bluuebunny/crossref_metadata_2025 huggingface dataset:
239. Sex Differences in Prosthetic Joint Infection
Authors: Mironenko Christine M , Kapadia Milan , Donlin Laura , Figgie Mark , Carli Alberto V , Henry Michael , Goodman Susan M , Miller Andy O
Published: December 2021

Background

Male sex has been demonstrated to be a non-modifiable risk factor for prosthetic joint infection (PJI) incidence in multiple studies. Given the known anatomical, genetic, and immunological differences between sexes, we compared the clinical characteristics of PJI among men and women.

Methods

A retrospective cohort of total hip and knee arthroplasty PJIs from 2009 to 2019 were identified using a single institution PJI database. Included cases met the 2013 MSIS criteria. Microbiology, acuity (defined by implant age and symptom days), and surgical outcomes were collected. Success was defined as no further PJI surgery at two years. Continuous variables were tested with either Student’s t test or Mann-Whitney U test. Categorical variables were tested with either Chi-squared test or Fisher’s exact test.

Results

We identified 1052 PJI patients, of whom 463 (44.0%) were women. In univariate analysis of the total cohort, women were younger (68.1 ± 11.2 vs 66.1 ± 11.8 years, p=0.01), had higher BMI (30.8 ± 7.78 vs 29.8 ± 6.0, p=0.04), and had a higher culture-negative rate (14.5% vs 9.0%, p < 0.01) than men, but no difference was noted in Charlson Comorbidity Index (Table 1). Among hip PJIs, women were likelier than men to present with acute PJI (15.9% vs 8.7%, p=0.03). There were no differences in debridement, antibiotics, and implant retention (DAIR) utilization (48.2% vs 44.1%, p=0.067), and overall treatment success (72.1% vs 71.6%, p=0.9), nor in any subanalysis of acute, hip, or knee PJIs.

Conclusion

Although females may present differently when diagnosed with PJI, overall outcomes and outcomes with respect to acuity and type of septic revision did not clearly differ in this single-center cohort. Further research in larger cohorts, including additional biomarkers and socioeconomic variables, may further elucidate relationships between sex and PJI characteristics including culture-negativity and symptom acuity.

Disclosures

All Authors: No reported disclosures
240. Epidural Involvement Complicating Pyogenic Spondylodiscitis
Authors: Hammami Fatma , Koubaa Makram , Chakroun Amal , Rekik Khaoula , Marrakchi Chakib , Smaoui Fatma , Jemaa Mounir Ben
Published: December 2021

Background

Pyogenic spondylodiscitis is an infection of the intervertebral disc(s) and/or adjacent vertebrae. It might be associated with epidural involvement. We aimed to study clinical, laboratory and evolutionary features of epidural involvement complicating pyogenic spondylodiscitis.

Methods

We conducted a retrospective study including patients hospitalized for spondylodiscitis with epidural involvement in the infectious diseases department between 2007 and 2019.

Results

We included 22 patients among whom 16 were males (72.7%). The mean age was 64±11 years. Eleven patients had diabetes mellitus (50%). The onset of the disease was acute in 18 cases (81.8%) and sub-acute in 4 cases (18.2%). The median delay to diagnosis was 4 [2-13] weeks. The revealing symptoms were back pain (95.5%), fever (68.2%) and asthenia (54.5%). Motor deficit was noted in 9 cases (40.9%), sensory deficit in 4 cases (18.2%) and sphincter dysfunction in one case (4.5%). Physical examination revealed spinal tenderness (77.3%), paravertebral tenderness (22.7%) and spinal stiffness (18.2%). Blood cultures were positive in 13 cases (59.1%) represented by Staphylococcus aureus (31.8%). Elevated C-reactive protein levels (81.8%) and accelerated erythrocyte sedimentation rate (63.6%) were noted. Imaging features showed vertebral body osteolysis (81.8%), inflammation of adjacent soft tissue (81.8%), spinal cord compression (40.9%) and psoas abscess (13.6%). Along with medical treatment, immobilisation (72.7%), abscess drainage (13.6%) and surgery (9.1%) were indicated. The disease evolution was favourable in 20 cases (90.9%). Two patients were dead (9.1%). Sequelae were noted in 9 cases (40.9%) represented by back pain (31.8%) and spinal deformity (9.1%).

Conclusion

Spondylodiscitis complicated with epidural involvement might lead to complications and sequelae if not promptly diagnosed and treated.

Disclosures

All Authors: No reported disclosures
241. A Comparison of Staphylococcal and Streptococcal Septic Arthritis with Lyme Arthritis
Authors: Kannangara Don , Pandya Dhyanesh
Published: December 2021

Background

Septic arthritis is considered the most important differential diagnosis in suspected Lyme arthritis. The present study sheds light on the most frequent misdiagnoses in Lyme arthritis cases and clues for differentiation from Staphylococcal and Streptococcal septic arthritis.

Methods

We studied patients with positive joint fluid cultures with Staphylococcus aureus (SA) and streptococci and Lyme polymerase chain reaction (PCR) positive joint fluid in 9 hospitals in Eastern Pennsylvania and 1 in Warren county, New Jersey over a 3 year period.

Results

One hundred and thirty four out of 7000 SA and 21 out of 1321 streptococcal isolates were from joint fluid. Twenty nine had Lyme arthritis, ages 5-74 ( 24 males,5 females). Twelve out of 29 were ages 10-18 with 20/29 under age 40. Predominant joint affected was a single knee 27/29. All had pain with or without swelling and little erythema. Two had fever. One reported a tick bite. None had other manifestations of Lyme disease. The diagnosis at the initial visit was sprain or sports injury in 5, osteoarthritis in 5, inflammatory arthritis or gout in 2 each, i septic arthritis, 1 viral syndrome and 1 ruptured Baker's cyst. Joint fluid count range was 3500-77,360 with only 3 over 50,000. White blood cell count (wbc) range was 3200-14,580. SA arthritis involved knee in 66 (49.3%), hip 31(23.9%), elbow 19 (14.2%), shoulder 14 (10.4%) with 2 wrist, 1 ankle and 1 sterno-clavicular joint. Fifty seven had a history of joint surgery. Eighty six were male and 48 female. age range 14-95 with a median age 65. Synovial fluid cell count was 335-470,000 and wbc 5,200-28,410 . Streptococcal septic arthritis ( 13 male 8 female) involved the knee in 17/21 with one each of hip, elbow, shoulder. The ages were 36-86 with 15/21 over age 60. Synovial fluid count was15,242-641,425 . Wbc count 11,140-25,080 .Nine out 21 had prior joint surgery.

Conclusion

Lyme arthritis patients were younger, mostly involving 1 knee, majority male without other manifestations of Lyme disease. Highest synovial fluid count was 77,360 and highest wbc count 14,580. Most frequent misdiagnoses were sports injury/sprain or osteoarthritis. SA and Streptococcal arthritis were mostly in elderly, with higher joint fluid cell and wbc counts. Only 1/29 Lyme arthritis was initially misdiagnosed septic arthritis.

Disclosures

All Authors: No reported disclosures
242. Rising Incidence of Finegoldia magna among Prosthetic Joint Infections
Authors: Turner Nicholas A , Charalambous Lefko T , Case Ayden , Byers Isabelle S , Seidelman Jessica
Published: December 2021

Background

Finegoldia magna is an anaerobic, Gram-positive coccus infrequently associated with osteoarticular infections. Since the adoption of matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF), F. magna has been increasingly reported as a cause of osteoarticular infections. Our objective was to determine the incidence of F. magna prosthetic joint infections (PJIs) within our institution.

Methods

We conducted a retrospective longitudinal survey from 1 January 2016 - 31 December 2020 at an academic tertiary care referral center. We constructed two Poisson count models to assess the incidence of Finegoldia magna PJIs: one consisting of a clinical microbiology database of synovial fluid and surgical tissue cultures and one using a PJI registry. Time served as the covariate of interest. We used number of cultures as an offset term in the clinical microbiology model, and number of PJI cases as the offset term in the prosthetic joint registry model –reflecting the relevant denominator for each dataset. The microbiology database was limited to synovial fluid aspirates and surgical tissue cultures to minimize risk of confounding by contaminants.

Results

The PJI registry included 44 F. magna infections occurring among 4,706 (0.9%) PJIs. The microbiology survey included 99 F. magna isolates from 43,940 (0.2%) cultures sent from joint aspirates or surgical tissue cultures. Among overall synovial and surgical tissue cultures, we found no significant increase in F. magna over time (incidence rate ratio [IRR] 1.0, 95% CI: 0.9-1.2, Figure 1A). Within the PJI registry, however, we observed a 40% per-year increase in F. magna incidence (IRR 1.4, 95% CI: 1.1-1.8, Figure 1B).

Figure 1

Incidence of Finegoldia magna Over Time

Conclusion

Adoption of MALDI-TOF has expanded the clinical microbiology laboratory’s capacity for rapid speciation, sometimes revealing previously unseen epidemiologic trends. While we saw no significant change in overall incidence of F. magna among synovial and surgical tissue cultures, we did detect a significant increase specifically among PJI cases. F. magna warrants attention as an emerging pathogen among PJI.

Disclosures

All Authors: No reported disclosures
243. Analysis of Risk Factors Associated with Adverse Outcomes Following Calcium Sulfate Bead Use in Periprosthetic Joint Infections
Authors: Pham Christine , Ross Holly E , Vijayan Tara , Bukata Susan , Mekheal Merna , Markovic Daniela , Silakar Sujan
Published: December 2021

Background

Calcium sulfate (CS) beads are increasingly utilized in orthopedic surgeries as a delivery vehicle to administer local antimicrobials intraoperatively. Hypercalcemia, AKI, and elevated serum antimicrobial levels have been reported as potential complications, especially with higher bead volumes. We analyzed the risk factors associated with adverse outcomes among patients with PJIs who received intraoperative CS beads loaded with tobramycin and vancomycin.

Methods

We conducted a retrospective review of adult patients with PJIs who received CS beads from October 2019 to October 2020. Primary outcomes included the incidence of AKI (defined using RIFLE criteria) and hypercalcemia (≥ 11 mg/dL). Logistic regression with forward entry selection of independent variables based on a liberal probability significance of α < 0.25 was used to model the relationships between our variables. Independent variables with clinical relevance that did not meet the conditional selection were also included in the model.

Results

A total of 171 adult patients were included for the analysis. Postoperative AKI occurred in 42 patients (24.6%) who received a mean bead volume of 32 cc. Hypercalcemia occurred in 16 patients (9.4%) who had a mean bead volume of 40 cc. In a univariate analysis, the odds of having AKI and hypercalcemia increased significantly per 10 cc of bead volume with ORs of 1.39 (95%CI, 1.06, 1.82) and 1.65 (95%CI, 1.20, 2.29), respectively. In a multivariate analysis, significant predictors of AKI included: increased bead volume (aOR 1.52; 95%CI, 1.10-2.10), female sex (aOR 2.77; 95%CI, 1.00-7.71), CHF (aOR 3.48; 95%CI, 1.08-11.28), and CAD (aOR 3.90; 95%CI, 1.25-12.18). In the adjusted model, serum tobramycin levels increased (OR 2.67; 95%CI, 1.83-3.90), calcium levels increased with a mean of 0.2 mg/dL (95%CI, 0.12, 0.28), and GFR decreased with a mean of 5.6% (95%CI, 2.8, 8.7) per 10 cc bead volume. In a subset analysis, individuals more likely to experience AKI were patients aged 65 and older (OR 1.9; P=0.039) and had CAD (OR 15.26; P=0.028).

Conclusion

Higher volume of CS beads loaded with vancomycin and tobramycin is associated with adverse outcomes. Older patients with heart disease may be at higher risk for adverse outcomes.

Disclosures

All Authors: No reported disclosures
245. Risk Factors Associated with Open Fracture Complications Following Antibiotic Prophylaxis
Authors: Cusack Elizabeth , Maynard Kaylee , Louie Ted , Gorczyca John , Jones Courtney M , Acquisto Nicole M , Shulder Stephanie
Published: December 2021

Background

Surgical site infection is concerning after an open fracture. The Eastern Association for the Surgery of Trauma guidelines provide antibiotic selection and duration recommendations based on open fracture type. Risk factors for open fracture complications (e.g. infection, acute kidney injury [AKI], multi-drug resistant organisms [MDRO], or Clostridioides infection [C. difficile]) and overall guideline adherence are unclear at our institution.

Methods

This was a single center, retrospective study of adult patients with an open fracture who received antibiotic prophylaxis and were admitted for at least 24 hours between March 2011 and October 2020. Patients were excluded if open fracture was due to gun-shot wound, had a history of renal replacement therapy, MDRO, or C. difficile infection, were an outside hospital transfer, received antibiotics for another indication, or had a delayed presentation. The primary outcome was to identify risk factors for infection and secondary outcomes to identify risk factors for AKI, MDRO, C. difficile infection, and to evaluate guideline adherence. Patient demographics including injury details and management, microbiologic cultures, and antibiotic information were collected. Data were analyzed by univariate analysis, as appropriate, and logistic regression.

Results

A total of 401 patients met study criteria; median age 46 years, 62% male, and 77% white. Fracture classifications were similar: 30% type I, 39% type II, and 30% type III. Infection occurred in 18% of patients, AKI in 18%, MDRO in 3%, and no patients developed C. difficile. Of those with culture-positive infection, 51% grew gram-positive organisms. In bivariate analysis, fracture classification (p=0.023), medical fracture management (p=0.034), and antibiotic choice (p=0.004) were associated with infection. The only independent risk factor associated with AKI was receiving a nephrotoxic medication (p=0.012). Eighty-one percent received guideline adherent antibiotics and of those that received too narrow antibiotics, 36% developed an infection (p=0.004).

Conclusion

Appropriate fracture classification and antibiotic choice is crucial to reduce infection following open fracture. Reducing concomitant exposure to nephrotoxic agents may reduce the risk of AKI.

Disclosures

All Authors: No reported disclosures
247. The Predictive Value of Methicillin-Resistant Staphylococcus aureus Surveillance Swabs in Septic Arthritis
Authors: Harder Samuel , Asiamah Kwame , Shumilak Geoffrey , Wudel Beverly J
Published: December 2021

Background

Septic arthritis is a destructive form of acute arthritis secondary to infection. With an annual incidence of 2 to 5 cases per 100 000 individuals, it is associated with significant morbidity and mortality. Prompt source control and antimicrobial therapy remain the mainstays of management. Epidemiology, microbiology studies, and local resistance patterns are important in guiding therapeutic decisions. Staphylococcal and streptococcal species are the most common pathogens with Methicillin-resistant Staphylococcus aureus (MRSA) becoming an increasingly important pathogen. The increasing incidence of MRSA provides clinicians with the challenge of deciding which patients require empiric coverage for MRSA. MRSA nasal screening has been shown to have a high negative predictive value in pneumonia, bloodstream infections, and nosocomial infections in critically ill patients. However, little is known about the diagnostic utility of MRSA surveillance swabs for predicting MRSA infections in septic arthritis.

Methods

A retrospective cohort study was performed in 3 tertiary hospitals from September 1, 2010 to December 31, 2020. All adult patients with confirmed septic arthritis of the ankle, wrist, knee, or hip and an MRSA surveillance swab performed within 72 hours of admission were included in the study. These data were used to calculate the sensitivity, specificity, positive predictive value and negative predictive value for MRSA surveillance swabs.

Results

One hundred seventy-two patients met inclusion criteria. Thirty patients had positive MRSA surveillance swabs. The prevalence of MRSA in joint cultures was 11.04%. The positive predictive value of MRSA surveillance swabs was 42.3% and the negative predictive value was 93.5% in all participants. The MRSA surveillance swab had a negative predictive value of 100% in participants with no risk factors for MRSA colonization.

Conclusion

The negative predictive value of MRSA surveillance swabs used independently is insufficient to confidently rule out MRSA as the causative pathogen in septic arthritis. When used in combination with MRSA risk factors, the absence of MRSA risk factors may help clinicians rule out MRSA as a causative pathogen.

Disclosures

All Authors: No reported disclosures
250. An Assessment of the Penicillin Allergy Label in Patients Undergoing Orthopedic Procedures at a VA Medical Center
Authors: Meledathu Sherin , Firek MacKenzie , Liappis Angelike P , Patel Pratish C
Published: December 2021

Background

Approximately 10% of the population is labeled as penicillin (PCN) allergic, while only 1% of these individuals have a true IgE mediated allergy. This label influences the prescription of the most appropriate antibiotic and ultimately leads to antimicrobial resistance, hospital readmission, increased length of hospital stays, use of critical care beds, and greater healthcare costs. Post-surgical complications in patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA) are also increased when patients receive an alternative antibiotic due to PCN allergy.

Methods

A retrospective chart review identified patients who underwent a TKA or THA during the 2018-2020 calendar years at the Washington DC VA Medical Center. Multiple operations at different times on the same patient were regarded as separate events. The primary outcome was patients who were evaluable for penicillin allergy de-labeling and the secondary outcome was perioperative antibiotic choice.

Results

Patients in both groups were predominantly male, Black, and over the age of 60. Of a total of 317 procedures performed, we identified 28 procedures in which patients carried a PCN allergy label (PAL) and received a β-lactam alternative antibiotic for surgical prophylaxis. No patients in the PAL group received cefazolin for prophylaxis, compared to 87% of the non-PAL group who were appropriately given cefazolin. In the group carrying the PAL, 62% of patients received vancomycin and 29% of patients received clindamycin for pre-operative prophylaxis. Only one of these patients had a formal allergy consult note, but the PCN allergy was not addressed during that visit. Fewer patients (4%) required ICU admission during their hospitalization in the non-PAL group versus 10% of patients in the PAL group.

Table 1. Patient Demographics and Procedure Detail

Conclusion

The use of alternative antibiotics in pre-procedural prophylaxis can contribute to adverse events associated with high-risk broader spectrum antimicrobials as well as increased costs associated with antimicrobials such as vancomycin. Our facility began implementation of a penicillin de-labeling program in 2018 via skin testing and direct oral challenge in collaboration with colleagues from Allergy and Immunology. Removal of PAL in this population can increase rates of appropriate prophylaxis.

Disclosures

All Authors: No reported disclosures
253. Clinical and Therapeutic Particularities of Brucellar Sacroiliitis
Authors: Hammami Fatma , Koubaa Makram , Chakroun Amal , Rekik Khaoula , Marrakchi Chakib , Smaoui Fatma , Jemaa Mounir Ben
Published: December 2021

Background

The misleading clinical presentation of brucellar sacroiliitis, which is usually confused with involvement of the lumbosacral hinge or the hip, is responsible for diagnostic and therapeutic delay. We aimed to study the epidemiological, clinical and therapeutic features of brucellar sacroiliitis.

Methods

We conducted a retrospective study including all patients hospitalized in the infectious disease department for brucellar sacroiliitis between 1992 and 2020. The diagnosis of brucellosis was based on positive wright agglutination test and/or positive blood cultures.

Results

We included 12 patients, among whom 8 were males. The mean age was 35±13 years. Ten patients consumed unpasteurized milk and 9 had a close contact with animals. Three patients were previously treated for brucellosis and 4 patients had a family history of brucellosis. The revealing symptoms were sacroiliac joint pain (7 cases) and low back pain (5 cases), associated with fever and night sweats (9 cases). There were 8 cases localized on the left side of the joint. Spondylodiscitis was associated with sacroiliitis in 3 cases and genitourinary brucellosis in one case. An accelerated erythrocyte sedimentation rate and elevated C-reactive protein levels were noted in 7 cases, anemia in 7 cases and leukopenia in 4 cases. X-ray examination of sacroiliac joints revealed thickening of the sacroiliac joint (3 cases). Bone scintigraphy, which was performed in 8 cases, showed hyperfixation of the sacroiliac joint. Sacroiliac computed tomography and magnetic resonance imaging, performed in 6 cases and 4 cases, respectively, showed signs of sacroiliitis in all cases and soft tissue abscess in 2 cases. Blood cultures were positive to Brucella in 2 cases. All patients received doxycycline and rifampicin, associated with trimethoprim/sulfamethoxazole in 2 cases. The median duration of treatment was 4.5 months [3-9 months]. The disease evolution was favorable in 10 cases. Sequelae represented by sacroiliac joint pain was noted in 4 cases. There were 2 relapsing cases.

Conclusion

The diagnosis of brucellar sacroiliitis is based mainly on the imaging results and serological testing. Respecting preventive measures is a priority in order to eradicate brucellosis.

Disclosures

All Authors: No reported disclosures
254. Excellent Outcomes with Oral Versus Intravenous Antibiotics for Bone and Joint Infections: A Single-Center Experience
Authors: Lang Amanda , Hilbers Jacey L , Halouska Mason , Van Roy Zachary A , Hewlett Angela , Hewlett Angela , Cortes-Penfield Nicolas W , Cortes-Penfield Nicolas W
Published: December 2021

Background

The OVIVA trial, published in 2019, demonstrated equivalent efficacy of oral (PO) versus intravenous (IV) antibiotics for bone and joint infections. We report our group’s one-year outcomes in a cohort of such patients who received PO or IV antibiotics.

Methods

Our orthopedic surgery and orthopedic infectious diseases (ID) groups agreed to employ early switch to PO in patients with a first episode of non-vertebral osteomyelitis (OM), native or prosthetic joint infection (NJA or PJI), or hardware infections when a pathogen susceptible to highly bioavailable antibiotics had been identified and the patient was perceived to be at low risk for medication non-adherence. We reviewed patients 19+ years old seen in the Ortho ID clinic for one of these conditions from July 1st through December 31st, 2019. Data recorded included patient demographics and comorbidities, infection type and site, microbiology, and surgical and antibiotic management. Primary outcome was treatment failure at 1 year, defined as death, unplanned surgery at same site, or chronic antibiotic suppression.

Results

Forty patients (all IV antibiotics, n=17; initial or switch to PO, n=23) were included. Median IV duration was 15 days. PJI was the most common diagnosis (n=22), followed by other hardware infection and OM (n=7 each). Of the PJIs, 13/22 were managed with 2-stage exchange and 11/13 of these received all-IV therapy. Of the hardware infections, 4/7 underwent debridement and retention or single-stage exchange and all of these received initial or switch to PO therapy. Staphylococci (n=14 S. aureus and n=7 coagulase-negative) and streptococci (n=12) were the most common pathogens. Amoxicillin (n=8), trimethoprim-sulfa (n=6), and levofloxacin (n=3) were the most-used PO antibiotics. The PO group received longer treatment (mean 67 vs 48 days). No treatment failures occurred in the patients who started or switch to PO antibiotics, whereas 35% of patients who received all-IV therapy experienced failure.

Conclusion

Adopting known risk factors for poor outcome in bone and joint infection such as prior treatment failure and no identified pathogen as exclusion criteria for early switch to PO antibiotic therapy led to excellent one-year treatment outcomes across a range of musculoskeletal infections.

Disclosures

Angela Hewlett, MD, MS, Mapp Biopharmaceutical (Scientific Research Study Investigator) Angela Hewlett, MD, MS, Mapp Biopharmaceutical, Inc (Individual(s) Involved: Self): Scientific Research Study Investigator Nicolas W. Cortes-Penfield, MD, Nothing to disclose
255. Utility of Magnetic Resonance Imaging in Predicting Failure of DAIR (Debridement, Antibiotics, and Implant Retention) for Treatment of Periprosthetic Joint Infection
Authors: Kapadia Milan , Burge Alissa , Bogner Eric , Sculco Peter , Carli Alberto V
Published: December 2021

Background

Debridement, antibiotics, and implant retention (DAIR) is commonly utilized to treat acute periprosthetic joint infection (PJI) where thorough debridement of affected tissues is considered essential. Small case series describe occurrences where PJI spreads into adjacent tissues (iliopsoas recess in hips; neurovascular bundle in knees) and bone (osteomyelitis). Surgeons often cite adjacent tissue/bone infiltration as a poor predictor for DAIR. We sought to evaluate if the presence of adjacent tissue/bony lesions on preoperative magnetic resonance imaging (MRI) was associated with poorer DAIR outcomes.

Methods

MSIS criteria-positive hip (n=22) and knee (n=12) PJI cases in our institution from 2010-2020, with preoperative MRI prior to DAIR treatment, were evaluated. Demographics, microbiology, chronicity, and host grade were recorded. MRIs were assessed by two board-certified radiologists blinded to treatment outcomes, scoring images based on the presence of 18 distinct findings. Inter-rater reliability was calculated using bias adjusted Kappa scores. Failure was defined as repeat surgery for PJI. Univariate analysis and logistic regression were used to determine predictors of DAIR success at 90 days and 2 years.

Results

When comparing successful and non-successful hip PJI cases, the presence of a psoas recess fluid collection on MRI was significantly predictive of a higher rate of treatment failure at 2 years (odds ratio=0.12; p = 0.045), with a moderate adjusted kappa score of 0.5. With regard to knee PJI cases, capsular disruption (40% [2/5] vs 100% [7/7], p= 0.046) and patellar tendon disruption (25% [1/4] vs 100% [8/8], p = 0.018) were independently associated with higher 90-day failure. However, knee MRI findings were not predictive of failure using regression.

Conclusion

In this preliminary study, preoperative MRI findings anecdotally linked with PJI treatment failure could be reliably identified. However, few predicted DAIR failure. Further studies are needed to clarify the role of MRI in predicting PJI treatment success.

Disclosures

All Authors: No reported disclosures
258. D-Dimer, Erythrocyte Sedimentation Rate, and C-Reactive Protein Sensitivity for PJI Diagnosis
Authors: Case Ayden , Charalambous Lefko T , Bowman Trevor , Duensing Ian , Hendershot Edward , Seidelman Jessica , Seyler Thorsten , Jiranek William
Published: December 2021

Background

Consensus criteria for the diagnosis of acute PJI now include D-dimer. Additionally, Erythrocyte Sedimentation Rate (ESR) is of questionable use in the diagnosis of acute PJI. There is scarce and contradicting evidence on the diagnostic value for these biomarkers, and further studies on larger cohorts are needed for validation. We sought to quantify the sensitivities of D-dimer and ESR compared to C-Reactive Protein (CRP) in the diagnosis of acute PJI at a tertiary referral center.

Sensitivity Table for D-Dimer and ESR

Methods

An institutional database was queried for patients undergoing revision procedures for PJI after total hip arthroplasty (THA) and total knee arthroplasty (TKA) from 2014 to present. Patients were included if they had a PJI diagnosis code with subsequent revision procedure CPT codes and PICC line placement within 21 days of revision surgery. Patients with inflammatory arthropathies were excluded. Diagnostic labs, including CRP, ESR, and D-dimer, were collected within 90 days pre- and post-operatively and sensitivities for the diagnosis of PJI were calculated. Cutoff values included CRP >1 mg/dL, ESR >30 mm/hr and >50 mm/hr, and D-dimer >860 ng/mL.

Results

In total, 961 PJI patients were identified. Of those, 904 had ESR and CRP values collected, and 123 had ESR, CRP, and D-dimer collected. In the cohort of patients with ESR and CRP, 603 patients had elevated CRP, 554 had ESR >30 mm/hr, and 379 had ESR >50 mm/hr, corresponding to sensitivities of 66.7%, 61.3%, and 41.9%, respectively. In the cohort of patients with all three biomarkers, 113 had an elevated D-dimer, corresponding to a sensitivity of 91.9%.

Conclusion

In this cohort, CRP and ESR were of comparable sensitivity in diagnosing PJI. D-dimer was the most sensitive, but further pooled studies are needed to confirm this. Providers should continue to use this information in the context of other data and MSIS criteria to inform decision-making.

Disclosures

Thorsten Seyler, MD/PhD, Depuy Synthes (Other Financial or Material Support, Resident Educational Support)Extrel Therapeutics (Board Member, Shareholder)Heraeus Medical (Consultant)MiCare Path (Board Member, Shareholder)OREF (Grant/Research Support)Pattern health (Board Member)Restor3D (Other Financial or Material Support, Royalties)Smith+Nephew, Inc. (Grant/Research Support, Speaker’s Bureau)Stryker (Other Financial or Material Support, Resident Educational Support)Total Joint Orthopedics, Inc. (Consultant)Wolters Kluwer Health (Other Financial or Material Support, Royalties)Zimmer Biomet (Grant/Research Support) William Jiranek, MD, Depuy Synthes (Other Financial or Material Support, Royalty/Licensing)
260. The Unfortunate Consequence of Immunosuppression in a Renal Transplant Patient
Authors: Mikell Franklin , Ghimire Rabindra
Published: December 2021

Background

Nocardia is a slow-growing aerobic-actinomycete that belongs to the family Nocardiaceae. Major predisposing factors include corticosteroid use, organ transplantation, low CD4 count, and hematologic malignancies. The most commonly affected organs are lungs, mainly via inhalation; however, the most common extrapulmonary site is central nervous system.

Methods

Matrix Assisted Laser Desorption Ionization - Time of Flight (MALDI-ToF) or 16srRNA sequencing are more reliable methodologies for accurate identification of Nocardia to the species level. To our knowledge, our patient represented the first U.S. case of N. bejingensis opportunistic disseminated infection in a renal transplant patient although similar cases have been previously reported outside the U.S.

GMS stain

Gram Stain of Nocardia

Results

We present a 31-year-old Caucasian male status post renal transplant four years ago on immunosuppressants with left arm myoclonic jerks. In addition, there was an associated unilateral left frontal headache of four to five day duration. His chest CT revealed consolidative process in the right lower lobe and pleural effusion. MRI of the brain revealed multiple ring-enhancing lesions. Patient underwent left frontal craniotomy with resection and a complete evacuation of brain abscess. His brain abscess and pleural fluid cultures revealed Gram positive rods, which were subsequently identified as Nocardia beijingensis by MALDI-TOF and confirmed by 16srRNA sequencing. He was treated with intravenous imipenem & trimethoprim – sulfamethoxazole with subsequent clinical improvement.

MRI Brain w/ contrast

Head CT s/p left frontal craniotomy with resection & evacuation of abscess

Chest CT

Conclusion

Different Nocardia species have a wide geographic distribution with varying pathogenic traits, and antimicrobial susceptibility. Hence, the identification of the specific species of Nocardia is crucial to provide a proficient level of patient care. Nocardia bejingensis is a newly discovered species of Nocardia that was first isolated in 2001 in China. Only six cases of N. beijingensis affecting CNS have been reported up to date in the United States. It is unclear of the geographic distribution and variable antimicrobial susceptibility of Nocardia bejingensis but we can confirm the first reported case of an opportunistic disseminated infection in a renal transplant patient in the United States.

Agar

Disclosures

All Authors: No reported disclosures
261. A Rare Case of Meningitis and Symptomatic Hydrocephalus by Listeria Monocytogenes in Dermatomyositis: A Case Report
Authors: Kiral Eylem , kacmaz Ebru , Bozan Gurkan , Arslanoglu Ozgur , Kilic Omer , Dinleyici Ener Cagri
Published: December 2021

Background

Listeria monocytogenes is a gram-positive, facultative anaerobic bacillus common in the intestinal flora of many animals and humans. We describe an unusual case of meningitis by Listeria monocytogenes (LM) complicated by hydrocephalus in a child with dermatomyositis.

Methods

A 15-year-old girl presented to an outside hospital (OH) after a three-day history of headache, fever and was hospitalized with a diagnosis of meningitis and lumbar puncture performed. CSF sample could not be evaluated clearly due to its hemorrhagic nature. Her past medical history was significant for dermatomyositis for five years. She had received induction of IVIG five days prior. She was also taking cyclosporin A and hydroxychloroquine. She was empirically treated with intravenous cefotaxime, vancomycin, and acyclovir. She was urgently transferred to the theatre for an external shunt placement in the right lateral ventricle. The interval between the first symptoms and the diagnosis of hydrocephalus was around 4 days. CSF from this catheter showed growth of LM with sensitivity to meropenem and resistance to erythromycin, ampicillin, and sulfamethoxazole-trimethoprim. Gram staining of CSF resulted negative for bacteria. Cefotaxime was switched to intravenous meropenem. Immunological screening of cellular and humoral immunity, complement, and blood iron levels were normal. SARS-Cov2 PCR and HIV tests were negative. Herpes virus, mycobacterium tuberculosis real-time PCR, respiratory viral panel studied in the CSF sample were negative. MRI and Angio of the brain showed no abnormality. She is being followed in the pediatric intensive care unit as intubated.

Results

In patients who received immunosuppressive medication, L. monocytogenes should be evaluated in the differential diagnosis of central nervous system infections. Even if effective antibiotic therapy has been initiated, this case highlights the need of recognizing early hydrocephalus as a consequence of Listeria meningitis in children with neurological deterioration a few days after initial presentation.

Conclusion

The literature on the management and outcome of Listeria meningitis-related hydrocephalus in children is limited.

Disclosures

All Authors: No reported disclosures
262. Epidemiology, Treatment, and Clinical Outcomes of Methicillin-Sensitive Staphylococcus aureus (MSSA) Bacteremia Complicated by Central Nervous System (CNS) Disease within the Veterans Affairs (VA) Healthcare System
Authors: Provaznik Jill , Sutton Jesse , Spivak Emily
Published: December 2021

Background

The epidemiology of methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia (BSI) complicated by central nervous system (CNS) involvement is not well defined or described. We aimed to identify patients with MSSA BSI with CNS disease using imaging reports and define the epidemiology, characteristics, management, and associated clinical outcomes.

Methods

We conducted a retrospective study of inpatients (1/1/2014 to 10/31/2019) with MSSA BSI and head imaging (± 7 days of BSI). Imaging reports were categorized into probable, possible, or no CNS involvement. Charts were reviewed to assess source and metastatic sites of infection, severity of illness, and clinical course. Demographics, comorbidities, antibiotic use, and morbidity and mortality were electronically extracted from the corporate data warehouse. Primary antibiotic treatment was defined as the antibiotic received for the highest proportion of treatment course.

Results

1852 patients had MSSA BSI and a head imagining performed. 151 (8%) had probable and 56 (3%) had possible CNS involvement. Embolic disease (n=167 [87%]) was the most common type of CNS disease (136 [83%] with probable CNS disease). Overall, high severity of illness defined by ICU admission (52%), vasopressor (7%), or mechanical ventilation (15%) was observed overall and was more common with probable CNS disease. Cefazolin was the most common primary antibiotic (71 [40%]), followed by nafcillin or oxacillin (51 [29%]). 16 (31%) patients had an adverse reaction to nafcillin. 69 (33%) patients died by day 30 and 88 (43%) by day 90. Recurrent CNS infections and bacteremia by day 90 was observed in 11 (6%) and 6 (3%).

Conclusion

We propose a definition of MSSA bacteremia complicated by CNS disease. CNS disease with MSSA bacteremia is infrequent with the most common manifestation being embolic disease. A significant number of patients with MSSA bacteremia were treated with cefazolin despite evidence of CNS disease. Overall mortality was high. Given higher rates of adverse drug events with nafcillin or oxacillin, comparative effectiveness studies are needed to further define the role of cefazolin for MSSA bacteremia with CNS disease.

Disclosures

All Authors: No reported disclosures
263. Antibody Spill-Over vs. True Coccidioidal Meningitis in a Patient with HIV/AIDS and Disseminated Coccidioidomycosis
Authors: Newby Renee E , Sam Danny L , Cooper Joseph
Published: December 2021

Background

The diagnosis of coccidioidal meningitis merits life-long antifungal therapy given high rates of disease recurrence. Accurate diagnosis is important. Antibody spill-over into cerebrospinal fluid (CSF) can happen when serum titers are high. We present a case of antibody spill-over vs. true fluconazole-resistant coccidioidal meningitis.

Methods

A 49-year-old man presented with 6 months of intermittent fever, myalgias, decreased appetite, vomiting, diarrhea, unsteadiness and 60-pound weight loss. He was recently diagnosed with HIV and a prior lymph node biopsy had grown Coccidioides immitis (C. i) for which he was given fluconazole 100 mg twice daily.

Figure 1. Timeline of Coccidioides immitis lab results in relation to treatment regimen. CF: Complement fixation, EIA: Enzyme immunoassay for Coccidioides antigen, CSF: Cerebrospinal fluid, c/mL: copies/mL, R: resistant, S: susceptible.

Results

Vitals revealed a temperature of 102°F. He was cachectic and a 0.5 cm right supraclavicular lymph node was palpable. No meningeal signs were appreciated. CD4 count was 50/µL (18%), HIV-1 viral load 2,969,945 copies/mL. Computed tomography (CT) of the abdomen/pelvis suggested lung and spleen involvement. Serum C. i enzyme immunoassay (EIA) was 1.38 ng/mL, immunodiffusion (ID) was positive and complement fixation (CF) titer was 1:256. C. i was isolated from expectorated sputum. CSF cell count was normal, but ID was positive and CF titer was 1:2 however, lab reported concern for spill-over due to high serum IgG titers. He left against medical advice with fluconazole 400 mg daily. He was hospitalized a month later for failure to thrive. MRI head revealed enlarged lateral and third ventricles with increased periventricular hyperintensity concerning for coccidioidal meningitis. Repeat serum studies were stable. CSF revealed CF 1:4 and C. i antigen by EIA 1.31ng/mL, distinguishing between spill-over and meningitis. Susceptibility results showed resistance to fluconazole and amphotericin B with minimum inhibitory concentrations (MICs) of 50 and 4 respectively, posaconazole susceptibility (MIC < 1) and itraconazole borderline (MIC 3.7). Despite amphotericin B resistance, it was used for bridge to posaconazole. ART was initiated after concern for immune reconstitution had resolved.

Conclusion

This case highlights the difficulty in making an accurate diagnosis of coccidioidal meningitis. It also describes a fluconazole-resistant C. i isolate in the setting of prolonged low-dose fluconazole therapy.

Disclosures

All Authors: No reported disclosures
264. A 20-year Study of Intracranial Pyogenic Complications of Sinusitis in Children
Authors: Tat Jennifer , Smiljkovic Mina , Richardson Susan E , Campigotto Aaron , Cushing Sharon , Wolter Nikolaus E , Dirks Peter , Bitnun Ari
Published: December 2021

Background

Intracranial pyogenic complications of sinusitis in children are relatively uncommon but can lead to serious sequelae. The objective of this study was to characterize the clinical, epidemiologic and microbiologic characteristics of children with such complications over a 20-year period (2000- 2019).

Methods

Single-center retrospective chart review. Cases were identified based on International Classification of Diseases (ICD)-10 diagnostic codes (intracranial abscess or granuloma, extradural and subdural abscess, Pott’s puffy tumor, acute or chronic sinusitis) and by reviewing all microbiological samples of intracranial pus, tissue or fluid.

Results

108 cases of clinically and/or radiologically diagnosed sinusitis were included after review of 1591 charts. The majority were adolescents (median age 12, IQR 9-14); 72 were male (67%). The most common presenting symptoms were fever (84%), headache (87%) and symptoms of upper respiratory tract infection (57%). Median symptom duration was 10 days (IQR 5-21) and 55 cases (51%) received oral antibiotics prior to admission. The most frequent complications were epidural empyema (n=50, 46%), subdural empyema (n=46, 43%) and Pott’s puffy tumor (n= 31, 29%). 50% (n=54) underwent neurosurgery, of which 20% (n=11) required multiple craniectomies. 38% (n=41) underwent otolaryngological surgery. Microbiological data from sterile specimens demonstrated single organisms in 36 cases (59%) and polymicrobial growth in 25 cases (41%). The most frequently identified pathogens were Streptococcus anginosus (n=40, 66%) followed by Fusobacterium species (n=10, 16%) and Prevotella species (n=10,16%). Most cases were treated with combination antibiotic therapy (n=68, 63%) and 14% (n=15) with a carbapenem. The median duration of intravenous antibiotic therapy was 51 days (IQR 42-80). One child died and 23% (n=25) suffered neurological sequelae (median follow-up 344 days). 48 cases (44%) occurred between 2014-2019.

Conclusion

Intracranial complications of sinusitis continue to cause significant morbidity in children. The predominant causative pathogen was Streptococcus anginosus. Polymicrobial infections are common, confirming the need for prolonged broad-spectrum antibiotic treatment.

Disclosures

Sharon Cushing, MD, MSc, FRCSC, Cochlear Corporation (Research Grant or Support)Cochlear Corporation (Speaker’s Bureau)Interacoustics (Speaker’s Bureau)Plural publishing (Other Financial or Material Support, Royalties: editor: manual of pediatric balance disorders)
266. A Rare Case of Human Herpesvirus-6 (HHV-6) Encephalitis in an Immunocompetent Host
Authors: Ayyash Ali M , Kurtom Muhannad , Ervin Charlie , Irwin Mark , Sampath Rahul
Published: December 2021

Background

Human Herpesvirus-6 (HHV-6) seroprevalence rates in the United States range from 72-95%, but clinical illness in the adult population is extremely rare, which often presents as meningoencephalitis in immunocompromised hosts. The literature on HHV-6 encephalitis in immunocompetent adults is limited to a select number of case reports, ultimately providing scant treatment guidance for clinicians.

Methods

This is a unique case describing the clinical course of confirmed HHV-6 encephalitis in an immunocompetent host.

Results

The patient is a 77-year-old immunocompetent female presenting with two days of global aphasia and increased muscle tone. She presented hypertensive with a leukocytosis. Work-up for acute stroke was unremarkable, but lumbar puncture revealed an elevated white blood cell (WBC) count of 39 leukocytes/mm3 with a lymphocytic predominance. BioFire FilmArray® Meningitis/Encephalitis panel (FAME) demonstrated positivity for HHV-6 with a viral load of 8,500 copies/mL in the cerebrospinal fluid (CSF) and 4.1 million copies/mL in serum. The patient experienced temporary improvement in her aphasia after being initiated on intravenous (IV) ganciclovir for 12 days. Shortly after the initiation of therapy, her aphasia worsened with repeat CSF studies demonstrating an increased viral load to 35,700 copies/mL. She was subsequently transitioned to IV foscarnet for HHV-6B coverage and discharged after completing 21 days of therapy with marked improvement in her symptoms. Two weeks later, the patient was readmitted for recurrence of aphasia. MRI brain at that time was unremarkable with repeat lumbar puncture demonstrating a WBC count of 8 with 113 copies/mL of HHV-6. Serum levels were also elevated to 4.7 million c/mL. The patient was restarted on foscarnet but continued to deteriorate clinically. She ultimately experienced multiple seizure-like episodes resulting in a noncommunicative, somnolent state. She was transitioned to hospice care and passed away 2 days after discharge.

Conclusion

Despite the use of recommended medical therapies, the mortality and clinical progression of HHV-6 in immunocompetent adults is still unpredictable. Further studies are needed in this population to provide guidance for clinicians.

Disclosures

All Authors: No reported disclosures
270. New Onset Seizure Presented as Neurosyphilis
Authors: Phyo Shwe S , Zin Cho T , Thet Zeyar
Published: December 2021

Background

The term “neurosyphilis” refers to infection of the central nervous system (CNS) by Treponema pallidum. It can occur at any time after initial infection. Early in the course of syphilis, the most common forms of neurosyphilis involve the cerebrospinal fluid (CSF), meninges, and vasculature (asymptomatic meningitis, symptomatic meningitis, and meningovascular disease). Late in disease, the most common forms involve the brain and spinal cord parenchyma (general paralysis of the insane and tabes dorsalis).

Methods

A 31-year-old man who suddenly developed a new onset generalized tonic clonic seizure, was admitted to the emergency department. He had no history of epilepsy and denied any vision or gait problems. The brain MRI showed no abnormalities. He had a history of rapid plasma reagent (RPR) titer 1:32 and a positive fluorescent treponemal antibody absorption (FTA-ABS) test in 2017. However, the RPR result was non-reactive when he retested a week later and therefore was not diagnosed with syphilis and did not get treated at that time. His most recent RPR titer was 1:16. HIV serology and other STD tests were all negative. His wife and his 3 kids were negative for syphilis. Due to serological evidence of syphilis and neurological symptoms, we arranged him to get a lumbar puncture to rule out neurosyphilis.

Results

His CSF study showed positive venereal disease research laboratory (VDRL), WBC cell count 44 cells/ul (lymphocytes 80%, Neutrophil 20%), Glucose 50 mg/dl, Protein 75 mg/dl. Based on the CSF study, he was diagnosed with neurosyphilis and was treated with intravenous Penicillin G 3-4 million units every 4 hours for 14 days, followed by Benzathine Penicillin 2.4million units intramuscularly on day 21.

Conclusion

This is an unusual case because his false negative RPR result has hindered the prompt diagnosis and management of syphilis. RPR is a nontreponemal test and therefore it is not always reliable as a diagnostic criteria. False negatives in RPR may occur in certain conditions such as in early primary or in late stage syphilis and prozone phenomenon. This case illustrates the importance of using a reverse sequence algorithm in diagnosing syphilis. Thorough history taking is also crucial in conjunction with serological tests to determine the diagnosis and to ensure appropriate treatment.

Disclosures

All Authors: No reported disclosures