bluuebunny/crossref_metadata_2025_split huggingface dataset:
1077. Heart Transplantation as Salvage Treatment for Intractable Infective Endocarditis
Authors: Tattevin Pierre , Muñoz Patricia , Moreno Asuncion , Hékimian Guillaume , Delahaye François , Duval Xavier , Castel María Ángeles , Hasse Barbara , Jamarillo Natalia , Vincelj Josip , Wray Dannah , Mestres Carlos , Miro Jose 
Published: November 2018

Abstract

Background
Infective endocarditis (IE) remains a severe disease with contemporary in-hospital mortality rates of 20%. Although valvular replacement is performed in 50% of patients during the acute phase, heart transplantation remains the last resort in selected patients with extensive perivalvular lesions or end-stage cardiac failure.

Methods
Cases were identified through the International Collaboration on Endocarditis (ICE) network. All patients who underwent heart transplantation during the acute phase of IE, with at least three months follow-up, were enrolled. Data were extracted from medical charts on a standardized questionnaire. Only patients who fulfilled Duke criteria for definite IE were enrolled.

Results
Between 1991 and 2017, 19 patients (6 women, 13 men), with a median age of 52 years (interquartile range, 41–61) underwent heart transplantation for IE refractory to optimized medical treatment and/or other cardiac surgery in Spain (n = 9), France (n = 6), and Colombia, Croatia, Switzerland, and the United States (one patient each). IE affected prosthetic (n = 10), native valves (n = 9), primarily aortic (56%), and mitral (28%). Pathogens were oral streptococci (n = 7), Staphylococcus aureus (n = 5, including two methicillin-resistant), Enterococcus faecalis (n = 2), and Mycoplasma hominis, Haemophilus para-influenzae, Candida albicans (one patient each). Two cases were not documented. Main cardiac lesions were vegetations (n = 17), severe regurgitation (n = 15), peri-annular abscesses (n = 9), prosthetic valve desinsertion (n = 4), and intra-cardiac fistula (n = 1). Seventeen patients underwent cardiac surgery at least once before transplantation, and four patients were on circulatory assistance (left ventricular assist-device, or extra-corporeal membrane oxygenation, two patients each). Median delay between first cardiac surgery and transplantation was 28 days (IQR, 18–71). Six patients died (32%), including four during the first month post-transplant. Thirteen patients survived, with a median follow-up of 44 months post-transplantation (IQR, 13–88).

Conclusion
Heart transplantation may be considered as salvage treatment in highly selected patients with intractable infective endocarditis.

Disclosures
All authors: No reported disclosures.
1079. When Does a Trans-Esophageal Echocardiogram (TEE) Change Management of Staphylococcus aureus Bacteremia (SAB)?
Authors: Lam John , Robinson Stephen , Gregson Daniel , Somayaji Ranjani , Conly John , Welikovitch Lisa , Parkins Michael 
Published: November 2018

Abstract

Background
The recognition of infective endocarditis (IE) as a serious complication of SAB has led to a low threshold for echocardiography, extended treatment (eTx) with anti-staphylococcal agents (anti-SA), and even surgery. However, indications for eTx outside of IE are numerous. We sought to determine the frequency in which findings from a TEE changed clinical SAB management.

Methods
Adults with SAB within the Calgary Health Zone between 2012 and 2014 were included if both a transthoracic echocardiogram (TTE) and TEE were performed within 7 days of each other. Patients potentially benefiting from eTx courses were a priori defined as having ≥1 of; (1) metastatic phenomena, (2) complicated SAB (defined as community acquired (CA), persistent fever/bacteremia at ≥48 hours), (3) intracardiac devices, and/or (4) Duke criteria defined IE (separately evaluated using TTE or TEE). Patient demographics, treatment (including changes to anti-SA duration and surgical indications), and clinical outcomes were extracted and evaluated.

Results
Of 961 SAB episodes, 179 (18% MRSA) met inclusion criteria (median 3.0 days, IQR 1.9–5.1 between TTE and TEE). Within the cohort 29% (n = 51) had metastatic phenomena (intracranial; 9% [n = 16], vertebral; 8% [n = 14]; empyema; 6% [n = 11]). Complicated bacteremia was present in 89% (n = 159), while 13% (n = 23) had intravascular hardware (39% pacemakers, 65% valve prostheses). IE was diagnosed in 22% (n = 40) of SAB episodes, with TTE identifying 58% of vegetations (n = 23) and TEE identifying an additional 30% (n = 15). Of the cohort, 89% (n = 160), 37% (n = 67), 4% (n = 7) of SAB had ≥1, 2, and 3 nonechocardiographic indications for eTx, respectively. Only one patient met criteria for eTx solely based on IE diagnosed from concordant TTE and TEE. Actual duration of therapy did not differ in SAB episodes that had ≥1 a priori eTx criteria but had a negative TEE relative to those who had a positive TEE (36.7 days, IQR 23.4–48.6 vs. 43.8 days, IQR 33.3–49.5, P = 0.17). Of the 15 episodes of TEE-only evident IE, 14 were CA, 12 had prolonged BSI, and nine embolic phenomena. Only 11 patients in the cohort required cardiac surgery, none were identified exclusively by TEE.

Conclusion
Routine performance of TEE may not be required in all SAB as many patients have alternate indications for eTx with anti-SA regardless of TEE findings.

Disclosures
All authors: No reported disclosures.
1081. Antimicrobial Activity of Dalbavancin Tested Against Gram-Positive Organisms Isolated From Patients With Infective Endocarditis in United States and European Medical Centers
Authors: Sader Helio S , Mendes Rodrigo E , Pfaller Michael A , Flamm Robert K 
Published: November 2018

Abstract

Background
The management of endocarditis requires aggressive and prolonged antimicrobial treatment. Dalbavancin (DALBA) has demonstrated potent in vitro activity against Gram-positive (GP) organisms commonly responsible for endocarditis and is being evaluated for treatment of complicated bacteremia and infective endocarditis.

Methods
A total of 626 GP organisms were collected from patients with a diagnosis of bacterial endocarditis in the United States (n = 222) and Europe (n = 404) from 2007 to 2017 via the SENTRY Antimicrobial Surveillance Program and were tested for susceptibility (S) against DALBA and comparators by CLSI broth microdilution.

Results
The most common organisms were S. aureus (48.4%), E. faecalis (EF; 19.6%), and viridans group streptococci (VGS; 12.5%). DALBA and daptomycin (DAPTO) showed complete activity (100.0%S) against S. aureus, but DALBA MICs were 4- to 8-fold lower (table). Linezolid (LZD) and teicoplanin were also active against all SA; whereas vancomycin (VAN) and trimethoprim–sulfamethoxazole were active against 99.7% of isolates. Ceftaroline (CPT) exhibited potent activity against methicillin-susceptible S. aureus (MSSA; MIC90, 0.25 mg/L; 100.0%S) and inhibited 78.4% of methicillin-resistant S. aureus (MRSA) isolates at ≤1 mg/L. All EF isolates were S to ampicillin, DAPTO, and LZD, whereas 97.6% (120/123) of isolates were S to DALBA (MIC90, 0.06 mg/L) and 96.7%S to VAN (MIC90, 2 mg/L). Against EF, DALBA MIC values were 16- to 32-fold lower than DAPTO and VAN. All VGS and coagulase-negative staphylococcal (CoNS) isolates were S to DALBA, DAPTO, VAN, and LZD, and the highest CPT MICs were 0.5 mg/L for VGS and 4 mg/L for CoNS (93.5% inhibited at ≤1 mg/L). Against E. faecium (EFM), 65.7% of isolates were inhibited at ≤0.25 mg/L of DALBA and 62.9% were VAN-S. All EFM were S to DAPTO and LNZ. β-Hemolytic streptococci (BHS) was S to most antimicrobial agents, and only 66.7% of S. pneumoniae (SPN) isolates were PEN-S at ≤0.06 mg/L.

Conclusion
DALBA exhibited potent in vitro activity against a large collection of GP isolates recovered from patients with endocarditis in the United States and Europe medical centers. These results support further investigations to determine the role of DALBA in the treatment of infective endocarditis.

Disclosures
H. S. Sader, Allergan: Research Contractor, Research support. R. E. Mendes, Allergan: Research Contractor, Research support. M. A. Pfaller, Allergan: Research Contractor, Research support. R. K. Flamm, Allergan: Research Contractor, Research support.
1083. Long-Term Prognosis of 448 Infectious Endocarditis Followed by an Endocarditis Team
Authors: Camou Fabrice , Greib Carine , Machelart Irène , Dijos Marina , Cornolle Claire , Barandon Laurent , Peuchant Olivia , Wirth Gaetane , Issa Nahema 
Published: November 2018

Abstract

Background
The management of infective endocarditis (IE) by an expert medico-surgical team through multidisciplinary consultation meetings is now recommended. While it seems clear that it can improve the short-term prognosis of patients, long-term data are still scarce.

Methods
All patients hospitalized between 2013 and 2017 in the three teaching hospitals of our center with an IE treated by the multidisciplinary team were followed prospectively at 1, 3, 6, and 12 months. The main objective was to determine the 1-year mortality of the entire cohort treated by the team.

Results
During the study, 493 patients had a certain or possible IE and the outcome at 1 year was known for 448 of them (4 lost to follow-up and 41 followed for less than 1 year): 254 had native valve IE (57%) and 194 had prosthetic valve IE (43%). The median age of IE patients was 69.3 years (155 patients were over 75 years old) and 329 (73%) were men. Healthcare-associated IE (HAIE) accounted for 47% of cases. A microorganism was isolated in 92% of cases (S. aureus = 24%), 252 patients (56%) had an embolic events and 68 (15%) had heart failure. The Charlson Median Comorbidity Index (ICC) was 5.0. Two hundred sixteen patients (48%) underwent surgery. The mortality rates at 1 month, 3 months, 6 months, and 1 year were, respectively, 14.1%, 19.0%, 23.2%, and 27.7%. The ICC at inclusion of patients who died at 1 year was 6.0 vs. 4.0 for survivors. Mortality at 1 year was significantly higher in case of HAIE (33% vs. 23%), documented S. aureus IE (39% vs. 24%), exclusive medical treatment (40% vs. 15%), and heart failure (43% vs. 25%).

Conclusion
While the management of IE by an endocarditis team seems to improve the short-term prognosis of IE, 1-year mortality remains high as patients are increasingly older and have severe comorbidities. Our study confirms that early prognostic factors remain in the long term and that the prognosis is better in community-acquired IE with surgery.

Disclosures
All authors: No reported disclosures.
1092. Tuning Down Clostridioides difficile PCR Sensitivity Reduces Treatment for C. difficile Infection in Toxin-Negative Patients With No Increase in Adverse Outcomes
Authors: Hitchcock Matthew , Holubar Marisa , Tompkins Lucy , Banaei Niaz 
Published: November 2018

Abstract

Background
Studies have shown that toxin detection identifies those who require treatment for C. difficile infection (CDI) and free toxin can be predicted with high negative predictive value from PCR cycle threshold (CT). CT-toxin was introduced at our institution in two phases: from October 2016 to October 2017, CT-toxin was reported with the PCR result (split reporting) and CDI therapy was discouraged if CT-toxin was negative (PCR+/CTtox−). Interim analysis showed that CDI treatment had no effect on outcomes in these CTtox− patients, so starting November 2017, only CT-toxin was reported. Outcomes in PCR+/CTtox− patients treated during split reporting and untreated during the toxin-only period are detailed here.

Methods
Patients tested from October 2016 to February. 2018 with a positive Xpert tcdB PCR (Cepheid, Sunnyvale, CA) and CTtox− result were included. Clinical data were collected by retrospective chart review in the split reporting period and prospective review in the toxin-only period and analyzed using SPSS at α = 0.01.

Results
Of 186 unique PCR+/CTtox- patients during split reporting, 99 (53%) were treated, compared with 6 (12%, n = 51) in the toxin-only period (P &lt; 0.001). In comparing treated patients during split reporting to untreated patients during toxin-only reporting (n = 45), there were no significant differences in age, sex, prior antibiotic use, CDI in the previous 6 months, Charlson Comorbidity Index, patient location, immune status, or data at testing, including WBC count, creatinine, albumin, and stools/day. There were no cases of fulminant CDI in either group and no difference in outcomes (table).

Conclusion
Reporting of CT-toxin alone significantly reduced treatment for CDI compared with split reporting in CTtox− patients with no increase in adverse outcomes in short-term follow-up. Further study is needed to confirm these findings in a larger cohort.

Disclosures
All authors: No reported disclosures.
1097. Is Early Bisphosphonate Treatment Safe or Effective for Pyogenic Vertebral Osteomyelitis With Osteoporosis?
Authors: Kim Jihye , Kim Tae-Hwan 
Published: November 2018

Abstract

Background
Patients with pyogenic vertebral osteomyelitis (PVO) are expected to have increased risk of bone loss. Therefore, early bisphosphonate therapy would be clinically effective for PVO patients with osteoporosis.

Methods
A retrospective case review was performed on PVO patients with osteoporosis. PVO patients were divided into three groups: group A (initiation of bisphosphonate within 6 weeks after PVO diagnosis); group B (initiation of bisphosphonate between 6 weeks and 3 months after PVO diagnosis), and group C (no treatment for osteoporosis). Cox proportional hazard model was used to evaluate long-term effectiveness and safety of bisphosphonate in PVO patients, and event of interests included surgical treatment, recurrence of infection, subsequent fracture of adjacent vertebral bodies, and death.

Results
A total of 360 PVO patients with osteoporosis were investigated for the four events of interest. Group A PVO patients had significantly lower hazard ratios for undergoing later (more than 6 weeks after diagnosis) surgery than group C PVO patients (P = 0.014 for model 1 and 2) (Figure 1) despite similar occurrences of overall surgery. Significant difference was also observed in the occurrence of subsequent fractures at adjacent vertebral bodies (P = 0.001 for model 1 and P = 0.002 for model 2), and group A and B PVO patients had significantly lower hazard ratios for subsequent fracture than group C PVO patients (Figure 2). There were no significant differences in the hazard ratios of recurrence and death among the three groups.

Conclusion
Early bisphosphonate treatment in PVO patients with osteoporosis was associated with significantly lower occurrence of subsequent vertebral fracture at adjacent vertebral bodies, and lower occurrence of later surgery.

Disclosures
All authors: No reported disclosures.
1100. Characterization of Enteropathogenic Escherichia coli (EPEC) in Cancer Patients With Diarrhea
Authors: Okhuysen Pablo , Olvera Adilene , Carlin Lily 
Published: November 2018

Abstract

Background
Biofire FilmArray multiplexed nucleic acid amplification tests (NAAT) for bacterial diarrhea include probes specific for EPEC. However, the platform does not differentiate typical EPEC (tEPEC, defined as carrying eaeA and bfp) which have strong epidemiologic associations with diarrhea from atypical EPEC (aEPEC, carrying eaeA but not bfp) for which there is a weaker association. Nevertheless, emerging data suggest that aEPEC subsets carrying efa1/lifA which encodes for adherence factor 1/lymphocyte inhibitory factor A, are associated with diarrhea. The role of EPEC and its subtypes as agents of bacterial diarrhea have not been well defined in immunosuppressed and cancer patients.

Methods
We characterized EPEC subtypes in stools from healthy individuals with no diarrhea (HI, N = 21), cancer patients with diarrhea and negative NAAT (DN, N = 25) and patients with diarrhea positive NAAT for EPEC (DP, N = 54). EPEC isolated from stool cultures were tested for eaeA and bfp, stx and other E. coli pathotypes. We estimated the number of fecal EPEC using a qPCR for eaeA, efa1/lifA that detected 5.6 × 101 to 5 × 107 cfu/mg of stool.

Results
Demographic characteristics and underlying malignancy were similar between DN and DP groups. DP were more likely to have diarrhea on admission than DN [46/52 (88%) vs. 13/25 (52%), P &lt; 0.01]. Stool cultures confirmed EPEC in 24/52 (60%) DP of which 23/24 (96%) were aEPEC. Fecal qPCR for eaeA confirmed EPEC in 43/52 (83%) of DP, 0/25 DN and in 3/21 (14%) of HI (P &lt; 0.001). DP excreted a higher number of EPEC cfu/mg of stool than HI (median 168 vs. 1.18 cfu/mg, P &lt; 0.001) and only DP excreted EPEC efa1/lifA (+) [14/52 DP (27%) vs. 0/25 DN and 0/21 HI; P &lt; 0.001]. When compared with DP EPEC efa1/lifA (-), DP EPEC efa1/lifA (+) had a longer median duration of illness (3 days vs. 1 days, P &lt; 0.05); more likely to be hematopoietic stem cell transplant recipients [7/14 (50%) vs. 7/38 (18%), P &lt; 0.05] and had a higher EPEC eaeA fecal burden (median 3885 vs. 84 cfu/mg, P &lt; 0.05). Co-infections with other pathogens were equally represented in efa1/lifA (−) and efa1/lifA (+) DP subgroups [8/14 (57%) vs. 21/38 (55%) P = NS].

Conclusion
Most EPEC in cancer patients with diarrhea are aEPEC acquired in the community and when carrying efa1/lifA (+), are associated with more severe disease.

Disclosures
All authors: No reported disclosures.
1108. Diagnostic Yield of the BioFire FilmArray Gastrointestinal Panel in Hospitalized Children at an Academic Children’s Center
Authors: Madigan Theresa , Rajapakse Nipunie , Patel Robin 
Published: November 2018

Abstract

Background
The BioFire FilmArray Gastrointestinal Panel (BioFire Diagnostics) (GIP) is a multiplex stool PCR test that detects 22 organisms. Studies in adults suggest that the diagnostic yield of the GIP in hospitalized patients is low. The utility of the GIP among hospitalized pediatric patients and indications for diagnostic stewardship of this test are not well described.

Methods
We conducted a retrospective chart review of hospitalized pediatric patients who had a GIP ordered between October 2015 and October 2017. Demographic, clinical, and laboratory information was extracted from the medical record. Statistical analysis was completed using JMP Pro 13.0.0 (SAS Institute Inc.).

Results
Over the 2-year study period, 193 GIPs were obtained on 155 individual pediatric patients. The mean patient age was 8 years and 59% were male. Forty-four percent of patients were immunocompromised and 21% had inflammatory bowel disease. The pediatric infectious disease (PID) team was consulted in 15% of patients at the time the test was ordered. The overall positivity rate of the GIP for one or more pathogens was 42% (Figure 1), with 76% of GIPs positive for one, 23% for two, and 1% for three pathogens. No parasitic infections were diagnosed. The GIP was more likely to be positive if GI symptom onset was prior to admission (48% vs. 24%, P = 0.004), if GI symptoms had been present for &lt; 2 weeks vs. ≥2 weeks (52% vs. 20%, P = 0.0001), and if GI symptoms were the primary reason for the hospital admission (50% vs. 32%, P = 0.012). Only Clostridioides difficile or viral pathogens were detected in patients whose symptoms began in the hospital (Figure 2). Among patients with a positive test, 40% received treatment targeted at one or more of the detected pathogens (Figure 1). Enteropathogenic E.coli (EPEC) and Enteroaggregative E.coli (EAEC) were never treated (Figure 3).

Conclusion
The GIP was positive for one or more pathogens in 42% of hospitalized children for whom the test was ordered, and led to specific therapy in 40% of those with a positive test. EPEC and EAEC were not treated. The diagnostic yield of the GIP was higher if GI symptoms were present for &lt;2 weeks, began before hospitalization, and were the primary reason for admission. The GIP was frequently obtained without guidance from the PID team.

Disclosures
R. Patel, CD Diagnostics, BioFire, Curetis, Merck, Hutchison Biofilm Medical Solutions, Accelerate Diagnostics, Allergan, and The Medicines Company: Grant Investigator, Research grant – monies paid to Mayo Clinic. Curetis, Specific Technologies, Selux Dx, GenMark Diagnostics, PathoQuest and Genentech: Consultant and Scientific Advisor, Consulting fee – monies paid to Mayo Clinic. ASM and IDSA: Travel reimbursement and editor’s stipends, Travel reimbursement and editor’s stipends. NBME, Up-to-Date and the Infectious Diseases Board Review Course: Varies, Honoraria. Mayo Clinic: Employee, Salary.
1109. Factors Impacting the Decision to Order Stool Diagnostic Testing in Patients With Acute Gastroenteritis Among Primary Care Providers
Authors: O’Leary Sean , Allison Mandy , Cardemil Cristina V , Hurley Laura , Crane Lori , Brtnikova Michaela , Beaty Brenda , Hall Aron J , Pierre Jeanette St , Ivey Kathryn , Lindley Megan C , Kempe Allison 
Published: November 2018

Abstract

Background
Diagnostic options for stool pathogens are evolving and expanding rapidly. The majority of acute gastroenteritis (AGE) patients seeking medical care are seen by primary care providers (PCPs), and stool testing may not be performed as AGE is generally self-limited. Little is known about how PCPs decide for which patients to order testing. Our objective was to describe among PCPs factors affecting the decision of whether to order stool diagnostic testing for pathogen detection in patients with AGE symptoms in the outpatient setting.

Methods
A national survey was conducted from January to March 2018 among primary care pediatricians (Peds), family physicians (FP), and internists (GIM).

Results
The response rate was 50% (689/1,383; Peds 59% [275/466], FP 49% [226/461], GIM 41% [188/456]). Factors most often reported as greatly increasing the likelihood of testing that did not differ significantly between specialties included patient history of travel to a high-risk area (75% Peds, 71% FP, 72% GIM), immunocompromised patient (Peds 67%, FP 60%, GIM 69%), and clinical suspicion of a pathogen that can be treated with antibiotics or antiparasitics (Peds 63%, FP 56%, GIM 65%). Factors with significant differences between specialties that were most often reported as greatly increasing likelihood of testing included presence of blood in stool (Peds 76%, FP 58%, GIM 48%, P &lt; 0.0001), history of recent antibiotic use (Peds 31%, FP 66%, GIM 72%, P &lt; 0.0001), history of recent hospitalization (Peds 29%, FP 61%, GIM 64%, P &lt; 0.0001), consideration of inpatient admission (Peds 36%, FP 57%, GIM 56%, P &lt; 0.0001), and fever ≥38.5 C (Peds 13%, FP 27%, GIM 40%, P &lt; 0.0001). Factors most often reported as greatly decreasing the likelihood of testing included presence of vomiting without diarrhea (Peds 49%, FP 43%, GIM 50%) and presence of vomiting and diarrhea together (Peds 12%, FP 7%, GIM 9%).

Conclusion
Physicians rely on a variety of factors when considering diagnostic testing for stool pathogens in AGE, with recent travel, caring for an immunocompromised patient, and antibiotic/antiparasitic treatment decisions often reported as increasing the likelihood of testing. Consideration of the clinical presentation and most common AGE pathogens by age group may be driving some of the differences between specialties.

Disclosures
All authors: No reported disclosures.