bluuebunny/crossref_metadata_2025_split huggingface dataset:
1232. Phylogenomics of Enterococcus faecium From South America: Revisiting Worldwide VRE Population Structure
Authors: Rios Rafael , Reyes Jinnethe , Carvajal Lina P , Kolokotronis Sergios-Orestis , Planet Paul , Narechania Apurva , Munita Jose , Arias Cesar , Diaz Lorena 
Published: November 2018

Abstract

Background
Previous studies have suggested that the population structure of E. faecium is composed of two main clades; a commensal clade (designated clade B) and a hospital-associated clade (Clade A) that encompass most of the clinical and animal isolates. The phylogenetic analyses leading to these results have been accomplished with the notable absence of isolates from diverse geographical regions (including South America). We aimed to refine the worldwide population structure of E. faecium by including 55 representative genomes from isolates obtained from five Latin American countries recovered between 1998 and 2014.

Methods
We sequenced our 55 representative isolates and selected other 285 genomes, from public databases, obtained across different regions (36 countries), different sources (animal, commensal, and clinical strains) and a wide range of dates of isolation (1946–2017). We characterized the genomes by presence/absence of resistance, virulence and mobile elements, and of CRISPR-cas systems. We analyzed the phylogeny of the entire population, selected the genomes belonging to clade A to examine recombination patterns and performed Bayesian molecular clock analysis excluding recombinant regions.

Results
Two major clades were identified, as previously reported. However, a higher degree of variation in clade A was found. Indeed, we identified a subclade (subclade I) that diverged ~894 years ago, and clearly distinguished clinical isolates from those of animal origin (distributed among a number of smaller early-branching subclades). A further split within the clinical subclade (subclade II) that diverged around ~371 years ago was also evident. Latin American isolates were distributed within subclades I (48%) and II (42%). Isolates in “animal” branches exhibited an average recombination of 34 Kbp, where it was 5 Kbp and 21 Kbp for subclades I and II, respectively. More resistance determinants were found in subclade II (62%), followed by I (54%) and absence of cas was the norm in the clinical subclades.

Conclusion
Inclusion of E. faecium isolates from diverse geographical region supports a continuous evolution of these organisms causing human infections. Important evolutionary events seem to favor emergence of novel subclades capable to cause important morbidity and mortality.

Disclosures
J. Munita, Pfizer: Grant Investigator, Research grant. C. Arias, Merck & Co., Inc.: Grant Investigator, Research support. MeMed: Grant Investigator, Research support. Allergan: Grant Investigator, Research support.
1250. Prevalence and Risk Factors for Acquiring Carbapenem-Resistant Enterobacteriaceae in an Intensive Care Unit at a Tertiary Hospital
Authors: Kang Jin Suk , Lee Soon Ok , Lee Jeong Eun , Kim So Ra , Kim Han Wool , Hong Seung Hyun , Kim Hye Won , Jang Mi Jin , Shin Sun Hea , Ha Hyun Jung , Park Nam Jeong , Ko Mee Kyung , Yi Jongyoun , Kim Kye-Hyung 
Published: November 2018

Abstract

Background
Active surveillance testing of carbapenem-resistant Enterobacteriaceae (AST-CRE) is recommended in high-risk settings, such as intensive care units (ICUs), to prevent CRE outbreaks or invasive infections. This study aimed to investigate the effects of AST-CRE by analyzing the prevalence and risk factors for acquiring CRE during the ICU care.

Methods
We conducted AST-CRE on rectal swabs of patients admitted to the ICU in the emergency room at a tertiary hospital in South Korea for 12.5 months. AST-CRE was performed upon admission and weekly thereafter. To assess the risk factors of acquiring AST-CRE during the admission period in adult patients, those colonized with CRE upon admission and aged &lt;18 years were excluded. AST-CRE was performed using Centers for Disease Control and Prevention methods. A polymerase chain reaction assay was performed to detect five carbapenemase genes (NDM, KPC, VIM, IMP, and OXA).

Results
A total of 810 patients were admitted during the study period. The acquisition rate and carbapenemase-producing CRE were 2.6% (21/810) and 42.9% (9/21), respectively. No invasive infection due to CRE was found. The most common species were Klebsiella pneumoniae (71.4%, 15/21), and eight KPC and one NDM genes were detected. In CRE-positive patients, in-hospital mortality and length of hospitalization were higher (P = 0.003) and longer (P &lt; 0.001), respectively. Multivariate analyses showed that male gender (adjusted odds ratio [aOR] 8.0; 95% confidence interval [CI] 1.7–36.8), previous hospitalization in the last year (aOR 5.1; 95% CI 1.6–16.4), co-colonization with multidrug-resistant Acinetobacter species (aOR 18.3; 95% CI, 4.2–79.2) and extended-spectrum β-lactamase-producing bacteria (aOR 3.4; 95% CI, 1.1–10.9), and length of ICU admission until CRE detection for ≥10 days (aOR 6.5; 95% CI 2.2–19.2) were independently associated with CRE acquisition.

Conclusion
To prevent CRE outbreak or invasive infections, patients admitted in the ICU should be screened using AST-CRE.

Disclosures
All authors: No reported disclosures.
1252. A Challenging Burkholderia Outbreak Investigation Across Multiple Units at an Academic Medical Center From June 2017 to February 2018
Authors: Greendyke William , Hill-Ricciuti Alexandra , Oberhardt Matthew , Green Daniel , Wu Fann , Whittier Susan , Saiman Lisa , Furuya E Yoko 
Published: November 2018

Abstract

Background
Most outbreak investigations involve short-term, geographically localized clusters. However, some organisms can form environmental reservoirs leading to more prolonged, widespread outbreaks. We describe a prolonged outbreak of Burkholderia at our institution.

Methods
An epidemiological investigation was conducted. Burkholderia isolates were genotyped using pulsed-field gel electrophoresis (PFGE) and recA gene sequencing. Initial isolates were sent to a national reference laboratory for multilocus sequence typing (MLST).

Results
32 patients on 12 units (see figure) had ≥1 positive culture for Burkholderia from June 2017 to February 2018. 21 had B. cenocepacia (PFGE pattern A, recA allele 365) and 11 had B. cepacia (PFGE pattern C, recA allele 53). MLST revealed that isolates with recA allele 365 were unique compared with previously identified B. cenocepacia strains. Of 32 patients, 28 (88%) had positive respiratory cultures. Of 32 patients, 3 (9%) had bacteremia. Thirty-day mortality was 4/29 (14%). A case–control study did not reveal a common point source. All surveillance cultures from asymptomatic patients were negative (n = 53). Two of nine sink drains in rooms of cases were positive for an unrelated strain of B. cepacia. Other environmental cultures were negative for Burkholderia (n = 49). Cases continued despite routine interventions (see figure), with some incident cases detected long after potential exposures. Ventilator/respiratory equipment (V/RE) cleaning was investigated. Multiple V/RE interventions were implemented: (1) ensuring a sterilization process for ventilator temperature probes (used in heated humidification) was occurring; (2) using disposable manometers on contact isolation patients; (3) reinforcing ventilator cleaning, including those in radiology suites after use.

Conclusion
No definitive source of the outbreak was found. New cases continued after reinforcement of basic infection control practices, but subsided after focused attention on V/RE cleaning practices. Control of this outbreak was challenging due to the complexity of a prolonged “latency period” for Burkholderia, difficulty identifying reservoirs, and multiple possible modes of transmission, especially for organisms like Burkholderia that can persist on environmental surfaces and equipment.

Disclosures
All authors: No reported disclosures.
1257. Assessing Risk Factors for an Outbreak of Burkholderia cenocepacia in Non-cystic Fibrosis (CF) Patients
Authors: Hill-Ricciuti Alexandra , Greendyke William , Oberhardt Matthew , Wu Fann , Green Daniel , Whittier Susan , Larson Elaine , Saiman Lisa , Furuya E Yoko 
Published: November 2018

Abstract

Background
Burkholderia spp. have been associated with outbreaks of healthcare-associated infections in non-CF patients, mostly attributable to point sources of contaminated solutions or medications. Fewer non-point source outbreaks have been described.

Methods
We conducted a matched case:control (1:3) study to assess risk factors for B. cenocepacia during an outbreak that occurred in 2017 in a 738-bed university-affiliated hospital involving patients hospitalized on several ICUs and non-ICUs. Clinical isolates identified as B. cepacia complex were speciated using sequencing of the recA allele and genotyped by pulsed field gel electrophoresis (PFGE). Case subjects were patients with a positive culture for the B. cenocepacia outbreak strain (PFGE pattern 17-A, recA 365) from June 1–December 31, 2017. Control subjects had negative respiratory cultures for Burkholderia spp. within 10 days of respective cases’ culture dates and were hospitalized on the same unit at the same time as respective cases. Potential risk factors including procedures, devices, and medications (previously linked to point source outbreaks) were examined. A 5-day exposure window was studied for procedures and devices as this was the shortest interval noted between a case subject’s negative and first positive culture. Exact conditional logistic regression was used to analyze risk factors; Mann–Whitney U and Fisher’s exact tests were used to compare demographic and clinic characteristics of case and control subjects.

Results
Seventeen cases (all with positive respiratory tract cultures) and 41 unit-matched controls were studied. Case and control subjects had similar demographic characteristics, illness severity, and comorbidities. No point source was identified. Only exposure to invasive mechanical ventilation was associated with case status (OR: 10.5, [CI95 1.9, ∞), P = 0.0083). Cases had longer hospital lengths of stay (52 vs. 33 days, P = 0.02) than controls, but similar in-hospital mortality (24% vs.12%, P = 0.43).

Conclusion
These findings suggest that suboptimal infection prevention and control practices related to respiratory interventions, including cleaning and disinfection of ventilators, may have contributed to the outbreak. Reinforcement of best practices helped reduce transmission of the outbreak clone.

Disclosures
All authors: No reported disclosures.
1259. The Local Hospital Milieu and Healthcare-Associated VRE Acquisition
Authors: Zhou Margaret , Li Jianhua , Salmasian Hojjat , Zachariah Philip , Yang Yu-Xiao , Freedberg Daniel 
Published: November 2018

Abstract

Background
The relationship between the local hospital environment and VRE acquisition is not fully understood. The objective of this study was to identify risk factors for healthcare-associated VRE acquisition related to the local hospital milieu.

Methods
This retrospective cohort study included patients admitted to six ICUs at an academic medical center from January 1, 2012 to December 31, 2016 with negative rectal VRE cultures on admission. VRE acquisition was defined as a positive subsequent surveillance swab performed at any time after the initial negative surveillance swab during the index hospitalization. VRE colonization pressure was defined to encapsulate the circulating VRE burden during the at-risk patient’s ICU stay (patient-days of VRE exposure based on concurrently colonized patients on the unit, divided by time at risk). VRE importation pressure was defined to encapsulate the VRE burden at the time of ICU admission (patient-days of VRE exposure on the unit during the preceding 30 days, divided by total patient-days). Multivariable Cox proportional hazards modeling was used, with patients followed until VRE acquisition, death, or for up to 30 days.

Results
There were 161 patients who acquired VRE among 8,485 patients with negative VRE cultures upon admission, including 1,131 patients who had repeat VRE cultures during the index hospitalization. On univariate analysis, patients with VRE acquisition were more likely to have received vancomycin, have had a neighboring patient who received vancomycin, have high VRE importation pressure, or have high VRE colonization pressure. On multivariable analysis, among these factors only high VRE colonization pressure was an independent predictor of VRE acquisition (aHR 1.79, 95% CI 1.19–2.70).

Conclusion
VRE colonization pressure was the most important risk factor for healthcare-associated VRE acquisition in this ICU population, regardless of VRE importation pressure or local use of vancomycin. Interventions seeking to reduce healthcare-associated VRE acquisition may wish to focus on ways to minimize transmission of VRE between patients with known VRE and the local hospital environment.

Disclosures
All authors: No reported disclosures.
1273. Routine Opt-out HIV Screening and Detection of HIV Infection Among Emergency Department Patients
Authors: Fadul Nada , Dortche Ciarra , Baltaro Richard , Reeder Tim 
Published: November 2018

Abstract

Background
The Southeastern United States bears a disproportionate burden of HIV infection, accounting for nearly half of all new cases. The Centers for Disease Control and Prevention released routine opt-out testing recommendations in 2006. Our emergency department collaborated with our infectious diseases clinic (ECU-ID) to implement suggested guidelines among adults since March 2017.

Methods
Our primary aim was to implement routine, opt-out HIV testing in the Vidant Medical Center Emergency Department (ED) for patients between 18 and 65 years of age who have blood work completed, and have not had a test documented in the electronic medical record (EMR) in the last year. A secondary aim was to successfully link HIV-positive patients to care at ECU-ID or preferred clinic. Methods defining programmatic success included developing nurse directed opt-out ordering protocol, integrating testing into normal ED workflow, utilizing the existing EMR to prompt testing, and hiring a linkage coordinator to initiate post-test counseling and linkage-to-care.

Results
Since March 2, 2017, a total of 7,109 HIV tests were performed; an average of 592 monthly tests conducted compared with a previous average of 10 stat tests. Testing increased 5,820% compared with 2015. Of the 21 HIV-positive patients found, 16 were newly diagnosed. Among those newly diagnosed, 14 (87.5%) were linked to care; and among the five known positives, two (40%) were linked to care. Reasons why patients could not be linked included incarceration, refusal to link to care, and re-location.

Conclusion
Joined with the implementation of a routinized ED HIV testing program, a seamless process was developed to link persons found to be positive in the ED to HIV care services; therefore, establishing a systems-level prevention model. Future plans include expanding testing to adolescents and utilizing similar methods to integrate Hepatitis C testing.

Disclosures
All Authors. Gilead Sciences, Inc.: Grant Investigator, Grant recipient and Salary.
1278. Comparing Rates of Routine HIV and HCV Screening to Estimate the Impact of Consent on Identifying Patients With Undiagnosed HIV
Authors: Tlamsa Aileen , Heo Moonseong , Thompson Devin , Moir Lorlette , Shukla Shuchin , Weiss Jeffrey , Litwin Alain , Felsen Uriel 
Published: November 2018

Abstract

Background
HIV and HCV are both treatable viruses for which routine screening among specific age cohorts is recommended. New York State requires patient consent prior to screening for HIV but not HCV. To estimate the impact of the consent requirement, we compared rates of HIV and HCV screening.

Methods
We performed a retrospective study of all adult patients admitted to a tertiary-care hospital in the Bronx, NY, between April 2015 and June 2016. During the study period, automated prompts in the electronic medical record facilitated screening for HIV among patients ages 21–64, and for HCV among patients born between1945-1965. We compared the proportions of patients qualifying for screening for HIV, HCV, or both who were appropriately screened prior to discharge to calculate an adjusted risk difference between performance of HIV and HCV screening. Using the local prevalence of undiagnosed HIV, we estimated the number of missed HIV diagnoses attributable to the difference in screening rates.

Results
A total of 21,413 unique hospitalized patients ages 21–64 and/or born between 1945–1965 were analyzed. Among those qualifying for screening for HIV alone or HCV alone, 39.7% and 58.6% were screened prior to discharge, respectively. Among those qualifying for both HIV and HCV screening, 6.7% were screened for HIV alone, 29.3% were screened for HCV alone, and 30.3% were screened for both. The risk difference between HCV and HIV screening adjusted for patient and admission characteristics was 22.0% (95% CI 20.6%-23.4%). Using an estimated prevalence of undiagnosed HIV of 0.2%, this risk difference corresponds to approximately four (95% CI 3.6–4.1) missed cases of HIV during the study period.

Conclusion
There was a large difference in the number of patients appropriately screened for HIV compared with HCV. While the requirement for consent was the only operational difference in performing routine screening for HIV compared with HCV, differences in how the two viruses are perceived may also have contributed to the observed difference in screening rates. Nevertheless, our findings suggest that removing the requirement for consent prior to HIV screening may increase the number of cases of previously undiagnosed HIV identified by routine screening.

Disclosures
All authors: No reported disclosures.
1282. Detection of HIV Transmitted Drug Resistance by Next-Generation Sequencing in a CRF01_AE Predominant Epidemic
Authors: Salvana Edsel Maurice , Dungca Nina , Arevalo Geraldine , Leyritana Katerina , Francisco Christian , Penalosa Christine , Destura Raul , Lim Jodor , Schwem Brian 
Published: November 2018

Abstract

Background
The Philippines has the fastest growing HIV epidemic in the Asia-Pacific. Concurrent with this is a subtype shift from B to CRF01_AE. We have previously documented transmitted drug resistance (TDR) locally. However, the lack of drug pressure and the insensitivity of Sanger-based sequencing (SBS) may leave archived drug-resistance mutations (DRMs) undetected. To better detect TDR, we performed next-generation sequencing (NGS) on treatment-naïve patients and compared this with SBS.

Methods
Following ethics approval, newly-diagnosed adult Filipino HIV patients were recruited from the Philippine General Hospital HIV treatment hub. Demographic data were collected, and blood samples underwent SBS with a WHO-approved protocol. Whole-genome NGS was performed using Illumina HiSeq through a commercial provider (Macrogen, Korea). Genotype and DRMs were analyzed and scored using the Stanford HIV Drug Resistance Database.

Results
113 patients were analyzed. Median age was 29 years (range 19–68), mean CD4 count was 147 cells/µL (range 0–556) and median viral load was 2.8 × 106 copies/mL. Genotype distribution was: CRF01_AE (93), B (13), possible CRF01_AE/B recombinants (5), CRF02_AG (1), possible URF (1). TDR prevalence by SBS and NGS at different minority variant cutoffs are shown in Table 1. All DRMs on SBS were found on NGS. Some samples had multiple DRMs. No factors were significantly associated with TDR, genotype, viral load or baseline CD4 count.

Conclusion
NGS is a more sensitive tool for detecting TDR compared with SBS. Nearly double the DRMs were found at an NGS cutoff of ≥5%, including INSTI DRMs. With increasing HIV drug resistance worldwide, switching to NGS may help decrease rates of initial treatment failure, especially in settings with limited repertoires of ARVs.

Disclosures
All authors: No reported disclosures.
1287. Seizing Opportunities for Intervention: Changing HIV Knowledge Among Men Who Have Sex With Men and Transgender Women Attending Trusted Community Centers in Nigeria
Authors: Jones Milissa , Omari Habib , Adebajo Sylvia , Gaydos Charlotte , Kokogho Afoke , Baral Stefan , Nowak Rebecca , Ake Julie , Charurat Manhattan , Robb Merlin L , Crowell Trevor A ,   TRUST/RV368
Published: November 2018

Abstract

Background
Knowledge of HIV risk factors and risk reduction strategies is essential for HIV prevention in key populations, including men who have sex with men (MSM) and transgender women (TGW). We described factors associated with HIV-related knowledge and evaluated the impact of counseling and care at trusted community health centers serving Nigerian MSM and TGW.

Methods
The TRUST/RV368 cohort recruits MSM and TGW via respondent driven sampling in Abuja and Lagos, Nigeria. Participants undergo a structured interview with five knowledge-testing questions at enrollment and after 9 and 15 months. Routine HIV/STI screening, free condoms/lubricants, and counseling about safer sex practice is provided. Multivariable Poisson regression with generalized estimating equations was used to calculate risk ratios (RRs) and 95% confidence intervals (CIs) for factors associated with answering more knowledge questions correctly. Pearson’s chi-squared test was used to compare the proportion of participants answering each question correctly at enrollment and subsequent visits.

Results
From March 2013 to December 2017, 2,090 biological males were enrolled with median age 23 [interquartile range 20–27] years, including 234 (11.2%) with female gender identity. Of 1691 participants with known HIV status, 836 (49.4%) were positive. The mean number of HIV knowledge questions correctly answered was 2.37, 2.98, and 3.09 at enrollment, 9, and 15 months, respectively. Participants demonstrated increased HIV knowledge after 9 (RR 1.15 [95% CI 1.03–1.28]) and 15 months (1.18 [1.05–1.32]). Factors associated with increased knowledge included HIV positivity (1.17 [1.11–1.23]), higher than senior secondary education when compared with less than senior secondary (1.24 [1.12–1.37]), and almost daily internet use when compared with never (1.17 [1.08–1.27]). Knowledge gains were driven primarily by improved understanding of condom and lubricant use (figure).

Conclusion
While HIV knowledge improved during enrollment in the cohort, it remained suboptimal. Multiple modalities may be needed to fully inform Nigerian MSM and TGW of risk reduction strategies. Interventions that involve internet access to deliver educational materials may be a useful adjunct to direct counseling at healthcare centers.

Disclosures
All authors: No reported disclosures.