The impact of environmental cleaning protocol featuring PX-UV in reducing the incidence of multidrug-resistant gram-negative healthcare-associated infection and colonization in intensive care units in Thailand

In this quasi-experimental study, implementing PX-UV to the standard environmental cleaning protocol was associated with a reduction in the overall incidence of multidrug-resistant (MDR) gram-negative organisms (P = .01) and MDR Acinetobacter baumannii (P = .001) in intervention intensive care units. However, the intervention did not reduce patient length of stay and 30-day mortality.

Antibiotic prescribing behavior among physicians in Asia: a multinational survey

Objective

To evaluate antibiotic prescribing behavior (APB) among physicians with various specialties in five Asian countries.

Design

Survey of antibiotics prescribing behavior in three stages (initial, on-treatment, and de-escalation stages).

Methods

Participants included internists, infectious diseases (ID) specialists, hematologists, intensivists, and surgeons. Participants' characteristics, patterns of APB, and perceptions of antimicrobial stewardship were collected. A multivariate analysis was conducted to evaluate factors associated with appropriate APB.

Results

There were 367 participants. The survey response rate was 82.5% (367/445). For the initial stage, different specialties had different choices for empiric treatment. For the on-treatment stage, if the patient does not respond to empiric treatment, most respondents will step up to broader-spectrum antibiotics (273/367: 74.39%). For the de-escalation stage, the rate of de-escalation was 10%-60% depending on the specialty. Most respondents would de-escalate antibiotics based on guidelines (250/367: 68.12%). De-escalation was mostly reported by ID specialists (66/106: 62.26%). Respondents who reported that they performed laboratory investigations prior to empirical antibiotic prescriptions (aOR = 2.83) were associated with appropriate use, while respondents who reported ID consultation were associated with appropriate antibiotic management for infections not responding to empiric treatment (aOR = 40.87); adherence with national guidelines (aOR = 2.57) was associated with reported successful carbapenem de-escalation.

Conclusion

This study highlights the variation in practices and gaps in appropriate APB on three stages of antibiotic prescription among different specialties. Education on appropriate investigation, partnership with ID specialist, and availability and adherence with national guidelines are critical to help guide appropriate APB among different specialties.

Risk Factors for Nontuberculous Mycobacteria Infections in Solid Organ Transplant Recipients: A Multinational Case-Control Study

BACKGROUND

Risk factors for nontuberculous mycobacteria (NTM) infections after solid organ transplant (SOT) are not well characterized. Here we aimed to describe these factors.

METHODS

Retrospective, multinational, 1:2 matched case-control study that included SOT recipients ≥12 years old diagnosed with NTM infection from 1 January 2008 to 31 December 2018. Controls were matched on transplanted organ, NTM treatment center, and post-transplant survival greater than or equal to the time to NTM diagnosis. Logistic regression on matched pairs was used to assess associations between risk factors and NTM infections.

RESULTS

Analyses included 85 cases and 169 controls (59% male, 88% White, median age at time of SOT of 54 years [interquartile range {IQR} 40-62]). NTM infection occurred in kidney (42%), lung (35%), heart and liver (11% each), and pancreas transplant recipients (1%). Median time from transplant to infection was 21.6 months (IQR 5.3-55.2). Most underlying comorbidities were evenly distributed between groups; however, cases were older at the time of NTM diagnosis, more frequently on systemic corticosteroids and had a lower lymphocyte count (all P < .05). In the multivariable model, older age at transplant (adjusted odds ratio [aOR] 1.04; 95 confidence interval [CI], 1.01-1.07), hospital admission within 90 days (aOR, 3.14; 95% CI, 1.41-6.98), receipt of antifungals (aOR, 5.35; 95% CI, 1.7-16.91), and lymphocyte-specific antibodies (aOR, 7.73; 95% CI, 1.07-56.14), were associated with NTM infection.

CONCLUSIONS

Risk of NTM infection in SOT recipients was associated with older age at SOT, prior hospital admission, receipt of antifungals or lymphocyte-specific antibodies. NTM infection should be considered in SOT patients with these risk factors.

The feasibility of procalcitonin and CPIS score to reduce inappropriate antibiotics use among severe-critically ill COVID-19 pneumonia patients: A pilot study

Antibiotics have been extensively used in COVID-19 patients without a clear indication. We conducted a study to evaluate the feasibility of procalcitonin along with the "Clinical Pulmonary for Infection Score" (CPIS) as a strategy to reduce inappropriate antibiotic use. Using procalcitonin and CPIS score (PCT-CPIS) successfully reduced inappropriate antibiotics use among severe-critically ill COVID-19 pneumonia patients (45% vs 100%; P < .01). Compared to "non PCT-CPIS" group, "PCT-CPIS" group was associated with a reduction in the incidence of multidrug-resistant organisms and invasive fungal infections (18.3% vs 36.7%; P = .03), shorter antibiotic duration (2 days vs 7 days; P < .01) and length of hospital stay (10 days vs 16 days; P < .01).

Impact of an infectious diseases pharmacist-led intervention on antimicrobial stewardship program guideline adherence at a Thai medical center

DISCLAIMER

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

To evaluate and compare antimicrobial stewardship program (ASP) guideline adherence (primary outcome) as well as length of stay, 30-day all-cause mortality, clinical cure, antimicrobial consumption, and incidence of multidrug-resistant (MDR) pathogens (secondary outcomes) between an infectious diseases (ID) pharmacist-led intervention group and a standard ASP group.

METHODS

A quasi-experimental study was performed at Thammasat University Hospital between August 2019 and April 2020. Data including baseline characteristics and primary and secondary outcomes were collected from the electronic medical record by the ID pharmacist.

RESULTS

The ASP guideline adherence in the ID pharmacist-led intervention group was significantly higher than in the standard ASP group (79% vs 56.6%; P < 0.001), especially with regard to appropriate indication (P < 0.001), dosage regimen (P = 0.005), and duration (P = 0.001). The acceptance rate of ID pharmacist recommendations was 81.8% (44/54). The most common key barriers to following recommendations were physician resistance (11/20; 55%) and high severity of disease in the patient (6/20; 30%). Compared to the standard ASP group, there was a trend toward clinical cure in the ID pharmacist-led intervention group (63.6% vs 56.1%; P = 0.127), while 30-day all-cause mortality (15.9% vs 1.5%; P = 0.344) and median length of stay (20 vs 18 days; P = 0.085) were similar in the 2 groups. Carbapenem (P = 0.042) and fosfomycin (P = 0.014) consumption declined in the ID pharmacist-led intervention group. A marginally significant decrease in the overall incidence of MDR pathogens was also observed in the ID pharmacist-led intervention group (coefficient, -5.93; P = 0.049).

CONCLUSION

Our study demonstrates that an ID pharmacist-led intervention can improve ASP guideline adherence and may reduce carbapenem consumption.

A Canker Barking at the Wrong Knee: Thyronectria austroamericana Septic Arthritis

The mold Thyronectria austroamericana is a plant pathogen that causes canker in honey locust trees. We describe the first case of this mold causing septic arthritis in humans.

Long-Term Mortality after Histoplasma Infection in People with HIV

Histoplasmosis is a common opportunistic infection in people with HIV (PWH); however, no study has looked at factors associated with the long-term mortality of histoplasmosis in PWH. We conducted a single-center retrospective study on the long-term mortality of PWH diagnosed with histoplasmosis between 2002 and 2017. Patients were categorized into three groups based on length of survival after diagnosis: early mortality (death < 90 days), late mortality (death ≥ 90 days), and long-term survivors. Patients diagnosed during or after 2008 were considered part of the modern antiretroviral therapy (ART) era. Insurance type (private vs. public) was a surrogate indicator of socioeconomic status. Out of 54 PWH infected with histoplasmosis, overall mortality was 37%; 14.8% early mortality and 22.2% late mortality. There was no statistically significant difference in survival based on the availability of modern ART (p = 0.60). Insurance status reached statistical significance with 38% of survivors having private insurance versus only 8% having private insurance in the late mortality group (p = 0.05). High mortality persists despite the advent of modern ART, implicating a contribution from social determinants of health, such as private insurance. Larger studies are needed to elucidate the role of these factors in the mortality of PWH.

A comparison of presentations and outcomes of histoplasmosis across patients with varying immune status

Few large cohorts have examined histoplasmosis in both immunocompromised and immunocompetent patients. We describe the differences in presentations and outcomes of histoplasmosis by immune and dissemination status. We assembled a retrospective cohort of adult patients diagnosed with histoplasmosis from 2002 to 2017. Patients were grouped by immune status: people living with HIV (PLWH), patients who were HIV negative but had other-immunocompromise (OIC), and immunocompetent patients. Patients were further classified into asymptomatic lung nodule (ALN), localized and disseminated disease groups, and outcomes were compared across patients by these immune status categories We identified 261 patients with histoplasmosis: 54 (21%) PLWH, 98 (38%) OIC, and 109 (42%) immunocompetent. Disseminated disease was more common among PLWH than among other groups (P < .001). In localized disease, median time from symptom onset to diagnosis was longer in immunocompetent patients than in other groups (P = .012), and was not significant in disseminated disease. The 90-day mortality was higher in PLWH (25%) and OIC (26%) with localized disease compared to the immunocompetent group (4%) (P = .009), but this difference was not seen in disseminated disease. Patients with localized disease had lower 90-day mortality (14%) compared to those with disseminated disease (21%) (P = .034). We conclude that immunocompetent individuals present with fewer typical symptoms, laboratory findings, and radiographic features of Histoplasma infection, leading to potential delays in diagnosis in this group. Despite this, immunocompetent patients have lower 90-day mortality in localized disease, and do not experience increased 90-day mortality in disseminated disease.

LAY SUMMARY

This article examines how the signs and symptoms of histoplasmosis vary by immune status and dissemination status. Immunocompetent patients with localized disease present with fewer typical signs and symptoms, are diagnosed later, but despite this have lower 90-day mortality.

1085. Epidemiology and Outcomes of Histoplasmosis in Transplant Recipients

Background

Histoplasmosis in transplant recipients is understudied. We reviewed a large cohort of histoplasmosis in patients with solid organ and stem cell transplants in an endemic area to describe the epidemiology, clinical findings and outcomes.

Methods

We performed a single-center retrospective cohort study of patients diagnosed with histoplasmosis between 2002 and 2017. Demographic data, clinical findings, diagnostic methods, treatment, and mortality were collected. We compared the characteristics of patients with history of transplant to non-transplant (NT) patients.

Results

We identified 261 patients with histoplasmosis. Of those, 28(11%) were transplant recipients; 8(29%) liver, 8(29%) lung, 6(21%) kidney, 3(11%) heart, and 3(11%) stem cell.

Median time from symptom onset to diagnosis was 6 vs 34 days in transplant vs NT groups (p=0.001). Lung was the most common organ involvement (89% in transplants vs 78% in NT, p=0.168). Spleen involvement was more commonly found in transplant patients (29 vs 14%, p=0.039). In patients with disseminated disease, urine antigen was 100% sensitive in transplant patients compared to 78% in the NT group (p=0.038). Duration of treatment was 13 vs 6 months in transplant vs NT patients (p= 0.003). Mortality was comparable between groups (14 vs 15% in transplant vs NT, p=0.918).

Median time from transplant to diagnosis was 4.21 years. However, five patients (18%) developed histoplasmosis within 6 months. For these early diagnosed patients, ICU admission rate was 80 vs 30% (p=0.04) and rate of mechanical ventilator use was 80 vs 22% (p=0.011) compared to patients diagnosed later.

Table 1: Patient characteristics

Table 2: Organ involvement

Table 3: Diagnostic test positivity

Conclusion

Transplant recipients with histoplasmosis are likely to be diagnosed early and be treated longer. Urine antigen is highly sensitive for diagnosis of disseminated disease. Histoplasmosis that occurs within the first 6 months after transplantation tends to be more severe.

Disclosures

Andrej Spec, MD, MSCI, Astellas (Grant/Research Support)Mayne (Consultant)Scynexis (Consultant)

923. Long-term Mortality after Histoplasma Infection in People Living with HIV

Background

Histoplasmosis is a common opportunistic infection afflicting people living with HIV (PLWH) globally. There are no data on long term survival of PLWH with histoplasmosis.

Methods

We conducted a single-center retrospective cohort study of PLWH diagnosed with histoplasmosis between 2002 and 2017. Data collected included demographics, clinical characteristics, treatment, and mortality. Patients were categorized into three groups based on length of survival after diagnosis: early mortality (death within 90 days), late mortality (death at or after 90 days), and survivors. Between group differences in demographic and clinical characteristics were assessed using Chi square for categorical variables and Mann-Whitney U non-parametric tests for continuous variables. Mortality was compared using Cox proportional hazards. Insurance type (i.e. private versus public option) served as a surrogate indicator of socioeconomic status (SES). Patients diagnosed with histoplasmosis in or after 2008 were considered a part of the modern ART era, regardless of treatment regimen.

Results

Our review found 54 PLWH infected with histoplasmosis from 2002-2017. Overall mortality was 37%, with 14.8% early mortality and 22.2% late mortality. Median survival time in the early mortality group was 13.5 days (IQR 2.5-41 days), and 338 days (IQR 180.5-803.3) in the late mortality group. Compared to the late mortality group, survivors were over 6 times more likely to have suppressed HIV viral load at last observation (HR 6.19, p=0.013). Median HIV viral load at last observation was lower among the survivors (2 log copies/ml, IQR 0, 4.5) compared to the late mortality group (4.1 log copies/ml, IQR 2.6,5.5) (p=0.010). Survivors were twice as likely to have private insurance, but this did not reach statistical significance (HR 2.19, p=0.14). There was no statistically significant difference in survival based on the availability of modern ART (p=0.85). The year of diagnosis made no difference with regards to survival (p=0.914).

Baseline Characteristics of PLWH with Histoplasmosis

HIV-related Characteristics of PLWH with Histoplasmosis

Conclusion

Histoplasmosis continues to be associated with high mortality among PLWH. Improved long-term survival is seen in patients with suppressed HIV viral loads.

Disclosures

Andrej Spec, MD, MSCI, Astellas (Grant/Research Support)Mayne (Consultant)Scynexis (Consultant)

Voriconazole versus Itraconazole for the Initial and Step-Down Treatment of Histoplasmosis: A Retrospective Cohort

BACKGROUND

Itraconazole is the preferred azole for histoplasmosis in the current Infectious Diseases Society of America guidelines. Voriconazole is increasingly used as treatment for histoplasmosis; it has in-vitro activity against Histoplasma capsulatum and has shown success in case reports and small case series but may have a lower barrier to resistance. No comparative studies have been published.

METHODS

We constructed a single-center retrospective cohort of adult patients diagnosed with histoplasmosis from 2002 to 2017. Individual charts were reviewed to gather clinical information including demographics, clinical features, immune status, treatments, and mortality. Patients were categorized based on initial choice of azole, either as initial treatment or as step-down therapy from amphotericin B. Initial therapies with other azoles were excluded. Mortality was compared using a multivariable Cox proportional hazards with Heaviside function at 42 days.

RESULTS

We identified 261 cases of histoplasmosis from 2002 to 2017. After excluding patients not treated with itraconazole or voriconazole, 194 patients remained. 175 (90%) patients received itraconazole and 19 (10%) received voriconazole. There were no significant demographic differences between patient populations receiving either azole as their initial azole treatment. Death at 180 days occurred in 41 patients (23.4%) in the itraconazole group and 6 patients (31.6%) in the voriconazole group. Patients on voriconazole had a statistically significant increase in mortality during the first 42 days after initiation of treatment when compared to patients receiving itraconazole (HR 4.30 [95% CI 1.3-13.9, p 0.015]) when controlled for other risk factors.

CONCLUSION

Voriconazole in histoplasmosis was associated with increased mortality in the first 42 days compared to itraconazole.

1699. Presentations and Outcomes of Histoplasma capsulatum Infection Vary by Immune Status: A Retrospective Cohort Study

Background

Few large cohorts have examined Histoplasma infection across patients with varying immune status in the era of modern antiretroviral therapy. We describe the differences in clinical presentation and outcomes of Histoplasma infection by immune status.

Methods

We conducted a single-center retrospective cohort study of adult patients diagnosed with histoplasmosis from 2002 through 2017. Data included demographics, clinical features, diagnostics, and mortality. Patients were separated into three groups based on their immune status: Immunocompetent (IC), People living with HIV (PLWH), and patients who were HIV-negative but were otherwise immunocompromised (OIC). OIC was defined as the presence of any of the following: cancer, chemotherapy, solid-organ or stem-cell transplant, or immunosuppressive medications. Immunocompetence was defined as the absence of HIV and any of the conditions that defined OIC. Localized histoplasmosis was defined as histoplasma infection confined to the lungs and/or hilar and mediastinal lymph nodes. Disease that occurred outside these locations was defined as disseminated.

Results

We identified 263 patients with histoplasma infection: 54 (21%) were PLWH, 99 (28%) were OIC, and 110 (42%) were IC. Disseminated disease was more common among PLWH (76%) and OIC (52%) than among IC patients (32%) (P < 0.001). For survival analysis the HIV and OIC groups were pooled to create a single immunocompromised group. In localized disease mean survival was longer in the immunocompetent group (12.7 years) than in the immunocompromised group (8.9 years) (P = 0.029). For patients with disseminated disease, however, there was no significant difference in mean survival between the immunocompetent group (9.4 years) and the immunocompromised group (9.1 years) (P = .838).

Conclusion

Disseminated disease was more common among immunocompromised than immunocompetent patients. In patients with localized histoplasmosis, mean survival was longer for immunocompetent patients, whereas for patients with disseminated disease there was no significant difference in mean survival.

Disclosures

All authors: No reported disclosures.

2108. Comparison of Voriconazole vs. Itraconazole in the Treatment of Histoplasmosis – A Retrospective Analysis

Background

The guideline-preferred azole for histoplasmosis (HP) is itraconazole (IC). While voriconazole (VC) has shown success in in-vitro and in retrospective analyses, there has not been enough data to include newer generation azoles as first-line treatment for infections with Histoplasma capsulatum.

Methods

We conducted a single-center retrospective cohort study of adult patients diagnosed with HP from 2002 through 2017. Data included demographics, clinical features and sites of infection, immune status, treatments, and mortality. Patients were categorized into two groups based on initial choice of azole (IC or VC) and mortality was compared between these two groups. The treatment groups were defined based on the first azole received, either IC or VC, as initial or as step-down therapy from amphotericin. Patients initiated on other azoles were excluded.

Results

We identified 263 cases of HP from 2002 to 2017. After excluding patients initiated on other azoles, 194 patients remained. 175 (90%) patients were started on IC and 19 (10%) were started on VC, either as stepdown or initial choice of antifungal. There were no significant demographic differences between patients receiving IC compared with VC as their initial azole treatment. Patients with hematologic malignancies tended to be prescribed VC more frequently but this was not statistically significant (OR 3.1 [0.77–12.4]). Death occurred in 40 (23%) patients from the IC and 5 (26%) patients from the VC group. The hazard ratio for mortality with the use of VC was 1.21 (CI 0.4–3.6, P = 0.73).

Conclusion

IC is the mainstay in the treatment for HP. It appears that VC has comparable outcomes to IC and can be considered an alternative treatment option for HP, at least for patients with contraindications to IC treatment.

Disclosures

All authors: No reported disclosures.

Nocardia intracranial mycotic aneurysm associated with proteasome inhibitor

We report a case of Nocardia farcinica ruptured intracranial mycotic aneurysm associated with bortezomib and corticosteroid treatment in a multiple myeloma patient. The patient was treated with trimethoprim-sulfamethoxazole and moxifloxacin together with surgical repairment of intracranial mycotic aneurysm.

Inappropriate Empirical Treatment of Uncomplicated Cystitis in Thai Women: Lessons Learned

A prospective study conducted in a Thai general practice clinic demonstrated a high prevalence (91.3%) of inappropriate empirical antibiotic use in women with uncomplicated cystitis and 42.6% Escherichia coli fluoroquinolone resistance. An annual update of antimicrobial resistance surveillance data of uropathogens may permit targeted treatment of patients in hospital care.

National Survey of Thai Infectious Disease Physicians on Treatment of Carbapenem-Resistant Acinetobacter baumannii Ventilator-Associated Pneumonia: The Role of Infection Control Awareness

OBJECTIVE To evaluate the expected and treatment outcomes of Thai infectious disease physicians (IDPs) regarding carbapenem-resistant Acinetobacter baumannii (CRAB) ventilator-associated pneumonia (VAP) METHODS From June 1, 2014, to March 1, 2015, survey data regarding the expected and clinical success rates of CRAB VAP treatment were collected from all Thai IDPs. The expected success rate was defined as the expectation of clinical response after CRAB VAP treatment for the given case scenario. Clinical success rate was defined as the overall reported success rate of CRAB VAP treatment based on the clinical practice of each IDP. The expected and clinical success rates were divided into low (80%) categories and were then compared with standard clinical response rates archived in the existing literature. RESULTS Of 183 total Thai IDPs, 111 (60%) were enrolled in this study. The median expected and clinical success rates were 68% and 58%, respectively. Using multivariate analysis, we determined that working in a hospital that implemented the standard intervention combined with an intensified infection control (IC) intervention for CRAB (adjusted odds ratio [aOR], 3.01; 95% confidence interval [CI], 1.17-7.73; P=.02) was associated with standard and high expected rates (>60%). Being a board-certified IDP (aOR, 5.76; 95% CI, 2.16-15.37; P60%). We identified a significant correlation between expected and clinical success rates (r=0.58; P<.001). CONCLUSIONS Awareness of IC among IDPs can improve physicians' expected and clinical success rates for CRAB VAP treatment, and treatment experience impacts overall treatment success. Infect. Control Hosp. Epidemiol. 2015;37(1):61-69.