Median Hospital Research Articles

Epidemiological Investigation of Unplanned Intensive Care Unit Admissions From the Operating Room After Elective Surgery: A Nationwide Observational Study in Japan

BACKGROUND: Over 75% of surgeries worldwide are elective and unplanned ICU admissions after these surgeries pose a major—albeit rare—challenge. However, few epidemiological studies have focused on patients requiring unplanned ICU admission directly from the operating room after elective surgeries are lacking. This study uses the Japanese Intensive Care Patient Database (JIPAD) to describe unplanned ICU admissions after elective surgeries. METHODS: We conducted a multicenter retrospective cohort study using data from the JIPAD from April 2015 to March 2022, focusing on patients with unplanned ICU admissions after elective surgery. Collected variables included patient characteristics, treatments, outcomes, reasons for ICU admission, and type of surgery. We categorized the reasons for ICU admission into 9 types: anaphylaxis, hemorrhage, anesthesia-related complications, respiratory-related complications, cardiovascular-related complications, neurological-related complications, surgical-related complications, electrolyte/acid-base abnormalities, and unknown causes. The type of surgery was classified using JIPAD definitions. RESULTS: Among 141,969 patients in the JIPAD who underwent elective surgery, 2666 patients (1.9%) required an unplanned ICU admission. Cardiac arrest before ICU admission occurred in 52 patients (2.0%), the median APACHE III score was 51, and 1218 patients (45.7%) required postoperative mechanical ventilation. The median hospital stay for patients with unplanned ICU admission was 21 days and in-hospital mortality was 3.3% (88/2666). The most common reason for ICU admission was respiratory complications (n = 440, 16.5%), followed by hemorrhage (n = 377, 14.1%). Cardiovascular-related complications had the highest in-hospital mortality at 6.8% (20/294). Hospital mortality exceeded ICU mortality, suggesting that patients expected to derive limited benefit from intensive care may have been transitioned out of the ICU to accommodate other patients with greater need. The most frequent surgeries requiring unplanned ICU admission were for gastrointestinal neoplasms (n = 464, 17.4%), followed by orthopedic surgeries (n = 303, 11.4%). Anaphylaxis occurred across a broad spectrum of surgeries. Respiratory-related complications were common in patients with other respiratory diseases and accounted for over half of the total number of cases according to surgery type. Neurological-related complications were most frequent in craniotomies for neoplasms. CONCLUSIONS: In our review of a nationwide ICU database from 2015 to 2022 we identified a 1.9% rate of unplanned ICU admission and found that mortality varied according to the reasons for ICU admission. Respiratory-related complications were most common, and cardiovascular complications were most associated with in-hospital mortality. Further research may help us to better understand the epidemiology of unplanned ICU admission after surgery.

Outcomes of surgical management for Kommerell's diverticulum associated with type b aortic dissection.

Kommerell's diverticulum presents a distinctive challenge in clinical management due to its rarity and diverse clinical manifestations, particularly when concurrent with type B aortic dissection. However, a consensus on the optimal treatment strategy has yet to be established. This study presents our experience with an open surgical approach to treating Kommerell's diverticulum associated with type B aortic dissection. This retrospective study evaluated 10 patients who underwent surgical repair for Kommerell's diverticulum with concurrent type B aortic dissection. Through median sternotomy, under cardiopulmonary bypass and deep hypothermic circulatory arrest + retrograde cerebral perfusion, a frozen elephant trunk stent graft was deployed in the descending thoracic aorta to address the type B aortic dissection and Kommerell's diverticulum. Aberrant subclavian arteries were reconstructed by bypassing the distal portion into the native ascending aorta or carotid artery, accompanied by proximal ligation of the aberrant artery. The median age of patient was 49 years (Interquartile range: 42.2-58.5). There were no in-hospital or 30-day post-operative deaths. All patients were discharged with a median hospital stay of 8.5 days (Interquartile range: 7.75-10.5). No cases of stroke or spinal cord ischaemia were observed. Follow-up was completed for all patients, with a mean duration of 27.4 (Standard deviation: 15.3) months, during which no adverse events occurred. This surgical approach for managing Kommerell's diverticulum with type B aortic dissection offers a safe and effective option, yielding favourable short-term outcomes. It may provide a durable alternative to traditional surgical methods and overcome limitations associated with endovascular surgeries.

Delirium Among Liver Transplant Recipients: ANational Analysis Using MarketScan.

Delirium is a common issue following liver transplantation (LT), but research has mainly focused on single-center cohorts. We studied delirium in a national cohort of adult LT recipients transplanted October, 2015-December, 2020 using the MarketScan database. Claims data were used to identify LT recipients with delirium. Characteristics and outcomes of LT recipients with and without delirium were compared using descriptive statistics. Among 2051 LT recipients, only 32 (1.6%) had a delirium claim. Recipients with versus without delirium were more likely to have a history of encephalopathy (21.9% versus 8.2%, P=0.006) but were of similar age and sex. Recipients with versus without delirium were more likely to be discharged to skilled care or rehabilitation facilities (37.5% versus 14.3%, P=0.003) and had longer median hospital stays (24 versus 14ds, P=0.03). Delirium claims were not associated with median hospitalization costs (P=0.15) or 30-d (P=0.32) and 60-d (P=0.99) readmission. Overall, only 1.6% of adult LT recipients had delirium claims, despite prevalence estimates of up to 47% in single-center studies. This underreporting-which is likely limited to the most severe cases-limits our ability to assess associated outcomes and highlights the need for better delirium recognition and reporting.

Multicenter study on 2-year outcomes of dual application of hydroxyapatite cranioplasty and a nasoseptal flap following endoscopic endonasal surgery for tuberculum sellae meningiomas or craniopharyngiomas.

The authors evaluated the intermediate-term outcomes of a skull base reconstruction technique using hydroxyapatite cranioplasty combined with a nasoseptal flap following endoscopic endonasal surgery (EES) for suprasellar tumors. Specifically, the evaluation focused on the avoidance of lumbar CSF drainage, prevention of CSF leakage, and incidence of postoperative complications, including meningitis and nasoseptal flap necrosis, during a minimum follow-up of 2 years. This multicenter study included patients who met the following criteria: 1) underwent EES for tuberculum sellae meningiomas or craniopharyngiomas, 2) received dual application of hydroxyapatite cranioplasty and reconstruction using a nasoseptal flap, 3) had a follow-up duration of at least 2 years, and 4) did not undergo lumbar drainage of CSF postoperatively. The success rate of reconstruction was determined based on postoperative CSF leakage, associated complications, meningitis, postoperative hospital length of stay (LOS), and would dehiscence. A total of 198 patients from three institutions diagnosed with tuberculum sellae meningioma (86 patients) or craniopharyngioma (112 patients) were included in this study. The median follow-up duration was 39 months. No patient underwent postoperative lumbar drainage of CSF. Postoperatively, only 3 patients (1.5%) experienced CSF leaks requiring reoperation. The median hospital LOS after surgery was 5 days. Other postoperative complications included atypical meningitis in 5 patients and wound dehiscence in 3 patients during the follow-up period. All patients with nonbacterial meningitis were treated with intravenous antibiotics and dexamethasone medication for 2 weeks. The combination of hydroxyapatite cranioplasty and a nasoseptal flap in reconstruction following EES decreased the requirement for postoperative lumbar CSF drainage and shortened hospital LOSs with minimal morbidities. Nevertheless, careful attention to the risks of meningitis and central necrosis of a nasoseptal flap is crucial for optimizing patient outcomes.

Impact of Locum Tenens Providers on Delivery of Pediatric Surgical Care.

We sought to understand the impact of locum tenens surgeons on pediatric surgical care delivery. We conducted a cross-sectional survey of Children's Hospital Association pediatric surgical practices. Anonymous electronic surveys were used to investigate locum tenens utilization, primary reason for use, limitations on clinical activities, and variations in practice standards or quality. Bivariate analysis and multivariable logistic regression were performed to evaluate for associations between practice characteristics and locum tenens use. Of 172 practices, 71% (n=122) completed the survey. Median hospital size was 203 beds (interquartile range=130-350). Median number of surgeons per practice was 5 (interquartile range=3-8). Thirty-seven practices (30%) employed locum tenens at primary (n=27) or satellite (n=12) sites. Locum tenens utilization was higher in suburban (odds ratio [OR]=3.78, P=0.006) and rural (OR=4.96, P=0.041) locations and lower at sites with a level 4 neonatal intensive care unit (OR=0.35, P=0.035). Most (51%) used locum tenens ≥ 1 time monthly but < 1 time weekly and for ongoing or interim coverage (87%). In total, 14% of practices reported clinical restrictions for locum tenens surgeons, including limitations on extracorporeal membrane oxygenation, neonatal index cases, and operative trauma. Most (76%) practices using locum tenens reported variations in practice standards or quality; all were perceived as negative (57%) or neutral (43%). Locum tenens providers are utilized most commonly in suburban and rural sites and hospitals without the highest level of neonatal intensive care. While locum tenens surgeons may help maintain access to pediatric surgical care where gaps exist, there may be a need to improve the quality and reliability of care rendered.

Impact of Ex Vivo Lung Perfusion on Inpatient Cost: A Propensity Score-Matched Analysis of the US Nationwide Healthcare Cost and Utilization Project Database.

The goal of this study was to investigate the association between ex vivo lung perfusion (EVLP) use and inpatient hospitalization cost for lung transplantation in a nationwide sample. Lung transplantation patients in 2018-2020 Nationwide Readmissions Database (NRD) were grouped based on use of EVLP. The primary outcome was total inpatient hospitalization cost. 1:2 propensity score matching by EVLP status was performed followed by multivariable linear regression to determine the association between inpatient cost and EVLP while adjusting for pre-transplant hospital days, high volume EVLP center status, and propensity score. There were 3902 lung transplants and 118 (3%) were recipients of EVLP lungs. Among EVLP patients, the median cost was $871468 (IQR: $608671-1274392), compared to $846516 (IQR: $531462-1439267, p=0.871) among the total non-EVLP cohort. After 1:2 propensity score-matched cohort, recipients of EVLP lungs had longer median hospital length of stay (p=0.046). In the multivariable model using the matched sample, increased cost was not associated with EVLP use (p=0.783); however, high volume EVLP centers were associated with decreased cost (p=0.018). EVLP use was not associated with greater inpatient costs and may be favorable at high volume centers.

Perioperative and long-term outcomes of bilateral cardiac sympathetic denervation via video-assisted thoracoscopic surgery in patients with refractory ventricular arrhythmias.

Bilateral cardiac sympathetic denervation (CSD) performed via video-assisted thoracoscopic (VAT) surgery shows potential in managing ventricular tachycardia (VT), thereby reducing arrhythmic burden. In this setting, the scarcity of studies addressing both perioperative and long-term outcomes creates a substantial gap in the optimal management of patients with multiple comorbidities and limited treatment options. This observational study aimed to assess the medical comorbidities, as well as the short- and long-term outcomes of patients who underwent CSD for VT refractory to catheter ablation and medical therapy at a referral tertiary teaching hospital. We retrospectively analyzed data of all patients with VT who underwent bilateral CSD-VAT surgery at a single center. Unadjusted Kaplan-Meier survival curves were generated to analyze the survival rates at 1-year and 2-years following the procedure. Ten consecutive patients were unrolled between August 2014 and March 2024. Bilateral CSD-VAT surgery was successfully performed in all patients. Pre-operative ejection fraction was 33% (26-41). Two patients (22%) suffered cardiogenic shock and 1 vasoplegia. Half (50%) of the patients necessitated inotrope/vasopressor support and 1 an intra-aortic balloon pump. Median hospital stay was 12 (9-19) days. Three (33%) patients required postoperative ICU admission. All patients were alive upon hospital discharge. Neither major surgical complications nor complications typically associated with VAT-CSD (e.g., Horner's syndrome) were observed. The 1-year survival was 80% while the survival at 24months was 60%. CSD-VAT is a feasible rescue treatment in patients with refractory VT and is associated with limited intra- and postoperative complications alongside an acceptable long-term survival rate.

Macronutrient intake is different across Europe: Results of a Belgian cohort of critically ill adults.

Medical nutrition therapy (MNT) is fundamental for ICU patients. This post-hoc subgroup analysis of the prospective observational EuroPN survey aimed to assess MNT in the participating Belgian ICUs. MNT practices in 9 Belgian ICUs (148 patients) were compared to 77 ICUs (1172 patients) from 11 European countries during the first 15days for patients staying ≥5days in ICU - and with the 2019 ESPEN guideline on clinical nutrition in ICU (<70% of estimated energy expenditure in week 1 and up to 1.3g/kg/d protein). Additionally, overfeeding was evaluated in the Belgian cohort. The Belgian cohort had longer median ICU and hospital length of stay, higher emergency room admission rates and delayed MNT initiation compared to overall (EN: day 2.5 [2.0;4.0] vs 2.0 [2.0;4.0] and PN: day 5.0 [3.0,7.0] vs 2.0 [2.0,4.0]). They received more often EN than PN. In week 1 overfeeding was on average present in 30% (energy) and 15% (protein) of observation days. Similar to overall, the Belgian subgroup received a daily average moderate caloric and low protein intake. The gradual intake increase aligned with ESPEN guidelines, though temporary overfeeding occurred in about one third of the patients.

Clinico-demographical Profile of Pelvis and Acetabular Fracture Presenting in Tertiary Care Center of Nepal: An Observational Study

Introduction: Pelvis and acetabular fractures are complex, high-energy trauma and are often associated with life threatening injuries. The majority of them require surgical intervention and extensive rehabilitation. The epidemic figures are necessary to make plan for their management and its complications. We aim to analyze epidemiological profile of patients presented with pelvis and acetabular fracture in our center.Methods: This was observational cross-section study, analyzed on patients admitted with pelvis and acetabular fracture at a tertiary care center through emergency and outpatient department between January to December 2023. The collected parameters were age, gender, mechanism of injury, site of injury, classification of fracture, associated other injuries, management operative or non-operative, early post-operative complications, duration of hospital stay, mortality and Intensive Care Unit admission and they were analyzed. Ethical approval was obtained from Institutinal Review Committee (Reference number: 19/2024)Results: There were 48 (7.27%) pelvis and/or acetabular fracture amongst 660 patient with traumatic fractures. Pelvic fracture was 29 (4.39%) and acetabular fracture was 16 (2.42%). The median age was 38 years (IQR: 25.25-46.75) and 36 (75%) were male. Thirty three (69%) patients required surgery, 17 (35%) patients had additional surgery for associated injury and 14 (29%) required intensive care unit admission. The median hospital stay was 12.5 days and mortality rate were 2%.Conclusions: The proportion of pelvis fracture was comparable to other studies while the proportion of actebular was comparatively higher in this study.

P-1021. Comparative Clinical profile, Anti-Fungal resistance rates and in-hospital mortality in hospitalized patients with Candidaemia caused by Candida Auris versus Non-Auris Candida in a tertiary-care centre

Abstract Background Candidemia, a severest manifestation of invasive candidiasis, often encountered in intensive care units (ICUs) is predisposed by prolonged ICU-stay, immunosuppression or mechanical ventilation. In India, while various species of Candida (C. tropicalis, C. albicans, C. auris and others) are involved in candidemia, C. auris is particularly known for displaying higher anti-fungal resistance. We investigated, whether there was a difference in the clinical pattern of candidemia caused by C. auris vs non-auris Candida in our tertiary-care centre.Figure 1.Comorbidities among patients with candidaemia: C. auris group versus non-auris candida group CANDIDA AURIS VS NON-AURIS CLINICAL RISK FACTORS Methods The analysis involved 65 unique episodes (one patient per episode) of documented candidemia in our tertiary-care centre during January 2022 to April 2024. The clinical data was retrieved from the blinded hospital records. The day of admission of patients in to ICU was considered as hospital day-1. Results Among 65 episodes, 17 (26.2%) and 48 (73.8%) were that of C. auris and non-auris candida, respectively. The time to blood culture positivity was longer with C. auris cohort compared to non-auris candida cohort (median hospital days 27 vs 19). Total hospitalization days (median) were 49 and 15.5, P value 0.002 respectively. In-hospital mortality was 58% in C. auris group and 62.5% in non-auris candida group. There was more proportion of cancer patients in non-auris candida cohort while use of immunosuppressive drugs was more frequent in C. auris cohort (Figure 1). Resistance rates to fluconazole, amphotericin, and echinocandins were higher in C. auris group (94.5% vs 25%; 70.5% vs 6.3%; 11% vs 2.1%, respectively)..Total Parenteral Nutrition &amp;gt; 5 days (26.2% vs 73.9%) P value 0.38, Transplant Patients (47.05% vs 14.58%) , immunosuppressive drugs (64.7% vs 39.6% ) P value 0.07 and Mechanical Ventilation (88.2% vs 52.1%) P value 0.008 respectively. Conclusion C. Auris has emerged as a notorious Non Albicans Candida species with substantial morbidity and mortality suggesting change in the epidemiology of candidaemia. Patients with Candida auris had longer hospital stay and blood to positivity than others. Fluconazole resistance remains highest in candida auris than other species of candida and majority of isolates of C.auris had high MICs for amphotericin B. Disclosures All Authors: No reported disclosures

P-211. Implications of Skilled Nursing Facility Origin on Clostridioides difficile Infection Hospitalizations in the United States

Abstract Background Clostridioides difficile infection (CDI) occurs in nearly half a million Americans annually. Skilled nursing facility (SNF) residents are at increased CDI risk due to older age, underlying comorbidities, and frequent healthcare exposure. The study sought to describe the implications of CDI originating in SNFs, including CDI acuity, health outcomes, transitions of care, and economics. Methods This was a retrospective cohort study using the Premier Healthcare Database, which represents approximately one-quarter of United States healthcare systems. Older adult (65+ years) patients were included if they had an index, non-recurrent CDI hospitalization (ICD-10 code A04.72) between July 1, 2019 and December 31, 2022. Patient and CDI characteristics, health outcomes (inpatient mortality, hospital length of stay [LOS], readmission for recurrent CDI [rCDI]), and hospital costs were compared between patients admitted from a SNF compared to a non-SNF point of origin. Results A total of 94,330 index CDI hospitalizations were included. Patients were predominantly female (58.4%), White race (81.6%), and treated in urban settings (86.5%). Only 5.3% (n=5,003) of CDI patients were admitted from a SNF; however, 28.4% (n=26,891) were discharged to a SNF. One-third (31.0%) of patients admitted from a non-healthcare location were discharged to a SNF. Patients admitted from a SNF were older (median age 79 vs. 76 years) and more likely to have a secondary CDI diagnosis (85.0% vs. 74.4%) and emergent admission (90.2% vs. 82.1%) compared to non-SNF patients. Patients admitted from SNFs were also more likely to experience poor CDI health outcomes, including higher inpatient mortality (12.8% vs. 8.2%), readmissions for rCDI (14.8% vs. 13.8%), median hospital costs ($17,728 vs. $14,832), and longer median hospital LOS (8 vs. 7 days) (p&amp;lt; 0.05 for all). Median costs were significantly higher for patients discharged to a SNF compared to a non-SNF location ($19,560 vs. $11,481). Conclusion Older, hospitalized CDI patients originating from SNFs disproportionately experience poor outcomes in health and financial burden. Over one-quarter of CDI patients were discharged to a SNF suggesting a major impact on physical function, quality of life, and associated risk. Disclosures Kelly Reveles, PharmD, PhD, AstraZeneca: Grant/Research Support|Ferring Pharmaceuticals: Advisor/Consultant

P-1814. Say it Ain't Steno - Impact of a Microbiology Nudge Comment on Treatment of Respiratory Colonization

Abstract Background Stenotrophomonas maltophilia (SM) is a known colonizer of the respiratory tract, in which treatment is not required. Microbiological comment “nudges” have been successful as passive stewardship interventions. The study objective was to describe the effect of a targeted SM respiratory culture nudge on antibiotic use in patients with colonization. Methods IRB approved quasi-experiment of adult patients with a SM respiratory culture between 01/01/2022-01/27/2023 (pre-nudge) and 03/27/2023-12/31/2023 (post-nudge). Patients with criteria for active community/hospital/ventilator-acquired pneumonia or on targeted antibiotics prior to culture were excluded. Nudge comment implemented 2/2023: “S. maltophilia is a frequent colonizer of the respiratory tract. Clinical correlation for infection is required. Colonizers do not require antibiotic treatment.” The primary outcome was absence of SM therapy; secondary outcomes were SM therapy &amp;gt; 72 hours, hospital and ICU length of stay (LOS), and in-hospital all-cause mortality. Safety outcomes included antibiotic-related adverse events. Results 94 patients were included: 53 (56.4%) pre- and 41 (43.6%) post-nudge. Most patients were men (53, 56.4%), had underlying lung disease (61, 64.8%), and required invasive ventilatory support (70, 74.5%). 11 (11.7%) patients were admitted from a long-term care facility. The absence of SM therapy was observed in 13 (23.1%) pre- vs 32 (78.0%) post-nudge patients (P&amp;lt; 0.001). There were no differences in SM therapy &amp;gt; 72 hours (36/40 [90%] vs. 8/9 [88.9%], P=1.0), mortality (11 [20.8%] vs. 7 [17.5%], P=0.69), median (IQR) hospital LOS (24 [10-49] vs. 16 [8-29]), P=0.37), and median (IQR) ICU LOS [15 [2-35] vs. 11 [3-25], P=0.40) between pre- and post-nudge groups, respectively. Safety outcomes of patients treated &amp;gt; 72 hours (n=41); elevated SCr 12 (29.3%), fluid overload 18 (43.9%), hyponatremia 17 (41.5%), and hyperkalemia 5 (12.2%). After adjustment for confounders, post-nudge was associated with 11-fold increased odds of the absence of SM therapy (Table 1). Conclusion A targeted SM nudge was associated with a reduction in treatment of SM colonization. Patient outcomes, including length of stay and all-cause mortality, were comparable between the two groups. Disclosures Rachel M. Kenney, PharmD, BCIDP, Medtronic Inc: Spouse is an employee, stockholder

P-1610. Assessing the Impact of Reflex Urine Cultures in Pediatrics

Abstract Background Obtaining a urine culture (UCx) in the absence of urinary symptoms and inflammation has been shown to result in misdiagnosis and over treatment of urinary tract infections (UTIs) and catheter-associated UTIs in adults. Reflex UCx is a diagnostic stewardship strategy to reduce unnecessary UCx by performing UCx only if a urinalysis (UA) meets criteria for infection. Although the AAP has recommendations for reflex UCx in pediatrics, there are little data to support this approach. We aimed to assess the potential impact of reflex UCx on reducing unnecessary UCx in children. Age, specimen type, and hospital location in children with positive and negative UCx. Methods We performed a retrospective review of children age 2 to 18 years at our network of 8 hospitals from the emergency department or inpatient settings from 11/1/2020 to 7/20/2023. We included children with a matched microscopic UA (mUA) and UCx on the same calendar day. Positive UCx was defined as ≥ 50,000 CFU/ml for catheterized specimens and ≥ 100,000 CFU/ml for clean catch or unspecified specimens. Pyuria was defined as ≥ 10 WBC/HPF. Manual chart review was performed for positive UCx when &amp;lt; 10 WBC/HPF to determine cases consistent with clinical UTI. Sensitivity, specificity, positive predictive value, and negative predictive value with 95% confidence intervals were calculated. Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of Pyuria Compared to Positive Urine Culture and Clinical UTI. Results During the baseline period, 10,235 patients had a mUA and UCx, of which 893 (8.7%) UCx were positive. Median age, specimen types and hospital location are listed in Table 1. Of the positive UCx, 162 (18%) were associated with &amp;lt; 10 WBC/HPF. Of these cases, 44 (27%) had conditions that would have excluded them from reflex UCx per our hospital guideline: 36 (22%) had urologic abnormalities, 5 (3.1%) were pregnant, 3 (1.9%) were renal transplant recipients, and 0 (0%) had neutropenia. Of the remaining 118 positive cultures with &amp;lt; 10 WBC/HPF, 93 (79%) were not consistent with clinical UTI. Table 2 shows the sensitivity and negative predictive value (NPV) of pyuria for a positive UCx and clinical UTI. Conclusion In our study, we demonstrated the safety of a reflex UCx approach in a large pediatric population. Reflex UCx had low risk for missing clinical UTIs and would have reduced the number of unnecessary UCx during the pre-implementation period as 7349 (72%) would not have been performed. Reflex UCx should become standard of care in pediatrics. Disclosures Lars Westblade, PhD, Accelerate Diagnostics, Inc: Grant/Research Support|bioMerieux, Inc: Grant/Research Support|Element Materials Technology: Grant/Research Support|Hardy Diagnostics: Grant/Research Support|Roche Molecular Systems, Inc.: Advisor/Consultant|Roche Molecular Systems, Inc.: Grant/Research Support|Selux Diagnostics, Inc.: Grant/Research Support|Shionogi, Inc: Advisor/Consultant|Talis Biomedical: Advisor/Consultant

P-1571. Risk Factors for Infections after Urological Procedures among Patients with Negative Urine Culture Screening

Abstract Background The increased demand for urological procedures had become significant complications and correlating with an elevated prevalence of multidrug-resistant organisms (MDROs) infections, prolonged hospital stay, and the cost of treatment. Table 1 Multivariate analysis of risk factors for infection after urological procedures among patients with negative urine culture screening Methods We conducted a retrospective cohort study to identify the risks for infections after urological procedures among patients with negative urine culture screening. The patients underwent transrectal ultrasound (TRUS) and biopsy of the prostate, transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate (HoLEP), percutaneous nephrolithotomy (PCNL), ureteroscopy (URS), retrograde intrarenal surgery (RIRS), and transurethral resection of bladder tumor (TURBT) between 2021 and 2023, at Thammasat University Hospital, Thailand. Results A total of 441 patients had the procedures. There were 55 patients (12.5%) developed infections including urinary tract infections (UTIs) (55/55; 100%) and sepsis (9/55; 16%). The significant risks of infections were chronic kidney disease (CKD) stage III-V (P=0.005), history of previous UTI within 3 months (P&amp;lt; 0.05), Revised Cardiac Risk Index (RCRI) for preoperative risk &amp;gt; 2 (P=0.002), and PCNL (P&amp;lt; 0.05). The patients received antibiotic prophylaxis with levofloxacin (26.5%) for TRUS and biopsy of the prostate and cefoxitin (73.5%) for other procedures. The most common causative pathogens of UTIs after the procedures were Escherichia coli (27/55; 49%), Pseudomonas aeruginosa (9/55; 16.4%) and Klebsiella pneumoniae (7/55; 12.7%). MDROs were identified including extended-spectrum cephalosporinase (24/55; 43.6%) and fluoroquinolone-resistant Gram-negative bacteria (12/55; 21.8%). The median hospital stay was 12 days (IQR 10-15) VS 3 days (IQR 3-4) for infection VS non-infection. Conclusion Our study emphasized the novel significance of CKD and RCRI scores as risk factors and severity indices for preoperative risk assessment, correlating with postoperative infections following urological proceOur study emphasized the novel significance of CKD and RCRI scores as risk factors and severity indices for preoperative risk assessment, correlating with postoperative infections following urological procedures. Disclosures All Authors: No reported disclosures

P-90. Culture negative vs Culture positive Acute Hematogenous Osteomyelitis in Pediatrics: A single study experience

Abstract Background Acute hematogenous osteomyelitis (AHO) is a rare but serious infection in children that can result in acute and chronic sequelae. Despite guidelines, optimal management continues to be a source of debate, particularly in children without positive cultures. We examined treatment approaches and outcomes in AHO patients stratified by culture positivity. Consort Flow Diagram of the Study on Culture Negative vs. Culture Positive Acute Hematogenous Osteomyelitis in Pediatrics. This diagram illustrates the participant flow through each stage of the retrospective study, including enrollment, allocation, follow-up, and analysis. The numbers of participants assessed for eligibility, included in the study, and analyzed for the primary outcome are detailed, alongside reasons for exclusions at each stage. Methods This retrospective cohort study included children (&amp;lt; 19y) admitted at CHOP from 2005-2020 with a primary diagnosis of AHO. Cases were identified by APR-DRG and ICD-9 codes followed by chart review to determine inclusion/exclusion criteria (Table 1). Patients were divided into culture-positive (CX+) and culture-negative (CX-) groups. Wilcoxon rank sum tests were used to compare continuous variables and Chi-square test was used to compare categorical variables between groups. Inclusion/Exclusion criteria for defining AHO cohort This table details the criteria used to identify pediatric patients for inclusion and exclusion in the Study on Culture Negative vs. Culture Positive Acute Hematogenous Osteomyelitis in Pediatrics. Inclusion criteria focus on patient characteristics and clinical presentation necessary for study entry, including age, hospitalization duration, diagnosis, symptomology, and relevant imaging findings. Exclusion criteria are subdivided into primary factors, which identify general patient disqualifications, and secondary factors, which specifically differentiate between culture-positive and culture-negative cases. These criteria ensure a focused and relevant patient cohort for analysis. Results Of 796 children with a primary diagnosis of AHO, 395 [236 (59.7%) culture-negative and 159 (40.2%) culture-positive] met no secondary exclusion criteria. Patient characteristics are shown in Table 2. Blood culture was performed more frequently in CX+ cases (94.3% vs 84.1%, p=0.004), as were bone cultures (54.8% vs. 11.1%, p&amp;lt; 0.001). The proportion of CX- cases decreased over time (2005-8: 66%, 2009-12: 60%, 2013-16: 59%, 2017-20: 57%; p=0.12). The most common organisms identified in CX+ group were MSSA (73.6%) and MRSA (21.4%). CX+ more often received narrow-spectrum beta-lactams empirically (27.5% vs. 10.1%, p&amp;lt; 0.001) and as definitive therapy (60.9% vs 18.0%, p&amp;lt; 0.001). CX+ less often received anti-MRSA antibiotics empirically (65.2% vs. 83.1%, p&amp;lt; 0.001) or as definitive treatment (30.4% vs 78.1%, p&amp;lt; 0.001). CX+ patients had a shorter median hospital stay (4 days) than CX- patients (5 days, p&amp;lt; 0.001). There was no difference in treatment duration, treatment failure or need for repeat surgical intervention. Features of culture-positive and culture-negative AHO cases This table summarizes the demographic and clinical characteristics, site of infection, presenting features, and laboratory values at admission for pediatric patients diagnosed with AHO, categorized by culture-positive and culture-negative cases. Data are presented as medians with interquartile ranges (IQR) or as numbers with percentages. Statistical significance between groups is evaluated and shown in the rightmost column as p-values, highlighting differences in infection sites, symptom presentation, and initial laboratory findings between the two groups. Conclusion Nearly two-thirds of AHO cases were culture-negative at our hospital. The benefits of obtaining cultures (narrower spectrum therapy, shorter hospital stay) should be weighed since outcomes were similar between these groups. Disclosures Kevin J. Downes, MD, Paratek, Inc.: Grant/Research Support|Veloxis Pharmaceuticals, Inc.: Grant/Research Support

P-643. Incidence and Clinical Characteristics of Invasive Group A Streptococcal Infections in Underhoused Adults in Toronto, Canada

Abstract Background Post-pandemic increases of invasive group A streptococcal disease (iGAS) have been reported in many areas of the world; increased risk associated with illicit intravenous (IV) drug use has also been identified. Methods Since 1995, the Toronto Invasive Bacterial Diseases Network (TIBDN) has conducted prospective, population-based surveillance for iGAS in residents of Toronto/Peel Region (pop, 4.5M) in Canada. Homeless adults admitted to hospitals in the surveillance area are counted as residents. General and homeless population estimates were taken from Statistics Canada and published literature (doi:10.1136/bmjopen-2019-030221). Canada's National Microbiology Laboratory performs emm typing. Results In 2022/23, 88 iGAS cases (14% of all iGAS cases, 17% of adult iGAS) occurred in homeless persons; all were adults. Estimated iGAS incidence in homeless adults was 210/100,000/yr, versus 5.4/100,000/yr in other adults. Homeless persons with iGAS were younger than other adults (median age 47 v. 59 yr, P&amp;lt; .001); 70% were male (v. 63% in other adults, P=0.2). Homeless adults were more likely than other adults to be smokers (53% v. 27%, P&amp;lt; .001), to use IV drugs (46% v. 10%, P&amp;lt; .001), to have non-intact skin (43% v. 27%, P&amp;lt; .001) and to report recent soft tissue trauma (27% v. 17 %, P&amp;lt; .001). Compared to other adults, homeless adults were more likely to have comorbidities (90% v. 79%, P&amp;lt; .001), but less likely to be immunocompromised (3% v. 19%, P&amp;lt; .001). Presentations differed in homeless versus other adults (Table 1). 16 (18%) homeless adults required ICU admission, 10 (11%) mechanical ventilation, and 5 (8.5%) died. After age adjustment, outcomes did not differ between homeless and other adults. The median hospital length of stay was 8.5 days (IQR: 4-22) for homeless adults, and 8 days (IQR: 5-18) for other adults (P=0.7). The distribution of emm types of isolates in homeless and other adults is shown in Figure 1. iGAS in homeless adults was less likely to be caused by isolates of emm 1 and 12, and more likely to be caused by isolates of emm 49 and 74. Conclusion Homeless persons are at very high risk of iGAS, with IV drug use and skin integrity issues contributing. Outcomes of iGAS are similar to other adults. Differences in the emm types of isolates may be relevant to future vaccine program planning. Disclosures Allison McGeer, MD, AstraZeneca: Honoraria|GSK: Honoraria|Merck: Honoraria|Moderna: Honoraria|Novavax: Honoraria|Pfizer: Grant/Research Support|Pfizer: Honoraria|Roche: Honoraria|Seqirus: Grant/Research Support|Seqirus: Honoraria

P-1907. Comparing Multisystem Inflammatory Syndrome in Children (MIS-C) Case Characteristics Across Periods of SARS-CoV-2 (SC2) Variant Predominance in Los Angeles County (LAC): 2020-2023

Abstract Background MIS-C is a rare condition in children associated with prior SC2 infection. Limited data show the impact of SC2 variants on the presentation of MIS-C. This study analyzes differences in the presentation of MIS-C cases in LAC when different variants were circulating. Characteristics of Multisystem Inflammatory Syndrome in Children (MIS-C) Cases, -- Los Angeles County*, California March 1, 2020- December 31, 2023 Methods This analysis includes MIS-C cases in people &amp;lt; 21 years of age reported to LAC with onset from 3/1/2020-12/31/2023. We defined confirmed SC2 infection as having a documented positive SC2 test with specimen collection date &amp;lt; 60 days prior to MIS-C symptom onset. Where SC2 positive results were not available, we imputed SC2 infection as occurring 30 days prior to MIS-C onset. Infection dates were used to classify cases by variant predominant periods, defined as weeks where &amp;gt; 50% of sequenced specimens reported to LAC were a particular variant as defined by the WHO as a variant of concern. Case demographics and clinical characteristics were compared across variant periods. Analyses were conducted for all reported MIS-C cases and for cases with confirmed SC2 infection. Statistical significance was tested with the Kruskal-Wallis test and chi-squared test [α=0.05]. Results 349 MIS-C cases were reported between 2020-2023 (Table 1). Of these, 102 (29.2%) had a documented SC2 infection. Median age at onset was 7.8 years. 168 (48.1%) had ≥ 1 comorbidity, 124 (35.5%) were admitted to the ICU, and median hospital length of stay (LOS) was 5 days. 18 cases were vaccinated prior to MIS-C onset. The most SC2 infections occurred during the Pre-Delta period (230, 65.9%), while the fewest occurred during the Delta period (57, 16.3%) (Table 2). Median age and proportion of children with ≥ 1 comorbidity decreased across variant periods (p &amp;lt; 0.0001, p=0.0102; respectively). The median LOS was lowest when SC2 infection occurred during the Omicron period (p=0.0370). ICU admission was not statistically different across variant periods. Conclusion The LOS, median age, and proportion of cases with comorbidities decreased when SC2 infection occurred during the Omicron period. This may be due to differences in variant pathogenicity, natural immunity decreasing the MIS-C susceptible pool, and younger children being the last group to be eligible for vaccination during later variant periods. Disclosures All Authors: No reported disclosures

P-178. Crotalic snakebites accidents: the clinical and epidemiological profile of patients treated at toxicology unit of a reference center in Brazil

Abstract Background In Brazil, about 30,000 snakebites accidents are reported every year. Crotalus durissus is responsible for 9% of the cases. This study aimed to assess the clinical, epidemiological and laboratory profile of victims of crotalic accidents treated at a major toxicological reference in Brazil and the incidence of clinical complications. Methods Retrospective cohort study that analyzed medical records from victims of crotalic accidents treated at the Toxicology Unity of the reference center between January/2011 and December/2022. Suspected crotalic accidents with lack of clinical and laboratory diagnosis were excluded. Multivariate logistic regression was performed to evaluate the association between the severity of crotalic accidents with its factors, reported as odds ratio (OR) and 95% confidence intervals. Results From 411 patients included (median age 40 years, interquartile range [IQR] 23–56), 79.8% were men, 70.0% pardo, 74.0% of the accidents happened in rural areas and 77.6% of the bites were in lower limbs. Overall, 29.0% were late-admitted to the hospital ( &amp;gt;6 hours after the accident. Accidents were more frequent in summer (63.3%). Median hospital length of stay was 3 days (IQR 2-4). From those who had local manifestations (90.3%), pain was the most frequent symptom (80.5%). Regarding patients who had systemic manifestations (74.0%), neuroparalytic were the most frequent (66.7%), followed by myotoxic and hemolytic (37.8%), vagal (20.4%) and renal (17.3%). Four deaths were reported (1.0%). Age &amp;gt; 50 years (OR 1.85 [95% CI 1.11-3.11]), non-identification of the snake (OR 4.24 [95% CI 2.07-8.97]) and &amp;gt;6h until medical admission (OR 4.23 [CI 95% 2.55-7.12]) were associated with severe cases. Conclusion The results show the importance of the adequate and early management of crotalic accidents focusing on the main manifestations. The establishment of epidemiological, clinical and laboratory profiles related to severe cases is also important to help understand the socio demographic characteristics of the patients. Disclosures All Authors: No reported disclosures

P-1149. Short versus Long Duration of Antibiotic Therapy in Pediatric Intensive Care Unit Patients with Uncomplicated Community Acquired Pneumonia: Impact of an Institutional Guideline Update

Abstract Background Community acquired pneumonia (CAP) is a significant cause of morbidity and antibiotic overutilization among pediatric patients. The 2011 Infectious Diseases Society of America (IDSA) guidelines recommend a treatment duration of 10 days for pediatric CAP but recognize that shorter courses may be appropriate in certain settings. In February 2022, based on newer literature and extrapolations from the adult population, Michigan Medicine updated its institutional guidelines to recommend an antibiotic duration of 5 days to treat uncomplicated CAP in hospitalized pediatric patients. However, there remains limited evidence to support a shorter duration of therapy for patients admitted to the pediatric intensive care unit (PICU). Baseline characteristics of patients treated for uncomplicated CAP in the PICU at Michigan Medicine from November 2020 to December 2023 Methods This was a single-center, retrospective cohort study of patients aged 6 months to 17 years old with CAP who were admitted to the PICU at Michigan Medicine from November 2020 to December 2023. Patients with complicated CAP, hospital acquired or ventilator associated pneumonia, cystic fibrosis, severe neutropenia, solid organ or stem cell transplant, tracheostomy dependence, sickle cell disease, or suspicion for fungal infection were excluded from the study. The primary outcome was treatment failure, defined as a composite of readmission, emergency department or outpatient visit, need for antibiotic retreatment, or death attributable to CAP within 30 days of completing antibiotic therapy. Clinical outcomes of patients treated for uncomplicated CAP in the PICU at Michigan Medicine before and after the institutional guideline update Results A total of 128 patients met eligibility criteria; 59 (46%) patients were treated before the guideline update and 69 (54%) were treated after the guideline update. The median antibiotic treatment duration was 7.71 days in the pre-guideline update group and 5.58 days in the post-guideline update group (P &amp;lt; 0.001). Three patients in the pre-guideline update group and five patients in the post-guideline update group experienced 30-day treatment failure, which was not a statistically significant difference (P = 0.615). There was no difference in the median hospital length of stay between groups. Conclusion This study demonstrated that a shorter course of antibiotic therapy did not increase the rate of treatment failure compared to a standard course of therapy for patients admitted to the PICU with uncomplicated CAP. Disclosures All Authors: No reported disclosures

P-1727. Impact of Four-Day Automatic-Stop Orders on the Duration of Antibiotic Treatment

Abstract Background Implementation of automatic antibiotic stop orders is an antimicrobial stewardship intervention that encourages timely antibiotic order re-evaluation for potential discontinuation, spectrum de-escalation, transition to oral therapy, or spectrum escalation if warranted based on emerging diagnostic results. This pre-post study was designed to evaluate the impact of a four-day automatic-stop order on antibacterial orders for patients admitted at a single community hospital site. Methods A single-center, retrospective pre-post study was conducted to compare outcomes following the re-introduction of a four-day automatic-stop order on antibacterial orders. The primary outcomes were hospital length of stay and median duration of antibiotic therapy. Secondary outcomes included hospital readmission within 30 days and the occurrence of C. difficile infections within 30 days. Data was compared between 2 non-consecutive weeks in the pre-implementation of the automatic-stop order policy with data from 2 non-consecutive weeks in the post-implementation of the automatic-stop order policy to ensure prescriber variability and prescribing practices. Patients admitted for fewer than 4 days, or who had orders with indications for meningitis, bacteremia, prosthetic material infection, bone and joint infections, endocarditis, C. difficile treatment, prophylaxis, or documented uncontrolled source were excluded to align with exclusions in the policy. Results The study included 362 patients in total, 167 in the pre-implementation group and 195 in the post-implementation group. The median hospital length of stay was 8.2 days in the pre-implementation group and 7.1 days in the post-implementation group (p=0.536). The median total treatment duration of antibiotic therapy was 6.2 days in the pre-implementation group and 5 days in the post-implementation group (p=0.02). Incidence of c. difficile was 3% in the pre-implementation group, compared to 1% in the post-implementation group (p=0.256). Conclusion An antimicrobial automatic stop policy of four days was associated with decreased antimicrobial days of therapy per patient, without differences in hospital length of stay. There were no safety concerns identified with this intervention. Disclosures All Authors: No reported disclosures