Osteomyelitis in Immunocompromised children and neonates, a case series

Background Osteomyelitis in immunocompromised children can present differently from immunocompetent children and can cause devastating sequelae if treated inadequately. We aim to review the aetiology, clinical profile, treatment and outcomes of immunocompromised children with osteomyelitis. Methods Retrospective review of all immunocompromised children aged < 16 years and neonates admitted with osteomyelitis in our hospital between January 2000 and January 2017, and referred to the Paediatric Infectious Disease Service. Results Fourteen patients were identified. There were 10 boys (71%), and the median age at admission was 70.5 months (inter-quartile range: 12.3–135.0 months). Causal organisms included, two were Staphylococcus aureus, two were Mycobacterium bovis (BCG), and one each was Mycobacterium tuberculosis, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Burkholderia pseudomallei and Rhizopus sp. One patient had both Clostridium tertium and Clostridium difficile isolated. Treatment involved appropriate antimicrobials for a duration ranging from 6 weeks to 1 year, and surgery in 11 patients (79%). Wherever possible, the patients received treatment for their underlying immunodeficiency. For outcomes, only three patients (21%) recovered completely. Five patients (36%) had poor bone growth, one patient had recurrent discharge from the bone and one patient had palliative care for underlying osteosarcoma. Conclusions Although uncommon, osteomyelitis in immunocompromised children and neonates can be caused by unusual pathogens, and can occur with devastating effects. Treatment involves prolonged administration of antibiotics and surgery. Immune recovery also seems to be an important factor in bone healing.

Acute Liver Failure and Fever of Unknown Origin

We describe a case of acute liver failure in a woman in whom a diagnosis was initially unable to be established. The patient rapidly deteriorated, requiring admission to the intensive care unit and was placed under consideration for liver transplantation. On consultation with the infectious disease service, thorough history taking was performed which uncovered salient epidemiologic information pointing toward the eventual diagnosis of disseminated histoplasmosis. We discuss aspects of diagnosis and management, including the management of immune reconstitution syndrome which complicated treatment.

Changing the Culture of Ordering Urine Cultures

Background: Inappropriate ordering of urine cultures and the resulting unnecessary use of antibiotics can lead to complications of antimicrobial therapy including resistance, adverse effects (eg, disruption of microbiome and C. difficile infection), and increased healthcare costs, as well as the erroneous determination of CAUTI in patients with Foley catheters. A retrospective analysis of patients with CAUTI revealed frequent ordering of urine cultures for conditions and symptoms not supported by current IDSA guidelines. As a result, we created an action plan to reverse the trend of inappropriate urine culture ordering. Methods: Our urine culture reduction campaign was developed with input from the infectious disease service, antibiotic stewardship team (AST), infection prevention, pharmacy, and the microbiology service. The following educational efforts were included: (1) distribution of outpatient pocket cards with communication to providers about appropriate ordering of urine cultures; (2) creation of an evidence-based order set for urinalysis and urine cultures distributed electronically as emails and screensavers on computer stations and in person via didactic sessions with physicians and nursing staff; (3) a practice pointer for staff nurses that included recommended changes to urine culture ordering and encouraged open dialogue with physicians regarding the appropriateness of urine cultures; (4) didactic and personal communications to counter long-standing myths, such as “Urine cultures always for change in mental status”; (5) a peer-review process to evaluate and justify deviations from the testing algorithm.Results: The first and second months after the introduction of the campaign, the microbiology laboratory reported 23% and 37% reductions in urine cultures ordered, respectively. During the same period, a 48% reduction in CAUTIs was reported for the entire health system. Conclusions: Reducing the number of inappropriate urine cultures is achievable with intense communication utilizing a multifaceted approach. With continued educational activities, we expect to sustain and even improve our successful reduction of inappropriate urine culture orders, ultimately improving patient outcomes.Funding: NoneDisclosures: None

Occupational health risk among healthcare workers of the Bashkortostan infectious diseases service

The a priori and a posteriori factors of occupational health risks among workers of the infectious service have been studied. It has been shown that workers with a high a priori risk (harmful Class 3.3) have minimal risk levels in terms of occupational morbidity (Ипр = 0,0005). The occupational morbidity of healthcare workers in the infectious disease service does not reflect the levels of actual risk for their health. On physical examination, only 4 % of workers were found to be practically healthy, most often diagnosed with diseases of the musculoskeletal system and connective tissue (19.8 %), as well as diseases of the circulatory system (18.8 %). Psychosocial effects leading to stress reactions with the development of chronic fatigue and occupational burnout syndrome (OBS) rank first among health problems of workers. The formed OBS was observed in 19.2 % of doctors and 29.2 % of nursing staff. The studies conducted indicate the probability of the prediction of the development of a high posterior risk to the health of workers of the infectious disease service.

197. Infective Endocarditis Over a Five-Year Period in an Academic Teaching Center: The Validity of ICD Codes vs. Manual Chart Review

Background Opioid dependence and overdose are at epidemic levels in the United States. Ohio has the third highest rate of opioid-related overdose deaths. Infectious complications of intravenous drug use (IDU) include increased acquisition of hepatitis C, HIV and infective endocarditis. In this study, we aimed to characterize cases of infective endocarditis admitted to our healthcare system over a five-year period. We additionally sought to determine the validity of using ICD codes to identify infective endocarditis cases and IDU. Methods Patients with ICD-9 or 10 discharge diagnosis codes for infective endocarditis were identified from our institution’s electronic health record. ICD codes pertaining to substance abuse were used to classify patients according to IDU status. Readmissions during the same episode of infective endocarditis were excluded. We compared chart review to ICD code for the identification of infective endocarditis and IDU in a random sample of 296 of 1590 cases. Results Of 296 charts reviewed, 133 (44.9%) were excluded because they did not meet criteria for definite infective endocarditis by modified Duke’s criteria or because the episode was a readmission. A total of 163 (55.1%) cases met inclusion criteria, all of whom were seen in consultation by the inpatient Infectious Disease service. Of these, 52 (31.9%) had ICD 9 or 10 codes linked to substance abuse. Following manual chart review, we established that in fact 86 of these 163 cases (52.8%) had evidence of substance abuse. Conclusion Misclassification due to use of ICD codes is a well-established challenge to epidemiological research. However, the extent of misclassification in this analysis was greater than expected. If prior research on IDU and infective endocarditis has relied on medical record data alone without verification through manual chart review, the observed epidemiological trends may not be accurate. Disclosures All authors: No reported disclosures.

1126. Three Cases of Neutropenic Enterocolitis Following Midostaurin Administration

Background Neutropenic enterocolitis is a life-threatening inflammation of the colon with a mortality rate above 50% primarily seen in neutropenic patients on cytotoxic chemotherapy. The following cases illustrate three patients with this condition following midostaurin administration after standard induction chemotherapy with daunorubicin/idrarubicin and cytarabine for acute myeloid leukemia (AML). Midostaurin is a multitargeted FMS-Like Tyrosine kinase 3 (FLT3) receptor inhibitor used in AML treatment after induction chemotherapy. Methods Review of records of three patients seen by the infectious disease service. Results In these cases, patients were diagnosed with AML with FLT3 mutation. All three were admitted and started on standard induction chemotherapy. Midostaurin was started on chemotherapy day 8 at which time all patients were neutropenic. The patients developed fevers, abdominal pain, and diarrhea within 36 hours of starting midostaurin and had abdominal CT findings consistent with neutropenic enterocolitis. For two patients, midostaurin was discontinued and symptoms improved upon discontinuation. One patient completed the course of midostaurin with symptom resolution after its completion. Of note, all were started on appropriate prophylactic antibiotics at chemotherapy initiation and were started on broad-spectrum antibiotics at onset of fevers and abdominal symptoms. Appropriate evaluation was also done for each patient to rule out other causes of abdominal symptoms, including testing for Clostridium difficile colitis. Conclusion These cases are significant because they illustrate individuals treated with standard induction chemotherapy for AML and started on midostaurin while neutropenic who began reporting symptoms of neutropenic enterocolitis within 36 hours of receiving midostaurin. This shows a possible increased toxicity when midostaurin is given after induction chemotherapy in the setting of neutropenia. Stone et al. showed increased intestinal symptoms with midostaurin, but no cases of neutropenic enterocolitis have been reported. With increased midostaurin use in the past year, further studies are warranted to establish and raise awareness of a possible direct association between midostaurin and gastrointestinal toxicity. Disclosures All authors: No reported disclosures.

Infectious morbidity and resource provision for infectious disease service in municipal districts of the Republic of Tatarstan

Aim. To conduct analysis of resource provision for medical care for patients with infectious pathology and to study primary infectious morbidity at the level of municipal districts of the Republic of Tatarstan. Methods. Study of primary infectious morbidity according to official statistics of the Federal Service for Supervision of Consumer Rights Protection and Human Well-Being in the Republic of Tatarstan based on form No. 2 with extracting data in 495 units, annual reports of Infectious Disease Service of the Ministry of Health of the Republic of Tatarstan for 2005-2015 - 66 units. The analysis of resource provision according to the central regional hospitals data, with extracting data in 70 units. Results. During the period of 2005-2015 the highest rates of primary infectious morbidity were observed in municipal districts where the administrative center is a city (13 054.01 per 100 000 population), the lowest - in rural areas (7953.6). The level of infectious morbidity in municipal districts is significantly lower than in average across the Republic of Tatarstan (р ˂0.05). 3 municipal districts having different types of administrative center are studied: Zainsky (urban population 72%), Apastovsky (rural people 73.9%), Drozhzhanovsky (rural people 100%) districts. The highest level of infectious morbidity in Zainsky District (2005 - 10 510; 2015 - 11 800.85 per 100 000 population), Apastovsky (7600.0 and 3612.44) and Drozhzhanovsky district (1629.68 and 4765.84). Differences in resource provision for infectious disease service are established: Zainsky district (there is an infectiologist, infectious beds, infectious disease office, specialized laboratory), Apastovsky district (service in infectious disease office is provided by part-time infectiologist), Drozhzhanovsky district (service in infectious disease office is provided by a nurse). In Drozhzhanovsky and Apastovsky districts there are no infectious beds and specialized laboratories. Conclusion. Level of infectious morbidity in municipal districts of the Republic of Tatarstan is closely related to the type of municipal district and resource provision for infectious disease service.