bluuebunny/crossref_metadata_2025_split huggingface dataset:
1391. Latent Tuberculosis Screening Cascade in Liver Transplant Candidates: A Single, Transplant Center Experience
Authors: Medvedeva Natalia , Cheung Harry , Wootton Elizabeth , Ventura Kara , Azar Marwan M , Malinis Maricar 
Published: October 2019

Abstract

Background
Screening for latent tuberculosis infection (LTBI) is an essential component of the pre-transplant evaluation and key in identifying patients at risk for TB reactivation post-transplantation. At our center, liver transplant candidates (LTC) are routinely referred to transplant infectious disease (TID) for pre-TID evaluation including LTBI screening. Our aim was to determine the effectiveness of our screening practices and identify barriers to LTBI treatment.

Methods
We conducted a medical chart review of actively wait-listed LTC as of February 18/2019. Data points collected included: TB risk factors, TID referral and completion of evaluation, intention to screen for LTBI (defined as placing an order), screening completion (with documentation of a test result), screening method (IGRA or PPD), screening test result, radiographic findings, and treatment initiation and completion, if applicable. A positive screen was defined as a positive IGRA or PPD result while a negative screen was defined as a negative result or an indeterminate result with lack of epidemiological risk factors and negative radiographic findings. The proportion of LTC who completed each step in the cascade of care for LTBI was determined.

Results
Of 102 LTC, 100 met inclusion criteria. Two were excluded due to past LTBI treatment. Of 100 LTC, 95 completed a pre-TID evaluation. For 94 (98.9%), there was intention to screen. Of those intended for screening, 91 (95.8%) successfully completed screening; 6 (6.6%) patients screened positive and 85 (93.4%) screened negative. All 6 LTC who tested positive were recommended for treatment. Five of 6 (83.3%) agreed to treatment, 3/6 (50.0%) started treatment, and all 3 completed treatment. Reasons for non-treatment included: deferral until completion of HCV treatment or hepatologist approval or patient refusal. Treatment regimens included rifampin (n = 1) and isoniazid (n = 2).

Conclusion
The prevalence of LTBI in our LTC cohort was low. Nonetheless, TID played a role in the successful completion of LTBI screening and identifying those appropriate for treatment in this vulnerable patient population. Barriers to successful LTBI screening and treatment completion are contingent on effective care coordination and addressing competing co-morbidities.

Disclosures
All authors: No reported disclosures.
1392. Tuberculosis Disease in Recipients of Organ-Transplantation, California 2010–2017
Authors: Katrak Shereen , Westenhouse Janice , BARRY Pennan , Flood Jennifer 
Published: October 2019

Abstract

Background
Tuberculosis (TB) disease in persons who have received organ transplantation causes high morbidity, but the epidemiology and clinical features of this problem remain poorly described.

Methods
Using California TB registry data from 2010–2017, we describe clinical features of all TB cases occurring in patients who previously received solid-organ transplantation. We compared TB cases with and without transplant, and examined mortality controlling for age.

Results
During 8 years of observation, the California TB Registry recorded 116 cases of post-transplant TB. A majority of patients with post-transplant TB were >45 year old (84%), nonwhite (90%), and born outside of the United States (84%). Of 116 cases, 48 (41%) had pulmonary disease, while 68 (59%) had extra-pulmonary or both pulmonary and extra-pulmonary disease, compared with 69% and 31%, respectively, in non-transplant-associated TB (P < 0.01). Common sites of extrapulmonary disease in transplant patients included pleura (19%), cervical lymph nodes (12%), and bone (12%). Controlling for age, transplant cases were nearly twice as likely to die as non-transplant-associated TB cases (OR = 1.92, CI = 1.13, 3.25). Among 49 post-transplant TB cases with a positive TB skin test (TST) or interferon-gamma release assay (IGRA), 12 (24%) had the test performed > 6 months prior to TB diagnosis.

Conclusion
Our findings suggest that post-transplant TB disease is more likely to be extra-pulmonary and result in death than non-transplant-associated TB, and that opportunities may exist for preventing TB disease through screening and treatment for LTBI in this population.

Disclosures
All authors: No reported disclosures.
1401. Minimal Cerebrospinal Concentration of Miltefosine Despite Therapeutic Plasma Levels during the Treatment of Amebic Encephalitis
Authors: Monogue Marguerite L , Prokesch Bonnie C 
Published: October 2019

Abstract

Background
Miltefosine is an alkylphosphocholine compound used primarily for the treatment of leishmaniasis that also demonstrates in vitro and in vivo anti-amebic activity against Acanthamoeba species. As such, recommendations for treatment of amebic encephalitis generally include miltefosine therapy. Data support a minimum amebicidal concentration (MAC) of at least 16 μg/mL is required for most Acanthamoeba species. Given the high mortality associated with amebic encephalitis and a paucity of data regarding miltefosine levels in the plasma and cerebrospinal fluid (CSF) in vivo, we sought to determine whether a patient being treated with oral miltefosine at a higher-than-recommended dose obtained therapeutic plasma and CSF concentrations.

Methods
A patient with brain-biopsy-confirmed Acanthamoeba encephalitis was initiated on miltefosine 50mg by mouth every 6 hours (q6h), a higher frequency of therapy than recommended in the scant available literature (which suggests doses of 50 mg every 8 hours). Plasma and CSF miltefosine concentrations were collected on day 7 of treatment. CSF was collected via an external ventricular drain over a period of 1 hour. The quantification of miltefosine was performed using a Waters Xevo TQ-S triple quadrupole mass spectrometer coupled with a Waters Acquity UPLC I-class system.

Results
The trough plasma and CSF concentrations (taken 8 hours post-dose) were 16.2 and 0.007 µg/mL, respectively, resulting in a miltefosine plasma to CSF ratio of 2,440:1 µg/mL. The patient had no adverse reactions during the initial course of miltefosine therapy, though ultimately succumbed to the disease.

Conclusion
This is the first report to describe plasma and CSF concentrations after administration of miltefosine 50mg q6h for the treatment of amebic encephalitis. The administration of miltefosine 50mg q6h resulted in plasma concentrations at the suggested MAC for Acanthamoebaspp. However, the miltefosine CSF concentration was extremely low compared with the plasma level and did not reach amebicidal concentrations. While miltefosine human brain parenchyma concentrations have yet to be described in the literature, this case questions if oral miltefosine is adequate to veritably treat patients with amebic encephalitis.

Disclosures
All authors: No reported disclosures.
1421. Microbiology and Resistance of Diabetic Foot Osteomyelitis in a Teaching Hospital in Santiago, Chile
Authors: Valenzuela Pablo Tomas , E. Mühlhauser Margareta , Palma Sofia , Escobar Carola , Marin Magdalena 
Published: October 2019

Abstract

Background
Diabetic foot ulcers are a frequent complication of patients with diabetes mellitus, two-thirds of these can become infected and up to 50% can develop a deep infection and osteomyelitis, which usually requires surgical management and prolonged antibiotic therapy. Microbiology is characterized by a predominance of Gram-positive (Staphylococcus aureus and negative coagulase), followed by enterobacteria and non-fermentors such as P. aeruginosa, but it is variable and factors such as the type of patient, wound characteristics, use of antibiotics, and the environment. In Chile, there are no recent data on microbiology or resistance in diabetic foot osteomyelitis, which is fundamental for the rational use of antibiotics. The objective of this study was the description of this microbiology and resistance in a teaching hospital in Santiago, Chile.

Methods
Retrospective study conducted at the DIPRECA Hospital. Residual bone cultures taken from the operating room were analyzed, from patients hospitalized for diabetic foot osteomyelitis between January 1, 2013 and December 31, 2018. Sex, age, the microorganism isolated in bone and its resistance profile were analyzed. The study is approved by the Hospital Ethics Committee.

Results
We analyzed 285 cultures of 107 patients. The mean age was 71 ± 9 years and 82% corresponded to male patients. 26% of the cultures were polymicrobial. Gram-positive cocci corresponded to 68.4% and gram-negative bacilli to 31.6%. The main microorganism were E. faecalis 24.2%, S. aureus 21.8%, S. coagulase negative 18.9%, P. aeruginosa in 6.3%, K. pneumoniae in 6% and E. coli in 3.5%. In relation to resistance, E. faecalis were 98.2% sensitive to ampicillin, S. aureus were 55.5% sensitive to cefoxitin and 100% to vancomycin, S. coagulase negative were 41% sensitive to oxacillin and 100% vancomycin, P. aeruginosa were 73% sensitive to imipenem and 66% sensitive to meropenem, K. pneumoniae was 87% ESBL, 100% sensitive to imipenem and 73% to meropenem and E. coli was 63% ESBL and 100% sensitive to carbapenems.

Conclusion
Osteomyelitis of the diabetic foot was characterized as being mainly monomicrobial, by E. faecalis, Staphylococcus, P. aeruginosa, and K. pneumoniae, with a high prevalence of resistance to methicillin, ESBL and to a lesser extent resistance to carbapenems.

Disclosures
All authors: No reported disclosures.
1442. Effect of Reflex Urine Culturing on Rates of Cultures and Infections in an Acute Care Hospital, Emergency Department, and Two Long-Term Care Facilities
Authors: Lynch Chelsea , Appleby-Sigler Andrea , Bork Jacqueline , Dave Rohini , Claeys Kimberly C , Zhan Min , Agnes Kathy , Sanikop Molly , Heath Dori , Clark Arlene , Morgan Daniel 
Published: October 2019

Abstract

Background
Urine cultures are often positive in the absence of urinary tract infection (UTI) leading to unnecessary antibiotics. Reflex culturing decreases unnecessary urine culturing in acute care settings but the benefit in other settings is unknown.

Methods
This was a quasi-experimental study performed at a health system consisting of an acute care hospital, an emergency department (ED), and two long-term care (LTC) facilities. Reflex urine criterion was a urine analysis with > 10 white blood cells/high-power field. Urine cultures performed per 100 bed days of care (BDOC) were compared pre- (August 2016 to July 2017) vs. post-intervention (August 2017 to August 2018) using interrupted time series regression. Catheter-associated UTI (CAUTI) rates were reviewed to determine potential CAUTIs that would have been prevented.

Results
In acute care, pre-intervention, 894 cultures were performed (3.6 cultures/100 BDOC). Post-intervention, 965 urine cultures were ordered and 507 cultures were performed (1.8 cultures/100 BDOC). Reflex culturing resulted in an immediate 49% decrease in cultures performed (P < 0.001). The CAUTI rate 2 years pre-intervention was 1.8/1000 catheter days and 1.6/1000 catheter days post-intervention. Reflex culturing would have prevented 4/14 CAUTIs. In ED, pre-intervention, 1393 cultures were performed (5.4 cultures/100 visits). Post-intervention, 1959 urine cultures were ordered and 917 were performed (3.3 cultures/100 visits). Reflex culturing resulted in an immediate 47% decrease in cultures performed (P = 0.0015). In LTC, pre-intervention, 257 cultures were performed (0.4 cultures/100 BDOC). Post-intervention, 432 urine cultures were ordered and 354 were performed (0.5 cultures/100 BDOC). Reflex culturing resulted in an immediate 75% increase in cultures performed (P < 0.001). The CAUTI rate 2 years pre-intervention was 1.0/1000 catheter days vs. 1.6/1,000 catheter days post-intervention. Reflex culturing would have prevented 1/13 CAUTIs.

Conclusion
Reflex culturing canceled 16%-51% of cultures ordered with greatest impact in acute care and the ED and a small absolute increase in LTC. CAUTI rates did not change although reflex culturing would have prevented 29% of CAUTIs in acute care and 8% in LTC.

Disclosures
All authors: No reported disclosures.
1444. Urine Screening Prior to Surgical Valve Replacement: Should It Be Performed?
Authors: LeVee Alexis , Beaulac Kirthana , Doron Shira 
Published: October 2019

Abstract

Background
Screening for and treatment of asymptomatic bacteriuria (ASB) is controversial prior to surgical valve replacement (SVR). The theoretical concern that the bacteria can translocate to the surgical site, causing infective endocarditis (IE), has not been well-described. At our institution, screening for and treatment of ASB is routine prior to SVR. This study aims to identify whether an association exists between ASB and post-op infections in patients undergoing SVR.

Methods
A single-center retrospective study was conducted for patients who had SVR between 2016 and 2018. Pre-op urinalyses (UAs) and cultures, symptoms of UTI, and antibiotic therapy were collected during the 60-day pre-op period. Infections, antibiotic therapy, development of resistance, 30-day readmission rates, and 30- and 90-day mortality rates were collected up to 3 months post-op. Statistical analysis was performed using the Chi-square and Fisher exact tests.

Results
Of the 358 patients who underwent SVR, pre-op UAs were performed in 329 (92%) patients; of whom, 296 (91%) were asymptomatic. Amongst those asymptomatic, 14 (5%) cultures were positive and 11 (79%) positive cultures were treated. Patients with ASB had no difference in post-op infection (1/14 [7%] vs. 32/282 [11%]; P = 1), 30-day readmission rate (1/14 [7%] vs. 44/282 [16%]; P = 0.7), or 90-day mortality rate (0/14 [0%] vs. 4/282 [1%]; P = 1) compared with those with negative urine cultures. Patients who were treated for ASB also showed no difference in these same outcomes compared with those not treated. IE was a complication in 3 of 358 (1%) cases, and none of these patients had ASB or symptomatic UTI prior to surgery. Antibiotic treatment prior to surgery was associated with acquisition of a multi-drug-resistant organism (9/68 [13%] vs. 15/290 [5%]; P = 0.02). There was a trend toward increased 30-day readmission rate (15/68 [22%] vs. 43/290 [15%]; P = 0.15) and development of resistance (1/68 [1%] vs. 0/290 [0%]; P = 0.19) in patients who received pre-op antibiotics.

Conclusion
In this study, ASB prior to SVR was not related to post-op infection, and treatment of ASB did not prevent future infection. Antibiotic treatment prior to SVR was associated with the development of MDROs. Urine screening prior to SVR should be avoided.

Disclosures
All authors: No reported disclosures.
1445. Antimicrobial Activity of Novel β-Lactamase Inhibitor Combinations Tested against Organisms Causing Complicated Urinary Tract Infections in United States Medical Centers
Authors: Sader Helio S , Carvalhaes Cecilia G , Shortridge Dee , Huband Michael D 
Published: October 2019

Abstract

Background
High-dose extended-infusion cefepime-tazobactam (FEP-TAZ) is in clinical development at 2g/2g q8 hours administered over 90 minutes. We evaluated the potency and spectrum of activity of FEP-TAZ, ceftolozane–tazobactam (C-T), ceftazidime–avibactam (CAZ-AVI), and comparators tested against gram-negative bacilli (GNB) causing complicated urinary tract infections (cUTIs) in United States (US) hospitals.

Methods
In 2018, 3,023 GNBisolates (1/patient) were consecutively collected and susceptibility tested against FEP-TAZ (TAZ at fixed 8 mg/L) and comparators by reference broth microdilution methods. Percentage of isolates inhibited at ≤8 mg/L (CLSI, cefepime high dose) and at ≤16 mg/L (pharmacokinetic/pharmacodynamic [PK/PD] susceptible [S] breakpoint based on extended infusion and high dosage) were evaluated.

Results
FEP-TAZ (99.9% inhibited at ≤16 mg/L; Table), CAZ-AVI (99.9%S), and meropenem (MEM; 99.5%S) were the most active agents against Enterobacterales (ENT). An ESBL phenotype (CLSI criteria) was observed in 12.5%, 12.9%, and 3.6% of E. coli (EC), K. pneumoniae (KPN), and P. mirabilis (PM), respectively. FEP-TAZ and CAZ-AVI exhibited complete activity against EC, whereas C-T and piperacillin–tazobactam (PIP-TAZ) were active against 91.5% and 88.1% of ESBL-phenotype EC isolates, respectively. The most active agents against KPN were FEP-TAZ (99.6% inhibited at ≤16 mg/L), CAZ-AVI (100.0%S), and amikacin (AMK; 99.4%S). All PM isolates were S to FEP-TAZ (highest MIC, 0.12 mg/L), C-T, CAZ-AVI, MEM, PIP-TAZ and AMK. FEP-TAZ was highly active against E. cloacae (n = 94; MIC90, 0.5 mg/L; 98.9% inhibited at ≤16 mg/L) and Citrobacter spp. (n = 91; MIC90, 0.12 mg/L; highest MIC, 0.5 mg/L). Against P. aeruginosa (PSA), FEP-TAZ inhibited 97.6% of isolates at ≤16 mg/L, with spectrum of activity similar to CAZ-AVI (96.4%S), C-T (99.4%S) and AMK (97.6%S), and greater than MEM (85.5%S) and PIP-TAZ (87.3%S).

Conclusion
FEP-TAZ showed potent activity against ENT and PSA isolated in US hospitals in 2018, with overall spectrum (ENT + PSA) similar to CAZ-AVI and greater than C-T, PIP-TAZ, and MEM when FEP-TAZ proposed PK/PD S breakpoint of ≤16 mg/L was applied. FEP-TAZ may represent a valuable option for treating cUTIs caused by resistant GNB.

Disclosures
All authors: No reported disclosures.
1446. The Impact of Enterobacteriaceae Isolate Breakpoints on Prescriber Treatment Choices for Discordant Pattern Urinary Tract Infections
Authors: Lee Philip , Guo Yi , Szymczak Wendy , Soma Vijaya L , Nori Priya 
Published: October 2019

Abstract

Background
Our institution revealed Enterobacteriaceae with discordant cefazolin (CEF)-resistant / ampicillin-sulbactam (SAM) susceptible patterns (CRASS-P). This discordance could be from the multiple MIC cephalosporin breakpoint adjustments from CLSI. SAM has higher resistance for gram-negative bacteria compared with cephalosporins such as CEF which is confirmed by our antibiogram. We sought to understand if narrow-spectrum antibiotic choices for CRASS-P urinary tract infections (UTIs) led to clinical cure (CC).

Methods
We conducted a retrospective review from January 2018 to February 2019 of all CRASS-P Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae isolates from urine cultures. Patients with any symptom related to a UTI, urinalysis with >10 white blood cells/high-powered field, urine culture with >10,000 colony-forming units/mL, and receipt of an antibiotic were included. CC was defined as symptom resolution within 48 hours with no return to care within 28 days of the positive urinary culture. “Group A” included patients prescribed narrow-spectrum antibiotics such SAM, CEF, or an oral cephalosporin (OC) vs. broad-spectrum antibiotics such as ceftriaxone, quinolones or sulfa-medications (“Group B”).

Results
There were 960/1356 (70.8%) CRASS-P urinary isolates and 244 patients met inclusion criteria. Of 244 patients, 72 were in Group A and 172 were in Group B. There was no difference in the diversity of the 3 uropathogens, P = 0.34 (Table 1). Median age was 69±20.3 and 67.5±23.9 years for Group A and Group B, respectively, P = 0.23. Females accounted for 73.6% and 77.9% in Group A and B, respectively, P = 0.51. Overall, patients reached CC in 98.6% (71/72) of Group A patients, compared with 92.4% (159/172) of Group B patients, P = 0.07. Antibiotics used in treatment are outlined in Figure 1. UTI was associated with bacteremia for 2 patients in Group A and 4 patients in Group B (P = 0.84). Both patients in Group A reached CC and used AMC for treatment. However, 1 out of 4 patients did not achieve CC in Group B.

Conclusion
The use of SAM or OC can spare the broad-spectrum antibiotics use for CRASS-P UTIs as there was no statistical difference in CC between the two groups. The use of SAM with CRASS-P bacteremia secondary to UTI is possible; however, future studies are needed.

Disclosures
All authors: No reported disclosures.
1453. Cephalexin and Cefadroxil Are Not Therapeutic Equivalents for Uncomplicated Cystitis (uUTI): Further Analysis of Cefazolin Surrogate Susceptibility Testing Criteria
Authors: Jones Ronald N , Nguyen Hien M 
Published: October 2019

Abstract

Background
Cephalexin (CLEX) and cefadroxil are first-generation oral cephalosporins (OC’s) with similar antimicrobial spectrums, side-effects, and high urine concentrations; and are US-FDA approved for uUTI. Some stewardship programs are replacing CLEX (4 × daily) with cefadroxil (2 × daily) for dosing convenience. The US Committee on Antimicrobial Susceptibility Testing (USCAST) and CLSI recommend a cefazolin (CZOL) UTI surrogate breakpoint (≤16 mg/L; ≥15 mm) to predict susceptibility (S) for 7 OC’s against indicated Enterobacteriaceae. Direct cefadroxil antimicrobial S testing (AST) does not exist in US breakpoint interpretive documents, limiting specific results.

Methods
We reanalyzed and compared the CZOL surrogate testing for cefadroxil, CLEX and 5 other OC’s using AST data previously reported (Schuetz et al., 2013; IHMA). Broth microdilution AST was used against 205 isolates: E. coli (92; 40% with β-lactamase), K. pneumoniae (62), P. mirabilis (31; 10% with β-lactamase), and other enteric bacilli (20). A CZOL surrogate S breakpoint (≤16 mg/L) was used to infer S for OC’s.

Results
CZOL X cefadroxil cross-S accuracy rate was only 91.6% (unacceptable; < 95%) and the false resistance was 1.0% (acceptable). Cross-S accuracy was ≥ 97.0% for all tested OC’s except cefadroxil and cephradine (80.1%). CZOL spectrum vs. tested, indicated species (81.0%) was essentially identical for CLEX, cefprozil, cefaclor and loracarbef (80.0–81.0%). In contrast, cefdinir, cefpodoxime, and cefuroxime axetil S rates were underestimated 5.3 to 10.7% by the surrogate test. CLSI and USCAST did not list cefadroxil or cephradine for CZOL surrogate uUTI prediction; however the current (2019) US-FDA website document states “cefadroxil may be deduced from testing CZOL” regardless of clinical indication.

Conclusion
Cefadroxil -S for guiding uUTI therapy cannot be accurately predicted by CZOL results at ≤16 mg/L (unacceptable surrogate accuracy and compromised spectrum/potency). Furthermore, direct cefadroxil AST does not exist in United States due to lack of breakpoint criteria (CLSI, USCAST) and reagent materials (MIC products or disks). CLEX or other OC’s remain preferred, more active (table) uUTI treatment choices having quality direct or surrogate AST guidances.

Disclosures
All authors: No reported disclosures.