We compared two Candida auris screening strategies in high-risk patients. The positivity rates for point prevalence survey (PPS) and admission screening were similar: 3.9% versus 3.4%, respectively, P = 1.00. Approximately 3% of high-risk patients are colonized, thus there is a need for a universal infection prevention approach for C. auris.

Background. There are no systematic measures of central line-associated bloodstream infections (CLABSIs) in patients maintaining central venous catheters (CVCs) outside acute care hospitals. To clarify the burden of CLABSIs in these patients, we characterized patients with CLABSI present on hospital admission (POA). Methods. Retrospective cross-sectional analysis of patients with CLABSI-POA in 3 health systems covering 11 hospitals across Maryland, Washington DC, and Missouri from November 2020 to October 2021. CLABSI-POA was defined using an adaptation of the acute care CLABSI definition. Patient demographics, clinical characteristics, and outcomes were collected via record review. Cox proportional hazard analysis was used to assess factors associated with the all-cause mortality rate within 30 days. Results. A total of 461 patients were identified as having CLABSI-POA. CVCs were most commonly maintained in home infusion therapy (32.8%) or oncology clinics (31.2%). Enterobacterales were the most common etiologic agent (29.2%). Recurrent CLABSIs occurred in a quarter of patients (25%). Eleven percent of patients died during the hospital admission. Among patients with CLABSI-POA, mortality risk increased with age (hazard ratio vs age <20 years by age group: 20-44 years, 11.2 [95% confidence interval, 1.46-86.22]; 45-64 years, 20.88 [2.84-153.58]; >= 65 years, 22.50 [2.98-169.93]) and lack of insurance (2.46 [1.08-5.59]), and it decreased with CVC removal (0.57 [.39-.84]). Conclusions. CLABSI-POA is associated with significant in-hospital mortality risk. Surveillance is required to understand the burden of CLABSI in the community to identify targets for CLABSI prevention initiatives outside acute care settings.

Purpose of Review Surgical site infections are healthcare-associated infections that cause significant morbidity and mortality. Best practices in prevention of these infections are combined in care bundles for consistent implementation. Recent Findings Care bundles have been used in nearly all surgical specialties. While the composition and size of bundles vary, the effect of a bundle depends on the number of evidence-based interventions included and the consistency of implementation. Bundles work because of the cooperation and collaboration among members of a team. Bundles for prevention of surgical site infections should address the multiple risk factors for infection before, during, and after the surgery. Summary Bundles increase standardization of processes and decrease operative variance that both lead to reductions in surgical site infections.

Background: Candida auris infection is associated with high morbidity and mortality. C. auris can persist in the healthcare environment and is associated with outbreaks. We compare screening strategies for C. auris in two high-risk patient populations. Methods: Our center is a tertiary, 865-bed hospital. In the context of known regional outbreaks of C. auris in post-acute care (PAC) facilities, we experienced extended clusters of apparent C. auris acquisition across several hospital units. Hospital acquisition was defined as new C. auris in clinical cultures in patients with no known history of C. auris colonization/infection. We performed point prevalence surveys (PPS) on affected units weekly until all tests were negative for two consecutive weeks. We also initiated admission screening for C. auris for patients admitted from PAC. All screening swabs were collected per CDC’s procedure. Tests were performed either by RT-PCR or Chromagar C. auris media, depending on availability. We compared the overall positivity rates of exposure PPS versus PAC admission screenings using Z-test for two proportions with statistical significance set at p < 0 .05 Results: From 2/2023-12/2023, a total of 533 tests on 367 unique patients were processed during PPS; 512 tests were negative and 21 were positive (3.9% positivity rate). Three additional samples were either unable to be processed or indeterminate. There were 68 patients who had repeat testing weekly for ≥2 weeks. Most remained negative, but 5 tested positive after variable amounts of negative-week intervals: 3 patients at week 2, 1 patient at week 4 and 1 patient at week 5. From 8/2023 to 12/2023, a total of 89 patients admitted from 35 different PAC facilities underwent admission screening for C. auris. Only three patients were positive (3.4%), each from a different facility. The difference in the positivity rates between PPS and PAC was not statistically significant (Z-score 0.25, p = 0.79). Discussion: Our C. auris screening strategies found similar positivity rates for patients admitted to the hospital from PACs compared to targeted PPS in the setting of apparent hospital acquisition events. These strategies may be considered as complementary. Facilities experiencing apparent acquisition events should consider screening high-risk admissions to identify and isolate colonized patients, particularly if standard infection prevention practices are being performed with high fidelity.

Background: Trimethoprim-sulfamethoxazole (TMP-SMX) is a first-line Pneumocystis pneumonia (PCP) prophylaxis agent, but monthly intravenous pentamidine (IVP) is used in immunocompromised hosts without human immunodeficiency virus (HIV) infection because IVP is not associated with cytopenia and delayed engraftment. Method: We performed a systematic review and meta-analysis to estimate breakthrough PCP incidence and adverse reactions in HIV-uninfected immunocompromised patients receiving IVP. MEDLINE, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov were searched from their inception until 15 December 2022. Results: The pooled incidence of breakthrough PCP with IVP was 0.7% (95% CI, 0.3–1.4%, 16 studies, 3025 patients) and was similar when used as first-line prophylaxis (0.5%; 95% CI, 0.2–1.4%, 7 studies, 752 patients). The pooled incidence of adverse reactions was 11.3% (95% CI, 6.7–18.6%, 14 studies, 2068 patients). The pooled adverse event-related discontinuation was 3.7% (95% CI, 1.8–7.3%, 11 studies, 1802 patients), but was lower in patients receiving IVP monthly (2.0%; 95% CI 0.7–5.7%, 7 studies, 1182 patients). Conclusion: Monthly IVP is an appropriate second-line agent for PCP prophylaxis in certain non-HIV immunocompromised hosts, especially in patients with hematologic malignancies and hematopoietic stem cell transplant recipients. Using IVP for PCP prophylaxis as an alternative to oral TMP-SMX while patients are unable to tolerate enteral medication administration is feasible.

Background Antimicrobial resistance (AMR) is an urgent global health challenge and a critical threat to modern health care. Quantifying its burden in the WHO Region of the Americas has been elusive-despite the region's long history of resistance surveillance. This study provides comprehensive estimates of AMR burden in the Americas to assess this growing health threat.Methods Weestimated deaths and disability-adjusted life-years (DALYs) attributable to and associated with AMR for 23 bacterial pathogens and 88 pathogen-drug combinations for countries in the WHO Region of the Americas in 2019. We obtained data from mortality registries, surveillance systems, hospital systems, systematic literature reviews, and other sources, and applied predictive statistical modelling to produce estimates of AMR burden for all countries in the Americas. Five broad components were the backbone of our approach: the number of deaths where infection had a role, the proportion of infectious deaths attributable to a given infectious syndrome, the proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of pathogens resistant to an antibiotic class, and the excess risk of mortality (or duration of an infection) associated with this resistance. We then used these components to estimate the disease burden by applying two counterfactual scenarios: deaths attributable to AMR (compared to an alternative scenario where resistant infections are replaced with susceptible ones), and deaths associated with AMR (compared to an alternative scenario where resistant infections would not occur at all). We generated 95% uncertainty intervals (UIs) for final estimates as the 25th and 975th ordered values across 1000 posterior draws, and models were cross-validated for out-of-sample predictive validity. Findings We estimated 569,000 deaths (95% UI 406,000-771,000) associated with bacterial AMR and 141,000 deaths (99,900-196,000) attributable to bacterial AMR among the 35 countries in the WHO Region of the Americas in 2019. Lower respiratory and thorax infections, as a syndrome, were responsible for the largest fatal burden of AMR in the region, with 189,000 deaths (149,000-241,000) associated with resistance, followed by bloodstream infections (169,000 deaths [94,200-278,000]) and peritoneal/intra-abdominal infections (118,000 deaths [78,600-168,000]). The six leading pathogens (by order of number of deaths associated with resistance) were Staphylococcus aureus , Escherichia coli , Klebsiella pneumoniae , Streptococcus pneumoniae , Pseudomonas aeruginosa , and Acinetobacter baumannii. Together, these pathogens were responsible for 452,000 deaths (326,000-608,000) associated with AMR. Methicillin-resistant S. aureus predominated as the leading pathogen-drug combination in 34 countries for deaths attributable to AMR, while aminopenicillin-resistant E. coli was the leading pathogen-drug combination in 15 countries for deaths associated with AMR. Interpretation Given the burden across different countries, infectious syndromes, and pathogen-drug combinations, AMR represents a substantial health threat in the Americas. Countries with low access to antibiotics and basic health-care services often face the largest age-standardised mortality rates associated with and attributable to AMR in the region, implicating specific policy interventions. Evidence from this study can guide mitigation efforts that are tailored to the needs of each country in the region while informing decisions regarding funding and resource allocation. Multisectoral and joint cooperative efforts among countries will be a key to success in tackling AMR in the Americas. Funding Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care using UK aid funding managed by the Fleming Fund.Copyright (c) 2023 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Background The management of invasive infections related to substance use disorder (SUD) needing parenteral antimicrobial therapy is challenging and may have poor treatment outcomes including nonadherence and lack of completion of parenteral antimicrobial therapy. Methods In this retrospective cohort of 201 patients with invasive infections related to SUD, we looked at frequency and determinants of unfavorable outcomes including nonadherence. Results Seventy-nine percent of patients with SUD-related infection completed parenteral antibiotic therapy in skilled nursing facilities. A total of 21.5% of patient episodes had documentation of nonadherence. Nonadherence was higher in patients with active injection drug use (IDU) (28.5% versus 15% in non IDU; adjusted odds ratio [OR] 2.36; 95% confidence interval [CI], 1.1-5.5; P = .024), patients with active SUD in the prior year (24.5% vs 11%, P = .047), patients with use of more than 1 illicit substance (30.3% vs 17%, P = .031), as well as in people experiencing homelessness (32.8% vs 15.7% in stably housed, P = .005). In a multivariate model, nonadherence was significantly associated with IDU (OR, 2.38; 95% CI, 1.03-5.5) and homelessness (OR, 2.25; 95% CI, 1.01-4.8) Medication for opioid use disorder was prescribed at discharge in 68% of overall cohort and was not associated with improved outcomes for any of the above groups. Conclusions Nonadherence to parenteral antimicrobial therapy is high in the most vulnerable patients with unstable high-risk SUD and adverse social determinants of health.

Abstract Background National estimates of central line-associated bloodstream infections (CLABSI) focus on acute care hospital settings. Little is known about CLABSI that develop outside of hospitals and are present on admission (CLABSI-POA). We aimed to describe the epidemiology of CLABSI-POA to develop appropriate prevention strategies. Methods We performed a retrospective cohort study of all adult and pediatric patients admitted from 11/01/2020 to 10/31/2021 in two large medical systems in the US, one in Maryland and one in Missouri. Adapting the National Healthcare Safety Network acute care CLABSI definition, we included patients who had a central venous catheter (CVC) present on admission (or had a CVC discontinued within 72 hours prior to admission) and a positive blood culture within 72 hours before and/or after admission. We performed descriptive statistics to characterize the epidemiology of CLABSI-POA. Results Of 402 patients with CLABSI-POA, 52% were male, 68% were age ≥45 years, and 45% had Medicare insurance as primary payer. Half of the cases had a hospitalization 30 days prior to the index admission, 22% had at least one prior CLABSI, and 40% received chemotherapy in the last 6 months. The most common indications for catheter placement were chemotherapy (34%), total parenteral nutrition (21%), dialysis (15%), and outpatient parenteral antimicrobial therapy (11%). Attribution of CLABSI-POA based on site where the catheter was routinely accessed included oncology clinics (34%), home infusion therapy (32%), hemodialysis centers (12%), and skilled nursing facilities (9%). The most common causative microorganisms were coagulase-negative staphylococci (23%), Staphylococcus aureus (21%), Enterococcus spp. (12%), Candida spp. (11%), Escherichia coli and Klebsiella pneumoniae (10% each), and Pseudomonas aeruginosa (7%). Forty-five (11%) cases were due to multidrug resistant organisms. Overall in-hospital mortality was 10%. Conclusion CLABSI-POA were common in those attending oncology clinics and receiving home infusion therapy. Lack of routine surveillance of CLABSI-POAs leads to an underestimation of the burden of CLABSIs in the healthcare system. Tailored prevention strategies should be focused in those groups at higher risk. Disclosures Stephanie Mayoryk, MAS BSN RN CIC, PDI: Honoraria Sara E. Cosgrove, MD, MS, Debiopharm: Advisor/Consultant|Duke Clinical Research Institute: Advisor/Consultant Carlos Mejia-Chew, MD, INSMED: Grant/Research Support|RevImmune: Grant/Research Support Sara C. Keller, MD, MPH, MSPH, Pfizer: Advisor/Consultant

Abstract Background Central line-associated bloodstream infections (CLABSI) lead to significant morbidity and mortality. Surveillance has contributed to reductions in the CLABSI rate in acute care hospitals. Although there are increasing numbers of patients with central venous catheters outside of acute care hospitals, the prevalence of and mortality risk associated with CLABSIs present-on-admission (POA) to acute care hospitals is unknown. To explore the burden of CLABSI POA and the risk factors associated with an all-cause mortality. Methods We identified patients presenting to hospitals with CLABSI (regardless of pre-admission location) in two large health systems based in Maryland, Washington DC, and Missouri between November 2020-October 2021. CLABSI was defined using an adaptation of the acute care CLABSI definition. Results Out of 402 patients identified with CLABSI POA, in-hospital mortality was 10.4%. Within six months of hospital presentation, 126 patients died (31.3%) (Figure 1). The median Pitt bacteremia score was 1 (interquartile range: 0-2), with 82 (20.4%) admitted to the adult intensive care unit (ICU), and 9 (2.2%) admitted to the pediatric ICU. The mean hospital length of stay was 8 days (interquartile range: 5-14). Compared with patients < 45 years of age, patients aged 45-64 and >65 had increased mortality within 6 months (OR: 3.49, 95% CI: 1.53-7.96; OR: 5.76, 95% CI: 2.24-14.81, respectively). Compared with patients receiving Medicaid, patients who were self-pay had increased mortality within 6 months (OR: 4.18, 95% CI: 1.13-15.43). Receipt of chemotherapy within the last 6 months and hospital discharge ≤ 30 days before presentation were associated with increased mortality within 6 months (OR: 2.53, 95% CI: 1.12-5.71; OR: 1.19, 95% CI: 1.13-3.23; respectively) (Table 1). Conclusion CLABSI POA was associated with a high mortality, with almost one in three patients deceased within 6 months. Patients at risk of higher mortality included those over the age of 44, self-pay insurance, receipt of chemotherapy in the last 6 months, and recent hospital discharge. These results underscore the need for CLABSI prevention initiatives outside acute care settings. Disclosures Stephanie Mayoryk, MAS BSN RN CIC, PDI: Honoraria Sara E. Cosgrove, MD, MS, Debiopharm: Advisor/Consultant|Duke Clinical Research Institute: Advisor/Consultant Carlos Mejia-Chew, MD, INSMED: Grant/Research Support|RevImmune: Grant/Research Support Sara C. Keller, MD, MPH, MSPH, Pfizer: Advisor/Consultant

Background: People with opioid use disorder and severe infections may complete their prolonged courses of outpatient parenteral antimicrobial therapy at a post-acute care facility due to adherence and safety concerns. We hypothesized that treatment with medications for opioid use disorder, such as methadone and buprenorphine, would increase antibiotic completion in these facilities. Methods: We performed a retrospective cohort study of people with opioid use disorder and severe infections who were discharged from the University of Maryland Medical Center to a post-acute care facility to complete intravenous antibiotic therapy. The primary outcome was completion of outpatient parenteral antimicrobial therapy. We compared the rate of antibiotic completion between patients prescribed and not prescribed medication for opioid use disorder at discharge from the acute care hospital. Results: A total of 161 patient encounters were included; the mean age was 43.4 years and 56% of patients were male. In 48% of the encounters, the patient was homeless and in 68% they recently injected drugs. The most common infectious syndrome was osteoarticular (44.1%). Medication for opioid use disorder was prescribed at discharge in 103 of 161 encounters and was newly started in 27 encounters. Similar rates of outpatient parenteral antimicrobial therapy completion were found in those who received (65/103) and did not receive (33/58) medication for opioid use disorder at discharge (odds ratio: 1.29; 95% confidence interval: 0.68–2.54; p = 0.44). Conclusion: Medication for opioid use disorder prescription at discharge was not associated with completion of outpatient parenteral antimicrobial therapy in a post-acute care facility. Our study is limited by possible selection bias and infrequent initiation of medication for opioid use disorder, which may have minimized the effect on antibiotic completion.

Abstract Background Patients with substance use disorder (SUD) are frequently admitted to hospitals for invasive infections and may have poor infection outcomes including non-adherence and lack of completion of therapy. Methods In this retrospective cohort of 263 hospital encounters among 201 patients for invasive infections due to SUD to an urban tertiary care facility, we looked at characteristics of SUD to assess whether there were differences in infections, their management, SUD interventions and parenteral antibiotic outcomes between groups. Results Among people with SUD, 79% of antibiotic courses were completed in skilled nursing facilities. Most common infectious syndromes were osteoarticular infections (123, 47%), infective endocarditis (IE) (54, 20%) and non-IE endovascular infection (23, 9%). Among SUD specific interventions, 64% of episodes had documentation of a consultation by substance use services and 68% episodes had documentation of medication for opioid use disorder (MOUD) being prescribed at discharge. Overall, completion of therapy was documented in 163 (62%) of encounters. Overall, treatment non-adherence was seen in 63 encounters (24%). Non-adherence was documented 32% of episodes with documentation of injection drug use (IDU), 28% of encounters where active substance use was documented in the prior year and 33% of encounters where use of more than one substance was documented (P< 0.05 for all 3 groups). Drug or catheter related adverse events seemed to be significantly higher in the IDU group (3.64/1000 OPAT days) and catheter abuse was documented in 7 encounters of which 6 were with IDU or active SUD active documented. Cumulatively an unfavorable outcome (including failure, 30-day readmission, drug or PICC related adverse event, non-adherence or death) seemed to occur in 58% of IDU encounters as compared to non-IDU encounters (42.5%, P=0.011). Medication for opioid use disorder (MOUD) was prescribed at discharge in 68% of overall cohort and was not associated with improved outcomes for any of the above groups. Demographics, infection details and outcomes by type of SUD Conclusion In patients hospitalized with SUD-related infections, interventions need to be focused on those with high risk, unstable SUD through MOUD optimization along transitions of care and linkage to care to improve OPAT outcomes and overall health events Disclosures Shyam Kottilil, MD, PhD, Arbutus Pharmaceuticals: Grant/Research Support|Gilead: Grant/Research Support|Merck: Grant/Research Support|Regeneron Pharmaceuticals: Advisor/Consultant|Silverback Therapeutics: Advisor/Consultant|The Liver Company: Advisor/Consultant|Yufan Biotechnologies: Advisor/Consultant.

Background The global burden of lower respiratory infections (LRIs) and corresponding risk factors in children older than 5 years and adults has not been studied as comprehensively as it has been in children younger than 5 years. We assessed the burden and trends of LRIs and risk factors across a groups by sex, for 204 countries and territories. Methods In this analysis of data for the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we used dinician-diagnosed pneumonia or bronchiolitis as our case definition for LRIs. We included International Classification of Diseases 9th edition codes 079.6, 466-469, 470.0, 480-482.8, 483.0-483.9, 484.1-484.2, 484.6-484.7, and 487-489 and International Classification of Diseases 10th edition codes A48.1, A70, B97.4 B97.6, 109-115.8, J16 J16.9, J20-121.9, J91.0, P23.0 P23.4, and U04 U04.9. We used the Cause of Death Ensemble modelling strategy to analyse 23109 site-years of vital r *stration data, 825 site-years of sample vital registration data, 1766 site-years of verbal autopsy data, and 681 site-years of mortality surveillance data. We used DisMod-MR 2.1, a Bayesian metaregression tool, to analyse age sex-specific incidence and prevalence data identified via systematic reviews of the literature, population-based survey data, and daims and inpatient data. Additio y, we estimated age sex-specific LRI mortality that is attributable to the independent effects of 14 risk factors. Findings Globally, in 2019, we estimated that there were 257 million (95% uncertainty interval [UI] 240-275) LRI incident episodes in males and 232 million (217-248) in females. In the same year, LRIs accounted for 1.30 million (95% UI 1.18-1.42) male deaths and 1.20 million (1.07-1.33) female deaths. Age-standardised incidence and mortality rates were 1.17 times (95% UI 1.16-1.18) and 1.31 times (95% UI 1.23-1.41) greater in males than in fe es in 2019. Between 1990 and 2019, LRI incidence and mortality rates declined at different rates across age groups and an increase in LRI episodes and deaths was estimated among all adult age groups, with males aged 70 years and older having the highest increase in LRI episodes (126.0% [95% UI 121.4-131.1]) and deaths (100.0% [83.4-115.9]). During the same period, LRI episodes and deaths in children younger than 15 years were estimated to have decreased, and the greatest dedine was observed for LRI deaths in males younger than 5 years (-70.7% [-77.2 to 61.8]). The leading risk factors for LRI mortality varied across age groups and sex. More than half of global LRI deaths in children younger than 5 years were attributable to child wasting (population attributable fraction [PAF] 53.0% [95% UI 37.7-61.8] in males and 56.4% [40.7-65.1] in females), and more than a quarter of LRI deaths among those aged 5-14 years were attributable to household air pollution (PAF 26.0% [95% UI 16.6-35.5] for males and PAF 25.8% [16.3-35.4] for females). PAFs of male LRI deaths attributed to smoking were 20.4% (95% UI 15.4-25.2) in those aged 15-49 years, 305% (24.1-36. 9) in those aged 50-69 years, and 21.9% (16. 8-27. 3) in those aged 70 years and older. PAFs of female LRI deaths attributed to household air pollution were 21.1% (95% UI 14.5-27.9) in those aged 15-49 years and 18 " 2% (12.5-24.5) in those aged 50-69 years. For females aged 70 years and older, the leading risk factor, ambient particulate matter, was responsible for 11-7% (95% UI 8.2-15.8) of LRI deaths. Interpretation The patterns and progress in reducing the burden of LRIs and key risk factors for mortality varied across age groups and sexes. The progress seen in children you - than 5 years was dearly a result of targeted interventions, such as vaccination and reduction of exposure to risk factors. Similar interventions for other age groups could contribute to the achievement of multiple Sustainable Development Goals targets, induding promoting wellbeing at all ages and reducing health inequalities. Interventions, including addressing risk factors such as child wasting, smoking, ambient particulate matter pollution, and household air pollution, would prevent deaths and reduce health disparities. Copyright 2022 The Author(s). Published by Elsevier Ltd.

Abstract Background Fungal blood cultures are usually ordered when sepsis secondary to disseminated fungal infection is suspected. We aimed to analyze whether positive fungal blood cultures had an added clinical impact over other conventional microbiological tests. Methods We performed a retrospective study of all patients for whom fungal blood cultures were performed for any indication at our institution from June 2018 to March 2022. We reviewed informatics database and medical records to assess the microbiological and clinical impact of positive fungal blood cultures during the initial admission. Assessment of clinical impact was analyzed using a list of predefined positive, negative, and no impact scenarios (Table 1) based by the treating team’s decisions. Results In total, 4447 fungal blood cultures were performed in 3648 admissions during our study period. The overall positivity rate of fungal blood cultures was 6.4% (n=284), of which only 130 (2.9%) were positive for fungi. The most common isolated fungi were Candida spp. (71, 55%), followed by Histoplasma spp. (16, 12%), Cryptococcus spp. (12, 9%), and unidentified mold (9, 7%) (Table 1). The median time to positivity was 106 hours (IQR 79-177). Only 21 (16%) fungal blood cultures resulted in a change in management. Positive fungal blood cultures for fungi led to a positive clinical impact in 17 (13%), negative clinical impact in 4 (3%), and no clinical impact in 109 (84%). Most fungal blood cultures confirmed other conventional microbiological diagnosis (71, 55%) or result was not acted upon (26, 20%). Organisms where fungal blood culture had a positive impact included C. albicans (n=4), and C. parapsilosis (n=3), while Cladosporium spp. (n=2) was the most frequent fungi with a negative clinical impact. Isolated fungi that had no clinical impact because of other confirmatory tests included Candida spp. (n=57), Histoplasma spp. (n=13) and Cryptococcus neoformans (n=10). Table 1.Microbiological characteristics and clinical impact of fungal blood cultures.Abbreviations: h hours; IQR, interquartile range.*Time to positivity was defined as the time from the fungal blood culture collection until growth and preliminary identification of a fungal organism on staining by the microbiology laboratory. **Time to identification was defined as the time from the fungal blood culture collection until identification of the fungal organism by the microbiology laboratory. Conclusion Most of positive fungal blood cultures for fungi resulted in no immediate clinical impact due to other microbiological tests available sooner or isolates thought to be non-clinically significant. Further studies should evaluate the long-term impact of fungemia and identify stewardship interventions to optimize clinical utility of fungal blood cultures. Disclosures All Authors: No reported disclosures.

Asbestos is a generic term for a group of naturally occurring fibers composed of hydrated magnesium silicate minerals. Transported worldwide to shipyards and factories, it is a material that was widely used in construction, mining, and manufacturing. Exposure to asbestos can cause significant benign and malignant lung, pleural, and pericardial disease. Usually asymptomatic, pleural plaques are the most common radiologic manifestation of asbestos exposure. We report a case of a man who presented with heart failure exacerbation and was incidentally found to have pleural and pericardial plaques from asbestos exposure.

A 47-year-old man with sudden-onset biventricular heart failure was transferred for device therapy and heart transplant evaluation. Originally from El Salvador and without known medical conditions, he immigrated to the United States 30 years prior and last visited the former 7 years ago. Five weeks prior to transfer he began to have exertional dyspnea associated with orthopnea, malaise, and generalized weakness, which worsened over the course of a week. He went to the emergency department, where he was found to be tachycardic, tachypneic, and hypoxic, requiring supplemental oxygen. Breath sounds were decreased in both lung bases. Electrocardiogram showed atrial fibrillation in rapid ventricular response and right bundle branch block. Chest radiograph revealed bilateral pleural effusions and cardiomegaly. He went into acute hypoxic respiratory failure and pulseless electrical activity arrest, and was intubated, with return of spontaneous circulation after 5 minutes of resuscitation. Multiple high-dose vasopressors were started for the cardiogenic shock. Echocardiogram showed dilated ventricles, global hypokinesis, and left ventricular ejection fraction of 10–15%. After 10 days of veno-arterial extracorporeal membrane oxygenation, he was decannulated. Coronary angiography showed normal arteries. Cardiac magnetic resonance imaging showed heterogeneous late gadolinium enhancement without myocardial edema. Antinuclear antibodies, human immunodeficiency virus, adenovirus, coxsackie, Borrelia, and Toxoplasma serology were all negative. Trypanosoma cruzi immunoglobulin G sent to the Centers for Disease Control and Prevention was positive (immunoglobulin M negative). Without a history of alcohol or illicit drug use and family history of heart disease, negative work-up (including normal troponin, thyroid function tests, and low transferrin saturation), and positive T. cruzi serology, the patient was diagnosed with cardiomyopathy secondary to chronic Chagas disease. Given the high risk of arrhythmia with episodes of nonsustained ventricular tachycardia, an implantable cardioverter-defibrillator was placed. He continued to improve and was discharged home to complete heart transplant evaluation as an outpatient.

OBJECTIVEQuantify the integrity, measured as completeness and concordance with a thoracic radiologist, of documenting pulmonary nodule characteristics in CT reports and assess impact on making follow-up recommendations.MATERIALS AND METHODSThis Institutional Review Board-approved, retrospective cohort study was performed at an academic medical center. Natural language processing was performed on radiology reports of CT scans of chest, abdomen, or spine completed in 2016 to assess presence of pulmonary nodules, excluding patients with lung cancer, of which 300 reports were randomly sampled to form the study cohort. Documentation of nodule characteristics were manually extracted from reports by 2 authors with 20% overlap. CT images corresponding to 60 randomly selected reports were further reviewed by a thoracic radiologist to record nodule characteristics. Documentation completeness for all characteristics were reported in percentage and compared using χ2 analysis. Concordance with a thoracic radiologist was reported as percentage agreement; impact on making follow-up recommendations was assessed using kappa.RESULTSDocumentation completeness for pulmonary nodule characteristics differed across variables (range = 2%-90%, P < .001). Concordance with a thoracic radiologist was 75% for documenting nodule laterality and 29% for size. Follow-up recommendations were in agreement in 67% and 49% of reports when there was lack of completeness and concordance in documenting nodule size, respectively.DISCUSSIONEssential pulmonary nodule characteristics were under-reported, potentially impacting recommendations for pulmonary nodule follow-up.CONCLUSIONLack of documentation of pulmonary nodule characteristics in radiology reports is common, with potential for compromising patient care and clinical decision support tools.

An 85-year-old man with an indwelling suprapubic catheter for bladder outlet obstruction due to prostatic hyperplasia and urethral stricture presented to the hospital with lethargy and weakness. His suprapubic catheter accidentally fell out 3 days prior. His medical history included recurrent urinary tract infections (UTIs), chronic kidney disease secondary to uncontrolled type 2 diabetes mellitus, and a prior transurethral resection of the prostate performed 13 years previously.