bluuebunny/crossref_metadata_2025_split huggingface dataset:
Risk Factors for Community Acquired Extended-Spectrum Β-lactamase (ESBL) Producing Enterobacteriaceae Urinary Tract Infections (UTIs)
Authors: Goyal Dheeraj , Dascomb Kristin , Jones Peter S , Lopansri Bert K 
Published: October 2017

Abstract

Background
Community-acquired extended-spectrum β-lactamase (ESBL) producing Enterobacteriaceae infections pose unique treatment challenges. Identifying risk factors associated with ESBL Enterobacteriaceae infections outside of prior colonization is important for empiric management in an era of antimicrobial stewardship.

Methods
We randomly selected 251 adult inpatients admitted to an Intermountain healthcare facility in Utah with an ESBL Enterobacteriaceae urinary tract infection (UTI) between January 1, 2001 and January 1, 2016. 1:1 matched controls had UTI at admission with Enterobacteriaceae but did not produce ESBL. UTI at admission was defined as urine culture positive for &gt; 100,000 colony forming units per milliliter (cfu/mL) of Enterobacteriaceae and positive symptoms within 7 days prior or 2 days after admission. Repeated UTI was defined as more than 3 episodes of UTI within 12 months preceding index hospitalization. Cases with prior history of ESBL Enterobacteriaceae UTIs or another hospitalization three months preceding the index admission were excluded. Univariate and multiple logistic regression techniques were used to identify the risk factors associated with first episode of ESBL Enterobacteriaceae UTI at the time of hospitalization.

Results
In univariate analysis, history of repeated UTIs, neurogenic bladder, presence of a urinary catheter at time of admission, and prior exposure to outpatient antibiotics within past one month were found to be significantly associated with ESBL Enterobacteriaceae UTIs. When controlling for age differences, severity of illness and co-morbid conditions, history of repeated UTIs (adjusted odds ratio (AOR) 6.76, 95% confidence interval (CI) 3.60–13.41), presence of a urinary catheter at admission (AOR 2.75, 95% CI 1.25 – 6.24) and prior antibiotic exposure (AOR: 8.50, 95% CI: 3.09 – 30.13) remained significantly associated with development of new ESBL Enterobacteriaceae UTIs.

Conclusion
Patients in the community with urinary catheters, history of recurrent UTIs, or recent antimicrobial use can develop de novo ESBL Enterobacteriaceae UTIs.

Disclosures
All authors: No reported disclosures.
Why and Where We Choose to Treat Children with Intravenous Antibiotic for Febrile Urinary Tract Infection/Pyelonephritis
Authors: Scanlan Barry , Ibrahim Laila , Hopper Sandy , Babl Franz , Davidson Andrew , Bryant Penelope 
Published: October 2017

Abstract

Background
Febrile UTI/pyelonephritis is a common diagnosis for children presenting to the Emergency Department (ED). A Cochrane review of the management of pyelonephritis in children showed no difference between intravenous (IV) and oral antibiotics. Despite this, many children are treated with at least initial IV antibiotics. The reasons are often unclear and it is uncertain whether this is appropriate as the Cochrane review excluded children at the worse end of the clinical spectrum. Our aim was to determine why physicians made these decisions as a first step in determining whether this is necessary.

Methods
A prospective observational study of children presenting to the ED at the Royal Children’s Hospital with UTI/pyelonephritis from Oct 2016 – Apr 2017. Data collection included demographic, clinical features, microbiology, treatment and outcomes. ED physicians were asked to record reasons for prescribing IV antibiotics and for treating the patient in hospital vs. in hospital-in-the-home (HITH).

Results
170 children were included, 123 (72%) were treated with oral antibiotics, 43 (25%) IV and 4 (3%) intramuscular – these are now included in the IV group. In the IV group, 32 (19%) were admitted, 3 (2%) were transferred directly to HITH from ED and 13 had a single dose of IV antibiotics in ED and were discharged. A comparison of the clinically significant features between the two groups is outlined (Table 1). The commonest reasons cited for using IV antibiotics and for hospital admission vs. HITH is shown (fig 1 and 2).

Conclusion
This is the first study of decision-making for IV antibiotics and hospital admission for UTI/pyelonephritis in children. The fact that the reasons cited for IV antibiotics were often not evident on objective clinical data suggests that there may be overuse of IV antibiotics. We will present an assessment of appropriateness and suggest alternatives to the traditional IV and hospital admission route.

Disclosures
All authors: No reported disclosures.
Assessment of Reflex Urine Culture Criteria Changes and its Impact on Treatment of Asymptomatic Bacteriuria
Authors: Wold Kirre , Brock Jeff , Percival Kelly , Rearigh Lindsey , Vocelka Lucas , Afroze Aneesa 
Published: October 2017

Abstract

Background
Asymptomatic bacteriuria (ASB) is a common clinical condition identified by the presence of bacteria in the urine of a patient without signs and symptoms of a urinary tract infection (UTI). Treatment of ASB leads to unnecessary antimicrobial use and can cause more harm than benefit in many patients. This study is to determine the impact of more stringent criteria for urinalysis with culture if indicated (UAC), implemented in September 2016, on the treatment of asymptomatic bacteriuria.

Methods
A pre-post descriptive study of patients was conducted with an order placed for UAC in the Emergency Department (ED) or hospital. Data was collected retrospectively via chart reviews. The data on ASB patients from November 2015 to April 2016 was compared with the post-implementation period October 2016 to January 2017. The number of UAC orders and cultures were averaged for 6 months pre and post implementation of the criteria change.

Results
A total of 580 patient charts were assessed post-implementation of the UAC criteria change. A majority of the orders originated from the ED, (N = 430, 72.8%). ASB was treated inappropriately at a rate of 60.4% (N = 64/106) pre-implementation and a rate of 65% (N = 41/63) post implementation, P = 0.542. The total number of UAC ordered before and after implementation did not change, (N = 2852 pre-intervention vs N = 2825 post-intervention, P = 0.744), as seen in Figure 1. However, the number of reflexed urine cultures did significantly decrease post criteria change,&#x2028; (N = 1056 pre-intervention vs. N = 603 post-intervention, P &lt; 0.0001). In addition, the number of positive urine cultures also significantly decreased, (N = 378 pre-intervention vs. N = 289 post-intervention, P = 0.0447). The impact the criteria change had on patient care is the number of potential antibiotic courses saved by reflexing fewer urine cultures off the UAC. Based on the decrease in positive urine cultures, it is estimated 702 courses of inappropriate antibiotics for ASB could be saved per year (59/month).

Conclusion
More stringent criteria for reflex urine cultures significantly decreases the number of urine cultures performed, therefore decreasing the number of patients treated with ASB. Additional stewardship measures are necessary to reduce the treatment of ASB for patients who have cultures performed.

Disclosures
All authors: No reported disclosures.
Assessment of Antimicrobial Susceptibility Testing Profiles of Urine Isolates from Veterans to Guide Empiric Therapy for Suspected Urinary Tract Infection
Authors: Marsh Ketzela J , Mundy Lesley , Holter John J , Johnson James R 
Published: October 2017

Abstract

Background
Urinary tract infection (UTI) is common among patients at Veterans Affairs Medical Centers (VAMCs), many of whom are elderly men with underlying medical or urological problems. Most UTI treatment guidelines address uncomplicated UTI in women and presume knowledge of local antimicrobial susceptibility testing (AST) patterns for uropathogens, which often are unknown or are inferred from E. coli. To inform selection of empiric therapy for UTI at our VAMC, we compiled AST data for one year’s urine isolates.

Methods
We compiled AST results (bioMerieux VITEK®) for the 2,494 significant urine isolates from the Minneapolis VAMC clinical microbiology laboratory from June 2013 through May 2014. For “drug-bug” combinations that were not tested we imputed results based on local or published data, and/or expert opinion. We then calculated cumulative % susceptible for 25 relevant antimicrobial agents, overall and stratified by Gram stain group and clinical site (intensive care unit, inpatient, outpatient, community residential centers, or extended care). In ambiguous situations susceptibility was analyzed as both 0% and 100%.

Results
The 2,494 urine isolates included 946 Gram-positive and 1,548 Gram-negative organisms. Species distribution varied significantly by clinical site. E. coli represented only 27% of isolates overall (9–37%, depending on site). Enterococcus (14%) and other Gram-positives (23%) were also prevalent. Cumulative AST profiles varied significantly (i) by Gram stain group, (ii) between E. coli and other Gram-negatives, and (iii) by clinical site. No tested oral agent provided ≥ 80% overall susceptibility. Although AST data were unavailable for fosfomycin, imputation suggested 82%-95% susceptibility overall.

Conclusion
Among urine isolates from veterans, E. coli was a minor contributor and a poor surrogate for total population AST profiles. The only oral agent that provided ≥ 80% susceptibility overall was fosfomycin, suggesting that it could be an important option for empiric lower UTI therapy for veterans. Urine isolate-specific antibiograms that reflect local AST data, stratified by Gram stain group and clinical site, could improve empirical UTI therapy for veterans, as could performance of urine Gram stains.

Disclosures
J. R. Johnson, Grant Investigator, Grant recipient Merck: Grant Investigator, Grant recipient Tetraphase: Grant Investigator, Grant recipient
Contemporary Epidemiology of Catheter-Associated Urinary Tract Infections (CAUTIs) in a Tertiary Care Center: Is Foley Re-Insertion a Novel Risk Factor?
Authors: Nowbakht Cima , Boston Kelley M , Harrison Nicole , Patel Bela , Katz Jeffrey , Ostrosky-Zeichner Luis 
Published: October 2017

Abstract

Background
CAUTIs are one of the most common causes of hospital-acquired infections. We report on a retrospective analysis performed on prospectively collected CAUTI surveillance data from 2014 to 2016 at a large tertiary care academic hospital

Methods
A total of 181 CAUTIs by NHSN definition were reviewed to describe contemporary demographics, risk factors, microbiology, and outcomes.

Results
The 181 CAUTIs involved 178 patients. 61% were female. Events mostly occurred in an ICU setting (65%), specifically our neurosurgical unit (23%), followed by floors (24%) and intermediate units (11%). Most episodes occurred within a week after the initial catheter insertion (60%). 40% of CAUTIs occurred within an average of 5.5 days (SD ± 5.12) after a Foley re-insertion. Of the 221 cultured micro-organisms, Gram-negatives accounted for 74% (predominately K. pneumoniae and E. coli), followed by Gram-positives and yeast at 18% and 8%, respectively. 8% of organisms showed multi-drug resistance, 8% of patients developed C. difficile co-infections, 23% had concomitant bacteremia, and the length of stay averaged 28 days (SD ± 26.74). 55% of patients were discharged to another facility. 12% of patients expired and 4% were discharged to hospice

Conclusion
We describe the contemporary demographics, microbiology and outcomes of CAUTIs in a large tertiary care center. We also found that 40% of our CAUTIS are associated with a Foley removal and re-insertion event. Reasons requiring catheter exchanges and reinsertions include leakage, bleeding, obstruction, failed voiding trial, and general malfunction. Although this observation needs to be confirmed case control studies and larger observational trials, this new insight may provide an opportunity to intervene and focus infection prevention interventions in this novel high-risk population.

Disclosures
All authors: No reported disclosures.
Antibiotic Prescription Practice for Pediatric Urinary Tract Infection in a Tertiary Center
Authors: Alghounaim Mohammad , Ostrow Olivia , Timberlake Kathryn , Richardson Susan E , Science Michelle 
Published: October 2017

Abstract

Background
Urinary tract infection (UTI) is a leading cause for acute care visits in pediatrics. A suspected UTI diagnosis is made based on typical clinical presentation and pyuria and confirmed by significant growth in an appropriate urine sample. Prescribing antibiotics for suspected UTI is a common practice, and may lead to unnecessary antibiotic exposure. We aimed to review the practice of UTI diagnosis and management in the Emergency Department (ED) to identify targets to improve antimicrobial prescribing practices.

Methods
Children (&lt; 18 years) who were discharged from the ED at the Hospital for Sick Children with a diagnosis of UTI between October to December 2016 were included. Patients were excluded if they were (1) under 12 weeks of age, (2) had underlying genitourinary abnormalities, (3) were admitted or transferred to another center, (4) were on antibiotics on presentation, (5) had urine testing done in another laboratory, or (6) were given conditional prescription. Demographic, clinical history, laboratory findings, and urine culture results were collected from patient charts. The sensitivity and specificity of nitrite and leukocyte esterase (LE) for UTI diagnosis were calculated. Logistic regression was used to examine the relationship between urinalysis characteristics and confirmed UTI.

Results
A total of 186 children with a median age of 4.2 (IQR 1.2, 7.3) were included; 82.3% were female. Almost all children were discharged home on antibiotics (n = 183, 98%) for a median duration of 7 days (IQR 7, 10). A total of 87 patients (46.8%) received antibiotics despite negative urine cultures and none of these patients received notification to stop. This led to 652 unnecessary antibiotic days. The presence of nitrites was the strongest predictor of UTI (OR 13.3, P &lt; 0.001) and was highly specific. An LE result of 2+ (OR 2.4, P = 0.04) or 3+ (OR 2.23, P = 0.016) was also predictive of UTI.

Conclusion
Current practice in managing suspected pediatric UTIs in our ED resulted in significant and unnecessary antibiotic exposure. We identified targets to reduce unnecessary antibiotic exposure including improving the diagnostic accuracy of UTIs, a process to discontinue antibiotics for negative cultures and standardizing antimicrobial duration.

Disclosures
All authors: No reported disclosures.
The Impact of Biofire Filmarray Respiratory Panel on Antibiotic Usage in the Emergency Department at an Academic Medical Center
Authors: Mehta Meera , Slain Douglas , Keller Lisa , Lasala P Rocco 
Published: October 2017

Abstract

Background
Biofire respiratory panel is a multiplex PCR test designed to detect 17 pathogens within 1 hour. It has greater sensitivity, specificity, and number of pathogens detected compared with older testing methods. The aim of this research was to evaluate the impact of Biofire respiratory panel on antibiotic usage in the emergency department (ED) of an academic medical center.

Methods
This was an observational chart review. Patients with positive RSV or influenza rapid antigen test or PCR test, and patients with a positive Biofire test were included. RSV or influenza tests were reviewed from July to December 2015, and Biofire tests were reviewed from July to December 2016. The primary outcome was to evaluate the duration of antibiotic therapy in patients with viral respiratory infections diagnosed with RSV and influenza rapid antigen and PCR testing compared with Biofire viral respiratory panel. Secondary outcomes included virus type, antibiotic prescription rates on discharge, number of addmissions, procalcitonin levels, and oseltamivir usage.

Results
In 2016, 67% (105/155) of biofire tests were positive. The most common pathogen was rhinovirus and enterovirus (42%). Of the positive results, 23/105 (22%) received antibiotics with 6 patients having antibiotics discontinued within 72 hours. Another 6 patients had bacterial coinfections. A total of 18/105 (17%) received antibiotic prescriptions on discharge. Median days of therapy (DOT) in hospital was 1 day and median DOT for prescriptions was 8.5 days. There were 5 procalcitonin tests and no oseltamivir usage. Overall 38/105 (36%) patients were admitted to inpatient. In 2015, 3% (20/1313) of RSV (14) and influenza (6) rapid antigen and PCR tests were positive. A total of 5/20 (25%) patients received antibiotics, with 3/20 (15%) patients receiving a prescription for outpatient antibiotics. Median DOT in the hospital was 3 days and median DOT for prescriptions was 10 days. There were 2 procalcitonin tests and 2 cases used oseltamivir. Overall 19 patients were admitted.

Conclusion
Antibiotics are witheld in the majority of patients with positive Biofire testing. Most patients were treated with supportive care measures only. Biofire continues to be a useful tool to identify candidates for antibiotic avoidance in the ED at our institution.

Disclosures
All authors: No reported disclosures.
Measles Oral Swab as Field-Based Screening Test in Children
Authors: Husada Dominicus , Handayani Kartika , Puspitasari Dwiyanti , Kartina Leny , Setiono Parwati , Moedjito Ismoedijanto 
Published: October 2017

Abstract

Background
Indonesia suffered from measles outbreak for many times, especially in the last five years. Most patients were children. WHO used measles specific Ig M from the blood as a gold standard but this test is invasive. Anti measles Ig M oral swab has been used as an alternative however there has not been any study about this method in Indonesia. The objective of this study was to validate anti measles Ig M oral swab for the diagnosis of measles in children.

Methods
This study was performed in Dr. Soetomo Hospital in Surabaya for three months period. Children with fever and rash suspected having measles according to WHO criteria were used as samples. Inclusion criteria included age 6 month until 15 year-old, with maculopapular rash, fever for at least three days, and at least one of cough, coryza, and conjunctivitis. Immunocompromized children and those with history of fever and rash or measles vaccination in the last 8–12 weeks were excluded. A blood specimen for serum anti measles Ig M and oral swab using transudate in gingivo-cervicular sulcus were taken at the same time. Method for oral swab specimen was microimmune(EIA) captured antibody assay for measles IgM. Measles specific IgM antibodies from blood specimen were measured by Enzygnost anti measles IgM. Mc Nemar test and kappa were used to analyze the results with P &lt; 0.05.

Results
There were fifty-six children in the study. The age range was 6 – 72 months. Boys outnumbered girls with ratio 1.6:1. Most patients came on day third-sixth of illness. As much as 75.7% of the children were not immunized. Antimeasles Ig M were truly positive by both methods in fifty sampes. Detection of Ig M antibodies were similar either by using serum or oral swab (Mc Nemar, P = 1,00). The best ROC curve to detect anti measles IgM by oral swab was shown at the value of 0.2 (sensitivity 98%, specificity 60%, Kappa 0.638 with P &lt; 0.0001, PPV 96%, and NPV 75%) For the value of 0.5 we had sensitivity 90%, specificity 80%, PPV 98%, NPV 44%, and Kappa 0.516 with P &lt; 0.001.

Conclusion
Anti measles IgM oral swab is highly sensitive and can be used as a field-based alternative screening method to diagnose measles infection.

Disclosures
All authors: No reported disclosures.
Cytomegalovirus Management in Adult Hematopoietic Stem Cell Transplant Patients with Pre-Engraftment Viremia: A Single-Center, Retrospective, Descriptive Study
Authors: Martin Isabella , Avery Robin , Gladstone Douglas , Ambinder Richard , Tucker Noah , Valsamakis Alexandra 
Published: October 2017

Abstract

Background
Scant data exist regarding cytomegalovirus (CMV) viremia in hematopoietic stem cell transplant (HSCT) recipients during the pre-engraftment period. The goal of this study was to describe management of CMV in neutropenic adult HSCT patients at our institution, and to assess the possible impact of different quantitative CMV PCR tests (QPCRs).

Methods
Post-HSCT monitoring at this center includes weekly CMV QPCR from plasma. Three different QPCR assays were used sequentially during the study period (1/2010–12/2015): two with lower limits of quantification (LLOQ) of 300 and 100 copies/mL through 4/2013, and after that the FDA-approved assay with LLOQ of 137 IU/mL. Medical records of first-time HSCT patients were reviewed. Pre-/peri-engraftment CMV was defined as detectable CMV DNA with [ANC] &lt; 1000 cells/mm3. Information collected included demographics, donor/recipient CMV serostatus, conditioning regimen, CMV QPCR and ANC results, dates of CMV treatment, CMV disease within 100 days, and death within 6 months of HSCT. Data were analyzed with STATA v14.

Results
Of 1151 total HSCT, 76 patients had a positive CMV QPCR when ANC &lt; 1000 cells/mm3. CMV was first detected a median of 12 days (0–48) post-transplant, and was above LLOQ at a median of 28 days (0–49). 71/76 (93%) were treated at a median of 33 days post-transplant (range 4–105 days), most with valganciclovir (40) or ganciclovir (30); 1 received foscarnet initially. 5 patients with low-level viremia were monitored without treatment. At initiation of therapy, median CMV level was 1471 (range 159–22,900) copies or IU/mL and ANC was 1202 (range 28–9680) cells/mm3. Median treatment duration was 34 days (range 9–392). Only 2 patients had possible tissue-invasive CMV disease.

Conclusion
Ganciclovir and valganciclovir were used to treat most pre- and peri-engraftment CMV viremia, despite potential bone marrow toxicity. The LLOQ of different CMV QPCR tests did not affect the viral threshold for starting treatment. The time between first CMV DNA detection (median day +12) and initiation of treatment (median day +33) suggests clinicians waited for CMV DNA and/or ANC to rise before treating. With this deferred-treatment approach, the proportion of patients with tissue-invasive disease remained low.

Disclosures
All authors: No reported disclosures.