This Clinical Insights discusses how the methicillin-resistant Staphylococcus aureus (MRSA) nares swab may be used alongside disease prevalence and clinical factors to determine when MRSA coverage is needed for common inpatient infections.

A 68-year-old male with active amphetamine use presented to the hospital with acute emesis, odynophagia, and mid-sternal chest pain. Imaging was initially concerning for esophageal perforation. After full evaluation including barium esophagram and serial computed tomography (CT) of the chest, no esophageal perforation was confirmed. He underwent endoscopy, which identified white, circumferential plaques along the length of the esophagus. Gross appearance on endoscopy was consistent with Candidal esophagitis. Ultimately, pathology was negative for fungal elements, and esophagitis was attributed to amphetamine use. We report a rare case of amphetamine-induced esophagitis and discuss the initial management of esophageal perforation, risk factors for, and diagnostic mimickers of Candidal esophagitis.

Background:Staphylococcus lugdunensis (S lugdunensis) is a species of coagulase-negative Staphylococcus and a constituent of human skin flora. S lugdunensis has gained notoriety for its virulence, which resembles Staphylococcus aureus (S aureus). S lugdunensis is now recognized as an important nosocomial pathogen and cause of prosthetic device infections, including vascular catheter infections.Case Presentation:A 60-year-old man with a history of uncontrolled type 2 diabetes mellitus and end-stage renal disease on home hemodialysis via arteriovenous fistula (AVF) presented to the emergency department for evaluation of subacute progressive low back pain. Initial laboratory tests were notable for elevated inflammatory markers. Magnetic resonance imaging with contrast of the thoracic and lumbar spine revealed abnormal marrow edema in the T11-T12 vertebrae with abnormal fluid signal in the T11-T12 disc space. Cultures grew methicillin-sensitive S lugdunensis. The patient's antibiotic regimen was narrowed to IV oxacillin. He was transitioned to IV cefazolin dosed 3 times weekly after hemodialysis and an outpatient dialysis center.Conclusions:Treatment of bacteremia caused by S lugdunensis or S aureus should be managed with prompt initiation of IV antistaphylococcal therapy, a thorough evaluation for the source of bacteremia as well as metastatic complications, and consultation with an infectious disease specialist. This case highlights AVF as a potential source for infection even without localized signs of infection. The buttonhole method of AVF cannulation was thought to be a major contributor to the development and persistence of our patient's bacteremia. This risk should be discussed with patients using a shared decision-making approach when developing a dialysis treatment plan.

Drug-induced liver injury (DILI) resulting from nonsteroidal anti-inflammatory drugs (NSAIDs) is a rare phenomenon; however, several cases have been reported in the literature and the LiverTox database. For ibuprofen in particular, only 22 cases have been reported, and the mechanism for liver injury is unclear. In this report, we discuss a case of ibuprofen-induced liver injury to highlight the evaluation of NSAID-induced DILI, as well as the likely mechanism of injury.

Background Preoperative medical evaluation serves to identify risk factors and optimize patients before surgery. Providing a telehealth option in the perioperative setting has played a significant role in reducing barriers to quality perioperative health care. Objective We aimed to evaluate how telemedicine preoperative evaluations using Clinical Video Telehealth (CVT) impact hospital length of stay. Methods We performed a retrospective chart review between 2016 and 2017 of adult patients who underwent evaluations in our hospitalist-run preoperative medicine clinic. Patients seen in our preoperative CVT program were compared to patients seen in person to evaluate the association of visit type (preoperative CVT versus in-person evaluation) with hospital length of stay, defined as hospital stay from postoperative day 0 to discharge. There were 62 patients included in this retrospective study. Results The adjusted incidence rate ratio (IRR) for hospital length of stay was significantly shorter in patients who underwent preoperative CVT compared to an in-person visit (IRR 0.52, 95% CI 0.29-0.92, P=.02). Conclusions After adjusting for age and comorbidities, we show that preoperative telemedicine in the perioperative setting is associated with a shorter hospital length of stay compared to in-person visits. This suggests that telemedicine can play a viable role in this clinical setting.

Bloodstream infections are a leading cause of morbidity and mortality. Molecular rapid diagnostic tests (mRDTs) are transforming care for patients with bloodstream infection by providing the opportunity to dramatically shorten times to effective therapy and speeding de-escalation of overly broad empiric therapy. However, because of the novelty of these tests which provide information regarding microbial identification and whether specific antibiotic-resistance mutations were detected, many front-line providers still delay final decisions until complete phenotypic susceptibility results are available several days later. Thus the benefits of mRDTs have been largely limited to circumstances where antimicrobial stewardship programs closely monitor these tests and intervene as soon as the results are available. We searched PubMed and Google Scholar for articles published from 1980 to 2019 using the terms antibiotic, antifungal, bacteremia, bloodstream infection, candidemia, candidiasis, children, coagulase negative staphylococcus, consultation, contamination, costs, echocardiogram, endocarditis, enterobacteriaceae, enterococcus, Gram-negative, guidelines, IDSA, immunocompromised, infectious disease or ID, lumbar puncture, meningitis, mortality, MRSA, MSSA, neonatal, outcomes, pediatric, pneumococcal, polymicrobial, Pseudomonas, rapid diagnostic testing, resistance, risk factors, sepsis, Staphylococcus aureus, stewardship, streptococcus, and treatment. With the data from this search, we aim to provide guidance to front-line providers regarding the interpretation and immediate actions to be taken in response to the identification of common bloodstream pathogens by mRDTs. In addition to antimicrobial therapy, additional diagnostic or therapeutic interventions are recommended for particular organisms and clinical settings to either determine the extent of infection or control its source. Pediatric perspectives are offered for those bloodstream pathogens for which management differs from that in adults.

Abstract Background Contaminant blood cultures can lead to unnecessary antibiotic use, longer admissions and increased costs. Rapid diagnostics, like the BioFire® FilmArray® Blood Culture Identification (BCID) Panel, can potentially lessen these harms. BioFire BCID was implemented at VA Greater Los Angeles in 7/2017. When providers review BCID results, they are also directed to an interpretation guide developed by our antimicrobial stewardship program. This study aimed to determine the impact of BioFire BCID with this interpretation guide on unnecessary vancomycin use for contaminant blood cultures growing CoNS. Methods This was a retrospective cohort study on adult inpatients with contaminant blood cultures positive for CoNS. We evaluated cases before BCID (April 2016–July 2017) and after BCID (July 7/2017–December 2018) implementation. Cases with patients who died or were discharged prior to preliminary results, polymicrobial cultures, no empiric vancomycin use, or where vancomycin was indicated were excluded. We defined a “case” as anytime a provider concurrently ordered blood cultures and empiric antibiotics. Our primary outcome was the duration of unnecessary vancomycin. Secondary outcomes were time to discontinuation/modification of any empiric antibiotic, length of stay (LOS), LOS in ICU and 30-day mortality. Results A total of 99 cases were included (N = 45 pre-BCID; N = 54 post-BCID). Demographics between the 2 groups were largely similar except the post-BCID group had more patients with end-stage renal disease (ESRD) (14 vs. 4, P = 0.037) and more frequent infectious disease (ID) consultation (21 vs. 8, P = 0.027). The post-BCID group had shorter mean duration of unnecessary vancomycin (53.0 hours vs. 38.1 hours, P = 0.0029). After controlling for ESRD and ID involvement, the mean duration of unnecessary vancomycin was not significantly different between the 2 groups (P = 0.30 and P = 0.49, respectively). There was no difference in time to modification/discontinuation of any empiric antibiotic (44.6 hr vs. 35.0 hr, P = 0.36). There was no difference in mean LOS, mean LOS in ICU, or 30-day mortality. Conclusion Shorter duration of unnecessary vancomycin for CoNS bacteremia after BCID implementation and provision of an interpretation guide may have been driven in part by more frequent ID consultation. Disclosures All authors: No reported disclosures.

Quantitation of Human Papillomavirus DNA in Plasma of Oropharyngeal Carcinoma Patients Hongbin Cao, M.S.,* Alice Banh, Ph.D.,* Shirley Kwok, M.D.,y Xiaoli Shi, Ph.D.,* Simon Wu, B.A.,* Trevor Krakow, B.Sc.,* Brian Khong, B.A.,* Brindha Bavan, B.A.,* Rajeev Bala, M.D.,y Benjamin A. Pinsky, Ph.D.,y Dimitrios Colevas, M.D.,z Nader Pourmand, Ph.D.,x Albert C. Koong, Ph.D.,* Christina S. Kong, M.D.,y and Quynh-Thu Le, M.D.* Departments of *Radiation Oncology, yPathology, and zMedicine, Stanford University School of Medicine, Stanford, CA; and xDepartment of Biomolecular Engineering, University of California Santa Cruz, Santa Cruz, CA

5596 Background: Lower socioeconomic status (SES) has been linked with higher incidence and lower survival in head and neck cancer (HNC) patients. However, there is little data on outcomes in Asians/Pacific Islanders (APIs) with HNC. The purposes of this study are to examine the effect of SES on overall survival (OS) in APIs with HNC and to compare their survival to that of other ethnicities using population-based registry data. Methods: 53,544 eligible HNC patients (of whom 4,711 were APIs) were identified from the California Cancer Registry from 1988 to 2007. Block-group SES, based on a composite of Census 1990 and 2000 data, was calculated for each patient based on address at diagnosis. SES was categorized into 2 groups for comparison (low SES = quintiles 1-3; high SES = quintiles 4-5). For each HNC site, descriptive data, treatment, and outcomes were recorded. OS was computed by the Kaplan- Meier method. Adjusted hazard ratios (HR) were estimated using Cox proportional hazards regression models. Results: In all patients combined, lower SES was significantly associated with poorer OS for all HNC sites. APIs had significantly better OS compared to Caucasians for OC, adjusted hazard ratio (HR) 0.83 (95% CI 0.76–0.90); LX/HP, HR 0.74 (95% CI 0.68–0.81); and NP, HR 0.82 (95% CI 0.74–0.90). OS benefit was preserved in both lower SES and higher SES strata (Table). After adjustment for other parameters, lower SES was significantly associated with poorer survival among APIs with OC, OPC, and LX/HP analyzed together. Conclusions: Neighborhood SES significantly influences survival in APIs with HNC, consistent with previous studies of other racial/ethnic groups. Unexpectedly, the higher median OS for APIs compared to Caucasians persisted for most HNC sites across levels of SES. This racial difference in HNC survival requires further elucidation for future individualized care. Median survival (months) by tumor site and SES for all, Caucasians, and API patients with HNC Tumor site All patients Caucasians API High SES Low SES High SES Low SES High SES Low SES Oral cavity (OC) 62.4 38.1 61.7 40.9 91.0 40.9 Oropharynx (OP) 85.4 36.7 86.2 43.7 101.7 38.8 Larynx/ hypopharynx (LX/HP) 74.6 49.3 73.9 50.8 119.1 59.3 Nasopharynx (NP) 100.9 61.3 64.1 35.4 148.4 83.1 No significant financial relationships to disclose.

Lower socioeconomic status (SES) has been linked to higher incidence of head and neck cancer (HNC) and lower survival. However, little is known about the effect of SES on HNC survival in Asians and Pacific Islanders (APIs). This study's purpose was to examine the effect of SES on disease‐specific survival (DSS) and overall survival (OS) in APIs with HNC using population‐based data.