bluuebunny/crossref_metadata_2025_split huggingface dataset:
1231. Patient-Level Factors Associated with Vancomycin-Resistant Enterococci Transmission to Healthcare Workers Gowns or Gloves
Authors: Blanco Natalia , Jackson Sarah S , Pineles Lisa , Thom Kerri A , Harris Anthony D 
Published: November 2018

Abstract

Background
Vancomycin-resistant Enterococcus (VRE) is transmitted from person-to-person, most commonly by healthcare workers (HCW) whose hands or attire have become contaminated while interacting with an infected or colonized patient. Our group recently found that VRE colonized patients transmitted this pathogen to HCW gowns or gloves 15% of the time. This study aims to describe patient-level factors associated with higher risk of transmission of VRE to HCW gowns or gloves and thus likely to subsequent patients.

Methods
We analyzed a prospective cohort that included 43 VRE-colonized patients and 215 HCW-patient interactions in medical or surgical intensive care units at the University of Maryland Medical Center. HCWs’ gowns and gloves were cultured for VRE after performing patient care and before doffing. Univariate and multivariable logistic regression models, using generalized estimating equations to account for patient clustering, were used to estimate the odds ratios associated with specific patient-level factors (i.e., age, race, Elixhauser comorbidity score components obtained by ICD-10 codes, diarrhea, and devices). Multivariable models with and without stool VRE burden were created.

Results
In the initial multivariable model, having a nasogastric tube, diarrhea, complicated diabetes, rheumatoid arthritis/collagen vascular diseases, neurological disorders or psychoses doubled (OR greater than 2) the patient’s risk of VRE transmission. After adjusting for VRE stool burden (OR 2.1 (95% CI 1.5–3.0)), having a nasogastric tube (OR 3.6 (95% CI 1.3–9.8)), diarrhea (OR 3.3 (95% CI 1.4–8.1)), or rheumatoid arthritis/collagen vascular diseases (OR 4.8 (95% CI 1.6–14.7)) remained significant in the model.

Conclusion
Patient-level factors associated with higher risk of VRE transmission to HCW gowns or gloves were identified even after adjusting for VRE stool burden, highlighting the importance of patient characteristics in VRE transmission. These patient-level factors may facilitate transmission by either increasing VRE stool shedding to the environment or the need for direct HCW-patient contact. These factors could be used to target more aggressive infection control interventions for these patients.

Disclosures
All authors: No reported disclosures.
1234. Racial Disparities in Invasive Staphylococcus aureus (iSA) Disease in Metropolitan Atlanta, a Population-Based Assessment, 2016
Authors: Overton Rahsaan , Fridkin Scott , Tunali Amy , Ray Susan M 
Published: November 2018

Abstract

Background
Disparities in incidence of invasive methicillin-resistant S. aureus (iMRSA) infections have been examined, suggesting that differences were in part driven by socio-economic factors. An analysis was conducted to determine whether similar disparities exist for invasive methicillin-susceptible S. aureus (iMSSA).

Methods
The Georgia Emerging Infections Program (GA EIP) conducts active, population-based surveillance for iSA within the 8-county area of Atlanta. Cases were defined as residents of the surveillance area with SA isolated from a normally sterile site, with cultures within a 30-day period considered a single case. Age- and race-specific incidence were calculated using 2016 US census data; other/unknown race were excluded from analysis (&lt;5% of cases). Incidence rate ratios (RR) between stratum and summary adjusted rate ratios (aRR) were calculated with the Mantel–Hanzel method.

Results
During 2016, 1,958 cases were identified (42% iMRSA and 58% iMSSA); crude incidence was 48.5/100,000. Rates were highest among those ≥ 65 years of age for both blacks and whites (Figure 1). When compared with iMSSA, iMRSA incidence was consistently lower across all age groups (aRR: 0.7; 95% CI: 0.7–0.8) (Figure 2). However, the incidence of iMRSA among black cases was double that among white cases (aRR: 2.0; CI: 1.7–2.3) across all age groups. This racial disparity was less pronounced in iMSSA: among younger cases (&lt;65 years old), iMSSA incidence among blacks was significantly higher than whites (aRR: 1.6; CI: 1.4–2.0), while rates were similar in older blacks and whites (≥65 years old) (aRR: 0.9; CI: 0.8–1.2). Bloodstream infections were the most common presentation overall; however, for iMSSA infections, joint/synovial infections were significantly less common among black cases than white cases (RR: 0.3; CI: 0.1–0.7).

Conclusion
In the Atlanta area, racial disparities in iSA were noted, with higher incidence among blacks than whites for both iMSSA and iMRSA. The racial disparity is more extreme for iMRSA. Notably the racial disparity is not observed in cases age 65 and over. Causes for these disparities should be investigated.

Disclosures
S. Fridkin, Pfizer Inc.: Grant Investigator, Research support.
1238. A National Comparison of Antibiograms Between Veterans Affairs Long-Term Care Facilities and Affiliated Hospitals
Authors: Tolg Maria-Stephanie , Caffrey Aisling , Appaneal Haley , Jump Robin , Lopes Vrishali , Dosa David , LaPlante Kerry 
Published: November 2018

Abstract

Background
Long-term care facilities (LTCFs) face several barriers to creating antibiograms. Here, we evaluate if LTCFs can use antibiograms from affiliated hospitals as their own antibiogram.

Methods
Facility-specific antibiograms were created for all Veterans Affairs (VA) LTCFs and VA Medical Centers (VAMCs) for 2017. LTCFs and affiliated VAMCs were paired and classified as being on the same campus or geographically distinct campuses based on self-report. For each pair, Escherichia coli susceptibility rates (%S) to cefazolin, ceftriaxone, cefepime, ciprofloxacin, nitrofurantoin, sulfamethoxazole/trimethoprim, ampicillin/sulbactam, piperacillin/tazobactam, and imipenem were compared. As guidelines discourage empiric use of antibiotics if susceptibility rates are &lt;80%, we assessed clinical discordance between each LTCF and affiliated VAMC antibiogram at a threshold of 80% susceptible. The proportions of concordant susceptibilities between LTCFs and VAMCs on the same campus vs. geographically distinct campuses were compared using Chi-square tests.

Results
A total of 119 LTCFs and their affiliated VAMCs were included in this analysis, with 70.6% (n = 84) of facilities located on the same campus and 29.4% (n = 35) on geographically distinct campuses. The table below shows the overall clinical concordance (agreement) of LTCFs with their affiliated VAMC in regards to E. coli %S to the compared antibiotics. No significant differences were found when comparing LTCFs on the same campus vs. geographically distinct campuses.

Conclusion
Antibiograms between LTCFs and affiliated VAMCs had a high concordance, except for sulfamethoxazole/trimethoprim, cefazolin and ceftriaxone in regards to susceptibility rates of E. coli. Facilities on the same campus were found to have similar concordance rates to geographically distinct facilities. Future studies are needed to investigate how the various approaches to creating LTCF-specific antibiograms are associated with clinical outcomes.

Disclosures
M. S. Tolg, Veterans Affairs: Investigator, Research grant. A. Caffrey, Veterans Affairs: Investigator, Research grant. H. Appaneal, Veterans Affairs: Grant Investigator, Research grant. R. Jump, Veterans Affairs: Investigator, Research grant. V. Lopes, Veterans Affairs: Investigator, Research grant. D. Dosa, Veterans Affairs: Grant Investigator, Research grant. K. LaPlante, Veterans Affairs: Investigator, Research grant.
1240. Antibiotic Prescribing in US Nursing Homes Using National Pharmacy Transaction Data
Authors: Palms Danielle , Kabbani Sarah , Bartoces Monina , Hyun David Y , Baggs James , Stone Nimalie D , Hicks Lauri A 
Published: November 2018

Abstract

Background
Antibiotics are frequently prescribed inappropriately in nursing homes (NHs); however, national estimates of NH antibiotic use are limited. We aimed to describe antibiotic prescribing in US NHs to identify potential targets for antibiotic stewardship.

Methods
A descriptive analysis was conducted using the 2014 proprietary IQVIA long-term care (LTC) Xponent database, which captures oral and intravenous antibiotic prescription transactions from sampled LTC pharmacies representing 70–85% of the LTC market. The data are projected to 100% of the US LTC market. Denominators for rate calculations were captured from the 2014 Minimum Data Set as the number of residents with at least one resident day in an NH in 2014. Antibiotic transaction counts and rates were calculated by resident gender, age, US census region, route of administration, antibiotic class and agent, and total transaction counts were summarized by provider type. Prescribing patterns for antibiotic classes and agents stratified by resident age were also calculated.

Results
In 2014, there were over 14 million antibiotic transactions in LTC pharmacies, for a rate of 3,302 per 1,000 residents. Female residents accounted for 62% of antibiotic transactions at a rate of 3,305 transactions per 1,000 residents compared with 3,240 per 1,000 male residents. Antibiotic prescribing was highest in the South at 3,752 transactions per 1,000 residents (vs. 2,601 per 1,000 residents in the West). Oral antibiotics accounted for 85% of transactions. Fluoroquinolones were the most frequently prescribed antibiotic class (22%; 723 transactions per 1,000 residents) and the most common agents were levofloxacin, ciprofloxacin, and sulfamethoxazole–trimethoprim. Stratified by age, the percent change in prescribing rates among residents aged &lt;85 to residents aged ≥85 was largest for fluoroquinolones (645 vs. 883) and urinary anti-infectives (210 vs. 319). Internal medicine and family practice providers accounted for 37% and 32% of all antibiotic transactions, respectively.

Conclusion
A potential antibiotic stewardship target in NHs is fluoroquinolone prescribing. Targeting states in the South for interventions may have the largest impact.

Figure. Antibiotic prescribing rates in long-term care by U.S. census regions

Disclosures
All authors: No reported disclosures.
1242. Quantitative Analysis of Microbial Burden on LTCF Environmental Surfaces
Authors: DiBiase Lauren , Powell Amy , Gergen Maria , Weber David J , Sickbert-Bennett Emily E , Rutala William A 
Published: November 2018

Abstract

Background
There is a lack of data on environmental surface contamination in long-term care facilities (LTCF), despite multiple reports of outbreaks of multi-drug-resistant organisms in these settings. Therefore, we conducted a quantitative analysis of the microbial burden and prevalence of epidemiologically important pathogens (EIP) found on LTCF environmental surfaces.

Methods
Microbiological samples were collected using Rodac plates from resident rooms and common areas in five LTCFs. At each facility, five samples from up to 10 different available environmental surfaces were collected from a room of a resident reported to be colonized with EIP, as well as from a room of a resident reported to be non-colonized. In addition, five samples from up to 10 different environmental surfaces were collected from two common areas in the facility. EIPs were defined as MRSA, VRE, C. difficile and multi-drug-resistant Gram negative bacilli. Data were analyzed for each environmental site sampled in a resident room or common area based on total bacterial colony forming units (CFU), mean CFU per Rodac, total EIP by site, and mean EIP counts per Rodac.

Results
The below table summarizes total EIP recovered from environmental sites by reported EIP colonization status of the resident. Rooms of residents with reported colonization had much greater EIP counts per Rodac (8.32, 95% CI 8.05, 8.60) than rooms of non-colonized residents (0.78, 95% CI 0.70, 0.86). MRSA was the most common EIP recovered from Rodacs, followed by C. difficile. Very few EIPs were recovered from the common areas sampled at these LTCFs.

Conclusion
We found varying levels of CFU and EIP on environmental sites at LTCFs. Colonization status of a resident was a strong predictor of higher levels of EIP being recovered from his/her room.

Disclosures
All authors: No reported disclosures.
1244. Evaluation of Antibiotic Prescribing Practices for Geriatric Patients in the Outpatient Setting in a Veterans Affairs Hospital: Identification of Stewardship Targets
Authors: Clark Collin , White Alexis , Sellick John , Mergenhagen Kari 
Published: November 2018

Abstract

Background
Antibiotics are frequently overused in the outpatient setting, however it is unknown how antibiotic use differs with age. Infections are a leading cause of hospitalization in elderly patients. Prescribing appropriateness for patients less than 65 years old was compared with patients at or above ≥65 years old in order to identify targets for antimicrobial stewardship in this population.

Methods
A retrospective review of all outpatient antibiotic prescriptions between June and September of 2017. Prescriptions were reviewed based on alerts in the electronic medical record when orders for antibiotics were signed by the provider. Appropriateness of antibiotics was assessed based on clinical practice guidelines. Retreatment and hospital admissions were documented. Those aged &lt;65 were compared with those ≥65 years of age using Student’s t-test and chi-squared tests. A multivariate logistic regression model was constructed to identify risk factors for inappropriate use of antibiotics between the two age groups.

Results
The study period yielded 1,700 prescriptions after exclusions 1,063 were included in the analysis. Patients aged ≥65 comprised 51% of the population. Older patients had significantly more comorbidities than the younger population. No significant difference was observed for antibiotic indicated (60%), correct drug (50%), or correct duration (75%) between the two age groups. Patients in the ≥65 cohort were statistically significantly more likely to receive an inappropriate dose (86% vs. 76%, P &lt; 0.002). In the multivariable analysis, patients with COPD were more likely to be appropriately with antibiotics OR 1.4 (95% CI: 1.03–1.9) compared with those without COPD. Older patients were not more likely to be retreated or admitted for the same indication within 30 days.

Conclusion
Antibiotics were frequently overused in the outpatient setting; however, they were not more frequently used in elderly patients. However, older adults were more likely to be prescribed an antibiotic at an inappropriate dose highlighting the need for increased caution with dosage selection in this population. Stewardship teams caring for elderly patients should be cognizant of dosing in this population.

Disclosures
All authors: No reported disclosures.
1247. Genomic Epidemiology of MRSA DURING Incarceration at a Large Inner-City Jail
Authors: Popovich Kyle J , Snitkin Evan S , Green Stefan J , Aroutcheva Alla , Schoeny Michael , Payne Darjai , Thiede Stephanie , Zawitz Chad , Hota Bala , Hayden Mary K , Weinstein Robert A 
Published: November 2018

Abstract

Background
Congregate settings may facilitate spread of USA300. Jails may be a location where individuals already colonized with MRSA (from preceding exposures) intermingle with others, potentially augmenting spread. We examined the rate of MRSA acquisition during incarceration and characterized the genomic epidemiology of MRSA strains entering the jail, MRSA acquisition isolates, and archived (2015–2017) clinical MRSA isolates from male detainees.

Methods
Males incarcerated at the Cook County Jail were enrolled within 72 hours of intake and surveillance cultures for MRSA carriage (nares, throat, groin) collected. Detainees in jail at Day 30 had cultures repeated to determine MRSA acquisition. A survey was administered and chart review performed to identify predictors of acquisition. Whole-genome sequencing and phylogenetic analysis of isolates were performed with integration of epidemiologic data.

Results
800 males were enrolled, with 19% colonized with MRSA at jail intake. 143 reached the Day30 visit (82% AA, 7% Hispanic), by which there were 12 MRSA acquisitions detected. Heroin use before entering the jail (OR 3.67, P = 0.04) and sharing personal items during incarceration (OR = 4.92, P = .01) were significant predictors of acquisition. Sequenced clinical isolates (n = 175) (largely skin infections) were more likely to resemble each other genetically than the diverse intake strains (P &lt; 0.001) (figure), suggesting clinical isolates may originate from transmission within the jail or be due to more virulent strains. 7/12 (58%) acquisition isolates were within 40 SNVs from another isolate; five were genomically similar to intake isolates and two were similar to clinical isolates. Acquisition strains from those sharing personal items (vs. not) tended to have closer relatedness (19 SNVs vs. 56 SNVs, P = 0.22).

Conclusion
There is a high burden of MRSA entering jail. Genomic analysis of acquisition and clinical isolates suggests potential spread of incoming strains and possible networks spread of prevalent strains during incarceration. Sharing of personal items during incarceration is associated with MRSA acquisition and could be a focus of an intervention. Future study of epidemiologic and location data may inform targeting of interventions within the jail.

Disclosures
All authors: No reported disclosures.
1249. Emergence of Diverse Carbapenem-Resistant Enterobacteriaceae (CRE) in the Dominican Republic
Authors: Fermin Rita Rojas , Macesic Nenad , Tolari Gilda , Guzman Anel , Annavajhala Medini , Uhlemann Anne-Catrin 
Published: November 2018

Abstract

Background
Despite the global threat of CRE, data from resource-limited regions such as the Dominican Republic (DR) are limited. A lack of novel antibiotics and molecular diagnostic tools for outbreak detection, coupled with the role of travel in circulating CRE to and from the DR represent significant challenges to limiting their spread. Here, we report the first molecular characterization of DR CRE isolates and compared them to geographically diverse CRE.

Methods
Isolates from DR (one Citrobacter freundii, three Klebsiella pneumoniae), obtained from patients with bacteremia (one) and pneumonia (three), were compared with CRE from a New York City hospital in a Dominican neighborhood, including isolates (two Enterobacter cloacae, one K. pneumoniae) from a patient transferred to NYC from another DR institution. Whole genome sequencing was used to determine multi-locus sequence type (MLST) and resistance gene profiles. Phylogenetic analyses of isolates with same ST were performed.

Results
Isolates from the DR and the Dominican patient were of unique genomic backgrounds including pandemic (K. pneumoniae ST11) and novel sequence types, and harbored either blaKPC-2 or blaKPC-3 (Table 1). Replicon typing suggested that these carbapenemase genes were located on distinct plasmids. Phylogenetic analyses using the NYC collection of ~400 sequenced CRE isolates indicated that DR and NYC K. pneumoniae ST307 isolates were related (33 SNPs). Further review showed that both patients had recent admissions in Puerto Rico (PR), highlighting the role of regional spread. K. pneumoniae ST11 isolates from DR and NYC, on the other hand, were not found to be closely related (1,418–1,440 SNPs).

Conclusion
Genotyping of DR CRE isolates revealed a high genomic diversity, suggesting multiple introductions. Phylogenetics of K pneumoniae ST307 place these within a global context, demonstrating links across the Caribbean and North America. International surveillance studies integrating genomics are needed to track and limit the spread of CRE in resource-limited settings such as DR.

Disclosures
A. C. Uhlemann, Merck: Investigator, Grant recipient.
1254. Outbreak of Mycobacterium chelonae Skin Infections Associated With Human Chorionic Gonadotropin Injections at Weight Loss Clinics
Authors: Mody Rajal , Rainbow Jean , Ferguson Beth , Wiberg Cody , Kupferschmidt Trudy , Horn Liz , Walters Maroya Spalding , Fagan Ryan , Chen Greta , Rosenman Karla 
Published: November 2018

Abstract

Background
In December 2016, a dermatologist notified the Minnesota Department of Health (MDH) of three patients with skin lesions after self-administration of human chorionic gonadotropin (HCG) injections supplied by same weight loss clinic chain (Chain X); one lesion had been diagnosed as a nontuberculous mycobacteria (NTM) infection. We investigated to identify the etiology, determine contributing transmission factors, and to prevent additional cases.

Methods
We defined a case as a skin or soft tissue lesion with a suspected infectious etiology in a Minnesota resident occurring within three months after HCG injection at or near an injection site. To find cases we sent health alerts to clinicians and clinical laboratories throughout Minnesota with diagnostic guidance, and we requested Chain X to notify all exposed patients. We visited two Chain X clinics to assess infection control practices, to collect invoices for product traceback, and to collect products for microbiological testing. All NTM isolates were identified by line probe assay and subtyped by pulsed-field gel electrophoresis (PFGE) at MDH.

Results
We identified six cases with illness onset dates ranging from April to November 2016. All patients were adult women who did not share HCG vials. Four patients had clinical specimens that grew NTM; all isolates were identified as Mycobacterium chelonae that were indistinguishable by PFGE. Three patients with confirmed M. chelonae infection obtained HCG at Clinic A, and one from Clinic B, but sharing of reconstituted HCG by the two clinics could not be excluded. We identified several infection control breaches at both clinics including improper reconstitution of HCG and incorrect use of single use vials. The most likely source of the HCG was an unregistered out-of-state compounding pharmacy.

Conclusion
This common source outbreak was likely due to contamination introduced either at a weight loss clinic or a compounding pharmacy. HCG injections are not US FDA-approved for weight loss, and their use may involve compounded products dispensed by alternative care settings that lack infection control expertise and regulatory oversight. This outbreak highlights the important role physician reporting of disease clusters plays in uncovering unsafe practices.

Disclosures
All authors: No reported disclosures.