bluuebunny/crossref_metadata_2025_split huggingface dataset:
113. Accuracy of the NHSN Central Line-Associated Bloodstream Infection (CLABSI) Definition
Authors: Hammadi Ahmed Al , Ostrosky-Zeichner Luis , Boston Kelley , McInnis-Cole Tawanna , Butler John 
Published: November 2018

Abstract

Background
CLABSIs are serious infections that cause prolonged hospital length of stay, increased cost, and mortality. Acute care hospitals must report CLABSIs to NHSN to participate in CMS programs. NHSN definitions must be met to attribute a secondary BSI (SBSI), or bacteremia is defaulted to CLABSI if a central line is present. The lack of CDC/NHSN definitions for certain secondary sites of infections or problems in the definitions may lead to over-labeling CLABSIs. We reviewed the accuracy of NHSN definitions in a large healthcare system.

Methods
We retrospectively reviewed medical records of 279 patients with positive blood cultures on or after hospital day 3 and a central line from 15 hospitals belonging to a large healthcare system from January 1 to November 27, 2017. A team of centralized infection preventionists (IPs) adjudicated each case as a CLABSI or as SBSI through routine surveillance following NHSN methodology. A clinical review was performed by a PGY6 infectious diseases fellow. Descriptive statistics are presented.

Results
A total of 279 bacteremia cases were analyzed. Of those 279 patients, 237 (85%) were ≥18 years old, 162 (58%) were males, 92 (33%) were white, 62 (22.2%) were black, 5 (1.8%) were Asian, and 12 (4.3%) were “other.” Ninety-seven (34.8%) were from the reference hospital. IPs classified 171 CLABSIs and 108 as SBSI. Of the 171 CLABSIs classified by IPs, in 62 patients (36.3%), a primary site infection clinically explaining the BSI, but which did not meet the NHSN infection criteria, could be attributed as follows during the clinical review: 30 pneumonia, 6 urinary tract infections, 4 surgical site infections, 2 vascular infections, 2 mucosal barrier injury associated blood stream infections, 7 gastrointestinal infections, 1 decubitus ulcer infection, 4 skin and soft-tissue infections, 2 left ventricular-assisted device infections, 2 endocarditis, and 2 infected thrombi. Misclassification most often occurred due to missing elements of the definitions or infections not defined by NHSN.

Conclusion
Current NHSN definitions may overestimate CLABSIs by nearly 30%. As hospitals continue to work in CLABSI reduction, accurate and precise definitions/methodology will be key in focusing efforts and attention of the engaged parties and avoiding penalties.

Disclosures
L. Ostrosky-Zeichner, Cidara Therapeutics: Grant Investigator, Research grant.
124. Microbiological Outcomes With Plazomicin (PLZ) Versus Meropenem (MEM) in Patients With Complicated Urinary Tract Infections (cUTI), Including Acute Pyelonephritis (AP) in the EPIC Study
Authors: Keepers Tiffany R , Cebrik Deborah S , Cloutier Daniel J , Komirenko Allison , Connolly Lynn , Krause Kevin 
Published: November 2018

Abstract

Background
PLZ is a next-generation aminoglycoside (AG) that is structurally protected from common AG-modifying enzymes (AMEs) in Enterobacteriaceae and with in vitro activity against multidrug-resistant Enterobacteriaceae, including ESBL-producing, AG-resistant, and carbapenem-resistant isolates. We report microbiological outcomes in the EPIC study, including outcomes for resistant pathogens and by the PLZ MIC.

Methods
EPIC was a multinational, randomized, double-blind study in hospitalized patients with cUTI or AP. Patients received IV PLZ (15 mg/kg q24h) or IV MEM (1 g q8h) for 4–7 days, followed by optional oral therapy, for a total of 7–10 days of therapy. The extended mMITT population included patients with ≥1 qualifying baseline pathogen (≥105 CFU/mL urine) who received study drug. Microbiological outcomes were assessed at TOC (day 15–19). Isolate identification and susceptibility testing were conducted by a central laboratory. Whole-genome sequencing was used to identify AME and β-lactamase genes.

Results
Of 609 patients enrolled, 407 (66.8%) were included in the extended mMITT population. The most common uropathogen was Escherichia coli (63.4%) followed by Klebsiella pneumoniae (19.7%). PLZ and MEM MIC50/90 for Enterobacteriaceae were 0.5/2 μg/mL (range: ≤0.06–&gt;128 mg/mL) and 0.015/0.06 mg/mL (range: ≤0.004–128 mg/mL), respectively. ESBL and AG-NS phenotypes were found in 29% and 27% of isolates, respectively. Genotyping detected β-lactamase and AME genes in 32.5% and 36.8% of isolates, respectively, most commonly blaCTX-M-15 (n = 98), blaOXA-1/OXA-30 (n = 82), aac(6′)Ib-cr (n = 79), and aac(3)-IIa (n = 56). Rates of microbiological eradication are shown in Table 1. All Enterobacteriaceae in the PLZ group with a PLZ MIC of 4 µg/mL (6/6) were eradicated at TOC (Table 2). Across 49 patients with concurrent bacteremia, 100% (27/27) and 96% (24/25) of Enterobacteriaceae were cleared from the blood at TOC in the PLZ and MEM groups, respectively.

Conclusion
PLZ demonstrated comparable or higher microbiological eradication rates compared with MEM for common Gram-negative uropathogens, including resistant pathogens. The results support PLZ as a potential treatment option for cUTI, including AP, caused by Enterobacteriaceae with PLZ MICs of ≤4 mg/mL.

Disclosures
T. R. Keepers, Achaogen, Inc.: Employee, Salary. D. S. Cebrik, Achaogen, Inc.: Employee, Salary. D. J. Cloutier, Achaogen, Inc.: Employee and Shareholder, Salary. A. Komirenko, Achaogen, Inc.: Employee and Shareholder, Salary. L. Connolly, Achaogen, Inc.: Consultant, Consulting fee. K. Krause, Achaogen, Inc.: Employee, Salary.
153. The Effect of Timing of Tetanus–Diphtheria and Pertussis Vaccine Administration in Pregnancy on The Avidity of Pertussis Antibodies
Authors: Raya Bahaa Abu , Giles Michelle , Kollmann Tobias , Sadarangani Manish 
Published: November 2018

Abstract

Background
Tetanus–diphtheria–pertussis (Tdap) vaccination in pregnancy is currently recommended in many countries. The optimal timing of pertussis immunization in pregnancy is not well established, leading to different recommendations. We aimed to determine the effect of timing of vaccination with Tdap in pregnancy on the umbilical cord avidity of antipertussis toxin (PT) immunoglobulin G (IgG).

Methods
Avidity of anti-PTIgG was assessed using ammonium thiocyanate (NH4SCN) at concentrations between 0.25 M (to measure low avidity antibodies) and 3 M (to measure high avidity antibodies). Anti-PT IgG levels achieved at each NH4SCN concentration were calculated. T-tests were used to compare anti-PT IgG levels between newborns of women vaccinated in early (28–32 weeks gestation) and late (33–36 weeks gestation) third trimester. Pearson correlation assessed the relationship between the timing of vaccination and anti-PT IgG levels.

Results
Newborns of women vaccinated with Tdap in early third trimester (n = 43) had higher anti-PT IgG levels at 1 M and 2 M NH4SCN concentrations compared with newborns of women vaccinated in late third trimester (n = 47), 2.4 international units (IU)/mL vs. 1.9 IU/mL (P = 0.0073) and 2.3 IU/mL vs. 1.7 IU/mL (P = 0.0354), respectively, after adjustment for gestational age at birth. There was a negative association between later timing of vaccination in third trimester and anti-PT IgG levels achieved at 0.5 M, 1 M, 1.5 M, and 2 M NH4SCN (all P ≤ 0.02). There was a positive association between increasing time between vaccination and delivery and anti-PT IgG levels achieved at 0.5 M, 1 M, 1.5 M, and 2 M NH4SCN (all P ≤ 0.02).

Conclusion
Vaccination against pertussis during early third trimester results in higher levels of high avidity antibodies compared with vaccination in late third trimester. High avidity antibodies may confer greater protection to the neonate supporting recommendations for vaccination at 28–32 WG vs. 33–36 WG.

Disclosures
All authors: No reported disclosures.
154. Diagnosis and Genotyping of Coxiella burnetii Causing Endocarditis in a Patient With Prosthetic Pulmonary Valve Replacement (PVR) Using Next-Generation Sequencing (NGS) of Plasma
Authors: Kondo Maiko , Dalai Sudeb , Westblade Lars , Venkatasubrahmanyam Shivkumar , Eisenberg Nell , Marks Kristen M 
Published: November 2018

Abstract

Background
Identification of Coxiella burnetii, the etiologic agent of Q Fever, in culture-negative endocarditis (CNE) remains challenging, and strain-level information is typically unavailable through conventional testing. We used a novel next-generation sequencing (NGS) assay on plasma cell-free DNA to facilitate rapid diagnosis and genotyping in a patient with C. burnetii CNE.

Methods
NGS was performed on plasma by Karius, Inc. (Redwood City, California). Human reads were removed and remaining sequences were aligned to a curated database of over 1,000 pathogens. Organisms present above a predefined significance threshold were reported. For C. burnetti strain-typing, alignments to different Coxiella strains in the pathogen database were compared by BLAST bit-score to determine the most closely related strain to the infecting organism. C. burnetii genotype group was also determined by in silico analysis of polymorphic ORF deletion markers known to distinguish groups I–VI.

Results
Twenty-nine-year-old male with history of Tetralogy of Fallot, multiple pulmonary valve replacement (PVR), and 18 months of intermittent fever and night sweats were admitted. Relevant history included travel in South and South East Asia, the use of a LivaNova 3T Heater-Cooler device during surgery (i.e., at risk for Mycobacterium chimaera), and drinking unpasteurized milk. Cardiac CT showed 2 pulmonary opacities concerning for septic emboli and echocardiography showed echodensity on pulmonic valve. Blood cultures were negative. NGS detected C. burnetii within 48 hours of sample receipt. On the basis of these results, hydroxychloroquine and doxycycline were initiated with symptomatic improvement. Strain-typing demonstrated highest relatedness to the CbuK_Q154 (group IV) strain typically seen in North America. Genotype group was independently confirmed by inference of a pattern of ORF deletion most similar to group IV (and highly related group VII). Serologic testing for C. burnetii confirmed the diagnosis. After 4 weeks of antibiotics, the patient underwent successful PVR with graft exchange.

Conclusion
NGS testing aided in diagnosis of C. burnetii CNE, enabling early targeted antimicrobial therapy. It also allowed inference of strain-level information, supporting further investigations regarding epidemiologic origins of this pathogen.

Disclosures
S. Dalai, Karius, Inc.: Consultant, Consulting fee. S. Venkatasubrahmanyam, Karius, Inc.: Employee, Salary.
155. Infective Endocarditis and Cardiac Valve Surgery During the Opioid Epidemic in North Carolina, 2007 to 2017
Authors: Schranz Asher , Fleischauer Aaron , Chu Vivian H , Rosen David 
Published: November 2018

Abstract

Background
Infective endocarditis (IE) associated with drug use (DA-IE) is rising nationally. North Carolina (NC), a state hard-hit by the opioid epidemic, saw an over 12-fold increase in DA-IE from 2010 to 2015. Concerns about surgery exist due to the risk of ongoing drug use and reinfection after valvuloplasty. We evaluated trends, characteristics, and outcomes of valve surgery for DA-IE, compared with IE not associated with drug use (non-DA-IE), in NC.

Methods
We analyzed the NC Discharge Database, which includes administrative data from all hospital discharges in NC. Using International Classification of Diseases codes, we identified all persons ≥18 years of age with IE from July 1, 2007 to June 30, 2017. Hospitalizations were deemed DA-IE by a diagnosis code related to illicit drug use, dependence, poisoning or withdrawal (excepting marijuana), or Hepatitis C in a person born after 1965. All others were labeled non-DA-IE. Procedure codes were queried to identify cardiac valve surgery. Year-to-year trends in surgery for IE by drug-associated status were reported. Demographics, length of stay (LOS), charges, and disposition were compared among DA-IE and non-DA-IE.

Results
A total of 22,809 hospitalizations were coded for IE. Valve surgery occurred in 1,652. Of surgical hospitalizations, 17% overall and 42% in the final study year were DA-IE. Hospitalizations for DA-IE where surgery was done increased from &lt;10 through 2012–2013 to 109 in 2016–2017 (figure). Compared with non-DA-IE, those undergoing surgery for DA-IE were younger (median age 33 vs. 56), female (47% vs. 33%), White (89% vs. 64%), uninsured (34% vs. 11%), insured by Medicaid (39% vs. 13%), and had tricuspid valve surgery (38% vs. 11%). DA-IE had longer median LOS (27 vs. 17 days) and were less often discharged home (51% vs. 59%). For the 287 DA-IE admissions with surgery, median hospital charges were $247,524, totaling over $79,000,000. All comparisons were significant at P &lt; 0.0001.

Conclusion
From 2007 to 2017, valve surgeries for DA-IE in NC rose over tenfold and are approaching half of all surgeries for IE. This phenomenon is an underappreciated and morbid component of the opioid epidemic that burdens hospital and state resources. Research into best practices for managing patients with DA-IE and addressing addiction in this setting is critically needed.

Disclosures
All authors: No reported disclosures.
161. Prevalence and Risk Factors for Candida auris Colonization Among Patients in a Long-term Acute Care Hospital—New Jersey, 2017
Authors: Rozwadowski Faye , McAteer Jarred , Chow Nancy A , Skrobarcek Kimberly , Forsberg Kaitlin , Barrett Patricia M , Greeley Rebecca , Fulton Tara , Wells Julia , Welsh Rory M , Dietz Stephanie , Derado Gordana , Jackson Brendan R , Vallabhaneni Snigdha 
Published: November 2018

Abstract

Background
Candida auris can be transmitted in healthcare settings, and patients can become asymptomatically colonized, increasing risk for invasive infection and transmission. We investigated an ongoing C. auris outbreak at a 30-bed long-term acute care hospital to identify colonization for C. auris prevalence and risk factors.

Methods
During February–June 2017, we conducted point prevalence surveys every 2 weeks among admitted patients. We abstracted clinical information from medical records and collected axillary and groin swabs. Swabs were tested for C. auris. Data were analyzed to identify risk factors for colonization with C. auris by evaluating differences between colonized and noncolonized patients.

Results
All 101 hospitalized patients were surveyed, and 33 (33%) were colonized with C. auris. Prevalence of colonization ranged from 8% to 38%; incidence ranged from 5% to 20% (figure). Among colonized patients with available data, 19/27 (70%) had a tracheostomy, 20/31 (65%) had gastrostomy tubes, 24/33 (73%) ventilator use, and 12/27 (44%) had hemodialysis. Also, 31/33 (94%) had antibiotics and 13/33 (34%) antifungals during hospitalization. BMI for colonized patients (mean = 30.3, standard deviation (SD) = 10) was higher than for noncolonized patients (mean = 26.5, SD = 7.9); t = −2.1; P = 0.04). Odds of colonization were higher among Black patients (33%) vs. White patients (16%) (odds ratio [OR] 3.5; 95% confidence interval [CI] 1.3–9.8), and those colonized with other multidrug-resistant organism (MDRO) (72%) vs. noncolonized (44%) (OR 3.2; CI 1.3–8.0). Odds of death were higher among colonized patients (OR 4.6; CI 1.6—13.6).

Conclusion
Patients in long-term acute care facilities and having high prevalences of MDROs might be at risk for C. auris. Such patients with these risk factors could be targeted for enhanced surveillance to facilitate early detection of C. auris. Infection control measures to reduce MDROs’ spread, including hand hygiene, contact precautions, and judicious use of antimicrobials, could prevent further C. auris transmission.
Acknowledgements
The authors thank Janet Glowicz and Kathleen Ross.

Disclosures
All authors: No reported disclosures.
162. Association Between Antibiotic Use and Multidrug-Resistant Organism Detection in Advanced Cancer Patients on Palliative Chemotherapy
Authors: Datta Rupak , McManus Dayna , Topal Jeffrey , Quagliarello Vincent , Juthani-Mehta Manisha 
Published: November 2018

Abstract

Background
Data suggest end-of-life antibiotics predispose to multidrug-resistant organism (MDRO) acquisition in intensive care units (ICUs). Less is known regarding antibiotics and MDRO acquisition in other palliative care populations.

Methods
We conducted a nested case–control study of advanced cancer patients aged ≥65 years started on palliative chemotherapy from January 2016 to September 2017 at Yale New Haven Hospital. We identified patients with (cases) and without (controls) new MDRO detected from clinical or surveillance cultures from the first hospitalization after starting palliative chemotherapy. All patients had no history of MDRO, and 3 controls were randomly selected per case. Antibiotic use was defined as exposure on or prior to the MDRO culture collection date in cases or during the entire hospitalization in controls. The association between antibiotics and MDRO detection was assessed with χ2 and multivariable logistic regression testing. Length of stay (LOS) was compared between groups.

Results
Of 1,181 advanced cancer patients started on palliative chemotherapy and subsequently admitted, we identified 45 cases and 135 controls (figure). Overall, median age was 75 years (range 65–95) and 48% (N = 87/180) were female. Antibiotic exposure was more likely in cases (91%, N = 41/45) vs. controls (75%, N = 101/135; P = 0.02). In regression testing adjusted for gender, LOS, and ICU stay, antibiotic use was associated with MDRO detection (OR = 3.23, 95% CI 1.1, 9.8; P = 0.04). Mean LOS was higher in those with (8.7 days, 95% CI 7.5, 10.0) vs. without (3.5 days, 95% CI 3.8, 6.1) MDRO detection (P = 0.002)

Conclusion
In older advanced cancer patients on palliative chemotherapy, antibiotic use is predictive of new MDRO detection, and patients with new MDRO detection have significantly longer LOS. These results suggest antibiotics should be used cautiously in palliative care patients in whom the burdens of MDRO detection, such as longer LOS and potential room isolation with contact precautions, may conflict with goals of care.

Disclosures
M. Juthani-Mehta, Iterum Therapeutics: Scientific Advisor, Consulting fee.
163. Development of an Electronic Flagging Tool for Identifying Cardiac Device Infections: Insights from the VA CART Program
Authors: Asundi Archana , Stanislawski Maggie , Mehta Payal , Mull Hillary , Schweizer Marin , Ho P Michael , Gupta Kalpana , Branch-Elliman Westyn 
Published: November 2018

Abstract

Background
Surveillance is an essential aspect of infection prevention. Despite the high morbidity and mortality associated with procedure-related Cardiac Implantable Electronic Device (CIED) infections, methods for identifying them are limited. The objective of this study was to develop an algorithm with electronic flags to facilitate detection of CIED infections in a large, multi-center cohort.

Methods
A sample of patients who underwent CIED procedures entered into the VA Clinical Assessment Reporting and Tracking Electrophysiology (CART-EP) program from FY 2007 to 2015 were included in the nested case–control study. After cohort creation, data from this review process were combined with electronic variables (e.g., microbiology orders, ICD 9/10 codes) to develop a preliminary algorithm that categorized patients as high, intermediate, or low risk of CIED infection.

Results
A total of 1,014 unique patients out of a cohort of 5,955 procedures underwent manual review. Among these cases, 59 CIED infections and 955 controls were identified. Electronic variables predictive of CIED infection included ICD 9/10 infection codes and microbiology orders (table). ICD 9/10 codes had excellent PPV for flagging infections but sensitivity was limited (47.5%, see figure). Adding microbiology order flags increased sensitivity but lowered specificity. Specificity in patients without either flag was outstanding (99%).

Conclusion
Absence of ICD 9/10 and microbiology orders is highly specific for ruling out CIED infections. The discriminatory abilities of the algorithm for intermediate probability flags (+microbiology/−ICD9/10) need improvement. In patients without ICD codes, at least microbiology orders should be used as a flag to streamline review of possible device infections. Refinement of this tool using other clinical flags may improve operating characteristics and clinical utility.

Disclosures
W. Branch-Elliman, Veterans’ Integrated Service Network Career Development Award: Investigator, Research grant. American Heart Association: Investigator, Research grant.
854. The Impact of the CMS SEP-1 Core Measure on Antimicrobial Utilization: a Multicenter Interrupted Time-Series (ITS) Analysis
Authors: Anderson Deverick J , Ashley Elizabeth Dodds , Parish Alice , Lokhnygina Yuliya , David Michael Z , Hsueh Kevin , Ryan Matthew , Cressman Leigh , Tolomeo Pam , Habrock-Bach Tracey , Hill Cherie , Moehring Rebekah W ,   CDC Prevention Epicenters Program
Published: November 2018

Abstract

Background
Hospitals began reporting the SEP-1 Core Measure to CMS in October 1, 2015, to promote the use of best practices for patients with sepsis. The impact of SEP-1 on overall antimicrobial utilization (AU), a potential unintended consequence, is unclear.

Methods
We performed an ITS analysis to evaluate changes in antimicrobial utilization after SEP-1 implementation. AU was measured as days of therapy (DOT)/1,000 days present (dp) for all adult inpatients who spent more than 24 hours in 18 hospitals in the southeastern United States. The 12-month period from October 1, 2014 to September 30, 2015 was defined as the “pre” period. After a 1-month wash-in, the 12-month period from November 1, 2015 to October 31, 2016 was defined as the “post” period. AU was aggregated by hospital by month for inpatient units. Total AU and NHSN AU categories were analyzed separately. ITS was modeled using a segmented regression analysis through a GEE model with negative binomial distribution and log link.

Results
A total of 362,460 patients had 688,583 DOT pre-SEP1 (mean 1.9 DOT/admission), and 291,884 patients had 530,382 DOT post-SEP1 (mean 1.8 DOT/admission). The diagnosis of sepsis (3.1%) and median length of stay (3, IQR 2–4) were unchanged after SEP-1. Utilization of combined vancomycin and piperacillin–tazobactam (P-T) increased 17% at SEP-1 implementation but this increase was not statistically significant (Table). Overall AU, anti-MRSA agents, and anti-pseudomonal agents were unchanged after SEP-1 (figure, table).

Conclusion
Implementation of the CMS SEP-1 measure did not lead to higher rates of AU in our cohort of hospitals, although this study did not assess adherence to SEP-1. Further research is needed to improve the use of antimicrobial therapy in hospitalized patients with suspected sepsis.

Disclosures
All authors: No reported disclosures.