bluuebunny/crossref_metadata_2025_split huggingface dataset:
735. Malaria Chemoprophylaxis Adherence Among U.S. Active Duty Service Members during Deployment to Endemic Regions
Authors: Collier Ryan P , Lindholm David A , Lalani Tahaniyat , Telu Kalyani , Kuo Huai-Ching , Fraser Jamie , Ganesan Anuradha , Kunz Anjali , Geist Charla , Yun Heather , Yun Heather , Tilley Drake 
Published: December 2021

Abstract

Background
Military members frequently deploy to malaria-endemic regions. Most cases of travel-related malaria occur due to prophylaxis non-adherence, impacting mission readiness. Factors assessing adherence are described in outbreak settings; we prospectively assess adherence in military travelers.

Methods
TravMil is a prospective, observational cohort study of US military beneficiaries traveling outside the US (2010-2019). Our analysis includes only active-duty service members traveling with a military purpose to malaria-endemic regions, who were prescribed malaria prophylaxis, and who completed a pre- and post-deployment survey; they could also enroll after return from deployment. All travelers received pre-travel counseling. Survey responses were assessed using descriptive statistics and multivariate regression to determine risk factors for adherence.

Results
1504 travelers were included (85% male; median age 28 years; 73% white). Median duration of travel was 77 days (12% traveled ≤ 14 days). Africa was the most common destination (33%). Primary prophylaxis included doxycycline (54%) and atovaquone/proguanil (43%). 969 (64%) were fully adherent to their regimen. The frequency of prophylaxis did not match expected values, as 3.6% of subjects reported taking prophylaxis weekly, and 2.9% did not know how often they took it. 103 (6.9%) did not take any of the prescribed regimen. On multivariate analysis, deployers were more likely to adhere if they traveled for ≤ 14 days or to Africa or practiced other mosquito-avoidance behaviors. Study enrollment post-deployment was associated with decreased odds of adherence, as was use of a tent. The use of daily versus weekly prophylaxis was not associated with a difference in adherence, though we had limited subjects prescribed weekly regimens.
Figure 1. Reasons for not taking any of the prescribed chemoprophylaxis (n = 103)

Table 1. Odds of full adherence to malaria chemoprophylaxis on multivariate logistic analysis

Conclusion
Short-duration travel, travel to highly endemic regions, and mosquito-avoidance behaviors were associated with increased adherence to prophylaxis. The lower rate of adherence in post-deployment enrollees may be a surrogate for inadequate counseling or recall bias. Our study highlights potential holes in counseling regarding malaria prophylaxis and the importance of ongoing provider and patient education on malaria.

Disclosures
Heather Yun, MD, American Board of Internal Medicine (Individual(s) Involved: Self): Board Member
736. Delays in Malaria Recognition and Door to Anti-malarial Time in a South London Hospital
Authors: Patel Nisha , Materski Tomasz , Gonzalez Elisa , Russom Solomon , Sandhu Gurjinder 
Published: December 2021

Abstract

Background
The prompt recognition and treatment of Plasmodium falciparum is necessary to prevent death. We reviewed data from a cohort of patients presenting with malaria to Kings College Hospital NHS Trust, London.

Methods
Retrospective review of electronic records and drug charts of patients diagnosed with malaria from Jan 2019- March 2021.

Results
109 cases of malaria were identified representing travellers from 11 Sub-Saharan African countries: Nigeria(38%), Sierra Leone(33%), Ivory Coast(10%). The age range varied from 4 to 76 years with a mean of 44, 66% of the cohort was male. 22 cases occurred during the COVID-19 Pandemic. The commonest symptoms were Fever (97%), Headache (92%) and malaise (72%). P. falciparum was present in 99% cases. A travel history was taken in 94% of cases. Malaria was considered by the first clinician in 82% of cases with the second highest differential being a viral illness. In 6 cases, it took 4 to 11 medical reviews before malaria was considered. 29 patients met the UK criteria for severe malaria. Door to antimalarial time varied from 1 to 128 hours, with a median of 7.4 hours. 46% of the cohort received intravenous Artesunate as their first antimalarial. Extreme delays occurred were clinicians did not consider malaria, patients had negative films or a patient did not declare a travel history when asked. 1 patient died of cerebral malaria with a door to needle time of 2hr 3min. Where a reason for delay is documented, drug availability represented the highest cause with mean delay from prescribing antimalarial to giving antimalarial of 2.7 hours. There was no difference in door to antimalarial administration during the COVID-19 Pandemic, but patients did have a delay in presentation to hospital from onset of symptoms, mean 6.2 days pre-pandemic, 10.5 days during pandemic, this was not statistically significant (P= 0.198). 3 patients presenting during the Pandemic had covid-19 swabs prior to admission and 10 had attended primary care services. Number of days between onset of malaria symptoms and presentation to the Emergency Department

Box plot demonstrating that patients were waiting longer post symptom onset to access care in the Emergency Department. 3 patients had covid swabs in the community and 10 accessed care through their primary care physician.

Conclusion
Our data show that malaria is being considered early in the emergency department however there remain significant delays in administration of treatment. In 6 cases where malaria was not considered early there were delays in diagnosis of up to 5 days. An audit cycle will be completed with the aim of reducing door to antimalarial time.

Disclosures
All Authors: No reported disclosures
739. Self-Reported Prevalence of Insect Bites During International Travel
Authors: Shoemaker Holly , Graves Michael , Ahmed Sharia , Birich Holly K , Benson Scott , Contreras John R , McAfee Colette , Leung Daniel T 
Published: December 2021

Abstract

Background
Vector borne diseases are responsible for almost one fifth of global infectious disease burden. International travelers are at risk for potentially life-threatening conditions when visiting areas with endemic vector borne disease, but this risk can be mitigated when proper insect precautions are taken. This study sought to evaluate the prevalence of insect precaution use and subsequent insect bites among Utah travelers who have attended pre-travel consultations.

Methods
A cross-sectional study at the University of Utah and Salt Lake County travel clinics was analyzed. Descriptive statistics and multivariable logistic regression were used to explore factors associated with insect repellant use, and reporting bug bites despite insect repellant use.

Results
A total of 463 individuals completed the survey and were included in our analytic sample. The majority of respondents (80%) reported using insect repellent, and close to half (45%) reported bug bites. Insect repellent use was positively associated with visiting rural/countryside (OR 2.78, 95% CI 1.50 – 5.15), and traveling to South East Asia (OR 3.16, 95% CI 1.40 – 7.26), or Americas regions (OR 3.34, 95% CI 1.45 – 7.92). Being of male gender (OR 0.37, 95% CI 0.21 – 0.64) or traveling to high altitude locations (OR 0.37, 95% CI 0.18 – 0.74) was negatively associated with using insect repellent. Longer trip duration (OR 1.01, 95% CI 1.00 – 1.02) was positively associated with reporting insect bites, while male gender (OR 0.51, 95% CI 0.33 – 0.80), older age (OR 0.96, 95% CI 0.95 – 0.98), and having an advanced degree (OR 0.47, 95% CI 0.22 – 0.99) were negatively associated.
Estimated Risk Factors of Insect Bites and Insect Repellent Use

Characteristics of international travelers were self-reported in a cross-sectional study. Use of insect repellent and reporting bug bites despite repellant use was examined through multivariate logistic regression and used to calculate odds ratios and 95% confidence intervals. Due to multicollinearity and data skewness, the following variables were omitted from the insect repellent model: Accommodation: Hotel/other enclosed structure, Location: European, Location: and Western Pacific. Reference categories are Gender: Female, Education: High school diploma/GED or less, Group size: 1 (Traveled alone), Location type: Urban, and Malaria region: No. All other categories are not mutually exclusive and evaluated as separate binary variables.

Conclusion
We show that gender, age, trip duration, and education level were associated with self-reported bug bites during travel abroad. Given the number of vector-borne diseases affecting health of travelers, our findings will contribute towards strategies to advise travelers for disease prevention.

Disclosures
All Authors: No reported disclosures
740. Elucidation of the Mode of Clostridioides difficile Transmission Based on One Health Approach
Authors: Yoshizawa Sadako , Sawa Tomoka , Komori Kohji , Sasaki Masakazu , Mori Nobuaki , Aoki Kotaro , Ishii Yoshikazu , Tateda Kazuhiro 
Published: December 2021

Abstract

Background
Community-onset Clostridioides difficile (C. difficile) infection (CACDI) has been increasing in recent years. To explore the transmission route of CACDI, we performed the whole-genome sequencing of C. difficile isolated from CACDI patients and compared it to the isolates from livestock, companion animals, and soil.

Methods
From October 2020 until April 2021, fecal specimens of cattle, poultry, swine, felines, canines, CACDI patients, their families, and soil from the CACDI patients' living environment were applied for isolation of C.difficile. Whole-genome sequencing of C. difficile was performed on the MiSeq system (Illumina). Using the draft genome obtained from these analyses, the house-keeping gene (tpi), MLST, toxin genes (tcdA, tcdB, cdtA, cdtB), and resistance genes (gyrA, gyrB, rpoA, rpoB, rpoC) were comprehensively analyzed.

Results
As of March 31, 2021, 275 specimens were collected. Forty-five fecal specimens of companion animal origin (23 feline and 22 canines) were collected and the positive rate of C.difficile was 28.9% (2 felines, 11 canines). In MLST analysis, ST 15 (4 strains), ST 26 (2 strains), ST 42, ST 3, ST 28, ST 100, and ST 185 were detected in canines, and ST 203 and ST 297 strains were detected in felines. Samples of livestock origin were collected from 135 cattle, 41 poultries, and 20 swine. The detection rate in cattle was 11%, toxin-gene positivity was 60%. MLST analysis of 9 strains revealed ST 11 (5 strains), ST 2, ST 15, ST 58, and ST 101. No isolates were found from poultry or swine. Patient-derived strains of CACDI were collected from 14 patients at 2 sites. MLST analysis revealed ST42, ST37, ST100, and ST203(two isolates, respectively), ST 224, ST 81, ST 28, and ST 47. 2 isolates were unclassifiable. One case was a healthy 1-year-old girl, whose family revealed no isolation of C.difficile. Impressively, the soil in the parks (A and B) related to the child detected C.difficile from 4/4 samples (toxin-gene positivity; 75%) in Park A and 1/4 samples (toxin-gene positive) in Park B. MLST analysis demonstrated ST 42, the same as that in the affected child and core-genome single-nucleotide polymorphisms(SNPs) analysis suggested closely related strain.

Conclusion
Our results suggest one health approach is fundamental to prevent the transmission of C.difficile.

Disclosures
All Authors: No reported disclosures
742. Evaluation of Chagas Disease Diagnostic Testing Practices in Four Hospital Systems in California and Texas
Authors: Kelly Emily A , Echeverri Alegre Jose I , Promer Katherine , Hayon Jesica , Iordanov Roumen , Zhang Jerry J , Fang Zian , Huang Cindy , Bittencourt Cassiana , Reed Sharon L , Andrade Rosa , Bern Caryn , Clark Eva , Whitman Jeffrey 
Published: December 2021

Abstract

Background
Chagas disease (CD) is a neglected parasitic disease that affects &gt;6 million people in the Americas, including &gt;200,000 people in the United States (US). Medical provider knowledge of CD is key to decreasing morbidity and transmission; however, few studies have assessed diagnostic practices in US health systems serving at-risk patients. Our study aimed to describe existing provider approaches to diagnosing CD in California and Texas.

Methods
Site-based research teams at four hospital systems (the University of California [UC] San Francisco [UCSF], San Diego [UCSD], Irvine [UCI], and the Harris Health System [HHS] in Houston, TX) retrospectively identified patients ≥18 years old tested for CD between 2016-2019 and systematically extracted electronic medical record data using complementary electronic data entry forms. Specifically, eligible patients were identified using laboratory orders at UCSF and UCI, while the remaining sites employed SlicerDicer (Epic Systems). This study was approved by institutional review boards at each site.

Results
We identified 333 patients tested for CD, including 109 from UCSF, 88 from UCSD, 25 from UCI, and 111 from HHS. These patients had 125, 99, 31, and 181 tests sent to commercial laboratories, respectively. Test reactivity varied by system with the greatest percent reactivity among tests ordered at UCI (23%) followed by UCSD (16%), HHS (15%), and UCSF (10%). Among patients who screened positive for CD by commercial assays, confirmatory testing through the Centers for Disease Control and Prevention was sought for 100% at UCI; 59% at HHS, 55% at UCSF, and 40% at UCSD. The medical specialty that most often ordered CD testing was Cardiology at all UC sites (UCSF, 50%; UCSF, 55%; UCI, 35%) and Internal Medicine at HHS (46%; Cardiology ordered 13%). Only one recorded CD test was ordered by an Obstetrics/Gynecology service at any site.

Conclusion
These early results report positivity rates between our healthcare systems and demonstrate inconsistency in attaining recommended confirmatory testing, as well as a paucity of CD testing ordered through Obstetrics/Gynecology despite risk of congenital transmission. These findings suggest areas of opportunity to improve provider awareness and lay a foundation for standardizing CD diagnostic practices in the US.

Disclosures
Caryn Bern, MD, MPH, UpToDate (Wolters Kluwer) (Other Financial or Material Support, Author Royalties)
744. Incidence and Duration of Diagnostic Delays Associated with Dengue Fever
Authors: Miller Aaron C , arakkal alan , koeneman scott , Polgreen Philip M , streit judy A 
Published: December 2021

Abstract

Background
Dengue fever is a prominent emerging arboviral infection in the tropics and subtropics, and an important cause of systemic febrile illness among some international travelers. Signs and symptoms are similar to more common infectious illnesses in temperate climates, and dengue may not be promptly considered when patients seek evaluation.

Methods
We conducted a retrospective cohort study of patients diagnosed with dengue fever using the IBM MarketScan Research database from 2001-2017. We identified cases of dengue fever where patients were enrolled ≥ 1 year prior to the index diagnosis. All healthcare visits in the year prior to the index diagnosis were collected and we identified visits with signs/symptoms compatible with dengue or a diagnosis made of an illness with similar symptoms (e.g., influenza) before the index dengue diagnosis. We used a time-series change-point analysis to identify the time before diagnosis in which symptoms of dengue became more prominent. We conducted a bootstrap-based simulation analysis to estimate the duration and frequency of missed diagnostic opportunities.

Results
We identified 4,449 cases of dengue fever that met eligibility criteria. We found that 2,791 (62.7%) had ≥ 1 healthcare visit(s) prior to diagnosis with characteristic symptoms of dengue recorded. Our simulations analysis supports that 32.9% (95% CI: 31.1-35.0) experienced 1 or more missed opportunities for diagnosis. Among these patients, the average duration of diagnostic delay was 8.26 (CI: 6.32-11.38) days and ~21% of patients had a diagnostic delay of 2 or more weeks. Patients with a delayed diagnosis averaged 2.2 (CI 2.11-2.29) healthcare visits which represented missed opportunities. Missed opportunities were more likely during weekend, ED or outpatient visits.

Conclusion
Dengue fever is not considered in the majority of patients at the time of the initial symptomatic evaluation in the U.S., indicating delays in diagnosis are common. Enhanced education of providers about dengue fever could lead to more prompt diagnosis that should help optimize patient management.

Disclosures
All Authors: No reported disclosures
745. Evaluation of a Pharmacist-driven Risk Factor Tool for the Prevention of Hospital-onset Clostridium difficile Infection in a Community Hospital
Authors: Weiss Jennifer , Patel Gargi , Cavanaugh Joseph 
Published: December 2021

Abstract

Background
Clostridium difficile infection (CDI) is the most frequently reported nosocomial infection and is the major cause of healthcare and antibiotic associated diarrhea. Guideline recommended preventative strategies include antibiotic stewardship, hand hygiene, barrier precautions, and disinfection of environmental spaces to reduce the risk of hospital onset CDI (HO-CDI); however, there is no standardized scoring method to tactically detect high-risk patients in order to prevent HO-CDI. The objective of this study was to implement a risk stratification procedure for a pharmacist to prospectively identify high-risk patients and make early interventions to prevent the incidence of HO-CDI.

Methods
In this single center, ambidirectional cohort study, patients who acquired HO-CDI from January 2019 to June 2020 were identified and evaluated to determine which modifiable risk factors were most prominent. A pharmacist prospectively screened patients who were admitted from October 2020 to February 2021 using a web-based screening tool to detect high-risk patients based on the previously identified risk factors. An interdisciplinary approach was used to make early interventions for high-risk patients such as discontinuation or de-escalation of antibiotics, discontinuation of gastric acid suppression, and early CDI testing before 72 hours of admission. The primary outcome was incidence of HO-CDI per 10,000 patient days and secondary outcomes were length of hospital stay and duration of non-CDI antibiotic therapy. Appropriate statistical tests were used to measure significance.

Results
The primary outcome of HO-CDI cases per 10,000 patient days occurred at a median rate of 3.95 (IQR 3.38 – 6.30) in the retrospective cohort versus 2.15 (IQR 1.68 – 3.04) in the prospective cohort [p &lt; 0.0125]. There were no significant differences in length of non-CDI antibiotic therapy or length of hospital stay.
Baseline Characteristics

Primary Outcome

Secondary Outcomes

Conclusion
In patients at high-risk of developing HO-CDI, pharmacist intervention resulted in a reduced rate of HO-CDI cases per 10,000 patient days.

Disclosures
All Authors: No reported disclosures
746. Clinical and Microbiological Characteristics of Clostridioides difficile Infection After a Change in Diagnostic Testing Algorithm
Authors: Crone Andrew S , Skinner Andrew M , Cheknis Adam , Johnson Stuart , Pacheco Susan M 
Published: December 2021

Abstract

Background
There is a lack of consensus on the most appropriate testing for C. difficile infection (CDI). The objective of this study was to determine the clinical and microbiological characteristics of CDI following a switch from stool PCR testing only to PCR reflexed to toxin testing.

Figure 1. PCR Cycle Threshold Values

Methods
We reviewed the characteristics and outcomes of 50 consecutive patients who tested positive for CD by PCR (Xpert CD, Cepheid) between October 2019 and January 2020 at the Hines VA Hospital. Cases were defined by results of reflex toxin testing (Cdiff quick check complete, Alere/TechLab) after a positive PCR result. Baseline characteristics, symptoms, initial laboratory data, and treatments were compared as well as patient outcomes, including hospital readmission due to CDI at 30 days, and recurrent CDI (rCDI) at 30 and 90 days. The cycle threshold for the stool PCR result was recorded. Stools were cultured anaerobically for CD, and restriction endonuclease analysis (REA) strain typing was performed on the recovered CD isolates.

Results
Toxin testing was positive in 19/50 (38%) cases. Compared to stool toxin-negative cases, toxin-positive cases were older (95% vs. 71% were age ≥ 65, p = 0.06), more likely to have a history of CDI (37% vs. 23%, p = 0.34), and have ≥ 1 CDI episodes within 6 months (37% vs. 19%, p = 0.26). Treatment for CDI was more common in patients who had a positive toxin text. (95% vs 61%, p= 0.009). Among the 38 patients that received treatment, 33 received vancomycin (87%) and 8 patients (21%) had rCDI at 30 days. Of the 8 patients with rCDI, 2 were re-admitted to the hospital for CDI. The average PCR cycle threshold was lower in the toxin-positive stools compared to toxin-negative stools (24.46 and 29.96, p&lt; 0.001; Fig. 1) The endemic REA group Y was the most common CD strain recovered (30%) and the previously epidemic and virulent REA group BI strain was recovered in 11% of the cases.

Conclusion
CDI cases diagnosed by positive stool PCR and positive toxin tests had more typical risk factors for CDI, a lower PCR cycle threshold and were more likely to have been treated for CDI. Outcomes were similar in this setting where infection with the virulent BI strain was uncommon.

Disclosures
Stuart Johnson, MD, Acurx Pharmaceuticals (Advisor or Review Panel member)Bio-K+ (Advisor or Review Panel member)Ferring Pharmaceutical (Advisor or Review Panel member)