bluuebunny/crossref_metadata_2025_split huggingface dataset:
925. Healthcare-Associated Legionnaires’ Disease, California, 2015–2017
Authors: Kim Janice , Rizzo Kyle , O’Malley Sean , Magro Monise , Rosenberg Jon 
Published: November 2018

Abstract

Background
Legionnaires’ disease (LD) causes significant morbidity and mortality to hospital patients and residents of skilled nursing facilities (SNF). In California, LD is reportable to local health departments via the California Reportable Disease Information Exchange (CalREDIE) surveillance system. Cases are classified as suspected or confirmed using Centers for Disease Control and Prevention (CDC) definitions. The California Department of Public Health (CDPH) Healthcare-Associated Infections (HAI) Program maintains a database of healthcare-associated LD (HA-LD) and consults with local public health departments for single cases and outbreaks.

Methods
We described characteristics of confirmed HA-LD cases in 2015–2017. We classified HA-LD as definite if patient had continuous exposure in a facility for 2–10 days prior to symptom onset and possible if patient had overnight exposure in a facility for a portion of 2–10 days prior to symptom onset.

Results
From 2015 to 2017, 125 (8%) of 1,554 confirmed LD cases were HA-LD. Of these, 73 (58%) were definite HA-LD and 52 (42%) were possible HA-LD. The majority of HA-LD cases (N = 99, 79%) occurred in southern California. SNF were associated with 57 cases (46%) and hospitals with 44 cases (35%); 23 cases (18%) had exposures in both SNF and hospitals during the incubation period. Among the definite HA-LD cases, 50 cases (68%) had exposures in a single SNF. The median age of patients with HA-LD was 77 years. The HAI Program consulted with 15 local public health agencies on 33 HA-LD investigations, including 7 outbreaks and 26 single-case investigations.

Conclusion
HA-LD represented a small but important percentage of LD in California; the majority occurred in SNF. To prevent HA-LD, California hospitals and skilled nursing facilities should implement water management programs, as recommended by CDC and required by the Centers for Medicare and Medicaid Services (CMS) since June 2017. Public health agencies should respond rapidly to investigate HA-LD cases and control outbreaks.

Disclosures
All authors: No reported disclosures.
928. Major Decrease in Prevalence of Hepatitis C Viremia in Key Populations following the Second Year of Treatment as Prevention for Hepatitis C (TraP HepC) Program in Iceland
Authors: Gottfredsson Magnus , Tyrfingsson Thorarinn , Runarsdottir Valgerdur , Hansdottir Ingunn , Bergmann Ottar M , Bjornsson Einar S , Johannsson Birgir , Sigurdardottir Bryndis , Fridriksdottir Ragnheidur H , Löve Arthur , Löve Thorvardur J , Sigmundsdottir Gudrun , Hernandez Ubaldo , Heimisdottir Maria , Olafsson Sigurdur 
Published: November 2018

Abstract

Background
Hepatitis C Virus (HCV) commonly affects people who inject drugs (PWID) and/or with history of injection drug use (IDU). They are also disproportionately represented in addiction treatment centers and the penitentiary system. In order to curtail spread of HCV it is therefore important to approach these groups. PWID and prisoners have been prioritized in the TraP HepC program. The impact can thus be assessed by monitoring HCV prevalence at sentinel sites, such as addiction hospitals and prisons.

Methods
TraP HepC offers direct-acting antiviral agents (DAAs) to all HCV patients in Iceland, starting in January 2016. HCV PCR is performed at the end of treatment and 12 weeks later (SVR12). PWID and prisoners are monitored for reinfection and retreated if needed. We compared the prevalence of HCV viremia among PWID admitted for treatment at Vogur addiction hospital and inmates of the penitentiary system, before and after 2 years of TraP HepC.

Results
Two years into the program 667 patients had been evaluated of which 632 were initiated on their first course of DAAs and 7 were pending, representing 80% of the estimated total patient population. Of those who completed first treatment according to guidelines the SVR12 is 95.5%. Drop-out from first treatment was 8.2%; nevertheless, the SVR12 was &gt;40% and most of the remaining viremic patients completed or are undergoing retreatment. In 2012–2015, prior to TraP HepC the prevalence of HCV viremia among actively injecting PWID admitted for addiction treatment was 47.9%, dropping to 39.8% in 2016 and 16.2% in 2017 (P &lt; 0.001). Likewise, the prevalence of viremia among patients with history of IDU but not recently injecting fell from 27.4% (2012–2015) to 19.8% in 2016 and 4.1% in 2017 (P &lt; 0.001). The prevalence of viremia among inmates of the penitentiary system was 29% prior to initiation of TraP HepC, dropping to 7% in 2017 (P &lt; 0.01). These results are not explained by declining IDU in the community.

Conclusion
On a population level the domestic transmission of HCV can be reduced by DAAs when combined with other efforts. Two years into the TraP HepC program the prevalence of viremia among two of the most important drivers of the epidemic has been markedly reduced. The program is ongoing, with further emphasis on increased intensity of screening, retreatment and harm reduction.

Disclosures
All authors: No reported disclosures.
964. Impact of Doxycycline as Malaria Prophylaxis on Risk of Influenza Like Illness Among International Travelers
Authors: Lago Kathryn , Telu Kalyani , Tribble David R , Ganesan Anuradha , Kunz Anjali , Geist Charla , Fraser Jamie , Mitra Indrani , Yun Heather 
Published: November 2018

Abstract

Background
International travelers are often at risk for both influenza like illness (ILI) and malaria. Doxycycline is active against many pathogens causing ILI and is routinely used for malaria prophylaxis. We evaluated the incidence of and risk factors for ILI, and whether the choice of malaria prophylaxis was associated with ILI.

Methods
TravMil is a prospective observational study enrolling subjects presenting to 6 military travel clinics. We analyzed pre- and post-travel surveys from travelers to regions outside of the continental United States, Western or Northern Europe, Canada, or New Zealand between July 2010 and August 2018. ILI was defined as subjective fever associated with either a sore throat or cough. Characteristics of trip and traveler and the use of malaria prophylaxis were analyzed to determine association with development of ILI. Poisson regression models with robust error variance were used to estimate relative risk of ILI.

Results
A total of 3,227 travelers were enrolled: 62.1% male, median age of 39 (IQR 27, 59), median travel duration 19 days (IQR 12, 49). 32% traveled to Africa, 40% to Asia, and 27% to the Caribbean, Mexico, and Central or South America. Military travel (46%) and vacation (40%) were most common reasons for travel. Twenty percent took doxycycline for malaria prophylaxis, 50% other prophylaxis (89% atovaquone–proguanil), and 30% took none. 8.7% developed ILI. Compared with those on no or other prophylaxis, doxycycline was associated with decreased risk of ILI [RR 0.65 (0.43–0.99), P = 0.046], as was military travel [RR 0.30 (0.21–0.43), P &lt; 0.01]. Increased risk of ILI was associated with female gender [RR 1.57 (1.24–1.98), P &lt; 0.01], travel to Asia [RR 1.37 (1.08–1.75), P = 0.01], cruises [RR 2.21 (1.73–2.83), P &lt; 0.01], and longer duration of travel [RR 1.01 (1.00–1.01, P &lt; 0.01].

Conclusion
The use of doxycycline is associated with a decreased risk of ILI compared with taking no or other malaria prophylaxis. The reasons for this are unclear but may be related to anti-inflammatory effects, activity against bacterial respiratory pathogens, effects on disease transmission in closed populations (e.g., military deploying groups), or other unmeasured factors. With few proven strategies for decreasing ILI risk in travelers, these findings bear further investigation.

Disclosures
All authors: No reported disclosures.
966. Infectious Diseases among US Resident Student Travelers after Return to the United States: A GeoSentinel Analysis, 2007–2017
Authors: Angelo Kristina M , Haulman Jean , Terry Anne , Leung Daniel , Chen Lin H , Barnett Elizabeth , Hagmann Stefan , Hynes Noreen , Connor Bradley , Anderson Susan , Hamer Davidson 
Published: November 2018

Abstract

Background
The number of US students studying abroad has more than tripled over the past 20 years. As study abroad programs diversify their destinations, more students are traveling to developing regions, increasing their risk of infectious diseases. Few data exist describing infections acquired by US students while traveling internationally. We describe the spectrum of disease among students who have returned from international travel and suggest how to reduce illness among these travelers.

Methods
GeoSentinel is a global network of travel and tropical medicine providers that monitors travel-related morbidity. Records of US resident student travelers, 17–24 years old, who returned to the United States and were given a confirmed travel-related diagnosis at one of 15 US GeoSentinel sites during 2007–2017. Those without ascertainable exposure regions were excluded. Records were analyzed to describe demographic and travel characteristics and diagnoses.

Results
There were 432 students included. The median age was 21 years; 69% were female. Over 70% had a pretravel consultation with a healthcare provider. The most common exposure region was sub-Saharan Africa (112 travelers; 26%); the most common exposure countries were India (44 students; 11%), Ecuador (28; 7%), Ghana (25; 6%), and China (24; 6%). Students presented to a GeoSentinel site a median of 8 days (range: 0–181) after travel; 98% were outpatients. The most common diagnosis categories were gastrointestinal (45%) and dermatologic (17%). Of 581 confirmed diagnoses, diarrheal illnesses were most common (165; 28%). Thirty-one (7%) students had a vector-borne disease; 14 (41%) of these were diagnosed with malaria (13 had a pretravel consultation) and 11 (32%) with dengue. Two students were diagnosed with acute HIV. Three had a vaccine-preventable disease (two typhoid; one hepatitis A).

Conclusion
Students experienced travel-related infections despite a large proportion receiving pretravel consultations. Students (especially those traveling to a less developed region) should receive specific pretravel instructions (including suggestions for behavioral modification, vaccination, and medication prophylaxis when applicable) to prevent gastrointestinal, vector-borne, sexually transmitted, and vaccine-preventable diseases.

Disclosures
All authors: No reported disclosures.
968. Managing Invasive Aspergillosis in the Era of Diagnostic PCR and Increasing Triazole Resistance: A Modeling Study of Different Strategies
Authors: Van De Peppel Robert , Van Der Beek Martha , De Boer Mark , Wallinga Jacco 
Published: November 2018

Abstract

Background
Triazole resistance in Aspergillus spp. is emerging and complicates prophylaxis and treatment of invasive Aspergillosis (IA) worldwide. New polymerase chain reaction (PCR) tests on broncho-alveolar lavage (BAL) fluid allow for detection of triazole resistance on a genetic level, which opened up new possibilities for targeted therapy. In the absence of clinical trials, a modeling study delivers estimates of the added value of resistance detection with PCR and which empiric therapy would be optimal when local resistance rates are known.

Methods
We performed a decision-analytic modeling study based on epidemiological data of IA, extended with estimated dynamics of resistance rates and treatment effectiveness. We compared 6 clinical strategies that differ in the use of PCR diagnostics (A: not used, B: used) and in empiric therapeutic choice in case of unknown triazole susceptibility: Voriconazole (1, VOR), Liposomal Amphotericin B (2, LAmB), or both (3). Outcome measures were proportion of correct treatment, survival, and serious adverse events.

Results
Implementing Aspergillus PCR tests was projected to result in residual treatment susceptibility mismatches of &lt;5% for a triazole resistance rate up to 20% (using VOR). Empiric LAmB outperformed VOR at resistance rates higher than 5–20%, depending on PCR use and estimated survival benefits of VOR over LAmB (Figure 1). Combination therapy of VOR and LAmB performed best at all resistance rates but the advantage over the other strategies should be weighed against the expected increased number of drug-related serious adverse events (Figure 2). The advantage of combination therapy over LAmB monotherapy became smaller at higher triazole-resistance rates.

Conclusion
Introduction of current Aspergillus PCR tests on BAL-fluid is an effective way to increase the proportion of patients that receive targeted therapy for IA. The results indicate that close monitoring of background resistance rates and of adverse drug events are important to attain the potential benefits of LAmB. The choice of strategy ultimately depends on the probability of triazole resistance, the availability of PCR, and individual patient characteristics.

Disclosures
All authors: No reported disclosures.
971. Breakthrough Invasive Fungal Infections (IFI) in Acute Leukemia (AL) Patients Receiving Antifungal Prophylaxis
Authors: Wasylyshyn Anastasia , Castillo Caroline , Linder Kathleen A , Zhou Shiwei , Kauffman Carol A , Miceli Marisa H 
Published: November 2018

Abstract

Background
A major challenge in patients with AL receiving chemotherapy is to decrease the risk of IFI during the prolonged neutropenic period. Even with antifungal prophylaxis, the incidence of breakthrough IFI can be as high as 14%. Our objectives were to determine the incidence of all IFI and breakthrough IFI, to define risk factors associated with IFI, and to assess outcomes.

Methods
Single-center retrospective cohort analysis of all adult patients admitted to the University of Michigan for AL from January 1, 2010 to December 31, 2013. Chart review determined co-morbidities, chemotherapy regimens, antifungal prophylaxis, occurrence of IFI as determined by EORTC/MSG criteria, and outcomes. Chi-square, Fischer’s, ANOVA, and binary logistic regression tests were performed when appropriate.

Results
Of 363 patients, all but 4 had acute myeloid leukemia (AML); 124 had a stem cell transplant (SCT). A total of 103 (28%) had proven (n = 13), probable (n = 22), or possible (n = 68) IFI. Considering only those 35 patients who had proven or probable IFI, the only risk factor for development of IFI by logistic regression analysis was IFLAG chemotherapy (P = .006). Mold infections occurred in 27 patients: Aspergillus (19), Mucorales (5), both Aspergillus and Mucorales (1), Alternaria (1), and Scedosporium (1). Additionally, 5 patients had invasive candidiasis and 3 had Pneumocystis. Eighteen of 35 patients (51%) had breakthrough IFI while on posaconazole suspension (6), fluconazole (5), micafungin (5) or voriconazole (2). Factors significantly associated with breakthrough IFI were SCT (P = .04), neutrophils &lt;500, ≥10 days at diagnosis (P = .002) and prophylaxis with posaconazole suspension (P = .003). Twelve-week mortality in proven and probable IFI was 31% (11/35). Nine of 11 deceased patients had breakthrough IFI; 8 of whom (5 with mold IFI and 3 with invasive candidiasis) died of the fungal infection.

Conclusion
Patients receiving chemotherapy for AL remain at risk for IFI despite the the use of antifungal prophylaxis. In our study, prophylaxis with posaconazole suspension was found to be an independent risk factor for breakthrough IFI. Mortality was high among patients with breakthrough IFI.

Disclosures
All authors: No reported disclosures.
974. Impact of Mandatory Infectious Disease (ID) Specialist Approval on Hospital-Onset Clostridium difficile (HO-CDI) Testing and Infection Rates: Results of a Pilot Study
Authors: Lin Michael Y , Wiksten Tiffany , Tomich Alexander , Hayden Mary K , Segreti John 
Published: November 2018

Abstract

Background
The 2017 IDSA C. difficile guidelines recommend the use of nucleic acid amplification testing alone for detection of HO-CDI if appropriate stool specimens are collected (e.g., patients not receiving laxatives and ≥3 unformed stools in 24 hours). The potential role of ID specialists in enforcing appropriate C. difficile testing is unclear.

Methods
At a single academic hospital, we performed a pilot study of an ID specialist-led approval process for C. difficile testing. During the baseline period (January 2016 and November 2017), HO-CDI testing appropriateness was enforced using a computerized decision support tool that discouraged inappropriate testing based on detected laxative use and stool frequency criteria; however, clinicians frequently ignored the computer alerts. During the intervention period (December 2017 and March 2018), all HO-CDI testing on hospital day 4 or later triggered a computer alert requesting mandatory testing approval by an ID specialist. Approvals were provided via telephone consultation 7 days a week between 8 a.m. and 5 p.m. (in both periods, CDI testing was not performed overnight). We analyzed differences HO-CDI testing and infection rates (defined by CDC’s LabID event) per 10,000 patient days using Poisson models. We also analyzed the number of approval pager calls, rates of C. difficile testing approval, and time burden.

Results
Two infectious diseases specialists (M.Y.L.; J.S.) primarily answered C. difficile pager approval requests; the remainder of approvals were provided by ID specialists already consulted on the patients. During the intervention period, ordering providers made 159 calls to the approval pager; 119 (75%) received approval. HO-CDI testing and infection rates declined between the baseline and intervention periods (figure). There was a mean of 1.3 pager approval requests per day (range, 0–4) with an average of 3 minutes of time spent per request.

Conclusion
An ID specialist-led C. difficile testing approval process was feasible and associated with a significant decrease in HO-CDI testing and infection rates, due to enforcement of appropriate testing. ID specialists can provide a key role in enforcing appropriate C. difficile testing, but more experience is needed with respect to sustainability.

Disclosures
M. Y. Lin, Stryker (Sage Products): Research support in the form of contributed product, Research support. OpGen, Inc: Research support in the form of contributed products, Research support. CareFusion Foundation (now BD): Grant Investigator, Research grant.
979. Standardizing Medical Student Learning for Infectious Diseases Consult Electives: Prioritizing Content
Authors: Abdoler Emily , Hauer Karen , Schwartz Brian 
Published: November 2018

Abstract

Background
The goals of 4th-year medical student electives vary, and students’ learning during clinical electives may occur solely through the subspecialty cases that students encounter. We aim to standardize learning during electives by creating a toolkit to guide elective directors in the development of curricula that reinforce basic science principles, highlight areas for high-value care, and provide opportunities for further inquiry. The first step is to determine the core specialty topics applicable to students regardless of career choice. Here, we describe this content prioritization process within the context of an infectious diseases (ID) elective pilot curriculum.

Methods
We conducted a modified, 2-round Delphi process to develop consensus on ID topics that all graduating medical students should know. Through review of the literature for common diagnoses and high value care, and the medical school curriculum, the authors generated an initial list of 16 topics. An interdisciplinary group of 90 expert faculty educators from Internal Medicine, Family Medicine, Emergency Medicine, and Surgery rated these topics’ importance using a 5-point Likert scale, from 0 (absolutely do not include) to 4 (very important). We considered items rated at least 3 (important) by at least 80% of participants to have reached consensus.

Results
Sixty of 90 (67%) educators responded to the initial survey, and 48/60 (80%) completed both surveys. Nine additional topics were proposed by first-round participants. After the second round, 14 topics met the consensus criterion. Many common conditions, several dangerous infections, and infectious issues overrepresented in the local population met consensus. However, while many of the topics failing to meet consensus addressed rare conditions or those typically managed by subspecialists, some were also common conditions.

Conclusion
Standardizing medical student learning during elective rotations begins with identifying key topics. Our process included a diverse group of educators to determine key topics. We will use this list to guide the content of a new asynchronous, online ID elective curriculum, and we will describe our process as part of a curriculum development toolkit for other elective directors.

Disclosures
All authors: No reported disclosures.
1633. A Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection in Adults and Children in Emergency Department and Urgent Care Settings (MITIGATE Trial)
Authors: Yadav Kabir , Meeker Daniella , Mistry Rakesh , Doctor Jason , Fleming-Dutra Katherine , Fleischman Ross , Gaona Samuel , Stahmer Aubyn , May Larissa 
Published: November 2018

Abstract

Background
Antibiotics are prescribed in approximately half of emergency department (ED) and urgent care center (UCC) visits for antibiotic inappropriate or presumed viral acute respiratory infection (ARI). Unnecessary antibiotic use increases adverse events, antibiotic resistance, and healthcare costs. Antibiotic stewardship in the ED and UCC requires specific implementation tailored to these unique settings.
Objective. To evaluate the comparative effectiveness of patient and provider education adapted for the acute care setting (adapted intervention) to an intervention with behavioral nudges and individual peer comparisons (enhanced intervention), on reducing inappropriate antibiotic use for ARI in EDs and UCCs.

Methods
Pragmatic, cluster randomized clinical trial conducted in 3 academic health systems (1 pediatric-only, 2 serving adults and children) that included 5 adult and pediatric EDs and 4 UCCs. Sites were block randomized by health system, and providers at each site assigned to receive the adapted or enhanced intervention. Implementation science strategies were employed to tailor interventions at each site. The main outcome was the proportion of antibiotic inappropriate ARI diagnosis visits that received an antibiotic. We estimated a hierarchical mixed effects logistic regression model for visits that occurred between November and February for 2016–2017 (baseline) and 2017–2018 (intervention), controlling for organization and provider fixed effects.

Results
Across all sites, there were 45,160 ARI visits among 534 providers, with overall antibiotic prescribing at 2.6%; the pediatric-only system had a lower baseline rate (1.6%) compared with the other 2 systems (5.0% and 7.1%), P &lt; 0.001). Despite the unusually low rate, we found a significant reduction in inappropriate prescribing after adjusting for health-system and provider-level effects from 2.6% to 1.4 % (odds ratio 0.52; 0.38–0.72). Reductions in prescribing between the 2 interventions were in the expected direction, but not significantly different (P &lt; 0.062).

Conclusion
Implementation of antimicrobial stewardship for ARI is feasible and effective in the ED and UCC settings. The enhanced behavioral nudging methods were not more effective in high-performance settings.

Disclosures
All authors: No reported disclosures.