bluuebunny/crossref_metadata_2025 huggingface dataset:
726. Investigation of Epidemiological Characteristics and Outcomes in Enteropathogenic Escherichia coli positive patients
Authors: Lusby Heather , Rand Kenneth , Beal Stacy
Published: January 2021

Background

New generation multiplex polymerase chain reaction (PCR) panels have led to the ability of rapid detection of Enteropathogenic Escherichia coli (EPEC). Although many studies have looked at the pathogenesis of this organism in the pediatric populations, fewer studies include adults. We aimed to determine if EPEC is pathogenic on its own, or has a predilection for certain populations based upon risk factors. This was achieved by comparing risk factors in patients positive for EPEC on the BioFire Gastrointestinal (GI) Pathogen Panel versus patients negative for all targets on the panel.

Methods

This is a single center case control study that was performed using a retrospective chart review from January 1, 2016 thru August 31, 2019. All patients were symptomatic with diarrheal illness and had a GI pathogen panel performed. The study group were patients that were EPEC positive. The control group were patients with a negative PCR panel that were matched three to one based upon age and gender. Chi-squared statistical analysis was used.

Results

792 patients were evaluated. In the adult group the EPEC positive actual length of stay (LOS) was 13.5 rather than 9.3 in the control. Although this was not statically significant this trended towards a longer LOS as seen in Table 1. In the pediatric population, both expected and actual LOS were statically longer viewed in Table 2. This may be due to these patients being more chronically ill at baseline, with a greater number of pediatric coronary artery disease and ulcerative colitis in the control. Males were more likely to test positive for EPEC at 69.86% in the pediatric population than in the adult population with statistical significance at p=0.0035. The pediatric population had more co-infections with EPEC at 57.53% with p< 0.0001. This can be further seen in Table 3.

Table 1

Table 2

Table 3

Conclusion

In the adult EPEC positive patients there was no statistically significant difference in length of stay in comparison to negative control. This raises the question to if this is truly a pathogen in adults. In the pediatric population, our control group was likely more ill, which made it difficult interpret the significance of differences in LOS.

Disclosures

Kenneth Rand, MD, BioFire Diagnostics, Inc (Consultant, Grant/Research Support, Advisor or Review Panel member, Research Grant or Support) Stacy Beal, MD, FilmArray BioFire (Grant/Research Support)
727. Outcomes of Antibiotic Use in Ischemic Colitis
Authors: Poenaru Sonia , Sherazi Adeel , Suh Kathryn , Stuleanu Tommy
Published: January 2021

Background

Ischemic colitis (IC) is caused by inadequate blood flow to the colon. Most cases resolve with conservative management. Isolated right-sided colitis, peritonitis, shock, and vascular risk factors are predictors of severe disease which can be life-threatening and require surgery. Current guidelines recommend antibiotics for moderate/severe disease. This is based on results from animal models and concern for gut translocation of bacteria; there have been no comparative studies in humans. This study aims to evaluate whether there is benefit to antibiotic use in non-severe IC.

Methods

This is a single-center retrospective cohort study of adult patients hospitalized with IC from 2015-2018. Inclusion in the study required endoscopic, radiologic, operative, or histologic evidence of ischemic colitis. Patients were divided into mild/moderate and severe IC cohorts as per 2014 American College of Gastroenterology Guidelines. Primary outcomes were length of stay (LOS) and any adverse event, which is defined as a composite measure of pre-specified secondary outcomes including mortality, need for surgery, 1-year relapse, and bacteremia.

Results

Of 191 patients enrolled in the study, 130 had mild/moderate IC and 61 had severe IC. In mild/moderate IC groups there was no significant difference in total adverse events, although use of antibiotics was associated with a significant increase in LOS (Table 1). In the severe IC groups there was no significant difference in any primary outcomes, but mortality was lower at 3 and 6 months among patients who did not receive antibiotics.

Table 1

Conclusion

Antibiotics did not improve outcomes in mild/moderate IC, suggesting that conservative management may be sufficient in this group. Antibiotic use was associated with increased LOS in mild/moderate IC and with increased mortality in severe IC; it is not clear whether these associations are true antibiotic-mediated adverse effects or whether they simply reflect a tendency to use antibiotics more frequently in patients who are more unstable. Future prospective research is needed to establish clear guidelines for antibiotic indications, agent selection, and optimal treatment duration.

Disclosures

All Authors: No reported disclosures
729. Real World Efficacy of Bezlotoxumab for Prevention of Clostridioides Difficile Recurrence in Immunosuppressed Patients
Authors: Perreault Sarah , Schiffer Molly , Ruggero Michael , McManus Dayna , Topal Jeffrey E
Published: January 2021

Background

Bezlotoxumab has been shown to prevent recurrent episodes of C. difficile infection (CDI) in high risk patients. Current studies define therapeutic efficacy within the first 12 weeks when the risk of recurrence is greatest. However, the risk of recurrent CDI can occur beyond the 12-week window in the immunosuppressed population. Given that bezlotoxumab has detectable serum levels for up to 24 weeks after infusion, the primary endpoint is to determine overall efficacy in immunosuppressed patients with recurrent CDI at 4 weeks, 12 weeks, and 24 weeks after initial infusion. Secondary endpoints consist of risk factors for recurrent CDI, treatment of CDI, and antibiotics usage before and after bezlotoxumab.

Methods

This analysis included immunosuppressed patients at high risk for CDI recurrence who received bezlotoxumab from February 2017 to December 2019. Patients were excluded if they were not immunosuppressed, had no follow-up appointments, and/or without a C. difficile positive test. High risk antibiotics included fluoroquinolones, beta lactamase inhibitors, third generation cephalosporins, or carbapenems.

Results

Twenty-seven bezlotoxumab doses were given to 26 patients. Baseline characteristics for CDIs prior to bezlotoxumab is reported in Table 1. The overall CDI recurrence rate at all intervals after bezolotoxumab was 4 (15%), one recurrent CDIs occurred at < 4 weeks, two recurrent CDIs occurred at 5-12 weeks, and one recurrent CDI at 13-24 weeks. High risk antibiotics were given in 2/4 (50%) of CDIs recurrences and 22/75 (29%) in the non-recurrence group. Of the four CDI recurrences, all were mild to moderate in disease severity given no evidence of colitis was seen on CT scan and a median Zar score of 1 (range 0-1) due to age > 60 years.

Table 1: Baseline Characteristics

Conclusion

In immunosuppressed patients with CDI, bezlotoxumab is effective at reducing CDI episodes up to 24 weeks. Additionally, this highly antibiotic exposed population continued to receive benefit up to 24 weeks after bezlotoxumab.

Disclosures

All Authors: No reported disclosures
731. The Emergence of Mobile Colistin Resistance (mcr) Genes among Enteric Pathogens in the United States — 2008–2019
Authors: Tobolowsky Farrell A , Friedman Cindy R , Ryan Matthew , Birhane Meseret , Chen Jessica , Webb Hattie E , Beukelman Rachel A , Bokanyi Rick , Byrd David J , Connor Diana , Hanna Samir , Kimura Akiko , Mason Jordan L , McNamara Sara E , Meyer Stephanie , Moet Gary , Phan Quyen , Robbins Amy , Watkins Louise Francois
Published: January 2021

Background

Colistin, once seldom used clinically, has resurged as a “last resort antibiotic” for multidrug-resistant infections and is still used in animal agriculture in countries outside the United States. During 2015–2018, 8 plasmid-mediated, mobile colistin resistance genes (mcr-1 to mcr-8) were each found in one or more clinical, animal, food, and environmental bacterial sources. We describe the epidemiology of mcr genes in enteric pathogens from US patients.

Methods

State public health laboratories have performed whole-genome sequencing on enteric bacterial pathogens since 2015, and some have sequenced older isolates. We screened sequences of isolates collected through 2019 for mcr genes using a workflow based on ResFinder 3.0. State health officials interviewed patients for clinical and epidemiologic information, including demographics, hospitalization, and travel history.

Results

We identified 41 patient isolates with mcr genes collected from stool, urine, and blood during 2008–2019. These included 37 nontyphoidal Salmonella (31 mcr-1, 6 mcr-3), 2 Vibrio (both mcr-4), and 2 Shiga toxin-producing E. coli (both mcr-1). The median patient age was 34 years (interquartile range: 24–54) and 54% were female. Of 23 patients with comorbidity data, 2 (9%) had immunodeficiency, 2 (9%) had past abdominal surgeries, and 1 (4%) had cancer. Patients sought care at doctor’s offices (46%), emergency rooms (35%), and urgent care clinics (19%); 24% were hospitalized for the enteric illness. None died. Among 36 with information, 35 (97%) travelled internationally in the 12 months before illness; 30 (94%) of 32 traveled in the 7 days before. Only 4 (15%) of 27 had contact with a healthcare setting during their trip; common destinations were the Dominican Republic (35%), Vietnam (24%), Thailand (15%), and China (12%).

Conclusion

The data strongly suggest that many patients acquired infection abroad. Nearly one in four were hospitalized, raising concerns that plasmids carrying mcr genes could spread among patients hospitalized with infections caused by multidrug-resistant pathogens for which colistin is the only available treatment. The acquisition of mcr genes by US travelers highlights the need for a global approach to antimicrobial stewardship.

Disclosures

All Authors: No reported disclosures
735. Trends and Cost Analysis of Aspergillus Galactomannan testing at a Tertiary Medical Center
Authors: Treutel Peyton R , Carr Anna , Bathina Pradeep
Published: January 2021

Background

Aspergillus is a fungus spread by inhalation of spores that can lead to invasive (IA), chronic, or allergic aspergillosis. Risk factors for IA include neutropenia, hematological malignancy, allogenic stem cell (HSCT) or solid organ transplant, severe immunodeficiency, or prolonged steroid use. An alternative to invasive tissue sampling, the serum Galactomannan (AGM) test detects a polysaccharide cell wall component of Aspergillus and can be used to determine a probable diagnosis of IA. Accuracy of AGM is related to disease burden and thus has the highest sensitivity and specificity in patients with hematologic malignancy or Hematopoietic stem cell transplantation (HSCT) at 70-82% and 86-92%, respectively. Studies have shown sensitivity to decline in other populations, with solid organ transplants as low as 20%.

Methods

We performed a retrospective study of all patients who received the AGM test at UMMC from January 3, 2013 to December 31, 2019. Patient Cohort Explorer was used to obtain de-identified patient data from EPIC. We obtained the number of encounters and patients on whom the AGM test was performed along with other variables. Billing offices provided the self-pay cost per AGM test.

Results

A total of 6,404 AGM tests were performed on 2,126 patients during 4,315 encounters in the study period. With a total of 499, 574, 984, 1140, 851, 1175 and 1181 tests done respectively from 2013 to 2019, a increasing trend was noted. The patients ages ranged from 1 to 89 with a median age of 52 years. A total of 3,055 tests were ordered in females, and 3,349 were ordered in males.

At a cut off value (optical density index) of > 0.5, 183 AGM tests resulted positive in 108 patients and at a cut of > 1.0, 113 tests are positive in 70 patients. The rate of a positive AGM tests at > 0.5 was at 2.85% and at > 1.0 was at 1.76% over the study period. With the self-pay cost of each test at $134.54 in 2019 USD, the total cost of 6,404 tests was $861,594.16.

Conclusion

To our knowledge this data set constitutes the largest sample size of AGM testing. From our data, it seems that the rate of ordering this test has increased yearly. Relatively low percentage of these tests are positive, suggesting that it is most likely a large amount of these tests could have been ordered inappropriately or in the wrong clinical context.

Disclosures

All Authors: No reported disclosures
736. Babesia microti: A study of 38 cases
Authors: Kannangara Don , Samia Hoda , Chichili Eiswarya
Published: January 2021

Background

Babesia microti is an intraerythrocytic infection transmitted by Ixodes scapularis in Eastern United States. The same vector transmits Borrelia burgdorferi, Anaplasma phagocytophilum, B miyamotoi and Powassan virus resulting in mixed infections. Spleen involvement, blood abnormalities and abnormal liver functions are common in babesiosis. Here we present the clinical findings of 38 B microti (smear or serology positive) patients.

Methods

We retrospectively evaluated charts of 38 patients, 20 male and 18 female, smear or serology positive for B. microti in our health network from 9 hospitals in Eastern Pennsylvania and one in adjacent Warren county New Jersey.

Results

Eleven had B microti and Lyme co-infections (9 western blot positive, 2 with erythema migrans) and 2 mixed infections with A. phagocytophilum (PCR+). Only 2 gave a history of a tick bite. Fourteen presented with fever. 9 were Babesia smear positive. All 9 smear positive patients had fever, 7 were anemic, 6 leukopenic and 8 had increased liver enzymes. Six out of 14 with fever and 6 out of 9 smear positive patients had low platelet counts. Two with left upper abdominal discomfort likely due to splenic inflammation were initially misdiagnosed as left pyelonephritis. One had splenomegaly. Both had anemia and thrombocytopenia. A patient with a low IGG titer 1:10 for B microti and chronic ITP with a platelet count 102,000 (NL 140-200,000) had a 1 cm splenic artery aneurysm. Four western blot negative patients 2 with joint pain and 2 with radiculopathy were not counted as mixed infections. A Lyme co-infected patient had sinus tachycardia and ST, T changes in the electrocardiogram suggestive of Lyme myocarditis. All mixed infections were treated with a combination of atovaquone, azithromycin and doxycycline, including one patient initially on quinine and clindamycin switched due to side effects.

Conclusion

I.scapularis transmitted mixed infections are not uncommon. The majority were due to B microti and B burgdorferi. Fever was the most common presentation in symptomatic patients. Anemia, leukopenia, thrombocytopenia and elevated liver enzymes were common in smear positive patents. Babesiosis should be suspected in patients presenting with left upper abdominal pain in tick endemic areas. Most did not give a history of a tick bite.

Disclosures

All Authors: No reported disclosures
739. A Two-Center Assessment of Histopathologic Diagnostic Performance for Fungal Organism Identification
Authors: Costales Cristina R , Butler-Wu Susan , She Rosemary
Published: January 2021

Background

Accurate detection and identification of invasive fungal pathogens relies on concordance of several complementary laboratory techniques, including fungal culture, serology, and histopathologic identification. Histopathologic stains such as the Gomori methenamine silver stain (GMS) are used to highlight fungal cell wall in tissue specimens. We sought to determine the diagnostic performance of histopathology fungal stains as compared to fungal culture for diagnosis of invasive fungal tissue infection at tertiary medical centers with dissimilar patient populations.

Methods

We performed a retrospective review of all surgical pathology specimens with reported GMS results and concurrent fungal culture at Keck Medical Center (Keck) and Los Angeles County + USC Medical Center (LAC). Ratios of GMS diagnostic performance were compared using chi-squared analyses, with fungal culture as the gold standard for detection.

Results

Of 1347 LAC surgical pathology specimens stained with GMS to evaluate for fungal infection, 229 (17.0%) had concurrent tissue specimens submitted for fungal culture. Of 1546 Keck GMS-stained surgical pathology specimens, 358 (23.2%) had concurrent tissue for fungal culture. GMS stain performance at LAC showed a sensitivity of 53.7% (95% CI: 37.4-69.3%) and specificity of 90.4% (95% CI: 85.2-94.2%). At Keck, GMS showed a sensitivity of 64.1% (95% CI: 52.4-74.7%), specificity of 88.9% (95% CI: 84.7-92.4%), without significant difference in performance between sites, (p=0.27) and (p=0.62), respectively. Among filamentous fungi, GMS false negative frequency at LAC was 5.3% (10/190) and 4.0% (11/277) at Keck, without significant difference (p=0.51). A subset of pathology reports suggested the fungus genus based on histologic morphology. Of 10 LAC pathology specimens with fungal genus specified, 2 (20.0%) reports gave the incorrect genus and 8/18 (44.4%) reports at Keck gave incorrect genus as per concurrent culture isolate result.

Table 1. Diagnostic performance of GMS histopathology stain on surgical pathology specimens compared to tissue fungal culture at LAC and Keck Medical Centers from July 2015 through December 2018.

Conclusion

GMS stain had low-to-moderate sensitivity when compared to fungal tissue culture. Increased submission of concurrent tissue for fungal culture is likely to improve detection. When genus level identification was attempted, fungal forms were incorrectly identified in about one-third of histopathology specimens.

Disclosures

All Authors: No reported disclosures
741. Antifungal Resistant Candida glabrata Are Most Commonly Colonized in Clostridioides difficile Infection (CDI) Patient Guts in Texas
Authors: Begum Khurshida , Haghighi Farnoosh , Alam M Jahanbgir , Garey Kevin W , Garey Kevin W
Published: January 2021

Background

Candida glabrata is the second most common cause of invasive candidiasis in the United States. The echinocandin class of antifungals, including caspofungin has become the preferred therapy for invasive candidiasis due to C. glabrata and other species demonstrating decreased azole susceptibility. Caspofungin resistance has been uncommon, but reports suggest that the incidence is increasing, particularly among C. glabrata isolates. The dysbiosis associated with Clostridium difficile allows for overgrowth of Candida spp. However, the prevalence of C. glabrata in stool of C. difficile infection (CDI) patients is not well studied. Therefore, our objectives were to investigate the incidence of potentially pathogenic species of C. glabrata in stool samples of CDI patients.

Methods

We collected 1,241 Clostridioides difficile infection (CDI) patient stool samples from two large hospitals in Houston, Texas and enrich the samples in brain heart infusion (BHI) broth at 37C for 48-72 hours and then sub-cultured onto selective HardyChrom Candida agar and incubated at 37C for 48 to 72 hours. Characteristic Candida colonies were stocked in cryovials and kept at -80C for further analyses. Isolates were then identified by multiplex PCR. C. glabrata isolates were screened for caspofungin resistance on Muller-Hinton agar (with 8.0 ug/ml).

Results

Overall, 14.8% (184/1241) samples were culture positive for Candida spp. The predominant species was C. glabrata (9.2 %) followed by C. albicans (2.3%), C. tropicalis (1.6%), C. parapsilosis (1.2%), C. krusei (0.6%) or not speciated (6.9%). The majority of C. glabrata isolates (70.2%; 80/114) were caspofungin resistant.

Conclusion

The results of this study showed that colonization of C. glabrata is common in patients with CDI and could be a source of antifungal-resistant pathogens.

Disclosures

All Authors: No reported disclosures
746. Comparing Hospital Course in Hospitalized Patients Infected with Babesiosis Versus Patients Coinfected with Lyme Disease and Babesiosis
Authors: Spector Rachel , Lum Michael D , Papamanoli Aikaterini , Reardon Kelsey , Garry Evan , Marcos Luis
Published: January 2021

Background

Research is currently lacking on the interplay between Babesiosis and Lyme disease (LD) and how this coinfection may translate into morbidity and mortality. The aim of this study is to compare the clinical features of patients with single-infection with Babesia microti to those co-infected with Borrelia burgdorferi and Babesia microti.

Methods

A retrospective review of all adult patients diagnosed with babesiosis and tested for LD at Stony Brook University Hospital between 2014 and 2019 was performed (n=40). Patients with single babesia infection (Group 1, n=22) were compared to those with Babesia and LD (Group 2, n=18). Babesiosis diagnosis was determined by microscopic visualization of Babesia spp under peripheral blood smear, and confirmed by PCR for B. microti. LD inclusion criteria included a positive screened ELISA test for lyme followed by positive IgM antibody by western blot per CDC criteria (2-3 positive bands). Statistical analysis of the data involved Fisher exact test, Chi-square test, independent t-test, and Wilcoxon rank sum tests. Statistical significance was considered as a p-value less than 0.05.

Results

There was no significant difference in gender, race, and age (p >.75) between both groups as well as comorbidities including hypertension, diabetes, heart conditions, and immunocompromised state (p=1.0). Maximum parasitemia (Group 1: 1.1%, Group 2: 1.7%, p= 0.26) and percentage admitted to the ICU (Group 1: 18.18%, Group 2: 22.22%, p=1.0) were similar among both groups. While lab values on admission including WBC, hemoglobin, platelets, LDH, ALT, and AST did not significantly differ (p >.09), the length of hospital stay in group 2 was significantly longer than group 1 (Group 1: 3.0 days, Group 2: 5.5 days; p=0.03). There was a 0% mortality rate among both groups.

Table 2: Biomarkers of Patients Monoinfected with Babesiosis Versus Patients Coinfected with Babesiosis and Lyme Disease.

Table 1: Demographics of Patients Monoinfected with Babesiosis Versus Patients Coinfected with Babesiosis and Lyme Disease.

Conclusion

It is remarkable that despite no differences in lab values on admission, comorbidities, and demographics, patients with a coinfection had a longer hospital stay than those with only babesiosis. This suggests that having a coinfection with babesiosis and LD may lead to a more severe illness than a single infection with babesiosis.

Disclosures

All Authors: No reported disclosures
747. Diagnostic Performance of Bronchoalveolar Lavage Fluid Galactomannan Assay in Patients with Negative Serum Galactomannan Assay Suspected with Invasive Pulmonary Aspergillosis
Authors: Lim So Yun , Kim Jinyeong , Park Sunghee , Jung Jiwon , Kim Min Jae , Lee Sang-Oh , Choi Sang-Ho , Kim Yang Soo , Kim Sung-Han
Published: January 2021

Background

There are limited data in real clinical practice on the diagnostic value of BAL (bronchoalveolar lavage) fluid galactomannan (GM) assay in patients with suspected invasive pulmonary aspergillosis (IPA) who had negative serum GM results.

Methods

This study was performed at Asan Medical Center, a 2700 bed tertiary-care hospital in Seoul, South Korea between May 2008 and April 2019. All patients with suspected IPA whose serum GM assays revealed negative results and sequentially underwent BAL were enrolled in this study. Patients were classified as proven, probable, possible or not IPA by the revised 2019 EORTC/MSG definition.

Results

A total of 341 patients with suspected IPA including 4 proven IPA, 38 probable IPA, 107 possible IPA, and 192 not IPA were enrolled. Of these 341 patients, 107 (31%) with possible IPA were excluded from the final analysis. Of 42 patients with proven or probable IPA who had initial negative serum GM results, 24 (57%) revealed positive BAL GM results (n=24) or BAL fungal culture (n=8). Among the remaining 18 (43%), 2 (5%) were diagnosed as proven IPA by the histopathologic exam from transbronchial lung biopsy, 6 (14%) as probable IPA by subsequent sputum fungal culture, and 10 (24%) as probable IPA by repeated serum GM assay after BAL. Of 192 patients with not IPA, 14 (7%) revealed positive BAL GM results (n=14) or BAL fungal culture (n=8). The diagnostic performance of various tests is shown in Table 1.

Table 1. Diagnostic performance of various diagnostic tests in patients with suspected IPA who had negative serum GM results

Conclusion

Sequential BAL in patients with suspected IPA who had initial negative serum GM results provided additional diagnostic yield in about half of patients.

Disclosures

All Authors: No reported disclosures
748. Epidemiology and Outcomes of Invasive Fungal Infections Following Civilian Trauma
Authors: Mazi Patrick B , Bochicchio Grant , Bochicchio Kelly M , Liang Stephen , Larson Lindsey , Aldana Jose A , Canas Melissa , Fonseca Ricardo A , Afzal Hussain , Rasane Rohit K , Rincon Javier E , McMullen James M , Zhang Christina X , Powderly William , Spec Andrej
Published: January 2021

Background

Invasive fungal infections (IFI) following traumatic injury are devastating complications that threaten life and limb. In military combat wounds, post-traumatic IFI patients have up to 6 times higher mortality rates and 2.6-5.1 times higher rate of high-level amputations compared to non-IFI patients, though no such data exists for the civilian population. This study is the first cohort to analyze a post-traumatic civilian population for IFI, its epidemiology and outcomes.

Methods

We conducted a single-center retrospective cohort study of all trauma patients over the age of 18 years admitted to a large tertiary referral hospital between 2004 to 2015 who required surgery for their injury and had operative cultures submitted from their wounds. Patient demographics, comorbid conditions, mechanisms of trauma, environmental exposures, and laboratory data were included for analysis. Patients with positive culture for fungus from a site compatible with IFI were considered IFI patients. Data was analyzed using descriptive statistics with p≤0.05 considered significant.

Results

Our cohort includes 1,107 patients that met inclusion criteria. Of these, 120 patients had a positive culture for fungus, 454 patients had a positive culture for bacteria and 533 patients had no positive culture from a site of interest. Basic patient demographics, geographical setting of the trauma, and anatomical site of injury were not significantly associated with having a positive fungal culture. Necrosis was present in 19 (15.8%) IFI vs. 74 (7.5%) non-IFI patients (p=0.002). Soil contamination of a wound was present in 6 (5.0%) IFI vs. 11 (1.1%) non-IFI patients (p=0.001). 55.8% of 120 IFI wounds penetrated below fascial layers compared to 26.7% of 987 non-IFI wounds (p< 0.001).

Presence of IFI increased likelihood of requiring amputation (6.7% vs. 2.7%, p=0.02) and prolonged hospitalization >14 days (77.5% vs. 57.4%, p< 0.001) compared to those without.

Conclusion

IFI significantly increased patient risk for amputation and prolonged hospital length of stay following traumatic injury in a civilian population. Presence of IFI was associated with wounds penetrating below the fascial layer, presence of wound necrosis, and soil contamination of a wound.

Disclosures

Andrej Spec, MD, MSCI, Astellas (Grant/Research Support)Mayne (Consultant)Scynexis (Consultant)
749. Impact of Infectious Disease Consultation in Patients with Candidemia: A Retrospective study, Systematic Literature Review and Meta-analysis
Authors: Kobayashi Takaaki , Marra Alexandre , Schweizer Marin L , Ten Eyck Patrick , Wu Chaorong , Alzunitan Mohammed , Salinas Jorge L , Siegel Marc O , Farmakiotis Dimitrios , Auwaerter Paul , Auwaerter Paul , Healy Heather , Diekema Daniel , Diekema Daniel
Published: January 2021

Background

Morbidity and mortality from candidemia remain unacceptably high. While infectious disease consultation (IDC) is known to lower the mortality from Staphylococcus aureus bacteremia, little is known on the impact of IDC in candidemia.

Methods

We conducted a retrospective observational cohort study of candidemia patients at a large tertiary care hospital between 2015 and 2019. All patients aged ≥18 years with blood cultures positive for Candida species were included. We only included the first episode of candidemia. Exclusion criteria were death or transfer to the palliative care unit within 48 hours from the time cultures became positive. The crude mortality rate was compared between those with IDC and without IDC. Then, we systematically searched five publication-databases through February 2020 and performed a meta-analysis of the impact of IDC on mortality of patients with candidemia. The study protocol has been submitted to the International Prospective Register for Systematic Reviews (PROSPERO) database (ID 156939) on April 2020.

Results

A total of 151 patients at our institution met the inclusion criteria, 129 (85%) of whom received IDC. Thirty-day, and 90-day mortality rates were significantly lower in the IDC group (18% vs 50%, P = .002; 23% vs 50%, P = .0022, respectively). Our systematic literature review returned 216 reports, of which, 13 studies including ours fulfilled the inclusion criteria. Among the 13 studies with a total 3687 patients, IDC was performed in 49% of patients. Mortality numbers were available in 10 studies. Overall mortality was 38.2% with a significant difference in favor of the IDC group (28.4% and 47.6%) with a pooled relative risk of 0.41 [95% Cl 0.35-0.49]. Ophthalmology referral (61%; 790/1279 and 21%; 273/1304, P < 0.001), echocardiogram (54%; 662/1219 and 28%; 369/1296, P < 0.001), and central line removal (78%; 830/1069 and 61%; 686/1116, P < 0.02) were performed more frequently among patients receiving IDC.

Overall mortality

Conclusion

This study is the first systematic literature review and meta-analysis to evaluate the association between IDC and candidemia mortality. IDC was associated with a lower mortality and should be standard of care in all patients with candidemia.

Disclosures

Dimitrios Farmakiotis, MD, Astellas (Grant/Research Support) Paul Auwaerter, Collidion (Consultant)DiaSorin (Consultant)Johnson and Johnson (Shareholder)MicroB-Plex (Research Grant or Support)Shionogi (Consultant) Daniel Diekema, bioMerieux, Inc (Grant/Research Support)JMI Laboratories (Consultant)
752. Management of 20 Patients Diagnosed with Posaconazole-Induced Pseudohyperaldosteronism
Authors: Gintjee Thomas J , Davis Matthew R , Nguyen Minh-Vu Hoang , Young Brian , Odermatt Alex , Thompson George R
Published: January 2021

Background

Posaconazole-induced pseudohyperaldosteronism (PIPH) has been associated with elevated posaconazole serum concentrations. Clinicians are faced with the difficult task of managing patients with PIPH while not compromising the efficacy of antifungal prophylaxis or treatment. Commonly, modifications to posaconazole therapy are utilized in managing PIPH including dosage reduction of posaconazole or therapeutic switch to an alternative antifungal.

Methods

We retrospectively reviewed 20 consecutive adult patients diagnosed with PIPH in this case series. Patient data including blood pressure, electrolytes, endocrine laboratory values, and posaconazole serum concentrations collected before and after therapeutic intervention.

Results

Out of 20 patients included, 17 patients (85%) underwent therapeutic modification with posaconazole dose reduction (N=11) as the most common change. Other modifications included posaconazole discontinuation (N=3), switch to an alternative antifungal (N=2), and addition of spironolactone (N=1). Clinical improvement (a decrease in systolic blood pressure and increase in serum potassium) was observed in 9 of 17 patients (52.9%).

Table 1. Management of Posaconazole-Induced Pseudohyperaldosteronism - p1

Table 1. Management of Posaconazole-Induced Pseudohyperaldosteronism - p2

Table 1. Management of Posaconazole-Induced Pseudohyperaldosteronism - p3

Conclusion

We report our experience with PIPH management, for which there is currently no universally effective strategy. We suggest a stepwise approach for PIPH management, starting with posaconazole dose reduction and repeat assessment of clinical and laboratory parameters. If resolution of PIPH is not achieved, an alternative triazole antifungal or the addition of an aldosterone antagonist are additional potential interventions. Even with this approach, it is possible for PIPH to persist after therapeutic modification. Thus, early diagnosis and continuous, close monitoring of patients is warranted.

Disclosures

All Authors: No reported disclosures
754. Performance Characterization of a Real Time PCR Assay for Pneumocystis jirovecii in Bronchoalveolar Lavage Fluid and Sputum
Authors: Bell Drew T , Koehlinger Jeremy , Schmitt Bryan H
Published: January 2021

Background

Pneumocystis jirovecii pneumonia (PJP) affects immunocompromised patients and contributes significantly to mortality. Outcomes depend on early treatment, making timely and accurate diagnosis critical. Typically, PJP diagnosis is through identification of trophozoite or cyst forms in bronchoalveolar lavage (BAL) fluid or sputum, a labor-intensive and insensitive process. Options for more accessible and sensitive molecular detection are limited. It is known that patients may be colonized, which can cast doubt on the clinical significance of low levels of DNA amplification in qualitative result reporting. In this study, we describe a real time (rt) PCR assay utilizing analyte specific reagent primers targeting the mtLSU gene of P. jirovecii and correlate amplification with morphological PJP identification.

Methods

IUHPL Clinical Microbiology assessed sputum or BAL fluid from 109 patients with clinical concern for PJP microscopically via fungal stains (GMS, calcofluor white). Comparative rtPCR was conducted as follows. First, 2µL of residual specimen or control were mixed with an 8µL combination of rtPCR mastermix, control DNA, and primer pairs (Simplexa). No nucleic acid extraction was performed. Real time PCR was executed and analyzed on the LIAISON MDX (DiaSorin) platform. Qualitative amplification results and cycle threshold (CT) values were correlated with microscopic methods to establish performance. Chart review was performed to assess the clinical impact of this assay.

Results

P. jirovecii was microscopically detected in 26% (29/109) of samples, while 31.1% (34/109) exhibited amplification by rtPCR. Agreement between the two methods was 95.4%; rtPCR demonstrated 100% sensitivity and 93.8% specificity in comparison.

Conclusion

Our results indicate that this assay has exceptional negative predictive value (100%), and therefore may be valuable as a screening test. Considering this data alone, the positive predictive value is lower (85.3%). Further examination of the data, however, revealed that 80% (4/5) of discrepant results demonstrated CT values of >34, while the highest CT for a microscopically positive sample was 31.2. Further clinical correlation may establish a CT cutoff that will reduce false positive and potentially clinically insignificant cases.

Disclosures

All Authors: No reported disclosures
755. Posaconazole versus voriconazole as antifungal prophylaxis for invasive fungal diseases in patients with hematological malignancies
Authors: Almutairy Reem F , Khan Mansoor , Alshamrani Majed , Marhabi Hassan , Naeem Doaa
Published: January 2021

Background

The incidence of Invasive Fungal Diseases (IFDs) has dramatically increased in patients with hematologic malignancies due to prolonged neutropenia. IFDs are associated with significant morbidity and mortality. Due to these risks, international guidelines have recommended antifungal prophylaxis for Acute Myeloid Leukemia (AML) and Myelodysplastic syndromes (MDS) patients. Posaconazole has been recommended as the prophylactic agent of choice. Also, voriconazole has been recommended by guidelines with different levels of recommendations. Data on a direct comparison between Posaconazole delayed-release tablets (DR) and Voriconazole for IFD prophylaxis are lacking. Therefore, we aim to compare the efficacy and safety of the fungal prophylaxis; voriconazole versus posaconazole in AML/MDS patients at Princess Nourah Oncology Center, Jeddah

Methods

Retrospective chart review study for eligible patients from January 2017 to February 2019 to identify the breakthrough IFD rates and assess the frequency of adverse events within AML/MDS patients at PNOC, Saudi Arabia

Results

A total of 48 patients (130 chemo cycles) were included in the study: 50 using posaconazole (DR) and 80 using oral voriconazole as antifungal prophylaxis. The incidence rates of IFD in the posaconazole group was 8 % (4/50) of those 2 were probable, and 2 were possible infections while 6.26 % (5/80) of patients in the voriconazole group have developed IFD of them 4 had a possible infection, and one had a probable infection (p=0.7325). A higher percentage of patients in the voriconazole group discontinued prophylaxis due to adverse events (5 patients vs. 2 patients). Use of voriconazole as antifungal prophylaxis for 15 days in 130 cycles in 48 AML/MDS patients would cost 175,500 SR in comparison to the cost of the posaconazole for the same duration of 1,350,130 SR. So, use of voriconazole would save 1.13 million SR and is more cost effective when used as antifungal prophylaxis in AML/MDS patients in comparison to posaconazole although later is category 1 recommended antifungal prophylaxis in international guidelines

Conclusion

Our study has shown that both posaconazole and voriconazole have comparable efficacy and safety in the prevention of IFD in AML and MDS receiving chemotherapy but voriconazole is more cost effective

Disclosures

All Authors: No reported disclosures
756. Use Risk Factors to Early Screen Pneumocystis Pneumonia in Hospitalized Patients
Authors: Luo Ruihong
Published: January 2021

Background

The diagnosis of Pneumocystis pneumonia (PCP) may be delayed or missed if the underlying risk factors are not recognized, particularly in HIV-uninfected patients.

Methods

The adult hospitalized patients (≥18 years) with pneumonia were selected from the Nationwide Inpatient Sample database (2005-2014). The in-hospital outcomes of PCP patients including mortality, length of hospital stay (LOS) and charge were analyzed. The risk factors for PCP were evaluated by Logistic regression. A risk-adjusted model to screen PCP in HIV-uninfected patients was developed by discriminant analysis.

Results

24,025,696 hospitalized patients with pneumonia were identified, including 135,749 PCP patients. The incidences of PCP in pneumonia patients were 0.12% in HIV-uninfected group and 30.5% in HIV-infected group respectively. Comparing with other pneumonia patients, those with PCP had higher mortality (11.8% vs. 8.2%), longer LOS (median 8 vs. 5 days) and increased hospital charges (median $40,082 vs. $26,980). HIV infection was the major risk factor for PCP (OR=270.2, 95% CI 264.5-276) in all patients with pneumonia. In HIV-uninfected patients, the comorbidities including lymphoma (OR=10.7, 95% CI 10.2-11.2), CMV infection (OR=8.1, 95% CI 7.6-8.7), leukemia (OR=6.8, 95% CI 6.4-7.1), metastatic cancer (OR=5.3, 95% CI 4.6-6.0), immune thrombocytopenic purpura (OR=5.0, 95% CI 4.5-5.5), chronic steroid use (OR=4.1, 95% CI 3.9-4.3), solid organ transplant (OR=3.5, 95% CI 3.3-3.8), inflammatory bowel disease (OR=2.6, 95% CI 2.4-2.8), connective tissue disease (OR=2.4, 95% CI 2.3-2.6) and non-metastatic solid tumor (OR=2.3, 95% CI 2.1-2.4) were associated with increased risk for PCP. A risk-adjusted model composed of risk factors above could help to screen PCP with the sensitivity 42.9%, specificity 94.4% and accurate rate 94.3% (Table 1).

Table 1

Conclusion

PCP should be considered as one of the differential diagnoses in patients with pneumonia if they have underlying risk factors other than HIV infection. The risk-adjusted model can help to early screen PCP for HIV-uninfected patients before the pathogen test.

Disclosures

All Authors: No reported disclosures
757. Association between cumulative febrile, respiratory and diarrheal illness in the first year of life and neurodevelopmental and growth outcomes among a cohort of children in rural Guatemala
Authors: Olson Daniel , Lamb Molly , Connery Amy , Bauer Desiree , Paniagua-Avila Alejandra , Colborn Kathryn L , Natrajan Muktha , Waggoner Jesse , Anderson Evan J , Calvimontes Mirella , Bolanos Guillermo Antonio , Holliday Andrea , El Sahly Hana , Munoz Flor M , Asturias Edwin
Published: January 2021

Background

Recurrent infections are associated with neurodevelopmental (ND) delay in infants, but the primary drivers are poorly understood. Leveraging an infant cohort from rural Guatemala designed to evaluate the effects of post-natal Zika virus on ND (DMID 16-0057), we evaluated the association between cumulative illness and ND delay and stunting.

Methods

Infants enrolled at 0-3 months of age underwent weekly at-home surveillance for caregiver-reported syndromic illness, including cough, fever and vomiting/diarrhea for a 12-month period. Anthropometric assessments and ND testing by Guatemalan psychologists using the Mullen Scales of Early Learning (MSEL) were perforrmed at 12-15 months of age. Multivariable generalized linear regression models were used to test associations between syndromic illness in infancy, 12-15-month MSEL Early Learning Composite (ELC) Score, and stunting (height-for-age < -2 SD) at 12-15 months.

Results

The cohort (n=425) had a mean enrollment age of 1.3 months; 202 (48%) were female, 387 (91%) self-reported a literate mother, and 301 (71%) were breastfeeding at study completion. Infants had reported illness for a median of 16 weeks during the surveillance period; cough was reported most frequently (median=11 weeks, range=0-37 weeks). Lower maternal education (p=0.007) and literacy (p=0.002) as well as infant age (p=0.007) and male gender (p=0.004) were associated with MSEL ELC Score <85 (-1 SD). After adjusting for gender, breastfeeding, age, and maternal literacy, the cumulative number of weeks with reported cough (p=0.0009), fever (p=0.0001), or any syndromic illness (p=0.0007) were associated with decreased 12-month MSEL ECL Score; there was no association with diarrhea/vomiting (p=0.36). There was no association between caregiver-reported syndromic illnesses (any type) and stunting at final study visit.

Conclusion

In a cohort of Guatemalan infants, cumulative fever and cough episodes were significantly associated with lower MSEL ELC Score, whereas there was no association with diarrhea/vomiting. In this low-resource community, these findings highlight the potential negative ND consequences of febrile illness and persistent cough in the first year of life. NIAID Contract HHSN272201300015I Task Order HHSN27200013 (Co-PIs: FMM and EJA).

Disclosures

Molly Lamb, PhD, BioFire (Grant/Research Support) Evan J. Anderson, MD, Sanofi Pasteur (Scientific Research Study Investigator)
759. Where can we find active TB? Case finding at community sites and alcohol based venues (ABVs) in rural South Africa
Authors: Choi Koeun , Shenoi Sheela , Moll Anthony , Friedland Gerald
Published: January 2021

Background

Community-based intensive case finding (CBICF) is an effective strategy for infectious disease case detection, particularly for hard-to-reach populations. Alcohol use is increasingly recognized as a risk factor for tuberculosis. We report on the association of alcohol use with tuberculosis case detection as part of a CBICF in a rural resource limited setting.

Methods

In rural KwaZuluNatal, South Africa, community health workers stationed outside ABVs, community centers, and public events conducted health education and voluntary confidential screening in a mobile clinic. A WHO endorsed TB symptom screen (with sputum collection for GeneXpert if ≥1 symptom), HIV rapid test, random glucose (elevated >7mmol/L), and blood pressure (elevated >140 or >90mmHg) were offered. Community members with positive results were referred to their primary care clinic. Alcohol Use Disorder Identification Test (AUDIT) was used to identify hazardous drinking (score ≥8for men, ≥6for women). Here we report on TB screening results only.

Results

Among 1438 participants, 91.2% were screened at ABV, 72.3% were male, median age was 30 (IQR 22-46), 25.9% were employed, 92.0% had electricity but only 29.4% had running water. Among those screened at all sites, 43.1% reported hazardous alcohol use, 39.3% tobacco use, and 13.9% cannabis use. Overall, 5 people with active TB were identified representing a number needed to screen of 288 to identify one case of TB. Bivariate analysis showed TB cases were more likely to be associated with older age (p=0.03), cigarette use (p=0.06), and hazardous alcohol use (p=0.01). Among only men who were screened, older age (p=0.01) and hazardous alcohol use (p=0.04) were associated with active TB disease. The mean AUDIT score among TB cases was 13.8 (SD 4.09) compared to non-TB cases 6.8 (SD 7.5) (p=0.04).

Conclusion

CBICF is a useful way to detect people with active TB, especially for hard-to-reach rural populations. Focusing screening efforts among those at ABVs is high yield and can be a useful adjunctive strategy for TB case finding efforts. These findings highlight a need for comprehensive substance abuse services to assist those at high risk for TB acquisition.

Disclosures

All Authors: No reported disclosures
763. Correlates of Antiretroviral Therapy Initiation Among Newly Diagnosed Older People with HIV in Ukraine
Authors: Allen Amy J , Zeziulin Oleksandr , Rozanova Julia , Litz Taylor , Zaviryukha Irina , Postnov Oleksandr , Kiriazova Tetiana , Shenoi Sheela
Published: January 2021

Background

Ukraine has a high burden of HIV, with only 52% of people living with HIV receiving Antiretroviral Therapy (ART) despite test and treat policies and free medications. An underrecognized but significantly increasing proportion of older people with HIV (OPWH) contribute 15% of new HIV diagnoses and demonstrate increased mortality compared to the age-matched general population. To assess the impact of age on HIV treatment outcomes, we examined correlates of ART initiation among newly diagnosed HIV patients in Ukraine.

Methods

A retrospective chart review was conducted of 400 patients newly diagnosed with HIV between July 1, 2017- Dec 1, 2018 in Odessa, Ukraine. OPWH were defined as those ≥50 years old at the time of diagnosis, while ART initiation was defined as prescription and dispensing of medication. Outcomes were censored 6 months from diagnosis. Demographic, clinical characteristics, and ART outcomes were examined and multivariable logistic regression models were used to estimate correlates of ART initiation with adjusted odds ratios at 95% confidence intervals.

Results

Of the 400 included patients, 198 (49.5%) were < 50 years old and 202 (50.5%) were ≥ 50 years old at the time of diagnosis. Patients ≥50 years old were more likely to have a lower CD4 count (median 148 (IQR 60-316) vs 295 (IQR 111-478), p=0.001). Correlates of ART initiation included age less than 50 and history of opportunistic infection within 12 months of diagnosis. After controlling for opportunistic infection history, OPWH were 51% less likely to receive ART than those < 50 years old at the time of diagnosis (AOR 0.496, CI 0.301-0.816, p=0.006).

Conclusion

OPWH exhibit an ART gap associated with advanced disease at presentation compared to younger individuals newly diagnosed with HIV. This is the first clinical data examining OPWH in Ukraine. Interventions to improve linkage to care for OPWH are urgently needed in a population already at increased risk for HIV related mortality. The results of this study emphasize the need for further studies to examine patient and systemic causes of decreased ART initiation among Ukrainian OPWH.

Disclosures

All Authors: No reported disclosures