideline in September 2016. Recommended antimicrobial dosing for inpatients <30 days old followed in November 2017. We reviewed the indications, cephalexin dosing, and clinical outcomes of patients before and after the release of our ASP’s cephalexin dosing guidelines.

Methods
Webi Universe was queried for cephalexin orders for inpatients ≤ 90 days old at the Inova Children’s Hospital from January 2016 to November 2018. Manual chart review extracted clinical points of interest and ensured that inclusion criteria were met. For patients <30 days old, the pre-intervention period was January 2016 to October 2017 and the post-intervention period was November 2017 to October 2018. For patients ≥30 days old the pre-intervention period was January 2016 to August 2016 and the post-intervention period was September 2016 to October 2018. Aggregate data from the two pre-intervention and two post-intervention periods were pooled, respectively.

Results
41 patients were identified: 25 in the pre-intervention period and 16 in the post-intervention period. The median age of patients in the pre-intervention period was 16 days compared with 31 days in the post-intervention period (P = 0.02). No patients had acute kidney injury requiring cephalexin renal dosing. Skin and soft-tissue infections (18) and urinary tract infections (10) were the most common infections in both periods. 24% of patients received the recommended cephalexin dose in the pre-intervention period compared with 63% in the post-intervention period (P = 0.02). Logistic regression controlling for pathogens and area of care showed that patient age predicted the use of recommended cephalexin dosing (OR 1.1, 95% CI: 1.01–1.21). There were no deaths or recrudescent infections.

Conclusion
Our ASP’s interventions improved adherence to standardized cephalexin dosing in inpatients ≤90 days old without any adverse clinical outcomes. Patients ≥30 days old were more likely to receive recommended cephalexin dosing. Opportunities remain to best define the optimal dose of cephalexin in infants ≤90 days old.

Disclosures
All authors: No reported disclosures.
1510. Improving the Management of Pediatric Complicated Pneumonia
Authors: Nuibe Andrew M , Tran Van , Levorson Rebecca E 
Published: October 2019

Abstract

Background
Pneumonia is a leading cause of pediatric hospitalization in the United States. Our Antimicrobial Stewardship Program (ASP) recognized significant variation in the management of pediatric complicated pneumonia. We developed and implemented a quality improvement (QI) intervention to align the management of complicated pneumonia with national guidelines and compared the medical care and clinical outcomes between a pre-intervention period and two post-intervention periods.

Methods
We queried Webi Universe for all ICD-9 and ICD-10-related admissions for pneumonia at our facility from November 15, 2015 to February 28, 2019. Manual chart review was done to extract clinical points of interest and to ensure that all included patients met inclusion criteria. Our first intervention (period 1) consisted of education to providers to increase use of chest tubes instilled with fibrinolytics and to decrease empiric antistaphylococcal therapy. Our second intervention (period 2) consisted of a care process model which codified the standardized management made by the first intervention, followed by several didactic sessions.

Results
29 patients were identified in the pre-intervention period, 11 in post-intervention period 1, and 27 in post-intervention period 2. Streptococcal species were the most common pathogens recovered in all periods. Following our interventions the number of video-assisted thorascopic procedures to drain complicated parapneumonic effusions decreased three-fold in favor of chest tubes instilled with fibrinolytics (P < 0.01). Our interventions also reduced empiric antistaphylococcal therapy within the first 48 hours of admission (P = 0.02) and decreased the use of empiric vancomycin three-fold (P = 0.01). Our interventions did not affect the median length of stay, frequency of pulmonary complications, number of 30-day readmissions, or duration of antimicrobial therapy.

Conclusion
Our ASP’s QI intervention decreased surgical drainage of complicated parapneumonic effusions and decreased the use of empiric antistaphylococcal agents without an increase in complications or readmissions. Opportunities remain to decrease the use of multiple antimicrobial agents within the first 48 hours of admission and to decrease the empiric use of antistaphylococcal therapy.

Disclosures
All authors: No reported disclosures.
1516. Early-Onset Neonatal Sepsis Due to Haemophilus influenzae
Authors: Varghese Alyssa , Korgenski Kent , Crandall Hillary , Bonkowski Anne 
Published: October 2019

Abstract

Background
Haemophilus influenzae causes serious invasive disease across all ages, but has not been widely described in neonatal early-onset sepsis (EOS). EOS, likely caused by organisms acquired from the mother, can lead to significant morbidity and mortality, particularly for preterm infants. There are reports of increasing ampicillin resistance in H. influenzae. We describe a case series of EOS due to H. influenzae at our institution.

Methods
Neonatal H. influenzae EOS was identified based on positive sterile site cultures at <72 hours of life in infants hospitalized at an Intermountain Healthcare (IHC) facility from 2007–2017. Demographics, clinical and microbiologic data were obtained through an IRB-approved electronic chart and microbiology review.

Results
Twelve neonates with H. influenzae EOS were identified over 11 years. Nine were preterm (<37 weeks); five were extremely preterm (<28 weeks). Eight had low birth weight (<2,500 g); five had very low birth weight (<1,500 g). Most (66%) mothers were primigravida; median maternal age was 24.5 years. Only four (33%) mothers had prolonged rupture of membranes (>24 hours).
All infants had signs and symptoms of sepsis within 24 hours of birth. The majority (10/12) had a blood culture positive for H. influenzae from the time of delivery. Two infants had negative delivery blood cultures but a H. influenzae-positive placental culture. No infant had > 1 day of bacteremia. One H. influenzae isolate was serotype b, one serotype c and one non-typeable, but most isolates (9/12) were not serotyped. Only one isolate produced a β-lactamase. All infants were empirically started on ampicillin and gentamicin at delivery. Nine infants underwent lumbar puncture, two were suggestive of meningitis but cultures were negative. Five infants developed interventricular hemorrhage and six required vasoactive medications. No infant died.

Conclusion
H. influenzae is an infrequent but important cause of neonatal EOS. H. influenzae EOS occurred in infants with known risk factors, including prolonged rupture of membranes, prematurity, and low birth weight. Recognition of H. influenzae as a potential pathogen in EOS has implications for the use of empiric antibiotic therapy particularly ampicillin, in septic neonates.

Disclosures
All authors: No reported disclosures.
1523. Clinical Epidemiology of Children with Orbital Cellulitis
Authors: Sharma Meghna , Espinel Alexandra , Ansusinha Emily , Hamdy Rana F 
Published: October 2019

Abstract

Background
The microbiology of pathogens causing orbital cellulitis in children is evolving over time, with studies from around 10 years ago describing MRSA as responsible for anywhere from 0 to 13% of cases of orbital cellulitis. However, the prevalence of community-acquired MRSA infections has declined over the past decade. A current understanding of the bacteria most commonly found to be responsible for orbital cellulitis would be important to inform the empiric antibiotic regimens for cases of orbital cellulitis in which no microbiologic data are available.

Methods
This is a single-center retrospective cohort study of children ≤18 years hospitalized with orbital cellulitis at Children’s National Medical Center between January 1, 2017 and July 31, 2018. We excluded children with immunocompromising conditions, cystic fibrosis, underlying craniofacial abnormality, or recent craniofacial or otolaryngologic surgery. Baseline clinical characteristics, microbiologic data, clinical outcomes, and antibiotic treatment data were abstracted through structured chart review and summarized with descriptive statistics.

Results
We identified 68 children that met inclusion criteria, with an average age of 8.2 years; 66.2% were male, 48.5% were African American, and 14.7% were Hispanic. Most (67.6%) had no underlying medical problems, 14.7% had asthma, and 22.1% had allergic rhinitis. The median duration of symptoms prior to presentation was 4 days. An abscess or phlegmon was identified in 41 of the 68 (60.3%). Three patients (4.4%) developed intracranial complications. About one-quarter (27.9%) of all patients in the cohort underwent surgical drainage. The most commonly identified pathogens were viridans group streptococci (7/19, 36.8%), followed by Staphylococcus aureus (4/19, 21.1%). Anti-MRSA therapy was provided empirically in almost all (95.6%) of patients.

Conclusion
One-quarter of all patients hospitalized for orbital cellulitis underwent surgical drainage, and viridans group streptococci and S. aureus were the most commonly isolated pathogens. While MRSA was isolated in only one patient (5.2%), almost all received empiric anti-MRSA therapy.

Disclosures
All authors: No reported disclosures.