Clostridioides (Clostridium) difficile Pacemaker Infection

Clostridioides difficile is the leading cause of antibiotic-associated nosocomial diarrhea, but extra-intestinal manifestations are rare. We describe the first documented case of bacteraemia with pacemaker pocket and lead infection with the toxigenic C. difficile ribotype 014 with a lack of abdominal symptoms. The patient underwent pacemaker extraction and treatment with intravenous and oral vancomycin. Genotyping and molecular subtyping revealed clonality between pacemaker and intestinal isolates. This case illustrates the risk of intravascular device infections due to C. difficile. Even asymptomatic C. difficile colonization might pose a risk for prosthetic material infection.

119. Nocardia Bacteremia Is Almost Always Associated with Immune Compromise or an Intravascular Device: Single-Center Case Series and Systematic Review of the Literature

Background Nocardia bacteremia is a rare but important phenomenon, with previous studies describing a 50% mortality rate. We undertake a single-center review and the largest systematic review of Nocardia bacteremia performed over the past 20 years. Methods A single-center review of cases of Nocardia bacteremia was performed using hospital microbiology records from January 1, 2010 to December 31, 2017. A systematic literature review was also performed to identify cases of Nocardia bacteremia described in the English language literature between January 1, 1999 and December 31, 2018 using the NCBI PubMed database and snowballing from citations of relevant publications. Results Single-center case series: Four cases of Nocardia bacteremia are described. Three patients had an intravascular device in situ prior to the onset of Nocardia bacteremia and three patients were immunocompromised; one patient had both risk factors. Systematic literature review: A systematic review identified 50 publications that described 85 cases with sufficient patient data to be reviewed in detail. Including the 4 cases described in our institution, 89 cases of Nocardia bacteremia were included in the analysis. The median age was 57 years [interquartile range (IQR) 42–68] and 69% were male. Eighty-two percent of cases were immunocompromised and 38% had endovascular devices. Pulmonary infection was the most common concurrent site of clinical disease (66%), followed by central nervous system (25%), pleural (17%) disease, and endocarditis (11%). Blood cultures were the only positive microbiological specimen that isolated Nocardia in 45% of cases. Median incubation time to blood culture positivity was 4 days [IQR 3–6]. Thirty-day all-cause mortality was 24% and overall all-cause mortality was 42%. Conclusion Four new cases of Nocardia bacteremia are described. Isolation of Nocardia from blood cultures is rare but represents serious infection with high associated overall mortality. Nocardia bacteremia is most frequently identified in immunocompromised patients and those with intravascular devices. Disclosures All authors: No reported disclosures.