bluuebunny/crossref_metadata_2025_split huggingface dataset:
1144. Modern Problem, Medieval Cure-Resistant Aeromonas in Medicinal Leeches
Authors: Parkes Leighanne Olivia , Barker Kevin , Poutanen Susan M , Grant Jennifer M , Libman Michael , Leis Jerome , Stapleton Patrick , Silverman Michael , Hota Susy 
Published: November 2018

Abstract

Background
Medicinal leeches are used primarily in plastic and reconstructive surgery when venous congestion threatens tissue viability. The associated infection risk ranges from 4.1 to 20%. Prophylactic antimicrobials such as fluoroquinolones (FQ) or trimethoprim-sulfamethoxazole (SXT) are recommended and target commonly isolated pathogen and gut symbiont, Aeromonas. However, resistance to these agents has been reported and detected in leeches, including at hospital systems across Canada that acquire their stock from the same supplier. Our objective was to describe the local epidemiology of leech-related Aeromonas resistant to one or more commonly used prophylactic agents, and determine if such resistance originates from the common supplier.

Methods
Six hospital systems across Canada using leech therapy, purchased from the same supplier, were surveyed. A 5-year retrospective review of all antimicrobial resistant leech-related Aeromonas, derived from clinical, leech, and tank fluid specimens was performed. All Aeromonas resistant to either FQ or SXT were included, and retained frozen isolates from each system were analysed by pulse-field gel electrophoresis (PFGE) using a published Aeromonas protocol.

Results
All six hospital systems reported leech-related Aeromonas resistant to one or more antimicrobials, totalling 15 isolates. Three systems only reported data from the last year. Four systems used FQ and two used SXT as prophylaxis. Fifteen of 15 were either FQ resistant or intermediate, and four of 15 were SXT resistant. Three of 10 isolates tested for ceftriaxone (CRO) susceptibility were resistant. Five of 15 of the isolates were resistant to two or more agents. Of the two leech quality control isolates, 2/2 were FQ resistant and 1/2 was FQ, SXT and CRO resistant. Only three isolates, each from a different, geographically distinct hospital system, had been retained. PFGE analysis indicated 2/3 are closely related (Figure 1).

Conclusion
Our preliminary investigation suggests that the presence of FQ and SXT resistance in leech-related Aeromonas might be more common than previously suspected, and that such resistance might originate from a common source. A broader study of the molecular epidemiology of leech-related Aeromonas is warranted.

Disclosures
All authors: No reported disclosures.
1147. Pseudo-Outbreak of Clostridium paraputrificum Related to Anaerobic Tent Contamination
Authors: Mitchell Kaitlin , Rece Luann , Duster Megan , Shirley Daniel , Safdar Nasia , Chen Derrick 
Published: November 2018

Abstract

Background
Over a 2-month period, eight patient cultures in our clinical microbiology laboratory were positive for Clostridium paraputrificum, an uncommon spore-forming microbe. The possibility of a pseudo-outbreak related to contamination in the laboratory’s anaerobic tent was considered.

Methods
This study occurred at a 505-bed tertiary care university-affiliated teaching hospital. Patient samples were cultured and evaluated following standard protocols, and isolates of C. paraputrificum were identified using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). To identify additional cases, MALDI-TOF MS testing reports were manually reviewed and matched to patient records. Concurrently, the laboratory’s anaerobic tent was sampled after cleaning with isopropyl alcohol (and later with bleach or sporicidal disinfectant) following standard procedures and protocols recommended by the tent manufacturer (Coy). Pulsed-field gel electrophoresis (PFGE) was performed on isolates from patients (n = 8) and the anaerobic tent (n = 6).

Results
Despite cleaning with isopropyl alcohol or bleach, surface samples from the anaerobic tent grew C. paraputrificum. PFGE analysis revealed all patient and anaerobic tent isolates to be indistinguishable, suggesting that they originated from a common source. Growth of the organism from patient samples was therefore regarded as potential contamination. Prior to this, six of the eight patients received antibiotics related to this positive culture and had Infectious Disease consultations. Providers of the patients were contacted regarding the contamination issue. The anaerobic tent manufacturer was consulted and ultimately recommended using Peridox Sporicidal Disinfectant. Six months later, the tent was re-sampled and did not yield positive cultures.

Conclusion
A pseudo-outbreak of the uncommon organism C. paraputrificum was related to insufficient disinfection practices of an anaerobic culture tent. This had negative effects on our institution and patient care in terms of cost, time, and unnecessary treatment. The use of sporicidal disinfectant has since proven effective to prevent contamination from spore-producing microbes.

Disclosures
All authors: No reported disclosures.
1163. Impact of Difficult-to-Treat Resistance on Survival in Gram-Negative Bacteremia: A Risk-Adjusted Analysis Using Electronic Health Record-based Clinical Data From 140 US Hospitals
Authors: Kadri Sameer S , Lai Yi Ling , Ricotta Emily E , Strich Jeffrey , Babiker Ahmed , Rhee Chanu , Klompas Michael , Dekker John P , Powers III John H , Danner Robert L , Adjemian Jennifer ,   NIH Antimicrobial Resistance Outcomes Research Initiative (ARORI)
Published: November 2018

Abstract

Background
In Gram-negative bacteremia (GNB), administrative data suggest that “difficult-to-treat resistance” (DTR; i.e., co-resistance to all first-line antibiotics) increases mortality. However, adequate risk-adjustment for severity of illness (SOI) may require granular laboratory and physiologic data.

Methods
Adult inpatients with GNB were identified from electronic health records (EHRs) of 140 hospitals in the Cerner Healthfacts database between 2009 and 2015. Mortality from DTR (intermediate/resistant in vitro to β-lactams including carbapenems and fluoroquinolones) was compared with GNB phenotypes susceptible to at least one first-line agent, but otherwise resistant to carbapenems (CR), extended-spectrum cephalosporins (ECR), or fluoroquinolones (FQR) per US Centers for Disease Control and Prevention surveillance definitions. Relative risk of mortality was adjusted (aRR) for age, sex, baseline Sequential Organ Failure Assessment (SOFA) score, Elixhauser comorbidity index, GNB source, taxon, hospital vs. community onset, year, and hospital region, bed capacity, and urban and teaching status using Poisson regression.

Results
Of 25,448 unique GNB encounters, 207 (1%) met DTR criteria. DTR patients were 2-fold more likely to receive intravenous colistin and 5-fold more likely to receive tigecycline compared with CR cases susceptible to ≥1 first-line agent. Crude mortality varied considerably by taxon and resistance phenotype, but resistance per se was associated with only a minority of overall deaths (DTR = 3% of deaths; any of the four resistance phenotypes = 28% of deaths; Figure 1). Inclusion of EHR-derived, baseline SOFA scores in SOI adjustments decreased aRR effect estimates; nonetheless, all resistance phenotypes still significantly increased mortality (Figure 2A). Among resistance phenotypes, aRR of mortality was similar for DTR vs. CR (aRR = 1.18; 95% CI, 0.91–1.54; P = 0.2), but higher for DTR vs. ECR (aRR = 1.26 [1.01–1.58]; P = 0.04), and DTR vs. FQR (aRR = 1.36 [1.08–1.70]; P = 0.008), respectively (Figure 2B).

Conclusion
DTR is associated with nonsurvival and greater use of reserve antibiotics in GNB, but adds little to the risk of death associated with CR. The impact of resistance on survival is attenuated but still present even after risk adjustment using granular clinical data.

Disclosures
All authors: No reported disclosures.
1166. Development of a Bedside Tool to Predict the Probability of Drug-Resistant Pathogens Among an Adult Population With Gram-Negative Infections
Authors: Lodise Jr. Thomas P , Bonine Nicole G , Ye J Michael , Folse Henry J , Gillard Patrick 
Published: November 2018

Abstract

Background
Identification of infections caused by antimicrobial-resistant microorganisms is critical to administration of early appropriate antibiotic therapy. We developed a clinical bedside tool to estimate the probability of carbapenem-resistant Enterobacteriaceae (CRE), extended spectrum β-lactamase-producing Enterobacteriaceae (ESBL), and multidrug-resistant Pseudomonas aeruginosa (MDRP) among hospitalized adult patients with Gram-negative infections.

Methods
A retrospective observational study of the Premier Hospital Database (PHD) was conducted. The study included adult hospitalized patients with complicated urinary tract infection (cUTI), complicated intraabdominal infection (cIAI), bloodstream infections (BSI), or hospital-acquired/ventilator-associated pneumonia (HAP/VAP) with a culture-confirmed Gram-negative infection in PHD from 2011 to 2015. Model development steps are shown in Figure 1. The study population was split into training and test cohorts. Prediction models were developed using logistic regression in the training cohort (Figure 1). For each resistant phenotype (CRE, ESBL, and MDRP), a separate model was developed for community-acquired (index culture ≤3 days of admission) and hospital-acquired (index culture &gt;3 days of admission) infections (six models in total). The predictive performance of the models was assessed in the training and test cohorts. Models were converted to a singular user-friendly interface for use at the bedside.

Results
The most important predictors of antibiotic-resistant Gram-negative bacterial infection were prior number of antibiotics, infection site, prior infection in the last 3 months, hospital prevalence of each resistant pathogen (CRE, ESBL, and MDRP), and age (Figure 2). The predictive performance was highly acceptable for all six models (Figure 3).

Conclusion
We developed a clinical prediction tool to estimate the probability of CRE, ESBL, and MDRP among hospitalized adult patients with community- and hospital-acquired Gram-negative infections. Our predictive model has been implemented as a user-friendly bedside tool for use by clinicians to predict the probability of resistant infections in individual patients, to guide early appropriate therapy.

Disclosures
T. P. Lodise Jr., Motif BioSciences: Board Member, Consulting fee. N. G. Bonine, Allergan: Employee, Salary. J. M. Ye, Allergan: Employee, Salary. H. J. Folse, Evidera: Employee, Salary. P. Gillard, Allergan: Employee, Salary.
LB3. Daptomycin Plus Fosfomycin vs. Daptomycin Monotherapy for Methicillin-Resistant Staphylococcus aureus Bacteremia: A Multicenter, Randomized, Clinical Trial
Authors: Pujol Miquel , Miro Jose-Maria , Shaw Evelyn , Aguado Jose Maria , Garrido Rafael San-Juan , Puig Mireia , Pigrau Carle , Calbo Esther , Montejo Jose Miguel , Rodriguez Regino , Garcia-Pais Maria Jose , Pintado Vicente , Escudero Rosa , Lopez-Contreras Joaquin , Morata Laura , Montero Milagro , Andres Marta , Pasquau Juan , Padilla Belen , Murillas Javier , Jover Alfredo , Lopez-Cortes Luis Eduardo , Garcia-Pardo Graciano , Gasch Oriol , Videla Sebastian , Tebe Cristian , Pallares Natalia , Hereu Pilar , Sanllorente Mireia , Dominguez Maria Angeles , Camara Jordi , Padulles Ariadna , Carratala Jordi 
Published: November 2018

Abstract

Background
Daptomycin plus fosfomycin combination has demonstrated synergistic and bactericidal effect in animal models of methicillin-resistant Staphylococcus aureus bacteremia (MRSAB), but there is lack of data in humans.

Method
A randomized (1:1), open-label, clinical trial involving adults with MRSAB was conducted at 18 medical centers in Spain. Patients were assigned to receive daptomycin, 10 mg/kg IV daily plus fosfomycin, 2 g IV/6 hour (combination therapy) or to receive daptomycin 10 mg/kg/24 h IV (monotherapy) during 10 up to 14 days for uncomplicated bacteremia and 28 up to 42 days for complicated bacteremia. The primary efficacy endpoints were: (a) treatment success at Test-of-Cure visit (ToC: 6 weeks after end of therapy) and (b) treatment success at 7 days (defined as alive at day 7 and clearance of bacteremia without relapse from 8 to 90 days after randomization), according with the proposed primary endpoints for use in clinical trials in bloodstream infections in adults.

Result
Between December 2013 and November 2017, 674 patients with MRSAB were evaluated and 155 patients were randomized: 74 received combination therapy and 81 monotherapy. In intention-to-treat analysis, (a) at ToC visit successful outcome was achieved in 40 of 74 patients (54,1%) who received combination therapy as compared with 34 of 81 patients (42%) who were given monotherapy (54.1% vs. 42.0%; absolute difference, 12.1%; 95% confidence interval, 0%-27.0%); (b) at 7 days after starting the therapy: a successful outcome was achieved in 69 of 74 patients who received combination therapy as compared with 62 out of 81 patients who received monotherapy (93.2% vs. 76.5%; absolute difference, 16.7%; 95% confidence interval, 5.4%–27.7%). Combination therapy was associated with lower rates of microbiologic failure than monotherapy at ToC visit (0 vs. 9 patients, P = 0.009). Combination therapy, as compared with daptomycin monotherapy, was associated with a nonsignificantly higher rate of adverse events due to study medication leading to treatment failure and discontinuation of therapy: 6/74 (8.1%) vs. 3/81 (3.7%) (P = 0.31).

Conclusion
The combination of daptomycin plus fosfomycin was more effective than daptomycin alone for treating MRSAB (NCT01898338).

Disclosures
All authors: No reported disclosures.
LB7. Contract Tracing Investigation Following First Case of Andes Virus in the United States
Authors: Kofman Aaron , Eggers Paula , Kjemtrup Anne , Hall Rebecca , Brown Shelley , Choi Mary , Yaglom Hayley , Duwell Monique , Knust Barbara , Klena John , Alvarado-Ramy Francisco , Shoemaker Trevor , Towner Jonathan , Nichol Stuart ,   The Andes Virus Investigation Working Group
Published: November 2018

Abstract

Background
In January 2018, a patient admitted to a Delaware hospital tested positive for New World hantavirus by IgM and IgG ELISA. Subsequent testing by CDC’s Viral Special Pathogens Branch (VSPB) confirmed Andes virus (ANDV) by reverse transcription polymerase chain reaction (RT-PCR) and sequencing. ANDV is transmitted to humans through contact with long-tailed rice rats endemic to Argentina and Chile. Unlike other hantavirus species, ANDV can be transmitted person to person, but transmission is typically limited to close contacts of ill persons. Because of this risk, a contact tracing investigation was initiated by CDC, state and county health departments.

Method
A suspect case was defined as a person with close contact with the traveler who became ill within the maximum incubation period (42 days) following last contact. A high-risk contact was defined as a person with exposure to the traveler’s body fluids. A low-risk contact was defined as a person who had provided care or in-flight service to, or was seated near the traveler for at least 1 hour, in the absence of exposure to body fluids. All contacts were advised to self-monitor their temperature daily for 42 days from last contact, and to seek medical care for any of the specified symptoms. Contacts that developed symptoms were tested for ANDV by RT-PCR and serology by VSPB.

Result
Fifty-three contacts were identified in six states; 51 were successfully reached. Of these, 28 were healthcare workers, 15 were airline contacts, seven were acquaintances of the traveler, and one was a hospital roommate. Two high-risk contacts were identified, both of whom remained asymptomatic. Six low-risk contacts reported influenza-like illness, diarrhea, or mild rhinitis during the incubation period. All six symptomatic low-risk contacts tested negative for ANDV by PCR, IgM, and IgG. The remaining low-risk contacts remained asymptomatic.

Conclusion
Hospitalized patients with ANDV should be managed with standard, contact, and droplet precautions. While the risk of human-to-human transmission is low, contact tracing should be considered to identify potential cases and limit additional exposures. Health providers should consider ANDV in returning travelers with a nonspecific febrile or acute respiratory illness who have traveled to the Andes region of Argentina or Chile in the preceding 6 weeks.

Disclosures
All authors: No reported disclosures.
SWAT Unit Proactive Search Warrant Deployments: A Mixed Effects Model Exploration
Authors: Dobrin Adam , Fallik Seth W , Mello Brian P 
Published: November 2018

Abstract
This research examines American police operations by Special Weapons and Tactics (SWAT) units. In this study, SWAT unit proactive search warrant deployments in Maryland over a 4-year period (2010–13) were analysed to see if they were influenced by violent crime rates, property crimes rates, vice crime rates, and the number of sworn law enforcement officers across four models (two random effects and fixed effects models). The results reveal an inverse relationship between proactive vice type arrests and SWAT unit proactive search warrant deployments. The results are discussed as they inform SWAT unit policies in a democracy.
Clinical Reasoning in Physical Therapy: A Concept Analysis
Authors: Huhn Karen , Gilliland Sarah J , Black Lisa L , Wainwright Susan F , Christensen Nicole 
Published: November 2018

AbstractBackgroundPhysical therapy, along with most health professions, struggles to describe clinical reasoning, despite it being a vital skill in effective patient care. This lack of a unified conceptualization of clinical reasoning leads to variable and inconsistent teaching, assessment, and research.ObjectiveThe objective was to conceptualize a broad description of physical therapists’ clinical reasoning grounded in the published literature and to unify understanding for future work related to teaching, assessment, and research.Design/MethodsThe design included a systematic concept analysis using Rodgers’ evolutionary methodology. A concept analysis is a research methodology in which a concept's characteristics and the relation between features of the concept are clarified.ResultsBased on findings in the literature, clinical reasoning in physical therapy was conceptualized as integrating cognitive, psychomotor, and affective skills. It is contextual in nature and involves both therapist and client perspectives. It is adaptive, iterative, and collaborative with the intended outcome being a biopsychosocial approach to patient/client management.LimitationsAlthough a comprehensive approach was intended, it is possible that the search methods or reduction of the literature were incomplete or key sources were mistakenly excluded.ConclusionsA description of clinical reasoning in physical therapy was conceptualized, as it currently exists in representative literature. The intent is for it to contribute to the unification of an understanding of how clinical reasoning has been conceptualized to date by practitioners, academicians, and clinical educators. Substantial work remains to further develop the concept of clinical reasoning for physical therapy, including the role of movement in our reasoning in practice.
RADIATION EXPOSURE FROM NATURAL RADIONUCLIDES IN BUILDING MATERIALS
Authors: Madruga M J , Miró C , Reis M , Silva L 
Published: November 2018

Abstract
Building materials from Iberian Peninsula (Portugal and Spain) were collected and analysed for 226Ra, 232Th and 40K using HPGe gamma-ray spectrometers. The results show that the highest mean value of 226Ra and 232Th activities are 2168 and 390 Bq kg−1, respectively, measured in zircon. For 40K, this value is 1290 Bq kg−1, measured in granite. The mean concentrations of the three radionuclides in the different building materials, excluding the zircon and the industrial by-products (ashes, gypsum and phosphogypsum), are 62, 31 and 519 Bq kg−1 for 226Ra, 232Th and 40K, respectively. The radiological health hazard parameters: radium equivalent activity (Raeq), activity concentration index (I) absorbed and effective dose rates, associated with these radionuclides, were evaluated. These values are within the EU recommended limits in building materials, except for same samples of aggregates, granites, ceramics, phosphogypsum and zircon. This study will contribute for the worldwide data pooling on the radioactivity of the building materials.
Perioperative Invasive Vascular Catheterization Associated With Increased Risk of Postoperative Infection in Lumbar Spine Surgery
Authors: Compton Edward , Heindel Patrick , Formanek Blake , Schoell Kyle , Buser Zorica , Wang Jeffrey C. 
Published: November 2018

Study Design:
This is a retrospective cohort study.

Objective:
This study’s objective was to determine whether perioperative invasive vascular catheter placement, independent of comorbid conditions, modified the risk of postoperative infection in lumbar spine surgery.

Summary of Background Data:
Infection is a risk inherent to lumbar spine surgery, with overall postoperative infection rates of 0.86%–8.5%. Patients experiencing postoperative infection have higher rates of mortality, revision surgeries, pseudarthrosis, and worsening pain and disability.

Methods:
Data were collected for patients undergoing lumbar spine surgery between January 2007 and October 2015 with records in the nationwide Humana private insurance database. Patients receiving fusion, laminectomy, and discectomy were followed for 3 months from the date of surgery for surgical site infection (SSI), 6 months for subsequent incision and drainage (I&D), and 1 year for vertebral osteomyelitis (VO). Risk factors investigated included central venous catheter and arterial-line placement.

Results:
Analysis of 114,259 patient records showed an overall SSI rate of 3.2% within 1 month and 4.5% within 3 months, overall vertebral osteomyelitis rate of 0.82%–0.83% within 1 year, and overall I&D rate of 2.8% within 6 months. Patients receiving a first-time invasive vascular catheter on the day of surgery were more likely to experience SSI within 1 month [risk ratios (RR), 2.5, 95% confidence interval (CI): 2.3–2.7], SSI within 3 months (RR, 2.4; 95% CI: 2.3–2.7), osteomyelitis within 1 year (RR, 4.2–4.3; 95% CI: 3.7–4.5), and undergo an I&D within 6 months (RR, 1.9; 95% CI: 1.8–2.0). These trends were consistent by procedure type and independent of the patient’s weighted comorbidity index score (Charlson Comorbidity Index).

Conclusions:
Perioperative invasive vascular catheterization was significantly associated with an increased the risk of postoperative infections in lumbar spine surgery, independent of a patient’s concomitant comorbidities. Therefore, in patients with an indication for invasive catheterization, surgeons should consider risks and benefits of surgery carefully.

Level of Evidence:
Level III.