bluuebunny/crossref_metadata_2025 huggingface dataset:
680. The Use of Plasma Next-Generation Sequencing Test in the Management of Immunocompetent and Immunocompromised Patients – A Single Center Retrospective Study
Authors: Francisco Denise Marie A , Woc-colburn Laila , Carlson Travis J , Lasco Todd , Barrett Miriam B , Mohajer Mayar Al
Published: January 2021

Background

Microbiological culture data is a longstanding gold standard in diagnostics. Unfortunately, yield from cultures have been inconsistent and slow, prompting the need for newer tests including the plasma-based next-generation sequencing (NGS) tool. This study aims to describe the use of NGS and the corresponding change in management.

Methods

A descriptive retrospective study was done on hospitalized adults at CHI-Baylor St. Luke’s in Houston, Texas with NGS tests from Jan 1, 2017 to Dec 31, 2018.

Graph 1 - Next Generation Sequencing Test Breakdown

Results

There were 167 NGS tests performed. Most patients were non-Hispanic (n=129) Caucasian (n=106) males (n=116) with a mean age of 52. Furthermore, 61 were immunocompromised patients [solid organ transplant (n=30), HIV-AIDS (n=14) and rheumatology patients on immunosuppression (n=12)].

During the study, the hospital staff prepared a list of indications for NGS testing including: systemic or deep seated infection where a biopsy or other workup is negative or not possible (n=50), fever of unknown origin (n=26), culture negative endocarditis (n=15), HIV/AIDS with fever (n=10), transplant patient with fever (n=5). There were 60 cases where the indications were not on this list (36%).

Results showed that 118/167 (71%) were positive. The most common organisms identified were gram-negative bacteria (54/118; 46%) followed by viruses (49/118; 42%), gram-positive bacteria (48/118; 41%), fungi (16/118; 14%), atypical bacteria (9/118; 8%), mycobacterium (4/118; 3%), and parasites (4/118; 3%). Blood cultures were concurrently obtained in 148/167 (89%) of the cases and returned negative in 137/148 (93%) of cases.

In terms of change of management, the largest change was found in glycopeptide use (36 fewer patients after NGS results). Next was on anti-mycobacterial drugs where 27 were added among 8 instances. Only 36 patients were taken off antibiotics, even though 49 patients had negative results. In total, 120 out of 160 cases had antibiotic changes.

Table 1 - Demographic and Laboratory Characteristics

Graph 2 - Change in Number of Antibiotics (Total: Before and After)

Graph 3 - Indications for Testing and Change in Number of Antibiotics

Conclusion

We observed a large decrease in glycopeptide use after NGS results which suggests physicians’ comfort in withdrawing MRSA coverage. In addition, anti-mycobacterial coverage increased corresponding to early mycobacterial detection with NGS. This study highlights the importance of clinical judgement in the age of rapid diagnostics.

Disclosures

All Authors: No reported disclosures
681. Induction Immunosuppression Selection in People Living with HIV Undergoing Deceased Donor Kidney Transplantation: U.S. National Trends from 2000 to 2018
Authors: Cano Edison J , Mullan Aidan , Vijayvargiya Prakhar , Shweta F N U , Gurram Pooja , Rizza Stacey , Mahmood Maryam , Badley Andrew , Dean Patrick , Cummins Nathan
Published: January 2021

Background

Human Immunodeficiency Virus (HIV) outcomes have significantly improved at the expense of other age-related diseases including chronic kidney disease. Early reports of people living with HIV (PLWH) undergoing deceased-donor kidney transplantation (DDKT) showed poor outcomes, but these have notably improved after introduction of antiretrovirals. Despite years of experience, the optimal induction immunosuppression (IIS) in PLWH remains subject of debate. Large-scale studies describing the current ISS practices in PLWH undergoing DDKT are lacking. Here, we describe the U.S. national trends of IIS used in PLWH undergoing DDKT from 2000 to 2018 using the United Network of Organ Sharing (UNOS) database.

Methods

We analyzed the UNOS database to determine the selection of IIS in PLWH undergoing first-time DDKT between 1/1/2000 and 12/31/2018. Cases with unknown HIV status at the time of transplant were excluded. Age, sex and demographics were analyzed. The regimen used for IIS was compared based on HIV serostatus and the change in induction regimen was trended over time.

Results

A total of 139,650 cases underwent DDKT during the study period. Among these, 1,384 were identified as HIV-positive. PLWH were significantly younger than HIV-negative (49±10 years vs. 51.6 ± 15.3 years; p< 0.001) (Table 1). A greater proportion of men was seen in the PLWH group compared to HIV-negative persons (76.2% vs. 60.4%; p< 0.0001). In the HIV-negative group, 12.1% undergoing DDKT did not receive IIS compared to 16.4% in PLWH (p< 0.0001). Medications that have significantly increased in use with years in PLWH included rabbit anti-thymocyte globulin (rATG), steroids, and basiliximab (3.54, 3.25, 2.28, respectively; p< 0.001). On our trend analysis (Figure 1), the percentage of PLWH receiving any IIS is increasing by 4.04% each year (p< 0.001).

Table 1

Figure 1

Conclusion

Our study suggests that IIS is an increasing practice in PLWH undergoing DDKT, predominantly using rATG, steroids, and basiliximab. Understanding the current practices might lead to further studies to determine the long-term outcomes after different induction regimens in PLWH.

Disclosures

All Authors: No reported disclosures
687. Iatrogenic Kaposi’s Sarcoma Following Treatment with Vedolizumab
Authors: Ajao Susanne O , Shaaban Hamid , Jayasingam Rajasingam
Published: January 2021

Background

Kaposi’s sarcoma (KS) is a vascular tumor caused by human herpes virus-8 infection (HHV-8) commonly involving the skin. We report a case of a patient with controlled HIV who developed Kaposi’s sarcoma on vedolizumab.

Darkened hyperkeratotic plaque on his left medial foot

Methods

A 39-year-old homosexual male with a history of Ulcerative Colitis (UC), Hodgkin’s lymphoma in remission and HIV presented with complaints of abdominal pain and bloody diarrhea. He had new tender lesions on his left foot which was absent at his previous admission a month ago. The lesions started as macules and later progressed to tender lesions. Mesalamine and oral corticosteroids were previously prescribed without symptomatic relief and he was started on vedolizumab 2 months ago. On physical exam he had abdominal tenderness, tender cervical and inguinal lymph nodes, and dark macules on his feet. Digital rectal exam revealed bloody mucoid stool. Laboratory showed white blood cell count of 12,600/mm3, ESR of 132 mm/hr and CRP of 4.6 mg/dL. His CD4 T-cell count was 873 cells/mm3 and viral load was 50 copies per milliliter. Cervical lymph node biopsy showed polymorphous population of lymphocytes but was negative for malignant cells. Biopsy of the foot plaques showed atypical intradermal vascular and spindle cell proliferation positive for HHV-8 and for vascular marker CD34. The results were consistent with the diagnosis of KS. Serology was also positive for HHV-8 with high viral titers of 74 copies/mL. Colonoscopy showed severe proctitis with deep ulcerations in a continuous pattern in the rectum with a normal sigmoid colon. Follow up colonoscopy showed improved proctitis and he was started on doxorubicin to treat KS with improvement of the foot lesion a month later following treatment.

Dark macules on the sole of both feet

Figure 3a: Spindle cells with irregular small vessel proliferation and red blood cell extravasation between tumor cells Figure 3b: Immunohistochemical stain showing HHV-8 expression of spindle cells

Improvement of the foot lesion

Results

Vedolizumab is a monoclonal antibody that prevents the recruitment of lymphocytes to the inflamed tissue. It is approved for the treatment of IBD and has shown efficacy and safety. The iatrogenic form of Kaposi’s sarcoma occurs in patients on immunosuppressive therapy, as this patient.

Conclusion

Patients with IBD on immunosuppressive drugs should be followed up closely and screened for latent viral infections prior to initiating therapy. As in the patient, HHV-8 should be recognized as a likely underlying opportunistic infection in immunocompromised patients with IBD.

Disclosures

All Authors: No reported disclosures
689. Nasal versus Nasopharyngeal Sample Collection for Diagnostic Nucleic Acid Amplification Testing for Influenza A, Influenza B, and Respiratory Syncytial Viruses
Authors: Schaack Grace A , Jung-Hynes Brittney , Chen Derrick
Published: January 2021

Background

Nucleic acid amplification testing (NAAT) for influenza A virus (IAV), influenza B virus (IBV), and respiratory syncytial virus (RSV) is a standard component of diagnosis of infections with these pathogens. At our institution, current standard of practice is to collect nasopharyngeal (NP) samples for such NAAT. In an effort to provide clinicians and patients a simpler, more comfortable sample collection option, we evaluated the use of nasal samples for NAAT, compared to NP samples.

Methods

Both nasal and NP specimens were collected from each of 58 patients seen in our emergency department (January – March 2020). NP samples were collected using minitip FLOQswabs; nasal samples were collected using regular or minitip FLOQswabs. Nasal and NP samples were processed using the same protocol and tested for influenza viruses and RSV using the Cepheid GeneXpert (Xpress Flu/RSV) platform.

Results

In total, 20 NP samples tested negative for virus and 38 tested positive (16 IAV-positive, 14 IBV-positive, 8 RSV-positive). There were 3 cases (5% of total cases) in which qualitative (positive/negative) results from the corresponding nasal samples were not in agreement with results derived from NP samples. These were considered false-negative results; one such discrepancy was resolved upon re-testing the same samples. Overall positive percent agreement between nasal- and NP-derived results was 92% (35/38), and negative percent agreement was 100% (20/20). Among samples testing positive for virus by both NP and nasal sampling methods, we found that the average cycle threshold (Ct) value for IAV detection was 5.1 cycles (n = 16, SEM = 0.83) higher for nasal samples than for NP samples. The average Ct for IBV detection was 3.3 cycles (n = 12, SEM = 1.87) higher for nasal than for NP samples. The average Ct for RSV detection was 1.9 cycles (n = 7, SEM = 1.57) higher for nasal than for NP samples.

Conclusion

These results suggest that recovery of viral RNA from nasal samples is lower than that from nasopharyngeal samples, particularly for influenza viruses. This decreased detection of viral RNA from nasal samples may explain the false-negative results seen in our discrepant cases. These data suggest that a decrease in recovery of viral RNA by nasal sampling may translate to decreased diagnostic accuracy.

Disclosures

All Authors: No reported disclosures
692. Secondary Infections and Coinfections in Coronavirus Disease 2019 (COVID-19)
Authors: Kaur Ikwinder P , Mughal Mohsin S , Dalmacion Denise L , Jaffery Ali , Koyoda Sai , Kramer Violet , Granet Kenneth , Eng Margaret
Published: January 2021

Background

While a common phenomenon in other viral illnesses, data regarding coinfection/superinfections in Coronavirus Disease 2019 (COVID-19) is limited and emerging. Superinfections may contribute to the overall high mortality in those suffering from severe COVID19. We aimed to study the rate of coinfections and secondary bacterial/fungal infections among SARS-CoV-2 positive cases in a community hospital.

Methods

This is a single-centre IRB approved, retrospective observational study. Adult patients with laboratory-confirmed SARS-CoV-2 by Real-Time Reverse Transcriptase–Polymerase Chain Reaction assay of nasopharyngeal swabs admitted from March 1st to April 20th 2020 were included. Relevant clinical and laboratory data were manually collected from electronic medical records.

Results

A total of 129 patients were included in the study. 91 patients had a respiratory pathogen panel PCR on admission. This panel includes testing for influenza, parainfluenza virus, respiratory syncytial virus, coronavirus, adenovirus, rhinovirus, Bordetella pertussis, Bordetella parapertussis, Chlamydophila pneumoniae, and Mycoplasma pneumoniae. Only one patient was positive for coinfection with the parainfluenza virus. None of them was found to be positive for bacterial coinfection at admission. Thirteen patients (10.1%) had secondary bacterial or fungal infections that developed during their respective hospital stays, 12 of them were critically ill. The mean duration from admission to the onset of secondary infection was 13 days.

Positive Blood Cultures

Positive Lower Respiratory Tract Cultures

Conclusion

Our data revealed that the rate of viral coinfection was 1.1 % and bacterial coinfection was 0% at admission. Study timing can play a role as upper respiratory virus infection rate is low in the population during March and April. Secondary infections were found to be common in patients admitted to the ICU. Potential explanations for this include compromised immunity in severely ill patients, extended ICU stay, central venous catheters and endotracheal intubation. It is evident that with severe COVID-19 illness, an extended hospital course often ensues, leading to increased risk of secondary infections and contributing to the overall high mortality of these patients.

Disclosures

All Authors: No reported disclosures
693. Shaking Things Up: Direct-to-PCR Viral Detection off Swabs Using Shaker-Mill Homogenization
Authors: Morehouse Zachary P , Proctor Caleb , Ryan Gabriella , Nash Rodney J
Published: January 2021

Background

As the number of viral diseases are on the rise, it is critical to continue to innovate and advance diagnostic, treatment, and surveillance methods surrounding viral infections. Currently, one of the most reliable methods for viral infection detection are polymerase chain reaction (PCR) based assays. These assays often involve procedures of swabbing a patient, processing the sample to lyse the virus, extract, and purify it’s nucleotides, and then run the purified genetic material via PCR for detection of a gene product needed to confirm the patient’s suspected diagnosis. This process requires time to complete and is dependent on the availability of the reagents and plastics required to complete the lysis, extraction, purification, and amplification procedures. Herein, we have developed a method to detect virus off a swab using solely shaker-mill based mechanical lysis and the transfer of the viral lysate directly to a PCR based assay, bypassing the reagent heavy and time consuming extraction and purification steps.

Methods

Using Human Coronavirus 229E (HCoV-229E) as a model system, we spiked swabs with clinically relevant levels of the virus for proof-of-concept testing. Swabs were spiked in serial dilutions from 1.2e7 copies/mL to 1.2e1 copies/mL. The swabs were then placed in 2mL tubes with viral transport media (VTM) to mimic the specimen collection procedures in the clinic prior to processing via shaker-mill homogenization. After homogenization, 1 uL of viral lysate was run in RT-qPCR for amplification of the nucleocapsid (N) gene, qualifying viral detection from the sample.

Results

HCoV-229E spiked swabs were run through the two-step process of homogenization direct to RT-qPCR for viral detection. After running 54 swabs, we confidently determined our limit of detection to be 1.2e3 viral copies/mL with 96.30% sensitivity in vitro.

Conclusion

We have successfully proven that shaker-mill homogenization provides sufficient viral lysis off swabs, where the resulting lysate can be used directly in PCR based assays for the detection of virus. This finding allows for decreased run time in traditional PCR based diagnostics and reduces the reagents and plastics required for each sample, ultimately reducing the cost and time of each viral test when compared to traditional PCR based methods.

Disclosures

Zachary P. Morehouse, MS, OMS-III, Omni International Inc (Consultant) Caleb Proctor, BS, Omni International Inc (Employee) Gabriella Ryan, BS, Omni International Inc (Employee) Rodney J. Nash, PhD, Omni International Inc (Employee)
694. Unexpected Diversity of Rotavirus Genotypes in Pediatric Population
Authors: Koukou Dimitra , Chatzichristou Panagiota , Tatsi Elizabeth-Barbara , Liakopoulou Theodota , Chronopoulou Genovepha , Michos Athanasios , Syriopoulou Vassiliki
Published: January 2021

Background

Rotavirus (RV) is the leading cause of viral gastroenteritis in children. Although RV genotypes differ geographically and temporally, five are the predominant genotypes circulating worldwide. Aim of our study was to monitor possible changes in distribution of Rotavirus genotypes circulating in Greek pediatric population during the post vaccine era.

Methods

Demographic data and fecal samples were collected from children ≤15 years old with symptoms of acute gastroenteritis who visited emergency units of Pediatric Hospitals in Greece from September 2016 to August 2019. Samples were tested for RV Group A antigen with rapid immunochromatographic assay. Positive samples were further G and P typed employing RT-PCR, semi-nested multiplex PCR and Sanger sequencing of the VP7 and VP4 genes.

Results

A total of 660 children participated in the study with median age 31±29 months. Males outnumbered females (59%). Most of them lived in urban cities (85%). RV genotyping distribution was G4P[8] (41%), G1P[8] (22%), G2P[4] (14%), G9P[8] (8%), G9P[4] (5,5%), G12P[8] (2%) and G3P[8] (1,8%). Unusual and mixed genotypes were identified in 3,2% and 2,5% of the samples respectively. During 2016-2017 and 2017-2018, G4P[8] was the predominant genotype in 67% and 51% of the annual samples. However, in 2018-2019 the most common genotypes were G9P[8] and G9P[4] (33% in total) followed by G2P[4] (27%). Interestingly, the genotype G9P[4] was not detected at all in the first two years of the study.

Conclusion

This study indicates diversity of the predominant RV genotypes in Greek children during 2016-2019. The emergence of G9 as the most common genotype as well as the significant detection of uncommon ones highlight the importance of continuous surveillance of RV genotyping during the post vaccine period.

Disclosures

All Authors: No reported disclosures
696. Bartonella quintana Endocarditis, A Case Series
Authors: Dieringer Thomas D , Huang Glen , Allyn Paul R , Klausner Jeffrey
Published: January 2021

Background

Homelessness has been a growing issue in the United States and worldwide. Bartonella quintana, the causative agent of “Trench fever”, is a well known illness among homeless populations in urban centers. While many cases of B. quintana are self limited, the disease can have advanced presentations including endocarditis. We present a short case series of three cases of B. quintana infective endocarditis (IE) in homeless individuals in Los Angeles and review the literature of cases of B. quintana IE in the homeless population.

Methods

Here we report three cases of B. quintana IE encountered in homeless individuals at the University of California, Los Angeles (UCLA) hospital system. A literature review was also conducted. PubMed was searched for published cases of human IE secondary to B. quintana in homeless individuals.

Results

All three patients were male with ages ranging from 39 to 57 years old with a history of homelessness and alcohol use. Presentations were subacute to chronic in nature consisting of constitutional symptoms as well as a range of symptoms corresponding with heart and renal failure. Each patient was found to have varying degrees of aortic insufficiency with either identified aortic valve vegetation or valvular thickening. Diagnosis was made with a combination of Bartonella serologies and whole genome sequencing PCR. All three patient’s courses were complicated by renal failure at varying points limiting the use of gentamicin for the full treatment course. Two patients ultimately underwent aortic valve replacement due to severe aortic insufficiency and completed therapy with doxycycline and rifampin. A single patient was discharged with plan to complete doxycycline and rifampin therapy however was lost to follow up.

A literature review of 10 manuscripts describing 13 cases of B. quintana IE were identified. All the patients were male and the median age was 45. Six of the cases were in Europe and eight were in North America. All cases had left sided valve involvement (10 aortic, 6 mitral, 3 both valves). No cases of right sided IE were identified.

Conclusion

B. quintana IE should be considered in homeless patients with a clinical presentation concerning for IE. A combination of serology and PCR testing can be useful in diagnosis of this uncommon cause of infective endocarditis.

Disclosures

Jeffrey Klausner, MD, MPH, Nothing to disclose
698. 8 Years of Infective Endocarditis in Intravenous and Non-Intravenous Drug Users a Single Center Experience
Authors: Alpizar-Rivas Rodolfo M , Balda Javier , Elarabi Salwa , Jaber Bertrand , Nader Claudia
Published: January 2021

Background

Despite advances in diagnosis and management, infective endocarditis (IE) is associated with considerable morbidity and mortality. Given the emergence of drug- resistant organisms, it is unclear whether this has impacted the characteristics and outcomes of IE among intravenous drug users (IDUs) and non-IDUs.

Methods

We conducted a single center retrospective cohort study. 306 records of hospitalized adults diagnose with IE by ICD-9/ICD-10 codes were identified from 2011 to 2018. 244 patients met criteria. IRB approval was obtained. The baseline demographic, microbiologic, echocardiographic variables and outcomes were extracted from the chart, and compared between IDUs and non-IDUs.

Results

112 (45.9%) patients were IDUs and significantly younger (mean age 36 vs. 64, p< 0.001). Both methicillin-sensitive (44.6% vs. 23.5%, p< 0.001) and methicillin-resistant (29.5% vs. 13.6%, p= 0.002) Staphylococcus aureus associated IE were more prevalent in IDUs compared to non-IDUs. Streptococcus species (22.7% vs 11.6%, p=0.02), excluding Enterococcus species, and coagulase-negative Staphylococcus (12.1% vs 1.8%, p=0.002) were significantly more prevalent in non-IDUs. IE in IDUs were more likely to have tricuspid valve vegetations (56.3% vs. 13.6%, p< 0.001), whereas non-IDUs were more likely to have mitral valve (39.4% vs. 25%, p=0.02) and aortic valve vegetations (46.2% vs. 15.2%, p< 0.001). 19% of patients with IE underwent valve replacement within 6 months, and 17% died within 90 days. A multivariable model that included age, gender, and IDU status, age was the only variable that remained independently associated with 90-day mortality (adjusted OR 1.031; 95% CI 1.006, 1.057; p< 0.01).

Conclusion

In this single-center experience, we found that methicillin-sensitive Staphylococcus aureus was the dominant organism among IDUs and non-IDUs. We also found that methicillin-resistant Staphylococcus aureus was significantly more prevalent among IDUs with IE. Provably related to an increase prevalence of colonization with resistant organisms in the community. Despite the shift in prevalence of methicillin-resistant Staphylococcus aureus among IDUs, there was no increased 90-day mortality risk after adjustment for age and gender.

Disclosures

All Authors: No reported disclosures
699. A Retrospective Review of the Progression of Cardiac Vegetations with treatment
Authors: Khan Roomana , Asghar Saleeha , Kak Vivek
Published: January 2021

Background

The purpose of our study was to assess the natural history of cardiac vegetations in native valves(NVIE) including changes in size and/or resolution with adequate treatment, as well as analyze factors that influence initial size.

Methods

We did a retrospective review of 102 patients discharged with a diagnosis NVIE at a community hospital. These patients were then screened to see if they received an adequate course of antimicrobial therapy and had follow up echocardiograms. The primary outcome measured was the change in vegetation size. We also assessed secondary measures including pathogen identified, the valve involved, complications, and associated IDU and any co-infections.

Results

31 patients fulfilled the study criteria and showed an initial mean vegetation size of 170mm upon initial echocardiography. The follow-up size after antibiotic treatment was 78mm suggesting a statistically significant relationship between antibiotic completion and reduction in vegetation size. (p-value 0.005).

T-Test was used for subgroup analysis and showed that the initial size of vegetations was significantly larger in IDUs (311) when compared to non-IDU (92)(p-value= 0.026).Patients who had embolic phenomena had significantly larger initial vegetations than those with no embolic complication.

Initial vegetation size was significantly larger for people with embolic complications (308 mm vs 82.65 mm, p-value 0.013).We also found that patients with Staphylococcal endocarditis had larger vegetations than those with non-staphylococcal endocarditis (264 vs 39, p-value 0.001). and treatment led to a larger decrease in vegetation size (152 vs 7, p value 0.007)

Conclusion

Our small study suggests that successful treatment of NVIE does lead to a decrease in vegetation size though resolution of the vegetation does not occur. We also found that embolic phenomenon tended to occur with larger vegetations with our study suggesting that a vegetation > 3 cm was more likely to embolize. Our study also shows that vegetations in NVIE in injection drug users were larger than those in non-IDU and vegetation size is larger in patients with staphylococcal endocarditis however successful treatment in these patients also leads to a larger decrease in size of these vegetations

Disclosures

All Authors: No reported disclosures
700. Ampicillin-Ceftriaxone Versus Ampicillin-Gentamicin for Definitive Therapy of Enterococcus faecalis Infective Endocarditis: A Propensity Score-Matched,Retrospective Cohort Analysis
Authors: Shah Niyati H , Shutt Kathleen A , Doi Yohei , Doi Yohei
Published: January 2021

Background

The mortality rate for Enterococcus faecalis infective endocarditis (EIE) is high. Ampicillin-ceftriaxone (AC) has emerged as an alternative antibiotic regimen with lower toxicity compared to ampicillin-gentamicin (AG), but evidence regarding its success in reducing EIE-associated mortality in the United States is limited. We retrospectively compared mortality in EIE patients treated with AG versus AC.

Methods

We conducted a retrospective, propensity score-matched, cohort analysis of EIE patients treated with AG or AC from 2010 to 2017 at three hospitals in Pittsburgh, Pennsylvania. Patients were included in the analysis if they were treated for EIE with either AC or AG as the pathogen-directed antibiotic regimen for at least forty-eight hours. We assessed 90-day mortality as the primary outcome, and in-hospital mortality, length of hospital stay, hospital readmissions, adverse events, and relapse of bacteremia as the secondary outcomes.

Results

A total of 190 patients with EIE (100 treated with AC and 90 with AG) were included. Ninety-day mortality was significantly higher in the AC group than the AG group (21% vs 8%, p = 0.02). After propensity score-matching, 56 patients in each group remained for the outcomes analysis. We observed similar rates of 90-day mortality (6% vs 4%, p = 0.55), bacteremia relapse (0 patients in both cohorts), treatment failure (0% vs 1%, p = 0.50), and 90-day hospital readmission (24% vs 23%, p = 0.85) in the AC and AG-treated patient cohorts. Adverse events were more common in patients treated with AG, and more patients in the AG cohort switched antibiotic regimens than in the AC group.

Conclusion

EIE patients treated with AC have similar mortality rates as those treated with AG, while AG is associated with increased toxicity and adverse events. Larger, multi-center studies are still needed to compare the two antibiotic regimens.

Disclosures

All Authors: No reported disclosures
702. Characteristics of Infective Endocarditis (IE) and Predictors of 90-day Mortality Among People Who Do and Do Not Inject Drugs with IE in Seattle, Washington
Authors: Corcorran Maria A , Stewart Jenell C , Lan Kristine F , Gupta Ayushi , Muggli Tanner N , Sharninghausen Jody C , Takasugi Jordan , Tietjen Ty J , Glick Sara N , Seshadri Chetan , Koomalsingh Kevin , Gibbons Edward F , Harrington Robert , Dhanireddy Shireesha , Dhanireddy Shireesha , Kim H Nina
Published: January 2021

Background

People who inject drugs (PWID) are at high risk for IE and account for a growing proportion of IE cases in the United States. We describe key characteristics of IE and predictors of 90-day mortality among people who do and do not inject drug at two large academic medical centers.

Methods

We used a string-searching and pattern-matching algorithm within all discharge (DC) summaries to query the electronic medical record (EMR) for cases of IE among adults ≥18 years of age at two academic medical centers in Seattle, Washington from December 1, 2013 to July 31, 2019. All cases were chart reviewed by a member of the study team to confirm a clinical diagnosis of IE and verify housing and PWID status, the latter defined as any injection drug use in the 3 months prior to admission. Microbiology and valve involvement were extracted from DC summaries and chart-reviewed where needed. Deaths were obtained from Washington state death index, which links to our EMR. Descriptive statistics were used to compare PWID and non-PWID with IE, and Kaplan-Meier log rank tests and Cox proportional hazard models were used to assess for predictors of 90-day mortality.

Results

We identified 387 patients with IE, 44% (n=166) of whom were PWID. When compared to non-PWID, PWID were younger (median age 33 vs. 55 years, p< 0.001) and more likely to be female (48% vs. 31%, p=0.001), homeless (41% vs. 9%, p< 0.001), have coagulase-positive Staphylococcal IE (69% vs. 32%, p< 0.001), and have right sided IE (66% vs. 26%, p< 0.001). Seventeen percent (n=64) of patients died within 90 days of admission, including 14% (n=23) of PWID and 19% (n=41) of non-PWID, with no difference in 90-day mortality between these groups (log-rank p=0.3). In univariate analyses, having left sided IE was the only predictor of 90-day mortality (HR 4.79, 95% CI 2.18 – 10.5).

Conclusion

Despite PWID being significantly younger and having a much higher frequency of right sided IE, they had similar 90-day mortality to non-PWID in this contemporary, urban cohort of hospitalized IE patients.

Table 1. Demographic Characteristics of People Who Do and Do Not Inject Drugs with Infective Endocarditis at Two Seattle Hospitals, 2014 – 2019

Disclosures

All Authors: No reported disclosures
704. Evaluation of Risk Factors and Outcomes of Early Left Ventricular Assist Device Infections
Authors: Shealy Stephanie , Milgrom Alexander , burns Stephen , Ferraro Hunter , Collins Amanda , Cox Jenna , Derrick Caroline , Mardis Andrew , Grubbs James , Weissman Sharon , Justo Julie Ann , Bookstaver P B
Published: January 2021

Background

Infection is a major complication of placement of left ventricular assist devices (LVADs) for patients with end stage heart failure. This study aimed to identify risk factors and evaluate outcomes of early LVAD specific and related infections in a community teaching hospital.

Methods

This was a single-center, retrospective cohort study that included adult patients with placement of LVAD from October 2012 – December 2019. LVAD specific infection was defined as a pump, cannula, pocket, or percutaneous driveline infection and LVAD related infection was defined as infective endocarditis, mediastinitis, or bloodstream infection. The primary outcome was early LVAD specific or related infection within 90 days of implantation. Secondary outcomes included time to infection, risk factors of and time to recurrent infection, and time to death. Multivariate logistic regression was used to ascertain risk factors for early infection. Cox regression was used to ascertain association with time to outcome variables.

Results

Of 160 patients who had LVADs placed during the study period, 26 experienced early LVAD infection. The majority of infections were caused by Staphylococcus spp. (32.1%). Risk factors for early infection are summarized in Table 1. Risk factors identified included placement of HeartMate III device when compared to HeartMate II and BMI > 40kg/m2. Increased hazard rate of infection was demonstrated for patients with HeartWare and HeartMate III devices compared to HeartMate II (HR 2.344; 95% CI 1.22,4.496; p-value 0.01; and HR 2.858; 95% CI 1.231, 6.635; p-value 0.015, respectively), those with BMI >40 (HR 2.437; 95% CI 1.131, 5.252; p-value 0.023), and those with history of diabetes (HR 1.736; 95% CI 1.012, 2.987; p-value 0.045). No risk factors were identified in the multivariate regression model for recurrent infection. Time to death was increased among patients with A1C > 6.4 at baseline (HR 1.028; 95% CI 1.002, 1.054; p-value: 0.032) and among patients who experienced early LVAD infection (HR 3.824; 95% CI 1.928, 7.584; p-value < 0.001).

Conclusion

HeartMate III device and BMI > 40kg/m2 were identified as risk factors for early LVAD infection. Time to mortality was decreased among patients that experienced an early LVAD infection.

Disclosures

Julie Ann Justo, PharmD, MS, BCPS-AQ ID, bioMerieux (Speaker’s Bureau)TRC Healthcare (Speaker’s Bureau)
707. Infective Endocarditis and Medication Assisted Treatment in Opioid Use Disorder
Authors: Loomis Katherine , Canamar Catherine , Dubè Michael
Published: January 2021

Background

A challenging feature in those with opioid use disorder-associated infective endocarditis (OUD-IE) is the duration and route of treatment, which often requires long inpatient stays. Those with OUD-IE often experience opioid withdrawal in the hospital, putting them at risk of leaving care prior to completion of treatment.

Initiation of medication-assisted treatment (MAT) with opioid agonists, including buprenorphine or methadone, has the potential to mitigate withdrawal and decrease morbidity and mortality among this high-risk population. We hypothesized that inpatient MAT will increase IE treatment adherence.

Methods

We conducted a single-center retrospective chart review study of adults (age > 18 years) with OUD-IE from 10/2015-09/2019. Vizient database was used to identify cases using ICD-9 and ICD-10 codes for IE and OUD. Manual chart review was done to confirm cases of OUD-IE using the modified Duke criteria for IE (Table 2) and evidence of active opioid use. Our primary outcome was treatment adherence defined as inpatient completion of treatment or transfer to another care facility for completion of treatment. Chi-squared test was used for categorical variables, t-test for continuous variables, and odds ratio (OR) with 95% confidence interval (CI) to evaluate our primary outcome.

Table 2

Results

There were 49 confirmed patients with 89 unique admissions associated with OUD-IE (Figure 1). Of those, 71% were male, and the median age was 45 years (range 20-72). The majority were homeless (63%) and hepatitis C antibody positive (82%) (Table 1).

There were 81 evaluable admissions with 8 (9%) excluded due to intubation. Of those, 18 (22%) received inpatient MAT and 63 (78%) did not. Mortality rate was high, with 11 inpatient deaths. Among those admissions where MAT was given, 14 of 18 (78%) adhered to treatment, compared to 21 of 63 (33%) who did not receive MAT (p< 0.001). Significantly, only 4 of 18 (22%) who received MAT left AMA, compared 39 of 60 (65%) who did not receive MAT (p=0.001), excluding 3 who died. Those who received inpatient MAT were 7 times more likely to adhere to treatment (OR=7.0; 95% CI=2.05, 23.91) compared to those who did not (Table 3).

Figure 1

Table 1

Table 3

Conclusion

Patients with OUD-IE were more likely to adhere to treatment if they receive inpatient MAT.

Disclosures

All Authors: No reported disclosures
713. The Clinical Impact of Implementation of a Multidisciplinary Endocarditis Team
Authors: El-Dalati Sami , Cronin Daniel , IV James Riddell , Shea Michael , Weinberg Richard , Washer Laraine , Stoneman Emily , Perry D Alexander , Bradley Suzanne F , Bradley Suzanne F , Burke James , Murali Sadhana , Fagan Christopher , Chanderraj Rishi , Christine Paul , Patel Twisha S , Fukuhara Shinichi , Romano Matthew , Yang Bo , Deeb Michael
Published: January 2021

Background

Infectious endocarditis is associated with substantial in-patient mortality of 15-20%. Effective management requires coordination between multiple medical and surgical subspecialties which can often lead to disjointed care. Previous European studies have identified multidisciplinary endocarditis teams as a tool for reducing endocarditis mortality.

Methods

The University of Michigan Multidisciplinary Endocarditis Team was formed on May 3rd, 2018. The group developed an evidence-based algorithm for management of endocarditis that was used to provide recommendations for hospitalized patients over a 1-year period. Mortality outcomes were then retroactively assessed and compared to a historical control that was identified using an internal research tool.

Figure 1

Table 1

Results

Between June 14th, 2018 and June 13th, 2019 the team provided guideline-based recommendations on 56 patients with Duke Criteria definite endocarditis and at least 1 American Heart Association indication for surgery. The historical control included 68 patients with definite endocarditis and surgical indications admitted between July 1st, 2014 to June 30th, 2015. In-hospital mortality decreased significantly from 29.4% in 2014-2015 to 7.1% in 2018-2019 (p< 0.0001). There was a non-significant increase in the rate of surgical intervention after implementation of the team (41.2% vs 55.4%; p=0.12).

Table 2

Table 3

Table 4

Conclusion

Implementation of a multidisciplinary endocarditis team was associated with a significant 1-year decrease in all-cause in-hospital mortality for patients with definite endocarditis and surgical indications. In conjunction with previous studies demonstrating their effectiveness, this data supports that widespread adoption of endocarditis teams in North America has the potential to improve outcomes for this patient population.

Table 5

Disclosures

All Authors: No reported disclosures
719. Clinical Outcomes of Single versus Double Anaerobic Coverage for Intra-abdominal Infections
Authors: Raymond Lendelle , Cani Eris , Zeana Cosmina , Lois William , Park Tae
Published: January 2021

Background

Double anaerobic coverage (DAC) is often used for intra-abdominal infections (IAIs) post-operatively. The primary objective of the study was evaluating length of hospital stay (LOS), in-hospital post-operative complications, and re-admission within 30 days of discharge due to post-operative complications in patients who received piperacillin/tazobactam plus metronidazole versus piperacillin/tazobactam for IAIs post-operatively. The secondary objective was comparing in-hospital mortality and hospital-acquired Clostridioides difficile infections (CDI) between the two groups.

Methods

This was a retrospective, cohort study including adults with surgically managed IAIs at an urban community hospital between January 1, 2016 and June 30, 2019. The following data were collected: age, sex, body mass index, comorbidities, Charlson Comorbidity Index (CCI), 5-day post-operative body temperature, American Society of Anesthesiologists (ASA) pre-operative assessment score, surgical wound classification, and IAI diagnosis. Multivariate analysis and aggregate resampling of the sampling distribution were conducted. An alpha of < 0.05 was considered statistically significant.

Results

Out of 163 patients, 96 patients received piperacillin/tazobactam plus metronidazole and 67 patients received piperacillin/tazobactam. The patients who received DAC were sicker with higher CCI (p=0.021) and 5-day post-operative body temperature (p=0.013). They were also at a higher risk for surgical site infections (p=0.002). Double anaerobic coverage was more often used for acute cholecystitis (p=0.0001) and gastrointestinal perforations (< 0.0001). After adjusting for these variables, DAC was associated with longer LOS (median 9 days vs. 4 days, p< 0.0001) and in-hospital post-operative complications (23% vs. 9%, p< 0.0001). There were more re-admissions within 30 days of discharge due to post-operative complications in the single anaerobic coverage group (4% vs. 1%, p=< 0.0001). In-hospital mortality (4% vs. 0%) and hospital-acquired CDI (1% vs. 0%) were only observed in DAC group.

Conclusion

Double anaerobic coverage was associated with no clinical benefit in surgically managed IAIs and in some cases may produce worse outcomes.

Disclosures

All Authors: No reported disclosures
720. Clinical Performance of Film Array Gastrointestinal Pathogen Panel in Diarrhea
Authors: Ananthanarayanan Rajalakshmi , Muhammed Niyas Vettakkara Kandy , Sasidharan Aswathy
Published: January 2021

Background

Infective diarrhea is a common problem. Multiplex Polymerase chain reaction (PCR) based pathogen diagnostics of diarrheal stool specimens are shown to be highly sensitive and rapid as opposed to conventional diagnostics.

Methods

We analyzed the performance of a multiplex PCR test, FilmArray (FA) gastrointestinal (GI) panel, on stool specimens in patients admitted with acute and chronic diarrhea to our hospital from December 2016 to December 2019 and compared the results with conventional diagnostic tests.

Results

A total of 98 patients were analyzed, 52 were males and 9 belonged to pediatric age. 92.9% patients presented with acute diarrhea. None were HIV positive. Among 98 tested, FA GI pathogen panel was positive for at least one pathogen in 39.8% patients. The yield was low for stool culture, 7.79%. In samples tested by FA GI pathogen panel, a single pathogen was identified in 27 patients (27.5%) while multiple targets were identified in 12 patients (12.2%). Majority (76.5%) had normal stool routine. Stool routine abnormality and positive GI pathogen panel did not correlate, as only 7 patients with abnormal stool routine had a positive result in FA GI pathogen panel, while 12 patients had negative result. Among the 39 patients with positive FA GI pathogen panel, only 6 had positive stool culture result. All stool culture positive sample also had GI pathogen panel positive result. Commonest organism in stool culture was Salmonella (5) while one patient had E. coli. Commonest organism in stool FA GI pathogen panel was also Salmonella, 12 isolates as a single pathogen and 5 as one among the multiple targets identified, making a total of 17 isolates. This is followed by Enteroaggregative E. coli (EAEC- 9) and Enteropathogenic E. coli (EPEC- 5). %). Only one had virus as pathogen (norovirus), no parasitic infection was identified. Multiple pathogens were identified in 12 patients. Clostridium difficile toxin was positive in 2 in whom multiple targets were identified. Among the chronic diarrhea syndrome, none had stool culture positivity while two had positive FA GI pathogen panel results and the organisms were Campylobacter and EAEC.

FA GI pathogen panel results

Multiple targets that are identified

Conclusion

FA GI panel detects a wide array of GI pathogens, better yield and has a quick turn-around-time compared to conventional tests like stool culture.

Disclosures

All Authors: No reported disclosures
725. Influence of An Emerging Pathogen, Streptococcus anginosus, on Clinical Outcomes in Pediatric Appendiceal Abscess
Authors: Watman Olivia F , Whyte Christine , Tristram Debra A
Published: January 2021

Background

Escherichia Coli is the most common primary pathogen in appendiceal abscess, but an increasing number involve Streptococcus anginosus (SA) as the primary isolate. Ten years of data from a regional medical center was reviewed to track changes in the microbiology and outcomes of this condition. We believe that SA is emerging as a significant pathogen in appendiceal abscess in children and it is associated with increased morbidity compared to more commonly encountered pathogens.

Methods

A medical records search was done (IRB#5194) for patients below age 18 from 1/2008 to 12/2017 with acute appendicitis with local/generalized peritonitis or peritoneal abscess. There were 557 records retrieved, of which 201 had appendiceal abscess. The records were further divided based on the type of operation and timing of abscess development. There were 104 laparoscopic, 34 open, 4 drain alone, 53 interval management with a drain, and 6 interval without a drain. The focus of the study is laparoscopic and open post operative abscess. 56 of the laparoscopic cases developed a postoperative abscess of whom 45 had culture and sensitivity data. 25 of the open cases developed a postoperative abscess of whom 24 had culture and sensitivity data.

Results

Of the 45 postoperative abscesses following laparoscopic procedure, the most common isolate was E. coli (34) followed by SA (13). Of the 24 postoperative abscesses following open procedure, the most common isolate was also E. Coli (17) followed by SA (6). Patients are divided into those who had any culture of SA (SA group), vs those who did not (non-SA group). For laparoscopic cases there was no difference between additional procedures needed. However for open procedures, the SA group had an average of 2.33 additional procedures needed compared to the 0.94 additional procedures for the non-SA group (p=0.024). Major adverse outcomes included one death from sepsis, abdominal compartment syndrome, and one patient needing bilateral salpingectomy, all in the SA group.

Conclusion

SA has emerged as an important and virulent pathogen in complex appendicitis in pediatric patients. It is sensitive to commonly used antibiotics, but is associated with increased risks of reoperation, additional drainage and adverse outcome for the sicker patients who require an open procedure.

Disclosures

All Authors: No reported disclosures