bluuebunny/crossref_metadata_2025_split huggingface dataset:
Varicella Vaccination Coverage among Adolescents Ages 13–17 Years, United States, National Immunization Survey, 2007–2014
Authors: Leung Jessica , Reagan-Steiner Sarah , Lopez Adriana S , Jeyarajah Jenny , Marin Mona 
Published: October 2017

Abstract

Background
Varicella is typically a self-limiting disease but it can be more severe in adolescents and adults. In 2007, 2-doses of varicella vaccine were routinely recommended for children, with a catch-up second dose for persons who received 1 prior dose.

Methods
We used 2007–2014 NIS-Teen data to examine trends in ≥2 dose varicella vaccination coverage and proportions of adolescents with/without evidence of immunity to varicella. Evidence of immunity included receipt of ≥2 doses of varicella vaccine or varicella disease history. Additionally, using 2014 data, we assessed characteristics of ≥2 dose varicella vaccination coverage: 1) factors associated with ≥2 dose vaccination, 2) timing of receipt of second dose and 3) missed opportunities for second dose vaccination among adolescents who had received 1 prior dose of varicella vaccine.

Results
During 2007–2014, the proportion of adolescents with ≥2 doses of varicella vaccine increased from 8.3% to 66.9% in 13–15 year olds, and from 3.6% to 56.7% in 16–17 year olds. The proportion of adolescents with evidence of varicella immunity also increased for both age groups, from 68.0% to 84.1% in 13–15 year olds and from 78.6% to 83.4% in 16–17 year olds. Among adolescents who received ≥2 doses of varicella vaccine by 2014, a higher proportion of 13–15 year olds received their second dose at 4–6 years compared with 16–17 year olds (13.4% vs. 3.2%). Factors significantly associated with lower ≥2 dose coverage included non-Hispanic White race/ethnicity; rural residence; living at &gt;133% of the income-to-poverty ratio; no 11- to 12-year well-child visit; not receiving an adolescent vaccine; and residence in a state with no 2-dose immunization school entry requirement. Among the 2,478 adolescents who received only 1-dose of varicella vaccine, 77.1% (1,922) had at least 1 missed opportunity to receive their second dose; potentially 2-dose coverage could have increased from 79.5% to 94.8%.

Conclusion
The ≥2-dose varicella vaccination coverage and the proportion of adolescents with evidence of immunity to varicella increased during 2007 to 2014, though 16% lacked evidence of immunity in 2014. Though catch-up campaigns have succeeded, decreasing missed vaccination opportunities will help with further improvement.

Disclosures
All authors: No reported disclosures.
Use of a Precision Antibiotic Therapy (PAT) Prediction Model to Identify Multidrug-Resistant (MDR) Enterobacteriaceae
Authors: Varga Alexandra , Cressman Leigh , Lautenbach Ebbing , Cluzet Valerie , Tolomeo Pam , Bilker Warren , Hamilton Keith 
Published: October 2017

Abstract

Background
Emergence of multidrug-resistant (MDR) Enterobacteriaceae complicates the selection of empiric antibiotic therapy. Software called Precision Antibiotic Therapy (PAT) (Teqqa, LLC; Jackson, WY) operationalizes a predictive model using patient factors to make real-time, personalized predictions of antibiotic susceptibility for each antibiotic, allowing prescribers to choose empiric therapy for patients at risk for resistant infections. The purpose of this study was to determine the performance of PAT software in identifying MDR Enterobacteriaceaebloodstream infections (BSI) as well as to determine optimal thresholds of predicted antibiotic susceptibility to choose a broader-spectrum antibiotic.

Methods
We conducted a retrospective cohort study including 475 unique patients with BSIs caused by Enterobacteriaceaefrom January 1, 2016 through December 31, 2016. First-line antibiotic therapy for BSI was defined as cefepime, piperacillin-tazobactam, levofloxacin, or aztreonam. Susceptibilities predicted by PAT were compared with known susceptibilities determined by routine laboratory testing. PAT thresholds for broadening antibiotics were assessed when predicted susceptibilities were 80%, 85%, 90%, and 95% using receiver-operating characteristic (ROC) curves. Performance characteristics were calculated for each threshold. Brier score calculations were then used to compare the accuracy of PAT predictions using the optimized predicted susceptibility threshold, to that of aggregate institutional susceptibility data.

Results
ROC curve analysis demonstrated an area under the curve of 0.82 for the 95% threshold. The sensitivity for the PAT prediction utilizing the 95% threshold was 91.7% with a specificity of 74.3%. The Brier score for the 2016 antibiogram to determine antibiotic therapy was 0.085, whereas the Brier score using PAT software was 0.071, representing a 16% improvement in accuracy.

Conclusion
PAT software demonstrated excellent capability to discriminate between Enterobacteriaceae BSIs resistant and susceptible to first-line therapy. A predicted susceptibility threshold of 95% should be used to indicate a need for escalation of empiric antibiotic therapy using PAT.

Disclosures
All authors: No reported disclosures.
Opportunities in the Acute Care Setting for Infectious Diseases/Hospitalist Patient Co-Management
Authors: Gupta Siddhi , Bansal Amit , Newman Eric , Martin Stanley 
Published: October 2017

Abstract

Background
In an inpatient setting, Infectious Diseases (ID) physician care may lead to lower mortality rates and readmissions. When consultation is performed earlier in the admission, outcomes may even be better. The model of individual consultative care that relies on primary services calling specialists to give recommendations can lead to missed opportunities for optimal diagnostic testing and antimicrobial utilization. Having ID specialists involved in the care of the hospitalized patient from the time of admission creates a unique opportunity for timely intervention that could have long-ranging effects.

Methods
Patients admitted to four of the non-teaching hospitalist services at Geisinger Medical Center over two separate weeks included automatic ID evaluation within 24 hours of admission. The ID physician reviewed the chart and records of each admission to determine whether the patient was being treated for an infection. Any potential ID-related interventions identified upon initial evaluation were recorded by the ID physician. Patients were excluded if formal ID consultation was requested.

Results
A total of 85 patients were admitted during the study and 84 were included for review. Forty-five (53.6%) were admitted for a total of 48 infection-related reasons and another 17 (20.2%) were found to have incidental infection-related findings. Seven patients had requests for formal ID consultation placed (8.3%). Of the remaining primary ID diagnoses on admission, 33 were accurate by ID physician assessment (68.8%) and empiric therapy was appropriate in 29 (60.4%). Of the incidental infection-related diagnoses, 12 (70.5%) were considered accurate and empiric therapy was appropriate in 12 (70.5%). Among primary ID diagnoses, 60 diagnostic testing opportunities and 25 potential therapeutic improvements were identified (Figures).

Conclusion
Despite the limitations of relying on medical records alone, when done in real time, a large number of opportunities exist to optimize diagnostic testing and antimicrobial use in the acute care setting. As healthcare moves away from fee-for-service models to population health, the concept of an ID physician/hospitalist co-management model of inpatient care should be explored further.

Disclosures
All authors: No reported disclosures.
Implementation of a Centralized Infectious Diseases Telehealth (IDt) Service for 16 Small Community Hospitals
Authors: Vento Todd J , Gelman Stephanie S , Veillette John J , Adams Mary A , Repko Katherine A , Jones Peter S , Webb Brandon J , Dascomb Kristin K , Lopansri Bert K , Stenehjem Edward A 
Published: October 2017

Abstract

Background
The majority of U.S. small community hospitals (SCHs) lack access to infectious diseases (ID) subspecialists. Telehealth can extend ID expertise to such facilities. We describe lessons learned from implementing a new IDt program for 16 SCHs in the Intermountain Healthcare system in Utah and Idaho.

Methods
From October 1, 2016 to April 30, 2017, we implemented an IDt service comprised of: a 24-hour ID physician advice line; an inpatient ID consult service that provided chart review and documentation (e-consults) and daytime telemedicine consultation (TC) using encrypted, HIPAA-compliant, synchronous, 2-way audio-video connection; and an ID pharmacist-led antibiotic stewardship program. The IDt service included a medical director, operations officer, ID pharmacist, analyst, and rotating ID physicians, and was implemented in a step-wise manner at 16 SCHs. IDt requests were received through a dedicated phone line with duplicate transcription to a monitored email inbox or generated from daily antibiotic stewardship rounds.

Results
The physician advice line was operational for all 16 SCHs on October 1, 2016. 312 advice-only calls were fielded (92 per 1000 hospital-days covered) through April 30, 2017. Common infections requiring phone advice included: bloodstream (16%), genitourinary (13%), and musculoskeletal (12%). E-consult and TC services were operational at 11 SCHs by April 30, 2017 (hospital-days covered: 1074). The IDt service completed 104 eConsults, 163 TCs, and 1198 stewardship reviews. Mean time [minutes (range)] spent per case was 16 (5–30) for eConsults and 55 (30–120) for TCs [on-camera time: 25 (12–46)]. Common infections requiring e-consult or TC were: bloodstream (45%), musculoskeletal (16%), and skin/soft tissue (11%). 22 patients (14%) seen by TC were surveyed: 100% felt the service improved their care and was necessary at their SCH. 97% of surveyed SCH staff felt the IDt service improved patient care and 90% felt it was a necessary service (32% response from 98 providers, nurses, pharmacists).

Conclusion
A new IDt service was well utilized and received by SCH staff and patients, with bloodstream infections being the most common reason for consultation. Future steps include evaluation of the IDt effect on clinical outcomes, financial metrics, and staff education on common ID conditions.

Disclosures
All authors: No reported disclosures.
Stability of Anidulafungin in Concentrated Pharmaceutical Solution
Authors: Yap Chien , Ho Chi Lui , Lim Yin Shan , Yeoh Siang Fei 
Published: October 2017

Abstract

Background
Currently, the reconstitution instructions in the package insert indicate that 100 mg of anidulafungin powder is to be dissolved in 30 ml of sterile water for injection and this reconstituted solution is to be further mixed with 100 ml of either normal saline (NS) or dextrose 5% (w/v) (D5) to give a final infusion solution of concentration 0.77 mg/mL. The compatibility of the reconstituted solution with diluents other than NS or D5 has not been established and there is no literature to support the the use of a more concentrated infusion solution. Thus, the infusion solution prepared strictly according to the method described by the manufacturer may pose a problem clinically in patients who are indicated for treatment with anidulafungin but require fluid restriction. In order to meet the needs of the abovementioned patient populations in the clinical setting, it is imperative to establish the stability of suitable anidulafungin infusion solutions prepared in diluents that are appropriate to the patients but differ from that set forth by the manufacturer

Methods
After an initial validation of the HPLC-MS/MS method, the concentration of the anidulafungin solutions was determined over 48/72 hours. Other parameters assessed were pH, osmolality and particulate matter.

Results
100 mg of anidulafungin powder was soluble in 15 ml of sterile water and this reconstituted solution was stable for at least 24 hours at 25. Anidulafungin infusion solutions of concentration 2 mg/mL prepared using diluents like NS, D5, half normal saline (HNS) and NSD5 were stable for at least 72 hours at 25. If the diluent was HNSD5, the infusion solution of concentration 2 mg/mL was stable for at least 48 hours at 25. All of the anidulafungin solutions tested were of acceptable standard for an injection in terms of pH, osmolality and particulate matter

Conclusion
The method of preparation employed yielded anidulafungin solutions of suitable stability for clinical use and can be adopted should there be a need to differ from the manufacturer’s recommended preparation method. We may use these concentrated preparations for patient with central line like in ICU or OPAT setting

Disclosures
All authors: No reported disclosures.
Incidence of Acute Kidney Injury Among Intensive Care Unit Patients Receiving Vancomycin in Combination with Cefepime or Piperacillin–Tazobactam
Authors: Rutter W Cliff , Burgess David S 
Published: October 2017

Abstract

Background
Combination therapy with piperacillin-tazobactam (TZP) and vancomycin (VAN) has been associated with increased AKI incidence when compared with cefepime (FEP) and VAN. However, this was not seen in critically ill patients, we hypothesized that critically ill patients receiving TZP+VAN would have a higher AKI incidence compared with those receiving FEP+VAN.

Methods
Clinical and demographic data were collected from the University of Kentucky Center for Clinical and Translational Science Enterprise Data Trust. Adult patients were included if they received TZP+VAN or FEP+VAN for ≥ 48 hours in the ICU. Patients were excluded for initial CrCl &lt; 30 mL/minute, receipt of other β-lactam agents, past medical history of CKD. AKI cases were identified via the RIFLE criteria. Variables were analyzed via appropriate statistical tests. Patients were propensity score matched on a 1:1 basis on variables that were significantly different at baseline or associated with AKI.

Results
Overall, 1871 patients were included in this study, with 1205 receiving TZP+VAN and 666 receiving FEP+VAN. At baseline, TZP+VAN patients were older (56 [45–65] vs. 52 [37–63] years; P &lt; 0.00001). Vasopressor exposure was more common in the FEP+VAN group (32.6% vs. 27.0%, P = 0.01). AKI incidence was higher in the TZP+VAN group (31.8% vs. 18.0%, P &lt; 0.00001). Following matching, 1282 patients were included with 641 patients in each group. The cohorts were similar in baseline AKI risk factors, except hypertension (TZP+VAN 59.4% vs. 53.4%, P = 0.03), and loop diuretic exposure (53.4% vs. 46.7%, P = 0.02). AKI was significantly more common in TZP+VAN patients (34.2% vs. 17.8%, P &lt; 0.00001) and after controlling for remaining confounders, TZP+VAN had 2.51 times the odds of experiencing AKI than those in the FEP+VAN (95% CI 1.9–3.34). Other factors associated with increased odds of AKI included: increasing severity of illness, higher baseline renal function, exposure to calcineurin inhibitors, vasopressors, and loop diuretics, diagnosis of heart failure, and duration of antimicrobial therapy &gt; 7 days.

Conclusion
TZP+VAN therapy is associated with significant increases in AKI in critically ill patients compared with those who received FEP+VAN independent of other AKI risk factors.

Disclosures
All authors: No reported disclosures.
Is There a Significant Difference in Acute Kidney Injury Incidence Among Patients Treated with Vancomycin Combined with Cefepime or Meropenem?
Authors: Rutter W Cliff , Burgess David S 
Published: October 2017

Abstract

Background
Acute kidney injuries (AKIs) are common among patients receiving concomitant vancomycin (VAN) and piperacillin-tazobactam, especially compared with cefepime (FEP) with vancomycin. It is unknown if there is a significant difference between therapeutic alternatives to piperacillin-tazobactam. We hypothesized that AKI rates would be similar in patients treated with FEP+VAN and meropenem (MEM)+VAN.

Methods
Demographic and clinical data were abstracted from the University of Kentucky Center for Clinical and Translational Sciences Enterprise Data Trust from 2008 through 2015. Patients were included if they received VAN and FEP or MEM in combination for ≥48 hours. Patients with baseline CKD and creatinine clearance &lt;30 mL/minute were excluded. AKI was defined as meeting any of the Risk, Injury, Failure, Loss, End-stage (RIFLE) criteria. Basic descriptive statistics were performed in addition to bivariable and multivariable logistic regression for AKI.

Results
In total, 3662 patients were included in this study with 3366 patients receiving FEP+VAN and 296 receiving MEM+VAN. Demographic characteristics were evenly distributed among both groups, with the exception of Charlson comorbidity index (MEM+VAN 4 [2–6] vs. 3 [1–6], P = 0.0002), and exposure to aminoglycosides (MEM+VAN 18.2% vs. 13.2%, P = 0.02) and calcineurin inhibitors (MEM+VAN 6.1% vs. 2.7%, P = 0.002). AKI incidence was similar between group (MEM+VAN 12.8% vs. FEP+VAN 10.8%, P = 0.33). After multivariable logistic regression, there was no significant increase in AKI odds with MEM+VAN compared with FEP+VAN (adjusted odds ratio = 1.02; 95% CI 0.67–1.50). Factors associated with increased AKI odds included: male gender, increased baseline comorbidity, age &gt;80, increased duration of antimicrobial therapy, hypotension, increased baseline renal function, and exposure to aminoglycosides, amphotericin B, non-steroidal anti-inflammatory drugs, loop diuretics, or vasopressors.

Conclusion
No difference in AKI incidence was found between patients treated with MEM+VAN or FEP+VAN. Other clinical factors, aside from AKI potential, should be considered when choosing between alternatives to piperacillin-tazobactam combined with vancomycin.

Disclosures
All authors: No reported disclosures.
Correlations Between Environmental Factors and Increasing Lyme Disease Incidence in Canada
Authors: Koffi Jues , Gasmi Salima 
Published: October 2017

Abstract

Background
Lyme disease (LD) is an emerging infectious disease in Canada due to northward expansion of the geographic range of Ixodes scapularis, the principal tick vector for the LD agent Borrelia burgdorferi, into central and eastern Canada. This study aims to i) summarize the surveillance data for LD cases reported in Canada between 2009 and 2015, ii) identify potential environmental risk factors and iii) develop an acarological risk indicator from passive surveillance for occurrence of human cases.

Methods
We described the distribution, trends, demographic and clinical characteristics of cases of the disease. Logistic regression models were used to identify risk factors for the occurrence of LD: 1) demographic (age and sex), and 2) environmental (type of forest cover, temperature and abundance of ticks). Passive surveillance data were used to develop an acarological indicator of at-risk areas for LD.

Results
The number of reported LD cases increased more than six-fold overall, from 144 cases in 2009 to 917 cases in 2015, mainly due to locally acquired infections. LD incidence in Nova Scotia has risen sharply since 2013 and was the highest in Canada over the study period. Children below 15 years and adults of the 55–74 age groups reported highest incidence. Significantly more men than women were infected and men had significantly more symptoms of late disseminated LD than women. Variability in clinical manifestations is observed between provinces, years, for children below 15 years and between age groups. The majority of cases were reported between April and November and there was an increase in risk areas. The abundance of Ixodes scapularis ticks collected on humans and deciduous forest cover were significantly associated with the occurrence of LD cases at the municipality scale. Passive surveillance provides a cost-effective alert tool for public health authorities to timely identify risk areas and target vulnerable populations and front-line health professionals by means of awareness campaigns.

Conclusion
These findings showed that LD continues to increase in Canada, both over time and geographically, underlining the need to implement better preventive strategies, early disease recognition and treatment and efficient surveillance systems.

Disclosures
All authors: No reported disclosures.
Patient Safety and Efficacy of Metronidazole 1 g Intravenous Every 24 Hours
Authors: Desai Alpa , Burdette Steven 
Published: October 2017

Abstract

Background
Metronidazole (MTZ) is an imidazole that is used to treat parasites and anaerobic infections. The traditional dose of 500 mg every 6 to 8 hours achieves adequate serum concentration to treat most anaerobic infections. MTZ has a concentration dependent bactericidal activity with a long half-life of 8 hours and also exhibits post-antibiotic effect. The literature lacks clinical data in regards to a once daily higher dose of IV MTZ.

Methods
A retrospective quality improvement project via electronic medical record review of 88 adults who received MTZ 1 gm IV daily at a single tertiary medical center, from April 2014 to October 2016. Inclusion criteria were patients &gt;/=18 years who received MTZ 1 gm IV every daily for &gt;/= 48 hours.

Results
Of the 88 patients who received 1 gm of MTZ, 66 met inclusion criteria. Mean age was 58 years (range 24 to 90 years). Indications for use are shown in Figure 1. Mean duration of therapy was 10 days (range 2 to 42 days). Twenty-nine (43.9%) received &lt;/= 6 days and 37 (56.1%) received &gt;/= 7 days. Fourteen (21%) were discharged home on MTZ 1 gm IV daily for 4–6 weeks duration. One patient had a documented adverse reaction (severe nausea) while the other 65 tolerated well. No documented treatment failure was reported.

Conclusion
MTZ has been used in combination with other antimicrobial agents to treat polymicrobial infections. It is generally well tolerated when administered in dosages of &lt;2gm per day. Pharmacodynamic studies have demonstrated activity for 12 to 24 hours after administration of 1 gm of MTZ. Our study showed no safety concerns with 1 gm daily dosing and no reported treatment failure. The limitation of our study includes lack of comparative cohort. The potential advantages of once daily dosing include optimized bacterial killing, minimization of drug administration, and reduction of the cost of antibiotics as well as the cost of administration. Our safety and quality improvement project support that MTZ 1 gm IV daily dose is potentially a safe, efficacious and cost effective alternative to three times dosing especially in hospitalized patients and may have role in OPAT.

Disclosures
All authors: No reported disclosures.