bluuebunny/crossref_metadata_2025 huggingface dataset:
183. Candidaemia in Children and Importance of Central Venous Catheter Removal
Authors: Arikan Kamile , Arıkan-Akdaglı Sevtap , Kara Ates
Published: October 2019

Background

Candida is the most common cause of invasive fungal infection in healthcare settings and is associated with significant increases in healthcare resource utilization and attributable mortality.

Methods

This study was conducted in a pediatric tertiary care hospital from Turkey. We conducted a retrospective analysis in children ≤18 years with blood culture-proven candidaemia identified between December 2013 and November 2017. Sociodemographic variables,underlying condition, mortality, additional risk factors, origin of specimens were all recorded.

Results

A total of 236 episodes of candidaemia were identified over the study period. The median age of the patients was 600 days (4-6482). 106 specimens (44.9%) were cultured from patients under 1 year of age and 15 of 106 specimens were cultured from neonates. The most frequently isolated Candida spp. were C. albicans (42.%), followed by C. parapsilosis (30.5%), C. glabrata (7.6%), C. tropicalis (6.4%), C. krusei (2.5%), C. lusitaine (2.5%), C. dubliniensis (2.1%), C. kefir (0.8%), and C. pelliculosa (0.4%). In 11 of the 236 episodes (4.5%), two Candida spp were cultured at the same time.The most common coinfection was C. albicans and C. parapsilosis. 112 of the 236 episodes (47.5%) was due to central venous catheter-related blood stream infection. 47.5% of these patients were receiving total parenteral nutrition at the time of candidemia. Concomitant coagulase negatif staphylococcus bacteremia was present in 50 of 236 candidemia episodes (21.2%). Of 236 isolates, 74 (31.4%) was cultured from peripheral blood culture only, 95 (40.3%) from central venous catheter only, 67 (28.4%) from both peripheral and central catheter blood culture.Trombocytopenia was noted in 117 episodes (49.6%) and neutropenia in 45 episodes (19.1 Of the 112 central venous catheter-related candidemia, 35 (31.3%) resulted in death within 30 days from the onset of candidaemia (Figure 1). In 49 (45.%) episodes of central venous catheter-related candidemia, catheter was not removed and 40% of these episodes resulted as death.Catheter removal, thrombocytopenia, total parenteral nutrion were found to be associated with increased mortality in children under 1 year of age (P < 0.001).

Conclusion

Clinicians must be aware of candidemia in children due to high risk of mortality.

Disclosures

All authors: No reported disclosures.
213. A Comparison of Medication Assisted Therapy Treatment Strategies for Opioid Use Disorder in Persons who Inject Drugs and are Hospitalized with Serious Infections
Authors: Marks Laura , Schwarz Evan , Liss David , Satish Munigala , Warren David K , Stephen Liang , Durkin Michael
Published: October 2019

Background

Persons who inject drugs (PWID) with opioid use disorder (OUD) are at increased risk of invasive bacterial and fungal infections, which warrant prolonged, inpatient parenteral antimicrobial therapy. Such admissions are complicated by opioid cravings and withdrawal. Comparisons of medications for OUD during prolonged admissions for these patients have not been previously reported. The aim of this study was to evaluate the impact of different OUD treatment strategies in this population, and their impact on ED and hospital readmissions.

Methods

We retrospectively analyzed consecutive admissions for invasive bacterial or fungal infections in PWID, admitted between January 2016 and January 2019 at Barnes-Jewish Hospital. Patients in our cohort were required to receive an infectious diseases consult, and an anticipated antibiotic treatment duration of >2 weeks. We collected data on demographics, comorbidities, length of stay, microbiologic data, medications prescribed for OUD, mortality, and readmission rates. We compared 90-day readmission rates by OUD treatment strategies using Kaplan–Meier curves.

Results

In our cohort of 237 patients, treatment of OUD was buprenorphine (17.5%), methadone (25.3%), or none (56.2%). Among patients receiving OUD treatment, 30% had methadone tapers and/or methadone discontinued upon discharge. Patient demographics were similar for each OUD treatment strategy. Infection with HIV (2.8%), and hepatitis B (3%), and hepatitis C (67%) were similar between groups. Continuation of medications for OUD was associated with increased completion of parenteral antibiotics (odds ratio 2.11; 95% confidence interval 1.70–2.63). When comparing medications for OUD strategies, methadone had the lowest readmission rates, followed by buprenorphine, and no treatment (P = 0.0013) (figure). Discontinuation of methadone during the admission or upon discharge was associated with the highest readmission rates.

Conclusion

Continuation of OUD treatment without tapering, was associated with improved completion of parenteral antimicrobials in PWID with invasive bacterial or fungal infections lower readmission rates. Tapering OUD treatment during admission was associated with higher readmission rates.

Disclosures

All authors: No reported disclosures.
219. Is the modified quick SOFA scale superior to quick SOFA in patients with diagnosed septic shock?
Authors: Akyol Deniz , Uyan Önal Ayşe , Önal Uğur , Akdağ Damla , Bulut Avşar Cansu , Uysal Serhat , Guliyeva Günel , Başkol Dilşah , Demir Melike , Mermer Sinan , Chousein Memetali Seichan , Şanlıdağ Gamze , Mert Merve , Sipahi Hilal , Ulusoy Sercan , Reşat Sipahi Oğuz
Published: October 2019

Background

In this study it was aimed to compare the effects of qSOFA (Quick Sequential Organ Failure Assessment) score with modified qSOFA score (PLoS One. 2018 Sep 26;13(9):e0204608) for predicting one month survival in patients with diagnosed septic shock (SS) in a tertiary-care educational university hospital in a developing country.

Methods

Modified qSOFA was created by adding age factor (>50 years=1 point) to patients with qSOFA scale 1 or 2 or 3 who had SS (sepsis+hypotension+adrenergic agent) and consulted by Infectious Diseases consultants between December 2013-December 2018. Arterial lactate level of >2 mmol/L criterion was added as an including criteria for SS according to 3rd International Sepsis and Septic Shock Consensus Statement after 23rd February 2016. Statistical analysis was performed via Chi-square test and a p-value <0.05 was considered significant.

Results

The number of patients with qSOFA score of 1 or 2 or 3 from 527 patients are in Table1 [some of the cases were diagnosed as septic shock according to elder definition (without lactate criterion) and there was a subgroup with qSOFA score 1]. Among the >50-year aged group, the 30-day survival rate was lower in patients with qSOFA3 vs. qSOFA 2 vs. qSOFA 1 (Table1, 3x2 Chi Square test, P = 0.0057). Among the <50 years group, the qSOFA one month survival rate was lower in patients with qSOFA 3 vs. qSOFA 2 vs. qSOFA 1 (Table, 3x2 Chi Square Test, P = 0.0052). According to modified qSOFA, there was a significant difference for one month survival among SS cases with scores of 1, 2, 3 and 4 (12/21 57% vs. Fifty/126 40% vs. 78/269 29% vs. 22/111 20%, 4x2 Chi-square test, P = 0.0003). On the other hand, there was no significant difference in terms of one month survival when we performed subgroup analysis in qSOFA score 1, 2, or 3 subgroups, as ≤50 years vs. >50 years (table, Chi-square test, 12/21 vs. 39/97 P = 0.224, 11/29 vs. 75/244 P = 0.526, 3/25 vs. 22/111 P = 0.572).

Conclusion

In terms of survival at one month, there was a significant difference between qSOFA score 1, 2, 3 and 4 subgroups. In patients with qSOFA score of 1 or 2 or 3, being under 50 years did not have a significant effect on one-month survival. Modified qSOFA may be beneficial to foresee the probable mortality but these findings need to be validated in larger cohorts

Disclosures

All authors: No reported disclosures.
244. Development, Qualification, and Clinical Validation of an Immunodiagnostic assay for the Detection of 11 Additional S. pneumoniae Serotype-Specific Polysaccharides in Human Urine
Authors: Vincent. Kalina Warren , Souza Victor , Wu Kangjian , Giardina Peter , McKeen Andrew , Jiang Qin , Tan Charles , Ren Yanhua , Belanger Kelly , McElhiney Sue , Unnithan Manu , Cheng Huiming , Giordano-Schmidt Donna , Gessner Bradford D , Jansen Kathrin U , Pride Michael W
Published: October 2019

Background

Identifying Streptococcus pneumoniae (Sp) serotypes by urinary antigen detection assay (UAD) is the most sensitive and specific way to evaluate the changing epidemiology of non-bacteremic community-acquired pneumonia (CAP) and efficacy of pneumococcal vaccines. We first described an UAD to detect the Sp serotypes 1,-3,-4,-5,-6A,-6B,-7F,-9V,-14,-18C,-19A,-19F,-23F covered by the 13-valent Sp conjugate vaccine PCV13. To assess the pneumococcal disease burden of additional serotypes, a UAD-2 assay was developed to diagnose 11 additional Sp serotypes (-2,-8,-9N,-10A,-11A,-12F,-15B,-17F,-20,-22F,-33F).

Methods

UAD-2 specificity was achieved by capturing highly purified pneumococcal polysaccharides with serotype-specific monoclonal antibodies using Luminex technology. Assay qualification assessed accuracy, precision, and sample linearity. Serotype positivity was based on cutoffs determined by non-parametric statistical evaluation of urine samples from individuals without pneumococcal disease. Clinical sensitivity and specificity of the positivity cutoffs were assessed in a clinical validation.

Results

The UAD-2 was shown to be specific and reproducible. Clinical validation using urine samples from invasive disease patients demonstrated assay sensitivity and specificity of 92.2% and 95.9%, respectively compared with a gold standard of isolating and typing (by Quellung) Sp bacteria from patient samples. Analysis of 11,087 CAP patients showed a UAD-2 and UAD-1 serotype prevalence of 4.33% and 4.60%, respectively (bacteremic and non-bacteremic CAP combined).

Conclusion

The qualified/clinically validated UAD-2 method has applicability in understanding the epidemiology of nonbacteremic Sp CAP as well as assessing vaccine efficacy of future pneumococcal conjugate vaccines.

Disclosures

All authors: No reported disclosures.
247. Evaluation of the T2Candida Panel as an Antifungal Stewardship Tool in Transplant and Non-Transplant Patients at a Tertiary Care Center
Authors: Sarfraz. Chaudhry Zohra , Vahia Amit T , Kathuria Priya , Doyon-Reale Nicole , Mayur Ramesh , Abreu Lanfranco Odaliz , Del Busto Ramon , Alangaden George J
Published: October 2019

Background

Invasive candidiasis (IC) has a mortality of >30% and likelihood of death increases 50% each day antifungal therapy (AF) is delayed. In patients with suspected IC early empiric AF improves outcomes but has the potential for overuse. Blood cultures (BC) detect ~50% of candidemia with a turn-around-time (TAT) of 2–5 days. T2Candida Panel (T2) an FDA-approved molecular diagnostic test, detects 5 Candida species directly in blood with specificity 99.4%, sensitivity 91.1%, and TAT of 3–5 hours. Our institutional guidelines permit the use of empiric AF in patients with suspected IC (Figure 1). We evaluated the utility of T2 as an AF stewardship tool to support these guidelines.

Methods

We reviewed patients that had T2 done January 2016 to May 2016 at Henry Ford Hospital, a 900-acute care bed teaching hospital in Detroit, MI. Patients with negative T2 [T2(−)] and negative concurrent BC [BC (−)] were evaluated. The primary endpoint was discontinuation (d/c) of AF after a T2 (−) result. Secondary endpoints were candidemia after d/c of AF and all-cause 30-day mortality. Comparative analyses were performed of transplant (txp) vs. non-transplant (non-txp) patients. Univariate analysis was done to determine the association of risk factors and outcomes. Multivariate regression using forward selection was used to model mortality risk. Time to d/c of AF were modeled using Kaplan–Meier estimators.

Results

500 consecutive patients with T2 (−) and BC (−) results were identified. Patients on AF for prophylaxis or treatment of fungal infection were excluded. 472 patients (93 txp patients) were included in the analyses. Characteristics of the txp and non-txp patients are in Table 1. Median TAT in hours (hr) of T2 was 6 (±2) vs. 123 (±25) for final BC (−) result. 264/472 (56%) patients were initiated on empiric AF. In patients with T2 (−) result, AF were d/c within 7 days in 97%; time to d/c of AF was 72 hr in 50% txp patients and 48 hr in 50% of non-txp patients respectively (Figure 2). No episodes of candidemia were diagnosed after d/c of AF. All-cause mortality was lower in txp patients (14%) vs. non-txp patients (34%) (P = 0.0002). Likelihood of mortality did not increase after d/c of AF (OR1.3, 95% CI 0.913–2.064).

Conclusion

T2 promotes d/c of empiric AF in txp and non-txp patients with suspected IC without a negative impact on clinical outcomes.

Disclosures

All authors: No reported disclosures.
280. Monitoring Serum Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) in Correlation with (1–3)-β-d-Glucan Levels in Vascular Pythiosis: A Preliminary Study
Authors: Torvorapanit Pattama , Reinprayoon Rongpong , Reinprayoon Navaporn , Manothummetha Kasama , Ratanawongphaibul Kitiya , Chindamporn Ariya , Permpalung Nitipong
Published: October 2019

Background

Vascular pythiosis, caused by Pythium insidiosum, is a life-threatening disease despite aggressive treatment. Our recent study showed that serum β-d-glucan (BG) trends can be used to monitor disease activity after treatment initiation. A significant decline in BG by 0.5 month indicated complete resection without residual disease. However, BG assay is cost probihitive and available only at King Chulalongkorn Memorial Hospital in Thailand. This study was conducted to preliminarily evaluate erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as monitoring tools.

Methods

A prospective study included proven vascular pythiosis patients receiving treatment with combination therapy from November 2018 to January 2019. Clinical information, BG, ESR, and CRP were collected at 0, 0.5, 1.5, and 3 months post diagnosis. Spearman’s correlation coefficient and analysis of response profiles were used.

Results

Six patients were enrolled. All had thalassemia. Four developed disease at popliteal artery, 1 at common iliac artery, and 1 at brachial artery. All underwent amputation with negative surgical margins achievement. All received itraconazole, azithromycin, and P. insidiosum immunotherapy. One received terbinafine and one received doxycycline additionally. All had positive BG > 500 pg/mL at diagnosis. After treatment initiation, means of ESR were significantly decreased at 0.5 months (P = 0.02). Means of CRP were not significantly changed until 1 month (P = 0.02) (Figure 1a and b). Correlation coefficients between BG and ESR vs. BG and CRP were 0.74 and 0.65, respectively. All survived without relapse at 3 months.

Conclusion

ESR and CRP are potentially valuable markers to monitor vascular pythiosis in resource-limited countries. However, ESR levels and trends seem to be correlated with BG better than CRP. Further studies are needed to enroll more patients, especially patients with incomplete resection or non-surgical candidates.

Disclosures

All authors: No reported disclosures.
302. HCV Care in Federally Qualified Health Centers During the Opioid Epidemic: A Retrospective Cohort Study
Authors: Assoumou Sabrina A , Wang Jianing , Nolen Shayla , Eftekhari Yazdi Golnaz , Mayer Kenneth H , Puro Jon , Salomon Joshua A , Linas Benjamin P
Published: October 2019

Background

Federally qualified health centers (FQHCs) serve diverse communities in the United States (US) and could function as important venues to manage hepatitis C virus (HCV) infections. Little is known on HCV outcomes in underserved communities as most of the current data are derived from clinical trials, commercially insured patients, or small health center samples. We aimed to determine the proportion of HCV testing, factors associated with treatment initiation, and real-world treatment outcomes in a large, national diverse sample of US FQHCs during the opioid epidemic.

Methods

We created a retrospective cohort of adults seen at 341 participating FQHCs in 19 US states. Inclusion criteria were: (1) clinical visit between January 01, 2012 and June 30, 2017; (2) ≥18 years of age. Outcomes included HCV testing proportion, stratified by diagnosis of opioid use disorder (OUD); treatment initiation rates; and sustained virologic response (SVR), defined as undetectable HCV RNA 3 months after treatment completion. We identified factors associated with testing, treatment initiation, and SVR using logistic regression.

Results

Of the 1,508,525 patients meeting inclusion criteria, 88,384 (5.9%) were tested for HCV, and 8,694 (9.8%) of individuals tested had reactive results. Of the 6,357 with HCV RNA testing, 4,092 (64.4%) had detectable RNA. Twelve percent of individuals with chronic HCV and evaluable data initiated treatment. Of those, 86% reached SVR. Having commercial insurance (aOR, 2.10, 95% CI, 1.45–3.02), older age (aOR, 1.07, 95% CI, 1.06–1.09) and being Hispanic/Latino (aOR, 1.35, 95% CI, 1.33–1.38) or Asian/Pacific Islander (aOR, 1.84, 95% CI, 1.79–1.90) were independently associated with higher odds of treatment initiation after multivariable adjustment. Only 8% of individuals with chronic HCV were tested for HIV, and 15% of individuals with identified OUD were tested for HCV.

Conclusion

During the opioid epidemic, fewer than 20% of individuals with identified OUD were tested for HCV at evaluated FQHCs. In addition, approximately 10% of patients initiated treatment and SVR was lower than expected. Expansion of HCV management into community clinics must consider measures to monitor and evaluate treatment effectiveness, and to improve outcomes if cure rates are low.

Disclosures

All authors: No reported disclosures.
317. Utility of a Hepatitis C Screening Best Practice Advisory in University-based Primary Care Practices
Authors: Donaghey Faith , Tuan Jessica , Agaraj Irini , Wakefield Dorothy , Chirch Lisa
Published: October 2019

Background

Hepatitis C virus infection (HCV) is a significant health concern in the United States, impacting an estimated 3 million people. Adults born between 1945 and 1965 (“baby boomers”) are 5 times more likely to have HCV infection compared with the general population. In 2012, the CDC recommended screening of adults born between 1945 and 1965. In April 2018 UConn Health transitioned from utilizing the Next Gen EHR system to Epic. At Epic launch, an HCV-screening Best Practice Advisory (BPA) was implemented, along with 13 other outpatient-based BPAs. This allowed for comparison of HCV screening rates before and after Epic launch.

Methods

Data were collected via retrospective chart review on adults born between 1945–1965 presenting to UConn primary care (PC) clinics one year prior to and 9 months post Epic launch. The BPA was set to fire for patients in the birth cohort who did not have an HCV antibody result or a history of hepatitis C in the medical record. Proportions were compared using chi-squared tests and Fisher’s Exact test.

Results

The HCV screening rate among PC providers 1-year pre-BPA was approximately 7.7%. Analysis of data nine months after BPA implementation demonstrated HCV screening rates were unchanged at 7.6%. Table 1 describes initial care cascade findings. During the post-launch monitoring period, a 0.2% [270/105,431] response rate was noted (as measured by follow-up actions taken from all BPAs, Table 2). During the same period, a significantly higher response rate to the HCV-screening BPA was noted (1.2% [287/24,532], P < 0.01) (Figure 1).

Conclusion

The aim of this study was to improve HCV case identification and to understand the utility of a BPA in this setting. Within the first nine months, the use of an HCV-screening BPA (Figure 2) in PC clinics did not increase screening rates in adults born between 1945 -1965. Alert fatigue may contribute to low screening rates post BPA, as evidenced by the low response rates across all BPAs introduced. Our long-term goal is to gather additional data to assess the efficacy of the HCV BPA and its effects on the HCV care cascade. Modifications to BPA functionality may be indicated.

Disclosures

All authors: No reported disclosures.
322. Prolonged Amenorrhea Is Associated with Decreased Hip Bone Mineral Density in Women Living with HIV
Authors: King Elizabeth , Nesbitt Ariel , Albert Arianne , Pick Neora , Cote Helene , Maan Evelyn , Prior Jerilynn , Murray Melanie
Published: October 2019

Background

Women living with HIV (WLWH) have higher rates of long-term amenorrhea (no flow for ≥12 months) than HIV-negative women. However, little is known about the consequences of amenorrhea for WLWH. Both amenorrhea and HIV are associated with lower areal bone mineral density (BMD); though the combined effect of both on BMD remains unclear. In this cross-sectional study we investigated whether prolonged amenorrhea adversely affects BMD among WLWH.

Methods

We investigated BMD (using a Hologic bone densitometer) and prolonged amenorrhea among WLWH and HIV-negative control women of similar socioeconomic backgrounds aged 19–68 in the CARMA cohort. Participants were stratified by HIV status and history of prolonged secondary amenorrhea defined as a self-reported absence of menses for at least one year in the past or present, occurring at age <45 years and not due to surgery, breastfeeding, pregnancy or hormonal contraception. Hip and spine Z-scores (age- and race- standardized BMD values) were compared between groups using linear models, followed by multivariable analysis of BMD-related factors.

Results

WLWH (N = 129) had significantly lower hip (mean±SD −0.4 ± 0.9 vs. 0.3 ± 1.1; P < 0.001) and spine (−0.5 ± 1.3 vs. 0.2 ± 1.3; P = 0.001) Z-scores vs. controls (N = 129). Multivariable linear regression found prolonged amenorrhea was independently related to lower hip (P = 0.01), but not spine (P = 0.94) BMD. Within WLWH, the effect of amenorrhea was also additive to that of HIV, with hip Z-scores of -0.8±0.9for those with amenorrhea vs. -0.3±0.8for those normally cycling (P = 0.01). Amongst WLWH, those with prolonged amenorrhea had higher rates of illicit substance use, smoking, chronic opioid therapy, hepatitis C viral infection, and poorer HIV viral control than those with normal menstruation.

Conclusion

These data suggest that WLWH having prolonged amenorrhea of ≥1 year’s duration are at increased risk for hip bone loss, a finding influenced by comorbid, HIV-associated conditions. Screening WLWH for menstrual history will allow early discovery of osteoporosis risk, and stimulate preventative measures to mitigate bone loss.

Disclosures

All authors: No reported disclosures.
324. Outcomes of Immunomodulatory and Biologic Therapy in People Living with HIV: A Report from Two Academic Hospitals
Authors: Peluso Michael J , Eshun-Wilson Ingrid , Henrich Timothy J , Chin-Hong Peter
Published: October 2019

Background

The use of immunomodulatory drugs (IMDs) is increasingly common. However, data on outcomes of IMD use in people living with HIV (PLWH) are limited and may be biased due to selective reporting of certain outcomes. Institution-level data reflecting patient-time at risk have not been described.

Methods

We systematically identified all PLWH prescribed non-steroidal IMDs from 2012 to 2019 at two centers. We defined a treatment episode (TE) as an uninterrupted period on a particular IMD regimen. Patients contributed multiple TEs if interrupting or switching therapy. We excluded those with lymphoproliferative disorders or transplants. We quantified infections and blips, defined as a detectable viral load following an undetectable result.

Results

35 patients contributed 55 TEs comprising 24,020 patient-days at risk. 29/35 (83%) were male, median age was 53 (IQR 39–59), median CD4 nadir was 197 (IQR 100–314), and 12/35 (34%) had a prior opportunistic infection. TEs utilized TNF inhibitors (19/55, 35%), PD-1 inhibitors (11/55, 20%), antimetabolites (7/55, 13%), interleukin inhibitors (7/55, 13%), and other agents (7/55, 13%). 4/55 (7%) involved in dual therapy. 32/35 (94%) patients were on antiretroviral therapy (ART) at IMD initiation; one was off therapy, one already on IMDs-acquired HIV, and one was an elite controller. Median CD4 count was 472 (IQR 337–807); CD4 was < 500 in 28/55 TEs (51%). Preceding plasma HIV RNA was undetectable in 36/55 (65%) TEs. Of these, 18 (50%) were associated with a viral blip within 1 year; one blip was >200 copies and none resulted in sustained viremia. Compared with other agents, PD-1 inhibitors were associated with a higher blip rate (incidence rate ratio 4.3, 1.3–12.3). 17/55 (32%) TEs were initiated with detectable plasma HIV RNA, which declined on ART in 13/15 (87%) TEs with follow-up testing; one patient stopped ART and one later suppressed. 9/55 (16%) TEs involved an infectious complication (7 soft-tissue infections, 2 pneumonias), although none was clearly attributed to IMDs. 36/55 (65%) TEs had good therapeutic response.

Conclusion

IMDs can be used without major complications in PLWH on ART, including those not yet suppressed or with CD4 counts < 500. PD-1 inhibitors may be associated with a higher rate of viral blips, although the clinical significance is unclear.

Disclosures

All authors: No reported disclosures.
330. Survival of HIV-Positive Patients with Hemophagocytic Lymphohistiocytosis
Authors: Brown Timothy J , Prokesch Bonnie C , Nagalla Srikanth , Wysocki Christian
Published: October 2019

Background

Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening disorder resulting from dysregulated cytokine production. The diagnosis of HLH requires five of eight abnormalities: fever, splenomegaly, bicytopenia, hypertriglyceridemia and/or hypofibrinogenemia, hyperferritinemia, hemophagocytosis on biopsy, low or absent NK cell activity, or elevated soluble CD25. The link between Human Immunodeficiency Virus (HIV) and HLH is incompletely understood; we sought to further define the characteristics and outcomes of this patient population.

Methods

We performed a retrospective study on HLH patients with and without concurrent HIV infection treated at our institution from January 2008 to July 2018. At the time of HLH diagnosis, we extracted data on the HIV status and associated malignancies. The primary outcome was overall survival from time of diagnosis of HLH in patients with HIV vs. those without HIV. Secondary analysis was performed with survival by HIV and malignancy status. Survival was analyzed by Kaplan–Meier curves with hazard ratios calculated using the log-rank test with significance set at P ≤ 0.05.

Results

Forty-three patients were included; 11 had HIV at the time of diagnosis of HLH and all met criteria for AIDS at time of inclusion. Patients with HIV who were diagnosed with HLH had similar survival compared with patients without HIV (Hazard ratio for death (HR) 0.87 [95% confidence interval (CI) 0.37–2.904]). All patients with malignancy had a worse survival (HR for death 3.648 [95% CI 1.804–9.169] P = 0.0009), regardless of HIV status. HLH in HIV patients with malignancy resulted in a trend toward worse survival (HR = 3.86 95% CI 1.09–22.60, P = 0.0578) compared with those without malignancy, although the limited number of patients prohibits a definitive conclusion. In HIV-negative patients, the presence of malignancy is associated with worse survival (HR 3.56 [95% CI 1.475–10.11] P = 0.0063).

Conclusion

In this retrospective, single-institution review of HLH patients, HIV was not associated with worse overall survival compared with patients without HIV. The presence of malignancy resulted in worse survival in the overall population. Further investigation is needed to optimize the care of these patients.

Disclosures

All authors: No reported disclosures.
350. Outcomes for Joint Arthroplasty in Persons Living with HIV
Authors: Mandimika Charisse L , Barakat Lydia A , Golden Marjorie
Published: October 2019

Background

Persons living with HIV (PLHIV) now have dramatically improved life-expectancy with age-related morbidities requiring total joint arthroplasties. We present here an institutional review of PLHIV who underwent total joint arthroplasty and prosthesis-related adverse outcomes at one year.

Methods

This was a retrospective chart review in a large academic medical center. Inclusion criteria were adult PLHIV undergoing total joint arthroplasty between 2013 and 2017. Arthroplasty-related adverse outcomes within the first-year post-surgery were recorded. Patients were identified using ICD-10 codes and classified as having a PJI using Infectious Diseases Society of America (IDSA) criteria.

Results

A total of 40 patients met the criteria. The median age was 59 years and 53% of patients were male. The median CD4 count and RNA viral load were 587 (range 94–1920) cells/mm3 and 0 (range 0—189,000) copies/mL, respectively. The most common procedure was hip replacement (55%) and the most common indication for arthroplasty was avascular necrosis (43%). Adverse outcomes including PJI, dislocation, prosthesis loosening, seroma and chronic pain were identified in 28% of patients. PJI occurred in two patients and both required surgical revision. Modifiable risk factors present in both patients were active smoking, history of substance use disorder, chronic pulmonary disease, depression and hepatitis C antibody positivity. Both patients had CD4 counts >600 cells/mm3. Both were on atazanavir containing antiretroviral regimens. Neither patient was screened for MRSA carriage. Causal organisms were MRSA and MSSA respectively and each patient received 6 weeks of antimicrobial therapy.

Conclusion

This study supports that when medically optimized, PLHIV have favorable outcomes. The two patients who developed PJI had multiple non-HIV modifiable risk factors predisposing them to PJI. In one case, the patient’s isolated organism was MRSA, for which the patient did not receive appropriate pre-operative antimicrobial prophylaxis. This highlights the importance of routine screening for appropriate pre-operative prophylaxis in patients undergoing joint arthroplasty, independent of HIV status.

Disclosures

All authors: No reported disclosures.
352. Characteristics Associated with Pre-Frailty in Older People Living with HIV
Authors: Mazonson Peter , Loo Theoren , Berko Jeff , Chan Sarah-Marie , Westergaard Ryan , Sosman James
Published: October 2019

Background

Frailty is a concern among older people living with HIV (PLHIV). There is a paucity of research characterizing PLHIV who are at risk of becoming frail (pre-frailty). To investigate how HIV impacts older PLHIV in the United States, a new study called Aging with Dignity, Health, Optimism and Community (ADHOC) was launched at ten sites to collect self-reported data. This analysis uses data from ADHOC to identify factors associated with pre-frailty.

Methods

Pre-frailty was assessed using the Frailty Index for Elders (FIFE), where a score of zero indicated no frailty, 1–3 indicated pre-frailty, and 4–10 indicated frailty. A cross-sectional analysis was performed on 262 PLHIV (age 50+) to determine the association between pre-frailty and self-reported sociodemographic, health, and clinical indicators using bivariate analyses. Factors associated with pre-frailty were then included in a logistic regression analysis using backward selection.

Results

The average age of ADHOC participants was 59 years. Eighty-two percent were male, 66% were gay or lesbian, and 56% were white. Forty-seven percent were classified with pre-frailty, 26% with frailty, and 27% with no frailty. In bivariate analyses, pre-frailty was associated with depression, low cognitive function, depression, multiple comorbidities, low income, low social support and unemployment (Table 1). In the multiple logistic regression analysis, pre-frailty was associated with having low cognitive function (Odds Ratio [OR] 8.56, 95% Confidence Interval [CI]: 3.24–22.63), 4 or more comorbid conditions (OR 4.00, 95% CI: 2.23–7.06), and an income less than $50,000 (OR 2.70, 95% CI: 1.56–4.68) (Table 2).

Conclusion

This study shows that commonly collected clinical and sociodemographic metrics can help identify PLWH who are more likely to have pre-frailty. Early recognition of factors associated with pre-frailty among PLHIV may help to prevent progression to frailty. Understanding markers of increased risk for pre-frailty may help clinicians and health systems better target multi-modal interventions to prevent negative health outcomes associated with frailty.

Disclosures

All authors: No reported disclosures.
363. Characterization of HIV/HBV Co-Infected Patients at an Outpatient HIV Clinic and Evaluation of Management Practices as a Measure for Quality Improvement
Authors: Ntem-Mensah Afua Duker , Chua Joel V , Sharaf Salma , Woo John S
Published: October 2019

Background

About 10% of patients living with the human immunodeficiency virus (HIV) are coinfected with chronic hepatitis B infection (HBV). Individuals with HIV are at increased risk of having HBV progress to chronic infection. Current guidelines recommend at least two active agents against HBV in HIV/HBV coinfected patients one of which must include tenofovir. Due to the increased risk of developing fibrosis and hepatocellular cancer (HCC) in this population, current guidelines recommend yearly evaluation of the liver function with imaging, liver function tests (LFTs), and vaccination against Hepatitis A. In our study, we sought to determine the characteristics of dual-infected patients in our clinic and our management practices in accordance with guidelines.

Methods

A retrospective, observational, single-center cohort study in adults coinfected with HIV and chronic HBV from 2013 to 2018 at an urban HIV outpatient practice. Patients with acute hepatitis B infection and isolated hepatitis B core antibody were not included in our study. The study assessed the management practices evaluating appropriate medication for HBV, screening for hepatocellular cancer, and Hepatitis A vaccination.

Results

Of the 3,248 HIV patients seen at our clinic within this period, 128 patients (3.9%) were HBV coinfected. Only active patients (N = 81) were included in the quality improvement analysis. Although 90% of coinfected patients were on appropriate anti-HBV therapy, and 96% had annual LFTs done, only 39.5% had documented hepatitis A vaccination and only a quarter (25.9%) had HCC screening done at the recommended interval.

Conclusion

Long-term management of HIV/HBV involves preventing and monitoring for liver failure and HCC. Based on our clinic data, our management practices for ensuring that our patients receive imaging for HCC will need to be revised.

Disclosures

All authors: No reported disclosures.
373. Immune Reconstitution Inflammatory Syndrome in Patients with HIV/AIDS and Histoplasmosis: A Case Series
Authors: Boulougoura Afroditi , Laidlaw Elizabeth , Roby Gregg , Mejia Yolanda , Pau Alice , Sheikh Virginia , Sereti Irini , Manion Maura
Published: October 2019

Background

Immune Reconstitution Inflammatory Syndrome (IRIS) in HIV infection is the unexpected clinical deterioration due to worsening (paradoxical) or uncovering (unmasking) of an infection or malignancy upon initiation of antiretroviral therapy (ART). Histoplasma capsulatum (H. capsulatum) is the most common endemic mycosis in patients with AIDS, usually manifesting as disseminated disease at CD4 counts < 150 cells/μl. In the ART era, histoplasmosis IRIS has been described in case reports, but there has been a limited description regarding clinical presentations and pathogenesis in the United States.

Methods

ART-naive HIV+ patients with a CD4+ T-cell count < 100 cells/µL enrolled in prospective studies at the National Institutes of Health (NIH) (NCT00286767, NCT02147405) were evaluated to identify those with histoplasmosis and followed after ART initiation to identify those who would eventually develop IRIS.

Results

From a total of 271 patients, we identified 9 patients with histoplasmosis. The median age, CD4+ count and HIV VL of these 9 patients was 36 years, 40 cells/mm3 and 193,184 copies/mL, respectively. Two patients developed IRIS only to histoplasmosis (1 unmasking and 1 paradoxical), 2 patients developed IRIS to both histoplasmosis and nontuberculous mycobacteria (NTM) and 3 patients developed IRIS to other infections (1 VZV, and 2 NTM). The manifestations of histoplasmosis IRIS in our cohort ranged from worsening lymphadenopathy to small bowel obstruction and worsening pulmonary symptoms.

Conclusion

Histoplasma-related IRIS can present with worsening lymphadenopathy, small bowel obstruction, and worsening pulmonary symptoms. The emergence of IRIS appears to be very common in people with HIV and disseminated histoplasmosis but the underlying trigger may be histoplasma, other co-infections or both.

Disclosures

All authors: No reported disclosures.
385. Arthroscopic vs. Open Surgery for Septic Arthritis of the Knee: A Systematic Review and Meta-Analysis
Authors: Sornprom Suthanya , Molloy Iida , Yong Taylor
Published: October 2019

Background

Septic arthritis is a joint-threatening and life-threatening infection, with the knee representing the most frequently involved joint. There is no definitive treatment algorithm for the management of this condition, which typically includes surgical debridement to decompress the joint, followed by organism-specific intravenous antibiotics.

Methods

Search Methods. MEDLINE (1965–2018), SCOPUS (1973–2018), The COCHRANE Library (2006–2017), EMBASE (1974–2018), reference lists, and scientific meetings were searched for relevant studies on the treatment of native knee septic arthritis by three independent reviewers. No language restrictions were used. Selection criteria included all studies reporting on native knee septic arthritis in adults treated with arthroscopy and open arthrotomy with irrigation and debridement. Data Collection and Analysis Studies were identified, subjected to inclusion and exclusion criteria, and reviewed by three independent reviewers. Patient characteristics, interventions, and outcomes were extracted, and the trials were rated for quality based on established criteria. A meta-analysis was conducted for the primary outcome, reoperation occurring after arthroscopic vs. open arthrotomy irrigation and debridement for the treatment of septic arthritis. We used a qualitative analysis for secondary outcomes physical function and hospital length of stay.

Results

From 624 abstracts, eight trials met inclusion criteria, one randomized controlled trial and seven retrospective cohorts. Quantitative meta-analysis showed arthroscopic irrigation and debridement resulted in fewer reoperations compared with open arthrotomy (RR = 0.76; 95% CI 0.59–0.97, P = 0.03, I2 = 24%), Figure 1. A qualitative summary of seven included studies assessing physical function showed arthroscopic debridement results in improved functional outcomes and range of motion compared with open arthrotomy. Based on four trials, qualitative summary demonstrated that arthroscopic debridement results in decreased hospital length of stay compared with open arthrotomy.

Conclusion

Arthroscopic irrigation and debridement is favored over open arthrotomy with regard to lower rates of reoperation, improved functional outcomes, and shorter hospital length of stay.

Disclosures

All authors: No reported disclosures.
394. Impact of Day of Admission and Time to Diagnostic Arthrocentesis on Mortality and Other Outcomes in Solid-Organ Transplant Recipients with Septic Arthritis: A Nationwide Analysis
Authors: Contreras Anez Gustavo , Arevalo Ana B , Murray Shane E , Olivo Freites Christian
Published: October 2019

Background

Multiple cases have been reported assessing the outcomes for solid-organ transplant recipients (SOTR) admitted to the hospital with septic arthritis of a native joint (SANJ); however, there are no data evaluating the outcome of these patients when they are admitted on the weekend compared with the rest of the week.

Methods

The NIS database of the year 2016 was utilized to identify all SOTR with SANJ using ICD-10 codes. SOTR status was defined as those adults with a history of a transplanted organ including heart, lungs, a combined heart and lung, liver, kidney, intestine or pancreas. Admissions between midnight Friday and midnight Sunday were classified as weekend admissions. Early arthrocentesis was defined as percutaneous arthrocentesis performed within 24 hours of admission. Odds ratios (OR) were calculated for primary and secondary outcomes including in-hospital mortality rate, rates of diagnostic arthrocentesis and early arthrocentesis, length o¬f stay and total hospital charges. These results were compared after univariable and multivariable logistic regression adjusted for age, gender, race, day of admission, Charlson comorbidity index and median household yearly income in the patient’s zip code. We used STATA-15 for statistical analysis.

Results

We identified 319 SOTR with SANJ. Compared with SOTR admitted with SANJ on weekdays, those admitted on weekends had increased in-hospital mortality rates (odds ratio[OR] 11; 95% [CI] 1.2–97.9, P < 0.05), but similar, length of stay (P > 0.05) and hospital charges (P > 0.05). However, regardless of the day of admission those who received an early arthrocentesis had a lower length of stay (P < 0.05), and lower total hospital charges (P < 0.05).

Conclusion

Our study showed that compared with SOTR admitted with SANJ on weekdays, those admitted on weekends had increased mortality rates but similar length of stays and total hospital charges. However, patients who received an early arthrocentesis had a significantly lower length of stay and hospital charges regardless of the day of admission. These results add weight to the hypothesis of negative outcomes in weekend admissions. Moreover, we believe that our findings require further investigation to establish the role of early arthrocentesis in the management of septic arthritis.

Disclosures

All authors: No reported disclosures.
405. Serum Antibody Responses Against Carbapenem-Resistant Klebsiella pneumoniae in Infected Patients
Authors: Banerjee Kasturi , Motley Michael , Diago-Navarro Elizabeth , Fries Bettina C
Published: October 2019

Background

Capsular polysaccharide (CPS) of Carbapenem-resistant K. pneumoniae ST258 (CR-Kp) is a potential vaccine target. CPS of these isolates generally falls within 2 homology groups named clade 1 and clade 2. We and others have made antibodies (Abs) that act against clade2 CR-Kp but failed to make therapeutic Abs against clade1 CR-Kp. Previous studies had shown that studying patient’s antibody responses could help in identifying suitable candidates for developing immunotherapies. Thus, we sought to identify potential vaccine candidates by investigating the humoral response CPS in CR-Kp-infected patients.

Methods

24 CR-Kp isolates and corresponding serums were collected from inpatients at Stony Brook Hospital. CPS was isolated and purified by size-exclusion column chromatography from CR-Kp strains 34 (clade 2), 36 (clade 1), and 38 (clade-Other). Anti-CPS Abs in patient’s serum were detected by enzyme-linked immunosorbent assay (ELISA) and bulk Abs from positive serum were purified using an affinity column. These Abs were tested for activity against CR-Kp by serum bactericidal and agglutination assays.

Results

50% of clade2 CR-Kp-infected patients had humoral responses against CPS34. 77% of clade 1-infected patients sera cross-reacted wtih CPS34, but none of them developed Abs against CPS36. Interestingly, 90% of clade1 and 60% of clade 2-infected patients, respectively, showed Abs binding to CPS38. Thus, we selectively purified Anti-CPS Abs from two clade-Other-infected patients and observed that they were cross-reactive with all three CPS. Further, these Anti-CPS Abs agglutinated all tested CR-Kp isolates (34, 36, and 38) when compared with control human IgG (P < 0.005). Additionally, these Anti-CPS Abs promoted killing of clade2 bacteria and inhibited the growth of clade1 bacteria in Ab-mediated serum bactericidal assay. These data elucidate that humoral responses developed in clade-Other CR-Kp-infected patients have therapeutic potential.

Conclusion

With the unavailability of effective antimicrobials for CR-Kp, approaches like developing novel anti-CPS vaccine could serve as an alternate therapy. Our data suggest that developing immunotherapies targeting CPS38 could potentially provide protection across both clade1 and clade2 bacteria in clinical settings.

Disclosures

All authors: No reported disclosures.
428. Lower Incidence Rates of Neisseria gonorrhoeae and Chlamydia trachomatis in Pre- Exposure Prophylaxis Patients Over Fifty Years Old Than in Younger Quartiles.
Authors: Morris-Haris Deborah Gail
Published: October 2019

Background

While Pre-Exposure Prophylaxis (PrEP) has been shown to be effective in preventing the acquisition of HIV, the cost of care is considerable. Public health efforts should be directed to those at highest risk to minimize the cost of a quality-adjusted life-year (QALY).

Given that sexually transmitted illnesses (STIs) increase the risk of acquiring HIV from 5–8 fold, their incidence rates can serve to define populations at highest risk for HIV within the community of men who have sex with men (MSM).

Methods

A retrospective cohort of PrEP patients with STI screening visits in two clinics in Dallas, Texas from January 2016 through April 2019 were reviewed. Three-site genital and extra-genital testing was routinely performed. Categorical variables were compared using Chi-Square. A binomial regression model was used to evaluate the odds of STI acquisition.

Results

201 PrEP patients had 999 screening visits. 17 were in the first quartile, ages (18–24) 35.3% were Black, 70.6% MSM; 105 were in the second quartile, ages (25–37) 23.8% Black, 58.1% MSM; 56 third quartile, ages (38–49) 17.9% Black, 62.5% MSM; 23 patients in the fourth quartile, age ≥50, 8.7% were Black, 47.8% MSM. The younger age group, first quartile contributed 16 person-years (py); the second quartile, 102 py; third quartile, 48 py; fourth quartile, ≥50, 25 py. The incidence rates for Neisseria gonorrhoeae (GC) or Chlamydia trachomatis (CT) from any site were higher in the first quartile, 166/100 py, CI 150–174; second quartile, 92/100 py, CI- 85–96; third quartile, 62/100 py, CI 48–75 than in those in the fourth quartile, ≥50 years old, 44/100 py, CI 27–63. The incidence of any rectal GCor CT in the first quartile, 86/100 py, CI 63–98; second quartile, 53/100 py, CI 43–62; third quartile, 29/100 py, CI 18–43 and those in the fourth quartile, ≥50, 32/100 py, CI 17–52. In a binomial regression model, the odds of acquiring any GC or CT for a PrEP patient ≥50 revealed an adjusted OR of 0.40, CI, 0.20–0.79 (adjusted for race and sexual orientation) P = 0.009 when compared with patients less than 50.

Conclusion

PrEP patients fifty and older have the lowest odds of acquiring STIs. Younger age groups with higher incidences of STIs may represent those with more episodes of condomless sex, at higher risk for HIV.

Disclosures

All authors: No reported disclosures.