bluuebunny/crossref_metadata_2025_split huggingface dataset:
665. Duration of Spontaneous Bacterial Peritonitis Prophylaxis in Acute Variceal Hemorrhage Patients
Authors: Tedeschi Carissa M , Hoff Abigail , Scherrer Nicole , Shigle Amanda , Burwell Sheena 
Published: November 2023

Abstract

Background
To prevent spontaneous bacterial peritonitis (SBP), re-bleeding, mortality, and long hospital stays in patients with acute variceal hemorrhage, the American Association for the Study of Liver Diseases recommends up to 7 days of ceftriaxone, with guidance to consider discontinuing when hemorrhage resolves and vasoactive drugs are stopped. Due to the ambiguous recommendation, practices vary surrounding duration of SBP prophylaxis. To our knowledge, no study has been completed on the duration of SBP prophylaxis within our current standard of care.

Methods
This was a retrospective, non-inferiority trial of adult patients receiving an octreotide infusion with confirmed variceal hemorrhage diagnosed via esophagogastroduodenoscopy at WVU Hospitals from 1/1/2020 - 12/31/2022. Medical records were reviewed to include demographic information, antibiotic selection, and duration of therapy for SBP prophylaxis, in addition to outcome measures such as infection, re-bleeding, length of stay, and mortality. Patients who received 5 or fewer days (shorter group) of prophylactic antibiotics were compared to those who received more than 5 days (longer group).

Results
84 patients were included: 39 patients in the shorter group, and 45 patients in the longer group. There was no statistically significant difference found between the shorter and longer groups in terms of demographic information. The primary outcome was development of infection. Four (10.3%) patients in the shorter group developed infection, and three (6.7%) patients in the longer group developed infection. The number of patients gathered met power for a 20% non-inferiority margin. There was no statistically significant difference found in any of the secondary outcomes.
Results
Primary and Secondary Outcomes

Conclusion
We can conclude that shorter durations of SBP prophylaxis are non-inferior to longer durations for preventing infections. In general, decreasing the duration of antibiotics to only what is necessary allows for preventing the development of resistance and fewer secondary infections. Additional studies are needed to confirm the results and impact guideline recommendations.

Disclosures
All Authors: No reported disclosures
693. Clinical and Economic Outcomes Associated with Fidaxomicin in Comparison to Vancomycin, Metronidazole, and FMT: a Systematic Literature Review
Authors: Li Qinghua , Obi Engels N , Marciniak Anne , Newman Rebecca 
Published: November 2023

Abstract

Background
Clostridioides difficile causes Clostridioides difficile infection (CDI), of which there are estimated half a million cases in the United States (US) each year. Fidaxomicin, vancomycin, and metronidazole are commonly used for the treatment of CDI, and fidaxomicin is recommended by clinical guidelines as the preferred treatment for patients with initial and recurrent CDI.
The aim of this systematic literature review was to explore the clinical and economic outcomes associated with the use of fidaxomicin with or without comparison to vancomycin, metronidazole, or fecal microbiota transplantation (FMT).

Methods
The Embase, Medline, EconLit, and Evidence Based Medicine (EBM) Reviews databases were searched from 1st January 2012 to 6th December 2022. Identified publications were assessed and extracted by two independent reviewers.

Results
Overall, 82 publications were included. In studies with ≥50 patients, ≥90 days post-treatment, clinical cure rate was 68–97% for fidaxomicin (N=12) and 66–92% for vancomycin (N=5), recurrence rate was 0–36% for fidaxomicin (N=19) and 17–29% for vancomycin (N=7), and all-cause mortality rate was 0–23% with fidaxomicin (N=4) and 4–39% with vancomycin (N=3). No relevant clinical outcomes were identified with metronidazole or FMT. There were limited healthcare resource use data. In studies with ≥50 patients (N=3), median hospital stay with fidaxomicin was 5.6–19.0 days.
Of 20 publications reporting cost-effectiveness, fidaxomicin was cost-effective compared to vancomycin in twelve, metronidazole in four, and FMT in one, as first-line treatment for non-severe CDI and in populations at high risk of recurrence. Six of 20 studies reported vancomycin or FMT as more cost-effective than fidaxomicin. Six of seven publications including patients aged ≥60 years, with cancer, renal impairment, or concomitant antibiotics found fidaxomicin cost-effective compared to vancomycin. Six publications stated that the high acquisition cost of fidaxomicin was offset by reduced recurrence and associated HCRU.

Conclusion
Fidaxomicin was clinically effective compared to vancomycin. Fidaxomicin is often reported as cost-effective compared to vancomycin, consistently within high-risk subpopulations.

Disclosures
Qinghua Li, PhD, Merck & Co Inc: Employee Engels N. Obi, PhD, Merck & Co Inc: Employee Anne Marciniak, MD, PhD, MPhil, MSc, Abbvie: Stocks/Bonds|Amgen: Stocks/Bonds|Pfizer: Stocks/Bonds
696. Effectiveness of Oral Vancomycin as Prophylaxis against Clostridioides difficile Infection in Hematopoietic Stem Cell Transplant Patients
Authors: Reitmeyer Kelly M , Rana Brijesh , Awad David A , Huang Esther , Park Jiyeon J , Yassin Arsheena , Mills John P , Azim Ahmed Abdul , Bhatt Pinki , Narayanan Navaneeth 
Published: November 2023

Abstract

Background
Patients receiving hematopoietic stem cell transplants (HSCT) are at increased risk for Clostridioides difficile infection (CDI) due to decreased immune function, frequent exposure to broad-spectrum antibiotics and chemotherapy, prolonged hospitalizations, and alteration in gut microbiome. The purpose of this study was to assess the effectiveness of oral vancomycin prophylaxis (OVP) for CDI in all patients admitted for HSCT.

Methods
This was a single-center, retrospective, cohort study conducted at a tertiary care academic medical center in New Jersey. Medical records of patients admitted between June 2019 to August 2022 to undergo an allogeneic or autologous HSCT were reviewed. Universal OVP from admission to discharge for HSCT patients began December 2019. Patients ≥ 18 years at the time of admission for the HSCT were included. Patients who were admitted less than 72 hours or who were being treated for an active CDI prior to HSCT were excluded. The primary endpoint was the incidence of in-hospital CDI. Secondary endpoints included incidence of vancomycin-resistant enterococci (VRE) bloodstream infections, VRE isolated from any clinical culture, gram-negative bloodstream infections, hospital survival, and hospital length of stay. Exploratory endpoints including one-year survival, relapse, and incidence of graft-versus-host disease were also collected. Confounding by relevant covariates were assessed and controlled for in a multivariable regression model.

Results
A total of 132 HSCT patients were included. There was one case (1/68, 1.47%) of CDI in the prophylaxis group compared to six CDI cases (6/64, 9.38%) in the no prophylaxis group (P=0.057). There were no significant (P&gt;0.05) between-group differences of incidence of gram-negative bloodstream infections, hospital survival, and length of stay. There were zero clinical cultures positive for VRE in either group.

Conclusion
In-hospital incidence of CDI in HSCT patients was decreased with the use of OVP but did not meet statistical significance. Randomized controlled trials are needed in this high-risk patient population to assess the efficacy and long-term risks of OVP for CDI.

Disclosures
Pinki Bhatt, MD, Sanofi: Grant/Research Support Navaneeth Narayanan, PharmD, MPH, BCIDP, Astellas: Honoraria|Beckman Coulter: Honoraria|Merck: Grant/Research Support|Shionogi: Grant/Research Support
701. Predicting hospital-associated Clostridioides difficile infection risk in hospitalized patients using routinely-collected electronic health record data
Authors: Ray Michael J , Strnad Luke , Furuno Jon P , Lofgren Eric , Gerber Jeffrey S , McGregor Jessina C 
Published: November 2023

Abstract

Background
Antibiotic therapy is a known risk factor for Clostridioides difficile infection (CDI), though the risk varies by agent. The antibiotic spectrum index (ASI) captures information on spectrum of antibiotic activity and days of therapy (DOT). We evaluated ASI and other routinely collected clinical data as predictors of hospital-associated (HA) CDI.

Methods
We developed and tested a model to predict HA-CDI in a cohort of adult inpatient encounters at a 576-bed academic medical center in Portland, OR. We excluded patients with recurrent or community-acquired CDI. We used encounter data from 2/2018 – 2/2020 to train and validate our model. Using a randomly-selected two-thirds of our data, we trained our logistic regression model using a stepwise variable selection process. We used the remaining one-third of our data to validate our model. Finally, we applied the model to the 3/2020 – 3/2021 period to test the model’s ability to predict HA-CDI. We generated receiver operating characteristic (ROC) curves and calculated area under the curve (AUC) to evaluate model discrimination. Finally, we compared observed and predicted HA-CDI counts by decile using the Hosmer-Lemeshow test.

Results
The training sample included 84 HA-CDI cases among 23622 encounters. The final model included ASI per DOT, time at-risk (days), patient age, number of hospitalized days in the 8 weeks prior, and inpatient receipt of a proton pump inhibitor or H2 receptor antagonist. When applied to the validation set (44 cases/11807 encounters), the model achieved an AUC of 0.79 (95% Confidence Interval: 0.71, 0.86) When applied to the test period (35 cases/12341 encounters), the AUC was 0.73 (0.66, 0.81). According to the Hosmer-Lemeshow test, our model fit the data reasonably well (p=0.2; Figure 1). Using ASI in the model achieved a significantly better prediction than DOT (Figure 2).

Conclusion
Using a combination of ASI and data that is routinely-collected for clinical practice, we were able to reasonably predict HA-CDI in our hospital using a small number of variables easy-to-obtain variables. The antibiotic spectrum index could be a valuable tool in predicting individual-level HA-CDI risk, though further work is required to test and implement a CDI risk score in a prospective environment.

Disclosures
All Authors: No reported disclosures
708. Three Stages of Laboratory Stewardship in Improving Appropriate Clostridiodes Difficile Testing
Authors: Beckman Shannon , Zimmerman Gretchen , Raza Khateeb , Ballard Samuel , Vijayam Naveen , Stibbe Bethany , Rykse Monica , Brown Joe , Klein Theresa , Skinner Andrew M , Wang Michael S 
Published: November 2023

Abstract

Background
Clostridioides difficile infections are a frequent cause of nosocomial infections and a large financial burden to the health care system. Molecular diagnostics such as PCR may frequently detect colonized patients and lead to overdiagnosis. Using the electronic medical record (EMR) system, we implemented multiple interventions to improve testing stewardship.

Methods
Over the span of 3 years, our Infection Control (IC) team implemented 3 separate testing interventions: in July 2019, a hard stop was implemented, requiring providers to document &gt;3 loose or watery stools and no laxative use within 48 hours. In July 2020, Stage 2 was implemented, requiring an infectious diseases (ID) physician to electronically approve a CDI test for all tests after 3 midnights. In April 2022, Stage 3 was implemented, changing the testing protocol to an algorithmic approach, with positive C. difficile PCR reflexing to a toxin immunoassay with regular surveillance by IC practitioners to ensure compliance.

Results
From 2019 to 2022, our CDI testing interventions resulted in a reduction of C. difficile tests completed from 21.22 tests/1000 patient days (PD) to 6.95 tests/1000 PD (p&lt; 0.01). The median number of tests completed in persons admitted for ≤ 3 days decreased from 63 (Interquartile Range (IQR):61 – 67) to 28 (IQR:26-35), p&lt; 0.01. The median number of tests completed in persons admitted for &gt; 3 days decreased from 34 (IQR:31 – 35) to 9 (IQR:7-10), p&lt; 0.01. and the median, decrease of 27.8% (36 to 26), and increase of 7.69% (26 to 28), p &lt; 0.01, respectively. The PCR percent positivity remained constant after the 1st intervention (15.3% vs. 14.4%, p=NS) but there was a slight increase in the test percent positivity between intervention 1 and 2 (19.2%, p=.08). After the 3rd intervention, the PCR percent positivity was 20.2% (80/316). However, the majority of these were PCR positive/toxin negative (74% vs 26%, p&lt; 0.01).

Conclusion
3 stages of EMR-based interventions, including testing indications, ID physician review, and 2-tiered testing plus IC review, were effective in reducing CDI tests. These interventions led to an upward trend in percent positivity indicating that persons appropriate for testing were not adversely impacted, but further study is necessary to determine the long-term impacts on patient outcomes.

Disclosures
Andrew M. Skinner, MD, Academy for Continued Healthcare Learning: Honoraria|American Society of Healthcare Pharmacists: Honoraria|Ferring Pharmaceuticals: Honoraria|MJH Life Sciences: Honoraria
711. High Prevalence of Positive Cell Cytotoxicity Neutralization Assay in Symptomatic and Asymptomatic Pediatric Oncologic Patients
Authors: Zhang David , Oram Ronda , Landry Meghan , Kumar Madan , Cherny Katie , Hillerbrand Addison , Kociolek Larry K , Davila Nathalia , Galvan Mariel , Knopoff Karyssa , Ansari Rasheed 
Published: November 2023

Abstract

Background
Clostridium difficile infection (CDI) is the most common cause of nosocomial diarrhea in the United States. This burden is more prevalent and severe in the oncologic population and is associated with greater morbidity and mortality. Diagnostic modalities are limited, and misdiagnosis is high with resultant mismanaged care – inappropriate antibiotics, and potentially missed opportunities for appropriate targeted care towards graft-versus-host disease or other etiologies. To date, no large-scale evaluations have been performed to characterize the incidence of true disease in this population or to help delineate predictive markers for true infections (cell cytotoxicity neutralization assay (CCNA) positivity).

Methods
This is a multi-center, prospective stool banking study from January 2020 to date enrolling pediatric patients with an oncologic diagnosis admitted at Advocate Children’s Hospital and Comer Children’s Hospital. Stool was collected weekly along with relevant clinical histories and symptomology. Isolates of C. difficile were cultured and CCNA performed. Stool was also collected during episodes of PCR diagnosed CDI.

Results
65 unique subjects were enrolled over 183 admissions. 11 samples from 10 patients were thought to represent CDI with PCR positivity noted. Five of these specimens were confirmed as CCNA positive while the remainder did not have active toxin presence. Bristol type 4 stools or &gt; 3 stools in 24 hours were significant factors for modeling CCNA positivity, but not for modeling PCR positivity. Notably 26 stool specimens were CCNA positive, and 21 did not have PCR tests done. Among all CCNA positive specimens, no significant difference was noted in symptomatology or antibiotic use.

Conclusion
Differentiating true CDI can be challenging. However, even in patients with high risk of alternative GI pathology, the frequency of stooling and stool characteristics can be used. Although considered the gold standard for assessment of disease, CCNA positivity in this population was noted in patients who were not evaluated for disease by their primary providers. Underdiagnosis is possible, but potentially less likely given the absence of clinically significant differentiation in symptoms. Host factors predisposing to disease are likely present.

Disclosures
Larry K. Kociolek, MD, MSCI, Merck: Grant/Research Support
717. Antimicrobial Resistance of Gram-Negative Bacteria in Respiratory Isolates from an Intensive Care Unit in Guatemala
Authors: Erdmenger Diego , Rodriguez Luis , Ochoa Fernando , Alfaro Andres , Portillo Carolina , de Leon Izabel , Valenzuela Laura 
Published: November 2023

Abstract

Background
Antimicrobial resistance (AMR) among Gram-negative bacteria (GNB) is a growing concern in public health, particularly in ICU settings. Over the past few decades, there has been a significant increase in ESBL and carbapenem resistance in Latin America, which has resulted in higher mortality rates and increased healthcare costs.
One way to understand local bacterial resistance profiles is to examine respiratory isolates, which can serve as a proxy for resistance observed in the clinical setting. It is critical for clinicians to be aware of these profiles in order to make informed decisions about treatment options.

Methods
A retrospective study was conducted on all respiratory isolates from the ICU of a third-level national hospital over a 6-month period. All respiratory isolates were analyzed for to identify microorganisms and their AMR to selected antibiotics, including Ceftriaxone (CRO), Ceftazidime (CAZ), Cefepime (CEF) and carbapenems.

Results
A total of 500 isolates were obtained during the study period, resulting in the isolation of 988 microorganisms. GNB represented 92.3% (n=912) of these isolates. Pseudomonas spp was the most common GNB identified (28.07%), followed by Acinetobacter (26.97%) and Klebsiella spp (20.94%).
Stenotrophomona isolates were excluded from the analysis as resistance profiling for this organism is not routinely performed in the institution, leaving a total of 868 isolates for AMR analysis.
A total of 527 GNB isolates (60.78%) were identified as resistant to both 3rd generation cephalosporines and CEF. Strains with this resistance pattern were considered highly suggestive of ESBL production. Moreover, 66.78% (n=579) of GNB’s analyzed evidenced resistance to carbapenems, with 13.61% (n=118) of strains having been identified as carbapenemase-producing bacteria.
Some GNB exhibited alarming levels of resistance as evidenced in table 1.Table 1.Resistance of selected GNBPercentage of bacterial strains from respiratory isolates resistant to selected antibiotics.

Conclusion
The high level or resistance observed in GNB from respiratory isolates in this study is concordant with other data from Latin America. While the prevalence of GNB in respiratory isolates does not necessarily correlates with clinical infection rates, the high level of resistance found may be an indicator of the AMR epidemiology of infections in this ICU.

Disclosures
All Authors: No reported disclosures
736. Risk Factors and Outcomes Associated with Daptomycin-nonsusceptible Enterococcus Bloodstream Infections
Authors: Failla Andrew J , Suleyman Geehan 
Published: November 2023

Abstract

Background
Enterococcus spp. are a common cause of nosocomial bloodstream infections (BSIs) with increasing resistance to currently available antibiotics and high mortality. Although the emergence of daptomycin-nonsusceptible Enterococcus (DNSE) has been reported, risk factors and outcomes associated with acquisition of daptomycin (DAP) resistance are not well characterized.

Methods
Retrospective cohort study of patients with enterococcal BSIs at Henry Ford Health in Southeast Michigan from 2014 to 2022. Cases included patients with DNSE; patients with persistent daptomycin (DAP)-susceptible Enterococcus (DSE) bacteremia ( &gt; 2 days of positive blood cultures) were used as controls. Outcomes included 30-day readmission and mortality.

Results
24 cases and 24 controls were included; median age was 67 years (IQR 59-72), 28 (58.3%) were male and 26 (54%) white. All patients were exposed to antibiotics within 90 days with no difference in DAP use between the two groups (8% vs 21%, p=0.220). The majority (90%) had prior hospitalization within the year, 44% were immune suppressed and 42% had end-stage renal disease. Hepatitis C virus (HCV) (17% vs 0, 0.037) and prior VRE (42% vs 21%, p &lt; 0.001) were more prevalent among cases. Indwelling urinary catheter (IUC) use was more common in cases (83% vs 54%, p=0.029), but there was no difference in central venous catheter use (75% vs 58%, p=0.221). Most common source of infection was intra-abdominal in both groups (54% vs 75%, p=0.188). Although not statistically significant, need for intensive care unit admission was higher (75% vs 50%, p=0.074) and length of stay was longer (54 vs 32 days, p=0.063) in cases compared to controls; treatment duration was significantly longer in controls (23 vs 16 days, p=0.04). There was no significant difference in readmission (12.5% vs 25%, p=0.267) or mortality (58% vs 46%, p=0.386) between the two groups.
Table 1
DNSE patient demographics, risk factors and outcomes

Conclusion
DNSE is an emerging pathogen associated with HCV, prior VRE and IUC use in our cohort; however, prior daptomycin exposure was not a significant risk factor for DNSE. Despite the high mortality, there was no difference in outcome between the two groups. Mechanism of DNSE in patients without prior DAP exposure should be explored to prevent potential spread of resistance.

Disclosures
All Authors: No reported disclosures
754. Utilization of Internal Special Program Review to Institute Change in an Academic ID Fellowship
Authors: Carey Adrienne , Pender Melissa , Cariello Paloma F 
Published: November 2023

Abstract

Background
Fellowship accreditation is crucial to ensure adequate clinical education for physicians in training, yet there is limited data on use of accreditation survey results for program quality improvement. The Accreditation Council for Graduate Medical Education (ACGME) administers annual surveys to trainees and core faculty to monitor education and identify potential non-compliance with ACGME accreditation standards. Our purpose is to describe the creation of an internal program review process for program improvement based on results of nationally implemented accreditation surveys.

Methods
We collected data from standardized ACGME survey responses administered to core faculty and fellows at our academic Infectious Diseases fellowship program. The identification of areas scoring lower than 20% in comparison with national average prompted creation of a Special Program Review (SPR) committee comprised of a program director, a program coordinator, and a trainee from programs outside of the program under review. This committee met separately with core faculty, trainees, and program leadership to compile an assessment of each survey component and opportunities for improvement. This review process of survey results was completed annually from 2020-2022.

Results
Between 2020-2022, surveys were completed by 100% of fellows (7/7 or 8/8) and up to 92% of core faculty (11/12). Key findings raised concerns involving clinical education, faculty supervision, patient safety, and teamwork. Actions taken in response to the SPR included the creation of: an updated backup and weekend coverage system, new didactic curricula, a morbidity and mortality conference, documentation limits, informal fellow/faculty dinners, opt out counseling, and a division culture committee.

Conclusion
A non-punitive internal review process mimicking accreditation standards is valuable for program assessment and improvement as means to identify areas of risk for accreditation issues at a national level. This review process is generalizable, as all accredited programs complete the survey annually. The quality improvement interventions taken will differ depending on survey findings and areas to be addressed.

Disclosures
All Authors: No reported disclosures