bluuebunny/crossref_metadata_2025_split huggingface dataset:
1091. Algorithmic Release of Clostridium difficile PCR Results From a Multiplex Gastrointestinal (GI) Panel in Children &lt;3 Years Old
Authors: Hecht Shaina , Wang Huanyu , Everhart Kathy , Ardura Monica I , Leber Amy 
Published: November 2018

Abstract

Background
Infants have a high rate of asymptomatic Clostridium difficile (CD) colonization, up to 37%. Given this, our laboratory does not release CD+ results from the BioFire FilmArray Gastrointestinal Panel (FGP) in patients &lt;3 years, unless requested by a physician. We sought to validate this model by comparing results from FGP to semi-quantitative CD PCRs for toxin B and glutamate dehydrogenase (GDH), enzyme immunoassay (EIA) for toxin A/B/GDH, and physician requests for CD results.

Methods
Retrospective analysis of children &lt;3 years with GI illness and FGP CD+ results between September 2016 and April 2018. CD PCRs for toxin B and GDH, CD EIA for toxin A/B/GDH were performed on convenience samples of frozen aliquots in Cary Blair. Physician request for release of CD results was used as a surrogate of possible role of CD on GI illness.

Results
Of 5,990 FGP, 2,267 (38%) were in children &lt;3 years: 619 (27%) were CD+. Of these 619, 602 (97%) were not reported per algorithm. 62% (386/619) of CD+ samples had copathogens detected; enteropathogenic Escherichia coli and norovirus most frequently. For CD PCRs and EIA performed in subset of 49 CD+, mean cycle threshold values (Cts) for toxin B were evaluated (Table 1). Of 48 samples with detectable CD by toxin B PCR, 14 (29%) had both GDH and toxin B detected, 24 (51%) had only GDH detected, and 9 (19%) had neither GDH nor toxin B detected.

Conclusion
Only 3% of FGP CD results in children &lt;3 years were released per physician request, suggesting limited clinical significance. A copathogen was detected in 62% of CD+ samples that may explain illness. Among evaluable samples, only 28.6% of CD+ had both GDH and toxin detected by EIA, possibly indicating low specificity of CD PCR. Ongoing testing and prospective studies are warranted to determine the validity of our algorithm and if semi-quantitative PCR or EIA can be useful to identify when CD detection by FGP in children &lt;3 years is clinically significant.

Disclosures
A. Leber, Nationwide Children’s Hospital: Research Contractor, Research support.
1094. Performance of Toxin Enzyme Immunoassays and PCR Cycle Threshold for Differentiating Clostridium difficile Infection From Colonization in Children With Diarrhea
Authors: Balaji Aakash , Espinosa Robyn , Todd Kathleen , Steed Kerry , Kociolek Larry 
Published: November 2018

Abstract

Background
Clostridium difficile colonization is common in children. PCR does not distinguish infection (CDI) from colonization. Toxin enzyme immunoassay (EIA) and PCR cycle threshold (Ct) may predict CDI in PCR+ adults, but assay performance in children is poorly understood.

Methods
Stools from children aged 2–21 years with laboratory-identified (labID) CDI (tcdB PCR+; GeneXpert) underwent: toxin EIA (QUIK CHEK Complete [QCC] and Immunocard [IC]); cell culture cytotoxicity neutralization assay (CCCNA); and C. difficile stool culture (Cx). Children were determined to have clinical CDI (cCDI) by chart review and/or parent communication if all were noted: at least three unformed stools (Bristol type 5–7) in 24 hours; response to CDI treatment within 5 days; and no other likely diarrheal etiology. EIA and PCR Ct performance were measured for various reference standards (RefStd) based on stool assay results and/or cCDI classification.

Results
A total of 253 PCR+ stools were included. All stools underwent QCC; 218 (86%) were quantity sufficient for IC. Discordant EIA results occurred in 19/218 (8.7%) stools. Table 1 lists EIA sensitivity (Sn), EIA specificity (Sp), and median PCR Ct for each RefStd. Figure 1 shows the receiver operating characteristic (ROC) curve for PCR Ct to identify PCR+/CCCNA+/cCDI+ children (area under curve = 0.76). The difference between sensitivity (71%) and specificity (72%) was minimized at Ct &lt; 23.5.

Conclusion
Only a minority of PCR+ children meets strict clinical and laboratory CDI criteria. More stringent CDI definitions are associated with increasing toxin EIA Sn and lower PCR Ct (i.e., greater stool C. difficile inoculum). However, both toxin EIA and PCR Ct perform suboptimally as stand-alone tests to distinguish CDI from colonization in PCR+ children.

Disclosures
L. Kociolek, Alere/Techlab: Investigator, Research support.
1095. The Value of Hardwiring Diagnostic Stewardship in the Electronic Health Record: Electronic Ordering Restrictions for PCR-Based Rapid Diagnostic Testing of Diarrheal Illnesses
Authors: Marcelin Jasmine R , Brewer Charlotte , Beachy Micah , Lyden Elizabeth , Winterboer Tammy , Hood Lauren , Fey Paul D , Van Schooneveld Trevor 
Published: November 2018

Abstract

Background
In 2015, the microbiology laboratory introduced a multiplex PCR test (FilmArray™ Gastrointestinal Panel (GIP)), replacing traditional stool culture. The GIP is faster and more sensitive than traditional stool culture, detecting 22 common viral, bacterial, and parasitic pathogens; but is significantly more expensive. The antimicrobial stewardship program (ASP) developed guidelines on test use and interpretation, recommending inpatient use only once per admission and not after hospital day 5. C. difficile test results from the GIP were not reported at any time.

Methods
Inpatient GIP use was reviewed over one year and considered inappropriate if performed &gt;3 days after admission or repeated. Noncompliance with ASP recommendations was common; no meaningful pathogens were detected upon review of all inappropriate GIP use. An inpatient GIP electronic order restriction was implemented in April 2017 eliminating the ability to order tests inappropriately. GIP testing outside the restriction could be approved by the microbiology lab director. We captured separate C. difficile testing rates as a counterbalance measure. We used Poisson regression models to compare the rate of GIP and C. difficile tests per month between Period 1 (July 2015–March 2017) and Period 2 (April 2017–March 2018) per 1,000 patient-days (PD).

Results
The restriction resulted in a 26% reduction in GIP ordering rates between the two periods (Table 1, Figure 1). Direct cost savings was approximately $63,000. Table 1 shows changes in C. difficile test ordering rates during Periods 1 and 2. When including GIP tests that were ordered but not completed, potential GIP testing was reduced by 46% for a savings of $131,000 (Figure 2). Only 42 test overrides were approved by the microbiology director since the intervention; of those only two were positive (Cryptosporidium and Norovirus).

Conclusion
Diagnostic stewardship of GIP using guidelines and electronic ordering restrictions can lead to meaningful improvements in test appropriateness and reduction in cost and waste, demonstrating the value of ASP interacting with the microbiology laboratory.

Disclosures
All authors: No reported disclosures.
1098. Clinical Features and Outcomes of United States Marine Corps Recruits Hospitalized With Shiga Toxin-Producing Escherichia coli Infection and Hemolytic–Uremic Syndrome
Authors: Sanders Terrel , Ellis Graham , Castrovinci Philip , Deiss Robert , Maves Ryan 
Published: November 2018

Abstract

Background
Shiga toxin-producing Escherichia coli (STEC) is associated with potentially life-threatening dysentery, along with its most feared complication, the hemolytic–uremic syndrome (HUS), occurring in up to 20% of STEC-infected patients. 10–30% of patients may experience chronic renovascular and neurologic sequelae after acute resolution. We describe clinical features and outcomes of a young, male military recruit population hospitalized for STEC infection and HUS in 2017.

Methods
Between October and November 2017, an STEC outbreak occurred at Marine Corps Recruit Depot San Diego (MCRD-SD) affecting 244 recruits, including 30 who required hospitalization. Polymerase chain reaction and pulsed-field gel electrophoresis of stool culture isolates demonstrated stx2-positive E. coli O157:H7. Thirty recruits required hospitalization; the remaining 214 underwent daily clinical evaluation and laboratory testing at MCRD with daily crystalloid volume expansion until the resolution of dysentery.

Results
50% (15/30) of hospitalized recruits developed HUS and were initially managed with volume expansion until the onset of oliguria. Five recruits with severe HUS required hemodialysis; six required intensive critical care unit (ICU) admission; and three suffered from respiratory failure requiring mechanical ventilation. Average length of hospitalization was 10 days. Patients requiring hemodialysis received an average 7.4 days of renal replacement. Three patients experienced encephalopathy with seizures and were managed with levetiracetam and corticosteroids for Stx-induced cerebral edema. One patient received eculizumab, a terminal complement inhibitor approved for atypical HUS, with resolution of seizures and return to his neurocognitive baseline but with persistent electroencephalographic abnormalities. There were no deaths, and all recruits had recovery of renal function.

Conclusion
This case series represents the largest STEC-HUS outbreak affecting a military population. Rates of HUS and mortality were lower than seen in prior outbreaks, in part due to a high level of baseline health and early detection and management of suspect cases. Early volume expansion and close monitoring of cases may have reduced the risk for HUS progression and long-term renal sequelae.

Disclosures
All authors: No reported disclosures.
1117. Avascular Necrosis of the Femoral Head as a Sequela of Shiga Toxin-producing Escherichia coli (STEC) Infection
Authors: Stone-Garza Kristi , Barlow Brian , Maves Ryan 
Published: November 2018

Abstract

Background
Shiga toxin-producing Escherichia coli (STEC) infection may be complicated by the hemolytic-uremic syndrome (HUS). Long-term sequelae of HUS are most often related to renovascular disease. Osteoarticular complications are rare. Avascular necrosis (AVN) has not been previously reported as a complication of STEC infection.

Methods
We report two cases of United States Marine Corps (USMC) recruits who developed AVN of the femoral head following STEC infection during a large outbreak.

Results
Between October and November 2017, an STEC outbreak occurred at Marine Corps Recruit Depot San Diego (MCRD-SD) affecting over 250 USMC recruits. Case 1: A 19-year-old recruit developed nine days of non-bloody diarrhea. Stool culture, Shiga toxin enzyme immunoassay (EIA), and polymerase chain reaction (PCR) demonstrated E. coli O157. Complete blood count (CBC) was normal 5 days after symptom resolution. One month after resolution of his infection, he developed right hip pain. Magnetic resonance imaging (MRI) revealed right femoral head AVN (Image 1). He was treated conservatively with nonsteroidal anti-inflammatory drug (NSAID) and physical therapy. Case 2: A 19-year-old recruit developed seven days of dysentery. Stool culture, Shiga toxin EIA and PCR demonstrated E. coli O157. He had a hemoglobin nadir of 8.0 g/dL and platelet nadir of 109 × 103/microL. Renal function was normal except for mild proteinuria and microscopic hematuria. One month after resolution of his infection, he developed non-traumatic left hip pain. MRI revealed left femoral head AVN with subchondral collapse (Image 2). He completed three months of bisphosphonate therapy prior to his left hip core decompression and sub-chondroplasty.

Conclusion
AVN of the hip is rare among healthy young adults and is not commonly observed in military recruits. We hypothesize that STEC-associated subclinical intravascular coagulopathy may cause microscopic occlusive disease. AVN should be considered in patients with new non-traumatic hip pain after known or suspected STEC infection.

Disclosures
All authors: No reported disclosures.
1122. Evaluation of Fecal Microbiota Transplant (FMT) in Elderly Patients With recurrent Clostridium difficile Infection (CDI)
Authors: Hassoun Ali , Edwards Jonathan 
Published: November 2018

Abstract

Background
CDI is a bacterial infection that typically occurs after the use of broad-spectrum antibiotics. Older adults are particularly susceptible to this potentially deadly disease and at higher risk of recurrence.

Methods
The study was approved by the hospital’s IRB. Patients 65 years of age and older with refractory or recurrent CDI who received FMT administered via colonoscopy or oral capsules were included. Patients with severe-complicated infection were excluded and ineligible to receive FMT. Each patient was evaluated 8 weeks post-transplant to assess for sustained clinical response and adverse events. Data collection included patient demographics, number of recurrent CDI episodes, CDI severity, previous antibiotic treatment regimens, clinical cure, adverse events, and donor information.

Results
Thirty-five patients were enrolled (23 colonoscopy FMT vs. 13 oral capsule FMT). One patient received FMT via colonoscopy twice. Mean age was 77 years [65–93], female 60%, median recurrent episode was 3, and median CDI severity score was 2. Total success rate was 69.4% (25/36), 60.9% (14/23) via colonoscopy vs. 84.6% (11/13) via capsule. Total success rate for female 67% vs. 73% male and age group of 65–75 was 60% vs. 76% in age group 75+. For capsules only, cure rate was 80% in female vs. 100% in male and 75% in 65–75 age group vs. 89% in patients older than 75 while in colonoscopy only group, success rate was 55% in female vs. 67% in males and 46% in 65–75 age group vs. 67% in age group 75+. There did not seem to be a correlation between FMT donor and success rate. No serious adverse events were reported in the study population.

Conclusion
FMT may be considered a potentially useful therapy for the treatment of refractory or recurrent CDI cases in patients 65 years of age and older. Further studies are needed to confirm the above findings.

Older adults are particularly susceptible to this potentially deadly disease

Disclosures
All authors: No reported disclosures.
1128. Utility of Anaerobic and Fungal Blood Cultures in the Pediatric Oncologic Population
Authors: Kumar Madan , Hanisch Benjamin 
Published: November 2018

Abstract

Background
In our institution, a febrile or ill appearing oncology patient will often be evaluated with aerobic, anaerobic, and fungal cultures. This is especially true in patients with persistent fevers without a clear etiology on empiric antimicrobial therapy. It is common for all three cultures to be repeated multiple times per admission.
Although this practice may seem sensible, there is to our knowledge little evidence to confirm its necessity in this population.

Methods
A record of all positive blood cultures originating from our institutions oncology ward was obtained from January 2010 to April 2017. Duplicate cultures (obtained on consecutive days with repeat organisms) were excluded. Each anaerobic and fungal culture was then evaluated for corollary positive aerobic cultures from the same time frame.

Results
A total of 10,950 blood cultures were evaluated for this study, including 2,391 anaerobic cultures and 1,980 fungal cultures. Forty-two unique anaerobic cultures (1.7%) were identified. The viridans group of Streptococcus was a large contributor with nine unique cultures. Only seven cultures of obligate anaerobes were observed: four cultures of Clostridial species, two Propionobacterium acnes, and one Peptostreptococcus species. Twenty-three unique fungal cultures (1.2%) were identified. Notably most of these isolates (14) were identified as having one colony present and regarded as probable contaminants. Penicillium, Cladosporium, and unidentified dermatiaceous molds were present in greatest frequency.

Conclusion
Over a 7-year period of routinely obtaining anaerobic and fungal cultures for febrile oncology patients only 42 unique anaerobic and 23 unique fungal cultures were identified. Given the predominance of facultative anaerobes, this may simply reflect the findings of increased blood sampling rather than added utility of the growth medium. Similarly, even among the limited unique fungal cultures the majority were of suspect validity given the presence of a single colony. These findings suggest judicious use of selective growth media in cases with higher clinical suspicion may be more useful than empiric evaluation.

Disclosures
All authors: No reported disclosures.
1138. Retrospective Cohort Analysis of Amphotericin B Nephrotoxicity in Kidney Transplant Recipients
Authors: Assi Mariam , Engracia Dominic , Yakubu Idris , Gupta Gaurav , Kurbanova Nargiza , Cruz Oveimar De La 
Published: November 2018

Abstract

Background
Treatment of invasive fungal infections with amphotericin B is a concern in kidney transplant patients due to fear of allograft loss. Reluctance to use amphotericin B may lead to suboptimal therapy and poor treatment outcomes. The risk of amphotericin B-related nephrotoxicity and allograft dysfunction has not been studied in kidney transplant patients. Our aim was to study the association between amphotericin B and acute kidney injury (AKI) as defined by the Acute Kidney Injury Network classification, allograft loss and patient mortality in kidney transplant recipients.

Methods
We used SPSS to conduct a descriptive analysis of a retrospective cohort of 30 adult kidney transplant recipients who were admitted to Virginia Commonwealth University Medical Center and received treatment with amphotericin B from 2005 to 2015.

Results
The median age in our cohort was 57. 40% were female, 60% were male. 60% had received a kidney transplant from a deceased donor; 13.3% from a living related donor; 13.3% from a living unrelated donor; and 13.3% had received a combined kidney–pancreas transplant. 63.3% of patients had received liposomal amphotericin B; 33.3% had received lipid-complex amphotericin B; 3.3% had received conventional amphotericin B. We found an association between cumulative amphotericin B doses above 5,000 mg and AKI, whereby 64.7% of patients exposed to less than 5,000 mg of amphotericin B developed AKI and 100% of patients exposed to more than 5,000 mg of amphotericin B developed AKI (P = 0.017). We did not find an association between cumulative amphotericin B doses above 5,000 mg and return to dialysis at 3 months and 12 months post-exposure (P = 0.436 and 0.288, respectively). We also did not find an association between such doses of amphotericin B and mortality at 30 and 90 days (P = 0.869 and 0.193, respectively).

Conclusion
In the first descriptive analysis of a retrospective cohort of kidney transplant patients exposed to amphotericin B, our results suggest that the risk of nephrotoxicity may be significantly increased when a cumulative dose of 5,000 milligrams is exceeded. Our results also suggest that amphotericin B doses associated with nephrotoxicity in kidney transplant patients may not have an effect on allograft survival and patient mortality.

Disclosures
All authors: No reported disclosures.
1143. Epidemiologic Characteristics of Outbreaks Associated With the Healthcare Environment
Authors: Kanamori Hajime , Weber David , Rutala William , Kaku Mitsuo 
Published: November 2018

Abstract

Background
The healthcare environment serves as a reservoir or a source for outbreaks. Single outbreaks via an environmental reservoir have often been described in healthcare settings, while the trend of these multiple outbreaks has not been understood well. Here, we investigated the epidemiologic features of outbreaks associated with the healthcare environment.

Methods
Structured data on environmental sources from Outbreak Database based on information from articles published worldwide were extracted. A total of 317 articles of outbreaks associated with the healthcare environment (e.g., environmental surfaces, patent care items, water and water-related appliances, and air and ventilation systems) in 48 countries during 1965–2016 were analyzed.

Results
Of the 317 outbreaks reviewed, 295 (93%) were monophasic. One hundred sixty-one outbreaks (51%) occurred in an ICU setting. The 6,317 infected patients and 338 healthcare personnel were involved in 317 healthcare-associated outbreaks via the environment. Two hundred fifty-one patients (4%) died of an infection. Two hundred sixty-five outbreaks (84%) caused at least one infection among patients involved, including 112 pneumonias (35%) and 104 bloodstream infections (33%) (Figure 1). Bacteria (N = 244, 77%) were the most frequent pathogen, followed by fungi (N = 49, 15%) and mycobacteria (N = 15, 5%) (Figure 2). Of the bacteria, nonfermenting Gram-negative bacilli (N = 100, 41%) was the most common, followed by Legionella (N = 56, 23%), Enterobacteriaceae (N = 35, 14%), and multidrug-resistant organisms (N = 31, 13%). One hundred thirty-six outbreaks (43%) were obviously transmitted by contact, followed by inhalation and invasive technique. Genotyping was performed in 66% of outbreaks (N = 209). Key control measures included modification of care/equipment (N = 181, 57%) and improved disinfection/sterilization (N = 170, 54%). Forty-seven (15%) and 5 (2%) outbreaks led to closure of the affected location and restriction of workload, respectively (Figure 3).

Conclusion
This study characterized epidemiologically outbreaks associated with healthcare environment, demonstrating the environmental role in healthcare-associated outbreaks. Analysis of structured data on multiple outbreaks can help develop infection prevention strategies in healthcare facilities.

Disclosures
D. Weber, PDI: Consultant, Consulting fee. W. Rutala, PDI: Consultant and Speaker’s Bureau, Consulting fee and Speaker honorarium.