bluuebunny/crossref_metadata_2025_split huggingface dataset:
Antibiotic Prescribing for Dental Procedures in Community-Associated Clostridium difficile cases, Minnesota, 2009–2015
Authors: Bye Maria , Whitten Tory , Holzbauer Stacy 
Published: October 2017

Abstract

Background
Clostridium difficile infections (CDIs) are the leading cause of healthcare-associated diarrhea. Two of the most significant risk factors for CDI are antibiotic use and healthcare exposure. Dentists write approximately 10% of all outpatient prescriptions in the USA; however, limited data are available regarding dental prescribing’s impact on CDI. We described characteristics of community-associated (CA) CDI cases following antibiotics for dental procedures.

Methods
The Minnesota Department of Health (MDH) performs active population- and laboratory-based surveillance for CDI as part of the CDC’s Emerging Infections Program (EIP). A case was defined as a positive C. difficile toxin or molecular assay on a stool specimen from a person &gt;1 years old without a positive test in the prior 8 weeks, living in one of the five EIP catchment counties. Cases were classified as CA if stool was collected ≤3 days of admission or as an outpatient, with no overnight stay in a healthcare facility in the past 12 weeks. Medical records were reviewed and interviews performed to assess CDI risk factors and potential exposures. Differences in antibiotic prescribing and documentation among CA CDI cases receiving dental procedures were explored.

Results
During 2009–2015, 2176 presumptive CA CDI cases were reported to MDH; 1626 (75%) were confirmed as CA and interviewed. In total, 926 (57%) were prescribed antibiotics and 136 (15%) for dental procedures. Cases prescribed antibiotics for dental procedures were significantly older (median age: 57 vs. 45 years, P &lt; 0.001), more likely to be prescribed clindamycin (50% vs. 10%, P &lt; 0.001), and less likely to be prescribed fluoroquinolones (6% vs. 19%, P &lt; 0.001) and cephalosporins (7% vs. 30%, P &lt; 0.001) than those prescribed antibiotics for other indications. Among cases who received antibiotics for a dental procedure, 31 (23%) reported antibiotics on interview which were also documented in the medical record and 46 (34%) reported antibiotics for any reason on interview without documentation in the medical record.

Conclusion
Dental antibiotic prescribing rates are likely underestimated. Stewardship programs should address dental prescribing and alert dentists to CDI subsequent to antibiotics prescribed for dental procedures.

Disclosures
All authors: No reported disclosures.
Etiology of Infectious Diarrhea in Patients Tested for Clostridium difficile: If It Isn’t Clostridium difficile, What Is It?
Authors: Kwon Jennie H , Hink Tiffany , Reske Kimberly , Dubberke Erik R , Burnham Carey-Ann D 
Published: October 2017

Abstract

Background
The objective of the study was to assay for alternative infectious causes of diarrhea in patients with negative EIA tests for Clostridium difficile.

Methods
A hard-stop alert was implemented at a tertiary care hospital to limit repeat testing for C. difficile within 96 hours of an initial negative EIA. Stool samples from patients with a negative (–) repeat EIA test for C. difficile within 96 hours in the 3 months pre- and postintervention underwent further evaluation: C. difficile toxigenic culture, GeneXpert C. difficile PCR, Biofire Gastrointestinal (GI) Panel, and culture on a blood agar plate.

Results
Of the 84 C. difficile EIA stool specimens evaluated, 8% were toxigenic culture positive (+), 8% tested + for C. difficile via the Biofire GI panel, and 5 (7%) + with the GenXpert C. difficile PCR (Table 1). Three of these patients were diagnosed with CDI within 30 days of a + test. Five patients were + for Norovirus via Biofire GI panel; none were tested for or diagnosed with Norovirus. Two patients were + for Enteropathogenic E. coli and one for Enteroaggregative E. coli via Biofire GI panel; none were tested for or diagnosed with E. coli infection. One patient was positive for Salmonella and Salmonella was isolated by stool culture.

Conclusion
Patients tested for C. difficile may have alternate causes of diarrhea. When evaluating hospitalized patients with diarrhea, C. difficile, along with alternate causes of diarrhea can be considered.

Disclosures
E. R. Dubberke, Merck: Consultant, Consulting fee; Biofire: one time talk, Speaker honorarium;; Alere: one-time talk, Speaker honorarium; Sanofi pasteur: Grant Investigator, Grant recipient; Pfizer: Consultant, Consulting fee; Rebiotix: Investigator, Research support; Rebiotix: Consultant, Consulting fee; valneva: Consultant, Consulting fee; C. A. D. Burnham, bioMerieux: Grant Investigator, Research grant; ThermoFisher: Consultant, Salary; Cepheid: Grant Investigator, Research grant
Risk Factors for Early Hip or Knee Prosthetic Joint Infection (PJI): Analysis of a Nationwide American Insurance Claims Dataset
Authors: Tande Aaron , Asante Dennis , Sangaralingham Lindsey , Osmon Douglas , Heien Herbert , Mabry Tad , Berbari Elie F 
Published: October 2017

Abstract

Background
While several studies have identified risk factors for PJI using insurance claims data, these data sets have been limited to a single regional insurance dataset or to the Medicare population. We sought to investigate risk factors for early PJI among patients undergoing total hip or knee arthroplasty (THKA).

Methods
All patients who underwent primary THKA between January 1, 2004 and July 31, 2014 with 12 months of continuous preceding medical and pharmacy insurance coverage were included in the study. The primary outcome of PJI required both a compatible procedure code and a diagnostic code during an inpatient stay from the time of THKA through 90 days after discharge. Comorbidities were based on ICD-9 codes in the preceding 12 months and patients with a prior diagnosis of PJI during that time period were excluded. Univariate and multivariate analysis was performed using logistic regression.

Results
A total of 147,053 patients underwent THKA during the study period, including 97,448 patients with TKA and 49,605 with THA. PJI occurred in 754 (0.5%) patients. Female gender was independently associated with lower odds of PJI (Figure). A number of biologically plausible factors were associated with increased risk, including chronic skin ulcer, obesity, substance use disorders, joint sarcoma, and malnutrition. The adjusted odds of PJI increased in a stepwise fashion with each increase in the Charlson comorbidity index (CCI), with those with a score of 4 or more having a nearly 2-fold adjusted odds of PJI compared with a score of 0 (OR 1.91; 95% CI 1.29 −2.82). Previously observed risk factors diabetes mellitus, rheumatoid arthritis, and chronic renal failure were associated with increased odds of PJI on univariate analysis, but not after adjustment.

Conclusion
These data identify several potentially modifiable risk factors for preoperative optimization, including obesity, malnutrition, chronic skin ulcers, and substance-use disorders. The level of comorbidity as assessed by the CCI provides a rough estimate of the increasing risk of PJI. The pathobiology of additional risk factors observed here deserves further study.

Disclosures
All authors: No reported disclosures.
Increasing Kingella Identification in Bone and Joint Infections in Young Children
Authors: Quick Rachel , Williams John , Cosgrove Peter , Kahlden Kyle , Fernandez Marisol , Thoreson Lynn , Hauger Sarmistha 
Published: October 2017

Abstract

Background
Kingella kingae is an increasingly recognized pathogen among young children with bone and joint infections. Antibiotics given to cover methicillin-resistant Staphylococcus aureus are not effective against Kingella, and necessitate additional empiric antibiotics in this age group. Improving Kingella identification can narrow antibiotic choices and improve efficacy for long-term oral therapy.

Methods
We implemented a bone and joint infection guideline at a free standing children’s hospital that called for early imaging, focal sampling, and polymerase chain reaction (PCR) testing for culture-negative specimens. The goal was to increase identification of Kingella and other pathogens to improve targeted antimicrobial therapy. Children 6 to ≤ 60 months of age with uncomplicated acute hematogenous osteomyelitis or septic arthritis between January 1, 2009–December 31, 2016, were included in this study. Outcomes of bacterial identification were measured.

Results
Charts for 49 cases that met criteria were reviewed. Prior to the algorithm, we identified Kingella in 4% (1/25) of cases. Following routine use of updated sampling and testing techniques, including PCR testing, Kingella kingae identification increased to 29% of cases (7/24; P = 0.02) and, in fact, was the predominant pathogen identified in this age group.

Conclusion
Identification of Kingella was enhanced as a result of changes to sampling and testing, including PCR testing (Figure 1). Post-implementation, Kingella was more commonly identified than Staphylococcus aureus. Widespread availability of PCR testing in the future may allow for the use of narrowed antibiotic therapy and targeted transition to oral antibiotics in young children with bone or joint infection.

Disclosures
All authors: No reported disclosures.
Concordance of Results of Blood and Tissue Cultures from Patients with Pyogenic Spondylitis
Authors: Bae Ji Yun , Kim Chung-Jong , Kim Uh Jin , Song Kyoung-Ho , Kim Eu Suk , Kang Seung Ji , Oh Myoung-Don , Park Kyung-Hwa , Kim Nam Joong 
Published: October 2017

Abstract

Background
The aim of this study was to investigate the concordance of results of blood and tissue cultures in patients with pyogenic spondylitis.

Methods
We searched the patients with pyogenic spondylitis in whom micro-organisms were isolated from both blood and tissue cultures by retrospective review of medical records in three tertiary university-affiliated hospitals between January 2005 and December 2015. The species and antimicrobial susceptibility patterns of isolates from blood and tissue cultures were compared with each other.

Results
Among 141 patients with pyogenic spondylitis in whom micro-organisms were isolated from both blood and tissue cultures, the species of blood and tissue isolates were identical in 135 patients (95.7%, 135/141). Excluding the four anaerobic isolates, we investigated antimicrobial susceptibility patterns of 131 isolates of same species from blood and tissue cultures. Antibiotic susceptibility patterns were identical in 128 patients (97.7%, 128/131). The most common isolates were Staphylococcus aureus (86 patients; 85 concordant and 1 discordant), followed by streptococcus (24 patients; 22 concordant and 2 discordant), and Escherichia coli (8 patients; all concordant).

Conclusion
We suggest that a positive blood culture from patients with pyogenic spondylitis could preclude the need for additional tissue cultures, especially when S. aureus and streptococcus grew in blood cultures.

Disclosures
All authors: No reported disclosures.
Does Detection of Respiratory Viral Infection in Upper Respiratory Tract (URT) Predict Lower Respiratory Tract (LRT) Disease in Hematopoietic Cell Transplant (HCT) Patients?
Authors: Vivek Meghana , Xie Hu , Pergam Steven A , Mielcarek Marco , Hill Joshua , Kuypers Jane , Jerome Keith , Limaye Ajit , Leisenring Wendy , Boeckh Michael , Waghmare Alpana 
Published: October 2017

Abstract

Background
HCT recipients are frequently infected with respiratory viruses (RVs) in the URT; however, diagnostic evaluation of the LRT by bronchoalveolar lavage (BAL) is less common. We sought to determine whether the detection of RVs in the URT is predictive of LRT detection and to identify factors that predict discordance between upper and lower RV detection.

Methods
HCT recipients with respiratory symptoms and LRT RV testing via multiplex PCR in BAL from July 2009 to October 2016 were included in the study. RV PCR results, including cycle threshold (CT) values, were compared with URT samples obtained within ±3 days. Logistic regression models were used to analyze risk factors for RV discordance between paired samples.

Results
Among 1,000 HCT recipients with BAL RV testing, 250 had URT testing within 3 days. In total, 75(30%) sample pairs were concordant for the same RV in both the URT and BAL (P/P); 132 (53%) were negative from both sites. Among 43 discordant pairs, 25 (10%) were only positive by URT but negative by BAL (P/N) and 18 (7%) were positive by BAL but negative by URT (N/P). In pairs with positive RV results in the URT or BAL, discordance was common for HMPV (44%), HRV (33%), and PIV-3 (28%); RSV was almost always concordant (92%) (Figure 1). In a multivariable model, the risk of discordance (P/N or N/P) was increased in the presence of a solitary nodule on radiography (OR 6.8; 95% CI 1.2–38.3) and with lymphocyte count &gt;500/mm3 (OR 3.1; 95% CI 1.08–9.0). Among P/P pairs, the median difference between CT values between URT and BAL samples was 0 (range −12 to +13), with 33 and 29% of subjects having lower and higher CT values (&gt;4, ~1 log10) in the BAL, respectively (Figure 2).

Conclusion
In symptomatic HCT recipients with RV PCR testing performed concurrently in the upper and lower tract, discordant results are relatively common, especially for HRV, HMPV, and PIV-3. The presence of a solitary nodule on imaging and the absence of lymphopenia are associated with discordant results, with BAL results more likely being negative in these situations. More than half of the P/P pairs had a &gt;4 difference in CT values between URT and LRT samples. Taken together, these data suggest that RV testing in BAL can provide useful diagnostic information that may guide management in HCT recipients.

Disclosure
S. A. Pergam, MERCK: Consultant and Investigator, Consulting fee.
Solid Organ Transplantation (SOT) and Data Mining: Bloodstream Infections (BSI) Have a Significant Impact on One-Year Survival, and qSOFA ≥ 2 Predicts 30-Day Mortality
Authors: Liu Terrence , Xie Donglu , Adams-Huet Beverley , Le Jade , Yek Christina , Ranganathan Dipti , Haley Robert W , Greenberg David , Hoz Ricardo La 
Published: October 2017

Abstract

Background
We created a retrospective and prospective database of SOT recipients using innovative data mining tools. This study describing the epidemiology of BSI in SOT serves as a proof of concept of such techniques in clinical research.

Methods
The design of the study was a retrospective, single-center, cohort study. Data mining tools were used to extract information from the electronic medical record and merged it with data from the SRTR (Figure 1). First SOT from January 1, 2010 to December 31, 2015 were included. Charts of subjects with positive blood cultures were manually reviewed and adjudicated using CDC/NHSN and SCCM/ESICM criteria. The 1-year cumulative incidence was calculated using the Kaplan–Meier method. Cox proportional hazards models were used to identify risk factors for BSI and 1-year mortality. BSI was analyzed as a time-dependent covariate in the mortality model. Fisher’s exact test and chi-square were used to identify risk factors for 30-day mortality and MDRO.

Results
A total of 917 SOT recipients met inclusion criteria. Seventy-five patients experienced at least one BSI. The cumulative incidence was 8.4% (95% CI 6.8–10.4) (Figure 2). The onset of the first BSI episode was: 30 episodes (40%) &lt;1 month, 33 (44%) 1–6 months, and 12 (16%) &gt;6 months. The most common pathogens were Klebsiella sp. (16%), Vancomycin-resistant E. faecium (12%), E. coli (12%), CoNS (12%), and Candida sp. (9.3%). Nineteen isolates (25%) were identified as MDRO; the risk of MDRO was highest &lt;1 month compared with 1–6 and &gt;6 months (44.8 vs. 12.1 vs. 16.7; P = 0.01). The most common source of BSI was CLABSI (29%) (Figure 3). In multivariable analysis, the risk of BSI was associated with organ type (HR [95% CI] = Multiorgan 3.5 [1.1–11.6], liver 2.5 [1.1–5.4], heart 2.4 [1.1–5.1]) and acquisition of a BSI was associated with a higher 1-year mortality (HR = 8.7 [5.1–14.7]). In univariable analysis, a polymicrobial BSI (14.7 vs. 57.1%; P = 0.02), qSOFA ≥ 2 (0.0 vs. 25.5%; P = 0.02) and septic shock (3.9 vs. 52.2%; P &lt; 0.001) were associated with an increased risk of death at 30 days.

Conclusion
A BSI significantly affects the 1-year survival of SOT recipients. A qSOFA ≥ 2 can be used to identify patients at risk for death. Additionally, this study illustrates the potential of data mining tools to study infectious complications.

Disclosures
All authors: No reported disclosures.
Investigation of a Contaminated, Nationally Distributed, Organ Transplant Preservation Solution — United States, 2016–2017
Authors: Stuckey Matthew , Novosad Shannon , Wilde Nancy , Annambhotla Pallavi , Basavaraju Sridhar , Moulton-Meissner Heather , Seiber Kathy , Perz Joseph , Quinlisk Patricia , Garvey Ann , Conrad Suzanne , Fewell Sarah , Hill Sam , Edmond Michael , Diekema Daniel , Ford Bradley , Reed Alan , Benowitz Isaac , Walters Maroya Spalding 
Published: October 2017

Abstract

Background
In December 2016, bacterial contamination of an organ preservation solution (OPS) was reported by Transplant Center A in Iowa. Annually, &gt;20,000 abdominal organs are transplanted in the United States; OPS is used for organ storage. We investigated the scope of OPS contamination and its association with adverse events in patients.

Methods
We assessed infection control practices related to OPS at Transplant Centers A and B in Iowa and the local organ procurement organization (OPO). We issued national notifications about OPS contamination and requested transplant centers to report product-related concerns or potential patient harm. Among transplant recipients at Center A, we compared adverse events (fever, bacteremia, surgical site infection, peritonitis, or pyelonephritis within 14 days of transplantation) during October–December 2015 with October–December 2016, the presumed window of exposure to contaminated OPS. Isolates from OPS were characterized.

Results
No infection control deficiencies were identified at Transplant Centers A, B, or the OPO. In January 2017, contaminated OPS from the same manufacturer was reported by Transplant Center C in Texas. Nationally, there were no reports of patient harm definitively linked to OPS. Post-transplant adverse events at Center A did not increase between fourth quarter 2015 (5/12 [42%]) and 2016 (2/15 [13%]). Organisms recovered from OPS included Pantoea agglomerans and Enterococcus gallinarum (Center A) and Pseudomonas koreensis (Center C). Five Pantoea isolates from ≥3 opened OPS bags were indistinguishable by pulsed-field gel electrophoresis. The OPS distributor issued recalls and suspended production. The US Food and Drug Administration identified deficiencies in current good manufacturing practices at manufacturing and distribution facilities, including inadequate validation of OPS sterility.

Conclusion
Bacterial contamination of a nationally distributed product was identified by astute clinicians. The investigation found no illnesses were directly linked to the product. Prompt reporting of concerns about potentially contaminated healthcare products, which might put patients at risk, is critical for swift public health action.

Disclosures
All authors: No reported disclosures.
Cefazolin plus Clavulanic Acid Overcomes the Inoculum Effect in a Methicillin-Susceptible Staphylococcus aureus (MSSA) Rat Endocarditis Model
Authors: Miller William , Singh Kavindra , Arias Cesar , Murray Barbara 
Published: October 2017

Abstract

Background
The inoculum effect (InE) refers to an increase in the MIC of an antibiotic when a large burden of bacteria is present. MSSA producing type A or C β-lactamase (β-lac) that display this effect may be at risk of clinical failure when treated with cefazolin (CFZ) for a deep-seated infection. We have previously shown that CFZ plus clavulanic acid (CL) abolished the InE in vitro. The aim of this study was to evaluate the effectiveness of the combination in vivo at clinically achievable concentrations of both CFZ and CL.

Methods
S. aureus TX0117, a type A Bla+ clinical isolate from a patient who failed CFZ therapy and TX0117-cured (TX0117c), a derivative of TX0117 which lacks β-lac activity, were used in a rat model of endocarditis. One animal per strain, in addition to historical controls (n = 22), was sacrificed at the start of therapy to assess colony forming units (CFU) per gram of vegetation at T = 0. CFZ 50mg/kg alone (n = 11) or CFZ 50mg/kg plus CL 4mg/kg (n = 7) was given IM every 8 hours for 72 hours. Doses were selected to mimic mean serum concentration of standard doses (given IM (CFZ) or PO (CL)) in humans. Rats were sacrificed 16 hours after the last antibiotic dose, aortic valves were aseptically excised, weighed, homogenized in 1ml of saline and the entire volume was plated in serial 10-fold dilutions on mannitol salt and/or brain-heart infusion agar. Representative recovered colonies were tested for β-lac activity using nitrocefin. Comparisons of CFU between groups were done by the Mann–Whitney, Wilcoxon unpaired test with significance at p &lt; 0.05.

Results
At baseline, there was no significant difference between the CFU/g of control animals infected with the two strains (TX0117 7.3±1.3 and TX0117c 7.89±0.83, mean log10 ± SD). Compared with untreated controls, the TX0117 group treated with CFZ alone had a reduction of 2±0.6 CFU/g, while the CFZ plus CL arm had a 7.1±0.5 CFU/g reduction, a statistically significant difference between the two arms (P = 0.0002). CFZ treatment of the TX0117c strain lacking blaZ activity was similar to CFZ+CL (6.5±0.6 log10 CFU/g reduction, P &lt; 0.0001).

Conclusion
Against Bla+ TX0117, the addition of CL, at a dose mimicking human PO kinetics, restored the efficacy of CFZ and overcame the InE. This provides a proof-of-concept for the use of oral CL with CFZ when there is a concern for the InE.

Disclosures
All authors: No reported disclosures.