bluuebunny/crossref_metadata_2025_split huggingface dataset:
430. Impact of a Pharmacist-Managed Sexually Transmitted Disease (STD) Test Result Review Service at a Veterans Affairs Medical Center
Authors: Dayo Yewande , Ashong Chester , Hunter Andrew , Rodriguez-Barradas Maria C 
Published: October 2019

Abstract

Background
The CDC recommends annual STD screenings in all sexually active women ³25 years old and men who have sex with men. Given the increased incidence of STDs and the need to improve their management, in September 2018 infectious diseases clinical pharmacists implemented a pharmacist-managed STD quality improvement project (QI) that reviewed positive STD test results with feedback to providers. We present the results of this QI project below.

Methods
The QI project consisted of prospective, daily reviews of all positive chlamydia, gonorrhea or syphilis tests (post-implementation period: 9/2018 to 2/2019). Patient electronic medical records were reviewed and assessed for the need for additional laboratory tests and to determine whether appropriate treatment was received, with feedback provided to the primary provider. In addition, risk factors were assessed to determine the appropriateness of human immunodeficiency virus (HIV) Pre-Exposure Prophylaxis (PrEP). A retrospective review of positive STD results from 9/2017 to 2/2018 was also conducted (pre-implementation period) for comparison. The purpose of this project was to evaluate the impact of pharmacist test result review on the appropriate testing, review appropriateness of prescribed treatments of patients diagnosed with any STD according to accepted clinical guidelines, and to inform the need for and the areas of focus for educating providers in the emergency room and primary care clinics on the management of these patients. Descriptive statistics, Chi square, and Fisher’s exacts tests were used to analyze the outcomes of the project.

Results
A total of 144 patients were included in the project (pre-implementation, n = 47; post-implementation n = 74). Please refer to the table for other results.

Conclusion
The implementation of a pharmacist-managed STD test review service decreased time to treatment and time to STD test result review. More patients in the post-implementation period received appropriate therapy compared with patients in the pre-intervention period. These findings indicate that there is a role for a pharmacist-managed STD test review service in assisting providers with quickly and appropriately connecting patients to care.

Disclosures
All authors: No reported disclosures.
433. Implementation of an Emergency Department Syphilis Screening Program
Authors: Chechi Tasleem , Sage Allyson C , Tran Nam , Waldman Sarah , May Larissa S 
Published: October 2019

Abstract

Background
Syphilis incidence across all regions of California increased by 22% compared with 2016 cases; with the largest number of chlamydia, gonorrhea, syphilis, and congenital syphilis cases among all states (CDC 2017). The USPSTF recommends targeted syphilis screening in patients at increased risk. However, in emergency departments (EDs) targeted syphilis screening is not routinely performed even when patients present for concerns of a sexually transmitted infection (STI). The purpose of this program was to implement routine syphilis screening among ED patients being tested for chlamydia and gonorrhea (CT/GC) through the use of an EHR enhancement to maximize the number of new syphilis diagnoses.

Methods
From November 27, 2018 to March 31, 2019, EHR-based syphilis screening was implemented in a quaternary care ED in Northern California serving urban and rural populations. EMR best practice alerts (BPA) were developed and populated on patients receiving STI testing. Syphilis testing employed a reverse sequence algorithm, which is suggested for high prevalence settings and provides rapid turnaround time. Patients were excluded if they opted out from testing. We determined the proportion of all CT/GC tested patients who underwent syphilis screening and the prevalence of syphilis among this group.

Results
During a four-month period, 649 ED patients with suspected STI received a BPA to screen for syphilis. Of those, 425 patients (65.5%) were screened for syphilis, 22 had a reactive IgG/IgM and RPR, while 5 patients had a reactive IgG/IgM and a nonreactive RPR which required a TPPA test to detect their infection. Fourteen of the 22 patients with a reactive RPR had titers of 1:32 or higher. Nine (32%) of those with a positive CT/GC test tested positive for syphilis.

Conclusion
Implementation of a syphilis screening program in patients undergoing testing for other STIs yielded 28 new diagnoses compared with those tested prior to the screening in 2018. Introducing an automated EMR-based syphilis screening program is an effective method to maximize syphilis screening in all ED patients seeking treatment for STIs. The screening data suggest that the majority of patients undergoing STI testing in our ED are not screened for syphilis, yet the prevalence of infection in those screened is substantial.

Disclosures
All authors: No reported disclosures.
451. High Rates of Hospitalization due to Skin and Soft-Tissue Infections in a Southwest American Indian Population
Authors: Davidson Anne M , Burgess Terry , Saguros Agafe , Jian Ma Chu , McAuley James , Close Ryan M 
Published: October 2019

Abstract

Background
Skin and soft-tissue infections (SSTIs) involve the skin, subcutaneous tissue, fascia, or muscle. Hospitalizations due to SSTIs represent a significant health disparity for American Indians (AI), but specific literature is limited. We characterized SSTI hospitalizations at our critical access hospital that exclusively serves an AI population in the American Southwest.

Methods
We identified patients hospitalized (admitted or transferred) with an SSTI from June 2017 to May 2018. Relevant cases underwent chart extraction for demographics, SSTI characteristics, laboratory and microbiologic data, relevant history and co-morbidities. All variables were summarized using descriptive statistics. Odds ratios and P-values with two-tailed tests were used to identify risk factors for multiple SSTI episodes.

Results
During the study period, 289 unique individuals comprised 343 SSTI hospitalizations / episodes (18% of the 1,883 total hospitalizations). The unadjusted annual rate of SSTI hospitalization was 2,018 per 100,000. There were 13 cases of necrotizing fasciitis (NF) with an unadjusted rate of 76 per 100,000 per year. Only 183 episodes (53%) had a wound culture performed, with 84% positive for a pathogenic organism, compared with 287 episodes (84%) with a blood culture performed, of which only 7% were positive for a pathogen. Methicillin-resistant Staphylococcus aureus (MRSA), methicillin-sensitive SA (MSSA)and/or Streptococcus pyogenes accounted for 74.9% (n = 125) and co-infection with these three organisms accounted for 22.2% (n = 37) of positive wound cultures (n = 167). An SSTI in the last year (49%), diabetes (41.9%), alcohol abuse (40%) and hypertension (39%) were common among all 289 individuals. Diabetes (OR 3.3, P < 0.01), hypertension (OR 2.8, P < 0.01), renal disease (OR 2.7, P < 0.05), previous SSTI (OR 3.0, P < 0.01) were associated with a higher risk of multiple SSTI hospitalizations.

Conclusion
The incidence rate of SSTI hospitalization in this Southwest AI population was 9-times greater than the general US population and 4-times greater than prior reports in Southwest AI. The NF rate was >10-times the general US population rate. We describe common co-morbidities among these SSTI episodes and potential risk factors for repeat hospitalization.

Disclosures
All authors: No reported disclosures.
454. Perinatal Risk Factors Associated with Skin Infection Hospitalisation in Western Australian Aboriginal and Non-Aboriginal Children
Authors: Barnes Rosanne , Bowen Asha C , Walker Roz , Tong Steven Y C , McVernon Jodie , Campbell Patricia T , Fathima Parveen , de Klerk Nicholas , Wu Yue , Blyth Christopher C , Carapetis Jonathan R , Moore Hannah C 
Published: October 2019

Abstract

Background
Hospitalisation with skin infection in Western Australian (WA) Aboriginal children is common, with the highest rates in infants and children from remote WA. We aimed to quantify infant, maternal, and sociodemographic risk factors for skin infection hospitalization in WA children, focusing on Aboriginal children aged <17 years.

Methods
We conducted a retrospective population-based cohort study with linked perinatal and hospitalization data on WA-born children (1996–2012), of whom 31,348 (6.7%) were Aboriginal. We used Cox regression to calculate adjusted hazard ratios and associated population attributable fractions (PAFs) for perinatal factors attributed to the first hospitalization with skin infection. To identify specific risk factors for early-onset infection, we further restricted the cohort to infants aged <1 year.

Results
Overall, 5,439 (17.4%) Aboriginal and 6,750 (1.5%) non-Aboriginal children were hospitalized at least once with a skin infection. Aboriginal infants aged <1 year had the highest skin infection hospitalization rate (63.2/1,000 child-years). The strongest risk factors in Aboriginal children aged <17 years were socio-economic disadvantage, very remote location at birth and multi-parity (≥3 previous pregnancies) accounting for 24%, 23% and 15% of skin infection hospitalizations, respectively. Other risk factors included maternal age <20 years, maternal smoking during pregnancy and low birthweight.

Conclusion
We have quantified the relative influence of perinatal risk factors associated with skin infection hospitalizations in WA children, providing measures indicating which factors have the potential to reduce the most hospitalizations. Our evidence supports existing calls for substantial government investment in addressing underlying social and environmental barriers to healthy skin in WA Aboriginal children but also identifies potential areas to target health promotion messaging at individuals/families on maternal smoking during pregnancy and skin hygiene for families.

Disclosures
All authors: No reported disclosures.
459. Gaps in Diabetic Foot Care in an Inner-City Hospital
Authors: Schechter Marcos C , Fayfman Maya , SMF. Khan Lubna , Patterson Sierra , Ziemer David , Umpierrez Guillermo , Rajani Ravi , Kempker Russell R 
Published: October 2019

Abstract

Background
Diabetic foot disease is the leading cause of preventable limb loss in the United States. Care continuum models to measure gaps in care are lacking.

Methods
Retrospective cohort study conducted in an urban safety-net hospital in Atlanta, GA (Grady Memorial Hospital). All patients admitted between January-May 2016 with diabetes-related foot ulcer, osteomyelitis, or for lower-extremity amputation were included. A care continuum model for inpatient and post-discharge outpatient metrics was developed based on national guidelines and available diabetes care continuum models (figure). We followed patients for 12 months after initial hospital admission.

Results
Among 123 patients, the median age was 56 (IQR 48–64) years and most were male (67%) and black (83%) (table). Prior to hospital admission, 12% of patients had a major amputation (above ankle) and 21% had a minor amputation (below ankle). Tobacco use (34%), homelessness (29%), and no medical insurance (20%) rates were high. Few patients (28%) had hemoglobin A1c (Hb1Ac) at goal (≤7.5%) and 10% had end-stage renal disease. Regarding inpatient care metrics, 59% had a median glucose at goal on the day of discharge (≤180 gm/dL). Few patient patients had a noninvasive vascular test (13%) or received a wound offloading device (16%) during hospitalization. Regarding post-discharge outpatient metrics, 33% had wound care ≤30 days after hospitalization, 14% with tobacco use at baseline quit, and 24% had Hb1c ≤7.5%. Emergency room (ER) visits and hospital readmissions within 12 months post-discharge were common (77% and 66%, respectively). Only 54% were retained in care (≥2 clinic visits ≥90 days apart). Outcomes during 12 months after the first day of initial hospital admission were poor: 6% died, 23% had a new major amputation and 22% had a new minor amputation. Including major amputations prior to initial hospital admission, 37% of patients died or were living with a major amputation 12 months after hospitalization.

Conclusion
Our care continuum model demonstrated large gaps in diabetic foot care. Over a third of these patients died or were living with major limb loss and there were high rates of ER visits and hospital readmissions. Implementing measures to close gaps in care could improve outcomes.

Disclosures
All authors: No reported disclosures.
466. Elevated Risk of Invasive Group B Streptococcal Infection Among Veterans with Poorly Controlled Diabetes Mellitus or at Extremes for Body Mass Index
Authors: Wilson Brigid , Zappernick Taissa , Banks Richard , Baechle2; Janet Briggs Daniel , Song Sunah , Perez Federico , Jump Robin L 
Published: October 2019

Abstract

Background
Diabetes mellitus (DM) and obesity have been identified as risk factors for invasive Group B Streptococcal (GBS) infection in non-pregnant adults. We used data from the US Veterans Health Administration (VHA) to confirm these findings and determine if poor diabetic control (elevated hemoglobin A1C (HbA1c)) or extreme weight (body mass index (BMI)) impacted risk.

Methods
We examined the VHA Corporate Data Warehouse to identify veterans active in VHA between 2008 and 2017 with invasive GBS infection according to the US Centers for Disease Control and Prevention surveillance definitions. We used International Classification of Disease (ICD) codes to determine a diagnosis of DM and stratified veterans by the highest HbA1c and first BMI in a given year. Absent HbA1c among those with DM were recorded as such. For years without BMI, the most recent BMI was carried forward.

Results
Between 2008 and 2017, the rate of invasive GBS infection for veterans with HbA1C ≥9.5% ranged from 55 to 104 /100,000 person-years (Figure 1). Rates in the next-highest risk group (HbA1c 7.5%–9.4%) were 24 to 36/100,000 person-years. Veterans with a BMI ≥40 (extremely obese; n = 798) or ≤18.5 (underweight; n = 99) had similarly elevated rates of invasive GBS infection (26 to 37/100,000 and 15 to 33/100,000 person-years, respectively) while those with BMI of 18.5–40 ranged from 6 to 13/100,000 person-years (Figure 2). Among those with HbA1c ≥9.5%, the most common type of infection was osteomyelitis (500/1,182; 42%; Table 1). Pneumonia was most common among patients with a BMI, Table 2.

Conclusion
Our study confirms that DM and obesity are notable risk factors for invasive GBS infection among veterans. The risk is substantially increased in patients with poorly controlled DM and morbid obesity. The high rate of invasive GBS infections among the small proportion of underweight veterans may reflect long-standing type 1 DM or other chronic diseases. Effective interventions to reduce the burden of invasive GBS infection among veterans should target individuals with poorly controlled DM, morbid obesity and those markedly underweight.

Disclosures
All authors: No reported disclosures.
484. Metallo-β-Lactamase-Positive Carbapenem-Resistant Enterobacteriaceae and Pseudomonas aeruginosa in the Antibiotic Resistance Laboratory Network, 2017–2018
Authors: Brown Allison C , Malik Sarah , Huang Jennifer , Bhatnagar Amelia , Balbuena Rocio , Reese Natashia , Lonsway David , Karlsson Maria 
Published: October 2019

Abstract

Background
Infections with metallo-β-lactamase (MBL)-producing organisms are emerging in the United States. Treatment options for these infections are limited. We describe MBL genes among carbapenemase positive carbapenem-resistant Enterobacteriaceae (CP-CRE) and Pseudomonas aeruginosa (CP-CRPA) isolates tested during the first two years of the Antibiotic Resistance Laboratory Network (AR Lab Network).

Methods
State and local public health laboratories tested CRE and CRPA isolates for organism identification, antimicrobial susceptibility, and PCR-based detection of blaKPC, blaNDM, blaOXA-48-like, blaVIM, and blaIMP carbapenemase genes. All testing results were sent to CDC at least monthly.

Results
Since January 2017, the AR Lab Network tested 21,733 CRE and 14,141 CRPA. CP-CRE were detected in 37% of CRE; 2% of CRPA were CP-CRPA. Among CP-CRE, 9% (686/8016) were MBL-producers (NDM, VIM, or IMP). Among MBL-producers, a blaNDM gene was detected most often (81%; 551/686). blaNDM were most common among Klebsiella spp. (47%; 261/551), blaIMP were most common among Providencia spp. (53%; 40/75), blaVIM was most common among Enterobacter spp. (19%; 25/62). Twelve percent (96) of MBL CP-CRE contained more than one carbapenemase gene. Among CP-CRPA, 73% (218/300) were MBL producers and blaVIM was the most common gene (62%; 186). Three (1%) MBL CP-CRPA contained more than one carbapenemase.

Conclusion
Increased testing of CRE and CRPA isolates through the AR Lab Network has facilitated early and rapid detection of hard-to-treat infections caused by MBL-producing organisms across the United States. The widespread distribution of MBL genes highlights the continued need for containment strategies that help prevent transmission between patients and among healthcare facilities. To support therapeutic decisions for severe infections caused by MBL-producing organisms, the AR Lab Network is now offering rapid susceptibility testing against aztreonam/avibactam, using digital dispenser technology. This testing program aims to close the gap between the availability of new drugs or drug combinations and the availability of commercial AST methods, thereby improving patient safety and antimicrobial stewardship.

Disclosures
All authors: No reported disclosures.
493. Laboratory Evaluation and Epidemiology of Carbapenemase-Producing Carbapenem-Resistant Enterobacteriaceae in Department of Veterans Affairs, 2017
Authors: Pfeiffer Christopher , Williams Holly B , Flegal Hannah , Klutts J Stacey , Evans Martin , Evans Martin , Jones Makoto M 
Published: October 2019

Abstract

Background
Carbapenemase-producing (CP)-carbapenem-resistant Enterobacteriaceae (CRE) pose a major threat to public health and are a priority target of national prevention and control efforts including within Department of Veterans Affairs (VA). The laboratory evaluation and epidemiology of CRE in VA is uncertain.

Methods
Using data from the Veterans Health Administration Corporate Data Warehouse, we identified all Veterans with ≥1 CRE result obtained during 2017 and reviewed their electronic health record. Two case definitions were used: (1) 2015 CDC CRE (Enterobacteriaceae resistant to any carbapenem or with documented carbapenemase production) and (2) 2017 VA CP-CRE (E. coli, Klebsiella spp., and Enterobacter spp. resistant to imipenem, meropenem, or doripenem or with documented carbapenemase production). Patients harboring carbapenemase-producers detected by rectal screening tests only were included. We reviewed patient charts whose isolates met both CRE definitions, extracting detailed microbiologic and travel data for the first positive 2017 result.

Results
We identified 904 unique Veterans with CRE; 577 (64%) patients had results meeting both CRE case definitions while 327 (36%) had results meeting CDC CRE criteria only (Figure 1). Of the 458 patients with clinical isolates meeting both case definitions, urine specimens predominated (64%) and were associated with the lowest crude 90-day mortality (16%); mortality was highest amongst patients with respiratory tract cultures (40%) and bloodstream isolates (34%) (Figure 2). Nearly half (48%) of VA CP-CRE were tested for carbapenemases (76% in-house; 24% send-out); of these, 75%tested positive with 78% being a KPC, 1% NDM, and 21% unspecified (Figure 3). Additionally, all 119 CRE carriers with an identified gene had KPC. Only 7 patients (1%) had documented overseas travel.

Conclusion
Currently the incidence of CP-CRE in the nation’s largest healthcare system is low relative to other problem pathogens such as MRSA and Clostridioides difficile but is associated with a high crude mortality especially with respiratory and bloodstream isolates. KPC comprised almost all carbapenemases identified. This provides an initial, granular snapshot of CRE in VA to serve as a roadmap for ongoing CP-CRE prevention and control.

Disclosures
All authors: No reported disclosures.
498. High Burden of CRO Colonization and Its Association with Infection Among Patients transferred to a Tertiary Care Hospital in India
Authors: Sarma Smita , Robinson Matthew , Mehta Yatin 
Published: October 2019

Abstract

Background
Infections with carbapenem-resistant organisms (CRO) are increasing worldwide and are associated with high mortality. Patients transferred from outside hospitals have been reported to be at increased risk of CRO colonization and infection. The rate of subsequent CRO infection in patients colonized with CRO is unclear in a high CRO burden setting

Methods
Medanta Hospital in Gurgaon, India instituted CRO colonization screening for patients transferred from outside hospitals for infection control purposes. From April 2018 to May 2018, patients transferred from other hospitals to the intensive care unit at Medanta were subjected to CRO colonization screening using Xpert Carba R (Cepheid) performed on the day of transfer. Subsequent recovery of CRO in cultures of blood, bronchoalveolar lavage fluid, urine in specimens with pyuria obtained from patients without urinary catheters, pus, and tissue were considered to be indicative of CRO infection. The association of CRO colonization with subsequent CRO infection was assessed with a Fisher exact test

Results
Among 457 patients screened, 205 patients (45%) were found to be colonized with CRO at admission. Genes for New Delhi Metallo-β-lactamase (NDM) were detected in 184 (40%) patients, OXA-48 in 97 (21%) patients, VIM in 18 (4%) patients, KPC in 5 (1%) patients, and IMP1 in 5 (1%) patients; >1 carbapenemase gene was detected in 95 (21%) patients. CRO infections were observed in 25 (5%) patients including 12 with bacteremia, 7 with pneumonia, 4 with urinary tract infection, and 2 with soft-tissue infection. Among patients with CRO colonization, 17 (8%) patients developed CRO infection during the course of hospitalization; among patients without admission CRO colonization, subsequent CRO infection was found in 8 (3%) patients. CRO admission colonization was associated with subsequent clinical infection with CRO (odds ratio = 2.8, P = 0.02)

Conclusion
CRO colonization was found in almost half of patients transferred from outside hospitals to a large tertiary care hospital in India and was associated with subsequent CRO infection. Further work is necessary to understand the role of CRO colonization screening in infection control and antimicrobial stewardship in a setting with high CRO burden

Disclosures
All authors: No reported disclosures.