bluuebunny/crossref_metadata_2025_split huggingface dataset:
582. Safety and Efficacy of High-Dose Ganciclovir versus Standard Dosing for Cytomegalovirus Viremia in Solid Organ Transplant (SOT) Recipients
Authors: Fitzmaurice Mary Grace , Srinivas Pavithra , Eckardt Jamie , Koval Christine , Koval Christine , Lum Jessica 
Published: January 2021

Abstract

Background
Standard dose ganciclovir (SD-GCV) for treatment of CMV infection/disease is 5 mg/kg every 12 hours, although higher doses (7.5–10 mg/kg every 12 hours) may be considered for resistant CMV. Literature on safety/efficacy of high dose GCV (HD-GCV) is limited. We sought to evaluate safety and clinical outcomes of SD-GCV vs HD-GCV strategies.

Methods
Retrospective single center study of adult SOT recipients with CMV viremia from 1/1/2017-1/31/2019 who received IV GCV therapy. Primary objective was to compare incidence of cytopenias between SD-GCV and HD-GCV. Secondary outcomes compared CMV viremia clearance, incidence of CMV disease and recurrent viremia within 30 days, granulocyte colony stimulating factor (G-CSF) use, and antiviral resistance testing rates.

Results
We evaluated 121 patients: 74 received SD-GCV, 47 received HD-GCV. Baseline characteristics were similar between groups. Most patients received a liver transplant (46% SD vs 36% HD) and had D+/R- CMV serostatus (55.4% SD vs 68% HD). Induction immunosuppression occurred in 75%, mostly with anti-thymocyte globulin. Median baseline CMV viral loads were similar (4620 IU/mL SD vs 7770 IU/mL HD, p=0.25).
Incidence of cytopenias was similar between groups: leukopenia (43% SD vs 43% HD, p=0.96), neutropenia (15% SD vs 13% HD, p= 0.75), thrombocytopenia (24% SD vs 31% HD, p=0.62). HD-GCV did not significantly impact CMV clearance (HR: 0.79 [95% CI 0.52–1.21], p=0.27). There was no difference in incidence of CMV disease (35% SD vs 38% HD, p=0.72) or incidence of recurrent CMV viremia (15% SD vs 28% HD, p=0.098).
G-CSF requirement was not different (23.7% SD vs 14.3% HD, p=0.295), however, patients on HD-GCV received more doses of G-CSF (median 2 SD vs 5 HD, p=0.001). More patients in HD-GCV group were tested for antiviral resistance: 15 (21%) SD vs 20 (43%) HD, p=0.01. Of these, there was no difference in rate of resistance detection (7/15 (47%) SD vs 11/20 (55%) HD, p=0.95).

Conclusion
Therapy with HD-GCV did not demonstrate increased incidence of cytopenias compared to SD-GCV, nor did we observe improved time to CMV clearance or incidence of CMV disease between groups. Opportunities exist for improving stewardship of antiviral resistance testing and use of G-CSF when considering HD-GCV therapy.

Disclosures
All Authors: No reported disclosures
583. Successful prevention of Strongyloides reactivation in liver transplant recipients with individualized screening and treatment: 10 year experience at a large transplant center in New York City
Authors: Rahman Farah , Taimur Sarah , Gitman Melissa R , Dunn Dallas , Baneman Emily , Fuller Risa , Jacobs Samantha E , Rana Meenakshi , Sullivan Timonthy 
Published: January 2021

Abstract

Background
Strongyloides stercoralis is an intestinal nematode that can establish chronic, asymptomatic infection in human hosts. Following solid organ transplantation, subclinical infection may progress to hyperinfection syndrome, which is associated with high morbidity and mortality. However, the optimal approach for screening and treatment of strongyloidiasis in liver transplant candidates in non-endemic areas is unknown.

Methods
We performed a retrospective chart review of all liver transplant (LT) recipients from 2010–2019. All patients were evaluated by an infectious diseases physician prior to transplant, and screening for Strongyloides exposure (with Strongyloides IgG antibody) was typically limited to those with risk factors for strongyloidiasis. Only patients with positive serologic testing or other evidence of strongyloidiasis were treated with ivermectin.

Results
One thousand and seventy-two LT cases (including 15 retransplants) were reviewed. Serologic testing was perfomed in 664 cases, of which 36 (5.4% of those tested, 3.4% of total) were positive. Of the 36 cases with positive serologic testing, 31 had identifiable risk factors including birth place, travel or eosinophilia. Eosinophilia (defined as peripheral eosinophila greater than 5%) was noted in 3 of the 36 recipients who had positive serology.
Of the total 36 cases with positive serology, 18 were treated both pre- and post-transplant, 7 were treated only pre-transplant and 9 were treated only post-transplant. One patient died prior to initiating treatment, and one did not have documented treatment. One patient with negative serologic testing was empirically treated due to persistent eosinophilia. There was one case of Strongyloides hyperinfection due to likely donor-derived infection. There were no cases of Strongyloides reactivation in the study cohort.

Conclusion
This study demonstrates that an individualized screening and treatment protocol can effectively prevent Strongyloides reactivation in LT recipients. Given the high mortality rate of Strongyloides hyperinfection, especially in solid organ transplant recipients, a methodical assessment of epidemiologic risk is essential for appropriate risk stratification and management of Strongyloides in LT candidates.

Disclosures
All Authors: No reported disclosures
585. A Cost-Effective Implementation Reducing The Number Of Urine Cultures In An Acute Care Community Hospital
Authors: Jain Rohit , Sahu Nitasa , Marsh Denise , Raines Shannon , Jones Kirk , Vunnam Ramarao , Bhatt Dhirisha , Golamari Reshma , Hussein Rezhan 
Published: January 2021

Abstract

Background
Asymptomatic bacteriuria is a common finding in hospitalized patients. This is defined as bacteriuria of ≥105 colony-forming units (cfu) per mL without any genitourinary signs or symptoms. Treatment for such leads to increased antimicrobial resistance and is especially common in the inpatient setting. One study showed a lack of appropriate clinical indication to order a urinalysis in more than half of the patients. In order to expedite a patient’s care, it is common to order a urinalysis and urine culture together and await the results. One study evaluated the impact of changing the order set in inpatients and yielded a 45% reduction in the urine cultures ordered and cost savings as high as $103,845. Reflex testing is used to facilitate effective and efficient patients care while remaining compliant with state and federal regulations in the ordering of lab test.

Methods
Starting October 25, 2019, the electronic medical record order set was changed so there were only 2 options from the previous 9 options. The modified options included a “Urine analysis with reflex culture” and “Urine analysis with microscopy.” The reflex was not encouraged to be used for those who were pregnant, neutropenic, or had any evidence of immunocompromise.

Results
Following the implementation of this initiative in October 2019, there was a decrease in overall urine culture cost. From Jan 2019 to September 2019, the cost ranged between $13428.96 to $15157.44/month in the Emergency Department. On the inpatient side, it ranged between $5141.12 to $6559.36/month. After revision of the new order set, the ED cost had dropped to as low as $5672.96/month and $3811.52/month for inpatients. This is a cost reduction of approximately $9484.48 and $2747.84 for the ED and inpatient, respectively.The total number of cultures also reduced from an average of 326/month in the ED to 193/month. The inpatient number of cultures dropped from an average of 130/month to 102/month.

Conclusion
Modifying the process of urine culture ordering has significantly cut down cost for both the hospital and patient. With clear education and modification of the electronic medical record, such interventions can dramatically improve the unnecessary testing for UTI’s.

Disclosures
All Authors: No reported disclosures
586. Classification of patients with sepsis according to immune cell characteristics: a bioinformatic analysis of two cohort studies
Authors: Zhang Shi 
Published: January 2021

Abstract

Background
Sepsis is well known to alter innate and adaptive immune responses for sustained periods after initiated by an invading pathogen. Identification the immune cell characteristics may shed light on the immune signature of patients with sepsis and further appropriate immune-modulatory therapy for distinct population. Therefore, we aimed to establish an immune model to classify sepsis into different immune endotypes via transcriptomics data analysis of previous published cohort studies.

Methods
Datasets from two observational cohort studies that included 585 consecutive sepsis patients admitted to two intensive care units were downloaded as training cohort and external validation cohort. We analyzed genome-wide blood gene expression profiles from these patients by machine learning and bioinformatics.

Results
The train cohort and the validation cohort had 479 and 106 patients respectively. Principal component analysis indicated that two immune sub-phenotypes for sepsis, designated immunoparalysis endotype and immunocompetent endotype could be distinguished clearly. In the train cohort, the worse prognosis was found in patients classified as immunoparalysis endotype and its hazard ratio is 2.32 (95% CI: 1.53 to 3.46 vs immunocompetent endotype). External validation furthermore demonstrates that present model could categorize sepsis into immunoparalysis and immunocompetent status precisely and efficiently. The percentage of 4 immune cells (Macrophages M0, Macrophages M2, B cells naïve, T cells CD4 naive) were found that associated with 28-day cumulative mortality significantly（P &lt; 0.05）.

Conclusion
The present study developed a comprehensive tool to identify immunoparalysis endotype and immunocompetent status in sepsis be hospitalized and provides novel clues for further targeting of therapeutic approaches.

Disclosures
All Authors: No reported disclosures
592. A Pilot Program to Evaluate Home Telemedicine Visits in an OPAT Program
Authors: Sheridan Kathleen R , Wingfield Josh , Clouse Natalie 
Published: January 2021

Abstract

Background
Outpatient parenteral antimicrobial therapy (OPAT) is a well-established and effective way of delivering and monitoring patients requiring long-term IV antibiotics1-2. OPAT follow-up appointments are typically in-office appointments. There is limited to no data regarding readmission rates and outcomes of OPAT patients that had home audio-visual (AV) telemedicine (TM) follow-up appointments3.
Our OPAT Program began in December 2013 and serves a major academic Level 1 trauma center as well as several smaller community hospitals within our health system. The OPAT team is a multidisciplinary team consisting of ID Physicians, Nurse Practitioners, Pharmacist, Nurses and a Coordinator. Historically, we have evaluated patients in the office within 1-2 weeks of hospital discharge and just prior to antibiotic completion. However, there are several barriers to visit completion including lack of transportation, lack of perceived benefit of appointment by the patient, and other mobility issues. In July 2019, we began a pilot program of offering home AV TM visits.

Methods
We conducted a retrospective chart review of commercially insured OPAT patients discharged to home from UPMC Presbyterian from July 2019 to February 2020 that had home AV TM visits. We evaluated 30-day readmission rates and complication rates.

Results
13 OPAT patients had a telemedicine video visit.. Patient demographics are listed in Table 1. 8 patients were female. The average age of the patients was 54 (range 35-75). 10 of the 13 (77%) patients were treated for osteomyelitis or septic arthritis. 9 of the 13 (69%)patients received a beta-lactam. 4 patients were readmitted, 3 had an ER visit and 1 patient had a PICC line complication (rash). (Figure 1). Half of the readmissions were due to non-infectious causes (OB delivery & pacemaker placement). 2 patients were readmitted due to ongoing infection but only one of these patients had a home TM appointment before their readmission. The other patient’s visit occurred after their readmission. Reasons for ER visits were PICC malfunction, dysuria, and syncope.
Patient Demographics

Clinical Outcomes

Conclusion
Home Telemedicine video visits could be an alternative to in-office appointments for OPAT patients. More studies should be done to evaluate this visit modality.

Disclosures
All Authors: No reported disclosures
593. Additional medical expenditures attributable to pneumococcal disease in Japan
Authors: Fukuda Haruhisa 
Published: January 2021

Abstract

Background
Japan requires a reexamination of its current vaccination policies to reduce the prevalence of pneumococcal disease (PD). Although the decision-making process for vaccination programs must be informed by cost-effectiveness analyses, the lack of cost data from Japan precludes such investigations. This study was therefore performed to quantify the medical expenditures attributable to PD in Japan.

Methods
The study was conducted using surveillance data from the Japan Nosocomial Infections Surveillance (JANIS) program’s Clinical Laboratory Division and insurance claims data under the Diagnosis Procedure Combination (DPC) system. Data from April 2015 to September 2017 were obtained from 145 hospitals throughout Japan. As the analysis focused on community-acquired infections, the medical expenditures incurred during the PD hospitalization episodes directly represented the additional expenditures attributable to these infections. The descriptive statistics of the medical expenditures (mean, standard deviation, median, and interquartile range) incurred by the PD cases were calculated from the linked JANIS data and DPC data. In addition, these descriptive statistics were also generated according to the presence/absence of IPD and age groups.

Results
The study sample comprised 1,689 PD cases from 29 hospitals during the study period. Of these, 77 were IPD cases and 1,612 were non-IPD cases. The mean medical expenditures (standard deviation) for all PD cases, IPD cases, and non-IPD cases were estimated to be 1,016,801 yen (1,704,067 yen), 1,660,477 yen (2,078,667 yen), and 986,055 yen (1,678,705 yen), respectively. In addition, the medical expenditures associated with patients aged 60–64 years (1,646,739 yen) and 65 years or older (1,646,286 yen) were substantially higher than those of younger patients aged 5–59 years (1,424,105 yen).

Conclusion
These estimates have applications in cost-effectiveness analyses of PD preventive measures, which can subsequently inform and guide national vaccination policies.

Disclosures
Haruhisa Fukuda, n/a, Pfizer Japan Inc. (Scientific Research Study Investigator)
594. Characteristics of an At-Risk Patient Population Presenting to a Philadelphia Student-Run Free Clinic within 30 Days of Hospital Visit
Authors: Thomesen Kaitlyn , Lipow Matthew , Munoz Tess S , Schultz Sara K 
Published: January 2021

Abstract

Background
30-day readmission rates are the parameter that hospitals and insurance companies use to measure clinical quality of care and set reimbursement levels for care (McCormack, et al., 2013). The 2019 readmission rate for United States hospitals was 14.9%; however, reported readmission rates vary in accuracy due to exclusion of at-risk populations or patients who seek care outside the hospital network (America’s Health Rankings, 2020; Gupta, et al., 2018). As coordinators of a student-run urgent care clinic operating within a Philadelphia syringe exchange and harm-reduction social services organization, we serve an at-risk patient population that includes a large portion of individuals who are transiently housed, people who engage in sex work, and people who use drugs (PWUD). We sought to determine our at-risk population’s impact on current readmission rates and the ability of hospitalization to meet their unique medical needs.

Methods
We conducted a retrospective review of 607 electronic charts for patients who sought care at our student run clinic associated with a syringe exchange in Kensington, Philadelphia from January 2017 to January 2020, and identified patients who visited our clinic within 30 days of self-reported hospitalization. We identified time since hospitalization, purpose for hospitalization, and reason for clinic visit.

Results
Of 607 visits, 100 (16.5%) self-reported hospitalization within 30 days clinic presentation. Of these 100 clinic visits, 64% presented with the same chief complaint as their reason for hospitalization, and 21% presented with a complication related to their hospital visit. 33% of visits associated with previous hospitalization were from infections associated with IV drug use, including abscess, cellulitis, and osteomyelitis. On average, patients presented 7.5 days following hospital departure.

Conclusion
We identified a high incidence of clinic visits for medical needs associated with recent hospitalization, particularly injection-related infection, which suggests insufficient hospital care for this at-risk population. The number of readmissions for this population is underestimated due to their ability to seek medical care outside of the hospital network.

Disclosures
All Authors: No reported disclosures
605. Factors Underlying Antifungal Price Trends in the United States
Authors: Thomas Christine , Shae Whitney , Koestler Devin , DeFor Terese , Bahr Nathan , Alpern Jonathan 
Published: January 2021

Abstract

Background
Antifungal drugs are used to treat conditions ranging from topical dermatologic disease to life-threatening systemic infections. Given their widespread use, understanding factors that affect antifungal pricing will help clinical and policy-related decisions. The purpose of this study was to identify factors associated with price trends among antifungal drugs.

Methods
Antifungal drug products available in the United States were identified using the Food and Drug Administration (FDA) Orange Book database. Multiple characteristics related to how a drug may be priced were identified using a variety of sources, including the number of FDA indications (IBM Micromedex), quantity of professional guideline recommendations and use as prophylaxis (Infectious Diseases Society of America guidelines for treatment of fungal infections), and route of administration. Wholesale acquisition cost per unit was identified for each drug from the first date listed through 2019 using the Medi-Span and First Databank databases. Statistical analysis was performed using R (version 3.6.3). Price trajectories over time observed on 138 antifungal drugs were clustered into three groups by the shape of their trajectory using the R package KmlShape (Genolini 2016). Clusters were characterized by stable prices, moderate price increases, and extreme price increases over time. Relationships between cluster membership and drug characteristics were assessed using Fisher’s Exact Test and Likelihood Ratio Tests. All tests were conducted at the 5% level of significance.

Results
The majority (n=116) of antifungal drugs were characterized by moderate price increase and an additional n=6 exhibited extreme price increases over time. Few (n=16) were stable. Associations were identified between drug characteristics and extreme price increase cluster membership. These included a fewer number of FDA indications (p=0.0028) and atypical route of administration (p=0.0025). No association was identified between cluster membership and quantity of guideline recommendations, or use as prophylaxis.

Conclusion
Nearly 90% of antifungal drugs exhibited at least moderate price increases over time. Extreme price increases were associated with a fewer number of FDA indications and atypical route of administration.

Disclosures
All Authors: No reported disclosures
608. Impact of Implementing Pharmacist Review and Monitoring of Outpatient Parenteral Antimicrobial Therapy
Authors: Kirkpatrick Emily R , Hand Elizabeth O , Hughes Darrel W , Badwal Jasmin K , Traugott Kristi A 
Published: January 2021

Abstract

Background
Given current efforts to increase the safety of outpatient parenteral antimicrobial therapy (OPAT) programs nationwide, this project sought to determine whether pharmacist managed OPAT review and monitoring improves adherence to standard of care laboratory monitoring recommendations.

Methods
A single-center, retrospective review of patients &gt; 18 years of age who received OPAT from University Health System was conducted. Patients who received OPAT between October 2018 and December 2018 served as the historical control group. After a pharmacist transitions of care program was implemented, patients who received OPAT between October 2019 and December 2019 were included in the intervention group. Patients were excluded if they received less than 7 days of OPAT, completed therapy prior to discharge, or died while inpatient. The primary endpoint was adherence to laboratory monitoring recommendations &gt; 75% of the duration of planned OPAT. Only patients followed by the OPAT clinic were included in this analysis. Recommendations provided in the 2018 Infectious Diseases Society of America OPAT guidelines were used to define appropriate lab monitoring. Secondary endpoints included 30-day readmissions.

Results
A total of 409 patients were included in this study: 198 patients in the pre-implementation group and 211 patients in the post-implementation group. In patients with OPAT clinic follow-up, the post-implementation group was significantly more likely to receive monitoring adherent to standard of care laboratory monitoring recommendations &gt; 75% of the duration of planned OPAT: 42/161 (26.1%) vs. 98/176 (55.7%), OR 3.6 (95% CI 2.2-5.6, p = 0.0001). There was no difference in 30-day readmission rates between groups in the overall population. Patients in the post-implementation group with OPAT clinic follow up had lower 30-day infectious disease-attributed readmissions: 18/161 (11.2%) vs. 14/176 (8.0%), p = 0.31.

Conclusion
Implementation of a transitions of care pharmacist significantly improved adherence to laboratory monitoring recommendations for patients receiving OPAT and numerically reduced 30-day infectious disease-attributed readmissions.

Disclosures
All Authors: No reported disclosures