bluuebunny/crossref_metadata_2025 huggingface dataset:
870. Mycobacterium chimaera Outbreak: Infection Control and Clinical Experiences in Edmonton, Alberta
Authors: Kula Brittany E , Smith Stephanie
Published: January 2021

Background

Mycobacterium chimaera is responsible for a global outbreak due to contaminated heater-cooler units (HCUs) used in cardiothoracic surgery and has been associated with high mortality. Optimal treatment is not known. The objectives of this study were to describe the Infection Control strategies utilized by the University of Alberta hospital and Mazankowski Heart Institute (MAZ) prior to availability of new HCUs, and outline the clinical course of locally acquired M. chimaera infection.

Methods

We reviewed interventions undertaken to mitigate the risk of M. chimaera infection. Any MAZ patient with M. chimaera isolated at an anatomic site with a history of cardiothoracic surgery from 2012-present were identified. Charts were reviewed for patient and infection characteristics.

Results

All manufacturer’s instructions for HCU cleaning-disinfection were followed. The MAZ was compliant with CDC recommendations for directing HCU ventilation exhaust away from the surgical field and to the use of filtered water. M. chimaera was isolated in 3/8 local HCUs. After decontamination procedure, 1 HCU grew M. chimaera but cleared after a second attempt. Smoke studies demonstrated aerosolization of HCU exhaust in October 2016 therefore the laminar air curtains were manipulated for increased flow in October and November 2016. By June 2017, HCUs were retro-fitted and in late 2017 all pre-2014 Sorin HCUs were replaced.

10 patients have been diagnosed with M. chimaera infection post-cardiothoracic surgery performed at the MAZ. None occurred after manipulation of the laminar air curtain. Mean patient age at time of cardiothoracic surgery was 62.3 years and 6 were male. All had implantation of prosthetic material. The most common culture-positive sites were blood in 9/10, urine in 5/10 and prosthetic material or surgical site in 3/10. 6/10 have died due to infection and mean life expectancy of those deceased from first positive culture is 123 days. An additional survivor has been transitioned to comfort care and lost to follow-up.

Conclusion

M. chimaera post cardiothoracic surgery has been challenging from an infection control perspective but the risk appears to have been mitigated through manipulation of the laminar air curtain. Locally, M. chimaera has been associated with significant (60%) mortality.

Disclosures

All Authors: No reported disclosures
886. Impact of Type of Surgical Management on the Incidence of Recurrent Surgical Site Infections Following Hip and Knee replacements in Calgary, Alberta
Authors: Chavda Swati , Leal Jenine , Puloski Shannon , May Elissa Rennert
Published: January 2021

Background

Recurrent surgical site infections (SSIs) are associated with decreased quality of life for patients and increased economic burden to healthcare systems. Positive cultures at reimplantation and patient co-morbidities have been shown to increase the risk of recurrent SSI in hip and knee surgical site infections. Two-stage exchange has been considered for the most appropriate surgical management for these SSI’s, however, it is unclear whether the type of revision arthroplasty and pathogen of the first SSI impacts recurrence rates.

Methods

A retrospective review of prospectively collected data on all complex SSIs following primary hip and knee arthroplasties between April 1 2012 and March 31, 2019, in Calgary, Alberta was performed. Patients were followed for two years post-index arthroplasty to determine initial management of first complex SSI (Debridement, antibiotics and implant retention (DAIR) vs DAIR+liner exchange vs one-stage vs two-stage), rate of recurrent complex SSI, and microbiological data for first and subsequent SSI’s.

Results

Of the 142 complex SSIs, 95 (66.9%) were managed with DAIR and liner exchange, 25 (17.6%) were managed with DAIR, 13 (9.1%) with one-stage and 8 (5.6%) with two-stage procedures. The recurrence rate was 19/95 (20%) for DAIR and liner, 8/25 (32%) for DAIR alone, 2/13 (15%) with one stage, and 3/8 (37.5%) with two-stage. There was no significant difference in recurrence rates of complex SSI when stratified by surgical management. Of the pathogens, Staphylococcus aureus (S.aureus) (including methicillin-resistant S. aureus (MRSA)) accounted for 35.2% of total first SSI and 50% of recurrences. A significantly higher proportion of S.aureus infections (including MRSA) ended up with a recurrent infection compared to all other pathogens (p=0.045). Of the 32 recurrences, 28.1% were due to the same pathogen as the initial SSI.

Conclusion

S.aureus was the most common pathogen causing initial and recurrent SSIs. This reinforces that S.aureus complex SSIs would likely benefit from early recognition and aggressive treatment. Recurrence of SSI was not impacted by type of revision arthroplasty. This study is limited by a small sample size. These findings contribute to the paucity of literature in this area and suggest a need for expansion to larger populations.

Disclosures

All Authors: No reported disclosures
887. Implementation of a Surgical Site Infection (SSI) Prevention Bundle: Patient Compliance and Experience
Authors: Hockett-Sherlock Stacey , Suh Daniel , Perencevich Eli N , Reisinger Heather Schacht , Streit Judy , Clore Gosia , Ohl Madeline , Herwaldt Loreen , Schweizer Marin L
Published: January 2021

Background

An evidence-based preoperative bundle including chlorhexidine gluconate (CHG) bathing, screening for S. aureus nasal carriage and decolonizing carriers with mupirocin was the standard of care for patients having total joint arthroplasty (TJA) at a VA medical center. We aimed to assess patient compliance with mupirocin and CHG, and characterize patient perceptions of barriers and facilitators to compliance.

Compliance with CHG Bathing & Mupirocin By Methicillin-resistant S. aureus (MRSA) or Methicillin-susceptible S. aureus (MSSA) Colonization Status

Methods

The bundle for S. aureus colonized patients having TJA included nasal mupirocin ointment twice daily and daily CHG bathing for 5 days before surgery. The bundle for non-carriers included CHG bathing the day before and the morning of surgery. From 7/2018-10/2019, inpatients completed a 31-item survey following their TJA.

Results

73 patients completed the survey (~29% of the TJA population). 17 patients (23%) carried S. aureus & 56 patients (77%) were non-carriers. Patients reported high compliance with home use of CHG for the full number of days directed (88% when prescribed for 2 days; 71% when prescribed for 5 days; overall 85% used as prescribed; Figure). 7 (10%) patients reported CHG side effects, including burning or itchy/dry skin. 99% of patients reported willingness to use the CHG before a future surgery. Compliance with home use of mupirocin was lower (53% used as prescribed). Reported side effects included stinging, itching or dryness (N=2, 12%), unpleasant taste (N=2, 12%) & runny or stuffy nose (N=3, 18%). 100% of patients reported willingness to use mupirocin before a future surgery. Barriers to patient compliance with the bundle included forgetfulness and difficulty bathing daily. Facilitators to patient compliance included high facility compliance with S. aureus screening (100% patients reported), patient education regarding CHG and mupirocin use (95% patients recalled), and access to prescribed medications (100% patients received). Most patients (93%) reported no financial burden for mupirocin and 95% of patients reported no financial burden for CHG.

Conclusion

Patients reported high willingness to use the prevention bundle, yet mupirocin compliance was sub-optimal. Replacing patient-applied home mupirocin with nurse-applied day-of-surgery decolonization should be assessed in order to facilitate increased compliance.

Disclosures

All Authors: No reported disclosures
899. Reduction of Surgical Site Infections Post Cesarean Section through Implementation of Novel Evidenced Based Bundle
Authors: Vacca Maria , Mapp Marilyn A , Hiester Ashlee , Vyas Nikunj M , Burke Julia , Covone Kenneth
Published: January 2021

Background

A frequent complication post cesarean section (C-section) is surgical site infections (SSI) which are associated with heightened maternal morbidity and mortality, decreased patient satisfaction, prolonged hospitalization, and increased costs. In Calendar Year 2019, our Infection Control Committee identified an increase in the incidence of post-operative C-section SSI rates over an 8 month period from January through August of 2019.. The purpose of this study was to develop, implement and measure the compliance and efficacy of a novel pre-operative bundle (POB) for patients undergoing C-section.

Calendar Year 2019 Jan. through Aug. C-Section Infections Raw Numbers

Methods

In October 2019, our multidisciplinary team consisting of Infection Control, Pharmacy, Nursing, and Physicians developed and implemented POB for patients undergoing C-section. The POB included the following:

1. Mandatory interventions of vaginal cleansing using povidone iodine

2. Chlorhexidine (CHG) 2% wipes to abdomen

3. Addition of Azithromycin 500mg x 1 dose as pre-operative antibiotic.

Primary endpoint of the study was to measure the overall C-section SSI incidence for 8 months period pre and 8 months post implementation of the POB. This Secondary endpoint of the study included POB compliance and efficacy of real-time prospective audit and feedback for non-compliance.

Novel Preoperative Bundle Auditing Compliance

Results

There were total of 212 patients who received C-section in Pre-POB group and 182 in Post-POB group. Baseline characteristics between the groups were similar. Overall C-section rates Pre-POB was 3.8 % vs 0% in Post-POB group. We noted a bundle compliance of 97.9% since implementation of POB. Real time prospective audit and feedback was provided to total of 122 cases after implementation of POB.

Comparison of C-Section Raw Numbers Calendar Year 2019 Pre and Post Novel Bundle Implementation

Conclusion

With implementation of POB, we noticed a significant drop in our C-section SSI. We observed a very high bundle compliance with implementation of prospective audit and feedback approach. This is the first study evaluating implementing a novel pre-operative bundle for patients undergoing C-section. Continued auditing and real time feed back of novel bundle will ensure continued success.

Disclosures

All Authors: No reported disclosures
65. Impact of a Multifaceted Stewardship Intervention on Oral Fosfomycin Prescribing for Treatment of Resistant Organisms in Cystitis
Authors: Pry Marie , Pillinger Kelly E , Dobrzynski David , Crowley Amber , Shulder Stephanie
Published: January 2021

Background

Fosfomycin is an oral antibiotic with activity against multi-drug resistant (MDR) bacteria that is recommended as first line treatment for cystitis. The ability to use an oral agent for these infections will be beneficial due to the decreased need for hospitalizations and clinic visits to manage IV therapy; therefore, reducing healthcare exposure for the patient.

Methods

This was a multi-site, observational study evaluating adult patients with a urine culture growing extended-spectrum beta-lactamase E. coli, vancomycin-resistant Enterococcus, or fluoroquinolone-resistant Pseudomonas urinary isolates and with documented cystitis between September – November 2018 (pre-implementation) and September – November 2019 (post-implementation). The primary outcome was the difference in the rate of fosfomycin use pre and post implementation of multiple stewardship interventions (routine fosfomycin susceptibility reporting on MDR organisms, creation of a fosfomycin order set and provider education).

Results

Of 306 patients reviewed, 148 patients met eligibility criteria (68 pre, 80 post). The majority of patients were female (80%), diagnosed with complicated UTI (82%), treated outpatient (88%), and with ESBL E. coli as the causative pathogen (91%). There was a significantly higher rate of fosfomycin use post-intervention (pre 1.5% vs. post 20%, p< 0.001). No difference was seen between groups in the rates of use of all other antibiotic classes. The most common antibiotic prescribed for empiric or definitive therapy was nitrofurantoin (empiric 43%, definitive 53%). Appropriate fosfomycin dosing was low in both groups (pre 9% vs. post 19%; p > 0.99). There was no difference in the rate of adverse reactions (pre 4% vs. post 5%, p > 0.99).

Conclusion

There was an increase in fosfomycin use after incorporating a multifaceted stewardship intervention. Fosfomycin provides an alternative oral option for MDR urinary isolates and was not shown to be associated with an increase in adverse effects. This was a simple stewardship intervention which made a measurable impact on antimicrobial use. Additional education for providers and pharmacists regarding appropriate dosing could be considered in the future to promote optimal use.

Disclosures

Kelly E. Pillinger, PharmD, BCIDP, Pharmacy Times (Other Financial or Material Support, Speaker)
920. Use of the Web by State and Territorial Health Departments to Promote the Dissemination of State Antimicrobial Resistance Surveillance Data, United States
Authors: Yin Xin , Hamilton Keith W , Tate Heather , M’ikanatha Nkuchia M
Published: January 2021

Background

Antimicrobial resistant (AMR) bacteria pose a serious threat to public health. The national response to this threat includes calls for promoting judicious use of antibiotics in humans and animals and strengthening integrated One Health surveillance of AMR bacteria in humans, animals, and environment. However, the extent to which public health jurisdictions are disseminating surveillance findings to promote judicious use of antimicrobials is unclear.

Methods

We used a standardized web audit tool to manually review and document the presence of AMR-related information on the websites of all public health jurisdictions that participate in national notifiable disease surveillance in the United States. We also emailed a survey to representatives in the 54 jurisdictions that participate in the National Antimicrobial Resistance Monitoring System (NARMS) activities coordinated by the Centers for Disease Control and Prevention. The survey asked questions about AMR-related information on their public health department website.

Results

Of the 37 (68.5%) jurisdictions that responded to the email survey, 26 (70.3%) indicated that their websites have information on appropriate antibiotic use for health professionals, veterinarians and general public, compared to 89.3% from the web survey (Figure). Eleven (29.7%) indicated that they have data on antimicrobial susceptibility for pathogens, or antibiograms, on their websites, compared to 48.2% from the web survey. While 11 (29.7%) jurisdictions indicated that they have highlighted appropriate antimicrobial use on the homepage, the web survey found no reference on the homepage.

Comparison of results from email and web survey on public health jurisdictions’ website, United States - 2020

Conclusion

Public health jurisdictions have begun to use websites to increase awareness about the threat of antimicrobial resistance. However, the limited presence of information on appropriate antimicrobial use for the public, health professionals and veterinarians suggest the need for improvement. Gaps exist between the awareness of the epidemiologists and laboratorians and the information reported on public health jurisdictions’ websites. Websites can be expanded and better leveraged to increase visibility of AMR and appropriate antimicrobial prescribing across One Health domains.

Disclosures

All Authors: No reported disclosures
926. Antibody Response to HPV Vaccination in Pediatric and Adolescent People Living with HIV (PLWH)
Authors: Al Hammoud Roukaya , Unger Elizabeth R , Panicker Gitika , Del Bianco Gabriela P , Heresi Gloria , Bell Cynthia , Murphy James , Perez Norma
Published: January 2021

Background

Immune dysfunction related to HIV infection is associated with an inability to clear HPV infection and may compromise the immunogenicity of quadrivalent HPV vaccine Gardasil® (4v HPV).

Methods

Between 2005 and 2017, males and females 7 to 20 years old age, were offered 3-dose 4v HPV vaccine. Plasma IgG titers to HPV 6 (H6), 11 (H11), 16 (H16) and 18 (H18) were measured using multiplex VLP-based ELISA. For the 36 patients, median interval from 1st dose to 2nd and 3rd doses were 73 and 216 days. Plasma sample 1 was collected at median of 91 days after dose 1, sample 2, 169 and sample 3, 740 after respective vaccine doses. A 4th sample was available for 26 patients, median 2327 days after dose 1. Rank-sum test, Χ 2 or Fisher’s Exact Test were employed.

Results

Before vaccination, 10 (28%) were seropositive to 1 or more HPV types. The baseline seropositives were older than seronegatives (16 years vs 11; p=0.007). After dose 3 all participants had an Ab response to at least 1 HPV type and 32 (89%) were seropositive for 4 HPV types. Seroconversions were H18, 87%; H16 97%; H11, 100%; H6, 97%. Seroconversions after 1 dose of 4v HPV among the baseline seronegatives were 61%, 90%, 86% and 86%, respectively and 22 became seropositive for all 4 types. The 4 baseline seronegative PLWH with partial seroconversion had higher median HIV viral load (VL) compared to baseline seronegative group with full seroconversion (12,920 vs 101 copies/ml; p = 0.052), but had comparable CD4 counts. The rate of post vaccination seropositivity and baseline to peak titer response for each HPV type was not significantly different for baseline sero-groups. Among baseline seronegative, all 19 sampled distant from vaccination remained seropositive to at least 1 HPV type (84% to 3 or more types) and 6 (32%) became seronegative (sero-reversion). Those showing sero-reversion had higher VL compared to the 14 who remained seropositive (9100 vs 48; p =0.015). Time from last dose of 4v HPV to sample 4, CD4%, age, gender, and race/ethnicity were similar between the groups.

Bar Graphs representing Ab response to the 4 HPV types following each dose of 4v HPV vaccine

Conclusion

In the complex environment of a pediatric HIV specialty clinic, most PLWH mounted Ab responses to 4v HPV that were durable. H18 was least immunogenic. Patients with higher HIV VL were less likely to seroconvert for all types and were more likely to sero-revert.

Disclosures

All Authors: No reported disclosures
930. Clinical Presentation, Treatment, and Outcomes for People with HIV with Histoplasmosis in Memphis, Tennessee
Authors: Cook Julia C , Lin Corey , Menzies Barbara E , Fuchs Christian J , Animalu Chinelo N , Mazumder Shirin A , Thomas-Gosain Neena , Summers Nathan A
Published: January 2021

Background

There is limited data on the presentation, treatment, and outcomes in persons with HIV (PWH) with histoplasmosis in the era of modern antiretroviral therapy (ART). We conducted a retrospective review of PWH presenting with histoplasmosis in Memphis, TN.

Methods

All cases of PWH with Histoplasmosis diagnosed or treated between January 1, 2013 and December 31, 2019 at Regional One Health were identified. Cases captured in obsolete and inaccessible EMRs were excluded. Baseline demographics, presentation data, treatment, duration of treatment, and outcomes were abstracted by chart review. A pooled T-test was performed to compare outcomes between those receiving short (≤ 7 days) and longer courses (> 7 days) of amphotericin.

Results

Thirty-four participants were included, of which 30 (88%) were diagnosed in the hosptial. The mean age of participants was 41 years, 25 (73.5%) were male, and 31 (91%) were black. Median CD4 cell count and HIV viral load were 15 cells/µL, and 415,220 copies/mL, respectively. Median length of time between HIV diagnosis and presentation with histoplasmosis was 3.25 years. Common presenting symptoms included weight loss (21, 61.76%), gastrointestinal symptoms (22, 64.76%), and respiratory symptoms (19, 55.88%). Twenty-seven (79.41%) of participants met SIRS criteria on presentation, two required intensive care, and two participants met HLH criteria. The time between presentation and initiation of appropriate anti-fungal treatment was a median of 1.5 days. The majority of participants received amphotericin B as initial treatment (67.65%, N = 23). Twenty-five (60%) participants ultimately received amphotericin, 14 of whom received it for 7 days or less. The median duration of hospitalization was observed to be shorter among the group receiving 7 days or less of amphotericin (7 vs. 10.5 days), although not statistically significant. Overall 30 day mortality was 0%.

Conclusion

This study describes a population of PWH presenting with histoplasmosis in Memphis, TN. Appropriate antifungal therapy was started quickly and patients did well whether they were treated with a short course (7 days or less) or long course of amphotericin. Further research on the duration of amphotericin B in this population is warranted.

Disclosures

All Authors: No reported disclosures
955. Addressing Gaps and Disparities in HIV testing in the Emergency Department
Authors: Huggett Ashley , Derrick Caroline , Shealy Stephanie , Ahuja Divya , Al-hasan Majdi , Weissman Sharon
Published: January 2021

Background

Early diagnosis of HIV is key to improving outcomes for persons living with HIV (PWH). The Emergency Department (ED) is a critical site for PWH to access care. Previous studies in South Carolina (SC) have shown that two-thirds of individuals newly diagnosed with HIV have visited a health care facility a mean 7 times prior to their HIV diagnosis. Over 80% of these visits were to the ED, thus representing missed opportunities. Failure to test results from a multitude of barriers, including avoidance of testing due to a perceived lack of follow up. To address this gap in care we established a rapid HIV engagement team (RHET) that assumes responsibility for post-HIV testing linkage and reporting. The goal of this study is to evaluate the effectiveness of this intervention.

Methods

This retrospective cohort study compared HIV testing rates and patterns in Prisma Health EDs from May 2018 through October 2018 (pre-RHET) to 5/2019 through 10/2019 (post-RHET). Included persons were ≥18 years of age and had ICD-10 codes for a sexually transmitted infection (STI), trichomonas, herpes simplex, and gonorrhea (GC) or Chlamydia (CT) NAAT, and/or presented with an initial complaint of a STI. Multivariable logistic regression analysis was utilized to examine impact of RHET implementation on HIV testing in ED.

Results

A total of 4104 individuals were identified, 2154 pre-RHET and 1950 post-RHET. Table 1 displays baseline characteristics for the two groups. Overall, 87% had GC testing; 9% had positive results; 95% had CT testing, 12.6% had positive results. Only 6% were tested for HIV pre-RHET implementation. HIV testing improved to 12% post-PHET implementation (p< 0.001). In the multivariate regression analysis predictors for HIV testing were presenting post-RHET (OR 2.27; 95% CI 1.81 to 2.85), male gender (OR 2.98; 95% CI 2.39 to 3.73), white race (OR 2.27; 95% CI 1.81 to 2.85), and presenting to ED for STI (OR 3.58; 95% CI 2.03 6.33).

Conclusion

HIV testing rates increased post-RHET yet, despite indications for HIV testing, only a small proportion received HIV testing. Further interventions are needed to improve HIV testing in EDs, particularly in women and blacks. The overall HIV testing rate remained low, representing ongoing missed opportunities for early HIV diagnosis.

Disclosures

All Authors: No reported disclosures
956. Delayed HIV diagnosis in Philadelphia
Authors: Spacek Lisa A , Higgins Dana , Brady Kathleen
Published: January 2021

Background

Ending the HIV Epidemic (EHE) requires prompt diagnosis and treatment of HIV to reduce transmission. Delayed HIV diagnosis and late entry into care remain challenging. Strategic deployment of testing resources may leverage both targeted and universal testing to accomplish the timely diagnosis of HIV infection.

Methods

We extracted data from the City of Philadelphia’s Enhanced HIV/AIDS Reporting System for 3,856 individuals diagnosed with HIV infection in Philadelphia, PA from 2012-2018, to determine characteristics associated with delayed diagnosis, defined as: AIDS diagnosed within 90 days of HIV or date of AIDS diagnosis prior to HIV diagnosis. Independent variables included: time since HIV diagnosis, age category, birth sex, current gender, race/ethnicity, transmission risk, insurance status, and receipt of care from Ryan White medical provider. We used Chi-square and multivariate logistic regression to assess factors associated with delayed diagnosis.

Results

From 2012 to 2018, the number of HIV diagnoses declined from 731 to 422; those with delayed diagnosis declined from 28% to 18%. Age category of 25-34 years comprised the majority of HIV diagnoses N=1402 (36%). The majority were: born male (78%), current gender male (76%), black (69%), MSM (51%), insured (54%), and participating in Ryan White care (71%). In multivariate regression, current gender male, heterosexual transmission, race/ethnicity Asian, American Indian, Alaska Native, or Multi-race, unknown insurance status, and receipt of care from a Ryan White medical provider were 3.7 (95%CI, 1.2-11.4), 1.3 (1.0-1.7), 1.8 (1.2-2.8), 5.9 (4.9-7.1), and 1.4 (1.2-1.7) times as likely to have delayed diagnosis, respectively, after adjustment for time since diagnosis, age category, and birth sex.

Participants’ Characteristics and Logistic Regression Results

Conclusion

EHE will only be successful by reaching all people living with HIV and creating opportunities for early diagnosis. Routine opt-out universal screening combined with repeated, targeted testing will allow for identification and early treatment of HIV infection. As a medical care safety net, Ryan White program provides care to a disproportionate number of people with delayed diagnosis of HIV. By diagnosing HIV as early as possible, we may eliminate delayed diagnosis and reduce the risk of AIDS-related events or death.

Disclosures

All Authors: No reported disclosures
961. Implementing an HIV Ambulatory Curriculum in Internal Medicine Residency Programs
Authors: Aoun-Barakat Lydia , McKay Sharen E , Danvers karina , Sideleau Robert J , Brooks Ralph P , Villanueva Merceditas
Published: January 2021

Background

The advancement of anti-retroviral therapy (ART) has transformed HIV into a chronic disease and resulted in prolonging the lives of people living with HIV. Therefore, there is a projected shortage of HIV providers nationally and there is a need for increased training of primary care physicians in management of HIV over the lifespan as well as alongside common comorbidities found in aging HIV population.

Methods

The Yale AIDS program developed an interactive HIV ambulatory curriculum that included a set of didactics and workshops for trainees in internal medicine residency programs. This 3-hour interactive curriculum was implemented in 5 hospitals in Connecticut and was led by experienced HIV providers at the MD and RN levels. Trainees included PGY1, 2 and 3 residents. Knowledge areas encompassed HIV Epidemiology, Testing, ART Treatment, and prevention including Pre Exposure Prophylaxis (PrEP). In addition, 2 role-play sessions were integrated. Pre and Post Test knowledge assessment was evaluated including questions on practice regarding HIV screening and PrEP prescribing.

Results

In this study, we report the results of knowledge assessments and professional practices administered prior to (pre-) and following (post-) interactive learning sessions.

From July 2017 to June 2020, 15 HIV ambulatory curriculum sessions were held, with an average 5 sessions annually. A total of 170 residents attended this curriculum with an average of 10-15 trainees per session and 25% from underrepresented minority group. The pre-test and the post- test knowledge assessment score rates were 51% and 83% respectively with an estimated 63% improvement. A large proportion of trainees reported implementing routine HIV testing (97.2%). However, self-reported willingness to prescribe PrEP was low among residents prior to the educational intervention (12.5%) and increased considerably following education (93.3%).

Conclusion

Focused interactive HIV curriculum could represent a viable method to improve knowledge and practices in HIV medicine amongst primary care residents. This novel educational intervention has the potential to be disseminated an implemented in other residency programs curricula.

Disclosures

All Authors: No reported disclosures
967. The Association between PrEP Awareness and Behavioral, Demographic, and Socioeconomic Factors in NYC
Authors: Adekunle Adewumi , Fletcher Gerald , Fagir Marwa , Brimah Idayat , Tijani Sulaiman , Aminata Kamara , Sheppard Richard , Beale Stefani , Mannheimer Sharon
Published: January 2021

Background

Despite significant gains in the treatment of Human Immunodeficiency Virus (HIV), there are still over 38,000 newly diagnosed with the illness annually in the United States. One strategy to reduce HIV infections is Pre-Exposure Prophylaxis (PrEP) for HIV infection. PrEP involves daily oral emtricitabine/tenofovir disoproxil fumarate (FTC/TDF or Truvada®) to reduce infections in those with exposure(s) to HIV or high-risk groups. Studies have shown reduction in HIV transmission with PrEP treatment.

The objective of the study is to investigate how behavioral, demographic, and socioeconomic status (SES) influences the awareness of PrEP treatment in NYC.

Methods

Data on economic, behavioral, PrEP awareness at the UHF neighborhood level was collected by the Community Health Survey (CHS) from the New York City Department of Health and Mental Hygiene and the American Community Survey from the U.S. Census. The population is a cross-sectional telephone survey of NYC residents with landlines and mobile phones for 2016 and 2017. Household income and neighborhood poverty level were used as proxies for SES.

Sex-stratified, multivariate logistic regression model was constructed to estimate adjusted associations and determine differences in awareness of PrEP. The model controlled for age group, race, education level, men sex with men status (MSM), and having had an HIV test in the preceding 12 months.

Results

The final study sample was 5,515 and 5,761 in 2016 and 2017, respectively. In 2016 crude PrEP awareness rate was 24.3% and in 2017 it was 35.4%. In the multivariate analysis for both 2016 and 2017, PrEP awareness was independently associated with age group, education level, male MSM, and having had an HIV test in the preceding 12 months (p < 0.01). The strongest predictors of PrEP awareness were participants with a preceding HIV test in the past 12 months and males who are MSM. PrEP awareness was associated with race for males in 2016 and 2017. PrEP awareness was associated with race for women in 2016, but not 2017.

Figure 1: (left) Median household income in NYC (right) HIV diagnoses and PrEP awareness for 2016 and 2017

Conclusion

Understanding the relationship of neighborhood socioeconomic status and PrEP awareness is essential for HIV epidemiology. By monitoring PrEP awareness, HIV diagnoses, and risk factors associated with the two, public health officials better target interventions and health policy.

Disclosures

All Authors: No reported disclosures
71. Impact of Prospective Audit and Feedback on Fluoroquinolone Use: A Large Academic Medical Center Experience
Authors: Simon Julio C , Vega Ana
Published: January 2021

Background

Fluoroquinolones are an effective class of antimicrobials; however, their use is not without consequence. Recent warnings have resulted in the FDA recommending to reserve this class for infections lacking alternative options. Antimicrobial stewardship significantly reduces targeted antimicrobial use, improves susceptibility patterns, decreases rates of Clostridium difficile infection (CDI), and reduces healthcare-associated costs. Literature on fluoroquinolone stewardship by antimicrobial stewardship programs report similar outcomes in addition to reductions in rates of extended-spectrum beta-lactamase (ESBL)-producing and methicillin-resistant S. aureus (MRSA) infection.

Methods

This study was a retrospective cohort study of adult patients receiving at least 3 days of a fluoroquinolone for an indication of pneumonia or urinary tract infection. Retrospective orders were assessed for prescribing patterns, duration of therapy, and antibiotic choice by indication. The primary outcome was reduction of fluoroquinolone consumption as a result of a prospective audit and feedback intervention, determined with days of therapy (DOT) and DOT per 1000 patient days. Secondary outcomes included hospital length-of-stay (LOS), 3-month post-exposure incidence of CDI, ESBL and MRSA infections, percentage of interventions accepted, and QT prolongation events. Mann-Whitney U was used to determine statistical significance for DOT and LOS, unpaired student t-test was used for DOT per 1000 patient days.

Results

333 patients were reviewed. Fluoroquinolone median days-of-therapy (DOT) was significantly reduced in the intervention phase (7 vs. 4 days, P < 0.001). Median LOS was 8 days for the cohort and did not differ between groups. After adjusting for identifiable alternative causes, no difference in QT prolongation, CDI or ESBL infection was observed. However, these results were limited by lack of diagnostic testing for QT prolongation and inability to assess for other contributing factors related to infection control.

Conclusion

Antimicrobial stewardship is an effective intervention to reduce fluoroquinolone use. An increased LOS was not observed despite patients switching to parenteral therapies. More data is needed to assess differences related to adverse events.

Disclosures

All Authors: No reported disclosures
979. Disparities in PrEP uptake and adherence among cisgender women using a pharmacologic measure
Authors: Hebel Shane , Kahn-Woods Elijah , Enghuus Casper , Koenig Helen , Lalley-Chareczko Linden , Radix Asa , Daughtridge Giffin
Published: January 2021

Background

HIV pre-exposure prophylaxis (PrEP) is 99% effective at preventing new HIV infections if taken daily. To be successful, PrEP requires concurrent efforts to optimize uptake, persistence, and adherence.

In 2018, cisgender (cis) women accounted for 19% of new HIV infections in the US but comprised only 7% of all PrEP users. Studies show poor PrEP adherence amongst cis women, but there is a paucity of real-world clinical data describing PrEP adherence among cis women and gender minority people.

Methods

An adherence test that measures the concentration of tenofovir in urine samples using a liquid chromatography mass spectrometry (LC-MS/MS) was used to assess recent PrEP adherence at 8 clinics. Urine samples were collected during routine visits and analyzed using the LC-MS/MS assay. Test results were retrospectively paired with gender data, when available, and sex assigned at birth (SAAB) data. Adherence data were aggregated and analyzed to assess non-adherence proportions by sub-population.

Results

Gender data were available from 1,461 patients at 5 clinics, 1,344 (92%) of whom were cis males (Figure 1).

From the 5 clinics where gender and SAAB data were available, 3,835 tests were conducted and 517 (13.5%) indicated non-adherence (Figure 2).

3 additional clinics conduct routine adherence testing and collect SAAB data (gender data not available). At these 8 clinics, SAAB data were available for 2,773 PrEP patients, totaling 5,602 urine tests (Figure 3).

Among these 5,602 adherence tests, 813 (14.5%) indicated non-adherence (Figure 4). SAAB females demonstrated significantly higher non-adherence than SAAB males (22% vs 14%, p< 0.001).

Across clinics, 89%-98% of PrEP patients are SAAB male (Figure 5).

Within these 8 clinics, SAAB female demonstrated consistently higher non-adherence (17%-44%, vs 12%-17% for SAAB males) (Figure 6).

Figures 1 and 2

Figures 3 and 4

Figures 5 and 6

Conclusion

Real-world data align with nationwide trends in PrEP utilization and show that the majority of PrEP patients are cis men. When initiated on PrEP, cis women exhibit higher rates of non-adherence than cis men. These data underscore the need to collect gender-identity data to monitor PrEP disparities and suggest that greater efforts are needed to target PrEP access, utilization, and accompanying support services to cis women and gender minority groups.

Disclosures

All Authors: No reported disclosures
72. Improving Antibiotic Prescribing in Interventional Radiology Using Clinical Decision Support Tools to Assess Penicillin Allergies
Authors: Atluri Vidya , Marsland Paula , Johnson Luke M , Jain Rupali , Pottinger Paul , Rampur Lahari
Published: January 2021

Background

Patients labeled with penicillin allergies often receive alternative antibiotics, leading to increased cost, higher risk of adverse events, and decreased efficacy of procedural prophylaxis. However, most of those patients can tolerate a cephalosporin. University of Washington Medical Center – Montlake (UWMC-ML) Interventional Radiology (IR) frequently administer a pre-procedure prophylactic cephalosporin. We worked with the clinicians in IR to develop tools to allow them to better assess penicillin allergies, make the most appropriate antibiotic choice, and update the patient’s allergy documentation.

Methods

We identified all patients who underwent procedures in IR between 2017–2019. Chart review was done to determine the procedures performed, patient demographic information, allergies, allergy documentation, and prophylactic antibiotics received.

In May 2020 we implemented new Clinical Decision Support tools, including an online assessment app (https://tinyurl.com/IRPCNAllAssess) and handouts to guide antibiotic decision making to clinicians in IR.

Results

From 2017 to 2019, 381 patients underwent 958 procedures in IR. Of those, 379 patients underwent 496 procedures for which the recommended first line choice for antibiotic prophylaxis is a cephalosporin. Of patients who received pre-procedure prophylactic antibiotics for those procedures, 15.9% [n=11] of patients with penicillin allergies received the first line antibiotic, compared to 89.9% [n=319] of patients without a reported penicillin allergy. Since implementation, the online app has been used to evaluate 9 patients, of whom 8 had penicillin allergies. All 8 patients safely received the first line antibiotic (3 were delabeled, 4 reported a history of mild reactions, and 1 reported a history of an immediate IgE mediated response to penicillin but safely received cefazolin).

Conclusion

IR evaluates hundreds of patients who may receive prophylactic antibiotics each year. By providing tools to assess penicillin allergies, we were able to improve both their prescribing and de-label patients which will provide a much broader impact on their care than on just their current procedure. Our free tool can be accessed at the website above, and we will demonstrate in person.

Disclosures

All Authors: No reported disclosures
992. Rethinking the 28-day HIV nPEP Dispensing Practice: A Pediatric ID Clinic Analysis
Authors: Zhang David , Rosebush Julia , Bhagat Palak , Nelson Allison , Ramaiah Veena , Seaton Elaine
Published: January 2021

Background

In July 2017, The University of Chicago Comer Children’s Hospital Emergency Department (ED) transitioned from a 5-day to a 28-day HIV nPEP (non-occupational post-exposure prophylaxis) dispensation model in an effort to increase adherence. Anecdotal reports of patients lost to follow-up after ED discharge called into question the utility and cost-effectiveness of this practice. We analyzed HIV nPEP follow-up rates in our clinic, explored reasons for nonadherence, and performed basic cost-savings analyses to inform potential changes to our dispensation model.

Methods

A retrospective review of both electronic health and pharmacy records was conducted for patients prescribed 28-days of HIV nPEP in the ED and scheduled for outpatient follow-up in Pediatric ID clinic from July 2017-June 2019. Clinic provider documentation of nPEP adherence and reasons for nonadherence were examined. Patients were given an initial dose of nPEP regimen in the ED and provided all subsequent doses to complete at home. Using average wholesale price (AWP), we calculated the total cost of each regimen and potential savings if a shorter duration of HIV nPEP supply was dispensed.

Results

50 patients received a 28-day supply of HIV nPEP. Please refer to Table 1 regarding baseline patient characteristics. Of these, only 19 (38%) patients had documented outpatient follow-up after nPEP initiation. Median time to follow-up was 6 days (IQR: 3.0-9.0 days). Of the 19 patients with follow-up, 3 admitted to medication non-adherence. Although side effects were elicited in a total of 9 patients (18%), only 1 cited medication intolerance as the reason for discontinuing their nPEP. Given the relatively short time to follow-up, a potential savings of $1720-2211/patient could be achieved if a 10-14 day supply was dispensed.

Conclusion

Outpatient follow-up after 28-day HIV nPEP dispensation in our ED was < 40%, calling into question the cost-effectiveness of this dispensation model. While our current practice alleviates nPEP interruption due to potential insurance issues and pick-up delays, follow-up and adherence are not assured. The significant cost-savings with a shorter supply at the outset may encourage more robust follow-up and adherence.

Disclosures

All Authors: No reported disclosures
1006. Contraception, Pregnancy and ART in Women of Child-Bearing Years
Authors: Hasan Hira , Richey Lauren E
Published: January 2021

Background

Simpler anti-retroviral (ART) regimens with less pill burden and fewer side effects can improve adherence and clinical outcomes. Warnings about dolutegravir possibly causing neural tube defects (NTD) are alarming and have the potential to limit ART options for women of child-bearing years. A recent preliminary analysis from an observational study group in Botswana prompted a warning from the US Department of Health and Human Services (DHHS), released in May 2018, about the use of dolutegravir during conception.

Methods

At a large urban HIV clinic in New Orleans, a retrospective chart review was performed on adult women up to age 40 who were seen in clinic in 2018 to assess for dolutegravir use, as well as discussion of NTD and pregnancy.

Results

132 woman in the age range were seen in 2018, the mean age was 33 years (range 19 to 40). Average age of HIV diagnosis was 26. Most were African-American (83%) and 81% had Medicaid or no insurance. Eleven percent were diagnosed with HIV due to testing during pregnancy and 17% during routine screening. Sexual exposure was the main reported risk factor for HIV (69%) and 48% had another STD. Only 61% had a documented discussion of contraception and pregnancy plans. Over their treatment at the clinic, 47 pregnancies occurred. Most of the women were on integrase regimens (65%), although 14% were on protease inhibitor regimens and 20% were on other regimens or combination regimens. Forty two percent of the women were ever on dolutegravir and 12 had NTD discussed, resulting in 3 regimen changes. The main reason it was not discussed was permanent sterilization, change to a different ART regimen prior to the warning, long-term contraception, or no sexual activity. Seven pregnancies occurred while on dolutegravir, three were prior to the warning, one after the first trimester, and one ended in abortion. None had an NTD reported.

Conclusion

Dolutegravir is very commonly used due to its tolerability and simplicity. While recent reports show the risk of NTD to be lower than previously thought, it is still elevated compared to other ART and a more open discussion of pregnancy plans, contraception, and NTD if applicable, needs to occur in women living with HIV.

Disclosures

All Authors: No reported disclosures
1009. Dolutegravir and Doravirine in Combination: When Standard Antiretroviral Regimens are Unacceptable
Authors: Denyer Rachel , Zemskova Julie , Beatty Daniel , Benator Debra A
Published: January 2021

Background

A drug-drug interaction study between dolutegravir and doravirine in healthy volunteers found no evidence of untoward interaction. Whilst we hypothesize that the combination would be safe and effective, there is no supportive clinical data. We aimed to assess the rationale for use of dolutegravir and doravirine in combination and clinical outcomes among persons with HIV infection (PWH) receiving care at the Washington DC VAMC.

Methods

A quality improvement initiative utilized the clinical case registry to identify all PWH receiving both dolutegravir and doravirine. We conducted chart review to examine (a) the reasons for switch from other ART to dolutegravir and doravirine, and comorbidities, HIV resistance mutations or drug interactions precluding the use of standard ART, (b) adverse events or side effects and (c) achievement of virologic suppression.

Results

A case registry search revealed 21 individuals receiving combination dolutegravir doravirine from 2018–2020 (Table 1 and Figure 1). Side effects were not noted except one patient developed mild diarrhea that improved with continuation of therapy. Four patients were hospitalized during the follow-up period for reasons unrelated to the medications. One patient who was admitted to the ICU with shock and multi-organ failure was switched on admission but died four days later and therefore was not included in the analysis of viral outcome (Table 2). One patient had cardiac arrest following missed dialysis, hyperkalemia and rectal hemorrhage from metastatic rectal cancer.

Table 1: Patient Demographics.

Figure 1: Reasons for Switching to Dolutegravir with Doravirine.

Table 2: Virologic Control Before and After Switching to Dolutegravir with Doravirine.

Conclusion

In an era of abundant ART options, we identified a subset of older PWH whose treatment options are defined by extensive comorbidities, viral resistance, and medication interactions or toxicities. Doravirine is attractive for this population as it can be used in renal impairment, moderate hepatic impairment, is unaffected by timing of meals, and (unlike rilpivirine) has no interaction with proton pump inhibitors. Dolutegravir is included in NRTI-sparing regimens that HHS guidelines suggest should be considered in older PWH, especially with CKD. We found that dolutegravir with doravirine is well tolerated, and achieves virologic suppression in the majority of PWH, indicating this combination is useful when other ART options cannot be used.

Disclosures

All Authors: No reported disclosures