bluuebunny/crossref_metadata_2025_split huggingface dataset:
2453. Prolonged Local Epidemic of an XDR P. aeruginosa Subclade of High-Risk Clonal Complex 298
Authors: Pincus Nathan B , Bachta Kelly E R , Ozer Egon A , Allen Jonathan P , Pura Olivia N , Marty Francisco M , Pandit Alisha , Mekalanos John J , Hauser Alan R 
Published: October 2019

Abstract

Background
Antimicrobial resistance (AMR) poses an increasing challenge to the treatment of the nosocomial pathogen Pseudomonas aeruginosa, with the majority of highly resistant infections caused by relatively few high-risk clones. We investigated the role of clonal complex 298 (CC298: ST298 and ST446) in multidrug-resistant (MDR) and extensively drug-resistant (XDR) infections at Northwestern Memorial Hospital (NMH).

Methods
We determined the AMR of 40 whole-genome sequenced CC298 isolates, including 30 from patients at NMH in Chicago (2000–2017), 7 from hospital environments (e.g., sinks) in Chicago (2017–2018), and 3 from patients at Brigham and Women’s Hospital (BWH) in Boston (2015–2016). We used phylogenetics to assess the population structure of these isolates and 38 additional publicly available CC298 genomes. We interrogated the genomes of NMH CC298 isolates to uncover drivers of AMR.

Results
NMH CC298 isolates showed high rates of AMR, with 76.7% (23/30) MDR and 46.7% (14/30) XDR. Phylogenetic analysis revealed that 21/23 MDR (13/14 XDR) isolates from NMH formed a subclade of ST298, termed ST298*, as of yet not seen elsewhere. A time-scaled phylogeny of ST298* indicates a last common ancestor in 1980 (mean 1980.8, 95% HPD interval 1973.3–1987.4), with XDR ST298* isolates seen between 2001 and 2017. Many ST298* isolates, including all XDR isolates, harbored a large plasmid with an AMR class 1 integron. This plasmid is part of a family of large Pseudomonas genus plasmids. By comparing a plasmid-cured strain to its parent, we show that the plasmid imparts resistance to gentamicin and piperacillin–tazobactam. In the parental strain we detect T83I GyrA and S87L ParC substitutions known to cause fluoroquinolone resistance, showing that mutational resistance also contributes to the high AMR of ST298*. Publicly available genomes and previous reports indicate that CC298 has caused infections worldwide with multiple instances of significant AMR.

Conclusion
The repeated isolation of XDR ST298* P. aeruginosa at NMH over 16 years raises concern for the ability of this strain to persist in the healthcare environment. With this local epidemic and additional reports of MDR CC298 isolates around the world, we argue that CC298 should be considered a high-risk clone.

Disclosures
All authors: No reported disclosures.
2455. Outbreak of carbapenemase-producing Enterobacteriaceae in cardiology units associated with contaminated water dispenser and sink drain in Korea
Authors: Jung Jiwon , Choi Hye-Suk , Lee Jeong-Young , Jee Hong Min , Hee Kwak Sun , Sung Heungsup , Kim Mi-Na , Kim Sung-Han 
Published: October 2019

Abstract

Background
There is a growing concern about the importance of hospital water environment for the transmission of carbapenemase-producing Enterobacteriaceae (CPE). Herein, we report a large outbreak in cardiology units involving intensive care units (ICU) and wards at a tertiary care hospital.

Methods
During a CPE outbreak between July and December 2018, contact tracing and environmental sampling were performed. For outbreak control, we performed education to healthcare workers, hand hygiene enforcement, active surveillance test, preemptive isolation, chlorhexidine bathing for CPE positive patients, and deep terminal cleaning including UV and hydrogen peroxide non-touch disinfection. Patients with CPE were isolated at a single room with dedicated staffs, contact precaution was implemented, and when case patients were located in multi-patient room, we performed surveillance culture for exposed patients in the room.

Results
A total of 87 patients with CPE infection or colonization were identified at two cardiology ICUs and three cardiology wards. CPE from the first two index patients were identified from sputum culture suspecting pneumonia, and the remaining 85 patients were identified to harbor CPE through surveillance culture (exposed patients n = 22, active surveillance test n = 63). Diverse organisms were identified; organisms with blakpc (n = 13), blaNDM-1 (n = 55), blaVIM or blaIMP (n = 12), blaOXA-48 (n = 3), and co-producing organisms (n = 4). We performed environmental culture; KPC-producing Escherichia coli was isolated from water dispenser in ICU and NDM-1 producing Citrobacter freundii and Enterobacter cloacae were isolated from sinks in the patient room. Outbreak ended after the removal of water dispenser and the replacement of sink drain with pouring bleach to the sink drain.

Conclusion
Water dispenser and sink drain were suspected for the possible reservoirs of CPE in this outbreak. Replacement of plumbing system and use of bleach for pouring to sink as well as the removal of water dispenser was needed to control outbreak. Investigation of water system is warranted for finding the source of CPE.

Disclosures
All authors: No reported disclosures.
2458. A comprehensive approach to ending an outbreak of rare OXA-72 producing carbapenem-resistant Acinetobacter baumannii at a Community Hospital, Kansas City, MO, 2018
Authors: McKinsey David S , Gasser Carolyn , McKinsey Joel P , Ditto Geri , Agard Alyssa , Zellmer Brianna , Poteete Carrie , Snippes Vagnone Paula , Dale Jennifer , Bos John , Hahn Rachael , Turabelidze George , Poiry Madison , Franklin Patrick , Vlachos Nick , McAllister Gillian A , Halpin Alison L , Glowicz Janet , Ham David , Epstein Lauren 
Published: October 2019

Abstract

Background
In 2018, an outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) containing a rare β-lactamase (OXA-72) was detected at Research Medical Center, a 511 bed community hospital in Kansas City, MO. We describe a coordinated effort among hospital infection control personnel and public health to control the outbreak.

Methods
We defined a case as isolation of OXA-72-producing CRAB from any clinical culture collected from a hospitalized patient during 2018. We assessed infection control practices, including adherence to transmission-based precautions and hand hygiene, environmental cleaning and patient transfers. After patients with CRAB were discharged, terminal cleaning was performed using bleach and environmental cultures were collected; rooms were closed to new patients until CRAB was not isolated. Whole-genome sequencing and bioinformatics analyses were performed.

Results
From January through October, CRAB was isolated from clinical cultures among 20 patients; 6 OXA-72-positive cases were identified during June and July. We found practices for cleaning and disinfection of shared medical equipment were not clearly delineated among nursing and environmental services staff and we ensured responsibilities were well defined. W restricted all patients with CRAB to certain medical units in order to limit the spread. In total, 248 environmental cultures were collected; 151 (61%) from inside patient rooms and 97 (39%) from shared medical equipment or surfaces outside patient rooms. Overall, Acintobacter baumannii was isolated from 39 (16%) environmental cultures (21 from inside rooms and 18 from outside rooms); 5 isolates were confirmed to contain OXA-72. Using WGS, we compared 6 clinical and 5 environmental OXA-72 CRAB isolates; all were determined to be genetically related (0–6 single nucleotide polymorphisms, 88.4% core genome) (figure). No additional cases were identified after these interventions.

Conclusion
We identified widespread CRAB environmental contamination, illustrating the challenges of eradicating CRAB from the hospital environment. We developed a comprehensive approach focusing on infection control, environmental cleaning and culturing, and patient movement to stop the outbreak.

Disclosures
All authors: No reported disclosures.
2467. Inferring Strain Type Attribution from Antibiotic Resistance Profiles among E. coli Causing Healthcare-Associated Infections in the United States, 2013–2017
Authors: Kourtis Athena P , Lutgring Joseph D , Sheriff Edward , Halpin Alison L , Rasheed James , Elkins Christopher , McDonald L Clifford 
Published: October 2019

Abstract

Background
E. coli is a leading cause of healthcare-associated infections; clonal group ST131, which has expanded worldwide with notable increased severity of infections, is commonly resistant to extended-spectrum cephalosporins (ESC) and fluoroquinolones (FQ). Herein, we relate ESC and FQ resistance profiles from CDC’s National Healthcare Safety Network (NHSN) with specific strain types from CDC laboratory surveillance collections.

Methods
NHSN isolate and antibiotic susceptibility testing data were collected from all E. coli associated with central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated events, or surgical site infections from 2013–2017. Resistance was scored as non-susceptibility to at least one drug per class [susceptible (S); resistant (R)]. ESC and FQ susceptibilities and multilocus sequence types (ST) using the Achtman 7 loci scheme were determined for a contemporaneous set of E. coli isolates collected through CDC laboratory surveillance.

Results
Of 96,672 E. coli infections reported to NHSN, 13% were ESC-R/FQ-R, 23% ESC-S/FQ-R, 4% ESC-R/FQ-S, and 60% were ESC-S/FQ-S. Among 105 ESC-R/FQ-R and 21 ESC-S/FQ-R laboratory isolates, the majority (67.6% and 52.4%, respectively) were ST131, whereas of 38 ESC-R/FQ-S and 53 ESC-S/FQ-S isolates, ST131 was a minority (18.4% and 7.5%, respectively). The odds of an isolate being ST131 were 10.5 if FQ-R (P < 0.001), 3.4 if ESC-R (P < 0.001), and 6.0 if ESC-R/FQ-R (P < 0.001). Using the national distribution of resistance combinations from NHSN, and assuming static ST-resistance distribution, we can infer that ST131 was responsible for 25.8% (95% CI, 23.9%-27.6%) of all E.coli healthcare-associated infections in the United States in 2013–2017.

Conclusion
Molecular inferences generated by applying laboratory data to resistance signature data in reportable datasets may make national E. coli ST burden estimates possible. Further characterization of resistance combinations with strain type, infection rates, and clinical outcomes may inform targeted prevention strategies at the local/regional level.

Disclosures
All authors: No reported disclosures.
2470. Readmission for Healthcare-Acquired Infections: Does Patient Disposition Matter?
Authors: Hoffman Geoffrey J , Min Lillian , Liu Haiyin , Marciniak Dan , Mody Lona 
Published: October 2019

Abstract

Background
Although common and preventable, healthcare-acquired infections (HAI) are associated with high risk for hospital readmission. This risk may increase when follow-up care is not provided. However, whether infection-related readmissions are more common in older adults discharged from the hospital to a skilled nursing facility (SNF) vs. home or home healthcare is unknown.

Methods
We used 2013–14 national discharge data and logistic regression models to retrospectively examine the relationship of discharge disposition (home, SNF, home healthcare) with unplanned readmission for the same HAI observed at the index admission, among Medicare beneficiaries 65, controlling for patient sociodemographics, comorbidity score, and length of stay during index hospitalization.

Results
Of 318,134 index admissions involving HAI treatment, 158,682 (50%) were discharged to a SNF, 76,523 (24%) to home, and 82,929 (26%) to home health. Overall, 7,867 (2.5%) of index admissions involving treatment for an HAI resulted in a linked HAI readmission. HAI readmissions were more common for Clostridium difficile infections (4.0%) and urinary tract infections (UTI, 2.3%) than for ventilator-acquired pneumonia (1.4%) or surgical site infections (1.1%) (P < 0.001). Being discharged home or to home healthcare, compared with a SNF, was associated with increased odds (OR: 1.63, P < 0.001 for each) of HAI readmission. This was equivalent to a 1.2% lower risk of a linked HAI readmission for those discharged to a SNF compared with home or home healthcare. This risk difference was observed to increase with greater patient comorbidity scores.

Conclusion
We conclude that Clostridium difficile and UTIs result in higher risk for readmission than other HAIs. Patients discharged to nursing facilities are protected from readmission. Further research into identifying modifiable mechanisms for HAI readmission, in order to improve post-hospital care of infection at home, is needed.

Disclosures
All authors: No reported disclosures.
2480. Communication During Patient Transfers: Describing Gaps in the Infectious Status Information Pipeline
Authors: Mayer Jeanmarie , Horth Roberta , Todd Madison , Gruninger Randon , Nakashima Allyn K 
Published: October 2019

Abstract

Background
Fragmented communication of patients’ infectious status across healthcare networks impact regional spread of multidrug-resistant organisms (MDRO). This study aimed to quantify gaps in communication of patient MDRO status across Utah healthcare facilities and to identify opportunities to improve.

Methods
This is a cross-sectional retrospective mixed-methods study of patient transfers from three purposively selected healthcare facilities: an acute care (ACF), long-term acute care (LTAC), and skilled-nursing facility (SNF). Patients with known MDRO transferred out of these facilities over the previous week were identified in bimonthly samples spanning 2 months. Infection preventionists and admission nurses from facilities receiving these patients were interviewed.

Results
Of 293 patients transferred to another facility, 13% (n = 38) had an active infection or colonization with an MDRO. These 38 patients were transferred to 26 healthcare facilities within the state (4 ACF, 3 LTAC, 19 SNF). Gram-negative organisms with resistance to a carbapenem accounted for 15.8% of those transferred with an MDRO. There was no documentation of the state infection control transfer form (ICTF) at the sending facility for 68.5% of MDRO patient transfers. Of 22 admitting nurses interviewed, 19 (86.4%) did not receive an ICTF, 6 (27.3%) received no communication regarding patients’ infectious status, and 11 (50%) had to contact the sending facility for additional information. Moreover, 18.2% of patients had not been put on appropriate precautions. Several nurses expressed confusion with MDRO definitions and lack of guidance regarding care of MDRO colonized patients. Among infection preventionists asked about general MDRO transfers (n = 26), 26.9% reported that communication on infectious status of MDRO patients was received in under 40% of incoming transfers. When asked about a planned statewide MDRO registry, 80.8% felt that such a system would be actively searched at their facility, and 96.2% felt that a system that pushes out alerts would be useful.

Conclusion
Given the widespread gaps in communication of infectious status of patients with MDROs transferred across the healthcare facilities sampled, efforts to standardize and improve MDRO communication in the region is warranted.

Disclosures
All authors: No reported disclosures.
2484. Patient Reported Outcomes After Switching to a 2-Drug Regimen of Dolutegravir + Rilpivirine: Week 148 Results from the Sword-1 and Sword-2 Studies
Authors: Oglesby Alan , Angelis Kostas , Punekar Yogesh , Chounta Vasiliki , Antela Antonio , Matthews Jessica , Kahl Lesley , Gartland Martin , Wynne Brian , Murray Miranda , Andre Van Wyk Jean 
Published: October 2019

Abstract

Background
The SWORD-1 and SWORD-2 studies previously demonstrated that high rates of virologic suppression were maintained for 148 weeks after switching virologically suppressed HIV-1 infected adults from their current 3- or 4-drug antiretroviral regimen (CAR) to the 2-drug regimen (2DR) of dolutegravir + rilpivirine on Day 1 (Early Switch (ES) DTG+RPV group). This abstract reports the pooled SWORD-1/2 results of patient reported outcomes (PRO) measures through Week 148.

Methods
HIV Treatment Satisfaction Questionnaire (HIVTSQ) and Symptom Distress Module (SDM) were secondary PRO endpoints in the SWORD trials. For HIVTSQ, high scores represent greater treatment satisfaction (range 0 to 60). SDM was assessed using the Symptom Bother Score with low values indicating less symptom bother (range 0 to 80). The EQ-5D-5L measure of general health status was assessed as an exploratory endpoint with maximum utility score of 1 to indicate perfect health. Change from Baseline in these endpoints was calculated for the ES subjects (over 148 weeks). Subjects randomized to CAR switched to DTG+RPV at Week 52 (Late Switch (LS) DTG+RPV group) and change from LS Baseline (i.e., last pre-switch assessment) was calculated (over 96 weeks).

Results
Low Symptom Bother (9.6 and 10.3) and high TSQ scores (54.4 and 54.3) were reported pre-switch in the ES and LS groups, respectively.
ES subjects reported modest improvements from Baseline in both symptom burden and overall treatment satisfaction in all visits through Week 148 (Figures 1 and 2). Among the LS group, there was little change in symptom burden but similar improvement in treatment satisfaction. Pre-switch health status was high in ES and LS groups (EQ-5D mean utility: 0.96 and 0.94, respectively) and remained stable in both groups at all time points.

Conclusion
High treatment satisfaction and low symptom burden that were observed in patients under CAR were maintained long term after switching to DTG+RPV. These results corroborate DTG+RPV as a well-tolerated 2DR alternative treatment option in patients currently suppressed on other 3/4-drug regimens without previous virologic failure.

Disclosures
All authors: No reported disclosures.
2485. Real-world Experience with Dolutegravir Plus Rilpivirine Two-Drug Regimen
Authors: Ward Douglas , Scheibel Steven F , Ramgopal Moti , Riedel David J , Garris Cindy , Oglesby Alan , Waller John E , Roberts Jenna , Mycock Katie L , Dhir Shelly , Bonnie Collins , Megan Dominguez , Mrus Joseph , Pike James 
Published: October 2019

Abstract

Background
Three-drug regimens (3DRs) have long been the mainstay of antiretroviral treatment (ART) for HIV. Dolutegravir-based two-drug regimens (DTG 2DRs) are now accepted alternatives to 3DRs, with the first 2DR single tablet regimen (STR), Juluca (DTG/rilpivirine [RPV]), FDA-approved in 2017. This study evaluated treatment patterns of DTG+RPV in clinical practice to understand use prior to availability of DTG/RPV STR.

Methods
A retrospective medical chart review was conducted across 10 US sites identified as using any DTG 2DRs. Eligible patients were adults initiated on DTG 2DR prior to July 31, 2017 and followed up to January 30, 2018. This analysis describes a subgroup who received DTG+RPV 2DR. Patient demographics, clinical characteristics and treatment history were abstracted from medical charts. Analyses were descriptive.

Results
From an overall sample of 278 DTG 2DR patients, 66 received DTG+RPV 2DR. In this DTG+RPV subgroup, mean age was 56 years, 79% were male and 68% were Caucasian. Most were treatment-experienced (97%), with an average 15.5 years of prior ART; 48% had received ≥ 4 prior regimens. The most common physician reported reasons for initiating DTG+RPV were avoidance of potential long-term toxicities (53%), toxicity/intolerance of ARVs (20%) and treatment simplification/streamlining (15%). Prior to initiation of DTG+RPV, 70% of patients were virologically suppressed (< 50 copies/mL); of those, 98% remained suppressed after switching to DTG+RPV. Of the 30% of patients with detectable viral load prior to DTG+RPV initiation, 60% achieved and maintained virologic suppression on DTG+RPV. Mean time on DTG+RPV was 1.6 years. Only 5 (8%) patients discontinued DTG+RPV by data cut-off, and one patient was lost to follow-up. Reasons for discontinuation were virologic failure (n = 2), treatment simplification/streamlining (n = 2) and toxicity/intolerance (n = 1). Physicians reported that most patients (91%) achieved the desired outcome from DTG+RPV use.

Conclusion
Prior to commercial availability of DTG/RPV STR in the United States, DTG+RPV was used primarily in treatment experienced patients, most commonly to avoid potential long-term toxicities. A high proportion of patients achieved the desired outcome and maintained virologic suppression while receiving DTG+RPV.

Disclosures
All authors: No reported disclosures.
2487. Low Rate of Virologic Failure in Antiretroviral Experienced Patients Prescribed Once Daily Raltegravir
Authors: Hsu Ricky , Schulman Kathy , Fusco Jennifer S , Marie Arduino Jean , Prajapati Girish , Fusco Gregory 
Published: October 2019

Abstract

Background
Raltegravir has been used to treat HIV infection for over a decade. In 2017, a 1200 mg, once-daily, formulation of raltegravir (RALQD) was approved. We sought to characterize the utilization and effectiveness of RALQD in ART-experienced, virologically suppressed, HIV+ adults in a real-world cohort of patients treated in the United States.

Methods
HIV+ adults, suppressed to <50 copies/mL at RALQD initiation (7/1/2017–December 31/2017), were identified in the OPERA® Observational Database, a collaboration following 100,000 people living with HIV through electronic medical records. Patients were followed until RALQD discontinuation, death, or study end (December 31/2018). Demographic and clinical characteristics were described at initiation. The primary study outcome was the incidence of virologic failure (VF), defined as 2 consecutive viral load (VL) test results > = 200 copies/mL or 1 VL ≥ 200 copies + RALQD discontinuation. Kaplan–Meier methods were used to describe VF.

Results
The study eligible population (n = 121) was older (median 54 years, IQR: 44, 61) than the overall ART experienced OPERA population (median 47 years, IQR: 35, 55), equally as likely to be male (84% vs. 83%), or African American (38%), but more likely to be Hispanic (23% vs. 20%) and receiving care in the southern United States (61% vs. 56%). RALQD initiators were also more likely to be heavily treatment experienced (≥3 lines ART) than the overall ART experienced OPERA population (57% vs 43%). They were also more likely to have at least one comorbid condition complicating their care (88% vs. 72%), most frequently hyperlipidemia (50%), hypertension (47%), anemia (26%), anxiety disorders (25%) and diabetes (22%). Half of all RALQD initiators had ≥3 comorbidities at the time of RALQD initiation. Two-thirds of RALQD initiators had baseline CD4 cell counts >500 cells/µL. Median (IQR) time on RALQD was 57 weeks (43–65); 89% of RALQD initiators had ≥1 VL test result during follow-up. Among these patients, VF occurred in 3 patients at a rate of 2.7 (0.9, 8.4) per 100 person years of observation. Figure 1 depicts Kaplan–Meier curves.

Conclusion
RALQD was found to be an effective treatment option in ART experienced patients who are virologically suppressed at initiation, and who often face challenges associated with managing comorbid conditions.

Disclosures
All authors: No reported disclosures.