bluuebunny/crossref_metadata_2025 huggingface dataset:
902. Selection of Antibiotics for Prophylaxis of Left Ventricular Assist Device Surgical Infections: More is Not More
Authors: Nguyen Peter T , Sam Teena , Colley Peter , Van Zyl Johanna , Berhe Mezgebe , Meyer Dan
Published: January 2021

Background

Surgical site infections (SSI) for implantation of left ventricular assist devices (LVADs) are associated with high mortality. Updated guidance from the International Society for Heart and Lung Transplant recommends that SSI prophylaxis regimens target Staphylococcus spp and recommend against broad regimens targeting gram-negatives and fungi. The purpose of this study was to compare outcomes between patients that received broad or narrow antimicrobial prophylaxis regimens after a change in institutional protocol.

Methods

This single center retrospective study included adult patients who underwent LVAD implantation between January 2015 and September 2019. Patients were excluded if post-surgical care was managed at an outside facility, were treated for an active infection at the time of implantation, or underwent re-implantation within 90 days. The narrow spectrum group consisted of patients that received cefazolin, vancomycin or both, while the broad spectrum group consisted of patients that received an anti-pseudomonal beta-lactam plus vancomycin ± other antibiotics. Data was compared using t-test or Wilcoxon rank sum test, Chi-Square test, or Fisher’s Exact. Cox-proportional hazards models and log-rank tests were used for survival analysis.

Results

A total of 104 patients were included, with 39 and 65 patients receiving narrow and broad spectrum prophylaxis, respectively. There was no difference in the primary outcome of SSI rate between the narrow and broad antimicrobial prophylaxis groups at 30 days (7.7% vs 7.7%, p=1.00) and 1 year (18.0% vs 18.5%, p=1.00) respectively. Secondary outcomes of time to mortality (HR 0.45, 95% CI 0.15-1.36, logrank P=0.15), time to first infection (HR 0.68, 95% CI 0.26-1.8, logrank P=0.44), or the composite outcome of mortality or infection (HR 0.55, 95% CI 0.24-1.23, logrank P=0.14) were not different between the groups. The majority of infections were due to gram-positive bacteria (73%), most commonly methicillin susceptible S. aureus (36%).

Time to Mortality

Time to First Infection

Composite Outcome (Time to First Infection or Death)

Conclusion

This study supports the use of narrow spectrum antimicrobial prophylaxis in LVAD implantation. These results highlight an opportunity to improve antibiotic use in LVAD implantation.

Disclosures

All Authors: No reported disclosures
903. SSI Trends in Community Hospitals from 2013 to 2018
Authors: Seidelman Jessica L , Baker Arthur W , Lewis Sarah S , Advani Sonali D , Smith Becky , Anderson Deverick J
Published: January 2021

Background

Surgical site infections (SSIs) are common causes of hospital-acquired infection. However, only sparse data are available on the recent epidemiology of SSIs in community hospitals.

Methods

We performed a retrospective analysis of prospectively collected SSI data at 32 community hospitals in the southeastern United States from 2013 to 2018. We calculated the annual prevalence rates (PRs) of SSI for 26 commonly performed procedures and stratified results by causative pathogen. We used log-binomial regression models to examine trends of SSI prevalence over time.

Results

Over the 6-year study period, 3,561 complex (i.e., deep incisional or organ space) SSIs occurred following 669,467 total procedures (PR, 0.53 infections per 100 procedures). The complex SSI PR did not change significantly during the study period (0.58/100 procedures in 2013 versus 0.53/100 procedures in 2018; PR ratio [PRR], 0.84; 95% CI 0.66–1.08, p=0.16). For commonly performed procedures, rates of SSI in community hospitals were higher than 2018 National Healthcare Safety Network (NHSN) benchmark SSI rates for colon surgery, hip arthroplasty, knee arthroplasty, and spinal fusion. (Table 1). Staphylococcus aureus was the most common pathogen to cause SSI each year and was responsible for 23.7% (n=843) of all complex SSIs. Methicillin-susceptible S. aureus (MSSA) complex SSIs [13.5%, n=480] were more common than complex SSIs caused by methicillin-resistant S. aureus (MRSA) [10.2%, n=363] (Figure 1). Compared to the 2013, the only significant decrease in S. aureus SSI PR occurred in 2017 (PRR 0.67 95% CI 0.49-0.90, p=0.01), which was primarily driven by the significant decrease in MRSA SSI PR in 2017 compared to 2013 (PRR 0.61 95% CI 0.42-0.89, p-value=0.01). The Escherichia coli SSI PRs did not change significantly during the study period, but E. coli became the second most prevalent pathogen in 2018, surpassing MRSA.

Table 1. Community Hospital SSI Prevalence Rates for Commonly Performed Procedures

Figure 1: Prevalence Rates of Community Hospital Complex SSIs by Causative Pathogen from 2013 to 2018

Conclusion

The complex SSI rate did not significantly decline in our cohort of community hospitals from 2013 to 2018. Baseline SSI rates were low, and statistically significant decreases in SSI rates may be difficult to achieve. However, the epidemiology of community hospital SSIs may be changing with a shift away from MRSA SSIs.

Disclosures

All Authors: No reported disclosures
904. Surgical Site Infection After Bariatric Surgery: a Small Risk that Defines Life and Death of Patients
Authors: Giarola Lucca G , Starling Carlos Ernesto Ferreira , Couto Braulio Roberto Gonçalves Marinho , de Carvalho Handerson Dias Duarte
Published: January 2021

Background

Surgical site infection (SSI) in bariatric surgery can lead to devastating outcomes such as peritonitis, sepsis, septic shock and organ space infection. The objective of our study is to answer four questions: a) What is the SSI risk after bariatric surgery? b) What are the risk factors for SSI after bariatric surgery? c) What are the main outcomes to SSI in bariatric surgery? d) What are the main bacteria responsible for SSI in bariatric surgery?

Methods

A retrospective cohort study assessed 8,672 patients undergoing bariatric surgery between 2014/Jan and 2018/Dec from two hospitals at Belo Horizonte, Brazil. Data were gathered by standardized methods defined by the National Healthcare Safety Network (NHSN)/CDC procedure-associated protocols for routine SSI surveillance. Outcome: SSI, hospital death and total length of hospital stay. 20 preoperative and operative variables were evaluated by univariate and multivariate analysis (logistic regression).

Results

77 SSI were diagnosed (risk = 0.9% [C.I.95% = 0.7%;1.1%]). Mortality rate in patients, without infection was only 0.03% (3/8,589) while hospital death of infected patients was 4% (3/77; RR = 112; p< 0.001). Hospital length of stay in non-infected patients (days): mean = 2, std.dev.= 0.9; hospital stay in infected patients: mean = 7, std. dev. = 15.6 (p< 0.001). Two main factors associated with SSI after bariatric surgery were identified by logistic regression: duration of procedure (hours), OR = 1.4;p=0.001, and laparoscopy procedure, OR = 0.3;p=0.020. From 77 SSIs, in 28 (36%) we identified 34 etiologic agents. The majority of SSI (59%) was caused by species of Streptococcus (32%), Klebsiella (15%), and Enterobacter (12%).

Conclusion

SSI is rare after bariatric surgery, however, when it happens, it’s a disaster for the patient. The incidence of SSI can be reduced significantly when laparoscopy procedure is used and the surgeon is able to perform a rapid surgery.

Disclosures

All Authors: No reported disclosures
905. Surgical Site Infections Following Colon Surgery in a Large Network of Community Hospitals
Authors: Seidelman Jessica L , Baker Arthur W , Ge Maojun , Lewis Sarah S , Advani Sonali D , Smith Becky , Anderson Deverick J
Published: January 2021

Background

Colon surgeries are commonly performed, and surgical site infections (SSIs) following these procedures are routinely reported to the National Healthcare Safety Network (NHSN). However, the impact of infections present at the time of surgery (PATOS) and emergent surgeries on the epidemiology of colon surgery SSIs has not been well described.

Methods

We retrospectively analyzed prospectively collected data on complex (i.e., deep incisional or organ space) SSIs following colon surgery performed at 34 community hospitals in the southeastern United States from January 2015 to June 2019. We excluded SSIs categorized as PATOS. We then stratified colon surgery SSI rates according to age, sex, body mass index (BMI), operation duration, diabetes diagnosis, American Society of Anesthesiologists (ASA) physical status, wound class, emergent procedure, endoscopic procedure, and hospital colon surgery volume. Finally, we explored effect measure modification of emergent surgery and open surgery on hospital volume using log-binomial modeling and tests of homogeneity.

Results

A total of 722 complex SSIs occurred following 28,642 colon surgeries (prevalence rate [PR], 2.52 per 100 procedures). After PATOS SSIs were excluded, 545 complex SSIs remained (PR 1.90 per 100 procedures). Risk factor analysis revealed that age < 75 years and operation time > 75th percentile (188 minutes) during the 5-year study period) significantly increased risk of SSI (Table 1). The most common pathogens that caused SSIs in this study cohort were Escherichia coli, Enterococcus, and Klebsiella. (Table 2) 105 (19%) SSIs were culture-negative and 378 (69%) of the SSIs were polymicrobial. We defined hospital volume as high (>500 procedures in the 5-year period) based on the median hospital volume in the dataset. No significant effect measure modification occurred between hospital volume and either laparoscopic surgery or emergent surgery (Table 3).

Table 1: Characteristics of patients who underwent colon surgery from January 2015 to June 2018 in 34 community hospitals.

Table 2: Count and frequency of pathogens that caused complex surgical site infections after colon surgery

Table 3: Colon surgery complex surgical site infection rates, stratified by emergent, elective, open, and laparoscopic procedures and hospital colon surgery volume

Conclusion

In our cohort, we found that one-fourth of colon surgery SSIs were categorized as PATOS, which are no longer publicly reported to the Centers for Medicare & Medicaid Services. While most SSI literature describes higher volume hospitals having lower SSI rates, high colon surgery volume was associated with increased SSI rates in our community hospital cohort.

Disclosures

All Authors: No reported disclosures
906. Surgical Site Infections in Children with Beta-Lactam Allergy: A Matched Cohort Study
Authors: Huang Felicia Scaggs , Mangeot Colleen , Sucharew Heidi , Simon Katherine , Courter Joshua D , Risma Kimberly , Schaffzin Joshua K
Published: January 2021

Background

Surgical site infections (SSIs) are a significant cause of morbidity and mortality. The administration of appropriate pre-operative antimicrobial prophylaxis (AMP) reduces SSI risk and beta-lactam antibiotics are considered the most effective agents. Studies in adult patients found increased SSI risk in patients with documented beta-lactam allergy (BLA) due to use of second line AMP agents. The SSI risk in BLA pediatric patients is not well-described.

Methods

We conducted a retrospective matched cohort study of patients (1-19 years-old) who underwent a surgical procedure at a quaternary pediatric hospital during 2010-2017. Patients with documented BLA at the time of surgery were matched 1:1 to patients with no BLA by age at surgery, National Surgical Quality Improvement Program (NSQIP) category, surgical calendar year, and presence of complex chronic conditions (CCC). AMP by BLA status was considered appropriate if recommended by the 2013 American Society of Health-System Pharmacists (ASHP) guidelines, antibiotic class appropriate, or recommended by an infectious disease physician. McNemar’s test was used to assess differences in SSI rates and antibiotic regimen appropriate for BLA status between BLA and no BLA groups.

Results

Of the 11878 surgical procedures among 9781 patients during the study period, 1021(9%) of patients had a reported BLA and we matched 972. SSI was rare in both groups and there was no significant difference in rates (18 (1.9%) in no BLA, 17 (1.8%) in BLA, p=1.0). BLA were more likely to receive an antibiotic regimen considered inappropriate for BLA status (22%) compared to no BLA (3%) with 89% receiving a beta-lactam-containing AMP regimen (p< 0.01).

Conclusion

BLA was not associated with increased SSI risk in the pediatric patients studied. Interestingly, a significant proportion of children with a documented allergy received a beta-lactam for AMP. This suggests some providers recognize that allergy labels are inaccurate and may be comfortable administering beta-lactam AMP regardless of allergy status.

Disclosures

All Authors: No reported disclosures
910. A Comprehensive, One Year, Hospital-Wide Snapshot of All Serious Infectious Complications in People Who Inject Drugs
Authors: Henderson John T , Cari Evelyn Villacorta , Leedy Nicole , Thornton Alice , Burgess Donna R , Porterfield J Zachary
Published: January 2021

Background

There has been a dramatic rise in IV drug use (IVDU) and its associated mortality and morbidity, however, the scope of this effect has not been described. Kentucky is at the epicenter of this epidemic and is an ideal place to better understand the health complications of IVDU in order to improve outcomes.

Methods

All adult in-patient admissions to University of Kentucky hospitals in 2018 with an Infectious Diseases (ID) consult and an ICD 9/10 code associated with IVDU underwent thorough retrospective chart review. Demographic, descriptive, and outcome data were collected and analyzed by standard statistical analysis.

Results

390 patients (467 visits) met study criteria. The top illicit substances used were methamphetamine (37.2%), heroin (38.2%), and cocaine (10.3%). While only 4.1% of tested patients were HIV+, 74.2% were HCV antibody positive. Endocarditis (41.1%), vertebral osteomyelitis (20.8%), bacteremia without endocarditis (14.1%), abscess (12.4%), and septic arthritis (10.4%) were the most common infectious complications. The in-patient death rate was 3.0%, and 32.2% of patients were readmitted within the study period. The average length of stay was 26 days.

In multivariable analysis, infectious endocarditis was associated with a statistically significant increase in risk of death, ICU admission, and hospital readmission. Although not statistically significant, trends toward mortality and ICU admission were identified for patients with prior endocarditis and methadone was correlated with decreased risk of readmission and ICU stay.

FIGURE 1: Reported Substances Used

FIGURE 2: Comorbidities

FIGURE 3: Types of Severe Infectious Complications

Conclusion

We report on a novel, comprehensive perspective on the serious infectious complications of IVDU in an attempt to measure its cumulative impact in an unbiased way. This preliminary analysis of a much larger dataset (2008-2019) reveals some sobering statistics about the impact of IVDU in the United States. While it confirms the well accepted mortality and morbidity associated with infective endocarditis and bacteremia, there is a significant unrecognized impact of other infectious etiologies. Additional analysis of this data set will be aimed at identifying key predictive factors in poor outcomes in hopes of mitigating them.

Disclosures

All Authors: No reported disclosures
911. Assessment of Representativeness of IPD Surveillance Conducted by the National Microbiology Laboratory of Canada
Authors: Nepal Rajeev M , Dion Stephane B , Grajales Ana Gabriela , Major Maria , Cane Alejandro , Vojicic Jelena
Published: January 2021

Background

Understanding the evolving epidemiology of Streptococcus pneumoniae serotypes is important for assessing the current and potential future immunization programs. In Canada, Invasive pneumococcal disease (IPD) is mandatory reportable to provincial/territorial public health. Provinces and territories voluntarily submit annual IPD data to the Canadian Notifiable Disease Surveillance System (CNDSS), which publishes information on IPD cases and incidence rates, however serotype data are not available. Provinces/territories also voluntarily submit IPD isolates to the National Microbiology laboratory (NML) for serotyping; provinces that conduct their own serotyping submit this information. The NML produces comprehensive IPD surveillance reports including serotype distribution; due to lack of population denominator, no incidence rates are available. The two surveillance programs are not linked. The objective of the study is to assess the representativeness of the NML surveillance as compared to the CNDSS and provincial reportable diseases databases.

Methods

Over the study time period (2010-2017), we compared annual IPD case counts between the NML and CNDSS reports. Due to the difference in age grouping between CNDSS and NML, comparison was limited to these groups: all age, < 5, 5-14 and > 15 years. In addition, the IPD counts from NML were compared to data from four largest provinces.

Results

For < 5 group, NML reported 91% of CNDSS case count whereas for 5-14 and > 15 years of age, it was 81% and 79%, respectively. Compared to the corresponding provincial databases, NML reported 91%, 97%, and 93% case counts for Ontario, British Columbia, and Alberta, respectively, while it was only 47% for Quebec. Further analysis revealed that the discrepancy in Quebec is the result of under-representation of >5 populations.

Figure 1: Comparison of age stratified IPD case counts between CNDSS and NML

Figure 2. Comparison of all age IPD case counts between NML and provincial databases

Conclusion

IPD surveillance conducted by NML has been instrumental to gain insight into the evolving epidemiology of S. pneumoniae serotypes in Canada. Comparisons of IPD counts from NML surveillance reports with reportable disease databases revealed different levels of concordance across provinces and age groups. The limitations of NML surveillance including incomplete or inconsistent reporting should be taken into consideration when interpreting the data.

Disclosures

Rajeev M. Nepal, PhD, Pfizer (Employee) Stephane B. Dion, PhD, Pfizer (Employee) Ana Gabriela Grajales, MD, Pfizer (Employee) Maria Major, B.Sc., MPH, Pfizer (Employee) Alejandro Cane, MD, Pfizer (Employee) Jelena Vojicic, MD, Pfizer (Employee)
912. Beyond the Usual Suspects in Invasive Mold Infections: Public Health Surveillance Identifies Clinical Diversity
Authors: Beer Karlyn , Kelly Hilary , Blakney Rebekah , Revis Andrew , Perry Lewis , Bentz Meghan , Berkow Elizabeth L , Lockhart Shawn R , matkovic Eduard , Thomas Stepy , Oliver Nora , Webster Andrew , Pouch Stephanie M , Pouch Stephanie M , Farley Monica M , Jackson Brendan R
Published: January 2021

Background

Invasive mold infections (IMI) such as aspergillosis and mucormycosis are often fatal among immunocompromised patients and cause high-profile outbreaks. Public health surveillance for IMI is challenging; most epidemiologic studies are limited to transplant and cancer patients at greatest risk of IMI. The established Mycoses Study Group (MSG) case definition is useful for clinical trials but lacks sensitivity. To address these challenges, we created IMI surveillance within the Georgia Emerging Infections Program. Here, we describe cases identified through this system, using both the MSG criteria and a novel, more sensitive surveillance case definition.

Methods

To identify potential IMI cases, we captured 2,363 positive fungal laboratory results, including cultures, histopathology, and galactomannan tests, within a 60-day window at three large Atlanta hospitals during April 2018–March 2019. We excluded yeast and dimorphic fungi, hair and nail specimens, and cystic fibrosis patients. Potential cases underwent chart review and were classified by 2 physicians as proven, probable, or non-case according to MSG criteria. Cases that partially met MSG probable criteria and included antifungal treatment were classified as surveillance cases; definitions were mutually exclusive (Fig 1).

Results

Of 120 potential IMI cases, 46 (38%) met an IMI case definition: 8 proven, 9 probable, and 29 surveillance cases (Fig 2). Of cases, 14 (30%) involved transplant or cancer in the previous year; 8 of these were proven or probable cases. IMI presented primarily as sinusitis among proven cases (50%), and pulmonary infections among probable (56%) and surveillance (45%) cases. Most surveillance cases were caused by Aspergillus spp. (72%) and accounted for all 5 cutaneous IMI (fig 3). Over 80% of cases vs. 10% of non-cases had antifungal treatment.

Conclusion

Of IMI cases identified, nearly two thirds had evidence of infection but did not meet an MSG case definition. MSG captured over half of transplant and cancer-associated cases, but these were uncommon overall, revealing most IMI lack classical risk factors. A more sensitive surveillance case definition can capture a broader spectrum of IMI patients receiving antifungal treatment to help guide clinical and public health interventions.

Disclosures

All Authors: No reported disclosures
914. Epidemiology of Patients with ESKAPE Pathogen Bloodstream Infection in the US Military Health System
Authors: Vostal Alexander C , Grance Melissa , Chukwuma Uzo , Morales Carlos , Lanteri Charlotte , Telu Kalyani , Parmelee Edward , Powers John H , Mende Katrin
Published: January 2021

Background

Bloodstream infections (BSI) are associated with both inpatient mortality and substantial morbidity in the United States. We sought to characterize the epidemiology of BSIs with ESKAPE pathogens on patients served by the United States Military Healthcare System (MHS), which actively prospectively captures clinical and microbiological data from US service members and their beneficiaries.

Methods

We performed a retrospective analysis of MHS patients with blood cultures positive for ESKAPE pathogens (E. faecium, S. aureus, K. pneumoniae, A. baumannii, P. aeruginosa, and Enterobacter spp.), as well as Neisseria gonorrhoeae and Raoultella spp. between January 2010 and December 2015. Microbiological data from the Navy and Marine Core Public Health Center was retrospectively collated with clinical and demographic data from the MHS Data Repository.

Results

We identified 7,404 patients who experienced 8,791 episodes of ESKAPE (including N. gonorrhoeae and Raoultella spp.) BSI. The patients were predominately active duty (N=688) or retired (N=2,517) Armed Forces service members and their dependents (N=2,361). Further, 59.4% were male and 47.5% were >65 years old. A total of 5,594 (75.5%) of BSI episodes were associated with hospital admission, with an average length of stay of 14.9 days (SD of 27.5 days) and 47.4% (N=2,650) of those admissions were associated with an ICU stay averaging 8.6 days (SD of 18.0 days). The most common pathogens detected were E. coli (34.6%, N= 3,042) followed by S. aureus (28.0%,N=2,464), with 7.6% and 40.7% of isolates resistant to ceftriaxone and methicillin, respectively. We found a larger proportion of E. coli BSI in females (47.4% versus 26.2%) and S. aureus BSI in males (32% versus 21.9%). The frequency of A. baumannii BSI in younger patients, ages 18-30, was an average 4.5 fold higher than in older age groups (30-50, 50-65 and >65).

Conclusion

We noted epidemiological differences in the burden of ESKAPE pathogen BSIs, in various populations including sex and age specific risk factors in a population served by the MHS. Further work is underway to evaluate risk factors for infection and outcomes with pathogens with in vitro resistance controlling for factors such as age, gender, co-morbid diseases and severity of illness.

Disclosures

All Authors: No reported disclosures
919. Understanding Intermittent Detection of Multidrug-Resistant Organisms (MDROs) in Rectally Colonized Patients
Authors: Sansom Sarah , Lin Michael Y , Schoeny Michael , Fukuda Christine , Bassis Christine , Shimasaki Teppei , Dangana Thelma E , Moore Nicholas M , Yelin Rachel , Liu Sophia , Young Vincent B , Rhee Yoona , Tabith Lina , Sheng Jianrong , Cisneros Enrique Cornejo , Murray John , Chang Kyle , Lolans Karen , Ariston Michelle , Rotunno William , Ramos Hazel , Li Haiying , Aboushaala Khaled , Iwai Naomi , Hayden Mary K
Published: January 2021

Background

MDRO detection in colonized patients may be intermittent for reasons that are incompletely understood. We examined temporal patterns of gut MDRO colonization after initial MDRO detection by rectal swab screening, and determined the relationship of culture positivity to the relative abundance of corresponding MDRO operational taxonomic units (OTUs) identified by 16S rRNA gene sequence analysis.

Methods

Rectal or fecal swabs were collected daily from MICU patients 1/11/2017-1/11/2018. First MICU admissions with ≥2 swabs and MICU stays ≥3 days were studied. Samples were cultured for vancomycin-resistant enterococci (VRE), carbapenem-resistant Enterobacteriaceae (CRE) and P. aeruginosa (CRPA), and extended-spectrum β-lactamase-producing (ESBL) Enterobacteriaceae by selective media. Resistance mechanisms were confirmed by phenotypic methods and/or PCR. Limit of detection was similar for different MDROs (24-52 CFU/sample). OTU categories corresponding to MDRO species were identified by taxonomy and BLAST. Multilevel regression models estimated the association between MDRO detection and relative abundance of the corresponding OTU.

Results

796 unique patients with 3519 swabs were studied. Median (IQR) age was 64 (51-74) years, MICU length of stay was 5 (3-8) days, and number of samples-per-patient was 3 (2-5). Following initial MDRO detection, the probability of subsequent detection varied by MDRO type, and was highest for VRE and lowest for CRPA [Figure 1]. Within each sample, we found a significant association between MDRO detection and relative abundance of the corresponding OTU [Table 1]. In contrast, relative OTU abundance in the first sample with MDRO detection was not predictive of odds of future MDRO detection (p >0.05 for all comparisons). Carriage of >1 MDRO did not affect the odds of MDRO detection in later samples.

Figure 1. Probability of Subsequent MDRO Detection after First Positive Varies by MDRO Type

Table 1. Higher Mean Corresponding OTU Relative Abundance Within Each Sample is Associated with MDRO Detection

Conclusion

MDRO culture positivity in rectally colonized patients was correlated with relative abundance of the corresponding OTU in the same sample. Serial detection of different MDRO types was variable, possibly due to distinct microbial community dynamics of different MDRO types. Intermittent failure to detect MDROs could result in misattribution of MDRO acquisition, resulting in inappropriate investigation or intervention.

Disclosures

All Authors: No reported disclosures
922. Increasing incidence of obstructive sleep apnea in patients with HIV: A nationwide database analysis
Authors: Mansoor Armaghan-e-Rehman , Badami Varun M , Sharma Sunil , Sarwari Arif R
Published: January 2021

Background

There is an increasing recognition of the burden of chronic non-communicable diseases in patients living with HIV. Fatigue, somnolence and mood symptoms are often reported in this patient population, leading to concern for undiagnosed OSA. We aimed to use the National Inpatient Sample (NIS) to determine incidence of OSA in patients with HIV, and its impact on inpatient outcomes.

Methods

All index admissions reported to the NIS between 2007 and 2016 were included in the analysis. Logistic regression models were used to determine demographic risk factors, as well as comorbid conditions associated with OSA, and the impact of OSA on inpatient outcomes

Results

There was a significant increase in the number of admissions for HIV patients with a comorbid condition of OSA from 766 in 2007 to 3250 in 2016 (p-value < 0.001), corresponding to an annual increase of 15.5%. In patients with OSA, obesity was less often reported in HIV patients (16.0%) vs non-HIV patients (18.6%). HIV-positive patients with OSA had a significant association with hypertension, heart failure, obesity, diabetes, lipodystrophy, renal failure and disorders of pulmonary circulation. OSA was not a risk factor for inpatient mortality. Peak incidence of OSA was reported earlier in females compared to males.

Conclusion

There has been a significant increase in the reported incidence of OSA in patients with HIV, likely representing an increase in awareness of OSA, as well as a true increase in OSA incidence in the post-combination antiretroviral therapy era.

Disclosures

All Authors: No reported disclosures
66. Impact of a Pharmacist-Driven Azithromycin De-escalation Protocol for Community-Acquired Pneumonia
Authors: Shakeraneh Pegah , Steele Jeffrey , Seabury Robert , Thomas Stephen J , Paolino Kristopher M , Miller Christopher , Probst Luke A , Kufel Wesley D
Published: January 2021

Background

Ceftriaxone and azithromycin are common empiric antibiotics for community-acquired pneumonia (CAP). Despite low suspicion for atypical infection, azithromycin is often continued for a full course. Negative laboratory data for atypical bacteria may assist with azithromycin de-escalation. Thus, a pharmacist-driven azithromycin de-escalation protocol was implemented for immunocompetent, non-intensive care unit (ICU) patients treated for CAP. The primary outcome was to compare azithromycin duration before and after protocol implementation. Secondary outcomes included hospital length of stay (LOS) and all-cause 30-day readmission.

Methods

This was a single-center, quasi-experimental study of hospitalized, non-ICU patients treated with azithromycin and a beta-lactam for CAP. The pre- and post-intervention cohorts were from 07/01/2018–04/30/2019 and 07/01/2019–04/30/2020, respectively. Patients were included if they were ≥18 years old, diagnosed with CAP, and had a negative Legionella pneumophila urinary antigen and negative nasopharyngeal swab PCR for Mycoplasma pneumoniae and Chlamydia pneumoniae. Patients were excluded if they were immunocompromised, admitted to an ICU, prescribed azithromycin for an alternative indication, or had evidence of atypical bacteria.

Results

After exclusion criteria were applied, 90 and 100 patients were included in the pre- and post-intervention cohorts, respectively. Demographic and clinical characteristics were mostly similar between cohorts. This initiative was associated with a statistically significant decrease in azithromycin duration (2 days (IQR 1–2.75) vs. 5 days (IQR 3–6), p < 0.001) and hospital LOS (3 days (IQR 2–5) vs. 5 days (IQR 3–8.25), p < 0.001). No statistically significant difference was observed for all-cause 30-day readmission (14 days (15.6%) vs 13 days (13.0%), p=0.614).

Conclusion

Implementation of a pharmacist-driven azithromycin de-escalation protocol for CAP was associated with reduced azithromycin duration and hospital LOS, but not all-cause 30-day readmission.

Disclosures

Jeffrey Steele, PharMD, Paratek Pharmaceuticals (Advisor or Review Panel member) Wesley D. Kufel, PharmD, Melinta (Research Grant or Support)Merck (Research Grant or Support)Theratechnologies, Inc. (Advisor or Review Panel member)
923. Long-term Mortality after Histoplasma Infection in People Living with HIV
Authors: Cherabie Joseph , Larson Lindsey , Rutjanawech Sasinuch , Franklin Alexander , Hendrix Michael J , O’Halloran Jane A , Presti Rachel M , Powderly William , Spec Andrej
Published: January 2021

Background

Histoplasmosis is a common opportunistic infection afflicting people living with HIV (PLWH) globally. There are no data on long term survival of PLWH with histoplasmosis.

Methods

We conducted a single-center retrospective cohort study of PLWH diagnosed with histoplasmosis between 2002 and 2017. Data collected included demographics, clinical characteristics, treatment, and mortality. Patients were categorized into three groups based on length of survival after diagnosis: early mortality (death within 90 days), late mortality (death at or after 90 days), and survivors. Between group differences in demographic and clinical characteristics were assessed using Chi square for categorical variables and Mann-Whitney U non-parametric tests for continuous variables. Mortality was compared using Cox proportional hazards. Insurance type (i.e. private versus public option) served as a surrogate indicator of socioeconomic status (SES). Patients diagnosed with histoplasmosis in or after 2008 were considered a part of the modern ART era, regardless of treatment regimen.

Results

Our review found 54 PLWH infected with histoplasmosis from 2002-2017. Overall mortality was 37%, with 14.8% early mortality and 22.2% late mortality. Median survival time in the early mortality group was 13.5 days (IQR 2.5-41 days), and 338 days (IQR 180.5-803.3) in the late mortality group. Compared to the late mortality group, survivors were over 6 times more likely to have suppressed HIV viral load at last observation (HR 6.19, p=0.013). Median HIV viral load at last observation was lower among the survivors (2 log copies/ml, IQR 0, 4.5) compared to the late mortality group (4.1 log copies/ml, IQR 2.6,5.5) (p=0.010). Survivors were twice as likely to have private insurance, but this did not reach statistical significance (HR 2.19, p=0.14). There was no statistically significant difference in survival based on the availability of modern ART (p=0.85). The year of diagnosis made no difference with regards to survival (p=0.914).

Baseline Characteristics of PLWH with Histoplasmosis

HIV-related Characteristics of PLWH with Histoplasmosis

Conclusion

Histoplasmosis continues to be associated with high mortality among PLWH. Improved long-term survival is seen in patients with suppressed HIV viral loads.

Disclosures

Andrej Spec, MD, MSCI, Astellas (Grant/Research Support)Mayne (Consultant)Scynexis (Consultant)
925. Adverse Events Due to Inappropriate Prescribing in Older Adults Living with HIV
Authors: Cinquegrani Mark , Cabanilla M Gabriela , Ryan Keenan L , Marzolini Catia , Jakeman Bernadette
Published: January 2021

Background

People living with HIV (PLWH) are aging and experience age-related comorbidities as well as physiological changes leading to a higher risk for polypharmacy, drug-drug interactions, inappropriate prescribing and related adverse events (AE). Prior studies have highlighted a growing concern for inappropriate prescribing in older PLWH. The objective of this study was to examine the prevalence of AEs resulting from inappropriate prescribing in PLWH > 65 years of age.

Methods

This was a retrospective chart review. PLWH followed-up at the outpatient HIV clinic at the University Hospital in New Mexico between 01/01/2015 and 08/21/ 2018 were eligible if they were > 65 years of age and had >1 potentially inappropriate prescriptions (PIP). PIP were identified using the Beers and STOPP/START criteria for inappropriate mediations in elderly, as well as drugs incorrectly dosed, and potentially deleterious drug-drug interactions (DDI). The University of Liverpool’s HIV interaction checker and Lexicomp’s interaction checker were used to screen for DDI between HIV and non-HIV drugs, and between non-HIV drugs. AEs related to PIPs were collected and their severity was classified using the WHO scale for grading of AEs.

Results

A total of 104 PLWH >65 years of age fulfilled the eligibility criteria. Most patients were male (88.5%) with an average age of 69 years. The majority of patients were virologically suppressed (89%), with an average CD4 cell count of 650 cells/µL. Polypharmacy (>5 non-HIV medications) was identified in all 104 patients; average number of non-HIV medications was 9.4 + 4.8. 30 (28.8%) patients experienced >1 AE, with a total of 53 AEs identified. Of those, 20 (67%) presented with a serious AE. 14 patients (47%) had to seek treatment at an emergency department and 2 patients (7%) had to be hospitalized. The most common AEs included falls (27/53 events; 51%), bleeds (7/53 events; 13%), fractures (4/53 events; 8%). Risk for an AE was significantly associated with increasing number of medications (OR 1.16; 95% CI 1.05-1.29).

Conclusion

PIP and related AEs are common in older PLWH. Interventions to prevent harm including medication reconciliation, medication review, and medication prioritization according to the risks/benefits of individual patients are warranted.

Disclosures

Keenan L. Ryan, PharmD, PhC, Theravance (Advisor or Review Panel member)
928. Barriers to Hepatitis C Elimination in an Urban Clinic Offering Integrated HIV/HCV Treatment
Authors: Correia Lauren A , Tseng Christopher C , Portilla Mario , Swaminathan Shobha
Published: January 2021

Background

Treatment of Hepatitis C virus (HCV) infection for persons with Human Immunodeficiency Virus (HIV) is dependent on consistent outpatient follow-up. We sought to identify factors that are associated with lower HCV treatment rates in HIV/HCV co-infected patients followed at Rutgers Infectious Diseases Practice (IDP), an integrated urban clinic.

Methods

Retrospective chart reviews were conducted for HIV/HCV co-infected patients treated at IDP in Newark, New Jersey between January 2017 and July 2018. We assessed factors associated with lack of HCV treatment in this practice. Data collected included demographics, HIV disease markers, liver function tests, HCV treatment history and response. Factors with p< 0.05, age and race were included in the multivariate analysis.

Results

We included 317 HIV/HCV co-infected patients with at least one visit between January 2017 and July 2018. Fifty eight percent were male, 79% black, 10% hispanic, 6% white, and 5% other; 21% reported heterosexual and 79% drug use (injection and non-injection) as their HIV risk factor The median CD4 was 522 cells/cm3, and 74% of patients had HIV viral load (VL) < 40 copies/ml. HCV treatment was started at IDP in 142 (45%) and of those 87% were cured. Data are awaited on 6%. Univariate analyses showed those not treated for HCV were more likely to be born female (57% vs 42%), have a CD4 count < 200 cells/cm3 (9% vs 27%), HIV VL >40 copies/ml (43% vs 17%), currently (58% vs 30%) or previously (89% vs 74%) used drugs, and have a higher APRI score (0.43 vs 1.6). Multivariate logistic regression showed that patients with untreated HCV were more likely to be female (OR 2.93, p< 0.001), report current drug/alcohol use (OR 2.43, p=0.004), and have HIV VL ≥40 copies/ml (OR 2.11, p< 0.001).

Table 1: Demographics/Risk Factors of Study Group

Table 2: Laboratory Studies

Table 3: Logistic Regression of Significant HCV Treatment Factors

Conclusion

Our results show that despite the availability of integrated treatment programs, concerted efforts need to be made for patients at high risk for not receiving HCV treatment, and who therefore remain at high risk for complications from HCV. Provider perceptions may play a role in withholding treatment for those with high HIV VL and current drug or alcohol use; whereas the rationale for why women were less likely to be treated is less clear and may be related to trauma and other factors not captured by this project that may negatively impact their access to care.

Disclosures

All Authors: No reported disclosures
929. Characteristics Associated with Pain in Older People Living with HIV
Authors: Karris Maile , Mazonson Peter , Loo Theoren , Berko Jeff , Spinelli Frank , Zolopa Andrew
Published: January 2021

Background

Pain impacts up to 55% of people living with HIV (PLWH) and negatively impacts function. To date, limited data exist regarding factors that contribute to pain in older PLWH.

Methods

Data were utilized from the Aging with Dignity, Health, Optimism and Community (ADHOC) cohort, an observational study of older PLWH from ten clinics across the U.S. that collects patient-reported outcomes (PROs) on socioeconomic, psychosocial, and health factors. To measure pain, ADHOC participants were asked whether they had been diagnosed with back pain, hip pain, joint pain, or muscle pain, and were also instructed to report chronic pain conditions that were not listed. Bivariate analyses were performed to determine the associations between pain and PROs.

Results

Of 1,051 participants, 66% reported at least one type of pain. Factors associated with pain included multimorbidity, low income, anxiety, loneliness, depression, tobacco use, and older age (Table 1). Factors negatively associated with pain included employment, higher cognitive function, higher quality of life, greater resilience, higher social well-being, and alcohol use.

Table 1. Characteristics associated with pain among older people living with HIV. Pairwise correlations are reported above using correlation coefficient r.

Conclusion

Improving pain management is currently a priority in the US healthcare system. Some factors identified in this study, including systemic issues such as socioeconomic status and employment, are not easily modifiable. Other factors, such as anxiety, depression, and smoking, are modifiable and therefore represent targets for interventions focused on improving pain and its sequelae in older PLWH.

Disclosures

Maile Karris, MD, Gilead Sciences (Grant/Research Support)Viiv Healthcare (Grant/Research Support) Peter Mazonson, MD, MBA, ViiV Healthcare (Grant/Research Support) Theoren Loo, MS, BS, ViiV Healthcare (Grant/Research Support) Jeff Berko, MPH, BS, ViiV Healthcare (Grant/Research Support) Frank Spinelli, MD, ViiV Healthcare (Employee) Andrew Zolopa, MD, ViiV Healthcare (Employee)
932. Creating a Statewide HCV Treatment Cascade for HIV/HCV Co-Infected Persons Using a Partnership with DPH
Authors: Wegener Maximilian D , Brooks Ralph P , Speers Suzanne , Villanueva Merceditas
Published: January 2021

Background

Treatment cascade models focused on persons with HCV mono-infection have been created based on estimates from multiple data sources. Approximately 25% of persons with HIV are coinfected with HCV; no comparable treatment cascade has been reliably generated due to inadequate HCV surveillance data. Using expanded surveillance capacity and validated HIV matching algorithms, we created an HCV treatment cascade for HIV/HCV coinfected persons in Connecticut.

Methods

Surveillance databases used: CTEDSS (CT Electronic Disease Surveillance System used for HCV) and eHARS (electronic HIV/AIDS Reporting System). eHARS data timeline includes all surveillance entries with labs from 1/1/2015-10/1/2019. Two CTEDSS timelines analyzed: One, all surveillance entries (1/1/1994-1/1/2020); Two, all surveillance entries with labs from 1/1/2016-1/1/2020. Matching CTEDSS and eHARS, coinfected lists were generated and patient HCV labs (AB & PCR) were assessed to determine HCV care status on the treatment cascade.

Inclusions and Exclusions for All HCV surveillance entries (1/1/1994 to 1/1/2020)

Inclusions and Exclusions for All HCV Surveillance Entries with Labs from 1/1/2016 to 1/1/2020

Results

All surveillance entries (1/1/1994 to 1/1/2020): The coinfected list had 3,689 entries; 1,938 had positive HCV screenings (AB+ and/or PCR+) and were eligible for further analysis based on lab dispositions: 567 HCV AB+ only; 721 HCV AB+ and PCR+; 149 PCR+ only; 453 AB+ then PCR+ then PCR-; 48 PCR+ then PCR-. Of 1,371 with evidence for chronic HCV, 501 had presumed sustained virologic response (SVR) (36.5%). All surveillance entries with HCV labs from 1/1/2016 to 1/1/2020: The coinfected list had 912 entries; 665 met inclusion criteria for positive HCV screenings with lab dispositions: 17 HCV AB+ only; 197 HCV AB+ and PCR+; 6 PCR+ only; 407 AB+ then PCR+ then PCR-; 38 PCR+ then PCR-. Of the 648 chronically infected, 445 had presumed SVR (68.6%).

Treatment cascade for all surveillance entries (1/1/1994 to 1/1/2020)

Treatment cascade for all surveillance entries with labs from 1/1/2016 to 1/1/2020

Conclusion

It is feasible to create statewide treatment cascades for HIV/HCV coinfected individuals. SVR rates improved from 36.5% to 68.6% with the use a of more recent HCV surveillance timeline. Contributing factors include: 2016 HCV case definition change (increased HCV PCR testing); electronic lab interface with CTEDSS being able to record negative PCRs in 2018; enhanced DAA availability and implementation. Future studies should adopt this approach which more accurately represents the HCV care status of the current co-infected population.

Disclosures

All Authors: No reported disclosures
933. Cured vs. Not Yet Treated: Population Differences for HIV/HCV Co-infected Patients Navigating the HCV Care Cascade in 11 Connecticut Clinics
Authors: Brooks Ralph P , Wegener Maximilian D , Speers Suzanne , Sideleau Robert J , Nichols Lisa G , Villanueva Merceditas
Published: January 2021

Background

Hepatitis C (HCV) care cascades for persons with HIV/HCV co-infection are hampered by incomplete HCV surveillance data, lack of standardized matching algorithms, and incomplete ability to determine HCV treatment status from surveillance alone. However, client-level data from individual clinics can be combined into multi-site cascades to assess progress toward micro-elimination goals. To achieve these goals, characterization of treatment gaps is crucial. Looking at trends in 11 HIV clinics, we examine correlates of not entering/initiating HCV therapy.

Methods

We established a partnership with CT Dept. of Public Health and 11 HIV clinics through a HRSA SPNS grant (047). Lists of HIV/HCV co-infected individuals obtaining care from these clinics from 1/2009-9/2018 were created using data from HIV (eHARS) and HCV (CTEDSS) surveillance, individual clinic rosters and a validated matching algorithm. Clinic personnel reviewed these lists to determine who were treatment eligible (TE) and their current HCV treatment status (e.g. treatment initiated, SVR documented, untreated but in clinical care). Clinic lists were updated regularly to reflect changes in overall patient status (e.g. deceased, relocated, transferred care). We performed bivariate analysis to identify correlates of treatment initiation including odds ratios with 95% confidence intervals.

Results

Of 7265 patients receiving HIV-related services, 2117 matched to HCV surveillance, representing 1496 unique patients. As of 6/1/2020, 821 patients were TE, 727 (89% of TE) were in active care, 630 (77%) initiated treatment, 620 (76%) completed treatment, 584 (71%) achieved SVR. Of the TE group, 77 (9%) had not yet initiated treatment. Compared to initiators of HCV therapy, patients not yet initiating treatment are more likely to be women (OR 1.7 95% CI 1.1-2.8), and black (OR 1.9 95% CI 1.1-3.1), with unsupressed HIV viral loads (OR 2.5, 95% CI 1.5-4.0).

Conclusion

This work capitalizes on the feasibility of creating a care cascade for HIV/HCV by Data to Care methods. Patients in partner clinics who had not yet initiated treatment were more likely to be women, black, and have poorly controlled HIV. Further efforts are needed to determine the barriers to treatment initiation among these groups.

Disclosures

All Authors: No reported disclosures