Grant Investigator Research Articles

495. Predictors of C. difficile Infection and Impact of Primary Prophylaxis Among Asymptomatic C. difficile Colonized Patients: A Cross-Sectional Study

BackgroundPatients who are colonized with C. difficile are at risk of developing C. difficile infections (CDI), but factors associated with disease onset are poorly understood. The objectives of this study were to identify predictors of hospital-onset CDI (HO-CDI) among asymptomatic C. difficile colonized patients and explore the potential benefit of primary prophylaxis to prevent CDI.MethodsWe performed a retrospective cross-sectional study of C. difficile colonized patients admitted to a tertiary academic institution in Quebec City between November 2013 and January 2017. Colonization status was determined upon hospital admission through a systematic screening program by detecting the TcdB gene by PCR on a rectal swab. Primary prophylaxis was defined as the preventive use of ≥1 dose of oral vancomycin or metronidazole in a patient without diarrhea. The choice and dosing of prophylaxis were left to the discretion of the treating physician. Univariate and multivariate logistic regression analyses were used to determine independent predictors of HO-CDI.ResultsOf 513 C. difficile colonized patients, 39 (7.6%) developed a HO-CDI, with a 30-day attributable mortality of 18%. We found that an increased length of hospital stay (adjusted odds ratio [aOR] per day, 1.03; P = 0.006), exposure to multiple classes of systemic antibiotics (aOR per class of antibiotic, 1.45; P = 0.03), the use of opioid analgesics (aOR, 2.70; P = 0.01) and cirrhosis (aOR, 5.57; P = 0.007), were independently associated with an increased risk of HO-CDI in multivariate analysis, whereas the use of laxatives was associated with a lower risk of CDI (aOR, 0.36; P = 0.01). Among the antimicrobials, B-lactam with B-lactamase inhibitors (OR, 3.65; P < 0.001), first-generation cephalosporins (OR, 2.38; P = 0.03), and carbapenems (OR, 2.44; P = 0.03) correlated with the greatest risk of HO-CDI. In contrast, patient age, exposure to proton pump inhibitors, and the use of prophylaxis were not significantly associated with occurrence of HO-CDI in this specific population.ConclusionThis study identifies several variables that are specifically associated with the development of CDI among C. difficile colonized patients. Whether modifying these risk factors could help prevent CDI should be further investigated.Disclosures S. Trottier, CIHR: Grant Investigator, Research grant. V. Loo, Merck: Consultant and Scientific Advisor, Consulting fee. Y. Longtin, Merck: Grant Investigator, Research grant. Becton Dickinson: Grant Investigator, Grant recipient.

934. Incidence of Skin and Soft-tissue Infection in People Living With HIV in a Large Urban Public Health Care System in Houston, Texas, 2009–2014

BackgroundSkin and soft-tissue infections (SSTIs) disproportionately impact patients with HIV. Recent declines have been noted in the incidence of SSTIs in the non-HIV population. We set out to study the epidemiology and microbiology of SSTIs in a population of 8,597 patients followed for HIV primary care in a large urban county system from January 1, 2009 to December 31, 2014.MethodsSSTIs were identified from the electronic medical record (EMR) by the use of ICD-9 billing codes. Charts were reviewed to confirm the diagnosis of acute SSTI and abstract culture and susceptibility data. We calculated yearly SSTI incidence using Poisson regression with clustering by patient.Results2202 SSTIs were identified. Of 503 (22.8%) cultured SSTIs, 332 (66.0%) included S. aureus as a pathogen, of which 287/332 (86.4%) featured S. aureus as the sole pathogen. Of S. aureus isolates with susceptibilities, 231/331 (69.8%) were methicillin-resistant, and the proportion did not vary by year (P = NS).The observed incidence of SSTI was 78.0 per 1,000 person-years (95% CI 72.9–83.4) and declined from 96.0 infections per 1,000 person-years in 2009 to 56.5 infections per 1,000 person years in 2014 (P < 0.001). Other significant predictors of SSTI incidence in both univariate as well as multivariate analysis included CD4 count, viral load, and being a Spanish-speaking Hispanic.ConclusionAlthough SSTI rates in a large urban HIV-infected outpatient cohort declined approximately 40% between 2009 and 2014, SSTIs remain a significant problem.Figure 1.SSTI incidence per 1000 person-years, 2009–2014Table 1:Univariate and Multivariate Poisson Regression ResultsFactorUnivariate IRR (95% CI)Multivariate IRR (95% CI)Male gender1.06 (0.92–1.22)–MSM1.09 (0.95–1.25)–Race/ethnicityWhite/Asian/otherRefRefNon-Hispanic African-American0.92 (0.76–1.11)0.86 (0.71–1.04)English-speaking Hispanic0.88 (0.69–1.12)0.88 (0.69–1.12)Spanish-speaking Hispanic0.46¥ (0.36–0.60)0.48¥ (0.37–0.62)CD4 count (cells/µL)100+RefRef50–1001.56* (1.19–2.04)1.23 (0.93–1.62)<502.28¥ (1.80–2.90)1.49* (1.16–1.92)Viral load (copies/mL)<1,000RefRef1,000+2.17¥ (1.91–2.46)1.90¥ (1.66–2.19)Year2009RefRef20100.89 (0.75–1.06)0.92 (0.78–1.10)20110.90 (0.75–1.07)0.96 (0.80–1.15)20120.91 (0.76–1.09)0.99 (0.83–1.19)20130.71¥ (0.58–0.85)0.77* (0.64–0.93)20140.59¥ (0.49–0.71)0.65¥ (0.54–0.79)*P < 0.01. ¥ P < 0.001.Disclosures C. Arias, Merck & Co., Inc.: Grant Investigator, Research support. MeMed: Grant Investigator, Research support. Allergan: Grant Investigator, Research support

1982. Multiplex PCR-Based Analysis of Enteric Pathogens in Faecal Samples from Patients with Clostridium difficile Infection in the Randomized, Controlled EXTEND Study Comparing the Efficacy of Extended-Pulsed Fidaxomicin With Vancomycin Therapy

BackgroundExtended-pulsed fidaxomicin (EPFX) was equivalent to standard vancomycin (SV) for resolving Clostridium difficile infection (CDI) in the EXTEND study. Sustained clinical cure (SCC) at 30 days after end of treatment (EOT) was achieved in 124/177 (70%) patients receiving EPFX vs. 106/179 (59%) patients receiving SV (difference 11%; P = 0.030). The BioFire platform, a multiplex PCR-based method, was used to detect possible enteric co-pathogens in patients from EXTEND.MethodsPatients aged ≥60 years with positive local test for CDI were randomized (1:1) to receive either EPFX (200 mg tablets, twice daily on Days 1–5 and once daily on alternate days on Days 7–25) or SV (125 mg capsules, four times daily on Days 1–10). Stool samples were collected from all patients at screening and analysed using the BioFire FilmArray Gastrointestinal (GI) panel (Biomérieux). The primary endpoint was the rate of SCC at 30 days after EOT, defined as clinical response (determined by the investigator) and no CDI recurrence. Patients were grouped according to BioFire results, and clinical outcomes were then compared using the chi-square test and logistic regression analyses.ResultsAt screening, all patients tested positive for C. difficile toxin A/B by local laboratory test, and 286/332 patients tested positive for C. difficile by BioFire (Figure 1). SCC rates at 30 days after EOT, by baseline presence/absence of enteric co-pathogens, are given in Figure 1, and logistic regression analyses of SCC at 30 days after EOT are given in Table 1. ConclusionSCC-related treatment differences were evident for patients with BioFire-positive C. difficile vs. those positive for other enteric pathogens, but were not statistically significant due to low patient numbers in comparator groups.Disclosures M. Wilcox, Astellas Pharma: Consultant and Grant Investigator, Consulting fee, Research grant, Speaker honorarium and This study was initiated and sponsored by Astellas. Medical writing support was provided by Cello Health MedErgy and funded by Astellas. O. A. Cornely, Astellas Pharma: Grant Investigator, Lecture speaker and Scientific Advisor, Research grant, Speaker honorarium and This study was initiated and sponsored by Astellas. Medical writing support was provided by Cello Health MedErgy and funded by Astellas. B. Guery, Astellas Pharma: Consultant, Consulting fee and This study was initiated and sponsored by Astellas. Medical writing support was provided by Cello Health MedErgy and funded by Astellas. C. Longshaw, Astellas Pharma: CL was a full-time employee of Astellas Pharma, Inc., during the study conduct and is now an employee of Shionogi Europe Ltd.; he also has a patent WO2015169451 A1 pending. and Employee, Medical writing support was provided by Cello Health MedErgy and funded by Astellas. and Salary. A. Georgopali, Astellas Pharma: Employee, Medical writing support was provided by Cello Health MedErgy and funded by Astellas. and Salary. A. Karas, Astellas Pharma: AK has patents WO2015169451 A1 and EP17167541.6 pending. and Employee, Medical writing support was provided by Cello Health MedErgy and funded by Astellas. and Salary. G. Kazeem, Astellas Pharma: Independent Contractor, Medical writing support was provided by Cello Health MedErgy and funded by Astellas. and Salary. J. A. Palacios-Fabrega, Astellas Pharma: AP-F has a patent EP17167541.6 pending. and Employee, Medical writing support was provided by Cello Health MedErgy and funded by Astellas. and Salary. M. J. G. T. Vehreschild, Astellas Pharma: Consultant and Grant Investigator, Consulting fee, Grant recipient and This study was initiated and sponsored by Astellas. Medical writing support was provided by Cello Health MedErgy and funded by Astellas.

556. Factors Associated with Integrase Strand Transfer Inhibitor Use Between 2008 and 2015

BackgroundUsed in conjunction with other antiretroviral drugs, integrase strand transfer inhibitors (INSTIs) are highly effective and well tolerated. First licenced in 2007, guidelines have recommended their use as an option for initial treatment of HIV since 2009. Here we examine factors associated with INSTI use.MethodsData on people living with HIV (PLWH) who were newly initiated on antiretroviral therapy (ART) was extracted from the Truven Health MarketScan® database for commercially insured and Medicaid covered adults between January 1, 2008 and December 30, 2015. New users were identified as those without an ART claim in the 6 months preceding study inclusion. Multivariable logistic regression was preformed to determine factors associated with INSTI use.ResultsBetween 2008 and 2015, 25,928 new initiators of ART were identified. Of those 6,000 (23%) were initiated on INSTI-based regimens (raltegravir 47%, elvitegravir 40%, dolutegravir 13%). Fifty-three percent of initiated regimens containing non-nucleoside reverse transcriptase inhibitors and 28% included protease inhibitors. Mean age was 40.4 years (10.9); 15,382 (76%) were male. As expected, the proportion of PLWH initiated on INSTI-based regimes increased from 117 (5%) in 2008 to 53% in 2015 (n = 1,082). Those on INSTI were more likely male (OR 1.21 [95% CI 1.11, 1.31) and not on Medicaid (1.41, [1.29, 1.54]). Although PLWH with a history of congestive cardiac failure (1.42 [1.12, 1.8]), previous stroke (1.87 [1.03, 3.38]) or renal failure (1.48 [1.12, 1.98]) were more likely to receive INSTIs, those with a history of ischemic heart disease or risk factors for cardiovascular disease including, hypertension, dyslipidemia, obesity or diabetes were not more likely to initiate INSTI-based regimens after controlling for age and year (all P > 0.05). INSTI prescribing did not differ between infectious diseases (ID) and non-ID providers.ConclusionDespite their good safety profile and recommendation for first-line treatment, a significant proportion of PLWH were initiated on non-INSTI-based regimens, even in the setting of underlying comorbidities.Disclosures M. A. Olsen, Pfizer: Consultant and Grant Investigator, Consulting fee and Grant recipient. sanofi pasteur: Grant Investigator, Grant recipient. W. Powderly, Merck: Grant Investigator and Scientific Advisor, Grant recipient. Gilead Sciences: Scientific Advisor, Consulting fee.

LB2. Switch to Doravirine/Lamivudine/Tenofovir Disoproxil Fumarate (DOR/3TC/TDF) Maintains Virologic Suppression Through 48 Weeks: Results of the DRIVE-SHIFT Trial

BackgroundDoravirine is a novel, non-nucleoside reverse-transcriptase inhibitor (NNRTI) that has demonstrated efficacy in two Phase 3 trials in treatment-naïve adults with HIV-1.MethodsThis open-label, active-controlled, noninferiority (NI) trial evaluated a once-daily single-tablet regimen of doravirine 100 mg, lamivudine 300 mg, and tenofovir disoproxil fumarate 300 mg (DOR/3TC/TDF) vs. continuation of current therapy in adults with HIV-1 virologically suppressed for ≥6 months on a stable regimen of two NRTIs plus a boosted protease inhibitor (PI), boosted elvitegravir, or NNRTI. Participants with screening HIV-1 RNA <40 copies/mL, no history of virologic failure on any regimen, and no resistance to DOR/3TC/TDF were randomized (2:1) to start DOR/3TC/TDF on Day 1 (immediate switch group, ISG) or after 24 weeks (delayed switch group, DSG). The primary endpoint was the proportion (%) of participants with HIV-1 RNA <50 copies/mL (FDA snapshot approach), with the primary comparison between ISG at Week 48 and DSG at Week 24 and a secondary comparison between the groups at Week 24; the NI margin was -8%. The % of participants with HIV-1 RNA ≥50 copies/mL was also analyzed (FDA snapshot approach; NI margin 4%).ResultsA total of 670 participants (447 ISG, 223 DSG) were treated and included in the analyses; 84.5% were male, 76.4% were white, and mean age was 43.3 years. At Week 24, 93.7% (419/447) of ISG vs. 94.6% (211/223) of DSG had HIV-1 RNA <50 copies/mL (difference −0.9% [−4.7, 3.0]), and 1.8% of each group had HIV-1 RNA ≥50 copies/mL. At Week 48, 90.8% (406/447) of ISG maintained HIV-1 RNA <50 copies/mL (vs. 94.6% of DSG at Week 24; difference −3.8%, 95% CI [−7.9%, 0.3%]), and 1.6% of ISG had HIV-1 RNA ≥50 copies/mL. In the ritonavir-boosted PI stratum, mean changes in fasting LDL-C and non-HDL-C at Week 24 were significantly lower (P < 0.0001) in ISG vs. DSG (table). Rates of any AE and of drug-related AEs at Week 24 were higher in ISG vs. DSG. AEs were mild in most ISG participants (64% of those with any AE; 80% of those with drug-related AEs).ConclusionA once-daily single-tablet regimen of DOR/3TC/TDF demonstrated non-inferior efficacy and acceptable safety compared with continuing therapy, and is an option for maintaining viral suppression in patients considering a change in therapy.Disclosures P. Kumar, Merck, Pfizer, Janssen,: Grant Investigator and Shareholder, Research grant. GSK, Gilead, Teratechnologies, TaiMed,: Grant Investigator, Scientific Advisor and Shareholder, Consulting fee and Research grant. J. M. Molina, Merck GIlead ViiV Janssen Teva: Ad Board and Speaker’s Bureau, Consulting fee. Gilead Sciences: Grant Investigator, Research support. G. Rizzardini, ViiV, Gilead Science, MSD, Angelini, and Abbvie: Board Member and Speaker’s Bureau, Speaker honorarium. Gliead, ViiV, and MSD: Research Contractor, Research grant. P. Cahn, Abbvie: Grant, Research grant. Merck: Grant, Advisory Board. ViiV Healthcare: Grant, Advisory Board. M. Bickel, Merck & Co., Inc.: Research Contractor, Research grant. Y. Zhou, Merck & Co., Inc.: Employee, Salary. C. Morais, Merck Sharp & Dohme, a subsidiary of Merck & Co., Inc.: Employee and Shareholder, May hold stock/stock options in the company and Salary. S. Kumar, Merck & Co., Inc.: Employee and Shareholder, Salary. P. Sklar, Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.: Employee and Shareholder, Salary. G. J. Hanna, Merck Sharp & Dohme, a subsidiary of Merck & Co., inc.: Employee and Shareholder, May hold stock/stock options in the company. and Salary. C. Hwang, Merck Sharp & Dohme, a subsidiary of Merck & Co., Inc.: Employee and Shareholder, Salary. W. Greaves, Merck Sharp & Dohme, a subsidiary of Merck & Co., Inc.: Employee, May hold stock/stock options within the company.

500. Efficacy of 30-Day Fidaxomicin for Treatment of Acute Clostridium difficile Infection With History of Multiple Recurrences

BackgroundMultiple recurrent Clostridium difficile (mrCDI) infections pose major challenges to patients and to the healthcare system. mrCDI is associated with multiple, prolonged hospitalizations and significantly higher costs. It can also lead to chronic, severe diarrhea, colectomy, or death. Fecal microbiota transplantation (FMT) is an effective treatment, but its long-term safety remains unknown, and approximately 10% of patients do not respond to multiple FMTs. A 30-day course of fidaxomicin was evaluated for treatment of acute episode of CDI superimposed on mrCDI, including those who did not respond to multiple FMTs. Fidaxomicin was chosen because it disrupts the fecal microbiome less than vancomycin.MethodsTwenty-nine adult patients with at least two episodes of recurrent CDI were initiated on fidaxomicin 200 mg when they experienced new episode of CDI (symptoms plus positive for CD toxin gene by polymerase chain reaction). These patients continued with fidaxomicin 200 mg twice daily for 10 days, and 200 mg once daily for 20 additional days in an open-label clinical trial. The primary endpoints were a clinical response at the completion of 30-day course of fidaxomicin and a sustained clinical response at week 8 from the last dose of fidaxomicin. Patient health-related quality of life was evaluated throughout the treatment using the RAND-36 Item Health Survey (copyright© the RAND Corporation).ResultsTwenty-four of the 29 patients (83%) experienced clinical resolution of CDI-related symptoms at the completion of 30-day fidaxomicin treatment. Twenty-two of the 29 patients had a sustained clinical response with the overall cure rate of 76% (22/29). Eleven of the 29 patients had multiple FMTs and were enrolled into this study as they failed FMTs. Eight of the 11 patients (73%) of these patients had a sustained clinical response. Statistically significant improvements (P < 0.05) in multiple domains of quality of life according to the RAND-36 Item Health Survey were also observed.ConclusionAn extended regimen of fidaxomicin is an effective treatment for adults with multiple rCDI and in restoring quality of life, including those who failed FMTs.Disclosures C. Lee, Rebiotix: Board Member and Grant Investigator, Consulting fee and Research grant. Merck: Research Contractor, Research grant. Pfizer: Grant Investigator, Research grant. Seres: Grant Investigator, Grant recipient. P. Kim, Rebiotix: Board Member, Consulting fee.

1952. Evaluation of Relapse and Reinfection Using Whole-Genome Sequencing of Clostridium difficile Isolates From Elderly Patients With C. difficile Infection (CDI) in the EXTEND Randomized, Controlled, Comparative Study of Extended-Pulsed Fidaxomicin and Vancomycin for the Treatment of CDI

BackgroundThe EXTEND study demonstrated reduced 90-day recurrence rates for an extended-pulsed regimen of fidaxomicin (EPFX) vs. standard vancomycin (SV) in the treatment of Clostridium difficile infection (CDI): treatment difference −13%, P = 0.00073.1 Whole-genome sequencing (WGS) is used to differentiate between same-strain relapse and new-strain reinfection of CDI. We used WGS of paired C. difficile samples from patients with CDI recurrence in the EXTEND study to assess EPFX and SV in relation to relapse and reinfection.MethodsPatients aged ≥60 years with CDI were randomized (1:1) to receive either EPFX (fidaxomicin 200 mg tablets, twice daily on Days 1–5 and once daily on alternate days on Days 7–25) or SV (125 mg capsules, four times daily on Days 1–10). Paired stool samples were collected from all patients at screening and from patients with recurrence after test-of-cure (TOC). Recurrence was defined as diarrhoea occurring to a greater extent than the frequency recorded at TOC, and confirmed positive for C. difficile toxin A/B and requiring further CDI therapy. C. difficile isolates from paired samples underwent WGS and single nucleotide variant (SNV) difference analysis. Paired samples with ≤2 SNV differences were considered relapses, paired samples with >10 SNV differences were considered reinfection, and those with >2 but ≤10 SNV differences (or without WGS) were considered indeterminate.ResultsAt Day 90, 11/177 (6%) patients in the EPFX arm and 34/179 (19%) patients in the SV arm had CDI recurrence. Of these, samples from 7/11 EPFX- and 19/34 SV-treated patients were available for paired WGS analysis. SNV analysis showed that most CDI recurrences were new-strain reinfections (table). ConclusionMost recurrences were reinfections, but small sample sizes limited definitive conclusions.Reference1. Guery et al. (2017). Lancet Inf Dis 18:296–307.Disclosures M. Wilcox, Astellas Pharma: Consultant and Grant Investigator, Consulting fee, Research grant, Speaker honorarium and This study was initiated and sponsored by Astellas. Medical writing support was provided by Cello Health MedErgy and funded by Astellas. O. A. Cornely, Astellas Pharma: Grant Investigator, Lecture speaker and Scientific Advisor, Research grant, Speaker honorarium and This study was initiated and sponsored by Astellas. Medical writing support was provided by Cello Health MedErgy and funded by Astellas. B. Guery, Astellas Pharma: Consultant, Consulting fee and This study was initiated and sponsored by Astellas. Medical writing support was provided by Cello Health MedErgy and funded by Astellas. C. Longshaw, Astellas Pharma: CL was a full-time employee of Astellas Pharma, Inc., during the study conduct and is now an employee of Shionogi Europe Ltd.; he also has a patent WO2015169451 A1 pending. and Employee, Medical writing support was provided by Cello Health MedErgy and funded by Astellas and Salary. A. Georgopali, Astellas Pharma: Employee, Medical writing support was provided by Cello Health MedErgy and funded by Astellas. and Salary. A. Karas, Astellas Pharma: AK has patents WO2015169451 A1 and EP17167541.6 pending. and Employee, Medical writing support was provided by Cello Health MedErgy and funded by Astellas. and Salary. G. Kazeem, Astellas Pharma: Independent Contractor, Medical writing support was provided by Cello Health MedErgy and funded by Astellas. and Salary. J. A. Palacios-Fabrega, Astellas Pharma: AP-F has a patent EP17167541.6 pending. and Employee, Medical writing support was provided by Cello Health MedErgy and funded by Astellas. and Salary. M. J. G. T. Vehreschild, Astellas Pharma: Consultant and Grant Investigator, Consulting fee, Grant recipient and This study was initiated and sponsored by Astellas. Medical writing support was provided by Cello Health MedErgy and funded by Astellas.

2498. Association of Increasing Age With Hospitalization Rates, Clinical Presentation, and Outcomes Among Older Adults Hospitalized With Influenza—US Influenza Hospitalization Surveillance Network (FluSurv-NET)

BackgroundFew data describe the epidemiology of influenza among adults ≥65 years old according to age strata. We evaluated age-related differences in influenza-associated hospitalization rates, clinical presentation, and outcomes among older adults at 14 FluSurv-NET sites during the 2011–2012 through 2014-2015 influenza seasons.MethodsStudy patients were hospitalized ≤14 days after and ≤3 days before a positive influenza test. Age strata were 65–74, 75–84, and ≥85 years old. We adjusted hospitalization rates for under detection and assessed for age-related trends in risk factors and symptoms. We used logistic regression to calculate odds ratios (OR) for pneumonia and in-hospital death adjusted for season, sex, nursing home residence, smoking, medical comorbidities, influenza vaccination, and study site.ResultsThere were 19,760 patients, including 5,956 aged 65–74 years, 6,998 aged 75–84 years, and 6,806 aged ≥85 years. There was a stepwise increase in hospitalization rates with age (figure). Increasing age was positively associated with female sex, nursing home residence, neurologic disorder, cardiovascular and renal disease, and vaccination, and inversely associated with morbid obesity, smoking, asthma, chronic metabolic disease, and immunosuppression (P < 0.01). Among 10,548 (53.3%) patients with symptom data from 2014 to 2015, increasing age was associated with a higher prevalence of altered mental status and lower prevalence of fever, myalgias, respiratory or gastrointestinal symptoms, and headache (P ≤ 0.01). Compared with 65–74 year olds, older patients had a higher risk of pneumonia (≥85 year-olds: OR 1.2, 95% CI 1.0, 1.3, P = 0.01) and death (75–84 year olds: OR 1.4, 95% CI 1.2, 1.7, P < 0.01; ≥85 year-olds: OR 2.1, 95% CI 1.7, 2.6, P < 0.01).ConclusionThere are age-related differences in the epidemiology, clinical presentation, and outcomes of older adults hospitalized with influenza. These may reflect differences in health status and healthcare provider practice patterns. Public health epidemiologists should consider using additional age strata in ≥65 year-olds when analyzing influenza surveillance data. Clinicians should be aware that influenza among the oldest adults may present atypically and that mortality is increased. Disclosures E. J. Anderson, NovaVax: Grant Investigator, Research grant. Pfizer: Grant Investigator, Research grant. AbbVie: Consultant, Consulting fee. MedImmune: Investigator, Research support. PaxVax: Investigator, Research support. Micron: Investigator, Research support. W. Schaffner, Merck: Member, Data Safety Monitoring Board, Consulting fee. Pfizer: Member, Data Safety Monitoring Board, Consulting fee. Dynavax: Consultant, Consulting fee. Seqirus: Consultant, Consulting fee. SutroVax: Consultant, Consulting fee. Shionogi: Consultant, Consulting fee.

2514. Pediatric Medically Attended Shingles in Alberta, Canada 2016; Preliminary Results

BackgroundHerpes zoster (shingles) is a reactivation of latent varicella virus. Shingles is uncommon in children and children vaccinated against varicella may be at a reduced risk of shingles. Alberta has a publicly funded healthcare system and added publicly funded varicella vaccine to the routine childhood vaccination schedule in 2001.MethodsWe used provincially held administrative health databases to examine the epidemiology of incident shingles cases in children under the age of 19. Incident shingles cases were defined as the earliest record of ICD-9-CM 053 OR ICD-10-CA B02 coded physician claims, hospital, or emergency room visits between 1985 and 2016, with incident cases in this cohort occurring between January 1, 2016 and December 31, 2016. Varicella immunization was identified through Alberta’s immunization repository and immunosuppressive comorbid conditions (neoplasms, HIV/AIDS, cystic fibrosis, and immune system disorders) were identified using ICD diagnostic codes from physician claims, hospital, or emergency room visits and Alberta’s Communicable Disease Control databases.Results1,003 incident shingles cases were identified in children under the age of 19 in 2016, a crude rate of 0.98/1,000 persons. Females comprised 54% of cases. The largest proportion of cases occurred among those aged 15–19 years. About 39% of cases were prescribed antiviral medication, most commonly those aged 15–19 years. The crude rate per 1,000 population increased with age: 0.5 for children under the age of 1, 1.2 for those 1–4 years, 1.25 for children 5–9 years, 2.19 for children 10–14 years, and 3.7 for children aged 15–19 years. Crude rates were similar among both males and females. Less than 3% of the cases had ever been immunized against varicella. Shingles diagnostic codes were not validated, which likely led to an overestimation of the true rates of disease.ConclusionAdditional studies are needed on pediatric shingles cases and factors that influence shingles in this group, as well as validation studies of ICD diagnostic coding in administrative data.Disclosures M. L. Russell, Novartis Pharmaceuticals Canada Inc.: Grant Investigator and Unconditional Research Grant, Grant recipient. Merck Frosst Canada Inc.: Grant Investigator and Unconditional Research Grant, Grant recipient.

2227. Short-Duration of Direct-Acting Antivirals in Hepatitis C Virus-Infected Cancer Patients

BackgroundShort-duration with an 8-week course of ledipasvir/sofosbuvir (LDV/SOF) or glecaprevir/pibrentasvir (GLE/PIB) is considered adequate to treat hepatitis C virus (HCV) infection in selected patients. However, immunocompromised patients with HCV/HIV are not eligible for this approach. Herein, we study the efficacy and safety of an 8-week therapy with direct-acting antivirals (DAAs) in HCV-infected cancer patients.MethodsHCV-infected patients with any type of cancer followed at MD Anderson Cancer Center (June 2014–April 2018) and treated with an 8-week course of LDV/SOF or GLE/PIB were enrolled in a prospective observational study. Efficacy was calculated based on achieving sustained virologic response at 12 weeks (SVR12) after end of treatment per intention to treat (ITT) analysis. A posthoc per-protocol (PP) analysis was done in patients with 12 weeks of follow-up post DAAs. Safety was assessed by emergence of adverse events (AEs) and clinically significant drug–drug interactions (DDIs).ResultsTwenty-four patients were treated with a short-duration of DAAs, 22 with LDV/SOF and two with GLE/PIB. General characteristics are described in Table 1. Five patients received concomitant cancer treatment (nivolumab, sorafenib, lenalidomide, tamoxifen and leuprolide), without DDIs noted. Among the patients who have completed DAAs, SVR rates were 87% per ITT (20/23) and 100% PP (20/20) analyses. No patients had grade 2, 3 or 4 AEs.ConclusionThis is the first prospective study to evaluate the use of short-duration of DAAs in HCV-infected cancer patients where these regimens were found to be effective and safe.Table 1.General CharacteristicsCharacteristicsPatients N (%)Number of patients24Age, median (interquartile range)61 (57–66)Male sex18 (75)Black race9 (38)Obesity (body mass index >30)10 (42)HCV genotype1a17 (71)1b5 (21)22 (8)Type of cancerHematologica6 (25)Solidb18 (75) a Multiple myeloma (2), acute myeloid leukemia (2), non-Hodgkin lymphoma (2). b Prostate (3), head and neck (3), lung (3), renal (2), anal (2), ovarian (2), breast (1), thyroid (1), gastrointestinal stromal tumor (1).Disclosures H. Torres, Gilead Sciences, Merck & Co., Inc.: Grant Investigator, Grant recipient. Vertex Pharmaceuticals: Grant Investigator, Grant recipient.

1874. Adherence to Practice Guidelines for Treating Diabetic Foot Infections: An Opportunity for Syndromic Stewardship

BackgroundAdherence to the Infectious Diseases Society of America (IDSA) guidelines for the treatment of diabetic foot infections (DFIs) has been associated with improved outcomes. Yet, compliance with these guidelines has been reported to be low. We initiated a quality improvement project aimed at improving guideline adherence for DFI management. Baseline results are reported here.MethodsWe reviewed all hospitalized primary DFIs newly initiated on antibiotics over 1 year (July 2014–June 2015). We collected demographics, DFI severity per IDSA guidelines, antibiotic use, and microbiology data. Guideline adherence for culturing and empiric antibiotic choice (based on severity) was assessed per IDSA guidelines. We then created an institutional guideline and electronic order set with built-in clinical decision support. Educational lectures on DFI best practices were given to providers who commonly treat DFIs.ResultsOne hundred seventy-seven DFI admissions were identified: 40% severe (n = 70), 47% moderate (n = 84), 8% mild (n = 14), and 5% with no evidence of infection (n = 9). Demographics: mean age 58 years; 68% male, mean HgbA1c 8.6%, length of stay 6.9 days, 3-year mortality 13%. Empiric antibiotic regimens were judged inappropriate in 36% (64/177) of cases. The most common reason for inappropriate antibiotic use was unnecessary coverage for Pseudomonas aeruginosa in 50% (54/107) of nonsevere cases. In 28% (39/140) of cases with an ulcer, wound or skin breakdown, a superficial swab culture was obtained which is inappropriate. Only 33.3% (n = 56) had a deep tissue culture obtained. In patients with deep tissue cultures, methicillin-resistant Staphylococcus aureus (MRSA) was found in 11% (6/56) of cases but covered for empirically in 88% (50/56). Pseudomonas was found in 2% (1/56) of cases but covered for empirically in 73% (41/56).ConclusionMRSA and Pseudomonas are uncommon DFI pathogens yet are frequently treated empirically. Inappropriate antibiotic use is often due to empiric coverage for Pseudomonas in nonsevere DFIs where it is a rare pathogen. Culture practices are also less than ideal with frequent superficial swabs and underutilization of deep cultures. Institutional guidelines were developed to specifically address these issues and data collection of the impact of this project is in process.Disclosures S. Bergman, Merck: Grant Investigator, Grant recipient. T. Vanschooneveld, Merck: Grant Investigator, Grant recipient.

2197. Hepatitis B Reactivation in Patients with Malignancies Undergoing Treatment for Hepatitis C Infection with Direct-Acting Antivirals

BackgroundReactivation of hepatitis B virus (HBV) can occur in patients after cancer therapies. Direct-acting antivirals (DAAs) are the effective therapies for hepatitis C virus (HCV) infection, and HBV reactivation in HCV/HBV co-infected patients treated with DAAs has been reported. We analyzed the risk of HBV reactivation among HCV/HBV co-infected cancer patients being treated with DAAs.MethodsWe prospectively followed patients with any type of cancer and HCV treated with DAAs between January 2014 and January 2018 at MD Anderson Cancer Center. Information on demographics, use of radiation, chemotherapy, immunotherapy, or anti-CD20 antibodies, and anti-HBV therapy were collected. All patients had the following tests at baseline, 2 and 4 weeks after initiation of DAAs, at end of treatment (EOT), and 12 weeks after completion of DAAs: alanine aminotransferase, total bilirubin, HBV surface antigen (HBsAg), hepatitis B core antibody (anti-HBc), and HBV DNA and HCV RNA levels. We defined the following outcomes by AASLD-recommended parameters: HBV reactivation (HBsAg reverse seroconversion, HBV DNA >2 log compared with baseline, HBV DNA >3 log if HBV DNA was undetectable, or >4 log if baseline was unavailable), hepatitis flare (ALT increase ≥3 times baseline and >100 U/L), and HBV-associated hepatitis (HBV reactivation and hepatitis flare). Patients were followed for 12 weeks after completion of DAAs.ResultsOf 169 cancer patients treated for HCV infection, 2.4% (n = 4) had chronic HBV infection (HBsAg+/anti-HBc+), and most (3/4) of these were on anti-HBV therapy. Past HBV infection (HBsAg-/HBcAb+) was noted in 30% (51/166), and none received anti-HBV therapy. Of these, 37% (19/51) had cancer therapy within 6 months prior to DAA treatment. HBV reactivation did not occur in any co-infected patients. Two patients had hepatitis flare, but none developed HBV-associated hepatitis.ConclusionThis is the first prospective study evaluating HBV reactivation in HCV/HBV co-infected cancer patients receiving DAAs. The risk of HBV reactivation in these patients seems to be low. Future studies with a larger cohort of co-infected cancer patients allowing personalized risk stratification are needed.Disclosures J. P. Hwang, Gilead Sciences: Investigator, Grant recipient; Merck & Co., Inc.: Investigator, Grant recipient. H. Torres, Gilead Sciences, Merck & Co., Inc.: Grant Investigator, Grant recipient; Vertex Pharmaceuticals: Grant Investigator, Grant recipient.

477. Trends in the Incidence of Community-Associated and Healthcare-Associated Clostridium difficile Infections in Quebec Over a 7-Year Period (2008–2015)

Background Clostridium difficile infections (CDI) affect hospitalized patients but also individuals in the community. The epidemiology of healthcare-associated (HA) CDI has received much scrutiny, but little is known regarding trends in the incidence rate of community-associated (CA) cases. We describe and compare long-term trends in the provincial incidence rate of CA-CDI and HA-CDI.MethodsHospitalized patients with CA-CDI and HA-CDI were identified prospectively between April 2008 and April 2015 through the Quebec CDI surveillance program (QCISP), a network of 95 acute-care institutions using standardized case definitions. Hospitalized CDI cases are classified as CA if they occur within 3 days of admission or >4 weeks after any inpatient or outpatient care. CDI cases are defined as HA-CDI if they occurred >3 days after admission and up to 4 weeks following discharge. Trends in the incidence of HA-CDI and CA-CDI were compared using time series with segmented regression and Poisson law.ResultsBetween 2008 and 2015, 28,850 CDI were detected in hospitalized patients. Of these, 4,481 (15.5%) were CA and 24,369 (84.5%) HA-CDI. The annual CA-CDI incidence rate increased by 35.2% from 0.51 to 0.68 per 100,000 population (incidence rate ratio [IRR] per 4-week period, 1.005; 95% confidence interval [CI], 1.004 to 1.006; P < 0.0001) whereas the incidence of HA-CDI remained stable from 6.6 to 7.0 per 10,000 patient-days (IRR per 4-week period, 1.000; 95% CI, 0.999 to 1.000; P = 0.23). There was a significant difference between the trends in incidence of CA-CDI and HA-CDI (IRR, 1.005; 95% CI, 1.004 to 1.006; P < 0.0001). Further analysis showed an inflection point in the incidence of HA-CDI in April 2011 with a reduction in slope (change in trend, IRR, 0.997; 95% CI, 0.995 to 0.999; P = 0.007). No concomitant change was seen in the trend of CA-CDI (change in trend, IRR, 0.997; 95% CI, 0.992 to 1.002; P = 0.2) despite a slight immediate change in level at inflection point (IRR, 1.131; 95% CI, 1.000 to 1.278; P = 0.05).ConclusionBetween 2008 and 2015, the provincial incidence of hospitalized CA-CDI has significantly increased while the incidence rate of HA-CDI has remained relatively stable. Further studies are required to investigate the factors underlying this increase.Disclosures Y. Longtin, Merck: Grant Investigator, Research grant. Becton Dickinson: Grant Investigator, Grant recipient.

716. Molecular Epidemiology of Respiratory Syncytial Virus in Children and Adults in Seattle, WA

BackgroundRespiratory syncytial virus (RSV) is the most important cause of pneumonia in children <5 years worldwide and may cause severe disease in elderly and high-risk adults. Multiple RSV strains co-circulate and evolve over seasons. We seek to describe the evolution of RSV over five seasons in Seattle, WA, USA with two seasons reported here.MethodsFrom 2014 to 2016, subjects 6 months and older seeking outpatient care for acute respiratory illness at Kaiser Permanente Washington were enrolled in the Influenza Vaccine Efficacy Network (Flu VE Network) and a respiratory swab was collected. Real-time polymerase chain reaction (RT-PCR) was performed to test and quantify RSV and subtype positive samples. A subset of RSV samples with cycle threshold (CT) value <30 will be sequenced using a metagenomic next-generation sequencing (NGS) approach. Specific RSV genotypes will be associated with severe disease, defined as requiring emergency department care or hospitalization, or chest radiographic findings.ResultsA total of 8,730 patients were enrolled in the Flu VE Network and PCR testing of seasons 2014/2015 and 2015/2016 resulted in 562 of 4,137 (13.6%) RSV-positive specimens. Of patients with RSV-positive specimens, 204 (36.5%) were adults 18–64 years and 112 (20.0%) were 65+ years. RSV-B predominated in the 2014/2015 season (n = 298; 83.7%), whereas RSV-A was more common in the 2015/2016 season (n = 154; 79.8%) (Figure 1). The median (IQR) CT value for RSV-A specimens was 26.7 (23.3–29.9) compared with 27.9 (25.2–31.3) for RSV-B.ConclusionOne RSV subtype predominated within each season. Similar RSV subtype distributions were seen across age categories. With multiple RSV vaccine candidates in development, understanding the genetic diversity and circulation of RSV various viruses within a population is important for analyzing the effects of a vaccine on the evolution of RSV. Figure 1, Total counts (A) and proportions (B) of RSV-A and RSV-B specimens collected from study patients in Seattle, WA during 2014/2015 and 2015/2016 seasons, by age category.Disclosures M. L. Jackson, sanofi pasteur: Grant Investigator, Research support. H. Chu, Sanofi-Pasteur: Grant Investigator, Grant recipient.

1378. Evaluation of the In vitro Activity of Meropenem-Vaborbactam Against Carbapenem-Resistant Enterobacteriaceae, Including Isolates Resistant to Ceftazidime–Avibactam

BackgroundMeropenem-vaborbactam (M-V) is a novel antibiotic for treatment of carbapenem-resistant Enterobacteriaceae (CRE) infections. Our objective was to determine the in vitro activity of meropenem-vaborbactam against genetically-diverse CRE isolates, including those that have developed resistance to Ceftazidime–Avibactam (C-A).MethodsMinimum inhibitory concentrations (MICs) were determined for meropenem (MER), M-V, and C-A by reference broth microdilution (BMD) methods in triplicate. Vaborbactam and avibactam were tested at fixed concentrations of 8 and 4 µg/mL, respectively. Quality control strains were used and within expected ranges. Polymerase chain reaction (PCR) with DNA sequencing was used to detect resistance determinants, including Klebsiella pneumoniae carbapenemase (KPC) subtypes and porin mutations.ResultsA total of 117 CRE isolates were tested, including K. pneumoniae (Kp; n = 83), E. cloacae (n = 17), E. coli (n = 10), and E. aerogenes (n = 7). Seventy-nine percent harbored blaKPC. KPC subtypes included KPC-2 (n = 32), KPC-3 (n = 41), KPC-3 variants (n = 16), and KPC [not typed] (n = 4, all E. coli). Among 74 K. pneumoniae, 95% had a premature stop codon in ompk35 and ompK36 genotypes included wild type (n = 48), IS5 insertion (n = 13), 135–136 DG duplication (n = 9), and other mutations (n = 4). The median (range) MICs for MER, C-A, and M-V were 8 (0.06 to ≥128), 1 (0.25 to ≥512), and 0.03 (0.015––16), respectively. Corresponding rates of susceptibility were 23, 84, and 98%, respectively. Fifty-three percent and 95% of C-A-resistant isolates were susceptible to MER and M-V, respectively. Among Kp, C-A MICs did not vary by KPC subtype or porin genotype. On the other hand, median M-V MICs were higher among KPC-2 than KPC-3 Kp (0.12 vs. 0.03; P = 0.002), and among Kp with ompK36 porin mutations compared with wild type (0.25 vs. 0.03; P < 0.001). Among Kp with KPC-3 variants (n = 16), the median M-V MIC was 0.03 (0.015––2); 100% were M-V susceptible. Median M-V MICs did not vary by CRE species. Only two isolates were M-V resistant, both were E. cloacae that did not harbor blaKPC.ConclusionM-V demonstrates high rates of in vitro susceptibility against diverse CRE isolates, including those that are resistant to C-A. As this agent is introduced into the clinic, it will be important to identify K. pneumoniae isolates harboring KPC-2 with ompK36 porin mutations that demonstrate higher MICs.Disclosures M. H. Nguyen, Merck: Grant Investigator, Research grant. Astellas: Grant Investigator, Research grant.

271. Diagnosis and Management of Polymicrobial Blood Stream Infections With Multiplex PCR in Hospitalized Children

BackgroundMultiplex PCR (mPCR) can be used to rapidly identify polymicrobial blood stream infections (BSIs) and guide empiric therapy. In addition rapid identification of potential contaminants, may limit unnecessarily broad empiric therapy. The purpose of this study was to describe the use of mPCR to diagnosis polymicrobial BSIs in hospitalized children, and the impact of this technology on antibiotic prescribing.MethodsWe retrospectively identified children at our institution with polymicrobial BSIs diagnosed by mPCR (Film Array Blood Culture Identification Panel, BioFire Diagnostics) from October 2014 to March 2018. A polymicrobial BSI was defined as any blood isolate with ≥1 bacterial or fungal species. Gram stain results, species identification by mPCR, and final species identification via matrix associated laser deionization time of flight (MALDI-TOF) were determined. Antibiotic prescribing for treatment of each BSI was reviewed.ResultsOverall, 622 patients experienced 961 blood stream infections. There were 54 patients who experienced 68 polymicrobial BSIs (7%). Of the polymicrobial BSIs, 55 (80.9%) were two organisms and 13 (19.1%) were three or more organisms. Of the 68, 44 (64.7%) had the same Gram stain morphology and 24 (35.3%) had different morphology. Antibiotic therapy was broadened, narrowed, and unchanged in 38 (56%), 16 (24%), 14 (21%) of infections, respectively. Common modifications of therapy included addition of aminoglycoside or meropenem when two Gram-negative bacilli were present, and addition of vancomycin when coagulase negative staphylococci (CoNS) were isolated.ConclusionThe use of mPCR commonly led to prompt modification of antibiotic therapy to treat polymicrobial blood stream infections. Identification of CoNS frequently led to broadening of antibiotic therapy, even when other organisms were present.Disclosures S. Patel, Merck: Grant Investigator, Grant recipient and Research grant. Pfizer: Grant Investigator, Research grant.

1017. Impact of Enterococcal Bloodstream Infection on Mortality in Patients With Acute Myelogenous Leukemia

BackgroundThough enterococcal bloodstream infection (EBSI) is common in patients with acute myelogenous leukemia (AML), its impact on mortality requires further elucidation. Our objectives were to: (1) determine attributable mortality to EBSI and (2) compare overall, 1-year, relapse-related mortality (RRM), and treatment-related mortality (TRM) between AML patients with and without EBSI.MethodsThis was a retrospective cohort receiving intensive chemotherapy for AML from 2010 to 2015. EBSI was defined by _1 positive blood culture for E. faecium or faecalis and fever, hypotension, or chills. Attributable mortality to EBSI was defined by failure to achieve BSI Clearance (_1 negative culture _24 hr after last positive culture and defervescence) by the date of death. Student’s t-test was used to compare continuous variables, and C2 test was used for categorical variables. Kaplan–Meier was used for survival analyses (unadjusted), and P-values were computed by log-rank.ResultsThree hundred eight patients were identified during the study period: 80 with EBSI and 228 without EBSI. 5/80 patients died with EBSI (6%) although 4/5 patients had concurrent infections at the time of death (Clostridium difficile colitis, candidemia, proven invasive aspergillosis, and probable invasive fungal disease, respectively). There were no significant differences between overall and 1-year mortality (Table 1). In the survival analyses, EBSI did not significantly impact overall survival, 1-year mortality, RRM, and TRM (Figure 1). However, patients with vancomycin-resistant EBSI (VRE) trended toward increased overall mortality.ConclusionAttributable mortality to EBSI is uncommon (6%) in AML. Additionally, EBSI does not significantly impact mortality in this vulnerable patient population that already has very high rates of RRM and TRM. However, as EBSI inflicted 26% of patients over the course of this study period, further investigation is needed to elucidate the morbidity suffered from this common infection and identify potentially modifiable risk factors.Table 1.EBSIN = 80 (26%)No EBSIN = 228 (74%) P Age AML diagnosis (median years, IQR)63(51–69)61(50–69)0.93Overall mortality (%)63/73 (86)154/198 (77)0.12Time AML diagnosis to death (median years, IQR)220 (67–541)273 (62–582)0.16 Disclosures A. Sung, Merck: Grant Investigator, Grant recipient. Enterome: Grant Investigator, Grant recipient.

746. Characteristics of Respiratory Syncytial Virus (RSV) Infection Among Hospitalized Adults, United States, 2014–2017

BackgroundRespiratory syncytial virus (RSV) vaccines are in clinical development for older adults. We described RSV infections among adults requiring hospitalization and risk factors for severe outcomes using a population-based platform, the Influenza Hospitalization Surveillance Network (FluSurv-NET).MethodsSurveillance occurred October 1–April 30 (2014–2017) at sites located in seven states (California, Georgia, Michigan, Minnesota, New York, Oregon, and Tennessee) covering an annual catchment population of up to 13 million adults ≥18 years. Laboratory-confirmed RSV cases were identified using hospital and state public health laboratories, hospital infection preventionists, and/or reportable condition databases. Medical charts were reviewed for demographic and clinical data. International Classification of Diseases (ICD) discharge codes were abstracted. Odds ratios (Oregon) and 95% confidence intervals (CIs) were determined to assess risk factors for ICU hospitalization and deaths.ResultsA total of 2,326 hospitalized RSV cases were identified. Over half were ≥65 years (62%, n = 1,438/2,326), female (59%, n = 1,362/2,326), white (70%, n = 1,301/1,855), and had ≥3 underlying medical conditions (52%, n = 1,204/2,326). 20% (n = 398/2,000) were hospitalized in the ICU (median length of stay, 3 days; interquartile range, 1–6 days), and 5% (n = 96/2,001) died in the hospital. Congestive heart failure (CHF; OR: 1.4, 95% CI: 1.1–1.8) and chronic obstructive pulmonary disease (COPD; OR: 1.3, 95% CI: 1.1–1.7) were associated with ICU admission, while age ≥80 years (OR: 4.1, 95% CI: 1.8–12.1) and CHF (OR: 2.4, 95% CI: 1.6–3.6) were associated with in-hospital deaths. RSV-specific ICD codes were listed in the first 9 positions in only 44% (879/1,987) of cases.ConclusionTo our knowledge, this is the largest US case series of RSV-infected hospitalized adults. Most cases were ≥65 years and had multiple underlying medical conditions. Older age, CHF, and COPD were associated with the most severe outcomes. Few cases had RSV-specific ICD codes, suggesting that administrative data underestimate adult RSV-related hospitalizations. Continued surveillance is needed to understand the epidemiology of RSV among adults as vaccine products move toward licensure.Disclosures E. J. Anderson, NovaVax: Grant Investigator, Research grant. Pfizer: Grant Investigator, Research grant. AbbVie: Consultant, Consulting fee. MedImmune: Investigator, Research support. PaxVax: Investigator, Research support. Micron: Investigator, Research support. H. K. Talbot, sanofi pasteur: Investigator, Research grant. Gilead: Investigator, Research grant. MedImmune: Investigator, Research grant. Vaxinnate: Safety Board, none. Seqirus: Safety Board, none.

2207. Barriers to HCV Treatment in a Safety-Net Hospital System

BackgroundIn 2016, we implemented a hepatitis C (HCV) screening program for baby boomers (BB) born between 1945 and 1965) using a best practice alert (BPA) in the electronic medical record and patient navigation (PN) in our safety-net hospital system. We now examine barriers to HCV treatment among those who received PN for linkage to care (LTC).MethodsThe BPA prompts providers to order a HCV antibody (Ab) for any unscreened BB who has an outpatient appointment. Those with HCV Ab+ with a confirmatory RNA receive telephone navigation, using a pre-defined script, if LTC did not occur within 2 months of RNA testing. After LTC, a person was considered as untreated if HCV treatment had not occurred within 1 year of initial visit. Insured patients received treatment through prior authorizations and uninsured through pharmaceutical patient assistance programs. We examined demographics, homelessness, insurance, fibrosis score, substance use, and psychiatric illness, as potential predictors to treatment initiation using univariate and multivariate logistic regression analysis.ResultsAmong the 16,363 BBs screened from March 1, 2016 to December 31, 2017, 1,445 (8.8%) were HCV Ab+ and 1,038 (72%) had HCV RNA completed. Among the 724 (5%) with confirmed HCV infection, 139 (19%) received LTC without navigation, 299 (41%) received navigation, and 286 (40%) could not be contacted after three attempts. Among those who received navigation, 225 (75%) completed a follow-up visit of which 81 (36%) did not start treatment, 34 (15%) are awaiting treatment initiation, and 110 (49%) started treatment. Gender, race/ethnicity, psychiatric illness, and homelessness were not predictive of starting HCV treatment. In univariate analysis, current substance use vs. none/past use (OR 0.52 (0.29, 0.93)) was associated lower likelihood of starting treatment and advanced fibrosis (OR 2.25 (1.20, 4.21)) was associated with higher likelihood of starting treatment). Compared with uninsured patients, Medicaid patients were less likely to start treatment (AOR 0.15 (0.67, 0.34)) in a multivariate analysis.ConclusionInsurance status was independent predictor of starting treatment among patients at our safety-net hospital. Medicaid remains a barrier to HCV treatment access in safety-net systems.Disclosures A. Singal, Gilead Sciences: Grant Investigator, Research support. M. K. Jain, Gilead Sciences: Grant Investigator, Grant recipient and Research support. Janssen: Investigator, Research support. GSK/ViiV: Investigator, Consulting fee and Research support. Merck: Investigator, Research support

1238. A National Comparison of Antibiograms Between Veterans Affairs Long-Term Care Facilities and Affiliated Hospitals

BackgroundLong-term care facilities (LTCFs) face several barriers to creating antibiograms. Here, we evaluate if LTCFs can use antibiograms from affiliated hospitals as their own antibiogram.MethodsFacility-specific antibiograms were created for all Veterans Affairs (VA) LTCFs and VA Medical Centers (VAMCs) for 2017. LTCFs and affiliated VAMCs were paired and classified as being on the same campus or geographically distinct campuses based on self-report. For each pair, Escherichia coli susceptibility rates (%S) to cefazolin, ceftriaxone, cefepime, ciprofloxacin, nitrofurantoin, sulfamethoxazole/trimethoprim, ampicillin/sulbactam, piperacillin/tazobactam, and imipenem were compared. As guidelines discourage empiric use of antibiotics if susceptibility rates are <80%, we assessed clinical discordance between each LTCF and affiliated VAMC antibiogram at a threshold of 80% susceptible. The proportions of concordant susceptibilities between LTCFs and VAMCs on the same campus vs. geographically distinct campuses were compared using Chi-square tests.ResultsA total of 119 LTCFs and their affiliated VAMCs were included in this analysis, with 70.6% (n = 84) of facilities located on the same campus and 29.4% (n = 35) on geographically distinct campuses. The table below shows the overall clinical concordance (agreement) of LTCFs with their affiliated VAMC in regards to E. coli %S to the compared antibiotics. No significant differences were found when comparing LTCFs on the same campus vs. geographically distinct campuses.Agreement Rates between LTCFs and Affiliated VAMCsAntibiotics90–100%Ampicillin/sulbactamImipenemNitrofurantoin80–89%CefepimeCiprofloxacinPiperacillin/tazobactam70–79%Sulfamethoxazole/trimethoprim60–69%CefazolinCeftriaxoneConclusionAntibiograms between LTCFs and affiliated VAMCs had a high concordance, except for sulfamethoxazole/trimethoprim, cefazolin and ceftriaxone in regards to susceptibility rates of E. coli. Facilities on the same campus were found to have similar concordance rates to geographically distinct facilities. Future studies are needed to investigate how the various approaches to creating LTCF-specific antibiograms are associated with clinical outcomes.Disclosures M. S. Tolg, Veterans Affairs: Investigator, Research grant. A. Caffrey, Veterans Affairs: Investigator, Research grant. H. Appaneal, Veterans Affairs: Grant Investigator, Research grant. R. Jump, Veterans Affairs: Investigator, Research grant. V. Lopes, Veterans Affairs: Investigator, Research grant. D. Dosa, Veterans Affairs: Grant Investigator, Research grant. K. LaPlante, Veterans Affairs: Investigator, Research grant.