bluuebunny/crossref_metadata_2025 huggingface dataset:
1882. Tuberculosis in the Department of Veterans Affairs: Missed Opportunities for Prevention
Authors: Oda Gina , Lucero-Obusan Cynthia , Schirmer Patricia , Holodniy Mark
Published: October 2019

Background

US and global elimination of tuberculosis (TB) is an important goal. Despite decreased incidence, CDC predicts elimination of TB in the US will not occur in the 21st century without improved detection and treatment of latent TB infection (LTBI). We describe the current burden of active TB infection and LTBI testing and treatment among patients within the Department of Veterans Affairs (VA).

Methods

Using the 2009 CDC case definition for laboratory-confirmed TB, we queried VA data sources from January 2010 to December 2018 for Mycobacterium tuberculosis detected via culture or nucleic acid amplification test (NAAT) from specimens from all body sites. For all TB patients, we extracted demographic, ICD-9 and ICD-10 risk factor, and LTBI testing and treatment data.

Results

Between 2010 and 2018, the average annual incidence of TB was 1.7 cases per 100,000 unique users of VA care (ranging from a high of 2.8 in 2010 to low of 0.8 in 2018). For 899 identified cases, demographic factors associated with highest TB rates were age between 45 and 64, Asian race, and residence in District of Columbia (Table 1). The most frequently occurring risk factors were substance abuse, diabetes, and homelessness. Of 90 patients with susceptibility documentation, 14 (15%) had resistance to 1 or more anti-TB drug (1 with multi-drug-resistant TB). Fifteen patients (1.7%) died within 7 days of their TB diagnosis; in all but 2 cases, TB was the primary cause of death (Table 2). Figure 1 depicts screening and treatment for LTBI among patients with TB. Only 228/899 (25.4%) TB patients had LTBI screening ≥ 3 months prior to diagnosis. Of the 347 TB patients never screened for LTBI, 264 (76%) had ≥ 1 documented TB risk factor. Among 228 patients screened for LTBI >3 months prior to active disease, 69 (30%) screened positive; however, only 24 (35%) had LTBI treatment initiated.

Conclusion

Although rates of TB infection are decreasing, VHA providers would benefit from education on recognizing patients with risk factors which place them at high risk for TB who should be screened for LTBI. CDC recommends preventive treatment of patients who screen positive for LTBI, and provider collaboration with local public health departments to provide directly observed therapy in cases where adherence may be in question.

Disclosures

All Authors: No reported Disclosures.
1887. Estimating the Burden of Waterborne Disease in the United States
Authors: Collier Sarah , Benedict Katharine , Fullerton Kathleen , Deng Li , Cope Jennifer R , Yoder Jonathan , Hill Vincent
Published: October 2019

Background

Treatment of drinking water is one of the greatest US public health achievements of the twentieth century and provides a safe, reliable water supply. However, waterborne disease and outbreaks continue to occur, and are associated with a variety of water sources and exposure routes. New estimates of the burden of waterborne disease in the United States will direct prevention activities and set public health goals.

Methods

We chose 17 waterborne diseases for which domestic waterborne transmission was plausible, substantial burden of illness or death was likely, and data were available. Diseases included were campylobacteriosis, cryptosporidiosis, giardiasis, Legionnaires’ disease, norovirus infection, nontuberculous mycobacteria [NTM] infection, otitis externa, Pseudomonas pneumonia and septicemia, salmonellosis, Shiga toxin-producing E. coli infection, shigellosis, and vibriosis. Adapting previously used methods, disease-specific multipliers were used to adjust the reported/documented number of cases of each disease for under-reporting, under-diagnosis, proportion domestically acquired, and proportion transmitted via water, to generate point estimates with 95% credible intervals (CrI). Data sources included surveillance data, population studies, and expert judgment if no other data were available. We estimated the number of illnesses, ED visits, hospitalizations, and deaths, and costs of ED visits and hospitalizations due to waterborne disease in the United States in 2014.

Results

7.2 million waterborne illnesses (CrI 3.9–12.0 million) from the selected diseases occur annually, including 600,000 (CrI 365,000–865,000) ED visits, 120,000 (CrI 85,000–150,000) hospitalizations, and 6,500 deaths (CrI 4,300–8,900) deaths, incurring US$3.2 billion (2014 dollars) in direct healthcare costs. Hospitalizations and deaths were predominantly caused by environmental pathogens commonly associated with biofilm in plumbing systems (NTM, Pseudomonas, Legionella) costing US$2 billion annually.

Conclusion

Millions of domestically acquired waterborne illnesses from these 17 infections occur in the United States each year, and incur billions of dollars in healthcare costs.

Disclosures

All Authors: No reported Disclosures.
1949. Putting Out Fires: Assessing Burnout within an Infectious Diseases Fellowship at an Academic Medical Center
Authors: Alexander Leslie-Ann , Blair Barbra M , Stead Wendy
Published: October 2019

Background

Burnout, “a psychological syndrome of emotional exhaustion (EE), depersonalization (DP), and reduced personal accomplishment (PA),” is a well-described problem in the medical community. National surveys report 45% of practicing physicians and 60% of residents and fellows are burnt out. A longitudinal study of medical students and residents reported 45% burnout, as well as career choice regret in 14% of trainees. There are little data about burnout in Infectious Diseases (ID) physicians, including fellows. We sought to measure burnout prevalence in an academic ID Division, identify factors that modified the risk of burnout, and assess knowledge and attitudes about fellow and faculty burnout in the division.

Methods

The study population included 33 ID physicians (10 fellows, 23 faculties). Level of burnout was assessed via the Maslach Burnout Inventory (MBI), a validated 22-item tool. An additional survey was distributed as a needs assessment to determine participant understanding of “burnout” and “wellness,” ability to recognize burnout in colleagues, attitudes about the scope of the problem, and specific programmatic and personal factors felt to contribute to burnout.

Results

The MBI was completed by 10 fellows and 16 faculties (76%). A high score in ≥ 1 domain of burnout was reported in 50% of respondents, and 19% received a high score in both EE and DP. Fellows had moderate to high levels of EE (90%) and DP (70%), though all fellows reported at least a moderate sense of PA.

The survey needs assessment was completed by 9 fellows and 17 faculties (79%). In a hypothetical case, 100% and 58% of participants correctly identified elements of DP and EE, respectively. Respondents identified several factors contributing to burnout risk, most commonly being lack of schedule autonomy (100%), increasing patient load (96%), and inability to attend teaching conferences (88%). Fellows felt burnt out when seeing ≥ 4 new consults per day and/or carrying a census of 10–11 patients.

Conclusion

ID fellows at an academic medical center recognize burnout and report levels on par with national data. Fellows and faculty can identify personal and programmatic factors that increase and decrease their risk of burnout. These data can guide programmatic and divisional interventions to improve trainee wellness.

Disclosures

All Authors: No reported Disclosures.
1963. PrEP Significantly Reduces the Rate of New HIV Diagnoses in US Metropolitan Statistical Areas Independent of Treatment as Prevention (2012–2017)
Authors: Mera-Giler Robertino M , Das Moupali , Hawkins Trevor , Magnuson David , Asubonteng Julius , McCallister Scott
Published: October 2019

Background

Tenofovir/Emtricitabine (TVD) was approved for a Pre-exposure Prophylaxis (PrEP) indication in the United States in July 2012. Biomedical HIV prevention tools can impact the rate of new HIV diagnoses but their relative contributions have not been described.

Methods

The analysis utilized CDC published data on HIV diagnoses in 105 US metropolitan statistical areas (MSAs), a Treatment as Prevention (TasP) proxy of HIV suppressed individuals from 38 US states and DC, and a national pharmacy and medical claims databases to track TVD PrEP use from 2012 to 2017. The calculation of person time at risk excluded time of those taking PrEP as well as those who became HIV positive. TVD PrEP use was categorized in quintiles. A multilevel Poisson regression model which considers changes over time of each MSA was utilized. Rates and rate ratios plus corresponding 95% confidence intervals were obtained for quintiles of PrEP utilization after adjusting for the effect of treatment as prevention and calendar time.

Results

The US MSA rate of HIV diagnoses decreased significantly at a rate of 5.1% (95% CI −4.8 to −5.3%) per year in the period 2012–2017. PrEP use increased from an average of 1.64+1.3 per 100 subjects with a PrEP indication in 2012 to 15.4 + 3.2 in 2017. HIV viral suppression also increased by 1.3% per year (95% CI 1.1 to 1.6%) during the same period among HIV treated subjects. A multivariate model showed that PrEP use was significantly associated with the decline in the rate of new HIV cases, independent of a significant TasP effect. During the period of observation, the lowest quintile of PrEP utilization saw a decline of −0.23% (95% CI −0.2 to −0.43%), while the highest quintile of PrEP utilization showed a statistically significant decline of −4.24% (95% CI −0.39 to −8.01%) per year. Treatment as prevention had a significant and independent effect of- 1.56% (−1.1 to −2.1%) per each percent increase of the proportion of HIV subjects with suppression.

Conclusion

From 2012 to 2017, HIV diagnoses declined most steeply in MSAs where PrEP use was the highest. The effect of PrEP use was significantly associated with this decline and was independent of treatment as prevention.

Disclosures

All Authors: No reported Disclosures.
2843. Maternal Fecal Transplantation to Infants Born by Cesarean Section: Safety and Feasibility
Authors: Helve Otto , Korpela Katri , Kolho Kaija-Leena , Saisto Terhi , Skogberg Kirsi , Dikareva Evgenia , Stefanovic Vedran , Salonen Anne , de Vos Willem M , Andersson Sture
Published: October 2019

Background

A complication of cesarean section delivery is its interference with the normal intestinal colonization of the infant, affecting the development of immune system in early life—a process that has been associated with long-term morbidity, such as allergy and diabetes. We evaluated, in CS-delivered infants, whether the normal intestinal microbiome and its early life development could be restored by immediate postnatal transfer of maternal fecal microbiota to the newborn.

Methods

Seventeen healthy mothers with planned elective CS were recruited and screened thoroughly for infections, after which 7 mothers were included in the study. A fecal sample was processed according to a transplantation protocol and an aliquot (3–7 mg) was orally administered in breast-milk to the newborn during the first feeding. The infants were followed and fecal samples were gathered during the first 12 weeks of age and subsequently at the age of 8–18 months.

Results

The bacterial communities in the fecal samples of the mothers and their offspring were analyzed by sequencing of 16S rRNA amplicons from isolated fecal DNA and compared with that of 11 nontreated CS-delivered infants and 34 vaginally delivered infants. The fecal microbiota at 3 and 12 weeks was similar between treated CS and vaginally delivered infants, in contrast to that of the untreated CS-delivered infants both in overall composition (P = 0.001, Figure) and development of early-life signature bacteria, i.e., bacteroides and bifidobacteria and clostridia (P < 0.0001).

Conclusion

The seeding of maternal fecal microbes to the newborn intestine can be safely and successfully mimicked in elective CS by transferring a small amount of maternal fecal microbiome orally to the newborn infant. In these infants, this process results in a microbial development that is highly similar to that of the vaginally born infants, and provides support for the hypothesis that microbial colonization in early life results from a maternal fecal transfer.

Disclosures

All Authors: No reported Disclosures.
1148. Antimicrobial Stewardship Program at a Long-term Care Hospital for Severely Handicapped Children and Adults
Authors: Ishii Sho , Uda Kazuhiro , Kudo Yasuko , Fukano Koji , Igari Masako , Kaneko Tetsuji , Morikawa Kazuhiko , Furushima Wakana , Fukuoka Kahoru , Koide Ayaka , Horikoshi Yuho
Published: October 2019

Background

Although antimicrobial stewardship program (ASP) is also recommended for a long-term care facility (LTCF), research on ASP in LTCFs is still limited. Our study was conducted at an LTCF offering chronic medical care for pediatric and adult patients with extensive medical needs since childhood. Our aim of this study was to evaluate the impacts of ASP in an LTCF.

Methods

A quasi-experimental study was conducted at Tokyo Metropolitan Fuchu Ryoiku Medical Center (250 beds) in Japan. The pre- and post-intervention periods were from April 2013 to March 2017 and April 2017 to March 2019, respectively. Periodic educational interventions were conducted throughout study period. ASP in post-intervention period consisted of mandatory consultation with infectious diseases service at an outside children’s hospital for prescription of restricted drugs. Fluoroquinolones, cefepimes, carbapenems and vancomycin were listed as restricted drugs. Intravenous and oral antimicrobial use was calculated by day of therapy (DOT) per 1,000 patient-days. Interrupted time series analysis was used for level and trend change for pre- and post-intervention periods.

Results

Oral agents comprised 89% of the total antimicrobial use. Oral antimicrobials were decreased by 39% in post-intervention with significant level change (P < 0.01) and without trend change (P = 0.61) (Figure 1). Among oral antimicrobials, macrolides, fluoroquinolones and third-generation cephalosporins were decreased by 72% in post-intervention with significant level change (P < 0.01) and without trend change (P = 0.42) (Figure 2). Intravenous antimicrobials were decreased by 40% without level change (P = 0.15) and trend change (P = 0.65) (Figure 3).

Conclusion

Combining education and mandatory consultation with infectious diseases service for restricted drug enhanced in decreasing total oral antimicrobials at an LTCF.

Disclosures

All authors: No reported disclosures.
1172. The Proper Maintenance Duration for Peripherally Inserted Central Catheter (PICC) In order to Prevent Central Line-Associated Bloodstream Infection
Authors: Park Seonghun , Moon Shinje , Pai Hyunjoo , Kim Bongyoung
Published: October 2019

Background

Prolonged maintenance of central venous catheter including peripherally inserted central catheter (PICC) is a major risk factor for central line-associated bloodstream infection (CLABSI).

Methods

A single-center retrospective study was conducted in an 828-bed tertiary hospital in Korea between January 2010 and December 2017. All hospitalized patients who underwent ultrasound-guided PICC insertion were enrolled. Patients were excluded if they: (1) were under 19 years old, (2) died, were discharged, or were transferred to other medical institutions within 3 days of PICC placement, and (3) had at least one result of absolute neutrophil count (ANC) under 500 cell/µL during catheterization. CLABSI was diagnosed using the definitions of the National Health Safety Network. CLABSI caused by PICC was defined as PICC-associated bloodstream infection (PABSI). For identifying the statistical correlation between catheter-days and PABSI, odd ratio for PABSI according to the continuous value of catheter-days was analyzed using restricted cubic spline splits with five knots. Receiver operating characteristic (ROC) curve was used to determine the diagnostic precision of applying catheter-days for PABSI. The optimal cut-off value of catheter-days was identified by maximizing the area under ROC curve (AUC).

Results

A total of 1,053 patients underwent ultrasound-guided PICC insertion during the study period. Of them, 36 cases were confirmed as PABSI (3.5%, 36/1,014; 1.14 per 1,000 catheter days). In the restricted cubic spline regression, catheter maintenance days showed a dose-dependent relationship with the risk of PABSI. The ROC for developing PABSI according to catheter maintenance duration showed that the AUC was 0.715 (95% CI 0.639–0.790) and the optimal cut-off value was 25 days.

Conclusion

The incidence of PABSI was 1.14 per 1,000 catheter days and the optimal cut-off value of catheter-days for preventing PABSI was 25 days.

Disclosures

All authors: No reported disclosures.
1174. The Impact of Multidisciplinary Central Line Stewardship Program to Decrease CLABSI Rates and Central Line Utilization Rates in an Academic Urban Medical Center
Authors: Bhatt Isha , Nakeshbandi Mohamed , Augenbraun Michael , Robert Gwizdala , Lucchesi Michael
Published: October 2019

Background

Central Line-Associated Blood Stream Infections (CLABSI) is a major healthcare dilemma, contributing to increased morbidity, mortality, and costs. We sought to reduce rates of CLABSI and device utilization by implementing a multidisciplinary Central Line Stewardship Program (CLSP).

Methods

In July 2017, the CLSP, multidisciplinary quality improvement project, was implemented at an academic medical center to ensure proper indication for all CVCs in the hospital and removal when no longer indicated. A CLSP team of executive leaders and infection preventionists performed daily rounds on all CVCs to review indications and maintenance. Nursing staff reported all CVCs daily. Information Technology modified the electronic health record to require daily physician documentation of CVC placement and indications, and to suggest alternatives to CVC when possible. In the event of a CLABSI, a root cause analysis was conducted within 72 hours, and feedback was shared with the clinical staff. A retrospective review was conducted 18 months before and after CLSP implementation. As a facility in a state with mandatory reporting of hospital-acquired infections, institutional data were readily available through the National Healthcare Safety Network (NHSN). To compare rates of CLABSI and device utilization pre- and post-CLSP, we reviewed the Incidence Density Rate (IDR), the standardized infection ratio (SIR), and standardized utilization ratio (SUR). Data from the NHSN website were analyzed using statistical tools provided by the NHSN analysis module. Two-tailed significance tests were conducted with α set at 0.05.

Results

Post-CLSP, there was a statistically significant decrease in SIR from 1.99 to 0.885, with risk reduction by 44.3% (P = 0.013, 95% CI 0.226 -0.831). CLABSI IDR per 1000 CVC days declined from 1.84 to 0.886 (P = 0.0213). CVC utilization per 1000 patient-days reduced from 155.08 to 142.35 (P < 0.001). There was also a trend toward fewer PICC line infections post-intervention (17 to 5).

Conclusion

With this novel CLSP, we achieved a significant reduction in rates of CLABSI and device utilization, suggesting that a multidisciplinary approach can promote sustainable prevention of line-associated infections through dedicated surveillance of CVC indications and maintenance.

Disclosures

All authors: No reported disclosures.
1175. Tandem Heart-Associated Fevers: Does the Fever Signify Infection?
Authors: Hasan Mustafa , Nagarakanti Sandhya , Bishburg Eliahu
Published: October 2019

Background

Tandem Heart (TH) is a percutaneously inserted ventricular assist device, this unique device connects an extracorporeal axial flow pump to a catheter that crosses the atrial septum and aspirates blood from the left atrium which is returned to the femoral artery. TH is used as a bridge to transplantation or to another surgically inserted device. Fever was noted in patients after TH insertion. The objective of this study was to evaluate whether the fever after TH insertion is associated with an infection.

Methods

A retrospective review in a 680-bed tertiary care hospital from 2013 to 2016. Patients with TH were included. Data were collected on demographics, clinical presentation, onset and duration of fever, type of infections when present, and outcome. Student t-test was used for analysis.

Results

TH was inserted in 52 patients; males 41 (79%), mean age 56 years (range 25–80) Indication for TH was an acute exacerbation of congestive heart failure in 37/52 (71%) and cardiogenic shock with acute cardiomyopathy in 15/52 (29%). Mean duration of TH 9.4 days (Range: 1–29). Comorbidities were DM 19 (37%), hypertension 23 (44%), chronic kidney disease (CKD) 13 (25%), smoking 10 (19%). Fever within 72 hours of TH insertion was noted in 23/52(44%), of these 6/23(26%) had a documented infection. Pneumonia in 3, Clostridium difficile colitis 1, candida line infection 1 and 1 patient had both pneumonia and Enterobacter bacteremia. The fever lasted an average of 127 hours in patients with a documented infection vs. 45 hours in patients without a documented infection. (P = 0.08). The duration of TH in patients with infection was 14 days (range: 6–22 days) and in patients without infection was 8 days (range: 1–29 days) (P = 0.07). Mortality was noted in 5/6 (83%) patients with infection and in 5/17 patients (29%) without infection (P = 0.28). No clear etiology was found in patients with fever without a documented infection.

Conclusion

In our patients with TH, fever was a prominent clinical feature; however infection was seen in only a quarter of patients after TH insertion. Fever duration was significantly longer in patients with a documented infection and their device was present for a longer duration. The mortality was higher in patients with fever and infection. The reason for fever without a documented infection remains obscure and requires further investigation.

Disclosures

All authors: No reported disclosures.
1262. Comparative Evaluation of Native and Migrant HIV+ Pregnant Women in Chile
Authors: silva macarena , Wolff Marcelo , Orellana Laura , Carrasco Catalina , Canals Andrea , Lizama Danae
Published: October 2019

Background

The reported data of HIV + pregnant women in Latin America (LA) is scarce. Given the political and social changes that have occurred in recent years, Chile has had to face immigration as a recent phenomenon. Based on this, the objective of this analysis was to determine the baseline characteristics, virological during pregnancy and postpartum, and the impact of immigration on adult women infected with HIV

Methods

The registry of HIV + pregnant women of Fundación Arriarán was analyzed since 2006. The baseline characteristics,undetectability at delivery, vertical transmission and retention were determined.Estimators as mean and median,standard deviation and interquartile range; absolute and relative frequencies were used and for the bivariate analysis the t-test and chi2,Mann–Whitney and Fisher’s exact. For follow-up, the Kaplan–Meier method was used.

Results

A total of 214 pregnancies in 198 HIV + women were included. A 54% of foreigners (of Haitian predominance) was found, 2/3 of the foreigners were enrolled after 2016. A 73% was diagnosed with HIV at the time of pregnancy. Average age was 28.6 years. Baseline CD4 cell count was 396 cel/mm3. A 7.7% were admitted with advanced pregnancy and 4.6% had a history of drug addiction. None of these variables had significant differences between both groups. The variables of gestational age at admission (15 vs. 21; P < 0.001), gestational age at the beginning of therapy (18 vs. 21; P < 0.001), CDC stage and baseline viral load (9750 vs. 644 copies/mL;P < 0.001) were statistically significant between Chileans and foreigners. 58% of the patients achieved undetectability at the time of delivery without differences between both groups. (55% vs. 63%; p0.42) Almost 90% of women with detectable viral load at delivery was less than 1000 copies/mL (88,9%). 93% received full vertical transmission protocol and the prematurity rate was 16.6%. The vertical transmission was 2.6% without differences between nationals and foreigners. In the postpartum follow-up,70% were retained, 73% of them undetectable on the latest follow-up visit.

Conclusion

Despite the cultural and language limitations, foreign patients maintained a compliance similar to those of Chile, achieving a low transmission rate vertical and good adherence to postpartum controls.

Disclosures

All authors: No reported disclosures.
1281. Awareness of U=U Among Gay and Bisexual Men Who Have Sex with Men
Authors: Clement Meredith E , Zimmerman Rick , Grimm Josh , Schwartz Joseph
Published: October 2019

Background

The “Undetectable = Untransmittable” (“U=U”) campaign is gaining traction, but prior studies from 2012–2017 have shown that the proportion of gay and bisexual men who have sex with men (GBMSM) who are aware of or have perceived accuracy of U=U is low. We report findings from a survey administered to GBMSM in 2018 to understand whether the landscape is changing with respect to U=U message dissemination.

Methods

GBMSM were recruited on gay dating apps to complete a 96 question survey. Survey data were collected in April-August of 2018. Collected data elements included demographic information, HIV status, ART and PrEP use, and beliefs and opinions regarding HIV transmission.

Results

969 GBMSM completed the survey; of whom, 678 had analyzable data (241 had never had anal sex with a man and 54 were missing ≥1 of the variables used in the analysis). Average age was 43 years, 65% were white, 15% black, 15% white, and 15% were HIV-infected (of whom 92% were on anti-retrovirals). Of the 85% who were HIV-uninfected, 39% were on PrEP. In response to the statement that a person with an undetectable viral load cannot transmit HIV to an HIV-uninfected person, 24% strongly agreed. Among HIV-negative GBMSM, 33% of those on PrEP agreed and 12% of those not on PrEP agreed. Among those living with HIV, 42% agreed. A multivariable logistic regression was run to explain correlates of strong agreement with U=U, using the following variables: age, education, being Black, being Hispanic, relationship status, number of lifetime male sexual partners, condom use with most recent anal sex, HIV status, PrEP use, and attitudes about living with HIV. Variables associated with strong agreement with U=U were living with HIV (AOR = 1.63, P < 0.001), taking PrEP (AOR = 2.85, P < 0.001), most recent encounter’s condom use (AOR = 2.22, P = 0.003), and having positive attitudes about living with HIV (AOR= 1.93, P < 0.001). Table 1 shows percentages for each of these variables (bivariate relationships) strongly agreeing with U=U.

Conclusion

Now that U=U has been scientifically proven, the challenge is public awareness. U=U awareness seems to be improving among GBMSM, with HIV-negative GBMSM making the greatest strides. Education around U=U and PrEP efficacy may help reduce guilt around HIV transmission and alleviate HIV stigma.

Disclosures

All authors: No reported disclosures.
1298. Analysis of Factors Influencing Consent for Opt-out HIV Screening Among High-Risk Groups Vulnerable to HIV in an Urban Emergency Department
Authors: Maheswaran Anjana , Reddy Abhinav K , Kate Mannion Mary , Lin Janet
Published: October 2019

Background

The University of Illinois Hospital Emergency Department (ED) implemented routine, electronic medical record (EMR)-driven opt-out HIV screening in November 2014. Programmatic data indicated an average consent rate of 79%, similar to other ED HIV screening programs in the country. However, there is limited evidence on the role risk factors play on consent rate. The objective of this study was to explore the relationship between patients’ risk factors for HIV and the likelihood of declining screening.

Methods

The ED screening algorithm has a nontargeted and targeted component qualifying individuals based on age and presence of risk factors, respectively. We retrospectively evaluated risk factors and consent responses of high-risk individuals identified by the targeted component of the EMR algorithm between January 2017 and March 2019. We performed a multivariate logistic regression analysis in R to explore the association between risk factors and the likelihood of declining screening.

Results

Of 47,197 screening eligible individuals, 27,044 were high-risk among whom 12% never consented. The majority of those who never consented had no history of intravenous (IV) drug use, homelessness, unsafe sexual practices, recent sexually transmitted infection (STI) and did not identify as homosexual, bisexual or transgender. Individuals who identified as homosexual, bisexual, or transgender (OR = 0.53), from high-risk zip code (OR = 0.77), with history of IV drug use (OR = 0.43), and with recent STI (OR = 0.60) were found to be significantly less likely to never consent compared with their counterparts. Also, patients who were male (OR = 1.14), White (OR = 1.38), Asian (OR = 1.57), Native Hawaiian or Pacific Islander, American Indian or Alaska Native (OR = 1.44) were significantly more likely to never consent compared with their counterparts.

Conclusion

Our results show that patients at high risk for HIV consent at higher rates for HIV screening in an opt-out setting. These findings suggest that while educational efforts on the importance of testing may have been successful in patients at the highest risk, additional efforts are needed to improve awareness among those who may not self-identify or be identified by medical providers as being at risk for HIV and reinforce the importance of universal screening.

Disclosures

All authors: No reported disclosures.
1306. Evaluation and Predictors of Antiretroviral (ART)-Related Medication Errors in Hospitalized People Living with HIV (PWLH)
Authors: Chastain Daniel B , Ladak Amber , Curtis Jessica , Tang Emily , Young Henry N
Published: October 2019

Background

As HIV has become a chronic condition, management of the disease and preventing resistance is paramount to improving patient outcomes. Medication errors can lead to suboptimal therapy and potential development of resistance. The purpose of this study was to identify the rate of antiretroviral (ART)-related medication errors in hospitalized people living with HIV (PWLH).

Methods

This was a multi-center, retrospective cohort study of patients diagnosed with HIV and/or AIDS based on International Classification of Diseases codes. Patients were included if they were at least 18 years old and hospitalized between March 2016 and March 2018. Patients were excluded if they were pregnant and only received intravenous zidovudine during their hospitalization. Of the patients eligible for inclusion, 400 were randomly selected and included in this study. The primary objective was to determine the rate of inpatient ART-related medication errors. Secondary objectives included the type of errors and rate of error resolution prior to discharge.

Results

A total of 203 ART-related medication errors occurred during the study period (mean 0.9 ± 1.2 errors per patient). Incorrect schedule was the most common type of error followed by incorrect or incomplete regimen. More errors occurred in male patients (P = 0.01), those known to be infected with HIV on admission (P < 0.05), and in patients with an undetectable viral load (P = 0.01). Approximately 30% of ART-related medication errors were resolved prior to discharge, of which pharmacists were responsible for 25%. Incorrect schedule, incorrect or incomplete regimen, and clinically significant drug-drug interaction (DDI) were the most common medication errors that persisted at discharge. Among resolved errors, resolution of clinically significantly DDI or incorrect/incomplete ART were the most common interventions.

Conclusion

ART-related medication errors continue to occur in hospitalized PLWH and frequently persist at discharge. Interventions should be developed to reduce rates of ART-related medication errors on admission. Antimicrobial stewardship programs serve as an ideal platform to incorporate ART stewardship into routine activities to help minimize errors while inpatient and during transitions of care.

Disclosures

All authors: No reported disclosures.
1309. Effects of a Pharmacist-Driven Antiretroviral Stewardship and Transitions of Care Service in Persons Living with HIV/AIDS
Authors: Brizzi Marisa B , Burgos Rodrigo M , Chiampas Thomas D , Michienzi Sarah M , Smith Renata , Badowski Melissa E
Published: October 2019

Background

Historical data demonstrate that PLWHA experience higher rates of medication-related errors when admitted to the inpatient setting. Prior to initiation of this program, rapid-start initiation of antiretroviral therapy (ART) was not implemented prior to discharge. The purpose of this study was to evaluate the impact of a pharmacist-driven antiretroviral stewardship and transitions of care service in persons living with HIV/AIDS (PLWHA).

Methods

This was a retrospective pre- and post-analysis of PLWHA hospitalized at University of Illinois Hospital (UIH). Patients included were adults following at UIH outpatient clinics for HIV care admitted to UIH for acute care. Data were collected between April 19, 2017 and October 19, 2017 for the pre-implementation phase, and between July 1, 2018 and December 31, 2018 for the post-implementation phase. The post-implementation phase included an HIV-trained clinical pharmacist (Figure 1). Primary and secondary endpoints included follow-up rates at UIH outpatient HIV clinics, 30-day readmission rates, and access to medications at hospital discharge. Statistical analysis included descriptive statistics and Fisher’s Exact test.

Results

A total of 119 patients were included in the analysis, 66 in the pre-implementation phase and 53 in the post-implementation phase. Patients included were mostly black males with median age of 48. In the pre-implementation phase 50 out of 65 (77%) patients attended follow-up visits for HIV care at UIH outpatient clinics, vs. 42 out of 47 (89%) patients in the post-implementation phase (P = 0.1329). Thirty-day readmission occurred in 17 of 62 (27%) patients in the pre-implementation phase vs. 5 of 52 (10%) of patients in the post-implementation phase (P = 0.0183). During the post-implementation phase, the HIV pharmacist secured access of ART and opportunistic infection medications prior to discharge for 22 patients (42%), 2 of which were new diagnoses.

Conclusion

A pharmacist-led antiretroviral stewardship and TOC program led to a decrease in 30-day readmission rates in PLWHA. Although not significant, the HIV-pharmacist led to higher rates of clinic follow-up. Finally, the HIV-pharmacist helped secure access to ART and initiate rapid-start therapy in newly diagnosed patients prior to leaving the hospital.

Disclosures

All authors: No reported disclosures.
1334. Performance of C-Reactive Protein and Procalcitonin in Immunocompromised Children with SIRS
Authors: Posch Leila C , Boge Craig L K , Gerber Jeffrey , Fitzgerald Julie , Weiss Scott L , Lautenbach Ebbing , Coffin Susan E , Downes Kevin J , Downes Kevin J
Published: October 2019

Background

Biomarkers (C-reactive protein [CRP], procalcitonin [PCT]) have been used in patients with systemic inflammatory response syndrome (SIRS) to identify those with and without bacterial infection. However, their performance in immunocompromised (IC) children is not well studied.

Methods

Retrospective chart review of episodes of SIRS in IC children <19 years old admitted to the PICU August 2012–June 2016 with: (a) blood culture, PCT, and CRP obtained within 6 hours of SIRS, (b) no recent SIRS episodes (> 30 days), and (c) no positive blood culture in 2 days preceding SIRS. We defined IC as neutropenia (ANC< 500), solid-organ transplant (SOT), hematopoietic cell transplant (HCT), and other (immunosuppressive medications or primary immunodeficiency). To identify a comparator group, we additionally reviewed a previously published cohort of non-IC children with SIRS (Downes, et al, JPIDS 2018), applying the same inclusion criteria. For each episode (first 48 hours after SIRS), we determined the presence of bacterial infection using NHSN definitions and viral infection as symptoms with positive PCR. We compared biomarkers in IC children with and without bacterial infection, and in IC and non-IC children, using Wilcoxon rank-sum tests.

Results

We identified 108 SIRS episodes in 94 IC children (neutropenia = 35, SOT = 18, HCT = 22, other = 33) and 278 episodes in 250 non-IC children. Age (P = 0.15) and gender (P = 0.70) were similar among IC and non-IC groups. 41% of episodes in both IC and non-IC children had bacterial infections (P = 0.96). PCT and CRP were significantly higher in IC children with bacterial infection than those without (Figure 1). Biomarkers did not differ significantly among episodes in IC and non-IC children with bacterial infection; however, among episodes without bacterial infection, biomarkers were higher in IC than non-IC children (Table 1). Detection of a viral infection did not affect biomarker values in IC or non-IC children when bacterial infection was absent (Table 2).

Conclusion

In IC children with SIRS, PCT and CRP were higher when bacterial infection was present. Meanwhile, in the subset of non-bacterial SIRS episodes, biomarkers were higher in IC compared with non-IC children. PCT and CRP may be valuable markers to discriminate bacterial from non-bacterial causes of SIRS in IC children.

Disclosures

Kevin J. Downes, MD, Merck: Grant/Research Support, Research Grant; Pfizer: Grant/Research Support.
1352. The Burden of Active Tuberculosis in an Integrated Healthcare System, 1997–2016: Incidence, Mortality, and Excess Healthcare Utilization
Authors: Wada Paul , Lee-Rodriguez Christian , Hung Yun-Yi , Skarbinski Jacek
Published: October 2019

Background

Active tuberculosis (TB) often results from reactivation of latent tuberculosis infection (LTBI). This can be prevented through LTBI screening and treatment, yet only 12% of Californians have undergone LTBI therapy. Updated estimates on the complete burden of active TB are needed to rationally allocate resources for LTBI program implementation.

Methods

We identified all patients with microbiologically confirmed active TB in a large, integrated health system (Kaiser Permanente Northern California, or KPNC) from 1997 to 2016. We calculated active TB incidence in KPNC and measured this against California’s reported cases. Within KPNC, we compared mortality, hospital, emergency department, and ambulatory care use among persons with active TB to age-, sex-, and year-of-diagnosis-matched cohort of persons without active TB.

Results

Active TB incidence was lower in KPNC (3.4/100,000 person-years) than in California (7.2/100,000 person-years). Among 2,522 active TB cases, early and delayed mortality was high with 7.0% dying within 1 year of diagnosis and 6.2% dying 1–5 years post-diagnosis. Of the 1,957 active TB patients who continued to receive care through KPNC for at least one year post-diagnosis, 603 (30.8%) had at least one hospitalization. In KPNC, active TB patients had higher healthcare utilization than the matched cohort in the one year following diagnosis: 0.6 vs. 0.1 hospitalizations, 9.5 vs. 4.6 days mean length-of-stay, 0.8 vs. 0.3 emergency department visits, and 14.6 vs. 5.9 ambulatory visits.

Conclusion

Patients with active TB disease have substantial mortality and high inpatient and outpatient healthcare utilization. By improving LTBI screening and treatment, large healthcare systems may be able to reduce the burden and costs associated with active TB.

Disclosures

All authors: No reported disclosures.
1365. Profiling Extrapulmonary Nontuberculous Mycobacteria Infections and Predictors for rapid-growing Species: A Multi-Center Retrospective Study
Authors: Ho Kim Jung , Ji Lee Woon , Seong Hye , Young Jung In , Jin Kim Eun , Eun Song Je , young Ahn Jin , Jin Jeong Su , su Ku Nam , yong Choi Jun , Yeom Joon-Sup , Goo Song Young
Published: October 2019

Background

Nontuberculous mycobacteria (NTM) disease is increasing worldwide and is an important cause of morbidity and mortality. It is found that 20 to 30% of NTM isolates are of extrapulmonary origin. However, Studies about extrapulmonary NTM infections have been limited. Thus, we aim to describe the diversity of NTM infections and correlate these observations with clinical data.

Methods

We analyzed all symptomatic patients with positive NTM cultures in sterile extrapulmonary sites at three tertiary care centers in South Korea between January 2006 and June 2018. We collected patient information including predisposing factors, diversity of NTM isolates, antimicrobial susceptibility testing, treatment regimens, and outcomes.

Results

A total of 117 patients (46 males vs. 71 females) were included. The median age of the patients was 54 years. There are a lot of infections associated with medical procedures like surgery, but about half of cases (54.7%) are unknown origin. Skin and soft-tissue infections predominated (34.2%), followed by bone and joint infections (28.2%). Of 117 NTM isolates, 66 NTM subspecies were identified. Mycobacterium intracellulare (34.8%) was the most common species identified, followed rapid-growing NTM (RGM) species such as M. fortuitum complex (21.2%), M. abscessus (15.2%), M. massiliense (10.6%), and M. chelonae (9.1%). In skin and soft-tissue infections, RGM species were predominantly identified (26/28, 92.9%), whereas slow-growing NTM (SGM) species were mainly identified in bone and joint infections (18/26, 69.2%). The difference of isolated sites was verified by post hoc test and female sex (OR 4.72; P < 0.001) and skin and soft-tissue infections (OR 25.33; P < 0.001) were identified as predictors of RGM by logistic regression analysis. Based on antimicrobial susceptibility testing, fluoroquinolone and macrolide were mainly used for RGM treatment, and rifamycin-ethambutol-macrolide-based regimen was predominantly used for SGM treatment.

Conclusion

Skin and soft-tissue infection were predominantly caused by RGM, whereas bone and joint infection is mainly caused by SGM. Species-specific and region-specific data that integrate clinical and microbiologic information is crucial in determining treatment direction.

Disclosures

All authors: No reported disclosures.
1374. Diagnostic Utility of Whole Body Positron Emission Tomography-Computerized Tomography (PET-CT) in Patients with Suspected Central Nervous System Tuberculosis: A Retrospective, Descriptive Study
Authors: Ramesh Venkat , Narreddy Suneetha , Barigala Ravikiran , Kumar Chennamchetty Vijay , Kumar Sudhir , Rao Jyotsna , Nanda Sagarika , Varahala Sneha
Published: October 2019

Background

There is difficulty in diagnosing central nervous system (CNS) tuberculosis (TB) in the early stages because features mimic viral and pyogenic meningitis. There is a need to determine alternate methods to diagnose CNS TB. Whole-body PET-CT, used mainly in oncology, has shown promise in the detection of tuberculosis and monitoring response to anti-tuberculous therapy. Utility in CNS TB is unexplored.

Methods

Retrospective, cohort, single-center study. Patients were included if they fulfilled the following criteria: (1) Probable/possible tuberculous meningitis as per the Lancet Consensus Score; (2) undergone whole-body PET-CT with 18-fluorodeoxyglucose and intravenous contrast; (3) less than one week of anti-tuberculous therapy at the time of PET-CT; (4) clinical response to antituberculous treatment and steroids; (5) no other etiological agent identified.

Results

We identified 9 patients that fulfilled the above criteria. 5 of these patients were immunosuppressed (4 had advanced AIDS, one patient was on immunosuppressive therapy). We found that 86.4% of patients (7 out of 9) had radiological features suggestive of probable active TB outside the CNS (Figure 1). Of these 7 patients, 5 patients had definite TB (defined as positive Ziehl–Neelsen stain or Gene Xpert MTB/RIF assay or culture for tubercle bacilli) outside the CNS while 2 had histopathological evidence of TB (granulomatous inflammation) (Figure 2). All strains of TB were rifampin sensitive. The sites of isolation of tuberculosis were (Figure 3). (a) Abdominal lymph node in 2 patients (40%); (b) cervical lymph node in 2 patients (40%); (c) sputum in 1 patient (20%). In patients with evidence of disease outside the CNS, the average maximum standardized uptake value (SUV Max) in diverse anatomical locations was 5.75 (range 1.9–11.2). The most frequent manifestation PET-CT manifestation suggestive of TB outside the CNS in decreasing order of frequency was cervical lymphadenopathy (in 55.5% of patients), pleural and pulmonary parenchymal involvement (44.4% in each), followed by mediastinal nodes and abdominal lymph nodes in 33.3% (Figure 4).

Conclusion

PET-CT is a valuable tool in treatment-naive (less than 1 week of anti-tuberculous therapy) patients with suspected CNS tuberculosis. A large proportion of patients have evidence of TB outside the CNS.

Disclosures

All authors: No reported disclosures.
1409. Next-Generation Sequencing-based Detection of Angiostrongylus cantonensis (AC) Using Microbial Cell-free DNA Sequencing of Plasma in Atypical Cases of Rat Lungworm Meningitis Presenting with Ascending Paralysis
Authors: Melish Marian , Casamina Chanel , Merrifield Rachael , Abe Keisuke , Ahmed Asim A , Hong David K , Blair Lily , Ching Natascha
Published: October 2019

Background

AC or Rat Lungworm meningitis usually presents as a self-limited illness with headache and sensory changes, rarely progressing to coma, death, or permanent brain damage. It is usually diagnosed by eosinophils in the CSF. Once limited to Asia and the tropical Pacific AC transmission via slugs and snails documented on US mainland in 2018. We describe 2 unusual, severe examples of AC infection in infants presenting with ascending paralysis and initial CSF without eosinophilia suggesting Guillain–Barre syndrome (GBS).

Methods

Conventional lab testing of serum and CSF, brain and spine MRI, AC PCR by Hawaii Department of Health, and mcfDNA next-generation sequencing (NGS) of plasma (Karius).

Results

Two infants, aged 8 and 11 months, presented with fever, lower extremity weakness, and ascending paralysis. An initial evaluation in both included normal brain/spine imaging and CSF with modest lymphocytic pleocytosis without eosinophils. Paralysis progressed despite IVIG. Case 1: 11-month male: Admitted on fever day 5. Paralysis progressed to respiratory failure requiring ventilation for 20 days. Illness day 16: MRI showed spinal cord swelling C3-C7, Brain normal. CSF#3: WBC 269 28% eos, ↑ protein. Visible 8 mm long young adult worms, PCR positive for AC. Rx high-dose corticosteroids, albendazole for >4 weeks. Day 29 illness MRI: Cerebral infarct L frontal lobe, worm tracks medulla, inflammation cauda equina. Slow improvement over 5 months. Case 2: 8-month-old female: Admitted fever day 8. Weakness progressed to arms and trunk. Day 10 illness: CSF #2: Visible worms present, WBC 84, 26% eos. PCR positive for AC. Rx: High-dose steroids and albendazole x4 weeks. MRI spine illness day 30: inflammation cauda equina. Weakness improved by illness day 37. McfDNA sequencing of plasma detected AC in acute stage peaks of 123 and 12 molecules/microliter in cases 1 and 2. Serial mcfDNA testing showed a decline in the AC DNA level in plasma which correlated with treatment and clinical response.

Conclusion

AC infection may mimic GBS or transverse myelitis. AC diagnosis may require repeat CSF testing. NGS detection of AC in plasma holds promise as rapid, noninvasive diagnosis and assessment of response to therapy. High-dose steroids with albendazole may be effective even in severe AC.

Disclosures

All authors: No reported disclosures.