Empirical Coverage Research Articles

The Multilingual Assessment Instrument for Narratives (MAIN): Adding Chuvash to MAIN

This paper describes the process of translating and adapting the Multilingual Assessment Instrument for Narratives (MAIN) to Chuvash. Chuvash is one of the largest minority languages in the European part of Russia. The Chuvash MAIN not only extends the empirical coverage of MAIN by including the only extant member of the Oghur (Bulgar) branch of the Turkic language family, but also offers an important tool to assess the narrative abilities of Russian-Chuvash bilingual children in their first language.

The association between mortality and door-to-antibiotic time: a systematic review and meta-analysis.

Previous studies evaluating the impact of antibiotic timing on mortality in sepsis have shown conflicting results. We performed a meta-analysis to evaluate the association between door-to-antibiotic time (each hour of delay) and mortality in sepsis. We searched PubMed and Embase through 10 November 2022 to identity cohort studies that evaluated the adjusted association between door-to-antibiotic time (each hour of delay) and mortality in adult patients with sepsis. The primary outcome was mortality. Analysis was based on inverse-variance weighting using a fixed-effects model. The variances were derived from the logarithms of the reported confidence intervals (CIs) for associations. We estimated the odds ratio, 95% CI, and number needed to treat for the pooled data. Fifteen cohort studies involving 106 845 patients were included in the meta-analysis. Door-to-antibiotic time (each hour of delay) was associated with increased risk of mortality (odds ratio: 1.07; 95% CI: 1.06-1.08; P < 0.0001; number needed to treat = 91), with high heterogeneity (I2 = 82.2%). The association was robust in sensitivity analyses and consistent in subgroup analyses. No publication bias was found. In adult patients with sepsis, each hour of delay in antibiotic administration is associated with increased odds of mortality. Key messages What is already known on this topic Sepsis is a common and lethal syndrome that affects millions of people worldwide. The updated 2018 Surviving Sepsis Campaign guidelines recommended initiating empirical broad-spectrum antibiotic coverage within 1 hour of identification of sepsis and septic shock. Delay in antibiotic administration may increase the risk of mortality in patients with sepsis. What this study adds This meta-analysis evaluates and quantifies the association between door-to-antibiotic time (each hour of delay) and mortality in patients with sepsis. Each hour of delay in antibiotic administration is associated with increased odds of mortality in sepsis. The number needed to treat (NNT) with delayed antibiotic administration for one additional death was 91. How this study might affect research, practice, or policy: More efforts should be made to speed up the diagnosis of sepsis or sepsis shock.

Meropenem allergy testing performed at the bedside of hospitalized patients labelled with a penicillin allergy

BackgroundMeropenem is a widely prescribed beta-lactam for hospitalized patients. There are few data on meropenem allergy assessments in inpatients with a reported history of penicillin allergy who require a treatment with meropenem. This can lead to the use of less effective second-line antibiotics that may increase antibiotic resistances. We aimed to evaluate the clinical outcomes of a meropenem allergy assessment in admitted patients with a reported history of penicillin allergy that required meropenem for the treatment of an acute infection. MethodsA retrospective analysis was performed on 182 inpatients labelled with a penicillin-allergy who received meropenem after an allergy assessment. The allergy study was performed bedside if meropenem was required urgently. The study included skin prick tests (SPTs) followed by an intradermal skin test (IDT) to meropenem, and a meropenem drug challenge test (DCT). If a non-immediate reaction to a beta-lactam was suspected, it was initiated with patch tests. ResultsThe median age of the patients was 59.7 years (range 28–95) and 80 (44%) were women. A total of 196 sets of diagnostic workups were performed, with 189 (96.4%) of them being tolerated. Only two patients had a positive meropenem IV DCT, both presenting a non-severe cutaneous reaction that completely resolved after treatment. ConclusionsThis study evidenced that a bedside meropenem allergy assessment of hospitalized patients labelled with a ‘penicillin allergy’ who require a broad-spectrum antibiotic for empiric coverage is a safe and effective procedure, avoiding the use of second-line antimicrobial agents.

Omadacycline in treating community-based infections: a review and expert perspective

ABSTRACT Introduction Omadacycline is approved for the treatment of community-acquired bacterial pneumonia (CABP) and acute bacterial skin and soft tissue infection (ABSSSI). The integration of newer agents into clinical use involves understanding the nuances of clinical decision-making. This review will provide an in-depth focus on omadacycline in clinical practice. Areas covered Literature review of omadacycline utilizing PubMed was performed to provide a comprehensive evaluation of omadacycline pharmacology, microbiology, registrational Phase 3 clinical trials, and post-marketing clinical studies. In addition, the immunomodulatory and other attributes of tetracycline class of antibiotics, of which omadacycline is a member, are reviewed, introducing the concept of antibiotic selection with attention to the bacterial pathogen and human host relationship. Expert opinion Omadacycline builds upon the favorable attributes of tetracycline antibiotics and provides very reliable empiric coverage for both Staphylococcus aureus and Streptococcus spp. Clinicians require a more robust understanding of antibiotics, including omadacycline, in order to optimize patient outcomes, streamline care, and reduce medical costs.

Regularized fingerprinting in detection and attribution of climate change with weight matrix optimizing the efficiency in scaling factor estimation

Detection and attribution analyses play a central role in establishing the causal effect of human activities on global warming. The most commonly used method in such analyses, optimal fingerprinting, is a multiple regression where each covariate has a measurement error whose covariance matrix is the same as that of the regression error up to a known scale. Inferences about the regression coefficients are critical not only for making statements about detection and attribution but also for quantifying the uncertainty in important outcomes derived from detection and attribution analyses. When there are no errors-in-variables (EIV), the optimal weight matrix in estimating the regression coefficients is the precision matrix of the regression error. This matrix, however, is never known and has to be estimated from climate model simulations with regularization. The consequence is that the optimal fingerprinting method is not optimal, as believed in practice. We construct a weight matrix by inverting a nonlinear shrinkage estimate of the error covariance matrix that minimizes loss functions directly targeting the uncertainty of the resulting regression coefficient estimator. The resulting estimator of the regression coefficients is asymptotically optimal as the sample size of the climate model simulations and the matrix dimension go to infinity together with a limiting ratio. When EIVs are present, the estimator of the regression coefficients, based on the proposed weight matrix, is asymptotically more efficient than that based on the inverse of the existing linear shrinkage estimator of the error covariance matrix. The performance of the method is confirmed in finite sample simulation studies mimicking realistic situations in terms of the length of the confidence intervals and empirical coverage rates for the regression coefficients. In an application to detection and attribution analyses of the mean temperature at different spatial scales, the method yielded shorter confidence intervals which are important for such analyses in practice.

Within State Variability of Antimicrobial Susceptibility: Missouri as an Archetype to Assess Guidelines for Antimicrobial Prophylaxis for Transurethral Procedures

To evaluate variability among hospitals in susceptibility of common uropathogens to antimicrobial agents frequently used in transurethral procedures in order to examine whether state-based guidelines might be more appropriate than national prophylactic guidelines. Hospital-level antibiograms were requested from all hospitals throughout the state of Missouri. We studied Escherichia coli, Klebsiella, and Proteus sensitivities to evaluate common guideline recommended antimicrobials including trimethoprim sulfamethoxazole (TMP-SMX), third-generation cephalosporins, cefazolin, penicillin combinations, gentamicin, and fluoroquinolones. We evaluated variability and association between hospital characteristics and antimicrobial sensitivities. Data was requested from 81 hospitals across the state and 38 provided the requested data (47% response rate). Susceptibility was highest for third-generation cephalosporins for E. coli (mean of 94%), Proteus (96%), and Klebsiella (96%). Gentamicin also had high susceptibility for the bacteria studied; 94% for E. coli and 96% for Klebsiella. Current first line recommended agents showed more modest coverage for E. coli (cefazolin 84%, TMP-SMX 78%), Proteus (cefazolin 82%, TMP-SMX 71%), and Klebsiella (cefazolin 90%, TMP-SMX 89%). Post transurethral procedure infections are common. Rates can be limited with appropriate prophylaxis. Deciding on empirical coverage must take into account local resistance patterns. There is substantial variability among and within states in antimicrobial susceptibility for common uropathogens. When selecting antimicrobial prophylaxis, urologists should consider local- rather than state- or nation-level antibiograms, given the considerable variability. Future studies should consider the merits of very-broad spectrum prophylaxis and the potential role of molecular urinary pathogen (and pathogen-resistance) testing when selecting an optimal regimen.

Simulation comparisons between Bayesian and de-biased estimators in low-rank matrix completion

In this paper, we study the low-rank matrix completion problem, a class of machine learning problems, that aims at the prediction of missing entries in a partially observed matrix. Such problems appear in several challenging applications such as collaborative filtering, image processing, and genotype imputation. We compare the Bayesian approaches and a recently introduced de-biased estimator which provides a useful way to build confidence intervals of interest. From a theoretical viewpoint, the de-biased estimator comes with a sharp minimax-optimal rate of estimation error whereas the Bayesian approach reaches this rate with an additional logarithmic factor. Our simulation studies show originally interesting results that the de-biased estimator is just as good as the Bayesian estimators. Moreover, Bayesian approaches are much more stable and can outperform the de-biased estimator in the case of small samples. In addition, we also find that the empirical coverage rate of the confidence intervals obtained by the de-biased estimator for an entry is absolutely lower than of the considered credible interval. These results suggest further theoretical studies on the estimation error and the concentration of Bayesian methods as they are quite limited up to present.

Extending mixture of experts model to investigate heterogeneity of trajectories: When, where, and how to add which covariates.

Researchers are usually interested in examining the impact of covariates when separating heterogeneous samples into latent classes that are more homogeneous. The majority of theoretical and empirical studies with such aims have focused on identifying covariates as predictors of class membership in the structural equation modeling framework. In other words, the covariates only indirectly affect the sample heterogeneity. However, the covariates' influence on between-individual differences can also be direct. This article presents a mixture model that investigates covariates to explain within-cluster and between-cluster heterogeneity simultaneously, known as a mixture-of-experts (MoE) model. This study aims to extend the MoE framework to investigate heterogeneity in nonlinear trajectories: to identify latent classes, covariates as predictors to clusters, and covariates that explain within-cluster differences in change patterns over time. Our simulation studies demonstrate that the proposed model generally estimates the parameters unbiasedly, precisely, and exhibits appropriate empirical coverage for a nominal 95% confidence interval. This study also proposes implementing structural equation model forests to shrink the covariate space of the proposed mixture model. We illustrate how to select covariates and construct the proposed model with longitudinal mathematics achievement data. Additionally, we demonstrate that the proposed mixture model can be further extended in the structural equation modeling framework by allowing the covariates that have direct effects to be time-varying. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Revisiting sample size planning for receiver operating characteristic studies: A confidence interval approach with precision and assurance.

Estimation of areas under receiver operating characteristic curves and their differences is a key task in diagnostic studies. Here we develop closed-form sample size formulas for such studies with a focus on estimation rather than hypothesis testing, by explicitly incorporating pre-specified precision and assurance, with precision denoted by the lower limit of confidence interval and assurance denoted by the probability of achieving that lower limit. For sample size estimation purposes, we introduce a normality-based variance function for valid estimation allowing for unequal variances of observations in the disease and non-disease groups. Simulation results demonstrate that the proposed formulas produce empirical assurance probability close to the pre-specified assurance probability and empirical coverage probability close to the nominal level. Compared with a frequently used existing variance function, the proposed function provides more accurate and efficient sample size estimates. For an illustration of the proposed formulas, we present real-world worked examples. To facilitate implementation, we have developed an online calculator openly available at https://dishu.page/calculator/.

Methicillin-Resistant Staphylococcus aureus Nasal Swab Is Insufficient to Withhold Empiric Methicillin-Resistant Staphylococcus aureus Pneumonia Coverage in a Trauma Population

IntroductionMethicillin-resistant staphylococcus aureus (MRSA) nasal colonization is a predictor of MRSA pneumonia in intensive care unit (ICU) patients. Negative nasal swabs have shown up to a 97% negative predictive value for MRSA pneumonia in nontrauma populations, though little investigation has been pursued in trauma patients. Materials and methodsAll trauma patients admitted to the ICU from April 2018 to February 2019 were screened for MRSA colonization by nasal swab. Patients with suspicion for pneumonia underwent bronchoalveolar lavage or quantitative sputum culture and were started on empiric antibiotic therapy based on the swab result. Swab-positive patients were started on empiric MRSA coverage and swab-negative patients were not. ResultsMRSA nasal swab screening was performed in 601 trauma ICU patients. Ninety-six patients subsequently underwent pneumonia workup and were started on an empiric antibiotic regimen based on nasal swab results. Seventeen (17.7%) patients were MRSA nasal swab positive on screening, and 22 (22.9%) patients subsequently had significant growth of MRSA on quantitative respiratory culture. The sensitivity of nasal swab was 50.0% and the specificity was 91.9%. Eleven patients had a negative MRSA nasal swab but a positive MRSA pneumonia (11.5%). Patients with inadequate antibiotic coverage had statistically longer hospital length of stay, ICU length of stay, ventilator days, and rates of unplanned intubation compared to patients with adequate antibiotic coverage. ConclusionsNasal swab screening was not sensitive enough in a trauma population with a high endemic incidence of MRSA colonization to warrant withholding empiric antibiotic MRSA coverage in patients with suspected pneumonia.

Conformal asymmetric multi-quantile generative transformer for day-ahead wind power interval prediction

With the rapid increase in the installed capacity of wind power, day-ahead wind power interval prediction is becoming more and more important. To solve such a challenging problem and provide intervals of higher quality, this paper proposes a prediction method based on conformal asymmetric multi-quantile generative transformer. Herein, the multi-quantile generative transformer is a deep learning model that generates multi-quantile forecast results for next day through one forward propagation process. Then, two quantiles, whose width is the smallest while satisfying the nominal confidence constraint, are selected from the predicted sequence as the upper bound and lower bound of the asymmetric interval. Furthermore, we introduce the conformal quantile regression to calibrate the bounds of the prediction interval to ensure that its coverage rate is as close as nominal confidence. The experiments show that the proposed method surpasses the benchmarks by providing narrower prediction intervals with more accurate empirical coverage probability. Under nominal confidence 90%, it gives prediction intervals with average empirical coverage probability of 90.50% and normalized average width of 0.44 on four wind farms. Compared with symmetric prediction intervals given by common benchmark quantile long short term memory network, the average width is reduced by 19.6%.

Adjusting for publication bias in meta-analysis via inverse probability weighting using clinical trial registries.

Publication bias is a major concern in conducting systematic reviews and meta-analyses. Various sensitivity analysis or bias-correction methods have been developed based on selection models, and they have some advantages over the widely used trim-and-fill bias-correction method. However, likelihood methods based on selection models may have difficulty in obtaining precise estimates and reasonable confidence intervals, or require a rather complicated sensitivity analysis process. Herein, we develop a simple publication bias adjustment method by utilizing the information on conducted but still unpublished trials from clinical trial registries. We introduce an estimating equationfor parameter estimation in the selection function by regarding the publication bias issue as a missing data problem under the missing not at random assumption. With the estimated selection function, we introduce the inverse probability weighting (IPW) method to estimate the overall mean across studies. Furthermore, the IPW versions of heterogeneity measures such as the between-study variance and the I2 measure are proposed. We propose methods to construct confidence intervals based on asymptotic normal approximation as well as on parametric bootstrap. Through numerical experiments, we observed that the estimators successfully eliminated bias, and the confidence intervals had empirical coverage probabilities close to the nominal level. On the other hand, the confidence interval based on asymptotic normal approximation is much wider in some scenarios than the bootstrap confidence interval. Therefore, the latter is recommended for practicaluse.

Abruptly Stopping an Adamantane Management for Fatigue in an Elderly Multiple Sclerosis Patient Provoked Acute Withdrawal Symptoms (AWS); A Case Report

Introduction: Health care workers are continuously being burdened with acute conditions especially with the current pandemic of Covid-19. Staying home and feeling trapped can be particularly detrimental to patients with history of depression or psychotic as well as multiple sclerosis. We present a case of a 63-year-old patient with Multiple Sclerosis whose condition is being managed with mainly dopamine agonists. Withdrawal symptoms arose acutely after abrupt cessation of Amantadine; a dopamine agonist. Amantadine is thought to work by raising the amount of dopamine available to brain cells. The purpose of this research is to report a case of a 63-yearold Multiple Sclerosis patient who presented with Acute Withdrawal Syndrome (AWS) after being managed with Amantadine for two years and abruptly stopping the medication. Case Presentation: A 63-year-old woman with past medical history of stroke and multiple sclerosis reported symptoms of AWS after abruptly stopping amantadine use for multiple sclerosis. The patient was on cyclobenzaprine for spasticity, gabapentin and lamotrigine for neuropathic pain and seizure disorder respectively. She also had a history of hypertension and hyperlipidemia and presented with 1-week history of nausea and vomiting followed by visual hallucination, tremor, slurred speech and lethargy. On presentation, the patient was afebrile and hemodynamically stable. This patient denies blurred vision and severe fatigue with bathing or exercise. Upon further evaluation, patient did not report electrical sensation down her limbs or back especially with neck flexion. The initial labs were remarkable for hemoglobin of 8.5mg/dL and hypokalemia of 3.2mmol/L. We suspected vasculitis of CNS. One of the proposed pathophysiology for this is the extensive inflammatory damage to the blood brain barrier, allowing inflammatory cell recruitment into the CNS. The patient was admitted for acute altered mental status with waxing and wanning symptoms. Her acute delirium symptoms lead to the withdrawal of amantadine and cyclobenzaprine. Within about 48-70 hours later, patient developed severe agitation requiring emergent intubation. EEG showed generalized medium voltage delta, theta, and fast activity throughout indicative of diffuse cerebral dysfunction, but no lateralized or epileptic activity was seen. CT brain was negative for acute stroke or bleed. The patient underwent lumbar puncture, and was started on empiric coverage with IV acyclovir, vancomycin, and ceftriaxone for possible meningoencephalitis along with methylprednisolone for possible multiple sclerosis flare vs autoimmune encephalitis. MRI showed stable extensive white matter T2 hyperintense lesions. CSF was negative for infectious processes, and vancomycin, ceftriaxone, and acyclovir were discontinued. The patient continued to require sedation for severe agitation. The severe agitation was suspected to be due to discontinuation of her home medications, one of which was amantadine. The amantadine was resumed with improvement of her mental status within 24 hours. Patient was extubated within 48 hours of initiation of amantadine and was transferred to the floor for continuity of care and eventually discharged home after 15 days of hospitalization. Conclusion: Acute Withdrawal Syndrome (AWS) symptoms are often as a result of abrupt cessation of a medication(s) particularly central acting agents like clonidine, beta adrenergic antagonists as well as diuretics but Amantadine is starting to be a strong culprit since it is also thought to act centrally as a dopamine agonist. Clinicians should always be mindful of AWS especially from patients on long term central acting medications that have been abruptly stopped.

Multifocal Neonatal Osteomyelitis: Case Report

Neonatal osteomyelitis may present with very few clinical signs and symptoms, which makes prompt diagnosis challenging. Delayed treatment may result in serious long-term consequences. Moreover, all patients should be followed up for orthopaedic sequelae. Here we describe a case of neonatal osteomyelitis, at multiple sites. A preterm male presented with fever and mild abdominal distension on the 14th day of life. Investigations were done to rule out sepsis, meningitis and other common cause of fever. Despite starting empiric antibiotic coverage immediately, fever continued followed by respiratory distress, tachypnea and tachycardia. Three weeks later baby became pale and irritable with cell count of 34,450/cumm and was shifted to neonatal intensive care unit. In subsequent days, baby developed swelling in right thigh and knee region with paucity of movements, however ultrasonography failed to detect any pathology. Blood culture revealed methicillin resistant staphylococcus aureus, after which injection vancomycin was started, after which fever subsided and the baby’s general condition improved clinically. Ultrasonography suggested effusion in left shoulder and right knee, probably of infective etiology. Drainage and decompression with arthrotomy helped us evacuate sero-sanguinous turbid fluid and granulation tissue, which were sent for histopathological examination which diagnosed pyogenic synovitis. On 40th day of life the patient was discharged healthy.

413: COST ANALYSIS OF EMPIRIC COVERAGE FOR PATIENTS WITH MDR GRAM-NEGATIVE INFECTIONS

Introduction: Gram-negative resistance to empiric antibiotic therapy has been associated with increased mortality rate, prolonged hospital length of stay and increase cost. The objective of this study is to compare total hospital costs associated with the appropriate and inappropriate empiric antibiotic therapy for critically ill patients with documented Gram-negative infections. Methods: Single-center, retrospective, cohort study conducted at a tertiary academic medical center. Data was collected from the electronic medical record for patients admitted from January 2015 to December 2017. Patients ≥18 years of age with culture-positive Gram-negative infection during the first 2 days of admission and started on antibiotics were included. Appropriate empiric coverage was defined as antibiotics with microbiological activity against the organism subsequently isolated in cultures within 24 hours collection. The primary outcome was the total hospital costs (fixed and variable) for the entire hospital stay. Descriptive statistics were performed and Mann-Whitney U, Fisher’s exact test, and χ-square test were conducted, where appropriate. Results: 832 patients were included in this study with 79 (9.5%) of the patients characterized as receiving inappropriate empiric antibiotics. There were no differences between patients receiving appropriate and inappropriate empiric therapy. Hospital and ICU length of stay were also statistically similar. There were significantly lower pharmacy costs incurred in patents receiving appropriate empiric therapy compared to inappropriate ($1,893 [3,319] vs. $2,252 [5,629], p=0.016). Total hospital costs incurred by patients receiving appropriate empiric therapy were numerically lower ($20,848 [30,377] vs. $23,006 [39,222], p=0.052). Conclusions: Inappropriate empiric antibiotics for patients with culture-positive Gram-negative infections was associated with significant increase in overall pharmacy cost and charges and numerically greater total hospital cost and charges.

1388. Seasonality of Microbiology of Combat-related Wound Infections in Afghanistan

Abstract Background We examined the seasonality of wounds and wound infections, including occurrence of multidrug resistance, among combat casualties injured in Afghanistan. Methods The Trauma Infectious Disease Outcomes Study is a retrospective observational study of infectious complications among military personnel wounded during deployment (06/09-12/14). Wound cultures obtained ≤7 days following injury in Afghanistan were assessed. Epidemiologic, clinical, and microbiologic data were analyzed by injury season [winter (1 Dec-28/29 Feb), spring (1 Mar-31 May), summer (1 Jun-31 Aug), and fall (1 Sep-30 Nov)]. Multidrug-resistant (MDR) determinations for Gram-negative and Gram-positive organisms were per standardized definitions. Results The study population included 316 patients with a median of 3.5 (IQR 3-5) days from injury to initial culture. Gram-negatives (N=188, 59.5%) were more commonly isolated from wound cultures in summer (N=81, 43.1%) and fall (N=57, 30.3%) versus winter (N=18, 9.6%) and spring (N=32, 17%) (p&amp;lt; 0.001). The MDR Gram-negatives (N=69, 21.8%) were more common in summer (N=26, 37.7%), and fall (N=26, 37.7%) versus winter (N=3, 4.3%) and spring (N=14, 20.3%) (p=0.028). Wound infections were diagnosed in 198 (63%) patients. The pattern for infecting Gram-negative isolates (N=143, 72.2%, Table 1) was similar to that of overall Gram-negative isolates: summer (79.5%) and fall (83.6%; p&amp;lt; 0.001); MDR Gram-negatives (summer, 25.6%) and (fall, 41.8%; p=0.015). Escherichia coli and Enterobacter spp. were the most common infecting Gram-negative bacilli with no significant difference across the seasons. There was a higher proportion of infecting Acinetobacter baumannii isolates in the summer and fall compared to winter and spring. Infecting Gram-positive isolates (N=128, 65%) were not significantly different by season. Anaerobes associated with infections were also identified (N=30, 15%) with a higher proportion in the winter compared to summer, fall, and spring (p=0.036). Conclusion Gram-negatives, including MDR Gram-negative infecting organisms, were more common in summer/fall months in service members injured in Afghanistan. This may have implications for empiric antibiotic coverage during these months. Disclosures David R. Tribble, DrPH, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response.

2035. Detecting Vancomycin-resistant Enterococci infection in an immunosuppressed population after screening

Abstract Background Vancomycin-Resistant Enterococci (VRE) are major pathogens for severely immunosuppressed patients. Because VRE are common pathogens in our institution, such patients are often empirically treated to cover VRE, exposing them to broad-spectrum antimicrobials. Analogous to nasal screening for Methicillin-resistant Staphylococcus aureus carriage, targeted VRE surveillance is performed to identify and isolate colonized patients to reduce transmission. To assess risks and benefits of empiric therapy, we evaluated this surveillance procedure. Methods All patients admitted to two inpatient hospital units from 01/01/2019 to 12/31/2021 had routine perirectal VRE surveillance ordered and results retrospectively reviewed. One swab from each Culturette set was tested by vanA PCR, and the other was inoculated on CHROMEID® VRE (Biomerieux) if the PCR was positive. Subsequent clinical cultures of any site within 14 days of surveillance screening were reviewed for VRE. Results 1133 patients were screened; 46 (4.1%) patients had VRE colonization. Within 2 weeks following VRE screening 20 patients had clinical samples that were positive for an Enterococcus species (14 in the first 7 days and 6 in days 8-14). The most common sites of clinical cultures were urine, 8 (40%), wound, 4 (20%), intra-abdominal, 4 (20%), and blood, 2 (10%). No clinical culture sample contained VRE. Conclusion The rate of VRE carriage was low in this population, raising the question of the value of broad-spectrum empiric therapy coverage for VRE. No VRE infections were subsequently detected in any patients irrespective of surveillance. The negative predictive value for clinical VRE infection was 100% with negative surveillance screening in this population. Disclosures All Authors: No reported disclosures.

956. Improving Understanding and Utilization of the Antibiogram among Medical Residents

Abstract Background The antibiogram is a powerful tool for providers when selecting empiric antibiotic coverage. Its use is recommended by the Infectious Disease Society of America, Center for Disease Control, and clinical decision support resources to aid in antibiotic stewardship and patient care. Antibiograms are a key component of antimicrobial stewardship programs. A quality improvement project was implemented for the family medicine, internal medicine, and surgery residency programs at Creighton University to assess and improve early trainees' comfort with, utilization of, and understanding regarding antibiograms. Methods Forty-two first year residents making up 100% of the post graduate year one classes of the family medicine, internal medicine, and surgery residency programs at a Midwest Academic institution were interviewed in April 2021. Questions collected data regarding the function of, knowledge regarding, comfort and personal experience with antibiograms, as well as past exposure to infectious disease training. Antibiogram training lectures, informational posters, and new methods of accessing the antibiogram were implemented in July 2021. Post implementation of these interventions thirty-seven second year residents and forty first year residents, consisting of 100% of the respective classes of the three residency programs, were interviewed in January 2022. Survey Questionnaire Nine-question survey to gather data regarding residents knowledge and use of antibiograms. Educational Poster Information about how to use an antibiogram and quick response codes to access institutions antibiogram. Posters were displayed in all residency team rooms. Results Our efforts resulted in statistically significant increase in resident reported understanding, utilization, and comfort with the antibiogram. A total of 24/42 of the 2021 residents and 69/77 of the 2022 residents surveyed reported correct understanding of the antibiogram (p &amp;lt; 0.001). Residents who reported knowing how to access the antibiogram increased from 24% to 78% (p &amp;lt; 0.01) and use of the antibiogram in patient care increased by 19% (p = 0.027). The average reported comfort level increased from 2.3 to 4.2 out of 5 (p &amp;lt; 0.01). Conclusion Previous literature documents that many residents are not comfortable with using antibiogram data. This quality improvement project demonstrates that simple inexpensive measures can improve physician's comfort, access, and utilization of the antibiogram. Disclosures Renuga Vivekanandan, MD, MDstewardship: Ownership Interest Christopher Destache, Pharm D, Shionogi Inc: Honoraria.

131 A MORE UNIQUE THAN RARE MYOPERICARDITIS - A CASE REPORT

Abstract A 33yo man, ex-convict, with a history of IV substance abuse, without previous cardiological history, was admitted at our emergency department in the clinical context of an acute pericarditis, intermittent fever in the last 10 days and non-itchy maculo-papular erythema of palms and thorax. EKG documented a diffuse ST-segment elevation, chest X-rays revealed a bilateral pleural effusion and echocardiography documented a normal biventricular morphology and function, normal valvular function, and a circumferential pericardial effusion (14mm). The patient was admitted at our Cardiology Unit after a negative PCR SARS-CoV-2 test. Blood chemistry showed elevated WBC count with an important neutrophilia (24.000/mm3; 90% neutrophils), elevated TnI-HS (236 ng/L; n.v. &amp;lt;18 ng/L), elevated C-reactive protein (340 mg/L; n.v. &amp;lt; 5mg/L). A classic anti-inflammatory therapy was set up with indomethacin + colchicine with little clinical benefit. Blood cultures, bacterial serology (i.e., Tubercolosis, T.gondii, Syphilis, Leptospirosis) and viral serology (i.e., HIV, HCV, HBV, EBV, HSV) resulted negative. However, an empirical antibiotic coverage was set up: sequentially with Piperacillin/Tazobactam, Vancomycin, Linezolid and Ceftriaxone. None of the antibiotics improved patient's clinical status. On the contrary, the patient developed an allergic reaction to Vancomycin and Linezolid. All autoantibodies tested resulted negative. After 10 days of hospitalization, the patient's clinical status continued to deteriorate. The intermittent fever (max 41°C) was not responsive to any treatment. The evanescent skin rash had spread to the whole body and was concomitant with the fever peaks. The indexes of inflammation were rising (C-reactive protein 400 mg/L) and so were the WBC count (36.000/mm3). The patient lost weight (-8kg), developed hand and feet arthralgia, diffuse myalgia, painful retronucal lymph nodes, pharyngodynia and abdominal pain. An abdominal echography and CT were performed with evidence of mild abdominal effusion and splenomegaly. Hepatic cytolysis indices began to rise (AST 100 U/L; ALT 150 U/L; LDH 385 U/L). At that point, on the basis of Yamaguchi's Criteria, we suspected our patient could be affected by Adult-onset Still's disease (AOSD) with an initial stage of hemophagocytic lymphohistiocytosis (HLH). Prednisone (IV 2 mg/kg/die) was administered for 72h with an incomplete clinical and biochemical response (C-reactive Protein 180 mg/L). Subsequently, Anakinra (SC 100 mg/die) was administered with a complete clinical response in less than 72h. AOSD is very uncommon. The annual incidence is 0.16/100.000 with an equal distribution between sexes. HLH have been observed in 15% of patients, meanwhile myopericarditis is a rare complication. Although rare, it is fair to know and consider AOSD in the complicated and tricky diagnostic process of myopericarditis. A noteworthy point of this case report is the extreme efficacy of Anakinra in contexts of systemic inflammation and myopericarditis. A point still to be clarified concerns the duration of the treatment and the down-titration of Anakinra in these complicated contexts.

2112. Incidence and outcomes of infections in liver transplant recipients during the first year post-transplant.

Abstract Background Despite the use of antimicrobial prophylaxis in liver transplant recipients (LTR), infection remains the most likely cause of death (18.94%) in the first year. There is limited data describing the characteristics, &amp; infections of LTR while hospitalized in the first year post-transplantation. We aimed to review the incidence and outcomes of infections in LTR in the first year post-transplant during hospitalization or re-hospitalization. Graph 1.Y-axis; Number of cultures collected, X-axis; type of organism dived over time. Site of bacterial infection Table 1.Number of bacterial infections divided by site/system, involved compared to timing of infection. Methods We performed a single-center retrospective cohort study at The University of Rochester. Electronic medical records of 298 first time adult LTR between 03/5/2011 and 04/01/2020 were reviewed. Demographic and comorbidity data was obtained at time of transplant. Microbiologic data and outcomes were obtained during the first year post-transplant. We compared mortality between those with infection and those without using log-rank survival analysis. Graph 2. Y-Axis; Number of patients with diagnosed viral infection. X-axis virus divided over time. Results 160 (53.7%) patients suffered at least 1 infection while hospitalized in the first year post-transplant. There were 178 bacterial infections in 130 patients of which 115 were intra-abdominal (table 1). The most common organism was Enterococcus sp. (n=102), 65 were vancomycin resistant (VRE). The most common site of fungal infection was abdominal (n=13) and the most common organism was C. glabrata (n=9). The most common viral infection was CMV at 7-12 months although other viral infections occurred between 1-6 months (graph 2). In a univariate chi-square model, bacterial infection at any time was associated with all-cause mortality in the first year (CI 1.7-8.9 p-adj= 0.002). Fungal infection between 2-6 months was also associated with increased mortality (CI 2.7-12.2 p-adj= 0.0005). Conclusion Bacterial infections are the most common type of infection in LTR and occur more frequently during the first 6 months. Bacterial infection at any point was independently associated with increased mortality in the first year post-transplant. The most common organism was Enterococcus with a high rate of VRE which should be taken into consideration for empiric coverage at our institution. Fungal infection between 2 to 6 months was associated with increased mortality. We observed that early bacterial and fungal infections are markers of poor prognosis. Disclosures All Authors: No reported disclosures.