Epidemiological approaches to multivariable models of health inequity: A study of race, rurality, and occupation during the COVID-19 pandemic

PURPOSE

Methods for assessing the structural mechanisms of health inequity are not well established. This study applies a phased approach to modeling racial, occupational, and rural disparities on the county level.

METHODS

Rural counties with disparately high rates of COVID-19 incidence or mortality were randomly paired with in-state control counties with the same rural-urban continuum code. Analysis was restricted to the first six months of the pandemic to represent the baseline structural reserves for each county and reduce biases related to the disruption of these reserves over time. Conditional logistic regression was applied in two phases-first, to examine the demographic distribution of disparities and then, to examine the relationships between these disparities and county-level social and structural reserves.

RESULTS

In over 200 rural county pairs (205 for incidence, 209 for mortality), disparities were associated with structural variables representing economic factors, healthcare infrastructure, and local industry. Modeling results were sensitive to assumptions about the relationships between race and other social and structural variables measured at the county level, particularly in models intended to reflect effect modification or mediation.

CONCLUSIONS

Multivariable modeling of health disparities should reflect the social and structural mechanisms of inequity and anticipate interventions that can advance equity.

Insights into Treatment Alternatives for Neurosyphilis: Systematic Literature Review and Meta-Analysis

ABSTRACT

We conducted a systematic literature review and meta-analysis to assess the efficacy of alternative treatments for neurosyphilis. We searched MEDLINE, CINAHL, Embase, Cochrane, Scopus, and Web of Science from database inception to September, 2023, for studies in neurosyphilis that compared penicillin monotherapy to other treatments. We focused on the impact of these therapies on treatment response, but also assessed data regarding reinfection and adverse drug events. Random-effect models were used to obtain pooled mean differences. Of 3,415 screened studies, six met the inclusion criteria for the systematic literature review. Three studies provided quantitative data that allowed for inclusion in the meta-analysis. Our analysis revealed that the efficacy of intravenous ceftriaxone 2 g daily for 10 days (51 patients) did not appear statistically different compared to intravenous penicillin G 18-24 million units daily for 10 days (185 patients) for neurosyphilis (pooled OR, 2.85; 95% CI, 0.41-19.56; I2 = 49%). No statistical difference between ceftriaxone and penicillin was identified in people living with HIV (pooled OR, 4.51; 95% CI, 0.50-40.49; I2 = 34%). We concluded that alternative therapy with IV ceftriaxone appears similar to penicillin, potentially expanding treatment options for neurosyphilis. Other treatment options including doxycycline warrant further study.

The effectiveness of the COVID-19 vaccines in the prevention of post-COVID conditions in children and adolescents: a systematic literature review and meta-analysis

Objective

We performed a systematic literature review and meta-analysis on the effectiveness of coronavirus disease 2019 (COVID-19) vaccination against post-COVID conditions (long COVID) in the pediatric population.

Design

Systematic literature review/meta-analysis.

Methods

We searched PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science from December 1, 2019, to August 14, 2023, for studies evaluating the COVID-19 vaccine effectiveness against post-COVID conditions among vaccinated individuals < 21 years old who received at least 1 dose of COVID-19 vaccine. A post-COVID condition was defined as any symptom that was present 4 or more weeks after COVID-19 infection. We calculated the pooled diagnostic odds ratio (DOR) (95% CI) for post-COVID conditions between vaccinated and unvaccinated individuals.

Results

Eight studies with 23,995 individuals evaluated the effect of vaccination on post-COVID conditions, of which 5 observational studies were included in the meta-analysis. The prevalence of children who did not receive COVID-19 vaccines ranged from 65% to 97%. The pooled prevalence of post-COVID conditions was 21.3% among those unvaccinated and 20.3% among those vaccinated at least once. The pooled DOR for post-COVID conditions among individuals vaccinated with at least 1 dose and those vaccinated with 2 doses were 1.07 (95% CI, 0.77-1.49) and 0.82 (95% CI, 0.63-1.08), respectively.

Conclusions

A significant proportion of children and adolescents were unvaccinated, and the prevalence of post-COVID conditions was higher than reported in adults. While vaccination did not appear protective, conclusions were limited by the lack of randomized trials and selection bias inherent in observational studies.

Syphilis Treatment: Systematic Review and Meta-Analysis Investigating Nonpenicillin Therapeutic Strategies

Background

Penicillin's long-standing role as the reference standard in syphilis treatment has led to global reliance. However, this dependence presents challenges, prompting the need for alternative strategies. We performed a systematic literature review and meta-analysis to evaluate the efficacy of these alternative treatments against nonneurological syphilis.

Methods

We searched MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane, Scopus, and Web of Science from database inception to 28 August 2023, and we included studies that compared penicillin or amoxicillin monotherapy to other treatments for the management of nonneurological syphilis. Our primary outcome was serological cure rates. Random-effect models were used to obtain pooled mean differences, and heterogeneity was assessed using the I2 test.

Results

Of 6478 screened studies, 27 met the inclusion criteria, summing 6710 patients. The studies were considerably homogeneous, and stratified analyses considering each alternative treatment separately revealed that penicillin monotherapy did not outperform ceftriaxone (pooled odds ratio, 1.66 [95% confidence interval, .97-2.84]; I2 = 0%), azithromycin (0.92; [.73-1.18]; I2 = 0%), or doxycycline (0.82 [.61-1.10]; I2 = 1%) monotherapies with respect to serological conversion.

Conclusions

Alternative treatment strategies have serological cure rates equivalent to penicillin, potentially reducing global dependence on this antibiotic.

Impact of metagenomic next-generation sequencing on clinical decision-making at an academic medical center, a retrospective study, Iowa, 2020-2022

We assessed the impact of metagenomic next-generation sequencing (mNGS) on patient care using previously established criteria. Among 37 patients receiving mNGS testing, 16% showed results that had a positive clinical impact. While mNGS results may offer valuable supplementary information, results should be interpreted within the broader clinical context and evaluation.

Low infectivity among asymptomatic patients with a positive severe acute respiratory coronavirus virus 2 (SARS-CoV-2) admission test at a tertiary care center, 2020-2022

We used a strand-specific RT-qPCR to evaluate viral replication as a surrogate for infectiousness among 242 asymptomatic inpatients with a positive severe acute respiratory coronavirus virus 2 (SARS-CoV-2) admission test. Only 21 patients (9%) had detectable SARS-CoV-2 minus-strand RNA. Because most patients were found to be noninfectious, our findings support the suspension of asymptomatic admission testing.

Cerebrospinal fluid shunting for the management of cryptococcal meningitis: a scoping review

Objective

This scoping review aimed to describe studies that evaluate the management of cryptococcal meningitis (CM) using cerebrospinal fluid (CSF) shunts, types of shunts used, and clinically relevant patient outcomes.

Methods

We searched in the following databases: PubMed, Web of Science/Core collection, Embase, the Cochrane Library, and clinicaltrials.gov on 1 April 2022. We included two-arm and one-arm cohort studies that evaluated clinically relevant patient outcomes. Case reports were used to describe the type of CSF shunts used and the rationale behind its selection. The selection and extraction processes were independently performed by two authors.

Results

This study included 20 cohort studies and 26 case reports. Only seven cohort studies compared two groups. Ventriculoperitoneal shunt was the most commonly used type of shunt (82.1%). The main indications for placing a shunt were persistently high opening pressure (57.1%) and persisting neurological symptoms or deterioration (54.3%). Cohort studies suggest that patients with shunt showed improvement in some outcomes such as neurological symptoms and hospital stay length. The most common shunt complications were post-operative fever (1-35.6%) and shunt obstruction (7-16%).

Conclusion

CSF shunts may improve some clinically relevant outcomes in patients with CM, but the evidence is very uncertain.

A review of extended coronavirus disease 2019 (COVID-19) isolation duration among inpatients in a tertiary-care hospital-Iowa, 2020-2022

Of the 2,668 patients admitted with coronavirus disease 2019 (COVID-19), 4% underwent prolonged isolation for >20 days. Reasons for extended isolation were inconsistent with Centers for Disease Control and Prevention (CDC) guidelines in 25% of these patients and were questionable in 54% due to an ongoing critically ill condition at day 20 without CDC-defined immunocompromised status.

Use of a severe acute respiratory coronavirus virus 2 (SARS-CoV-2) strand-specific assay to evaluate for prolonged viral replication >20 days from illness onset

Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) real-time reverse-transcription polymerase chain reaction (rRT-PCR) strand-specific assay can be used to identify active SARS-CoV-2 viral replication. We describe the characteristics of 337 hospitalized patients with at least 1 minus-strand SARS-CoV-2 assay performed >20 days after illness onset. This test is a novel tool to identify high-risk hospitalized patients with prolonged SARS-CoV-2 replication.

The effectiveness of COVID-19 vaccine in the prevention of post-COVID conditions: a systematic literature review and meta-analysis of the latest research

Objective

We performed a systematic literature review and meta-analysis on the effectiveness of coronavirus disease 2019 (COVID-19) vaccination against post-COVID conditions (long COVID) among fully vaccinated individuals.

Design

Systematic literature review/meta-analysis.

Methods

We searched PubMed, Cumulative Index to Nursing and Allied Health, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science from December 1, 2019, to June 2, 2023, for studies evaluating the COVID-19 vaccine effectiveness (VE) against post-COVID conditions among fully vaccinated individuals who received two doses of COVID-19 vaccine. A post-COVID condition was defined as any symptom that was present four or more weeks after COVID-19 infection. We calculated the pooled diagnostic odds ratio (DOR) (95% confidence interval) for post-COVID conditions between fully vaccinated and unvaccinated individuals. Vaccine effectiveness was estimated as 100% x (1-DOR).

Results

Thirty-two studies with 775,931 individuals evaluated the effect of vaccination on post-COVID conditions, of which, twenty-four studies were included in the meta-analysis. The pooled DOR for post-COVID conditions among fully vaccinated individuals was 0.680 (95% CI: 0.523-0.885) with an estimated VE of 32.0% (11.5%-47.7%). Vaccine effectiveness was 36.9% (23.1%-48.2%) among those who received two doses of COVID-19 vaccine before COVID-19 infection and 68.7% (64.7%-72.2%) among those who received three doses before COVID-19 infection. The stratified analysis demonstrated no protection against post-COVID conditions among those who received COVID-19 vaccination after COVID-19 infection.

Conclusions

Receiving a complete COVID-19 vaccination prior to contracting the virus resulted in a significant reduction in post-COVID conditions throughout the study period, including during the Omicron era. Vaccine effectiveness demonstrated an increase when supplementary doses were administered.

Diagnostic Stewardship: A Systematic Review and Meta-analysis of Blood Collection Diversion Devices Used to Reduce Blood Culture Contamination and Improve the Accuracy of Diagnosis in Clinical Settings

Background

Blood culture contamination may lead to misdiagnosis, overutilization of antibiotics, and prolonged length of stay. Blood specimen diversion devices can reduce contamination rates during blood culture collection procedures. We performed a systematic literature review and meta-analysis evaluating the influence of blood specimen diversion devices in blood culture contamination rates.

Methods

We searched Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane, Scopus, and Web of Science, from database inception to 1 March 2023, for studies evaluating the impact of a diversion device on blood culture contamination. Blood culture contamination was a positive blood culture with microorganisms not representative of true bacteremia, but rather introduced during collection or processing the blood sample. Random-effects models were used to obtain pooled mean differences, and heterogeneity was assessed using the I2 test.

Results

Of 1768 screened studies, 12 met inclusion criteria for this systematic literature review. Of them, 9 studies were included in the meta-analysis. Studies were substantially heterogeneous, but stratified analyses considering only high-quality studies revealed that venipuncture using a diversion device was associated with a significant reduction in blood culture contamination in comparison to the standard procedure of collection (pooled odds ratio [OR], 0.26 [95% confidence interval {CI}, .13-.54]; I2 = 19%). Furthermore, the stratified analysis showed that the adoption of a diversion device did not reduce the detection of true infection (pooled OR, 0.85 [95% CI, .65-1.11]; I2 = 0%).

Conclusions

Blood culture diversion devices was associated with decreased contamination rates and could improve quality of care, reduce costs, and avoid unnecessary antibiotic use.

Coronavirus disease 2019 (COVID-19) among nonphysician healthcare personnel by work location at a tertiary-care center, Iowa, 2020-2021

We describe COVID-19 cases among nonphysician healthcare personnel (HCP) by work location. The proportion of HCP with coronavirus disease 2019 (COVID-19) was highest in the emergency department and lowest among those working remotely. COVID-19 and non-COVID-19 units had similar proportions of HCP with COVID-19 (13%). Cases decreased across all work locations following COVID-19 vaccination.

Longer-term effectiveness of a heterologous coronavirus disease 2019 (COVID-19) vaccine booster in healthcare workers in Brazil

Objective

To compare the long-term vaccine effectiveness between those receiving viral vector [Oxford-AstraZeneca (ChAdOx1)] or inactivated viral (CoronaVac) primary series (2 doses) and those who received an mRNA booster (Pfizer/BioNTech) (the third dose) among healthcare workers (HCWs).

Methods

We conducted a retrospective cohort study among HCWs (aged ≥18 years) in Brazil from January 2021 to July 2022. To assess the variation in the effectiveness of booster dose over time, we estimated the effectiveness rate by taking the log risk ratio as a function of time.

Results

Of 14,532 HCWs, coronavirus disease 2019 (COVID-19) was confirmed in 56.3% of HCWs receiving 2 doses of CoronaVac vaccine versus 23.2% of HCWs receiving 2 doses of CoronaVac vaccine with mRNA booster (P < .001), and 37.1% of HCWs receiving 2 doses of ChAdOx1 vaccine versus 22.7% among HCWs receiving 2 doses of ChAdOx1 vaccine with mRNA booster (P < .001). The highest vaccine effectiveness with mRNA booster was observed 30 days after vaccination: 91% for the CoronaVac vaccine group and 97% for the ChAdOx1 vaccine group. Vacine effectiveness declined to 55% and 67%, respectively, at 180 days. Of 430 samples screened for mutations, 49.5% were SARS-CoV-2 delta variants and 34.2% were SARS-CoV-2 omicron variants.

Conclusions

Heterologous COVID-19 vaccines were effective for up to 180 days in preventing COVID-19 in the SARS-CoV-2 delta and omicron variant eras, which suggests the need for a second booster.

Retrospective Screening of Clinical Samples for Monkeypox Virus DNA, California, USA, 2022

We retrospectively screened oropharyngeal and rectal swab samples originally collected in California, USA, for Chlamydia trachomatis and Neisseria gonorrhoeae testing for the presence of monkeypox virus DNA. Among 206 patients screened, 17 (8%) had samples with detectable viral DNA. Monkeypox virus testing from mucosal sites should be considered for at-risk patients.

A deep-learning algorithm to classify skin lesions from mpox virus infection

Undetected infection and delayed isolation of infected individuals are key factors driving the monkeypox virus (now termed mpox virus or MPXV) outbreak. To enable earlier detection of MPXV infection, we developed an image-based deep convolutional neural network (named MPXV-CNN) for the identification of the characteristic skin lesions caused by MPXV. We assembled a dataset of 139,198 skin lesion images, split into training/validation and testing cohorts, comprising non-MPXV images (n = 138,522) from eight dermatological repositories and MPXV images (n = 676) from the scientific literature, news articles, social media and a prospective cohort of the Stanford University Medical Center (n = 63 images from 12 patients, all male). In the validation and testing cohorts, the sensitivity of the MPXV-CNN was 0.83 and 0.91, the specificity was 0.965 and 0.898 and the area under the curve was 0.967 and 0.966, respectively. In the prospective cohort, the sensitivity was 0.89. The classification performance of the MPXV-CNN was robust across various skin tones and body regions. To facilitate the usage of the algorithm, we developed a web-based app by which the MPXV-CNN can be accessed for patient guidance. The capability of the MPXV-CNN for identifying MPXV lesions has the potential to aid in MPXV outbreak mitigation.

Case Report: Mpox - Not Just a Rash

Mpox (formally monkeypox) is an Orthopoxvirus associated with both zoonotic and person-to-person spread. Human mpox classically presents with rash and systemic symptoms. Although sporadic outbreaks of mpox have occurred worldwide, the 2022 outbreak is the first of pandemic significance. Thousands of geographically dispersed cases were reported beginning in May 2022. The clinical presentations and outcomes of mpox infection have varied greatly based on viral clade. Further guidance is needed for clinicians to diagnose and treat this emerging infection. We present five clinical vignettes of confirmed cases diagnosed in June and July 2022 in northern California to demonstrate the range of mpox disease, including myocarditis, pharyngitis, epididymitis, and proctitis. We note a significant overlap with HIV infection and a high rate of concurrent sexually transmitted infection. Given the heterogenous presentations of mpox disease, clinicians should maintain a high degree of suspicion in patients with oropharyngeal or genital lesions, proctitis, or new rash.

Hospitalization risk among patients with Mpox infection-a propensity score matched analysis

Background

Monkeypox (Mpox) is a reemerging, neglected viral disease. By May 2023, worldwide Mpox cases surpassed 87,000. Predictive factors for hospitalization with Mpox are lacking.

Objective

We aim to compare clinical characteristics and outcomes in hospitalized and nonhospitalized patients with Mpox infection.

Design

A multicenter retrospective case-control cohort of patients with Mpox infection.

Methods

We performed a propensity score match analysis from a global health network (TrinetX). We compare clinical characteristics and outcomes between hospitalized and nonhospitalized patients with Mpox.

Results

Of 1477 patients, 6% were hospitalized, 52% required an ED visit, and 29% received treatment at urgent care. After propensity score matching, 80 patients remained in each group. Hospitalizations were more common among Black persons (51% versus 33%, p = 0.01), people with HIV (50% versus 20%, p < 0.0001), and those with proctitis (44% versus 12.5%, p < 0.001).

Conclusion

Independent predictive factors of hospitalization in our cohort for Mpox included people who are Black with a diagnosis of HIV, severe proctitis, pain requiring opioids, and elevated lactate dehydrogenase. Greater recognition of factors associated with increased risk of Mpox severity and hospitalization is paramount.

The effectiveness of coronavirus disease 2019 (COVID-19) vaccine in the prevention of post-COVID-19 conditions: A systematic literature review and meta-analysis

BACKGROUND

Although multiple studies have revealed that coronavirus disease 2019 (COVID-19) vaccines can reduce COVID-19-related outcomes, little is known about their impact on post-COVID-19 conditions. We performed a systematic literature review and meta-analysis on the effectiveness of COVID-19 vaccination against post-COVID-19 conditions (ie, long COVID).

METHODS

We searched PubMed, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science from December 1, 2019, to April 27, 2022, for studies evaluating COVID-19 vaccine effectiveness against post-COVID-19 conditions among individuals who received at least 1 dose of Pfizer/BioNTech, Moderna, AstraZeneca, or Janssen vaccine. A post-COVID-19 condition was defined as any symptom that was present 3 or more weeks after having COVID-19. Editorials, commentaries, reviews, study protocols, and studies in the pediatric population were excluded. We calculated the pooled diagnostic odds ratios (DORs) for post-COVID-19 conditions between vaccinated and unvaccinated individuals. Vaccine effectiveness was estimated as 100% × (1 - DOR).

RESULTS

In total, 10 studies with 1,600,830 individuals evaluated the effect of vaccination on post-COVID-19 conditions, of which 6 studies were included in the meta-analysis. The pooled DOR for post-COVID-19 conditions among individuals vaccinated with at least 1 dose was 0.708 (95% confidence interval (CI), 0.692-0.725) with an estimated vaccine effectiveness of 29.2% (95% CI, 27.5%-30.8%). The vaccine effectiveness was 35.3% (95% CI, 32.3%-38.1%) among those who received the COVID-19 vaccine before having COVID-19, and 27.4% (95% CI, 25.4%-29.3%) among those who received it after having COVID-19.

CONCLUSIONS

COVID-19 vaccination both before and after having COVID-19 significantly decreased post-COVID-19 conditions for the circulating variants during the study period although vaccine effectiveness was low.

Human Monkeypox without Viral Prodrome or Sexual Exposure, California, USA, 2022

We report human monkeypox in a man who returned to the United States from the United Kingdom and reported no sexual contact. He had vesicular and pustular skin lesions but no anogenital involvement. The potential modes of transmission may have implications for the risk of spread and for epidemic control.

Development and evaluation of a structured guide to assess the preventability of hospital-onset bacteremia and fungemia

OBJECTIVE

To assess preventability of hospital-onset bacteremia and fungemia (HOB), we developed and evaluated a structured rating guide accounting for intrinsic patient and extrinsic healthcare-related risks.

DESIGN

HOB preventability rating guide was compared against a reference standard expert panel.

PARTICIPANTS

A 10-member panel of clinical experts was assembled as the standard of preventability assessment, and 2 physician reviewers applied the rating guide for comparison.

METHODS

The expert panel independently rated 82 hypothetical HOB scenarios using a 6-point Likert scale collapsed into 3 categories: preventable, uncertain, or not preventable. Consensus was defined as concurrence on the same category among ≥70% experts. Scenarios without consensus were deliberated and followed by a second round of rating.Two reviewers independently applied the rating guide to adjudicate the same 82 scenarios in 2 rounds, with interim revisions. Interrater reliability was evaluated using the κ (kappa) statistic.

RESULTS

Expert panel consensus criteria were met for 52 scenarios (63%) after 2 rounds.After 2 rounds, guide-based rating matched expert panel consensus in 40 of 52 (77%) and 39 of 52 (75%) cases for reviewers 1 and 2, respectively. Agreement rates between the 2 reviewers were 84% overall (κ, 0.76; 95% confidence interval [CI], 0.64-0.88]) and 87% (κ, 0.79; 95% CI, 0.65-0.94) for the 52 scenarios with expert consensus.

CONCLUSIONS

Preventability ratings of HOB scenarios by 2 reviewers using a rating guide matched expert consensus in most cases with moderately high interreviewer reliability. Although diversity of expert opinions and uncertainty of preventability merit further exploration, this is a step toward standardized assessment of HOB preventability.

Corowa-kun: A messenger app chatbot delivers COVID-19 vaccine information, Japan 2021

Background

There is a long history in Japan of public concerns about vaccine adverse events. Few studies have assessed how mobile messenger apps affect COVID-19 vaccine hesitancy.

Methods

Corowa-kun, a free chatbot, was created on February 6, 2021 in LINE, the most popular messenger app in Japan. Corowa-kun provides instant, automated answers to 70 frequently asked COVID-19 vaccine questions. A cross-sectional survey with 21 questions was performed within Corowa-kun during April 5–12, 2021.

Results

A total of 59,676 persons used Corowa-kun during February–April 2021. Of them, 10,192 users (17%) participated in the survey. Median age was 55 years (range 16–97), and most were female (74%). COVID-19 vaccine hesitancy reported by survey respondents decreased from 41% to 20% after using Corowa-kun. Of the 20% who remained hesitant, 16% (1,675) were unsure, and 4% (3 6 4) did not intend to be vaccinated. Factors associated with vaccine hesitancy were: age 16–34 (odds ratio [OR] = 3.7; 95% confidential interval [CI]: 3.0–4.6, compared to age ≥ 65), female sex (OR = 2.4; Cl: 2.1–2.8), and history of a previous vaccine side-effect (OR = 2.5; Cl: 2.2–2.9). Being a physician (OR = 0.2; Cl: 0.1–0.4) and having received a flu vaccine the prior season (OR = 0.4; Cl: 0.3–0.4) were protective.

Conclusions

A substantial number of people used the chabot in a short period. Mobile messenger apps could be leveraged to provide accurate vaccine information and to investigate vaccine intention and risk factors for vaccine hesitancy.

Effectiveness of Heterologous Coronavirus Disease 2019 (COVID-19) Vaccine Booster Dosing in Brazilian Healthcare Workers, 2021

BACKGROUND

Little is currently known about vaccine effectiveness (VE) for either 2 doses of Oxford-AstraZeneca (ChAdOx1) viral vector vaccine or CoronaVac (Instituto Butantan) inactivated viral vaccine followed by a third dose of mRNA vaccine (Pfizer/BioNTech) among healthcare workers (HCWs).

METHODS

We conducted a retrospective cohort study among HCWs (aged ≥18 years) working in a private healthcare system in Brazil from January to December 2021. VE was defined as 1 - incidence rate ratio (IRR), with IRR determined using Poisson models with the occurrence of laboratory-confirmed coronavirus disease 2019 (COVID-19) infection as the outcome, adjusting for age, sex, and job type. We compared those receiving viral vector or inactivated viral primary series (2 doses) with those who received an mRNA booster.

RESULTS

A total of 11 427 HCWs met the inclusion criteria. COVID-19 was confirmed in 31.5% of HCWs receiving 2 doses of CoronaVac vaccine versus 0.9% of HCWs receiving 2 doses of CoronaVac vaccine with mRNA booster (P < .001) and 9.8% of HCWs receiving 2 doses of ChAdOx1 vaccine versus 1% among HCWs receiving 2 doses of ChAdOx1 vaccine with mRNA booster (P < .001). In the adjusted analyses, the estimated VE was 92.0% for 2 CoronaVac vaccines plus mRNA booster and 60.2% for 2 ChAdOx1 vaccines plus mRNA booster, when compared with those with no mRNA booster. Of 246 samples screened for mutations, 191 (77.6%) were Delta variants.

CONCLUSIONS

While 2 doses of ChAdOx1 or CoronaVac vaccines prevent COVID-19, the addition of a Pfizer/BioNTech booster provided significantly more protection.

Blood culture practices in patients with a central line at an academic medical center-Iowa, 2020

We analyzed blood-culture practices to characterize the utilization of the Infectious Diseases Society of America (IDSA) recommendations related to catheter-related bloodstream infection (CRBSI) blood cultures. Most patients with a central line had only peripheral blood cultures. Increasing the utilization of CRBSI guidelines may improve clinical care, but may also affect other quality metrics.

Risk factors, management, and outcomes of Acanthamoeba keratitis: A retrospective analysis of 110 cases

Purpose

To evaluate the risk factors, medical and surgical management, and visual outcomes of patients affected by Acanthamoeba keratitis (AK) over a 16-year period.

Observations

Records were reviewed retrospectively for all AK patients treated at University of Iowa between 2002 and 2017. Main outcomes measured were risk factors, time to diagnosis, coinfection types, initial and final visual acuities, and treatment outcomes, with failure of medical therapy defined as need for therapeutic keratoplasty (TK). Effects of steroid use on these outcomes were determined. Among all AK cases occurring during the study period (N = 110), the median age of the AK cohort was 31 years (range 8–80 years), and 49.1% were men. Contact lens wear was the primary risk factor for AK (95/100, 86.4%), and the median time to diagnosis was 0.70 (0.23–1.23) months. Forty-four AK patients (40%) failed medical therapy. Vision outcomes were better for AK patients with successful medical therapy compared to those requiring TK (LogMAR 0.00 v. 0.30; p < 0.0001). Corticosteroid use was associated with increased time to diagnosis (1.00 v. 0.50 months; p = 0.002), decreased final vision (LogMAR 0.10 v. 0.00; p < 0.05) and increased need for TK (40/77 v. 4/33; p < 0.001).

Conclusions and importance

Acanthamoeba keratitis cases have increased over the past two decades at our institution. In this large retrospective study, AK was commonly misdiagnosed with delayed diagnosis and high rates of failed medical therapy. Corticosteroid use before AK diagnosis led to poorer outcomes. Our findings underscore the need for ophthalmologists to suspect Acanthamoeba in the setting of contact lens-associated keratitis before topical steroids are initiated.

Impact of COVID-19 on an infection prevention and control program, Iowa 2020-2021

Background

The COVID-19 pandemic has affected infection prevention and control (IPC) programs worldwide. We evaluated the impact of COVID-19 on the University of Iowa Hospitals & Clinics IPC program by measuring the volume of calls to the program, changes in healthcare-associated infection rates, and team member perceptions.

Methods

We retrieved the IPC call log and healthcare-associated infection trends for 2018-2020. We defined 2 periods: pre-COVID-19 (2018-2019) and COVID-19 (January-December 2020). We also conducted one-on-one interviews and focus group interviews with members of the IPC program and describe changes in their working conditions during the COVID-19 period.

Results

A total of 6,564 calls were recorded during 2018-2020. The pre-COVID-19 period had a median of 71 calls and/or month (range: 50-119). During the COVID-19 period, the median call volume increased to 368/month (range: 149-829), and most calls were related to isolation precautions (50%). During the COVID-19 period, the central line-associated bloodstream infection incidence increased significantly. Infection preventionists reported that the ambiguity and conflicting guidance during the pandemic were major challenges.

Conclusions

Our IPC program experienced a 500% increase in consultation requests. Planning for future bio-emergencies should include creative strategies to increase response capacity within IPC programs.

Short-term effectiveness of COVID-19 vaccines in immunocompromised patients: A systematic literature review and meta-analysis

OBJECTIVES

We aimed to assess the short-term effectiveness of COVID-19 vaccines among immunocompromised patients to prevent laboratory-confirmed symptomatic COVID-19 infection.

METHODS

Systematic review and meta-analysis. We calculated the pooled diagnostic odds ratio [DOR] (95% CI) for COVID-19 infection between immunocompromised patients and healthy people or those with stable chronic medical conditions. VE was estimated as 100% x (1-DOR). We also investigated the rates of developing anti-SARS-CoV-2 spike protein IgG between the 2 groups.

RESULTS

Twenty studies evaluating COVID-19 vaccine response, and four studies evaluating VE were included in the meta-analysis. The pooled DOR for symptomatic COVID-19 infection in immunocompromised patients was 0.296 (95% CI: 0.108-0.811) with an estimated VE of 70.4% (95% CI: 18.9%- 89.2%). When stratified by diagnosis, IgG antibody levels were much higher in the control group compared to immunocompromised patients with solid organ transplant (pOR 232.3; 95% Cl: 66.98-806.03), malignant diseases (pOR 42.0, 95% Cl: 11.68-151.03), and inflammatory rheumatic diseases (pOR 19.06; 95% Cl: 5.00-72.62).

CONCLUSIONS

We found COVID-19 mRNA vaccines were effective against symptomatic COVID-19 among the immunocompromised patients but had lower VE compared to the controls. Further research is needed to understand the discordance between antibody production and protection against symptomatic COVID-19 infection.

Clinical Decision Support Systems to Reduce Unnecessary Clostridoides difficile Testing Across Multiple Hospitals

BACKGROUND

Inappropriate C. difficile testing has adverse consequences for the patient, hospital, and public health. Computerized Clinical Decision Supports (CCDS) in the Electronic Health Record (EHR) may reduce C. difficile test ordering; however, effectiveness of different approaches, ease of use, and best fit into the healthcare providers' (HCP) workflow, are not well understood.

METHODS

Nine academic and 6 community U.S. hospitals participated in this 2-year cohort study. CCDS (hard- or soft-stop) triggered when duplicate C. difficile test order attempted, or if laxatives were recently received. The primary outcome was the difference in testing rates pre- and post-CCDS interventions, using incident rate ratios (IRR) and mixed effect Poisson regression models. We performed qualitative evaluation (contextual inquiry, interviews, focus groups) based on a human factors model. We identified themes using a codebook with primary- and sub-nodes.

RESULTS

In 9 hospitals implementing hard-stop CCDS and 4 hospitals implementing soft-stop CCDS, C. difficile testing IRR reduction was 33% (95% CI, 30-36%), and 23% (95% CI 21-25%), respectively. Two hospitals implemented a non-EMR based human intervention with IRR reduction of 21% (95% CI 15-28%). HCPs reported generally favorable experiences, and highlighted time efficiencies such as inclusion of the patients most recent laxative administration on the CCDS. Organizational factors including hierarchical cultures, and communication between HCPs caring for the same patient, impact CCDS acceptance and integration.

CONCLUSIONS

CCDS reduced unnecessary C. difficile testing and were perceived positively by HCPs when integrated into their workflow, and when displayed relevant patient specific information needed for decision-making.

439. Corowa-kun: Impact of a COVID-19 Vaccine Information Chatbot on Vaccine Hesitancy, Japan 2021

Background

Japan has one of the highest vaccine hesitancy rates in the world. According to a previous study, less than 30% of people strongly agreed that vaccines were safe, important, or effective. We created a COVID-19 vaccine information chatbot in a popular messenger app in Japan to answer COVID-19 vaccine frequently asked questions (FAQs) via text messages. We assessed the impact of chatbot text messages on COVID-19 vaccine hesitancy by conducting a cross-sectional survey among chatbot users.

Methods

LINE is the most popular messenger app in Japan; about 86 million people in Japan (roughly two-thirds of the population) use this messenger app. Corowa-kun, a free chatbot, was created in LINE on February 6, 2021. Corowa-kun provides instant, automated answers to frequently asked COVID-19 vaccine questions. A cross-sectional survey assessing COVID-19 vaccine hesitancy was conducted via Corowa-kun during April 5 to 12, 2021. We included persons ages 16 years old and older who had not received a COVID-19 vaccine. The survey was written in Japanese and consisted of 21 questions.

Corowa-kun’s Consultation Room

Corowa-kun is the mascot of an online chatbot. This chatbot in LINE is used to answer COVID-19 vaccine frequently asked questions (FAQs) via text messages. As of May 10th, 70 FAQs are available.

Results

A total of 59,676 persons used Corowa-kun during February to April 2021. The most commonly accessed message categories were: “I have (select comorbidity), can I get a COVID-19 vaccine?” (23%); followed by questions on adverse reactions (22%) and how the vaccine works (20%). 10,192 users (17%) participated in the survey. Median age was 55 years (range 16 to 97), and most were female (74%). Intention to receive a COVID-19 vaccine increased from 59% to 80% after using Corowa-kun (p < 0.01). Overall, 20% remained hesitant: 16% (1,675) were unsure, and 4% (364) did not intend to be vaccinated. Factors associated with vaccine hesitancy were: age 16 to 34 (odds ratio [OR] = 3.7, 95% confidential interval [CI]: 3.0–4.6, compared to age ≥65), female sex (OR = 2.4, Cl: 2.1–2.8), and history of another vaccine side-effect (OR = 2.5, Cl: 2.2–2.9). Being a physician (OR = 0.2, Cl: 0.1-0.4) and having received a flu vaccine the prior season (OR = 0.4, Cl: 0.3-0.4) were protective.

COVID-19 vaccine acceptance increased and hesitancy decreased after using Corowa-kun, Japan, 2021 (n=10,192)

*There was a statistically significant difference in responses between before and after using Corowa-kun (p < 0.01, Chi-square test).

Univariable logistic regression models of factors associated with COVID-19 vaccine hesitancy, Japan, 2021 (n=10,192)

Ref: reference NA: Logistic regression was not performed due to too small number (n≤3)

Conclusion

Corowa-kun reduced vaccine hesitancy by providing COVID-19 vaccine information in a messenger app. Mobile messenger apps could be leveraged to increase COVID-19 vaccine acceptance.

Disclosures

All Authors: No reported disclosures

Stable Clostridioides difficile infection rates after the discontinuation of ultraviolet light for terminal disinfection at a tertiary care center, Iowa 2019-2020

We compared the incidence of Clostridioides difficile infection before and after the discontinuation of Ultraviolet light used in addition to bleach in terminal disinfection of hospital rooms. We found no difference in C. difficile infection rates but found a decreased turn over time. The benefit of Ultraviolet light may be diminished in hospitals with a high thoroughness of manual cleaning.

Immediate preoperative hyperglycemia correlates with complications in non-cardiac surgical cases

Study objective:

Assess for a relationship between immediate preoperative glucose concentrations and postoperative complications.

Design:

Retrospective cohort study.

Setting:

Single large, tertiary care academic medical center.

Patients:

A five-year registry of all patients at our hospital who had a glucose concentration (plasma, serum, or venous/capillary/arterial whole blood) measured up to 6 h prior to a non-emergent surgery.

Interventions:

The glucose registry was cross-referenced with a database from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). We applied an outcomes review to the subset of patients for whom we had data from both registries (n = 1774).

Measurements:

Preoperative glucose concentration in the full population as well as the subgroups of patients with or without diabetes were correlated with adverse postsurgical outcomes using 1) univariable analysis and 2) full multivariable analysis correcting for 27 clinical factors available from the ACS NSQIP database. Logistic regression analysis was performed using glucose level either as a continuous variable or as a categorical variable according to the following classifications: mild (≥140 mg/dL; ≥7.8 mmol/L), moderate (≥180 mg/dL; ≥10 mmol/L), or severe (≥250 mg/dL; ≥13.9 mmol/L) hyperglycemia. A third analysis was performed correcting for 7 clinically important factors (age, BMI, predicted duration of procedure, sex, CKD stage, hypoalbuminemia, and diabetic status) identified by anesthesiologists and surgeons as immediately available and important for decision making.

Main results:

Univariable analysis of all patients and the subgroups of patients without diabetes or with diabetes showed that immediate preoperative mild or moderate hyperglycemia correlates with postoperative complications. Statistical significance was lost in most groups using full multivariable analysis, but not when correcting for the 7 factors available immediately preoperatively. However, for all patients with diabetes, moderate hyperglycemia (≥180 mg/dL; ≥10 mmol/L) continued to significantly correlate with complications even in the full multivariable analysis [odds ratio (OR) 1.79; 95% Confidence Intervals (CI) 1.10, 2.92], and with readmission/reoperation within 30 days [OR 1.93; 95% CI 1.18, 3.13].

Conclusions:

Preoperative hyperglycemia within 6 h of surgery is a marker of adverse postoperative outcomes. Among patients with diabetes in our study, a preoperative glucose level ≥ 180 mg/dL (≥10 mmol/L) independently correlates with risk of postoperative complications and readmission/reoperation. These results should encourage future work to determine whether addressing immediate preoperative hyperglycemia can improve complication rates, or simply serves as a marker of higher risk.

A 28-Year-Old Pregnant Woman With a Lung Abscess and Complicated Pleural Effusion

CASE PRESENTATION

A 28-year-old woman G1P0 at 22 weeks of gestation and with no significant medical history presented to the ED complaining of worsening dyspnea and right-sided pleuritic chest pain. Symptoms started 2 weeks before presentation, with minimal productive cough and dyspnea on exertion. One week after the initial symptoms, the patient started noticing right-sided chest and shoulder pain along with subjective fevers and night sweats. She denied hemoptysis, weight loss, abdominal pain, diarrhea, nausea, vomiting, arthralgia, or rash. Her pregnancy had so far been uncomplicated. The patient did not use tobacco, alcohol, or recreational drugs. She worked at a daycare center but denied any particular sick contacts. She moved to the United States 7 years ago from Sudan and denied any recent travel.

Palliative care consultation in patients with Staphylococcus aureus bacteremia

BACKGROUND

Palliative care consultation has shown benefits across a wide spectrum of diseases, but the utility in patients with Staphylococcus aureus bacteremia remains unclear despite its high mortality.

AIM

To examine the frequency of palliative care consultation and factors associated with palliative care consult in Staphylococcus aureus bacteremia patients in the United States.

DESIGN

A population-based retrospective analysis using the Nationwide Inpatient Sample database in 2014, compiled by the Healthcare Costs and Utilization Project of the Agency for Healthcare Research and Quality.

SETTING/SUBJECTS

All inpatients with a discharge diagnosis of Staphylococcus aureus bacteremia (ICD-9-CM codes; 038.11 and 038.12).

MEASUREMENTS

Palliative care consultation was identified using ICD-9-CM code V66.7. Patients' baseline characteristics and outcomes were compared between those with and without palliative care consult.

RESULTS

A total of 111,320 Staphylococcus aureus bacteremia admissions were identified in 2014. Palliative care consult was observed in 8140 admissions (7.3%). Palliative care consultation was associated with advanced age, white race, comorbidities, higher income, teaching/urban hospitals, Midwest region, Methicillin-resistant Staphylococcus aureus bacteremia and the lack of echocardiogram. Palliative care consult was also associated with shorter but more expensive hospitalizations. Crude mortality was 53% (4314/8140) among admissions with palliative care consult and 8% (8357/10,3180) among those without palliative care consult (p < 0.001).

CONCLUSIONS

Palliative care consultation was infrequent during the management of Staphylococcus aureus bacteremia, and a substantial number of patients died during their hospitalizations without palliative care consult. Given the reported benefit in other medical conditions, palliative care consultation may have a role in Staphylococcus aureus bacteremia. Selecting patients who may benefit the most should be explored.

Asymptomatic Pre-Operative COVID-19 Screening for Essential and Elective Surgeries: Early Results of Universal Screening at a Midwestern Academic Medical Center

BACKGROUND

During the novel Coronavirus 2019 (COVID-19) worldwide pandemic, viral testing has largely focused on patients presenting with fever and respiratory symptoms. Although Centers for Disease Control has reported 1,551,095 cases in the United States as of May 21, 2020, asymptomatic infection rates remain unknown within the U.S., especially in geographically disparate regions.

METHODS

On April 7, 2020 our hospital established universal SARS-CoV-2 screening using RT-PCR RNA detection from nasopharyngeal swabs from asymptomatic patients prior to essential and elective surgeries. This study included 1,997 asymptomatic patients undergoing surgical procedures and 1,797 admitted for medical management at a Midwestern academic hospital between April 7, 2020 and May 21, 2020.

RESULTS

As of May 21, asymptomatic testing for SARS-CoV-2 infection had been completed for 1,997 surgical patients and 1,797 non-surgical patients. Initial testing was positive in 26 patients, with an additional four positive tests occurring during repeat testing when greater than 48 hours had elapsed since initial testing. Overall asymptomatic infection rate was 0.79%. Asymptomatic infection rate was significantly lower in surgical patients (0.35% vs. 1.28%, p=0.001). Surgical patients tended to be older than non-surgical patients, although this was not statistically significant (51, IQR 27-65 vsx 46, IQR 28-64, p=0.057). Orthopedic surgery patients were significantly younger than those from other surgical services (42 vs. 53 yrs, p<0.001), however orthopedic and non-orthopedic surgical patients had similar asymptomatic infection rates (0.70% vs. 0.25%, p=0.173).

CONCLUSION

Among asymptomatic patients tested at a Midwestern academic medical center, 0.79% were infected with SARS-CoV-2 virus. These findings will help guide screening protocols at medical centers while providing essential and elective procedures during the COVID-19 pandemic. While the asymptomatic infection rate was low, this data substantiates the threat of asymptomatic infections and potential for community viral spread. These results may not be generalizable to large urban population centers or areas with high concentrations of COVID-19, each region must use available data to evaluate the risk-benefit ratio of universal testing vs universal contact precautions.Level of Evidence: IV.

749. Impact of Infectious Disease Consultation in Patients with Candidemia: A Retrospective study, Systematic Literature Review and Meta-analysis

Background

Morbidity and mortality from candidemia remain unacceptably high. While infectious disease consultation (IDC) is known to lower the mortality from Staphylococcus aureus bacteremia, little is known on the impact of IDC in candidemia.

Methods

We conducted a retrospective observational cohort study of candidemia patients at a large tertiary care hospital between 2015 and 2019. All patients aged ≥18 years with blood cultures positive for Candida species were included. We only included the first episode of candidemia. Exclusion criteria were death or transfer to the palliative care unit within 48 hours from the time cultures became positive. The crude mortality rate was compared between those with IDC and without IDC. Then, we systematically searched five publication-databases through February 2020 and performed a meta-analysis of the impact of IDC on mortality of patients with candidemia. The study protocol has been submitted to the International Prospective Register for Systematic Reviews (PROSPERO) database (ID 156939) on April 2020.

Results

A total of 151 patients at our institution met the inclusion criteria, 129 (85%) of whom received IDC. Thirty-day, and 90-day mortality rates were significantly lower in the IDC group (18% vs 50%, P = .002; 23% vs 50%, P = .0022, respectively). Our systematic literature review returned 216 reports, of which, 13 studies including ours fulfilled the inclusion criteria. Among the 13 studies with a total 3687 patients, IDC was performed in 49% of patients. Mortality numbers were available in 10 studies. Overall mortality was 38.2% with a significant difference in favor of the IDC group (28.4% and 47.6%) with a pooled relative risk of 0.41 [95% Cl 0.35-0.49]. Ophthalmology referral (61%; 790/1279 and 21%; 273/1304, P < 0.001), echocardiogram (54%; 662/1219 and 28%; 369/1296, P < 0.001), and central line removal (78%; 830/1069 and 61%; 686/1116, P < 0.02) were performed more frequently among patients receiving IDC.

Overall mortality

Conclusion

This study is the first systematic literature review and meta-analysis to evaluate the association between IDC and candidemia mortality. IDC was associated with a lower mortality and should be standard of care in all patients with candidemia.

Disclosures

Dimitrios Farmakiotis, MD, Astellas (Grant/Research Support) Paul Auwaerter, Collidion (Consultant)DiaSorin (Consultant)Johnson and Johnson (Shareholder)MicroB-Plex (Research Grant or Support)Shionogi (Consultant) Daniel Diekema, bioMerieux, Inc (Grant/Research Support)JMI Laboratories (Consultant)

COVID-19 Serial Testing among Hospitalized Patients in a Midwest Tertiary Medical Center, July-September 2020

We implemented serial COVID-19 testing for inpatients with a negative test on admission. The conversion rate (negative to positive) on repeat testing was one percent. We identified patients during their incubation period and hospital-onset cases, rapidly isolated them, and potentially reduced exposures. Serial testing and infectiousness determination were resource intensive.

Impact of Infectious Disease Consultation in Patients With Candidemia: A Retrospective Study, Systematic Literature Review, and Meta-analysis

BACKGROUND

Morbidity and mortality from candidemia remain unacceptably high. While infectious disease consultation (IDC) is known to lower the mortality from Staphylococcus aureus bacteremia, little is known about the impact of IDC in candidemia.

METHODS

We conducted a retrospective observational cohort study of candidemia patients at a large tertiary care hospital between 2015 and 2019. The crude mortality rate was compared between those with IDC and without IDC. Then, we systematically searched 5 databases through February 2020 and performed a meta-analysis of the impact of IDC on the mortality of patients with candidemia.

RESULTS

A total of 151 patients met the inclusion criteria, 129 (85%) of whom received IDC. Thirty-day and 90-day mortality rates were significantly lower in the IDC group (18% vs 50%; P = .002; 23% vs 50%; P = .0022, respectively). A systematic literature review returned 216 reports, of which 13 studies including the present report fulfilled the inclusion criteria. Among the 13 studies with a total of 3582 patients, IDC was performed in 50% of patients. Overall mortality was 38.2% with a significant difference in favor of the IDC group (28.4% vs 47.6%), with a pooled relative risk of 0.41 (95% CI, 0.35-0.49). Ophthalmology referral, echocardiogram, and central line removal were performed more frequently among patients receiving IDC.

CONCLUSIONS

This study is the first systematic literature review and meta-analysis to evaluate the association between IDC and candidemia mortality. IDC was associated with significantly lower mortality and should be considered in all patients with candidemia.

Contamination of health-care workers' hands with Escherichia coli and Klebsiella species after routine patient care: a prospective observational study

OBJECTIVE

To compare the frequency of health-care worker (HCW) hand contamination by Escherichia coli versus Klebsiella species after patient care and to determine activities associated with contamination.

METHODS

We conducted a prospective observational study at two tertiary-care centres. We observed HCWs caring for patients colonized/infected with E. coli or Klebsiella. HCW hands were cultured before room entry and after patient care. Contamination was defined as detecting E. coli or Klebsiella on HCW hands. Risk factors for contamination were analysed using logistic regression. Patient-to-HCW transmission was confirmed by pulsed-field gel electrophoresis (PFGE).

RESULTS

We performed 466 HCW observations: 290 from patients with E. coli, 149 with Klebsiella, and 27 with both species. Eighty-seven per cent of observations (404/464) occurred in patients who had received chlorhexidine bathing within 2 days. HCW hand contamination rates were similar between E. coli (6.2%; 18/290) and Klebsiella (7.4%; 11/149) (p 0.6). High-risk activities independently associated with contamination were toilet assistance (OR 9.34; 95% CI 3.10-28.16), contact with moist secretions (OR 6.93; 95% CI 2.82-17.00), and hygiene/bed-bathing (OR 3.80; 95% CI 1.48-9.80). PFGE identified identical/closely related isolates in the patient and HCW hands in 100% (18/18) of E. coli and 54.5% (6/11) of Klebsiella observations.

CONCLUSIONS

We did not find a difference in HCW hand contamination rates between E. coli and Klebsiella after patient care. Hand hygiene should be reinforced after high-risk activities. Discrepancies in matching patient and HCW hand isolates occurred more frequently for Klebsiella than for E. coli; differences in species-level transmission dynamics might exist.

1004. Interactive Dashboards for Antimicrobial Usage and Standardized Antimicrobial Administration Ratio Data

Background

Antimicrobial stewardship (AMS) programs can report to the NHSN Antimicrobial Usage and Resistance (AU) module and receive Standardized Antimicrobial Administration Ratios (SAARs) to allow for inter- and intra-facility benchmarking. Output from NHSN for antimicrobial usage is a line listing, rate table, pie chart, or bar chart showing one location at a time, and a line listing for SAAR data We aimed to create interactive data visualization dashboards for end-user’s consumption and for the AMS program staff to identify potential areas of intervention.

Methods

A multidisciplinary work group consisting of data analysts, infectious diseases physicians, and infectious diseases pharmacists determined dashboard content, layout, and comparison charts. Graph types were tested to determine the best visual output for antimicrobial usage data and SAAR. Patient-days and antimicrobial usage data based on bar-code administration were captured from the electronic medical record and imported into the NHSN platform for analysis. Analyzed data were then exported from the NHSN site for building the dashboards.

Results

A multi-faceted dashboard was developed in Tableau® to view antimicrobial usage data and SAAR. Dashboard capabilities include the option to view as facility wide, location type, or at a specific unit level for comparison of the usage of antimicrobial classes, specific agents, or SAARs for multiple locations. It can be visualized as a monthly or quarterly display. This allows for quick direct comparison of antimicrobial usage on the same graph by unit to determine outliers (Figure 1). The dashboard allows visualization of all SAAR types by location and unit level on one page showing the entire picture for the location type or unit (figures 2,3). These dashboards give the ability to trend antimicrobial usage and SAARs across units easier than reviewing a line listing or graph of each unit individually.

Conclusion

We developed interactive antimicrobial usage and SAAR dashboards. These dashboards can be used by hospitals reporting to NHSN for informing front line staff and for decision-making at the AMS program level.

Disclosures

All authors: No reported disclosures.

Bacillus Calmette-Guérin Cases Reported to the National Tuberculosis Surveillance System, United States, 2004-2015

Mycobacterium bovis bacillus Calmette-Guérin (BCG) is used as a vaccine to protect against disseminated tuberculosis (TB) and as a treatment for bladder cancer. We describe characteristics of US TB patients reported to the National Tuberculosis Surveillance System (NTSS) whose disease was attributed to BCG. We identified 118 BCG cases and 91,065 TB cases reported to NTSS during 2004-2015. Most patients with BCG were US-born (86%), older (median age 75 years), and non-Hispanic white (81%). Only 17% of BCG cases had pulmonary involvement, in contrast with 84% of TB cases. Epidemiologic features of BCG cases differed from TB cases. Clinicians can use clinical history to discern probable BCG cases from TB cases, enabling optimal clinical management. Public health agencies can use this information to quickly identify probable BCG cases to avoid inappropriately reporting BCG cases to NTSS or expending resources on unnecessary public health interventions.

Long-term outcomes of Guillain-Barré syndrome possibly associated with Zika virus infection

Background

This prospective cohort investigation analyzed the long-term functional and neurologic outcomes of patients with Zika virus-associated Guillain-Barré syndrome (GBS) in Barranquilla, Colombia.

Methods

Thirty-four Zika virus-associated GBS cases were assessed a median of 17 months following acute GBS illness. We assessed demographics, results of Overall Disability Sum Scores (ODSS), Hughes Disability Score (HDS), Zung Depression Scale (ZDS), and Health Related Quality of Life (HRQL) questionnaires; and compared outcomes indices with a normative sample of neighborhood-selected control subjects in Barranquilla without GBS.

Results

Median age at time of acute neurologic onset was 49 years (range, 10–80); 17 (50%) were male. No deaths occurred. At long-term follow-up, 25 (73%) patients had a HDS 0–1, indicating complete / near complete recovery. Among the group, HDS (mean 1.4, range 0–4), ODSS (mean 1.9, range 0–9) and ZDS score (mean 34.4, range 20–56) indicated mild / moderate ongoing disability. Adjusting for age and sex, Zika virus-associated GBS cases were similar to a population comparison group (n = 368) in Barranquilla without GBS in terms of prevalence of physical or mental health complaints, though GBS patients were more likely to have an ODSS of ≥ 1 (OR 8.8, 95% CI 3.2–24.5) and to suffer from moderate / moderate-severe depression (OR 3.89, 95% CI 1.23–11.17) than the comparison group.

Conclusions

Long-term outcomes of Zika virus-associated GBS are consistent with those associated with other antecedent antigenic stimuli in terms of mortality and ongoing long-term morbidity, as published in the literature. Persons with Zika virus-associated GBS more frequently reported disability and depression after approximately one year compared with those without GBS.

Disseminated pulmonary histoplasmosis in immunocompetent patients: a common epidemiological exposure

We describe the initial presentation, diagnostic work-up and treatment of three adult immunocompetent men who presented within a short time frame of each other to an academic medical centre with acute respiratory distress syndrome. Their presentation was found to be secondary to a large inoculum of histoplasmosis from remodelling a building with bat droppings infestation. We discuss the pathophysiology of histoplasmosis and highlight the importance of exposure history in patients with acute respiratory failure and why patients with the occupational risk of exposure to fungal inoculum should wear protective respirator gear.

Plasmodium vivax Parasite Load Is Associated With Histopathology in Saimiri boliviensis With Findings Comparable to P vivax Pathogenesis in Humans

Background

Plasmodium vivax can cause severe malaria with multisystem organ dysfunction and death. Clinical reports suggest that parasite accumulation in tissues may contribute to pathogenesis and disease severity, but direct evidence is scarce.

Methods

We present quantitative parasitological and histopathological analyses of tissue sections from a cohort of naive, mostly splenectomized Saimiri boliviensis infected with P vivax to define the relationship of tissue parasite load and histopathology.

Results

The lung, liver, and kidney showed the most tissue injury, with pathological presentations similar to observations reported from autopsies. Parasite loads correlated with the degree of histopathologic changes in the lung and liver tissues. In contrast, kidney damage was not associated directly with parasite load but with the presence of hemozoin, an inflammatory parasite byproduct.

Conclusions

This analysis supports the use of the S boliviensis infection model for performing detailed histopathological studies to better understand and potentially design interventions to treat serious clinical manifestations caused by P vivax.

688. Impact of Expanded Influenza Post-exposure Prophylaxis on Healthcare Worker Absenteeism at a Tertiary Care Center During the 2017–2018 Season

Background

A severe 2017–2018 influenza season was expected for the United States. We hypothesized that a surge in influenza cases paired with decreased vaccine effectiveness could increase healthcare worker (HCW) absenteeism. Because of a potential public health emergency during the 2017–2018 season, we offered oseltamivir post-exposure prophylaxis (PEP) to exposed HCWs regardless of vaccination status. We describe PEP uptake, cost, and impact on absenteeism at the University of Iowa Hospital and Clinics (UIHC).

Methods

UIHC serves as a referral and safety net health system for Eastern Iowa. Influenza seasons were defined as the period between Week 40 from 1 year to Week 13 of the following year. During the 2016–2017 season, PEP (75 mg/day for 7 days) was offered free of charge to unvaccinated exposed HCWs. Exposure was defined as proximity within 3 ft of a confirmed influenza-infected person for ≥10 minutes without mask protection, or direct contact with respiratory secretions. During the 2017–2018 season, PEP was expanded to all exposed HCWs regardless of vaccination status. We reviewed surveillance, employee health, pharmacy, and human resources records for the 2016–2017 and 2017–2018 seasons. We defined PEP uptake as prescriptions picked up/all referrals and absenteeism rate as sick-leave requests/scheduled hours.

Results

During the 2016–2017 and 2017–2018 seasons, we detected 373 and 427 confirmed influenza cases among patients at UIHC. HCW vaccination rates were similar: 89.7% and 90.9%. PEP was recommended in 49 exposures during 2016–2017 and 280 exposures during 2017–2018. A total of 22 (44.9%) and 133 (47.5%) HCWs picked up oseltamivir from the pharmacy during the 2016–2017 and 2017–2018 seasons. The estimated cost of oseltamivir was $1,791 and $10,828, respectively. Overall, 6,187 sick-leave requests (median = 12 hours, absenteeism rate = 3.2%), and 6,174 sick-leave requests (median = 12 hours, absenteeism rate = 3.4%) were reported during the 2016–2017 and 2017–2018 seasons.

Conclusion

Influenza case counts mildly increased from the 2016–2017 to the 2017–2018 season. Expanding PEP to all exposed HCWs, regardless of vaccination status, had moderate uptake and was costly. Absenteeism rates remained similar during both seasons.

Disclosures

All authors: No reported disclosures.

Factors Associated With All-Cause Mortality Among Patients With Multidrug-Resistant Tuberculosis-United States, 1993-2013

We assessed characteristics associated with all-cause mortality among US patients with multidrug-resistant tuberculosis. Mortality decreased from 31% during 1993-2002 to 11% during 2003-2013. Directly observed therapy coverage increased from 74% to 95% and was protective against all-cause mortality after accounting for demographics, clinical characteristics, human immunodeficiency virus status, and period of treatment.

Metabolome-wide association study of peripheral parasitemia in Plasmodium vivax malaria

BACKGROUND

Plasmodium vivax is one of the leading causes of malaria worldwide. Infections with this parasite cause diverse clinical manifestations, and recent studies revealed that infections with P. vivax can result in severe and fatal disease. Despite these facts, biological traits of the host response and parasite metabolism during P. vivax malaria are still largely underexplored. Parasitemia is clearly related to progression and severity of malaria caused by P. falciparum, however the effects of parasitemia during infections with P. vivax are not well understood.

RESULTS

We conducted an exploratory study using a high-resolution metabolomics platform that uncovered significant associations between parasitemia levels and plasma metabolites from 150 patients with P. vivax malaria. Most plasma metabolites were inversely associated with higher levels of parasitemia. Top predicted metabolites are implicated into pathways of heme and lipid metabolism, which include biliverdin, bilirubin, palmitoylcarnitine, stearoylcarnitine, phosphocholine, glycerophosphocholine, oleic acid and omega-carboxy-trinor-leukotriene B4.

CONCLUSIONS

The abundance of several plasma metabolites varies according to the levels of parasitemia in patients with P. vivax malaria. Moreover, our data suggest that the host response and/or parasite survival might be affected by metabolites involved in the degradation of heme and metabolism of several lipids. Importantly, these data highlight metabolic pathways that may serve as targets for the development of new antimalarial compounds.