bluuebunny/crossref_metadata_2025_split huggingface dataset:
2844. Butyrogenic Bacteria After Acute Graft vs. Host Disease Associate with the Development of Steroid Refractory GVHD
Authors: Golob Jonathan L , DeMeules Martha M , Loeffelholz Tillie , Quinn Z Z , Dame Michael K , Silvestri Sabrina , Wu Michael , Schmidt Tom , Fiedler Tina L , Hoostal Matthew , Mielcarek Marco , Spence Jason , Pergam Steven A , Fredricks David 
Published: October 2019

Abstract

Background
Steroid refractory acute graft- vs. -host-disease (GVHD) after hematopoietic cell transplantation (HCT) is highly morbid with limited treatment options. Murine studies show protection from GVHD with butyrate exposure but direct exposure of stem/progenitor cells to butyrate inhibits colonic stem cell proliferation.

Methods
Stool samples were collected weekly in a cohort of HCT recipients (n = 210) undergoing allogeneic transplant, and underwent 16S rRNA sequencing to determine the number and relative abundance of butyrogens. Dissociated primary human colonoid cell aggregates (200,000 per well) were plated onto collagen IV-coated transwells (0.4 µm pore size, 0.33 cm2, PET) in stem cell medium for 24 hours. From 24 hours onwards, the basal-lateral chamber was switched to differentiation medium; the apical chamber was Hanks Buffered Salt Solution (HBSS), HBSS with 10 mM butyrate sodium salt early (24 hours onwards) or late (72hours onwards). Trans-epithelial electrical resistance was measured daily.

Results
Retrospective chart review identified 27 recipients who developed acute GVHD of the gut, stratified to be either steroid refractory GVHD (failed to respond to 2 mg/kg of methylprednisolone) or responsive. The presence of butyrogens in the gut microbiome after the onset of severe acute GHVD of the gut associated with increased risk of steroid refractory GVHD (Figure 1; P < 0.05). Direct exposure of human colonic stem/progenitor cells to butyrate inhibits the development of trans-epithelial electrical resistance; exposure after differentiation had no inhibition of barrier formation (Figure 2; P < 0.05 by T-test).

Conclusion
Butyrogens may help prevent the development of acute GVHD of the gut, but once severe GVHD has developed may inhibit recovery due to the loss of crypt architecture exposing colonic stem cells to microbe-produced butyrate with impaired differentiation and cell replacement.

Disclosures
All Authors: No reported Disclosures.
2850. Burden of Difficult-to-Treat Antibiotic-Resistant (DTR) Gram-Negative Infections in the United States, 2012–2017
Authors: Kadri Sameer S , Baggs James , Yi Sarah H , Strich Jeffrey R , Ling Lai Yi , Ricotta Emily , Rebecca Prevots D , Danner Robert L , Wolford Hannah , Olubajo Babatunde , Hatfield Kelly M , Reddy Sujan , Jernigan John A 
Published: October 2019

Abstract

Background
Difficult-to-treat resistance (DTR) is a metric for clinically relevant “pan-resistance” to available high-efficacy, low-toxicity antibiotic treatment options at any given time. Previous DTR prevalence estimates in Gram-negative (GN) bloodstream isolates from 2009 to 2014 have ranged between 1 and 1.5%. We sought to estimate the national burden of DTR GN isolates and more recent trends by region, site, and species.

Methods
Clinical cultures with GN isolates were identified from inpatient encounters in hospitals reporting at least one culture with susceptibility testing for a given month to Premier Healthcare Database or Cerner Health Facts Database from 2012 to 2017. DTR was defined as intermediate susceptibility or resistance to all tested carbapenems, other β-lactams, and fluoroquinolones, but not including agents introduced 2014 onwards. For each year, a raking procedure generated weights to extrapolate the sample estimate to match American Hospital Association distributions based on US census division, hospital bed capacity, teaching status, and urban designation. A weighted means survey procedure was used to extrapolate the sample estimate to obtain national DTR burden. Trends in DTR incidence were examined by using weighted multivariable logistic regression.

Results
Extrapolating from a 373-hospital sample, the estimated 2017 US inpatient burden of DTR isolates was 3,315 (1.3%) among sterile-site and 31,509 (1.7%) among all cultures, ranging from 0.5% to 3.3% in Mountain and New England regions respectively. P. aeruginosa was the most common species overall (37%), while A. baumannii was most common among sterile sites (31%). Between 2012 and 2017, there was no annual percent change in DTR incidence for sterile sites [OR 0.99 (0.93, 1.06)] but for all cultures it decreased 4.1% annually [OR 0.95 (0.91, 0.99)], including 9% annually for A. baumannii [OR 0.905 (0.860, 0.953)] and K. pneumonia [OR 0.903 (0.824, 0.991)], respectively.

Conclusion
The US inpatient burden of GN isolates displaying DTR is relatively low, varies by region, and has remained stable or declined slightly in recent years. Periodic inclusion of emerging antibiotics in the DTR classification will allow for a dynamic index between resistance and available agents.

Disclosures
All Authors: No reported Disclosures.
2892. The Relationship Between Inpatient and Post-discharge Antimicrobial Use at the Hospital-level Across an Integrated Healthcare Network
Authors: Livorsi Daniel J , Feller Jade , Lund Brian , Alexander Bruce , Nair Rajeshwari , Beck Brice , Goto Michihiko , Heintz Brett , Perencevich Eli N 
Published: October 2019

Abstract

Background
Hospital-based antimicrobial stewardship interventions and metrics have typically focused only on inpatient antimicrobial exposure. However, single-center studies have found a large portion of antimicrobial exposure occurs immediately after hospital discharge. We sought to describe antimicrobial-prescribing upon hospital discharge across the Veterans Health Administration (VHA) and to compare inpatient and post-discharge antimicrobial use at the hospital-level.

Methods
This retrospective study used national VHA administrative data to identify all acute-care admissions from January 1, 2014 to December 31, 2016. Post-discharge antimicrobials were defined as oral outpatient antimicrobials prescribed at the time of hospital discharge. We measured inpatient-days of therapy (DOT) and post-discharge DOTs. At the hospital-level, inpatient DOTs per 100 admissions were compared with post-discharge DOTs per 100 admissions using Spearman’s rank-order correlation.

Results
Among 1.7 million acute-care admissions across 122 VHA hospitals, 46.1% were administered inpatient antimicrobials and 19.9% were prescribed an oral antimicrobial at discharge. Fluoroquinolones were the most common antimicrobial prescribed at discharge among 335,396 antimicrobial prescriptions (38.3%). At the hospital-level, median inpatient antimicrobial use was 331.3 DOTs per 100 admissions (interquartile range (IQR) 284.9–367.9) and median post-discharge use was 209.5 DOTs per 100 admissions (IQR 181.5–239.6). Thirty-nine percent of the total duration of antimicrobial exposure occurred after hospital discharge. The metrics of inpatient DOTs per 100 admissions and post-discharge DOTs per 100 admissions were weakly correlated at the hospital-level (rho = 0.44, P < 0.0001).

Conclusion
Antimicrobial-prescribing at hospital discharge was common and contributed substantially to the total antimicrobial exposure associated with an acute-care hospital stay. A hospital’s inpatient antimicrobial use was only weakly correlated with its post-discharge antimicrobial use. Antimicrobial stewardship interventions should specifically target antimicrobial-prescribing at discharge.

Disclosures
All Authors: No reported Disclosures.
1137. Variability of Antibiotic Use in Neonatal Intensive Care Units in the United States
Authors: Dantuluri Keerti , Griffith Hannah , Thurm Cary , Banerjee Ritu , Banerjee Ritu , Howard Leigh M , Grijalva Carlos G 
Published: October 2019

Abstract

Background
Although antibiotics are often indicated to treat early-life infections, such exposure may lead to serious adverse outcomes. Few studies have characterized patterns of antibiotic use among neonatal intensive care units (NICUs).

Methods
We performed a cross-sectional study of antibiotic use in 51 NICUs participating in the Pediatric Health Information System (PHIS), a database that includes clinical and resource utilization data for standalone children’s hospitals in the United States. Assessments were conducted on a single mid-week day of 2017. We examined the use of any antibiotic and broad-spectrum antibiotics using charge data in children admitted in each NICU on the study day. We compared antibiotic use among NICUs and geographical regions, and assessed its association with the NICU median case mix index (CMI) (as a surrogate for clinical complexity).

Results
2813 infants were hospitalized in NICUs on the study day; the median number of patients at each study site was 47 (IQR = 34 – 62). 90% were <1 month old, 56% were male, 46% were white, and 62% were extremely/very preterm. Overall, 23% received at least one antibiotic and 6% received broad-spectrum antibiotics. Broad-spectrum antibiotic use was twice as prevalent in surgical compared with medical patients. Antibiotic use prevalence varied by region, ranging from 19% in the Midwest to 26% in the West (table). Ampicillin, gentamicin and vancomycin were the most common antibiotics used (25.2%, 18.8% and 9.9%, respectively). Antibiotic use prevalence varied substantially across NICUs (Figure 1). There was a moderate but significant positive correlation between overall or broad-spectrum antibiotic use and median NICU CMI (Figure 2).

Conclusion
There is substantial variability in antibiotic use among US NICUs, which seems partially explained by patient case-mix. Additional studies are needed to identify drivers of unwarranted variability in antibiotic use among NICUs.

Disclosures
Ritu Banerjee, MD, PhD, Accelerate Diagnostics: Grant/Research Support; BioFire: Research Grant; Biomerieux: Research Grant; Roche: Research Grant.
1153. National Trend of Urinary Catheter Device Utilization by Hospital Type, National Healthcare Safety Network (2015–2019)
Authors: Soe Minn M 
Published: October 2019

Abstract

Background
Reducing unnecessary urinary catheter use and optimizing insertion techniques and catheter maintenance and care practices are the most important urinary tract infection (CAUTI) prevention strategies. To monitor device use (DU) as quality improvement activity, the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN) developed the risk adjusted, standardized urinary catheter device utilization ratio in 2015. This study aims to assess national trends of DU from the baseline year 2015 through 2019.

Methods
For our trend analysis, we analyzed DU data (catheter days per 100 inpatient-days) that acute care hospitals (ACHs), long-term acute care hospitals (LTACHs), inpatient rehabilitation facilities (IRFs), and critical access hospitals (CAHs) reported to NHSN from 2015Q1 through 2019Q1. The ward and intensive care unit patient care locations included in our analysis are those that ACHs, LTACHs, IRFs and CAHs are required to report to CMS to comply with CMS Inpatient Quality Reporting program requirements. We regressed DU by quarterly period using generalized estimating equation modeling with the negative-binomial distribution, after adjusting for factors associated with corresponding SUR models of 2015 baseline and accounting for autocorrelation of error terms within a location. For graphic display, we also computed quarterly DU using marginal predictive models.

Results
The DU decreased over time (P ≤ 0.05, average percent change per quarter (%change): −0.54 [95% CI: −0.54, −0.53]) among ACHs (Table 1, Figure 1), and −0.54 [95% CI: −0.58, −0.49] among LTACHs (Table 1, Figure 2). Among IRFs, quarterly DU in 2015Q2–2016Q3 were similar relative to 2015Q1, but decreased from 2016Q4 onward (P ≤ 0.05, % change: −0.51 [95% CI: −0.61, −0.40]) (Table 1, Figure 3). Among CAHs, quarterly DU in 2015Q2–2016Q4 were similar relative to 2015Q1, but decreased from 2017Q1 onward (P ≤ 0.05, % change: −0.22 [95% CI: −0.39, −0.04]) (Table 1, Figure 4).

Conclusion
There was a statistically significant decrease in National DU of urinary catheter during 2015–2019 across NHSN, although the magnitude of change per quarter was not large. Further research is needed to explore causal factors associated with such reduction.

Disclosures
All authors: No reported disclosures.
1155. CAUTI Path to Zero: A Triple-Pronged Approach to Minding Our Pees and Cues
Authors: Henry Sharen , Arocha Doramarie , Brown Dawn , Sutterfield Hope , Kielpinkski Lisa , Fisher Ruth , Reed Mary-Grace , Flahaven Emily , Olson Michelle L , Trivedi Julie B 
Published: October 2019

Abstract

Background
Catheter-associated urinary tract infections (CAUTIs) account for nearly 30% of all hospital-acquired infections. From 2009 to 2013, the frequency of CAUTIs increased by 6% with associated increases in length of stay, antibiotic usage and mortality (2.3%); they are also a risk factor for secondary bloodstream infections. In 2017, the CAUTI SIR for the UTSW University hospitals was 0.990 for Clements University Hospital (CUH) and 1.224 for Zale-Lipshy (ZL), placing UTSW above the 50th percentile compared with similar academic medical centers. By the end of 2018, the aim of the quality improvement project was to reduce CAUTIs by 25% or improve the SIR to 0.78, which is at or below the 50th percentile.

Methods
Baseline data included identifying indications and duration of catheter placement as well as performing debriefings on all CAUTIs along with analysis of adherence to the CAUTI bundle. Using evidence-based guidelines, the three primary interventions were (1) streamlining indications for insertion, (2) ensuring prompt removal and (3) providing alternative care pathways after removal. We observed insertion technique and catheter care; nursing services were engaged to understand barriers to catheter removal and subsequently informed of other options such as in-and-out protocols, bladder scanners and female external catheters. Nursing leadership also performed daily necessity audits of all patients with indwelling catheters.

Results
Urine output monitoring in acute/critical illness and urinary obstruction/retention were the top two indications for use. Catheter utilization rates have decreased since 2016. The average dwell time at CUH was 51 hours (excl. urology) and 40 hours at ZL. There was actually a 34% decrease in the total number of CAUTIs from 38 in 2017 to 25 in 2018, exceeding the goal of 25% reduction; the 2018 SIR for CUH was 0.818 and 0.496 for ZL. The prevention of 13 CAUTI events from 2017 to 2018 resulted in ~$180,000 savings.

Conclusion
Successful reduction of CAUTI is an interdisciplinary effort requiring consistent attention and support from infection prevention, nursing, education, quality improvement, IT and hospital administration. Empowering nursing staff, providing clear protocols post-removal and options for alternative external urinary devices is key.

Disclosures
All authors: No reported disclosures.
1166. Infection Rate in Venous–Venous Extracorporeal Membrane Oxygenation (VV-ECMO)
Authors: Wang Joseph , Christensen Cason , Merritt-Genore Helenmari , Siddique Aleem , Cawcutt Kelly , Cawcutt Kelly 
Published: October 2019

Abstract

Background
The Extracorporeal Life Support Organization (ELSO) Infectious Disease Taskforce has identified infection rates as an area requiring further study. We aimed to evaluate our patients on venous–venous extracorporeal membrane oxygenation (VV ECMO) for infection rates, organisms, and specific factors that may alter infection risk.

Methods
Retrospective data were collected from September 2012 to 2015 for adult patients on VV ECMO. Demographic information as well as type and location of cannulation, antibiotics prior to and during cannulation, and presence of bacteremia were obtained. Counts and percentages are reported for categorical variables.

Results
47 patients between 18 and 82 years of age with a median of age of 58 years were included. 76.6% (N = 36) were male. The average number of hospital days until cannulation was 7.8 days. 400 ECMO days were captured with a range of time on ECMO of 1–41 days. 46.8% (N = 22) of patients were alive at the time of discharge. 70.2% (N = 32) of cannulations were in the OR (Figure 1). 55% (N = 26) of patients had a Right Ventricular Assist Device (RVAD) with in-line oxygenator. 66% (N = 31) of all patients were on antibiotics prior to cannulation for other indications while 53% (N = 25) of all patients received perioperative antibiotics (Figure 2). 59% (N = 28) of all patients had blood cultures while on ECMO, with only 8% (N = 4) of all patients returning positive. Of the positive cultures, 2 were true bacteremia resulting in an infection rate of 5 per 1,000 ECMO days (Figure 3). One patient grew Escherichia coli while the other grew Escherichia coli and Streptococcus pneumoniae. Neither patient received antibiotics perioperatively or for other indications (Figure 4). Due to the low number of infected patients, further statistical analysis could not be performed.

Conclusion
We report a low rate of bloodstream infection amongst our VV-ECMO patients. Further investigation to ascertain trends in infection rate with cannulation location/type as well as association with antibiotic is currently being pursued. Other avenues of research will include a comparison of infection rates between VV and Venous Arterial (VA) ECMO. Information from these investigations will help aid the development of guidelines to minimize the rate of nosocomial infections in ECMO patients.

Disclosures
All authors: No reported disclosures.
1168. Trends in Central-Line-Associated Blood Stream Infections in a Community Teaching Hospital: A Multi-Intervention Quality Improvement Project
Authors: Wei Abraham , Markert Ronald , Connelly Christopher , Polenakovik Hari 
Published: October 2019

Abstract

Background
Central line-associated bloodstream infection (CLABSI) is a preventable medical condition that results in increased patient morbidity and mortality as well as increased medical costs. We sought to describe the impact of various quality improvement interventions on the incidence of CLABSI in a large 990-bed community teaching hospital from the period of January 1, 2013 to December 31, 2017.

Methods
Retrospective study of CLABSI events as defined by the CDC’s National Healthcare Safety Network was completed. Between 2013 to 2017, we introduced mandatory real-time root cause analysis for each CLABSI event to identify defects that could be used for quality improvement interventions. We implemented a bundle of interventions for proper central venous catheter (CVC) insertion and maintenance based on CDC recommendations and the results of the internal analysis. Interventions included utilizing chlorhexidine gluconate (CHG) skin preparation and maximum sterile barrier precautions, optimal site selection (avoiding femoral site), using antimicrobial-coated CVCs and antithrombotic Bioflo peripherally inserted central catheters (PICC), minimizing multi-lumen CVC and PICC use, de-escalating CVC to midline or preferential use of midline catheters while minimizing unnecessary PICC and CVC insertion, adding Curos disinfection caps on central lines and other vascular access sites, weekly scheduled CVC site dressing changes with Tegaderm CHG I.V. Securement Dressing, CHG baths for patients with CVCs, avoidance of blood culture draws from central lines, and daily review of line necessity with timely removal. Medical staff members received ongoing education on the implementation of the CLABSI bundle. Both ICU and non-ICU CLABSI cases in the adult patient population were analyzed.

Results
A comparison of 2013 with 2017 shows a 69% decline in a number of CLABSI cases from 36 to 11 patients (Figure 1). There was a 30% decline in CVC days from years 2014 to 2017 (No CVC days data for 2013 due to change in data collection system). Over the same period, CLABSI events per 1,000 CVC days decreased from 0.624 to 0.362 (Figure 2)—a 42% decline.

Conclusion
Study findings show that our comprehensive bundle of interventions for CVC insertion and maintenance resulted in decreased rates of CLABSI.

Disclosures
All authors: No reported disclosures.
1169. Preventing Central Line-Associated Bloodstream Infections in Long-Term Acute Care
Authors: Jacob Jerry , Morace Ann , Park Jisuk , Renzi Nina 
Published: October 2019

Abstract

Background
Long-term acute care hospitals (LTACHs) care for chronically, critically ill patients with high utilization of central lines and high risk for morbidity from central line-associated bloodstream infections (CLABSIs). Our 38-bed LTACH noted a substantial increase in the incidence of CLABSIs (as defined by the National Healthcare Safety Network) between fiscal year (FY) 2016 and FY 2018 (Figure 1). Detailed case review identified a large number of CLABSIs which were clinically consistent with blood culture contaminants from central lines. Feedback from bedside staff also suggested gaps between practice and evidence-based measures for central line care.

Methods
A three-pronged CLABSI prevention project was implemented in July 2018 consisting of (1) staff education regarding daily chlorhexidine (CHG) bathing for all patients, combined with an electronic audit report to identify patients without active CHG orders; (2) change in practice to the use of venipuncture alone for blood culture collection, combined with an electronic audit report to identify blood cultures collected from central lines; and (3) a recurring 6-part educational series for nurses focused on central line care. The pre-intervention period was defined as the 12-month period between July 1, 2017 and June 30, 2018 (FY 2018). The primary outcome was the fiscal year CLABSI rate. A secondary outcome was the proportion of blood cultures drawn from central lines.

Results
After 9 months of the intervention, one CLABSI had been reported for FY 2019 year-to-date at a rate of 0.4 per 1,000 CL-days, representing an 86% decrease from the FY 2018 rate of 2.8 per 1,000 CL-days. The 12-month rolling CLABSI rate decreased to 1.6 per 1,000 CL-days (Figure 2). The proportion of blood cultures collected from central lines decreased from 10.5% (69/658) to 4.5% (15/334), representing a 57% reduction. The proportion of patients ordered and receiving CHG bathing in the intervention period was >95%.

Conclusion
A multidisciplinary effort focused on CHG bathing, central line care, and blood culture collection led to a substantial reduction in CLABSIs in our LTACH. The use of electronic audit reports was particularly useful in achieving high adherence to practice changes.

Disclosures
All authors: No reported disclosures.