bluuebunny/crossref_metadata_2025 huggingface dataset:
250. Comparison of T2Candida Assay with Blood Culture, Candida Sepsis Score and Serum β-d-glucan in Diagnosis of Candidemia
Authors: Nizami Sobia , Zacharioudakis Ioannis , Aguero-Rosenfeld Maria E , Neumann Henry J
Published: October 2019

Background

Although blood cultures are the clinical diagnostic standard for candidemia, their delay in results and low sensitivity has lead to increasing the use of alternate tests and diagnostic algorithms. The T2Candida magnetic resonance assay (T2C) results in a few hours, but concomitant cultures are also needed. We compared results from the T2C with β-d-glucan (BDG), blood cultures (BCx) and the Candida Sepsis Score (CSc) in diagnosis and management of candidemia.

Methods

This retrospective observational study included patients from July 2017 to December 2018 who had a T2C as well as BCx. Positive (+) and negative (–) results of BCx and BDG within 24 hours (24 h) of T2C were recorded, with clinical data to determine CSc at the time of T2C (recent surgery, severe sepsis, parenteral nutrition, multifocal candida colonization).

Results

There were 648 T2Cs done over the study period. Only the first +T2C for patients with multiple T2Cs on admission was included. There were 41 patients with +T2, in which 31 had a 24hBCx. Two patients were of pediatric age. There were 7 neutropenic, 1 post-transplant, and 27 intensive care (ICU) patients. Reasons for ordering T2C included sepsis and persistent fevers. In 18 (44%) patients, antifungals were given prior to the T2C. Eight among 31 24hBCx were positive for concordant Candida spp. (26%). Six of these 8 patients were on antifungal therapy when T2C was sent. Seventeen patients had a 24hBDG, with 7 positive (41%). Overall mean CSc in 27 ICU patients with +T2C was 2.2 ± 0.8, and 40% of adult non-neutropenic ICU patients had a CSc of 3 or above. A central line was present in 26 patients, and was removed in 16 after +T2. In 213 patients with −T2C who had 24hBCx, only 1 BCx was positive, from a PICC line in a 2-year-old patient. Seven of the 41 patients with +T2C were treated for deep-seated candidiasis with 6 weeks antifungal therapy or longer; others received 1 to 4 weeks. Thirteen patients died while on antifungal therapy.

Conclusion

T2Candida was used for diagnosis and management of candidemia in patients who had concomitant blood culture positive in 26%, β-d-glucan positive in 41%, and ICU Candida sepsis score 3 or above in 40% patients. It did not miss candidemia in adults, compared with blood culture within 24 hours. Positive T2Candida helped expedite source control e.g line removal.

Disclosures

All authors: No reported disclosures.
267. Fungal Culture Diagnostic Stewardship: An Avenue for Antimicrobial Stewardship in the Immunocompromised Host
Authors: Gurram Pooja , Vashistha Kirtivardhan , O’Horo John C , Shah Aditya
Published: October 2019

Background

Bronchoalveolar lavage (BAL) is a widely used procedure in the diagnosis of pneumonia in critically ill and immunocompromised hosts. Fungal smears and cultures are commonly performed on these samples. We evaluated the yield of various fungi, including but not limited to Candida species, Aspergillus species, Penicillium species, isolated from BAL specimens at our institution to determine the yield of this test and its impact on decision making.

Methods

We identified adult immunocompromised patients who underwent “Bronchoscopy with Immunocompromised Host Protocol (ICH),” which consists of an exhaustive list of diagnostic tests for various pathogenic organisms, over a one year period from January 1, 2017 to December 31, 2017. We reviewed if positive fungal cultures led to a change in management and if this was appropriate.

Results

582 patients underwent bronchoscopy with ICH protocol. There were 285/582 (48.9%) positive fungal cultures of which 177 (62%) grew Candida species. The most common species was Candida albicans (142/177, 80%). 53(18%) were Aspergillus species of which Aspergillus fumigatus was the most common (26/53). 16/285 (5.6%) patients underwent intervention based on the results, 14(87.5%) of which were appropriate. 176/177 (99.4%) patients with Candida species in BAL cultures were not treated.10/53 (18. 8%) patients with Aspergillus species in BAL cultures were treated of which 80% were appropriate interventions based on proven/probable invasive fungal infections criteria as were rest of the 6/16 patients with other fungal organisms (Table 4). Patients with Aspergillus species in BAL cultures are 8 times more likely to have an intervention (OR: 8. 7, P = < 0. 0001) while patients with Candida species in BAL cultures are not likely to be intervened upon (OR: 0. 26, P = 0. 0098) (Table 3).

Conclusion

Although Candida species is commonly isolated in BAL cultures its clinical significance is minimal in the absence of disseminated disease even in immunosuppressed hosts. Evaluating the way that Candida cultures are communicated for respiratory specimens, along with diagnostic stewardship may be a route for antimicrobial stewardship. Consulting ID service early on is essential in assessing the significance of fungal culture data thereby resulting in appropriate changes in management.

Disclosures

All authors: No reported disclosures.
271. Fungal Diagnostic Studies in Histoplasmosis
Authors: Krishnan Gayathri , Power Margaret , Bariola J Ryan , Dare Ryan K
Published: October 2019

Background

Histoplasmosis (histo) is a common cause of invasive fungal infection in endemic regions and accurate diagnosis is difficult without direct tissue culture or pathology. Indirect fungal antigen testing for various fungal pathogens is typically performed to assist with diagnostic workup though cross-reaction can lead to difficulty interpreting results. We aimed to evaluate the prevalence of positive antigen testing for non-Histoplasma fungal pathogens in patients with proven invasive histo.

Methods

We performed a retrospective review of adult patients with proven invasive histo from 2010–2018 at our institution. For inclusion purposes, histo was confirmed by either fungal culture and/or cytology. Patient demographics, clinical characteristics and results of fungal antigen testing for Histoplasma, Blastomyces, Aspergillus, Cryptococcus and β-d-glucan were evaluated. Two different urine Histoplasma antigen assays were used during the study period.

Results

57 (31%) of 182 patients diagnosed with histo during the study period had culture or cytology evidence of disease and were included in all further analysis. Thirty-two (56%) of these patients were male, 35 (61.4%) were Caucasian and the mean age was 50.1 years. HIV (20; 35%) and being on immunosuppressive medications (21, 37%) were common in this population. The majority of cases were classified as disseminated histo (40, 70%) followed by acute pulmonary (10; 18%) and chronic pulmonary (7, 12%) disease. Results of fungal antigen testing are documented in the table. Chi-squared analysis was performed.

Conclusion

There is a frequent cross reaction of non-Histoplasma fungal tests in patients with histo. In our review, there was a high rate of cross reaction with Blastomyces antigen, which can be confusing in regions where both pathogens coexist. Elevation of β-d-glucan was high in these patients. Urine Histoplasma antigen sensitivity was higher with MiraVista testing for disseminated disease in our review. While noninvasive fungal tests are helpful in diagnosis of these infrequent infections, clinicians must still maintain knowledge of the clinical differences between these fungal pathogens and be aware of the limitations of these tests. A prospective study is needed to better define differences between individual Histoplasma tests.

Disclosures

All authors: No reported disclosures.
272. Invasive Pulmonary Aspergillosis: Comparative Analysis in cancer patients with Underlying Hematologic Malignancy vs. Solid Tumor
Authors: Wilson Dib Rita , Khalil Melissa , Fares Johny , Dandachi Dima , Hachem Ray Y , Jiang Ying , Hajjar Chaftari Anne-Marie , Raad Issam I
Published: October 2019

Background

Over the years, the profile of patients with invasive pulmonary aspergillosis (IPA) has extended beyond the commonly associated population with hematologic malignancy (HM) and is now comprising patients with solid tumors and patients with lung diseases. We therefore aimed to compare the clinical characteristics, diagnostic approach and therapeutic outcome of IPA in cancer patients with hematologic malignancies vs. solid tumor (ST).

Methods

We conducted a retrospective study evaluating consecutive cases of proven and probable IPA from March 2004 to December 2016 in a tertiary cancer center. We included patients >18 years with an underlying ST, HM, or Hematopoietic Cell Transplantation (HCT) within 1 year of IPA diagnosis.

Results

A total of 311 patients were analyzed: 225 had HM including HCT and 86 ST. Patients with ST were more likely to have had COPD (33% vs. 8%, P > 0.01) or other underlying pulmonary diseases when compared with HM patients (76% vs. 43%, P < 0.01). Radiation therapy prior to the infection was also notably higher in the ST group than the HM group (48% vs. 14%, P < 0.01). Patients with HM were more likely to have received steroid (38% vs. 15%, P = 0.0001) and have concurrent neutropenia 37% vs. 2%, P < 0.0001). A. fumigatus was most commonly recovered in patients with ST than in patients with HM (66% vs. 38%, P < 0.01). Monotherapy and voriconazole-based primary antifungal therapy were more often prescribed in patients with ST than in patients with HM (87% vs. 56%, P < 0.0001 and 77% vs. 53%, P = 0.0002 respectively). Complete or partial successful response to therapy was recorded in 66% of patients with ST compared with 40% in the HM group (P = 0.0001). IPA attributable mortality within 12 weeks was significantly higher in the HM than in the ST group (30% vs. 18%, P = 0.04).

Conclusion

Monotherapy with voriconazole were more often prescribed in patients with ST than in patients with HM. Patients with ST had a better response to antifungal therapy and a lower IPA attributable mortality within 12 weeks compared with those with HM.

Disclosures

All authors: No reported disclosures.
273. Low Positive Predictive Value of β-d-Glucan in Hematology Patients Receiving Antimold Prophylaxis
Authors: Jin Chang Eui , Il Jun Kang , Mi Moon Song , Beom Park Wan , Hwan Bang Ji , Suk Kim Eu , Won Park Sang , Bin Kim Hong , Kim Nam-Joong , Kyung Kang Chang , Oh Myoung-don
Published: October 2019

Background

Detection of β-D-glucan (BDG) in serum is recognized as the mycological evidence in the diagnosis of invasive fungal infection (IFI). However, its diagnostic value in low prevalence of IFI has not been elucidated. We aimed to examine the performance of BDG in hematology patients receiving antimold prophylaxis.

Methods

We retrospectively reviewed all BDG results performed for the purpose of diagnosis or surveillance for IFI in hematology patients receiving posaconazole or micafungin prophylaxis from January 2017 to February 2019 in a tertiary hospital. At least two consecutive positive results of BDG were regarded as positive BDG. All the episodes were classified into true-positive (TP, positive BDG with probable/proven IFI), true-negative (TN, negative BDG without probable/proven IFI), false-positive (FP, positive BDG without probable/proven IFI), false-negative (FN, negative BDG with probable/proven IFI), and nonevaluable (could not be determined for the occurrence of breakthrough IFI). When BDG test was performed in the setting of persistent fever ≥72 hours in spite of broad-spectrum antibiotics or with a suspicion of IFI, it was defined as a diagnostic BDG episode, while others were defined as a surveillance BDG episode.

Results

Of a total of 140 episodes, 24 episodes were non-evaluable. Among 116 evaluable episodes, 75 received induction chemotherapy for acute leukemia or myelodysplastic syndrome, 35 underwent stem cell transplantation, and 10 had intensive treatment for graft-vs.-host disease. There were three episodes of probable/proven IFI (2.6%). Ninety-one (78.4%) were performed with diagnostic purpose, while 25 (21.6%) were performed for surveillance. TP, TN, FP, and FN were 2 (1.7%), 91, 22, and 1, respectively. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value were 66.7%, 80.5%, 8.3% and 98.9%, respectively. PPV was 13.3% and 0% in diagnostic and surveillance BDG episodes, respectively.

Conclusion

The PPV of BDG was low in hematology patients receiving antimold prophylaxis, even in the diagnostic-driven episodes. The routine screening of BDG is not helpful, and the BDG test may be used for exclusion of IFI rather than for diagnosis in these patients.

Disclosures

All authors: No reported disclosures.
282. Epidemiology of Candidemia in Patients with Solid Tumors of the Gastrointestinal Tract
Authors: Vasylyeva Olga , Chen Tara , Hanna John J , Hassan Hamza , Ogunsesan Yetunde
Published: October 2019

Background

The Gastrointestinal (GI) tract is considered as an important source of candidemia. Numerous studies indicate that the majority of patients with candidemia and cancer have an underlying solid tumor mostly of the GI tract. Widespread use of antifungal prophylaxis among patients with selected hematological malignancies resulted in a proportional redistribution of the frequency of candidemia among patients with various malignancies, but the incidence of candidemia among patients with GI solid malignancies is unknown.

Methods

A retrospective chart review of patients diagnosed with GI malignancies from 2010 to 2018 at Rochester Regional Health, Lipson Cancer Institute was conducted, and the incidence of candidemia was determined.

Results

A total of 2783 patients with GI malignancies were analyzed. Fifty-six percent were males, and a mean age was 67 years. Sites of malignancy included large intestine (n = 1269), pancreas (n = 394), any part of the mouth and associated organs (n = 282), liver and biliary system (n = 273), stomach (n = 235), esophagus (n = 135), small intestine (n = 110), and others (n = 85). Over the period of review, total mortality was 49%. Only 0.7% (n = 19) patients developed candidemia, with a total of 22 events. Nine episodes of candidemia happened prior to diagnosis of cancer, and 13 episodes developed after or at the time of diagnosis. There was no commonality in GI solid malignancy site among patients with candidemia. C. albicans was the most common isolate (9 episodes), followed by C. parapsilosis (8), C. glabrata (3), and C. dubliniensis (2). At the same time, there were 273 episodes of bacteremia in 230 patients (8%).

Conclusion

In our study candidemia among patients with GI solid-organ malignancies was very rare.

Disclosures

All authors: No reported disclosures.
283. Potentially Achievable Hepatitis A Vaccination Coverage with Simultaneous Administration of Vaccines Among Young Children in the United States
Authors: Zhao Zhen , Hill Holly , Elam-Evans Laurie , Chen Michael , Singleton James A
Published: October 2019

Background

The Advisory Committee on Immunization Practices recommends simultaneous administration of all age-appropriate doses of vaccines. We estimated the vaccination coverage for ≥2 doses of hepatitis A vaccine (≥2 HepA) that could have been achieved if opportunities for simultaneous administration with other recommended childhood vaccines had not been missed.

Methods

We analyzed National Immunization Survey-Child data for 2008–2017 in the United States. We defined potentially achievable ≥2 HepA coverage by age 24 months as the possible coverage if opportunities for simultaneous administration with other age-appropriate doses of vaccines for children by age 24 months had not been missed. We compared potentially achievable vaccination coverage to reported ≥2 HepA vaccination coverage by birth years 2007 to 2015. For children born in 2015, we stratified estimates by state and by selected socio-demographic factors. Both potentially achievable and reported ≥2 HepA coverage were evaluated using a Kaplan–Meier survival procedure to account for censoring of vaccination status.

Results

Compared with reported vaccination coverage, potentially achievable coverage for ≥2 HepA was at least 10 percentage points higher across birth years 2007 to 2015 and would have surpassed the 85% target of Healthy People 2020 for children born in 2015 (Figure 1). For the 2015 birth cohort, potentially achievable ≥2 HepA coverage exceeded the 85% Healthy People 2020 target in ten states (Figure 2). In addition, potentially achievable vaccination coverage was higher than reported coverage across all selected socio-demographic factors, with differences ranging from 20.1 percentage-points (private insurance only) to 31.7 percentage-points (non-Hispanic Black) (Table 1).

Conclusion

Potentially achievable coverage with ≥2 HepA consistently exceeded reported coverage for children from nine recent birth cohorts and across all selected socio-demographic characteristics. Coverage could increase substantially if missed opportunities were eliminated. Evidence-based interventions such as establishment of standing orders, use of provider reminders, and use of immunization information systems are recommended to increase HepA coverage among young children.

Disclosures

All authors: No reported disclosures.
294. Hepatitis C Virologic Response in Hepatitis B and C Coinfected Persons Treated with Directly Acting Antiviral Agents: Results from ERCHIVES
Authors: Butt Adeel A , Yan Peng , Aslam Samia , Sherman Kenneth , Siraj Dawd , Safdar Nasia , Hameed Bilal
Published: October 2019

Background

There are scant data regarding hepatitis C (HCV) virologic response to directly acting antiviral agents (DAAs) in chronic hepatitis B (HBV) and HCV coinfected persons. HCV treatment response in those with spontaneously cleared HBV infection is unknown.

Methods

All HCV-infected persons treated with a DAA regimen in ERCHIVES were identified and categorized into HBV/HCV-coinfected (HBsAg, HBV DNA or both positive), HCV-monoinfected, and resolved HBV (isolated HBcAb+). SVR rates were determined and compared for all groups. A logistic regression model was used to determine factors associated with SVR.

Results

Among 115 HCV/HBV-coinfected, 38,570 HCV-monoinfected persons, and 13,096 persons with resolved HBV, 31.6% of HCV/HBV-coinfected, 24.6% of HCV-monoinfected and 26.4% with resolved HBV had cirrhosis at baseline. SVR was achieved in 90.4% of HCV/HBV-coinfected, 83.4% of HCV-monoinfected and 84.5% of those with resolved HBV infection (P = 0.04 HCV/HBV vs. HCV monoinfected). In a logistic regression model, those with HCV/HBV were more likely to achieve SVR compared with HCV monoinfected (OR 2.25, 95% CI 1.17, 4.31). For HCV/HBV coinfected, the SVR rates dropped numerically with increasing severity of liver fibrosis (P-value non-significant). Factors associated with a lower likelihood of attaining SVR included cirrhosis at baseline (OR 0.85, 95% CI 0.80, 0.92), diabetes (OR 0.93, 95% CI 0.87, 0.99) and higher pretreatment HCV RNA (OR 0.86, 95% CI 0.84, 0.87).

Conclusion

HBV/HCV-coinfected persons have higher overall SVR rates with newer DAA regimens. The virologic response is graded, with decreasing SVR rates with increasing degree of liver fibrosis as determined by the FIB-4 scores.

Disclosures

All authors: No reported disclosures.
298. Collocation of Hepatitis C Care Continuum with MAT for High-Prevalence, High-Risk Population
Authors: Narayanan Shivakumar , Abutaleb Ameer , Hoffmann Jennifer , Greenblatt Aaron , Kottilil Shyam , D’Amore Aaron , Brokus Christopher , Kattakuzhy Sarah
Published: October 2019

Background

The hepatitis C virus (HCV) epidemic in the United States disproportionately impacts people who inject drugs (PWID) who account for 80% of new infections and have a high prevalence of chronic infection. Baltimore City has the highest case rate of HCV in the state of Maryland with over 25% of new cases statewide occurring in the city. Only 10% of PWID have access to directly acting antiviral (DAA) therapy and are cured of HCV. Medication-assisted treatment (MAT) is currently offered in isolated facilities with limited access to other specialty care. In this study, we collocated HCV care continuum in a MAT facility offering opioid agonist therapy and psychosocial interventions

Methods

Collocation of HCV care was initiated in an MAT (methadone and buprenorphine) clinic, the University of Maryland Drug Treatment Center (UMDTC) serving over 700 patients, for Opioid Use Disorder (OUD) in Baltimore City (Figure 1). Screening for HCV was expanded through health education of patients and staff and expanded testing. HCV antibody-positive patients were linked to care with an experienced HCV provider or referred to hepatologists (decompensated cirrhosis).

Results

Most of the attendees were African-American with an average age of 52 years. 354 out of 701 clients attending clinic for methadone/suboxone (50.5%) were screened for HCV. Of the 251 patients who were hepatitis C antibody positive (70% of tested), 54 had undetectable HCV RNA. 46 had no HCV RNA labs available. 151 of the remaining HCV Ab positive patients who had a detectable HCV RNA result were evaluated for treatment (Figure 2). At initial assessment, 45 (48%) with liver fibrosis staged greater than F3, including 25 (27%) with cirrhosis. Sixty-four patients initiated DAA therapy. Fifty-four patients completed treatment (84%). Forty patients achieved sustained virologic response (100%) and 14 patients who completed treatment await SVR labs.

Conclusion

Collocation of HCV care continuum in MAT setting is an effective way to achieve micro elimination of HCV. The follow-up of this marginalized population still remains challenging given the high rates of homelessness and incarceration. In this regard, coordinated care between MAT settings and prisons are likely to demonstrate successful elimination of hepatitis C.

Disclosures

All authors: No reported disclosures.
299. “Where the Rubber Meets the Road”: Stakeholders’ Perspectives about the Current State of HCV Care Delivery in Massachusetts Jails
Authors: Wurcel Alysse G , Reyes Jessica , Zubiago Julia , Burke Deirdre , Concannon Tom , Freund Karen , Wong John , Beckwith Curt , LeClair Amy
Published: October 2019

Background

HCV is highly prevalent in criminal-justice involved populations (CJIP). Nationally, the operationalization of guideline-driven HCV care (including testing and treatment) for CJIP has been challenging, prompting this study to understand barriers and facilitators.

Methods

We used purposeful sampling strategies to recruit key stakeholders including people who are incarcerated, clinicians providing care in jail, clinicians providing care outside of jail, corrections administrators, and representatives of industry, public health and public policy. Semi-structured interviews were performed in Spanish or English, based on preference of participant. Written notes were used to capture details from interviews in jails and interviews outside of jail were recorded. People interviewed outside of jail were offered a stipend. Interviews were coded and analyzed with a compare and consensus approach.

Results

Of 120 people, 49 (41%) people agreed to be interviewed in each of the stakeholder categories including 21 men who were incarcerated (mean age 32 [IQR 25, 39], 60% non-White). Barriers to HCV care delivery included (1) Fragmented healthcare delivery because of transient nature of CJIP (2) Frustration and disempowerment experienced by people incarcerated in jail and (3) Heterogeneous views on stakeholders responsible for providing and financing HCV care in jails. Facilitators to HCV care delivery included (1) Incarcerated population’s interested in HCV care for public and personal health and (2) An existing strong public health infrastructure in place supporting HIV care delivery.

Conclusion

Understanding various stakeholders’ views of barriers to HCV care in jails is a necessary first step to building improved care pathways. Mutual recognition may help to focus limited administrative and fiscal resources on HCV care for this transient population.

Disclosures

All authors: No reported disclosures.
305. Using Big Data to Re-Engage Hepatitis C-infected Persons: A UK Operational Delivery Network’s Experience
Authors: Osborne William , Sheikh Noorann , Bosworth Andrew , Bufton Sally , Mutimer David , Tahir Mamoona , Atabani Sowsan F
Published: October 2019

Background

The prevalence of hepatitis C (HCV) varies across different risk groups in the UK. In England, responsibility for the co-ordination and administration of DAAs (direct-acting antivirals) to HCV PCR positive patients is with 22 regional “Operational Delivery Networks” (ODNs). To attempt to eliminate Hepatitis C before 2030, Public Health England (PHE) and NHS England (NHSE) are attempting to re-engage previously diagnosed infected persons. To this end, ODNs have been supplied with historical antibody result data to target and reengage individuals for PCR testing and intervention if required.A study was designed to evaluate these data to help with informing ODN decisions. This study aimed to ensure that the data accurately identified patients that were PCR positive for HCV and thus fit the current criteria for receiving DAAs.

Methods

The regional ODN for the West Midlands was provided with 4540 patients with historical positive HCV antibody results, collected by a PHE surveillance system, to target for DAA intervention. DAA-treated patients had been excluded. Patient details were cross-referenced with all PCR results from January 1, 1996 up to January 1, 2019 at several regional laboratories (Public Health England Birmingham, the Queen Elizabeth Hospital, City and Sandwell Hospital) and national treatment data.

Results

PCR data were found for 988, 276 (28%) of whom had received treatment. Of the 712 persons untreated, 347 (49%) were PCR negative and thus would not fit the criteria for receiving DAAs. 365 (51%) had a positive PCR result without a record of treatment would be eligible for DAAs (see Figure 1).

Conclusion

Our study suggests approximately one-third of patients identified by cross-referencing NHSE treatment and PHE epidemiological HCV antibody databases will be PCR-positive and suitable for re-engagement. Epidemiological data needs to be accurately curated when implementing public health control measures. Using “Big Data” to target interventions has several limitations but can be useful. DAAs for HCV are not without risk and administration should be clinically justified. Re-testing individuals prior to intervention is essential and other methods of elimination, for example “test and treat,” may be more efficient and accurate.

Disclosures

All authors: No reported disclosures.
308. Slow Adoption of a Nurse-Driven Protocol for Universal Hepatitis C Virus Screening in a Hospital Emergency Department: Lessons Learned
Authors: Wasti Zainab , Coppock Dagan , Szep Zsofia , Scott Tiffany , Franks Taneesa , Kesaris Anna , Chou Edgar , Heun Lee Dong
Published: October 2019

Background

In areas with a high prevalence of hepatitis C virus (HCV) infection, emergency department (ED) visits may provide unique opportunities for screening. The catchment area for Hahnemann University Hospital (HUH) has an HCV seroprevalence rate of >20%. However, limited data exist addressing HCV testing strategies in the ED. This study describes the experience of piloting a nurse-driven HCV screening protocol in an urban hospital ED.

Methods

A nurse-driven HCV screening protocol was developed and implemented on August 1, 2018. We performed a retrospective analysis of the protocol’s performance from July 1, 2018, through December 31, 2018. Patients who were evaluated in the ED and had blood collected were analyzed. We provided universal HCV screening regardless of age or risk factors. If HCV-positive by antibody screen and viral load confirmation, an attempt was made to link patients to care. Linkage was defined as having received an inpatient evaluation by either infectious diseases or hepatology physician.

Results

Among 20,705 unique patients seen in the ED, 7841 (38%) had blood work collected. 821 (10.5%) patients had HCV antibody testing. After the implementation of the nurse-driven protocol, the testing rate increased from 68/1340 (5.1%) to 753/6501 (11.6%). 260 Baby Boomers (born between 1945–1965) were screened, of which 60 (23.1%) had positive screens. 561 non-Baby Boomers were screened, of which 30 (5.4%) had positive screens. Barriers of implementing nurse-driven protocol were: (1) multiple steps of the ordering process in the electronic medical record (EMR), (2) the complexity of staff schedules, and (3) staff concerns regarding the disclosure of HCV test results. Among the patients who were diagnosed with chronic HCV, 60 % were linked to care for treatment.

Conclusion

We piloted a nurse-driven universal HCV testing protocol in the ED of a hospital with high HCV prevalence. Though the screening rate doubled, it was still low. We identified barriers that may be addressed to improve future screening rates. In areas with a high seroprevalence of HCV, universal screening may be an excellent public health intervention to identify asymptomatic HCV-infected patients.

Disclosures

All authors: No reported disclosures.
311. Hepatitis C Screening Within a Large FQHC Network in Brooklyn, New York: How We Measure Across an Ethnically Diverse Population
Authors: Hayon Jesica , Dapkins Isaac , Shahin George , Colella Doreen , Jrada Morris , Bhakta Dimpal , Allen. Pasco Neil
Published: October 2019

Background

With over 100,000 unique lives and 600,000 visits in 2018, The Family Health Centers at NYU Langone (FHC) is one of the largest Federally Qualified Health Center network based primarily in Southwest Brooklyn New York. Within the catchment area 48% of the population report being born out of the United States, with 30% of the population describing themselves of Asian ethnicity and 42% as Latino [1]. Effective January 1, 2014 New York State law mandated hepatitis C screening to be offered to every individual born between 1945 and 1965 receiving health services. Now five years later, with the advancements in treatment options and increased access for patients where cost has become prohibitive we retrospectively reviewed how our performance has been prior to embarking on a goal of 60% screening compliance.

Methods

We performed a retrospective chart review looking at a denominator of patients born between 1945 and 1965 who were seen in the FHC for a visit in 2018. Patients who were previously screened since 2016, have a diagnosis of hepatitis C, history of hepatitis C documented in either past medical history, problem list or ICD code were excluded. Data abstraction for compliance in the numerator included patients who have a resulted hepatitis C antibody or have indicated current treatment (with a hepatitis C viral load).

Results

51% of patients based on the aforementioned methodology have been screened in 2018. 11,577 patients were eligible with 650 patients having a documented refusal. 261 new diagnosis were made in 2018 and compliance for non-screened patients without any prior screening was 35%. Regarding racial/ethnic composition of the practice sites compared with patients screened, one practice site with an 87% Asian non-Hispanic population had a 35% compliance rate with screening where as the most predominate Hispanic population site (81% of total patients seen) had a 54% compliance rate.

Conclusion

Overall screening rates within the network are commendable, yet more work is being done to drive provider awareness on the need for compliance. Differences in racial/ethnic backgrounds and compliance of screening completion can be seen within the FHC network. Current efforts are focused on increasing culturally appropriate awareness amongst the patient population as well as the providers.

Disclosures

All authors: No reported disclosures.
313. Bringing Hepatitis C into FOCUS: Evaluating the Efficiency of a Linkage to Care Program in Improving the Hepatitis C Care Cascade
Authors: Battle Brittany M , Gierlach Michael , Allen Brian , Jenkins Melissa O , Avery Ann
Published: October 2019

Background

In 2016, The MetroHealth System began enhanced hepatitis C (HCV) screening through decision support, coupled with linkage of newly diagnosed patients to specialty care by a Linkage to Care coordinator (LTCC). Prior to this, patients were notified of their HCV diagnosis by a provider and given a referral to a specialist. We hypothesized that an LTCC would shorten time from HCV diagnosis to HCV treatment.

Methods

Patients newly diagnosed with HCV between June 1, 2015 and December 31, 2015 (Pre-LTCC), were compared with patients newly diagnosed between January 1, 2016 and March 31, 2017 (Post-LTCC). Patients who were HCV RNA negative were excluded. The time between diagnosis and linkage, linkage and treatment start date, and diagnosis and treatment start date for each population were compared using unpaired t-tests.

Results

125 newly diagnosed patients were identified in the Pre-LTCC population. 83 (66%) were linked to specialty care and 27 (22%) received HCV treatment. 446 newly diagnosed patients were identified in the Post-LTCC population. 211 (47%) were linked to specialty care and 70 (16%) HCV positive persons were treated. No significant difference was noted between the groups in days between diagnosis and specialty care linkage (Pre-LTCC mean = 120 days; Post-LTCC mean = 102 days). The time from linkage to treatment was significantly longer in Pre-LTCC (260 days) than Post-LTCC persons (152 days), P < 0.05. The average time from diagnosis to treatment in pre-LTCC persons was also significantly longer than in Post-LTCC (332 days vs. 237 days, P < 0.05) (See Table).

Conclusion

We demonstrate that post-implementation of an LTCC program for HCV, the time between diagnosis and treatment of HCV was significantly reduced. This reduction, however, did not seem to be due to faster linkage to specialty care. A limitation of the study is that differences in HCV care (insurance restrictions, availability of new regimens) between the pre-LTCC and post-LTCC period were not considered. Although the linkage rate in the post-LTCC period was lower, some patients in post-LTCC may still be awaiting linkage. While there was an observed reduction in time between linkage and treatment, further research is needed to determine the causes of this reduction.

Disclosures

All authors: No reported disclosures.
315. Prenatal Hepatitis C Viral (HCV) Screening Practices and HCV-Associated Fetal, Neonatal and Pregnancy Outcomes in a Large Regional Healthcare System
Authors: Adhikari Tripti , Scott Rachel , Timalsina Utsav , Amgalan Ariunzaya , Sawney Shari L , Tefera Eshetu , Fernandez Stephen , Fishbein Dawn
Published: October 2019

Background

Prevalence of HCV in pregnancy is 0.1–3.6%. AASLD and IDSA now recommend HCV screening in pregnancy although CDC, USPSTF, or ACOG still do not—though HCV can be perinatally transmitted and carries associated complications for the mother and fetus. Our study objectives were to analyze prenatal HCV screening practices at a large regional healthcare system and the prevalence of HCV-associated maternal and fetal/neonatal outcomes.

Methods

We performed a nested propensity score (PS) case–control study of pregnant women who tested HCV Ab+ in a cross-sectional study of women presenting for prenatal care at a large regional healthcare system from January 17 to December 18. We collected retrospective EHR data, including state of residency, HCV Ab, RNA, care engagement, HCV risk factors, comorbidities, maternal and fetal/neonatal morbidity, and neonatal HCV testing (when available). Mixed and generalized linear models were used to examine differences in continuous and categorical variables, respectively, between cases and controls

Results

14,363 women were seen for prenatal care; 4,891 (34%) were HCV tested, 75 (1.5%) tested HCV Ab+. Demographic and comorbidity data are shown in Table 1. HCV Ab+ cases had more co-morbidities, including obesity, heart disease, opioid use, and behavioral health issues compared with the controls. HCV risk factors included IVDU (64%) and tattoos (24%) (Figure 1). Neither past/current pregnancy-related complications nor fetal or neonatal adverse events (Figure 2) were statistically significantly different except for cholestasis in HCV Ab+ cases (5.3 vs. 0%, P = 0.04).

Conclusion

Our study showed only one-third of pregnant women are currently HCV screened in our health system. Universal screening would likely increase the number of HCV-infected women identified. Early HCV detection, repeated testing, and behavioral health intervention of those at high-risk may decrease further horizontal and vertical transmission of HCV in pregnancy.

Disclosures

All authors: No reported disclosures.
316. Hepatitis C and Engagement in Health Care Among Persons Who Inject Drugs and Persons Who Use Non-Injection Drugs, Philadelphia
Authors: Addish Eman , Zellman Hannah , Kostman Jay , Viner Kendra , Kuncio Danica , Trooskin Stacey
Published: October 2019

Background

The growing opioid epidemic is driving increasing rates of hepatitis C virus (HCV) infections in the United States. HCV transmission is most frequently attributed to unsafe injection behaviors, but can occur via other unsafe drug use and sexual behaviors. Differences in demographics, HCV rates and associated risk factors in non-injecting PWUD (NIPWUD), compared with people who inject drugs (PWID) must be understood in order to target elimination strategies.

Methods

Change is Philadelphia’s program to eliminate HCV among PWUD and enrollment includes HCV testing, linkage services, and an interviewer-administered survey including risk behaviors and healthcare engagement. This interim analysis includes the first 835 enrollees that identified as PWUD. For this analysis, PWID are enrollees who indicated ever injecting drugs and those who had not are NIPWUD.

Results

Among enrollees, 76% (N = 637) reported ever injecting drugs. PWIDs were younger and non-Hispanic (NH) white while NIPWUD were older and NH Black (age: P = 0.003; race/ethnicity: P < 0.0001). NIPWUDs had a high seropositivity rate though significantly lower than PWIDs (24% vs. 85%, respectively; P < 0.0001). Among PWID enrollees, 94% (N = 596) ever snorted. Of enrollees, 63% (N = 124) of NIPWUD and 56% (N = 356) of PWID identified having a PCP (P =0.07). PWIDs are more likely than NIPWUD to have overdosed (OD) (40% vs. 9%; P < 0.0001) though high rates of both groups ever witnessed an OD (84% vs. 67%, respectively). While 80% (N = 105) of NIPWUDs know how to use Narcan, 60% (N = 79) carry it, {94% (N = 503) and 71%(N = 381) in PWID, respectively}. NIPWUDs are more likely to be interested in drug treatment (P < 0.0001) and to have received it in the last 12 months (P = 0.0008).

Conclusion

Notable HCV infection exists among non-injecting PWUD reinforcing the need for harm reduction counseling and access to drug use equipment used for smoking and snorting. NIPWUD may be able to access drug and HCV treatment through PCPs and fatal ODs may be prevented by ensuring NIPWUDs have access to Narcan. In addition, PWID are likely to snort as well and should be counseled on non-injecting harm reduction methods. To succeed in micro elimination among PWUD, a focus on NIPWUDs as well as PWIDs is necessary to mitigate transmission of HCV.

Disclosures

All authors: No reported disclosures.
319. SWORD 1 and 2: Switch from TDF Containing Regimen to DTG+RPV Maintains Bone Mineral Density and Decreases Bone Turnover Markers Over 148 Weeks
Authors: Kahl Lesley , McComsey Grace A , Coronado Poggio Monica , Lupo Sergio , de Wet Joss , Parks David A , Wynne Brian , Gartland Martin , Angelis Kostas , Aylott Alicia , Cupo Michael , Vandermeulen Kati , van Wyk Jean A , Smith Kimberly
Published: October 2019

Background

HIV infection and antiretroviral therapy (ART), particularly tenofovir (TDF), is associated with loss of bone mineral density (BMD). The SWORD studies demonstrated noninferiority of the 2-drug regimen (2DR) dolutegravir (DTG) + rilpivirine (RPV) to continuing current triple-therapy ART (CAR) at 48 weeks and continued viral suppression on DTG+RPV through Week 148. A substudy of SWORD 1 and 2 evaluated a change in BMD by DEXA for those participants who switched from triple ART containing TDF to DTG+RPV. The primary analysis reported at 48 weeks showed a significant increase in total hip and lumbar spine BMD and a significant decrease in bone turnover markers in patients receiving DTG+RPV compared with CAR. Here we present data through Week 148.

Methods

HIV-infected adult patients with HIV-1 RNA < 50 c/mL received ART containing TDF for ≥6 months prior to randomization to DTG+RPV (Early Switch group, ES) or CAR on Day 1 (Baseline, BL) through Week 48 in SWORD-1/2. CAR patients suppressed at Week 48 switched to DTG+RPV at Week 52 (Late Switch group, LS). Hip and lumbar spine BMD were measured by DEXA scans read centrally. Secondary endpoints include a change in BMD and bone turnover markers through Week 148.

Results

Following switch to DTG+RPV significant increases were observed for total hip in the ES and LS groups through 100 weeks with a non-significant increase at Week 148 in ES (Figure 1a). Lumbar spine BMD significantly increased from BL at 48 weeks post switch, remained increased, though not significantly from BL through Week 148 (Figure 1b). The BMD of the LS group was similar to that of the ES group through 100 weeks exposure. The majority of patients remained in their pre-switch T-score category or improved a category for both hip and spine through Wk148 (Table 1). Through Wk148, BMI increased minimally and bone turnover markers significantly decreased (P < 0.001 to 0.042 across markers) from BL/LS BL except Type I Collagen C-Telopeptide at Wk148 in the LS group (P = 0.279).

Conclusion

Switch to the DTG+RPV 2DR was associated with sustained improvements in BMD through Week 148, along with a reduction in bone markers. The favorable effects on skeletal health were observed despite the ageing of study patients and other factors decreasing BMD. A switch to DTG+RPV in suppressed patients provides a robust option for preserving bone health while continuing suppressive HIV treatment.

Disclosures

All authors: No reported disclosures.
320. UK-HOPS (HIV Osteoporosis Prevention and Screening)-Gaps in the Care of HIV Patients with Bone Disease
Authors: Maibam Amita , Rao Madhumathi , Lia Castellanos Ana , Lima Florence , Stivers Tiffany , Holleman Donald , Thornton Alice
Published: October 2019

Background

With increasing life expectancy among people living with Human Immunodeficiency Virus (HIV), long-term complications such as osteoporosis/osteopenia and fractures are frequently seen. Although screening guidelines exist for bone disease in the HIV population, quantitative and qualitative gaps exist in screening and prevention. Bone disease in HIV is multifactorial, and FRAX may not accurately predict fracture risk. The aim of our study is to describe diagnostic features of bone disease and estimate the population at risk, and evaluate the frequency of screening, referral and treatment in patients attending an HIV Clinic.

Methods

We performed a retrospective analysis of 1220 patients with HIV infection ≥40 years of age who attended the HIV clinic under the Ryan White program, during January 2016 to December 2018, at University of Kentucky. We obtained demographic details (Table 1), comorbidities, laboratory testing, bone mineral density (BMD) testing and specialty bone clinic referral data from electronic health records, applying ICD -10 and CPT codes. We estimated the frequency of BMD measurement and prevalence of risk factors for bone disease specific to this population.

Results

BMD testing was performed in only 158 (13%) patients (CMS targets 60% for testing at-risk populations). Of these patients, 76 (48%) had osteopenia and 59 (37%) had osteoporosis; 22 (14%) received treatment (Figure 1). Seven patients with osteoporosis/osteopenia and fracture had bone biopsy, with low bone turnover in four (57%). Potential risk factors for secondary osteoporosis are presented in Table 2; at least one factor was present in 98% of patients. Fracture prevalence was likely underestimated because the ICD-10 /CPT coding was available only in 23 (2%) patients.

Conclusion

Bone disease is under-recognized and undertreated, and targeted screening programs are needed for earlier diagnosis and management in this population. Bisphosphonates may not be optimal first-line therapy for all HIV patients with bone loss. In addition to stress or fragility fractures and worsening osteoporosis, metabolic bone work-up should be performed in patients with secondary osteoporosis related to CKD, renal phosphate loss, prior bisphosphonate/Tenofovir/glucocorticoid treatment.

Disclosures

All authors: No reported disclosures.
323. Fragility Fracture Risk in HIV: Awareness Among Primary Care Providers
Authors: Abbate Anne , Chirch Lisa , Christopher. Thompson Michael , Wakefield Dorothy , Mirza Faryal , Zawadzka Sabina
Published: October 2019

Background

Recommendations on screening HIV-infected (+) patients for bone disease exist. We sought to characterize awareness of and adherence to HIV-specific recommendations and assess risk factors for fracture in this population.

Methods

Primary care provider (PCP) and ID specialist awareness of screening recommendations was assessed using an anonymous electronic survey. We conducted interviews of 45 HIV+ patients and chart review. We calculated risk using the fracture risk assessment tool (FRAX). Email notifications were sent if an indication dual-energy x-ray absorptiometry (DXA) scans was identified. Chart review was repeated 12 months later to assess response. Statistical methods included chi-square and Fisher’s exact test for categorical data, and t-tests or Wilcoxon rank-sum tests for continuous data. A multivariate logistic regression examined the relationship between adult fragility fractures and covariates.

Results

No immunologic or virologic factors or exposure to specific antiretroviral therapies (ART) were associated with FFX (Table 1). FRAX score (hip, major osteoporotic fracture) successfully predicted FFX history (P = 0.002, P = 0.001, respectively). Overall, 35 (78%) patients qualified for DXA; 23 (66%) were men, only 8 (23%) had a previous DXA. Following provider notification, an additional 5 patients had DXA ordered. DXA was recommended for all patients with FFX, compared with 68% without a fracture (P = 0.02). In logistic regression modeling, increasing age, male sex, and months of ART therapy were associated with FFX (Table 2). Twenty-seven providers responded to the pre-intervention survey, of whom only 35% were aware of screening recommendations for HIV+ patients. Of the 18 providers who responded post-intervention, 63% were aware of these recommendations (Table 3).

Conclusion

A brief educational intervention resulted in increased awareness of HIV-specific screening recommendations, but this translated into adherence to a lesser extent. HIV+ men were more likely to have a history of fragility fracture compared with females. No specific ART or immunologic marker predicted fracture risk or history. Fostering a greater understanding of unique characteristics and risks in this population is crucial to ensure appropriate preventive care.

Disclosures

All authors: No reported disclosures.