bluuebunny/crossref_metadata_2025_split huggingface dataset:
195. Duration of Therapy for Streptococcal Bacteremia
Authors: Boulos John M , Fabre Valeria , Dzintars Kate , Dzintars Kate , Jones George , Cosgrove Sara E , Cosgrove Sara E , Bernice Fidelia , Tamma Pranita , Tamma Pranita 
Published: December 2021

Abstract

Background
Shorter durations have shown similar clinical outcomes as longer durations for uncomplicated (source-controlled) Gram-negative bloodstream infections (BSI). There is limited data on the outcomes of patients with non-pneumococcal streptococcal BSI receiving shorter durations of therapy compared to usual durations.

Methods
This was a retrospective, multicenter study of adults hospitalized between January 2018 and March 2019 with ≥ 1 blood culture positive for Streptococcus spp. Exposed patients were those who received ≤ 10 days of antibiotics (i.e., short course therapy) and unexposed patients were those who received 11-21 days of antibiotics (i.e., prolonged course therapy). Patients were excluded if they had S. pneumoniae BSI, suspected contamination, did not receive or complete therapy, or treated for &gt; 21 days. The primary outcome was a composite of recurrent bacteremia with the same pathogen, hospital readmission, or all-cause mortality, all within 30 days from completing therapy. The odds of achieving the primary outcome was compared between exposed and unexposed patients using multivariable logistic regression analysis.

Results
A total of 176 patients met eligibility criteria. 35 (20%) received a short course (median 8 days) and 141 (80%) received a prolonged course (median 15 days) of antibiotic therapy. Baseline characteristics were similar between short and long course groups. The most common pathogens were viridans group streptococci (22%) and S. agalactiae (23%). The most common BSI source was skin and soft tissue infection (SSTI) (40%). The primary outcome occurred in 26% (9/35) and 23% (33/141) of patients in the short course and prolonged course groups, respectively (p = 0.774). The proportion of patients in the short course and prolonged course groups who experienced recurrent BSI, hospital readmission, or all-cause mortality were also non-significant. After adjusting for receipt of an infectious diseases consult, Pitt bacteremia score, and SSTI source, the adjusted odds of meeting the composite outcome remained unchanged (aOR 1.41, 95% CI 0.55 – 3.61, p = 0.466).
Table 1. Cohort Characteristics

Table 2. Source/Microbiology

Table 3. Outcomes

Conclusion
Approximately a week of antibiotic therapy may be associated with similar clinical outcomes as longer antibiotics courses in patients with uncomplicated streptococcal BSI.

Disclosures
Kate Dzintars, PharmD, Nothing to disclose Sara E. Cosgrove, MD, MS, Basilea (Individual(s) Involved: Self): Consultant Pranita Tamma, MD, MHS, Nothing to disclose
198. Evaluation of Oral Step-down versus Continued Intravenous Antimicrobial Therapy in Immunocompromised Patients Hospitalized with Gram-Negative Bacteremia
Authors: Savage Heather , Vu Catherine H , Mitchner DeMaurian , Zaki Amir 
Published: December 2021

Abstract

Background
Bloodstream infections are associated with considerable morbidity and mortality in the United States. Most patients initially receive parenteral antibiotics for gram-negative bacteremia, and more data is emerging supporting de-escalation to oral (PO) antibiotics to complete treatment. Previous studies evaluating PO antibiotics for gram-negative bacteremia often exclude or have underrepresented immunocompromised patients. This study evaluated clinical failure in immunocompromised patients receiving intravenous (IV) antibiotics compared to patients transitioned to PO antibiotics for gram-negative bacteremia.

Methods
A single center, retrospective cohort study was conducted at 446-bed academic medical center. Patients were included if they were immunocompromised and admitted with a positive blood culture for E. coli, Klebsiella spp., Citrobacter spp., Serratia spp., Enterobacter spp., Proteus spp., P. aeruginosa. between November 4, 2017 to November 4, 2020. Patients were excluded from this study if they had polymicrobial bacteremia, no source control within the first 5 days, or an indication for prolonged duration of treatment. The primary endpoint of this study was clinical failure defined as an escalation from PO to IV antibiotics, worsening clinical status, or readmission for the same infection within 30 days of discharge. The secondary endpoints included 30-day mortality, 90-day mortality, 30-day readmission, and time to microbiologic clearance.

Results
A total of 31 immunocompromised patients were included in the study with 26 patients receiving PO step-down therapy and 5 patients being continued on IV treatment for gram-negative bacteremia. There was no difference in the primary outcome of clinical failure between the PO step-down group versus the IV therapy group (15.4% vs 20%; p = 0.613). The most common immunocompromised state in both groups was being HIV positive. Patients in the PO step-down group had a significantly shorter hospital length of stay (7.4 days vs. 13.6 days; p = 0.016).

Conclusion
Oral step-down therapy for gram-negative bacteremia showed similar clinical failure rates to continuous IV therapy in the immunocompromised patient population and may be an option to shorten hospital length of stay.

Disclosures
All Authors: No reported disclosures
222. Clinical and Microbiological Characteristics of Common Bacterial Bloodstream Infections in the US Military Health System
Authors: Vostal Alexander C , Grance Melissa , Chukwuma Uzo , Morales Carlos , Lanteri Charlotte , Poitras Beth , Parmelee Edward , Powers John H , Mende Katrin 
Published: December 2021

Abstract

Background
Bloodstream infections (BSI) are associated with inpatient morbidity in the United States. We sought to characterize the epidemiology of common bacterial BSIs in individuals receiving care within the US Military Health System (MHS), which actively prospectively captures clinical and microbiological data from both retired and active-duty US Uniformed Service members and their beneficiaries.

Methods
We performed a retrospective cohort study analyzing MHS patients with blood cultures positive for all bacterial pathogens, between January 2010 and December 2019. Microbiological data captured by the Navy and Marine Corpse Public Health Center, excluding cultures isolating contaminants, were retrospectively collated with clinical and demographic data from the MHS Data Repository.

Results
The most frequent nine bacterial pathogens, as well as Acinetobacter spp. represented 17,206 episodes of BSI from 14,531 individuals. The cohort was predominantly male (59.4%) and ≥65 years old (48.7%). Most individuals were retired (N=5,249) or active duty (N=1,418) service members and their dependents (N=5,236). Median Updated Charlson Comorbidity Index Score was 2. Chronic pulmonary disease was the most frequent comorbid condition. Hospital admission was associated with 13,733 (79.8%) BSI episodes, including 5,870 admissions to the ICU. Overall, inpatient mortality was 8.3%. E. coli (29.7%, N= 5,114) was isolated with the highest frequency, followed by S. aureus (22.4%, N=3,853). Further, 9.5% of E. coli and 36.9% of S. aureus isolates were resistant to ceftriaxone and oxacillin, respectively. Beta-hemolytic streptococci represented the highest percentage (6.3%) of recurrent BSI episodes occurring at least 14 days post-initial BSI. Males or Native American race were most commonly infected with S. aureus. E. coli BSI was most common in all other demographic categories.
Frequency of Bacterial Blood Stream Infections in the US Military Health System

The most frequent nine bacterial pathogens, as well as Acinetobacter spp. in the US Military Health System.

Conclusion
We assessed the epidemiologic features of all individuals with BSI receiving care in the MHS over a 10-year period. We noted demographic differences in the occurrence of microbiological causes of BSI including S. aureus. Further assessments are underway into BSI-related risk factors for occurrence, antimicrobial resistance and mortality, after controlling for comorbidities and disease severity.

Disclosures
All Authors: No reported disclosures
244. Risk Factors Associated with Complications/Sequelae in Pediatric Patients with Osteomyelitis
Authors: Aguilar Gómez Nancy Evelyn , Atri Aaron Espinosa , Santamaría Vásquez Rafael Oscar , Andrade Alejandra Aquino , Vera Isabel Medina , Alonso Oscar Daniel Isunza , Simental Leonor Patricia Saltigeral 
Published: December 2021

Abstract

Background
Osteoarticular infections are serious invasive pathologies in the pediatric population. They have high morbidity, especially if antimicrobial treatment is inadequate and late. Based on pediatric series patients with osteomyelitis require prolonged antibiotic schemes, long stay and high hospital costs, multiple surgical procedures and develop short and long-term sequelae.

Methods
A retrospective, observational, longitudinal and analytical study was conducted in patients under 17 years of age diagnosed with osteomyelitis at the National Institute of Pediatrics from January 2009 to January 2019. Demographic information, clinical presentation, microbiological, treatment and six-month follow-up were recorded.

Results
A total of 109 patients were included, 57 (52%) males with median age of 98 (1-205) months with predominance in previous healthy (66%). By temporality, the chronic form predominated in 72%. The history of trauma was identified in 26% and fracture 19%. The most affected bone was femur 26%. Blood culture was performed in 55%, secretion culture in 52.2% with isolation in 56%. Methicillin-susceptible Staphylococcus aureus (MSSA) was the main agent identified. Complications occurred in 37%, the most frequent was surgical wound infection in 13% followed by fracture 11%. Risk factors for complications were chronic osteomyelitis RR 5.7 (CI 1.8-17.9), Sepsis/Shock RR 3.8 (CI 1.08-13-8) and MSSA infections RR 2.7 (CI 1.01-7.5); Risk factors for surgical site infection included initial fracture RR 3.5 (CI 1-11), local ulcer RR 4.2 (CI 1.3-13.06) and MSSA infection RR 5.9 (CI 1.8-19.4). Risk factors for limitation to movement included chronic osteomyelitis RR 4.87 (CI 1.6-14), fever RR 2.5 (CI 1.15-5.5), Sepsis/shock RR 5.3 (CI 1.3-20) (p 0.013) and MSSA infection RR 4.1 (CI 1.4-11.9).

Conclusion
Osteomyelitis is still a health problem in our country. The diagnosis of osteomyelitis may be challenging as lack of suspicion often leads to delayed diagnosis. Knowledge of the risk factors for complications in pediatric patients could be useful to give early and proper antibiotic and surgical treatment. It is a priority to have a multidisciplinary team for the diagnosis and treatment of osteoarticular infections.

Disclosures
All Authors: No reported disclosures
246. Particularities of Non-axial Osteoarticular Tuberculosis Among Adults
Authors: Hammami Fatma , Koubaa Makram , Chakroun Amal , Rekik Khaoula , Marrakchi Chakib , Smaoui Fatma , Jemaa Mounir Ben 
Published: December 2021

Abstract

Background
Osteoarticular tuberculosis (TB) represents 1% to 3% of all TB cases, among which spondylodiscitis is the most common presentation of the disease. Non-axial TB is less frequent. We aimed to study the clinical, therapeutic and evolutionary features of non-axial osteoarticular TB.

Methods
We conducted a retrospective study including all patients hospitalized in the infectious diseases department for non-axial osteoarticular TB between 1999 and 2019.

Results
We encountered 51 cases, among which 26 cases were males (51%). The mean age was 41±20years. Ten patients were previously treated for TB (19.6%). The revealing symptoms were fever (70.5%), asthenia (68.6%), weight loss (60.7%) and night sweets (43.1%). Arthritis was noted in 20 cases (39.2%) represented by TB of the hip (10 cases), knee (4 cases), shoulder (4 cases) and elbow (2 cases). There were 12 cases of sacroiliac osteoarthritis (23.5%) and 6 cases of femur osteomyelitis (11.7%). Other affected sites included sternum (7.8%), toe (5.9%), tibia (5.9%), mandible (2%), clavicle (2%) and mastoid bone (2%). Multifocal TB was noted in 12 cases (23.5%). Pulmonary TB was associated to osteoarticular TB in 13.7% of cases. The mean duration of antitubercular therapy was 10±5months. Fixed dose combinations were prescribed in 17.6% of the cases. The disease evolution was favorable in 47 cases (92.1%). Relapse was noted in 3 cases (5.8%) and death in one case (2%).

Conclusion
Non-axial osteoarticular TB was not a rare disease. Multiple sites might be involved which facilitate the diagnosis confirmation. Prolonged antitubercular therapy might be required.

Disclosures
All Authors: No reported disclosures
248. Outcomes of Patients with Prosthetic Septic Arthritis with Debridement and Implant Retention
Authors: Mahatanan Rattanaporn , Altomare Antonia 
Published: December 2021

Abstract

Background
IDSA has published guidelines for the diagnosis and management of prosthetic joint infection (PJI). However, we have observed significant variability in the interpretation and application of these guidelines with respect to the management of those with PJI following debridement and implant retention (DAIR). It is not clear if variations in antimicrobial management are affecting clinical outcomes.

Methods
We performed a retrospective review at an academic hospital in rural New Hampshire. We included all adult patients from 1/1/2017 to 12/31/2018 with PJI of hip or knee who underwent DAIR. The demographic data, microbiology data, antibiotics treatment and duration were collected. The primary endpoint was overall re-infection rate within 2 years of surgery. Secondary endpoint was re-infection rate stratified by organism and antimicrobial type and duration.

Results
A total of 26 patients were included in our study. 65% involved knee joint. 50% had late-onset infection ( &gt;12 months). The top organisms were Streptococcus spp. (34%), CoNS (26 %) and MSSA (18 %). 15% were associated with bacteremia. Ceftriaxone was the most common antibiotic used (54 %). 38 % of patients received Rifampin PO along with IV antibiotics. All patients received PO antibiotic(s) after completing the course of IV therapy, and 7 patients were also on concomitant rifampin PO. The duration of PO antibiotic therapy was varied. 30% of patients received PO antibiotics for 6 months post IV treatment. Life-long suppression therapy were noted in 9 patients. Treatment failure within 2 years occurred in 8 patients (31%). Among those, 75% had Staphylococcal infection. All patients required hardware removal except one patient who required amputation. 2 patients developed recurrent PJI after completing 6 months and one year of PO suppression therapy, one patient had a recurrent infection while on life-long suppression. Staphylococcal infection was significantly associated with treatment failure.

Conclusion
Treatment of PJI with DAIR is challenging. Despite long-term IV therapy followed by oral antibiotics, there was a high rate of treatment failure (31% in our study) particularly with Staphylococcal infection. There was no association of variation of treatments and outcomes in our small cohort.

Disclosures
All Authors: No reported disclosures
252. Joint Decisions: Optimal Duration of Chronic Suppressive Antibiotics in Adults with Prosthetic Joint Infections Who Underwent Debridement, Antibiotics, Irrigation, and Retention of Prostheses
Authors: Lin Aung , Jagtiani Anil C 
Published: December 2021

Abstract

Background
Hip and knee arthroplasties are associated with complications including prosthetic joint infections (PJI). Management ranges from explantation to debridement, antibiotics, irrigation, and retention of prostheses (DAIR). In DAIR, patients receive intravenous antibiotics followed by chronic suppressive antibiotics. Current guidelines on suppressive antibiotic use after DAIR are unclear and based on expert consensus. This study seeks to elucidate the optimal duration of chronic suppressive antibiotics after DAIR.

Methods
This is a retrospective cohort study of adults in the Southern California Kaiser Permanente System with hip and knee prosthetic joint infections who underwent DAIR from 2007-2017. Culture data and durations of suppressive antibiotics were collected and patients were followed for 1 year after completion. Treatment failure was determined by mortality, re-infection, or prosthesis removal. Patients who received no antibiotics vs. less than 3 months vs 3 to 6 months vs greater than 1 year were compared.

Results
350 charts were reviewed and 145 patients were included. There were 87 knee and 58 hip PJIs with 32 patients (22%) who failed treatment. There were more cases of failure when patients didn’t receive suppressive antibiotics (27%) vs those who received any (19%), however the results were not significant. There were no significant differences in failure rates between short vs longer suppressive antibiotic courses regardless of the duration (Staph vs non-Staph, hip vs knee). Patients with Staphyloccocal infections and knee infections were significantly more likely to fail treatment (p=0.0196 & 0.0150, logistic regression).

Conclusion
This study shows the importance of suppression with oral antibiotics after PJIs are treated with DAIR. The lack of difference in treatment failure between the durations of suppressive antibiotics makes it prudent to consider shorter courses of antibiotics, while placing attention on patients with knee and Staphylococcal infections as they are more likely to fail treatment. Limitations include sample size, difficulty in quantifying extent of initial infection and debridement, and provider dependent prolonging of antibiotic duration.

Disclosures
All Authors: No reported disclosures
257. Outcomes in Fungal Prosthetic Joint Infection
Authors: Hollingshead Caitlyn M , Duggan Joan , Redfern Roberta , Georgiadis Gregory , Tank Jason 
Published: December 2021

Abstract

Background
There is a paucity of data in the literature regarding the most effective treatment and related outcomes of fungal prosthetic joint infection. The majority of reported cases are treated using a two stage revision method in which the initial prosthesis is removed and the patient is treated with systemic antifungal medications and potentially irrigation of the joint cavity with antifungal and antibacterial agents. Alternately, others have suggested a one-stage revision in order to prevent a period of significant functional impairment and potentially improved functional outcomes and lower overall costs. Cases of radical removal of the prosthesis without replacement have been reported. To date, the largest studies of total hip arthroplasty and total knee arthroplasty have included 37 and 45 patients, respectively.

Methods
A retrospective record review of patients admitted within two health systems between January 1, 2007 and December 31, 2018 with prosthetic joints and a deep culture of the joint positive for fungal organisms was performed.

Results
Eighteen patients fit criteria. Nine patients had knee replacements and nine patients had hip replacements. The average age at time of infection was 61. Ten patients were female. Average BMI was 32.1. Twelve presented with a painful joint, eight presented with drainage, and one with dehiscence. Average WBC count was 9.3, average ESR was 47, and average CRP was 11.8. All patients were noted with Candida species. Eight patients were treated with two stage revisions, three received one stage revisions as destination therapy. One required amputation. All but one patient was associated with concurrent bacterial infection. Of the twelve patients that had known outcomes, six were noted with cure and six were noted with relapse. All patients that were cured received two stage exchange or girdlestone procedure.

Conclusion
In our study, fungal prosthetic joint infection was associated with poor outcomes. All of the patients in our study were noted with Candida species, which is in concordance with the known literature. Two stage exchange was associated with better outcomes.

Disclosures
All Authors: No reported disclosures
265. Rocky Mountain Spotted Fever Encephalopathy
Authors: Isaac Sangeetha , Pasha Mohammed Afraz , Vincent Jean H , Chahal Khushdeep 
Published: December 2021

Abstract

Background
Rocky mountain spotted fever (RMSF) is a rickettsial disease with incidence of 11 per million and is rarely associated with encephalopathy. Here we discuss a patient with RMSF encephalopathy, highlighting the natural course.

Methods
A 54 year old man with history of hypertension and chronic progressive external ophthalmoplegia, presented with waxing and waning confusion, headache, slurred speech, agitation and difficulty swallowing. He was afebrile and hemodynamically stable. Investigations showed leukocytosis of 15400 and mild transaminitis. Computed-tomography (CT) head was unremarkable. Lumbar puncture revealed normal pressure. Cerebrosopinal fluid (CSF) analysis was notable for WBC 7, glucose 76 and moderately elevated total protein 114. Urine drug screen was negative. Blood, fungal, and CSF cultures were sent and empiric therapy with vancomycin, ceftriaxone, ampicillin and acyclovir commenced, for suspected encephalitis. High dose solumedrol 1gm/day was given due to suspicion of autoimmune encephalitis. MRI brain showed cerebral atrophy. There was slight abnormal FLAIR/T2 signal within the medial aspect of the temporal lobes, right more than left.

Results
Occupational history revealed that he was a logger by profession, which steered our focus on tick borne diseases. Extensive serologic evaluation was requested and RMSF IgG titres came back positive at 1:512. Doxycycline was added, while ampicillin and ceftriaxone were discontinued. With doxycycline, patient made remarkable recovery and was discharged home well. However, he returned within 48 hours with recurring encephalopathy. His clinical presentation remained convincing for RMSF encephalitis, with the natural course of the illness spanning over weeks, with waxing and waning symptoms. Patient was managed with IV doxycycline for 72 hours following which he returned to his baseline mental status.
Figure 1. MRI findings

Figure 2. Serological investigations

Figure 3. CSF studies

Conclusion
Patient’s occupation played a pivotal role in establishing diagnosis. In RMSF, IgM and IgG antibodies appear 7 to 10 days after the onset of the illness, and a fourfold rise in IgG is diagnostic of seroconversion and recent illness. Patient’s waxing and waning symptoms, persisting for weeks and remarkable response to doxycycline, are typical features of RMSF encephalitis.

Disclosures
All Authors: No reported disclosures