National survey of infectious disease fellowship program directors: A call for subspecialized training in infection prevention and control and healthcare epidemiology

OBJECTIVE

The importance of infection prevention and control and healthcare epidemiology (IPC/HE) in healthcare facilities was highlighted during the COVID-19 pandemic. Infectious disease (ID) clinicians often hold leadership positions in IPC/HE teams; however, there is no standard for training or certification of ID physicians specializing in IPC/HE. We evaluated the current state of IPC/HE training in ID fellowship programs.

DESIGN

A national survey of ID fellowship program directors was conducted to assess current IPC/HE training components in programs and plans for expanded offerings.

SETTING AND PARTICIPANTS

All ID fellowship program directors in the United States and Puerto Rico.

METHODS

Surveys were distributed using Research Electronic Data Capture (REDCap) to program directors in March 2023, with 2 reminder emails; the survey closed after 4 weeks.

RESULTS

Of 166 program directors, 54 (32.5%) responded to the survey. Among respondent programs, 49 (90.7%) of 54 programs reported didactic training in IPC/HE averaging 4.4 hours over the course of the fellowship. Also, 18 (33.3%) of 54 reported a dedicated IPC/HE training track. Furthermore, 23 programs (42.6%) reported barriers to expanding training. There was support (n = 47, 87.0%) for formal IPC/HE certification from a professional society within the standard fellowship.

CONCLUSIONS

Despite the COVID-19 pandemic highlighting the need for ID medical doctors with IPC/HE expertise, formal training in ID fellowship remains limited. Most program directors support formalization of IPC/HE training by a professional organization. Creation of standardized advanced curriculums for ID fellowship training in IPC/HE could be considered by the Society of Healthcare Epidemiology of America (SHEA) to grow, retain, and enhance the IPC/HE physician workforce.

Separating the rash from the chaff: novel clinical decision support deployed during the mpox outbreak

A clinical decision support system, EvalMpox, was developed to apply person under investigation (PUI) criteria for patients presenting with rash and to recommend testing for PUIs. Of 668 patients evaluated, an EvalMpox recommendation for testing had a positive predictive value of 35% and a negative predictive value of 99% for a positive mpox test.

Real-World Dalbavancin Use for Serious Gram-Positive Infections: Comparing Outcomes Between People Who Use and Do Not Use Drugs

Background

Dalbavancin has been used off-label to treat invasive bacterial infections in vulnerable populations like people who use drugs (PWUD) because of its broad gram-positive coverage and unique pharmacological properties. This retrospective, multisite study examined clinical outcomes at 90 days in PWUD versus non-PWUD after secondary treatment with dalbavancin for bacteremia, endocarditis, osteomyelitis, septic arthritis, and epidural abscesses.

Methods

Patients at 3 teaching hospitals who received dalbavancin for an invasive infection between March 2016 and May 2022 were included. Characteristics of PWUD and non-PWUD, infection highlights, hospital stay and treatment, and outcomes were compared using χ2 for categorical variables, t test for continuous variables, and nonparametric tests where appropriate.

Results

There were a total of 176 patients; 78 were PWUD and 98 were non-PWUD. PWUD were more likely to have a patient-directed discharge (26.9% vs 3.1%; P < .001) and be lost to follow-up (20.5% vs 7.14%; P < .01). Assuming loss to follow-up did not achieve clinical cure, 73.1% of PWUD and 74.5% of non-PWUD achieved clinical cure at 90 days (P = .08).

Conclusions

Dalbavancin was an effective treatment option for invasive gram-positive infections in our patient population. Despite higher rates of patient-directed discharge and loss to follow-up, PWUD had similar rates of clinical cure at 90 days compared to non-PWUD.

Analysis of the Infectious Diseases Fellowship Program Directors Postmatch 2023 Survey

The 2023 United States infectious diseases (ID) fellowship match resulted in a large percentage of programs with unfilled positions. A survey was sent to ID program directors nationwide to better understand their perceptions on the match. Program directors perceived geography, a small applicant pool, and low specialty pay as contributing factors to the match results. Developing specialized fellowship tracks, increasing funding for the ID trainee pipeline, and national advocacy for higher compensation were identified as areas to focus on to increase the applicant pool. Areas of controversy, such as decreasing the number or size of fellowship programs, require further discussion.

High-Volume, High-Acuity, and High-Impact Learning: Tips and Tricks for Infectious Diseases Training Programs

The Infectious Diseases Society of America Training Program Directors Committee met in October 2022 and discussed an observed increase in clinical volume and acuity on infectious diseases (ID) services, and its impact on fellow education. Committee members sought to develop specific goals and strategies related to improving training program culture, preserving quality education on inpatient consult services and in the clinic, and negotiating change at the annual IDWeek Training Program Director meeting. This paper outlines a presentation of ideas brought forth at the meeting and is meant to serve as a reference document for infectious diseases training program directors seeking guidance in this area.

Should Contact Precautions Be Used for Patients with MRSA Infection and Colonization in Acute Care Settings?

Are Contact Precautions for Patients with MRSA Useful?MRSA infections lead to substantial morbidity and mortality. Hospitals commonly implement "contact precautions" to reduce MRSA transmission; however, recent studies have challenged the effectiveness of this strategy, and the use of contact precautions has been associated with certain adverse events. This article reviews the existing evidence and proposes a randomized trial to assess the efficacy of contact precautions in preventing MRSA transmission.

Surgeons' Perspectives on Valve Surgery in People With Drug Use-Associated Infective Endocarditis

BACKGROUND

Hospitalizations for drug-use associated infective endocarditis (DUA-IE) have led to increasing surgical consultation for valve replacement. Cardiothoracic surgeons' perspectives about the process of decision making around operation for people with DUA-IE are largely unknown.

METHODS

This multisite semiqualitative study sought to gather the perspectives of cardiothoracic surgeons on initial and repeat valve surgery for people with DUA-IE through purposeful sampling of surgeons at 7 hospitals: University of Alabama, Tufts Medical Center, Boston Medical Center, Massachusetts General Hospital, University of North Carolina-Chapel Hill, Vanderbilt University Medical Center, and Rhode Island Hospital-Brown University.

RESULTS

Nineteen cardiothoracic surgeons (53% acceptance) were interviewed. Perceptions of the drivers of addiction varied as well as approaches to repeat valve operations. There were mixed views on multidisciplinary meetings, although many surgeons expressed an interest in more efficient meetings and more intensive postoperative and posthospitalization multidisciplinary care.

CONCLUSIONS

Cardiothoracic surgeons are emotionally and professionally impacted by making decisions about whether to perform valve operation for people with DUA-IE. The use of efficient, agenda-based multidisciplinary care teams is an actionable solution to improve cross-disciplinary partnerships and outcomes for people with DUA-IE.

Alternate Care Site Infection Prevention and Control Practices: A Rapid Systematic Review

Alternate care sites (ACSs) are temporary medical locations established in response to events that disrupt or limit the ability of established medical facilities to provide adequate care. As with established medical facilities, ACSs require careful consideration of infection prevention and control (IPC) practices to mitigate risk of nosocomial transmission and occupational exposure. We conducted a rapid systematic review of published literature from the date of inception of each database until the date the search was run (September 2021) on the IPC practices in ACSs. The practices described were categorized using the National Institute of Occupational Safety and Health hierarchy of controls framework, including elimination, substitution, engineering controls, administrative controls, and personal protective equipment. Of 313 articles identified, 55 were included. The majority (n=45, 81.8%) were case reports and described ACSs established in the context of infectious disease outbreaks (n=48, 87.3%), natural disasters (n=5, 9%), and military deployments (n=2, 3.6%). Implementation of engineering and/or administrative control practices predominated, with personal protective equipment emphasized in articles related to infectious disease outbreaks. These findings emphasize both a need for more high-quality research into the best practices for IPC in ACSs and how to incorporate the most effective strategies in these settings in response to future events.

Inclusion, Diversity, Access, and Equity in Infectious Diseases Fellowship Training: Tools for Program Directors

The Infectious Diseases Society of America (IDSA) has set clear priorities in recent years to promote inclusion, diversity, access, and equity (IDA&E) in infectious disease (ID) clinical practice, medical education, and research. The IDSA IDA&E Task Force was launched in 2018 to ensure implementation of these principles. The IDSA Training Program Directors Committee met in 2021 and discussed IDA&E best practices as they pertain to the education of ID fellows. Committee members sought to develop specific goals and strategies related to recruitment, clinical training, didactics, and faculty development. This article represents a presentation of ideas brought forth at the meeting in those spheres and is meant to serve as a reference document for ID training program directors seeking guidance in this area.

If you don't test, they will not treat: Impact of stopping preoperative screening for asymptomatic bacteriuria

Objective

Screening for asymptomatic bacteriuria (ASB) is not recommended outside of patients undergoing invasive urological procedures and during pregnancy. Despite national guidelines recommending against screening for ASB, this practice is prevalent. We present outcomes from a quality-improvement intervention targeting patients undergoing cardiac artery bypass grafting surgery (CABG) at Massachusetts General Hospital, a tertiary-care hospital in Boston, Massachusetts, where preoperative testing checklists were modified to remove routine urinalysis and urine culture. This was a before-and-after intervention study.

Methods

Prior to the intervention, screening for ASB was included in the preoperative check list for all patients undergoing CABG. We assessed the proportion of patients undergoing screening for ASB in the 6 months prior to and after the intervention. We estimated cost savings from averted laboratory analyses, and we evaluated changes in antibiotic prescriptions. We additionally examined the incidence of postoperative surgical-site infections (SSIs), central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs) and Clostridioides difficile infections (CDIs).

Results

Comparing the pre- and postintervention periods, urinalyses decreased by 76.5% and urine cultures decreased by 87.0%, with an estimated cost savings of $8,090.38. There were 50% fewer antibiotic prescriptions for bacteriuria after the intervention.

Conclusions

Removal of urinalysis and urine culture from preoperative checklists for cardiac surgery led to a statistically significant decrease in testing without an increase in SSIs, CLABSIs, CAUTIs, or CDI. Challenges identified included persistence of checklists in templated order sets in the electronic health record.

159. Antibiotic and diagnostic stewardship surrounding pre-operative testing in patients undergoing cardiac surgery

Background

Despite national guidelines from the US Preventative Services Task Force and the Infectious Diseases Society of America that recommend against screening for asymptomatic bacteriuria (ASB, defined as &gt; 105 CFU of an organism) in most circumstances, pre-operative screening urine culture (UCx) continues. Detection and treatment of ASB leads to antibiotic exposure and risk of antibiotic-associated adverse events like drug reactions, Clostridioides difficile infection (CDI), and colonization by drug-resistant organisms. We describe the implementation of eliminating pre-operative screening for ASB in patients undergoing cardiac surgery. Figure 1Pre-operative checklist for cardiac surgery prior to intervention

Methods

This was a pre-post study of practice change involving removing ASB screening as part of the pre-cardiac surgery checklist (Figure 1). The pre-intervention period was 08/18/21 – 11/17/21, the post intervention period was 12/1/21 – 3/1/22. We identified all patients who underwent a cardiac arterial bypass graft procedure with or without vein harvesting. We reviewed pre-operative UCx, test indication, antibiotic administration pre-operatively due to culture growth, and post-operative CDI and CAUTI within 30 days post procedure identified through routine infection prevention and control surveillance.

Results

Pre-intervention, 117/128 (91.4%) patients undergoing cardiac surgery had a UCx collected. Of the UCx, 100% were ordered as part of the pre-operative checklist and not for symptoms. Five patients pre-intervention had ASB detected. Four patients received antibiotics to treat ASB. A fifth patient received antibiotics for bacteriuria which did not meet ASB count threshold. Post-intervention, 15/123 had a UCx (12.3%). Of these, 12/15 were ordered as part of the pre-operative checklist (80%), and the remaining three had symptoms documented. Post-intervention, one patient had ASB detected and did not receive antibiotics. Pre- and post-intervention there were 2 cases of CDI (2/128, 1.6% and 2/123, 1.6%, respectively). There were no CAUTIs either pre- or post-intervention.

Conclusion

Standard pre-operative UCx is known to be a low-value test and is not recommended by national guidelines. In this single-center diagnostic stewardship intervention, screening was reduced by 87.2%. There was no change in infectious outcomes.

Disclosures

All Authors: No reported disclosures.

Creation of a Multidisciplinary Drug Use Endocarditis Treatment (DUET) Team: Initial Patient Characteristics, Outcomes, and Future Directions

Background

Consensus guidelines recommend multidisciplinary models to manage infective endocarditis, yet often do not address the unique challenges of treating people with drug use–associated infective endocarditis (DUA-IE). Our center is among the first to convene a Drug Use Endocarditis Treatment (DUET) team composed of specialists from Infectious Disease, Cardiothoracic Surgery, Cardiology, and Addiction Medicine.

Methods

The objective of this study was to describe the demographics, infectious characteristics, and clinical outcomes of the first cohort of patients cared for by the DUET team. This was a retrospective chart review of patients referred to the DUET team between August 2018 and May 2020 with DUA-IE.

Results

Fifty-seven patients were presented to the DUET team between August 2018 and May 2020. The cohort was young, with a median age of 35, and injected primarily opioids (82.5% heroin/fentanyl), cocaine (52.6%), and methamphetamine (15.8%). Overall, 14 individuals (24.6%) received cardiac surgery, and the remainder (75.4%) were managed with antimicrobial therapy alone. Nearly 65% of individuals were discharged on medication for opioid use disorder, though less than half (36.8%) were discharged with naloxone and only 1 patient was initiated on HIV pre-exposure prophylaxis. Overall, the cohort had a high rate of readmission (42.1%) within 90 days of discharge.

Conclusions

Multidisciplinary care models such as the DUET team can help integrate nuanced decision-making from numerous subspecialties. They can also increase the uptake of addiction medicine and harm reduction tools, but further efforts are needed to integrate harm reduction strategies and improve follow-up in future iterations of the DUET team model.

Baseline procalcitonin as a predictor of bacterial infection and clinical outcomes in COVID-19: A case-control study

PURPOSE

Coronavirus disease-2019 (COVID-19) is associated with a wide spectrum of clinical symptoms including acute respiratory failure. Biomarkers that can predict outcomes in patients with COVID-19 can assist with patient management. The aim of this study is to evaluate whether procalcitonin (PCT) can predict clinical outcome and bacterial superinfection in patients infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).

METHODS

Adult patients diagnosed with SARS-CoV-2 by nasopharyngeal PCR who were admitted to a tertiary care center in Boston, MA with SARS-CoV-2 infection between March 17 and April 30, 2020 with a baseline PCT value were studied. Patients who were presumed positive for SARS-CoV-2, who lacked PCT levels, or who had a positive urinalysis with negative cultures were excluded. Demographics, clinical and laboratory data were extracted from the electronic medical records.

RESULTS

324 patient charts were reviewed and grouped by clinical and microbiologic outcomes by day 28. Baseline PCT levels were significantly higher for patients who were treated for true bacteremia (p = 0.0005) and bacterial pneumonia (p = 0.00077) compared with the non-bacterial infection group. Baseline PCT positively correlated with the NIAID ordinal scale and survival over time. When compared to other inflammatory biomarkers, PCT showed superiority in predicting bacteremia.

CONCLUSIONS

Baseline PCT levels are associated with outcome and bacterial superinfection in patients hospitalized with SARS-CoV-2.

956. Neurosurgical Infectious Disease Curriculum for Infectious Disease Fellows and Application of a Novel Surgical Infectious Disease Framework

Background

Infectious disease (ID) consultations from surgical services account for 30-41% of all ID consults at academic medical centers. However, adult ID fellows in the United States complete residency training in Internal Medicine and may have limited prior exposure to patients on surgical services. We surveyed 16 first and second-year fellows of the combined Massachusetts General Hospital/Brigham and Women’s Hospital ID Fellowship to evaluate their self-perceived ability to approach ID consults from surgical services. While 75% self-reported confidence in their ability to approach general surgery consultations, only 33% reported confidence with neurosurgical related consultations.

Methods

We created a novel framework for approaching surgical ID consult questions (Figure 1). We then developed two interactive case-based discussion sessions for first-year fellows to address common neurosurgical consult scenarios (post craniotomy/ craniectomy surgical site infections and cerebral spinal fluid shunt infections). The session materials, including images of common surgical approaches and risk factors for infection, were reviewed by a neurosurgeon content expert. An ID faculty member facilitated the discussions. Each discussion took place during a 30-minute teleconference. The learners then completed a self-assessment survey to evaluate the extent to which they could meet the educational objectives (Table 1) using a 1-5 Likert scale.

Figure 1. Surgical Infectious Diseases Framework

Table 1. Educational Objectives for Case 1 and 2

Results

All sixteen learners (eight per case) completed the educational objective self-assessment surveys. The educational objectives were achieved with all questions reaching a mean response of 4 or greater indicating that the mean of learners agreed (4) or strongly agreed (5) that they were able to meet the outlined educational objectives after participating in the discussion session for Case 1 (Figure 2) and Case 2 (Figure 3).

Figure 2. Educational Objective Self-Assessment Scores for Case 1

Figure 3. Educational Objective Self-Assessment Scores for Case 2

Conclusion

Based on self-assessment surveys, our educational objectives were achieved. In turn, these first-year fellows may be better prepared to address ID consults from neurosurgical services in the future. While the case-based discussions were designed to address specific neurosurgical ID cases, our standardized framework could be adapted to a variety of surgical ID cases.

Disclosures

Molly L. Paras, MD, Deckermed (Other Financial or Material Support, Payment for book chapter)

The Time is Now: A Call for Renewed Support of Infectious Diseases Physician-Scientist Trainees in the Era of Coronavirus Disease 2019

Infectious diseases fellows’ futures have been uniquely imperiled by the pandemic. In this article, we issue a call to action to sustain their careers as the future leaders of infectious diseases inquiry.

Remdesivir use and outcomes during the FDA COVID-19 emergency use authorization period

Background:

Remdesivir (RDV) was approved for treatment of coronavirus disease 2019 (COVID-19), in May 2020 under US Food and Drug Administration emergency use authorization (EUA). Clinical outcomes related to RDV use in hospitalized patients during the EUA period are not well described.

Methods:

We conducted a retrospective study of patients who received RDV under EUA. The primary outcome was clinical recovery by day 14 as determined by an eight-category ordinal scale. Secondary outcomes included recovery and survival to day 28, and adverse events. Recovery and survival were calculated using a stratified log-rank Kaplan–Meier estimator and a Cox proportional hazards model.

Results:

Overall, 164 patients received RDV between May and October 2020, and 153 (93.3%) had evaluable data. Most (77.1%) were hospitalized within 10 days of symptom onset, and 79.7% started RDV within 48 hours. By days 14 and 28, 96 (62.7%) and 117 patients (76.5%) met the definition of clinical recovery, respectively. Median time to recovery was 6 days [interquartile range (IQR) 4–12]. Mortality rates were 6.5% and 11.8% by days 14 and 28, respectively. Age and time to start of RDV after hospital admission were predictive of recovery and 28-day mortality.

Conclusions:

In this real-world experience, outcomes after 5 days of RDV therapy were comparable to those of clinical trials. Disease severity, age, and dexamethasone use influenced clinical outcomes. Time to RDV initiation appeared to affect recovery and 28-day mortality, a finding that should be explored further. Mortality rate decreased over the analysis period, which could be related to dexamethasone use and improved management of COVID-19.

Is Resident-Driven Inpatient Care More Expensive? Challenging a Long-Held Assumption

PURPOSE

The financial impact of graduate medical education (GME) on teaching hospitals remains poorly understood, while calls for increased federal support continue alongside legislative threats to reduce funding. Despite studies suggesting that residents are more "economical" than alternative providers, GME is widely believed to be an expensive investment. Assumptions that residents increase the cost of patient care have persisted in the absence of convincing evidence to the contrary. Thus, the authors sought to examine resident influence on patient care costs by comparing costs between a resident-driven service (RS) and a nonresident-covered service (NRS), with attention to clinical outcomes and how potential cost differences relate to the utilization of resources, length of stay (LOS), and other factors.

METHOD

This prospective study compared costs and clinical outcomes of internal medicine patients admitted to an RS versus an NRS at Massachusetts General Hospital (July 1, 2016-June 30, 2017). Total variable direct costs of inpatient admission was the primary outcome measure. LOS; 30-day readmission rate; utilization related to diagnostic radiology, pharmaceuticals, and clinical labs; and other outcome measures were also compared. Linear regression models quantified the relationship between log-transformed variable direct costs and service.

RESULTS

Baseline characteristics of 5,448 patients on the 2 services (3,250 on an RS and 2,198 on an NRS) were similar. On an RS, patient care costs were slightly less and LOS was slightly shorter than on an NRS, with no significant differences in hospital mortality or 30-day readmission rate detected. Resource utilization was comparable between the services.

CONCLUSIONS

These findings undermine long-held assumptions that residents increase the cost of patient care. Though not generalizable to ambulatory settings or other specialties, this study can help inform hospital decision making around sponsorship of GME programs, especially if federal funding for GME remains capped or is subject to additional reductions.

709. Multidisciplinary Drug Use Endocarditis Team (DUET): Results From an Academic Center Cohort

Background

Guidelines recommend multidisciplinary models for the management of infective endocarditis but have failed to incorporate the unique challenges of treating drug-use associated infective endocarditis (DUA-IE). Given the drug use and overdose epidemic with rising cases of DUA-IE, we created a multidisciplinary Drug Use Endocarditis Team (DUET), which convened monthly case conferences among the specialties involved, including Infectious Diseases, Cardiothoracic Surgery, Cardiology and Addiction Medicine. Objective: To conduct a retrospective cohort study of the patients presented at the DUET conferences from August 2018 to February 2020 to (1) assess clinical and demographic characteristics and (2) describe clinical outcomes.

Methods

A retrospective chart review was conducted to analyze 57 patient cases, including descriptive statistical analyses of demographics, clinical characteristics, and outcomes.

Results

Among our DUET cohort, 43.8% represented isolated right-sided endocarditis, and 84% involved native valve. Methicillin-susceptible Staphylococcus aureus was the most common microorganism isolated. ID was consulted in 94.7% of cases and overall 43.9% completed the planned antimicrobial course. The 7 patients who developed relapse/recurrent IE were initially managed medically, and 5 did not complete the initial antimicrobial course. Formal cardiothoracic surgery consultation was obtained in 57.9% and 24.6% were managed operatively. Of the patients managed operatively, 64.3% completed the antimicrobial course. The rate of antibiotic completion was higher among patients managed operatively but did not reach statistical significance (p=0.08). Formal addiction medicine consultation was obtained in 85.9% of cases, with 63.1% discharged on medications for opioid use disorder (MOUD). The rate of MOUD on discharge was not significantly different between patients managed operatively and non-operatively.

Figure 1: Patient Characteristics

Figure 2: Infection Characteristics

Figure 3: Outcome Analyses

Conclusion

ID is nearly universally involved in the care of patients with DUA-IE, but this patient population requires input from numerous sub-specialties. Multidisciplinary care teams provide a promising framework for DUA-IE to enhance and integrate nuanced decision-making.

Disclosures

Sarah E. Wakeman, MD, Celero Systems (Advisor or Review Panel member)Optum Labs (Grant/Research Support)UpToDate (Other Financial or Material Support, Author)

1482. Local validation of the drug resistance in pneumonia clinical prediction score at a large academic medical center and a community hospital

Background

Community-acquired pneumonia (CAP) is responsible for ~1 million emergency department (ED) visits yearly and the leading cause of infection-related deaths. Given that increasing antibiotic resistance rates complicate appropriate empiric antibiotic selection, clinicians may benefit from tools to help identify patients at risk for drug-resistant pathogens (DRPs). Limitations of traditional tools, such as healthcare-associated pneumonia criteria (HCAP), have led to development of novel scoring tools such as the drug resistance in pneumonia (DRIP) score. Webb et al. showed the DRIP score was more predictive of CAP caused by DRPs than HCAP criteria. The objective of this study was to validate the DRIP score in a local population of hospitalized patients at an academic and a community medical center.

Methods

Patients who presented to the ED between May 2017 and May 2019 were included in this retrospective review. Patients were included if they were ≥ 18 years diagnosed with CAP by radiographic evidence with respiratory culture positivity and susceptibility results. Exclusion criteria were: presence of non-bacterial non-respiratory pathogens, patients with cystic fibrosis, lung transplant or systemic co-infections. The primary outcome was validation of the DRIP score by comparing the sensitivity, specificity, negative and positive predictive values (NPV/PPV) to the derivation and validation study by Webb et al. Secondary outcomes were the percentage of CAP cases with DRPs and the predictability of DRP using the DRIP score versus HCAP criteria.

Results

A total of 164 patients were included; 60.4% were male with a median age of 70 years. The primary outcome shown in Table 1 demonstrated similar sensitivity, specificity, NPV, and PPV of the DRIP score to those in the study by Webb et al. Staphylococcus aureus (32.9%) and Streptococcus pneumoniae (27.4%) were the most commonly isolated pathogens and CAP due to DRPs occurred in 30.5% of patients. The DRIP score also demonstrated improved performance in predicting DRPs in CAP compared to the HCAP Criteria as shown in Table 2.

Table 1. DRIP Score Validation

Conclusion

Our results further validate the DRIP score derived by Webb et al. in predicting DRPs in CAP. These results encourage a local prospective evaluation of the DRIP score as an antimicrobial stewardship tool.

Disclosures

All Authors: No reported disclosures

61. Evaluation of the Impact of a Micafungin Time-Out Protocol for Hospitalized Patients

Background

Echinocandin overuse is associated with increased prevalence of non-albicans Candida spp, resistance, and high costs. Prospective review of micafungin prescribing by an Antimicrobial Stewardship Pharmacist (ASP) has shown reduced rates of inappropriate therapy. The aim of this study was to describe ASP’s interventions following introduction of a micafungin time out (MTO) protocol.

Methods

The approved MTO protocol was implemented in November 2019. Active micafungin orders for hospitalized patients were reviewed Monday through Friday at initiation and on day five. The MTO algorithm assessed micafungin use based on patient risk factors for Candida infection and de-escalation was guided by clinical status, culture data, and susceptibility testing. Micafungin use and ASP’s interventions were reviewed post-implementation between 12/01/2019 and 02/29/2020. Micafungin use was also characterized between 12/01/2018 and 02/28/2019 to serve as a control.

Results

A random sample of 50 patients who received micafungin for ≥ 48 hours during the pre- and post- protocol periods were included. 39 (78%) and 38 (76%) patients in the pre- and post-MTO cohort had indications for micafungin initiation according to algorithm. In the post-MTO group, 9 (75%) of the 12 micafungin initiations outside of algorithm approval were intervened on successfully by the ASP, increasing appropriate antifungal therapy to 47 (94%) patients. On day five, 18 (50%) and 25 (65.8%) (p=0.17) micafungin orders were according to algorithm in the pre- and post-MTO groups, respectively. Culture data on day five revealed 18 (50%) in the pre-MTO and 13 (34.2%) in the post-MTO group were eligible for de-escalation. An ASP-initiated MTO on day five identified 23 opportunities for antifungal therapy optimization in the post-MTO group. Interventions included de-escalation (13; 61.9%), discontinuation (6; 28.6%), and dose optimization (4; 19%). Of the 23 ASP interventions on day 5, 10 (43.4%) led to micafungin discontinuation or de-escalation, increasing the overall antifungal appropriateness to 35 (92.1%) patients.

Conclusion

An ASP-initiated MTO can facilitate appropriate and timely optimization of antifungal therapy. The most frequent interventions were de-escalation from micafungin or therapy discontinuation.

Disclosures

All Authors: No reported disclosures

Jamestown Canyon virus in Massachusetts: clinical case series and vector screening

Jamestown Canyon virus (JCV) is a neuroinvasive arbovirus that is found throughout North America and increasingly recognized as a public health concern. From 2004 to 2012, an average of 1.7 confirmed cases were reported annually in the United States, whereas from 2013 to 2018 this figure increased over seventeen-fold to 29.2 cases per year. The rising number of reported human infections highlights the need for better understanding of the clinical manifestations and epidemiology of JCV. Here, we describe nine patients diagnosed with neuroinvasive JCV infection in Massachusetts from 2013, the year of the first reported case in the state, to 2017. Because current diagnostic testing relies on serology, which is complicated by cross-reactivity with related orthobunyaviruses and can be negative in immunosuppressed patients, we developed and evaluated an RT-qPCR assay for detection of JCV RNA. We tested this on the available archived serum from two patients, but did not detect viral RNA. JCV is transmitted by multiple mosquito species and its primary vector in Massachusetts is unknown, so we additionally applied the RT-qPCR assay and confirmatory RNA sequencing to assess JCV prevalence in a vector candidate, Ochlerotatus canadensis. We identified JCV in 0.6% of mosquito pools, a similar prevalence to neighboring Connecticut. We assembled the first Massachusetts JCV genome directly from a mosquito sample, finding high identity to JCV isolates collected over a 60-year period. Further studies are needed to reconcile the low vector prevalence and low rate of viral evolutionary change with the increasing number of reported cases.

The Struggling Infectious Diseases Fellow: Remediation Challenges and Opportunities

Remediation of struggling learners is a challenge faced by all educators. In recognition of this reality, and in light of contemporary challenges facing infectious diseases (ID) fellowship program directors, the Infectious Diseases Society of America Training Program Directors' Committee focused the 2018 National Fellowship Program Directors' Meeting at IDWeek on "Remediation of the Struggling Fellow." Small group discussions addressed 7 core topics, including feedback and evaluations, performance management and remediation, knowledge deficits, fellow well-being, efficiency and time management, teaching skills, and career development. This manuscript synthesizes those discussions around a competency-based framework to provide program directors and other educators with a roadmap for addressing common contemporary remediation challenges.

Natural history of colonization with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE): a systematic review

Background

No published systematic reviews have assessed the natural history of colonization with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE). Time to clearance of colonization has important implications for patient care and infection control policy.

Methods

We performed parallel searches in OVID Medline for studies that reported the time to documented clearance of MRSA and VRE colonization in the absence of treatment, published between January 1990 and July 2012.

Results

For MRSA, we screened 982 articles, identified 16 eligible studies (13 observational studies and 3 randomized controlled trials), for a total of 1,804 non-duplicated subjects. For VRE, we screened 284 articles, identified 13 eligible studies (12 observational studies and 1 randomized controlled trial), for a total of 1,936 non-duplicated subjects. Studies reported varying definitions of clearance of colonization; no study reported time of initial colonization. Studies varied in the frequency of sampling, assays used for sampling, and follow-up period. The median duration of total follow-up was 38 weeks for MRSA and 25 weeks for VRE. Based on pooled analyses, the model-estimated median time to clearance was 88 weeks after documented colonization for MRSA-colonized patients and 26 weeks for VRE-colonized patients. In a secondary analysis, clearance rates for MRSA and VRE were compared by restricting the duration of follow-up for the MRSA studies to the maximum observed time point for VRE studies (43 weeks). With this restriction, the model-fitted median time to documented clearance for MRSA would occur at 41 weeks after documented colonization, demonstrating the sensitivity of the pooled estimate to length of study follow-up.

Conclusions

Few available studies report the natural history of MRSA and VRE colonization. Lack of a consistent definition of clearance, uncertainty regarding the time of initial colonization, variation in frequency of sampling for persistent colonization, assays employed and variation in duration of follow-up are limitations of the existing published literature. The heterogeneity of study characteristics limits interpretation of pooled estimates of time to clearance, however, studies included in this review suggest an increase in documented clearance over time, a result which is sensitive to duration of follow-up.

Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis

OBJECTIVE

To systematically assess the evidence for an association between sexual abuse and a lifetime diagnosis of psychiatric disorders.

PATIENTS AND METHODS

We performed a comprehensive search (from January 1980-December 2008, all age groups, any language, any population) of 9 databases: MEDLINE, EMBASE, CINAHL, Current Contents, PsycINFO, ACP Journal Club, CCTR, CDSR, and DARE. Controlled vocabulary supplemented with keywords was used to define the concept areas of sexual abuse and psychiatric disorders and was limited to epidemiological studies. Six independent reviewers extracted descriptive, quality, and outcome data from eligible longitudinal studies. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled across studies by using the random-effects model. The I(2) statistic was used to assess heterogeneity.

RESULTS

The search yielded 37 eligible studies, 17 case-control and 20 cohort, with 3,162,318 participants. There was a statistically significant association between sexual abuse and a lifetime diagnosis of anxiety disorder (OR, 3.09; 95% CI, 2.43-3.94), depression (OR, 2.66; 95% CI, 2.14-3.30), eating disorders (OR, 2.72; 95% CI, 2.04-3.63), posttraumatic stress disorder (OR, 2.34; 95% CI, 1.59-3.43), sleep disorders (OR, 16.17; 95% CI, 2.06-126.76), and suicide attempts (OR, 4.14; 95% CI, 2.98-5.76). Associations persisted regardless of the victim's sex or the age at which abuse occurred. There was no statistically significant association between sexual abuse and a diagnosis of schizophrenia or somatoform disorders. No longitudinal studies that assessed bipolar disorder or obsessive-compulsive disorder were found. Associations between sexual abuse and depression, eating disorders, and posttraumatic stress disorder were strengthened by a history of rape.

CONCLUSION

A history of sexual abuse is associated with an increased risk of a lifetime diagnosis of multiple psychiatric disorders.

Sexual abuse and lifetime diagnosis of somatic disorders: a systematic review and meta-analysis

CONTEXT

Many patients presenting for general medical care have a history of sexual abuse. The literature suggests an association between a history of sexual abuse and somatic sequelae.

OBJECTIVE

To systematically assess the association between sexual abuse and a lifetime diagnosis of somatic disorders. Data Sources and Extraction A systematic literature search of electronic databases from January 1980 to December 2008. Pairs of reviewers extracted descriptive, quality, and outcome data from included studies. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled across studies by using the random-effects model. The I(2) statistic was used to assess heterogeneity.

STUDY SELECTION

Eligible studies were longitudinal (case-control and cohort) and reported somatic outcomes in persons with and without history of sexual abuse.

RESULTS

The search identified 23 eligible studies describing 4640 subjects. There was a significant association between a history of sexual abuse and lifetime diagnosis of functional gastrointestinal disorders (OR, 2.43; 95% CI, 1.36-4.31; I(2) = 82%; 5 studies), nonspecific chronic pain (OR, 2.20; 95% CI, 1.54-3.15; 1 study), psychogenic seizures (OR, 2.96; 95% CI, 1.12-4.69, I(2) = 0%; 3 studies), and chronic pelvic pain (OR, 2.73; 95% CI, 1.73-4.30, I(2) = 40%; 10 studies). There was no statistically significant association between sexual abuse and a lifetime diagnosis of fibromyalgia (OR, 1.61; 95% CI, 0.85-3.07, I(2) = 0%; 4 studies), obesity (OR, 1.47; 95% CI, 0.88-2.46; I(2) = 71%; 2 studies), or headache (OR, 1.49; 95% CI, 0.96-2.31; 1 study). We found no studies that assessed syncope. When analysis was restricted to studies in which sexual abuse was defined as rape, significant associations were observed between rape and a lifetime diagnosis of fibromyalgia (OR, 3.35; 95% CI, 1.51-7.46), chronic pelvic pain (OR, 3.27; 95% CI, 1.02-10.53), and functional gastrointestinal disorders (OR, 4.01; 95% CI, 1.88-8.57).

CONCLUSION

Evidence suggests a history of sexual abuse is associated with lifetime diagnosis of multiple somatic disorders.