bluuebunny/crossref_metadata_2025_split huggingface dataset:
123. Impact of Enterococcal Bacteremia on Clinical Outcomes in Patients with Liver Cirrhosis
Authors: Phe Kady , Won Isabel , Carlson Travis J , Ryan Russo Hannah , Yau Raymond 
Published: October 2019

Abstract

Background
Patients with liver cirrhosis are at an increased risk for bacterial infections due to bacteria overgrowth and dysregulation of the intestinal barrier function. These infectious complications are associated with significant morbidity and mortality. Currently, there is a paucity of literature evaluating the clinical outcomes of patients with enterococcal bacteremia and cirrhosis. We hypothesized that patients with cirrhosis and subsequent enterococcal bacteremia would have a higher odds of mortality.

Methods
This was a retrospective, case–control study including adult patients (>18 years) with liver cirrhosis and >1 positive blood culture with Enterococcus species (ENT) admitted from June 2013 through August 2018. These cases were then matched with cirrhotic patients without enterococcal bacteremia (NO ENT) in a 1:1 ratio based on the Model for End-Stage Liver Disease (MELD) score. The primary endpoint was all-cause inpatient mortality. Multivariable logistic regression was used to control for other patient covariates.

Results
A total of 136 patients were identified during the study period (68 ENT and 68 NO ENT). The median length of stay was significantly longer in ENT patients (24.5 vs. 9 days, P < 0.001), while NO ENT patients were more likely to have renal dysfunction (55.9% vs. 83.8%, P < 0.001). All other baseline characteristics between the two groups were similar. Inpatient mortality was found to be significantly higher in ENT patients than NO ENT patients (51.5% vs. 29.4%, P = 0.009). In the multivariable analysis, risk factors found to be independently associated with mortality included enterococcal bacteremia (OR 3.96, 95% CI 1.61–9.73), MELD score (OR 1.11, 95% CI 1.05–1.19), and APACHE II score (OR 1.14, 95% CI 1.06–1.23).

Conclusion
Enterococcal bacteremia, MELD score, and APACHE II score were found to be independent risk factors for all-cause inpatient mortality in patients with liver cirrhosis. Future studies are needed to elucidate how treatment choice and bacterial characteristics might also influence patient outcomes.

Disclosures
All authors: No reported disclosures.
2302. A Meta-Analysis of Risk Factors for Herpes Zoster Infection
Authors: Parhar Kamalpreet K , Huang Bill , Vadlamudi Nirma K , Marra Fawziah 
Published: October 2019

Abstract

Background
The burden of herpes zoster (HZ) is significant worldwide, with millions affected and the incidence rising. Current literature has identified some risk factors for this disease; however, there is yet to be a comprehensive study that pools all evidence to provide estimates of risk. Therefore, The purpose of this study was to identify various risk factors, excluding immunosuppressive medication, that may predispose an individual to developing herpes zoster.

Methods
The literature search was conducted in MEDLINE, EMBASE, Cochrane Central, Cochrane Systematic Reviews, Web of Science, CAB Direct, yielding case–control, cohort and cross-sectional studies that were pooled from January 1966 to September 2018. Search terms included: zoster OR herpe*OR postherpe*OR shingle*AND riskOR immunosupp*OR stress OR trauma OR gender OR ethnicity OR race OR age OR diabetes OR asthma OR chronic obstructive pulmonary disease OR diabetes. Risk ratios for key risk factors were calculated via natural logarithms and pooled using random effects modeling.

Results
From a total of 4417 identified studies, 93 were included in analysis (n = 3826134 HZ cases). Immunosuppression through HIV/AIDS (RR 3.25; 95% CI 2.47–4.27) or malignancy (RR 2.17; 95% CI 1.86–2.53) significantly increased the risk of HZ compared with controls. Family history was also associated with a greater risk (RR 2.48; 95% CI 1.70–3.60), followed by physical trauma (RR 2.01; 95% CI 1.39–2.91) and older age (RR 1.68; 95% CI 1.41–2.01). A slightly smaller risk was seen those with psychological stress, females, and comorbidities such as diabetes, rheumatoid arthritis, cardiovascular diseases, renal disease, SLE, and IBD compared with controls (RR range: 2.08 to 1.25). We found that black race had lower rates of HZ development RR 0.69 (95% CI 0.56–0.85).

Conclusion
This study demonstrated patients with family history of HZ, older age, female sex, have particular comorbidities or are immunosuppressed have an elevated risk of herpes zoster. Patients with these characteristics are prime candidates for vaccination.

Disclosures
All authors: No reported disclosures.
2303. Chronic Hepatitis B Virus Infection and Risk of Herpes Zoster: A Cohort Study
Authors: Cheong Haesuk , Kim Bomi , Jeong Joo Eun , Chang YooSoo , Yoo Seungho 
Published: October 2019

Abstract

Background
No cohort studies have evaluated the effect of hepatitis B virus (HBV) infection on the risk of herpes zoster. We investigated the association of HBV infection with the development of herpes zoster.

Methods
We performed a cohort study of 224,691 non-cirrhotic adult men and women free of herpes zoster at baseline who underwent serologic testing for hepatitis B surface antigen (HBsAg) and were followed annually or biennially for a median of 4.2 years. Incident cases of herpes zoster were ascertained using the Korean Health Insurance and Review Agency (HIRA) database. A Cox proportional hazard model was used to estimate the adjusted hazard ratio (aHR) with 95% confidence interval (CI) for incident herpes zoster according to HBsAg seropositivity status.

Results
During 830,073.4 person-years of follow-up, 11,061 cases of incident herpes zoster were identified. HBsAg seropositivity was inversely associated with the development of herpes zoster. After adjustment for possible confounders, the multivariable-adjusted hazard ratios (95% CI) for herpes zoster comparing HBsAg-positive to HBsAg-negative participants was 0.83 (0.75–0.93).

Conclusion
In a large cohort of Korean adults, HBsAg seropositivity was associated with lower risk of herpes zoster, suggesting that HBV seems to inhibit the reactivation of varicella-zoster virus.

Disclosures
All authors: No reported disclosures.
126. Cascade of Care for Opioid Use Disorder in Patients with Infective Endocarditis
Authors: Saldana Carlos S , Bal Gabriella , Shrestha Nabin K , Englund Kristin , Gordon Steven M 
Published: October 2019

Abstract

Background
The term “Cascade of Care” has been used to analyze care delivered by a health system for conditions such as HIV, hepatitis C, tuberculosis, and diabetes. It outlines sequential steps required to reach a specific outcome (i.e., viral suppression in the case of HIV). This allows to estimate the proportion of patients achieving each step and to identify gaps in care. Medication-assisted treatment (MAT) is integral in the treatment of patients with infective endocarditis (IE) and opioid use disorder (OUD). We propose a Cascade of Care aiming to identify fundamental milestones in the management of these patients.

Methods
A retrospective cohort study examined patients with IE in the setting of OUD hospitalized between July 1, 2007 and January 1, 2015 to the Cleveland Clinic. We identified 4 key steps along the treatment cascade of these patients and estimated the proportion of patients: (1) evaluated by an addiction treatment service, (2) prescribed MAT while in-patient, (3) prescribed MAT at discharge, and (4) continued MAT at least 90 days after discharge.

Results
Of 273 patients with IE in the setting of OUD, 134 (49%) were evaluated by an addiction treatment service; 45 (17%) were prescribed MAT while in-patient; only 22 (8%) were prescribed MAT at discharge. At 90 days following discharge, there was evidence of continuing MAT for all 22 patients (8%).

Conclusion
Describing the process of addiction treatment for patients with IE and OUD in the format of a cascade of care provides a powerful quantitative method to identify gaps in care and can be used as a resource to implement interventions to address losses. We found only 8% of these patients continued MAT in the community after discharge. This study provides an estimate of how compromised the potential benefits from medical and surgical treatment for IE are by the lack of an effective approach to OUD after hospital discharge.

Disclosures
All authors: No reported disclosures.
2332. Low Serum Vitamin D Levels Are Related to Life-Threatening Respiratory Syncytial Virus Infection in Previously Healthy Infants
Authors: Martin Ferolla Fausto , Walter Yfran Eduardo , Gabriela Ballerini Maria , Toledano Analia , Caratozzolo Ana , Clara Giordano Ana , Carrizo Barbara , Feldman Florencia , Anselmino Cecilia , Chiormi Agustina , Visingardi Gabriela , Retta Alejandra , Reyero Mariana , Dastugue Monica , Mascardi Normando , Neira Pablo , Ropelato Gabriela , Marta Contrini Maria , Luis Lopez Eduardo 
Published: October 2019

Abstract

Background
Serum 25-hydroxy-vitamin D (VD) effects on lung growth and immune system modulation might affect respiratory infections outcomes. Data are controversial regarding the role of VD status in the severity of Respiratory Syncytial Virus (RSV) infection. The aim of this study was to assess serum VD levels and its association with life-threatening disease (LTD) in previously healthy infants infected with RSV.

Methods
Prospective cohort study including previously healthy infants <12 months, hospitalized with a first RSV infection in 2017–2018. Viral load (VL) was assessed by qRT–PCR in nasopharyngeal aspirates and serum VD levels measured by ECLIA, in samples obtained on admission. VD deficiency was defined as levels <20 ng/mL, VD insufficiency 20–29 ng/mL, and LTD as need of intensive care and mechanical or noninvasive ventilation

Results
98 patients, mean age 4.5 months (±3.1), 55 (56.1%) male. VD status: 18 (18.4%) with deficiency, 32 (32.6%) with insufficiency; 14 (77.8%) patients with deficiency had not received VD supplementation. There was no relationship between VD deficiency and anemia (P = 0.28) or age (P = 0.27). LTD was observed in 17 infants, with no significant differences in socioeconomic, pregnancy and infant variables compared with other RSV cases. Patients with LTD had significantly lower levels of VD (17.5 ng/mL [IQR 15.2–26.3] vs. 31.8 ng/mL [IQR 23.5–52.1, P < 0.001)], Figure 1. 15 patients, 88.2% of all infants with VD levels ≤29 ng/mL developed LTD compared with a study population frequency of LTD of 17.3%. Multivariable regression analysis including breastfeeding confirmed VD deficiency as a risk factor for LTD (aOR 14.3, 95% CI 3.9–51.5, P < 0.001). Normal VD values conferred protection (aOR 0.1, 95% CI 0.02–0.49, P = 0.004). VD levels inversely correlated with days of hypoxemia (P = 0.007); VD deficiency increased the risk of requiring O2 supplementation >7 days (aOR 8.5, P < 0.001). VL did not correlate with VD levels (P = 0.696), length of stay (P = 0.378), days of hypoxemia (P = 0.681). VL was not associated with LTD (P = 0.42).

Conclusion
Vitamin D deficiency was a risk factor for LTD in previously healthy infants with RSV infection. Viral titers did not correlate with VD levels. These findings provide additional evidence for the development of low-cost preventive and therapeutic strategies.

Disclosures
All authors: No reported disclosures.
127. Novel Treatment Approach for Left Ventricular Assist Device-related Infections
Authors: Yalcin Yunus C , Verkaik Nelianne , Bax Hannelore I , Croughs Peter D , Bogers Ad J J C , Caliskan Kadir 
Published: October 2019

Abstract

Background
Left ventricular assist device (LVAD) implantation has become an effective treatment option for patients with severe heart failure. However, infections remain a substantial risk. Therefore, the aim of this study was to gain insight in the incidence and outcome of LVAD infections in our center and develop an up-to-date flowchart for the management of LVAD-related infections.

Methods
A retrospective study was performed which included all patients with an LVAD implanted between 2006 until 2019, along with a rigorous review of the current literature. Clinical records and microbiological laboratory results of all patients were reviewed. In view of local infectious complications, a flowchart was developed for the contemporary management of LVAD-related infections (Figure 1).

Results
Overall, 106 patients (median age 54 years [IQR 47–60], 78% male) were included, of whom 92 (87%) as bridge-to-transplantation/decision and 14 (13%) as destination therapy. LVAD-related infections occurred in n = 30 (28%) of the patients. The median time until first infection was 308 days [IQR 115–528], and the median duration of hospital stay was 16 days [IQR 4–29]. Eighty percent of LVAD-related infections were driveline-related. The most common causative pathogen was Staphylococcus aureus, which was present in almost half of the cases (40%). Patients who experienced infections were younger (46 [IQR 37–57] vs. 56 [IQR 52–62]; P < 0.001).The survival rate at 3 years was 76% in the infected vs. 94% not infected patients; P = 0.037). A secondary infection occurred in 10 patients (33%). At 3 years of follow-up, 31 patients were successfully transplanted. Six patients with deep S. aureus driveline infections were treated according to the standardized protocol of whom 2 with suppressive therapy by cephalexin, with clinical success so far.

Conclusion
LVAD infections occur frequently and lead to prolonged periods of hospital admissions and death. The lack of standardized treatment regimens complicates the treatment of LVAD-related infections. A comprehensive flowchart to treat future LVAD-related infections in a protocolized fashion was developed, based on our single-center experience. While the preliminary results look promising, more follow-up time of the treated patients is needed.

Disclosures
All authors: No reported disclosures.
2346. Cost Savings Associated with Implementation of Clinical Decision Support for Clostridiodes difficile Testing
Authors: Hoegg Cindy L , Williams Katie L , Shelov Eric , Metjian Talene A , Maria Cardenas Ana , Kelsen Judith , Hayes Molly , Lori Handy K 
Published: October 2019

Abstract

Background
Clinical decision support for Clostridioides difficile infection (CDI) diagnostics reduces inappropriate testing, leading to decreased need for isolation and antibiotic use. Our institution utilized manual discontinuation by laboratory staff of CDI testing for inappropriate specimens, including formed stool and age < 1 year. We aimed to assess the financial impact of instituting a CDI best practice alert at a quaternary care children’s hospital.

Methods
A multidisciplinary team mapped inappropriate testing criteria identified from literature review with discrete fields in our electronic health record (EHR, EpicCare) to design an alert. The exclusion criteria identified included: (1) age < 1 year; (2) positive C. difficile test within past 14 days; (3) less than or equal to 3 unformed stools in past 24 hours; (4) current receipt of CDI-directed therapy; or (5) laxative use or barium exposure in prior 48 hours. 6 months of data prior to implementation were reviewed to estimate impact of the alert. At implementation, any exclusion criteria detected in the EHR at the time of order entry triggered an alert to deter CDI testing. Cost estimates for averted tests (Quick Check Complete Assay/Illumigene) included cost of test ($50), cost of isolation/personal protective equipment ($159/day), and cost of treatment with oral vancomycin in false-positives ($2250/treatment course).

Results
In a 6-month pre-implementation period, 586 tests for CDI were ordered; of which, 23% were identified by our criteria as inappropriate. During the first 3 months of alert implementation, 256 tests were ordered, of which 105 (41%) caused the alert to fire. Of those, 56 tests were not ordered, for a 22% reduction in testing. Laboratory staff continued to manually stop tests not meeting criteria, such as patient age <1 year when possible. Based on avoidance of testing, use of PPE, and 10 day antibiotic treatment for false-positives (assumed 25% by literature review), this translated to cost savings of $69,916, and an annual cost savings of $279,664.

Conclusion
Implementation of an alert for select patients using a bioinformatics algorithm reduced inappropriate CDI testing. Clinical decision support for CDI can lead to substantial cost savings for both antibiotic use and isolation precautions.

Disclosures
All authors: No reported disclosures.
2352. Clinician Assessment of Pretest Probability for Clostridioides difficile Infection and Disease Severity While Using Multiplex, Syndromic Molecular Panel in Patients Presenting with Diarrhea
Authors: Throneberry S Kyle , Lopansri Bert K , Grisel Nancy A 
Published: October 2019

Abstract

Background
The role of nucleic acid amplification tests (NAAT) for diagnosing Clostridioides difficile (CD) infection remains controversial. Adding CD to multiplex molecular panels (GIPCR) that detects multiple GI pathogens of community origin, has the potential to introduce confusion leading to delayed diagnosis and unnecessary antibiotic use especially if pretest probability is not considered.

Methods
We conducted a retrospective study to determine the frequency at which clinicians characterize pretest probability and disease severity in adult patients with diarrhea who tested positive for CD by GIPCR (BioFire, Inc.) from July 1, 2017 to October 16, 2018. We excluded immunocompromised patients. Routine testing includes reflex to GDH and toxin A/B detection when GIPCR is positive for CD. Charts were reviewed and clinical suspicion (PTP) was assigned as high, medium, low, or not done. Disease severity was classified as mild, moderate and severe. Exposure to systemic antibiotic within 90 days prior to testing and stool frequency was also captured.

Results
In total, 447 patients were included in the analysis: 110 (24.6%) were positive for both GDH and Toxin (G+/T+), 158 (35.3%) were G+/T−, 179 (40%) were G−/T−, and 149 (33%) were not classified. Toxin positivity was highest in the setting of high PTP (67%) (figure). In contrast, toxin was negative in most cases when suspicion for CDI was low or not characterized (81%). For medium suspicion, only 36% were T+. Antibiotic exposure prior to testing was observed in 203 (45%) of the cases. More G+/T+ patients received antibiotics (63%) before testing and 66% of G−/T− did not receive antecedent antibiotics. Clinicians did not characterize frequency of diarrhea in 261 (58%) of the patients tested and 95% of cases did not undergo severity classification. When documented, 24% of tested patients had < 3 diarrheal episodes/day (Table 1). Most cases where multiple pathogens were detected were T− (84.5%) and G−/T− (44%) (Table 2).

Conclusion
Overall, characterization of diarrheal illness was poor and PTP was frequently omitted. A large proportion of GIPCR results positive for CD (40%) were negative for both GDH and Toxin. CD results in molecular testing with syndromic panels should be interpreted with caution.

Disclosures
All authors: No reported disclosures.
2362. Back to the Future: The Impact of Multi-Step Algorithm C. difficile Testing at a Large Tertiary Medical Center
Authors: Bork Jacqueline , Claeys Kimberly C , Johnson J Kristie , Jones Jennifer , Obiekwe Uzoamaka , Lusby Martha , Heil Emily , Leekha Surbhi 
Published: October 2019

Abstract

Background
Antibiotic stewardship and infection control programs rely on C. difficile infection (CDI) test results to measure CDI incidence in the hospital setting. C. difficile carriage is common and distinguishing infection from colonization is difficult with the highly sensitive nucleic acid amplification testing (NAAT) commonly used. Current guidelines recommend a multi-step algorithm for testing. The impact on patient outcomes and CDI metrics are largely unknown.

Methods
This was a pre-post study at the University of Maryland Medical Center, evaluating the impact of a CDI testing strategy (introduced October 2018) that simultaneously reported NAAT and confirmatory enzyme immunoassay (EIA) when used with existing best practice alerts for appropriate testing. Pre-intervention (November 2017–September 2018) and post intervention (October 2018–March 2019) periods were compared for mean CDI incidence (CDI per 10,000 admissions) defined by: (1) positive NAAT, (2) reported CDI (last positive test), and (3) treated CDI (receiving oral vancomycin). Both community and hospital-onset cases were included. The NAAT CDI incidence was used as the pre-intervention comparison for all 3 measures. In addition, oral vancomycin days of therapy (DOT) per 1,000 patient-days (PD) was compared. Pre–post comparisons of mean CDI incidence and mean DOT rates were done using Student t-test.

Results
There were 3,237 samples tested (2,269 pre and 968 post-intervention) with 376 NAAT positive (262 pre and 114 post-intervention). Of the 99 tests with reflex EIA, there were 74 discordant tests (NAAT +/EIA -) with 35 (47%) treated for CDI. Mean NAAT CDI incidence pre-intervention was 54 per 10,000 admissions. Post-intervention mean CDI incidence decreased as follows: 45 NAAT CDI per 10,000 admissions (P = 0.13), 15 reported CDI per 1000 admissions (P < 0.0001), and 28 treated CDI per 10,000 admissions (P = 0.0007). Oral vancomycin DOT per 1,000 PD decreased from 16 to 9 (P = 0.0002).

Conclusion
C. difficile NAAT testing with confirmatory EIA, in combination with best practice alert, decreased reported and treated cases of CDI, which may distinguish infection vs. colonization and avoid unnecessary treatment, beyond that achieved with alerts that improve appropriate patient selection for testing.

Disclosures
All authors: No reported disclosures.