bluuebunny/crossref_metadata_2025_split huggingface dataset:
Impact of Vancomycin Serum Trough Concentrations and Vancomycin AUC/MIC on Vancomycin Response, In-Hospital Outcomes and Acute Kidney Injury in Pediatric Staphylococcus aureus Pneumonia
Authors: McNeil Jonathon , Rosas Louie , Hulten Kristina , Mason Edward O , Kaplan Sheldon L 
Published: October 2017

Abstract

Background
Vancomycin AUC/MIC &gt; 400 was initially shown to be beneficial in adults with staphylococcal pneumonia. Current practice guidelines recommend targeting serum vancomycin trough concentrations (VTC) of 15–20 µg/ml in adults with severe MRSA infection to approximate these AUC/MIC goals. Small studies have shown no benefit to VTC &gt; 15 µg/ml in children with osteomyelitis or bacteremia. We describe the impact of VTC and AUC/MIC on outcomes of pediatric S. aureuspneumonia.

Methods
Cases of S. aureuspneumonia from January 1, 2011 to December 31, 2016 were reviewed. Patients treated with vancomycin &lt;48 hours were excluded. Suboptimal vancomycin response (SVR) was considered any combination of duration of fever, bacteremia or ICU stay &gt; 75%-tile, need for re-operation, or mortality. The highest VTC and AUC obtained in the first 96 hours of therapy was used in analyses. Vancomycin MIC was determined with the E-test. Acute kidney injury (AKI) was defined as a doubling of the baseline serum creatinine.

Results
Thirty-six patients were identified meeting inclusion criteria with a median age of 0.74 years. 75% of isolates were MRSA and 70.4% were USA300. 80.6% of patients were admitted to the ICU and 52.8% were intubated. No benefit was observed in terms of duration of fever, bacteremia, ICU stay, ventilator or hospital days or rates of SVR between patients with VTC &gt; or &lt;15 µg/ml. There were substantial increases in rates of AKI with higher VTC (66.7 vs. 24.2%, P &lt; 0.001). Among 23 patients for whom AUC/MIC determinations were possible, none achieved an AUC/MIC &gt;400; the median AUC/MIC = 42 (IQR: 32–51). Eighty-eight% of isolates had an MIC ≥1.5 µg/ml. There was no correlation between values of AUC/MIC and length of ICU or hospital stay or SVR (AUROC 0.45).

Conclusion
While the sample size is limiting, VTC &gt;15 µg/ml did not provide clinical benefit to children with S. aureus pneumonia compared with lower VTC levels while at the same time predisposing to nephrotoxicity. AUC/MIC &gt; 400 is rarely achieved in children with S. aureus pneumonia and may not be a realistic goal in this infection given the rarity with which this occurs, the frequency of high MICs and the very young age of the typical patient. Large multicenter studies are required to understand optimal vancomycin dosing and monitoring in children with invasive MRSA infections.

Disclosures
J. McNeil, NIAID, NIH: Grant Investigator, Grant recipient; &#x2028;S. L. Kaplan, Allergan: Grant Investigator, Grant recipient and This grant pertains to unrelated research
Microbiology of Vertebral Osteomyelitis and Implications on Empiric Therapy
Authors: Clark Abbye , Sharma Neha , Weissman Sharon , Al-Hasan Majdi N , Derrick Caroline , Sanasi-Bhola Kamla 
Published: October 2017

Abstract

Background
The management of vertebral osteomyelitis (VO) includes empiric antibiotic therapy while clinical cultures are being processed. Optimal antimicrobial therapy for VO, particularly when Gram-negative (GN) organisms are involved, is an area of ongoing debate. Narrow spectrum and oral antimicrobial therapy are preferred. The objective of this study was to identify characteristics of local pathogens and to formulate an institution-specific antibiotic protocol for empiric treatment of VO.

Methods
We conducted a retrospective case series study of adults diagnosed with VO from August 1, 2010 to August 31, 2015 at Palmetto Health Hospitals in Columbia, South Carolina. Cases identified by ICD-9 codes were included in the analysis if they met clinical, imaging and microbiology, criteria.

Results
Analysis is based on 150 cases of VO with a mean age of 61 years, a male predominance (91; 61%), and an average body mass index of 29kg/m2. Comorbidities included diabetes mellitus (69; 46%), tobacco use (33; 22%), and hemodialysis (20; 13%). Thirty-seven (25%) cases had recent related injury or vertebral surgery, and 14 (9%) had prior hardware. Bone, disc, or adjacent tissue cultures were obtained in 129 (86%) of cases; 60 (40%) of these had &gt;1 sample taken. The remaining 14% had blood cultures alone. Thirty-six cases (24%) had culture negative VO. In the remaining 114 cases, 132 organisms were isolated. A total of 111 (84%) organisms were Gram-positive cocci (GPC). Of those, the majority was Staphylococcus aureus. (66; 59%) (26/66 were methicillin-resistant), coagulase-negative staphylococci (20; 18%) and Streptococcus spp. (17; 15%). Enterobacteriaceae accounted for 13/17 Gram-negative bacilli (GNB), with only one isolate of Pseudomonas aeruginosa. Of the GNB, 11/17 were susceptible to either ceftriaxone or ciprofloxacin.

Conclusion
There was a predominance of VO due to GPC suggesting that intravenous vancomycin monotherapy may be reasonable for empiric therapy in noncritically ill patients while awaiting Gram stain and clinical culture results. Addition of either ceftriaxone or ciprofloxacin to vancomycin would increase cumulative antimicrobial coverage from 84 to 92%.

Disclosures
All authors: No reported disclosures.
A Multicenter Study on Clinical Outcomes of Infections within 200 Days of Liver Transplantation among Recipients Age 65 Years and Older
Authors: Malinis Maricar , Ngo Tue , Garcia-Diaz Julia , Taimur Sarah , Mueller Nicolas , Eid Albert , Vergidis Pascalis , Pursell Kenneth , Bhaskaran Archana , La Hoz Ricardo , Bran Andres , Lee Dong , Pouch Stephanie , Avery Robin , Baddley John W 
Published: October 2017

Abstract

Background
Liver transplantation is increasingly performed in patients aged ≥65 years. Per the United Network for Organ Sharing data, infections are the leading primary and contributory cause of death in older liver transplant (LT) recipients. This study aims to describe the epidemiology and outcomes of infections within the first 200 days of LT in older adults.

Methods
We performed a retrospective, observational multi-center study of patients aged ≥65 years who underwent primary LT from January 1, 2010 to June 30, 2015. Data collection included patient demographics, co-morbidities, transplant data, infection event in 200 days of LT and death. Severe infection was defined as the presence of sepsis, septic shock, or sepsis with multi-organ failure.

Results
A total of 255 patients met inclusion criteria with median follow-up of 690 days (range 1– 2095). The mean age was 67.6 years (SD 2.4). Majority were male (67%) and white (85%). Frequent indications of LT were hepatocellular carcinoma (46%) and hepatitis C (32%). The median MELD score at the time of LT was 22 (range 6–47). Only 3% of recipients received thymoglobulin for induction. Acute rejection within 200 days of LT occurred in 31 (12%); graft failure in 8 (3%); and re-transplantation in 5 (2%). One hundred twenty-seven patients (50%) developed 274 infections; 63 (25%) had 1 infection and 64 (25%) had ≥ 2 infections. Median time to first infection after LT was 26 days [IQR 9–72]. Out of 274 infections, 182 (66%) occurred in &lt;90 days. Severe infection occurred in 40/127 (31%). Cystitis (16%), colitis (12%), and pneumonia (11%) were common. Bacterial, viral, and fungal infections were 61%, 22%, and 7%, respectively. Common bacterial pathogens were Enterococcus sp. (15%), Clostridium difficile (12%) and E. coli (8%). Thirty-five (13%) opportunistic infections (OI) occurred due to Cytomegalovirus [CMV] (26), Candida (4), Cryptococcus (3), HHV-8 (1), and Aspergillus (1). Mortality due to infection was 3%, while all-cause mortality was 12%. Frequency of discharge to sub-acute or extended care facility after infection was 23%.

Conclusion
Infections are common in this older LT cohort and occurred mainly in the early post-LT period. OIs were infrequent except for CMV. Despite concerns for immunosuppression and immunosenescence, the outcome of infection within the 200 days of LT was overall favorable.

Disclosures
All authors: No reported disclosures.
Missed Opportunities to Initiate Pre-exposure Prophylaxis in South Carolina—2013–2016
Authors: Okoye Stella , Chang Man-Huei , Weissman Sharon , Dufffus Wayne 
Published: October 2017

Abstract

Background
PrEP, regular use of antiretroviral medications by HIV-negative individuals to prevent new HIV infections, has not been widely adopted by some young, high-risk populations. This study investigated the characteristics and estimated percentage of newly diagnosed HIV-infected individuals in South Carolina (SC) who had visited a health care facility (HCF) while HIV-negative and missed opportunities for initiating PrEP.

Methods
We used a unique person-level identifier to link case reports from the SC enhanced HIV/AIDS Reporting System and records from a statewide all payer HCF database. The HCF data include inpatient (IP), outpatient (OP), and emergency department (ED) visits to SC facilities. Because the Food and Drug Administration approved PrEP in 2012, we analyzed data for individuals diagnosed with HIV during January 2013–September 2016 with initial CD4 count ≥500 cells (recent infection) and HC visits during 2011 through the date of diagnosis. We used the two-tailed chi-square statistics with a significant threshold of P &lt; 0.05 in SAS to investigate the association between the absence of a PrEP prescription and patient factors including demographics, behavioral risk, visit setting (IP, OP or ED), frequency of previous visits, and residence at diagnosis.

Results
A total of 785 patients were diagnosed with recent HIV infections (initial CD4 ≥500 cell) during January 2013–September 2016. Of these, 504 (64.2%) visited an SC HCF at least once before being diagnosed, 72.4% were males, 52.4% aged &lt;30 years, 54% were men who have sex with men (MSM) or injection drug users (IDU) and 70.2% resided in urban areas. Mean number of HCF visits before HIV diagnosis was 6.6; 84.3% had ED visits; 5.9% had IP visits; and 7.0% had OP visits. Persons of female sex, Black race, younger age and urban residence were more likely to access HCF visit before HIV diagnosis (P &lt; 0.05).

Conclusion
We now know the characteristics and percentage (64.2%) of persons with recent HIV infections captured in two large state-wide databases in SC who missed opportunities to be screened and initiated PrEP during visits to HCFs before HIV diagnosis during 2013–2016.

Disclosures
All authors: No reported disclosures.
Programmatic Congenital CMV Universal Screening Program
Authors: Carrillo-Marquez Maria , Rohde Benjamin , Tomlinson Ryan , Blanch Jacqueline , Bradford Lana , Kim-Hoehamer Young-In , Harrison Lisa , Pace Stephen , Davis Joe , Patel Chirag , Patel Anami , Arnold Sandra R , Devincenzo John P 
Published: October 2017

Abstract

Background
CMV is the most common congenital infection (cCMV). Traditional identification strategies including hearing screen and physical exam are insensitive and miss affected infants. To improve identification of infected &#x2028;newborns, we established a universal, institutional cCMV newborn screening program.

Methods
All newborns born or transferred to nurseries in a hospital system in Memphis, Tennessee between March 2016 and April 2017 were screened for cCMV. Infant saliva was collected on a Copan swab prior to discharge and within 2 weeks of birth. Specimens were centrally processed using a real-time CMV PCR assay (Simplexa™ CMV) (DiaSorin, Cypress CA) amplifying the UL83 gene, and the 3M Integrated Cycler. Parents received educational materials on cCMV testing and natural history prior to specimen collection. All patients with a positive screen had a full evaluation including physical exam, eye exam, hearing testing, CBC, chemistries and head ultrasound (HUS).

Results
There were 35/6,114 (0.6%) positive screens. Of 35, 16 (45.7%) were male and 5 (14%) were less than 37 weeks gestation. Thirty-one of 35 saliva specimens were collected on day 0 or 1 of life. All patients were evaluated by an infectious disease specialist at a median of 15 days of age. Confirmatory urine PCR was positive in 25/33 (76%) tested. Overall, 11/25 (44%) with confirmed congenital CMV were symptomatic. This included 28% with microcephaly and 20% with low birth weight. Six (24%) failed newborn hearing screening of one or both ears. Other abnormalities included thrombocytopenia (5%), elevated ALT (10%), elevated direct bilirubin (5%), and abnormal HUS (11/25, 44%), of which 7/11 had lenticulostriate vasculopathy and 2/11 had intracranial calcifications. Twelve infected infants had an eye examination and none had retinitis. Eleven infants were offered therapy and five were treated. Ten of 25 congenitally infected infants had audiology follow-up by 6 months with four abnormal. All infants were referred for early intervention.

Conclusion
We have demonstrated the feasibility of implementing large-scale, saliva-based cCMV screening program within one hospital system. Universal screening detected twice as many infected infants than would have targeted screening based on newborn hearing screen and growth parameters.

Disclosures
J. P. Devincenzo, AstraZeneca/MedImmune: Investigator, Research support
Infectious Disease Consultation Is Associated with Decreased Mortality with Enterococcal Bloodstream Infections
Authors: Lee Rachael A , Vo Daniel , Zurko Joanna , Griffin Russell , Rodriguez J Martin , Camins Bernard 
Published: October 2017

Abstract

Background
Enterococcal bloodstream infections (EBSI) have been attributed with significant morbidity and mortality. The objective of this study was to determine whether IDC is associated with improved mortality in patients hospitalized with EBSI.

Methods
This is a cross-sectional study of patients admitted to the University of Alabama Health System between January 1, 2015 and June 30, 2016 who had EBSI. Patients who died within 2 days of hospitalization were excluded. Categorical variables were analyzed with chi-square or Fisher’s exact test and continuous variables were analyzed with a t-test or Wilcoxon rank-sums test when appropriate. A P-value &lt; 0.05 was considered significant. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CI) for factors associated with 30-day in-hospital mortality.

Results
A total of 213 patients met the case definition. One hundred and thirty-four (63%) received IDC. Baseline patient demographics and comorbidities were similar in both groups. Patients with IDC were more likely to have repeated blood cultures (99% vs. 72%, P &lt; 0.001), echocardiogram performed (77% vs. 46%, P &lt; 0.001), and interventions for source control (19% vs 6%, P = 0.01). Patients without IDC were more likely to have inappropriate antibiotic treatment or no antibiotics (20% vs. 0%, P &lt; 0.001) as well as inappropriate duration of therapy (54% vs. 10%, P &lt; 0.001). There were no differences in the rates of recurrent bacteremia or readmission within 60 days. Patients who did not receive IDC had higher 30-day in-hospital mortality (27% vs. 13%, P = 0.02). Having an echocardiogram (OR 2.75, 95% CI 1.36–5.55), surgical intervention (OR 3.11, 95% CI 1.07–9.05) and an IV catheter (OR 3.90, 95% CI 1.39–10.88) were associated with increased likelihood of IDC while inappropriate duration of antibiotics was associated with an 87% decreased likelihood of IDC (OR 0.13, 95% CI 0.06–0.29). The strongest association observed with 30-day mortality was inappropriate duration of antibiotics (OR 4.93, 95% CI 1.93–12.61).

Conclusion
IDC was associated with reduced 30-day in-hospital mortality in patients with EBSI. Although further investigation is warranted, the results of this study suggest that early involvement of ID specialists in EBSI may lead to better outcomes.

Disclosures
All authors: No reported disclosures.
Is there Failure to Screen for Hepatitis C in Newborns Suffering from Neonatal Abstinence Syndrome?
Authors: Myers John , Smith Michael , Espinosa Claudia , Woods Charles , Duncan Scott 
Published: October 2017

Abstract

Background
Enormous advances in treating/curing patients suffering from Hepatitis C (HepC) infection have occurred; resulting in many states mandating screening for HepC for older individuals. Unfortunately, no protection of screening exists for newborns. In Kentucky, rates of HepC among pregnant women are the second highest within the U.S., which has been associated to high intravenous drug use. Infants born to those women are at risk of HepC infection and other conditions such as neonatal abstinence syndrome (NAS). The current study examined the rate of HepC screening in a high-risk cohort (newborns suffering from NAS) and it’s impact on policy-making for this vulnerable population.

Methods
Kentucky Medicaid records, from 2015, were obtained to develop a detailed demographic, behavioral, clinical, and diagnostic data set (n = 152,749). NAS was defined by ICD-9 code 779.5 and ICD-10 code P96.1. HepC screening was defined by CPT codes (CPT 87520 [HCV, direct probe], 87521 [HCV, amplified probe], and 87522 [HCV RNA, Quantitative] or antibody [CPTs 86803–4]). Initially a descriptive study was performed, then multiple logistic regression techniques were used to test what variables impacted the odds of not being screened for HepC.

Results
A total of 1234 newborns with NAS were identified. The majority showed signs of NAS within 24 hours (64%), were white (68%) and were admitted to the hospital for an average of 24.8 days. Only one-in-three newborns with NAS (n = 412, 33.4%) were screened for HepC. Non-Whites (OR = 1.58, 95% CI 1.45–1.71, P &lt; 0.001) and those living in non-urban areas (OR = 1.42, 95% CI 1.28–1.56, P &lt; 0.001) were the only study variables to significantly impact the odds of not being screened for HepC (for newborns suffering from NAS).

Conclusion
A high-risk and vulnerable population for HepC may not be getting screened for HepC and thus are being underserved by the health care system. Non-Whites and those in rural areas are the most affected. Solutions and policies need to be focused on this population and area where screening is lacking. Optimization of maternal screening for HepC is crucial in high-risk populations.

Disclosures
All authors: No reported disclosures.
Assessing The Impact of The National Healthcare Safety Network’s (NHSN’s) New Baseline on Acute Care Hospital Standardized Infection Ratios (SIRs)
Authors: Soe Minn , Nkwata Allan , Edwards Jonathan R , Dudeck Margaret , Pollock Daniel 
Published: October 2017

Abstract

Background
To more accurately measure the progress of healthcare-associated infection (HAI) prevention efforts, the CDC’s National Healthcare Safety Network (NHSN) surveillance system updated risk-adjustment models for computation of updated Standardized Infection Ratios (SIRs), the primary HAI summary measure by NHSN. This study sought to examine how the updated SIRs varied from the previous SIRs calculated using older baselines for acute care hospital HAIs.

Methods
We analyzed NHSN data for healthcare facility-onset laboratory-identified Clostridium difficile [CDI] and methicillin-resistant Staphylococcus aureus [MRSA] bacteremia reported in accordance with the CMS’ inpatient quality reporting program requirement. The unit of analysis was CMS certification number (CCN) facility reporting in 2015. We compared overall distributions of CCN-level SIRs (CCN-SIRs) between new risk-adjustment models using a 2015 baseline (SIR_NEW) and old models using a 2011 baseline (SIR_OLD) and tested location shift (median away from null) of pairwise differences. We also examined the magnitude of shift in SIR from old to new baseline.

Results
For each HAI, the national pooled mean SIR of the new baseline was ~1.0. For CDI, the overall distributions of CCN SIR_NEW and CCN-SIR_OLD were different, and the median of pairwise difference was away from null with CCN-SIR_NEW slightly higher. For MRSA, the SIR differences were not significant. Most CCN-SIRs (83% for CDI, 93% for MRSA) remained in the same significance category across the old and new baselines (“worse,” “better, ‘not different from national benchmark’), and few CCN-SIRs were reclassified to a less favorable category. For 75% of CCN-SIRs, their relative position in the quartile distributions of SIR_NEW and SIR_OLD remained the same. The discrepancies between SIR_NEW and SIR_OLD tended to be larger among CCNs with high SIRs.

Conclusion
The updated national pooled mean SIRs were close to 1.0, validating the potential use of new risk adjustment models and baseline as updated benchmarks for tracking CDI and MRSA prevention progress. The shifts in CCN-level SIRs between old and new baselines were not large, indicating a modest impact of new baselines at the CCN level, except among hospitals with high SIRs.

Disclosures
All authors: No reported disclosures.
Corticosteroid Use Following the Onset of Invasive Aspergillosis is Associated with Increased Mortality: A Propensity Score-Matched Study
Authors: Abers Michael , Vyas Jatin 
Published: October 2017

Abstract

Background
The safety of corticosteroid use (CSU) during active infection is controversial. In the invasive aspergillosis (IA) literature, CSU is typically defined using the time period prior to IA onset. Clinicians caring for patients with IA are unable to control prior CSU. The more clinically relevant question is whether CSU after IA onset is harmful.

Methods
Patients hospitalized at our institution from 2004 to 2014 with IA were retrospectively identified. CSU, defined as the average daily prednisone equivalent dose during the 7-day period following IA onset, was calculated for each patient. A CSU cut-off of 7.5mg was used to assign patients to treatment (&gt;7.5mg) or control (&lt;7.5mg, including no CSU) groups. A propensity score (PS) was generated to predict group assignment. Nearest neighbor matching was performed with a caliper width of 0.2. A Cox proportional hazards model was used to assess survival 6 weeks after IA onset.

Results
PS matching generated 61 matched pairs (122 patients). Baseline characteristics did not differ significantly between groups (Table). CSU was associated with increased mortality (PS adjusted hazard ratio [HR] 2.91, 95% CI 1.32–6.40). In the CSU group, a trend towards lower mortality was noted if corticosteroid dose was tapered to 7.5mg/day (HR 0.68, 95% CI 0.46–1.02).

Conclusion
CSU after IA onset is associated with increased mortality. In IA patients with CSU, efforts to reduce corticosteroid dose may be beneficial.

Disclosures
All authors: No reported disclosures.