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Background: Methicillin-resistant Staphylococcus aureus (MRSA) infection in neonates is associated with significant morbidity, mortality, and hospital cost. Multiple studies have shown that these infections are often preceded by colonization, but no consensus has been established for MRSA surveillance. The impact of changing the surveillance strategy on vancomycin utilization has not been evaluated previously. Methods: Retrospective chart review of infants who underwent MRSA screening in a level IV NICU with all outborn neonates. A weekly surveillance PCR was obtained from the nares between July 2016 and June 2017 (phase 1) and only on admission and discharge between July 2017 and June 2018 (phase 2). Patients with a positive PCR were placed on contact precautions without decolonization. The χ2 test was performed to compare the 2 phases of screening, and the Student t test and the Fisher exact test were used to compare the characteristics of MRSA colonized infants. Vancomycin utilization was measured in days of therapy (DOT) per 1,000 NICU patient days. Results: In total, 689 infants underwent MRSA screening during the study period; 324 infants had weekly MRSA surveillance and 365 infants had screening at admission and discharge. There was no statistically significant difference in MRSA colonization rates (4.3% vs 3.0%) or MRSA colonization acquisition (negative to positive, 1.8% vs 1.0%) between the phases. Among MRSA-colonized patients, nearly 60% were colonized on admission. Nearly 40% of the infants became colonized with MRSA during their hospitalization, none of whom developed MRSA infections prior to discharge. Mean vancomycin utilization decreased from 38.55 to 30.16 DOT per 1,000 NICU patient days between the 2 study periods. Conclusions: In a level IV NICU with relatively low MRSA prevalence, the change in MRSA screening practice from weekly surveillance to surveillance upon admission and discharge demonstrated no difference in MRSA acquisition or infection. Overall vancomycin utilization also decreased during this period, suggesting a culture shift around antibiotic utilization. Further study is needed to evaluate the utility of MRSA screening, decolonization, and isolation practices in low-prevalence NICUs and to identify additional drivers of vancomycin utilization.Funding: NoneDisclosures: None

Background In April 2005, our Antimicrobial Stewardship Program (ASP) started to require prescribers to select an indication as part of an antimicrobial (AM) order. The ASP developed a list of approved indications for each AM with an unlimited number of options including “other.” In 2015–2016, we modified the indication lists to decrease the number of options. The goal of this project is to compare the frequency of indication “other” and the appropriateness of provider-selected indications before and after the intervention. Methods We performed a retrospective cohort study of cefepime, ceftriaxone, piperacillin/tazobactam, and ciprofloxacin (IV) orders for all children in our facility excluding orders placed in ambulatory locations and the emergency department. AM orders and provider-selected indications from January to March 2014 (preintervention) and 2017 (postintervention) were compared. Chart review was performed on a sample of pre- and postmodification orders to assess the appropriateness of provider-selected indications. An indication was considered appropriate if the provider-selected indication matched the clinical indication documented. Results A total of 747 orders were included in the data analysis, 350 and 397 orders from pre- and postintervention period, respectively. Ceftriaxone was the most commonly prescribed AM:13.7 and 17.2 orders per 1,000 inpatients-days during pre- and postintervention periods. The percent of indication “other” orders increased in the postintervention period for ceftriaxone while it decreased for ciprofloxacin and remained about the same for cefepime and piperacillin/tazobactam. Most prescribers who selected indication “other” for ceftriaxone during the postintervention period did not provide a reason (29.8%). The agreement between clinical and provider-selected indications was consistent in pre- and postintervention period except piperacillin/tazobactam (RR = 0.56). Conclusion Requiring selection of an indication encourages prescribers to evaluate their rationale for initiating an AM. Decreasing the number of indication options for some AMs was associated with increased use of indication “other,” suggesting that the prescriber could not find an indication that matched their needs. Disclosures All authors: No reported disclosures.

The Society for Healthcare Epidemiology of America (SHEA) guideline “Infection Prevention and Control in Residential Facilities for Pediatric Patients and Their Families” is the first infection prevention and control (IPC) guideline to address preventing transmission of infectious agents in “home away from home” residential settings, of which the Ronald McDonald Houses (RMHs) serve as a prototype. These types of facilities provide support services, including overnight lodging, for ill and injured children and their families. Food preparation occurs in common areas, and cleaning of rooms or apartments is performed by the occupants during their stay and before departure. Pediatricpatientsare frequent guests of the family-centered facilities while receiving or recovering from specialized medical therapy. Examples of high-risk populations served in these facilities include families of patients with cancer, recipients of stem cell or solid organ transplants, surgical and/or very-low-birthweight infants who receive care in neonatal intensive care units (NICUs), those with cystic fibrosis, and women with high-risk pregnancies awaiting delivery in a nearby medical center. Such facilities are located worldwide and vary in their physical structure and the predominant population served.

Mycoplasma pneumoniae is a common cause of community-acquired respiratory illness in the adolescent population. Stevens-Johnson syndrome is an extrapulmonary manifestation that has been associated with M pneumoniae infections. Three adolescent males presented within a 1-month period with M pneumoniae respiratory illnesses and severe mucositis but without the classic rash typical of Stevens-Johnson. Diagnosis was facilitated by the use of a polymerase chain reaction–based assay. This case series highlights the potential for M pneumoniae–associated Stevens-Johnson syndrome to occur without rash and supports the use of polymerase chain reaction for early diagnosis.

First described by Paul Ehrlich in 1879, who noted its characteristic staining by acidophilic dyes, for many years, the eosinophil was considered to be an end-effector cell associated with helminth infections and a cause of tissue damage. Over the past 30 years, research has helped to elucidate the complexity of the eosinophil’s function and establish its role in host defense and immunity. Eosinophils express an array of ligand receptors which play a role in cell growth, adhesion, chemotaxis, degranulation, and cell-to-cell interactions. They play a role in activation of complement via both classical and alternative pathways. Eosinophils synthesize, store and secrete cytokines, chemokines, and growth factors. They can process antigen, stimulate T cells, and promote humoral responses by interacting with B cells. Eosinophils can function as antigen presenting cells and can regulate processes associated with both T1 and T2 immunity. Although long known to play a role in defense against helminth organisms, the interactions of eosinophils with these parasites are now recognized to be much more complex. In addition, their interaction with other pathogens continues to be investigated. In this paper, we review the eosinophil’s unique biology and structure, including its characteristic granules and the effects of its proteins, our developing understanding of its role in innate and adaptive immunity and importance in immunomodulation, and the part it plays in defense against parasitic, viral, fungal and bacterial infections. Rather than our worst enemy, the eosinophil may, in fact, be one of the most essential components in host defense and immunity.

Background/Aims: Infants are especially at risk for intracranial injuries from dog bites due to their small stature and thin skull. Only 21 case reports have been published in the literature. We aim to add knowledge and treatment recommendations based on a more substantial sample. Methods: Ten pediatric patients with a penetrating skull injury as a result of a dog bite, treated at our institution between 1992 and 2010, were identified and analyzed descriptively. A literature review of the 21 case reports was also conducted. Results and Conclusion: Early diagnosis and treatment can prevent complications from hemorrhage or infections. Based on our results, we recommend obtaining a head CT for all victims sustaining injuries to the head, early use of broad spectrum antibiotics, debridement and irrigation of tissue, and follow-up to identify late infectious complications.

finding the equivalent of a wild-type thermodynamic state of an existing gene segment in other (unknown) instantiations of the biologic system, in both noncoding and coding gene regions. In coding regions, TT processes amino acid sequences in a codonbased 3-letter code with additional information about choice of codon alternatives. Differences in TT (mutant-wt, case-control) were used to assess objectives 1 and 2 for the genes coding for human CD14, TLR4, tumor necrosis factor (TNF), and activated protein C (APC). Results: Comparison of calculated TT profiles of the human CD14, TLR4, TNF, and APC genes with 16 species–based conservation profiles (ENCODE http://genome.ucsc.edu/) validated the evolutionary relevance of TT profiles, showing a significant correlation of interspecies conservation to low thermodynamically tolerant regions. Network analysis of context similarities captured by TT descriptors in TNF revealed a hierarchical block structure of this network that directly identifies precursor and mature protein segments, structural domains in the mature protein structure, and noncontiguous regions that are in direct contact in the folded TNF. For CD14 and APC, TT analysis gave insights with regard to protein-protein interaction sites in the oligomeric structure, and the correlation of structural periodicity to the periodicity of the TT characterization of the coding sequence. Thermodynamic tolerance profiles were used for interspecies comparisons of human-mouse (H-M) pairs, based on the assumption that optimal alignment of sequence H and M is the alignment in which the difference between TT(H) and TT(M) is minimal. This approach was used to obtain optimal unbiased differential TT potentials for H and M paralogs that were compared with various aspects of function. Conclusions: Thermodynamic tolerance analysis is a novel method that appears applicable to various types of analysis of inflammationrelated genes. This approach of using networks of TT-based similarities captured in corresponding adjacency matrices allows for the combination of both local and global impact of a given SNP at a particular locus. Differences between wild-type and mutant coding sequence TT descriptors in and adjacency matrices capturing networks of TT-based similarities are useful for the single sequence–based quantitative characterization of structural or functional impact of a mutation on a given gene.

We thank Schalock and Dinulos for their thoughtful review of our article.1 Their comments underscore the importance of the use of accurate terminology in the discussion of mucocutaneous disorders such as Stevens-Johnson syndrome (SJS). Schalock and Dinulos disagree with …