bluuebunny/crossref_metadata_2025_split huggingface dataset:
1367. Tele-TB: Using TeleMedicine to Increase Access to Directly Observed Therapy for Latent Tuberculosis Infections
Authors: Donahue Megan L , Eberly Matthew , Stagliano David , Rajnik Michael 
Published: October 2019

Abstract

Background
Otherwise healthy patients with latent tuberculosis infection (LTBI) have a 10 percent lifetime risk of progression to active TB disease. This risk is higher in recently exposed persons, young children, and the immunocompromised. Treatment of LTBI decreases the risk of progression. However, traditional treatment regimens required either daily isoniazid (INH) for 9 months, with historically poor compliance, or 12-week directly-observed therapy (DOT) with INH and rifapentine (RPT), with improved compliance but challenges of coordinating weekly clinic visits, further complicated if patients must travel a great distance for care and/or miss considerable amounts of time from work or school to attend encounters.

Methods
Our referral area is complicated by congested traffic often resulting in one-way commutes in excess of 2 hours. These travel times would be prohibitive for conducting traditional weekly in-clinic DOT. In an effort to improve access to DOT, we implemented TeleMedicine LTBI DOT within a military pediatric infectious diseases clinic. Local providers were requested to refer patients aged two and older diagnosed with LTBI to our DOT TeleMedicine clinic. All patients without absolute contraindications for receiving INH and/or RPT were offered LTBI treatment via weekly TeleMedicine DOT or daily INH. If the family opted for TeleMedicine DOT, the first visit was performed in person to discuss treatment options, demonstrate use of the TeleMedicine software, and to ensure the patient was able to take the medications. Baseline information about patient travel time to our facility for patients enrolled in the LTBI DOT clinic was determined.

Results
To date, seven patients have completed LTBI treatment via TeleMedicine DOT. Average one-way travel time to our facility for patients participating in the TeleMedicine DOT was 72 minutes. Actual time spent in the TeleMedicine DOT encounters was less than 10 minutes. Appointments were arranged to take place outside usual school and work hours so patients could complete DOT with minimal interruptions to daily life, resulting in 100% treatment compliance and completion.

Conclusion
Conducting DOT using TeleMedicine is a viable and time-saving measure that still allows for high levels of patient compliance and treatment completion while minimizing interruptions to academic and work schedules.

Disclosures
All authors: No reported disclosures.
1371. Tuberculosis and HIV Coinfection in the Bahamas: A Retrospective Review of Cases Diagnosed Between 2014 and 2016
Authors: McIntosh Javardo , Moss Kevin , Forbes Nikkiah , Frankson M Anthony C 
Published: October 2019

Abstract

Background
Tuberculosis (TB) is one of the oldest diseases known to man, yet the world health organization reports that TB is one of the top 10 causes of death worldwide. HIV infection is the most potent biologic risk factor for developing tuberculosis. The HIV epidemic has been responsible for increasing the burden of TB worldwide and The Bahamas has been no exception. The aim of this study was to determine the HIV testing rate as well as prevalence of TB-HIV coinfection for The Bahamas and compare cases of TB based on HIV status for clinical presentation, radiologic findings, TST results and Smear and Culture results. We also evaluated cases of TB-HIV for degree of immunosuppression and compliance to antiretroviral therapy.

Methods
A retrospective chart review of cases of Tuberculosis diagnosed at the Princess Margaret Hospital, Nassau, Bahamas. 189 cases of active tuberculosis diagnosed between 2014 and 2016 and all cases were evaluated for demographics, risk factors, HIV status, clinical manifestation, radiologic findings, and smear and culture results.

Results
Of the 189 cases of notified tuberculosis between 2014 and 2016, 109 (59.9%) were HIV negative and 73 (40.1%) were HIV positive. For patients who were HIV positive, 54(74%) were previously diagnosed with HIV and 19(26%) were newly diagnosed. Of the patients who were previously diagnosed with HIV, 14(25.9%) were on antiretroviral (ARV) medications and compliant, 34(63.0%) were on ARVs and noncompliant and 6(11.1%) were not on ARVs. 4(8.2%) patient had a CD4 count ≥500, 8(16.3%) patients had a CD4 count between 499–200 and 37(75.5%) had a CD4 counts 1000.

Conclusion
HIV is a major risk factor for Tuberculosis in the Bahamas and it is advised that all patients diagnosed with TB be tested for HIV. Routine screening of HIV patients for TB is recommended. Noncompliance with antiretroviral therapy remains a public health issue as it increases susceptibility to TB infection.

Disclosures
All authors: No reported disclosures.
1387. Women Living with HIV (WLWH) Lose IFNγ Responses Diagnostic of Latent TB Infection (LTBI) during Pregnancy and after INH Prophylactic Treatment (IPT)
Authors: Weinberg Adriana , Aaron Lisa , Montepiedra Grace , Sterling Timothy , Chaktoura Nahida , Browning Renee , Mmbaga Blandina T , Vhembo Tichaona , Nandkumar. Naik Shilpa , Pahwa Savita , Mathad Jyoti S , LaCourse Sylvia , McCarthy Katie S , Bradford Sarah , Costello Diane G , Zimmer Bonnie , Flore Pierre Marie , Gupta Amita , Theron Gerhard B 
Published: October 2019

Abstract

Background
TB is the most common opportunistic infection in PLWH. IPT is recommended for PLWH in endemic areas and for those with LTBI diagnosed by Quantiferon gold-in-tube (QGIT) or tuberculin skin test (TST) in other areas. We report on the performance of QGIT and TST in pregnant WLWH who received IPT antepartum (AP) or postpartum (PP).

Methods
WLWH participating in IMPAACT P1078, a randomized, double-blind, placebo-controlled study comparing 28 weeks of IPT AP vs. PP, were tested by QGIT at entry (14–34 weeks gestation) and by QGIT and TST at delivery (L&D) and 44 weeks PP. Serial QGIT positivity was assessed by logistic regression using generalized estimating equations.

Results
Among 944 women with study entry mean (SD) of 29 (6) years of age, 521 (245) CD4+ cells/µL, on ART, including 63% with undetectable HIV plasma RNA, 284/944 (30%) were QGIT+ AP, 215/862 (25%) at L&D and 246/764 (32%) PP (P < 0.001), while 127 (15%) were TST+ at L&D and 126 (17%) PP. QGIT was more likely positive than TST at L&D (Odds ratio = 4.3; 95% CI = 2.8–6.8) and PP (6.4; 3.9–10.7; P < 0.001). QGIT and TST agreement coefficients (95% CI) were 0.4 (0.3–0.5) at L&D and 0.5 (0.4–0.5) PP. Among women QGIT+ AP, 59 (24%) reverted to QGIT- or indeterminate at L&D. However, 37 (63%) reverters recovered QGIT+ results PP, suggesting transient suppression of IFNg responses during pregnancy. Responses to the mitogen-positive QGIT kit control were absent in 60 (7%) women AP, 116 (16%) at L&D, but only 3 (0.4%) PP (P < 0.01), supporting the notion of transient immune suppression during pregnancy. Among women QGIT- AP, 33 (7%) converted to QGIT+ PP. Among AP QGIT+ women, 24 (11%) reverted to QGIT- PP after finishing IPT. None of the results differed between treatment arms (P ≥ 0.13).

Conclusion
In WLWH on ART, the loss of IFNγ responses to TB antigen and mitogen in pregnancy decreased the diagnostic value of QGIT. TST was similar at L&D and PP but was less sensitive than QGIT. QGIT conversions likely resulted from a combination of PP immune reconstitution and new TB infections. QGIT reversions might represent a change in TB-specific immunity in response to IPT. Reversions have been reported in adults without HIV after treatment of active TB. The clinical significance of QGIT reversions in PLWH needs further investigation.

Disclosures
All authors: No reported disclosures.
1394. Clinicopathologic Features of Infectious and Noninfectious Tissue Granulomas in Transplant Patients
Authors: Zachary Nussbaum Eliezer , Abi Raad Rita , Malinis Maricar , Azar Marwan M 
Published: October 2019

Abstract

Background
There is a paucity of literature about the implications of granulomatous disease in hematopoietic stem cell transplant (HSCT) and solid-organ transplant (SOT) patients. Given the broad range of infectious and noninfectious etiologies as well as the heightened risk for severe infection, it is important to characterize the clinicopathologic features of granulomas in this population and to develop a framework to guide further evaluation.

Methods
We performed chart reviews of 1,280 transplant recipients (791 SOT and 489 HSCT) at Yale-New Haven Hospital from 2009 to 2019 to identify patients with granulomas in pathologic specimens obtained peri-transplantation. Data on histopathology, microbiology, indication for biopsy, patient characteristics, and clinical presentation were recorded. Morbidity and mortality were noted at 1, 3, and 12 months after granuloma diagnosis.

Results
We identified 28 patients with granulomas (9 SOT, 19 HSCT); an incidence of 2.2%. None had explicit risk factors for MTB. Most granulomas (93%) were non-necrotizing. Common sources were lung (n = 9) and lymph node (n = 5). Most were found post-transplant (n = 19) and biopsies were prompted mostly by symptoms (n = 13) or incidental imaging findings (n = 9). Most granulomas were not associated with an infectious process (n = 20). Among infectious granulomas, bacterial soft-tissue infection (n = 2), bartonellosis (n = 2), and fungal infection (1 Cryptococcus and 1 Blastomyces) were most common. MTB PCR was negative in 4 specimens. Among granulomas discovered in SOT patients, 44% were infectious compared with 21% in HSCT recipients. Most infectious granulomas were found in symptomatic patients (75%). One granuloma-related adverse outcome occurred in a case of cryptogenic organizing pneumonia discovered pre-HSCT that worsened with tapering of immunosuppression post-HSCT.

Conclusion
Granulomas were uncommon in a large transplant population. Most were deemed noninfectious and their presence alone was not associated with adverse outcomes post-transplant or with increased immunosuppression. Granulomas were more likely to be infectious in SOT recipients and those with symptoms. Symptoms should guide the extent of microbiologic evaluation and reflexive MTB PCR testing is not warranted if risk factors are absent.

Disclosures
All authors: No reported disclosures.
1405. Infectious Causes of Chronic Meningitis in HIV-Negative Patients: A Case Series
Authors: Rivera Jose E , Bae Eunice H , Crissinger Tyler , Baldwin Kelly 
Published: October 2019

Abstract

Background
Chronic meningitis can be defined as inflammation of the cerebrospinal fluid (CSF) with the presence of >5 white blood cells/mm3 of CSF for 4 weeks. There is little literature available on defining the infectious causes or risk factors of chronic meningitis, and there are no studies that have looked at mortality in this group of patients. Our aim for this study was to evaluate the epidemiology, risk factors, and mortality of infectious causes of chronic meningitis within our healthcare system.

Methods
A total of 59 cases were identified through a systematic retrospective review from our electronic medical record database from 2004 to 2018 and were identified by having the presence of two consecutive lumbar punctures with a white blood cell count in CSF >5 WBC/mL3 in a 4-week period, or by having 4 weeks of meningeal symptoms with one lumbar puncture with >5 WBC/mL3. All cases were manually reviewed. We excluded patients with diagnosis of human immunodeficiency virus (HIV) infection. We included a review of comorbidities that could impair the immune system such as diabetes mellitus, alcohol use, chronic kidney disease (CKD) stage III or greater use of chemotherapy, immunotherapy, or chronic use of steroids and previous transplant recipients. The study was approved by the institutional review board

Results
59 cases of chronic meningitis attributable to an infectious etiology were identified. The most common pathogens were Borrelia burgdorferi (37%), Cryptococcus sp. (27%), and Candida sp. (10%). Other etiologies which were less common included viral etiologies (13%). Finally, there were two cases secondary to Streptococcus pneumonia. Regarding the total number of patients with the comorbidities studied, 13 (22%) had diabetes, 12 (20%) had CKD, 12 (20%) were under some form of chemo/immunotherapy including chronic steroid use and 3 (5%) of patients were transplant recipients.

Conclusion
Our study identified common infectious pathogens causing chronic meningitis in a rural, HIV-negative population. Our findings indicate that cryptococcus should be considered even within HIV-negative individuals, and Lyme disease should be considered in all endemic areas. Mortality was significant among patient with cryptococcal meningitis, where patients with Lyme meningitis did very well.

Disclosures
All authors: No reported disclosures.
1410. Serious Cryptococcal Infections with Ruxolitinib Use: A Case of Meningitis and a Review of the Literature
Authors: Harvey Jeremy , Tran Ly , Sampath Rahul , White Chris , Campanile Teresa 
Published: October 2019

Abstract

Background
Ruxolitinib is an inhibitor of Janus kinase (JAK) 1 and 2 and is approved for the treatment of myelofibrosis and polycythemia vera. Infectious complications associated with its use include reactivation of herpes simplex, zoster, hepatitis B, and tuberculosis, mucormycosis, and progressive multifocal leukoencephalopathy.

Methods
Seven cases of ruxolitinib-associated cryptococcal infections have been reported: three cases of meningitis, two cases of pulmonary disease, and two cases of disseminated disease (Table 1).

Results
We present a 72-year-old male with a history of JAK-2-positive polycythemia vera with secondary myelofibrosis, and concurrent multiple myeloma who presented with 3 weeks of chronic cough and 3 days of fever with severe bifrontal headache after remodeling a large birdcage in his backyard. The patient was on ruxolitinib, ixazomib, and weekly dexamethasone. Cerebrospinal fluid (CSF) analysis showed an elevated opening pressure of 29 cm of CSF, 173 leucocytes with a predominance of lymphocytes, protein of 87 mg/dL and a normal glucose level. BioFire FilmArray® Meningitis/Encephalitis panel detected targets for Cryptococcus in the CSF, and CSF cryptococcal antigen was positive at 1:4. CSF fungal cultures were subsequently positive for Cryptococcus neoformans, susceptible to liposomal amphotericin B (LAMB) and fluconazole. Ruxolitinib was discontinued, treatment with LAMB and flucytosine (5-FC) was associated with significant improvement of headache over the next week. Repeat CSF analysis in 2 weeks was culture negative with a negative cryptococcal antigen test. The patient completed 3 weeks of LAMB and 5-FC and then transitioned to oral fluconazole for a year.

Conclusion
Ruloxitinib and other JAK inhibitors suppress host immunity through impaired T-cell activation and downregulation of cytokines. The JAK-Signal Transducer and Activator of Transcription pathway is one of the most active pathways in host defense against cryptococcus, and use of JAK inhibitors like ruxolitinib may predispose to severe cryptococcal infections. Bird exposure is a risk factor, making environmental contact counseling for patients on ruxolitinib important. Fluconazole prophylaxis needs to be considered in select cases.

Disclosures
All authors: No reported disclosures.
1422. Evaluation of Diabetic Foot Infections and Osteomyelitis in a Veteran Population: Targets for Improved Outcomes
Authors: Carter Michael T , Trivedi Grishma , Fodero Kristen , Wattengel Bethany A , Sellick John , Mergenhagen Kari A 
Published: October 2019

Abstract

Background
Diabetic foot infections (DFI) complicated with osteomyelitis are a difficult infection to treat often resulting in poor outcomes. DFIs often require amputations, including serial amputations due to inadequate initial intervention and infection progression. This study examines various diagnostic and treatment strategies aimed to improve outcomes.

Methods
This retrospective cohort study included patients greater than or equal to 18 years of age with a DFI as identified via ICD 9 and ICD 10 codes from January 2005 to December 2018. Outcomes were analyzed to measure the impact of baseline characteristics on outcomes. The severity of infection was defined by PEDIS score (perfusion, extent, depth, infection, and sensation). Descriptive statistics were used to report differences.

Results
One hundred and thirty patients were included, 72% with osteomyelitis. The median PEDIS score was 3 (interquartile range 2–3). Magnetic resonance imaging was used to evaluate 38% of the population. Osteomyelitis patients who had an MRI performed were noted to have a higher rate of appropriate treatment and cure (56%) when compared with a similar group of patients who did not receive an MRI (25%) (P = 0.005). Comparing prolonged (> 4 weeks) therapy to short therapy, there was a significantly higher proportion of cures noted (62.71% vs. 36.62%, P < 0.0001). Failure was associated with less than 4 weeks of therapy (66.7%, P = 0.03) and presence of residual inflammation/infection after amputation (58.3%, P < 0.0001). Route of antibiotic had no impact on failure rates. However, patients with an initial drug-bug mismatch were more likely to fail. Sixty-six percent of patients with decreased ankle brachial index failed (P = 0.02).

Conclusion
Diabetic foot infections have serious consequences. Over a third of patients required further amputation or additional antibiotic therapy. Risk of failure was associated with short durations of therapy, poor perfusion, and residual inflammation after amputation. However, a higher rate of cures was noted with use of an MRI and prolonged therapy in patients. Stewardship initiatives may wish to focus on ensuring prolonged treatment courses and appropriate surgical intervention rather than on route of antibiotic therapy as there was no difference in failure rates.

Disclosures
All authors: No reported disclosures.
1429. Diagnosis and Management of Osteomyelitis Associated with Stage IV Pressure Ulcers: Report of a Query to the Emerging Infections Network of the Infectious Diseases Society of America
Authors: Kaka Anjum S , Beekmann Susan E , Gravely Amy , Polgreen Philip M , Johnson James R 
Published: October 2019

Abstract

Background
Despite the high prevalence and morbidity of stage IV pressure ulcers, there are few clinical studies to guide diagnosis and treatment of osteomyelitis in such patients.

Methods
The Emerging Infections Network conducted an electronic survey of adult ID physicians in 2018 to determine their approach to managing patients with stage IV pressure ulcers (exposed bone, tendon, or muscle) and osteomyelitis.

Results
The overall response rate was 42% (558/1,332). Of the respondents, 94/558 (17%) had not seen such patients in the last year, so opted out. Of the remaining 464 respondents, 276 (60%) usually felt confident in diagnosing osteomyelitis by physical examination, and laboratory or imaging test results; the strongest indicator of osteomyelitis was thought to be palpable or visible bone at the ulcer base (Figure 1). Approaches to diagnosing osteomyelitis in patients with visible and palpable bone varied: 41% would assume osteomyelitis was present, 27% would try local wound care and pressure-offloading before doing tests, 22% would do diagnostic tests immediately, and 10% would follow another strategy. The preferred tests for osteomyelitis were bone biopsy (for culture or histopathology) and MRI (Figure 2). Regarding treatment, respondents differed widely regarding favored route(s) of antimicrobial therapy (all IV, partly IV and partly oral, or all oral), regardless of presumed pathogen (Figure 3). Respondents also differed widely regarding preferred duration of antimicrobial therapy, but generally would treat longer in the absence of full surgical debridement (P < 0.001 overall) (Figure 4). Overall, 62% of respondents believed that osteomyelitis under stage IV pressure ulcers usually or almost always is treated excessively. Most respondents (59%) had multiple suggestions for future research, primarily regarding the duration and utility of antimicrobial therapy in this context.

Conclusion
ID physicians (i) report significant practice variability in their approach to diagnosing and treating osteomyelitis underlying stage IV pressure ulcers, (ii) are concerned about excessive antibiotic use in such patients, and (iii) perceive a critical need for additional research in this area.

Disclosures
All authors: No reported disclosures.
1458. Burden of Illness in Patients with Urinary Tract Infections With or Without Bacteremia Caused by Carbapenem-Resistant Gram-Negative Pathogens in US Hospitals (2014 to 2018)
Authors: Shields Ryan K , Kanakamedala Hemanth , Zhou Yun , Cai Bin 
Published: October 2019

Abstract

Background
Urinary tract infections (UTIs) are the most frequent infections caused by Gram-negative (GNB) bacteria in the USA. We aimed to characterize the burden of UTIs caused by carbapenem-resistant (CR) or -susceptible (CS) GNB in hospitalized patients with or without bacteremia.

Methods
Data from the Premier Healthcare Database of adult patients hospitalized between January 1, 2014 and June 30, 2018 with UTIs (defined as positive urine culture and receipt of GN antibiotics within −2 to 3 days of the index urine culture) with bacteremia (defined as positive blood culture with the same pathogen from the urine) or without bacteremia caused by CR or CS GNB were analyzed retrospectively. Stenotrophomonas maltophilia were presumed to be CR but rarely tested. Patient characteristics and outcomes (mortality, different types of length of hospital stay [LOS], ICU admission, discharge status and hospitalization charges) were compared.

Results
A total of 46,076 UTI patients were included. 11,212 patients with bacteremia were significantly more likely to have UTI index culture on the day of the admission vs. 34,864 patients without bacteremia (82.0% vs. 65.9%, P < 0.001, respectively). The same results were seen when stratified by CR status (CR: 68.59% vs. 61.23%, P < 0.047; CS: 82.29% vs. 66.19%, P < 0.001, respectively). UTI patients with bacteremia were also more likely to have a positive blood culture for the same pathogen on the same day of index urine culture (CR: 85.86%; CS: 95.45%). Pseudomonas aeruginosa was the most frequent CR pathogen (50.03%), followed by K. pneumoniae (14.28%) and Stenotrophomonas maltophilia (10.76%), and CR patients with bacteremia were more likely to die in the hospital and less likely to be discharged home than other groups. They also had longer median overall and infection-associated LOS, were more likely to be admitted to the ICU and had higher hospitalization charges (table).

Conclusion
UTIs complicated by bacteremia exacerbates the burden of illness in patients hospitalized with UTIs, increasing mortality, LOS, and hospitalization charges. The presence of CR pathogens further exacerbates this burden.

Disclosures
All authors: No reported disclosures.