bluuebunny/crossref_metadata_2025 huggingface dataset:
1666. Community Beliefs about Ebola and Implications for Disease Control in Eastern Democratic Republic of the Congo
Authors: Mian Qaasim , Masumbuko Claude Kasereka , Hawkes Michael
Published: October 2019

Background

The current Ebola epidemic in Eastern Democratic Republic of the Congo (DRC) has surpassed 1,300 cases and 800 deaths. Social resistance is a major barrier to control efforts, and invites an exploration of community beliefs around Ebola and its origins.

Methods

Mixed-methods study, using focus group discussions (FGDs) with key community informants and a 19-item survey questionnaire broadly sampling the outbreak zone.

Results

Between 4 to 17 August, 2018, we conducted 4 FGDs (20 participants) and surveyed 286 community members across Eastern DRC. FGDs revealed a widespread rumor in Mangina early in the epidemic of two twins bewitched by their aunt after eating her cat, who developed bleeding symptoms and triggered the epidemic. However, this myth appeared to dissipate as the epidemic progressed and biomedical transmission became generally accepted (medical syncretism). In our survey, 6% of respondents endorsed supernatural origins of Ebola. This subgroup did not differ from other respondents in terms of knowledge of biomedical modes of transmission or resistant attitudes toward infection control measures, but was more likely to believe that traditional healers could cure Ebola. Wild animals of the forest were recognized as sources of the Ebola virus by 53% of survey respondents. Our findings suggest that skepticism and/or denial of the biomedical discourse, coupled with and mistrust and fear of ETUs may fuel “underground” transmission of Ebola outside western-style medical facilities, as patients seek care from traditional healers, who are ill-equipped to deal with a highly contagious biohazard.

Conclusion

A deeper understanding of beliefs around Ebola origins may illuminate strategies to engage communities in control efforts.

Disclosures

All authors: No reported disclosures.
1672. Imported Enteric Fever in an Ethnically Diverse Area of London
Authors: Gorgui-Naguib Hannah , Aali Adnan , Papineni Padmasayee
Published: October 2019

Background

Typhoid is a leading cause of fever in returning travelers, particularly those visiting friends and relatives in the Indian subcontinent. We reviewed a cohort of patients with enteric fever from our hospitals in North West London, which serves a large Indian resident population.

Methods

Retrospective analysis of electronic laboratory, microbiology and medical records of all patients with blood cultures positive for Salmonella enterica serotypes typhi (S.typhi) or paratyphi (S.paratyphi) A, B and C from January 1, 2016 to December 31, 2018 at London North West University Healthcare NHS Trust. Organisms were cultured on selective media and identified by API 20E (BioMerieux) or MALDI TOF MS (Bruker).

Results

37 blood cultures positive for S.typhi were identified from 26 patients and 37 blood cultures positive for S.paratyphi were identified from 23 patients. The median age was 28 years (range 1–79 years). Infection was more common in males (27/49, 55%) compared with females (22/49, 45%) but this was not statistically significant. Most patients (31/49) had traveled to India. Travel history was not identified for 9 patients. Laboratory results at presentation were available for all patients. Lymphopenia (defined as <1.5 × 109/L) was found in 12/23 (52%) patients with S.paratyphi compared with 10/26 (38%) of those with S. typhi. Thrombocytopenia (defined as <150 × 109/L) was found equally in both groups (22% in S. paratyphi, 27% in S. typhi). Raised alanine transferase (ALT) (defined as >35 IU/L) was seen in 14/23 (61%) in S. paratyphi compared with 19/26 (73%) in S. typhi. Median platelet count was similar in both groups (199 × 109/L in S. paratyphi, 202 × 109/L in S. typhi). Absolute eosinopenia was seen in all patients, consistent with other observational studies. For 3 patients, antibiotic sensitivities were not available. Regarding S. paratyphi cases, 16/21 (76%) were resistant to ciprofloxacin compared with 20/25 (80%) in S. typhi. Azithromycin resistance was seen in 5/46 (11%). All isolates were susceptible to third-generation cephalosporins.

Conclusion

There is a high rate of ciprofloxacin resistance in this cohort of patients with enteric fever, confirming that the use of third-generation cephalosporins and macrolides in travelers to India is most appropriate for treatment.

Disclosures

All authors: No reported disclosures.
1674. Orthopedic Complications of Congenital Zika Syndrome in Brazil
Authors: Nogueira Mendes Neto Nilson , Queiroz Igor T , da S. Maia Jessika T , Zacarkim Marcelo , Labeaud A Desiree , Aronoff David , Fernandes Kalyana , de Alcantara Tabata
Published: October 2019

Background

Congenital Zika Syndrome (CZS) has a broad spectrum of clinical presentations that are still being described. This cohort study aimed to describe the orthopedic complications in children with microcephaly (MCP) related to Zika virus (ZIKV).

Methods

We evaluated 36 children with CZS up to 17 months of age followed at a pediatric rehabilitation center in the northeast of Brazil. Cohort enrollment occurred with children born between January 2015 and May 2016. We assessed their social profiles and orthopedic findings.

Results

Of the 36 cases, 25 were male. All of them lived in rural area. 25 had at least one congenital orthopedic alteration. Hip subluxation was the most common problem detected (n = 15); other lower limb abnormalities included knee subluxation (n = 7), clubfoot (n = 7); congenital vertical talus (n = 4); plano-valgus foot (n = 5). In relation to the upper limbs, 11 children presented with some shoulder and/or elbow abnormality and 16 had some alteration in the hand and/or on the wrist.

Conclusion

Orthopedic problems appear to be common in children with CZS and should be a focus of larger clinical studies. An initial orthopedic assessment may provide a better quality of life by helping children avoid further complications/deformities. Our results emphasize the orthopedic problems associated with CZS and the need to better describe many complications in the natural history of this infection.

Disclosures

All authors: No reported disclosures.
1686. Maternal Knowledge and Perceptions about Routine Immunization in a Slum Area of Pakistan
Authors: Mannan Mustafa Abdul , Mustafa Ghulam
Published: October 2019

Background

To know the baseline coverage and potential obstacles for children vaccination before starting a health awareness program.

Methods

A cross-sectional study on immunization coverage in the slum area of Multan, Pakistan was conducted and a total of 312 mothers were interviewed face to face for Knowledge, Attitudes, and Perceptions (KAP).

Results

Among the children less than 3 years, 33% fully, 46% partially and 21% were not at all immunized. High levels of BCG and OPV zero rates (79%) and low rates of OPV3/DPT3 (48%) and measles (41%) vaccines were found. Majority of the mothers were satisfied with the program. Most of the mothers were aware about the importance of vaccination but were ignorant for the need to complete the schedule. There were many misconceptions and beliefs among the mothers of partial and unimmunized children. The majority were of view that vaccines contain ingredients that will make the children infertile.

Conclusion

There is a need to enhance the maternal knowledge about the vaccine-preventable diseases and importance of completing the immunization schedule. Also the misconception about the vaccines need be specifically addressed.

Disclosures

All authors: No reported disclosures.
1694. Predictors of Septic Shock in Adult Patients with Candidemia: A Single-Center Experience Over 13 Years
Authors: Woong Suh Jin , Yeon Kim Jeong , Seung Chung You , Lee Hojin , Bean Kim Sun , Kyung Yoon Young , Wook Sohn Jang , Ja Kim Min , Hun Kim Jong
Published: October 2019

Background

Although the incidence of candidemia has been increased recently, factors associated with septic shock in adult patients with candidemia have not been well defined. We performed a study to identify septic shock risk factors.

Methods

This retrospective study was conducted among adult patients ≥19 years of age with candidemia who were diagnosed from 2006 to 2018 at a single tertiary care medical center. Clinical data were collected. Patients were excluded if they were noted to have concomitant bacteremia or to have received antifungal treatment <5 days.

Results

After application of the exclusion criteria, 46 patients (25.1%) were classified as having septic shock presentation out of 183 patients. Between the septic shock and non-septic shock patients, there were no differences regarding comorbidities. Variables associated with septic shock in the univariate analysis were non-remission of candidemia [23/46 (67.6%) vs. 100/137 (83.3%) P = 0.044], central venous catheter [41/46 (89.1%) vs. 98/137 (67.9) P = 0.005], hemodialysis [12/46 (26.1%) vs. 15/137 (10.9%) P = 0.012], neutropenia [10/46 (21.7%) vs. 14/137 (10.2%) P = 0.045], and previous hospitalization to the intensive care unit (ICU) [24/46 (52.2%) vs. 47/137 (34.3%) P = 0.031]. The group of other Candida species consisting of [C. guilliermondii, C. haemulonii, C. famata, C. lusitaniae, and unknown] was more common in the septic shock patients (10.9%) than in the non-septic shock patients (1.5%), P = 0.004. The mortality of patients with septic shock was significantly higher than that of patients without septic shock [37/46 (80.4%) vs. 59/137 (43.1%) P < 0.001]. Multivariate analysis showed central venous catheter (odds ratio [OR] 4.00, 95% confidence interval [CI] 1.12 – 14.30, P = 0.033) and abnormal aspartate aminotransferase [AST] (OR 2.76, 95% CI 1.06 – 7.16, P = 0.024) were significantly associated with septic shock. Presence of other Candida species (OR 6.78, 95% CI 0.87 – 53.03, P = 0.068) showed borderline significance.

Conclusion

Our findings suggest that venous catheter and abnormal AST were significant factors associated with septic shock in adult patients with candidemia. Also, candidemia caused by other Candida species may need to be monitored closely for the development of septic shock presentation.

Disclosures

All authors: No reported disclosures.
1702. Prevalence and Risk Factors for Endogenous Fungal Endophthalmitis in Adult Patients with Candidemia at a Tertiary Care Hospital in South Korea Over 13 years
Authors: Hun Kim Jong , Woong Suh Jin , Seung Chung You , Kyung Yoon Young , Wook Sohn Jang , Ja Kim Min
Published: October 2019

Background

Endogenous fungal endophthalmitis is one of the critical complications of candidemia in adult patients. We conducted a study to investigate the prevalence and risk factors for endogenous fungal endophthalmitis in adult patients with candidemia.

Methods

Adult patients ≥19 years with candidemia who underwent ophthalmological examination after the diagnosis of candidemia at a tertiary care hospital in South Korea from 2006 to 2018 were enrolled, and clinical data were collected.

Results

There was a total of 152 adult patients with candidemia who underwent an ophthalmological examination. Endogenous fungal endophthalmitis was found in 29 patients (19.1%). Patients were categorized into two groups (Non-endophthalmitis [NE] and endophthalmitis [E]). Between two groups, there was no significant difference in terms of age, sex, underlying comorbidities. Also, no difference in clinical conditions at the diagnosis of candidemia was noted including concomitant bacteremia, presence of septic shock, receipt of recent surgery, presence of neutropenia, total parenteral nutrition, central venous catheter, urinary catheter, ventilator, dialysis, use of antibiotics, and Candida spp. colonization. However, there was a higher rate of abnormal alanine aminotransferase (ALT) in the E (35.7%) than in the NE (14.8%), P = 0.008. Moreover, the proportion of C. albicans candidemia was higher in the E (65.5%) than in the NE (35.8%), P = 0.003. In contrast, C. parapsilosis candidemia was more common in the NE (27.6%) than in the E (6.9%), P = 0.018. Although there was a trend of higher mortality rate in the E (51.7%) than in the NE (35.0%), no statistical significance was observed, P = 0.095. Multivariate logistic analysis showed C. albicans candidemia (odds ratio [OR] 4.122, 95% confidence interval [CI] 1.653–10.280, P = 0.002) and abnormal ALT (OR 3.839, 95% CI 1.427–10.333, P = 0.008) were significantly associated with E cases.

Conclusion

Endogenous fungal endophthalmitis occurred in 19% of adult patients with candidemia. C. albicans candidemia and abnormal ALT were significantly associated with endophthalmitis. Adult patients with candidemia caused by C. albicans or having abnormal ALT need to be closely monitored for the possibility of endophthalmitis.

Disclosures

All authors: No reported disclosures.
1705. Clinical Characteristics and Outcomes of Cryptococcosis in a Tertiary Care Center in Kentucky, 2005 to 2017
Authors: Bhatt Mahesh , Ribes Julie A , Arora Vaneet , Myint Thein
Published: October 2019

Background

Cryptococcosis is an invasive fungal infection that causes pneumonia and extrapulmonary infection. This study explores its presentations, diagnostic tests, and outcome in different groups over a 12-year period at an academic medical center.

Methods

This was a retrospective study of the patients treated at University of Kentucky HealthCare from October 16, 2005 to October 15, 2017. Inclusion criteria were positive cryptococcal antigen (Ag), positive culture, or presence of yeast morphologically consistent with Cryptococcus on cyto- or histopathology. Patients were divided into HIV-infected, solid-organ transplant (SOT) recipients, and non-HIV/non-transplant groups. Cryptococcal meningitis comprised of either positive CSF Ag, culture, cytology or histopathology.

Results

A total of 114 patients were identified; 23 HIV-infected, 11 SOT recipients and 80 non-HIV/non-transplant patients (Table 1). Cryptococcus neoformans was the most common yeast isolated (91.8%). Cryptococcal meningitis was seen in 56% of total patients whereas 27% had isolated cryptococcal pneumonia (P < 0.01). Blood cultures and serum Ag were positive in 34% and 70%, respectively. Only 8.7% of HIV-infected patients had isolated pulmonary cryptococcosis compared with 36.4% in SOT recipients (P < 0.01). In patients with cryptococcal meningitis, abnormal CSF cell count, protein, or glucose was noted in 85.3%; India ink was positive in 61.3% and CSF culture was positive in 73.4% (Table 2, Figure 1). CSF cryptococcal Ag was detected in 95.6% cases if CSF cultures were positive, whereas serum Ag was positive in only 85.1% of meningitis cases. Mortality was seen in 48.6% (17/35) of patients with cirrhosis/liver disease, compared with 21.5% (17/79) of non-cirrhosis/liver disease (P = 0.003). Transplant group had 54.5% mortality compared with 26.1% in HIV group (P = 0.016).

Conclusion

Cryptococcal meningitis was the most common presentation for cryptococcal disease in all three groups. Isolated pulmonary disease was least common in the HIV-infected group. Inpatient mortality rate was higher in patients with cirrhosis/liver disease and transplant group compared with those without cirrhosis/liver disease and HIV group, respectively. It is imperative to rule out meningitis in immunosuppressed patients with cryptococcal pneumonia.

Disclosures

All authors: No reported disclosures.
1714. Testing a Novel Clinical Surveillance Case Definition for Invasive Mold Infections
Authors: Beer Karlyn , Kelly Hilary , Blakney Rebekah , Chambers Taylor , Perry Lewis , Singleton Sabrina , Matkovic Eduard , Hale Gillian , Thomas Stepy , Oliver Nora , Dretler Alexandra , Tsay Sharon , Farley Monica M , Jackson Brendan R
Published: October 2019

Background

Invasive mold infections (IMI) such as aspergillosis and mucormycosis are often fatal among immunosuppressed patients and have caused high-profile outbreaks. Surveillance for IMI is challenging because distinguishing a case from colonization or contamination is complex. The established case definition, Mycoses Study Group (MSG) criteria, lacks sensitivity. Because the need for surveillance remains, we designed a pilot IMI surveillance system within the Georgia Emerging Infections Program. Here, we describe cases identified through this system, using both the MSG criteria and a novel, more sensitive clinical case definition.

Methods

To identify potential IMI cases, we captured fungal cultures positive for mold, histopathology specimens with evidence of fungal tissue invasion, and positive galactomannan results within a 60-day window at three large hospitals in Atlanta during March 2017–2018. We excluded dimorphic fungi and hair and nail specimens. Of 194 potential cases, we selected 24 for complete medical chart review. Two physicians classified cases as proven, probable, or non-case according to MSG criteria. Cases that partially met MSG probable criteria and included antifungal treatment were classified as clinical cases; definitions were mutually exclusive (Figure 1).

Results

Of 24 potential IMI cases, 16 (66%) met an IMI case definition, including 5 proven, 2 probable and 9 clinical cases. Inter-rater agreement was 92%., Most (5/7) MSG cases involved Aspergillus and were more likely to have cancer, a transplant, or other immunosuppression compared with clinical cases (Figure 2 and 3). Clinical cases included conditions not specified in MSG criteria, including burns (1), wounds (1) or eye (4) infections. MSG and clinical cases more often had antifungal treatment (16/16 vs. 1/8) or died (4/16 vs. 0/8) compared with non-cases.

Conclusion

In this preliminary analysis of potential IMI cases, most represented true invasive infections, indicating effective exclusion of most colonization. Most of the 16 cases were classified as clinical, however, and would have been missed in a system relying on the MSG criteria alone. Results suggest that a less-specific clinical case definition incorporating antifungal treatment may improve the sensitivity and utility of IMI surveillance.

Disclosures

All authors: No reported disclosures.
1715. Coccidioidomycosis Outcomes Among Hospitalized Pregnant and Postpartum Women—California, 2000–2016
Authors: Chu Victoria , Sondermeyer Cooksey Gail L , Readhead Adam , Vugia Duc , Jain Seema
Published: October 2019

Background

Coccidioidomycosis (CM) in pregnancy has been associated with severe, disseminated disease. Publications are largely limited to case reports. Using California administrative hospital and birth registry data, we describe maternal and neonatal outcomes among pregnant and post-partum women hospitalized with CM.

Methods

We extracted California records from 2000 to 2016 for women 14–45 years, hospitalized with CM discharge codes; and used the birth registry to identify women who were pregnant or post-partum (≤30 days of childbirth) during their hospitalization. We used chi-squared tests to compare pregnant/post-partum women hospitalized with CM to nonpregnant women hospitalized with CM, and birth outcomes for infants of mothers hospitalized with CM to other California infants. We used multivariable logistic regression, controlling for demographics and comorbidities, to determine the risk of pregnancy on CM dissemination.

Results

We identified 2,372 women with ≥1 CM hospitalization; 187 (8%) were pregnant/post-partum and there were 188 infants (one set of twins). Pregnant/post-partum women were more likely to be Hispanic (59% vs. 44%, P < 0.01), younger (median age 27 vs. 35 years, P < 0.01), without comorbidities (60% vs. 36%, P < 0.01), and have disseminated CM (32% vs. 21%, P < 0.01) than nonpregnant women. Hospitalized pregnant/post-partum women with CM were more likely to have CM dissemination compared with hospitalized non-pregnant women with CM (odds ratio 2.0, 95% confidence interval 1.4–2.8). Among infants of pregnant women hospitalized with CM, 18 (10%) were born < 34 weeks gestational age and 11 (8%) of 134 term (>37 weeks) infants had a birth weight <2,500 g; compared with 3% and 3% (P < 0.01) of other California liveborns, respectively.

Conclusion

This study is the largest cohort of pregnant women hospitalized with CM to date and corroborates that pregnant/post-partum women are more likely to develop disseminated CM than non-pregnant women. Their infants may be more likely to be born <34 weeks gestational age and have a low birth weight. This highlights the need for clinicians caring for pregnant/post-partum women who may live or travel to an area where CM occurs to be aware of the risks for these women and their infants.

Disclosures

All authors: No reported disclosures.
1728. A Retrospective Analysis of 49 Cases of Histoplasmosis in Inflammatory Bowel Disease Patients on Tumor Necrosis Factor-α Antagonists
Authors: Harris Courtney , Jansson-Knodell Claire , Loftus Edward , Walker Randall , Enzler Mark , Virk Abinash
Published: October 2019

Background

Tumor necrosis factor (TNF)-α antagonist therapy has revolutionized the practice of management of inflammatory bowel disease (IBD); however, these medications carry a boxed warning from the Food and Drug Administration for risk of serious infection. We aimed to study the invasive fungal infection, histoplasmosis, in the setting of TNF-α antagonist therapy.

Methods

We performed a retrospective review of patients with IBD receiving TNF-α antagonist therapy who developed histoplasmosis during the time period January 2001–May 2018 at the Mayo Clinic, Rochester, MN. The medical records of patients were reviewed for demographics, medications, symptoms, diagnosis, treatment, and outcomes including mortality. IBD was diagnosed by biopsy, radiographic, or endoscopic evidence of disease.

Results

We identified 49 patients (age range 19–74; median 44 years) with a confirmed diagnosis of histoplasmosis while receiving a TNF-α antagonist. 73.5% of cases were classified as disseminated. Median time from starting TNF-α antagonist to histoplasmosis diagnosis was 2.1 years. Liposomal amphotericin B was given in 17 cases as the initial treatment. Itraconazole was given to all 49 patients. Initial treatment was split evenly between inpatient (49%) and outpatient (51%) locations with 6 patients (12%) requiring ICU-level care. Median length of stay was 9.5 days. The total length of treatment for all antifungals was 38.4 weeks, with 20.4% of patients developing documented antifungal side effects. TNF-α antagonist was continued in 9 patients (18.4%) and another 10 patients resumed TNF-α antagonist. Half of those who resumed TNF-α antagonists were on antifungal therapy. There was one histoplasmosis recurrence while off TNF-α antagonist, and three deaths (6%).

Conclusion

Histoplasmosis outcomes in IBD patients on TNF-α antagonists were mostly favorable; however, approximately half required hospitalization. Many patients were young with few co-morbidities, and over one-third were able to continue or resume TNF-α antagonists without documented recurrence of histoplasmosis. Practitioners should be vigilant for histoplasmosis infections in this patient population who reside in histoplasma-endemic regions.

Disclosures

All authors: No reported disclosures.
1733. Voriconazole Prophylaxis Following Allogeneic Hematopoietic Stem Cell Transplant: How Much Is Enough, Are Low Voriconazole Levels Associated With Opportunistic Infections, and What Are the Reasons for Discontinuation?
Authors: Hadjivassiliou Giorgos , Rummage Claire , Hoesley Craig , Brown Matthew L
Published: October 2019

Background

Patients who undergo allogeneic hematopoietic stem cell transplantation (alloHSCT) are at increased risk for invasive fungal infections with associated high morbidity and mortality that necessitates the use of prophylactic antifungals. Voriconazole is commonly used for prophylaxis, but there are no recommendations for therapeutic drug monitoring. The purpose of this study was to characterize voriconazole therapeutic drug monitoring and associated outcomes in this patient population.

Methods

AlloHSCT patients receiving voriconazole prophylaxis at the University of Alabama at Birmingham Hospital between March 2015 and March 2018 were included in the analysis. Serum voriconazole levels (SVL) were evaluated to determine what percentage of patients achieved prophylactic or therapeutic concentrations. Incidence of invasive fungal infections (IFI) and voriconazole discontinuation was also assessed.

Results

Voriconazole prophylaxis was used in 151 of 162 alloHSCT patients, and 120 patients (79%) had SVL drawn correctly (≥4 days after initiation of course). We found that 35 (29%) patients achieved a subtherapeutic level (<0.5 μg/mL), 17 (14%) prophylactic level (0.5 to 1 μg/mL), 68 (57%) therapeutic level (1 to 5.5 μg/mL), and no patients achieved a supratherapeutic level (level ≥5.5 μg/mL). Voriconazole prophylaxis was discontinued early in 60 of 151 patients. Most common etiologies for discontinuation included liver function test abnormalities (44%) and encephalopathy (21%). The average SVL was 1.2 μg/mL in those requiring discontinuation. Four patients (3%) developed an IFI while receiving prophylactic voriconazole, of which only 1 had subtherapeutic level.

Conclusion

Even though approximately one-third of patients achieved a subtherapeutic SVL, there was no correlation with breakthrough IFI. There was also no linear correlation between SVL and risk of adverse effects requiring discontinuation. Our observational data do not support a need for therapeutic drug monitoring in alloHSCT patients receiving prophylactic voriconazole.

Disclosures

All authors: No reported disclosures.
1735. Epidemiology of Invasive Fungal Infections During Induction Chemotherapy in Adults With Newly Diagnosed Acute Myeloid Leukemia Without Antifungal Prophylaxis: A Retrospective Cohort Study
Authors: Miranti Eugenia , Enriquez Kyle , Medeiros Bruno , Subramanian Aruna , Ho Dora , Epstein David J
Published: October 2019

Background

While invasive fungal infections (IFIs) are common in patients with acute myeloid leukemia (AML) undergoing induction chemotherapy, little current data exist on the epidemiology of IFIs in this patient population given widespread use of antifungal prophylaxis. Because our institution does not administer antifungal prophylaxis, we are in a unique position to study the natural history of IFIs in these patients.

Methods

We evaluated the incidence of IFIs using established definitions in adults with AML undergoing induction chemotherapy at Stanford Health Care from 2012 to 2017. We also analyzed incidence of antifungal treatment, impact of IFI diagnosis on survival, and risk factors for IFI development. Patients were followed for up to 12 weeks after beginning induction chemotherapy.

Results

Of 488 patients analyzed, 243 were eligible for inclusion. The median age was 57 (interquartile range 45–65). Men composed 134 (55%) of the patients and 157 (65%) where white. Fifty-four (22%) had antecedent myelodysplastic syndrome; most received a “7 + 3” regimen involving cytarabine and an anthracycline. Thirty-one (13%) developed a proven or probable IFI; 104 (43%) developed a proven, probable, or possible IFI. Most IFIs were due to lower respiratory tract disease. Eighteen identified organisms were Candida, including six C. albicans. Eight organisms were mold, including four Aspergillus isolates (all but one A. fumigatus) and one isolate each of Fusarium solani, Rhizomucor, Rhizopus, and Scedosporium apiospermum/Pseudallescheria boydii. One hundred ninety patients (78%) received antifungals during their initial admission and 99 (46%) of patients surviving their initial admission were discharged on antifungals. Only 66.7% of patients with a proven or probable IFI survived through 12 weeks, compared with 92.2% of those without (P = 0.007). Baseline absolute neutrophil count ≤500 cells/μL and longer duration of neutropenia were significantly associated with development of proven or probable IFIs.

Conclusion

Among patients receiving induction chemotherapy for AML, IFIs due to Candida and mold remain frequent absent antifungal prophylaxis and are associated with worse survival. Our findings support the use of antifungal prophylaxis in this patient population.

Disclosures

All authors: No reported disclosures.
1736. Evaluation of Targeted vs. Universal Antifungal Prophylaxis (AP) for Invasive Fungal Infections (IFI) After Lung Transplant (LTx)
Authors: Linder Kathleen A , Patel Twisha S , Kauffman Carol A , Fitzgerald Linda J , Miceli Marisa H , Miceli Marisa H
Published: October 2019

Background

LTx patients (pt) are at increased risk for IFI. Systemic AP is widely used, but the optimal strategy remains unclear. Our LTx program changed from universal to targeted AP in July 2016; we compared outcomes between the 2 strategies.

Methods

All adult pt who underwent LTx at U. Michigan from July 1, 2014 to December 31, 2017 were studied for 18 mo post-LTx. Universal AP consisted of itraconazole (itra) ± inhaled liposomal amphotericin-B (iAmB) for 6 months. Pt received targeted AP with voriconazole for 3 months if they had a history of pre-LTx Aspergillus colonization or invasive pulmonary aspergillosis (IPA); 14 days of a yeast-active azole was given if donor or recipient had Candida colonization at the time of LTx. All other pt received no AP. Demographics, LTx characteristics, occurrence of proven/probable IFI defined by EORTC/MSG criteria, and mortality data were recorded.

Results

Of 105 LTx patients, 73 (70%) were men and 84 (80%) received a double LTx. The most common indication for LTx was idiopathic pulmonary fibrosis (38, 36%). Of 59 pt receiving universal AP, 36 (61%) received itra, and 23 (39%) received itra+iAmB; outcomes did not differ between these 2 regimens. Of 46 patients in the targeted AP cohort, 10 (22%) received antifungals based on predefined criteria. Overall, 19 proven/probable IFI occurred: 14 IPA, 3 invasive Candida infections, 1 Cryptococcus pneumonia, and 1 mold wound infection. IFI occurred in 5 patients (8%) in universal AP group vs. 13 patients (28%) in targeted AP group, P = .008. All but 1 IFI in the targeted AP group occurred among pt for whom antifungals were not recommended or given. IPA occurred in 4 patients (7%) in universal AP group and 9 patients (20%) in targeted AP group, P = 0.05; Candida infections occurred only among patients in the targeted AP cohort. Time to IFI was similar between the 2 AP strategies with the majority occurring <180 days post-LTx (median 109 days). Death occurred in 11 patients (8 in the universal AP cohort and 3 in the targeted AP cohort, P = .34); no deaths were related to IFI.

Conclusion

When compared with universal AP, targeted AP strategy was associated with a significant increase in IFI post-LTx. Universal AP for 6 months appears to be more effective than our targeted AP strategy for prevention of IFI post-LTx.

Disclosures

Marisa H. Miceli, MD, FIDSA, Astellas: Advisory Board, Research Grant; Scynexis: Research Grant.
1740. Title: Outcomes of a Clinical Algorithm for the Early Diagnosis and Treatment of Invasive Fungal Sinusitis among Children with Hematologic Malignancy or Prior Hematopoietic Stem Cell Transplantation
Authors: Warraich Gohar , Winick Naomi , Slone Tamra , Aquino Victor M , Donner Kimberly , Shah Gopi , Sue Paul K
Published: October 2019

Background

Invasive fungal sinusitis (IFS) is a cause of significant morbidity and mortality among children with hematologic malignancy and hematopoietic stem cell transplant (HSCT) recipients, with an estimated mortality of 18–80%. Since 2007, our center has employed a clinical algorithm for the early detection and treatment of IFS among children with prolonged febrile neutropenia.

Methods

We reviewed all EORTC defined cases of proven IFS among children with underlying hematologic malignancy or prior HSCT admitted to our institution between July 1, 2004 and December 31, 2018, and compared clinical characteristics and outcomes (including underlying malignancy, chemotherapy regimen at the time of viremia, absolute neutrophil count, absolute lymphocyte count, treatment regimens, and 6 month mortality) between the pre (July 1, 2004–December 31, 2006) and post-protocol (January 1, /2007–December 31, 2018) periods.

Results

We identified 33 cases of proven IFS during the study period, with 6 in the pre-protocol and 27 in the post-protocol period. The most common underlying primary diagnosis was acute lymphoblastic leukemia (ALL) at > 50% with 8% of individuals with prior HSCT. Twenty-five cases (92%) during the protocol period were diagnosed via nasal endoscopy per protocol, with 17 (63%) reporting no clinical complaints of sinusitis. Median absolute neutrophil count (ANC) at the time of IFS diagnosis was 155/mm3 (IQR 0 – 375/ mm3; n = 12) with median duration of neutropenia 16.5 days (IQR 10.5–18.25, n = 12) at the time of diagnosis. Most individuals required one definitive debridement. Isolated fungal specimens included Bipolaris spp. (24%), Aspergillus spp. (20%), Curvularia spp. (20%), with Fusarium and Exserohilum spp. each at 12%, and Rhizopus spp. At least one patient had a co-infection with more than one fungal species. Pre-protocol cause-specific mortality at 6 months was 33.3% compared with 14.8% (P = 0.29) in the post- protocol period.

Conclusion

IFS is a cause of significant morbidity and mortality among children with hematologic malignancy or prior HSCT. An aggressive protocol with early nasal endoscopy and targeted debridement may help decrease morbidity and mortality associated with this entity. Additional well-designed studies are needed to assess the potential benefits of this approach in the diagnosis and management of IFS among high-risk children.

Disclosures

All authors: No reported disclosures.
1761. A Single-Center Experience with Cidofovir for the Treatment of Double-Stranded (ds) DNA Viruses in Hematopoietic Cell Transplant (HCT) Recipients
Authors: Stern Anat , Su Yiqi , Neofytos Dionysis , Papanicolaou Genovefa
Published: October 2019

Background

Cidofovir (CDV), a nucleotide analog antiviral, is active against multiple dsDNA viruses relevant in HCT recipients. Despite a broad spectrum of activity, CDV utility is limited due to nephrotoxicity. We describe our experience with CDV in a large contemporary cohort from a single Institution.

Methods

Retrospective review of adult HCT recipients who received CDV for any indication from 2011 to 2017. Initiation and duration of CDV treatment were at physicians’ discretion. CDV exposure and indications, Serum Creatinine (SCr) and outcomes were extracted from medical records and hospital databases.

Results

Of 1,235 HCT recipients, 54 (4.4%) received ≥1 dose of CDV. Stem cell source was peripheral blood in 39 (72%) patients, cord blood in 13 (24%) and marrow in 2(4%); 42 (78%) patients received CD34+ selected HCT. At CDV initiation, 23 (43%) patients had active GvHD and 16 (30%) received systemic steroids. CDV was started a median of 85.5 days (range 14–335) post HCT, given for a median of 3 doses (range 1–13) for a median of 2 weeks (range 1–17). Indications were adenovirus (ADV) infection in 35 patients, CMV in 19, BK virus in 21 and HHV6 in 3 patients. Nineteen (35%) patients had >1 dsDNA virus. Forty-one (76%) patients received CDV (3–5 mg/kg) once weekly, mainly for ADV or CMV, and 13 received CDV (≤1 mg/kg) once to thrice weekly, mostly for BK hemorrhagic cystitis (N = 12).

Baseline sCr was mean 0.88 mg/dL (standard deviation [SD] = 0.37) at CDV initiation, mean 1.07 mg/dL at end of treatment (EOT) (SD = 0.57, N = 48, P = 0.004) and mean 1.23 mg/dL at EOT + 2 weeks (SD = 0.72, n = 28, P = 0.027). At EOT, 13 patients (24%) had acute kidney injury (AKI, ≥1.5-fold increase from baseline sCr). Of those, 12 (92%) received concomitant nephrotoxic drugs. AKI was attributed to other etiologies by treating physician in six patients. Of 51 patients with follow-up at EOT, 29 (57%) had clinical response to CDV treatment. Nineteen (35%) patients died ≤ 4 weeks from last CDV dose.

Conclusion

24% of highly immunocompromised HCT patients experienced AKI following CDV treatment for dsDNA viruses. The co-administration of nephrotoxic medications and the direct effect of infection limit our ability to assess the relative impact of CDV on renal function. Our data underscores the need for safer treatment options for HCT patients with life-threatening infections with dsDNA viruses.

Disclosures

All authors: No reported disclosures.
1780. Congenital Cytomegalovirus: What Are the Rates of Maternal Screening, Diagnostic Amniocentesis, and Elective Termination?
Authors: Njue Annete , Marguilis Andrea , Lyall Matthew , Nuabor Weyinmi , Marks Morgan , Russell Kevin , Sinha Anushua
Published: October 2019

Background

Congenitally transmitted cytomegalovirus (CMV) is the leading infectious cause of deafness and intellectual impairment among infants. Due to lack of effective preventive and curative treatments, routine CMV screening of pregnant women is generally not recommended by clinical guidelines or public health authorities, but is conducted on an opportunistic basis by specific healthcare systems and providers. This targeted review describes the rate of reported maternal screening for CMV infection and subsequent pregnancy outcomes.

Methods

PubMed and Embase were searched to identify English-language articles reporting the rate of screening for CMV maternal infection (Objective 1), the acceptance rate for diagnostic amniocentesis (Objective 2), and the elective termination rates due to CMV infection (Objective 3) in Europe and Israel. No date limit was applied.

Results

Seventeen articles published between 2000 and 2018 were included. Routine CMV screening of pregnant women in the absence of country-level guidelines appears to be common in France and Israel (table). Conversely, in Portugal, where country-level guidelines exist for preconception screening, a high proportion of women are not screened (table). Acceptance rates of diagnostic amniocentesis among women with CMV infection vary considerably across countries, with the highest rates reported in Israel (73%) and the lowest in Italy (16%). Elective termination rates were higher among women who underwent amniocentesis vs. those who did not and those with primary CMV infection vs. those with nonprimary infection. Conversely, one study in Israel showed higher termination rates among patients who did not undergo amniocentesis vs. those who did (35.5% vs. 7.3%).

Conclusion

The available data indicate that routine screening is carried out in some countries to a variable degree. There is an unmet need for effective prevention and management options to help prevent unnecessary termination of pregnancy.

Disclosures

All authors: No reported disclosures.
1785. Dengue Outbreaks and Predominant Circulating Virus Serotypes and Genotypes over More Than Two Decades in a Hyper-endemic Region
Authors: Dar Lalit , Choudhary Aashish , Brijwal Megha , Sahu Monalisa , Sachdev Janya
Published: October 2019

Background

Dengue is the most widespread arboviral disease globally. Serotyping of dengue viruses and their genotyping is important in tracing the epidemiology of the disease, monitoring trends and anticipating the possibility of outbreaks in a community.

Methods

This study is a retrospective analysis, based on data from a tertiary care center from Delhi, India and their correlation with reported literature on circulation and outbreaks of dengue in this region of north India since 1996, when the first virus isolation confirmed outbreak of dengue was reported by our virology laboratory (an Apex Laboratory of the National Vector Borne Disease Control Program, Government of India).Circulating serotypes of DENV were detected and identified from serum samples of suspected dengue patients with fever of 5 days duration or less, by virus isolation in cell culture and/or by real-time or conventional reverse transcription polymerase chain reaction (PCR). Representative serum samples of patients with suspected dengue with duration of fever <5 days were inoculated onto the C6/36 clone of Aedes albopictus cells, and the isolates were identified by indirect immunofluorescence using serotype-specific monoclonal antibodies. Sequencing was done for representative strains as required.

Results

The predominant serotypes identified were DENV 2 (1996), followed temporally by DENV 1 (1997–2002), DENV 3 (2003–2007), DENV 1 (2008–2012), DENV 2 (2013–2015), and DENV 3 (2016–2018). In 2003, Delhi became hyper-endemic for dengue, with all dengue serotypes co-circulating. Predominant serotypes continued to circulate for 3–6 years. Outbreaks occurred either in the year a serotype was re-introduced after a gap of a few years to become the predominant serotype, or in the following year; except in 2015, when there was a genotypic lineage change in a DENV 2 serotype which had been predominant since 2 years prior to the outbreak year.

Conclusion

Re-introduction of a dengue serotype which was out of circulation for a few years can precipitate an outbreak. Analysis of temporal patterns and close monitoring of circulating virus strains, particularly at either end of the transmission season, may help in early prediction of the trend for a given year, providing an opportunity to put in place control measures well in time.

Disclosures

All authors: No reported disclosures.
1789. Frequency of Chikungunya, Dengue, and Zika Virus in Acute Febrile Illness in Paired Urine and Serum Samples in Mexico
Authors: Perez Alba Eduardo , Alfaro Rivera Christian G , Bocanegra Ibarías Paola , Flores Treviño Samantha , Camacho-Ortiz Adrian , Morfin-Otero Rayo , Garza-González Elvira
Published: October 2019

Background

Given the nonspecific clinical presentation that dengue (DENV), Zika (ZIKV), and chikungunya viruses (CHIKV) have, nucleic acid amplification tests have become the primary diagnostic tool. Multiplex real-time PCR assays have been approved for their use in the qualitative detection of ZIKV in urine but there are few data regarding CHIKV and DENV. We report the frequencies of PCR detection for DENV, ZIKV and CHIKV in paired urine and serum samples in Mexico.

Methods

We included patients with acute febrile illness from five centers, located in Guadalajara and Monterrey, from September 2016 to December 2018. Viral RNA was extracted from samples, reverse transcribed and subjected to real-time PCRs specific for DENV, CHIKV, and ZIKV. Patients were considered a positive case if any of the three tests were positive. The obtained data were analyzed using descriptive statistics.

Results

A total of 978 patients were included. A positive result was obtained in 331 patients (33.84%): 184 for ZIKV, 129 for DENV, and 18 for CHIKV. The tests were positive in both specimens in 56 (30.4%), 29 (22.4%), and 4 (22%) of the cases, respectively, while an isolated positive urine test was found in 74 (40%), 5 (3%) and 4 (22%) of the cases. Two patients were positive for both ZIKV and DENV, and two were positive for both ZIKV and CHIKV.

Conclusion

Acute febrile illness was potentially attributable to infection with one or two of the studied arboviruses in up to 34% of our patients. Out of all the cases, 25% were positive only in urine samples. Therefore, some diagnosis could be missed when analyzing only serum-based tests. Paired serum and urine sampling should be recommended when detecting arbovirus in acute febrile illness.

Disclosures

All authors: No reported disclosures.
1979. Five-Year Impact of an Antimicrobial Stewardship Program on Nosocomial Candidemia: An Interrupted Time-Series Analysis Study
Authors: Bedini Andrea , Meschiari Marianna , Franceschini Erica , Mussini Cristina
Published: October 2019

Background

Antimicrobial stewardship programs allow a reduction in antibiotic prescription and, consequently, in the incidence of multidrug-resistance infections. However, the impact on nosocomial candidemia is still unclear.

Methods

The present study is an interrupted time-series (ITS) before-after study, based on an ecological time-trend analysis. Since 2014, an antimicrobial stewardship program (ASP) has been implemented at an Italian tertiary-care hospital. The first objective of the program was to reduce carbapenem consumption, through an active and computerized surveillance of all carbapenem prescriptions, each of which was checked and validated by ID specialists always after audit of the cases with treating physicians. We retrospectively evaluated the changing in the consumption of antimicrobials, carbapenems, and in the incidence of candidemia, during two study periods: before (2007–2013) and after (2014–2018) the implementation of the ASP.

Results

The implementation of ASP was followed by a significant decrease in antibiotic consumption, which was consistent through the following 5 years. At the end of the study, total antibiotic consumption has decreased by 38.476 DDDs per 100 patient-days (PDs) per quarter (95% CI: −21.784 to −55.168; P < 0.001) and carbapenems decreased by 4.452 DDD per 100 PDs per quarter (95% CI: −3.658 to −5.246; P = 0.001). After 5 years of ASP, incidence of candidemia decreased by 2.034 episodes per 1,000 PDs per quarter (95% CI: −0.738 to −3.330; P = 0.003), decreasing, at the end of 2018, by 53% compared with the expected value if the program had not been implemented.

Conclusion

At our Institution, the ASP had a positive impact on the consumption of carbapenems, and antimicrobials. The incidence of candidemia was also favorably affected by the program, reversing the trend after 2014. The ASP, even if not directly targeted to fungal infections, indirectly caused a reduction in the incidence of candidemia, probably reducing the number of patients colonized by Candida spp.

Disclosures

All authors: No reported disclosures.
1990. A Strategy of Mandatory Infectious Disease Consultations on Hospital-acquired Clostridium difficile Infection and Antimicrobial Utilization
Authors: Hou Cindy , Vyas Nikunj M , Levin Todd P , Condoluci David
Published: October 2019

Background

An antibiotic stewardship program (ASP) is critical to ensure the appropriateness of treatment for infections and to help avert Clostridium difficile infection (CDI). In a three-hospital system, infection preventionists (IP) found that hospital-acquired CDI rates were higher than expected in spite of a robust ASP program. The Medical Executive Board mandated infectious diseases (ID) consults for all patients with sepsis, severe sepsis, and septic shock. If consults to ID are mandatory, the hypothesis is that this may help to lower antibiotic days of therapy (DOT)/1,000 patient-days (PD) and HO-CDI rates.

Methods

The ASP program started in November 2014, and mandatory ID consults for all types of sepsis started in March 2016. Data were selected from the time period between 2014 (Quarter 1) to 2017 (Quarter 2). The IP assessed the HO-CDI, and business intelligence generated a monthly report of the total number of ID consults (for any infectious diagnosis). The researchers retrospectively analyzed the data and then performed Pearson correlation statistics.

Results

Data on ID consults at hospital sites A, B, and C were correlated against DOT/1000 PD. Hospital A was statistically significant (P = 0.015) for a moderate correlation—where higher ID consults contributed to decreased DOT/1,000 PD. Hospital B showed moderate significance (P = 0.002), and the strongest correlation was at hospital C (P = 0.0007). Then ID consults at all three hospital sites were compared against HO-CDI rates. Hospital A (P = 0.76) and Hospital B (0.18) did not achieve any correlation. Hospital C was strongly correlated (P = 0.004).

Conclusion

In a three-hospital system, mandatory ID consults led to moderate to strong correlations with decreased DOT/1,000 PD. However, HO-CDI rates were most likely to decrease at only of the hospitals. Overall, ID consultations should be considered as an antimicrobial stewardship strategy to address the appropriateness of antibiotics and to combat CDI.

Disclosures

All authors: No reported disclosures.