bluuebunny/crossref_metadata_2025 huggingface dataset:
296. The Hepatitis C Cascade of Care across Four Safety Net Settings in the Southeast
Authors: Schranz Asher J , Kovasala Michael , Givens Candice , Hilton Alison , Maierhofer Courtney , Sena Arlene
Published: October 2019

Background

Despite advances in antivirals, disparities in hepatitis C (HCV) treatment remain. We evaluated persons diagnosed with HCV in 4 safety net sites in a large Southeastern county, using care cascades to conceptualize milestones in treatment.

Methods

Persons diagnosed with HCV in 4 screening sites across Durham County, North Carolina, from December 2015 to May 2018 were included, allowing for 9 months of follow-up. Sites included the county health department (CHD), a federally qualified health center (FQHC) where providers trained in HCV care, jail and community outreach. Persons with HCV were eligible for a bridge counselor intervention to enhance linkage to care with an HCV-treating provider (either primary care or specialist). Outcomes were monitored by chart review. Persons linked to care in the prison (n = 36) were censored from subsequent cascade steps due to inability to obtain records. Cascades were compared by the site of diagnosis. Multivariable logistic regression was used to evaluate predictors of being prescribed antivirals.

Results

505 persons were diagnosed with HCV: 216 in the FQHC, 158 in the jail, 72 in the CHD, and 59 in community outreach. Overall, 89% were counseled on their diagnosis, 65% were linked to care, 41% prescribed antivirals, 38% started medications, 34% completed medications and 24% achieved sustained viral response at 12 weeks (SVR-12). Progression through the cascade was highest for those diagnosed at the FQHC (figure). In analyses adjusted for demographics and risk factors, diagnosis in a community outreach setting had lower odds of antiviral prescription, compared with diagnosis in the FQHC (OR 0.33, 95% CI 0.12–0.89). Linkage to care at a specialist clinic (vs. primary care) was associated with antiviral prescription (OR 3.82, CI 1.95–7.46). Sex, race/ethnicity, insurance status and HCV risk factors were not associated with antiviral prescription.

Conclusion

Among persons diagnosed with HCV across four safety net sites, a quarter achieved SVR-12. Those diagnosed in community outreach had lower odds of antiviral prescription, and those who were linked to a specialist were more likely to receive antiviral prescription. Improving progression through cascade milestones across safety-net settings is integral to improving population-based HCV outcomes.

Disclosures

All authors: No reported disclosures.
306. CD8+ T-Cell Responses to Chronic Hepatitis C in Pregnancy
Authors: Brooks Stephanie , Coss Samantha , Walker Christopher , Honegger Jonathan
Published: October 2019

Background

Chronic hepatitis C virus (HCV) infection is marked by stable, high -level viremia and a failed T-cell response. HCV-specific CD4+ helper T cells are rare, and CD8+ cytotoxic T cells are functionally exhausted or ineffective due to viral escape mutations. Postpartum, a subset of infected women experience a substantial drop in viremia. Preliminary data indicate that this unusual viral decline may be linked to a resurgence of HCV-specific CD4+ T cells producing Th1 cytokines. How improved CD4+ helper T-cell function might affect viral replication in this scenario is not established. Here we tested the hypothesis that improved CD4+ T cell help mediates control of chronic HCV replication through enhanced CD8+ T-cell function.

Methods

We examined plasma HCV RNA viral load (VL) and HCV-specific T-cell responses in 33 women with chronic HCV during the third trimester (T3) and at 3 months postpartum (3P). HCV-specific CD4+ and CD8+ T-cell IL2 and IFNγ responses were measured by intracellular cytokine staining following stimulation of peripheral blood mononuclear cells with peptide pools corresponding to the HCV proteins NS3, NS4a, and NS4B.

Results

Median VL dropped from 5.87 log10 at T3 to 5.25 log10 at 3P (P < 0.0001, Wilcoxson signed rank), with a wide range from +0.4 log10 to -4.2 log10. The degree of decline correlated significantly with improved frequencies of HCV-specific CD4+ T cells producing IFNγ (P = 0.015 Spearman) but did not correlate with CD8+ T-cell changes. Nevertheless, improved T helper function correlated with increased HCV-specific CD8+ T-cell function (ΔCD4+IL2+ vs. ΔCD8+IFNγ+, P = 0.015 Spearman, graph 1; ΔCD4+IFNγ+ vs. CD8+IFNγ+ at 3P, P = 0.004 Spearman, graph 2).

Conclusion

Despite no significant association between virus-specific CD8+ T-cell Tc1 cytokine production and postpartum viral control, our data suggest that recovery of CD4+ T-cell help may augment CD8+ T-cell function. Further study incorporating viral genomic sequences to focus on intact class I epitopes is needed to clarify the relationship of improved CD8+ function and viral control in this unique model of immune restoration.

Disclosures

All authors: No reported disclosures.
325. Cancer Screening Disparities among Persons Living with HIV (PLWH)
Authors: Hysell Kristen , He Wei , Chang Yuchiao , Dryden-Peterson Scott , Triant Virginia A
Published: October 2019

Background

Cancer is now the leading cause of mortality for persons living with HIV (PLWH) in the United States, but it is uncertain whether PLWH access cancer screening that could lower this burden. We sought to assess cancer screening for breast, cervical, and colon cancer among PLWH compared with the HIV-uninfected population at a multicenter healthcare system over the past two decades.

Methods

Data were obtained from a prospective, observational HIV clinical care cohort comprised of PLWH engaged in care in the Partners Healthcare System. Patients eligible for cancer screening between the years 2002 and 2016 were included. Patients were matched in a maximum of 1:4 ratio with HIV-uninfected patients from the Massachusetts General Primary Care Practice-Based Research Network based on age, sex, race, year of study entry, and length of follow-up. The mean proportion of time in which eligible patients were guideline concordant for cervical, breast, and colon cancer screening was assessed. Non-parametric tests were used to compared screening rates between PLWH and HIV-infected and on the basis of multiple clinical and sociodemographic factors.

Results

During the observation period, a total of 495 PLWH were eligible for breast cancer screening, 1011 for cervical cancer screening, and 1965 for colon cancer screening. For each screening group, the majority of PLWH were on antiretroviral therapy (ART) and had relatively high CD4 cell counts (Table 1). Screening rates for PLWH compared with controls were 67.3% vs. 82.8% (P < 0.0001) for breast cancer, 49.0% vs. 73.3% (P < 0.0001) for cervical cancer, and 92.7% vs. 91.2% (P = 0.96) for colon cancer (Figure 1). Among PLWH, factors significantly associated with lower rates of screening guideline concordance were older age, lower CD4 count, HIV-1 RNA >1000 copies/mL, and HIV duration < 5 years for breast cancer, and older age, white race, English language, and lack of ART use for cervical cancer.

Conclusion

Among patients engaged in longitudinal care, PLWH had significantly lower rates of screening for breast and cervical cancer than HIV-uninfected. Disparity is not explained by racial or primary language differences. Further work to improve access to cancer screening for PLWH is needed.

Disclosures

All authors: No reported disclosures.
333. Weight Gain Among HIV-Infected Patients in Southern India on Treatment with Integrase Strand Transfer Inhibitor-based Antiretroviral Therapy
Authors: Khan Rifa , Pradeep Amrose , Devaraja Chithra , Krishnan Bala
Published: October 2019

Background

Addition of integrase strand transfer-inhibitors (mainly dolutegravir) has strengthened anti-retroviral therapy (ART), to sustain viral suppression in HIV-1 and 2-infected patients. For judicious use in the future, we examine weight gain in ART-naïve, and those exposed to INSTI-based regimens as first, second, and third-line ART.

Methods

We undertook a retrospective cross-sectional study of patients initiated on INSTI-based regimens from 15 January 2017 to 22 December 2018 (n = 333). Descriptive statistical analyses were performed using STATA 15.1. Cross-tabulation and stratification were conducted to measure the strength of association. A linear regression model was used to study the increase in weight per unit of time.

Results

331 patients are infected with HIV-1 and 2 with HIV-2. 66% are male, median age= 38 years (IQR 31–44). Median CD4 count at INSTI initiation was 226 cell/cubic mL (IQR 87–395). Median viral load at initiation of INSTI-based therapy was log104.768 copies/mL (IQR 2.9—5.63). Most common opportunistic infections were pulmonary tuberculosis (n = 97), oral candidiasis (n = 84), and herpes zoster (n = 44). Median hemeoglobin was 12gm% (IQR 10.5–13.8). 39% were initiated on TDF+3TC+DTG and 32% were initiated on TDF+FTC+DTG. 74% experienced weight gain; average increase was 3.69 Kg (SD 3.56) at 3 months. 19.5% gained >4 kg; median BMI at initiation of therapy was 22.56 kg/m2 (IQR 19.8–25.1) and 25.4 kg/m2 (IQR 22.5–28.7) at an average of 9.5 months post initiation of dolutegravir-based ART. 70% of ART naïve (n = 73) experienced weight gain; 17.8% gained 8.36 kg at 9 months. Higher weight gain was observed in patients with opportunistic infections. Association with gender (OR = 0.9 95%, CI 0.54 -1.5; P = 0.70) and age (OR=0.9, 95% CI 0.97–1.01;P = 0.71) was not significant. Weight gain was positively correlated with time (r=+1); predicted increase in weight per 0.1 months after initiation of INSTI-based regimen (F=4.62, P = 0.032).

Conclusion

Access and adherence to INSTI have positively influenced viral suppression of HIV-infection.To ensure the prevention of obesity and apt use of ART for malnourished patients, it is imperative to monitor weight gain in patients who are initiated on INSTI-based regimens. Further research to study the mechanism of weight gain is warranted.

Disclosures

All authors: No reported disclosures.
336. Disparities in Cardiovascular Disease Prevention Among Persons Living with HIV in the United States Military Natural History Study
Authors: Thomas Larson Derek , Won Seunghyun , Deiss Robert G , Ganesan Anuradha , Maves Ryan , Okulicz Jason , Kronmann Karl , Chu Xiuping , Schofield Christina , Agan Brian
Published: October 2019

Background

The use of antiretroviral therapy has reduced morbidity and mortality associated with HIV infection primarily due to the reduction of AIDS-related events. Although guidelines have aimed to standardize preventive care, disparities in prevention of cardiovascular disease remain prevalent across multiple cohorts.

Methods

The US Military HIV Natural History Study is an open cohort of Department of Defense beneficiaries. We included subjects aged 21–75 whose most recent study visit was between October 2015 and September 2016 and conducted a retrospective cross-sectional analysis of established cardiovascular disease risk factors and statin use. To determine statin eligibility we used the American College of Cardiology/American Heart Association 2013 atherosclerotic cardiovascular disease management guidelines and included subjects who had all necessary data elements for analysis.

Results

The participants (n = 1223) were predominantly middle-aged (median 47 years, Interquartile Range [IQR] 33–55), male (95%), and were racially diverse (46% African-American, 16% Hispanic/other). The rate of tobacco use was 16%, diabetes was 11%, and 36% had hypertension. In total, 486 (40%) patients met criteria for statin therapy, with 17% of those being for secondary prevention. As of their last visit, 52 (4%) had a detectable HIV viral load. Statins were prescribed to only 302 (62%) of those with an indication, with lower prescription rates in African Americans (52%) and Hispanics (58%) than Caucasians (73%). Average blood pressure, rates of tobacco use, and prevalence of diabetes were equal between the African American and Caucasian groups.

Conclusion

We found significant racial disparities in both primary and secondary cardiovascular disease mitigation within the military healthcare system. Previous studies have found similar racial differences attributed to socioeconomic factors and higher rates of intravenous drug use. As active duty service members have a stable income, open access to healthcare, and low rates of injection drug use, our findings challenge that premise. Understanding whether this is due to prescribing practices, physician-patient relationships, or healthcare uptake is critical to narrowing this major gap in care.

Disclosures

All authors: No reported disclosures.
340. Prevalence of Type II Diabetes Mellitus Among Patients Living with HIV in the United States
Authors: Birabaharan Morgan , Strunk Andrew , Garg Amit , Hagmann Stefan
Published: October 2019

Background

An aging HIV-infected population has growing recognition for its increasing prevalence of type 2 diabetes mellitus (T2DM). Most studies of T2DM prevalence among patients living with HIV involve selected samples and/or small cohorts which limit generalizability. We sought to evaluate the overall prevalence of T2DM among patients living with HIV in the United States as well as within specific demographic subgroups.

Methods

A cross-sectional analysis was performed using a large, multi-institutional database (Explorys), where clinical information across 27 healthcare networks are matched and standardized to create longitudinal records for each unique patient. At present, the database contains 63 million unique lives, representing 18% of the population across all 4 census regions of the United States. Patients with all types of insurance as well as those who are self-pay are represented. The analysis included adult patients with an active status in the database during April 2014- April 2019 who, not missing data on age, gender, race, and body mass index. The Systematized Nomenclature of Medicine—Clinical Terms (SNOMED-CT) of “Human Immunodeficiency Virus,” “diabetes mellitus type 2,” “disorder due to type 2 diabetes mellitus,” and “Type II diabetes mellitus uncontrolled” were used to identify patients with HIV and T2DM.

Results

We identified 90,900 patients with HIV. The overall prevalence of T2DM among patients with HIV was 22.1% (20,080/90,900) compared with 14.9% (2,679,490/17,946,580) in the general population. In subgroup analysis, the prevalence of T2DM was highest among patients with HIV who were female, older, other race, obese, hypertensive, hyperlipidemic, smokers, alcoholics, and those with a history of hepatitis C infection. Patients with no exposure to antiretroviral therapy (ART) had higher prevalence of T2DM than those with exposure (24.9% vs. 17.6%).

Conclusion

In this US population-based study, we found 1 in 5 people living with HIV had prevalent T2DM. In addition, we observed that HIV-associated T2DM may not depend on chronic ART exposure. Physicians caring for patients with HIV should be aware of the association and should monitor for signs and symptoms of T2DM.

Disclosures

All authors: No reported disclosures.
342. The Impact of Glycemic Control on CD4 Cell Count in Persons Living with HIV and Diabetes Mellitus—Washington, DC
Authors: Powers Happ Lindsey J , Monroe Anne K , Young Heather A , Ma Yan , Greenberg Alan E , Benator Debra A , Horberg Michael A , Castel Amanda
Published: October 2019

Background

Among persons living with HIV (PLWH) with type 2 diabetes mellitus (DM) there is limited research on the effect of DM control on CD4 count. Current guidelines recommend that PLWH with DM maintain a hemoglobin A1c (HbA1c) <7%. This analysis examined the impact of HbA1c on trends in CD4 count among PLWH receiving care in Washington, DC.

Methods

We used data from the DC Cohort, a longitudinal observational cohort of patients receiving HIV care at 14 clinics between 2011–2018. Participants with DM on an ongoing antiretroviral regimen with ≥1 year of follow-up, ≥2 HbA1c results, and ≥2 CD4 count results were included. Participants were compared based on the most recent HbA1c result categorized into one of three control levels control: strict, HbA1c < 7.5%; moderate, HbA1c between 7.5–9.0%; and uncontrolled, HbA1c >9.0%. All statistical tests were performed within the framework of the linear mixed-effects (LME) model. The rates of increase in CD4 count by DM control were compared using an LME model with random slopes and random intercepts, adjusted for sex, BMI, nadir CD4, a history of AIDS, or cancer diagnosis.

Results

Among 554 participants (median age 53.5; 70.8% male; 82.7% Black), there were 5,138 total CD4 count measurements. In unadjusted analysis, participants with moderate or uncontrolled HbA1c had higher mean CD4 counts over the follow-up period than those with strict HbA1c control (strict: 690 cells/μL, moderate: 712 cells/μL uncontrolled: 711 cells/μL; P = 0.0156 strict vs. moderate, 0.049 strict vs. uncontrolled). All DM control groups had a similar temporal increase over time in CD4 count (P = 0.46). In multivariate analysis, only moderate vs. strict control showed a significant difference in CD4 count (mean difference=18.1; P = 0.02). Results showed CD4 count change was not affected by the duration of HIV diagnosis or diabetes diagnosis. See Table 1 for additional results.

Conclusion

PLWH and DM with moderate HbA1c control had higher CD4 counts than those with strict HbA1c control and similar CD4 counts compared with those with uncontrolled HbA1c levels, while the rate of increase in CD4 count was similar in the three groups. These results show that moderate DM control may benefit CD4 count, which should be considered when revising DM control guidelines for PLWH.

Disclosures

All authors: No reported disclosures.
351. HIV and Aging: Multimorbidity in Older People Living with HIV in One Southeastern HIV Clinic
Authors: Crowder Arant Elizabeth , Harding Ceshae , Targonski Paul V , McManus Kathleen A
Published: October 2019

Background

While morbidity and mortality related to HIV are decreasing, age-related chronic conditions are becoming more common in people living with HIV (PLWH). We hypothesized that multimorbidity prevalence among PLWH would increase from 2006 to 2016 and that multimorbidity would be associated with demographic and healthcare system-level factors.

Methods

Cohorts included PLWH aged 45–89 who received care at the University of Virginia (UVA) Ryan White HIV clinic in 2006 (Cohort 1) and 2016 (Cohort 2). Multimorbidity was defined as the co-occurrence of ≥2 age-related chronic diseases. Demographics, HIV-specific clinical characteristics and multimorbidity were compared between the cohorts using a generalized linear model fit using a generalized estimating equation that accounted for repeated measures. Within each cohort, multivariable binary logistic regression was used to assess the association between participants’ characteristics and multimorbidity.

Results

Cohort 1 had 198 participants, and Cohort 2 had 378 participants. Cohort 1 represented 33% of the 2006 clinic population, and Cohort 2 represented 54% of the 2016 clinic population. Less Cohort 2 participants were uninsured (5% vs. 22%, P < 0.001) and more had private insurance (44% vs. 26%, P < 0.001). The prevalence of multimorbidity was higher in Cohort 2 (28% vs 21%, P < 0.001). For Cohort 1, multimorbidity was less likely for those with private insurance (8%, adjusted Odds Ratio [aOR] 0.81, 95% Confidence Interval [CI] 0.69–0.90) compared with those with Medicare (32%). For Cohort 2, multimorbidity was more likely for those with incomes < 100% Federal Poverty Level (FPL; 34%) compared with those with incomes 101–250% FPL (27%, aOR 0.86, 95% CI 0.74–1.00) and 251–500% FPL (21%, aOR 0.78, 95% CI 0.64–0.95). For Cohort 2, multimorbidity was associated with female sex (40%, aOR 1.21, 95% CI 1.01–1.45) compared with male sex (24%).

Conclusion

Older PLWH represented an increasing proportion of the studied Southeastern clinic population. Multimorbidity prevalence was higher in 2016 compared with 2006. Insurance status was associated with multimorbidity for Cohort 1. For Cohort 2, incomes < 100% FPL and female sex were associated with increased likelihood of multimorbidity. Future research will need to assess the reasons for these disparities.

Disclosures

All authors: No reported disclosures.
353. A Comparison Study of Prevalence and Risk Factors for Nonalcoholic Fatty Liver Disease (NAFLD) and Nonalcoholic Steatohepatitis (NASH) by Transient Elastography (TE) in HIV-Infected Patients
Authors: Choe Sunny , Al-Saleh Hend , Fallon James , Galang Herbert , Mathew Justin , Lakkasani Saraswathi , Malekazari Pegah , Shukla Prerak , Slim Jihad
Published: October 2019

Background

There are limited data on the prevalence and risk factors of NAFLD and NASH in HIV-infected individuals receiving ART. A large study on this subject was presented at Glasgow 2018, from the University Hospital of Palermo (UHP).

Methods

We prospectively collected data on epidemiology, comorbidities, CD4, HIV virus load and ART from November 2017 to September 2018 in patients undergoing TE examination with Controlled Attenuation Parameter (CAP) in our HIV clinic at Saint Michael’s Medical Center in Newark, NJ. We used the same parameters to define NAFLD and fibrosis severity that were used for the UHP (CAP >248 dB/m and TE > 7.1 Kpa). We present comparative data between those 2 cohorts.

Results

We enrolled 624 consecutive HIV-infected individuals (group 1) their baseline epidemiologic characteristics were not significantly different from the UHP cohort (group 2) for age and sex. Prevalence of NAFLD was 51.6% in group 1compared with 42.7% in group 2, and the prevalence of significant fibrosis in those with NAFLD was 31% in group 1, and 23% in group 2. The main differences we found between those 2 cohorts were race: group 1, 68% black and group 2, 87% White, incidence of Diabetes mellitus was 20% in group 1, and 6% in group 2, despite the fact that BMI was not significantly higher in group 1. Other important differences were the mean time on ART, it was 5 years longer for group 1. Finally, there was a trend for a higher incidence of hypertension, a lower percentage of patients with Virus load < 20 c/mL, a lower mean CD4 count, and a higher percentage of integrase strand transfer inhibitors current users in group1.

Conclusion

NAFLD prevalence is alarming high in patients with HIV disease, it is of utmost importance to understand its natural history, in order to prevent the potentially severe consequences of NASH. Our study suggests that a longer duration on ART might correlate with higher incidence of NAFLD, which would suggest better monitoring of liver health with new ART.

Disclosures

All authors: No reported disclosures.
369. Association Between Depression and HIV Treatment Outcomes in a US Military Population with HIV Infection
Authors: Carney Brandon , Daniels Colton , Xu Xiaohe , Sunil Thankam , Ganesan Anuradha , Blaylock Jason M , Kronmann Karl , Schofield Christina , Tahaniyat Lalani , Agan Brian , Okulicz Jason
Published: October 2019

Background

Depression is common among HIV-infected individuals and may contribute to suboptimal adherence to antiretroviral therapy (ART) and reduced rates of viral load (VL) suppression. We evaluated longitudinal HIV treatment outcomes in US Military HIV Natural History Study (NHS) participants with or without a diagnosis depression.

Methods

Male NHS participants with available ICD-9 data for mental health diagnoses and self-reported adherence (SRA) were included (n = 549). Groups were defined as having a history of depression (n = 188, 34.2%), classified as major depressive disorder and/or anxiety disorder, or no history of depression (n = 361, 65.8%). Delay in ART initiation was defined as the time from HIV diagnosis to ART start greater than the group mean (4.91 ± 4.69 years). SRA was defined as taking ≥95% of ART doses and continuous ART was defined as longitudinal ART use with gaps < 30 days. Continuous VL suppression was defined as maintaining VLs < 200 c/mL on ART. Logistic regression analysis was performed comparing variables for those with and without a coded diagnosis of depression.

Results

Participants had a mean age of 33 (±8.36) years at HIV diagnosis, and similar proportions were Caucasian (44.3%) or African American (40.8%). At ART initiation, the mean CD4 count was 370 (±154 cells/μL) and 362 (±163 cells/μL) for those with and without a history of depression, respectively. Overall, older participants at HIV diagnosis had greater odds of having high SRA (OR 1.07, 95% CI 1.03–1.11), and compared with Caucasians, African Americans had lower odds of having high SRA (OR 0.43, 95% CI 0.25–0.75; table). Participants with a history of depression had greater odds of experiencing delayed ART initiation (OR 2.12, 95% CI 1.11–4.05). However, they also had greater odds of remaining on continuous ART (OR 1.38, 95% CI 0.95–2.02) during follow-up compared with those without a history of depression.

Conclusion

Although HIV-infected individuals with depression were more likely to experience delays in ART initiation, there were no observed differences in SRA or VL suppression. Continued efforts to identify and aggressively manage mental health disorders are important to success along the HIV care continuum.

Disclosures

All authors: No reported disclosures.
397. Operative Intervention in Pediatric Lyme Arthritis Increases Healthcare Resource Utilization Without Improved Outcomes
Authors: Tout Andrew R , Nowalk Andrew J , Campfield Brian T
Published: October 2019

Background

Lyme arthritis commonly presents as an acute inflammatory monoarticular arthritis, frequently challenging to distinguish from septic arthritis. While management for Lyme arthritis focuses on antibiotic therapy, septic arthritis requires operative debridement plus antibiotic therapy. Delay in Lyme serology results may complicate decisions on surgical intervention in Lyme endemic areas. During the transition period of western Pennsylvania to a Lyme endemic region many children ultimately diagnosed with Lyme arthritis were managed by operative intervention due to diagnostic ambiguity. The impact of an operative intervention on outcomes of pediatric Lyme arthritis is unknown.

Methods

We conducted a retrospective chart review from 2008 to 2018 of patients admitted to UPMC Children’s Hospital of Pittsburgh and diagnosed with Lyme arthritis. We recorded the clinical presentation, laboratory data, details of hospitalization and follow-up, costs and outcome after therapy to compare the impact of antibiotic therapy alone (non-operative group) vs. antibiotics plus operative debridement (operative group).

Results

We identified 164 patients admitted for management of arthritis with the eventual diagnosis of Lyme arthritis. Fifty-two patients underwent operative debridement in addition to antibiotic therapy. Operative debridement plus antibiotics was associated with increased duration of admission, increased the cost of hospitalization, and increased PICC line placement compared with antibiotics alone. In patients for whom follow-up information was available, resolution of symptoms was documented in 62 of 66 patients in the non-operative group and 46 of 47 patients in the operative group with a median duration to symptom resolution of 17 and 23 days,, respectively.

Conclusion

Operative debridement for pediatric patients with Lyme arthritis was associated with increased cost and duration of hospitalization, and a greater number of procedures, while being similarly efficacious to non-operative management with antibiotic therapy alone.

Disclosures

All authors: No reported disclosures.
398. Description of a Large Pediatric Lyme Arthritis Cohort in an Endemic Region
Authors: Abney Ancil J , Reinhard Megan , Sharon Bazak
Published: October 2019

Background

In endemic areas, Lyme arthritis (LA) is a leading cause of joint swelling. Due to the shared inflammatory nature and common clinical features, acute LA is often misdiagnosed as septic arthritis (SA) while recurrent disease is at times difficult to differentiate from other causes of chronic arthritis. In Minnesota, there has been a steady increase in cases of Lyme disease. This has not been met by a clear guideline and there is no consensus for the management of pediatric arthritis. In this context, we sought to characterize the epidemiology and clinical presentation of a large local cohort.

Methods

This is a retrospective review of medical charts from children with confirmed LA, presented at a large academic medical organization in the Upper Midwest between January 2011 to December 2017. Demographic, clinical, and laboratory data were collected and analyzed.

Results

Lyme arthritis was confirmed in 109 children. Acute presentation was more common (67) while the rest (42) had either persistence or reoccurrence of symptoms [Figure 1]. Elevated inflammatory markers and synovial pleocytosis were common, unlike fever and refusal to bear weight which were seen occasionally [Figure 2]. Seasonal distribution and the clinical setting for initial presentation as well as admissions are summarized in Figure 3. The knee was involved in all but 2 patients, both had acute monoarthritis (elbow and hip) [Figure 4].

Conclusion

LA causes a spectrum of disease, is seen year round, and across the clinical setting continuum. Acute knee monoarthritis is the most common presentation (54% in our cohort) and is often misdiagnosed as SA leading to unnecessary hospitalizations and aggressive interventions. This occurs more frequently at the ED setting and for children with significant synovial pleocytosis. When evaluating a child with arthritis, laboratory findings are none specific and should be used in caution. Pediatric providers in endemic regions, especially those in primary, hospital, or emergency care must be familiar with the clinical presentation and have a high index of suspicion for LA in order to prevent mismanagement.

Disclosures

All authors: No reported disclosures.
423. Self-Reported Screening for Rectal Sexually Transmitted Infections Among Men Who Have Sex with Men
Authors: William. Menza Timothy , Lipira Lauren , Bhattarai Amisha , Ramirez Joseph , Orellana Roberto
Published: October 2019

Background

Rectal gonorrhea and Chlamydia are common and predict HIV acquisition among men who have sex with men (MSM); however, screening for rectal sexually transmitted infections (STIs) is not routine.

Methods

In 2017, we recruited sexually-active MSM in the Portland, Oregon metropolitan area through venue-based sampling. Our outcome of interest was self-reported rectal STI screening in the prior 12 months. Stratified by HIV status, we assessed the prevalence and demographic, healthcare, clinical, and behavioral predictors of screening.

Results

Of 448 participants, 168 (37.5%) reported rectal STI screening. One hundred twenty-seven (35.8%) of 355 HIV-negative men, 41 (58.6%) of 70 HIV-positive men, and none of 23 men who did not know their HIV status reported screening. Among HIV-negative men, having a healthcare provider who offered HIV testing (adjusted prevalence ratio [aPR]=2.09; 95% confidence interval [CI]: 1.43, 3.04), a syphilis diagnosis (aPR=1.32; 95% CI: 1.03, 1.69), use of pre-exposure prophylaxis (aPR=1.57; 95% CI 1.21, 2.04), and condomless anal sex with casual partners in the prior 12 months (aPR=1.74; 95% CI: 1.36, 2.22) independently predicted screening for rectal STI in multivariable analysis. HIV-positive men who reported having a provider who always or often initiates conversations about sex were significantly more likely to report screening compared with men who did not have such a provider (aPR=1.48; 95% CI: 1.06, 2.06).

Conclusion

Rectal STI screening is not universal in a venue-based sample of sexually-active MSM. Implementing innovative, acceptable, and accessible screening practices and improving provider comfort with talking about sex are paramount to increasing rectal STI screening.

Disclosures

All authors: No reported disclosures.
436. Skin and Soft-tissue Infections Are a Common Reason for Potentially Inappropriate Antimicrobial Use among Inpatients in Sri Lanka
Authors: Sheng Tianchen , Wijayaratne Gaya B , Dabrera Thushani M , Nagahawatte Ajith , Bodinayake Champica K , Kurukulasooriya Ruvini , Nagaro Kristin J , De Silva Cherin , Ranawakaarachchi Hasini , Thusitha Sudarshana Arambegedara , Anderson Deverick J , Drew Richard H , Drew Richard H , Ostbye Truls , Woods Chris W , Tillekeratne L Gayani
Published: October 2019

Background

Skin and soft-tissue infections (SSTI) are a common reason for antimicrobial use in the outpatient and inpatient settings. Inappropriate antimicrobial use for SSTI is common. We determined the prevalence of SSTI and associated inappropriate antimicrobial use among inpatients in Sri Lanka.

Methods

A point-prevalence study of antimicrobial use was conducted using one-day cross-sectional surveys at five public hospitals in Southern Province, Sri Lanka from Jun-August 2017. Inpatients’ medical records were reviewed for clinical data including antimicrobials prescribed. Inappropriate antimicrobial use was identified as (1) antimicrobial use discordant with guidelines by the Sri Lanka College of Microbiologists (SLCM), and (2) redundant combinations of antimicrobials.

Results

Of 1,709 surveyed patients, 935 (54.7%) received antimicrobials, of whom 779 (83.3%) had a specified or inferred indication for antimicrobial use. Among patients with an indication for antimicrobial use, SSTI was the second leading indication (181 patients, 23.2%) after lower respiratory tract infection (194, 24.9%). One-third (62, 34.2%) of patients with SSTI had a history of diabetes. Commonly used antimicrobials for SSTI included amoxicillin and clavulanic acid (40.3%), extended-spectrum penicillins (24.9%), and metronidazole (22.1%). inappropriate antimicrobial use was observed in 53.0% of SSTI patients, with redundant antibiotic therapy in 35.9% and antimicrobials discordant with SLCM guidelines in 32.6%.

Conclusion

SSTI was a common reason for antimicrobial use among inpatients in Sri Lanka, with more than half of patients receiving potentially inappropriate antimicrobial therapy. We identified targets for future antimicrobial stewardship efforts.

Disclosures

All authors: No reported disclosures.
438. Dalbavancin Clinical Experience at an NCI Designated Cancer Center
Authors: McDaneld Patrick , Smith Devlin , Tverdek Frank
Published: October 2019

Background

Dalbavancin (DAL) is a long-acting lipoglycopeptide, which allows for up to 2 weeks of therapy from a single dose. Outside of its FDA-approved indication for the treatment of acute bacterial skin and skin structure infections (ABSSSI), there is a growing interest in the utilization of DAL for other indications, including catheter-related bloodstream infection (CRBSI). The long-acting formulation potentially facilitates patient discharge or admission deferral without the need for daily outpatient parenteral antimicrobial therapy (OPAT). However, there is limited experience reporting DAL utilization in an oncology population. The objective of this study was to report our experience with DAL in an oncology patient population at a National Cancer Institute (NCI) Designated Cancer Center.

Methods

We conducted a retrospective review of all patients receiving DAL therapy in June 2016–June 2017. The primary outcome was a clinical success at 30 days (complete/partial resolution of symptoms without readmission for a same/similar infection), with secondary outcomes including readmission rate, acute kidney injury (AKI) incidence (Acute Kidney Injury Network [AKIN] criteria) and additional antimicrobial use within 30 days.

Results

We identified 76 unique subjects, with 77 unique infectious episodes, receiving 78 DAL doses. The majority of the subjects were male (57%), the median age was 61 years old, 55% had a solid tumor type and most were treated for ABSSSI (86%). Doses were administered inpatient 76% of the time and most patients received 1500 mg (90%). The most common pathogen isolated was Staphylococcus aureus (19%). Patients frequently received additional methicillin-resistant Staphylococcus aureus active oral antibiotics (39%). Clinical success was reported in 78% of infections. Potential DAL-related AKI was identified in 4 subjects (5%).

Conclusion

We reported on the use of DAL in a variety of oncology patients at a major cancer center. Clinical success was often achieved in ABSSSI with a single DAL dose and nephrotoxicity was infrequently encountered. Limitations include the frequent use of additional, potentially active antimicrobials and difficulty in assessment of clinical success and AKI in patients after discharge.

Disclosures

All authors: No reported disclosures.
440. Necrotizing Soft-Tissue Infections Involving Actinomyces Species
Authors: Jakharia Niyati , Schrank Gregory , Luethy Paul , Rabinowitz Ronald
Published: October 2019

Background

Actinomyces sp. are associated with numerous clinical diseases in humans; however, there are few case reports of necrotizing soft-tissue infections (NSTIs) involving these organisms. Their role in NSTIs has not been well described. At our medical center, we noted an increase in Actinomyces sp. isolated from the tissue specimens of patients with NSTIs, prompting further evaluation.

Methods

Microbiology databases were utilized to identify patients with clinical cultures growing Actinomyces sp. from January 2008 to December 2018. Adult patients admitted to the R Adams Cowley Shock Trauma Center with a diagnosis of NSTI were included for analysis.

Results

Nine patients were identified meeting inclusion criteria, the first in February 2018–none prior. Organisms isolated from culture included Actinomyces turicensis (n = 3), Actinomyces europeaus (n = 1), and five organisms identified only as Actinomyces species. 89% of patients had additional co-pathogens identified in their tissue cultures. Eight patients had NSTIs of the lower extremity (n = 5) and/or the genitourinary area (n = 6), and one had chronic decubitus ulcers. Comorbidities included diabetes mellitus (77%), chronic kidney disease (33%). 44% patients were in septic shock at presentation. Surgical debridement was performed in all patients. Eight patients were discharged on amoxicillin, with a mean treatment duration of 75 days (range 31–90). One patient was treated with ampicillin–sulbactam. Readmission rate at 90 days was 37%; only one was related to the index infection. One death occurred during the index hospitalization, secondary to NSTI. No patients experienced adverse drug reactions during therapy.

Conclusion

We describe one of the largest case series to date of Actinomyces sp. associated with NSTI. The startling appearance of Actinomyces sp. at our institution directly followed the implementation of matrix-assisted laser desorption/ionization time of flight mass spectrometry in January 2018. Actinomyces sp. may act as co-pathogens contributing to the severity of NSTIs, augmenting the virulence of other organisms. As more advanced technology is used in laboratories to identify these organisms, further study is needed to determine pathogenicity and appropriate treatment.

Disclosures

All authors: No reported disclosures.
443. The CHROME Study, a Real-World Experiential Registry of the Use of Oritavancin for Treatment of Gram-Positive Infections
Authors: Redell Mark , Sierra-Hoffman Miguel , Assi Maha , Bochan Markian , Chansolme David , Gandhi Anurag , Sheridan Kathleen R , Soosaipillai Ivan , Walsh Thomas L , Massey Jill
Published: October 2019

Background

Oritavancin (ORI) is a long-acting lipoglycopeptide antibiotic indicated for the treatment of adult patients with acute bacterial skin and skin structure infections (ABSSSI) caused or suspected to be caused by susceptible Gram-positive (GP) pathogens.

Methods

Data collected from a retrospective observational registry program (2014–2017), Clinical and Historic Registry and Orbactiv Medical Evaluation (CHROME), describe the utilization, outcomes, and adverse events (AEs) associated with ORI in 440 patients treated at 26 US sites.

Results

Mean (SD) age was 58 (16) years; 37% of patients were = 65 years old (range, 18–98). Mean (SD) BMI was 32.8 (9.0) (range, 14–65). At least 1 co-morbidity was observed in 85% of patients. Patients were treated for cellulitis (61%), wound infection (15%) or abscess (15%); 32 patients received ORI to treat other infections, such as bone and joint. Ten patients received single-dose ORI for completion of osteomyelitis therapy. Of recovered GP isolates, MRSA was the most common (46%). Infusion of ORI was mostly in infusion center settings (72%). Clinical success was 88% in the single-dose group (387 patients) and 86% in the multi-dose group (51 patients). A cohort of 32 patients received 2 to 10 ORI doses separated by no more than 14 days for complicated GP infections. Clinical success was observed in 30 of 32 patients (94%), including 10 of 11 (91%) patients with bone and joint infections and 7 of 8 (88%) patients with osteomyelitis. AEs were observed for 29 of 440 (6.6%) of patients; there was a single serious AE. Six (1.4%) patients discontinued ORI infusions due to an AE.

Conclusion

The CHROME program confirms that ORI is an effective and well-tolerated long-acting lipoglycopeptide antibiotic for the treatment of a range of Gram-positive infections.

Disclosures

All authors: No reported disclosures.
455. Gender Differences in Clinical, Microbiological and Treatment Characteristics of Adult Hospitalized Patients with Cellulitis: A Large, Prospective Multicenter Study
Authors: Collazos Julio , De la Fuente Belén , De la Fuente Javier , Garcia Alicia , Gomez Helena , Rivas-Carmenado Maria , Suárez-Zarracina Tomás , Enriquez Hector , Sánchez Paula , Alonso María , López-Cruz Ian , Martin-Regidor Manuel , Martinez-Alonso Ana , Guerra José , Artero Arturo , Blanes Marino , Asensi Victor
Published: October 2019

Background

Studies comparing gender differences between cellulitis features are lacking and might be useful for the knowledge, prevention and management of this infection.

Methods

Prospective, observational, multicenter study of 606 adult patients (314, 51.8% men) with cellulitis. Comorbidities, microbiological, clinical, lab, diagnostic, and treatment data were analyzed. Multiple logistic regression modeling was performed to determine the variables independently associated with gender.

Results

Women were older (P < 0.0001), less likely to have prior wounds (P = 0.02), and more likely to have venous insufficiency (P = 0.0002), edema/ lymphedema (P < 0.0003) and prior cellulitis episodes than men (P = 0.07). Cellulitis location also differed between genders (P = 0.02). Regarding microbiology, male patients were more likely to have positive pus cultures than women (P = 0.0008), mainly monomicrobial (P = 0.03).There were differences in microorganisms isolated from pus (P = 0.002), with higher S.aureus infection rates among men than women (P = 0.04).Drawing of blood for culture was also more common in men (P = 0.03). Overall, any microorganism (P = 0.006) and the causative microorganism (P = 0.04) were more commonly identified in male than in female patients, due exclusively to the pus culture results, because there were no differences in the positivity of blood cultures (P = 0.9).Of the 61 S.aureus isolates 15 (24.6%) were methicillin-resistant, without significant differences between genders (P = 0.5). Regarding therapy, men had longer treatments (P = 0.03) and higher rates of antibiotic treatment after discharge (P = 0.04). Factors independently associated with female gender in multivariate analysis were:older age (P < 0.0001), prior episodes of cellulitis (P = 0.01), presence of edema/lymphedema as predisposing factor (P = 0.004), negative pus culture (P = 0.0002) and location of cellulitis in thorax/abdomen (P = 0.035) and head/neck (P = 0.0003) as compared with lower extremities

Conclusion

Cellulitis in women as compared with men present at older ages, recur more frequently, are more commonly related to edema/lymphedema, affect more frequently other locations compared with lower extremities, and have less frequently positive pus cultures.

Disclosures

All authors: No reported disclosures.
469. Contributions of Infections among Persons Who Inject Drugs to the Changing Incidence of Healthcare-Associated, Community-Onset Methicillin-Resistant Staphylococcus aureus Infections, 2009–2017
Authors: Jackson Kelly A , Gokhale Runa Hatti , Nadle Joelle , Petit Susan , Ray Susan , Harrison Lee , Lynfield Ruth , Dumyati Ghinwa , Schaffner William , See Isaac
Published: October 2019

Background

Recently, overall reductions for invasive MRSA infections (isolation from a normally sterile site) have slowed. Healthcare-associated community-onset (HACO) invasive methicillin-resistant Staphylococcus aureus (MRSA) infections are those with recent healthcare exposures who develop MRSA infection outside acute care hospitals, and account for most invasive MRSA infections. HACO incidence decreased 6.6% per year during 2005–2008; the contribution of persons who inject drugs (PWID) to HACO incidence has not been reported.

Methods

We identified invasive MRSA infections using active, population- and laboratory-based surveillance data during 2009–2017 from 25 counties in 7 sites (CA, CT, GA, MD, MN, NY, TN). Cases were HACO if culture was obtained from an outpatient, or ≤3 days after hospitalization in a patient with ≥1 of the following healthcare exposures (HEs): hospitalization, surgery, dialysis, or residence in a long-term care facility (LTCF) in the past year; or central vascular catheter ≤2 days before culture. We calculated incidence (per census population) overall, for PWID cases and others, and for cases associated with each HE. For each HE, we calculated the proportion of overall incidence increase for PWID and others.

Results

HACO MRSA incidence declined overall from 2009 to 2016 but increased from 2016 to 2017 overall (8%), for both PWID (63%) and others (5%) (figure). For both PWID and non-PWID, incidence from 2016 to 2017 increased by 0.5 cases/100,000 population; 91% of the increase in PWID occurred in cases with a past year hospitalization while 78% of the increase in cases not associated with injection drug use (IDU) occurred in cases with past year LTCF residence. Past year LTCF residence was less common among PWID (16%) then among other cases (38%, P < 0.01).

Conclusion

After years of declines, HACO MRSA incidence increased equally in 2017 for cases associated with IDU and in cases unrelated to IDU. Increases in PWID-associated cases account for half the overall increase, indicating that efforts to reduce HACO MRSA should address PWID risk factors as these infections may be due to self-injection. In addition, increases not related to PWID, if sustained, would be a reversal of historic trends and require further investigation into causes.

Disclosures

All authors: No reported disclosures.