bluuebunny/crossref_metadata_2025_split huggingface dataset:
392. Epidemiology and Treatment Outcome of Gram-Negative Polymicrobial, Gram-Positive Polymicrobial and Mixed Polymicrobial Prosthetic Joint Infection
Authors: Hooshmand Babak , Youssef Dima , Riederer Kathleen M , Szpunar Susan M , Coyle Meredith M , Bhargava Ashish 
Published: October 2019

Abstract

Background
Polymicrobial prosthetic joint infections (PMPJIs) are rare but treatment is usually challenging. Published studies described the PMPJIs without differentiating the component pathogens. We assessed clinical features and treatment outcome among Gram-negative polymicrobial (GNPM), Gram-positive polymicrobial (GPPM) and mixed polymicrobial (MPM) PJIs.

Methods
A retrospective cohort was studied at three Ascension hospitals in Detroit from January 2012 to December 2018. Cases were identified using the International Classification of Diseases, 9th and 10th Revision code specific for PJIs. Patient’s electronic medical records were reviewed.

Results
38 patients with PMPJI with a mean age of 67 years. were identified. 71% patients were female and caucasians. Nineteen (50%) patients had MPM, 16 (42%) had GPPM and 3 had GNPM. Among MPM PJIs, 14 (74%) involved hips, 4 (21%) knee and 1 (5%) ankle joint. Among GPPM PJIs, 7 (44%) involved hips, 8 (50%) knee and 1 (6%) shoulder joints. Among GNPM PJIs, 1 (33%) involved hip and 2 (67%) involved knee joints. 4 (21%), 1 (6%), and 1 (33%) patients had diabetes among MPM, GPPM and GNPM, respectively. Symptom onset of less than a week was noted in 13 (68%), 5 (31%), 3(100%) and of more than 3 weeks in 3 (16%), 7 (43%) and in 0 among MPM, GPPM and GNPM, respectively. 18 (95%), 12 (75%) and 2 (67%) patients presented with pain; 16 (84%), 6 (38%) and 3 (100%) patients had drainage among MPM, GPPM and GNPM, respectively. Among MPM PJIs, 12 (63%) underwent debridement, antibiotics and implant retention (DAIR), 2 (11%) for two stage exchange, 4 (21%) for chronic suppressive therapy and 1 (5%) had an amputation. 6 (58%) were readmitted within 6 months; 3 (50%) required prosthesis removal, 1 (4%) each died, was made hospice and was lost to follow-up. Among GPPM PJIs, 12 (75%) underwent DAIR and 4 (25%) went for two stage exchange. 9 (69%) patients among GPPM PJIs were readmitted in 6 months and 3 (50%) required prosthesis removal. All 3 of GNPM PJIs underwent DAIR and none were readmitted in 6 months.

Conclusion
Pain and drainage were common presenting symptoms. All GNPM PJIs presented within 1 week of symptoms and were treated successfully with DAIR. MPM and GPPM PJIs had high readmission rates and 6/26 (23%) managed with DAIR required prosthesis removal.

Disclosures
All authors: No reported disclosures.
410. Influence of Pre-season Antibody Titers to Influenza on Influenza Risk in a Cohort of Healthcare Personnel
Authors: Rattigan Susan M , Gorse Geoffrey , Kirpich Alexander , Cummings Derek , Rodriguez-Barradas Maria C , Simberkoff Michael , Bessesen Mary T , Gibert Cynthia L , Nyquist Ann-Christine , Price Connie S , Reich Nicholas , Brown Alexandria , Radonovich Lewis , Perl Trish M , Perl Trish M 
Published: October 2019

Abstract

Background
Influenza (flu) and other respiratory viruses circulate regularly throughout healthcare systems, often placing healthcare personnel (HCP) at high risk for illness. Hemagglutination inhibition (HAI) titers are associated with protection from flu illness, though few studies have characterized HAI in HCP. The Respiratory Protection Effectiveness Clinical Trial (ResPECT), provided HAI titers and data to assess infection risk based on four flu seasons. Participants from multiple outpatient settings wore respiratory protection within six feet of symptomatic patients.

Methods
Serological samples obtained at the beginning and end of each season and anterior nasopharyngeal swabs were taken randomly and when participants reported respiratory symptoms were assessed. Our primary outcome was PCR-confirmed influenza.

Results
During 5,180 participant-seasons of observation, 128 PCR-confirmed influenza A infections (20 H1N1, 108 H3N2) and 34 PCR-confirmed influenza B infections. 4,041 (78%) reported receiving an annual influenza vaccine. Each log base 2 increase in titer subtype-specific titer reduced the hazard of influenza infection with A/H3N2 by 18%(Relative Risk (RR) 0.82 95% CI 0.72,0.94), by 28% for influenza B (RR 0.72 95% CI 0.56,0.92 and by 25% for influenza A H1N1 (RR 0.75 95% CI 0.57–1.0). After adjusting for HAI titers, age was not significantly associated with risk for any of the subtypes.

Conclusion
In this prospective cohort of monitored HCPs, these findings support the current literature demonstrating that HAI titers are associated with protection from influenza infection. The relationship between HAI titers, influenza, and vaccination is complex, however. Vaccination was not shown to be associated with infection outcome in our model, though their effect may be difficult to separate from their effect on HAI titers.

Disclosures
Trish M. Perl, MD, MSc, 7–11: Advisory Board; medimmune: Research Grant.
418. Testing and Positivity Rates for Gonorrhea and Chlamydia in a Large Federally Qualified Health Center System
Authors: Douglas Claudia M , O’ Leary Sonja C , Tomcho Margaret M , Wu Florence J , Federico Steven J , Frost Holly M 
Published: October 2019

Abstract

Background
Gonorrhea (GC) and Chlamydia (CT) are the most reported sexually transmitted infections in the United States. Little is known about testing and positivity rates for GC/CT in clinical practice, particularly for male patients. In this study, we analyzed rates of GC/CT testing and positivity among 11–24 years old patients presenting to a system of federally qualified health centers (FQHC).

Methods
This retrospective data review was conducted at Denver Health (DH) in Denver, CO. Data were abstracted for 11–24 years old who were seen at least once at a DH FQHC in 2018. Abstracted data included patient age, gender, clinic location, and testing for GC/CT. The percentage of patients tested ≥1 time within the preceding year and the percentage of tested patients that were positive for GC and/or CT ≥1 time were calculated along with Wald 95% confidence intervals.

Results
In total, 34,416 unique patients were included. GC/CT testing was completed for 7.3% (95% CI: 6.8%, 7.6%) of 11–15 years old, 30.6% (95% CI: 29.5%, 31.6%) of 16–18 years old, and 45.6% (95% CI: 44.8%, 46.4%) of 19–24 years old. Rates of testing varied by gender and age and were lowest among males and younger patients (Figure 1). Of patients tested, 11.4% (95% CI: 10.7%, 12.1%) of females and 9.1% (95% CI: 7.8%, 10.4%) of males were positive for CT and 1.7% (95% CI: 1.4%, 2.0%) of females and 2.3% (95% CI: 1.6%, 2.9%) of males were positive for GC (Figure 2). Though less likely to be tested than older patients, females 11–15 years old had the highest rates of GC (2.1%; 95% CI: 1.2%, 3.0%) and the second highest rate of CT (13.5%; 95% CI: 11.3%, 15.6%) among females tested.

Conclusion
Despite efforts to improve GC/CT screening, less than 50% of 11–24 years old patients were tested within the prior year. Rates of GC/CT were higher than previously reported, particularly for females less than 16 years old. Male patients were less likely to be tested; however, the males who were tested had higher GC positivity rates and only slightly lower rates of CT than females who were tested. Future studies evaluating the effectiveness of interventions to reduce GC/CT among 11–24 years old are critically needed.

Disclosures
All authors: No reported disclosures.
421. Return of Results in Sexually Transmitted Infection Research: The Ethics of Notification and Treatment
Authors: Grubbs Joshua C , Rietmeijer Cornelis , Millum Joseph , Kilmarx Peter H 
Published: October 2019

Abstract

Background
In prevalence studies of sexually transmitted infections (STI), investigators often provide syndromic management for symptomatic participants, but may provide no specific treatment for asymptomatic individuals with positive test results due to the delays between sample collection and processing. It is unknown how frequently positive test results are returned to participants so that they know to seek treatment. The potential outcome, untreated study participants with documented infection, is concerning given the history of ethical lapses in STI research and the vulnerability of many STI study populations.

Methods
To characterize the extent of this issue, 82 prevalence studies from the World Health Organization’s (WHO) Report on global sexually transmitted infection surveillance, 2018, were reviewed to determine whether return of test results were reported. Studies were classified as either results returned, unspecified, or other. Publications were coded by country income in accordance with World Bank designations based on the study population’s location(s).

Results
Nearly half (45%) of the cited studies did not specify if participants were notified of their STI test results. Most study populations (78%) were in lower- and middle-income countries (LMIC) while 20% were in high-income countries (HIC). The remaining 2% of studies screened populations in both LMIC and HIC. Return of results was similar across income groups. Half of papers (50%) in HIC clearly indicated the return of results, whereas 44% were unspecified and one publication (6%) indicated results were not returned due to an unlinked-anonymized testing protocol (other). Results were returned in 53% of studies conducted in LMIC and not specified in 47%.

Conclusion
A substantial proportion of STI prevalence studies cited in a 2018 WHO report did not specify if participants received their test results. Institutional approval and informed consent are critical, but insufficient for ethical research. Clinically relevant results should be returned to study participants and treating clinicians to ensure appropriate management of identified infections, if not treated during research. This is especially important in STI research in vulnerable populations.

Disclosures
All authors: No reported disclosures.
427. Putting the ‘Eye’ in Spirochetes
Authors: Khalil Sarwat , Fida Madiha , Challener Douglas W , Tan Eugene , Sohail Muhammad R , Abu Saleh Omar 
Published: October 2019

Abstract

Background
Ocular syphilis is an infrequent presentation of Treponema pallidum infection. It is often seen in association with neurosyphilis but can occur in isolation as well. Here we describe a case series of 10 patients with ocular syphilis seen at our institution.

Methods
Patients with a diagnosis of ocular syphilis at the three sites of Mayo Clinic were identified from June 2006 to February 2019. Patient’s baseline characteristics, clinical presentation, diagnostic testing, and treatment were abstracted from Electronic Medical Records.

Results
We identified 10 patients (17 eyes) during the study period, half being diagnosed in the last 5 years. The median age was 51 years (IQR 21–66), and the majority were males (7/10). Characteristics of the patients are outlined in Table 1. Common presenting symptoms included vision loss (8/10), photophobia (4/10), and irritation (5/10). Seven of 10 patients had bilateral involvement. Of the 17 eyes, 59% had pan-uveitis and 82% had disc edema (Table 2). Rapid Plasma Reagin (RPR) was positive in 9 patients and median serum RPR was 1:128 (IQR 1:2-1:1024). One patient was diagnosed with a positive TP-PA, and characteristic ocular findings. One patients had positive 16S Ribosomal RNA Gene PCR/Sanger Sequencing on vitreous humor specimen for Treponema species. The majority of patients had isolated ocular symptoms at presentation; two patients also had an associated skin rash. All patients underwent a lumbar puncture (LP). Half had pleocytosis (TNC > 5) and elevated protein elevated (mean 63.6 mg/dL), although not significantly high. 3/10 patients had VDRL positive in the CSF. Protein levels were much higher in those with positive VDRL. Each patient was treated with intravenous (IV) penicillin for at least 2 weeks. Nine patients received ocular steroids as well. At last available follow-up, 8 had complete and 1 had partial resolution. One had worsened eye findings with eventual scarring.

Conclusion
Our findings are congruent with increasing incidence of ocular syphilis nationwide. Bilateral eye involvement and pan-uveitis were the most common ocular findings. Although only 3 patients had a positive VDRL in the CSF, pleocytosis and elevated protein were found in a large number of patients. Majority of the patients had clinical resolution with appropriate treatment.

Disclosures
All authors: No reported disclosures.
432. Qualitative Differentiation of Genital Ulcer Disease Etiology via Nucleic Acid Amplification Testing (NAAT)
Authors: McGowin Chris L , McCune Stephen , Engstrom-Melnyk Julia 
Published: October 2019

Abstract

Background
Genital ulcers (GUs) remain a common reason that both men and women seek treatment at US sexual health clinics. Presumptive diagnosis based solely on the macroscopic lesion characteristics is insensitive for differentiating between the common etiologies of GUs, which include HSV1/2, VZV, and syphilis. Given the ongoing and rapidly-expanding Syphilis epidemic, more accurate and timely identification of GU etiology would facilitate accurate therapeutic decision making, promote antibiotic stewardship, and have positive impacts on public health. The current study describes diagnostic workflows that allow for sequential/reflex or parallel GU testing, relying on a combination of IVD and published NAAT-based solutions, performed on the cobas® 4800 and/or cobas® 6800 Systems, to detect HSV1/2, VZV, and T. pallidum from a single specimen.

Methods
Commercially available control material for HSV1, HSV2, VZV, and T. pallidum were spiked into MSwab™ and cobasâ PCR medium at varying concentrations. The spiked medium was either aliquoted directly to cobas® PCR Media Secondary Tubes (for testing on the cobasâ 6800 System) or MSwabs were dipped directly into the spiked specimen vials and transferred to their respective collection tubes (cobasâ 4800 System). GU testing on the cobas® 4800 System was sequential: performing the cobas® HSV1 and 2 Test first, followed by VZV and T. pallidum detection using residual DNA eluates and the User Defined Workflow (UDF) software. Testing on the cobas® 6800 System allowed for parallel processing and simultaneous detection of the 4 targets utilizing the cobas omni Utility Channel, which supports a complete, automated Lab Developed Test workflow.

Results
Qualitative detection of HSV1, HSV2, VZV and T. pallidum was demonstrated on both systems.

Conclusion
Novel solutions that aim to reduce empiric therapy, or shorten the interval to treatment success, are critical for both diagnostic and antibiotic stewardship. Through parallel or sequential testing algorithms, panel testing schematics on either the cobas® 4800 and 6800 Systems allow for more accurate discrimination between GU etiologies that may help address the re-emergence of Syphilis in the USA.

Disclosures
All authors: No reported disclosures.
445. A Case of Disseminated Microsporidia Manifesting as Skin Lesions in a Patient with Acute Lymphoblastic Leukemia
Authors: Kaul Christina M , Kim Angela 
Published: October 2019

Abstract

Background
We present a case of a 65-year-old male with a history of acute B-cell lymphoblastic leukemia (ALL) who presented with fevers and skin lesions. The patient achieved remission after induction chemotherapy. Nineteen months after diagnosis, while on maintenance therapy, the patient presented as noted above. He was instructed to hold maintenance therapy and sent to the hospital.

Methods

Results
On examination, the patient was febrile. He had papules present on the forehead, chest, arms, legs, and back. Physical examination was otherwise unremarkable. Labs were notable for a white blood cell count of 3600/uL (absolute neutrophil 3100/uL) and creatine kinase (CK) of 593 U/L. Blood and urine cultures, Histoplasma, Varicella, Toxoplasma, HIV, and an acute hepatitis panel were negative. CT of the chest, abdomen, and pelvis was unremarkable. He was empirically started on micafungin and valacyclovir. However, he continued to have fevers and myalgias. Wound culture was negative for fungus after four weeks of growth. Skin biopsy immunostains were consistent with an unknown protozoan. Specimens were sent to an outside facility and yielded a diagnosis of Anncaliia algerae. Antibiotics were changed to albendazole and voriconazole, with subsequent improvement in all symptoms.

Conclusion
Microsporidia most commonly infect immunocompromised hosts. Clinical manifestations of microsporidiosis are extremely diverse. Oftentimes, symptoms are not present in those found to be infected with Microsporidia. A disseminated disease has been identified but remains rare. Although Microsporidia have been identified as a cause of infection in immunocompromised patients, there are few reports of infection in those diagnosed with cancer, and only a few cases have been due to Anncaliia algerae. In studies pertaining to ALL patients, roughly one-fifth of patients were identified as being infected with Microsporidia, but most did not have symptoms. This is the first reported case of disseminated Microsporidia in a patient with ALL and the first disseminated infection presenting as a skin manifestation. Of identified cases of disseminated Microsporidial infection, mortality was high. Thus, prompt recognition of Microsporidia as a cause of infection in patients with ALL is of utmost importance.

Disclosures
All authors: No reported disclosures.
449. Epidemiology of Combat-Related Deep Soft-Tissue Wound Infections
Authors: Stewart Laveta , Li Ping , Blyth Dana M , Blyth Dana M , Petfield Joseph , Campbell Wesley R , Tribble David 
Published: October 2019

Abstract

Background
Deep soft-tissue infections (DSTIs) are a common complication of combat-related extremity trauma. We present an epidemiologic assessment of combat-related DSTIs among wounded military personnel.

Methods
Wounded personnel were included in the analysis if they sustained an open combat-related extremity wound (2009–2014), were admitted to a participating US military hospital, had a DSTI as the first confirmed extremity wound infection (within 30 days post-injury), started antibiotics ±3 days of DSTI diagnosis, and received ≥5 days of directed antibiotic treatment.

Results
Among 1961 combat casualties with open extremity wounds, 259 had a DSTI diagnosis with 173 (67%) having only 1 index DSTI and 86 (33%) having >1 index DSTI diagnosed on the same day. Nearly all patients (95%) were injured via a blast mechanism. Patients with >1 index DSTI were more severely injured (median injury severity score: 35 vs. 33; P = 0.009) and required large volume blood transfusions within 24 hours of injury (median units: 23 vs. 17; P < 0.001). Initial empiric antibiotic treatment largely involved carbapenem and vancomycin (77% and 72% of patients, respectively). For diagnosis timing, 130 (50%) patients had an early DSTI diagnosis (≤7 days post-injury), while the remaining 129 (50%) patients had a delayed diagnosis (>7 days post-injury). Patients with early DSTI diagnoses more often had >1 index DSTI (47% vs. 19% with delayed DSTI; P < 0.001). Polymicrobial DSTIs were common (73% of early DSTIs; 58% of delayed DSTIs) with Enterococcus spp. most frequently identified (56% of early DSTIs; 31% of delayed DSTIs) as well as Enterobacter spp., Escherichia coli, Pseudomonas aeruginosa, and Acinetobacter spp. Moreover, 26% and 39% of early and delayed DSTIs had multidrug-resistant Gram-negative bacteria. Receipt of >20 units of blood within 24 hours of injury and having >1 index DSTI were independently associated with an early DSTI diagnosis (odds ratio [OR]: 3.21; 95% CI: 1.47–7.02 and OR: 2.98; 95% CI: 1.63–5.42, respectively).

Conclusion
Multiple index DSTIs and massive blood transfusion requirement are associated with early infection onset post-injury. Awareness of wound microbiology findings relative to DSTI onset provides guidance on empiric antimicrobial therapy.

Disclosures
All authors: No reported disclosures.
458. Diagnostic Accuracy and Management of Suspected Moderate to Severe Cellulitis Referred to an Infectious Diseases Outpatient Parenteral Antibiotic Clinic: A Prospective Cross-Sectional Study
Authors: Piszczek Jolanta , Partlow Eric , Daniels Shay-Anne , Semproni Milena , Ghesquiere Wayne 
Published: October 2019

Abstract

Background
Moderate to severe cellulitis is a common reason for presentation to the emergency department and administration of intravenous antibiotics. Misdiagnosis of cellulitis occurs frequently as the disease can masquerade as a wide variety of noninfectious and infectious problems. There are currently no studies evaluating the impact of infectious diseases physicians on the diagnostic accuracy and management of cellulitis referred to an outpatient parenteral antibiotic clinic from the emergency department. The objective of this study was to quantify the prevalence of misdiagnosed moderate to severe cellulitis through an evaluation by an infectious diseases specialist, characterize the alternative diagnoses, and assess variables associated with misdiagnosis.

Methods
A prospective cross-sectional study of adults referred from emergency departments with presumed moderate to severe cellulitis to an outpatient parenteral antibiotic clinic staffed by infectious diseases specialists.

Results
301 consecutive patients with presumed cellulitis were evaluated over a 6-month period. A concurring diagnosis of cellulitis was found in 170 patients (56.5%), for a misdiagnosis rate of 43.5% (131/301). Table 1 summarizes the alternative diagnoses. Infectious conditions other than cellulitis were the most common (63/301; 20.9%), with abscess being present in 23 (7.6%) of patients. Fifty-two of 301 (17.3%) of the diagnoses were noninfectious and 16/301 (5.3%) patients had a dual diagnosis where minor cellulitis was present, but secondary to another, predomintating condition. The presence of stasis dermatitis (OR 6.62, P = 0.013) and a history of physical trauma (OR 1.76, P = 0.046) were associated with a misdiagnosis. 31.9% (107/335) of antibiotic regimens prescribed by emergency physicians were inappropriate or sub-optimal compared with 7.9% (22/280) of those ordered by infectious disease doctors.

Conclusion
Moderate to severe cellulitis was incorrectly diagnosed in nearly half of the patients referred for intravenous antibiotics and resulted in a high rate of unstewardly antimicrobial use. Infectious diseases physicians at an outpatient antibiotic clinic improved the diagnostic accuracy and management of this complicated condition.

Disclosures
All authors: No reported disclosures.