183. Optimization of an Outpatient Antimicrobial Stewardship Process for Patients Discharged from the Emergency Department at an Academic Medical Center

Background Suboptimal antimicrobial therapy has resulted in the emergence of multi-drug resistant organisms. The objective of this study was to optimize the time to antimicrobial therapy modification for patients discharged from the emergency department (ED) of an academic medical center through implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative (ASI). Methods This was a pre-post, quasi-experimental study that evaluated the impact of a pharmacist-driven outpatient antimicrobial stewardship initiative at a single academic medical center. The pre-cohort was evaluated through manual electronic medical record (EMR) review, while the post-cohort involved a real-time notification alert system through an electronic clinical surveillance application. The difference in time from positive culture result to antimicrobial therapy optimization before and after implementation of the pharmacist-driven ASI was collected and analyzed. Results A total of 166 cultures were included in the analysis. Of these, 12/72 (16%) in the pre-cohort and 11/94 (12%) in the post-cohort required antimicrobial therapy modification, with a 21.9-hour reduction in median time from positive culture result to antimicrobial optimization in the post-cohort (43 h vs. 21.1 h; p < 0.01). Similarly, the median time from positive culture result to review was reduced by 20 hours with pharmacist-driven intervention (21.1 h vs. 1.4 h; p < 0.01). Conclusion The implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative resulted in a significant reduction in time to positive culture review and therapy optimization for patients discharged from the ED of an academic medical center set in Philadelphia, PA. Disclosures All Authors: No reported disclosures

Epidemiology of tuberculosis in Sabah, Malaysia, 2012–2018

Background: Tuberculosis (TB) is of high public health importance in Malaysia. Sabah State, located on the island of Borneo, has previously reported a particularly high burden of disease and faces unique contextual challenges compared with peninsular Malaysia. The aim of this study is to describe the epidemiology of TB in Sabah to identify risk groups and hot spots of TB transmission. Methods: We conducted a retrospective review of TB cases notified in Sabah, Malaysia, between 2012 and 2018. Using data from the state’s ‘myTB’ notification database, we calculated the case notification rate and described trends in the epidemiology, diagnostic practices and treatment outcomes of TB in Sabah within this period. The Chi-squared test was used for determining the difference between two proportions. Results: Between 2012 and 2018 there were 33 193 cases of TB reported in Sabah (128 cases per 100 000 population). We identified several geographic hotspots, including districts with > 200 cases per 100 000 population per year. TB rates increased with age and were highest in older males. Children < 15 years accounted for only 4.6% of cases. Moderate or advanced disease on chest X-ray and sputum smear positivity was high (58% and 81% of cases respectively), suggesting frequent late diagnosis. Multi-drug resistant (MDR) TB prevalence was low (0.3% of TB cases), however, rapid diagnostic test coverage was low (1.2%) and only 18% of all cases had a positive culture result. Treatment success was 83% (range: 81–85%) in those with drug-sensitive TB and 36% (range: 25–45%) in cases of MDR-TB. Conclusion: Between 2012 and 2018, TB notifications in Sabah State equated to 20% of Malaysia’s total TB notifications, despite Sabah representing only 10% of Malaysia’s population. We found hotspots of TB in urbanised population hubs and points of migration, as well as evidence of late presentation and diagnosis. Ensuring universal health coverage and expansion of GeneXpert® coverage is recommended to reduce barriers to care and early diagnosis and treatment for TB.

An epidemiological review of tuberculosis in Sabah, Malaysia, 2012-2018

Background: Tuberculosis (TB) is of high public health importance in Malaysia. Sabah State, located on the island of Borneo, has previously reported a particularly high burden of disease and faces unique contextual challenges compared with peninsular Malaysia. The aim of this study is to describe the epidemiology of TB in Sabah to identify risk groups and hot spots of TB transmission.Methods: We conducted a retrospective review of TB cases notified in Sabah, Malaysia, between 2012 and 2018. Using data from the state’s ‘myTB’ notification database, we calculated the case notification rate and described trends in the epidemiology, diagnostic practices and treatment outcomes of TB in Sabah within this period. Results: Between 2012 and 2018 there were 33,193 cases of TB reported in Sabah (128 cases per 100,000 population). We identified several geographic hotspots, including districts with >200 cases per 100,000 population per year. TB rates increased with age and were highest in older males. Children <15 years accounted for only 4.6% of cases. Moderate or advanced disease on chest x-ray and sputum smear positivity was high (58% and 81% of cases respectively), suggesting frequent late diagnosis. Multi-drug Resistant (MDR) TB prevalence was low (0.3% of TB cases), however, rapid diagnostic test coverage was low (1.2%) and only 18% of all cases had a positive culture result. Treatment success was 83% in those with drug-sensitive TB and 30% in cases of MDR-TB. Conclusion: Between 2012 and 2018, Sabah State accounted for 20% of Malaysia’s TB notifications, despite representing only 10% of Malaysia’s population. We found hotspots of TB in urbanised population hubs and points of migration, as well as evidence of late presentation and diagnosis. Ensuring universal health coverage and expansion of GeneXpert® coverage is recommended to reduce barriers to care and early diagnosis and treatment for TB.

An epidemiological review of tuberculosis in Sabah, Malaysia, 2012-2018

Background Tuberculosis (TB) is of high public health importance in Malaysia. Sabah State, located on the island of Borneo, has previously reported a particularly high burden of disease and faces unique contextual challenges compared with peninsular Malaysia. The aim of this study is to describe the epidemiology of TB in Sabah to identify risk groups and hot spots of TB transmission.Methods We conducted a retrospective review of TB cases notified in Sabah, Malaysia, between 2012 and 2018. Using data from the state’s ‘myTB’ notification database, we calculated the case notification rate and described trends in the epidemiology, diagnostic practices and treatment outcomes of TB in Sabah within this period.Results Between 2012 and 2018 there were 33,193 cases of TB reported in Sabah (128 cases per 100,000 population). We identified several geographic hotspots, including districts with > 200 cases per 100,000 population per year. TB rates increased with age and were highest in older males. Children < 15 years accounted for only 4.6% of cases. Moderate or advanced disease on chest x-ray and sputum smear positivity was high (58% and 81% of cases respectively), suggesting frequent late diagnosis. Multi-drug Resistant (MDR) TB prevalence was low (0.3% of TB cases), however, rapid diagnostic test coverage was low (1.2%) and only 18% of all cases had a positive culture result. Treatment success was 83% in those with drug-sensitive TB and 33% in cases of MDR-TB.Conclusion Between 2012 and 2018, Sabah State accounted for 20% of Malaysia’s TB notifications, despite representing only 10% of Malaysia’s population. We found hotspots of TB in urbanised population hubs and points of migration, as well as evidence of late presentation and diagnosis. Ensuring universal health coverage and expansion of GeneXpert® coverage is recommended to reduce barriers to care and early diagnosis and treatment for TB.

Serial Detection of Circulating Mucorales DNA in Invasive Mucormycosis: A Retrospective Multicenter Evaluation

Invasive mucormycosis is a fungal infection with high mortality. Early diagnosis and initiation of appropriate treatment is essential to improve survival. However, current diagnostic tools suffer from low sensitivity, leading to delayed or missed diagnoses. Recently, several PCR assays for the detection of Mucorales DNA have been developed. We retrospectively assessed the diagnostic and kinetic properties of a commercial Mucorales PCR assay (MucorGenius®, PathoNostics) on serial blood samples from patients with culture-positive invasive mucormycosis and found an overall sensitivity of 75%. Importantly, a positive test preceded a positive culture result by up to 81 days (median eight days, inter-quartile range 1.75–16.25). After initiation of appropriate therapy, the average levels of circulating DNA decreased after one week and stabilized after two weeks. In conclusion, detection of circulating Mucorales DNA appears to be a good, fast diagnostic test that often precedes the final diagnosis by several days to weeks. This test could be especially useful in cases in which sampling for culture or histopathology is not feasible.

Evaluation of the Production Processes of Different Brands of Sachet Water Sold in the Open Market in Ado-Ekiti, Southwest, Nigeria

Life on earth is practically impossible without water, in fact, the presence of water on our planet is one of the critical factors that make life possible on earth. Apart from commercial, agricultural, industrial, domestic and sundry uses of water, humans, like other living organisms, require water for their physiological needs. However, as vital as water is to humans, if the water consumed by them is not potable or is unwholesome, it can lead to serious and sometimes life-threatening illnesses. This thus makes it important to periodically assess and monitor the potability and wholesomeness of any form of drinking water, particularly the ones presented to the public. In this study, twenty-two different brands of commercial sachet-water sold in the open market in Ado-Ekiti, southwest, Nigeria were consecutively sampled and analysed. The factories where the brands were manufactured were also visited and served structured self-administered questionnaires that were filled by their respective production managers. Data from the questionnaires were analysed and juxtaposed with the outcome of laboratory investigations with a view to identifying the factors responsible for the un wholesomeness of any of the brands. Out of the twenty-two sachet-water brands sampled, none (0%) had physically visible colour; none (0%) had physically perceivable odour; none (0%) had detectable taste. All (100%) were physically clear; 1 (5%) was bagged in a 60-cl cellophane sachet, while 21 (95%) were bagged in 50-cl cellophane sachets; all (100%) claimed to have NAFDAC (the regulatory agency responsible for the control and regulation of food, drugs and allied products in Nigeria) registration number- going by what was written on their finished products. Nearly all- 21 (95%)- all the sampled brands had a pH value of 5, while 1 (5%) had pH value of 6, resulting in a mean pH of 5. More than half of the brands sampled from the open market- 11 (50%)- yielded a positive culture result, 3 (14%) of which were coliforms. According to WHO standards there shouldn’t be a single coliform bacterium in drinking water, which makes it quite unsettling that three of the brands contained coliforms which of course could be enteric coliform- an indication of the fact that these brands had come in contact with human faeces. The public heath implication of this is discussed and appropriate recommendations made.

P3662Relationships between bacteria and echocardiographic manifestations in infective endocarditis - data from the Swedish endocarditis registry

Introduction Echocardiography (ECHO) is a method of choice for direct visualization of infective endocarditis (IE) - induced cardiac manifestations. Purpose To investigate the correlations between certain bacteria causing the IE and specific IE manifestations diagnosed by ECHO in the population from the Swedish Endocarditis Registry. Methods A cohort study based on selected data from the Swedish Endocarditis Registry including patients aged 18 and above, admitted between 2008 and 2017 with positive culture result from blood or surgical material, in total 570 patients (mean age 58±18 years, 33% female, 67% male patients). For numeric variables, Student's t-test was used. Correlations between the variables were estimated using odds ratio (OR) and 95% confidence intervals (CI). P<0.05 was considered significant. Results Of 570 patients 165 (29%) had a history of drug abuse; 21 (4%) had a bicuspid aortic valve and 110 (19%) had prosthetic valves. Significant correlations were seen between patients with aortic valve IE and coagulase negative staphylococci (OR 2.88, p=0.01, CI 1.26–6.88) and enterococcus spp (OR 2.31, p<0.01, CI 1.30–4.16), specifically enterococcus faecalis (2.45, p<0.01, CI 1.34–4.54), mitral valve IE and streptococcus spp (OR 1.92, p<0.01, CI 1.31–2.83), specifically group B streptococci (OR 8.16, p<0.01, CI 1.71–77.03), tricuspid valve IE (OR 6.55, p<0.01, CI 3.93–11.23) and pulmonic valve IE (OR 7.53, p=0.03, CI 1.0–335.25), and staphylococcus spp, specifically staphylococcus aureus (tricuspid valve: OR 6.55, p<0.01, CI 3.93–11.23 and pulmonic valve: OR 9.26, p=0.01, CI 1.22–412.22), abscess and coagulase negative staphylococci (OR 4.13, p<0.01, CI 1.13–12.25), pacemaker or ICD-associated IE and HACEK (OR 7.60, p=0.01, CI 1.66–27.06). Conclusions Significant correlations were found between certain bacteria and specific IE manifestations detected by ECHO, i.e. on aortic valve, mitral valve, tricuspid valve or pulmonic valve, abscess and pacemaker or ICD-associated IE.

Fatores Clínico-Laboratoriais Associados ao Internamento Prolongado em Doentes com Celulite/Erisipela

Introduction: Cellulitis and erysipelas represent the most frequent cause of hospitalization in the dermatology department of Santa Maria Hospital in Lisbon, Portugal. The aim of this study was to investigate whether patient demographics, comorbidities, previous episodes of cellulitis/erysipelas, the presence of complications, laboratory markers at admission, microbial isolation or previous use of antibiotics, are associated with prolonged stays.Material and Methods: Retrospective analysis, including patients admitted with cellulitis/erysipelas in the inpatient dermatology department of Santa Maria Hospital between July 1st 2012 and June 30th 2017.Results: There were 372 admissions, corresponding to 348 patients. The median length of stay was 11 days. Increased age (p = 0.002, OR 1.03, 95% CI 1.01 – 1.04), previous episode of cellulitis/erysipelas requiring hospitalization (p = 0.005, OR 4.81, 95% CI 1.63 – 14.23), the presence of cellulitis/erysipelas-associated complications (p = 0.001, OR 3.28, 95% CI 1.63 – 6.59), leukocytosis (p = 0.049, OR 1.81, 95% CI 1.00 – 3.30), high levels of C-reactive protein (p = 0.035, OR 1.03, 95% CI 1.00 – 1.06) and a positive culture result (p = 0.002, OR 2.59, 95% CI 1.41 – 4.79) were associated with prolonged hospitalization.Discussion: Prolonged hospitalization for cellulitis/erysipelas is associated with higher costs, additional clinical investigation, invasive treatments, prolonged courses of antibiotic therapy, risk of nosocomial infections, and delayed return to activities of daily living. Thus, the investigation of clinical-laboratory factors associated with prolonged hospitalization for cellulitis / erysipelas is essential and may beuseful for the construction of a severity score.Conclusion: The knowledge of the characteristics that are associated with prolonged stay among patients with cellulitis/erysipelas may be relevant to improve health care, by reducing the length of hospital stay and associated risks and costs.

Atypical Bacterial Growth within Units of Platelets Challenges Transfusion Medicine Dogma

ABSTRACT Although transfusion-transmitted bacterial infection is relatively rare, mitigation of bacterial contamination of platelet units is arguably the top current transfusion-related safety concern. Several different technologies have been employed to detect or neutralize bacteria in platelet concentrates. However, studies of the efficacy of these systems have been hampered by problematic definitions of what represents a “true-positive” versus a “false-positive” culture result. In the current issue of the Journal of Clinical Microbiology (M. Cloutier, M.-È. Nolin, H. Daoud, A. Jacques, M. J. de Grandmont, É Ducas, G. Delage, and L. Thibault, J Clin Microbiol 56:e01105-18, 2018, https://doi.org/10.1128/JCM.01105-18), it was demonstrated that the growth of Bordetella holmesii is inhibited by the platelet storage environment, which may explain why the results of initial positive platelet cultures are not always confirmed by subsequent cultures later during the storage period. This important finding is at odds with the generally held belief within the field of transfusion medicine that initially positive platelet cultures that are not confirmed on repeat testing are instrumentation-based false positives. The clinical risk profile of organisms demonstrating storage-related low viability is worthy of further study.

Microbiology and biofilm of corneal sutures

AimTo investigate the relationships between corneal suture bacteriology, biofilm and the clinical setting using culture studies and scanning electron microscopy (SEM).MethodsThis is a prospective, observational study of patients with a history of penetrating keratoplasty presenting to a tertiary cornea clinic for routine or symptoms-related corneal suture removal. We documented for each patient the suture clinical setting (quiescent, exposed and keratitis-related), retention time, antimicrobial therapy, bacterial growth on culture studies, and bacterial presence and biofilm coverage on SEM.ResultsThere were significantly different culture positivity rates between the quiescent (8%), exposed (12%) and keratitis-related (60%) suture groups (p=0.039). As expected, keratitis-related sutures had the longest retention time compared with quiescent and exposed ones (p=0.02). The biofilm coverage score was higher for sutures from the keratitis-related and exposed groups, although this trend was not statistically significant (p=0.90). Higher biofilm scores were seen in samples that also yielded a positive culture result (p=0.36) and in samples with bacterial presence on SEM images (p=0.16 and p=0.73). Both of these were important trends but not statistically significant.ConclusionsEvidence for active bacterial and biofilm presence on corneal sutures was found. Corneal sutures should be considered for removal sooner, before becoming exposed and/or keratitis-related. Traditional culture studies and SEM imaging are helpful in investigating biofilm and its clinical importance. More studies of the spectrum of bacterial growth on embedded biomedical devices such as corneal sutures are needed.