bluuebunny/crossref_metadata_2025 huggingface dataset:
1152. Implementation of Enhanced Data Surveillance Methods to Reduce Catheter-Associated Urinary Tract Infections
Authors: Ehni Jordan , Moss Marie , Koll Brian , Mazo Dana , Javaid Waleed , Latrace Maria , Mahoney Christine D , Barnett Barbara
Published: October 2019

Background

Urinary tract infections (UTIs) continue to be one of the most common types of healthcare-associated infections (HAIs). Instrumentation of the urinary tract using devices such as indwelling urinary catheters (IUCs) is the leading cause of healthcare-associated UTIs. Every day that a patient has an IUC increases their risk of acquiring a UTI. After an increase in the number of catheter-associated urinary tract infections (CAUTIs), a mid-sized acute care hospital in the Northeast United States used an electronic surveillance system to monitor IUC order compliance and appropriateness in order to reduce IUC utilization and prevent CAUTIs.

Methods

Using an Infection Prevention (IP) electronic surveillance system, a line list was generated of patients who had an IUC documented in the urinary flow sheet of their electronic medical record. This list contained variables such as: catheter insert date, catheter order status, and catheter indication. IP staff sent this list in a daily e-mail to clinical leadership and front line staff over a 14 month period. The e-mail notified providers when their patients had an IUC without an order. Clinical staff was directed to discontinue the IUC if it was no longer indicated or to place a new IUC order if still indicated. The National Healthcare Safety Network (NHSN) CAUTI definition and data functions were used for the purposes of this study.

Results

A statistically significant (P = 0.017) reduction in the hospital CAUTI rate was found when a comparison was made between the 14-month pre-intervention baseline period (1.12 CAUTI per 1,000 catheter days) and the 14 month post-intervention period (0.29 CAUTI per 1,000 catheter days). A statistically significant decrease (P = 0.0004) in IUC utilization was also noted for the same time period, decreasing from 8.2 catheters per 100 patient-days to 7.8 catheters per 100 patient-days.

Conclusion

A significant reduction in CAUTIs and IUC utilization was seen over the 14-month IP-driven e-mail intervention. This study suggests that regular electronic communication of surveillance system information to providers may reduce CAUTIs.

Disclosures

All authors: No reported disclosures.
188. Which patients with gram-negative bacteremia need follow-up blood cultures?
Authors: Jung Jongtak , Mi Moon Song , Suk Kim Eu , Bin Kim Hong , Hwan Bang Ji , Won Park Sang , Beom Park Wan , Kim Nam-Joong , Oh Myoung-don , Song Kyoung-Ho
Published: October 2019

Background

Universal follow-up blood culture (FUBC) in gram-negative bacteremia (GNB) is not recommended, but it has been routinely conducted in many acute-care hospitals. In contrast with Staphylococcus aureus bacteremia, risk factors for positive FUBC in GNB have not been well investigated. Therefore, we tried to identify the risk factors for and develop predictive scores of positive FUBC.

Methods

All adults (≥18 years-old) with GNB were identified in a tertiary-care hospital during the 2-year period, retrospectively. Death within 2 days of GNB and polymicrobial infection with gram-positive bacteria or fungus were excluded. GNB were classified into eradicable and non-eradicable source of infection groups, according to the possibility of source removal. We performed multivariate analyses for identifying risk factors for positive FUBC and built prediction scores using the coefficients of the multivariate logistic regression models.

Results

Of total 1,473 GNB, FUBC was drawn in 1,268 (86%) patients and 122 (9.6%) had positive results. In patients with eradicable source of infection, ESBL-producing microorganism, catheter-related bloodstream infection, unfavorable treatment response, and quick sequential organ failure assessment (qSOFA) score (≥2) were associated. On the other hand, administration of effective antibiotics and adequate source control were negatively associated with positive FUBC. In non-eradicable source of infection, end-stage renal disease on hemodialysis, and unfavorable treatment response were related to positive FUBC and administration of effective antibiotics was negatively associated (Table 1). When we built prediction scores according to the coefficients, the areas under the curves were 0.864 (95% confidence interval [CI95] 0.816–0.912) and 0.792 (CI95, 0.721–0.861), respectively. When we applied a cutoff of 0, specificities/negative predictive values in eradicable and non-eradicable source of infection groups were 84.7%/95.6% and 95.5%/95.0%, respectively (Table 2).

Conclusion

Our prediction scores based on adequate source control and use of effective antibiotics showed high specificities and negative predictive values. Therefore, we could expect these score systems to contribute to reducing unnecessary FUBC in GNB.

Disclosures

All authors: No reported disclosures.
199. Infections in VADers: A True Villain of the Force
Authors: Seidelman Jessica , Barac Yaron , Junpaparp Parichart , Jawitz Oliver K , Blue Laura J , Milano Carmelo , Wolfe Cameron R
Published: October 2019

Background

Ventricular assist devices (VADs) are increasingly used for the management of end-stage heart failure, but infection is a complication that has not been thoroughly studied. The purpose of our study was to compare patients who had surgical debridement vs. medical therapy alone for VAD-related/specific infections.

Methods

We performed a retrospective chart review on patients at Duke University Hospital (DUH) from 2015 to 2017. Patients with VAD-related/specific infections were included, per 2011 ISHLT definitions. We reviewed electronic medical records for demographics, VAD implantation data, infectious episodes, surgical debridements and mortality. Descriptive statistics compared patients with and without debridement and compared with and without relapse.

Results

We found 94 infections in 72 patients. Descriptive statistics of the cohort and comparisons with and without debridement can be seen in Table 1. Sixty-one cases (65%) included debridement and 5 (5%) required pump exchange. Notably, patients with fever or bacteremia were more likely to undergo debridement. Of the patients that had a preoperative CT, sensitivity for deep infection (pump, pocket, or deep to the muscle) was 38%, yet specificity was 95%. For superficial infections (involving the driveline or superficial to the muscle), preoperative CT sensitivity was 95%; specificity 65%. Table 2 shows intraoperative culture data. When the preoperative driveline culture grew Staphylococcus species or Pseudomonas aeruginosa there was strong correlation with intraoperative organism (matched in >75% of cases). Table 3 compares treatments among patients with and without infective relapse. Relapse rate appeared the same if patients received 2, 4, or ≥6 weeks of intravenous antibiotics.

Conclusion

We present a large single-center cohort [DCWM1] examining VAD-related/-specific infections. While patients chosen for debridement may be sicker, these patients had a longer hospital stay and relapsed more often. Preoperative CT should be used with caution as it underestimates the extent of disease. However, preoperative driveline cultures correlated strongly with intraoperative cultures for most common pathogens. There was no association between initial intravenous therapy duration and infection relapse.

Table 1. demographic characteristics of total cohort and comparisons among patients who underwent debridement for treatment of infection and patients who did not undergo debridement for treatment of infection

Table 2. Organisms found intraoperatively and the number of organisms found preoperatively that are the same as the intraoperative cultures

Table 3. Comparing treatment and cultures in patients who suffered an infection relapse

Disclosures

All authors: No reported disclosures.
200. Real-World Experience with Dalbavancin for Complicated Gram-Positive Infections: A Multicenter Evaluation
Authors: Alosaimy Sara , Pearson Jeffrey , Veve Michael , Dionne Brandon , Aleissa Muneerah , Jorgensen Sarah C J , Rybak Michael J
Published: October 2019

Background

Dalbavancin (DAL) received Food and Drug Administration (FDA) approval for the treatment of acute bacterial skin and skin structure infections (ABSSSI) caused by Gram-positive organisms including Methicillin-resistant Staphylococcus aureus (MRSA). Due to its unique activity and dosing schedule, use in non-FDA approved indications has been increasing. We evaluated the clinical and safety outcomes of patients treated with DAL for various infections.

Methods

A multicenter, retrospective observational study was conducted from April 2017 to February 2019. We included adult patients who received 1 dose of DAL for any indication. The primary outcome was clinical success defined as 30-day survival from DAL initiation, resolution of signs and symptoms of infection, and absence of therapy escalation/change. Reasons for DAL therapy selection were also investigated.

Results

A total of 30 patients were included. The median age was 49 (35–58) years, 50% were female and 93.3% were Caucasian. Median APACHE II score was 9 (5–12). Persons who inject drugs (PWID) comprised 50%. Common DAL indications were bacteremia (53.3%), bone and joint infections (33.3%) and ABSSSI (26.7%). Pathogens were MRSA (43.3%), coagulase-negative Staphylococci (23.3%) and methicillin-susceptible S. aureus (MSSA) (13.3%). Previous antibiotics were administered in 93.3% of patients for a median of 9 (7–15) days and (13.3%) received combination antibiotic therapy with DAL. In a subgroup of patients with confirmed microbiological eradication (73.3%), DAL was initiated at a median of 8 days (4–14) after clearance. Clinical success was achieved in 80% of patients and 10% were de-escalated to oral therapy. Rash/pruritus and hypotension occurred in two and one patient, respectively. DAL was selected because of ease of administration (60%), inability to be discharged with a line (43.3%), poor candidacy for outpatient therapy (36.7%), and/or inadequate adherence (30%).

Conclusion

DAL appears to be well tolerated and results in high clinical success. Larger studies with longer follow would be valuable to more precisely define the role of DAL in complicated Gram-positive infections, particularly in comparison to other long-acting lipoglycopeptides.

Disclosures

All authors: No reported disclosures.
202. The effectiveness of combination therapy of anti-methicillin-resistant Staphylococcus aureus agents and β-lactam agents in patients complicated with febrile neutropenia after bone marrow transplantation
Authors: Sugiyama Soichiro , Shimizu Hiroyuki , Hashimoto Shinya , Tsukiji Jun
Published: October 2019

Background

Febrile neutropenia (FN) is one of the most frequent and serious complications of hematopoietic stem cell transplantation such as bone marrow transplantation (BMT). Anti-Pseudomonas agents should be initiated in all patients complicated with FN without delay, while anti–methicillin-resistant Staphylococcus aureus (MRSA) agents are exclusively recommended in the case of central venous (CV) line infection. Most BMT patients have the potential risk of catheter-related blood stream infection because of long-lasting catheterization including indwelling CV line. Therefore, the patients may also be received anti-MRSA agents empirically in addition to anti-Pseudomonas agents. So far, there are little reports that verify the effectiveness of the combination therapy under FN condition after BMT. The purpose of this study was to address the effectiveness.

Methods

BMT was performed at Yokohama City University Medical Center between April 2012 and March 2018, and 44 patients who developed FN after BMT were enrolled. We analyzed patient information retrospectively. We used the duration of fever to evaluate the additive effect of anti-MRSA agents to β-lactam anti-Pseudomonas agents. We classified the patients during FN period into two groups whether anti-MRSA agents were administered (Ad group; 34 patients) or not (non-Ad group; 10 patients). Fever is defined as a single axillary temperature measurement of over 37.5 Celsius degrees. The study design and protocol were approved by the ethics committee at the Review Board of our hospital (ID：D1602011).

Results

Baseline characteristics were similar between the two groups. Blood cultures were performed onset of FN in all cases, in which five showed positive (11.4%). Bacteria requiring administration of anti-MRSA drugs were detected in the four cases. Nonetheless, duration of fever was not significantly shorten (6.8 ± 4.0 vs. 5.2 ± 2.5, P = 0.171) and there was no difference in the hospitalization period. The renal dysfunction was significantly higher in Ad group and the cost of anti-MRSA agents totaled about $ 36,000.

Conclusion

Our study indicates that no use of empirical combination therapy of anti-MRSA agents in addition to anti-Pseudomonas agents under FN condition after BMT, even if CV line is inserted.

Disclosures

All authors: No reported disclosures.
205. Comparing Cefazolin and Nafcillin in Treatment of Methicillin-Susceptible Staphylococcus Aureus Bacteremia: A Retrospective Study in a Single Center in the South Bronx
Authors: Chiu Chia-Yu , Sarwal Amara , Feinstein Addi
Published: October 2019

Background

Methicillin-Susceptible Staphylococcus Aureus (MSSA) bacteremia treatment includes B-lactams as first-line therapy; however, comparative effectiveness within B-lactams has not been well studied in literature. Herein, we look at definitive treatment with nafcillin or cefazolin in patients with MSSA bacteremia.

Methods

This retrospective study included patients admitted at Lincoln Medical Center from January 2000 to March 2019 who had a positive blood culture for MSSA and was treated with either nafcillin or cefazolin. We excluded patients who received both nafcillin and cefazolin. In addition to this, included patients had to have (1) bacteremia alone with 14 days treatment after first negative blood culture or (2) endocarditis or osteoarthritis with 6 weeks treatment after first negative blood culture.

Results

Of the 186 patients identified to have at least one positive culture for MSSA during the study period, only Eighty-two patients met our set criteria. Seventy of our patients were treated with nafcillin while 12 patients were treated with cefazolin. Outcome measures included duration of bacteremia (P = 0.151), ICU admissions (P = 0.542) and development of Clostridium difficile (P = 0.475). All-cause 30 day mortality and recurrent MSSA bacteremia were not different between the two treatment groups with an incidence of 17% for cefazolin vs. 21% for nafcillin (P =1) and 1% for cefazolin vs. 0% for nafcillin (P =1), respectively.

Conclusion

The average price of nafcillin is approximately 174 USD/day, while cefazolin is 33 USD/day. In addition to being economically practical, especially in a city hospital such as Lincoln Medical Center, cefazolin also has the benefit of only being administered every 8 hours rather than every 4 hours that nafcillin requires. This decreases the need for staff and supplies, allowing for the cefazolin regimen to be administered more easily. In this single-center study, patients who received cefazolin and nafcillin had no statistically significant difference in incidence of recurrence of bacteremia or mortality rate therefore, physicians may consider prioritizing cefazolin for treatment of MSSA bacteremia.

Disclosures

All authors: No reported disclosures.
210. Step-down from IV to oral therapy in patients with bacteremia due to Enterobacteriaceae: fluoroquinolones (FQ) vs. ß-lactams (BL) or trimethoprim-sulfamethoxazole (TMP-SMX)
Authors: Meng Lina , Gombar Saurabh , Callahan Alison , Jung Ken , Holubar Marisa , Chang Amy , Mui Emily , Deresinski Stan
Published: October 2019

Background

Patients with Gram-negative bloodstream infection (GN BSI) commonly transition from intravenous (IV) to oral therapy after clinical improvement. Some clinical reports suggest similar outcomes with oral step down to TMP/SMX or BL compared with FQ in uncomplicated GN BSI, despite questionable pharmacodynamic target achievement with oral administration of the former. We sought to compare clinical outcomes in Stanford Health Care (SHC) patients with GN BSI who received step-down therapy with FQ vs. BL or TMP/SMX.

Methods

This was a retrospective cohort study of patients treated at SHC from 1/2010–December 2018 for Enterobacteriaceae bacteremia with oral stepdown to FQ vs. non-FQ (TMP-SMX, BL) initiated by day 7 of therapy. Preliminary data were obtained from electronic health records (EHR) and analyzed via the GreenButton informatics consult service at SHC. The primary outcome was 30-day mortality. Secondary outcomes included 30 and 90-day recurrent BSI, and 90-day C.difficile infection (CDI). Survival analysis was completed for each outcome using the log-rank test to calculate hazard ratio (HR). Cohorts were compared without adjustment and with basic matching controlling for age, sex, length of EHR record, and number of encounters with SHC.

Results

Of 529 eligible patients, 414 were in the FQ vs. 115 in the non-FQ oral stepdown cohorts. In unadjusted analysis, 30-day mortality was similar between the FQ and non-FQ groups, (5.8% vs. 6.1%, HR 1.06; 95% CI, 0.46–2.46), P = 0.89. Thirty-day recurrent BSI (1.2% vs. 2.6%, HR 2.20; 95% CI, 0.53–9.20) P = 0.27) and 90-day CDI rates (3.1% vs. 1.7%, HR 0.56; 95% CI 0.13–2.48, P = 0.44) were similar between groups. Ninety-day recurrent BSI was higher in the non-FQ group (1.9% vs. 5.2%, HR 1.38; 95% CI, 0.31–6.15. P = 0.0485).(Table 1) In matched analysis (n = 61), 30-day mortality was similar between groups (5.8% vs. 6.1%; HR 1.06, 95% CI 0.46–2.46, P = 0.89). Matched analysis found no statistically significant differences between groups for all secondary outcomes. (Table 2)

Conclusion

In this study, 30-day mortality was not different among patients that received oral step down to an FQ vs. non-FQ for the treatment of Enterobacteriaceae bacteremia. Larger, prospective trials are warranted to validate observations and determine optimal dosing of oral antibiotics in this setting.

Disclosures

All authors: No reported disclosures.
257. Aspergillus Galactomannan Lateral Flow Assay for Rapid Diagnosis of Invasive Aspergillosis in Bronchoalveolar Lavage
Authors: Hoenigl Martin , Reed Sharon L , Mehta Sanjay R , Law Nancy , Aslam Saima , Taplitz Randy , Jenks Jeffrey D
Published: October 2019

Background

Early diagnosis and treatment of invasive pulmonary aspergillosis (IPA) remain the most important factor to reduce mortality. Diagnosis remains a challenge, however, due to unspecific clinical presentation and radiological findings. Only very recently rapid tests for IPA have been developed. The objective of this study was to evaluate the performance of the new CE-marked Aspergillus Galactomannan Lateral Flow Assay (LFA; IMMY, Oklahoma, USA; figure) for IPA in patients with and without hematological malignancies.

Methods

The Aspergillus Galactomannan LFA was retrospectively performed according to the manufacturer’s instructions in 106 previously frozen bronchoalveolar lavage fluid (BAL) samples from 106 patients at risk for IPA (23% with underlying hematological malignancies). Samples were collected between September 2016 and September 2018 at the University of California, San Diego. Performance of the LFA was compared with Galactomannan, BAL culture and the Aspergillus-specific LFD (another rapid test for IPA). IPA was classified according to revised EORTC/MSG criteria.

Results

Overall, 22 patients met criteria of probable or proven IPA, 9 possible IPA, while 75 patients did not fulfill criteria of IPA. Sensitivity of the Apergilllus Galactomanann LFA for probable/proven IPA was 77% (17/22). Sensitivity was similar to BAL GM (77% with a cutoff of 1.0 ODI), but higher compared with the Aspergillus-specific LFD (59%), and BAL culture (23%). The LFA resulted negative in 7/9 cases with possible IPA and 47/73 cases without IPA (overall specificity 66%, 54/82). The less than perfect specificity was driven particularly by non-neutropenic patients (specificity 62%, 43/69), while specificity was 85% among patients with underlying hematological malignancies. Lower specificity among non-neutropenic patients was also observed for the BAL GM (overall 77%, non-neutropenic patients 72%), the Aspergillus-specific LFD (overall 70%, non-neutropenic patients 67%) and BAL culture (overall 90%, non-neutropenic 88%).

Conclusion

Our study indicates that the LFA may be useful for rapid diagnosis of IPA in BALF when IPA is clinically suspected. The lower specificity in non-neutropenic patients may be explained by limited applicability of the EORTC/MSG criteria in those patients.

Disclosures

All authors: No reported disclosures.
284. Using Epidemiologic Investigation and Viral Sequencing to Describe and Provide Public Health Response to an Outbreak (OB) of Acute Hepatitis A Virus Infection (HAV) in the San Fernando Valley (SFV), California
Authors: Civen Rachel H , Haddix Meridith , Baker Shiarron , Gounder Prabhu
Published: October 2019

Background

California (CA) experienced a large hepatitis A OB in 2017–2018 associated with genotype IB strains, primarily among persons experiencing homelessness and/or using drugs. In October and November 2018, we identified a cluster of three HAV cases among persons linked by drug use and homelessness in the San Fernando Valley (SFV), CA. We describe how molecular epidemiologic methods linked an additional four OB cases that lived or were associated with a senior housing facility (SHF) and guided hepatitis A vaccine outreach.

Methods

Suspect HAV cases were reported to DPH through provider and electronic lab reports with positive serum HAV IgM and resided in a 2 mile2 area in SFV. A case report and extended interview were completed on suspects to assess risk factors associated with HAV transmission and contacts. HAV IgM positive serum specimens were sent to the CA DPH Viral and Rickettsial Disease Laboratory for HAV RNA detection and molecular sequencing. Extracted nucleic acids were amplified using nested, RT-PCR targeting the VP1-P2B region, and a 315 nt fragment was sequenced using Sanger sequencing. Contacts to cases received HAV prophylaxis and HAV vaccine outreaches occurred in at-risk settings.

Results

We identified 7 HAV cases with symptom onsets from October 2018 to January 2019. All 7 cases had positive serum HAV IgM, ≥ALT 3 X normal or had a specimen matching the OB strain and were epi- linked to a case previously identified. Of 3 homeless cases, 2 had genotype 1B, CA cluster A; one specimen was unavailable. Four additional SHF cases were 2 residents, one staff, and one visitor. Among the 4 cases associated with the SHF, three had genotype 1B, CA cluster A; one specimen was unavailable. Two elderly residents reported severe fatigue, without nausea, diarrhea and vomiting. Among the 3 homeless individuals, no direct link to the SHF was established. In total, 948 HAV vaccines were provided at the SHF, homeless shelters and other settings. HAV vaccine coverage for SHF residents and food handlers was 70% and 62%,, respectively.

Conclusion

Two clusters of HAV cases were identified among homeless persons and individuals associated with an SHF were linked through a common HAV genotype. Two elderly cases had atypical symptoms that may not have been confirmed as HAV without viral sequencing and prompted vaccine campaign to prevent additional HAV cases.

Disclosures

All authors: No reported disclosures.
285. Fibrosis Progression and Clinical Outcomes in HCV/HBV Coinfected Persons in the ERCHIVES Cohort
Authors: Butt Adeel A , Yan Peng , Aslam Samia , Sherman Kenneth , Siraj Dawd , Safdar Nasia , Hameed Bilal
Published: October 2019

Background

Progression of liver disease and clinical outcomes in HCV/HBV coinfected persons and how they differ from HCV monoinfected persons and HCV infected persons with resolved HBV infection are not well characterized. We compared incidence of cirrhosis, hepatic decompensation and overall mortality in these three groups.

Methods

Using the Electronically Retrieved Cohort of HCV-infected Veterans (ERCHIVES), we identified those with HCV infection only, HCV/HBV coinfection (HbsAg or HBV DNA or both positive) or HCV with resolved HBV (HbcAb+ in absence of HbsAg or HBV DNA positivity). We excluded those with HIV coinfection or hepatocellular carcinoma at or before baseline, and those who received any HCV or HBV treatment. Incident rates (95% CI) were determined for cirrhosis, first hepatic decompensation event and overall mortality in the three groups.

Results

We identified 60,368 HCV monoinfected (Gp A), 151 HCV/HBV coinfected (Gp B) and 19,802 HCV infected with resolved HBV infection (Gp C). Mean age was 61.0, 60.9, and 63.0 years in the three groups and 96.5%, 96.0%, and 97.9% were males. Median baseline FIB-4 index was 2.0, 2.2, and 2.1, respectively. Incident cirrhosis (among those without cirrhosis at baseline) was increased 2- to 2.5-fold in HCV/HBV coinfected persons with baseline FIB-4 of 1.46–3.25. Hepatic decompensation and mortality were also increased several-fold in the HCV/HBV coinfected who had minimal or mild/moderate fibrosis at baseline. However, among those with cirrhosis at baseline, the difference was small among HCV/HBV coinfected and the other groups.

Conclusion

HCV/HBV coinfected persons with minimal or mild/moderate fibrosis at baseline have a much higher risk of developing cirrhosis, hepatic decompensation and mortality. However, once cirrhosis has is established, the difference is diminished. This underscores the need to intervene early when HCV/HBV coinfected persons still have minimal or mild/moderate fibrosis.

Disclosures

All authors: No reported disclosures.
288. Hepatitis B Virus Reactivation in Patients with Hematologic Malignancies after Anticancer Therapy Which Included Ibrutinib
Authors: Malek Alexandre , Nieto Yago , Szvalb Ariel D , Siddiqui Shaheer , Shafi Mehnaz A , Hwang Jessica P , Raad Issam I , Torres Harrys A
Published: October 2019

Background

Several cases of severe bacterial, fungal, and viral infections have been reported following ibrutinib therapy. Here, we report a case of a patient with non-Hodgkin lymphoma who developed hepatitis B virus (HBV)–associated liver failure after anti-cancer treatment most recently with ibrutinib. We also review reported cases of HBV reactivation (HBVr) after ibrutinib.

Methods

We searched the Medline and Embase databases and identified 5 patients with HBVr related to ibrutinib for a total of 6 study patients, including our case (figure). HBV-related outcomes were defined according to the 2018 AASLD HBV guidance document.

Results

All 6 patients were men and most (5 or 83%) had chronic lymphocytic leukemia and past HBV infection (table). Three patients (50%) developed HBV-related hepatitis and 2 of them progressed to liver failure. Four patients (67%) had a remote history (≥24 months) of other potential risk factors besides ibrutinib that could contribute to HBVr, including the use of direct-acting antivirals for hepatitis C co-infection (1 pt), hematopoietic cell transplant (HCT) (1 pt) and rituximab use (4 patients). HBVr occurred at least 6 months after initiation of ibrutinib in most patients (4 or 67%), with a median of 9.7 months (range, 1.5–42). In all 4 patients pretreated with rituximab, that treatment was completed at least 24 months before HBVr. Two of these patients received anti-HBV prophylaxis that was stopped 12 months after the completion of rituximab; the other 2 patients were only monitored without antivirals. The HCT recipient received anti-HBV prophylaxis per guidelines. None of the 6 patients treated with ibrutinib were receiving anti-HBV prophylaxis at the time of HBVr, but 5 patients were started on anti-HBV drugs at the first sign of HBVr. Four received entecavir and 1, tenofovir. All treated patients recovered from HBVr. No pt died of HBVr.

Conclusion

Life-threatening HBVr can occur following ibrutinib therapy in patients with past or chronic HBV infection. The temporal association between ibrutinib therapy and reactivation indicates that ibrutinib is the likely cause of the HBVr, and clinicians should be aware of the risk of HBVr in these patients. A provisional approach could be HBV monitoring at regular intervals with initiation of antiviral therapy at the earliest sign of HBV reactivation.

Disclosures

All authors: No reported disclosures.
289. Importance of Universal Screening for Hepatitis B in Cancer Patients: Quality Improvement Project in Japan
Authors: Mori Nobuyoshi , Motoki Tsutomu , Matsuo Takahiro , Ohde Sachiko
Published: October 2019

Background

Hepatitis B virus (HBV) reactivation after immunosuppressive therapy in cancer patients is associated with significant morbidity and mortality. In the United States (US), infection rate of previous HBV infection and chronic HBV infection in cancer patients is 6.5% and 0.6%,, respectively. Universal screening of HBV including surface antigen (HBsAg) and core antibody (HBcAb) in cancer patients has not been recommended in the United States, but it may be warranted to prevent viral reactivation and adverse clinical outcomes in endemic countries such as Japan.

Methods

We conducted a retrospective chart review at a tertiary care hospital in Tokyo, Japan from July 2003 through March 2019 and collected the data of HBV screening tests in patients with cancer and without cancer. (1) We compared the positive results of HBsAg and HBcAb between patients with cancer and without cancer during the study period. (2) We started a quality improvement (QI) project in 2012 to raise the rate of HBV screening tests in cancer patients and analyzed the rate of HBV screening tests by comparing pre vs. post QI intervention.

Results

Overall, the positivity rate of HBsAg and HBcAb was 1.18% (10,979/929,024) and 20.2% (3,538/17,537), respectively. When we compared positive results of cancer patients with non-cancer patients, HBsAg was significantly higher (1.85% [424/22,934] vs. 1.16% [10,555/906,090], P < 0.001) (Figure 1), and HBcAb showed lower tendency (14.1% [701/4,981] vs. 22.6% [2,837/12,556], P = 0.086) (Figure 2). Annual trend of screening tests in cancer patients are shown at Figures 3 and 4. Through our QI project, the rate of both HBsAg and HBcAb tests significantly increased from 91.2% (5,064/5,551) to 99.4% (7,748/7,798) (P < 0.001) and from 3.9% (215/5,469) to 81.2% (6.304/7,767) (P < 0.001), respectively, from 2011 to 2018.

Conclusion

Prevalence of HBV is much higher in Japan than the United States. Universal screening tests of HBV in cancer patients is warranted especially in endemic countries to prevent reactivation and adverse clinical outcomes. The rate of screening tests dramatically increased through our QI project.

Disclosures

All authors: No reported disclosures.
297. Accessible Care Intervention for Engaging People Who Inject Illicit Drugs in Hepatitis C Virus Care: Preliminary Results from a Randomized Clinical Trial
Authors: Eckhardt Benjamin , Aponte-Meledez Yesenia , Fung Chunki , Kapadia Shashi , Davis La , Smith Melinda , Mateu-Gelabert Pedro , Marks Kristen
Published: October 2019

Background

To achieve hepatitis C elimination, treatment programs need to be developed to engage, treat, and cure people who are actively injecting drugs.

Methods

We present preliminary data from the first 65 participants in the Accessible Care intervention for engaging people who inject illicit drugs (PWID) in hepatitis C (HCV) care. The randomized clinical trial compares the effectiveness of Accessible Care (low-threshold care in a syringe service program located in New York City) with Usual Care (referral to existing services) in facilitating linkage, engagement, and retention in HCV care. Eligible participants were HCV RNA positive and had injected drugs in the past 90 days. We compared the percentage of participants in each arm linked to HCV care (defined as one visit with HCV treatment provider), and initiated direct-acting antiviral (DAA) treatment within 6 months of enrollment.

Results

Among the 65 participants, the mean age is 41.2 years; 28% are females; 73% homeless; 6% black, 51% Latina/o and 39% white. 82% of participants had injected drugs in the last 30 days, with an average of 13.2 injections/month (median 10). Nearly all participants had health insurance, 88% public insurance, 6% uninsured. Thirty-two participants were randomized to the Accessible Care arm. Within 6 months of enrollment 79% of the Accessible Care arm and 25% of the Usual Care arm had linked to HCV care, and 69% and 13% had been started on DAA therapy, respectively. Of the 26 participants in the Accessible Care arm started on DAA therapy, the median time from enrollment to treatment initiation was 87.5 days [range 22–180].

Conclusion

Among HCV-infected PWID enrolled at a syringe service program, higher rates of linkage to care and treatment initiation were seen in the Accessible Care arm where stigma- and shame-free treatment was located within a community-based location.

Disclosures

All authors: No reported disclosures.
332. Exploring the Prevalence and Characteristics of Weight Gain and other Metabolic Changes in Patients with HIV Infection Switching to Integrase Inhibitor Containing ART
Authors: Zimmerman Matty , DeSimone Joseph , Schafer Jason J
Published: October 2019

Background

Excessive weight gain in patients living with HIV (PLWH) can have considerable health-related consequences. Recent observational studies suggest that patients initiating or switching to integrase strand transfer inhibitor (INSTI)-based antiretroviral therapy (ART) may experience weight gain. The prevalence and extent of weight gain as well as the presence of other metabolic changes following switches to INSTI-based ART remain unclear.

Methods

This retrospective study evaluated changes in weight, body mass index (BMI), cholesterol and hemoglobin A1C in virologically suppressed PLWH who switched from non-INSTI to INSTI-based ART at a single academic medical center from May 2015 to December 2017. Adult patients on non-INSTI-based ART for ≥1 year before switching to INSTI-based regimens were included. Body weight, BMI, cholesterol and A1C values were collected for the year prior to and 18 months following the switch. The unadjusted distributions of pre- and post-switch values were compared with the Wilcoxon signed-rank test and predictors of weight gain were determined with simple linear regression.

Results

A total of 90 patients met criteria for analysis (Table 1). In unadjusted analyses, there were significant increases in weight and BMI (each P ≤ 0.001, Table 2), but not cholesterol or A1C values following switches to INSTI-based ART (Table 3). On average, patient weight increased by 2.2 kg after switching, though 26% of patients gained ≥4.5 kg. Patients switching from non-nucleoside reverse transcriptase inhibitors vs. protease inhibitors had numerically greater mean increases in weight (Table 3). A similar trend occurred for those switching to elvitegravir as opposed to dolutegravir. In the linear regression model, neither pre-switch nor post-switch ART components were identified as predictors for weight gain. This was also true for differences in gender, race, and pre-switch BMI. Increasing age was protective against weight gain in the model.

Conclusion

Weight gain in patients switching to INSTI-based ART observed in this analysis did not correspond to changes in cholesterol or glycemic control. Some patients receiving INSTIs in this sample gained substantial amounts of weight. The mechanisms and risk factors for substantial weight gain require further study.

Disclosures

All authors: No reported disclosures.
339. Implementing a Smoking Cessation Intervention Among People Living With HIV (PLWH)
Authors: Beckett Sadie , Richey Lauren E
Published: October 2019

Background

PLWH who smoke have increased mortality and decreased quality of life. Our clinic is a large, urban academic center that cares for over 1,600 PLWH with a large proportion of smokers (recent estimates 61% current, 16% former). Our goal was to assess the outcomes of our new clinic-wide smoking cessation intervention. We hypothesize that our intervention will increase smoking cessation among our patients.

Methods

A multidisciplinary committee met to design a cessation pathway to increase smoking cessation in the clinic. The pathway began with an assessment of smoking during triage. The provider then discussed cessation during the visit and patients who were ready to quit were referred to a health educator. Upon referral, participants were enrolled in the smoking cessation trust (SCT) which is a free program for patients who have been smoking before 1988 (N = 33) and provides NRT. Participants who were born after 1980 (N = 10) received their NRT through the Ryan White formulary. The intervention consisted of a baseline interview and 5 modules. Participants received their NRT or pharmacologic agent prior to the intervention. Participants (N = 43) were PLWH from our clinic who smoke and were referred from May 1, 2018 through March 1, 2019.

Results

Participants were 79% black, 74% male and on average were 47 years old. Among participants, 21 participants met with a health educator for the initial interview and participated in the intervention, while 22 only met with the health educator for an introductory interview to determine which pharmacologic/NRT agent would work best for them. Of the 43 participants, 30 participants received pharmacologic/NRT agents. Among all participants, 23% of individuals quit smoking cigarettes within 2 months of completing the baseline interview and first module. Of those that quit, 50% used Chantix and 70% attended counseling sessions with the health educators. Of the participants who did not quit, 21 participants cut down on the amount they smoked with almost 81% of them cutting the number of cigarettes they smoked in half.

Conclusion

A multidisciplinary intervention consisting of assessment, counseling, and pharmacologic therapy and/or NRT can improve cessation in PLWH that smoke (23%). Future studies are needed to confirm these results among larger populations.

Disclosures

All authors: No reported disclosures.
367. Use of a Brief Task-Based Measure to Assess the Functional Consequences of Cognitive Impairment in HIV
Authors: Agan Brian , Smith Bryan , Hsieh Hsing-Chuan , Won Seunghyun , Ganesan Anuradha , Maves Ryan , Utz Gregory , Tramont Edmund , Nath Avindra , snow Joseph
Published: October 2019

Background

In spite of viral suppression with antiretroviral therapy (ART), neurocognitive impairment (NCI) affects ~20% of those infected with HIV; most are asymptomatic or only mildly impaired based on instrumental activity of daily living (IADL) self-reported questionnaires. Previous studies have shown a strong association between depression, common among HIV+, and self-reported IADL impairment, potentially confounding evaluation of the functional impact of NCI. We studied a brief (15–20 minutes) task-based measure of function, the Texas Functional Living Scale (TFLS), in the context of HIV, NCI, and depression.

Methods

Baseline data were analyzed from parallel, longitudinal cohort studies of neurocognitive function among HIV+ and demographically matched HIV-subjects enrolled at NIH and DoD sites. Subjects recruited at NIH were on ART with viral suppression (VS) ≥1 year and nearly all in the DoD also had long-term VS. All participants underwent a standardized, comprehensive neurocognitive battery (7 domains), as well as the TFLS. Global deficit score (GDS) ≥0.5 defined neurocognitive impairment (NCI) and TFLS impairment was defined as T-score >1 standard deviation below mean (i.e., < 40).

Results

420 subjects were evaluated with demographics in Table 1. Eighty-five subjects (20%) had NCI by GDS and 57 (13%) subjects had TFLS impairment. 17% had a Beck Depression Inventory II (BDI) score ≥13 indicating significant depressive symptoms. In univariate analysis of Table 1 variables, only HIV status was not significantly different between those with or without TFLS impairment, however after adjustment using multivariable logistic regression, only education level, race, and NCI were associated with TFLS impairment; depressive symptoms (BDI ≥13) were not associated with functional impairment measured by TFLS.

Conclusion

In parallel DoD and NIH cohorts of well-treated HIV+ and matched HIV- subjects, task-based functional impairment measured by TFLS was strongly associated with NCI, but not with depressive symptoms, suggesting the potential utility of this measure to better understand the functional consequences of HIV associated neurocognitive disorders. While the association of TFLS with education was expected, that with race was not and requires further study.

Disclosures

All authors: No reported disclosures.
372. Prevalence of Urethral, Rectal, and Pharyngeal Gonorrhea and Chlamydia among Newly Diagnosed Filipino HIV Patients
Authors: Li Kingbherly L , B. Valencia Jose Carlo , Taladtad Florida F , Hernaez Mary Grace T , Luzentales Vivienne V , Abad Cybele Lara R , Salvana Edsel Maurice T
Published: October 2019

Background

The Philippines has the fastest-growing HIV epidemic in the Asia-Pacific. Concurrent sexually-transmitted infections increase the risk of HIV transmission and complications. The prevalence of Neisseria gonorrheae (NG) and Chlamydia trachomatis (CT) infection among Filipino HIV patients is unknown and screening is not universal. A symptom-based approach likely underestimates the prevalence of NG and CT among men who have sex with men (MSM). We determined the rectal, pharyngeal, and urethral prevalence of gonorrhea and chlamydia infection in our patient population using nucleic acid testing (NAT).

Methods

This is a single-center, prospective cross-sectional study at Philippine General Hospital. Following ethical approval and informed consent, pharyngeal, rectal, and urine samples from newly-diagnosed, treatment-naïve HIV adult patients were tested using the Xpert® CT/NG assay (Cepheid, Sunnydale, CA). Patients with recent (≤21 days) antibiotic use with activity against NG or CT were excluded. Demographic and clinical data were also collected.

Results

46 subjects were enrolled. Mean age was 31 years (range 19–49), 83% (38/46) were male, 96% (44/46) were asymptomatic, and 92% (35/38) of the males were MSM. Median CD4 count was 225 cells/μL (range 0–1,335). The overall prevalence of CT/NG was 33% (15/46). Table 1 shows the prevalence of CT and NG by site. Four patients had both genital and rectal CT. More patients had rectal NG/CT compared with urethral and pharyngeal sites. No gonorrhea was found in the urine specimens; no chlamydia was found in the pharynx.

Conclusion

The prevalence of CT and NG among newly diagnosed Filipino HIV patients at 33% is sufficiently high to warrant routine NAT screening. Urine testing alone will miss a significant number of cases in an MSM-predominant population. We recommend NAT screening of both urethral and rectal sites for newly-diagnosed Filipino HIV patients.

Disclosures

All authors: No reported disclosures.
399. Treatment and Outcome of Prosthetic Joint Infection in Unicompartmental Knee Arthroplasty
Authors: Carli Alberto V , Kapadia Milan , Chiu Yu-fen , Henry Michael , Miller Andy O
Published: October 2019

Background

Unicompartmental knee arthroplasty (UKA) is an increasingly popular alternative to total knee replacement due to easier recovery and greater satisfaction. However, limited evidence guides the management of periprosthetic joint infection (PJI) in UKA specifically. We retrospectively reviewed the largest cohort of UKA PJI to date, providing our experience in a high volume tertiary institution.

Methods

An institutional PJI database was queried from 2008 to 2016 to identify all PJI cases with an index procedure of UKA. Treatment, diagnostic criteria, Charlson Comorbidity Index (CCI) and microbiology data were collected. Success was defined as no further surgical treatment for infection at 2 years. A chi-square test or Fisher’s exact test was used for comparisons between treatment success and failure groups. Survival probability was calculated using the Kaplan–Meier method.

Results

A total of 24 UKA PJIs were identified with 22 meeting MSIS criteria. Median age at infection was 65.9 years (range, 50.8–87.4), median BMI was 26.7 kg/m2 (range, 21.2–49.5), 75% male (18/24).The average follow-up time was 2.83 years. 9 patients presented with early (4 weeks of symptoms). 63% (15/24) of PJI cases were staphylococcal and 8.3% (2/24) were culture negative. Patients were either treated with 1 stage exchange (n = 3, 100% success), two-stage exchange (n = 5, 80% success) or implant retention (n = 16, 75% success). Overall survivorship was 79% at 2 years (95% confidence interval [CI], 63%–95%). Overall there was no significant association between success and CCI (P = 0.46), infection type (P = 0.29), surgical therapy (P = 0.62), and microorganism (P = 0.05).

Conclusion

In this series, UKA PJIs tended to present more often as early post-operative or hematogenous infections. We observed no significant benefit with revision surgery and therefore conclude that implant retention should be considered as first-line surgical treatment. Outcomes of UKA PJI appear comparable to those in TKA PJIs.

Disclosures

All authors: No reported disclosures.
404. miRNA-Gene Pairs Associated with Shock and Renal Failure in Filipino Septic Patients
Authors: Deguit Christian Deo T , Yoro Manuel D , Erric Cinco Jude , Sonia Salamat Maria , Adrian Buensalido Joseph , Silao Catherine , Alejandria Marissa M , Nevado Jose
Published: October 2019

Background

Small non-coding microRNAs (miRNAs) are increasingly recognized as key regulators of the host response to sepsis. However, the molecular mechanisms implicated in the role of miRNAs during sepsis progression is still unclear. It is hypothesized that differentially expressed genes in septic patients with worse outcomes are associated with dysregulation of miRNA expression. This study aimed to identify specific miRNA-gene pairs that may be implicated in the development of shock and renal failure in sepsis.

Methods

miRNA from serum and RNA from PBMCs were acquired from n = 40 participants in a prospective cohort of Filipino septic patients: n = 15 developed septic shock and n = 17 developed renal failure. RT-qPCR was done to measure the expression of 21 sepsis-associated miRNAs. Differentially expressed miRNAs (DEMs) for each outcome was identified, followed by gene target prediction for each DEM. Gene expression microarrays covering 18,616 genes were also performed to identify differentially expressed genes (DEGs; P < 0.05, log FC> |0.3|) for each outcome. Significant miRNA-gene pairs were selected by evaluating the overlap of the predicted gene targets of the DEMs with the DEGs for each corresponding outcome. Given the gene-silencing mechanism of miRNAs, overlap analysis was performed on only the downregulated DEGs when the specific DEM was upregulated (and vice versa).

Results

Septic participants who developed shock, compared with those who did not, had higher expression of 1 DEM, miR-223-5p, and downregulation of 20 DEGs. NUS1 was the only predicted gene target of miR-223-5p that was also downregulated in septic shock. Participants who developed renal failure, vs. those who did not, had lower expression 6 DEMs and upregulation of 6 DEGs. KPNA4 is a gene target of the DEMs, miR-126-5p, and miR-181a-5p, that was also upregulated in renal failure.

Conclusion

Significant miRNA–gene pairs related to worse clinical outcomes in sepsis were identified: miR-223-5p with NUS1 for shock and either miR-126-5p or miR-181-5p with KPNA4 for renal failure. While the biological significance of these miRNA-gene pairs still needs to be evaluated, these findings can potentially help future efforts in developing prognostic markers or therapeutic targets for shock and renal failure in sepsis.

Disclosures

All authors: No reported disclosures.