bluuebunny/crossref_metadata_2025_split huggingface dataset:
838. Oral Vancomycin Prophylaxis Works!
Authors: Van Hise Nicholas W , Hines David , Didwania Vishal , Beezhold David , Chundi Vishnu , Fliegelman Robert , Han Alice , Van Hise Allyssa , Chundi Vaishali , Manian Farrin , Petrak Russell M 
Published: October 2019

Abstract

Background
Clostridium difficile infections (CDI) cause approximately 500,000 cases a year with an estimated cost that exceeds $4.8 billion. Despite interventions that addressed environmental disinfection, antibiotic stewardship, and infection control, many institutions continue to have a significant burden of disease. Public reporting and “pay for performance” have increased the impetus for better control of CDI. We describe the use of an unpublished scoring system to assess the risk of CDI with subsequent use of OVP to prevent exsporulation and infection in high-risk groups.

Methods
A large urban hospital in the Chicago area of approximately 400 beds, after following recommended guidelines for prevention of C. difficile, instituted an assessment tool to predict the risk of developing C. difficile infection.This is an observational, cohort study reviewing the pre- and post-implementation of OVP (oral Vancomycin prophylaxis) in hospitalized patients. From January 2017 to December 2017, eligible patients were assessed for risk of C. difficile. The intervention period, from January 2018 to December 2018, we prospectively gave eligible patients oral vancomycin (OVP) 125 mg twice daily if the risk score was 13 or above. No changes in environmental cleaning, antimicrobial stewardship, or restriction of testing were instituted during the periods of enrollment. The analysis was approved by the institutional review board.

Results
In 2017, 82 patients had a score of 13 or over. Of the 82 patients, 72 (87.8%) developed CDI. In 2018, 62 eligible patients had a score of 13 or over and were given OVP. Of the 62 patients, 5 (8%) developed CDI. The relative risk comparing C. difficile in ≥13 vs. <13 patients (RR = 19.2652; 95% CI = 7.3656, 50.3899). The tool is associated with a specificity of 88.54% and sensitivity of 94.67%, along with a negative predictive value of 95.51% and positive predictive value of 86.59%. Fisher’s exact test was performed between OVP and no OVP in relation to the development of CDI in high-risk patients (P < 0.01). VRE rates reported on the antibiogram remained consistent throughout the study period. No significant differences in baseline characteristics were noted.

Conclusion
In institutions where appropriate infection control measures and antibiotic stewardship have been implemented, the use of a prediction tool to guide OVP is effective in preventing C. difficile.

Disclosures
All Authors: No reported Disclosures.
839. Effect of Clostridioides difficile (C. difficile) Toxin Test Reporting on Clinical Treatment and Outcomes of Toxin-Negative PCR-Positive Patients at Five California Hospitals
Authors: Polage Christopher R , Grein Jonathan , Morgan Margie , Doernberg Sarah B , Miller Steve , Chinn Raymond , Woerle Cathy , Yim Jennifer , Bittencourt Cassiana , Krishna Sneha , Anne Ocampo Nicolle , Gibbs Laurel , Mabalot Shannon C , Quan Kathleen A , Khusbu Usme , Madey Keith M , Ganzon Czarina , Memar Fatemeh , Pascual Christian B , Cohen Stuart , Liu Catherine , Yokoe Deborah S , Huang Susan S 
Published: October 2019

Abstract

Background
Guidelines support the use of toxin tests after C. difficile antigen detection or nucleic acid amplification tests (e.g., PCR) to help clinicians distinguish colonization from infection and reduce overdiagnosis but the safety of toxin-based diagnostic approaches remains controversial.

Methods
Five California hospitals monitored hospitalized adults with C. difficile testing before and after operational changes to reduce test-related overdiagnosis (2016–2018). Four added a toxin test to an existing GDH antigen/PCR-based approach and/or changed reporting to encourage the use of toxin results for clinical decision-making (i.e.,“toxin-dominant reporting”). One used the same test (toxin only) and reporting strategy throughout. All used a standardized tool to document clinical outcomes and treatment four days after testing (i.e., Day 5).

Results
In total, 1,034 patients had a Day 5 assessment with PCR-dominant reporting (pre-operational changes); 2,511 patients had a Day 5 assessment with toxin-dominant reporting (post-operational changes and single facility with no test change). Fewer Toxin-negative/PCR-positive (Toxin−/PCR+) patients received treatment with toxin-dominant reporting (median change: −52.1% [interquartile range (IQR): −35.1%, −69.1%]; aggregate P < 0.001). Day 5 outcomes were similar or better with toxin-dominant reporting despite less treatment. Patient discharge rates and in hospital diarrheal recovery was greater in the subset of Toxin−/PCR+ patients during the toxin-dominant reporting period: median discharge rate change = 8.8% [IQR: 1.5%, 11.9%] (aggregate P = 0.04); median diarrheal recovery rate change = 11.8% [IQR: 8.8%, 18.2%] (aggregate P = 0.018).

Conclusion
In a 5-center study, toxin-dominant test result reporting decreased anti-C. difficile treatment and improved discharge rates and diarrheal recovery in Toxin−/PCR+ patients. More work is needed to determine the rate of C. difficile-related adverse events in Toxin−/PCR+ patients.

Disclosures
All Authors: No reported Disclosures.
847. The Effect of Antimicrobial Administration on Blood Culture Positivity in Patients with Severe Manifestations of Sepsis
Authors: Cheng Matthew P , Stenstrom Robert , Paquette Katryn , Stabler Sarah , Akhter Murtaza , Davidson Adam , Gavric Marko , Lawandi Alexander , Jinah Rehman , Saheed Zahid , Demir Koray , Huang Kelly , Mahpour Amirali , Shamatutu Chris , Caya Chelsea , Troquet Jean-Marc , Clark Greg , Yansouni Cedric , Sweet David 
Published: October 2019

Abstract

Background
Current guidelines recommend obtaining blood cultures prior to antimicrobial therapy in patients with sepsis. Administering antimicrobials immediately without waiting for blood cultures could potentially decrease time to treatment and improve outcomes, but it is unclear the degree to which this strategy impacts diagnostic yield.

Methods
We performed a patient-level, single-arm, diagnostic trial. Seven urban emergency departments affiliated with academic medical centers across Canada and the United States participated in the study. Adults ≥18 years of age presenting to the emergency department with evidence of severe manifestations of sepsis, including a systolic blood pressure <90 mmHg and/or a serum lactate ≥4 mmol/L were included. Study participants had 2 sets of blood cultures drawn prior to and immediately following antimicrobial administration. The primary outcome was the difference in blood culture pathogen recovery rates before and after administration of antimicrobial therapy.

Results
Of the 3,164 participants screened, 325 were included in the study (mean age, 65.6 years; 63.0% men) and had repeat blood cultures drawn after the initiation of antimicrobial therapy (median time of 70 minutes, IQR 50 to 110 minutes). Pre-antimicrobial blood cultures were positive for one or more microbial pathogens in 102/325 (31.4%) patients. Fifty-four participants (52.9%) had matching blood culture results after initiation of antimicrobial treatment. The absolute difference in pathogen recovery rates was 14.5% ([95% CI 8.0 to 21.0%]; P < 0.0001) between pre- and post-antimicrobial blood cultures. Results were consistent in an analysis of the per-protocol population (absolute difference, 13.3% [95% CI 6.1 to 20.4%]; P < 0.0001). Including the results of other microbiological cultures done as part of routine care, microbial pathogens were recovered in 69 of 102 (67.7%) participants (absolute difference, 10.2% [95% CI 3.4 to 16.8%]; P < 0.0001).

Conclusion
Among patients with severe manifestations of sepsis, the administration of empiric antimicrobial therapy significantly reduces the yield of pathogen recovery when blood cultures are drawn shortly after treatment initiation.

Disclosures
All Authors: No reported Disclosures.
887. High Rates of Virologic Suppression Achieved in HIV-1–Infected Adults Rapidly Starting Antiretroviral Therapy (ART) with the Single-Tablet Regimen (STR) of Darunavir/Cobicistat/Emtricitabine/Tenofovir Alafenamide (D/C/F/TAF) 800/150/200/10 mg Regardless of Baseline Disease Characteristics: Week 48 Subgroup Analyses From the Phase 3 DIAMOND Trial
Authors: Huhn Gregory D , Ramgopal Moti , Crofoot Gordon , Gathe Joseph , Seyedkazemi Sareh , Cosler Patricia , Bruce Simonson Richard , Luo Donghan , Dunn Keith 
Published: October 2019

Abstract

Background
Rapid initiation of ART requires that clinicians start therapy prior to having baseline laboratory Results. High rates of virologic suppression and retention were reported in the DIAMOND trial. Efficacy and safety are presented, according to baseline disease characteristics.

Methods
DIAMOND (ClinicalTrials.gov: NCT03227861), a phase 3, single-arm, open-label, prospective, multicenter study, assessed efficacy/safety of D/C/F/TAF in rapid initiation. Adults enrolled within 14 days of diagnosis and started D/C/F/TAF without baseline laboratory results; investigators reviewed results as they became available. Primary endpoint was virologic suppression (HIV-1 RNA < 50 copies[c]/mL; intent-to-treat (ITT); Food and Drug Administration [FDA] snapshot) at Week 48. Virologic suppression <50 c/mL and <200 c/mL were also assessed via an observed analysis, excluding patients with missing data.

Results
Overall, 109 patients were enrolled; 25% had HIV-1 RNA ≥100,000 c/mL and 21% had CD4+ < 200 cells/μL (Table 1). 21% of patients started therapy within 24 hours of diagnosis. At Week 48, 84%, and 88% of patients had HIV-1 RNA <50 c/mL and <200 c/mL (FDA snapshot), respectively. In the observed analysis, 96% and 100% of patients had HIV-1 RNA <50 c/mL and <200 c/mL, respectively, at Week 48. Earlier ART initiation, HIV-1 RNA <100,000 c/mL, and CD4+ >200 cells/μLwere associated with numerically higher virologic suppression rates (ITT-FDA snapshot; Table 2). No patient discontinued due to lack of efficacy or met protocol-defined virologic failure (PDVF) criteria. In the observed analysis, virologic suppression rates were consistent across all subgroups; all patients were suppressed <200 c/mL at Week 48. One patient discontinued due to an adverse event (AE); incidences of grade 3/4 (10%) and serious (9%) AEs were low, with no serious AEs related to study drug and no deaths.

Conclusion
In the first phase 3 study of an STR in a rapid initiation model, no patients rapidly starting D/C/F/TAF discontinued therapy due to lack of efficacy or had PDVF through 48 weeks. High rates of virologic suppression were achieved and maintained with a variety of baseline characteristics, and treatment was safe and well tolerated, indicating D/C/F/TAF as a preferred ART option for patients rapidly starting treatment.

Disclosures
All Authors: No reported Disclosures.
896. A Safe, More Cost-Effective Protocol: Universal Decolonization vs. MRSA Screening and Contact Precautions
Authors: Whitaker Jacqueline , Kusha Barmak , Longcoy Joshua , Rutter Amanda H , Ferrier Sheryl , Marzi Caitlin R , Montalvo Gonzalez Leslie 
Published: October 2019

Abstract

Background
A trial of universal decolonization (alcohol-based nasal antiseptic plus chlorhexidine gluconate bathing) was instituted for 12 months, in a 536-bed short-term acute care hospital, as a replacement for nasal screening, contact precautions (CP) and decolonization of methicillin-resistant Staphylococcus aureus (MRSA)-colonized patients. The impact on the rate of MRSA bacteremia and costs associated with nasal screening tests, isolation, and gown use was assessed.

Methods
Prior to the universal decolonization trial, patients at high-risk for MRSA colonization were screened using a nasal polymerase chain reaction (PCR) test, and those that tested positive were decolonized with 5 days of mupirocin nasal ointment and daily CHG bathing, and were placed in CP. Starting in April 2018, a universal decolonization protocol was instituted for all hospitalized patients, with a twice-daily alcohol-based nasal antiseptic (in place of mupirocin), and daily bathing with CHG foam soap (in place of CHG cloths). Nasal screening of high-risk patients, targeted decolonization and CP for MRSA-colonized patients, was discontinued during the 12-month universal decolonization trial period. Outcome measures for the trial included MRSA bacteremia per National Healthcare Surveillance Network (NHSN) multi-drug-resistant organism (MDRO) Lab ID definition, isolation day count, utilization of gowns, and nasal screening tests with estimated costs associated. Measures for the 12-month trial period were compared with those of the prior 12-month period, i.e., April 2017–March 2018.

Results
Compared with prior 12-month period, during the universal decolonization trial, there was a 42% reduction in isolation days ($118/day), a 74% reduction in nasal PCR tests ($36/each), and an 11% decrease in the monthly use of gowns ($12/each). The total cost avoidance (after accounting for the cost of the alcohol-based nasal antiseptic and CHG soap) was $1,394,685. There was no statistical change in the MRSA bacteremia rate (0.067 to 0.070) per 1,000 patient-days.

Conclusion
Replacement of nasal screening, decolonization, and CP for colonized MRSA patients with universal decolonization, using twice daily alcohol-based nasal antiseptic paired with daily CHG bathing, was found to be a safe and cost-saving protocol.

Disclosures
All Authors: No reported Disclosures.
963. Extragenital Chlamydia and Gonorrhea Among Females Visiting an STD Clinic
Authors: Maynard Michaela , Nunez Hector R , Tao Jun , Montgomery Madeline , Almonte Alexi , Sowemimo-Coker Genoviva , Chu Christina , Sosnowy Collette , Chan Philip , Chan Philip 
Published: October 2019

Abstract

Background
Rates of chlamydia (CT) and gonorrhea (GC) are increasing in the United States. Annual screening for urogenital infection is recommended for sexually active females less than 25 years and older females at risk. CT and GC can be detected at pharyngeal and rectal sites and are commonly asymptomatic. Currently, extragenital screening is only recommended in men who have sex with men (MSM). Data among females on extragenital CT and GC are limited.

Methods
We reviewed all females presenting to a sexually transmitted diseases (STD) clinic in Providence, Rhode Island from May 2014 to December 2018. During this time, urogenital, pharyngeal, and rectal screenings were offered to all females presenting for care. We evaluated demographics, behaviors, and laboratory data on urogenital, pharyngeal and rectal CT/GC. Univariate and bivariate analyses were performed to determine the characteristics of demographic and behavioral variables associated with extragenital infection.

Results
During the study period, 2,672 females presented for STD screening. Median age was 26 years (interquartile range [IQR]: 33–22). Most patients (95%) reported engaging in sex with male partners. More than half (59%) had at least one extragenital (pharyngeal or rectal) test performed (77% pharyngeal only, 0.4% rectal only, 23% both). During the study period, there were 334 CT and 66 GC infections identified across all three anatomical sites. Of individuals with a positive CT result (N = 273), 85% (N = 233) had a positive urogenital, 19% (N = 53) a positive pharyngeal, and 18% (N = 48) a positive rectal specimen. Of individuals with a positive GC result (N = 50), 62% (N = 31) had a positive urogenital, 54% (N = 27) a positive pharyngeal, and 16% (N = 8) a positive rectal specimen. Among individuals with a positive CT or GC result, (N = 315), 17% (N = 55) had an extragenital infection in the absence of a positive urogenital result. No single risk factor was statistically associated with an extragenital CT or GC infection. Most individuals (82%) were asymptomatic at presentation.

Conclusion
In an STD clinic setting, a significant number of pharyngeal and rectal CT/GC infections may be missed in the absence of extragenital screening. Settings which engage at-risk females should consider implementation of routine CT/GC extragenital screening.

Disclosures
All Authors: No reported Disclosures.
967. Concordance of Antibiotic Prescribing with the Proposed American Dental Association Acute Oral Infection Guidelines within Veterans Affairs (VA) Dentistry
Authors: Carlsen Daniel , Suda Katie J , Patel Ursula C , Gibson Gretchen , Jurasic Marianne M , Poggensee Linda , Fitzpatrick Margaret A , Echevarria Kelly , Durkin Michael , McGregor Jessina C , Evans Charlesnika T 
Published: October 2019

Abstract

Background
US dentists prescribe 10% of outpatient antibiotics. However, assessing the appropriateness of dental antibiotic prescribing has been challenging due to a lack of guidelines for common infections. In 2019, the American Dental Association proposed clinical practice guidelines (CPG) on the management of common acute oral infections for the first time. Our objective was to describe national baseline antibiotic prescribing for the treatment of irreversible pulpitis, apical periodontitis, and acute apical abscess prior to the release of the proposed CPG.

Methods
We performed a cross-sectional analysis of national VA data from January 1, 2017 to December 31, 2017. We identified cases of irreversible pulpitis, apical periodontitis, and acute apical abscess using ICD-10-CM codes. Patient demographics, facility location, medical conditions, dental procedure codes (“CDTs”), and diagnostic (ICD-10-CM) codes were extracted from the VA Corporate Data Warehouse. Antibiotics prescribed by a dentist within 7 days of a visit were included. Multivariable logistic regression identified variables associated with antibiotic prescribing for each infection.

Results
Of the 470,039 VA dental visits with oral infections coded, 25% of irreversible pulpitis, 41% of apical periodontitis, and 61% of acute apical abscess visits received antibiotics. Amoxicillin was prescribed most frequently. Although the median days’ supply was 7 days, prolonged use of antibiotics was frequent (9.2% of irreversible pulpitis, 17.8% of apical periodontitis, 28.7% of acute apical abscess received antibiotics for ≥8 days). Of the irreversible pulpitis visits with antibiotics prescribed, 20.0% received ≥2 antibiotics. Patients with high-risk cardiac conditions, prosthetic joints, and certain dental procedures were associated with receipt of antibiotics (table).

Conclusion
Prior to the release of the ADA guidelines, 75.8% and 59.4% of irreversible pulpitis and apical periodontitis were concordant with proposed recommendations. These data identify opportunities to improve prescribing and serve as a benchmark for future outpatient antimicrobial stewardship efforts. Future work should assess definitive dental treatment and populations without access to oral health care.

Disclosures
All Authors: No reported Disclosures.
979. BMI and ASCVD Risk Score Changes in Virologically Suppressed Patients with HIV Switching from TDF to TAF Containing ART
Authors: Schafer Jason J , Sassa Kaitlin , O’Connor Jaclyn , Shimada Ayako , Keith Scott , DeSimone Joseph 
Published: October 2019

Abstract

Background
Switching from tenofovir disoproxil fumarate (TDF) to tenofovir alafenamide (TAF) containing antiretroviral therapy (ART) can preserve or improve renal function as well as bone mineral density in patients living with HIV infection (PLWH). The switch can also negatively influence cholesterol, but potential changes in body mass index (BMI) and atherosclerotic cardiovascular disease (ASCVD) risk are unknown.

Methods
This retrospective observational study evaluated BMI and ASCVD risk score changes in virologically suppressed PLWH who switched from TDF to TAF without switching any other ART regimen components. Adult patients on TDF for ≥1 year with two consecutive HIV viral loads <200 copies/mL in the year prior to a TAF switch were included. Bodyweight, BMI, cholesterol, ASCVD risk score, and other variables were collected for the year prior to and following the switch. The unadjusted distributions of pre- and post-switch values were compared with the Wilcoxon signed-rank test. Repeated-measures generalized estimating equations were constructed to evaluate changes in BMI and ASCVD risk scores associated with TDF to TAF switches. These were adjusted for predictors retained in the model if their P-values were <0.05. ASCVD risk scores were skewed right, so those data were log-transformed prior to modeling.

Results
A total of 110 patients met the criteria and were included for analysis (Table 1). In unadjusted analyses, there were significant increases in weight, BMI, total cholesterol, LDL, HDL, and ASCVD score in the year after switching from TDF to TAF (each P ≤ 0.01, Table 2). Only gender was retained in the adjusted BMI model, which suggested switching from TDF to TAF lead to an increase of 0.45 kg/m2 in the expected mean for BMI (95% CI: 0.14, 0.76). Age, gender, race, concomitant medications that can cause weight gain, and time since HIV diagnosis were retained as covariates in the adjusted ASCVD model. This model suggested that switching from TDF to TAF was associated with a 13% increase in the expected mean for ASCVD risk score (95% CI: 4%, 23%).

Conclusion
We observed significant increases in BMI and ASCVD risk in PLWH 1 year following a switch from TDF to TAF without changes in other ART regimen components. The mechanism of these metabolic changes is unclear and requires further study.

Disclosures
All Authors: No reported Disclosures.