bluuebunny/crossref_metadata_2025 huggingface dataset:
1252. Development of a Surgical Site Infection at a Tertiary Hospital in Colombia: A Clinical and Microbiological Profile
Authors: Vallejo Marta , Cuesta Diana , Florez Luz E
Published: October 2019

Background

Surgical site infections (SSIs) are the most common healthcare-associated infections in developing countries, it represents a problem of patient safety and as well as evidence of quality of care. The objective of the study was to estimate the incidence of SSIs in surgical procedures of the surgical service, the microbiological profile and clinical evolution of patients.

Methods

Design: A retrospective, longitudinal cohort study using electronic health record data. Settings: Conducted between January and December of 2017 at tertiary hospital in Medellín, Colombia. Participants: Patients whose primary surgical procedures of gastrointestinal surgeries and abdominal wall hernias were included and followed up for 30 days after discharge. Main outcome measures: demographics, surgical risk scale, surgical procedures data, SSI according to NHSN-CDC criteria, microbiological isolates and clinical outcomes were registered and descriptive measures were obtained.

Results

There were 546 clinical charts analyzed, 55% were women, the mean age was 47 years (SD: 21), 74% at intermediate or high surgical risk. Antibiotic prophylaxis was administered at least 120 minutes before the incision and the cefazolin + metronidazole scheme was the most frequent to 70% of the patients. The incidence of SSIs was 12% (64/546), 1% superficial incisional SSIs, 3% deep incisional SSIs and 8% organ / space. Among them, 52% were NHSN-2, 55% had dirty wounds and 43% contaminated. E. coli were isolated in 16% (7/10 were BLEE+), S. aureus in 10% (all MRSA−). SSI was more frequent in laparotomy due to intra-abdominal infection in 36%, 20% colectomy, and 19% appendicectomy. The SSIs were treated in 27% with imipenem and 19% imipenem + vancomycin, for a median of 7 days (p25-p75: 7–10); 36% of the patients with SSIs underwent percutaneous drainage, 30% have been reoperated, 34% were unplanned readmission and 9% died, only two death were attributable to SSIs; the median of length of post-procedure stay days was 12 (p25-p75: 7–23) and overall 14 (p25-p75: 8–32).

Conclusion

The incidence of SSIs was higher than reported in the literature, perhaps due to the greater complexity and risk of the patients. It is necessary to implement preventive strategies in health personnel in order to reduce their incidence and complications.

Disclosures

All authors: No reported disclosures.
1261. Alarming High Rate of HIV Detected by Testing and Prevention Opportunities: Observations From the Largest HIV Program in Liberia
Authors: Ogbuagu Onyema , Watchekwa Ian , Donato Sean , Nuta Cecilia , Barakat Lydia A
Published: October 2019

Background

HIV/AIDS remains one of the world’s most significant public health challenges. Sub-Saharan Africa is home to only 12% of the world’s population, yet accounts for 71% of the global burden of HIV infection. While the HIV prevalence among reproductive aged Liberians (age 15–49 years) is estimated at 1.9%. As the critical first step in HIV disease management is detection of cases, it is important to optimize HIV testing particularly among high-risk groups. Identifying these high-risk groups for HIV infection also provides information on prevention opportunities. We report on 5 year HIV testing data at a tertiary hospital in Monrovia, Liberia stratified by age and gender.

Methods

A single-center academic hospital-based retrospective analysis of HIV testing data over a period of 5 years (January 2014 to December 2018) obtained from the Infectious Disease Center (IDC) of John F. Kennedy Medical Center in Monrovia, Liberia. The IDC has a peer-led counseling program on site and offers HIV testing daily. Data on the study population (all individuals screened for HIV disease at the center) was extracted from ledgers and registries within the IDC. The following information was collected on all participants: age, sex, and pregnancy status. Positive test results are reported as simple proportions of either all patients or all individuals tested within the category reported.

Results

Over the 5-year study period, 41,343 individuals were screened for HIV disease including 2 key demographics - 7875 individuals aged 15–24 years and 24,913 pregnant women. 4,066 individuals were diagnosed with HIV (a case detection rate of 10%), and ranged from 7% (909/12821) in 2018 to 13% (678/5079) in 2014. Case detection rates for individuals aged 15–24 were 7%, 5%, 4%, 6% and 3% for years 2014, 2015, 2016, 2017 and 2018, respectively. From 2014–2018, 2–3% of all pregnant women tested were diagnosed with HIV infection. Almost three-quarters (74%) of diagnosed cases were subsequently enrolled in an HIV clinic.

Conclusion

A peer-led HIV testing program is effective in HIV case detection, with young individuals (aged 15–24 years) and pregnant women having higher case detection rates than expected. These findings highlight opportunities for HIV prevention targeting these high-risk groups.

Disclosures

All authors: No reported disclosures.
1270. Population-Based Estimates of PrEP Access in Oregon, 2012–2016
Authors: Menza Timothy William , Capizzi Jeff
Published: October 2019

Background

PrEP is an important HIV prevention modality. Population-based metrics of PrEP uptake and access are critical to the evaluation of public health efforts to increase PrEP use.

Methods

Using the Oregon All Payers All Claims administrative dataset, we determined the number of unique individuals at least 16 years of age starting PrEP, defined as at least one prescription of >30 days of Truvada, each year from 2012–2016. People with HIV or hepatitis B were excluded. We created two metrics of PrEP access in 2016: the number of individuals starting PrEP per 100K population and the number of individuals with a PrEP prescription in each of the four quarters of 2016 per 100K population (i.e., prevalent users). Using public health surveillance data, we created three metrics of PrEP need in 2016: the number of HIV diagnoses per 100K population; the number early syphilis and gonorrhea diagnoses per 100K population; and the number of acute or chronic hepatitis C diagnoses among patients aged 16–30 years per 100K population. We calculated six metrics of PrEP access-to-need by dividing each of the access measures by the need measures.

Results

The number of individuals with a new PrEP prescription increased from 8 in 2012 to 571 in 2016. Most new PrEP users were men, aged 25–34 years, identified as white, lived in an urban area, had commercial insurance, and had an internal medicine PrEP prescriber. In 2016, there were 17.2 PrEP starts and 9.9 individuals with a PrEP prescription in all four quarters of 2016 per 100K population. There were 6.7 HIV cases, 136.0 early syphilis and gonorrhea cases, and 109.1 acute and chronic hepatitis C cases per 100K population. Per HIV diagnosis, there were 2.6 PrEP starts and 1.5 prevalent users. However, there were 0.13 PrEP starts and 0.07 prevalent users per early syphilis and gonorrhea diagnosis and 0.16 PrEP starts and 0.09 prevalent users per hepatitis C diagnosis. Women, people aged 16–24, people of color, and people in rural areas experienced lower PrEP access-to-need.

Conclusion

Access metrics based on prevalent users (a measure of longer-term adherence to PrEP), STI diagnoses (a measure of HIV acquisition risk), and HCV diagnoses among those less than 30 years of age (a measure of need among people who inject drugs) may provide a more complete assessment of PrEP access-to-need than those based on PrEP starts and HIV diagnoses.

Disclosures

All authors: No reported disclosures.
1275. Factors Associated with Patient-Provider Discussions about Preexposure Prophylaxis Among Young Men Who Have Sex with Men in Washington, DC
Authors: Ware Chelsea , Yellin Hannah , Kulie Paige , Levy Matthew E , Magnus Manya , Kuo Irene , Siegel Marc O
Published: October 2019

Background

The CDC estimates that 1.2 million people in the United States are eligible for HIV pre-exposure prophylaxis (PrEP). However, only about 120,000 people have received PrEP prescriptions through 2017. Healthcare providers’ (HCP) willingness to engage patients in discussions regarding sexual health, including PrEP, is integral to increasing PrEP uptake in the United States. Our objective was to identify factors associated with patients having discussions about PrEP with their HCP.

Methods

Men who have sex with men (MSM) aged 16–25 in the Washington, DC metro area recruited from the community completed a web-based survey in 2016 about their perceptions of and experiences with PrEP. We used multivariable logistic regression to calculate adjusted odds ratios (aOR) for associations between sociodemographic characteristics (including: age, race/ethnicity, insurance, student/employment status, education, income, living arrangements, social support, depressive symptoms) and patient-provider discussions, including willingness to have or ever having a discussion about PrEP.

Results

Among 239 MSM, 51% were Black, 25% were White, and 16% were Hispanic. 154 participants (65%) were willing to ask a HCP about PrEP without their HCP bringing it up. 159 participants (67%) reported that a HCP had never talked to them about PrEP, although 100 of the 159 (63%) expressed interest in discussing PrEP with a HCP. Participants aged <21 were less willing to ask a HCP about PrEP (aOR: 0.49, 95% CI 0.28–0.85) and insured participants were more willing to ask their HCP about PrEP (aOR: 3.64, 95% CI 1.42–9.33). In multivariable analyses, no sociodemographic characteristics were associated with having talked to a HCP about PrEP, and among those who had never talked to a HCP about PrEP, no characteristics were associated with wanting to do so.

Conclusion

There is a need to increase PrEP uptake in populations at high risk for HIV exposure. While MSM >21 and those with health insurance were more willing to ask their HCP about PrEP, there were no other differences across multiple demographic groups. Our study suggests that a wide PrEP engagement strategy that encourages HCPs to address PrEP with their patients regardless of their demographics would be beneficial to increase PrEP uptake.

Disclosures

All authors: No reported disclosures.
1276. Changes in Primary Care Pre-exposure Prophylaxis prescribing in a Large Healthcare System after the Implementation of an HIV Screening Alert and Educational Intervention
Authors: Ludden Thomas , Shade Lindsay , Thomas Jeremy , Mohanan Sveta , Leonard Michael , Tapp Hazel
Published: October 2019

Background

The number of providers that prescribe pre-exposure prophylaxis (PrEP) for HIV remains low. Primary care providers (PCPs) are less knowledgeable than HIV providers (HIVPs) with regards to PrEP: fewer PCPs had heard of PrEP (76% vs. 98%), knew about prescribing PrEP (28% vs. 76%), or ever had prescribed it (17% vs. 64%). PCPs limited knowledge about PrEP and questions about insurance coverage were identified as barriers to prescribing PrEP. Additional information on changes in prescribing PrEP in primary care within a large healthcare system is limited.

Methods

12 practices were part of a systemwide implementation of an HIV screening Electronic Medical Record (EMR) alert in October 2017 for patients ages 18–64. The 12 primary care practices were also included as part of an educational intervention regarding HIV prevention presented in the first quarter of 2018. As part of the educational intervention, information on prescribing PrEP was included along with resources for linkage-to-care and insurance coverage. The number of PrEP prescriptions were summarized for all 12 practices one year prior to the EMR alert and one-year post-EMR alert. Paired T-test statistics were used to test the number of patients prescribed PrEP by each practice pre- and post-EMR alert. The same analysis was conducted one-year pre- and post- the educational intervention.

Results

Across the 12 practices, 62 PrEP prescriptions were written one year prior to the implementation of the EMR alert (M=5.2, SD=7.3) and 88 post-EMR alert (M=7.3, SD=6.4), a 42% increase (P = 0.02). There were no differences in PrEP prescriptions one-year pre- and post- the educational intervention (n = 69).

Conclusion

While the number of PrEP prescriptions written showed significant increase after the implementation of the EMR alert, the overall number of prescriptions in primary care are still relatively low. While there has been national attention to increase PrEP prescribing through initiatives with local health departments, efforts to increase PrEP uptake require additional interventions above and beyond education interventions to increase the knowledge, comfort, and skills of providers to prescribe PrEP.

Disclosures

All authors: No reported disclosures.
1282. A Major Hurdle for HIV Elimination: How Do We Promote Pre-Exposure Prophylaxis Persistence among Men Who Have Sex with Men in the Deep South?
Authors: Gravett Ronnie M , Westfall Andrew O , Kudroff Kachina , Overton Edgar T , Marrazzo Jeanne
Published: October 2019

Background

Pre-Exposure Prophylaxis (PrEP) effectively prevents HIV acquisition in men who have sex with men (MSM), if taken appropriately. Effective PrEP requires persistence in PrEP care. We defined the PrEP care continuum in a Deep South PrEP clinic and examined factors related to persistence in care among MSM.

Methods

We reviewed data for MSM at a university-affiliated PrEP clinic in Birmingham, AL from 2014–2018 to define the PrEP continuum at five major steps: screening, initial visit, follow-up visit, current persistence, and self-reported adherence. We defined persistence as attending a PrEP clinic visit in the last 6 months and nonpersistence as prior attendance without a visit in the last 6 months. We compared demographics, insurance status, and patient-reported behaviors from initial and most recent visits between those who persisted (“persisters”) and did not (“non-persisters”) using Wilcoxon rank sum, chi-square, or Fisher’s exact test.

Results

226 (100%) MSM were screened, 141 (62%) MSM attended an initial visit, 116 (51%) MSM attended follow-up, 43 (19.0%) persisted in PrEP care, and 29 (13%) MSM self-reported good adherence (figure). Among 139 MSM (46 persisters, 93 nonpersisters), persisters were older than nonpersisters (33 vs. 32 yr, P = 0.03), and were less likely to report inconsistent condom use at their initial visit (48% vs. 73%; P = 0.01) as compared with their last visit (69% vs. 63%, P = 0.13). 23% of persisters and 29% of nonpersisters were black (P = 0.39), and 98% of persisters and 90% of nonpersisters were insured (P = 0.50). 60% of persisters and 74% of nonpersisters had multiple sex partners at initial visit (P = 0.19) as compared with 56% and 60% at their last visit, respectively (P = 0.83).

Conclusion

At a Deep South PrEP clinic, persistence overall was poor for MSM. More nonpersisters had inconsistent condom use, indicating higher risk despite nonpersistence. Although not statistically significant, nonpersisters were more likely to be black, uninsured, and have multiple sexual partners when compared with persisters. Disparities seen nationally in new HIV diagnoses are reflected in nonpersisters. Nonpersisters may not realize the extent of their risk of HIV acquisition and warrant intensive engagement interventions.

Disclosures

All authors: No reported disclosures.
1286. Healthcare Provider Attitudes and Knowledge Around Pre-Exposure Prophylaxis (PrEP) for the Prevention of HIV-Infection in Tennessee
Authors: Moore Emily , Kelly Sean , Alexander Leah , Luther Patrick , Cooper Robert , Rebeiro Peter , Zuckerman Autumn , Hargreaves Margaret , Bourgi Kassem , Schlundt David , Bonnet Kemberlee , Pettit April
Published: October 2019

Background

Daily pre-exposure prophylaxis (PrEP) is very effective at preventing HIV acquisition. PrEP use in the southern United States is low despite high regional HIV prevalence. Prior surveys of primary care providers (PCPs) regarding PrEP occurred before recent guideline updates, were not constructed using a theoretical behavioral framework and validated, or did not focus on the South.

Methods

We conducted a cross-sectional survey of Tennessee (TN) PCPs from March-April 2019 to assess PrEP knowledge, attitudes, and prescribing practices. Survey development was guided by the COM-B framework (capability, opportunity, motivation and behavior) and validated by pilot testing and cognitive interviews. Knowledge scores were calculated as +1 point for each correct option and 0 points for each incorrect option (maximum score=8). Wilcoxon rank-sum tests were used to compare scores, and Fisher’s exact tests were used to compare categorical variables, between PrEP prescribers and nonprescribers.

Results

Among 69 respondents, 39% (n = 27) had prescribed PrEP. There were no differences in beliefs about PrEP or sense of obligation to prescribe PrEP between prescribers and nonprescribers. Patient inquiry about PrEP was significantly associated with prescription (P < 0.001); 100% of prescribers had ≥1 patient ask about PrEP in the past year vs. 29% of nonprescribers. Prescribers’ median PrEP knowledge scores were higher than nonprescribers’ (Figure 1). Prescribers had higher self-reported ability to take sexual histories for MSM and heterosexual male patients than nonprescribers (P = 0.007, P = 0.007), and higher self-reported comfort with taking sexual histories for MSM, heterosexual male, and heterosexual female patients (P = 0.061, P = 0.005, P = 0.026, respectively). Nonprescribers frequently cited a need for training in PrEP contraindications and eligibility, cost of PrEP, and administrative burden as barriers to provision.

Conclusion

Less than half of TN PCPs we surveyed prescribed PrEP despite similar senses of obligation and PrEP-related beliefs between prescribers and nonprescribers. Future interventions to improve PrEP provision among PCPs in TN should target PrEP knowledge, ability and comfort with sexual history taking, and patient awareness of and ability to inquire about PrEP.

Disclosures

All authors: No reported disclosures.
1289. Douching and Rectal Inflammation in Sexual Minority Men: Implications for HIV Acquisition
Authors: McGaugh Angela , Miller Charlene , King Justice , McManus Kate , Alcaide Maria L , Bauermeister Jose , Grov Christian , Manuzak Jennifer , Broedlow Courtney , Klatt Nichole , Carrico Adam
Published: October 2019

Background

Rectal douching is the practice of rinsing the anus and rectum prior to, or after, anal sex. Among gay, bisexual, and other men who have sex with men (sexual minority men), rectal douching is likely to enhance HIV acquisition by amplifying inflammation of the rectal mucosa. This study evaluated the association of rectal douching with rectal inflammation among sexual minority men at risk for HIV infection.

Methods

HIV uninfected sexual minority men who reported receptive anal intercourse in the past 3 months (N = 197) were recruited from four STI clinics in South Florida, the leading region for new HIV infections among sexual minority men in the United States. A brief survey assessed rectal douching practices and sexual behaviors in the previous 3 months. Rectal inflammation was assessed by measuring 13 human rectal inflammatory cytokines/chemokines in rectal swabs using the LEGENDplex Human Inflammation Panel in a sample of 38 participants who reported douching and condomless receptive anal intercourse (CRAI).

Results

Average age was 35.8 years (SD=15.4). The sample was multi-ethnic: 42% Caucasian, 38% Hispanic/Latino, 13% Black/African American, and 7% other ethnic minority. Approximately two-thirds of participants (65%) reported any rectal douching in the past 3 months and the median number times participants douched was five. Participants who douched had more CRAI partners (Cohen’s d = 0.4587; P < 0.01), and more CRAI partners to ejaculation (Cohen’s d = 0.4813; P < 0.01) compared with participants who did not douche. Participants who reported douching five or more times in the past 3 months displayed significantly higher levels of IL-8 (Cohen’s d = 0.79; P = 0.02) than those who douched less than five times.

Conclusion

Among sexual minority men who engage in CRAI, more frequent douching is associated with higher levels of rectal inflammation. Assessment of rectal douching should be included when evaluating HIV prevention interventions among sexual minority men, as those who douche are more likely to engage in CRAI and are at higher risk for acquisition of HIV and other sexually transmitted infection. Further mechanistic studies are needed to assess the role of rectal douching in promoting rectal inflammation.

Disclosures

All authors: No reported disclosures.
1291. Comparison of Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV) Screening Rates Before and After Implementation of a Quality Improvement (QI) Project Aimed at Incorporating Routine “Opt-Out” Testing at a Primary Care Resident Clinic in Columbia, SC
Authors: Pinkney Jodian , Ahuja Divya , Derrick Caroline , Faulkenberry Shannon B , Durkin Martin
Published: October 2019

Background

Southern states account for the majority of new cases of Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV) in the United States. Despite this, routine screening for these viruses in asymptomatic individuals remains low and patients often present with advanced disease.

Methods

We examined the screening rates for HIV and HCV before and after implementation of a Quality Improvement (QI) project aimed at routine “opt out” testing in asymptomatic individuals. The QI project was implemented at a single primary care clinic in February 2019 and will continue until August 2019. Persons were considered eligible for testing if they were between the ages of 18–65 years for HIV and 18–74 years for HCV. Screening rates were determined by calculating the percentage of eligible patients tested within the study period and compared with baseline screening rates of patients seen June–July 2018. Characteristics of the study population were valued by using descriptive statistics. Chi-square test was used to compare categorical variables. A significance level of P < 0.05 was considered statistically significant. We present 4-week data.

Results

532 patients were seen for the month of February 2019 (347 (65%) females and 185 (35%) males). Mean age was 57 years (SD = 19). Patients seen were predominantly black females. After QI implementation, the screening rate for HIV was 45% compared with the baseline screening rate of 30% (P = 0.014). Similarly, the screening rate for HCV was 47.2% compared with baseline screening rate of 20% (P < 0.001). Gender, age, chief complaint and insurance coverage did not impact screening rates. The major reason persons were not screened was opting out due to patient preference. 34% of eligible persons opted out of HIV testing, while 33% of eligible persons opted out of HCV testing. Provider engagement was initially high but tapered off. No new cases of HIV were found. 4 new cases of HCV with active viremia were identified.

Conclusion

While the implementation of routine “opt-out” testing significantly increased the percentage of individuals screened, a significant number of people are still choosing to opt out of testing. The percentage of persons opting out is higher than that seen in previous studies and may be contributing to the southern epidemic.

Disclosures

All authors: No reported disclosures.
1297. Examining the Successes and Challenges of Implementing HIV Testing Clinical Decision Support in the Emergency Department
Authors: Powell Mariah , Gierlach Michael , Werner Sandra L , Bar-Shain David S , Avery Ann
Published: October 2019

Background

In 2016, MetroHealth System (MHS) launched the FOCUS (Frontlines of Communities in the United States) project to routinize HIV testing in the emergency department (ED). Before 2016, clinical decision support (CDS) for HIV testing was not in place, nor was there a policy to support the importance of opt-out, nontargeted screening. The purpose of this study was to outline the progress of HIV testing after the integration of CDS, as well as describe the implementation challenges, and how certain events impacted HIV testing.

Methods

HIV testing data from MHS EDs were collected from October 1, 2015 to March 31, 2019 and graphed into a run chart. The dataset was mapped with the following events: project start date, ED testing begins (without CDS), CDS implementation, the staffing of the ED Testing Coordinator (EDTC), and optimization of CDS (Figure 1). To determine whether observed variation in the dataset is due to random or special cause variation, these run chart rules were applied: Run, Shift (Figure 2), and Trend.

Results

There were 42 data points and 4 runs. With 42 points, the lower limit of runs was 16 and the upper limit of runs was 28. This signals that one or more special cause variations were present. A total of three distinct shifts were observed indicating special cause variation. The run chart did not include any downward or upward trends. Testing increased as much as 3971% (7 tests in October 2015 vs. 285 tests in March 2018).

Conclusion

HIV testing increased from 7 tests to 86 tests (Shift 1). This coincided with establishment of an ED testing policy in April 2016. Testing increased to 266 tests in October 2016 (Shift 2). This directly related to implementation of CDS in the ED. December 2017 displayed the lowest testing with 117 tests. This was due to lack of policy awareness, and to the rarely-visited location of the HIV screening tool during the triage process. Staff was re-educated and the HIV screening tool was moved to a more visible location. This resulted in 227 tests in February 2018, and was followed by the highest testing month with 285 tests (Shift 3). Continued challenges prohibit sustained upward trends in ED testing. A control chart may be the appropriate next step to identify new control limits

Disclosures

All authors: No reported disclosures.
1303. Impact of Pharmacy Type on HIV Viral Suppression at a University-Based HIV Clinic in the Midwest
Authors: Havens Josh , New-Aaron Moses , Gao Yangyang , He Qingfeng , Nada Fadul , Bares Sara H
Published: October 2019

Background

People with HIV (PWH) utilize various pharmacy types beyond the traditional local pharmacy including mail order and specialty pharmacies. Some pharmacies often provide additional adherence services such as refill reminders, expedited delivery, and adherence packaging. Limited data are available describing the relationship between pharmacy type and HIV viral suppression (VS). We evaluated the impact of pharmacy type on VS.

Methods

We conducted a single-center, retrospective cohort study of PWH (≥19 years) receiving care at a Midwestern HIV clinic between January 1, 2018, and December 31, 2018, with at least 1 HIV RNA reading during the study period. We collected sociodemographic information, ART regimen, adherence (PDC—percentage of days covered), and clinical characteristics. Patients were stratified by pharmacy type: local (traditional pharmacy without adherence services), local specialty (traditional pharmacy with adherence services and same-day, couriered delivery), and mail order (mail order pharmacy with or without adherence services). Pearson Chi-squared tests and binary logistic regression were used to examine the effect of pharmacy type on VS (HIV viral load ≤50 copies/mL).

Results

A total of 1014 patients met study criteria; 164 (16%) utilized a local, 720 (71%) local specialty, and 130 (13%) mail order. VS rates were similar between pharmacy types: local (91%), semi-specialty local (88%), and mail order (96%). After adjusting for sociodemographic characteristics, ART regimen, ART adherence and other clinical characteristics, there was no association between pharmacy type and VS when comparing local and mail to local specialty pharmacy types (local—aOR: 0.98, 95% CI, 0.46–2.12; mail—aOR: 1.65, 95% CI, 0.46–6.0). Factors found to be negatively associated with VS were single marital status (aOR: 0.49; 95% CI, 0.24–0.95), current or historical opportunistic infection (aOR: 0.51; 95% CI, 0.26–0.99), and usage of a multiclass or dual ART regimen (aOR: 0.40; 95% CI, 0.16–0.98).

Conclusion

Despite additional services offered by some pharmacies, no differences were observed in HIV VS between pharmacy types.

Disclosures

All authors: No reported disclosures.
1322. A Mobile Technology-Based Intervention Improves HIV Care Continuum for Young People Living with HIV
Authors: Du Ping , Zurlo John , Eshak Tarek , Crook Tonya , Whitener Cynthia
Published: October 2019

Background

Young people living with HIV (YPLWH) have lower rates of retention in care and HIV viral suppression. Multiple barriers exist to engage YPLWH in care. As nearly all YPLWH use their mobile phones to access health information and to communicate with other people, we implemented a mobile technology-based intervention with the goal to improve HIV care continuum in YPLWH.

Methods

YPLWH were eligible for this study if they were: (1) aged 18–34 years; (2) newly diagnosed with HIV; (3) having a history of being out of care; or (4) not virally suppressed. We recruited YPLWH during January 2017-May 2018 and followed them every 6 months. We developed a HIPAA-compliant mobile application, “OPT-In For Life,” and let participants use this app to manage their HIV care. The app integrated multiple features that enabled users to communicate with the HIV treatment team via a secure messaging function, to access laboratory results and HIV prevention resources, and to set up appointment or medication reminders. We obtained participants’ demographics, app-usage data, and medical records to evaluate if this mobile technology-based intervention would improve HIV care continuum among YPLWH. We used a quasi-experiment study design to compare the rates of retention in care and HIV viral suppression every 6 months between study participants and YPLWH who were eligible but not enrolled in the study.

Results

92 YPLWH participated in this study (70% male, 56% Hispanics or Blacks, 54% retained in care, and 66% virally suppressed at baseline). On average study participants used the app 1–2 times/week to discuss various health issues and supportive services with HIV providers, to access HIV-related health information, and to manage their HIV care. At the 6-month evaluation, compared with 88 eligible YPLWH who were not enrolled in this intervention, study participants had increased rates of retention in care (baseline-to-6-month between participants and nonparticipants: 54%–84% vs. 26%–25%) and HIV viral suppression (66%–80% vs. 56%–60%).

Conclusion

Our study demonstrates using a HIPAA-compliant mobile app as an effective intervention to engage YPLWH in care. This intervention can be adapted by other HIV programs to improve HIV care continuum for YPLWH or broader HIV populations.

Disclosures

All authors: No reported disclosures.
1330. Evaluation of Multiple Host Response-Based Strategies to Classify Acute Respiratory Illness
Authors: Ross Melissa H , Henao Ricardo , Burke Thomas W , McClain Micah T , Ginsburg Geoffrey S , Woods Chris W , Tsalik Ephraim L , Tsalik Ephraim L
Published: October 2019

Background

Host response-based diagnostics are an alternative to pathogen-based tests. Host response strategies include proteomic and transcriptomic approaches. Here, we compare three host response strategies for ARI diagnosis: Procalcitonin (PCT), a 3-protein panel, and an mRNA panel.

Methods

PCT, a 3-protein panel (CRP, IP-10, TRAIL), and a host gene expression mRNA panel were measured in a cohort of 286 participants presenting to one of the four Emergency Departments with ARI due to bacterial (n = 47), viral (n = 162), or noninfectious (n = 77) etiologies. Multinomial logistic regression and leave-one-out cross-validation were used to train and evaluate the protein and mRNA panels. Performance characteristics were calculated for each method, and their combination, for the ability to discriminate bacterial vs. non-bacterial infection and viral vs. nonviral infection. PCT was not evaluated for viral vs. nonviral discrimination since it does not discriminate viral and noninfectious etiologies. McNemar’s test was used to compare overall accuracy of mRNA and protein panels.

Results

For discriminating bacterial vs. non-bacterial etiologies, the mRNA panel had an AUC of 0.93 vs. 0.83 for both the protein panel and PCT. A model utilizing all three strategies was the same as mRNA alone. Using previously established cutoffs, overall accuracy was similar between mRNA and protein panels, but the protein panel had widely discordant sensitivity (43%) and specificity (92%). When selecting an optimal cutoff for the protein panel that balanced the two (82% and 73%, respectively), the mRNA panel had a significantly greater overall accuracy (P < 0.001). Similar results were found when discriminating viral vs. non-viral subjects: the mRNA panel (AUC = 0.93) outperformed the protein panel (AUC = 0.84). Combining the mRNA and protein panels was equivalent to the mRNA panel alone.

Conclusion

A host-based gene expression signature is the most effective platform for classifying subjects with bacterial, viral, or noninfectious ARI. A gene expression approach, when translated to a clinically available platform, may facilitate diagnosis and clinical management of acute infectious diseases, mitigating antibiotic overuse.

Disclosures

Ephraim L. Tsalik, MD, MHS, PhD, Immunexpress: Consultant; Predigen, Inc.: Officer or Board Member, Research Grant.
1335. A Translational Nephrotoxicity Model to Probe Acute Kidney Injury with Vancomycin and Piperacillin–Tazobactam
Authors: Pais Gwendolyn M , Liu Jiajun , Avedissian Sean N , Hiner Danielle , Xanthos Theodoros , Chalkias Athanasios , d’Aloja Ernesto , Locci Emanuela , Gilchrist Annette , Prozialeck Walter , Rhodes Nathaniel J , Lodise Thomas , Fitzgerald Julie , Downes Kevin J , Downes Kevin J , Zuppa Athena , H. Scheetz Marc
Published: October 2019

Background

Vancomycin and piperacillin–tazobactam (VAN+TZP) are two of the most commonly utilized antibiotics in the hospital setting and are reported in clinical studies to increase acute kidney injury (AKI). However, no clinical study has demonstrated that synergistic AKI occurs, only that serum creatinine increases with VAN+TZP. Previous preclinical work demonstrated that novel urinary biomarkers and histopathologic scores were not increased in the VAN+TZP group compared with VAN alone. The purpose of this study was to assess changes in urinary output and plasma creatinine between VAN, TZP, and VAN+TZP treatments.

Methods

Male Sprague–Dawley rats (n = 32) received either saline, VAN 150 mg/kg/day intravenously, TZP 1,400 mg/kg/day intraperitoneally, or VAN+TZP for 3 days. Animals were placed in metabolic cages pre-study and on drug dosing days 1–3. Urinary output, plasma creatinine, urinary biomarkers were compared daily and kidney histopathology was compared at the end of therapy between the groups. Mixed-effects, repeated-measures models were employed to assess differences between the groups.

Results

In the VAN-treated rats, urinary output was increased on days 1, 2 and 3 compared with baseline and saline (P < 0.01 for all), whereas it increased later for VAN+TZP (i.e., day 2 and 3 compared with saline, P < 0.001). No changes in urinary output were observed with saline and TZP alone. Plasma creatinine rose for VAN on days 1, 2, and 3 from baseline and VAN+TZP on day 3 (P < 0.02 for all), but no treatment group was different from saline. In the VAN-treated rats, urinary KIM-1 and clusterin were increased on days 1, 2, and 3 compared with controls (P < 0.001). Elevations were seen only after 3 days of treatment with VAN+TZP (P < 0.001 KIM-1, P < 0.05 clusterin). No changes in urinary biomarkers output were observed with saline and TZP alone. Histopathology was only elevated in the VAN group compared with saline (P < 0.002). No histopathology changes were noted with VAN+TZP.

Conclusion

All groups with VAN demonstrated kidney injury; however, VAN+TZP did not cause more kidney injury than VAN alone in a rat model of VIKI when using plasma creatinine, urinary output, or urinary biomarkers as outcomes. Histopathology data suggest that adding TZP did not worsen VAN-induced AKI and may even be protective.

Disclosures

Kevin J. Downes, MD, Merck: Grant/Research Support, Research Grant; Pfizer: Grant/Research Support.
1348. Mycobacterium Chimera Infection Following Cardiac Surgery: A Review of a Large Cohort of Cases in the United States
Authors: Kim Jani M , Costales Jessica K , Modjtahedi Bobeck , Bluestone Gary , Nomura Jim H
Published: October 2019

Background

Mycobacterium chimera (MC) is a nontuberculous mycobacterium associated with infections originating from heater-cooler devices following cardiac surgery globally from 2012 to 2016. Twenty-eight cases occurred within our health system in Southern California, the largest number of cases in the United States to date. We aim to summarize the clinical features, diagnosis, treatments, and outcomes of these cases.

Methods

We reviewed the electronic health records of 28 patients with identified MC infection who had index coronary artery bypass (CABG) and/or valve replacement surgery between 2014 and 2016. All diagnoses were confirmed by cultures speciated to MC by 16S partial DNA sequencing or Karius testing, except for one case. Patients were grouped by clinical presentation of disseminated disease (n = 18) or localized disease (n = 10). Treatment delay was calculated from the time of initial presentation to the start date of antibiotics and evaluation for surgical intervention.

Results

All patients who underwent CABG alone (n = 5) developed localized sternal wound infections, whereas patients who had valve replacement surgery (n = 23) developed either localized or disseminated disease. Disseminated disease carried a mortality rate of 40% in those with surgical source control vs. 72% in patients who were not surgical candidates (OR 6.6, 95% CI 0.8–55). The mortality rate of patients with localized sternal wound infections was 11% after incision/drainage and sternal wire removal (n = 9). Delay of antimicrobial treatment greater than 6 months in all 28 patients was associated with a mortality rate of 54% compared with 35% in patients who started treatment within 6 months (OR 2.2, 95% CI 0.47–10.35). Overall mortality rate of patients with MC infection was 42%.

Conclusion

Disseminated MC infection should be considered early in at-risk patients presenting with constitutional symptoms. In this review of 27 confirmed and 1 probable case of MC infection, disseminated infection only occurred in patients who underwent valve surgery while localized disease occurred in patients who underwent CABG. Surgical source control with early initiation of antimicrobial therapy is associated with improved outcomes. Optimal duration of antimicrobial treatment is still unknown.

Disclosures

All authors: No reported disclosures.
1349. Risk Factors for Extrapulmonary Tuberculosis in Greece, a Low Tuberculosis Burden and High Immigrant Receiving Country
Authors: Vassalos Constantine , Papaventsis Dimitrios , Koutelekos Ioannis , Panagi Marina , Vogiatzakis Evangelos , Vassalou Evdokia , Karabela Simona
Published: October 2019

Background

Although the most common site of tuberculosis (TB) is the lungs, spreading may occur to any part of the body, resulting in extrapulmonary tuberculosis (EPTB). We conducted a study to describe the clinical and epidemiological features of EPTB in Greece, a low TB burden country (<50 TB cases/million), in which immigrants from high TB burden countries make up >7% of the population.

Methods

We retrieved data for adults presenting with signs/symptoms consistent with EPTB from 2014 to 2015 registries of the Athens Chest Disease Hospital. EPTB was clinically, histologically or microbiologically diagnosed. We recorded age, gender, immigrant, or native status, site of disease, history of diabetes, smoking, and immunological status. Proportion ratios (PR) and 95% confidence interval (CI) were calculated to estimate risk factors for developing EPTB.

Results

We identified 277 (153 males) adult patients, 254 (91.7%) natives, and 23 (8.3%) immigrants, with signs/symptoms consistent with EPTB. Of 118/277 (42.6%) EPTB cases, 67 (57.6%) were males. No association with gender, diabetes, or smoking was shown between EPTB cases and non-cases. Immigrants were twice as likely to develop EPTB as natives (PR = 1.86 95% CI: 1.38–2.51 P < 0.001). Immigrants from high TB burden countries were 2 times as likely to develop nodal, pericardial, or pleural TB as the native population (Tables 1 and 2). Native patients > 60 years of age presenting with lymph node enlargement or with a pleural effusion were 3 times as likely to have TB disease as those aged <60 years (Table 2). In contrast, all immigrants with lymph node enlargement were EPTB cases (Table 1) and were <45 years old. Impaired immunological status increased the risk of developing EPTB by 62% in the native population (PR = 1.62 95% CI: 1.20–2.33 P < 0.001).

Conclusion

In a low TB burden country, EPTB is associated with old age and weak immune system due to possible extrapulmonary dissemination of latent TB. Considered to be at high-risk for developing EPTB, immigrants from high TB burden countries with signs and/or symptoms consistent with EPTB, albeit not transmitting the disease, need to be priority-wise tested for TB in order to be adequately treated.

Disclosures

All authors: No reported disclosures.
1360. Disseminated Mycobacterium abscessus Infections in Patients with Neutralizing Anti-interferon-gamma Autoantibodies Treated with Rifabutin-based Combination Regimens
Authors: Cheng Aristine , Sun Hsin-Yun , Wu Un-in , Sheng Wang-Huei , Chen Yee-Chun , Chang Shan-Chwen
Published: October 2019

Background

This prospective study aimed to describe the treatment and safety outcomes of rifabutin-based combinations which has been shown to be synergistic in vitro, for patients with refractory M. abscessus infections and neutralizing anti-IFNγ antibodies.

Methods

Patients failing at least two standard macrolide-based regimens were recruited from hospitals across Taiwan since August 2017. They received rifabutin (RFB > 300 mg/day) initially with azithromycin (AZR 500 mg/day) and at least one parenteral agent and were monitored thereafter clinically on a monthly basis and by 3–6 monthly PET-CT imaging.

Results

Of 12 referred patients, only four had complete evaluations. The median age was 41 years and follow-up duration was 543 (range 307–668) days. All patients had lung and lymph node disease, two also had liver, bone and joint involvements and all were HLA-DR 16:02, HLA-DQ 05:02 positive. Prior to starting RFB–AZR, they had received at least four successive antimycobacterial regimens, but showed progression of existing lesions (2) or new lesions (2). Following RFB–AZR, all four patients experienced adverse reactions, including reactive dermatoses (2), fevers (2), leukopenia (2), thrombocytopenia (1), hearing loss (1), acute kidney injury (1), which necessitated withdrawal of rifabutin (4), short-term steroid use (2), and replacement of tenofovir with entecavir for chronic hepatitis B (1). All patients recovered fully from these adverse effects. Rifabutin was successfully restarted on first attempt (3) and on third attempt (1). The longest symptom-free interval on RFB–AZR was 331 days and the lowest maintenance dose was RFB 150–AZR 250 thrice weekly. Follow-up PET-CT confirmed good resolution of previous hot spots (mean SUVmax −4.5) except for the patient who did not tolerate RFB 300 due to fever and nausea on the first re-challenge, whose PET-CT detected a slight increase in mean SUVmax +0.6 and was hospitalized for dry cough on daily AZR–ciprofloxacin. The latter eventually tolerated a lower daily dose RFB 150–AZR 250 and became asymptomatic.

Conclusion

Rifabutin is an oral agent that can be effectively combined with azithromycin in long-term maintenance regimens against M. abscessus in immunodeficient adults. Adverse effects are frequent early on; however, rechallenge appears to be safe and outcomes favorable.

Disclosures

All authors: No reported disclosures.
1362. A Case Series of Miliary Tuberculosis in North West London
Authors: Gorgui-Naguib Hannah , Cootauco Che , Sandhu Gurjinder , Papineni Padmasayee
Published: October 2019

Background

Miliary tuberculosis (mTB) is a severe presentation of TB with high mortality. We reviewed data from a cohort of patients with mTB in an area of London serving an ethnically diverse population with the highest TB endemicity in the UK.

Methods

Retrospective analysis of laboratory and medical records, radiology and microbiology results of patients with mTB identified from the London TB register from 2012 to 2019 from London North West Hospitals University NHS Trust.

Results

60 cases with mTB were recorded. 67% of the patients were male. Median age at diagnosis was 36 years (range 13 to 88 years). 60% of patients were South Asian ethnicity. Two patients were HIV positive and 4 had received anti-TNF treatment. 73% (44 patients) patients had miliary nodular opacities on chest radiograph. Of the 16 patients with no chest radiograph evidence of mTB, 14 had computed tomography (CT) of the chest which confirmed miliary nodules. Eleven patients were sputum acid-fast bacilli (AFB) smear-positive, and in 49 patients, culture of sputum isolated Mycobacterium tuberculosis. Ten patients did not have any positive microbiology but were treated for mTB on clinico-radiological basis. Forty patients had fully-sensitive TB; 2 were isoniazid-resistant and 1 multi-drug-resistant. 5 patients in our cohort also had spinal TB. Evidence of cerebral TB was found in 5/17 patients who had a CT brain. Tuberculomas were seen in 10/24 patients who had magnetic resonance imaging (MRI). Only 8 patients had both CT and MRI; MRI revealed2 patients with cerebral TB that CT did not, but this was not statistically significant (P = 0.1573). 7 patients were investigated with lumbar puncture, of which cerebrospinal fluid was smear and culture negative for all. All patients were treated with standard therapy with a mean length of treatment of 11 months. 33 patients have completed therapy. 7 patients died and 2 were lost to follow-up. Those who died had a mean age of 69 years compared with those who survived (44.2 years).

Conclusion

The diagnosis of mTB requires a high index of suspicion for central nervous system disease. Our cohort demonstrates that spinal disease needs to be considered in addition to cerebral TB, for which MRI may be the preferred imaging modality. Mortality in our cohort was associated with older age.

Disclosures

All authors: No reported disclosures.