bluuebunny/crossref_metadata_2025 huggingface dataset:
1293. Bundled HIV/Hep C testing 4 Years of Implementation at 9 Emergency Departments in the Houston Metropolitan Area
Authors: Rodriguez Gilhen , Prater Samuel , Heresi Gloria , Murphy James , Wanger Audrey , Murphy Daniel , Del Bianco Gabriela P , Aguilera Elizabeth A , McCarthy James
Published: October 2019

Background

Individuals living with HIV infection and/or Hep C infection and unaware of their infected status are at risk of significant morbidity and a risk to public health. It has been recommended that all conscious adults presenting to Emergency Departments (EDs) be tested for HIV and increasingly testing for Hep C. Testing of all arrivals is important because a majority of both infections may not present signature signs or symptoms associated with the reason for the ED visit. For these reasons, the implementation of a bundled HIV/HepC testing protocol is reported here.

Methods

Data from 4 years of HIV/Hep C screening of patients 18 to 64 years old made in 9 EDs in the Houston Metropolitan Area are reviewed. Screening for HIV was using HIV fourth-generation ADVIA Centaur™ Ag/Ab COMBO (Siemens) and Hep C was tested for using Gilead Hep C Ab testing.

Results

During January 2013 until October 2016, 3,976 HIV/Hep C test bundles were performed. There were 40 (1.0%) HIV+ and 407 (10.2%) Hep C positive detected. Nine (0.2%) of these individuals were positive for both HIV and Hep C. A 22.5% of HIV-positive patients were co-infected with Hep C. The population had a median age of 53 years, comprising an equal number of males and females.

Conclusion

A significant prevalence of Hep C (10%) and HIV (1%) was found in patients presenting for any cause of major EDs in the Houston region. Bundled HIV/Hep C testing of all arrivals to EDs is an effective way to identify individuals that need to be directed to antiviral and linkage to care.

Disclosures

All authors: No reported disclosures.
1300. Symptom Driven Testing Is not Enough: A Retrospective Review of Patients Enrolled into HIV Care 2015–2018 at a Ryan White Patient-Centered Medical Home in Pittsburgh, Pennsylvania
Authors: Cheronis Nicholas , Bean Holly , Tremoglie Marissa , Magrini Cindy , Blazejewski Lucas , Hsiao Chiu-bin
Published: October 2019

Background

While current CDC guidelines recommend screening between the ages of 13–64 at least once and annually for high-risk individuals, this is often not practiced. Early diagnosis has become key to preventing the spread of HIV. It has been suggested that a late diagnosis, one where a patient is symptomatic, implies a loss of 10.5 years in their lifespan.

Methods

From January 1, 1, 2015 to December 31, 2018, 113 newly diagnosed HIV-infected patients enrolled in care at The Positive Health Clinic (PHC), a Ryan White funded clinic, located in Pittsburgh, PA.

Results

The median age was 32, 78% male, 64% MSM (Figure 1). At the time of HIV diagnosis, the median CD4 count was 325 U/L and HIV viral load was 65,000 copies. 32 patients (28%) had a CD4 count <200 and 13 had an AIDS-defining illnesses (Figure 2). Only 50% of HIV diagnoses were based on a provider’s clinical suspicions, 26% were driven by patient request, and 24% were the result of system driven screenings. 90.2% of patients had prior healthcare contact before the HIV diagnoses, suggesting missed opportunities. Of all the newly diagnosed HIV patients, 62% were symptomatic, prompting them to be tested for HIV (Figure 3). In 20% of the symptomatic cases, the patient requested to be tested for HIV, highlighting missed opportunities for clinicians to include HIV in their differential. A previous test for HIV within one year of their HIV diagnosis positively correlated with early diagnosis (CD4 >200 copies) (P = 0.007). System driven screenings for HIV also positively correlated with early diagnosis (CD4 >200 copies) (P < 0.001).

Conclusion

Waiting for clinical suspicion is not enough. To prevent patients from developing life-threatening AIDS-defining illnesses screening must be done at each interaction with the healthcare system for high-risk patients and annually for patients without risk factors.

Disclosures

All authors: No reported disclosures.
1301. Graphical Analysis of HIV Guidelines Adherence Finds System-Wide Anomalies in Diagnostic Testing
Authors: Hauser Ronald George , Bhargava Ankur , Chartier Maggie , Maier Marissa
Published: October 2019

Background

The misuse of HIV diagnostic tests can delay HIV diagnosis, contribute to HIV transmission, incur unnecessary costs, and pose legal risks. Prompted by case reports of misused HIV diagnostic tests, we developed a method to systematically evaluate HIV diagnostic testing that utilized an observational medical database, evaluated performance at different levels (e.g., system, facility, clinician), adjudicated clinical practice patterns as adherent or nonadherent to guidelines, quantified the impact of clinical practice deviations, and identified targets for intervention.

Methods

We used graph theory to assess patterns of HIV testing in a national healthcare system. We obtained all HIV screening tests, viral loads, and resistance tests performed January 1, 2015–January 31, 2019, excluding HIV-positive and deceased individuals (Figure 1). We modeled the CDC’s HIV diagnostic testing guidelines as a directed graph (Figure 2A). Each node in the graph represented a test, and the edges pointed from one test to the next in chronological order. We then graphed each patient’s HIV testing. This set of patient-level graphs was aggregated into a single graph. Finally, we compared the two graphs, the first representing the CDC’s recommended approach to HIV diagnostic testing and the second representing the observed patterns of HIV testing, to assess for clinical practice deviations.

Results

The HIV diagnostic testing of 1.643 million patients from 130 facilities provided 8.790 million HIV diagnostic test results for analysis (Figure 1). Significant deviations from recommended practice were found including the use of HIV resistance tests (n = 3,007) and HIV nucleic acid tests (n = 16,567) instead of the recommended HIV screen (Figure 2B). The estimated costs of nonadherent testing totaled $2.427 million in 2018 dollars.

Conclusion

We developed a method that modeled a complex medical scenario as a directed graph. When applied to HIV diagnostic testing, we identified deviations in clinical practice from guideline recommendations. The model enabled the identification of intervention targets and prompted systemwide policy changes to reduce nonadherent orders and enhance HIV detection (Figure 3). This approach could be applied to diverse medical scenarios.

Disclosures

All authors: No reported disclosures.
1302. HIV Testing in Adults Presenting with Central Nervous System (CNS) Infections
Authors: Ma Bert , Vigil Karen J , Hasbun Rodrigo
Published: October 2019

Background

The Centers for Disease Control and Prevention recommends that all patients be tested for HIV while in a healthcare setting. HIV testing is especially important in patients with a central nervous system (CNS) infection because it impacts the differential diagnosis. In this study, we determined the rate of HIV testing in patients who presented with a CNS infection.

Methods

We performed a multicenter retrospective study of 1,312 patients over the age of 17 years with community or healthcare-acquired meningitis, aseptic meningitis or encephalitis admitted to 18 hospitals in New Orleans, LA and Houston, TX from July 1, 1998 through December 31, 2017. Prospective patients were identified using ICD 9 coding, physical examination findings, and cerebrospinal fluid analysis. The electronic medical records for these patients were reviewed for HIV testing and diagnosis. Aseptic meningitis cases were also reviewed for HIV RNA PCR testing. 100 patients with a known HIV diagnosis were excluded (2 aseptic meningitis, 82 encephalitis, and 16 community-acquired meningitis).

Results

Out of 1,312 patients presenting with a confirmed CNS infection, 664 (50.6%) had an HIV test done. A total of 81 patients (12.2%) were newly diagnosed with HIV during admission. Patients who underwent HIV testing were more likely to be non-caucasian, have no underlying comorbidities, lower Glasgow coma scale, and more seizures on presentation (P < 0.05). HIV testing also varied by type of CNS infection: community-acquired meningitis (98/142, 69.0%); encephalitis (180/261, 69.0%), aseptic meningitis (300/643, 46.6%), and healthcare-associated meningitis (86/289, 29.7%). In only 35 out of 547 patients (6.4%) presenting with acute aseptic meningitis was an HIV RNA PCR test ordered; 26 out of the 35 (74%) HIV RNA PCRs were positive with 9 patients being diagnosed with acute HIV seroconversion syndrome.

Conclusion

HIV testing is done in only one-half of patients with CNS infections with only a minority of patients presenting with acute aseptic meningitis being evaluated for acute HIV seroconversion syndrome. Clinicians should order an HIV test on all patients with CNS infections and consider testing for HIV RNA PCR in patients presenting with acute aseptic meningitis especially in those where the etiologic diagnosis remains unknown.

Disclosures

All authors: No reported disclosures.
1312. Increasing Care Engagement Amongst People Living with HIV Through a Text Messaging Intervention at a Tertiary Center
Authors: Gupta Nupur , McBeth Sarah , Kaplan Ella , Valdisera Greg , McMahon Deborah
Published: October 2019

Background

HIV has transitioned from an acute illness to a chronic disease due to potent antiretroviral therapy (ART). People living with HIV (PLWH) must be highly compliant which is difficult due to multiple barriers. The HIV care continuum was developed as a series of steps that PLWH take in their treatment cascade. At our HIV clinic, 90% of the patients are virally suppressed (viral load <200 copies/mL). Although this is higher than the national average, PLWH who are not virally suppressed and not retained in care carry the highest risk of transmission. We have several resources to engage patients, but text messaging has not been utilized for at-risk patients at the clinic or at the academic center.

Methods

The aim is to demonstrate that a pilot study of a text messaging-based intervention will increase the proportion of PLWH along the care continuum. The pre-intervention data consists of the clinic population with a viral load ≥200 copies/mL between July 1, 2017 and June 30, 2018. After chart review, eligible patients were consented to receive weekly text messages with content regarding appointment and medication reminders, and motivational messages. In the consented group, effectiveness of the intervention will be measured by tracking their appointments, viral loads, and ART prescriptions.

Results

After chart review, 80 patients were eligible, and 18 patients were consented for the intervention. In the eligible group, the average length of care is 8 years (range 0 to 26) and average number of years since initial ART prescription is 6.8 (range 0 to 20). The average viral load is 27,372 copies/mL. Amongst the consented group (n = 18), compared with the pre-intervention, there was a 6% increase in those who made an appointment, 33% increase in those who kept an appointment, 50% increase in those who had a viral load <200, and 62% increase in those who had ART dispensed post-intervention.

Conclusion

The intervention group is small due to difficulties in consenting this vulnerable population. This is an observational study that demonstrated the impact of text messaging a high-risk population with minimal harm that not only improved the local HIV care continuum, but also addressed the barriers to care. The next steps are to determine how this method can link other at-risk patients to care at a large HIV clinic at a tertiary center.

Disclosures

All authors: No reported disclosures.
1316. Gathering Trauma Narratives: A Qualitative Study on the Impact of Traumas on People Living with HIV (PLWH)
Authors: Pierson Doris , Mujumdar Vaidehi , Briceño Brittany , Cummer Elaina , Hemal Kshipra , Golden Shannon , Wiseman Kimberly , Tanner Amanda , Schafer Katherine R
Published: October 2019

Background

Trauma—emotional, physical, and psychological—is common and associated with increased risk behaviors, low rates of care engagement and viral suppression, and overall poor health outcomes for people living with HIV (PLWH). In the United States, there are limited data on how trauma affects reproductive health beliefs for PLWH and even less data on HIV providers’ understanding and consideration of these experiences in their approach to patients.

Methods

Fifteen semi-structured interviews were conducted with PLWH and nine semi-structured interviews were conducted with HIV care and service providers at an academic medical center in the Southeastern United States. Transcripts were analyzed using thematic analysis. Each transcript was coded by two investigators and discussed to ensure consensus.

Results

Participants’ narratives described diverse traumas, including sexual abuse (n = 6), the loss of a loved one (n = 8), and personal illness (n = 7). Types of trauma shared with providers included physical, sexual, illness, loss, and psychological. For patients, trauma was both a motivation for having children and a reason to stop having children. Providers perceived a variety of effects of trauma on both sexual behaviors and reproductive intentions. Reproductive counseling by HIV care providers (n = 5) focused on maintaining a healthy pregnancy and less on reproductive intentions prior to pregnancy. Reproductive discussions with pregnant female patients typically centered on reducing the risk of transmission in utero (including the importance of medication adherence to maintain viral suppression), what will happen during delivery, and breastfeeding risks. Reproductive discussions with males typically centered on preventing infection or re-infection of the mother.

Conclusion

PLWH interpret their trauma experiences differently, particularly when considering reproduction. Providers may not incorporate this information in counseling around reproductive health, highlighting the need fora trauma-informed healthcare practice that promotes awareness, education on the effect of past traumas on health, and access to appropriate resources.

Disclosures

All authors: No reported disclosures.
1332. Identification of Genetic Markers Linked to Recurrent Methicillin-Resistant Staphylococcus aureus Skin and Soft-Tissue Infections
Authors: Sims Matthew
Published: October 2019

Background

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most common and problematic causes of bacterial skin and soft-tissue infections (SSTI). MRSA tends to form complex skin infections, furuncles, boils and abscesses. Many patients go on to have recurrent infections, requiring significant additional therapy to treat each infection as well as needing to undergo decolonization of the skin in order to remove the bacteria and try to prevent future infections. A test to distinguish patients at risk for recurrence can allow earlier more aggressive treatment for those at risk for recurrent infection. This can potentially reduce healthcare costs, prevent future hospital admissions and surgical procedures, and reduce loss of productivity experienced by patients suffering from multiple recurrences.

Methods

A genome-wide association study using the Affymetrix gene array was performed on 11 patients with confirmed recurrent MRSA SSTIs and 3 controls who never developed an SSTI despite confirmed heavy exposure to MRSA in order to identify single nucleotide polymorphisms (SNP) associated with recurrent MRSA. The 10 genes identified were then fully sequenced using an Illumina NextSeq 500 to identify additional SNPs.

Results

A total of 22 SNPs were found in 10 separate genes which distinguished patients with recurrent MRSA from patients without recurrent MRSA despite heavy exposure. The 10 genes are shown in Table 1 along with a representative SNP. The P-values for each individual SNP were between 3.5 × 10−5 and 1.2 × 10−7.

Conclusion

This study provides the first evidence of a genetic risk for those patients who develop recurrent MRSA SSTIs. The majority of the genes involved are related directly to the skin, not to immune functions thus it appears the major risk factor for development of recurrent MRSA SSTI is related to the barrier function of the skin and not to an immune defect. Being able to determine which patients are at risk for recurrence at the time they first present with an MRSA SSTI would be of great help in preventing future recurrences, reducing morbidity and reducing healthcare costs.

Disclosures

All authors: No reported disclosures.
1333. Utility of Admission Procalcitonin Level in Patients Presenting to the Hospital with Bloodstream Infection: Real-World Evidence from 250 US Hospitals
Authors: Kadri Sameer S , Ling Lai Yi , Warner Sarah , Strich Jeffrey R , Ricotta Emily , Rebecca Prevots D , Demirkale Cumhur Y , Babiker Ahmed , Rhee Chanu , Klompas Michael , Danner Robert L
Published: October 2019

Background

Serum procalcitonin (PCT) may aid in early detection and treatment of bacterial bloodstream infections (BSI), yet evidence for this indication is inconclusive. We leveraged real-world data to examine biological variability in PCT across host and pathogen factors and its utility for ruling out BSI on admission.

Methods

PCT measurements within 24 hours of admission were examined in patients presenting with monomicrobial BSI to 250 hospitals in the Cerner Healthfacts Database. The reliability of admission PCT for ruling out BSI at hospital presentation was assessed using two different thresholds (<0.5 and <0.25ng/mL) and then stratifying results by presence vs. absence of sepsis (using CDC Adult Sepsis Event criteria), fever or hypothermia vs. normothermia, various presumed sources of BSI, and organism taxon.

Results

Between 2007 and 2017, PCT was measured on admission in 4,358/42,465 (10.3%) adults with BSI present on admission at 60 hospitals. Of these, 870 (20%) met CDC surveillance criteria for sepsis. The median admission PCT was 4.89 [0.93, 23.98] and varied by taxon, BSI source, patient temperature, and the presence and severity of sepsis; acute illness severity was the greatest driver of high PCT levels (Fig 1). Using a threshold of ≥ 0.50 ng/mL, the sensitivity of PCT for detection of BSI was 84% for all patients. Notably, BSI without sepsis was 4-fold more likely to yield a false negative PCT (<0.5ng/mL) than bacteremic sepsis. Sensitivity ranged from 77% with normothermia to 83% with fever/hypothermia (P = 0.06), between 81 and 88% across sources of BSI (P = 0.13) and more widely between 64 and 91% across taxa (P = 0.02). Enterococcal BSI was 2- and 4-fold more likely to have a falsely negative PCT than S. aureus or S. pneumoniae BSIs, whereas non-glucose fermenters other than P. aeruginosa had a 2 and 3-fold higher likelihood of being missed compared with P. aeruginosa and Enterobacteriaceae BSIs respectively (Fig 2). Pathogen-level variation in PCT sensitivity was also observed for BSI without sepsis (62–90%; P = 0.02) and upon using a stricter rule-out threshold of <0.25 ng/mL (P = 0.01).

Conclusion

PCT levels and the reliability of this test for ruling out bacteremia at hospital presentation varies by pathogen, presenting signs, and presence vs. absence of sepsis.

Disclosures

All authors: No reported disclosures.
1343. Infectious Diseases Consultation Avoided Delayed Therapy and Unnecessary Exposures in the Majority of GeneXpert® MTB/RIF and AFB Smear Negative Pulmonary Tuberculosis Cases in the US County Hospital in Houston, Texas
Authors: Balason Arabella R , Saldana Andrew G , Chavez Violeta , Masayuki Nigo
Published: October 2019

Background

In 2017, Harris County had a total of 281 cases of newly diagnosed tuberculosis (Mtb), which was the highest incidence in Texas, United States. Lyndon B. Johnson (LBJ) hospital is one of the two HarrisHealth county hospitals which serve a wide population including immigrants and an indigent population. GeneXpert® MTB/RIF (GeneXpert) was implemented in our hospital since 4/2016. However, pulmonary Mtb cases with negative GeneXpert/AFB smears carry significant challenges in the initiation of therapy and hospital infection control. Our aim was to describe how Infectious diseases (ID) consultations helped to identify the cases of both GeneXpert and AFB smear-negative pulmonary Mtb cases without delaying therapy and unnecessary exposures.

Methods

The patients with newly diagnosed pulmonary Mtb in LBJ hospital were identified between January 2017 and December 2018. The patient’s characteristics, GeneXpert results, AFB smear results, and the presence of ID consultation were retrospectively collected. Delayed therapy is defined as the initiation of active four-drug Mtb therapy until the positive culture results.

Results

A total of 52 cases with newly diagnosed pulmonary Mtb confirmed by positive culture were identified, of which 44 cases who had GeneXpert on at least one sputum specimen were included in the final analysis. 7 out of 44 (20%) had negative GeneXpert on the first specimen and all three or more AFB smears were negative. The patients were the median age of 51 years and predominantly female (57%). 5 cases were Hispanic and 2 had HIV/AIDS. In 6 out of the 7 cases, ID consultation was made and anti-tuberculous therapy was empirically initiated without delay and all remained in the isolation. Only one case had delayed therapy despite ID consultation, three consecutive AFB sputum samples, and one GeneXpert was properly performed. The patient had newly diagnosed AIDS (CD4 of 2 cells/µL) and 3 weeks of chronic cough with normal lung parenchyma and minimal right pleural effusion on CT chest at his presentation.

Conclusion

We had 7 cases (20%) of GeneXpert and AFB smear-negative pulmonary Mtb. ID consultation properly identified 6 cases without delayed therapy. Early involvement of ID should be considered when pulmonary Mtb is suspected.

Disclosures

All authors: No reported disclosures.
1347. Tuberculosis Caused by Mycobacterium bovis in Children: A Retrospective Review of Cases From 2010 to 2019 in a Pediatric Tertiary-care Center in Mexico
Authors: Gonzalez Saldaña Napoleon , Macias Parra Mercedes , Arias de la Garza Eduardo , Pérez Murillo Sairy , Eugenio Narro Flores Manuel , Tamez Rivera Oscar
Published: October 2019

Background

Tuberculosis (Tb) is a leading cause of death worldwide. The most common cause of Tb is due to M. tuberculosis, however, M. bovis is considered a public health issue and an often-undetected cause of Tb. Information regarding Tb by M. bovis in children is scarce.

Methods

Retrospective analysis of culture-proven cases of Tb by M. bovis from 2010 to 2019 in a pediatric tertiary-care center in Mexico. Clinical and paraclinical characteristics were compared.

Results

We included 22 cases of Tb by M. bovis in children younger than 18 years of age. 64 percent were men, mean age was 3.8 years. All subjects had a positive history of BCG immunization. Eight subjects (36.4%) consumed unpasteurized dairy products, 3 (13.6%) referred contact with Tb-infected people, and none had contact with cattle. Twelve patients (54.5%) had an immunodeficiency (ID). The most common ID was defects in the IL-12/IFN-γ axis (36.3%), followed by severe-combined ID (9%). All of the subjects presented any form of extrapulmonary Tb, and 8 (36.4%) had disseminated Tb. The most common extrapulmonary presentations were lymph-node (40.9%), abdominal (18.2%), and skeletal Tb (13.6%). Fever was present in 21.3% of the cases, weight-loss in 12%, and diaphoresis in 9.3%. Hepatomegaly was present in 83% of patients with abdominal Tb (P = 0.001). We found a negative association between lymph-node enlargement and skeletal Tb by M. bovis (P = 0.01). Five cases (22.7%) were identified as M. bovis BCG strain. Infection by BCG strain was associated with a shorter time of presentation (< 4 months) (P = 0.005). Polydrug resistance (resistance to ≥2 drugs, excluding those classified as MDR) was observed in five strains (22.7%). We detected 3 RIF-resistant strains (19%), 2 INH-resistant strains (9.1%), and 1 EMB-resistant strain (4.5%). No MDR strains were detected. We report an 86% cure rate, and 5% mortality. Nine percent are still in treatment.

Conclusion

We report 22 cases of culture-proven cases of Tb by M. bovis, from 2010 to 2019 in a pediatric tertiary-care center in Mexico. Disseminated presentation was common, as well as extrapulmonary involvement. Infection by M. bovis BCG strain was associated with a shorter time of presentation. Further studies are required in order to expand our knowledge on M. bovis infection in children.

Disclosures

All authors: No reported disclosures.
1357. Mycobacterium abscessus Native Tricuspid Valve Endocarditis. Is a 6-Week Course of Combination Antibiotic Therapy Enough?
Authors: Matthew. Wooten William , Lebron Dora , Winters Niki , Lagasca Alicia , Cook Paul P , Ghimire Rabindra
Published: October 2019

Background

Infective endocarditis of the native heart valves due to M. abscessus has been reported in individuals who inject drugs. Only one case thus far has been reported with survival beyond 4 months after completion of antibiotic therapy. 24-year-old Caucasian woman with a history of intravenous drug use presented with intermittent fevers for 3–4 months. She was having chills, night sweats, and productive cough. She acknowledged using intravenous cocaine and heroin every few days after being discharged from our hospital 6 months previously when she was treated for tricuspid valve endocarditis. Chest radiograph demonstrated right lower lobe airspace disease suggestive of pneumonia. Three days later her blood cultures grew acid-fast bacilli, later identified as M. abscessus.

Methods

She was empirically treated with azithromycin, amikacin, and imipenem. Transthoracic and transesophageal echocardiograms were suggestive of tricuspid valve endocarditis. CT angiogram of the chest showed filling defects within several large right lower lobe pulmonary arteries and dense right lower lobe consolidation with pleural effusion. The patient underwent bronchoscopy with bronchoalveolar lavage (BAL) and therapeutic thoracoscopy with drainage and thoracostomy tube placement. BAL cultures also grew AFB. Multiple sets of blood cultures drawn after commencement of antibiotic therapy during the hospital course were negative. Drug susceptibilities were available 3 weeks later. The isolate was susceptible to amikacin. Linezolid, imipenem, and cefoxitin exhibited intermediate activity, and TMP/SMX, ciprofloxacin, moxifloxacin, doxycycline, minocycline, and clarithromycin were reported resistant. Inducible erm gene was present. Azithromycin and linezolid were discontinued and tigecycline was added.

Results

Patient completed 6 weeks of antibiotics from the day of the first negative blood culture. Repeat TTE 1 month after completion of therapy revealed a decrease in tricuspid valve vegetation. Blood culture done 3 months later was sterile. AFB blood cultures done a year later did not report any growth.

Conclusion

This case opens a debate, if in a selected group of patients, a short course of combination antibiotic therapy is enough to obtain cure. This will require further analysis.

Disclosures

All authors: No reported disclosures.
1359. Clinical Experience and Challenges Utilizing Clofazimine in the Treatment of Nontuberculous Mycobacterial Pulmonary Infections
Authors: Mercurio Amanda , Fredenrich Jaela , Gompf Sandra
Published: October 2019

Background

Nontuberculous mycobacterial (NTM) pulmonary infections are increasingly common and associated with significant morbidity and mortality. Treatment is challenging given high rates of antimicrobial resistance, the need for prolonged therapy with multiple agents, and poor medication tolerability. Clofazimine (CFZ), an antimicrobial available under an investigational new drug (IND) program, has excellent in vitro activity but limited clinical data. We present an 18-month experience of clofazimine as part of a multidrug regimen as salvage therapy for NTM pulmonary infections at the James A. Haley Veterans’ Affairs Hospital in Tampa, FL.

Methods

We conducted a single-center, retrospective review of the medical records of 11 patients with NTM pulmonary infections who were approved for treatment with CFZ-containing regimens between September 2017 and February 2019. Basic demographics, clinical characteristics, as well as symptomatic, radiologic, and microbiologic responses to therapy were evaluated.

Results

Approval for the IND program took approximately 15 months. We then treated 8 patients with pulmonary NTM infection with CFZ-containing regimens. Of these, 88% had cavitary disease, 63% were active smokers, and all had underlying pulmonary disease. The most common etiologic organisms were Mycobacterium avium complex and Mycobacterium abscessus. All patients were required to follow up every 3 months while on therapy. For patients who had at least 3 months of follow up, 100% reported symptomatic improvement. 50% achieved negative cultures with an average time to clearance of 25 weeks. All had stable or improved imaging. CFZ was well tolerated with no significant adverse effects.

Conclusion

Once available, CFZ-containing regimens were moderately effective in treating NTM pulmonary infections with minimal adverse effects. Close patient follow up was necessary to assess response to treatment.

Disclosures

All authors: No reported disclosures.
1364. Pretreatment Chest X-ray Stability Duration and Tuberculosis Disease in San Diego County, 2012–2017
Authors: Barber Casey , Oren Eyal , Cheng Yi-Ning , Slater Madeline , Graves Susannah
Published: October 2019

Background

Repeated chest X-rays serve as an essential screening tool to identify and describe new or stable (i.e., unchanged) lung abnormalities suggestive of pulmonary tuberculosis (TB) disease. The time for which a patient’s chest X-ray has not demonstrated appreciable change prior to treatment, or pretreatment chest X-ray stability duration, has been considered clinically useful in distinguishing inactive from active disease at four or 6 months. This relationship, however, has not been previously quantified.

Methods

This study relied on retrospective medical record review to assess the relationship of documented pretreatment chest X-ray stability duration thresholds relative to four and 6 months with a future clinical or culture-confirmed (Class 3) diagnosis of pulmonary TB disease. Multivariable logistic regression quantified this association among 146 patients who were evaluated and started on treatment for pulmonary TB disease in the San Diego County tuberculosis clinic between May 2012 and March 2017.

Results

After adjusting for age and Class B1 TB, Pulmonary status, a CXR stability duration of 4 months or more was not significantly associated with a Class 3 pulmonary TB diagnosis (adjusted odds ratio [AOR], 0.830; 95% confidence interval [CI], 0.198–3.48). Results were similar for the 6-month cut-point after adjusting for age and Class B1 Pulmonary status (AOR, 0.970; 95% CI, 0.304–3.10). Compared with less than 4 months, CXR stability durations of four to 6 months (AOR, 0.778; 95% CI, 0.156–3.89) and greater than 6 months (AOR, 0.875; 95% CI, 0.187–4.10) were also not significantly associated with a Class 3 TB diagnosis after adjusting for covariates.

Conclusion

Repeated chest X-rays remain a valuable tool for clinicians identifying and describing new or unchanged lung abnormalities suggestive of pulmonary TB disease. This study found no statistically significant association between pretreatment chest X-ray stability duration and subsequent TB disease diagnosis, with a wide range of estimates compatible with the data, suggesting the stability duration cut points relative to four and 6 months may not be as informative as previously understood.

Disclosures

All authors: No reported disclosures.
1375. Laboratory Abnormalities Among Patients with Pulmonary Mycobacterium avium Complex Infections
Authors: Varley Cara D , Henkle Emily , Strnad Luke , Ku Jennifer , Brunton Amanda , Winthrop Kevin L
Published: October 2019

Background

Limited data are available regarding laboratory abnormalities in patients with pulmonary Mycobacterium avium complex (MAC) disease.

Methods

We included patients without cystic fibrosis who had pulmonary MAC and met ATS/IDSA disease criteria from the Northwest NTM Biobank with a complete blood count (CBC) 6 months prior and up to 30 days after study enrollment. The biobank is a cohort of patients with Nontuberculous mycobacterium (NTM) infections identified through statewide laboratory surveillance and OHSU regional referral NTM clinic; a complete clinical history is collected by chart review at enrollment. We evaluated the proportion of pulmonary MAC patients with abnormal laboratory tests. We examined differences using a chi-square test between patients who were antimycobacterial treatment naïve, on therapy at enrollment or previously treated, in addition to cavitary and non-cavitary disease and those who also had previous sputum isolation of additional organisms (co-isolation).

Results

147 patients had CBCs available; 112 (76.2%) were female with a median age of 69 years (22–88 years). 64 (43.5%) were antimycobacterial treatment naïve, 65 (44.2%) were on therapy at enrollment and 18 (12.2%) were previously treated. Lymphocyte count was below normal in 105 (73.4%) patients; 70 (49.3%) had lymphocyte counts below 1500 cells/mL and 27 (18.9%) were lymphopenic. Elevated monocyte percent was seen in 54 (37.2%) patients. Lymphopenia was more common in those on therapy, P = 0.01. There were no predominant laboratory abnormalities in 108 patients with metabolic panels. 34 patients had a c-reactive protein (CRP) collected, which was elevated, after age and gender correction, in 31 patients (91.2%). There was no significant difference between treatment groups. Eleven patients had cavitary disease with no differences in laboratory values compared with those with non-cavitary disease. Patients with co-isolation were more likely to be anemic (P = 0.03), have thrombocytosis (P = 0.04) and were less likely to have a monocytosis (P = 0.03).

Conclusion

A large proportion of patients with pulmonary MAC disease have low lymphocyte counts, elevated monocyte percent and CRP. Further evaluation of the meaning of these abnormalities as well as changes during therapy is needed.

Disclosures

All authors: No reported disclosures.
1376. Physician Practice Patterns for Screening and Treatment of Latent Tuberculosis Infection in the South Asian Population in Central New Jersey
Authors: Gulati Nupur , Ram Pentakota Sri , Feja Kristina N , Ghoshal Bishakha , Bhavaraju Rajita , Jindani Arpita , Sunanda Gaur , Kalyoussef Sabah
Published: October 2019

Background

New Jersey (NJ) has a significant burden of tuberculosis (TB) cases (ranked 8th in the United States) and 22% of the cases are among foreign-born (FB) individuals. We have approximately 33% FB residents in our targeted counties in Central NJ of whom 43% are originally from high TB burden areas of South Asia. Central NJ is home to the county with the second highest TB case rate in NJ. Latent tuberculosis infection (LTBI) treatment remains a key component of the World Health Organization TB elimination strategy. We sought to survey community physicians about their LTBI screening and treatment practices in South Asian (SA) patients.

Methods

An IRB-approved anonymous survey was distributed online to practicing staff physicians at local hospitals over a 2-month period. The primary outcome measure was whether physicians appropriately screen for LTBI. A secondary outcome measure was whether follow-up after medication initiation was provided. Predictors measured included: age, gender, self -identification of physician as SA, years in practice, and if they were a foreign medical graduate (FMG). Descriptive statistics were provided using counts and proportions. Chi-square tests were used for bivariate analyses to look for factors associated with LTBI screening and treatment.

Results

A total of 218 physicians responded to the survey; of whom, 137 identified themselves as primary care physicians (i.e., pediatrics (62%), internal medicine (30%), or family medicine (8%)). About half of them were FMG and 40% identify themselves as SA. Three out of four of these physicians (n = 101) indicated they routinely screen their patients for LTBI. Bivariate analyses using chi-square did not find any statistically significant associations with LTBI screening. A quarter of the physicians screened with an IGRA and 60% reported always offering treatment for LTBI. Isoniazid was the most common medication prescribed. A majority of respondents did not report prescribing Rifampin or Rifapentine. Follow-up after initiation of treatment was provided at least every other month by 52.7% of physicians.

Conclusion

There is wide variability in LTBI screening, treatment, and follow-up among our physician sample. Physicians have not yet adopted newer treatment regimens suggesting the need for an educational intervention.

Disclosures

All authors: No reported disclosures.
1377. Use of Interferon-Gamma Release Assays (IGRAs) Reduced Latent Tuberculosis Infection (LTBI) Diagnosis in Refugee and Immigrant Children
Authors: Kushner Lauren E , Mony Vidya , Vu David M
Published: October 2019

Background

For foreign-born children from countries with high tuberculosis (TB) burden, positive tuberculin skin test (TST) results, associated with Bacillus Calmette Guerin (BCG) vaccination, paradoxically increase the risk for overdiagnosis and overtreatment of latent TB infection (LTBI) during immigration. The higher specificity of interferon-gamma release assays, such as QuantiFERON-TB (QFT), may help distinguish LTBI from positive TSTs due to BCG or non-TB Mycobacteria. However, data on QFT usage in pediatric populations, particularly refugee and immigrant children, are sparse. Our objective was to assess the impact of QFT on LTBI diagnosis and treatment in the vulnerable child refugee and immigrant population.

Methods

We initiated a retrospective study of children (≤15 years) seen in Santa Clara County Refugee/Immigrant Clinic for post-immigration TB re-evaluation in 2017. We collected information from the Electronic Disease Notification system and post-immigration clinic records, including laboratory studies, imaging, and clinical impression. The primary outcome was post-immigration LTBI diagnosis in patients with positive pre-immigration TB screening. Patients with prior active TB or LTBI treatment were excluded.

Results

102/135 clinic encounters examined to date were post-immigration encounters. Median age was 9 years (range 14mo to 15y). Most (82.5%) were from Asia, primarily the Philippines (n = 48), Afghanistan (n = 10), Iran (n = 9), and Vietnam (n = 8). Sixty-six (64.7%) had documented BCG vaccination. Among 102 encounters, 71 (69.6%) were of children diagnosed pre-immigration with LTBI based on positive TST and normal chest radiograph. After post-immigration evaluation with retesting by QFT, 13/71 (18%) were diagnosed with LTBI (Table 1). There were no active TB cases among 102 patients, though long-term follow-up varied (mean 5.5 ± 6.5 months).

Conclusion

QFT use for post-immigration LTBI re-evaluation reduced LTBI diagnosis by 82% in children as young as 2 years old. Preliminary data suggest the preferential use of QFT over TST in non-United States-born children, in accordance with new California Department of Public Health TB screening recommendations for children ≥2 years, could reduce unnecessary diagnosis and treatment of LTBI in refugee and immigrant children.

Disclosures

All authors: No reported disclosures.
1382. Acid-Fast Bacilli Testing Trends at 43 In- and Outpatient Facilities and Nontuberculous Mycobacterial Pulmonary Isolation Rate, United States, 2009–2015
Authors: Ling Lai Yi , Ricotta Emily , Olivier Kenneth , Kadri Sameer S , Prevots D Rebecca
Published: October 2019

Background

The prevalence of nontuberculous mycobacterial pulmonary disease (NTM PD) is increasing in the United States and globally. The reasons for this increase are not clear but could be related to both gained awareness leading to increased mycobacterial testing, or to a true NTM PD increase. To further examine the role of testing rates in the observed increase, we studied trends in Acid-Fast Bacteria (AFB) testing and NTM isolation positivity using a large Electronic Health Record (EHR) dataset in the United States.

Methods

Using the Cerner Health Facts EHR dataset, we extracted microbiologic, demographic, and clinical data for patient encounters (inpatient or outpatient), with ≥1 orders for AFB respiratory cultures. The analysis was limited to the 43 facilities reporting continuously for the period 2009–2015. A patient with at least one AFB test was considered tested (AFB) and a patient with at least one pathogenic NTM respiratory isolate was considered positive. Trends in AFB testing and NTM positivity were estimated using log-linked Poisson regression (P < 0.05).

Results

From 2009 through 2015, of 14.8 million patients, 65,010 had 142,315 AFB tests, averaging 2.2 AFB tests/patient, for an overall testing prevalence of 0.43%; the annual testing prevalence remained unchanged during the study period (P = 0.44) (Figure 1). Of the 65,010 patients with AFB tests, 3,942 (6.1%) had ≥1 pathogenic NTM species, for an overall pulmonary NTM isolation prevalence of 2.7/10,000 patients represented in Cerner Health Facts dataset. Of the patients that had at least one pathogenic NTM, 3,094 (78%) had M. avium complex, and 265 (7%) had M. abscessus/chelonae, (Figure 2). Among patients with at least 1 NTM-positive culture, 138 patients had concomitant growth of M. tuberculosis.

Conclusion

Increases in NTM PD are not explained by increases in AFB testing, which remained constant in the population represented here.

This study was funded in part by the Division of Intramural Research, NIAID, NIH.

Disclosures

All authors: No reported disclosures.
1388. Characteristics of Non-Tuberculous Mycobacterial Infections in Hematopoietic Stem-Cell Transplant Patients
Authors: Gleeson Shana E , Azar Marwan M , Malinis Maricar
Published: October 2019

Background

Hematopoietic stem cell transplantation (HSCT) recipients are at increased risk for non-tuberculous mycobacterial infections (NTMI), but little data exists regarding NTMI in this population. This study aimed to better define the clinical and epidemiological characteristics of NTMI in HSCT patients.

Methods

We performed a retrospective review of patients age ≥ 18 who underwent HSCT between 2000 and 2017 at Yale-New Haven Hospital, and who subsequently had an NTMI based on ATS/IDSA criteria or a culture that grew NTM. We reported patient demographics, illness severity, treatment, and outcomes.

Results

Of 1371 HSCT recipients between 2000 and 2017, 17 (1.2%) had an NTMI or were culture positive. Most patients were male (76.5%), received allogeneic HSCT (70.6%), had graft vs. host disease (GVHD) (70.6%), and received immunosuppression (64.7%). Mycobacterium avium complex (MAC) was isolated in 16 (94.1%). Cultures were mainly positive in respiratory specimens (8 bronchoalveolar lavage, 2 sputum, and 1 lung tissue). Nine of 17 patients (52.9%) were deemed colonized whereas 8 (47.1%) were considered infected. In the infected group, isolated pulmonary infection was the most common presentation (n = 5, 62.5%). Two of the 8 infected patients (25%) had MAC bacteremia. Of those with NTMI, MAC was isolated in 6 (75%), MAC and M. abscessus/chelonae in 1 (12.5%), and M. kansasii in 1 (12.5%). Among those with NTMI, 3 were hypoxic (37.5%) and 4 (50%) had sepsis, though only 1 case of sepsis was directly attributable to NTM. Seven infected patients received antimycobacterial therapy. Four patients (50%) died but none were directly attributed to NTM. Diagnosis was often delayed in these patients, with a median of 44 days (range 14–155 days) from time of initial presentation to diagnosis of NTMI. Median time to death from time of NTMI diagnosis was 75 days (range 16–1825 days).

Conclusion

NTMI, including disseminated infection, was uncommon in a large cohort of HSCT patients. Careful evaluation of positive cultures in these patients is needed to distinguish infection from colonization. High mortality in HSCT patients may not be directly attributable to NTMI, but the presence of NTM may be a predictor of poor outcomes.

Disclosures

All authors: No reported disclosures.
1396. Risk Factors for Brain Abscess: A Nationwide Population-based Nested Case–Control Study
Authors: Bodilsen Jacob , Dalager-Pedersen Michael , van de Beek Diederik , Brouwer Matthijs C , Nielsen Henrik
Published: October 2019

Background

Knowledge of risk factors for brain abscess is limited and relies on single-center cohorts without control groups.

Methods

We accessed nationwide medical registries to conduct a population-based nested case–control study of risk factors for brain abscess. We applied risk set sampling for selection of population controls (1:10) individually matched by age, sex, and area of residence. Conditional logistic regression was used to compute adjusted odds ratios (aOR) with 95% confidence intervals (CIs). Next, population attributable fractions were calculated.

Results

We identified 1,384 brain abscess patients in Denmark from 1982 through 2016 and 13,839 matched population controls. The median age was 50 years (interquartile range 33–63) and 37% were female. Cases often had a Charlson comorbidity score>2 (16%) compared with controls (3%). Adjusted ORs were: head trauma 2.15 (1.72–2.70), neurosurgery 19.3 (14.3–26.0), dental infection 4.61 (3.39–6.26) or surgery 2.57 (1.71–3.84), ear-nose-throat infection 3.81 (3.11–4.67) or surgery 2.85 (2.21–3.70), congenital heart disease 15.6 (9.57–25.4), diabetes mellitus 1.74 (1.33–2.29), alcohol abuse 2.22 (1.58–3.11), liver disease 2.37 (1.53–3.68), kidney disease 2.04 (1.30–3.20), and lung abscess or bronchiectasis 8.15 (3.59–18.5). The aORs were 4.12 (3.37–5.04) and 8.77 (5.66–13.6) for solid and hematological cancer, 12.0 (6.13–23.7) for HIV, and 5.71 (4.22–7.75) for immuno-modulating treatments. Risks were twice as high when risk factors were observed within 5 years before brain abscess. Population attributable fractions showed that neurosurgery (12%), solid cancer (11%), ear-nose-throat infections (7%) and immuno-modulating treatments (5%) were substantial contributors to occurrence of brain abscess.

Conclusion

Important risk factors included neurosurgery, cancer, ear-nose-throat infections and immuno-modulating treatments

Disclosures

All authors: No reported disclosures.