bluuebunny/crossref_metadata_2025_split huggingface dataset:
388. Does This Patient Have C. difficile Infection? A Systematic Review and Meta-Analysis
Authors: Manzoor Fizza , Manzoor Saba , Pinto Ruxandra , Brown Kevin , Langford Bradley J , Daneman Nick 
Published: December 2022

Abstract

Background
The clinical features of Clostridioides difficile infection overlap with many conditions. Accurate and early diagnosis of C. difficile is essential for reducing morbidity and mortality. We performed a systematic review to evaluate the diagnostic utility of clinical findings associated with C. difficile.

Methods
We included all studies that reported clinical features of C. difficile, a valid reference standard test for confirming diagnosis of C. difficile, and a comparison among patients with a positive and negative test result. The MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched up to September 2021. Meta-analyses using univariate and bivariate methods were used to determine estimates of sensitivity, specificity, and likelihood ratios (LRs).

Results
A total of 11,231 articles were screened and 46 were included for final analysis, enabling evaluation of 67 features for their diagnostic utility for C. difficile (10 clinical examination findings, 4 laboratory tests, 10 radiographic findings, prior exposure to 14 antibiotic types, and 29 clinical risk factors). Of the ten features identified on clinical examination, none were associated with increased likelihood of C. difficile infection. Features that increased likelihood of C. difficileinfection were stool leukocytes (LR 5.31, 95% CI 3.29-8.56), hospital admission in prior three months (LR 2.39, 95% CI 1.68-3.30), leukocytosis (LR 1.50, 95% CI 1.24-1.75), and low serum albumin (LR 1.43, 95% CI 1.06-1.97). Some clinical co-morbidities increased likelihood of C. difficile including congestive heart failure (LR 3.01, 95% CI 2.26-3.80) and end-stage renal disease (LR 3.85, 95% CI 1.73-7.57). Several radiographic findings also strongly increased the likelihood of C. difficile infection like pericolonic stranding (LR 10.72, 95% CI 9.59-11.84) and ascites (LR 2.91, 95% CI 1.76-4.80).

Conclusion
There is limited utility of bedside clinical examination alone in detecting or ruling out C. difficile infection. Accurate diagnosis of C. difficile infection requires a combination of thoughtful clinical assessment and interpretation of test results. However, microbiologic testing is needed for confirmation in all suspected cases.

Disclosures
All Authors: No reported disclosures.
396. Incidence and Attributable Mortality of Clostridioides difficile Infection Among US Adults 18-64 Years of Age
Authors: Yu Holly , Alfred Tamuno , Zhou Jingying , Judy Jennifer , Olsen Margaret A A 
Published: December 2022

Abstract

Background
Studies characterizing the burden of Clostridioides difficile infection (CDI) have largely focused on older adults, with limited data among those &lt; 65 years of age insured under commercial plans.

Methods
This retrospective cohort study from 2012–2020 used Optum’s de-identified Clinformatics® Data Mart of about 42 million commercially insured persons. CDI was defined by ICD9/ICD10 diagnosis codes or a combination of CDI diagnosis/testing with antibiotic receipt; cases occurring ≤60 days after prior CDI occurrences were excluded. Annual CDI incidence was evaluated among individuals who were 18–64 years old and enrolled in an Optum commercial plan by January 1 of the corresponding year. Mortality was evaluated in persons with CDI from 2016–2018 who were continuously enrolled in the database for ≥12 months prior; follow-up occurred through the earliest of 12 months, disenrollment, or death. To assess CDI-attributable mortality, CDI+ cases were matched 1:1 to CDI– controls by the propensity score for CDI. Mortality was stratified by age group, acquisition type, and hospitalization status.

Results
CDI incidence was generally stable from 2012–2016 (217–220 and 112–118 episodes per 100,000 person-years (PY) in the 50–64- and 18–49-year age groups, respectively) before decreasing gradually between 2016 and 2020 to 139 episodes per 100,000 PY (50–64-year age group) and to 66 episodes per 100,000 PY (18–49-year age group) (Figure 1). In the 50–64-year age group, CDI-attributable mortality increased to 2.2% at 12 months (CDI+, 4.2%; CDI−, 2.0%), with larger attributable differences observed among hospitalized (healthcare associated [HA], 18.1%; community associated [CA], 7.0%) vs nonhospitalized (HA, 3.3%; CA, −0.1%) patients (Figure 2). The CDI-attributable mortality rate of 0.6% at 12 months among the 18–49-year age group was lower than that in the 50–64-year age group but trended similarly (CDI+, 1.2%; CDI−, 0.6%).

Conclusion
As reported previously, both CDI incidence and attributable mortality among US individuals 18–64 years increased with age. Identifying high-risk groups among non-elderly adults is warranted to develop better strategies for effective prevention.
Funded by Pfizer Inc.

Disclosures
Holly Yu, MSPH, Pfizer Inc: Employee|Pfizer Inc: Stocks/Bonds Tamuno Alfred, PhD, Pfizer Inc: Employee|Pfizer Inc: Stocks/Bonds Jingying Zhou, MA, Pfizer Inc: Employee|Pfizer Inc: Stocks/Bonds Jennifer Judy, MS, PhD, Pfizer Inc: Employee|Pfizer Inc: Stocks/Bonds Margaret A A. Olsen, PhD, MPH, Pfizer Inc: Advisor/Consultant|Pfizer Inc: Grant/Research Support.
411. Characterization of Antibiotic Prophylaxis Prior to Trans Rectal Ultrasound Guided Prostate Needle Biopsy (TRUS PNB): A 5-Year Nationwide Study among Patients in the United States Veterans Health Administration
Authors: Issa Jamil Abou , Saroufim Paola , Saade Elie , Donskey Curtis 
Published: December 2022

Abstract

Background
Prophylactic antibiotics are used prior to TRUS PNB to reduce risk for infectious complications such as UTI, prostatitis, epididymitis, orchitis, bacteremia and sepsis. Fluoroquinolones have been commonly used for prophylaxis, however, the incidence of post TRUS PNB infections caused by fluoroquinolone resistant Escherichia coli has increased. The purpose of this study was to characterize the prophylaxis agents used nationwide in the Veterans Health Administration (VHA) prior to TRUS PNB.

Methods
We conducted a review of records of all patients undergoing TRUS PNB in the VHA database from January 1st, 2013 to December 31st, 2018. We collected data about outpatient oral prophylaxis antibiotics, inpatient injectable antibiotics and microbiology results from rectal swabs and urine cultures performed within 90 days prior to the procedure.

Results
Of 153,055 patients undergoing prostate biopsy between January 1st, 2013 and December 31st, 2018, 27.6% (n=42,319) had urine cultures and 3.9% (n=5,294) had rectal swab cultures done within the 90-day window prior to the procedure. Among these who had urine and rectal swabs culture, 3.0% (n=1,292) and 20.1% (n=1,062) were positive for E. coli, respectively; 40.2% of E. coli isolates recovered from urine and 89.6% recovered from rectal swabs were resistant to fluoroquinolones. Table 1 shows the frequencies and percentages of oral prophylactic agents administered within the 90 days prior to the procedure and injectable antibiotics administered on the day of the procedure.
Frequency and percentage of oral prophylactic agents administered within the 90 days prior to the procedure and injectable antibiotics administered on the day of the procedure
Frequency and percentage of oral prophylactic agents administered within the 90 days prior to the procedure and injectable antibiotics administered on the day of the procedure

Conclusion
Despite the high rate of recovery of fluoroquinolone-resistant E. coli in pre-procedure urine and rectal swabs, oral fluoroquinolones remained the most frequently used prophylactic agents prior to TRUS PNB. This inadequate prophylactic coverage may increase the risk of infectious complications following prostate biopsy.

Disclosures
Elie Saade, MD, MPH, FIDSA, Janssen: Advisor/Consultant.
414. Detection of Colonized Patients with Organisms Resistant to Carbapenems by a Fast Molecular Method at a Hospital in Nicaragua.
Authors: López-Navarro Jilmer , Porras-Cortés Guillermo D 
Published: December 2022

Abstract

Background
The resistance to carbapenems has significant implications regard the clinical outcomes of the patients. Strategies to detect colonized patients with carbapenems-resistant organisms are useful to start isolation measures to prevent intrahospital transmission. GeneXpert Carba-R is a fast molecular test to detect rectal colonization by this type of microorganisms. The aim of this study was to detect colonized patients transferred from other countrywide hospitals in Nicaragua, to have an epidemiological panorama of the circulation of genes that confers resistance to carbapenems.

Methods
This is a retrospective cohort study in a referral hospital (Hospital Dr. Fernando Vélez Paiz) in Managua, Nicaragua. The period of the study was between January 2020 and October 2020. Patients referred to our ICU that had been stayed more than 48 hours in the originating health-care center were recruited. Rectal swab were processed by GeneXpert Carba-R to identify any of the genes of resistance (NDM, KPC, VIM, IMP, OXA-48). An association between colonization and clinical outcomes was evaluated.

Results
Eighty-nine patients were included in the study and 27 (30.3%) of them had a positive test of Xpert Carba-R. In four patients more than one gene was detected. The most frequent gene detected was NDM (66.6%). Other detected genes were VIM and KPC. Patients colonized with this kind of microorganims were identified coming from 9 countrywide hospitals and from 6 hospitals of the capital city (Managua). Independent risk factors for colonization by organisms resistant to carbapenems were previous exposition to this class of antibiotic (OR: 9.82; CI95%: 3.29-29.30) and qSOFA ≥ 2 points at the admission (OR: 7.36; CI95%: 2.60-20.76). The mortality in the colonized patients was 33.3% vs 9.6% in the control group (p=0.006), with an odds ratio of 4.6 (CI95%: 1.46-14.90).
Map of Nicaragua showing the wide distribution of the detection of genes conferring resistance to carbapenems in patients referred to Hospital Dr. Fernando Vélez Paiz in the capital city of Managua.

Conclusion
The prevalence of rectal colonization by organisms resistant to carbapenems in patients transferred to a referral hospital in Nicaragua is high. The most frequent gene detected was NDM. There are presence of these genes in countrywide hospitals. The previous use of carbapenems and the severity of the illness at the admission were risk factors for colonization. To be colonized with this microorganism increased the risk to die.

Disclosures
All Authors: No reported disclosures.
417. Factors associated with 30-day Mortality in Carbapenems-resistant Enterobacteriaceae Infections
Authors: Osaithai Naphol , Meesing Atibordee , So-Ngern Apichart 
Published: December 2022

Abstract

Background
Carbapenem-resistant Enterobacteriaceae (CRE) infections are the serious conditions and provide high mortality. The studies of risk factors of death in CRE infection have been limited particularly in our center. Hence, the study was conducted for evaluating mortality and factors associated with CRE infection.

Methods
A retrospective cohort study was conducted between January 1st, 2015, and December 31st, 2019 in sigle center medical university. All patients diagnosed CRE infections who aged ≥ 18 years were included and reviewed. The multivariate logistic regression was used for evaluating the factors associated with 30-day mortality.

Results
Ninety-three patients enrolled in the study. The 30-day mortality occurred in thirty-five patients (37.6%). The non-survive patients had significantly higher simplified acute physiology (SAP) II score, sepsis at the time of diagnosis, and pneumonia (p&lt; 0.05) than survive patients. The most common pathogen was Klebsiella pneumoniae, Escherichia coli and Enterobacter spp. The most common CRE isolates were susceptible to fosfomycin, tigecycline, and colistin (96.7%, 95.7%, 90.3%, respectively). The independent factors associated with 30-day mortality were having simplified acute physiology (SAP) II score &gt; 30 [adjusted odds ratio (aOR) of 12.98 (95% confidence interval (CI), 2.84-59.34, p=0.001)], sepsis at the time of diagnosis [aOR of 4.77 (CI 1.19-19.20, p=0.03)], pneumonia [aOR of 4.64 (CI 1.31-16.47, p=0.01)], and improper empiric antibiotic [aOR of 7.83 (CI 1.84-33.37, p=0.01)].

Conclusion
The mortality of CRE infections were high. The factors associated with 30-day mortality were having SAP II score &gt; 30, sepsis at the time of diagnosis, pneumonia, and improper empiric antibiotic.

Disclosures
All Authors: No reported disclosures.
425. Spread of Carbapenem-resistant Enterobacteriaceae in Intensive Care Unit and effective preventative strategies: Agent-based model study
Authors: Baek Yae Jee , Cho Nathan , Kim Chansoo , Lee Jeehyun , Choi Jun Yong 
Published: December 2022

Abstract

Background
Carbaepenem-resistant Enterbacteriaceae (CRE) could propagate through person-to-person contacts such as contaminated hands of staff, contamination of the environment, or the use of contaminated medical equipment by spreading carbapenemase encoded in plasmid and cause healthcare associated infections (HAIs). Critically ill patients in a compact space of Intensive care unit (ICU) are at significantly high risk of CRE infection, which should be protected by effective infection control strategies. Agent-based model (ABM) has been employed to examine the spread of infectious organisms and estimate the impact of intervention as it reflects behaviors of heterogeneous individuals. We aimed to create an ABM reflecting the medical ICU and identify preventative strategies to reduce CRE infection in the ICU.

Methods
The blueprint of the medical ICU in a tertiary hospital in Republic of Korea was obtained. Researchers had a meeting with the head staffs to get information about healthcare workers (HCWs), patients, and the spatial unit. In this unit, HCWs visiting a patient in ICU are required to wash their hands and wear personal protective equipment. We did a survey to collect data of the routes and the handwashing rates of HCWs. An ABM was made using Python’s Mesa library which simulates the situation in the ICU and the status of CRE. Figure 1.(A) Blueprint of ICU in Severance Hospital, (B) Simulated ICU in agent-based modelFigure 2.Dynamics between agents and environment

Results
Medical ICU consists of two units, and each unit holds fifteen beds. Five nurses work in each unit and six doctors and three technicians take rounds daily, contacting patients in the ICU. The dynamics among agents and environment were constructed.. Parameters were set up from the real world data or the clinical studies. At any given moment, there are about 2.5 patients infected with CRE, and transmission probability and isolation factors were calibrated according to this target. Interventions were enhanced environment cleansing, handwashing of HCWs, and prompt isolation of infected patients through tests and actions. We found those interventions effectively reduced HAIs, and combining effects lead to better results. Figure 3.Parameters and variables in agend-based modelFigure 4.Healthcare associated infections in study periods according to (A) interval of clensing environment, (B) handwashing of HCWs, (C) isolation of infected patients, (D) combined of environmental cleansing and patient isolation

Conclusion
Increasing handwashing rates, environment cleansing, and prompt isolation of infected patients have drastic effects of reducing HAIs caused by CRE in this model, and bundle approach should be considered to prevent the spread of CRE.

Disclosures
All Authors: No reported disclosures.
433. COVID-19 Vaccination Uptake Among Health Care Workers (HCW) Requesting Medical Exemptions to Vaccination.
Authors: Shaw Jana , Brown Loren , Thomas Stephen J , Cleary Lynn M , Bagatell Jarrod 
Published: December 2022

Abstract

Background
New York State adopted a COVID-19 vaccination requirement for all healthcare workers in September 2021, but they allowed medical exemptions. We examined reasons and frequency of medical exemption requests in an academic medical center.

Methods
We conducted active surveillance of all medical exemption requests in a tertiary care academic center in Central NY. Age, gender, reason for request, prior acceptance of other required vaccines, letter of support from employee provider, adjudication of the request, and impact of the decision on COVID-19 vaccine acceptance were collected prospectively since the mandate became effective.

Results
Among 8,776 HCWs, 108 requested medical exemptions, among those 57 (53%) were denied, 39 (36%) were granted temporary exemption, and 12 (11%) were permanent (Table). Females were more likely to request medical exemptions compared to males, 92 (85%) versus 16 (15%), respectively. Overall, 94 (87%) of the HCWs had a letter from their provider in support of their exemption. Nevertheless, only 47% of those qualified for permanent or temporary exemption using CDC guidelines. The most common reasons for requesting exemption included: having natural immunity, receiving monoclonal antibodies, experiencing a common reaction to previous COVID-19 vaccination, and having an underlying medical condition (Figure 1). The majority of individuals who had a request denied or who received a temporary medical exemption were subsequently vaccinated, 63% and 79%, respectively (Figure 2).
Demographic and other characteristics among health care workers (HCW) requesting medical exemptions. Table
Reasons for requesting medical exemption from COVID-19 vaccination requirement by request determination. Figure 1
COVID-19 vaccine uptake among health care workers (HCW) requesting medical exemptions to COVID-19 vaccination. *One HCW received alternative COVID-19 vaccine. Figure 2

Conclusion
Females were more likely to request a medical exemption to vaccination and their requests were often supported by their providers. Future efforts should focus on educating both health care providers and the public about actual medical contraindications or precautions to vaccination to improve overall vaccination rates.

Disclosures
Jana Shaw, MD,MS,MPH, Pfizer: Advisor/Consultant Stephen J. Thomas, MD, Clover: case adjudication committee (compensated for time)|EdJen: Advisor/Consultant|Icosavax: data monitoring (compensated for time)|Island Pharma: Ownership Interest|Merck: Advisor/Consultant|Moderna: chair, safety monitoring committee (compensated for time)|New Day Diagnostics: Honoraria|Pfizer: Advisor/Consultant|PrimeVax: Ownership Interest|Sanofi Pasteur: Advisor/Consultant|Takeda: Advisor/Consultant|Takeda: case adjudication committee (compensated for time)|Vaxxinity: data monitoring committee (compensated for time).
467. Antifungal Therapy in Candida Intra-abdominal Infections Following Source Control
Authors: Buck Margaret , Carr Dustin R , Bremmer Derek N , Jenniches Daniel , Babowice James , Chung Eunice L 
Published: December 2022

Abstract

Background
Current literature suggests that many surgical patients with Candida isolated from an intra-abdominal source do not develop symptomatic infections, however, Infectious Disease Society of America (IDSA) Guidelines recommend antifungal treatment in Candida intra-abdominal infections. An article published by Fabre et al found similar incidence of treatment failure between patients appropriately treated for Enterococcus intra-abdominal infections compared to patients without Enterococcus coverage following source control. Enterococcus and Candida are both low-virulent microorganisms, questioning the necessity of antifungal therapy following source control in Candida intra-abdominal infections.

Methods
This was a retrospective, cohort study of adult patients with intra-abdominal infections who underwent source control and isolation of Candida in intra-abdominal cultures. Eligible patients were separated based on receipt of antifungals. Patients were excluded if they received between 24 hours and 3 days of antifungal therapy, had candidemia prior to intervention, or received prophylactic or therapeutic antifungals within 7 days of intervention. The antifungal group and non-antifungal group were assessed for incidence of treatment failure, defined as death or additional unplanned surgical or antimicrobial interventions for intra-abdominal infections.

Results
A total of 125 patients were included with 77 patients (61.6%) receiving antifungal therapy and 48 patients (38.4%) not receiving antifungal therapy. Patients who received antifungal therapy had a higher median SAPS II score (29 vs 22.5; p = 0.003). There was no difference in the incidence of treatment failure at 30 days between the antifungal and non-antifungal groups (41.6% and 35.2%, respectively; p = 0.62). Median hospital length of stay (14 vs 8.5 days; p &lt; 0.001) and median total duration of antimicrobial therapy (10 vs 7 days; p = 0.667) was longer in the antifungal group compared to the non-antifungal group, respectively.

Conclusion
Patients with Candida intra-abdominal infections that underwent source control had a similar rate of treatment failure at 30 days regardless of receipt of antifungal therapy. However, those who received antifungal therapy had a higher severity of illness.

Disclosures
Dustin R. Carr, PharmD, BCPS, BCIDP, Merck: Honoraria Derek N. Bremmer, PharmD, BCPS-AQ ID, Thermo Fisher Scientific: Honoraria.
479. Predisposing factors and outcomes of infections due to rare yeasts: a study from an apex medical center in India (2018-2020).
Authors: Singh Gagandeep , Xess Immaculata , Chowdhury Souradeep , Soneja Manish , Sachdev Janya , Iram Azka 
Published: December 2022

Abstract

Background
Fungi are ubiquitous in the environment, and for patients with risk factors, they can present as pathogens. Unusual fungi often pose a diagnostic challenge and when encountered in practice, albeit infrequently, can delay diagnosis and treatment.

Methods
Over a period of three years (2018-2020), such cases were followed up till death or discharge and all details were noted down. All patients were diagnosed to have invasive fungal disease according to the EORTC/MSG criteria. Species identification was performed using MALDI-TOF MS and antifungal susceptibility testing (AFST) was done using standard CLSI guidelines.

Results
A total of 14 cases of rare yeasts were noted out of a total of 155 infections due to yeasts. Among these 5 presented with fungemia and 9 with invasive fungal infections (IFI). Of the IFI clinical isolates, there were 2 pus samples and 7 sterile fluids. The majority of these 14 patients were male (11) and belonged to extremes of age (8). The risk factors included CKD (2), prior history of tuberculosis (2), CLD (1), congenital heart disease (2), and type 2 diabetes mellitus (1). Pathogens isolated were Candida guilliermondii (2), Candida pelliculosa (2), Lodderomyces elongisporus (1) from the blood samples, and Trichosporon asahii (6), Candida guilliermondii (1), Candida kefyr (1), and Geotrichum spp. (1) from the other samples. Certain Candida species showed higher MICs to azoles and echinocandins. Trichosporon and Geotrichum showed higher MICs to azoles.
Unfortunately, half of the patients (7) received no antifungals. Of those who did, 4 received mono therapy with azoles or Amphotericin B, while other 3 received combination or sequential therapy with azoles, echinocandins and Amphotericin B. Of the 14 patients, 3 patients expired. The etiological agents in these cases were Candida pelliculosa (fungemia) and Trichosporon asahii (IFI, 2 cases).

Conclusion
This study aims to highlight the clinical presentation of uncommon yeasts, presenting both as bloodstream infections (BSI) and as invasive disease. Improved methods of detection will help us improve our diagnostic accuracy of uncommon pathogens. The clinician should liaise closely with the laboratory, and treatment should be instituted according to the AFST data.

Disclosures
All Authors: No reported disclosures.