Background The spotted fever rickettsioses (SFR), including Rocky Mountain spotted fever, are tick-borne infections with frequent neurologic involvement. High morbidity and mortality make early recognition and empiric treatment critical. Most literature on SFR meningoencephalitis predates widespread magnetic resonance imaging (MRI) utilization. To better understand the contemporary presentation and outcomes of this disease, we analyzed clinical and radiographic features of patients with SFR meningoencephalitis. Methods Patients were identified through hospital laboratory-based surveillance or through the Tennessee Unexplained Encephalitis Study. Cases meeting inclusion criteria underwent medical records review and, when available, independent review of the neuroimaging. Results Nineteen cases (11 children, 8 adults) met criteria for SFR meningoencephalitis. Rash was significantly more common in children than adults (100% vs 50%, respectively), but other clinical features were similar between the 2 groups. Cerebrospinal fluid pleocytosis and protein elevation were each seen in 87.5% of cases, and hypoglycorrhachia was present in 18.8% of cases. The “starry sky” sign (multifocal, punctate diffusion restricting or T2 hyperintense lesions) was seen on MRI in all children, but no adults. Ninety percent of patients required intensive care unit admission and 39% were intubated. Outcomes were similar between adults and children, with only 46% making a complete recovery by the time of discharge. Conclusions SFR meningoencephalitis is a life-threatening infection. The clinical presentation varies between adults and children based on the presence of rash and brain MRI findings. The starry sky sign was ubiquitous in children and should prompt consideration of empiric treatment for SFR when present.

Burkholderia cepacia prosthetic valve endocarditis (PVE) is extremely rare, with few cases in the literature. A report of a patient with PVE is described, followed by a literature review on B. cepacia PVE. A 38 year old man with poor dentition and a history of intravenous drug use (IVDU) and mitral valve replacement was found to have a mitral valve vegetation. Five sets of blood cultures on different days grew B. cepacia. Individual sets of blood cultures on different dates also isolated S. viridans (outside hospital culture), methicillin-resistant S. epidermidis (hospital day 1), and Bacillus spp. (hospital day 6). He was successfully treated with ceftazidime and levofloxacin as dual therapy for B. cepacia PVE, in addition to vancomycin for gram positive coverage. This case report and review highlights the possibility of B. cepacia PVE in immunocompetent patients with poor dentition, with the potential for a successful outcome following combination antimicrobial therapy.

BackgroundImproving internal medicine (IM) trainees skills in managing common infectious diseases is essential to their development as competent physicians. We currently lack quantitative data of the knowledge and attitudes of IM housestaff regarding their management of common infectious diseases. We applied the knowledge, attitude, and behavior model to a pre-intervention survey aimed to uncover housestaff knowledge gaps and discomfort in managing several of the most commonly encountered infectious diseases at our institution. Using this information, we plan to develop a targeted post-survey intervention to increase self-efficacy and improve antimicrobial prescription practices among trainees.MethodsSurvey questions were based on Infectious Disease Society of America (IDSA) guidelines and developed using an iterative process involving interviews of infectious disease physicians and IM housestaff. We chose to focus on cystitis, pneumonia, and skin and soft-tissue infections. The anonymous survey tool was developed using a secure, online platform, and distributed in January 2018. Participation was voluntary and no remuneration for participation was offered.ResultsOut of 165 survey recipients, 50 trainees (30%) responded. Fifty-eight percent of trainees stated that they possessed only an average level of knowledge regarding the management of cystitis, pneumonia, and cellulitis. While 98% of housestaff confirmed that they utilized additional resources for information, only 24% felt routinely comfortable making decisions without an infectious disease consultation. Ninety-six percent of trainees felt that an institution-specific guide describing the management of common infectious diseases would be highly beneficial.ConclusionTrainees still lack the knowledge and confidence to make decisions regarding the empiric management of cystitis, pneumonia, and skin and soft-tissue infections at our academic medical center. There is a strong desire for an institution-specific educational resource to provide guidance for these decisions. Increasing trainee self-efficacy and improving their antimicrobial prescription practice patterns should be an educational priority. Disclosures All authors: No reported disclosures.

BackgroundOsteomyelitis is a common complication of advanced stage pressure ulcers and known to be associated with increased mortality, length of stay (LOS), and treatment costs. However, limited data and lack of guidelines regarding appropriate diagnosis and treatment result in variability in management. We sought to investigate whether microbiology data are associated with reduced antibiotic utilization in patients with osteomyelitis secondary to decubitus ulcers.MethodsThis retrospective cohort study included hospitalized patients from 2007 to 2015 with an advanced stage (IV or unstageable) sacral decubitus ulcer and clinical concern for osteomyelitis. The exposure group was those who underwent tissue culture (superficial swab, deep bedside or surgical tissue, or bone biopsy). The primary outcome was antibiotic days of therapy (DOT). Additional secondary outcomes including clinical characteristics at presentation, LOS, readmission rates, and antibiotic-related complications were evaluated using Fisher’s exact or Wilcoxon-Mann–Whitney test for continuous variables.ResultsA total of 220 cases of advanced-stage decubitus ulcer with clinical concern for osteomyelitis were identified. Data abstracted from 40 cases show that tissue cultures were obtained in 22 (55%). Bacterial growth was identified from 100% of samples sent for culture. Antibiotic use prior to admission was the most significant predictor of failure to obtain tissue cultures (P = 0.0002). MRI was performed in 15% of abstracted cases, with radiographic evidence of osteomyelitis noted in 100%. Bone biopsy was performed in 4 cases; bone pathology was not sent in any of these instances. Median antibiotic DOT was 84 days in both groups. ConclusionIn cases of sacral osteomyelitis secondary to decubitus ulcers, antibiotic use prior to admission was inversely related to the likelihood of obtaining a tissue culture. When tissue cultures were obtained, they were uniformly positive; however, in our preliminary analysis of 40 cases, this did not appear to influence antibiotic utilization as determined by DOT. Bone biopsy was rarely performed, and when done, was not sent for pathology despite this being recognized as the gold standard in the diagnosis of osteomyelitis. Disclosures All authors: No reported disclosures.