Unspecified Infection Research Articles

Investigation of infections status in pediatric patients with acute myeloid leukemia during the induction period-a retrospective study in two medical centers.

This study aims to investigate the clinical characteristics of infections following induction chemotherapy for acute myeloid leukemia (AML) in children and identify risk factors associated with severe infections. Newly diagnosed children with AML treated at the Hematology Oncology Center of Beijing Children's Hospital affiliated to Capital Medical University (referred to as the "Beijing ward") and Baoding Hospital of Beijing Children's Hospital (referred to as the "Baoding ward") between November 2019 and August 2022 were enrolled. The diagnosis and treatment of the patients were carried out in accordance with the CCLG-AML 2019 protocol. Their essential information and infection-related indicators were collected. The various indicators between the two centers were compared. The incidence of infection in children with AML was 100%, with a severe infection rate of 15.3% and an infection-related mortality rate of 2.4%. Respiratory infections accounted for 39.7% of all infections events, and unspecified site infection for 32.2%. Bacterial infections were predominant at 51.2%. The bed unit area (BUA) varied significantly with 4.1 m2 in the Beijing ward and 10 m2 in the Baoding ward. Significant differences were observed in gastrointestinal infections (P < 0.001) and severe infections (P = 0.014) between the two wards. Several factors were identified as risk factors for severe infections, including BUA difference (OR = 4.353, 95% CI: 1.078-17.578), time of entering neutropenia phase after chemotherapy (OR = 6.369, 95% CI: 1.713-23.675) and bloodstream infection (OR = 7.466, 95% CI: 1.889-29.507). Respiratory tract infections and infections of unspecified site are most common during induction phase for pediatric AML. Bacteria, especially G- bacteria, are the leading pathogens. Risk factors for severe infections include a small BUA, entering neutropenia phase ≤ 5.5days after chemotherapy, and bloodstream infection. Recognizing these risk factors can aid in the early identification and intervention of severe infections.

Acute hemorrhagic leukoencephalitis: a case report and systematic review of factors associated with severe disability and death.

Acute hemorrhagic leukoencephalitis (AHLE), a rare form of acute disseminated encephalomyelitis (ADEM), has a generally poor prognosis. However, significant variation is observed, and even complete recovery has been reported. The recent increase in the frequency of AHLE case reports is possibly contributed by the advent of COVID-19 and may have added to the heterogeneity of cases. We report a fatal case of AHLE with a preceding unspecified respiratory infection, then perform a systematic review of AHLE, in an effort to delineate factors that may be associated with an ultimate outcome of severe disability (defined as modified Rankin scale score of 4 or 5) or death. Descriptions of 31 cases of AHLE were found in 21 identified articles, with our case being the 32nd case. The most common antecedent event was an infection (20 patients, 62.5%), with nearly half of these being COVID-19 (9 patients). The majority of patients had a subacute progression (1 to 10days) from onset to clinical nadir. We found that an altered mental status (AMS) and a Glasgow Coma Scale (GCS) score of less than12 were associated with a final outcome of severe disability or death. An abnormal upgoing plantar response was associated with a final outcome of death. COVID-19 and its vaccines were not associated with either outcome. AMS, depressed GCS, and an upgoing plantar response at presentation may be associated with a poor outcome in AHLE. Our findings may serve as a springboard to much-needed research into the stratification of AHLE.

Capturing anatomy in computed tomography scans for genital pathology.

In this cross-sectional study,we aimed to characterize how frequently the anatomy of interest (AOI) was excluded when evaluating genital pathology using the current CT pelvis protocol recommended by the American College of Radiology and evaluate how AOI exclusion affects patient management. We retrospectively reviewed medical records, using diagnosis and CPT codes, of patients admitted with genital pathology who obtained a CT scan at our institution from July 1, 2020-April 30, 2023. Baseline patient demographics were included. Data about each index CT scan (scan obtained at our institution) were recorded and assessed for exclusion of the AOI. Statistical analysis was performed to determine the rate of AOI exclusion and to compare patient management between patients with AOI excluded versus those without AOI exclusion. 113 presentations for genital pathology included an index CT scan and were included for analysis. Patients were primarily men (98%) with a mean age of 53.1 years (SD 13.9). The most common diagnoses were Fournier's gangrene (35%), scrotal abscess (22%) and unspecified infection (19%). 26/113 scans (23%) did not capture the entire AOI. When the AOI was missed during the index scan, there was a higher rate of obtaining additional scans (38% vs. 21%), but a similar rate of intervention (77% vs. 63%) when compared to index scans that captured the entire AOI.35 scans (31%) had protocol-extending instructions;index scans that captured the entire AOI were more likely to have specific protocol-extending instructions(38% vs. 8% p < 0.01). Creating a specific CT protocol for genital pathology could decrease the amount of inappropriate irradiation and improve AOI capture rates without relying on specific request for protocol deviation.

MACCABI-RED, community emergency care at the press of a button: a descriptive study.

Maccabi-RED is a new service developed in Israel that allows primary care staff to direct urgent cases to specialists in the community for evaluation in their local clinics on the same day as an alternative to an emergency department (ED) visit. A primary care physician or a nurse can activate the service, and all nearby specialists receive "a call" and can decide if they are willing to accept it, thus allowing the patient to avoid an unnecessary visit to the ED. To quantify and characterize the medical care provided by this service in a large national healthcare system. Multicenter, community-based, retrospective cohort study. All Maccabi-RED visits recorded between September 2021 and August 2022 were included. Patient characteristics were compared to national demographics. Descriptive statistics were used to present data regarding recorded diagnoses, treating physicians, treatments or referrals provided, and subsequent emergency department admissions or hospitalizations. 31831 visits were recorded. Most frequent diagnoses were musculoskeletal pain (12.1%), otitis or otalgia (7.8%), contusions (7.6%), fractures (7.1%), foreign body (6.7%), pregnancy-related symptoms (6.3%), and upper-respiratory or unspecified viral infection (6.3%). The most common treatments reported were foreign body removal (5%) and cast application (3.5%). Only 7.8% of visits resulted in emergency department admission within seven days (any cause). The average time from patient request to physician treatment was 91 min. Maccabi-RED is being widely used by patients nationwide. Additional studies are needed to investigate whether Maccabi-RED reduces emergency department visits and costs.

Clinical Phenotypes of Sepsis in a Cohort of Hospitalized Patients According to Infection Site.

Clinical sepsis phenotypes may be defined by a wide range of characteristics such as site of infection, organ dysfunction patterns, laboratory values, and demographics. There is a paucity of literature regarding the impact of site of infection on the timing and pattern of clinical sepsis markers. This study hypothesizes that important phenotypic variation in clinical markers and outcomes of sepsis exists when stratified by infection site. Retrospective cohort study. Five hospitals within the Wake Forest Health System from June 2019 to December 2019. Six thousand seven hundred fifty-three hospitalized adults with a discharge International Classification of Diseases, 10th Revision code for acute infection who met systemic inflammatory response syndrome (SIRS), quick Sepsis-related Organ Failure Assessment (qSOFA), or Sequential Organ Failure Assessment (SOFA) criteria during the index hospitalization. None. The primary outcome of interest was a composite of 30-day mortality or shock. Infection site was determined by a two-reviewer process. Significant demographic, vital sign, and laboratory result differences were seen across all infection sites. For the composite outcome of shock or 30-day mortality, unknown or unspecified infections had the highest proportion (21.34%) and CNS infections had the lowest proportion (8.11%). Respiratory, vascular, and unknown or unspecified infection sites showed a significantly increased adjusted and unadjusted odds of the composite outcome as compared with the other infection sites except CNS. Hospital time prior to SIRS positivity was shortest in unknown or unspecified infections at a median of 0.88 hours (interquartile range [IQR], 0.22-5.05 hr), and hospital time prior to qSOFA and SOFA positivity was shortest in respiratory infections at a median of 54.83 hours (IQR, 9.55-104.67 hr) and 1.88 hours (IQR, 0.47-17.40 hr), respectively. Phenotypic variation in illness severity and mortality exists when stratified by infection site. There is a significantly higher adjusted and unadjusted odds of the composite outcome of 30-day mortality or shock in respiratory, vascular, and unknown or unspecified infections as compared with other sites.

Abstract CT182: OXC-101 shows favorable safety profile in first in human phase 1 trial in patients with advanced solid cancer

Abstract Purpose: Many cancers suffer from dysfunctional redox status. MTH1 protects cancer cells from oxidative DNA damage by preventing incorporation of oxidized nucleotides. OXC-101 (Karonudib) is a dual-action mitotic disruptor and MTH1 inhibitor, preventing exit from mitosis and sanitation of oxidative damage to DNA subunits in cancer cells. MASTIFF, (MTH1, A Phase I, Study on Tumors Inhibition, First in Human, First in Class), is a first- in- human phase 1 study, with the primary aim to assess safety, tolerability, and pharmacokinetics (PK) of OXC-101 in patients (pts) with advanced solid malignant tumors (NCT03036228). Methods: Phase 1a study with 3+3 design and intra-patient dose escalation. New cohorts were opened following review of safety and PK data by the safety data monitoring board after the first treatment cycle of 4 weeks (w). All patients had progressive stage IV disease with no treatment options in SOC at inclusion. Radiological tumor response evaluation (RECIST 1.1) was performed 8w of the first 24w, 12w thereafter. The first 29 patients (cohort 1-10) obtained an oral solution. From cohort 11 pts obtained 100mg tablets. Results: 50 subjects (50% female, 50% male) were enrolled at 16 dose levels of OXC-101 at varying posology: 25-900 mg BID, 800-1000mg QD; every second day, once or twice weekly. Mean age was 52 years (range:20-74). 92% of pts had received previous chemotherapy (mean: 5 lines, range:0-34), 18% endocrine therapy and 52% other therapies (incl immunotherapy). OXC-101 was generally well tolerated and with manageable toxicity for dose levels for an average of 121 days (range:2-513 days), and 43/50 subjects discontinued due to disease progression. A total of 20 SAEs were reported: 8 SAEs in 7 subjects were considered related/possibly related to OXC-101 and included pneumonia (3/8), febrile neutropenia (2/8), ileus (1/8), unspecified infection (1/8) and fever (1/8). There were 14 dose-limiting toxicities (DLTs) reported in 7 subjects. At 510mg every second day (1785mg weekly) 2/5 subjects reported G4 neutropenia; at 500mg BID/1000mg QD, twice per week (2000 mg weekly) 2/9 subjects reported G4 neutropenia; at 900mg BID, once weekly (1800 mg weekly) 3/3 subjects reported decrease in white blood count incl. neutropenia. PK was robust and predictable with good exposure correlation between solution and tablet formulation, with an average half-life of 10 hrs in plasma. 15/49 (31%) of the subjects showed stable disease at first radiological evaluation. One subject had stable disease during 73 weeks on OXC-101 treatment. IHC and western blot analysis on tumor biopsies confirmed mechanism of action. A dose of 900mg (500mg mane, 400mg nocte) twice a week (total weekly dose 1800mg) was determined as the Recommended Phase 2 Dose (RP2D). This will be further explored in tumor specific cohorts. Conclusion: OXC-101 has a favorable safety profile with an RP2D of 900mg twice a week. Citation Format: Jeffrey Yachnin, Lars Ny, Teresa Sandvall, Kumar Sanjiv, Martin Scobie, Björn Platzack, Pawel Barancewski, Olof Breuer, Vassilis Gorgoulis, Ioannis S. Pateras, Maria Klockare, Austin Smith, Ulrika Warpman Berglund, Thomas Helleday. OXC-101 shows favorable safety profile in first in human phase 1 trial in patients with advanced solid cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 2 (Clinical Trials and Late-Breaking Research); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(8_Suppl):Abstract nr CT182.

Interesting Case of Disseminated Herpes Infection in A Healthy Female Patient Resembling Monkeypox

Normally we find cases of disseminated cutaneous herpes-simplex in immunocompromised individuals. With the advent of monkeypox, many reports have been falsely purporting cases of this disease when the lesions were either herpes simplex or an unspecified skin infection. In this case report we document the finding of a healthy 31-year-old female with herpetic lesions on her arms, legs, and vulvar area.

529. BV Score (Based on TRAIL, IP-10 and CRP) Accurately Distinguishes Between Bacterial and Viral Infection in Febrile Children: A Multi-Cohort Analysis

Abstract Background BV is a score for differentiating between bacterial and viral etiologies. Recently FDA cleared, it is based on computational integration of the blood levels of three host-proteins (TRAIL, IP-10, CRP). Here we report a multi-cohort analysis validating its diagnostic performance in comparison to a microbiology confirmed reference standard for children recruited in the Netherlands, Germany, Italy, Israel and the United States. Methods Febrile pediatric patients (age &amp;lt; 18) were recruited in Emergency Departments and Urgent Care Centers in the Apollo (NCT04690569), Autopilot (NCT03052088) and Opportunity (NCT01931254) studies. Eligibility criteria included suspicion of acute bacterial or viral infection symptoms for &amp;lt; 7 days in patient deemed to be immunocompetent. BV is indicative of bacterial or viral infection (MeMed BV®) based on pre-defined thresholds: 0 ≤ score &amp;lt; 35 indicates viral (or other non-bacterial) infection, 35 ≤ score ≤ 65 indicates equivocal and 65 &amp;lt; score ≤ 100 indicates bacterial infection (or co-infection). BV performance was assessed against the reference standard. Three experts independently reviewed comprehensive patient data including follow-up data but were blinded to BV. A bacterial or viral microbiology confirmed reference standard required all 3 experts to assign the same etiology in addition to a positive microbiology result supporting the experts’ decision (Figure legend). Results Among the 1,747 children recruited in the 3 studies, 861 were assigned a microbiology confirmed reference standard, with 811 viral and 50 bacterial cases (bacterial prevalence 6%). The median age was 1.8 years (interquartile range: 0.9-3.5 years), 42.3% were female, and 72.7% were diagnosed with respiratory tract infection or unspecified viral infection. BV yielded sensitivity and specificity of 95.6% (95% confidence interval: 84.9%-99.5%) and 95.4% (95%CI: 93.6%-96.8%), and negative predictive value of 99.7% (95%CI: 98.9%-99.9%), with 9.6% of cases yielding equivocal scores. Conclusion BV accurately distinguishes bacterial from viral etiology in microbiology confirmed cases and has the potential to support clinical diagnosis in children presenting to acute care settings. Disclosures Sheldon L. Kaplan, MD, MeMed: Advisor/Consultant|MeMed: Grant/Research Support|Pfizer: Grant/Research Support|Pfizer: Honoraria Cesar A. Arias, MD, PhD, Entasis Phramceuticals: Grant/Research Support|MeMed Diagnostics: Grant/Research Support|Merck: Grant/Research Support Richard G. Bachur, M.D., Appendicitis Biomarker: U.S. Patent|MeMed: Advisor/Consultant|MeMed: Grant/Research Support|UpToDate.com: Honoraria|Wolters-Kluwer: Honoraria Louis J Bont, M.D., MeMed: Principal Investigator (Payment made to institution for conduct of the Opportunity study) Adi Klein, M.D., MeMed: Principal Investigator (Payment made to institution for conduct of the Apollo study) Cihan Papan, M.D., MeMed: Grant/Research Support.

Headache frequency among 71,267 admissions to an adult medical emergency in the city of Recife in 2021

Introduction Pain is a warning sign that can mean great suffering and risk of death, and makes the patient seek a medical emergency for evaluation by specialists. Objective To verify the frequency of patients with headache disorders among those with pain admitted to the emergency department of a private hospital in Recife, Brazil, during the year 2021, using the international classification of diseases (ICD). Methods This is a retrospective study. The authors used the Business Intelligence (BI) tool to verify the number of admission by the ICD 10 recorded in 2021 in the emergency room of Hospital Unimed Recife III. The sample described in this study covers only the ICDs that had the word DOR (pain in Portuguese) or pain be the main symptom of the condition represented by the respective ICD. We selected only ICDs used in at least five admissions in 2021 (January to December), independent of readmission of the same patient. Results There were 71,267 consultations in 2021 using 2,296 different ICDs. Of these, the Headache (CEFALEIA) ICD was the 7th most frequent (n= 2,121) behind the following ICDs: Unspecified viral infection (n= 4,327); Influenza with other respiratory manifestations, due to unidentified virus (n= 3,335); Respiratory infection by the new coronavirus (Covid-19) (n= 2,927); Low back pain (n=2,759) and Diarrhea and gastroenteritis of presumptive infectious origin (n=2,739). In 27,853/71,267 (39.1%), the consultations were related to pain in any part of the body (with 258 ICDs). In the group of patients with pain of traumatological, orthopedic, or rheumatic origin, there were 10,148 consultations (142 ICDs); Abdominal or pelvic pain (5,675, with 23 DICs); Spinal pain (3,805, with 10 ICDs); and Chest pain, including coronary ischemia (1,786, with 10 ICDs)... (To see the complet abstract, please, check out the PDF.)

Infections in the first year of life and development of beta cell autoimmunity and clinical type 1 diabetes in high-risk individuals: the TRIGR cohort

Aims/hypothesisAccumulated data suggest that infections in early life contribute to the development of type 1 diabetes. Using data from the Trial to Reduce IDDM in the Genetically at Risk (TRIGR), we set out to assess whether children who later developed diabetes-related autoantibodies and/or clinical type 1 diabetes had different exposure to infections early in life compared with those who did not.MethodsA cohort of 2159 children with an affected first-degree relative and HLA-conferred susceptibility to type 1 diabetes were recruited between 2002 and 2007 and followed until 2017. Infections were registered prospectively. The relationship between infections in the first year of life and the development of autoantibodies or clinical type 1 diabetes was analysed using univariable and multivariable Cox regression models. As this study was exploratory, no adjustment was made for multiple comparisons.ResultsAdjusting for HLA, sex, breastfeeding duration and birth order, those who had seven or more infections during their first year of life were more likely to develop at least one positive type 1 diabetes-related autoantibody (p=0.028, HR 9.166 [95% CI 1.277, 65.81]) compared with those who had no infections. Those who had their first viral infection aged between 6 and 12 months were less likely to develop at least one positive type 1 diabetes-related antibody (p=0.043, HR 0.828 [95% CI 0.690, 0.994]) or multiple antibodies (p=0.0351, HR 0.664 [95% CI 0.453, 0.972]). Those who had ever had an unspecified bacterial infection were more likely to develop at least one positive type 1 diabetes-related autoantibody (p=0.013, HR 1.412 [95% CI 1.075, 1.854]), to develop multiple antibodies (p=0.037, HR 1.652 [95% CI 1.030, 2.649]) and to develop clinical type 1 diabetes (p=0.011, HR 2.066 [95% CI 1.182, 3.613]).Conclusions/interpretationWe found weak support for the assumption that viral infections early in life may initiate the autoimmune process or later development of type 1 diabetes. In contrast, certain bacterial infections appeared to increase the risk of both multiple autoantibodies and clinical type 1 diabetes.Graphical abstract

Editor's Choice – Epidemiology, Diagnostics, and Outcomes of Acute Occlusive Arterial Mesenteric Ischaemia: A Population Based Study

The exact incidence and outcomes of acute occlusive arterial mesenteric ischaemia (AMI) are unclear as most studies include only patients diagnosed correctly while alive. The aim of this study was to assess the incidence, mortality, and diagnostics of AMI by also including patients diagnosed post-mortem. This retrospective study comprised patients diagnosed with AMI either alive or post-mortem between 2006 and 2015 within a healthcare district serving 1.6 million inhabitants. Key exclusion criteria were venous or non-obstructive ischaemia. A total of 470 patients were included in the study of which 137 (29%) were diagnosed post-mortem. The most common misdiagnoses on those not diagnosed alive were unspecified infection (n= 19, 17%), gastrointestinal bleeding (n= 13, 11%), and ileus (n= 13, 11%). Of those diagnosed alive (n= 333), 187 (56%) underwent active surgical or endovascular treatment. During the 2006 - 2015 period, the overall incidence of AMI was 3.05 (95% CI 2.78 - 3.34)/100 000 person years and 26.66 (95% CI 24.07 - 29.45) for those aged 70 years or more. The mean autopsy rate during the study period was 29% for the overall population (32% during 2006 - 2010 and 25% during 2011 - 2015) and 18% for those aged 70 years or more. Overall, the 90-day mortality was 83% in all patients. The ninety day mortality decreased, being 87% during the first period (2006 - 2010) and 79% during the second period (2011 - 2015) (p= .029), while at the same time the proportion of patients diagnosed alive rose from 71% to 80% (p= .030) and the number of endovascular revascularisations rose from 1% to 5% (p= .022). A significant proportion of patients with AMI are not diagnosed alive, which is reflected in the mortality rates. Post-mortem examinations and autopsy rate data continue to be key factors in epidemiological studies on AMI.

Adverse events associated with AXIOS stents: Insights from the manufacturer and user facility device experience database.

ABSTRACTBackground and Objectives:The AXIOS stent is indicated for transgastric or transduodenal drainage of symptomatic pancreatic pseudocysts and symptomatic walled off necrosis. The AXIOS stent functions as a conduit which allows solid and liquid pancreatic fluid collections (PFC) contents to pass into the luminal GI tract and also allows the passage of standard and therapeutic endoscopes into the PFC to perform endoscopic debridement. We aim to investigate the number and type of complications associated with AXIOS stents.Materials and Methods:We analyzed postmarketing surveillance data from the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database January 2016 to February 2021.Results:During the study period, approximately 588 reports with 579 device issues and 250 patient complications were identified. Most device complications were due to stent positioning problems or stent malpositioning (n = 206; 35.6%), followed by stent migration (n = 72; 12.4%), premature deployment (n = 61; 10.5%), material integrity (n = 56; 9.6%), deployment failure (n = 47; 8.1%), and difficulty removing the stent (n = 45; 7.7%). The most reported patient adverse events were hemorrhage/bleeding (n = 81; 32.4%), perforation (n = 26; 10.4%), pain (n = 22; 8.8%), unspecified infection (n = 20; 8.0%), and death (n = 17; 6.8%).Conclusions:Findings from the MAUDE database highlight patient and device complications which endoscopists should be aware of before AXIOS stent placement.

1348. A Novel Host-Protein Signature Comprising TRAIL, IP-10 and CRP Differentiates Bacterial from Viral Infection in COPD Patients with Suspected Lower Respiratory Tract Infection

BackgroundIdentifying infectious etiology is often challenging, yet essential for patient management, including antibiotic use. Studies have shown that a host signature comprising TNF-related apoptosis induced ligand (TRAIL), interferon gamma induced protein-10 (IP-10) and C-reactive protein (CRP) accurately differentiates bacterial from viral infection with negative predictive value >98%. Performance data was lacking in chronic obstructive pulmonary disease (COPD) patients with suspected lower respiratory tract infection (LRTI).MethodsAdults aged >18 years with suspected LRTI were prospectively recruited at 3 medical centers (OBSERVER; grant #684589; NCT003011515). Reference standard infection etiology was adjudicated by 3 independent experts based on clinical, laboratory, microbiological, radiological and follow-up data. Host signature generates a bacterial likelihood score (0-100), providing three results: viral (0-35), equivocal (35-65) and bacterial (65-100). Experts were blinded to the signature result.ResultsOut of 583 adults recruited with suspected LRTI, 422 met infectious criteria, of whom 48 had a recorded history of COPD. 19 cases were adjudicated by the experts as bacterial, 14 as viral and 15 were indeterminate (Figure 1). The mean age was 68.2 years (standard deviation 12.3); 33 (68.8%) presented after two or more days of symptoms and 38 (79.2%) were hospitalized for a median of 6 days. 15 (31.2%) were female. For the patients adjudicated bacterial or viral labels (n=33), the discharge diagnoses were: COPD exacerbation, 12 cases (36.4%); pneumonia, 12 cases (36.4%) (3.0%); acute bronchitis, 2 cases (6.1%); upper RTI ,1 case; unspecified viral infection 1 case (3.0%); or other, 5 cases (15.2%). Host signature correctly classified all 19 bacterial cases and 8 of the viral cases, providing accurate etiology labels for 27/33 COPD patients with reference standard labels (81.8%). The remaining 6 viral cases received equivocal scores (18.2%).COPD patient enrollment and etiology labels in the Observer study ConclusionHost signature accurately differentiates between bacterial and viral infections in patients with COPD history, supporting potential to improve management among these patients frequently admitted for RTIs.Disclosures Michal Stein, MeMed (Employee) Meital Paz, MD, MeMed (Employee) Tanya Gottlieb, PhD, MeMed (Employee, Shareholder) Eran Barash, MA, MeMed (Employee) Roy Navon, MSc, MeMed (Employee, Shareholder) Einat Moscoviz, BSc+ MBA, MeMed (Employee) Tahel Ilan Ber, MD, MeMed (Employee, Shareholder) Liran Shani, MD, MeMed (Employee) Olga Boico, PhD, MeMed (Employee) Einav Simon, PhD, MeMed (Employee, Shareholder) Noa Avni, PhD, MeMed (Employee) Kfir Oved, MD, PhD, MeMed (Board Member, Employee, Shareholder) Eran Eden, PhD, MeMed (Board Member, Employee, Shareholder)

Infection Hospitalization Trends Among US Home Healthcare Patients, 2013–2018

Background: Infections are a frequent cause of hospital (re)admissions for older adults receiving home health care (HHC) in the United States. However, previous investigators have likely underestimated the prevalence of infections leading to hospitalization due to limitations of identifying infections using Outcome and Assessment Information Set (OASIS), the standardized assessment tool mandated for all Medicare-certified HHC agencies. By linking OASIS data with inpatient data from the Medicare Provider Analysis and Review (MedPAR) file, we were able to better quantify infection hospitalization trends and subsequent mortality among HHC patients. Method: After stratification (by census region, ownership, and urban or rural location) and random sampling, our data set consisted of 2,258,113 Medicare beneficiaries who received HHC services between January 1, 2013, and December 31, 2018, from 1,481 Medicare-certified HHC agencies. The 60-day HHC episodes were identified in OASIS. Hospital transfers reported in OASIS were linked with corresponding MedPAR records. Our outcomes of interest were (1) hospitalization with infection present on admission (POA); (2) hospitalization with infection as the primary cause; and (3) 30-day mortality following hospitalization with infection as the primary cause. We identified bacterial (including suspected) infections based on International Classification of Disease, Ninth Revision (ICD-9) and ICD-10 codes in MedPAR. We classified infections by site: respiratory, urinary tract, skin/soft tissue, intravenous catheter-related, and all (including other or unspecified infection site). We also identified sepsis diagnoses. Result: From 2013 through 2018, the percentage of 60-day HHC episodes with 1 or more hospital transfers ranged from 15% to 16%. Approximately half of all HHC patients hospitalized had an infection POA. Over the 6 years studied, infection (any type) was the primary cause of hospitalization in more than a quarter of all transfers (25.86%–27.57%). The percentage of hospitalizations due to sepsis increased from 7.51% in 2013 to 11.49% in 2018, whereas the percentage of hospitalizations due to respiratory, urinary tract, or skin/soft-tissue infections decreased (p &lt;0.001). Thirty-day mortality following a transfer due to infection ranged from 14.14% in 2013 to 14.98% in 2018; mortality rates were highest following transfers caused by sepsis (23.14%-26.51%) and respiratory infections (13.07%-14.27%). Conclusion: HHC is an important source of post-acute care for those aging in place. Our findings demonstrate that infections are a persistent problem in HHC and are associated with substantial 30-day mortality, particularly following hospitalizations caused by sepsis, emphasizing the importance of infection prevention in HHC. Effective policies to promote best practices for infection prevention and control in the home environment are needed to mitigate infection risk.Funding: NoDisclosures: None

Pulmonary cavitation in patients with COVID-19

Pulmonary cavitation in patients with COVID-19

Clinical mimickers of calciphylaxis: A retrospective study

Calciphylaxis is an ischemic vasculopathy with high morbidity and mortality. Early and accurate diagnosis is critical to management of calciphylaxis. Clinical mimickers may contribute to delayed or misdiagnosis. To assess the rate and risk factors for misdiagnosis and to identify clinical mimickers of calciphylaxis. A retrospective medical record review was conducted of patients with calciphylaxis at a large urban tertiary care hospital between 2006 and 2018. Of 119 patients diagnosed with calciphylaxis, 73.1% were initially misdiagnosed. Of patients not initially misdiagnosed, median time to diagnosis from initial presentation was 4.5days (interquartile range, 1.0-23.3), compared to 33days (interquartile range, 13.0-68.8) in patients who were initially misdiagnosed (P=.0002). The most common misdiagnoses were cellulitis (31.0%), unspecified skin infection (8.0%), and peripheral vascular disease (6.9%). Patients who were misdiagnosed frequently received at least 1 course of antibiotics. Patients with end-stage renal disease were less likely to be misdiagnosed than those without this disease (P=.001). Single-center, retrospective study. Understanding the risk factors for misdiagnosis of calciphylaxis is an opportunity for further education concerning this rare disease.

The impact of educational interventions on antibiotic prescribing for acute upper respiratory tract infections in the ambulatory care setting: A quasi‐experimental study

AbstractObjectiveTo identify the proportion of viral acute upper respiratory tract infections (AURTI) inappropriately treated with antibiotics before and after the implementation of a multimodal outpatient antibiotic stewardship initiative in a real‐world setting.DesignPre‐post, quasi‐experimental study.PatientsAdult patients with a diagnosis of either acute bronchitis, influenza, unspecified viral infection, or unspecified AURTI who visited internal medicine (IM) or family medicine (FM) ambulatory care clinics at an urban, academic health system in 2016 and 2017.InterventionsProvider education including the dissemination of an institutional guideline and algorithm for the treatment of AURTI occurred in FM and IM clinics. In the FM clinics, a roundtable discussion with clinicians promoting safe and appropriate antibiotic prescribing was conducted, and patient‐facing educational posters were placed in exam rooms and clinic waiting areas describing the FM teams' commitment to using antibiotics only when necessary.ResultsA total of 2817 patient encounters met study inclusion criteria. In total, inappropriate antibiotic prescribing had a relative decrease of 24% after implementation of the interventions (17.2% [235/1362] preintervention vs 13.1% [191/1455] postintervention; P = .02). During the preintervention period, 25.4% (143/563) of the encounters in the IM clinics were associated with inappropriate antibiotic prescribing compared with 19% (108/568) in the postintervention period (P &lt; .01). Relative to the IM clinics, the FM clinics had a lower proportion of encounters associated with inappropriate antibiotic prescribing at baseline. In FM clinics, 11.5% (92/799) of encounters were associated with inappropriate antibiotic prescribing during the preintervention period compared with 9.4% (83/887) during the postintervention period (P = .15).ConclusionsSimple educational interventions may decrease inappropriate antibiotic prescribing for AURTIs in outpatient settings. In addition, the incremental benefit of patient‐facing education may be limited outside of randomized studies or in settings with low baseline antibiotic prescribing rates for AURTIs. Therefore, additional studies outside of randomized trials are needed.

Eco-evolutionary agriculture: Host-pathogen dynamics in crop rotations.

Since its origins, thousands of years ago, agriculture has been challenged by the presence of evolving plant pathogens. Temporal rotations of host and non-host crops have helped farmers to control epidemics among other utilities, but further efforts for strategy assessment are needed. Here, we present a methodology for developing crop rotation strategies optimal for control of pathogens informed by numerical simulations of eco-evolutionary dynamics in one field. This approach can integrate agronomic criteria used in crop rotations—soil quality and cash yield—and the analysis of pathogen evolution in systems where hosts are artificially selected. Our analysis shows which rotation patterns perform better in maximising crop yield when an unspecified infection occurs, with yield being dependent on both soil quality and the strength of the epidemic. Importantly, the use of non-host crops, which both improve soil quality and control the epidemic results in similar rational rotation strategies for diverse agronomic and infection conditions. We test the repeatability of the best rotation patterns over multiple decades, an essential end-user goal. Our results provide sustainable strategies for optimal resource investment for increased food production and lead to further insights into the minimisation of pesticide use in a society demanding ever more efficient agriculture.

Differential Diagnosis of Acute Liver Failure in Children: A Systematic Review.

PurposeTo develop a probability-based differential diagnosis for pediatric acute liver failure (PALF) based on age and socioeconomic status of the country of origin.MethodsComprehensive literature search using PubMed, EMBASE, and SCOPUS databases was performed. Children 0–22 years of age who met PALF registry criteria were included. Articles included >10 children, and could not be a case report, review article, or editorial. No language filter was utilized, but an English abstract was required. Etiology of PALF, age of child, and country of origin was extracted from included articles.Results32 full text articles were reviewed in detail; 2,982 children were included. The top diagnosis of PALF in developed countries was acetaminophen toxicity (9.24%; 95% CredI 7.99–10.6), whereas in developing countries it was Hepatitis A (28.9%; 95% CredI 26.3–31.7). In developed countries, the leading diagnosis of PALF in children aged <1 year was metabolic disorder (17.2%; 95% CredI 10.3–25.5), whereas in developing countries it was unspecified infection (39.3%; CredI 27.6–51.8). In developed countries, the leading diagnosis in children aged >1 year was Non-A-B-C Hepatitis (8.18%; CredI 5.28–11.7), whereas in developing countries it was Hepatitis A (32.4%; CredI 28.6–36.3).ConclusionThe leading causes of PALF in children aged 0-22 years differ depending on the age and developmental status of their country of origin, suggesting that these factors must be considered in the evaluation of children with PALF.

Zika virus infection in pregnancy: Establishing a case definition for clinical research onpregnant women with rash in an active transmission setting.

Defining cases of Zika virus (ZIKV) infection is a critical challenge for epidemiological research. Due to ZIKV’s overlapping clinical features and potential immunologic cross-reactivity with other flaviviruses and the current lack of an optimal ZIKV-specific diagnostic assay, varying approaches for identifying ZIKV infections have been employed to date. This paper presents the laboratory results and diagnostic criteria developed by the Microcephaly Epidemic Research Group for defining cases of maternal ZIKV infection in a cohort of pregnant women with rash (N = 694) recruited during the declining 2015–2017 epidemic in northeast Brazil. For this investigation, we tested maternal sera for ZIKV by quantitative reverse transcription polymerase chain reaction (qRT-PCR), Immunoglobulin (Ig) M and IgG3 enzyme-linked immunosorbent assays (ELISAs), and Plaque Reduction Neutralization Test (PRNT50). Overall, 23.8% of participants tested positive by qRT-PCR during pregnancy (range of detection: 0–72 days after rash onset). However, the inter-assay concordance was lower than expected. Among women with qRT-PCR-confirmed ZIKV and further testing, only 10.1% had positive IgM tests within 90 days of rash, and only 48.5% had ZIKV-specific PRNT50 titers ≥20 within 1 year of rash. Given the complexity of these data, we convened a panel of experts to propose an algorithm for identifying ZIKV infections in pregnancy based on all available lines of evidence. When the diagnostic algorithm was applied to the cohort, 26.9% of participants were classified as having robust evidence of a ZIKV infection during pregnancy, 4.0% as having moderate evidence, 13.3% as having limited evidence of a ZIKV infection but with uncertain timing, and 19.5% as having evidence of an unspecified flavivirus infection before or during pregnancy. Our findings suggest that integrating longitudinal data from nucleic acid and serologic testing may enhance diagnostic sensitivity and underscore the need for an on-going dialogue regarding the optimization of strategies for defining cases of ZIKV in research.