bluuebunny/crossref_metadata_2025_split huggingface dataset:
1762. The Adjusted Ranking Metric (ARM) and Its Use in Composite Measures for HAI Prevention in the National Healthcare Safety Network (NHSN)
Authors: Sapiano Mathew R P , Edwards Jonathan R , Pollock Daniel 
Published: November 2018

Abstract

Background
The National Healthcare Safety Network (NHSN), developed and used by the Centers for Disease Control and Prevention (CDC) for surveillance of healthcare-associated infections (HAIs), provides benchmark measures, such as standardized infection ratio (SIRs), that CDC and its partners in healthcare and public health use for prevention purposes. NHSN provides benchmarks for each HAI measure separately, but a composite HAI measure could provide a more rounded assessment of HAI problems and prevention opportunities.

Methods
Several issues must be addressed to produce a sound HAI composite measure, the most of which is that the SIR can be inaccurate for facilities with low HAI exposure (e.g., low device days, operative procedure volume). We remedy this issue with the Adjusted Ranking Metric (ARM), a new measure that reliability-adjusts the SIR using a Bayesian mixed effects model. The ARM is particularly useful in the production of a composite measure because ARMs are well-suited to comparison between facilities. The composite was therefore produced by applying adjustments to the ARMs to account for (1) differences between exposure to separate HAI types within facilities and (2) differences in frequency and severity between HAIs. The composite is calculated for 6 HAIs based on 2015 data.

Results
Case studies of 3 facilities (table) show that the new composite measure provides a meaningful measure of overall facility performance that is less prone to the biases that afflict simple combinations of SIRs.

Conclusion
We introduce a framework for calculating a composite HAI measure that is flexible, customizable, and transparent. The current implementation of the framework is intended to assist in prevention efforts and can be easily modified to include cost weights, if desired. Flexibility in weighting the HAIs provides an opportunity for different stakeholders to customize the composite measure to their own needs.

Disclosures
All authors: No reported disclosures.
1773. Impact of Antibiotics Used to Treat Community Acquired Pneumonia on the Gut Microbiome and Resistome in Healthy Volunteers
Authors: Anthony Winston , Wang Bin , Cass Candice , Hink Tiffany , Reske Kimberly , Seiler Sondra , Dubberke Erik R , Burnham Carey-Ann D , Dantas Gautam , Kwon Jennie H 
Published: November 2018

Abstract

Background
Antibiotics (ABX) are frequently inappropriately used to treat nonbacterial causes of respiratory illnesses. The goal of this prospective cohort study was to characterize the impact of ABX used to treat community-acquired pneumonia (CAP) on the fecal microbiome and resistome in healthy volunteers (HV).

Methods
Twenty HVs were randomized to receive 5 days of levofloxacin (LV), azithromycin (AZ), cefpodoxime (CF), or AZ+CF. Stool was collected before, during, and after ABX, then underwent microbiologic culture and shotgun sequencing. DNA was extracted, then sequenced using the Illumina NextSeq platform. Relative abundance of bacterial taxa was estimated by MetaPhlAn and antibiotic resistance gene (ARG) composition by ShortBRED. Analysis was in R.

Results
The mean HV age was 37 (range 24–59) and 10 were female. Species diversity measured via Shannon Index and richness were significantly lower in samples taken from all HVs 3 days post-ABX (P &lt; 0.01 for all). While nonmetric multidimensional scaling (NDMS) ordination shows high interpatient dissimilarity (Bray–Curtis) for most samples, the post-ABX intrapatient dissimilarity varies by ABX. The AZ group exhibited chronic alterations in taxa dissimilarity and the CF group had increases in dissimilarity directly post-ABX. The CF+AZ group displayed both acute and persistent perturbations (Figure 1). Although there was no significant change in ARG richness post-ABX, there was a significant increase in overall ARG abundance across all samples (P &lt; 0.003). Within each ABX, there were unique changes in ARG abundance, and groups with CF had increases in ARG abundance (Figure 2).

Conclusion
ABX used to treat CAP can cause acute microbiome disruptions, as evidenced by decreased microbiome species diversity and richness, and an increase in ARG abundance post-ABX. The duration of this impact is variable. To prevent microbiome disruptions, measures to prevent inappropriate ABX use via ABX stewardship are necessary.

Disclosures
E. R. Dubberke, Rebiotix: Consultant and Investigator, Consulting fee and Research support. Pfizer: Consultant and Grant Investigator, Consulting fee and Research grant. Synthetic biologics: Consultant, Consulting fee. Merck: Consultant and Investigator, Consulting fee and Research support. Valneva: Consultant, Consulting fee. Achaogen: Consultant, Consulting fee. Alere: webinar, Speaker honorarium. Biofire: webinar, Speaker honorarium.
2568. Variability in Pediatric Antibiotic Prescribing for Upper Respiratory Illnesses by Provider Specialty
Authors: Frost Holly M , McLean Huong , Chow Brian 
Published: November 2018

Abstract

Background
Antibiotic prescribing varies among providers, contributing to antibiotic resistance and adverse drug reactions.
Objective. To evaluate variation in antibiotic prescribing between pediatric and nonpediatric providers for common upper respiratory illnesses.

Methods
Patient encounters for children aged &lt;18 years from a regional healthcare system were identified. Electronic medical records from 2011 to 2016 were extracted for diagnoses of upper respiratory infection (URI), pharyngitis, acute otitis media (AOM), and sinusitis. Encounters with competing medical diagnoses, recent hospitalization, and antibiotic prescriptions within 30 days were excluded. Adherence to antibiotic guidelines was assessed by provider training (pediatric, nonpediatric physicians, and advance practice providers [APP]). Additional factors assessed included clinic or urgent care setting, calendar year, and patient’s age, gender, insurance status, and number of sick visits in the prior year.

Results
Across 6 years, 141,361 visits were examined: 43,914 for URI, 43,701 for pharyngitis, 43,925 for AOM, and 9,821 for sinusitis. Pediatricians were more likely than APPs and nonpediatric providers to have guideline-concordant prescribing for pharyngitis (pediatricians 66.7 (54.5, 77.0)%, nonpediatricians 49.1 (36.3, 62.0)%, APPs 52.2(39.4, 64.7)%, P &lt; 0.0001) and sinusitis (pediatricians 70.8(53.8, 83.4)%, nonpediatricians 63.3(46.8, 77.2)%, APPs 62.1(45.1, 76.5)%, P = 0.48) and to withhold antibiotics for URI than APPs and nonpediatric providers (pediatricians 86.6(81.2, 90.6)%, nonpediatricians 80.8(73.0, 86.8)%, APPs 76.8(68.4, 83.5)%, P &lt; 0.0001). Pediatricians were less likely to prescribe antibiotics for pharyngitis without a positive Group A Streptococcus test than APPs and nonpediatric providers (pediatricians 15.1(10.4, 21.6)%, nonpediatricians 29.4(20.8, 39.6)%, APPs 27.2(19.3, 36.9)%, P &lt; 0.0001). First-line antibiotic prescribing for pharyngitis and AOM did not differ between provider specialties. A trend toward more guideline-concordant prescribing was seen for pharyngitis and sinusitis over the study period.

Conclusion
Pediatricians were more likely to adhere to guidelines for pediatric acute respiratory infections. Pediatric antibiotic stewardship efforts should also target non-pediatricians.

Disclosures
All authors: No reported disclosures.
1192. Identification of a Novel Enterobacter cloacae Isolate Producing an IMP-13 Metallo-β-Lactamase
Authors: Abid Muhammad Bilal , Buchan Blake , Ledeboer Nathan , Munoz-Price L Silvia , Graham Mary Beth 
Published: November 2018

Abstract

Background
Metallo-β-lactamases (MBLs) have been identified as emerging resistance determinants in Enterobacteriaceae, A. baumanii, and P. aeruginosa. Early identification of carbapenemase-producing organisms (CPOs) is essential to prevent dissemination within healthcare settings. We report a case of a patient who was blood culture positive for a multidrug-resistant E. cloacae which was subsequently found to be positive for the MBL blaIMP-13.

Methods
A 74-year-old female, with no significant past medical or travel history, developed sepsis 2 days after undergoing debulking surgery for stage IIIc ovarian carcinoma. Blood cultures were positive for Gram-negative bacilli and the organisms identified as Enterobacter spp. with blaIMP MBL (Verigene). Antimicrobial susceptibility testing demonstrated high-level resistance to all penicillins, ureidopenicillins, cephalosporins, and β-lactam/inhibitor antibiotics, and susceptibility to colistin, tigecycline, and monobactams.

Results
Further testing using micro-broth dilution, BD phoenix, and Etest, demonstrated susceptible MICs to meropenem and imipenem, with intermediate to resistant MICs to ertapenem. The patient was treated with a combination therapy of amikacin, aztreonam, and ceftazidime-avibactam and responded clinically. Per standard protocol, the organism was sent to WI Laboratory of Hygiene for further characterization. Phenotypic testing using the modified carbapenem inactivation test (mCIM) was positive, indicating the presence of a carbapenemase; however, results using Xpert CarbaR (Cepheid) were negative. Subsequent sequencing of the isolate confirmed the presence of blaIMP-13.

Conclusion
This was an important case for several reasons. First, blaIMP-13 is historically reported in Pseudomonas aeruginosa. Indeed, this was the first report of Enterobacteriaceae harboring blaIMP in WI. Second, it had unique susceptibility pattern to carbapenems and was not detected by the CarbaR. Third, these data demonstrate clinical success in treating an MBL CPO with a combination anti-microbial regimen, based on an understanding of resistance mechanisms involved. This report calls for more vigilant screening for CPO using both phenotypic and genotypic methods.

Disclosures
N. Ledeboer, Luminex: Consultant, Consulting fee.
1194. Carbapenem-Resistant Enterobacteriaceae in Kentucky: Initial 6 Months of Mechanism Testing
Authors: Spicer Kevin , Cox Katelyn , Zinner Rachel , Flinchum Andrea 
Published: November 2018

Abstract

Background
A global rise in carbapenem-resistant Enterobacteriaceae (CRE) has been noted over the past two decades. State and local data on CRE are necessary to better inform public health interventions.

Methods
Reporting of CRE (i.e., Enterobacteriaceae resistant to any carbapenem or shown to produce a carbapenemase) was mandated in Kentucky in 2015. Voluntary submission of isolates to the Antibiotic Resistance Laboratory Network regional laboratory for carbapenemase testing began September 2017. Demographic data collected as part of reporting included age, sex, county of residence, and inpatient/outpatient status. Descriptive and chi-square analyses were performed.

Results
Between September 1, 2017 and February 28, 2018, 149 CRE were reported to the Kentucky Department for Public Health. Testing for presence of a carbapenemase was performed on 115 isolates (77.2%); 44 (38.3%) were carbapenemase producing (CP)-CRE and Klebsiella pneumoniae carbapenemase (KPC) was identified from 38 (86.4%). Also identified were Verona integron-encoded metallo-β-lactamase (VIM; 5, 11.4%) and New Delhi metallo-β-lactamase (NDM; 1, 2.3%). Identification of carbapenemase varied among genera: Citrobacter (3/4, 75%), Klebsiella (21/40, 52.5%), Serratia (2/5, 40%), Escherichia (6/20, 30%), Enterobacter (11/41, 26.8%), Proteus (0/4, 0%), other genera (1/2, 50%). CRE isolates from urban or suburban areas were more likely CP-CRE than were those from rural areas (30/65, 46.2% vs. 14/50, 28%, P = 0.047). Carbapenemase was identified more often among CRE isolates from currently hospitalized patients than from patients whose cultures were collected outside of an acute care hospital (37/70, 52.8% vs. 7/45, 15.6%; P &lt; 0.001).

Conclusion
The percentage of CRE that were CP-CRE in Kentucky was comparable with that reported for the United States (38 vs. 32%). Klebsiella spp., the genera historically associated with CP-CRE, made up less than half of CP-CRE. CP isolates were identified from urban, suburban, and rural settings and more frequently from isolates collected in hospitals compared with the community. The additional epidemiology obtained as part of this reporting system has identified metropolitan areas of the state as targets for CRE prevention efforts.

Disclosures
All authors: No reported disclosures.
1203. Molecular Screening for Multi-Drug Resistance Genes in Hospitalized Veterans
Authors: Alsamarai Sarah , Biedron Caitlin , Holen Barrett , Goodman Jesse , Yoon Bona , Liappis Angelike P 
Published: November 2018

Abstract

Background
Gene-based screening is a tool to detect and track multi-drug-resistant organisms (MDROs) in hospitalized patients. MDRO acquisition and colonization during the duration of a hospital stay and their persistence over time are not well described.

Methods
A peri-anal swab was collected within 48 hours of admission from patients on medical wards and the MICU at the Washington DC VA Medical Center and repeat swabs were obtained day 7 and 14 on patients consenting to participate. Clinical and laboratory data from admission to 12mo post discharge was reviewed. Genes associated with VRE (VanA), ESBL (CTX-M), carbapenase-producing organisms or CPOs (OXA-23, OXA-51) and CREs (KPC,NDM,VIM, IMP, OXA-48) were tested on swabs by the Acuitas-MDRO Test (OpGen, Inc.).

Results
Between July 2015 and August 2016, 565 hospitalized patients were screened with 210 swabs collected from 182 subjects. One swab was nonevaluable. Subjects had a mean age 67.5 ± 12.0 years (26–94 years, 38% ≥70 years) and 39% received empiric antibiotics at admission. Subjects were hospitalized for 1037 cumulative bed-days (1–81 days) with median LOS of 3 days; 84% (152/182) had a stay of a week or less. Among those who remained hospitalized long enough for serial testing, 45% were willing or able to provide &gt;1 swab. Those with &gt;1 swab were significantly older (+4.9 years, P = 0.03), more likely to have to have been admitted for an infectious diagnosis (48% vs. 24%, P = 0.02). All subjects negative for MDRO genes on admission with &gt;1 swab remained negative on serial sampling. Sixteen subjects (8.8%) had one or more genes present on screening and all three with &gt;1 swab had persistence of that gene on repeat sampling. Genes harbored included CTX-M (4.4%), VanA (4.4%), OXA-51(0.6%), KPC (0.6%).

Conclusion
The rate of occult MDRO colonization was low in our predominately elderly hospitalized patients. The majority of consenting participants were discharged before swabs could be repeated. Serial sampling revealed that results of swabs persisted over time in the same subject despite treatments received during hospitalization, including exposures to antibiotics. The identification of occult MDRO carriage during a hospitalization, even when obtained after admission, may have utility in guiding treatment for providers.

Disclosures
All authors: No reported disclosures.
1216. Cost-Effectiveness of Penicillin Skin Allergy Testing in Methicillin-Sensitive Staphylococcus aureus (MSSA) Bacteremia
Authors: Meninger Stephen , Heil Emily , Mattingly II T Joseph 
Published: November 2018

Abstract

Background
β-Lactams remain the gold standard for treatment of MSSA bacteremia due to superior outcomes compared with vancomycin. Approximately nine in 10 patients receiving penicillin skin testing (PST) will be de-labeled of a penicillin allergy and able to receive a β-lactam antibiotic. The study aims to evaluate the cost-effectiveness of penicillin allergy confirmation during acute care admission for methicillin-sensitive staphylococcus aureus (MSSA) bacteremia through a PST service.

Methods
A decision tree analysis was used to compare a PST intervention in patients with a registeredpenicillin allergy during an inpatient admission for MSSA bacteremia vs. usual care (No PST). The model was created from the health sector perspective with a 1-year time horizon. Patients with a penicillin allergy label were expected to receive vancomycin while patients with no penicillin allergy were expected to receive cefazolin. Potential inpatient, outpatient, and adverse reaction costs were considered in all arms of the model. The effects were measured in quality adjusted life years (QALY) and were calculated for patients who were cured, hospitalized, experienced severe adverse events, or died from MSSA infection.

Results
Patients who received PST services had a mean yearly cost of $12,802, mean quality adjusted life years (QALY) of 0.70, and mean cost/QALY of $18,311. The comparator group not receiving PST services had a mean yearly cost of $12,264, mean quality adjusted life years (QALY) of 0.64, and mean cost/QALY of $19,192. The model produced a final base case ICERof $8,966/QALY for receiving a PST during a hospital admission for the treatment of methicillin-sensitive staphylococcus aureus (MSSA) bacteremia.

Conclusion
Penicillin allergy confirmation through PST services was cost-effective for patients with a reported penicillin allergy admitted for MSSA bacteremia. Additional research to determine potential benefits of PST services beyond one year could further improve the cost-effectiveness of this intervention.

Disclosures
S. Meninger, ALK-Abelló: Grant Investigator, Research grant. E. Heil, ALK-Abelló: Grant Investigator, Research grant. T. J. Mattingly II, ALK-Abelló: Grant Investigator, Research grant.
1220. Impact of Mandatory Infectious Diseases Consultation on the Use of Core Measures and Mortality in Staphylococcus aureus Bacteremia (SAB) at an Academic Medical Center
Authors: Gancher Elizabeth , Maslak Gregory , Lustgarten Jonathan , Schultz Sara , Ingilizova Marinela 
Published: November 2018

Abstract

Background
Multiple studies have shown that Infectious Diseases (ID) consultation significantly improves adherence to guidelines for patients with SAB and decreases mortality. Data from a prior retrospective study done at Hahnemann University Hospital showed that ID consultation improved the use of guideline-based core measures for SAB management. Based on these data, a mandatory ID consultation was established at our institution in November 2016.

Methods
A retrospective, observational study was conducted to evaluate patient characteristics, adherence to core measures for SAB, and in-hospital mortality. All patients with at least one documented blood culture positive for S. aureus were stratified into two groups: pre-mandatory consult (January 1, 2014–November 1, 2016) and post mandatory consult (November 2, 2016–February 1, 2018).

Results
Three hundred seventy-three discrete episodes of SAB were included in the final analysis, 238 episodes before mandatory consult, and 135 episodes after the mandatory consult policy was enacted. Mandatory consultation significantly improved the use of the following core measures for SAB: surveillance blood cultures (87.7% pre vs. 99.2% post, P &lt; 0.001), echocardiography (81.9% vs. 96.9%, P &lt; 0.001), early targeted antimicrobial therapy with nafcillin or cefazolin in MSSA (71.7% vs. 88.6%, P &lt; 0.001), and appropriateness of final antibiotic choice (80.2% vs. 95.2%, P &lt; 0.001). In addition, in-hospital mortality (15.4% vs. 6.2%, P = 0.011), and infection-related mortality (14.3% vs. 5.6%, P = 0.011) were found to be statistically significantly lower in the post mandatory consultation patients.

Conclusion
Implementation of a mandatory ID consultation for patients with SAB at our institution was associated with increased adherence to guideline-based core measures for management of SAB, and decreased in-hospital and infection-related mortality. Our results suggest that mandatory ID consultation for SAB should be considered at all institutions.

Disclosures
All authors: No reported disclosures.
1222. Risk Factors and Outcomes for Daptomycin Nonsusceptible Methicillin-Resistant Staphylococcus aureus Bloodstream Infections
Authors: Hadid Hind , Rizvi Hira , Misikir Helina , Baratz Nathalie , Bardossy Ana Cecilia , Sundaram Ayesha , Haddad Lillian , Perri Mary Beth , Zervos Marcus , Herc Erica 
Published: November 2018

Abstract

Background
Daptomycin (dap) has been approved and successfully used for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections. However, reports of daptomycin nonsusceptible (DNS) MRSA strains have emerged over the recent years. This study describes the clinical characteristics of patients with DNS MRSA bloodstream infections (BSIs) with the objective of identifying risk factors and outcomes.

Methods
This is a retrospective case–control study in a tertiary healthcare system in southeast Michigan. Cases included 34 patients with DNS MRSA BSI between September 24, 2005 and March 31, 2018. Cases were matched with controls with MRSA BSI based on age, source of BSI, and time-period of BSI in a 1:1 ratio. Charts were reviewed for clinical and laboratory data. Vancomycin (van) and dap minimum inhibitory concentrations (MICs) were determined by E-test. DNS was defined as an MIC &gt;1.0 µg/mL. Chi-square test, Fisher’s exact test, and t-test were used to determine statistical significance.

Results
In the case cohort, the source of BSI was endovascular in 11(32%) patients, central-line associated in 3(9%), secondary BSI in 13(38%), and unknown in 7(21%). Table 1 is a summary of the results.

Conclusion
Prior exposure to dap and van, and higher van MIC in MRSA isolates are risk factors for DNS MRSA BSI. DNS is associated with significantly higher risk of 90-day MRSA BSI recurrence.

Disclosures
All authors: No reported disclosures.