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Background In March 2020, an influx of admissions in COVID-19 positive patients threatened to overwhelm healthcare facilities in East Baton Rouge Parish, Louisiana. Exacerbating this problem was an overall shortage of diagnostic testing capability at that time, resulting in a delay in time-to-result return. An improvement in diagnostic testing availability and timeliness was necessary to improve the allocation of resources and ultimate throughput of patients. The management of a COVID-19 positive patient or patient under investigation requires infection control measures that can quickly consume personal protective equipment (PPE) stores and personnel available to treat these patients. Critical shortages of both PPE and personnel also negatively impact care in patients admitted with non-COVID-19 illnesses. Methods A multisectoral partnership of healthcare providers, facilities and academicians created a molecular diagnostic lab within an academic research facility dedicated to testing inpatients and healthcare personnel for SARS-CoV-2. The purpose of the laboratory was to provide a temporary solution to the East Baton Rouge Parish healthcare community until individual facilities were self-sustaining in testing capabilities. We describe the partnership and the impacts of this endeavor by developing a model derived from a combination of data sources, including electronic health records, hospital operations, and state and local resources. Findings Our model demonstrates two important principles: the impact of reduced turnaround times (TAT) on potential differences in inpatient population numbers for COVID-19 and savings in PPE attributed to the more rapid TAT.

BackgroundIn March 2020, an influx of admissions in COVID-19 positive patients threatened to overwhelm healthcare facilities in East Baton Rouge Parish, Louisiana. Exacerbating this problem was a shortage of diagnostic testing capability, resulting in a delay in time-to-result return. An improvement in diagnostic testing availability and timeliness was necessary to improve the allocation of resources and ultimate throughput of patients. The management of a COVID-19 positive patient or patient under investigation requires infection control measures that can quickly consume personal protective equipment (PPE) stores and personnel available to treat these patients. Critical shortages of both PPE and personnel also negatively impact care in patients admitted with non-COVID-19 illnesses.MethodsA multisectoral partnership of healthcare providers, facilities and academicians created a molecular diagnostic lab within an academic research facility dedicated to testing inpatients and healthcare personnel for SARS-CoV-2. The purpose of the laboratory was to provide a temporary solution to the East Baton Rouge Parish healthcare community until individual facilities were self-sustaining in testing capabilities. We describe the partnership and the impacts of this endeavor by developing a model derived from a combination of data sources, including electronic health records, hospital operations, and state and local resources.FindingsOur model demonstrates two important principles: the impact of reduced turnaround times (TAT) on potential differences in inpatient population numbers for COVID-19 and savings in PPE attributed to the more rapid TAT.InterpretationOverall, we provide rationale for and demonstration of the utility of multisectoral partnerships when responding to public health emergencies.

Supplemental Digital Content is available in the text., Objectives: Sepsis is a common cause of morbidity and mortality. A reliable, rapid, and early indicator can help improve efficiency of care and outcomes. To assess the IntelliSep test, a novel in vitro diagnostic that quantifies the state of immune activation by measuring the biophysical properties of leukocytes, as a rapid diagnostic for sepsis and a measure of severity of illness, as defined by Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation-II scores and the need for hospitalization. Design, Setting, SUBJECTS: Adult patients presenting to two emergency departments in Baton Rouge, LA, with signs of infection (two of four systemic inflammatory response syndrome criteria, with at least one being aberration of temperature or WBC count) or suspicion of infection (a clinician order for culture of a body fluid), were prospectively enrolled. Sepsis status, per Sepsis-3 criteria, was determined through a 3-tiered retrospective and blinded adjudication process consisting of objective review, site-level clinician review, and final determination by independent physician adjudicators. MEASUREMENTS AND MAIN RESULTS: Of 266 patients in the final analysis, those with sepsis had higher IntelliSep Index (median = 6.9; interquartile range, 6.1–7.6) than those adjudicated as not septic (median = 4.7; interquartile range, 3.7–5.9; p < 0.001), with an area under the receiver operating characteristic curve of 0.89 and 0.83 when compared with unanimous and forced adjudication standards, respectively. Patients with higher IntelliSep Index had higher Sequential Organ Failure Assessment (3 [interquartile range, 1–5] vs 1 [interquartile range, 0–2]; p < 0.001) and Acute Physiology and Chronic Health Evaluation-II (7 [interquartile range, 3.5–11.5] vs 5 [interquartile range, 2–9]; p < 0.05) and were more likely to be admitted to the hospital (83.6% vs 48.3%; p < 0.001) compared with those with lower IntelliSep Index. CONCLUSIONS: In patients presenting to the emergency department with signs or suspicion of infection, the IntelliSep Index is a promising tool for the rapid diagnosis and risk stratification for sepsis.

INTRODUCTION: Limited information is available to guide antimicrobial stewardship interventions in COVID-19 infections Two meta-analyses have been published to date showing a rate of bacterial co-infection between 7-8% in COVID-19, with only 1 case of methicillin-resistant Staphylococcus aureus (MRSA) among those publications METHODS: In an effort to optimize use of anti-MRSA therapy, the COVID-19 Task Force at this large, hybrid community and academic medical center implemented routine MRSA nasal swabs for all COVID-19 patients, suspected or confirmed, requiring anti-MRSA therapy This retrospective review was conducted to evaluate the use of MRSA nasal swabs in patients admitted between April 13, 2020 and July 26, 2020 Electronic health record-generated reports were created to identify patients with a diagnosis code of COVID-19 infection or COVID-19 rule out who also received an MRSA nasal swab RESULTS: Out of 263 patients identified with MRSA nasal swabs, 113 patients were included in the final analysis Almost 75% of patients required ICU admission and the overall mortality rate was 41 6% A total of 12 swabs (10 6%) resulted as positive for MRSA In response to swab results, 54 patients (47 8%) had anti-MRSA agents discontinued and another 37 patients (32 7%) were never started on anti-MRSA therapy (collectively referred to as ?discontinued? in this report) The median duration of anti-MRSA therapy overall was 12 hours (12 hours in the discontinued group versus 120 hours in the continued group) Sputum cultures were obtained in 29 patients, with pathogens identified in 13 Most pathogens were gram-negative, including Pseudomonas aeruginosa in 8 cases Methicillin-resistant Staphylococcus aureus was isolated in sputum cultures of two patients;both had MRSA positive nasal swabs and were continued on anti- MRSA therapy CONCLUSIONS: With implementation of MRSA nasal swabs in COVID-19 patients, anti-MRSA therapy was reduced in 80 5% of patients in the study cohort, with median duration 12 hours for anti-MRSA therapy Of the 22 patients with therapy continued, 11 were for pneumonia and MRSA positive swab and 10 for treatment of an alternative indication MRSA nasal swabs may serve as an effective antimicrobial stewardship tool in COVID-19 pneumonia

Ceftaroline is a fifth-generation cephalosporin with potent antimicrobial activity against Gram-positive and Gram-negative pathogens. Neutropenia is a rare serious adverse event for the class of cephalosporins; however, we observed several cases of severe neutropenia in our outpatient infectious disease practice believed to be associated with ceftaroline use. The aim of this study was to determine the incidence of neutropenia among patients receiving ceftaroline therapy for more than 7 days. We conducted a retrospective cohort analysis of patients admitted to an 800-bed regional medical center between June 2012 and December 2014 who received ceftaroline for more than 7 days to assess the incidence of developing clinically significant neutropenia. Demographic and patient care data points as well as underlying admitting and chronic diagnoses were retrospectively collected from the medical record. Clinically significant neutropenia was defined as an absolute neutrophil count (ANC) less than 1,500 cells/mm 3 . Analysis was performed to determine the incidence, severity, and outcome of neutropenia following ceftaroline administration. A total of 39 patients were included in the cohort. The median duration of therapy was 27 days. Seven patients (18%) developed neutropenia while on ceftaroline therapy. Four (10%) of the neutropenic patients had an ANC of 3 . The median first neutropenic day was day 17, with the median ANC nadir of 432 cells/mm 3 on day 24. We determined that extended ceftaroline infusion is associated with the development of neutropenia. We recommend obtaining a complete blood count (CBC) with differential at the onset of therapy and weekly thereafter. Should the ANC fall below 2,500 cells/mm 3 , then twice-weekly CBCs should be monitored for the duration of ceftaroline therapy, and therapy should be discontinued if the ANC falls to 1,500 cells/mm 3 or less.

BACKGROUND Francisella novicida is a rare cause of human illness despite its close genetic relationship to Francisella tularensis, the agent of tularemia. During April-July 2011, 3 inmates at a Louisiana correctional facility developed F. novicida bacteremia; 1 inmate died acutely. METHODS We interviewed surviving inmates; reviewed laboratory, medical, and housing records; and conducted an environmental investigation. Clinical and environmental samples were tested by culture, real-time polymerase chain reaction (PCR), and multigene sequencing. Isolates were typed by pulsed-field gel electrophoresis (PFGE). RESULTS Clinical isolates were identified as F. novicida based on sequence analyses of the 16S ribosomal RNA, pgm, and pdpD genes. PmeI PFGE patterns for the clinical isolates were indistinguishable. Source patients were aged 40-56 years, male, and African American, and all were immunocompromised. Two patients presented with signs of bacterial peritonitis; the third had pyomyositis of the thigh. The 3 inmates had no contact with one another; their only shared exposures were consumption of municipal water and of ice that was mass-produced at the prison in an unenclosed building. Swabs from one set of ice machines and associated ice scoops yielded evidence of F. novicida by PCR and sequencing. All other environmental specimens tested negative. CONCLUSIONS To our knowledge, this is the first reported common-source outbreak of F. novicida infections in humans. Epidemiological and laboratory evidence implicate contaminated ice as the likely vehicle of transmission; liver disease may be a predisposing factor. Clinicians, laboratorians, and public health officials should be aware of the potential for misidentification of F. novicida as F. tularensis.

Background The definition of sepsis evolves with improved understanding of the pathophysiology, but the presence of infection remains essential for the diagnosis. Despite this fact, there are currently no universal objective definitions for infections, which increases the variability in sepsis diagnoses. This variation makes interpretation of diagnostic studies, therapeutic interventions, and prognostic tools challenging. In this study, we compared physician adjudication of infection to standardized definitions of infection in patients meeting two of four Systemic Inflammatory Response Syndrome (SIRS) criteria. Methods In a prospective observational study performed in two academic medical centers, patients with two of four SIRS criteria were enrolled in Emergency Departments from February 2016 to December 2016. Diagnostic and physiologic data were abstracted for 151 patients at admission. Each medical record was independently reviewed by one Emergency Medicine and one critical care (CC) physician from a 10-member adjudicating committee to determine the presence of infection. In the case of disagreement, a third CC physician served as the tiebreaker. Objective definitions of infection were derived from consensus surveillance definitions. Results Overall, both adjudicators and the objective definitions agreed on the presence of infection 93% of the time and on the absence of infection 82.7% of the time. Of the patients adjudicated as indeterminate or not infected, eight and 13 met one objective definition of infection, respectively. The greatest discordance between physician adjudicated infection and objective definitions occurred in pneumonia patients (Table 1). Physician Adjudication Objective definition of infection Infected Indeterminate Not infected Not infected 4 11 62 Infected (Pneumonia) 53 8 (5) 13 (4) Total 57 19 75 Conclusion Implicit to the definition of sepsis is the presence of infection. Therefore, standardized methods of defining infections are necessary to decrease the variability in diagnoses and allow comparability among clinical trials. The application of objective definitions could prove to be a reproducible and reliable foundation for use by clinical investigators. Disclosures All authors: No reported disclosures.

Background The diagnosis of C. difficile infection (CDI) in the hospital is challenging asymptomatic colonization rates vary between 3% and 26%. Guidelines recommend multistep testing for CDI diagnosis. On July 1, 2018 a two-step testing algorithm was implemented at our institution. Positive nucleic acid amplification test (NAAT) results reflexed to a toxin enzyme immunoassay (EIA) test. The EIA test result was then used for NHSN reporting; however, both test results were visible to the clinician. Updated guidance on the interpretation of the test and treatment of CDI was released to the medical staff in July. We compared the incidence of CDI lab ID events per 1000 patient-days and the rate of C. difficile antibiotic starts before and after the implementation of the testing algorithm. Methods A retrospective observational study was performed at an 800 bed regional medical center. CDI lab ID events between January 1 and December 31, 2018 were reviewed. Antibiotic initiation of intravenous (IV) and oral (PO) metronidazole and PO vancomycin was collected for all hospitalized patients diagnosed with C. difficile. The incidence of hospital onset (HO) and community-onset (CO) lab ID events as well as the rate of antibiotic starts were compared before and after implementation of the algorithm using a two-sided z test for proportions with an alpha of 0.05. Results The incidence of HO and CO lab ID events per 1000 patient-days decreased significantly from 0.56 to 0.16 (P < 0.0001) and 1.18 to 0.3 (P < 0.0001) after implementation of the testing algorithm (Figure 1). The CDI SIR decreased from 0.729 to 0.322, (P = 0.0048). The rate of antibiotic starts per 1,000 patient-days for IV and PO Metronidazole decreased significantly from 1.1 to 0.45 (P < 0.0001) and 0.86 to 0.35 (P < 0.0001), respectively. PO Vancomycinstarts decreased from 1.51 to 1.23 (P = 0.11) (Table 1). Conclusion A two-step algorithm for diagnosing CDI decreases the overall number of HO and CO C. difficile lab ID events and decreases overall antimicrobial use for CDI. Disclosures All authors: No reported disclosures.

Hypereosinophillia is a rare clinical entity. It is associated with a wide differential diagnosis including neoplasm, infection, and allergic etiologies. Clinicians should have a well defined approach to hypereosinophilia in order to find treatable causes. We present a case of hypereosinophillia caused by parasitic infection with Toxocara canis. We also review epidemiology, transmission, microbiology, and management of Toxocara canis.

Background Diagnosing meningitis and encephalitis is challenging in the immunosuppressed population. Cerebrospinal fluid (CSF) culture is the gold standard diagnostic test for cryptococcal meningitis (CM), but is time intensive and requires a high index of suspicion. The BioFire FilmArray Meningitis/Encephalitis (ME) panel offers an option for rapid diagnostic testing. Recent studies suggest similar performance of the ME panel compared with CSF culture in the initial diagnosis and relapse of CM. We investigated the performance of the ME panel in the diagnosis of cryptococcal disease in patients presenting with meningitis. Methods A retrospective observational study was performed at an 800 bed regional medical center between June 1, 2016 and March 1, 2018. Laboratory results for all patients admitted with CSF or serum cryptococcal testing were reviewed. We abstracted the results from 14 distinct hospitalizations involving 12 patients (Figure 1) with CM who had an ME panel and CSF culture. Diagnostic performance was determined by comparison of ME panel to CSF culture. Table 1. ME and culture results of 14 CSF cryptococcal antigen positive specimens. Figure 1: Demographics and description of CSF specimens. Results The ME panel demonstrated a 71.43% (95% CI: 29.04–96.33) sensitivity and 100% (95% CI: 59.04–100) specificity for diagnosing CM for the population described in Table 1. ME panel detected all four patients with an initial diagnosis of CM and one of three patients with culture positive relapse. Conclusion Our findings suggest that a negative cryptococcal result on the ME panel should not be used to rule out cryptococcal disease, particularly in patients with a previous diagnosis of CM. Additional testing may increase cost, but until larger studies validate the use of rapid diagnostics, fungal culture remains the gold standard for the diagnosis of CM and should not be eliminated from routine evaluation. Disclosures All authors: No reported disclosures.

Background HSV encephalitis is a life-threatening disease process that requires prompt treatment. Diagnosis is often dependent upon nucleic acid studies of CNS samples. We introduced the Film Array Meningitis/Encephalitis (ME) Panel, a qualitative multiplexed nucleic acid-based diagnostic test for a variety of CNS pathogens, including HSV, in June 2016. It replaced an equivalent reference laboratory nucleic acid amplification test. The intent was to provide a more timely result and decrease unnecessary drug exposure to the patient. Methods We conducted a retrospective chart review of adult patients (>18 yo) admitted between June-September 2015 and June-September 2016 who underwent CSF testing for HSV and received empiric acyclovir. The aim was to determine whether the newly available test resulted in fewer doses of acyclovir in those who tested negative for a herpes virus as compared with those tested with the previously available assay. We excluded those found to be positive for HSV-1, HSV-2, or VZV in the CSF. We defined a dose as any administration of acyclovir or valacyclovir to the patient. Results Results of the diagnostic assay returned significantly faster after institution of the ME panel (4.9 days (118 hours) vs .09 days (2.25 hours)). Due to the non-normal distribution of acyclovir dosing, comparisons were made with the Wilcoxson Rank-sum. The institution of the ME panel for all CSF studies significantly impacted our use of acyclovir, as patients with negative tests for HSV PCR in the CSF received fewer doses of acyclovir after implementation of the ME panel (median (25th–75th percentiles) 6 (2–13.5) vs 3 (1–6), P = .018). Conclusion Implementation of a rapid diagnostic PCR based test for HSV 1 and HSV 2 in 2016 significantly reduced the number of empiric acyclovir doses administered during the summer of 2016 compared with the summer of 2015 in patients testing negative for the condition. Disclosures All authors: No reported disclosures.

Background Diagnosing Clostridium difficile infection (CDI) requires clinical understanding of the disease and knowledge of diagnostic testing limitations. It is important for providers to utilize CDI testing only in patients with suspected disease. Real-time polymerase chain reaction (PCR) assays are sensitive but cannot differentiate between symptomatic and asymptomatic patients. Individual hospitals have reported a 50% to 100% increase in the rate of CDI after substituting toxin tests with molecular tests such as PCR. We conducted a quality improvement project, implementing clinical decision support in ordering diagnostic testing of CDI, while measuring the number of diagnostic tests ordered and positive results. Methods We implemented evidence based clinical decision support into Cerner order entry system on March 1, 2016. The Cepheid Xpert C. difficile molecular test is used for diagnosis of CDI at our facility. The decision support included a message stating Òuse the test with caution in patients who are receiving tube feeds or recent laxative useÓ and prompted ordering providers to select one of three indications for using the test: 3 or more diarrheal stools per 24 hour period, leukocytosis with abdominal pain, or ileus. A control chart was used to monitor the number of tests ordered and positive tests per month (inpatient adults) for a total of 24 months; 14 months pre-intervention and 10 months post-intervention. Results A decrease in the number of tests ordered per month was seen post intervention. Average number of monthly tests ordered was 207 pre-intervention and 163 post-intervention. After controlling for patient-days per month, there was a 13.5% decrease in the number of tests ordered from a mean of 14.29 vs.. 12.37 tests per thousand patient-days per month. This resulted in special cause variation (Figure 1). There was no special cause variation detected with the number of positive PCRs per month, pre and post intervention. Conclusion Implementing decision support into the electronic medical record may assist providers with evidence-based utilization of the C. difficile PCR by decreasing unnecessary testing. This decrease may also have an impact on overall hospital costs, antibiotic utilization, and public reporting related to CDI. Disclosures All authors: No reported disclosures.

Infections with resistant Enterobacter spp. are increasingly described, yet data on outcomes associated with these infections are limited.A retrospective cohort study was conducted to investigate outcomes of hospitalized patients with third-generation cephalosporin-resistant (CR) Enterobacter bacteremia. Cephalosporin resistance was detected using cefotaxime and cefpodoxime. Patients with Enterobacter spp. bacteremia from January 2006 through February 2008 defined the population. We defined cases as those with CR isolates; controls were patients with bacteremia due to non-CR isolates. Treatment failure was defined as persistence of the presenting signs of infection 72 h after initial culture collection.Of the 95 Enterobacter cases identified, 31 (33%) were CR. CR cases were significantly associated with treatment failure (odds ratio (OR) 2.81, 95% confidence interval (CI) 1.14-6.94). This association was not seen after adjustment for age, simplified acute physiology score (SAPS II), and inappropriate empiric antibiotic therapy. Inappropriate empiric therapy (adjusted OR 3.86, 95% CI 1.32-11.31) and SAPS II score (adjusted OR 1.09, 95% CI 1.02-1.16) were significantly associated with treatment failure in the multivariate analysis.Third-generation cephalosporin-resistant Enterobacter bacteremia is associated with treatment failure due to receipt of inappropriate empiric antibiotic therapy and severity of illness.