Search

Background The annual incidence of invasive β-hemolytic group A streptococcus (GAS) infections in the United States is approximately 3.8 cases per 100,000 patients with 10–30% mortality. But data in GAS orthopedic infections is limited. We sought to characterize patient factors, medical and surgical management, and clinical outcomes from GAS orthopedic infections at our medical center. Methods A total of 12 patients with GAS orthopedic infections (necrotizing fasciitis, osteomyelitis, prosthetic joint infection, septic arthritis, or tenosynovitis) from July 2017 and March 2019 were included. Medical records were reviewed for site of positive GAS culture (blood, wound, joint fluid, or tissue cultures), demographics, comorbidities, surgical management, and antibiotic regimen and duration. The primary outcome was cure at 90 days defined as clinical improvement without recurrent or new infection, or further surgical or medical management at 90 days after treatment completion. The secondary outcome was erythrocyte sedimentation rates (ESR) before and after treatment. Results The median age of the 12 patients was 56 years (range 3–75); 58% were female and 58% had a body mass index ≥30 kg/m2. The median Charlson comorbidity index score was 3 (range 0–7) with 58% having diabetes mellitus. Two patients had either rheumatoid arthritis or monoclonal gammopathy (Table 1). Most patients had severe infections; 33% with necrotizing fasciitis and 25% with orthopedic implants. All patients had an elevated initial ESR, including 75% with ESR >40 mm/h. 92% required surgery, including 42% amputations and 17% prosthesis removals. Patients were mostly treated with β-lactams and vancomycin (92%); only 50% received clindamycin or linezolid. Most patients (75%) required at least 2 weeks of antibiotics. Five patients (42%) were not cured at 90 days, and 1 died of infectious complications (Table 2). Conclusion Severe GAS orthopedic infections necessitate both surgical management and prolonged antibiotics. 42% of our patients were not cured at 90 days and most eventually required amputation. Toxin mediators, clindamycin and linezolid, were underutilized. Chronic suppressive antibiotics should be considered for patients with orthopedic implants, especially those with durable immune suppression. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background We implemented a syndromic gastrointestinal pathogen panel (GIP) in May 2018, for rapid diagnosis of infectious diarrhea. GIP Clostridioides difficile polymerase chain reaction (PCR) results were suppressed due to concerns about oversensitivity. All positive (+) GIP and standard of care (SOC) C. difficile results were reviewed to understand C. difficile epidemiology and clinical outcomes. Methods Between May and December 2018, an audit of all adult patients with C. difficile (+) GIP results was conducted. Stewardship team obtained daily GIP results, reviewed patient charts, recommended a confirmatory SOC test, isolation, and treatment as indicated. Patients were classified as true C. difficile infection (CDI) with diarrhea and toxin or PCR positivity (Figure 1). We also reviewed GIP (+)/SOC negative (−) tests, and GIP (−)/SOC (−) tests (control group). GIP (+) patients with no confirmatory SOC test were excluded from the analysis. A multivariable logistic regression model was used to compare CDI at 3 months among groups. Results We reviewed 274 patients with a GIP C. difficile (+) result (Table 1). Seventy-one (26%) had no SOC sent. Of positive SOCs, 45 patients (37%) were positive by toxin A/B enzyme immunoassay (EIA), and 77 (63%) by PCR only (Figure 2A). There were 2153 total SOC tests sent, of these 332 (15%) were positive; 130 (39%) by toxin, and 202 (61%) by PCR only (Figure 2B). Mortality and 30-day re-admission were not significantly different between groups (Table 2). CDI rates within 3 months were not significantly different between GIP (+) only and control group (P = 0.11). In contrast, those with SOC (+) tests had more true CDI within 3 months, compared with controls (P < 0.001) (Table 2). Conclusion Forty percent of patients analyzed with GIP (+) C. difficile result were (−) by SOC test, suggesting that true CDI was not present in these patients. The percentage of toxin vs. PCR only (+) results from all the GIP positive patients mirrors that of all SOC (+) tests, indicating that the majority of CDI patients at our institution are PCR (+) only. Our results suggest that an additional PCR-based test may potentially over-report colonization as true infection. We strongly support diagnostic stewardship of C. difficile results within syndromic gastrointestinal panels. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

• Critically-ill COVID-19 patients with New Delhi Metallo-beta-lactamase producing Enterobacterales infections at our medical center had poor outcomes, including death in 4 of 5 cases • Multiple insults contributed to the occurrence of co-infection in these patients, including prolonged hospitalization, intubation, invasive devices, extensive antibiotic use, immunosuppressive therapy and environmental factors • There are few antibiotic options for treatment of infections with New Delhi Metallo-beta-lactamase producing Enterobacterales , contributing to poor outcomes • Hospitals and public health authorities should be vigilant for extensively drug resistant bacterial co-infections in patients hospitalized with COVID-19 [ABSTRACT FROM AUTHOR]

Background Severe sepsis and septic shock bundles have been shown to reduce mortality. Infectious Diseases (ID) consultation, particularly early in a hospital course, is associated with improved patient outcomes. Antibiotic Stewardship Program (ASP) decision support in the ED has also shown clinical benefit. We aim to examine the addition of early ID consultation to existing ASP decision support in the Emergency Department (ED) in patients with sepsis with organ dysfunction and/or shock (SODS) who completed the 3-hour bundle. Methods This is a retrospective study of 248 adult patients with clinical SODS who met inclusion criteria per Center for Medicare and Medicaid Services SEP-1 core measure in the ED and completed the recommended 3-hour sepsis bundle using ASP decision support tools. Patients who received ID consultation in the first 12 hours after ED triage (n = 111) were compared with patients who received standard care (n = 137). Pearson's chi-square test was used to compare groups for all-cause 30-day readmissions and in-hospital mortality. Logistic regression was used to adjust for covariates (age, race/ethnicity, Charlson score, lactate level ≥4, hypotension, recent hospital admission, recent IV antibiotics, history of MDR organisms, intra-abdominal source of infection). Time from ED triage to death and time to hospital discharge alive were analyzed using Fine and Gray models for competing risks. Results In-hospital mortality was lower among patients who received early ID consultation (24.3% vs. 38.0%, P = 0.0220). This association persisted after adjustment for covariates (odds ratio 0.49, 95% CI 0.26–0.91, P = 0.0236). There was no significant difference in 30-day readmissions between groups (22.6% vs. 23.5%, P = 0.8883). Early ID consultation was predictive of time to death (adjusted hazard ratio 0.58, 95% CI 0.35–0.98, P = 0.0406) and time to hospital discharge alive (adjusted hazard ratio 1.51, 95% CI 1.07–2.12, P-value 0.0174) after adjustment. Conclusion Early ID consultation was associated with lower mortality and time to hospital discharge among patients receiving the 3-hour severe sepsis/septic shock bundle. Further investigation is needed to explore specific interventions by ID consultants that might reduce the risk of mortality in this population. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]