Identified micro-organisms in hospitalized community-acquired pneumonia patients living near goat and poultry farms

Background In the Netherlands, an increased risk of community-acquired pneumonia (CAP) has been reported for adults living near goat and poultry farms. Previous results of respiratory microbiome studies in hospitalized CAP patients near poultry farms suggested a higher relative abundance of Streptococcus pneumoniae. This retrospective study, using routine laboratory data from hospitalized CAP patients, aims to explore possible aetiologic micro-organisms of CAP in relation to livestock exposure. Methods Patient characteristics and PCR and urinary antigen test results were retrieved retrospectively from electronic medical records of CAP patients admitted to the Jeroen Bosch Hospital or Gelre Hospital in the Netherlands during 2016–2017. Distances between the patients’ home address and the nearest poultry and goat farm were calculated. Differences in laboratory test results between CAP patients with and without goat or poultry farms within 2 km of their home address were analyzed using Fisher’s exact test. Results In total, 2230 CAP episodes with diagnostic results were included. In only 25% of the CAP episodes, a micro-organism was detected. A positive urinary antigen test for S. pneumoniae was found more often in patients living within two kilometers of goat (15.2% vs. 11.3%) and poultry farms (14.4% vs. 11.3%), however these differences were not statistically significant (p = 0.1047 and p = 0.1376). Conclusion Our retrospective analysis did not show statistically significant differences in the identified micro-organisms in hospitalized CAP patients related to livestock farming. The study was hampered by limited statistical power and limited laboratory results. Therefore, the potential increased CAP risk around goat and poultry farms will be further explored in a prospective study among CAP patients in primary care.

68. Impact of Streptococcus pneumoniae Urinary Antigen Testing in Patients with Community-Acquired Pneumonia Admitted within a Large Academic Medical System

Background Limited data support the use of pneumococcal urinary antigen testing (PUAT) for patients admitted with community-acquired pneumonia (CAP) as a stewardship tool to curtail the use of broad-spectrum antimicrobials. At NYULH, CAP guidelines and admission order set were developed to standardize diagnostic testing, including PUAT. In this study we describe patients with positive versus negative PUAT and evaluate de-escalation and patients’ outcomes. Methods This was a retrospective study of adults admitted with diagnosis of CAP between January-December 2019 who had a PUAT performed. The primary outcome was incidence and timing of de-escalation of antimicrobials following PUAT result. Among patients with a positive PUAT we compared hospital length of stay (LOS), incidence of Clostridioides difficile infection (CDI), infection-related readmission within 30 days, and in-hospital mortality among those who were de-escalated versus those who were not de-escalated/required escalation. Results We evaluated 910 patients, of which 121 (13.3%) were PUAT positive. No difference in baseline characteristics, including severity of illness as represented by the Pneumonia Severity Index (97 [IQR 76-117] vs 89 [IQR 67-115], p=0.083) and Charlson Comorbidity Index, were observed between PUAT positive and negative groups. Time to PUAT testing occurred shortly after presentation to the hospital in both cohorts (16h [IQR 16-27] vs 13h [IQR 8-22], p=0.140). Initial de-escalation occurred in 97/117 (82.9%) and 629/775 (81.2%) of PUAT positive and negative patients, respectively (p = 0.749). Median time to de-escalation was shorter in the PUAT positive cohort (1 [IQR 0-2] vs 1 [IQR 1-2] day, p = 0.01). Among the PUAT positive group, hospital LOS stay was shorter in patients who were de-escalated compared to those who were not de-escalated/required escalation (6 days [IQR 4-10] vs 8 days [IQR 7-12], p=0.0005) with no difference in the incidence of CDI (2 [2.1%] vs 1 [3.7%], p=0.535), in-hospital mortality (4 [4.3%] vs 3 [11.1%], p=0.185), or 30-day infection-related readmission (2 [2.1%] vs 1 [3.7%], p=0.535). Conclusion PUAT positivity resulted in quicker time to targeted therapy for CAP. Among patients with a positive PUAT, initial de-escalation of antimicrobials did not lead to worse patient outcomes. Disclosures All Authors: No reported disclosures

33. Evaluating the Safety and Effectiveness of a Non-Severe Community-Acquired Pneumonia Pharmacist Pathway

Background One of the main roles of the SSM Health WI Regional Antimicrobial Stewardship Program is to create infection treatment pathways based on the Infectious Diseases Society of America (IDSA) practice guidelines. Treatment pathways are used to guide provider prescribing of antimicrobials for disease states such as community-acquired pneumonia (CAP). The objective of this study was to evaluate the safety and effectiveness of a non-severe CAP pharmacist pathway based on the updated IDSA and American Thoracic Society 2019 CAP practice guideline. Methods A retrospective chart review was performed on all patients placed on the non-severe CAP pharmacist pathway at SSM Health St. Mary’s Hospital in Madison, WI from September 2020 through April 2021. Patients who initially started on the pathway were removed if they met prespecified criteria (Table 1). The primary outcome in this study was 30-day respiratory-related readmission rate. Secondary outcomes included average total length of antibiotic therapy, pharmacist interventions [intravenous (IV) to oral (PO) conversion, antibiotic de-escalation (including discontinuation of azithromycin with negative legionella urinary antigen), duration of therapy], and 30-day all-cause readmission rate. Table 1. Criteria for Removal from the Pathway Figure 1. Pharmacist Interventions Results A total of 119 patients were initiated on the non-severe CAP pharmacist pathway, of which 47 patients (40%) completed the pathway and 72 patients (60%) were removed from the pathway. Of the 47 patients who completed the pathway, there were no respiratory-related readmissions with a 30-day all-cause readmission rate of 6.4% (N=3/47). The average total duration of beta-lactam therapy was 6.8 days and the average total duration of macrolide therapy was 1 day due to de-escalation with a negative legionella urinary antigen result. A total of 61 pharmacist-driven interventions were completed [IV to PO conversion (N=15), de-escalation (N=27), and duration of therapy (N=19)]. Table 2. Summary of Results Conclusion The findings of this study suggest that implementation of a non-severe CAP pharmacist pathway is safe and effective. No readmissions were related to non-severe CAP management and pharmacists completed guideline-driven interventions related to antimicrobial de-escalation, IV to PO conversion, and duration of therapy. Disclosures All Authors: No reported disclosures

Importance of vaccination for disease prevention in post-splenectomy patients

A fit middle aged man presented to the emergency department with headache, myalgia, vomiting, fever and rigours. He was hypotensive with mottled peripheries, tachycardic and dyspnoeic. The only significant medical history noted was an emergency splenectomy 30 years previously following a road traffic accident. The patient had been on prophylactic antibiotics initially and was vaccinated in line with recommendations at the time following splenectomy with no significant health issues in the intervening years. The patient was treated empirically for septic shock and meningitis based on presentation and admitted to the intensive care unit for pressor support and subsequently required intubation and ventilation. Investigations revealed bilateral pneumonia. Streptococcal pneumoniae urinary antigen and serum S. pneumoniae PCR were positive supporting a diagnosis of invasive pneumococcal infection. A lumbar puncture was negative for meningitis. Distal mottling affecting all limbs progressed with resultant bilateral upper limb digit and below knee amputation. The patient subsequently required extensive rehabilitation. Following a prolonged tertiary and rehabilitation hospital admission, the patient made an exceptional recovery and was discharged home with ongoing appropriate support and home adaptation.

Severe bilateral pleuropneumonia caused by Legionella sainthelensi: a case report

Background Legionella spp. are ubiquitous freshwater bacteria responsible for rare but potentially severe cases of Legionnaires’ disease (LD). Legionella sainthelensi is a non-pneumophila Legionella species that was first isolated in 1980 from water near Mt. St-Helens (USA). Although rare cases of LD caused by L. sainthelensi have been reported, very little data is available on this pathogen. Case presentation We describe the first documented case of severe bilateral pleuropneumonia caused by L. sainthelensi. The patient was a 35-year-old woman with Sharp’s syndrome treated with long-term hydroxychloroquine and corticosteroids who was hospitalized for an infectious illness in a university hospital in Reunion Island (France). The patient’s clinical presentation was complicated at first (bilateral pneumonia, multiloculated pleural effusion, then bronchopleural fistula) but her clinical condition eventually improved with the reintroduction of macrolides (spiramycin) in intensive care unit. Etiological diagnosis was confirmed by PCR syndromic assay and culture on bronchoalveolar lavage. Conclusions To date, only 14 documented cases of L. sainthelensi infection have been described worldwide. This pathogen is difficult to identify because it is not or poorly detected by urinary antigen and molecular methods (like PCR syndromic assays that primarily target L. pneumophila and that have only recently been deployed in microbiology laboratories). Pneumonia caused by L. sainthelensi is likely underdiagnosed as a result. Clinicians should consider the possibility of non-pneumophila Legionella infection in patients with a compatible clinical presentation when microbiological diagnostic tools targeted L. pneumophila tested negative.

Evaluation of OIDx Histoplasma Urinary Antigen EIA

A sandwich enzyme immunoassay (EIA) for the detection of Histoplasma antigens (Ag) in urine, developed by Optimum Imaging Diagnostics (OIDx) was evaluated. A verification using a standardized reference panel of urine samples found sensitivity of 92%, specificity of 32% and accuracy of 51%. In this study, the OIDx Histoplasma urinary Ag EIA displayed high sensitivity, however, in non-histoplasmosis cases this EIA displayed false-positive results in 68% of specimens tested.

Impact of Pneumococcal Urinary Antigen Testing in COVID-19 Patients: Outcomes from the San Matteo COVID-19 Registry (SMACORE)

Despite low rates of bacterial co-infections, most COVID-19 patients receive antibiotic therapy. We hypothesized that patients with positive pneumococcal urinary antigens (PUAs) would benefit from antibiotic therapy in terms of clinical outcomes (death, ICU admission, and length of stay). The San Matteo COVID-19 Registry (SMACORE) prospectively enrolls patients admitted for COVID-19 pneumonia at IRCCS Policlinico San Matteo, Pavia. We retrospectively extracted the data of patients tested for PUA from October to December 2020. Demographic, clinical, and laboratory data were recorded. Of 469 patients, 42 tested positive for PUA (8.95%), while 427 (91.05%) tested negative. A positive PUA result had no significant impact on death (HR 0.53 CI [0.22–1.28] p-value 0.16) or ICU admission (HR 0.8; CI [0.25–2.54] p-value 0.70) in the Cox regression model, nor on length of stay in linear regression (estimate 1.71; SE 2.37; p-value 0.47). After adjusting for age, we found no significant correlation between urinary antigen positivity and variations in the WHO ordinal scale and laboratory markers at admission and after 14 days. We found that a positive PUA result was not frequent and had no impact on clinical outcomes or clinical improvement. Our results did not support the routine use of PUA tests to select COVID-19 patients who will benefit from antibiotic therapy.