bluuebunny/crossref_metadata_2025_split huggingface dataset:
1300. Symptom Driven Testing Is not Enough: A Retrospective Review of Patients Enrolled into HIV Care 2015–2018 at a Ryan White Patient-Centered Medical Home in Pittsburgh, Pennsylvania
Authors: Cheronis Nicholas , Bean Holly , Tremoglie Marissa , Magrini Cindy , Blazejewski Lucas , Hsiao Chiu-bin 
Published: October 2019

Abstract

Background
While current CDC guidelines recommend screening between the ages of 13–64 at least once and annually for high-risk individuals, this is often not practiced. Early diagnosis has become key to preventing the spread of HIV. It has been suggested that a late diagnosis, one where a patient is symptomatic, implies a loss of 10.5 years in their lifespan.

Methods
From January 1, 1, 2015 to December 31, 2018, 113 newly diagnosed HIV-infected patients enrolled in care at The Positive Health Clinic (PHC), a Ryan White funded clinic, located in Pittsburgh, PA.

Results
The median age was 32, 78% male, 64% MSM (Figure 1). At the time of HIV diagnosis, the median CD4 count was 325 U/L and HIV viral load was 65,000 copies. 32 patients (28%) had a CD4 count <200 and 13 had an AIDS-defining illnesses (Figure 2). Only 50% of HIV diagnoses were based on a provider’s clinical suspicions, 26% were driven by patient request, and 24% were the result of system driven screenings. 90.2% of patients had prior healthcare contact before the HIV diagnoses, suggesting missed opportunities. Of all the newly diagnosed HIV patients, 62% were symptomatic, prompting them to be tested for HIV (Figure 3). In 20% of the symptomatic cases, the patient requested to be tested for HIV, highlighting missed opportunities for clinicians to include HIV in their differential. A previous test for HIV within one year of their HIV diagnosis positively correlated with early diagnosis (CD4 >200 copies) (P = 0.007). System driven screenings for HIV also positively correlated with early diagnosis (CD4 >200 copies) (P < 0.001).

Conclusion
Waiting for clinical suspicion is not enough. To prevent patients from developing life-threatening AIDS-defining illnesses screening must be done at each interaction with the healthcare system for high-risk patients and annually for patients without risk factors.

Disclosures
All authors: No reported disclosures.
1301. Graphical Analysis of HIV Guidelines Adherence Finds System-Wide Anomalies in Diagnostic Testing
Authors: Hauser Ronald George , Bhargava Ankur , Chartier Maggie , Maier Marissa 
Published: October 2019

Abstract

Background
The misuse of HIV diagnostic tests can delay HIV diagnosis, contribute to HIV transmission, incur unnecessary costs, and pose legal risks. Prompted by case reports of misused HIV diagnostic tests, we developed a method to systematically evaluate HIV diagnostic testing that utilized an observational medical database, evaluated performance at different levels (e.g., system, facility, clinician), adjudicated clinical practice patterns as adherent or nonadherent to guidelines, quantified the impact of clinical practice deviations, and identified targets for intervention.

Methods
We used graph theory to assess patterns of HIV testing in a national healthcare system. We obtained all HIV screening tests, viral loads, and resistance tests performed January 1, 2015–January 31, 2019, excluding HIV-positive and deceased individuals (Figure 1). We modeled the CDC’s HIV diagnostic testing guidelines as a directed graph (Figure 2A). Each node in the graph represented a test, and the edges pointed from one test to the next in chronological order. We then graphed each patient’s HIV testing. This set of patient-level graphs was aggregated into a single graph. Finally, we compared the two graphs, the first representing the CDC’s recommended approach to HIV diagnostic testing and the second representing the observed patterns of HIV testing, to assess for clinical practice deviations.

Results
The HIV diagnostic testing of 1.643 million patients from 130 facilities provided 8.790 million HIV diagnostic test results for analysis (Figure 1). Significant deviations from recommended practice were found including the use of HIV resistance tests (n = 3,007) and HIV nucleic acid tests (n = 16,567) instead of the recommended HIV screen (Figure 2B). The estimated costs of nonadherent testing totaled $2.427 million in 2018 dollars.

Conclusion
We developed a method that modeled a complex medical scenario as a directed graph. When applied to HIV diagnostic testing, we identified deviations in clinical practice from guideline recommendations. The model enabled the identification of intervention targets and prompted systemwide policy changes to reduce nonadherent orders and enhance HIV detection (Figure 3). This approach could be applied to diverse medical scenarios.

Disclosures
All authors: No reported disclosures.
1302. HIV Testing in Adults Presenting with Central Nervous System (CNS) Infections
Authors: Ma Bert , Vigil Karen J , Hasbun Rodrigo 
Published: October 2019

Abstract

Background
The Centers for Disease Control and Prevention recommends that all patients be tested for HIV while in a healthcare setting. HIV testing is especially important in patients with a central nervous system (CNS) infection because it impacts the differential diagnosis. In this study, we determined the rate of HIV testing in patients who presented with a CNS infection.

Methods
We performed a multicenter retrospective study of 1,312 patients over the age of 17 years with community or healthcare-acquired meningitis, aseptic meningitis or encephalitis admitted to 18 hospitals in New Orleans, LA and Houston, TX from July 1, 1998 through December 31, 2017. Prospective patients were identified using ICD 9 coding, physical examination findings, and cerebrospinal fluid analysis. The electronic medical records for these patients were reviewed for HIV testing and diagnosis. Aseptic meningitis cases were also reviewed for HIV RNA PCR testing. 100 patients with a known HIV diagnosis were excluded (2 aseptic meningitis, 82 encephalitis, and 16 community-acquired meningitis).

Results
Out of 1,312 patients presenting with a confirmed CNS infection, 664 (50.6%) had an HIV test done. A total of 81 patients (12.2%) were newly diagnosed with HIV during admission. Patients who underwent HIV testing were more likely to be non-caucasian, have no underlying comorbidities, lower Glasgow coma scale, and more seizures on presentation (P < 0.05). HIV testing also varied by type of CNS infection: community-acquired meningitis (98/142, 69.0%); encephalitis (180/261, 69.0%), aseptic meningitis (300/643, 46.6%), and healthcare-associated meningitis (86/289, 29.7%). In only 35 out of 547 patients (6.4%) presenting with acute aseptic meningitis was an HIV RNA PCR test ordered; 26 out of the 35 (74%) HIV RNA PCRs were positive with 9 patients being diagnosed with acute HIV seroconversion syndrome.

Conclusion
HIV testing is done in only one-half of patients with CNS infections with only a minority of patients presenting with acute aseptic meningitis being evaluated for acute HIV seroconversion syndrome. Clinicians should order an HIV test on all patients with CNS infections and consider testing for HIV RNA PCR in patients presenting with acute aseptic meningitis especially in those where the etiologic diagnosis remains unknown.

Disclosures
All authors: No reported disclosures.
1312. Increasing Care Engagement Amongst People Living with HIV Through a Text Messaging Intervention at a Tertiary Center
Authors: Gupta Nupur , McBeth Sarah , Kaplan Ella , Valdisera Greg , McMahon Deborah 
Published: October 2019

Abstract

Background
HIV has transitioned from an acute illness to a chronic disease due to potent antiretroviral therapy (ART). People living with HIV (PLWH) must be highly compliant which is difficult due to multiple barriers. The HIV care continuum was developed as a series of steps that PLWH take in their treatment cascade. At our HIV clinic, 90% of the patients are virally suppressed (viral load <200 copies/mL). Although this is higher than the national average, PLWH who are not virally suppressed and not retained in care carry the highest risk of transmission. We have several resources to engage patients, but text messaging has not been utilized for at-risk patients at the clinic or at the academic center.

Methods
The aim is to demonstrate that a pilot study of a text messaging-based intervention will increase the proportion of PLWH along the care continuum. The pre-intervention data consists of the clinic population with a viral load ≥200 copies/mL between July 1, 2017 and June 30, 2018. After chart review, eligible patients were consented to receive weekly text messages with content regarding appointment and medication reminders, and motivational messages. In the consented group, effectiveness of the intervention will be measured by tracking their appointments, viral loads, and ART prescriptions.

Results
After chart review, 80 patients were eligible, and 18 patients were consented for the intervention. In the eligible group, the average length of care is 8 years (range 0 to 26) and average number of years since initial ART prescription is 6.8 (range 0 to 20). The average viral load is 27,372 copies/mL. Amongst the consented group (n = 18), compared with the pre-intervention, there was a 6% increase in those who made an appointment, 33% increase in those who kept an appointment, 50% increase in those who had a viral load <200, and 62% increase in those who had ART dispensed post-intervention.

Conclusion
The intervention group is small due to difficulties in consenting this vulnerable population. This is an observational study that demonstrated the impact of text messaging a high-risk population with minimal harm that not only improved the local HIV care continuum, but also addressed the barriers to care. The next steps are to determine how this method can link other at-risk patients to care at a large HIV clinic at a tertiary center.

Disclosures
All authors: No reported disclosures.
1316. Gathering Trauma Narratives: A Qualitative Study on the Impact of Traumas on People Living with HIV (PLWH)
Authors: Pierson Doris , Mujumdar Vaidehi , Briceño Brittany , Cummer Elaina , Hemal Kshipra , Golden Shannon , Wiseman Kimberly , Tanner Amanda , Schafer Katherine R 
Published: October 2019

Abstract

Background
Trauma—emotional, physical, and psychological—is common and associated with increased risk behaviors, low rates of care engagement and viral suppression, and overall poor health outcomes for people living with HIV (PLWH). In the United States, there are limited data on how trauma affects reproductive health beliefs for PLWH and even less data on HIV providers’ understanding and consideration of these experiences in their approach to patients.

Methods
Fifteen semi-structured interviews were conducted with PLWH and nine semi-structured interviews were conducted with HIV care and service providers at an academic medical center in the Southeastern United States. Transcripts were analyzed using thematic analysis. Each transcript was coded by two investigators and discussed to ensure consensus.

Results
Participants’ narratives described diverse traumas, including sexual abuse (n = 6), the loss of a loved one (n = 8), and personal illness (n = 7). Types of trauma shared with providers included physical, sexual, illness, loss, and psychological. For patients, trauma was both a motivation for having children and a reason to stop having children. Providers perceived a variety of effects of trauma on both sexual behaviors and reproductive intentions. Reproductive counseling by HIV care providers (n = 5) focused on maintaining a healthy pregnancy and less on reproductive intentions prior to pregnancy. Reproductive discussions with pregnant female patients typically centered on reducing the risk of transmission in utero (including the importance of medication adherence to maintain viral suppression), what will happen during delivery, and breastfeeding risks. Reproductive discussions with males typically centered on preventing infection or re-infection of the mother.

Conclusion
PLWH interpret their trauma experiences differently, particularly when considering reproduction. Providers may not incorporate this information in counseling around reproductive health, highlighting the need fora trauma-informed healthcare practice that promotes awareness, education on the effect of past traumas on health, and access to appropriate resources.

Disclosures
All authors: No reported disclosures.
1332. Identification of Genetic Markers Linked to Recurrent Methicillin-Resistant Staphylococcus aureus Skin and Soft-Tissue Infections
Authors: Sims Matthew 
Published: October 2019

Abstract

Background
Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most common and problematic causes of bacterial skin and soft-tissue infections (SSTI). MRSA tends to form complex skin infections, furuncles, boils and abscesses. Many patients go on to have recurrent infections, requiring significant additional therapy to treat each infection as well as needing to undergo decolonization of the skin in order to remove the bacteria and try to prevent future infections. A test to distinguish patients at risk for recurrence can allow earlier more aggressive treatment for those at risk for recurrent infection. This can potentially reduce healthcare costs, prevent future hospital admissions and surgical procedures, and reduce loss of productivity experienced by patients suffering from multiple recurrences.

Methods
A genome-wide association study using the Affymetrix gene array was performed on 11 patients with confirmed recurrent MRSA SSTIs and 3 controls who never developed an SSTI despite confirmed heavy exposure to MRSA in order to identify single nucleotide polymorphisms (SNP) associated with recurrent MRSA. The 10 genes identified were then fully sequenced using an Illumina NextSeq 500 to identify additional SNPs.

Results
A total of 22 SNPs were found in 10 separate genes which distinguished patients with recurrent MRSA from patients without recurrent MRSA despite heavy exposure. The 10 genes are shown in Table 1 along with a representative SNP. The P-values for each individual SNP were between 3.5 × 10−5 and 1.2 × 10−7.

Conclusion
This study provides the first evidence of a genetic risk for those patients who develop recurrent MRSA SSTIs. The majority of the genes involved are related directly to the skin, not to immune functions thus it appears the major risk factor for development of recurrent MRSA SSTI is related to the barrier function of the skin and not to an immune defect. Being able to determine which patients are at risk for recurrence at the time they first present with an MRSA SSTI would be of great help in preventing future recurrences, reducing morbidity and reducing healthcare costs.

Disclosures
All authors: No reported disclosures.
1333. Utility of Admission Procalcitonin Level in Patients Presenting to the Hospital with Bloodstream Infection: Real-World Evidence from 250 US Hospitals
Authors: Kadri Sameer S , Ling Lai Yi , Warner Sarah , Strich Jeffrey R , Ricotta Emily , Rebecca Prevots D , Demirkale Cumhur Y , Babiker Ahmed , Rhee Chanu , Klompas Michael , Danner Robert L 
Published: October 2019

Abstract

Background
Serum procalcitonin (PCT) may aid in early detection and treatment of bacterial bloodstream infections (BSI), yet evidence for this indication is inconclusive. We leveraged real-world data to examine biological variability in PCT across host and pathogen factors and its utility for ruling out BSI on admission.

Methods
PCT measurements within 24 hours of admission were examined in patients presenting with monomicrobial BSI to 250 hospitals in the Cerner Healthfacts Database. The reliability of admission PCT for ruling out BSI at hospital presentation was assessed using two different thresholds (<0.5 and <0.25ng/mL) and then stratifying results by presence vs. absence of sepsis (using CDC Adult Sepsis Event criteria), fever or hypothermia vs. normothermia, various presumed sources of BSI, and organism taxon.

Results
Between 2007 and 2017, PCT was measured on admission in 4,358/42,465 (10.3%) adults with BSI present on admission at 60 hospitals. Of these, 870 (20%) met CDC surveillance criteria for sepsis. The median admission PCT was 4.89 [0.93, 23.98] and varied by taxon, BSI source, patient temperature, and the presence and severity of sepsis; acute illness severity was the greatest driver of high PCT levels (Fig 1). Using a threshold of ≥ 0.50 ng/mL, the sensitivity of PCT for detection of BSI was 84% for all patients. Notably, BSI without sepsis was 4-fold more likely to yield a false negative PCT (<0.5ng/mL) than bacteremic sepsis. Sensitivity ranged from 77% with normothermia to 83% with fever/hypothermia (P = 0.06), between 81 and 88% across sources of BSI (P = 0.13) and more widely between 64 and 91% across taxa (P = 0.02). Enterococcal BSI was 2- and 4-fold more likely to have a falsely negative PCT than S. aureus or S. pneumoniae BSIs, whereas non-glucose fermenters other than P. aeruginosa had a 2 and 3-fold higher likelihood of being missed compared with P. aeruginosa and Enterobacteriaceae BSIs respectively (Fig 2). Pathogen-level variation in PCT sensitivity was also observed for BSI without sepsis (62–90%; P = 0.02) and upon using a stricter rule-out threshold of <0.25 ng/mL (P = 0.01).

Conclusion
PCT levels and the reliability of this test for ruling out bacteremia at hospital presentation varies by pathogen, presenting signs, and presence vs. absence of sepsis.

Disclosures
All authors: No reported disclosures.
1343. Infectious Diseases Consultation Avoided Delayed Therapy and Unnecessary Exposures in the Majority of GeneXpert® MTB/RIF and AFB Smear Negative Pulmonary Tuberculosis Cases in the US County Hospital in Houston, Texas
Authors: Balason Arabella R , Saldana Andrew G , Chavez Violeta , Masayuki Nigo 
Published: October 2019

Abstract

Background
In 2017, Harris County had a total of 281 cases of newly diagnosed tuberculosis (Mtb), which was the highest incidence in Texas, United States. Lyndon B. Johnson (LBJ) hospital is one of the two HarrisHealth county hospitals which serve a wide population including immigrants and an indigent population. GeneXpert® MTB/RIF (GeneXpert) was implemented in our hospital since 4/2016. However, pulmonary Mtb cases with negative GeneXpert/AFB smears carry significant challenges in the initiation of therapy and hospital infection control. Our aim was to describe how Infectious diseases (ID) consultations helped to identify the cases of both GeneXpert and AFB smear-negative pulmonary Mtb cases without delaying therapy and unnecessary exposures.

Methods
The patients with newly diagnosed pulmonary Mtb in LBJ hospital were identified between January 2017 and December 2018. The patient’s characteristics, GeneXpert results, AFB smear results, and the presence of ID consultation were retrospectively collected. Delayed therapy is defined as the initiation of active four-drug Mtb therapy until the positive culture results.

Results
A total of 52 cases with newly diagnosed pulmonary Mtb confirmed by positive culture were identified, of which 44 cases who had GeneXpert on at least one sputum specimen were included in the final analysis. 7 out of 44 (20%) had negative GeneXpert on the first specimen and all three or more AFB smears were negative. The patients were the median age of 51 years and predominantly female (57%). 5 cases were Hispanic and 2 had HIV/AIDS. In 6 out of the 7 cases, ID consultation was made and anti-tuberculous therapy was empirically initiated without delay and all remained in the isolation. Only one case had delayed therapy despite ID consultation, three consecutive AFB sputum samples, and one GeneXpert was properly performed. The patient had newly diagnosed AIDS (CD4 of 2 cells/µL) and 3 weeks of chronic cough with normal lung parenchyma and minimal right pleural effusion on CT chest at his presentation.

Conclusion
We had 7 cases (20%) of GeneXpert and AFB smear-negative pulmonary Mtb. ID consultation properly identified 6 cases without delayed therapy. Early involvement of ID should be considered when pulmonary Mtb is suspected.

Disclosures
All authors: No reported disclosures.
1347. Tuberculosis Caused by Mycobacterium bovis in Children: A Retrospective Review of Cases From 2010 to 2019 in a Pediatric Tertiary-care Center in Mexico
Authors: Gonzalez Saldaña Napoleon , Macias Parra Mercedes , Arias de la Garza Eduardo , Pérez Murillo Sairy , Eugenio Narro Flores Manuel , Tamez Rivera Oscar 
Published: October 2019

Abstract

Background
Tuberculosis (Tb) is a leading cause of death worldwide. The most common cause of Tb is due to M. tuberculosis, however, M. bovis is considered a public health issue and an often-undetected cause of Tb. Information regarding Tb by M. bovis in children is scarce.

Methods
Retrospective analysis of culture-proven cases of Tb by M. bovis from 2010 to 2019 in a pediatric tertiary-care center in Mexico. Clinical and paraclinical characteristics were compared.

Results
We included 22 cases of Tb by M. bovis in children younger than 18 years of age. 64 percent were men, mean age was 3.8 years. All subjects had a positive history of BCG immunization. Eight subjects (36.4%) consumed unpasteurized dairy products, 3 (13.6%) referred contact with Tb-infected people, and none had contact with cattle. Twelve patients (54.5%) had an immunodeficiency (ID). The most common ID was defects in the IL-12/IFN-γ axis (36.3%), followed by severe-combined ID (9%). All of the subjects presented any form of extrapulmonary Tb, and 8 (36.4%) had disseminated Tb. The most common extrapulmonary presentations were lymph-node (40.9%), abdominal (18.2%), and skeletal Tb (13.6%). Fever was present in 21.3% of the cases, weight-loss in 12%, and diaphoresis in 9.3%. Hepatomegaly was present in 83% of patients with abdominal Tb (P = 0.001). We found a negative association between lymph-node enlargement and skeletal Tb by M. bovis (P = 0.01). Five cases (22.7%) were identified as M. bovis BCG strain. Infection by BCG strain was associated with a shorter time of presentation (< 4 months) (P = 0.005). Polydrug resistance (resistance to ≥2 drugs, excluding those classified as MDR) was observed in five strains (22.7%). We detected 3 RIF-resistant strains (19%), 2 INH-resistant strains (9.1%), and 1 EMB-resistant strain (4.5%). No MDR strains were detected. We report an 86% cure rate, and 5% mortality. Nine percent are still in treatment.

Conclusion
We report 22 cases of culture-proven cases of Tb by M. bovis, from 2010 to 2019 in a pediatric tertiary-care center in Mexico. Disseminated presentation was common, as well as extrapulmonary involvement. Infection by M. bovis BCG strain was associated with a shorter time of presentation. Further studies are required in order to expand our knowledge on M. bovis infection in children.

Disclosures
All authors: No reported disclosures.