bluuebunny/crossref_metadata_2025_split huggingface dataset:
1142. Implementation and Impact of a Tracheitis Diagnosis and Management Guideline in a Pediatric Intensive Care Unit
Authors: Iacono Denise , Tanweer Ammara , Sweberg Todd , Hagmann Stefan , Chua Vincent , DeCelie-Germana Joan , Tsirilakis Kalliopi 
Published: October 2019

Abstract

Background
Ventilator-associated tracheitis (VAT) is a common intensive-care unit entity considered in febrile patients with endotracheal intubation or with tracheostomy. Prospective-Audit-And-Feedback activities had identified an overall increased and high inter-provider-variability in the use of antibiotics for VAT. By developing a VAT-specific guideline, we intended primarily to decrease the amount of respiratory fluid cultures (RFCx) submitted, and secondly decrease the overall antibiotic use (AU) in the PICU, while not increasing the incidence of ventilator-associated events (VAE).

Methods
A multidisciplinary team developed a guideline for patients with fever or change in baseline respiratory support with endotracheal intubation or with tracheostomy who had no radiographic evidence of pneumonia consisting of three parts: A) When to send an RFCx, B) Diagnosis of VAT, C) Antibiotic management of VAT: A) To obtain a RFCx, patient needed to have an abnormal white cell count (WBC) ( <5 K/uL or >14.5 K/uL) AND purulent or increased amount of endotracheal secretions PLUS either abnormal body temperature (T <36°C or ≥38.3°C) or change in baseline respiratory support. B) A diagnosis of VAT is allowed if RFCx shows Gram stain with ≥+3 WBC AND ≥+3 bacteria. C) Empiric antibiotic treatment with antipseudomonal activity (informed by previous RFCx if exist) to be started after RFCx have been obtained. Reassessment and possible modification at 48H based on final RFCx results. Duration of AU to be limited to 5 days. Guideline education was completed at multiple PICU meetings from September 2017 through June 2018. Manual audits were used to analyze adherence to the guideline. Data on RFCx order utilization, ventilator days, and AU from January 2017 to December 2018 were analyzed.

Results
Since the initiation of the guideline, we observed a downward trend of RFCx orders (Fig1.A) with an average decrease of 19% after guideline implementation. The overall AU (Fig1.B) in PICU decreased by an average of 24% while the incidence of VAE has remained stable.

Conclusion
Efforts to standardize diagnosis and treatment of VAT in patients with endotracheal intubation or tracheostomy resulted in a decreased number of RFCx, and reduced overall AU without increasing the risk of VAE.

Disclosures
All authors: No reported disclosures.
1147. Improving Accessibility and Antibiotic Prescribing with an Enhanced Digital Antibiogram
Authors: Yarahuan Julia K , Hunter Brandon , Nadar Devin , Gujral Nitin , Fine Andrew M , Flett Kelly 
Published: October 2019

Abstract

Background
Institutional antibiograms play a key role in antimicrobial stewardship and may provide a venue for clinical decision support. Our institution recently transitioned our paper antibiogram to an enhanced digital antibiogram with antibiotic recommendations for common pediatric infections. The objectives of this study were (1) to improve the accessibility of our institutional antibiogram through a digital platform and (2) to improve trainee confidence when selecting empiric antibiotics by integrating clinical decision support.

Methods
The digital antibiogram was developed and evaluated at a tertiary children’s hospital. The tool was developed iteratively over one year by our innovation and digital health accelerator with recommendations for empiric antibiotic selection provided by experts in pediatric infectious diseases (see Figure 1 for example). Usability pilot testing was performed with a group of ordering providers and the tool was released internally in October 2018. A paired pre- and post- implementation survey evaluated residents’ perceptions of the accessibility of the paper vs. digital antibiogram and their confidence when selecting empiric antibiotics. Data were analyzed by Fisher exact test.

Results
During the 3 months after release, the digital antibiogram was accessed 1014 times with similar proportions of views for susceptibility data, dosing, and empiric antibiotic recommendations. Of the 31 pediatric residents who responded to both pre- and post- implementation surveys, only 59% had access to a copy of the paper antibiogram. Following release of the digital antibiogram, residents referred to antibiotic susceptibilities more frequently (P < 0.05, Figure 2) and were more frequently more confident when selecting the correct antibiotic dose (P < 0.01, Figure 3). See Figure 4 for dosing recommendation example.

Conclusion
Providing antibiotic susceptibility and dosing recommendations digitally improved accessibility and resident confidence during antibiotic prescribing. Our digital tool provides a successful platform for displaying the antibiotic data and recommendations that enable appropriate antibiotic use.

Disclosures
All authors: No reported disclosures.
1179. Rates and Causative Pathogens of Device-Associated Bloodstream and Urinary Tract Infections Attributed to Solid-Organ Transplant Units, 2015–2017
Authors: Chea Nora , Zhou Liang , Magill Shelley , Guh Alice , Edwards Jonathan R , Epstein Lauren , Sapiano Matthew 
Published: October 2019

Abstract

Background
Due to complex invasive medical procedures and compromised immunity, solid-organ transplant (SOT) patients are at high risk for infections. However, whether SOT patients are at higher risk than other hospitalized patients for selected healthcare-associated infections (HAI), such as central line-associated bloodstream infections (CLABSI) or catheter-associated urinary tract infections (CAUTI), or for infections with antimicrobial-resistant (AR) pathogens, is not well described. We analyzed data reported to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) from inpatient SOT units and compared CLABSI and CAUTI rates and AR in hospitals with both SOT and non-SOT units.

Methods
We analyzed 2015–2017 CLABSI and CAUTI data reported to NHSN from hospitals with adult or pediatric inpatient SOT units. We calculated CLABSI and CAUTI incidence rates per 1,000 central-line days (CLD) and urinary catheter days (UCD), respectively, and compared rates, pathogen distributions, and AR among events attributed to three unit types: (1) SOT units; (2) adult, pediatric, and neonatal critical care units; and (3) adult and pediatric medical, surgical, and combined medical-surgical wards. We compared proportions using χ 2 tests and determined statistical significance at P ≤ 0.05.

Results
CLABSI and CAUTI rates in SOT units were lower than rates in critical care units, but higher than rates in wards (table). Although the most common CLABSI and CAUTI pathogens were similar in all three unit types, the prevalence of individual pathogens differed (figure). Among CLABSI pathogens, Enterococcus faecium, Escherichia coli, and Klebsiella pneumoniae or oxytoca were significantly more prevalent in SOT compared with critical care units. Vancomycin resistance among CLABSI E. faecium was significantly lower (71.4% vs. 87.5%) and fluoroquinolone resistance among CAUTI E. coli was significantly higher (49.3% vs. 32.5%) in SOT compared with critical care units.

Conclusion
SOT units have lower CLABSI and CAUTI rates compared with critical care units. Differences in pathogens and AR among device-associated HAIs in SOT units should be considered when implementing infection prevention and treatment policies.

Disclosures
All authors: No reported disclosures.
1189. Effectiveness of Multimodal Intervention Strategies to Improve Hand Hygiene Compliance at an Academic Medical Center
Authors: Navalkele Bhagyashri D , Tate Myrtle , Dunaway Jeff , Fletcher Sheila , Inman Barbara , Hankins Phillip , Hung Leroy , Guy Rachel , Parham Jason 
Published: October 2019

Abstract

Background
Since the early 19th century, hand hygiene (HH) has been recognized as the most important factor in preventing healthcare-associated infections (HAI). Still, improving HH compliance is a major hurdle for most healthcare facilities. Our study objective was to evaluate effectiveness of bundled intervention tools in increasing hand hygiene (HH) compliance.

Methods
The study was performed at the University of Mississippi Medical Center located in Jackson, MS. A multidisciplinary HH team was established in January 2016. Team members included infection prevention, nurse managers, physician, resident, housekeeping, process engineers, and ancillary staff. Hand hygiene compliance was determined based on room entry and exit observations. Intervention strategies were based on Joint Commission Center’s Targeted Solutions Tool (TST) to identify barriers in HH compliance, standardization of data collection, covert observer training and Just-in-time training of providers. Other strategies implemented included education and feedback, rewards and recognition, and system change measures during the 3-year study period (timeline in Table 1). Hand hygiene compliance was calculated based on number of compliance opportunities/total number of observations. One-way Analysis of Variance (ANOVA) was performed to analyze HH data. We did not assess the concomitant reduction in HAI rates as simultaneous HAI prevention strategies confounded analysis.

Results
Based on total 95,491 observations performed (January 2016- December 2018), there was a statistically significant improvement in HH compliance during the study period from 66.5% in 2016 to 73% in 2017 and 79.5% in 2018 (P = 0.04).

Conclusion
At our institution, we observed a 56% improvement in hand hygiene compliance over 36-months timeframe. Multidisciplinary team involvement and multimodal intervention strategies play crucial role in improvement and sustainment of HH compliance.

Disclosures
All authors: No reported disclosures.
1205. Healthcare Personnel Knowledge, Attitudes, and Beliefs Towards Infection Prevention and Control Measures for Protection from Respiratory Infections
Authors: Bessesen Mary T , Radonovich Lewis , Rattigan Susan M , Cummings Derek , Rodriguez-Barradas Maria C , Simberkoff Michael , Gibert Cynthia L , Nyquist Ann-Christine , Price Connie S , Gorse Geoffrey , Gaydos Charlotte A , Perl Trish M , Perl Trish M 
Published: October 2019

Abstract

Background
Healthcare personnel (HCP) knowledge and attitudes toward Infection Prevention and Control (IPC) measures are important determinants of practices that can protect them from acquisition of infectious diseases from patients. We aimed to describe HCP knowledge and attitudes concerning IPC measures over time in the context of a clinical trial.

Methods
ResPECT was a multi-center, multi-season cluster randomized clinical trial designed to compare the effectiveness of medical masks (MM) and N95 respirators (N95) for preventing acute respiratory illnesses in HCP employed in outpatient clinical settings. At the beginning of each respiratory virus season, participants completed a survey instrument to measure IPC knowledge. At the beginning and end of each season participants completed a survey to assess attitudes and beliefs about IPC measures, especially MM and N95.

Results
A pre-study and post-study survey pair was available for 88.1% of participant seasons. There were no significant differences in demographic variables or job assignment between survey respondents and nonrespondents for each participant season. Participants correctly identified 59.8% to 63.4% of IPC measures that should be used by HCP when exposed to patients with symptoms of acute respiratory illness, or at high risk of infection. There was modest improvement in the knowledge score over time among providers who participated for multiple years in the study. In the first pre-study survey of IPC attitudes and beliefs, 88.5% and 87.9% of participants identified at least one reason to avoid using either MM and N95, respectively (Figure 1). At the post-season survey, the proportion of participants reporting a reason to avoid MM fell to 39.6% (IRR for pre- vs. post-season 0.15, 95% CI 0.13–0.17) and 53.6% reported a reason to avoid N95 (IRR 0.57, 95% CI 0.51–0.66).

Conclusion
HCPknowledge of IPC precautions was poor, suggesting a need for better IPC education and accountability in the outpatient setting. When given incentives to comply with processes toward which they had negative attitudes at baseline, HCP realized that medical masks and N95 respirators were comfortable enough to wear for patient encounters and interfered with their work processes less than expected.

Disclosures
Trish M. Perl, MD; MSc, 7–11: Advisory Board; medimmune: Research Grant.
1210. Investigating a Staphylococcus aureus Outbreak in a Clinical Intensive Care Unit: What Is the Role of the Mobile Phones?
Authors: Espinoza Evelyn Patricia Sanchez , Neto Lauro Viera Perdigão , dos Santos Sania Alves , Risek Camila , Franco Maria Renata Gomes , Martins Roberta C R , Pereira Gaspar C O , Guimaraes Thais , Boszczowski Icaro , Rossi Flavia , Pinheiro Freire Maristela , Sara Shafferman Levin Anna , Costa Silvia F 
Published: October 2019

Abstract

Background
Staphylococcus aureus (Sa) outbreaks are serious infections that if not controlled in time can be life-threating. The aim of this study was to describe the investigation and control of a Sa outbreak in an intensive care unit including analysis of MP.

Methods
During a microbiological research of MP conducted in December 2018 in a clinical intensive care unit (ICU) of a tertiary university hospital two patients had an MRSA infection. Since this unit had not reported MRSA infections during the last year it was recognized as an outbreak. The CDC criteria was applied to define MRSA colonization and infection. Hand hygiene (HH) adhesion in this unit was 47%,it has 9 beds and 30 Healthcare professionals (HP). Nasal Swab (NS) of all the HPs and of the patients in the same unit as well. HP’s MP were also analyzed. The samples were subjected to MALDI-TOF (Biomerieux), phenotypical tests, PCR for detection of gene coA and mecA, pulsed-field gel electrophoresis (PFGE), and whole-genome sequence to access resistance, virulence profile and sequence type. Feedback of microbiology results, reinforcement of hand hygiene and MP cleaning was discussed with the unit staff.

Results
A total of 34 samples were collected, 25 were Sa, 13 NS of all HPs and patients, 7 from the MPs and 3 from HPs hands. During the time of the outbreak 5 patients were in the unit.
Patients with infection by MRSA (n = 2), had Methicillin-susceptible Sa in their NSs. Another patient that from the same unit had a MRSA in the NS that when submitted to PFGE was seen to be closely related with the MRSA that originated the outbreak. The patients isolates were assigned to different STs and they had more virulent and resistance genes in comparison with two samples of MPs. The Sa recovered from the MPs belonged to the same ST, same resistance gene and same virulent genes. Figure 1, Table1. Since the feedback to the unit no cases of MRSA have been reported in the last 4 months.

Conclusion
The outbreak was controlled using simply measures (feedback, reinforcement of HH and MP cleaning). The ST398 from the MP has already been described in outbreaks in literature. It seems that MP can be a reservoir for Sa There was more than one Sa lineage in the ICU. Our findings highlighted the need of rethinking the MP cleaning policy in our hospital.

Disclosures
All authors: No reported disclosures.
1264. Characterization of HIV-Positive Patients with Low-Level Viremia in a Community HIV Clinic Between 2014 and 2018
Authors: Sanchez Eduardo , Borgman Jody , Joffe Aviva , Holdsworth Catherine 
Published: October 2019

Abstract

Background
Low-level viremia (LLV) has been defined as an HIV RNA level detectable by newer generation viral load quantification assays but that is ≤200 copies/mL.Contributing factors may include intermittent low-level releases of virus from existing reservoirs, random laboratory variation and decreased ART adherence.

Methods
This retrospective chart review aimed to characterize patients who developed LLV in a community HIV clinic between 2014 and 2018. LLV was defined as two consecutive detectable HIV RNA measurements ≤200 copies/mL. Possible factors that could be associated with viral rebound (VR), defined as an HIV RNA >200 copies/mL, were evaluated by using multivariate logistic regression.

Results
Of a total of 666 patients, 111 met criteria for LLV. Seventy-seven were male and 34 were female. The majority were African American (85.6%) with Hispanic and white accounting for 5.4% each. Fifty-five percent were heterosexual and 31.5% were men that have sex with men. Analyzing CD4 counts at the moment or just prior to the development of LLV, 42 of them (37.8%) had a CD4 between 501 and 800 cells/mm3, 25 (22.5%) between 200 and 500 cells/mm3 and only 3.6% had CD4 counts <200 cells/mm3. The majority (60.3%) were on integrase inhibitors (INSTI). Of the 111 patients, only 59 of them had at least 1-year follow-up post LLV. Those who were followed for less than 12 months post-LLV were not included in the statistical analysis to try and find potential factors associated with VR post LLV. Twelve (20.3%) of the 59 developed VR. HIV RNA levels between 51 and 100 copies/mL and 101 and 200 copies/mL were associated with higher odds of VR (OR 3.77 95% CI 0.37–38.77, 3.09 95% CI 0.27–35.88, respectively). Patients with STIs, heterosexuals and those on INSTI were also associated with higher odds of VR (OR 1.48 95% CI 0.12–18.5, 3.13 95% CI 0.75–13.03 and 1.61 95% CI 0.35–7.38, respectively). These results did not achieve statistical significance.

Conclusion
This community HIV clinic has a low prevalence of LLV. Most of the patients did not develop VR. Although some clinical factors were found to be associated with viral rebound in patients with LLV, the associations did not achieve statistical significance. LLV is a phenomenon that requires further research, specifically regarding predictors of VR, particularly now in the INSTI era.

Disclosures
All authors: No reported disclosures.
1304. Pharmacist Impact on HIV Management in a Psychiatric Patient Population
Authors: Margulis Alice , Uhlyar Stepan , Chin-Beckford Nafeesa , Salazar Veronica , DeRonde Kailynn , Abbo Lilian , Vega Ana D 
Published: October 2019

Abstract

Background
Patients with mental illnesses are more than four times more likely to have human immunodeficiency virus (HIV) compared with the general population. HIV management can be especially challenging in these patients due to potential substance abuse, drug interactions, and nonadherence. The purpose of this study was to determine the impact of pharmacist management of antiretroviral (ARV) therapy in a psychiatric patient population.

Methods
This is an institutional review board-approved, single-center, retrospective study of patients admitted to a psychiatric hospital with an order for one or more ARV medication(s) between October 2016 and March 2017 (no pharmacist involvement), October 2017 and March 2018 (partial pharmacist involvement), and November 2018 and January 2019 (consistent pharmacist involvement). Patients were excluded if less than 18 years of age, pregnant, incarcerated, or taking ARV medication(s) for a non-HIV indication. The primary outcome was difference in appropriateness of ARV therapy prior to and during pharmacist involvement. Secondary outcomes were appropriateness of opportunistic infection (OI) prophylaxis and laboratory testing.

Results
A total of 37 patients were included per group. A greater number of appropriate ARV regimens were initiated with partial pharmacist involvement compared with no pharmacist involvement (62% vs. 32%, P = 0.0096), as well as with consistent pharmacist involvement compared with partial pharmacist involvement (84% vs. 62%, P = 0.0327). There was a trend toward increased HIV viral load draws with partial vs. no pharmacist involvement (54% vs. 43%, P = 0.24) and additionally with consistent vs. partial pharmacist involvement (62% vs. 54%, P = 0.32). With consistent pharmacist involvement, more patients had a resulted CD4 cell count (65%) than with both partial and no pharmacist involvement (57%). Of the patients requiring OI prophylaxis, appropriate prophylaxis was initiated in more patients with consistent pharmacist involvement (57%) than with partial pharmacist involvement (50%) or no pharmacist involvement (11%).

Conclusion
Pharmacist involvement in HIV management in a psychiatric patient population increased appropriateness of ARV therapy, laboratory testing, and OI prophylaxis.

Disclosures
All authors: No reported disclosures.
1323. Clinic-Level Factors Associated with Antiretroviral Prescription Rates
Authors: Hayes Craig P , D’Aquila Erica , Bertolino Daniel , Abraham Bisrat K 
Published: October 2019

Abstract

Background
Despite overall high antiretroviral (ARV) prescription (Rx) rates for the treatment of HIV in New York City (NYC), clinic-level Rx rates can vary greatly by clinic. Previous literature suggests reasons for deferring ARV Rx include patient readiness or comorbidities and provider biases. We investigated the impact of these and other factors on clinic-level ARV Rx rates within NYC.

Methods
Data were obtained from the 2016 HIV Clinic Survey which contained questions related to clinic capacity and other clinic and patient characteristics. Multivariate linear regression models were developed from literature sourced variables and manual stepwise selection. These models were evaluated for predictive strength based on their respective root mean square error (RMSE) and adjusted R-squared (AR2) values.

Results
Among the 104 HIV primary care clinics, representing the care of 49,654 people living with HIV (PLWH), ARV Rx rates ranged from 41.4% to 100.0% (IQR: 92.1%-99.6%). An increase in clinic-level ARV Rx rates was found to be significantly associated with an increase in clinic-level viral load suppression rates. In the stepwise multiple linear regression model (Table 1), decreases in ARV Rx rates were associated with several factors: (1) care delivered at three specific healthcare networks; (2) infrequently seeing patients with excessive alcohol use; (3) a high proportion of PLWH ages 24 and below; (4) a low proportion of the clinic population that were PLWH; (5) a low proportion of Hispanic/Latino patients; (6) and a high number of other medical services available on-site (P < 0.05). This model was found to have a 20.4% reduction in the RMSE and a 335.4% increase in the AR2 value when compared with the literature sourced model (Table 1), indicating greater predictive accuracy and greater explanation of the variability in clinic-level ARV rates.

Conclusion
ARV Rx rates were better predicted by the model adjusting for clinic-level factors previously unreported in the literature including network affiliations, the number of medical services provided, and the proportion of PLWH seen at the clinic. Given the role of ARVs in clinical outcomes, it is important to further explore and address how these clinic-level factors may support or obstruct the prescribing of ARVs in order to support the care of PLWH.

Disclosures
All authors: No reported disclosures.