bluuebunny/crossref_metadata_2025_split huggingface dataset:
857. A Tele-Antibiotic Stewardship Program Influences Antibiotic Use at 2 Rural Veterans Affairs Medical Centers
Authors: Wilson Brigid , Banks Richard , Crnich Christopher , Ide Emma , Viau Roberto , El Chakhtoura Nadim G , Jones Yvonne , Cherry Jason , Anderson Brett , Urban Andrew , Jump Robin 
Published: November 2018

Abstract

Background
Telehealth offers the possibility of supporting antibiotic stewardship in settings with limited access to people with infectious diseases (ID) expertise. Previously, we described preliminary results from a pilot project that used the Veterans Affairs (VA) telehealth system to facilitate a Videoconference Antimicrobial Stewardship Team (VAST) which connected a multidisciplinary team from a rural VA medical center (VAMC) with ID physicians at a remote site to support antibiotic stewardship. Here, we present 3 distinct metrics to assess the influence of the VAST on antibiotic use at 2 intervention sites.

Methods
Outcomes assessed antibiotic use in the hospital and long-term care units of 2 rural VAMCs in the year before and after VAST implementation, allowing for a 1-month wash-in period in the first month of the VAST. Using VA databases, we determined 3 metrics: the rate of antibiotic use (days of therapy per 1,000 bed days of care); the mean length of therapy (days); and the mean patient antibiotic spectrum index (ASI), a measure of antibiotic spectrum increasing from narrow to broad. Using segmented regression on monthly measures of each metric with a knot at the wash-in month (gray square), we calculated predicted values (solid lines), and confidence intervals (dashed lines) to examine trends before (black squares) and after (white squares) implementing the VAST.

Results
The rate of antibiotic use, mean length of therapy, and ASI decreased at Site A. As indicated in the figure, the effect was more pronounced in long-term care compared with the hospital, where the VAST sustained but did not accelerate downward trends. At Site B, the most notable influence of the VAST was on the ASI for the hospital and long-term care units.

Conclusion
The VAST is a feasible, sustainable program that is effective at inducing change in antibiotic use at 2 VAMCs. The influence of the VAST differed between the 2 sites and, at Site A had a more pronounced effect on the long-term care compared with hospital units. These distinct metrics capture changes in overall antibiotic use, length of therapy, and agent selection. Tele-antibiotic stewardship programs hold potential to improve antibiotic use at facilities with limited access to people with antibiotic stewardship expertise.

Disclosures
All authors: No reported disclosures.
858. Preoperative “Dirty” Urinalysis Leads to Antibiotic Use Without Benefit
Authors: Gallegos Jaime , Obrien William , Strymish Judith , Itani Kamal , Branch-Elliman Westyn , Gupta Kalpana 
Published: November 2018

Abstract

Background
Pyuria is often used as a surrogate for bacteriuria and may trigger antibiotic use even in the setting of negative cultures. The impact of preoperative pyuria on empirical antibiotic use and on postoperative outcomes has not been evaluated in large multisite studies. Thus, we investigated rates and outcomes associated with treated versus untreated preoperative pyuria in a national cohort of surgical patients.

Methods
All patients who underwent standardized Surgical Quality review after cardiac, orthopedic implant, or vascular surgery within the national VA health care system from October 1, 2008 to September 30, 2013 and had a urinalysis performed in the 30 days before surgery were eligible. Rates of preoperative pyuria (≥5 WBCs and/or positive leukocyte esterase) and antibiotics were measured. Adjusted rates of 30-day postoperative surgical (SSI) and urinary tract (UTI) infections were determined by a trained nurse reviewer using CDC definitions and compared between pyuria patients who did or did not receive antibiotics before surgery.

Results
Among 17,749 preoperative urinalyses, 755 were culture-positive and 16,994 were culture-negative. Among culture negative patients, 1,812/16,994 (10.7%) had urinalyses diagnostic of pyuria. Antibiotics were prescribed to 574 (32%) of pyuria-positive, culture-negative patients. After adjusting for diabetes, smoking, age, and ASA score, the rate of post-op SSI was similar among antibiotic-treated pyuria patients (13/574, 2.3%) compared with those not treated (21/1,238, 1.7%), aOR 1.33, 95% (0.66–2.69, P = 0.41). Post-op UTI was also not reduced among pyuria treated (17/351, 4.8%) vs. untreated (39/893, 4.4%), aOR 1.09, 95% (0.60–1.96, P = 0.76).

Conclusion
In this large national study cohort, almost 1/3 of pyuria-positive preoperative patients received antibiotics despite negative cultures. Antibiotic treatment was not associated with clinical benefits, including no reduction in post-operative SSI or UTI. There is an opportunity for diagnostic stewardship to reduce preoperative urinalysis testing and unnecessary antibiotic exposure.

Disclosures
K. Itani, Pfizer: Grant Investigator, Research grant. Sanofi: Grant Investigator, Research grant. K. Gupta, Iterum Therapeutics: Consultant, Consulting fee. Paratek Pharmaceutical: Consultant, Consulting fee. Tetraphase: Consultant, Consulting fee.
859. Same-Day HIV Pre-exposure Prophylaxis (PrEP) Initiation During Drop-in STD Clinic Appointments Is a Safe, Feasible, and Effective Method to Engage Patients at Risk for HIV in PrEP Care
Authors: Kamis Kevin , Scott Kenneth , Gardner Edward , Wendel Karen , Marx Grace , Scott Mia , Montgomery Angela , Rowan Sarah 
Published: November 2018

Abstract

Background
Patients at risk for HIV generally do not have immediate access to PrEP. We hypothesized that by offering free, 30-day PrEP starter packs and navigation support during drop-in STD clinic appointments, individuals would be likely to initiate and continue PrEP.

Methods
Individuals aged ≥18 years presenting for drop-in appointments in the Metro Denver STD Clinic and indicated for PrEP were eligible for the study. Exclusion criteria were history of renal dysfunction, chronic hepatitis B (HBV), HIV, pregnancy, and indications for postexposure prophylaxis. Eligible individuals were provided PrEP education and offered a free, 30-day PrEP starter pack and navigation support for cost assistance. Participants were tested for creatinine, HBV, HIV, and pregnancy at enrollment, and navigated to an appointment for ongoing PrEP care. Participants’ medical records were reviewed for a minimum of 4 months after enrollment. Descriptive statistics and logistic regression were used to characterize the study population and follow-up.

Results
From April to October 2017, 100 individuals filled a tenofovir–emtricitabine prescription (figure). Median participant age was 28 years, 98% were male, 53% were non-Hispanic White, 8% non-Hispanic Black, and 34% Hispanic. Median annual income was $24,000, 62% had health insurance, 26% had a primary care provider (PCP), and 50% had a recent bacterial STI. No participants had abnormal baseline creatinine or HBV. 77% completed ≥1 PrEP follow-up visit during the study period; 57% completed their first visit within 31 days. 56% completed a second follow-up visit. No HIV seroconversions were detected during follow-up. Factors significantly associated with attending ≥1 follow-up appointment were age ≥ 30 years, higher income, and having health insurance or a PCP at enrollment. In multivariate logistic regression, only higher income was associated with attending ≥1 follow-up appointment (median income for those with ≥1 follow-up visit vs. no follow-up: $24,960 vs. $14,000, P &lt;0.01).

Conclusion
Providing immediate access to PrEP during drop-in STD clinic visits is a safe and feasible approach to initiation of PrEP care. Additional resources are needed to support PrEP continuity care, particularly for low-income individuals.

Disclosures
K. Kamis, Gilead Scienes: Research Coordinator, Research grant. S. Rowan, Gilead Sciences: Investigator, Research grant.
862. Spatial Distribution of HIV Transmission in Ethiopia and Characteristics of HIV Clusters
Authors: Ying Roger , Fekadu Lelisa , Schackman Bruce R , Verguet Stéphane 
Published: November 2018

Abstract

Background
HIV prevalence in Ethiopia has decreased by nearly 75% in the past 20 years with the implementation of antiretroviral therapy, but HIV transmission continues in certain high-risk regions around the country. Identification of the spatial and temporal trends of these transmission clusters, as well as their epidemiologic correlates, can lead to refinement of targeted interventions.

Methods
We used data from the 2005, 2011, and 2016 Ethiopia Demographic and Health Survey program (DHS). The spatial-temporal distribution of HIV was estimated using the Kuldorff spatial scan statistic, which determines the likelihood ratio of HIV within possible circular clusters across the country. Significant clusters (P &lt; 0.05) were identified and compared based on known HIV risk factors using descriptive statistics to compare them to the noncluster area of the country. All analyses were conducted in SaTScan and R.

Results
Data from 11,383, 29,812, and 26,753 individuals with HIV were included in the 2005, 2011, and 2016 DHS, respectively. Four HIV clusters were identified consistently over the 3 time points, with the clusters representing 17% of the total population and 47% of all HIV cases. The 4 clusters were centered on the Addis Ababa, Afar, Dire Dawa/Harare, and Gambella regions, respectively. Cluster 1 is characterized by higher levels of unsafe injections (4.9% vs. 2.2%, P &lt; 0.001) and high-risk occupations, such as truck drivers (5.7% vs. 1.7%, P &lt; 0.001), when compared with noncluster regions, but by lower levels of transactional sex (18.6% vs. 23.0%, P &lt; 0.001). Cluster 2 is also characterized by higher levels of high-risk occupations (2.8% vs. 1.7%, P &lt; 0.01), whereas cluster 4 is characterized by a lower prevalence of circumcised men (59.1% vs. 91.3%, P &lt; 0.01). No cluster had significantly higher levels of having more than one sexual partner in the last 12 months, although cluster 3 had a significantly lower level (0% vs. 1.7%, P &lt; 0.001).

Conclusion
HIV in Ethiopia is composed of heterogeneous clusters of HIV transmission that appear to be driven by different risk factors. Further decreasing the HIV burden will likely require targeted and prioritized interventions in specific regions rather than uniform national policies.

Disclosures
All authors: No reported disclosures.
923. Rapid Emergence of Candida auris in the Chicago Region
Authors: Kerins Janna L , Tang Angela S , Forsberg Kaitlin , Jegede Olufemi , Ealy Michelle , Pacilli Massimo , Welsh Rory M , Murphy Elizabeth B , Fealy Amy , Walters Maroya Spalding , Raczniak Gregory , Vallabhaneni Snigdha , Black Stephanie R , Kemble Sarah K 
Published: November 2018

Abstract

Background
In 2016, Candida auris was first reported in the United States, with 2 Illinois patients among the first cases. In response, the state and 3 Chicago-area health departments (HDs) investigated clinical cases and performed point prevalence surveys (PPSs) to identify colonized cases.

Methods
Clinical cases had positive C. auris cultures obtained for clinical care; colonized cases had positive surveillance cultures during PPSs. In August 2016–January 2018, PPSs were performed in Chicago-area acute care hospital (ACH) intensive care units, long-term acute-care hospitals (LTACHs), and high-acuity floors of skilled nursing facilities (SNFs) and SNFs caring for ventilated patients (vSNFs). Facility and HD staff obtained composite axilla/groin swabs from assenting patients to detect colonization. Facilities with an epidemiologic link to a clinical case or a shared patient population with a facility housing a clinical case were prioritized for PPSs.

Results
During May 2016–January 2018, Chicago-area facilities reported 24 clinical cases, including 10 bloodstream infections. HDs performed 33 PPSs at 20 facilities (5 ACHs, 5 LTACHs, 3 SNFs, and 7 vSNFs) during August 2016–January 2018. Of 1,364 patients screened, 92 (6.7%) were colonized with C. auris; 10 (50%) facilities had ≥1 colonized patient. A significantly higher proportion screened positive from September 2017 to January 2018 (84/822, 10.2%) than in August 2016–August 2017 (8/542, 1.5%; z-test P &lt; 0.01). Prevalence of C. auris colonization was highest in vSNFs (median: 7.7%; range: 0%–43.3%), compared with ACHs (0%; 0%–6.3%), LTACHs (0%; 0%–14.3%), and SNFs (0%, 0%–1.5%). PPSs in vSNFs identified 91% (84/92) of colonized cases. Among 5 vSNFs with repeat PPSs, 4 had higher prevalence on repeat screening (median: 26.1%; range: 0%–43.3%) than at baseline (1.2%; 0%–17.0%).

Conclusion
C. auris has rapidly emerged in the Chicago area. Increasing prevalence of C. auris colonization during repeat PPSs indicates transmission and amplification within vSNFs. To prevent spread, state and local HDs provided infection control recommendations, disseminated health alerts, and recommended placing vSNF patients from high-acuity floors on transmission-based precautions.

Disclosures
All authors: No reported disclosures.
933. Serum Albumin Is Associated With Higher Inflammation and Carotid Atherosclerosis in Treated HIV Infection
Authors: Dirajlal-Fargo Sahera , Kulkarni Manjusha , Sattar Abdus , Funderburg Nicholas , McComsey Grace A 
Published: November 2018

Abstract

Background
Lower serum albumin has recently been associated with cardiovascular disease and non-AIDS malignancies in HIV. This analysis explores the associations between serum albumin and markers of inflammation and atherosclerosis.

Methods
We conducted a nested study within in the SATURN-HIV trial in which 147 HIV+ adults on stable antiretroviral therapy (ART), were virally suppressed, and had an LDL-cholesterol level &lt;130 mg/dL were randomized to 10 mg daily rosuvastatin or placebo. Measures of serum albumin, carotid intima media thickness (IMT, surrogate marker of atherosclerosis), inflammation, T-cell and monocyte immune activation were assessed at baseline, 24, 48, and 96 weeks later. Spearman correlations and linear-mixed effects models with random intercept and slope were conducted to assess associations with albumin.

Results
Mean age was 45 years, 80% were male, 69% were African American, and 46% were receiving protease inhibitors. Mean serum albumin was not significantly different between the groups at any time points (4.05–4.08 g/dL in statin arm vs. 4.01–4.11 g/dL in placebo arm, P = 0.08–0.35). Low serum albumin significantly correlated with elevated levels of interleukin-6 (IL6), d-dimer, fibrinogen, and high sensitivity C-reactive protein (hsCRP) at all time points (P ≤ 0.04). Low serum albumin also correlated with higher inflammatory monocytes (CD14+CD16+) at week 24 and week 96 (P ≤ 0.03) but not with markers of T-cell activation at any time point (P ≥ 0.10). Lower baseline albumin significantly predicted larger changes in IMT (P = 0.03), IL6, d-dimer, tumor necrosis factor-α receptor 1, fibrinogen, and hsCRP (P ≤ 0.02) over 96 weeks. After adjusting for age, gender, smoking, body mass index, vascular cell adhesion molecule and creatinine clearance, every 1 g/dL decrease in albumin remained associated with a 0.5 mm increase in IMT over 96 weeks (P = 0.05).

Conclusion
Lower serum albumin in controlled HIV is associated with higher markers of chronic inflammation, hypercoagulation, and monocyte activation, which could explain the prior observation that albumin predicts non-AIDS events in HIV. Our findings suggest that serum albumin may predict progression of carotid atherosclerosis independent of traditional risk factors.

Disclosures
G. A McComsey, Gilead: Consultant, Consulting fee and Research support. Merck: Consultant, Consulting fee and Research support. Viiv: Consultant, Consulting fee and Research support. Roche: Research Contractor, Research support. Astellas: Research Contractor, Research support.
934. Incidence of Skin and Soft-tissue Infection in People Living With HIV in a Large Urban Public Health Care System in Houston, Texas, 2009–2014
Authors: Hemmige Vagish , Arias Cesar , Pasalar Siavash , Giordano Thomas P 
Published: November 2018

Abstract

Background
Skin and soft-tissue infections (SSTIs) disproportionately impact patients with HIV. Recent declines have been noted in the incidence of SSTIs in the non-HIV population. We set out to study the epidemiology and microbiology of SSTIs in a population of 8,597 patients followed for HIV primary care in a large urban county system from January 1, 2009 to December 31, 2014.

Methods
SSTIs were identified from the electronic medical record (EMR) by the use of ICD-9 billing codes. Charts were reviewed to confirm the diagnosis of acute SSTI and abstract culture and susceptibility data. We calculated yearly SSTI incidence using Poisson regression with clustering by patient.

Results
2202 SSTIs were identified. Of 503 (22.8%) cultured SSTIs, 332 (66.0%) included S. aureus as a pathogen, of which 287/332 (86.4%) featured S. aureus as the sole pathogen. Of S. aureus isolates with susceptibilities, 231/331 (69.8%) were methicillin-resistant, and the proportion did not vary by year (P = NS).
The observed incidence of SSTI was 78.0 per 1,000 person-years (95% CI 72.9–83.4) and declined from 96.0 infections per 1,000 person-years in 2009 to 56.5 infections per 1,000 person years in 2014 (P &lt; 0.001). Other significant predictors of SSTI incidence in both univariate as well as multivariate analysis included CD4 count, viral load, and being a Spanish-speaking Hispanic.

Conclusion
Although SSTI rates in a large urban HIV-infected outpatient cohort declined approximately 40% between 2009 and 2014, SSTIs remain a significant problem.

Disclosures
C. Arias, Merck & Co., Inc.: Grant Investigator, Research support. MeMed: Grant Investigator, Research support. Allergan: Grant Investigator, Research support
963. Whole Blood Transcriptome Analysis Reveals Differences in Erythropoiesis and Neurologically Relevant Pathways Between Cerebral Malaria and Severe Malarial Anemia
Authors: Nallandhighal Srinivas , Park Gregory , Ho Yen-Yi , Opoka Robert , John Chandy , Tran Tuan 
Published: November 2018

Abstract

Background
Plasmodium falciparum malaria can rapidly progress to severe disease that can lead to death if left untreated. Severe malaria cases commonly present as severe malarial anemia (SMA), defined in children as hemoglobin (Hb) &lt;5 g/dL with parasitemia, or as cerebral malaria (CM), which manifests as parasitemia with acute neurological deficits and has an inpatient mortality rate of ~20%. The molecular and cellular processes that lead to CM and SMA are unclear.

Methods
In a cross-sectional study, we compared genome-wide transcription profiles of whole blood obtained from Ugandan children with acute CM (n = 17) or SMA (n = 17) and community children without P. falciparum infection (n = 12) who were enrolled in a parent cohort study of severe malaria. We determined the relationships between gene expression, hematological indices, and plasma biomarkers, including inflammatory cytokines.

Results
Both CM and SMA demonstrated enrichment of dendritic cell activation, inflammatory/TLR/chemokines, monocyte, and neutrophil modules but depletion of lymphocyte modules. Neurodegenerative disease and neuroinflammation pathways were enriched in CM. Increased Nrf2 pathway gene expression corresponded with increased plasma heme oxygenase-1 and the heme catabolite bilirubin in a manner specific to children with both SMA and sickle cell disease. Reticulocyte-specific gene expression was markedly decreased in CM relative to SMA despite higher Hb levels and appropriate increases in plasma erythropoietin. Viral sensing/interferon regulatory factor (IRF) 2 module (M111) expression and plasma IP-10 levels both negatively correlated with reticulocyte-specific signatures, but only M111 expression independently predicted decreased reticulocyte-specific gene expression after controlling for leukocyte count, Hb level, parasitemia, and clinical syndrome by multiple regression.

Conclusion
Differences in the blood transcriptome of CM and SMA relate to neurologically relevant pathways and erythropoiesis. Erythropoietic suppression during severe malaria is more pronounced during CM versus SMA and is positively associated with IRF2 blood signatures. Future studies are needed to validate these findings.

Disclosures
All authors: No reported disclosures.
973. Inter-facility Patient Sharing and Clostridium difficile Incidence in the Ontario Hospital Network: A 13-Year Longitudinal Cohort Study of 116 Hospitals
Authors: Brown Kevin , Daneman Nick , Schwartz Kevin , Langford Bradley , Johnstone Jennie , Adomako Kwaku , Etches Jacob , Garber Gary 
Published: November 2018

Abstract

Background
Inter-facility patient movement plays an important role in the dissemination of antimicrobial resistance and C. difficile infection (CDI) throughout healthcare systems. However, the relative performance of different patient sharing metrics for predicting CDI incidence is not known. We compared 3 different measures of inter-facility patient sharing as they relate to CDI incidence in Ontario facilities.

Methods
A retrospective cohort analysis was used to predict incident CDI (ICD-10 = A04.7 identified from Discharge Abstract Database records) across Ontario hospitals (Nhospitals = 116) between April 1, 2003 to March 31, 2016. Patients with a stay of &lt;3 days and those with a history of CDI in the prior 90 days were excluded from the risk set but not from patient sharing metrics. Poisson regression models with facility-level random effects were used to predict facility CDI incidence (per 1,000 admissions) and measure the percent change in facility-level variance (PCV). The 3 metrics of inter-facility patient sharing included: (1) “importation”—the rate of patients with a discharge from another distinct facility in prior 90 days, (2) “incidence-weighted importation”—equal to importation weighted by the incidence of CDI in the previous facility, and (3) “case importation”—importation of patients with a history of CDI.

Results
Over the 13-year period, we observed 58,427 cases of healthcare-associated CDI among 12,750,000 admissions. Facility CDI incidence ranged from 2.9 to 19.6 per 1,000 admissions (6.8-fold range). Patient sharing metrics were strongly related to facility CDI incidence (figure). In models adjusting for facility risk factors, all 3 measures still explained an important portion of inter-facility variation in CDI incidence: importation (PCV = 5%, P = 0.01), incidence-weighted importation (PCV = 15%, P &lt; 0.001), and “case importation” (PCV = 48%, P &lt; 0.001).

Conclusion
We observed a substantial variation in facility CDI incidence that was explained by linkages between acute care facilities, especially linkage to other facilities with a high incidence of CDI. Facility infection prevention staff should consider incorporating the facility CDI incidence into risk stratification assessments of patient transfers.

Disclosures
All authors: No reported disclosures.