bluuebunny/crossref_metadata_2025 huggingface dataset:
332. Spinal Infections: Clinical and Microbiological Characteristics in our Urban Referral Health Center
Authors: Ogbebor Osakpolor , Abdulmassih Rasha , Como James D , Bhanot Nitin
Published: January 2021

Background

There has been an increasing trend in spinal infections (SI) in the U.S. over recent years. We sought to characterize the clinical and microbiological characteristics of SI at our hospital.

Methods

We conducted a retrospective review of SI over a 3-year period (2016 - 2019) utilizing ICD codes for data retrieval. Search terms included vertebral osteomyelitis, discitis, and epidural abscess. SPSS was used to compute the data.

Results

Of the initially screened 254 patients, 166 were included for analysis. Pertinent demographics were: mean age 59 years, male (61.4%), obese (44.5%), diabetic (25%), and drug-users (20%). Lumbosacral involvement was most common (69.8%); epidural abscess was present in 51.8% of patients. 15.7% had existing hardware. Overall, 79.5% (132/166) of cases had a positive culture from at least one site: blood 56.6% (94/166), CT-guided 83.5% (56/67), and surgical 51.1% (24/47). Of those patients with negative blood cultures, 22% (16/72) had pathogen recovery by CT-guided methods and 33% (24/72) from surgical specimens. S aureus was the most common pathogen isolated at 53.7% (71/132): MSSA comprised 38.6% (51/132) and MRSA 15.2% (20/132).

The mean CRP (8.46 vs 15.83 mg/dL; P< 0.001), and WBC (9.08 vs 13.18 k/mcL; P< 0.001) were higher in culture-positive as compared to culture-negative cases. Mean ESR and temperature more than 100.4 oF did not differ significantly between these two groups. The 8-week median recurrence rate was 11.4%, of which nearly half had index S aureus bacteremia.

Frequency of organisms isolated

Association of mean inflammatory markers with positive cultures

Conclusion

Our study affirmed that S aureus is the most common cause of SI, of which MSSA was predominant. Epidural abscess was encountered in a substantial fraction of our case population. Leukocytosis and elevated CRP tended to predict culture-positive infection, whereas ESR and fever did not. As recommended in the IDSA Vertebral Osteomyelitis guidelines, blood cultures were obtained in all cases, which yielded positive results in more than half of patients. Pathogen recovery was further improved to nearly 80% with supplemental deep tissue sampling, thus highlighting the opportunity to enhance microbiological diagnosis at our institution.

Disclosures

All Authors: No reported disclosures
336. Neurocysticercosis in a non-endemic region: A large case series from New York City
Authors: Berto Cesar G , Coyle Christina
Published: January 2021

Background

Neurocysticercosis (NCC) is associated with significant morbidity and a variety of clinical presentations We describe our experience with NCC at a New York City hospital.

Methods

A retrospective review of consecutive patients with a confirmed diagnosis of neurocysticercosis who attended to Jacobi Medical Center in New York City was done. Demographic data, symptoms at presentation, and cysticercosis serology were retrieved from the medical records. The cases were classified according to the location of the cysts. Demographic and clinic variables were compared to assess for differences according to the cyst location.

Results

A total of 260 cases of NCC were included. Of these cases, 163 (62.7%) were male, and the median age was 36.7 ± 13.7 years. A total of 245 patients (94.2%) were immigrants from 22 different countries. The most common countries of origin were Mexico (28.8%) and Ecuador (24.2%). Parenchymal NCC alone was seen in 139 patients (53.5%); of these, 31 patients had viable cysts. Forty patients (15.4%) were diagnosed with subarachnoid NCC (SANCC) alone and 19 patients (7.3%) had intraventricular NCC alone. Sixty-two patients (23.8%) had parenchymal and extra parenchymal NCC. Additionally, 24.7% of SANCC cases had concomitant spinal NCC. The median time from immigration to presentation was 9.5 years. SANCC cases had significantly longer time from immigration than parenchymal disease. The most common symptom among patients with only parenchymal NCC was seizures (68.4%). Among patients with only SANCC, 28 patients (70.0%) reported headache. Fifteen patients (37.5%) had intracranial hypertension and 12 required shunt placement. Eight patients (20.0%) of the SANCC group presented as an ischemic event. Cysticercus antigen was measured in 172 patients and was positive in 38 patients (14.6%); all but one with a positive antigen had extra-parenchymal NCC.

Conclusion

This is the largest series of NCC reported in the US and highlights the importance of SANCC disease, a more severe form of NCC. Our data suggests that those with SANCC present with intracranial hypertension and have longer latency than other forms. The NCC recombinant antigen was more likely to be positive in extra-parenchymal disease. This is a complex disease and ID physicians should be aware of the many presentations.

Disclosures

All Authors: No reported disclosures
343. CNS Mold Masquerading as Brain Metastases
Authors: Geneva Ivayla I , She Robert , Mahapatra Rahul
Published: January 2021

Background

Histoplasmosis is known to cause CNS infection with or without disseminated disease and immunosuppression is a risk factor. It can mimic brain tumor and present a diagnostic challenge.

Methods

Case report and literature review using PUBMED.

Results

A 64-year-old white female with myasthenia gravis on mycophenolate mofetil, history of Meniere’s Disease, presented with worsening ataxia and left-sided facial weakness for 4 days. MRI revealed multiple enhancing lesions within the brainstem and supratentorial parenchyma (Figure 1), consistent with metastases but either too small or inaccessible for biopsy. Work up for primary cancer with CT thorax, abdomen-pelvis, transvaginal US, mammogram, bone scan, and CSF cytology were negative. The CSF BioFire PCR and culture were negative. Prednisone taper was started for brain vasogenic edema. Patient presented again two months later with worsening lethargy, vertigo, and recurrent falls. At that time the brain lesions showed continued enlargement on repeat imaging, and stereotactic biopsy was performed. Histopathology showed non-necrotizing granulomas, no evidence of malignancy, but after 12 days a mold was isolated on culture prompting Infectious Diseases consultation. Initial morphologic features were non-diagnostic and empiric voriconazole was initiated. Fungal culture evolved Histoplasma capsulatum and voriconazole was switched to liposomal amphotericin B at 5 mg/kg intravenously every 24 hours. Histoplasma serology was positive at low titer, urine histoplasma antigen was negative. An 8 weeks course of Amphotericin, followed by lifelong suppression with fluconazole, was planned.

Figure 1

Conclusion

The diagnosis of our patient’s brain lesions was challenging as biopsy was not an option initially. An anchoring bias likely existed as the investigations had focused on malignancy, while a more robust evaluation for opportunistic endemic fungi, such as Histoplasma, took place at a later stage. Brain lesions in the immunosuppressed patient can masquerade as malignancy. To ensure timely diagnosis, a multimodal investigational approach should be applied early to include imaging and laboratory evaluation for endemic opportunistic pathogens, as well as biopsy when possible.

Disclosures

All Authors: No reported disclosures
347. Etiologies in a Cohort of Pediatric Patients Who Underwent CSF Metagenomic Next Generation Sequencing
Authors: Wilson-Murphy Molly , Lamb Gabriella S , Gorman Mark P , Ahmed Asim A
Published: January 2021

Background

The differential diagnosis in pediatric patients presenting with concern for CNS infections and/or autoimmune disorders is broad. Despite recent advances in diagnostic modalities, many cases may remain undiagnosed. For example, approximately 50% of pediatric patients with encephalitis do not have an identified etiology. Use of metagenomic next-generation sequencing (mNGS) may improve the diagnostic yield. This study evaluated etiologies in a cohort of pediatric patients who underwent CSF mNGS.

Methods

Retrospective cohort study of all hospitalized patients < 21-years-old who underwent CSF mNGS at a tertiary pediatric hospital from June, 2017 - February, 2020. Final diagnosis was assigned by two independent study physician reviewers (pediatric infectious disease and neurologist) based on documentation including discharge summaries, consult notes, and subsequent clinic notes where available.

Results

Thirty-seven patients (59% female, median age 9 (1–17) years) were identified (21 with encephalitis). Twenty-six (70%) had a definite diagnosis – 10 (27%) infectious, 11 (30%) autoimmune, 5 (14%) other. The most common etiology was anti-MOG antibody associated meningoencephalitis (n=4, 11%). Among infections, Powassan virus encephalitis (n=3, 8%) was most common; other infectious etiologies included EBV, neuroborreliosis, rubella, and Eastern Equine encephalitis. Eight (22%) had a positive result on CSF mNGS; 7 were clinically significant including change in management in 5 of 8 (63%) patients.

Conclusion

In this cohort of pediatric patients who underwent CSF mNGS, an etiology was identified in 70%. Eight patients had a positive result on mNGS which resulted in change in management for the majority of patients. These data suggest that CSF mNGS is high-yield and impacts clinical care. However, given the significant cost of mNGS, future directions include cost analyses to determine when and in whom CSF mNGS should be sent.

Disclosures

Asim A. Ahmed, MD, Karius (Employee)
349. Hardware-Associated Multidrug-resistant Pseudomonas aeruginosa Meningitis Treated with Ceftolozane-Tazobactam
Authors: Li Caitlin , Jones Sarah , Levy Ofer , Dixit Avika
Published: January 2021

Background

Although new treatment options for resistant gram negative rods have been recently developed, data on the use of these novel antibiotics for the treatment of central nervous system (CNS) infections is limited.

Methods

We present the case of a 9-year-old with a complex medical history including cerebral palsy and ventriculoperitoneal shunt dependence who was found to have highly resistant Pseudomonas aeruginosa growing from multiple cerebrospinal fluid (CSF) cultures. Susceptibility testing revealed resistance to multiple classes of antibiotics including carbapenems. Multiple antibiotics were considered for treatment; factors including molecular size, lipophilicity, plasma protein binding, and active transport as well as previously published data were weighed in selecting an antibiotic.

Results

The patient was treated with 28 days of ceftolozane-tazobactam. CSF cultures cleared following externalization of the ventriculoperitoneal shunt to an external ventricular drain. There was no recrudescence of Pseudomonas aeruginosa in the CSF following clearance.

Conclusion

We present the first reported case of ceftolozane-tazobactam used as the sole agent for treatment of resistant gram negative rod infection in the CNS. This agent may be a reasonable choice for other patients requiring treatment of highly resistant infections in this protected space.

Disclosures

Ofer Levy, MD, PhD, Avidea (Other Financial or Material Support, collaboration)Exicure (Other Financial or Material Support, collaboration)Multiple patents (Other Financial or Material Support, I am a named inventor on patents related to vaccine adjuvants)
351. Neurocysticercosis: Clinical Experience in Large Urban Safety Net Hospital in Chicago
Authors: Pendyala Bharath , Lingamaneni Prasanth , DeMarais Patricia , Warrior Lakshmi , Huhn Gregory
Published: January 2021

Background

Neurocysticercosis is a major cause of adult-onset epilepsy and premature death in adults. We aimed to describe the clinical and demographic features in a large patient population in Chicago of which published data is limited.

Methods

A retrospective chart search with ICD9/ICD10 diagnostic code for Neurocysticercosis and neuroimaging suggestive of Neurocysticercosis was performed for clinical encounters in the hospital or affiliated clinics between 2013–2018. After a careful chart review, patients who were clinically diagnosed with Neurocysticercosis were included in the study. A descriptive analysis of the data is presented.

Results

Out of a total of 90 patients all of whom were immigrants, the country of origin was reported in 60% and the majority were from Mexico (83.3%). The mean age at the time of diagnosis was 32.3 years (median 29.5, range < 1 to 67). The most common presenting complaints were seizures (62.1%) and headache (27.6%). The most common type of seizure was generalized (48.8%) followed by focal (36.6%). Approximately a third of patients also had hydrocephalus (33.7%). Many patients had > 1 lesion on neuroimaging (70.7%) out of which the most common type were parenchymal lesions (60.9%) followed by ventricular and subarachnoid. Calcified (45.5%) and cystic lesions (44.2%) were found in about equal number of cases. A minority had both types of lesions (10.4%). Contrast enhancement or edema surrounding the lesion was found in about half (47.2%) of the cases. The number of years since the last visit to an endemic country before diagnosis was reported in 46.6% of cases and the mean was 9.8 years (range 0 to 30) and it was found that per year increase since the last visit increased the chance of having contrast enhancement/edema surrounding the lesion in neuroimaging or requiring treatment with antiparasitic medications. (OR 1.77 (1.08–2.90), P= 0.03).

Conclusion

Our study agrees with previously reported data regarding seizure being the most common presenting complaint, generalized seizures being the most common type. The increasing risk of active lesions with increasing duration since the last visit to an endemic country raises the concern of clinically consequential delay in diagnosis.

Disclosures

All Authors: No reported disclosures
355. Variability in the Current Evaluation and Management of Pediatric Encephalitis: Survey Results from an Emerging Infections Network Survey
Authors: Dehority Walter , Janowski Andrew B , Messacar Kevin , Messacar Kevin , Polgreen Philip M , Beekmann Susan E
Published: January 2021

Background

Childhood encephalitis causes severe morbidity and mortality. Difficulty identifying causative organisms and a lack of effective therapies leads to variability in management. The recent emergence of novel diagnostic tools and the increased recognition of auto-immune encephalitides has the potential to change the approach to this disease. Our objective was to assess the current evaluation and management of childhood encephalitis.

Methods

An 11-question confidential, web-based survey was distributed by the Emerging Infections Network (EIN) of the Infectious Disease Society of America to 370 Pediatric Infectious Disease (ID) physicians between January 29th and February 17th, 2020. Respondents were characterized by practice region, experience since fellowship, place of employment and primary hospital type. Responses were analyzed with SAS, v 9.4.

Results

Responses were obtained from 222 of 370 members (60%) (Table). Of the 222 respondents, 196 (88%) reported caring for children with suspected encephalitis and form the basis for this report. Multi-plex PCR testing of cerebrospinal fluid (CSF) in the initial evaluation of most children with suspected encephalitis was reported by 56% (with 65% of these respondents reporting the use of pathogen-specific confirmatory testing). CSF metagenomic next generation sequencing (mNGS) had been used by 47%, with 74% of all respondents stating they would use this test if likely diagnoses were excluded via standard testing (and 64% of these only using the test if the child was not improving). Variability in the interpretation of negative CSF mNGS results was reported (Fig 1a). Primary involvement of ID physicians in the diagnostic evaluation of auto-immune encephalitis was reported by 33%, yet only 55% of ID physicians reported feeling comfortable diagnosing this condition. Marked variation existed regarding criteria for the use of immunomodulating agents (Fig 1b) and the need for testing for autochthonous tropical viruses in the U.S. (Fig 1c).

Background of 222 Respondents to an Emerging Infections Network Survey Assessing the Evaluation and Management of Pediatric Encephalitis. ID=Infectious Disease; VA=Veterans Affairs; DOD=Department of Defense *Respondents were significantly more likely than non-respondents to have <5 years of ID experience (p=0.04).

Figure 1 Approaches to the Interpretation of CSF mNGS Results, Use of Immunomodulating Agents and Testing for Autochthonous Tropical Viral Pathogens in Children with Encephalitis

Conclusion

Variation exists in the evaluation and management of childhood encephalitis, including the application of new diagnostic modalities and management of autoimmune encephalitides. Updated standardized management guidelines may improve implementation of advances in this realm.

Disclosures

All Authors: No reported disclosures
356. Clinical characteristics of critically ill patients with COVID-19 and invasive pulmonary aspergillosis: a case series from Mexico City
Authors: VALENTE-ACOSTA Benjamin , Moreno-Sanchez Francisco , Espinosa-Aguilar Luis , Hoyo-Ulloa Irma , Mendoza-Aguilar Raquel , Garcia-Guerrero Javier , Ontañon-Zurita Diego , Gomez-Gomez Brenda , Olvera-Guzman Claudia , Cebada-López Margarita , Zuñiga-Mejía Beatriz
Published: January 2021

Background

COVID-19, caused by SARS-CoV-2, has emerged as a global public health emergency and has been the main cause of intensive care admission during the pandemic. Invasive pulmonary aspergillosis (IPA) superinfection has been reported in case series of critically ill patients. Mexico has been widely affected by SARS-CoV-2. We present a case series of COVID-19-associated IPA at a teaching hospital in Mexico City.

Methods

We performed a retrospective analysis of COVID-19 patients admitted to the ABC Medical Center from March 13 to June 1, 2020. Only those with severe or critical COVID-19 were hospitalized. Patients with a diagnosis of putative IPA were analyzed. SARS-CoV-2 was diagnosed by Real-Time PCR from nasopharyngeal swabs. Aspergillus antigen testing in tracheal aspirate and serum was done with Aspergillus-specific galactomannoprotein (GP) ELISA (Euroimmun Medizinische Labordiagnostika).The study was approved by the hospital ethics committee.

Results

Among the 47 admitted patients who required invasive mechanical ventilation (IMV), we identified seven (14.9%) cases of IPA. The mean age was 59.7 ± 17.8 years and five were male. All our patients had comorbidities, but none were under previous immunosuppressive treatment. All had critical COVID-19 pneumonia requiring IMV. All but one patient received corticosteroids, and five patients were treated with tocilizumab before IPA diagnosis. Putative IPA was diagnosed in six cases (86%) by a positive GP in tracheal aspirate, additionally in one of these, the tracheal aspirate culture also grew Aspergillus niger. The remaining one (14%) had a positive serum GP. The median time from COVID-19 to IPA diagnosis was 10 days. There were five bacterial co-infections, three with Pseudomonas aeruginosa, one with Stenotrophomonas maltophilia, and one with Mycobacterium tuberculosis. Six patients were treated with isavuconazole and one voriconazole. As of June 17, 2020, three patients had died, two patients had been discharged, and two were still in the intensive care unit receiving IMV.

Aspergillus niger isolated from a tracheal aspirate of a critically-ill COVID-19 patient

Conclusion

COVID-19-associated IPA had a lower prevalence than previously reported in other series. However, it appears to be linked to high mortality and could be associated with other bacterial coinfections.

Disclosures

All Authors: No reported disclosures
357. Complications and Outcomes of Obese Patients Hospitalized with COVID-19
Authors: Shallal Anita , Morrison Austin R , Brar Indira , Suleyman Geehan
Published: January 2021

Background

Coronavirus disease 2019 (COVID-19) has greatly affected the US, where obesity is present in over 40% of the population. Evidence suggests that obesity is associated with a higher risk of developing severe disease and complications. The objective of this study was to assess the relationship between body mass index (BMI) and outcomes in hospitalized patients with COVID-19.

Methods

A retrospective cohort study of patients with confirmed COVID-19 infection at Henry Ford Health System in metropolitan Detroit from March-May 2020. Demographics, comorbidities, severity of illness, complications, treatment and outcomes of obese (BMI > 30) and non-obese (BMI < 30) patients were compared. Data were analyzed using SPSS.

Results

Summary of results comparing non-obese and obese patients is presented in tables 1 and 2. Median BMI (kg/m2) in each group was 26 and 36.5, respectively. Age and black race differed significantly between the two groups (p< 0.001). Younger patients were more obese compared to older patients. Diabetes and obstructive sleep apnea (OSA) were significantly more common in obese patients. Obese patients were significantly more likely to receive antibiotics in the ED (p=0.015), require vasopressors for shock (p=0.004), and undergo renal replacement therapy (p=0.005). Although 37% of obese patients were intubated, obesity was not a significant risk factor for mechanical ventilation (MV). 30-day readmission and mortality were significantly higher in non-obese patients. In the regression analysis, age over 60, tachypnea at admission, acute kidney injury, and diabetes were significantly associated with need for MV, but not BMI.

Conclusion

In our cohort, a high frequency of obesity is noted among black and younger patients. Obese patients were more likely to require intensive treatments, including renal replacement therapy and vasopressors but not mechanical ventilation. Complications and outcomes in COVID-19 should be further evaluated by BMI categories.

Disclosures

Indira Brar, MD, Gilead (Speaker’s Bureau)janssen (Speaker’s Bureau)ViiV (Speaker’s Bureau)
358. Sociodemographic and clinical features of children and adolescents with SARS-CoV-2 infection in Nashville, Tennessee
Authors: Howard Leigh , Garguilo Kathryn , Gillon Jessica , Webber Steven , Halasa Natasha B , Banerjee Ritu , Banerjee Ritu
Published: January 2021

Background

Little is known regarding the full spectrum of illness among children with SARS-CoV-2 infection across integrated healthcare settings, as many published pediatric cohorts focus on hospitalized patients with SARS-CoV-2 infection.

Methods

Active surveillance was performed for SARS-CoV-2 detections among symptomatic and asymptomatic children and adolescents ≤18 years of age in a quaternary care academic hospital laboratory in the Southeastern U.S. For symptomatic patients with a positive respiratory specimen for SARS-CoV-2 by polymerase chain reaction (PCR), and for neonates born to SARS-CoV-2-positive mothers, we performed phone follow-up and medical record review at days 2, 7, and 30 after diagnosis. Testing was initiated 3/12/20 for symptomatic patients and 5/4/20 for screening asymptomatic patients.

Results

By 6/14/20, SARS-CoV-2 tests were positive in 193/5306 (3.6%) specimens from unique patients ≤18 (Table 1), compared to 2653/36503 (7.2%) specimens in patients >18 years. Specimens from 181/2638 (6.8%) symptomatic and 12/2768 (0.4%) asymptomatic children were positive. Nine infants born to SARS-CoV-2 infected mothers had negative PCR tests at birth; 1 infant subsequently acquired SARS-CoV-2 infection at 5 weeks of age. Sociodemographic and clinical data for 181 SARS-CoV-2-positive symptomatic children are displayed in Table 2 and Figure 1. The most common symptoms were cough (59%), fever (50%), and rhinorrhea (39%). Nine/181 symptomatic patients (5%) were hospitalized, primarily for respiratory symptoms. Symptom resolution occurred by follow-up day 2 in 82/178 (46%) and day 7 in 128/164 (78%) patients with complete assessments to date. 131/181 (72%) of children had known SARS-CoV-2 positive contacts. We observed no cases of multisystem inflammatory syndrome in children.

Conclusion

In our community, pediatric SARS-CoV-2 prevalence was low, but was much higher among symptomatic than asymptomatic children. Symptoms were mild, and the duration of symptoms brief, in the majority of these patients captured within an integrated ambulatory and hospital-based healthcare system, capturing the full spectrum of the disease profile in this age group.

Disclosures

Natasha B. Halasa, MD, MPH, Genentech (Other Financial or Material Support, I receive an honorarium for lectures - it’s a education grant, supported by genetech)Karius (Consultant)Moderna (Consultant)Quidel (Grant/Research Support, Research Grant or Support)Sanofi (Grant/Research Support, Research Grant or Support)
359. Ventilator-associated pneumonia in patients with SARS-CoV-2–associated acute respiratory failure requiring mechanical ventilation: a retrospective cohort study
Authors: Luyt Charles-Edouard , Vidal Pauline , Burrel Sonia , Hekimian Guillaume , Brechot Nicolas , Schmidt Matthieu , Combes Alain , Boutolleau David , Robert Jérôme , Chastre Jean
Published: January 2021

Background

Data on incidence, clinical presentation and outcomes of ventilator-associated pneumonia (VAP) in patients with severe coronavirus disease 2019 (COVID-19) pneumonia requiring mechanical ventilation (MV) are limited.

Methods

Case series of patients with COVID-19 pneumonia admitted to a single ICU in France. All consecutive patients requiring MV with RT-PCR–confirmed SARS-CoV-2 infection between March 12th and April 24th, 2020 were included. Frequency, clinical characteristics, responsible pathogens and outcomes of VAP were assessed, and compared to an historical cohort of patients with severe influenza-associated pneumonia requiring MV admitted to the same ICU during the preceding three winter seasons.

Results

Fifty-four consecutive patients with COVID-19–associated respiratory failure requiring MV were included (median (IQR) age 48 (42–58) years; 74% male; 93% requiring veno-venous ECMO). VAP occurred in 46 (85%) of them (median (IQR) prior MV duration before the first episode, 11 (8–16) days) (Table 1). Pathogens responsible for VAP were predominantly Enterobacteriaceae (72%), and particularly inducible AmpC-cephalosporinase producers (41%), followed by Pseudomonas aeruginosa (35%) (Table 2). Pulmonary infection recurrence and death were observed in 46 (85%) and 17 (31%) patients, respectively. Details on recurrent episodes and pathogens responsible for recurrences are given in Table 3. Most recurrences were relapse (i.e. infection with the same pathogen), with a high proportion occurring during antimicrobial treatment despite its adequacy. Despite a high rate of P. aeruginosa VAP in patients with influenza-associated ARDS, pulmonary infection recurrence rate was significantly lower than in patients with COVID-19. Overall mortality was similar in the two groups.

Baseline characteristics of patients

Characteristics of first ventilator-associated pneumonia episode

Characteristics of recurrent VAP episodes in Covid-19 and influenza patients.

Conclusion

Patients with severe COVID-19–associated respiratory failure requiring MV had a very high late-onset VAP rate. Inducible AmpC cephalosporinase–producing Enterobacteriaceae and Pseudomonas aeruginosa appeared to be frequently responsible for VAP, with multiple subsequent episodes and difficulties to eradicate the pathogen from the lung.

Disclosures

All Authors: No reported disclosures
365. Characteristics and outcomes of COVID-19 patients admitted to a regional health system in the southeast
Authors: Teixeira Charles , Shiflett Henry , Jandhyala Deeksha , Lewis Jessica , Curry Scott R , Salgado Cassandra
Published: January 2021

Background

COVID-19, first described in Wuhan, China, is now a global pandemic. We describe a cohort of patients (pts) admitted to our academic health system (HS) in the southeast, where demographics and comorbidities differ significantly from other regions in the U.S.

Methods

This was a retrospective review of 161 consecutive pts admitted with COVID-19 from 3/12/20 to 6/1/20. We assessed demographics, comorbidities, presenting symptoms, treatments and outcomes and compared pts who died during hospitalization to those who survived to discharge (EpiInfo 7.2, Atlanta, GA).

Results

Mean age was 60.5 years, 51.6% were female, 72% African American (AA) and 69.6% admitted from home. 54.5% had a BMI >30, 72% had HTN, 47.2% diabetes, and 33.6% COPD or asthma. The majority (68.8%) presented with fever (>38.0) and required supplemental oxygen within 8 hours of admission (63.4%). Cough (65.6%), dyspnea (57.5%), myalgias (30.6%) and diarrhea (23.8%) were also common. 40.4% received hydroxychloroquine, 23.6% steroids and 19.9% convalescent plasma. 42.9% required ICU care, 27.3% were intubated, and 19.3% died. Characteristics associated with death included older age, male sex, HTN, ESRD on HD, and cancer. Symptoms associated with death included absence of cough, absence of myalgias, previous admission for COVID-19, tachypnea, need for supplemental oxygen, elevated BUN and creatinine, and elevated ferritin. Interventions associated with death included use of steroids, receipt of ICU care, intubation, delay to intubation, and use of vasopressors or inotropes. Complications associated with death included development of a new arrhythmia, bacteremia, pneumonia, ARDS, thrombosis, and new renal failure requiring HD (Table).

Table 1. Patient Characteristics by Death

Table 2. Patient Characteristics by Death

Table 3. Patient Characteristics by Death

Conclusion

COVID-19 pts admitted to our southeast U.S. HS had significant comorbidities, most commonly obesity, HTN, and diabetes. Additionally, AA comprised a disproportionate share (72%) of our cohort compared to the general population of our state (30%), those tested in our region (32.9%), and those found to be positive for COVID-19 (35.8%). In-hospital mortality was 19.3% and intubation, particularly if delayed, was associated with death as were several complications, most notably arrhythmia, ARDS, and renal failure with HD.

Disclosures

All Authors: No reported disclosures
371. Cluster of carbapenemase-producing Enterobacterales secondary infections during the COVID-19 crisis at a New York City hospital
Authors: Gomez-Simmonds Angela , Annavajhala Medini K , McConville Thomas H , Dietz Donald E , Shoucri Sherif M , Laracy Justin C , Nelson Brian , Whittier Susan , Uhlemann Anne-Catrin , Uhlemann Anne-Catrin
Published: January 2021

Background

Patients with COVID-19 may be at increased risk for secondary bacterial infections. At our quaternary care hospital in New York City, the rapid escalation of COVID-19 cases was accompanied by a massive surge in the need for hospital and critical care capacity. During this time, we noted a increase in infections caused by carbapenemase-producing Enterobacterales (CPE).

Methods

We retrospectively assessed microbiology data to identify patients with positive testing for SARS-CoV-2 who had clinical cultures with meropenem-resistant and/or carbapenemase gene-positive Enterobacterales. We obtained microbiological and clinical data by manual chart review. Available clinical isolates underwent long-range genomic sequencing using the MinION (Oxford) for rapid genotyping, resistance gene detection, and phylogenetic analysis.

Results

From March 1 to May 18, we identified 33 CPE isolates from 13 patients, including 29 Klebsiella pneumonia and four Enterobacter cloacae. Most patients (11/13) had a positive respiratory culture, and 7/13 developed bacteremia. All patients had prolonged, complex hospitalizations with extensive antibiotic exposure. We performed long-range sequencing on 19 isolates from 12 patients. 15/16 K. pneumoniae isolates belonged to sequence type (ST) 258 encoding KPC (14 KPC-2; 1 KPC-3); one ST70 isolate encoded KPC-2. All four E. cloacae isolates belonged to ST270 and encoded NDM-1. Phylogenetic analysis of ST258 isolates including historical isolates from our hospital revealed a distinct lineage of isolates from COVID-19 patients (72% bootstrap support), with expected clustering of isolates from the same patient and patients that were cohorted together.

Conclusion

While CPE have declined substantially in New York City in recent years, increased detection in patients with COVID-19 may signal a reemergence of these highly resistant pathogens in the wake of the global pandemic. System-level factors, such as the rapid scale-up of critical care capacity, while clearly needed to address the unprecedented reach of COVID-19, may have contributed to isolate clustering in these patients. Increased surveillance and antimicrobial stewardship efforts will be needed to mitigate the impact of CPE in the future.

Disclosures

All Authors: No reported disclosures
374. Complication with Bacterial Pneumonia in Hospitalized Patients with Coronavirus Disease 2019 (COVID-19)
Authors: Kang Minji , Haste Nina , Legaspi Jamie , Torriani Francesca J , Abeles Shira
Published: January 2021

Background

Early reports have indicated widespread empiric antimicrobial usage in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As data regarding bacterial complications in patients with Coronavirus Disease 2019 (COVID-19) are limited and emerging, it is important to delineate the burden of complications with bacterial pneumonia in patients with COVID-19 and its implication on antimicrobial usage.

Methods

We conducted a retrospective cohort study of all hospitalized patients diagnosed with COVID-19 based on detection of SARS-CoV-2 on RT-PCR from March 1, 2020 to May 10, 2020. Data were collected retrospectively to determine the presence of bacterial pneumonia among patients hospitalized with COVID-19 and to identify demographics, comorbidities, or laboratory values that may help to distinguish patients with bacterial pneumonia. Fisher’s exact test was used to analyze categorical data and Student’s t test was used to analyze differences between means.

Results

Among 99 patients hospitalized with COVID-19 during the study period, complication with bacterial pneumonia was seen in 17 (17%) based on sputum, tracheal aspirate or lower respiratory tract cultures performed 8.9 ± 7.8 (mean ± SD) days from the detection of SARS-CoV-2 on RT-PCR. Staphylococcus aureus was the causative organism in 8 (47%) cases while Enterobacteriaceae were isolated in 7 (41%) cases, Burkholderia cepacia in one (6%) and Rahnella aqualitis in one (6%) case. There were no significant differences in demographics, comorbidities, or laboratory findings between patients with or without complication with bacterial pneumonia. However, those with complication with bacterial pneumonia were more likely to be intubated (24% vs. 88%, p< 0.01), on vasopressors (23% vs. 82%, p < 0.01), and require intensive care unit admission (37% vs. 94%, p< 0.01).

Conclusion

Nosocomial and ventilator-associated pneumonia were commonly seen among hospitalized patients with COVID-19 requiring intubation and intensive care use admission. With complications of bacterial pneumonia common among critically-ill patients infected with SARS-CoV-2, widespread antimicrobial usage may increase the selective pressure for antibiotic resistance in this patient population.

Disclosures

All Authors: No reported disclosures
376. COVID-19 Severity in HIV+ Patients Receiving Tenofovir
Authors: Homsi Nora , Vermeulen Kendra , Snyder Mitchell , Cennimo David J , Sonyey Alexandra
Published: January 2021

Background

Early in the COVID-19 pandemic, tenofovir (TAF/TDF) was identified as a potential agent for SARS-CoV-2 due to binding to RNA-dependent RNA polymerase similarly to remdesivir. This led to the hypothesis that TAF/TDF may be lessening the severity and improving outcomes of COVID-19 infection.

COVID-19 Severity

COVID-19 Infection Outcomes

Methods

Patients were identified by searching for HIV infection and SARS-CoV2 PCR testing. Type of antiretroviral therapy (ART), CD4+ cell count, HIV viral load (VL), comorbidities, presenting symptoms, severity of COVID infection, and outcomes were analyzed. COVID disease was classified as mild, moderate, severe, or critical based on World Health Organization criteria. We primarily sought to determine the effect of TAF/TDF on the severity of COVID infection. The secondary endpoint was to determine the effect of low CD4 count and HIV VL on the severity of infection.

Results

39 HIV+ patients were tested at least once for SARS-CoV2 by PCR at VA NJ Health Care System. 18 of 39 patients were PCR positive. In those, common presenting symptoms included: fever (15/18), cough (7/18), and lethargy/fatigue (6/18). 16 of the 39 HIV+ patients’ ART included TAF/TDF; 8 of 18 COVID+ and 8 of 21 COVID-. In the COVID- group, 2 patients had CD4 count < 200 cells/mm3, 3 patients had HIV VL >200, and 19 of 21 had at least 1 comorbidity. In the COVID+ group, 3 had CD4 count < 200 cells/mm3, none had detectible HIV viremia, and all but one had comorbidities. Of COVID+ infections, 7 were mild, 3 moderate, 8 severe, and 5 patients died. 4 of the 5 patients that did not survive were in non-TAF/TDF group. All 3 patients with CD4 count < 200 cells/mm3 had severe disease. 6 out of 8 patients developed mild disease in TAF/TDF group vs. 1 out of 10 patients in non-TAF/TDF group. 1 out of 8 and 7 out of 10 patients had severe or critical disease in TAF/TDF vs non-TAF/TDF groups respectively.

Conclusion

In this sample of 18 HIV+ patients with COVID-19 infection, patients receiving TAF/TDF were more likely to develop mild disease and have full recovery than those who were on TAF/TDF-free regimens (75% vs. 10% and 87.5% vs. 50%, respectively). Patients not on TAF/TDF-based regimens had a higher rate of developing severe and critical COVID-19 disease (40% vs. 0% and 30% vs. 12.5%, respectively).

Disclosures

All Authors: No reported disclosures
379. Epidemiology of Antimicrobial Use Among SARS-CoV-2 Positive and Negative Admissions in the US: A Multicenter Evaluation
Authors: Puzniak Laura A , Bauer Karri A , Finelli Lyn , De Anda Carisa , Moise Pamela , Yu Kalvin , Vankeepuram Latha , Parikh Prashant , Gupta Vikas
Published: January 2021

Background

SARS-CoV-2, a novel coronavirus, emerged in Wuhan, China in December of 2019, and became a pandemic. Increases in bacterial/fungal co-infections have occurred during influenza pandemics and early data from this pandemic indicate high utilization of antimicrobial therapy. We compared the utilization of antimicrobials and health outcomes between SARS-CoV-2 positive and negative patients.

Methods

Patients hospitalized at 271 US acute care facilities from 3/1/20–5/30/20 with ≥1 day length of stay (LOS) and ≥24 hours of antimicrobial therapy tested for SARS-CoV-2 were included in the study (BD Insights Research Database [Becton, Dickinson & Company, Franklin Lakes, NJ]). Demographics, antimicrobial utilization, duration of antimicrobial therapy, hospital LOS and ICU LOS data were analyzed by SARS-CoV-2 test results.

Results

142,054 patients were tested for SARS CoV-2 and 12% (n=17,075) were SARS-CoV-2 positive. SARS-CoV-2 negative and positive patients did not differ regarding presence of a positive bacterial culture. Total LOS, % ICU admission, and ICU LOS were higher among SARS-CoV-2 positive patients (Table). In total 48% of admissions were prescribed antimicrobial therapy; rates were higher in SARS-CoV-2 positive versus negative admissions (68% vs. 46%). The most common antimicrobials and classes are in Table.

Antimicrobial therapy and outcomes in hospitalized SARS-CoV-2 tested patients.

Conclusion

Almost half of patients tested for SARS-CoV-2 were prescribed antimicrobials, with antimicrobial use higher among those with SARS-CoV-2, despite similar rates of positive cultures. On average, antimicrobials were prescribed within 10 hours from the time to admission among patients tested. These treatment patterns may highlight the difficulties in making treatment decisions and concerns over potential bacterial superinfection in SARS-CoV-2, but also indicate potential overuse of antimicrobials. Collateral damage from antimicrobial overuse include increase selection of antimicrobial resistance, adverse effects of drugs, and unnecessary treatment costs. It will be important to continue to evaluate the utilization and appropriateness of antimicrobial use among SARS-CoV-2 patients.

Disclosures

Laura A. Puzniak, PhD, Merck (Employee) Karri A. Bauer, PharmD, Merck Research Laboratories (Employee) Lyn Finelli, DrPH, MS, Merck & Co Inc, (Employee) Carisa De Anda, PharmD, Merck & Co Inc, (Employee) Pamela Moise, PharmD, Merck & Co., Inc. (Employee, Shareholder) Kalvin Yu, MD, Becton, Dickinson and Company (Employee)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Latha Vankeepuram, MS, BD (Employee) Prashant Parikh, n/a, Becton, Dickinson and Company (Employee) Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)GlaxoSmithKline plc. (Other Financial or Material Support, Funding)
381. HIV Patients with COVID-19 Hospitalized in a Tertiary Care Center in Mexico City
Authors: Espejo Ortiz Cristian E , Serrano Pinto Yamile G , Sierra Madero Juan G , Iñiguez Alvaro Lopez , Crabtree-Ramírez Brenda
Published: January 2021

Background

The main risk factors for severe COVID-19 described are diabetes, hypertension, cardiovascular disease, obesity, chronic lung and renal disease. HIV infection has not been found to be an independent factor for severe COVID-19, however, only small case series of HIV and COVID-19 have been reported. The aim of this study is to describe clinical characteristics and outcomes of HIV positive patients with COVID-19 hospitalized in a tertiary care hospital in Mexico City.

Methods

A single-center review of HIV-infected patients diagnosed with COVID-19 was performed using medical records from March 1st, 2020 to May 20th, 2020. We describe the clinical characteristics and outcomes

Results

A total of 11 PLWH were diagnosed with COVID-19, only 9 were hospitalized and are described here. One died, 6 were discharged and 2 remain hospitalized (table 1). Overall, the median age was 46 years, all males and most (7/9) were on INSTI based ART regimen and undetectable HIV viral load (9/9), with a median of CD4 counts of 581 cell/mm3. The median days since onset of COVID19 symptoms was 7 days. 6/9 had at least one comorbidity: hypertension (3/9) and chronic kidney disease (3/9). 7/9 had body max index >25. 7/9 had moderate to severe lung disease, evidenced by computed tomography. 4/9 required invasive mechanical ventilation, and all were successfully extubated.

Table 1. Characteristics and outcomes *

Conclusion

Most of the HIV patients who required hospitalization due to COVID19 had comorbidities. In spite of severe and critical presentations, most patients have recovered. Outcomes appear no different from those seen for non-HIV infected patients, however larger studies to determine the risk that HIV infection confers to COVID19 outcomes are needed.

Disclosures

All Authors: No reported disclosures
384. Invasive aspergillosis in COVID-19 patients in an intensive care unit in Mexico City
Authors: Velez-Pintado Mariana , Aguilar-Soto Mercedes , Camiro Antonio , Cuenca-Abruch Dalia , Pérez-Doramae Renzo Alberto , Crabtree-Ramirez Brenda , Mercado-Atri Moises
Published: January 2021

Background

An elevated incidence of invasive pulmonary aspergillosis (IPA) in patients with COVID-19 without traditional risk factors for IPA has been recently reported around the world. This co-infection has been described in patients requiring treatment in an intensive care unit. The risk factors for its development are still unclear.

Methods

We conducted a nested case-control study using the COVID-19 registry of the ARMII study group, based in the Centro Médico ABC, a private hospital in Mexico City. We included all patients that required admission to the intensive care unit (ICU) from March 12 to June 15, 2020, and excluded patients without serum galactomannan measurements or bronchial secretion cultures. We used the modified definition of IPA proposed by Schauwvlieghe et al for IPA in influenza patients. The control group was formed by patients with ruled-out IPA (negative galactomannan and secretion cultures). We compared both groups to identify risk factors for IPA using the chi-squared test or the Mann-Whitney U test as applicable.

Results

Out of a total 239 patients, 54 met the inclusion criteria. We identified 13 patients with IPA (24.07%) that met the definition of IPA (2 with positive cultures and 11 with positive galactomannan) and 41 without IPA. Only three patients with IPA had important comorbidities (COPD, chronic kidney disease, and HIV). Patients with IPA tended to have a higher median age (64.6 vs 53.59, p=0.075) and a higher serum glucose at their arrival (145 vs 119, p=0.028). All patients with IPA presented to the hospital with ARDS (100% vs 72.5%, p=0.034), but ultimately did not have a higher requirement for mechanical ventilation (100% vs 82.93%, p=0.110). There were no statistical significant differences in use of Tocilizumab, use of glucocorticoids, mortality (23.07% vs 17.50%, p=0.563) or length of stay.

Conclusion

It has been previously described that patients with acute respiratory disease syndrome triggered by viral infection, like the influenza virus, are prone to invasive aspergillosis even in the absence of underlying immunodeficiency. The use of antifungals to prevent aspergillosis in COVID-19 patients should be assessed because of the gravity presented in the patients with this co-infection.

Disclosures

All Authors: No reported disclosures