bluuebunny/crossref_metadata_2025_split huggingface dataset:
205. Comparing Cefazolin and Nafcillin in Treatment of Methicillin-Susceptible Staphylococcus Aureus Bacteremia: A Retrospective Study in a Single Center in the South Bronx
Authors: Chiu Chia-Yu , Sarwal Amara , Feinstein Addi 
Published: October 2019

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

Disclosures
All authors: No reported disclosures.