bluuebunny/crossref_metadata_2025_split huggingface dataset:
924. Reducing Rates of Hospital Acquired Clostridium Difficile Infection by Switching to Two-Step Testing
Authors: Barchuk Andriy , Dorobisz Monica , Oconnell Kathleen , Zainah Hadeel 
Published: December 2022

Abstract

Background
Clostridium difficile infection (CDI) tests have various degrees of sensitivity, making diagnosis challenging. Polymerase chain reaction (PCR) positive tests in colonized patients can impact rates of hospital-acquired CDI (HACDI). A negative toxin A/B enzyme immunoassay (EIA) as a second step can help determine colonization but is not as sensitive. We aimed to study the impact of a two-step testing strategy on rates of HACDI and CDI treatment outcomes.

Methods
Two-step testing consisted of C. difficle DNA PCR, which if positive, was followed by toxin A/B EIA (Figure 1). We conducted a retrospective study in a 359-bed hospital from March 2020 to July 2021. Patients with positive PCR and negative EIA results were included and further classified based on CDI treatment status. The primary outcome was the number of HACDI cases avoided. Secondary outcomes included location at the time of testing, symptoms, leukocytosis, discharge disposition and readmission.

Results
Ninety-six patients were included. Sixty-five patients (68%) were treated while 31 (32%) were not. HACDI was avoided in 18 cases (18.8%). There were more HACDI avoided in the non-treated group compared to the treated group (32.3% vs 12.3%; p=0.026). Most non-treated patients were tested on medical-surgical units (77.4%), whereas 49.2 % of the treated patients were tested in more acute areas such as emergency or intensive care. Treated patients were more likely to have leukocytosis and/or fever (66.2%) compared to non-treated patients (29%; p= 0.0009), while there was no difference in abdominal pain, diarrhea, bloody stool, or constipation (Table 1).
Most patients had an abdominal CT scan (70.8%). Of those that had a CT, colitis was found in 48.5%. Patients in the treated group were more likely to have had a CT completed that showed colitis vs the non-treated patients (43.1% vs 16.1%; p&lt; 0.011).
Finally, compared to the non-treated patients, treatment did not affect home disposition on discharge or 30-day readmission rate (80% vs 71%, P=0.436) and (25 % vs 29%, P= 0.63) respectively.
Symptoms Associated with C. difficile infection.
Schematic of C. difficile test interpretation.

Conclusion
CDI two-step testing led to decreased HACDI rates without affecting discharge disposition or readmission rates in patients with PCR positive and toxin EIA negative results regardless of treatment status.

Disclosures
All Authors: No reported disclosures.
925. Remdesperate for Stewardship: Impact of a Remdesivir Stewardship Strategy on the Care of Patients with COVID-19 Admitted to a Community Teaching Hospital
Authors: Hayes Jillian , Ghonim Ahmed , Wooten Leslie , Sippel-Tompkins Jenny , Herrera Victor , Carr Amy L 
Published: December 2022

Abstract

Background
The use of remdesivir (RDV) in patients hospitalized with COVID-19 has resulted in a significantly shorter time to recovery, especially in patients receiving low flow oxygen. Despite the shortened time to recovery, concerns have been raised regarding the $3,120 cost of a five-day course. This price was originally justified by the suggestion that RDV would save hospitals approximately $12,000 per patient by shortening hospital length of stay (LOS) by four days, however, this has not been consistently demonstrated in clinical practice. A preliminary review of RDV orders at our facility revealed hospital discharges were being delayed to complete a five-day course of treatment in patients otherwise medically ready to discharge.

Methods
This single-center, retrospective, comparative study was conducted at AdventHealth Orlando, a 1,368-bed community teaching hospital in central Florida. In January 2021, the campus stewardship committee devised a RDV stewardship strategy including targeted education and escalation of orders not meeting institutional criteria at time of order verification. This study compared pre-intervention patients who received RDV from December 1, 2020, to January 7, 2021, to post-intervention patients who received RDV from January 8, 2021, to February 28, 2022. The primary objective of this study was to assess the impact of a pharmacist-driven RDV stewardship initiative on the duration of therapy in hospitalized patients with COVID-19.

Results
A total of 2104 remdesivir orders were included in the study (209 pre-intervention and 1895 post-intervention). Overall, patients had a median age of 59 years and 49% were male. Majority of patients in both groups required low flow supplemental oxygen at the time of RDV initiation. Significantly more orders in the intervention group aligned with institutional criteria at the time of order entry (47% vs 84%, p&lt; .001). Patients completing the full 5-day course of remdesivir therapy decreased from 79 to 53% (p&lt; .001). A decreased duration of therapy and length of stay were observed in the intervention group.

Conclusion
Pharmacist-driven RDV stewardship increased adherence to the institutional algorithm and reduced duration of therapy.

Disclosures
Amy L. Carr, PharmD, BCIDP, Shionogi: Advisory Board.
935. Antibiotic Use (AU) Adjustment by Infection-Related Patient Volume Across a Health System
Authors: Spires Steven Shaefer , Dodds Ashley Elizabeth , Jones Travis M , Dyer April , Nelson Alicia , Anderson Deverick J , Johnson Melissa D , Zurawski Christine , Parker Todd , Moehring Rebekah W , Master Moiz , Diaz Melina , Corry-Wiggins Oida , Davis Angelina 
Published: December 2022

Abstract

Background
Benchmarking AU is important to identify opportunities and allocate resources within a health system. Patient level factors such as infection diagnosis codes further refine risk adjustments but have not been more widely adopted because of the burden of accurately collecting and submitting granular data. The goal of this study was to evaluate a novel metric to estimate facility-level infection burden as a potential factor to use in adjustment of AU.

Methods
We conducted a retrospective analysis of hospital administrative data (for calendar year 2020) from 8 hospitals in a single health system using a common electronic health record and coding department. We identified inpatient encounters with an infection-related primary ICD-10 code (I-PDX), based on the health system’s coding department determination and extracted the length of stay (LOS) for each encounter. For any encounter with an I-PDX, the entire LOS was classified as infection-related patient days (IPD). Overall AU in days of therapy (DOT) was adjusted using two novel infection diagnoses denominators. The first was based on proportion of total patient days (PD) attributable to I-PDX encounters (% I-PDX x PD). Since LOS tends to be longer in I-PDX, we also calculated DOT with adjustment for actual extracted IPDs. We then rank ordered study hospitals based on standard DOT / 1,000 PD, NHSN SAAR metrics, and our novel DOT / (% I-PDX x PD) and DOT / 1,000 IPD metrics.

Results
The proportion of I-PDX was highly variable among hospitals, with a system-wide median of 37.27% (range 23.48 - 43.32) (Figure 1). Using DOT / 1,000 patient days for 1 year, Hospital A was the lowest in the system and hospital H was the highest (Figure 2). However, after adjusting for the proportion of patients with I-PDX encounters and IPDs, hospital rank changed considerably, i.e. Hospital H and C respectively ranked lowest and Hospital A was highest.

Conclusion
These novel infection diagnoses PD denominators more closely associated facility level infection burden with AU, for a more refined rank order within the health system. These metrics provide an example of a parsimonious adjustment using patient level data that is already collected at any facility. Next steps might include indirect standardization using PDX categories and other patient level factors readily collected.

Disclosures
Melissa D. Johnson, PharmD, Charles River Laboratories: Grant/Research Support|Entasis: Honoraria|Merck: Grant/Research Support|Pfizer: Grant/Research Support|Scynexis: Grant/Research Support|Theratechnologies: Grant/Research Support|UpToDate: Honoraria Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties Angelina Davis, PharmD, M.S., Merck & Co.: Honoraria.
973. Clinical Outcomes and Resource Utilization in Children Who Develop Acute Kidney Injury Following Vancomycin Use for Treatment of MRSA Bacteremia and Acute Hematogenous Osteomyelitis
Authors: Challa Lasya , Challa Lasya , Ma Yuhan , Jo Chan-Hee , Copley Lawson Ashley 
Published: December 2022

Abstract

Background
Children with acute hematogenous osteomyelitis (AHO) and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia are often treated with vancomycin (vanc) with risk of nephrotoxicity. This study evaluates resources used, and outcomes, of children with or without acute kidney injury (AKI) when vanc is used in this setting.

Methods
Children with AHO and MRSA bacteremia treated with vanc from 2009 to 2019 were retrospectively studied. AKI was assessed by chart review, for clinical diagnosis and by Kidney Disease Improving Global Outcomes (KDIGO) criteria. Cohorts of children with or without KDIGO AKI were compared for differences of illness severity, treatment, resource utilization, and outcomes. Multivariate logistic regression analysis was accomplished to identify factors associated with risk for AKI. Cost analysis was performed using Pediatric Health Information System (PHIS) and Healthcare Cost and Utilization Project (HCUP) databases.

Results
Among 631 children with AHO, 85 children with MRSA bacteremia were treated with vanc for a sufficient duration to allow trough measurements. Of these, 14 (16.5%) had chart-diagnosed AKI, whereas 24 (28.2%) children met KDIGO criteria. Children with AKI had more febrile days and higher rates of thrombosis. They had longer duration of vanc treatment (8 vs 5 d) and higher troughs (27.8 vs 17.5 mg/L). The AKI group had more blood cultures, vanc troughs, creatinine levels, and longer length of stay (LOS; 19.9 vs 11.1 days). Multivariate analysis revealed that maximum vanc trough level (odds ratio 1.05) with a cutoff of 21.7 mg/L was a significant predictor of AKI.
PHIS data of 3,133 children with AHO treated with vanc identified 75 (2.4%) with AKI who had significantly longer LOS (13 vs 7 d) and higher billed charges ($117K vs $51K) than children without AKI. HCUP data of 13,223 children with AHO identified 384 (2.9%) with AKI who had longer LOS (27 vs 6 d) and higher billed charges ($317K vs $37K) than those without.

Conclusion
Clinical diagnosis of AKI (16.5%) grossly underestimated the KDIGO occurrence (28.2%) in our population. This study showed vanc associated AKI results in significant increases in resource utilization and healthcare costs. A high vanc trough &gt;21.7 mg/dL is a significant contributing factor to AKI.

Disclosures
All Authors: No reported disclosures.
974. Correlation of Magnetic Resonance Imaging (MRI) and Bone Histopathology in the Diagnosis of Foot Osteomyelitis in Diabetic Patients.
Authors: Mishra Abhay , Bamberger David , Cheng An-Lin , Steigerwalt Kristy 
Published: December 2022

Abstract

Background
Inaccurate diagnosis of osteomyelitis (OM) in the setting of foot infection may lead to inappropriate therapy. Recommended imaging to discern OM is magnetic resonance imaging (MRI), but studies have shown varied sensitivity and specificity. The goal of our study is to determine the accuracy of MRI by comparing with bone biopsy histopathology.

Methods
Retrospective chart review of adult patients with diabetes mellitus and foot infection with concern for OM. They had MRI with contrast and subsequent bone biopsy, resection or amputation with histologic examination. A second, blinded musculoskeletal radiologist reviewed all reports in which there was diagnostic uncertainty.
Exclusion criteria: foot tumor or recent foot surgery or injury.

Results
63 eligible patients with 87 episodes of foot infection (50 males, 13 females, mean age 55 years) met study criteria. Time gap between biopsy and MRI was mean 6 days (range 0 to 23 days). 72 MRIs were positive (including 7 highly suspicious MRI reads), 11 negative and 4 indeterminate. 53 of the histologic results were positive for OM and 34 were negative. Two scenarios were created by placing 4 indeterminate MRI reads as positive in scenario 1 and negative in scenario 2.
In scenario 1, there was only 1 false negative MRI but 24 false positives. In scenario 2, there were 2 false negative MRI and 21 false positives.
Out of 74 bone specimens of those not on recent antimicrobial therapy, bone cultures were positive for pathogenic organisms on 22 specimens without histologic evidence of OM.

Conclusion
In both the above scenarios, sensitivity was high. Specificity was found to be lower than the reported specificity of MRI in the diagnosis of diabetic foot OM, which has been reported as 40% to 100%. Our data demonstrate that MRI is useful to rule out OM if negative but performs poorly in ruling in OM. Bone specimen for histopathology is essential to confirm the diagnosis. Bone culture is helpful to guide antimicrobial therapy rather than diagnosing OM. Prospective studies are warranted.

Disclosures
All Authors: No reported disclosures.
977. Effect of Antibiotic Administration Prior to Bone Sample Obtainment on Bone Culture Yields in Diabetic Foot Osteomyelitis
Authors: Zmarlicka Monika , Bangart Ryan , Roth Bryan J , Quan Asia N , Bhattarai Bikash , Hartmann Carlos , Kassis Christelle 
Published: December 2022

Abstract

Background
Optimal timing of bone culture obtainment relative to antibiotic initiation in diabetic foot osteomyelitis is unknown. This study aims to determine whether antibiotic administration prior to bone sample collection affects microbiological yield.

Methods
This was a single-center retrospective study. Patients at least 18 years old admitted for diabetic foot osteomyelitis management were included. Patients included in the study had an evaluable bone sample and met the following criteria: presence of imaging demonstrating osteomyelitis, documentation of wound probing to bone, or visible bone in wound; plus an elevated erythrocyte sedimentation rate or elevated C-reactive protein. Patients included also received at least one dose of antibiotics during the hospitalization. Patients with necrotizing fasciitis and those who left against medical advice were excluded.

Results
One hundred and fifteen patients were included; 78 received antibiotics prior to bone sample obtainment (prior group), and 37 received antibiotics post sample obtainment (post group). Average time from admission to bone sample obtainment in the prior group was 1.8 ± 2.1 days and 1.1 ± 1.0 days in the post group. There was a non-significant difference in microbiological yields between the two groups (78.2% vs 75.7%, p = 0.762). Further examining the prior group, the average time between the antibiotic initiation and bone sample obtainment was not significantly different between those who had microbiological growth versus those who did not (2 ± 1.4 versus 1.6 ± 2.3 days [p = 0.0942]). Logistic regression analysis did not show association of microbiological yield with any of the following variables: peripheral vascular disease, end-stage renal disease, biopsy type (bedside vs open), type of osteomyelitis (acute vs chronic vs acute-on-chronic), antibiotic use prior to admission, or types of antibiotics administered.

Conclusion
Our data suggests that approximately two days of antibiotics prior to bone biopsy does not affect microbiological yield on cultures. Bone samples were obtained expeditiously within our cohort, which may account for the lack of difference seen. Further studies are needed to better define the duration of antibiotic therapy at which a difference in bone culture yields will be expected.

Disclosures
Asia N. Quan, PharmD, BCPS, BCCCP, Shionogi: Honoraria|Trevena: Honoraria Carlos Hartmann, MD, Viiv Pharmaceuticals: Speaker.
978. Effectiveness of oral cephalexin as completing treatment for bacteremic vertebral osteomyelitis caused by Methicillin-susceptible Staphylococcus aureus
Authors: Okumura Nobumasa , Hayakawa Kayoko , Yamamoto Kei , Yamada Gen , Mezaki Kazuhisa , Ohmagari Norio 
Published: December 2022

Abstract

Background
Methicillin-susceptible Staphylococcus aureus (MSSA) is the most common causative microorganism of pyogenic vertebral osteomyelitis (VO). Oral antimicrobial therapy with first-generation cephalosporins can treat MSSA infection, but data on pyogenic VO are scarce.

Methods
This retrospective study included adult patients treated with oral cephalexin as the completing treatment for pyogenic VO with bacteremia due to MSSA at the National Center for Global Health and Medicine Hospital, Japan from 2012 to 2020. Treatment effectiveness of cephalexin was evaluated by comparing the improvement in symptoms and laboratory and imaging results after intravenous (IV) administration of antimicrobial agents and after oral cephalexin treatment, using a 5-point scale (Table). A score of 4 or 5 indicated treatment success.

Results
This study included 15 patients (8 [53%] females), with median age 75 years (interquartile range [IQR], 67.5–80.5), median body weight 57.0 kg (IQR, 45.5–62.5), and median Charlson comorbidity index score 2 (IQR, 0–4). Ten patients (67%) had lesions in the lumbar spine. Six patients had lesions at multiple sites (cervical and thoracic, n=1; cervical and lumbar, n=2; thoracic and lumbar, n=1; and lumbar and sacral, n=2). Twelve patients (80%) had spinal abscesses and four (27%) had remote abscesses, but none had concomitant endocarditis. In 11 patients with normal renal function, 1,500–2,000 mg/day of cephalexin was administered. Surgical intervention was performed in five cases (33%). The median duration of IV antibiotics, cephalexin, and total treatment was 36 (IQR, 32–61; range, 21–86), 29 (IQR, 19–82; range, 8–251), and 86 (IQR, 59–125; range, 37–337) days, respectively. Majority patients (≥80%) received either cefazolin or ceftriaxone as IV therapy. Two patients used oral antimicrobials other than cephalexin outside of the cephalexin treatment period. Treatment success rate after cephalexin therapy was 87%. None of the patients had recurrence during a median follow-up of 119 days (IQR, 48.5-350).

Conclusion
In patients with bacteremic VO due to MSSA, completing treatment with cephalexin is a reasonable option, even in cases with spinal abscess, if at least 3 weeks of effective IV antimicrobial therapy is provided.

Disclosures
All Authors: No reported disclosures.
982. Microbiologic Composition and Failure Rates of Prosthetic Hip and Knee Infections Managed with Debridement, Antibiotics and Implant Retention.
Authors: DeBiase Joseph M , Day Shandra R , Smith Jessica M , Agnello Sydney 
Published: December 2022

Abstract

Background
Success rates of prosthetic joint infections (PJI) managed by debridement, antibiotics, and implant retention (DAIR) vary according to recent literature. Our aim is to evaluate the success/failure rate of PJI managed by DAIR with respect to the microbiologic composition, antimicrobial selection, and treatment duration.

Methods
A single-center retrospective cross-sectional study was conducted from January 2017 to December 2021. All patients ≥ 18 years of age who underwent DAIR were identified from an existing internal database. Patients were included if they received at least 3 weeks but no more than 8 weeks of parenteral therapy with or without consolidative or chronic therapy. Data collection was completed via chart review including demographics, microbiologic data, antimicrobial therapy and outcomes. Failure was defined as any subsequent need for surgical intervention, infection related mortality, persistent infection, new infection, or probable treatment failure measured at a minimum of two year follow up from index DAIR.

Results
A total of 49 patients were included (15 hip, 34 knee) with 21 failures (43%) and 28 in remission (57%). Table 1 shows the breakdown of cases including time to PJI from index procedure, duration of symptoms prior to DAIR procedure, chronic antibiotics, and microbiologic composition. DAIR procedure occurred &lt; 3 weeks from onset of symptoms in 43 patients (88%) but no observed difference in outcomes was seen based on patient’s time to PJI or symptoms duration. Staphylococcus aureus was the most common pathogen identified, n=14 (29%) and encompassed 43% of the total failures. Mean antimicrobial therapy was 42 and 180 days for parenteral and oral respectively with 17 (35%) patients on chronic/indefinite therapy. Of the failures, 48% occurred while on parenteral therapy. Need for further surgical intervention was the leading cause of failure at 37%.

Conclusion
Despite early intervention, our study found a failure rate of 43% in patients with knee and hip PJI managed with DAIR. We observed similar success rates across multiple organisms and antimicrobial treatments. Further evaluation of failure cases would help to inform which patients are the best candidates for DAIR procedures.

Disclosures
All Authors: No reported disclosures.
986. Pseudomonas Prosthetic Joint Infections: Is there a role for monotherapy?
Authors: Kim Billy I , Schwartz Andrew , Wixted Colleen M , Prado Isabel P , Polascik Breanna , Hendershot Edward F , Jiranek William A , Seidelman Jessica , Seyler Thorsten M 
Published: December 2022

Abstract

Background
Pseudomonas species are a less common but devastating pathogen family in prosthetic joint infections (PJI). Despite advancements in management, Pseudomonas PJI remains particularly difficult to treat due to fewer antibiotic options and robust biofilm formation. The purpose of this study was to better evaluate outcomes after Pseudomonas PJI treatment.

Methods
All hip or knee PJIs, at a single institution, with positive Pseudomonas culture were analyzed. 51 patients (29 hips and 22 knees) meeting inclusion criteria were identified. The primary outcome of interest was infection clearance at 1-year after surgical treatment, defined as reassuring aspirate without ongoing antibiotic treatment or death within one year post-operatively. Monomicrobial and polymicrobial infections were evaluated separately.

Results
Among monomicrobial PJIs, ten (50.0%) patients were clear of infection at one year post-operatively. Patients treated with 2-stage exchange (n=11) had a 1-year clearance rate of 54.5% compared to 60.0% with DAIR (n=5) and 25.0% with resection or amputation (n=4). Two of six patients treated with fluoroquinolone monotherapy met 1-year infection clearance, despite fluoroquinolone sensitivity, compared to four of five patients meeting 1-year clearance when treated with combined intravenous and oral therapy for at least 6 weeks. Resistance to anti-pseudomonal agents was infrequent (20%, n=4/20), and three of ten mono- and polymicrobial PJI patients with recurrent Pseudomonas PJI developed resistance to anti-pseudomonal therapy. Polymicrobial infections were the most common presentation (54.9%) of Pseudomonas positive PJI with a mortality rate of 46.4% (n=13/28) at a median follow-up of 4.2 years [IQR: 3.4-5.7].

Conclusion
Despite surgical and antibiotic treatment regimens consistent with traditional treatment algorithms, our data portrays poor clearance rate of Pseudomonas PJI with relatively poor outcomes in patients treated with oral or intravenous monotherapy. Pseudomonas infections are difficult to eradicate and likely require deviations from classical therapeutic protocols to improve treatment success.

Disclosures
William A. Jiranek, MD, Biomech Holdings LLC: Stocks/Bonds|DePuy, A Johnson & Johnson Company: IP royalties Thorsten M. Seyler, MD, PhD, Heraeus: Paid consultant|Pattern Health: IP royalties|Restor3d: IP royalties|Smith & Nephew: Paid consultant|Total Joint Orthopedics: Paid consultant|Zimmer: research.