bluuebunny/crossref_metadata_2025_split huggingface dataset:
1255. First Outbreak Due to Vancomycin-Resistant Enterococcus Epidemic Clone ST796 in Europe
Authors: Wassilew Nasstasja , Rolli Eveline , Fietze Yvonne , Casanova Carlo , Seth-Smith Helena , Egli Adrian , Marschall Jonas , Buetti Niccolo 
Published: November 2018

Abstract

Background
A large outbreak with different clones of vancomycin-resistant enterococci (VRE) affected the Bern University Hospital group for several months. The aim of this study was to describe the extent of the outbreak, using whole-genome sequencing (WGS).

Methods
Triggered by two cases of VRE bloodstream infections on our hemato-oncology ward, an outbreak investigation was started. Microbiological diagnosis of VRE was obtained by culture and PCR. Epidemiological links were assessed by meticulous chart review and supplemented with WGS analyses. Multiple infection control measures were implemented to avoid further transmissions.

Results
Between December 2017 and April 2018, 2,877 screening samples were obtained from 1,200 patients. Three out of six hospitals within the Bern University Hospital group were affected. Eighty-three patients (6.9%) were colonized with VR Enterococcus faecium. Of those, 76 (91.6%) had a strain carrying vanB, with 70 (84%) isolates virtually identical (separated by up to two alleles) by cgMLST and identified as MLST type ST796 (figure). The remaining seven patients (8.4%) were colonized with vanA carrying strains from five different STs. Five patients (7%) developed an invasive infection with VRE ST796. Temporo-spatial links were found in most patients carrying the outbreak strain. In order to control the outbreak, extensive infection control measures were implemented. By April 2018 the outbreak was contained with these specific measures.

Conclusion
This VRE outbreak was characterized by a rapid intra- and inter-institutional spread of the emergent clone ST796. This clone was recently described in Australia and New Zealand but never before in Europe.1,2 A multi-faceted infection control led to the containment of the outbreak.

References
1. Mahony AA, et al. Vancomycin-resistant Enterococcus faecium sequence type 796—rapid international dissemination of a new epidemic clone. Antimicrob Resist Infect Control. 2018:7:44.
2. Leong KWC, et al. Emergence of vancomycin-resistant Enterococcus faecium at an Australian Hospital: a whole genome sequencing analysis. Sci Rep. 2018:8(1):6274.
3. de Been M, et al. Core genome multilocus sequence typing scheme for high- resolution typing of Enterococcus faecium. J Clin Microbiol. 2015:53(12):3788–97.

Disclosures
All authors: No reported disclosures.
1265. Application of the ALERT Influenza Trigger for Enhanced Prevention Activities
Authors: Veach Lisa , Gibbons Julie , Smolka Katarina , Ramachandran Veena 
Published: November 2018

Abstract

Background
Accurate prediction of the onset of increased influenza activity in a healthcare setting can allow for optimal use of enhanced prevention activities. The ALERT (Above Local Elevated Respiratory Illness Threshold) algorithm, described by Reich et al. (2015), utilizes historical weekly case counts of laboratory-confirmed influenza infections to set a trigger point of cases/week that anticipates elevated disease incidence. This can then be used in real-time, during subsequent influenza seasons, for initiation of enhanced prevention, including masking by nonvaccinated healthcare workers.

Methods
Historical data collected from UnityPoint Health-Des Moines (3-hospital, 800-bed system), between 2011 and 2014, was analyzed using the ALERT method (Reich et al. 2015) to set a threshold number of diagnosed influenza cases per week to predict the start of the influenza season. Each following year the threshold was re-analyzed, adding the most recent year’s data to the historical data set. Our goal was to capture at least 80% of influenza cases within our “ALERT period,” without prolonging the duration of heightened prevention efforts.

Results
For the initial year of real-time application (2015–2016), the threshold was defined as seven cases. In subsequent years, the threshold was 5. Compared with the 3 years prior, use of the ALERT method resulted in more accurate and consistent identification of the influenza season, including anticipating the increase in cases and defining the total duration of the season.

Conclusion
The ALERT method utilizes health system specific historical data to more precisely define the period of high influenza incidence allowing for focused utilization of enhanced measures to prevent transmission. This results in a safer environment, optimal use of resources and improved employee and patient satisfaction.

Disclosures
All authors: No reported disclosures.
1268. Transmissibility of Candida auris by Type of Inpatient Healthcare Facility
Authors: Paul Prabasaj , Forsberg Kaitlin , Vallabhaneni Snigdha , Lockhart Shawn R , Litvintseva Anastasia P , Kerins Janna L , Tang Angela S , Jegede Olufemi , Barrett Patricia M , Ross Kathleen , Slayton Rachel , Jernigan John A 
Published: November 2018

Abstract

Background
Candida auris is a multidrug-resistant yeast causing outbreaks in healthcare settings. Stopping the spread of C. auris requires rapid identification of healthcare facilities at risk of higher transmission to help targeted implementation of infection control measures. We used data collected during public health investigations to quantify transmissibility of C. auris by type of healthcare facility.

Methods
In two states, 3,159 patient swabs were collected during 96 C. auris point prevalence surveys conducted at 36 inpatient healthcare facilities in November 2016 and April 2018. We estimated facility transmissibility and facility reproduction number (number infected by one index colonized patient per day, and per stay, respectively, at the facility) of C. auris based on estimated colonization pressure, a count of newly colonized patients between successive surveys at the same facility, and mean lengths of stay at facilities (estimated from CMS administrative data). The results were summarized by facility type: acute care hospital (ACH), long-term acute care hospital (LTACH) or ventilator unit at skilled nursing facility (VSNF), and were compared with previous estimates for transmissibility of carbapenem-resistant Enterobacteriaceae (CRE).

Results
Swabs were collected from 13 ACHs, 12 LTACHs, and 11 VSNFs. The C. auris facility reproduction number may exceed the critical value of 1 in both ACHs and VSNFs, and may exceed that for CRE in ACHs (table).

Conclusion
Transmissibility of C. auris is comparable to that of CRE. The transmissibility within VSNFs emphasizes their potential role as amplifiers in the outbreak. Understanding transmissibility by facility type helps evaluate the potential impact of interventions in various settings.

Disclosures
All authors: No reported disclosures.
1269. HIV Testing in a Large Community Health Center Serving a Multi-cultural Population: A Qualitative Study of Providers
Authors: James Anthony , Marable Danelle , Cubbison Caroline , Tarbox Andrew , Oo Sarah , Freedberg Kenneth , Levison Julie 
Published: November 2018

Abstract

Background
In the United States, 15% of people with HIV (PWH) do not know their serostatus, leading to both individual morbidity and HIV transmission to others. While CDC guidelines recommend HIV screening for all individuals aged 13–64 years, racial and ethnic minorities in the United States continue to present to care with advanced HIV infection.

Methods
Our objective was to assess providers’ perspectives on barriers to and facilitators of HIV testing at an urban community health center serving a predominantly racial/ethnic minority population of low socio-economic status. Study staff conducted five focus groups from January 2017 to November 2017 with 74 health center staff: 20 adult medicine/primary care providers, 28 community health workers (CHWs), six urgent care physicians, six community health administrators, and 14 behavioral health providers. Each focus group ranged from six to 20 participants. In addition to exploring participants’ views on HIV testing in this setting, we also explored potential interventions to improve HIV testing. Interviews were digitally recorded. Data were analyzed using a grounded theory approach. We used open coding to develop themes and compared themes among provider groups.

Results
The main facilitators of routine HIV testing were clinical training in HIV/hepatitis care and CHWs engaging patients in topics that intersect with HIV risk factors. Providers’ perceptions of key barriers were patients’ cultural perceptions of HIV (e.g. HIV-related stigma), patients’ concerns about test confidentiality, competing medical and social issues, and provider lack of HIV knowledge. All groups agreed that HIV testing should occur through the primary care provider though acknowledged that patients may be seeking healthcare more frequently through mental health, urgent care, or social services than primary care. Primary care physicians wanted easier mechanisms to identify patients in need of HIV testing and assistance with offering the test to non-English language speaking patients.

Conclusion
Specific, focused efforts can lead to improved HIV testing in racial ethnic minorities in community health centers. Training to improve provider comfort, increasing CHW engagement, and a focus on patients’ cultural beliefs may all have an impact.

Disclosures
All authors: No reported disclosures.
1270. Are HIV-Related Diagnostics Excessively Ordered? A Pilot Intervention Study to Improve Test Use in the Inpatient Setting
Authors: Asl Daryush Tabatabai , Sikand Harminder , Sullivan Eva , Crum-Cianflone Nancy 
Published: November 2018

Abstract

Background
Excessive ordering of HIV-related laboratory tests (CD4 counts, HIV RNA levels, and HIV genotypes) may result in increased healthcare costs, unneeded interventions (e.g., response to low CD4 in acute illness), and patient anxiety. Recent data have evaluated methods to reduce excessive testing in outpatients, but there are limited data in the inpatient setting. The purpose of this study was to evaluate if implementation of a pharmacist-driven intervention protocol based on published guidelines improved utilization of HIV-related diagnostics in the inpatient setting.

Methods
A pre-interventional study performed on HIV diagnostics usage over a 1-year period, followed by a 3-month post-interventional study at a large academic medical center to evaluate and improve HIV test ordering. Patients were included if ≥18 years old with suspected or documented HIV infection and CD4 count, HIV RNA level, or HIV genotype ordered. A pharmacist-driven intervention was undertaken in which ordered tests were evaluated and canceled if deemed inappropriate per pre-specified criteria based on CDC and DHHS guidelines, and clinicians were provided education on appropriate ordering. Results were tabulated and presented as descriptive statistics, and financial data were calculated based on in-hospital costs.

Results
In the pre-intervention arm, 87% (296/341) of total tests ordered did not meet criteria for appropriate ordering (160 unneeded CD4 counts, 126 RNA levels, and 10 genotypes). These tests resulted in excessive financial burden of $24,600. Post-intervention, 63% (32/51) of HIV-related tests were canceled netting an initial savings of $2,700. Most common cancelation reason was recent outpatient laboratories readily available. Post-intervention, HIV-related testing decreased over time, likely due to the intervention audit and feedback provided to clinicians.

Conclusion
A pharmacist-driven intervention reduced the number of unnecessary HIV-associated tests by 63% and offered significant cost savings. These data suggest the importance of evaluating the appropriateness of HIV-related diagnostic testing in the inpatient setting to improve test usage and reduce excessive healthcare costs.

Disclosures
All authors: No reported disclosures.
1271. Prevalence and Factors Associated With HIV Testing Among Sexually Experienced 18–49-Year-Old Hong Kong Residents
Authors: Zhao Yanping , Parish William , Yang Li-Gang , Emch Michael , Ho King Man , Fong Francois Yeung , Miu Heidi Yin Hai , Tucker Joseph D , Wong William Chi Wai 
Published: November 2018

Abstract

Background
The main HIV transmission route in Hong Kong is sex, accounting for 78.0% of the total reported cases. The majority of HIV cases were identified among those 20 to 49 years of age. In this study, we explored the prevalence and factors associated with HIV testing among 18 to 49 years old residents in Hong Kong.

Methods
A population-based survey on sexual practice and health behavior was conducted in Hong Kong with a sample of 881 participants drawn from geospatial modeling, proportional to the district population sizes. Invitation letters were sent to selected households and interviewers were sent to recruit one subject per household. Once recruited, face-to-face interviews were carried out with a computer-assisted self-interview. The final data were weighted according to the 2011 Hong Kong census and factors identified through logistic regression.

Results
Among 881 participants, 81.6% reported having sex before, among whom, 19.5% (137) had ever taken HIV tests. The main reasons for the 75.5% of participants not taking HIV testing are they do not think they are at risk of HIV infection (59.1%) or think they are very healthy (29.4%). The main places for HIV testing among those tested were public hospital/clinic (39.7%), private clinic/hospital (34.7%), and another 22.0% was tested in antenatal check-up or Hong Kong Red Cross. Among the sexually experienced residents, factors associated with HIV testing include marital status and number of sexual partners. Compared with single participants, those cohabiting, married, or with marital history were about seven times more likely to be tested (aOR = 6.73, 95% CI 2.23–20.31). Those who had &gt;1 sexual partners were about twice as likely to be tested (aOR = 1.84, 95% CI 1.05–3.25). Other factors such as condom use, sexual orientation, anal sex behaviors or sexually transmitted infections history were not associated with HIV testing.

Conclusion
HIV testing among Hong Kong residents is comparatively low. Though those with more than one sexual partner are more likely to be tested, those single, nonconsistent condom users, or with risky behavior such as anal sex behaviors do not associate with higher HIV testing. More HIV testing campaign and awareness raising shall be targeted toward people with at-risk behaviors.

Disclosures
All authors: No reported disclosures.
1274. Universal HIV and HCV Screening in San Diego Emergency Departments: Implications for Other Settings With a High Density of Free of Charge HIV Screening Programs
Authors: Hoenigl Martin , Coyne Chris , Blumenthal Jill , Vilke Gary , Little Susan 
Published: November 2018

Abstract

Background
While HIV and HCV testing targeted to high-risk groups results in substantially higher proportions of HIV diagnoses, universal HIV and HCV screening in emergency department (ED) settings is expected to reach populations who do not perceive themselves to be at risk or are otherwise less likely to participate in HIV and HCV testing. As a consequence the CDC recommends routine HIV screening for persons 13–64 years of age, and routine HCV screening for the birth cohort (born between 1945–1965). The objective of this analysis was to evaluate the yield of universal opt-out HIV and HCV screening in the two EDs at the University of California San Diego (UCSD).

Methods
In July 2017, electronic medical record (EMR) based universal opt-out HIV screening (Architect HIV antibody [Ab]/HIV p24 antigen detection) for persons aged 13–64 years (excluding persons known HIV+ or reporteing an HIV test within the last 12 months) was implemented in our EDs. The EMR algorithm also identified HIV+ individuals who had been out of care for &gt;12 months. In March 2018, EMR based universal HCV screening for birth cohort was added in both EDs.

Results
Over a period of 9 months 7,303 HIV tests were conducted, resulting in 24 (0.3%) new HIV diagnoses, of which 21 were successfully linked to care. In five individuals without HIV infection Architect gave a false-positive result (specificity 99.93%). In addition, the EMR algorithm identified 38 out of care HIV+ individuals of which 21 were successfully relinked to care. During the 1-month HCV birth cohort screening 963 HCV Ab tests were conducted, of which 106 (11%) resulted positive. At the time being 78 of those seropositive individuals had HCV RNA testing, of which 36 (53%) resulted positive (3.7% of all participants).

Conclusion
In San Diego, a setting with a high density of free-of charge HIV screening programs, 1/300 HIV tests in the ED yielded a new HIV diagnosis and in total 21 newly diagnosed individuals were linked to care. Identification of HIV+ out of care individuals yielded in an equivalent number of individuals relinked to care. The rate of newly diagnosed HCV infections exceeded the rate of newly diagnosed HIV infections by &gt;10-fold outlining the importance of screening for HCV in the ED.

Disclosures
All authors: No reported disclosures.
1288. Adolescents’ Knowledge and Acceptance of Pre-exposure Prophylaxis (PrEP) in the Capital District Region of New York
Authors: Santos Roberto P , Adams Mary Ellen , Lepow Martha , Tristram Debra 
Published: November 2018

Abstract

Background
In 2015, adolescents 13–24 years were disproportionately affected and accounted for 22% of new HIV infections in the United States. In New York State (NYS), the rate of adolescents (13–19 years) living with HIV infection is more than twice the national rate (44.4 vs. 19.4 per 100,000 population). As part of the ending the epidemic (ETE) program, the NYS Department of Health spearheaded access to pre-exposure prophylaxis (PrEP) for high-risk individuals to keep them HIV negative. This study aims to test the hypothesis that adolescents at risk may not be utilizing PrEP and that there are barriers to adopting it.

Methods
A cross-sectional survey (Qualtrics) was conducted from Aug 2017 to May 2018 using a 13-item multiple choice and Lickert scale validated questionnaire that takes &lt;5 minutes to complete. Descriptive and nonparametric tests (GraphPad Prism v5.04) were used to characterize knowledge and acceptance of PrEP among adolescents in Capital District NY after the initiation of the ETE program in NYS.

Results
There were 97 respondents and 89 (92%) completed all questions. Most of the respondents identify themselves as female (36%), straight (27%), middle aged adolescents 15–17 years (64%), African American (46%) and currently in high school (69%). Majority have seen a medical provider in the past 12 months (90%), at the doctor’s office (61%), and majority have never been offered HIV test (60%). Majority have not heard of a medicine that can prevent HIV infection (58%), most have not heard of PrEP (57%), and many do not know where to go to learn more about PrEP (56%). Most have not been offered PrEP (86%) and respondents were split in adopting PrEP (yes 49% vs. no 51%). The reasons for not agreeing to start PrEP are shown in Figure 1. Majority are interested in attending educational program on PrEP (57%). Adolescents are likely to adopt PrEP if they heard about it (P = 0.01), if they know where to go to learn about it (P = 0.02), and if someone offered it (P = 0.03).

Conclusion
Adolescent knowledge of PrEP may be suboptimal and presents barriers to adopting it. However, they are willing to accept PrEP if offered. This study demonstrates potential avenues for intervention and provider-initiated programs should be evaluated in scaling-up PrEP into adolescent health services.

Disclosures
All authors: No reported disclosures.
1293. The Next Step in PrEP: Evaluating Outcomes of a Pharmacist-Run HIV Pre-Exposure Prophylaxis (PrEP) Clinic
Authors: Ryan Keenan , Lewis Jessica , Sanchez Daniel , Anderson Beverly , Mercier Renee-Claude 
Published: November 2018

Abstract

Background
PrEP has been proven as an effective option for preventing the transmission of HIV; however, there are limited numbers of providers willing to prescribe PrEP. Pharmacists are an underutilized resource that are able to provide PrEPservices in many states. In Albuquerque, New Mexico, one of the nation’s first pharmacy-run HIV PrEP clinics was established in July 2015. The objective of this study was to describe the outcomes of an alternative model for HIV prevention.

Methods
The electronic medical record was used to identify and retrospectively review patients of the PrEP clinic from July 2015 to July 2017. Pertinent information including: risk factors for HIV acquisition, sexually transmitted infections (STIs) history, laboratory and medication-related data were captured. Data on partner HIV status and HAART regimen was collected when available. Adherence was evaluated by self-reported missed doses and the compliance rate was calculated from the patient’s medication fill history. Descriptive statistics was performed using SPSS.

Results
The first PrEP appointment was attended by 136 patients during study period. Baseline demographics are reported in Table 1. Two patients tested positive for HIV at baseline. PrEP was started in 127 patients with tenofovir/emtricitabine(TDF/FTC). There were no HIV seroconversions among those who started PrEP. Only one patient discontinued due to side effects. No significant elevation in Scr was noted over time. Overall, patients demonstrated a high adherence rate with an average of &lt;1 missed doses per month and a median compliance rate of 0.99.

Conclusion
A pharmacist run PrEP clinic is an alternative model to increase patient access to PrEP. TDF/FTC was provided to high-risk individuals and well-tolerated. Providers were able to promote high level of adherence.

Disclosures
All authors: No reported disclosures.