bluuebunny/crossref_metadata_2025 huggingface dataset:
67. Impact of a Pharmacist-Driven Collaborative Initiative on Staphylococcus aureus Bacteremia Management
Authors: Kufel Wesley D , Mastro Keri A , Wang Dongliang , Steele Jeffrey , Riddell Scott W , Paolino Kristopher M , Thomas Stephen J
Published: January 2021

Background

Infectious diseases (ID) consultation has been associated with improved outcomes for Staphylococcus aureus bacteremia (SAB) largely by providing guidance to follow widely accepted standards. However, ID consultation may be delayed due to numerous factors. ID pharmacists may be able to facilitate timely and optimal management of SAB in collaboration with ID providers and microbiology. The primary outcome of this study was to evaluate the impact of a pharmacist-driven collaborative initiative for SAB.

Methods

This was a single-center, quasi-experimental study of patients with SAB before (8/1/16–7/31/17) and after (8/1/18-7/31/19) implementation of pharmacist-driven collaborative initiative for SAB management. After direct notification of SAB and penicillin-binding protein assay results from microbiology personnel, the ID pharmacist promptly contacted the primary team to facilitate ID consultation and identified opportunities to optimize treatment or diagnosis prior to consult. Recommendations were also collaboratively discussed with the ID consult service. Included patients were ≥18 years old with SAB. Excluded patients were < 18 years old, under palliative care or expired prior to S. aureus speciation, refused care against medical advice, pregnant, incarcerated, or had polymicrobial bacteremia.

Results

Ninety and 111 patients were included in the pre- and post-intervention cohort, respectively. Demographic data were similar between cohorts. Most SAB cases were community-acquired (72% vs 81%, p=0.137), complicated (83% vs 71%, p=0.059), and methicillin-susceptible (57% vs 65%, p=0.236). The most common sources were catheter (23%) and skin and soft tissue (30%) in pre- and post-intervention cohorts, respectively. Table 1 displays compliance with evidence-based SAB measures and clinical outcomes. Compliance with the SAB bundle was significantly higher in the post-intervention cohort (91% vs 50%, p< 0.001).

Table 1. Compliance with Evidence-Based Staphylococcus aureus Bacteremia Management Bundle Elements and Clinical Outcomes

Conclusion

Increased compliance with evidence-based SAB recommendations decreased SAB duration, time to targeted antibiotics, and infection-related hospital length of stay after implementation of a pharmacist-driven collaborative initiative for SAB.

Disclosures

Wesley D. Kufel, PharmD, Melinta (Research Grant or Support)Merck (Research Grant or Support)Theratechnologies, Inc. (Advisor or Review Panel member) Jeffrey Steele, PharMD, Paratek Pharmaceuticals (Advisor or Review Panel member)
935. Effect of Tesamorelin in People with HIV with and without Dorsocervical Fat: Post Hoc Analysis of Phase III Double Blind Placebo Control Trial
Authors: Rahman Farah , de Chantal Marilyn , Mesquita Pedro , Aberg Judith A
Published: January 2021

Background

Lipohypertrophy is defined as excess fat deposition in abdominal defined as visceral adipose tissue (VAT) as well as in the dorsocervical region, breasts, trunk, and along with possible fat deposition in liver, muscle, myocardium and epicardium. Multiple factors have been described as contributing to lipohypertrophy in people living with HIV (PLWH), including patient characteristics, antiretroviral therapy (ART) and also impaired growth hormone (GH) secretion. Tesamorelin, a synthetic form of growth-hormone-releasing hormone (GHRH), is indicated for reduction of excess abdominal fat in PLWH with lipodystrophy

Methods

Post-hoc analysis was done on phase 3 randomized, double-blind, multicenter trials. Patients were eligible if between 18 and 65 years of age, had confirmed HIV infection, had evidence of excess abdominal fat accumulation and on stable ART regimen for 8 weeks or more. Participants were randomized to receive tesamorelin 2 mg daily or placebo daily for 26 weeks. Only tesamorelin responders, defined as patients with at least 8% decrease in VAT and who were adherent to the medication, were used for this analysis. Results are reported for patients with and without dorsocervical (DC) fat deposition.

Results

Demographic characteristics of responders at week 26 are shown according to presence or absence of DC fat (Table 1). At week 26, on average, the patients with DC fat deposition had higher BMI and waist circumference (WC) than the group without DC fat. Most patients in both groups had lipoatrophy. Metabolic and anthropometric parameters were measured at week 26 in patients with and without DC fat (Table 2). There was a decrease in VAT and also an improvement in their WC at week 26 in both groups.

Table 1: Baseline Characteristics of Tesamorelin Responder Subjects at Week 26, by Dorsocervical Status

Table 2: Change in Abdominal Adiposity, Insulin-Like Growth Factor-1 Levels, and Metabolic Parameters Between Baseline and Week 26 Among Tesamorelin Responders

Conclusion

This data demonstrates that tesamorelin is effective at reducing VAT in both patients with and without DC fat. The medication was well tolerated without significant changes to metabolic based measurements. Treatment of excessive VAT with tesamorelin has seemingly positive results in fat reduction in patients with or without DC fat deposition and our study contributes to the growing literature.

Disclosures

Marilyn de Chantal, PhD, Theratechnologies Inc (Employee) Pedro Mesquita, PhD, Theratechnologies, Inc. (Employee) Judith A. Aberg, MD, Theratechnology (Consultant)
936. Evaluating the Impact of Polypharmacy on Virologic Success in People with HIV
Authors: Jimenez Humberto R , Boachie Naana , Park Sangwon , Suh Jin
Published: January 2021

Background

As people with HIV (PWH) have experienced reductions in antiretroviral pill burden, there has been an increase in medications to manage non-AIDS-related co-morbidities. Previous studies have linked virologic failure to an increased pill burden. This study assessed whether polypharmacy and other variables affect success of HIV management in our population.

Methods

A retrospective, cross-sectional analysis of PWH receiving care at a Ryan White-funded clinic in New Jersey was performed. Eligible patients were ≥18 years old, had ≥2 visits in 2019 and were receiving antiretroviral therapy (ART). The primary endpoints were to determine the effect polypharmacy (defined as 5 or more non-ART pills per day) on virologic response rates (HIV RNA < 200 copies/mL). Secondary endpoints accounted for the impact of age, gender, race/ethnicity, HIV transmission risk factor, and AIDS diagnosis on virologic response. A descriptive analysis of comorbidities and medication classes was also completed. Logistic regression, chi square and student’s t test were used for statistical analysis.

Results

964 patients were included in the analysis, with 355 (37%) meeting the criteria for polypharmacy. Most patients were male (60%) and the mean age was 49 years of age. The racial/ethnic breakdown was 46% Hispanic, 45% Black and 8% White. Polypharmacy was associated with higher rates of virologic success compared to those with a lower pill burden: 94% vs 86% had an HIV RNA < 200 copies/mL (P=0.0003), respectively. ART pill burden was statistically, but not clinically higher among those with polypharmacy (1.34 vs 1.45, P=0.025). Virologic response was found to be higher among Hispanics and Whites in comparison to Black patients (OR 2.2, CI 1.4-3.5 and 3.0, CI 1.1-8.2). Patients with an AIDS diagnosis were less likely to achieve virologic response (OR 0.64, CI 0.42-0.99).

Conclusion

Patients with polypharmacy were more likely to achieve virologic success than paitents with a low pill burden in our population.

Disclosures

Humberto R. Jimenez, PharmD, BCPS, AAHIVP, Gilead (Speaker’s Bureau)
939. Immunity to Hepatitis A and/or Hepatitis B Viruses Among Inmates Living with HIV
Authors: Poondi Nivedha , Hou Jysheng , Michienzi Sarah M , Patel Mahesh C , Badowski Melissa E
Published: January 2021

Background

Hepatitis A (HAV) and B viruses (HBV) are vaccine-preventable diseases where screening upon entry into prison provides an ideal public health opportunity to assess vaccination status and administer vaccination while incarcerated.

Methods

A retrospective, electronic medical record review evaluated incarcerated adults receiving human immunodeficiency virus (HIV) telemedicine care in 26 prisons in Illinois, USA, from 01/01/19 through 12/31/19. Included subjects were living with HIV, incarcerated in the Illinois Department of Corrections (IDOC), and had available data for HAV/HBV serologies, viral load, and CD4 count during incarceration. The primary objective was to assess rates of HAV and/or HBV immunity in individuals with HIV. The secondary objective was to assess factors associated with vaccination status. Statistical analysis included Chi-squared testing and descriptive statistics.

Results

Among the 524 patients analyzed, the majority were Black men (75%) with an average age of 44 years. 429 patients had existing data for HAV vaccination where 79% had documented immunity. 397 patients had existing data for HBV vaccination where 5% had HBV infection, 1.4% had an equivocal HBV surface antibody and negative HBV surface antigen, and 70% had documented immunity. In total, 387 patients had existing data for HAV and HBV vaccination status where 213 (55%) were immune to both HAV and HBV while (7%) had no immunity to both HAV and HBV. Immunity did not vary based on CD4 count, age, gender, or race (p > 0.05).

Conclusion

Assessing serologies and providing Hepatitis A and B vaccinations while incarcerated, where indicated, can increase immunity to these vaccine-preventable viruses and thereby reduce transmission of HAV and HBV. This is of particular importance for patients living with HIV as this is an indication for vaccination. Based on these findings, the telemedicine study team has been able to assess serologies and advocate for vaccination for inmates living with HIV entering the IDOC. Over time, we expect our interventions to result in further improvements in rates of immunity.

Disclosures

All Authors: No reported disclosures
941. Incarcerated patients living with HIV: Atherosclerotic cardiovascular disease risk and management
Authors: Michienzi Sarah M , Chiampas Thomas D , Valkovec Amy , Arzuaga Siria , Patel Mahesh C , Borgetti Scott , Badowski Melissa E
Published: January 2021

Background

The 2018 American Heart Association and American College of Cardiology (AHA/ACC) 2018 Guideline on the Management of Blood Cholesterol included human immunodeficiency virus (HIV) as an atherosclerotic cardiovascular disease (ASCVD) risk enhancer for the first time. Our study investigates if patients living with HIV in the Illinois Department of Corrections (IDOC) were prescribed appropriate HMG-CoA reductase inhibitor (statin) therapy following release of these guidelines based on risk.

Methods

This was a retrospective study of patients with > 1 visit in our multidisciplinary HIV IDOC Telemedicine Clinic from 1/1/19-6/1/19. Our prescriptive authority is limited to HIV and directly related conditions, and we provide recommendations to on-site providers for other comorbidities. Included patients were > 18 years of age, HIV positive, and incarcerated within IDOC. Excluded patients had existing ASCVD. Data from the first visit in the study period were extracted from the electronic medical record and analyzed utilizing descriptive statistics. Primary objectives were to quantify ASCVD risk and appropriate statin use in our population.

Results

Of the 158 patients included, average age was 42 years. The majority were male (89%), Black (73%), overweight/obese (117/148, 79%), on an integrase single-tablet regimen (78%), with CD4 >200 cells/µL (97%), and HIV RNA < 20 copies/mL (85%). Of the 18 females, 8 were transgender. Within the prior year, 65% had a lipid panel. For the 50 patients meeting criteria for 10-year ASCVD estimation, median (range) risk was 6.6% (0.8% - 31.9%). Only 12 patients were on statins. Of these, all were indicated per AHA/ACC guidelines with 10 prescribed appropriate intensity. An additional 45 patients had indications for statins but were untreated. In total, 47 patients (30%) were not receiving appropriate statin therapy.

Conclusion

Results of our study suggest ASCVD risk management is an area of improvement for inmates living with HIV, especially as we look towards caring for an aging HIV population. Future directions include comparing these data to data from a later time point to evaluate time for guideline uptake.

Disclosures

Thomas D. Chiampas, PharmD, BCPS, AAHIVP, Gilead (Employee)
944. Pneumocystis-Tuberculosis Co-infection in the HIV Positive Host
Authors: Nair Sashi N , Brar Indira , K.P. Gireeshkumar
Published: January 2021

Background

Concurrent infection with Pneumocystis Jirovecii (PJP) and Tuberculosis (TB) has been described in HIV infected patients. Developed countries, where guidelines on the treatment of PJP have been created have dramatically lower rates of latent and active TB than developing countries. PJP may obscure the diagnosis or delay the treatment of TB. Furthermore, treatment of PJP with corticosteroids may be detrimental to the course of TB. The objective of this study was to examine the frequency and the clinical characteristics of the co-infection of PJP and TB in HIV.

Methods

The clinical details of all HIV patients being treated at Amrita Hospital in South India have been prospectively collected in an electronic database since 2006. We compiled the data from 2006 to 2018 and further examined the clinical and laboratory results from electronic charts of patients admitted with PJP. Statistical analysis of the data was performed with descriptive analysis.

Results

A total of 21 of the 576 HIV patients were had admissions for PJP. Of these, 43% were co-infected with PJP and TB. In all cases PJP was the opportunistic infection leading to a HIV diagnosis. When comparing the PJP and MTB group with the PJP only group, the dual infected group was younger (40 vs 45), however there was no difference in length of stay (16.5 days vs 11.8), ICU admission rate (33% vs 36%), or mortality (0 vs 3 patients died).

Demographic Data

Comparison of TB-PCP and PCP only groups

Conclusion

Our report highlights the need to increase awareness of occurrence of this dual infection in HIV infected patients, as both infections can mimic each other clinically and radiologically, and are potentially fatal if not recognized promptly. Furthermore tuberculosis has the risk of transmission to health care personnel and other patients. In addition we report a much higher rate of underlying TB in our patients with PJP than what has been generally reported in the literature and conclude that higher clinical suspicion for this entity is warranted, particularly in countries with a high prevalence of TB.

Immunology and Pathophysiology of HIV-PJP-TB triple infection

Disclosures

Indira Brar, MD, Gilead (Speaker’s Bureau)janssen (Speaker’s Bureau)ViiV (Speaker’s Bureau)
945. Prevalence of HIV Associated Non-AIDS Conditions and Associated Risk Factors among Hospitalized HIV-infected Patients in India
Authors: Jereen Amyeo A , Kucera Celia , Pervin Saniya , Varma Muralidhar , Rajesh Radhakrishnan , Menezes Lynette , Lakshmi Seetha
Published: January 2021

Background

HIV-associated non-AIDS (HANA) conditions are becoming common as People Living with Human Immunodeficiency Virus (PLWHIV) age. However, data estimating the prevalence of HANA conditions and associated risk factors is lacking in developing countries. This study evaluates reasons for hospitalizations among PLWHIV in Udupi, India in the antiretroviral era, and describes associated risk factors.

Methods

Demographic and clinical data were extracted from medical charts of 1280 HIV-infected patients 18 years and older who were admitted to Kasturba Hospital, Manipal, India between January 1, 2013 and December 31, 2017, for a total of 2157 hospitalizations. Primary reasons for hospitalization were categorized into AIDS-defining vs Non-AIDS-defining and HANA vs Non-HANA conditions (Fig 1). Multivariate logistic regression analysis was performed to estimate demographic and clinical factors associated with hospitalizations due to AIDS-defining illness and HANA conditions.

Categorization of Reasons for Hospitalization

Results

Patients’ median age was 45 (18-80) years; 70% male. Median age of patients with AIDS-defining illness (45% of hospitalizations) was lower at 44 (18-75) years compared with HANA (15% of hospitalizations) at 48 (21-80) years.

Age (OR, 95% CI) (0.985, 0.974-0.995), admission CD4 (0.998, 0.997 - 0.998), history of hypertension (HTN) (0.59, 0.42-0.82), stroke (0.49, 0.24 - 0.93), diabetes (1.56, 1.10 - 2.19), and AIDS-defining cancers (1.74, 1.05 - 2.89) were associated with AIDS-defining hospitalizations (Fig 2).

Additionally, age (1.016, 1.001 - 1.031), history of HTN (1.70, 1.16 - 2.46), coronary artery disease (CAD) (4.02, 1.87- 9.02), chronic kidney disease (CKD) (2.30, 1.15 - 4.61), stroke (2.93, 1.46 - 5.96), Hepatitis B (3.32, 1.66- 6.72), Hepatitis C (16.1, 2.84 - 314), sexually transmitted disease (STD) (3.76, 1.38- 10.8), and HANA-associated cancer (2.44, 1.28- 6.42) were associated with HANA hospitalizations (Fig 3).

Patient Risk Factors for AIDS-related Hospitalization

Patient Risk Factors for HANA-related Hospitalization

Conclusion

Prevalence of HANA conditions was lower than AIDS-defining illnesses possibly because of a younger population. Patients with AIDS-defining illnesses were also likely to have HANA conditions. Early detection and effective treatment of both HIV and HANA conditions is essential to decrease hospitalizations in low-resource settings.

Disclosures

All Authors: No reported disclosures
946. Risk factors and Metabolic Implications of Integrase Inhibitor Associated Weight Gain
Authors: Asundi Archana , Olson Alex , Jiang Wenqing , Patel Swati , White Laura F , Sagar Manish , Lin Nina H
Published: January 2021

Background

Excessive weight gain associated with integrase strand transfer inhibitor (InSTI) antiretrovirals is an emerging issue in the current antiretroviral treatment (ART) era. Despite the known association between excess weight and impaired glucose tolerance in the general population, the metabolic implications of InSTI-associated weight gain have not been established. The objective of this study was to evaluate the presence of InSTI-associated weight gain amongst a diverse, urban population and to investigate potential risk factors and metabolic implications.

Methods

We obtained demographic, pharmacy and laboratory data from the hospital clinical data warehouse for ART-naïve adult HIV+ patients at Boston Medical Center between fiscal year (FY) 2007-2017. We compared patients who initiated on an InSTI to those with an alternate regimen (i.e. PI, NNRTI) who remained on their initial regimen for at least 18 months. Individuals with diabetes mellitus (DM) prescription or ICD 9/10 code prior to ART initiation were excluded. Our primary outcome was percent weight change in the first 24 months of ART estimated by linear mixed effects model fit by restricted maximum likelihood. Our secondary outcome was incident DM diagnosis in the 18 months after ART using progression-free survival (PFS). PFS rates were estimated by the Kaplan-Meier method and log-rank test, and Cox proportional-hazards model were determined, all using R v3.6.2.

Results

Between FY 2007-2017, 139 patients were initiated on InSTIs and 1117 were initiated on alternative anchor regimens. Approximately, one third of the cohort was female and more than 75% were non-white. InSTI use in women was associated with increased weight gain in the first 24 months of ART compared to non-InSTIs (+9.57%, p = 0.002, Figure 1). InSTI use was associated with more incident DM diagnoses in the first 18 months of ART compared to non-InSTI regimens (HR = 3.27, p = 0.014).

Figure 1: Percentage weight change from baseline at ART initiation between InSTI and non-InSTI regimens

Conclusion

Females have higher InSTI-associated weight gain which suggests they may be more susceptible to adverse metabolic issues. InSTI use appears to be associated with an increased incidence of DM diagnoses following ART initiation. Further prospective and controlled studies will be necessary to describe the mechanism of this effect and refine HIV management strategies.

Disclosures

Archana Asundi, MD, Gilead (Scientific Research Study Investigator)Merck (Scientific Research Study Investigator)ViiV (Scientific Research Study Investigator) Nina H. Lin, MD, Gilead Sciences (Scientific Research Study Investigator)ViiV (Scientific Research Study Investigator)
947. Stroke demographics and risk factor profile in HIV infected individuals in Florida
Authors: Ayoade Folusakin , Jayaweera Dushyantha
Published: January 2021

Background

The risk of ischemic stroke (IS) is known to be higher in people living with HIV (PLWH) than uninfected controls. However, information about the demographics and risk factors for hemorrhagic stroke (HS) in PLWH is scant. Specifically, very little is known about the differences in the stroke risk factors between HS and IS in PLWH. The goal of this study was to determine the demographics and risk factor differences between HS and IS in PLWH.

Methods

We retrospectively analyzed the demographic and clinical data of PLWH in OneFlorida (1FL) Clinical Research Consortium from October 2015 to December 2018. 1FL is a large statewide clinical research network and database which contains health information of over 15 million patients, 1240 clinical practices, and 22 hospitals. We compared HS and IS based on documented ICD 9 and 10 diagnostic codes and extracted information about sociodemographic data, traditional stroke risk factors, Charlson comorbidity scores, habits, HIV factors, diagnostic modalities and medications. Statistical significance was determined using 2-sample T-test for continuous variables and adjusted Pearson chi square for categorical variables. Odds ratio (OR) and 95% confidence intervals (CI) between groups were compared.

Results

Overall, from 1FL sample of 13986 people living with HIV, 574 subjects had strokes during the study period. The rate of any stroke was 18.2/1000 person-years (PYRS). The rate of IS was 10.8/1000 PYRS while the rate of HS was 3.7/1000 PYRS, corresponding to 25.4% HS of all strokes in the study. Table 1 summarizes the pertinent demographic and risk factors for HS and IS in PLWH in the study.

Table 1: Summary of pertinent demographic and risk factors for hemorrhagic and ischemic strokes in people living with HIV from One Florida database

Conclusion

In this large Floridian health database, demographics and risk factor profile differs between HS and IS in PLWH. Younger age group is associated with HS than IS. However, hypertension, hyperlipidemia and coronary artery disease are more likely to contribute to IS than HS in PLWH. Further research is needed to better understand the interplay between known and yet unidentified risk factors that may be contributing to HS and IS in PLWH.

Disclosures

All Authors: No reported disclosures
948. The Changing Dynamics of Hospitalizations Among People Living with HIV Over Time
Authors: Gujaran Shruti , Stafford Kristen A , Riedel David J
Published: January 2021

Background

As antiretroviral therapy for HIV has become more successful, people living with HIV (PLWH) are aging. Nearly half (48%) of all PLWH in the U.S. are now ≥ 50 years old, and this proportion is expected to continue to grow. The aging population of PLWH offers new challenges to the healthcare system beyond HIV management, with increased risks for chronic comorbidities and other complications of aging. Few studies have examined the causes and outcomes of hospitalizations among PLWH or how these diagnoses have changed over time.

Methods

Using U.S. hospitalization data from 1993 to 2014 from the National Inpatient Sample, we compared the primary diagnosis at admission among PLWH to HIV-negative hospitalizations and how this changed over time. We also compared the mean age at admission, hospital length of stay, total charges, and hospital disposition.

Results

There were 654,783,064 hospitalizations recorded from 1993 - 2014, with 5,370,749 among PLWH (0.8%) and 649,412,315 among HIV-negative patients (99.2%). The mean age of PLWH on admission increased from 37.4 years in 1993 to 48.1 years in 2014 and was lower than HIV-negative patients every year (Figure 1). There was a significant decrease in the proportion of admissions with HIV as the primary diagnosis for PLWH between 1993 - 2014 (53.1% to 24.2%) with a corresponding increase in non-HIV diagnoses over that time (Figure 2). The proportions of primary admission diagnoses for HIV-Negative patients were largely unchanged over the period. Although mean hospital lengths of stay for PLWH decreased over time, they were consistently longer than HIV-negative patients (Figure 3). Similarly, mean total charges for PLWH increased over time but were consistently higher than those for HIV-negative patients (Figure 3). The proportion of PLWH who died during hospitalization declined from a peak of 8.8% in 1993 to 2.4% in 2014 while inpatient mortality among HIV-negative patients declined from 3.2% to 2.2% over the same time.

Figure 1. Trends of Mean Age for PLWH and HIV-Negative Admissions from 1993 – 2014

Figure 2. Trends of HIV vs. non-HIV as the Primary Admission Diagnoses for PLWH from 1993 – 2014

Figure 3. Trends of Length of Hospital Admission and Total Charges for PLWH and HIV-Negative Patients from 1993 – 2014

Conclusion

The primary admission diagnoses for PLWH has shifted from HIV to non-communicable causes as PLWH are living longer. PLWH are typically younger on admission and have longer and more expensive hospitalizations than HIV-negative patients.

Disclosures

All Authors: No reported disclosures
949. Use of Optical Coherence Tomography Angiography to Assess Microvascular Health Among Persons with HIV: Employing the Retina as a Convenient Window
Authors: Collins Lauren F , Shantha Jessica G , Nesper Peter L , Sheth Anandi N , Fawzi Amani A , Yeh Steven , Ofotokun Ighovwhera
Published: January 2021

Background

Mechanisms underlying the rising burden of non-AIDS comorbidities (NACM) among persons with HIV (PWH) remain unclear. Microvasculopathy may link HIV-related chronic inflammation and premature multimorbidity, similar to diabetes and other conditions characterized by inflammatory end-organ damage. We used a novel retinovascular imaging tool, optical coherence tomography angiography (OCTA), to evaluate the retina as a convenient assessment of microvascular health among PWH.

Methods

Data from 4 PWH who underwent OCTA (Zeiss CIRRUSTM HD-OCT 5000) at the Emory Eye Center from 2018-2020 were analyzed. Demographics, HIV-specific indices and NACM were summarized at the time of OCTA. Images were reviewed qualitatively and metrics of microvascular health – the foveal avascular zone (FAZ) area and vessel density (VD) from the superficial capillary plexus (SCP) – were calculated by ImageJ.

Results

The median age was 39 years, 100% were male, 100% were black, 25% had ever smoked, and median body mass index was 25.4 kg/m2. Median time since HIV diagnosis was 19 years, all patients had a history of clinical AIDS, including 2 with prior cytomegalovirus retinitis. Median current CD4 count was 84 cells/mm3, 100% were prescribed antiretroviral therapy and 50% had HIV viral suppression. Prevalent NACM included (each n=1): hypertension, dyslipidemia, diabetes, chronic kidney disease and asthma.

Qualitatively, all 7 of the eyes evaluated by OCTA had evidence of microvascular pathology: 2 eyes demonstrated diffuse capillary nonperfusion, while the remaining 5 eyes had focal areas of nonperfusion around the FAZ. Mean FAZ area was 0.31 (SD±0.10) mm2 and mean VD of the SCP was 43.9% (SD±10.9%). Retinovascular pathology identified by fundoscopy and OCTA is shown in the figure.

Figure. Retinal imaging of a PWH with bilateral retinal vasculitis. Fundus photos of the right (A) and left (C) eyes show retinal vasculitis highlighted by the red arrows. OCTA of the right (B) and left (D) maculae (3X3 scan Zeiss AngioplexTM) show the FAZ areas outlined in yellow, both of irregular contour. OCTA of the left macula demonstrates areas of significant flow voids marked by the asterisks and the FAZ area is enlarged.

Conclusion

Among patients with longstanding HIV, OCTA identified microvascular abnormalities in all retinae examined. Retinovascular evaluation by OCTA is a feasible, non-invasive technique for assessing microvascular health and findings support additional study in a larger, more diverse group of PWH. Screening tools targeting microvasculopathy among PWH may aid in earlier detection of those at greatest risk of NACM and allow for aggressive risk-modification strategies.

Disclosures

All Authors: No reported disclosures
69. Impact of antimicrobial stewardship interventions on post-elective caesarean antibiotic prophylaxis and surgical site infections
Authors: Seah Xue Fen Valerie
Published: January 2021

Background

Antimicrobial stewardship programs (ASP) aim to improve appropriate antimicrobial use. This study aims to evaluate the impact of ASP interventions on post-elective caesarean (eLSCS) oral antibiotic prophylaxis use. In a subgroup of those without surgical site infection (SSI) risk factors, 30-day SSI rates was compared in those who received post-eLSCS oral antibiotics vs. those without.

Methods

This pre-post quasi-experimental study was conducted over 9 months (2 months pre- and 7 months post-intervention) in all women admitted for eLSCS in our institution. Interventions included eLSCS surgical prophylaxis guideline dissemination, where a single antibiotic dose within 60 minutes before skin incision was recommended. Post-eLSCS oral antibiotics was discouraged in those without SSI risk factors (e.g. obesity). This was followed by ASP intervention notes (phase 1) for 3 months, and an additional phone call to the ward team for the next 4 months (phase 2).

Results

A total of 894 women were reviewed. There were 244 women in the pre-intervention phase, 274 in post-intervention phase 1 and 376 in phase 2. Pre-intervention post-eLSCS antibiotic prescribing rates was 82% (200), compared to 54% (148) in phase 1 and 49% (180) in phase 2 (p< 0.001). There were 560 women without SSI risk factors. Of these, only 4 of 301 (1.3%) who received oral antibiotics, and 3 of 259 (1.2%) without oral antibiotics developed post-op SSI (p=1.000).

Conclusion

ASP can reduce post-eLSCS antibiotic prophylaxis. In those without SSI risk factors, use of post-eLSCS oral antibiotics did not impact SSI rates.

Disclosures

All Authors: No reported disclosures
954. Missed opportunities for HIV Screening in the Emergency Department
Authors: Hirsch Amanda , Carpenter Christopher F
Published: January 2021

Background

There are 1.14 million people infected with human immunodeficiency virus (HIV) in the United States, and only about 86% are diagnosed. HIV diagnosis is the first step to care and expanded testing is essential to reduce transmission. Individuals with undiagnosed HIV have a transmission rate 3.5 times higher than those aware of their infection. Individuals seeking testing and treatment for sexually transmitted infections (STIs) represent a higher risk population for HIV infection. Despite revised Centers for Disease Control and Prevention (CDC) recommendations to expand HIV testing in healthcare settings, testing remains low. A significant obstacle to expanded testing, especially in emergency departments (EDs), is concern about ensuring appropriate HIV test tracking and follow-up.

Methods

We performed a retrospective chart review of patients presenting with symptoms of an STI between January 1, 2015 and July 8, 2019 at eight Beaumont Health EDs in Southeast Michigan. De-identified data was collected from the electronic health record (EHR) for patients aged 10 and older who had testing for one or more STIs including gonorrhea, syphilis, and chlamydia. Patients were evaluated for concurrent HIV testing during the encounter, and patients known to be HIV infected were excluded.

Results

Of 32,640 encounters during which patients not known to be HIV infected were tested for STIs, only 68 (0.21%) included HIV antibody/antigen screening. Of those tested, only one (1.47%) returned reactive. The remaining 67 screenings returned non-reactive. Applying only 10% of this diagnosis rate to the total number of STI encounters suggests an opportunity to diagnose 47 additional individuals; applying 50% of this rate and the corresponding value is 239 individuals.

Conclusion

These results highlight the need for expanded HIV screening in EDs. Systematic HIV test tracking and follow-up removes this burden from ED providers and enables expanded HIV testing in these settings.

Disclosures

All Authors: No reported disclosures
960. Implementation and Evaluation of Alcohol Screening Tool in HIV Patients
Authors: Brickner Evan D , Mathew Trini , Johnson Paul
Published: January 2021

Background

In November 2018, the US Preventative Service Task Force (USPSTF) advised screening for Alcohol Use Disorder (AUD) in primary care settings for all adults. Given the consequences of AUD for immunocompromised patients, this recommendation was implemented using the Alcohol Use Disorders Identification Test (AUDIT) for patients with Human Immunodeficiency Virus (HIV) at Beaumont Hospital in Royal Oak, Michigan. This is a medical-student led, retrospective study to determine the impact of AUD in HIV patients that were screened using the AUDIT self-administered questionnaire.

Methods

All HIV patients undergoing outpatient care at the Beaumont Hospital HIV clinic were provided this self-administered AUDIT questionnaire as part of routine, check-in procedure by clinic staff starting on February 5, 2019. Scores were divided into “At Risk” or “Not At Risk” categories. Men (aged 18-60) screened positive for at-risk drinking if they scored 8 or higher. Men (older than 60) and women of all ages screened positive for at-risk drinking if they scored 4 or higher. This categorization of risk was determined using the criteria established by the National Institute on Alcohol Abuse and Alcoholism. Analysis between groups was made using T-Tests, Chi-Square tests, and odds ratios (OR), with corresponding 95% Confidence Intervals.

Results

A total of 121 HIV patients completed at least one AUDIT form. There were a total of 157 patient encounters. The mean age of “At Risk” drinkers was significantly higher than the mean age of “Not at Risk” drinkers, at initial visits and all visits, respectively (55.75 years vs. 46.25 years, p = 0.0117; 55.33 years vs. 46.29 years, p = 0.0075). These findings are depicted in Tables 1 and 2.

Table 1: Differences in Health Status between “At Risk” and “Not at Risk” Individuals (Initial Visit Only)

Table 2: Differences in Health Status between “At Risk” and “Not at Risk” Individuals (All Visits)

Conclusion

The preliminary results of this study demonstrate the importance of screening for AUD within the vulnerable HIV patient population. More specifically, it highlights the value of screening older individuals who may be at increased risk of hazardous drinking. In March 2020, the COVID-19 pandemic required transitioning to a telemedicine platform, thereby preventing completion of AUDIT paper forms. Thus, we will leverage technology by incorporating the AUDIT into electronic medical records, in effort to fortify this quality improvement initiative and ensure patient centered care.

Disclosures

All Authors: No reported disclosures
962. Linkage to Care Outcomes among Known HIV-Positive Patients at a High Prevalence Urban Hospital Emergency Department
Authors: Sudyn Alexander W , Paer Jeffrey M , Kodali Swetha , Maldonado Samuel , Nyaku Amesika , Swaminathan Shobha
Published: January 2021

Background

Retention in care of persons with HIV (PWH) is essential for achieving viral suppression and decreasing community transmission. CDC estimates that the 23% of known PWH not retained in care account for 43% of all new transmissions. This study seeks to describe the impact of an opt-out ED screening with navigator-assisted linkage to care (LTC) protocol for out of care PWH.

Methods

An IRB-approved retrospective chart review was conducted among PWH (prior positive) inadvertently retested in the ED between 2015 and 2018. Univariate and multivariate logistic regression was used to identify factors associated with LTC with patient navigator (PN) support. Factors with p ≤ 0.1 were included in the multivariate analysis as were age and sex at birth. Patients who died were excluded from statistical analyses.

Results

Among 464 patients who tested positive, 338 (73%) were known positive with 120 (35%) of those out of care at the time of screening. Mean age for this group was 47 (SD 11.9); 57% male, 81% non-Hispanic black, 10% Hispanic, and 6% non-Hispanic white. Fifty-five (46%) patients were successfully LTC, 54 (45%) referred to the state for linkage, and 11 (9%) died. A total of 109 patients were included in the analysis. Univariate analysis was performed for age (F(1, 107) = 0.98, p = 0.324) and female sex at birth (OR = 1.42 [95% CI 0.66, 3.05], p = 0.373) as well as Hispanic race (OR = 3.33 [95% CI 0.84, 13.04], p = 0.085), heterosexual HIV risk (OR = 2.76 [95% CI 1.27, 5.99], p = 0.011), IDU (OR = 0.49 [95% CI 0.21, 1.11], p = 0.088), and other SUD (OR = 0.42 [95% CI 0.19, 0.94], p = 0.035). Only heterosexual HIV risk (OR = 3.01 [95% CI 1.23, 7.32], p = 0.015) maintained significance in the final multivariate model.

Conclusion

Opt-out ED screening revealed >30% of known positive PWH were out of care at the time of testing; of whom nearly 50% were LTC with PN support. It is possible that persons reporting heterosexual HIV risk may feel less stigmatized and therefore are more likely to LTC. Similarly, the association with SUD, albeit non-significant, may reflect underrepresentation of individuals with SUD in remission among patient navigators. Future opt-out ED screening protocols should build upon diverse care teams to further engage patients with SUD and those at risk for non-heterosexual HIV transmission.

Disclosures

All Authors: No reported disclosures
963. Non-Invasive Detection of Cardiovascular Risk in People Living with HIV in Miami
Authors: Salguero Douglas , Galo Jason , Rodriguez Jornan , Pester Mollie , Chedebau Alejandro , Lang Barbara , Parker Meela , Gonzales Alex , Alcaide Maria L , Hurwitz Barry , Schneiderman Neil , Martinez Claudia
Published: January 2021

Background

HIV is a risk factor for Cardiovascular Disease (CVD), and CVD is the leading cause of mortality among Hispanics (H). Hispanics in the US are disproportionately affected by HIV with higher rates of HIV related morbidity and mortality, as well as adverse CVD outcomes. This study sought to identify early markers of CVD risk among Hispanics living with HIV.

Methods

Interim analysis of 38 H and non-Hispanics (NH) people living with HIV (PLWH), stable on antiretroviral regimen, 30-50 years of age, without previously detected CVD. Demographics, CD4 T cells, HIV RNA viral load, traditional early markers of CVD risk were collected. CVD risk markers were obtained with non-invasive tools: epicardial adipose tissue (EAT) thickness was assessed by echocardiogram; arterial stiffness was assessed by applanation tonometry sequentially at the carotid, femoral and radial arteries (including central augmentation index - AI, peripheral AI, radial pulse wave velocity - PWV, and femoral PWV). The Framingham Coronary Event Risk Score (FCER) was calculated for each subject. Descriptive and linear regression analysis for predictors of FCER measures were age adjusted.

Results

Among the 38 participants enrolled the mean age was 42 years, 80% male, H 76%, NH 24%, Black 16%, with mean BMI of 26.7. 45% met clinical criteria for metabolic syndrome: high waist girth 24%, high blood pressure 18%, high Fasting Glucose 16%, high total cholesterol 21%, high triglycerides 26%, low HDL 45%, high LDL 18%, high TC/HDL ratio 68%. The mean EAT was 3.8 mm, mean central AI 20.2 %, mean peripheral AI 73%, mean femoral PWV 28.8 m/s, mean radial PWV 8.7 m/s. Older age was associated with greater central AI (r = 0.37, p =.01) and peripheral AI (r = 0.38, p =.01) but not with increased EAT. Regression analysis predicting FCER relationships showed radial PWV as an independent predictor of increased FCER (r = 0.36, p < .05).

Conclusion

Risk factors leading to CVD are common among this group of PLWH and radial PWV is a moderate predictor of increased FCER. Although measures of arterial stiffness are available, they are not routinely used to assess CVD risk. Further studies should evaluate the use of noninvasive methods for diverse PLWH, to prevent the development of CVD.

Disclosures

All Authors: No reported disclosures
70. Impact of Fluoroquinolone Susceptibility Suppression on Discharge Prescribing for Acute Uncomplicated Cystitis
Authors: Hayden Dillon , White Bryan , Neely Stephen , Bennett Kiya
Published: January 2021

Background

Fluoroquinolones (FQ) are associated with multiple adverse effects and increasing resistance. Acute uncomplicated cystitis (AUC) treatment remains a frequent reason for FQ use. Previous data suggests that suppression of FQ susceptibility results can decrease inpatient use, but may not reduce prescribing at discharge. The purpose of this study was to investigate the impact of FQ susceptibility suppression on discharge prescribing for AUC.

Methods

This was a retrospective, quasi-experimental study in adult patients at a 350-bed academic medical center. The effect of suppression of FQ susceptibilities on pan-susceptible urine isolates for Klebsiella sp. and E. coli on FQ prescribing and appropriateness at discharge was compared one year before and after the intervention, starting in March 2018. Risk factors for FQ use were also examined. Exclusion criteria included pyelonephritis, urinary hardware, pregnancy, concomitant infections treated with FQ, and organisms not susceptible to FQ. Risk ratios of FQ use were calculated for pre-/post-groups and stratified by discharging team for adjusted rates (aRR) using a Cochran-Mantel-Haenszel approach. For secondary outcomes, Chi-Square statistics and generalized regression models were used to assess odds of FQ use among variables.

Results

Overall discharge FQ prescribing decreased from 41.1% to 21.1% after the intervention, corresponding to a 53% lower adjusted risk (aRR 0.47 [95% CI 0.28–0.81]). One-hundred percent of FQ use was inappropriate, largely due to organism susceptibility to a guideline-preferred agent (n = 33/38). After adjusting for the intervention and clustering of discharge team, the odds of outpatient FQ use was 3.46 times higher for uninsured vs. insured patients, and 13.4 times higher among those who received FQ while inpatient.

FQ Use at Discharge

Other Antibiotic Use

Risk Factors for FQ Use at Discharge

Conclusion

Suppression of FQ susceptibilities on pan-susceptible urine isolates for Klebsiella sp. and E. coli was associated with a decrease in FQ prescribing at discharge for AUC. Patients who received FQ while inpatient were 13.4 times more likely to be continued on FQ at discharge. Overall, prescribing of FQ for AUC was inappropriate, and stewardship programs should implement FQ suppression policies to improve FQ prescribing at discharge.

Disclosures

All Authors: No reported disclosures
966. Pregnancy Outcomes and Engagement in HIV Care for Pregnant Women Living with HIV in Rhode Island 2012-2019
Authors: Byrd Katrina M , Henebeng Esther , McCarthy Meghan L , Gillani Fizza S , Hardy Erica , Holland Sabina D
Published: January 2021

Background

Prevention of mother to child transmission (PMTCT) of Human Immunodeficiency Virus (HIV) requires a comprehensive approach and understanding the cultural backgrounds of pregnant women living with HIV (PWLH). In Rhode Island (RI), 70% of women newly diagnosed with HIV are foreign-born (FB) despite only representing 14% of RI’s population. Understanding the similarities and differences of pregnancy characteristics and engagement in postpartum HIV care between United States born (USB) and FB women is needed to ensure PWLH remain engaged in care and that appropriate resources are provided to all women with HIV in our state to maintain successful PMTCT of HIV.

Methods

A retrospective review of pregnant women living with HIV and their HIV-exposed infants evaluated in our hospital system were analyzed from 2012-2019. Clinical data were derived from medical records. Association between country of origin and sociodemographic, clinical, or lab variables were evaluated using chi-square test.

Results

A total of 72 pregnancies in 64 PWLH were included. Median # of pregnancies were 9 per year, median age at delivery 33 years, 54% of PWLH Black or African American, 33% Hispanic; 67.1% FB, most (56%) from Sub-Saharan Africa. Sixty-one % (n=42) with detectable (> 20 copies/mL) viral load (VL) during pregnancy, 23% (n=15) at delivery, only 1 VL > 200 at delivery. Pregnancy complications seen in 51%; 60% delivered vaginally; most (74%) at term. Engagement in postpartum HIV care declined from 71% at 6 months to 37% at 24 months. There was also decline in engagement in HIV care for the HIV exposed infants- 89% presented to the initial visit their children, from 89% attending the initial visit to 69% attending their last. DCYF involvement was more likely to occur in USB women compared to FB (P < 0.05). Other comparisons between FB & USB women including adherence to care were insignificant.

Conclusion

USB PWLH are at higher risk of DCYF involvement compared to FB women. Investigation into this disparity is warranted, given the cultural and language differences between groups. Additional research to determine barriers to long-term postpartum follow up for women and their infants is urgently needed.

Disclosures

All Authors: No reported disclosures