bluuebunny/crossref_metadata_2025_split huggingface dataset:
374. Lymphogranuloma Venereum (LGV) Outbreak Among People Living with HIV (PLWH): Michigan, 2015–2018
Authors: Convery Christine , Kent James B 
Published: October 2019

Abstract

Background
Sexually transmitted infections (STIs) have increased in recent years both nationally and in Michigan. At the same time, HIV prevention is shifting toward intense efforts to “ending the epidemic.” Detecting and mitigating outbreaks, as well as monitoring co-infections in people living with HIV (PLWH), will be critical in these efforts. Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by a serovar of Chlamydia trachomatis and may present with proctitis, lymphadenopathy, or genital ulcers.

Methods
While not nationally reportable, LGV remains on the list of reportable conditions in Michigan. No cases were reported between 2009 and 2014, but from August 12, 2015 to December 4, 2018, 68 cases of LGV were identified in 66 patients and reported by providers and laboratories through the Michigan Disease Surveillance System (MDSS). These reported cases were analyzed by specimen collection date and matched to other communicable disease databases for HIV co-infection status and STI history using SAS 9.4.

Results
The outbreak was local to Southeast Michigan where all but three patients resided; 72% cases lived in Detroit (Figure 1). 94% of cases were co-infected with HIV, including 4 who were co-diagnosed within 30 days of LGV diagnosis. Among the 60 cases of PLWH (excluding co-diagnoses), 62% were virally suppressed (VS) and 32% were in care but not suppressed at the time of LGV diagnosis. The majority (88%) of outbreak patients had between 1 and 7 additional bacterial STIs in the two years prior to LGV. All reported cases were men who have sex with men (MSM) with two patients also reporting injection drug use (MSM/IDU).

Conclusion
Testing for LGV is not routine and in some settings not available so there are likely unreported cases missing from this outbreak analysis. HIV care outcomes differed from statewide estimates with outbreak patients more likely to be receiving care but not sufficiently engaged compared with all PLWH (Figure 2). A high proportion of cases with additional STI history combined with lower than average VS rate means transmission of HIV is likely. This highlights a need to integrate HIV care support with STI services. Additional analyses of HIV co-infection with syphilis or other STIs are needed to further inform these strategies.

Disclosures
All authors: No reported disclosures.
381. Clinical Outcome of Polymicrobial Prosthetic Joint Infection Managed with Debridement, Antibiotics, and Implant Retention (DAIR)
Authors: Hooshmand Babak , Youssef Dima , Riederer Kathleen M , Szpunar Susan M , Bhargava Ashish 
Published: October 2019

Abstract

Background
Polymicrobial (PM) prosthetic joint infections (PJIs) account for 4% to 37% of all PJIs. There is limited literature on surgical debridement, antibiotics and implant retention (DAIR) in PMPJIs. We aimed to assess clinical outcomes of PMPJIs managed with DAIR.

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
Twenty-six PMPJIs managed with DAIR were identified. Mean age of the infected patients was 66 years. 18 (69%) patients were female and 19 (73%) were caucasians. Infected sites were hip in 15 (58%), knee in 10 (38%) and ankle in 1 (4%) patient. 22 (85%) patients had osteoarthritis, 3 (12%) had diabetes, 3 (12%) were on steroids and 1 (4%) had rheumatoid arthritis. Symptom onset of less than a week was noted in 14 (58%) and 3 or more weeks in 8 (31%) patients. Pain, swelling and drainage were present in 21 (81%), 13 (50%) and 18 (69%) cases. Fever on admission was noted in 7 (27%) patients. 11 (42%) patients were re-admitted in the following 12 months after DAIR. 2 (19%) patients developed superficial surgical site infection (SSI) while 9 (81%) had deep SSI. Implant removal was needed in 6 (55%) patients. 5 (2 superficial and 3 deep) patients required further debridement and antibiotics. 5 (19%) had good outcome with 3–6 months of antibiotics. 3 (12%) patients required long-term chronic suppressive therapy. One patient died from a cardiac event during follow-up.

Conclusion
In our study, PMPJIs managed with DAIR had high readmission rates and deep surgical site infections. DAIR failure, noted in 23% of our cases, required implant removal within 12 months of follow-up.

Disclosures
All authors: No reported disclosures.
387. A Rare Manifestation of a Common Disease: Tenosynovitis Associated with Clostridium difficile: Case Report and Review of Literature
Authors: Josephson Greta M , Ajmal Saira R 
Published: October 2019

Abstract

Background
Reactive arthritis typically develops following enteric or genitourinary infection. The most common offending pathogens are Chlamydia, Salmonella, Shigella, Yersinia and Campylobacter. We report a unique case of a patient with tenosynovitis attributed to Clostridium difficile (C. difficile), and review of the literature.

Methods
We searched PubMed for “reactive arthritis” and “C. difficile” and found 53 cases. Two additional cases were excluded as they were published in French.

Results
An 18-year-old healthy male presented with nine days of abdominal pain and diarrhea, and two days of pain and swelling of bilateral fingers with an erythematous/ecchymotic rash over the second and third digits. Four weeks prior to symptom onset he received antibiotics for streptococcal pharyngitis. On presentation he had diffuse abdominal tenderness and edema of the PIP/DIP joints with tenderness throughout the phalangeal soft tissue, consistent with tenosynovitis. He had a leukocyte count of 33.0 thou/ μL and C-reactive protein of 12.0 mg/dL (normal < 1.0 mg/dL). C. difficile toxin PCR was positive, toxin EIA was negative. CT scan of the abdomen/pelvis demonstrated mural thickening consistent with extensive severe colitis. He received 14 days of oral vancomycin, with complete symptom resolution, including the tenosynovitis. Our literature review revealed 22.6% (12/53) of cases had involvement of hands, although all also had involvement of other joints. Our patient’s isolated tenosynovitis of bilateral hands is unique, and has only been reported once prior to our knowledge. Literature suggests treatment of the underlying C. difficile infection should result in rapid clinical improvement of tenosynovitis symptoms, as in our patient.

Conclusion
C. difficile continues to pose a significant threat to health and burden on the healthcare system. The association of reactive arthritis and C. difficile was first reported in 1976, with only 53 subsequent cases reported. Reactive arthritis classically presents as asymmetrical oligo- or polyarthritis involving lower extremities or large joints. Our case demonstrates isolated tenosynovitis of the hands may also be a possible presentation. Given the continued rise of C. difficile, it is imperative that this pathogen is considered in such cases.

Disclosures
All authors: No reported disclosures.
390. Treatment and Outcome of Methicillin-Resistant Staphylococcus aureus Hip and Knee Prosthetic Joint Infection
Authors: Henry Michael , Carli Alberto V , Kapadia Milan , Chiu Yu-fen , Brause Barry , Miller Andy O 
Published: October 2019

Abstract

Background
Methicillin-resistant Staphylococcus aureus (MRSA) total hip and knee prosthetic joint infections (PJI) can be highly morbid and difficult to treat. Other clinical factors notwithstanding, explantation is usually recommended, although comparative treatment data are lacking. We sought to compare the success of implant retention to two-stage exchange in MRSA-infected PJI to better understand treatment options in this difficult cohort.

Methods
A retrospective cohort of hip and knee PJIs from 2009 to 2016 were identified by ICD code and surgical treatment. All cases met MSIS criteria for PJI, and had culture-confirmed MRSA from synovial or intra-articular tissue culture. PJIs were either treated with exchange arthroplasty or debridement with antibiotic and implant retention (DAIR). Success was defined as no further surgical treatment for infection at two years. Kaplan–Meier estimates were used to calculate the 2-year survival rate free from treatment failure. Univariate logistic regression was performed to identify risk factors associated with treatment failure.

Results
65 MRSA PJIs were identified with 42 undergoing explantation and 23 undergoing DAIR. Demographics, Charlson comorbidities, infection type (early post-operative, hematogenous or late chronic), and history of prior PJI were not significantly different between treatment groups. Survivorship at two years was 75% (95% confidence interval [CI] 61–88%) for exchange compared with 29% (95% CI 10–48%) for DAIR, P = 0.0002. Within the exchange group, knee PJIs were more likely to fail than hip PJI (odds ratio [OR] 7.1, CI 1.3–38, P = 0.02), and patients with diabetes were more likely to fail (OR 17, CI 1.6–178, P = 0.02).

Conclusion
MRSA PJIs treated with DAIR have worse outcomes than those treated with prosthesis exchange. Further investigation is needed to identify predictors of DAIR success, to optimize surgical treatment choice, and to improve outcomes of these difficult infections.

Disclosures
All authors: No reported disclosures.
400. Comparison of Tolerance and Microbiological Efficacy of Cefepime and Piperacillin/Tazobactam in Combination with Vancomycin as Empirical Antimicrobial Therapy of Prosthetic Joint Infection: A Propensity-Matched Cohort Study
Authors: Triffault-Fillit Claire , Mabrut Eugenie , Corbin Karine , Becker Agathe , Braun Evelyne , Tod Michel , Goutelle Sylvain , Henri Fessy Michel , Dupieux Celine , Laurent Frederic , Lustig Sebastien , Chidiac Christian , Ferry Tristan , Valour Florent 
Published: October 2019

Abstract

Background
The use of piperacillin/tazobactam with vancomycin as empirical antimicrobial therapy (EAT) for prosthetic joint infection (PJI) has been associated with an increased risk of acute kidney injury (AKI), leading to propose cefepime as an alternative since 2017 in our reference center. The present study compared microbiological efficacy and tolerance of these two EAT strategies.

Methods
All adult patients with PJI empirically treated by vancomycin-cefepime (n = 89) were enrolled in a prospective observational study, and matched with vancomycin-piperacillin/tazobactam-treated historical controls (n = 89) according to a propensity score including age, baseline renal function and concomitant use of other nephrotoxics. The two groups were compared using Kaplan–Meier curve analysis and non-parametric tests (Fisher exact test and Mann–Whitney U-test) regarding: (i) the proportion efficacious empirical regimen (i.e., at least one of the two molecules active against the identified organism(s) based on in vitro susceptibility testing); and (ii) the incidence of empirical therapy-related adverse events (AE), classified according to the Common terminology criteria for AE (CTCAE).

Results
Among the 146 (82.0%) documented infections, the EAT was considered as efficacious in 77 (98.7%) and 65 (98.5%) of the piperacillin–tazobactam and cefepim-treated patients, respectively (P = 1.000). The rate of AE, and in particular AKI, was significantly higher in the vancomycin–piperacillin/tazobactam (n = 27 [30.3%] and 23 [25.8%%]) compared with the vancomycin-cefepim (n = 13 [14.6%] and 6 [6.7%]) group (P = 0.019 and <0.001, respectively; figure), leading to a premature EAT discontinuation in 20 (22.5%) and 5 (5.6%) patients (P = 0.002). Of note, no significant differences were observed between the two groups regarding sex (91 males; 51.1%), median age (68-year-old; IQR, 59.3–75), main comorbidities including baseline renal function and proportion of patients receiving other nephrotoxics, and vancomycin plasmatic overload.

Conclusion
The empirical use of vancomycin-cefepim in PJI was as efficient as vancomycin–piperacillin/tazobactam, and was associated with a significantly lower incidence of AKI.

Disclosures
All authors: No reported disclosures.
406. Cloning Antibodies Against Kawasaki Disease from Acute Plasmablast Responses
Authors: Baron Sarah , Sojar Hakimuddin T , Hicar Mark D 
Published: October 2019

Abstract

Background
Kawasaki Disease (KD) is a childhood vasculitis, marked by prolonged fevers and coronary artery inflammation/aneurysms in near one-quarter of those untreated. The cause remains unknown; however, epidemiologic and demographic data support a single preceding infectious agent may lead to KD. Plasmablasts (PBs) are a stage of transitional B-cells that lead to plasma cells, the long-lived antibody-producing cells of the bone marrow. After initial infection, peripherally circulating PB populations are enriched for cells with antibodies against the preceding infection. We have recently published data showing children with KD have similar PB responses to children with infections. We sought to define the antibody characteristics, including clonality, of these PBs during KD.

Methods
We used antibody repertoire next-generation sequencing to characterize memory and PB populations. Additionally, pairing of heavy and light chains was performed with Chromium Single Cell Gene Expression (10x Genomics, Pleasanton, CA) using the Human B cell Single Cell V(D)J Enrichment Kit.

Results
From subject 24, antibody sequences using VH4-34 and a 19 amino acid length complementarity determining region 3 showed a massive expansion between day 4 and 6 of fever. Chromium single-cell sequencing produced over 946 heavy and light chain paired sequences. Sequence comparison showed 40% of sequences demonstrated markers of clonal expansion, which represented 100 clonal groups. Seven other KD subjects are being processed and comparative analysis will be presented.

Conclusion
This clonal expansion within plasmablast populations supports that Kawasaki disease is caused by an infection. Antigen targeting of these monoclonal antibodies is currently being explored.

Disclosures
All authors: No reported disclosures.
412. Host Response Biomarkers Predict Clinical Failure in Patients with Staphylococcus aureus Bacteremia (SAB) Treated with Flucloxacillin (FLU) or Vancomycin (VAN)
Authors: Aycock Anna , Holmes Natasha , Howden Benjamin , Hayney Mary , Sakoulas George , Rose Warren 
Published: October 2019

Abstract

Background
Imbalance among innate mediators such as IL-1β, IL-10, and TNF-α portends poor outcomes of persistence and death in patients with SAB. Previous studies did not consider the role of antibiotic treatment in this important host–pathogen relationship. In this study of SAB, we determined cytokine signatures that correlate with the composite endpoint of clinical failure (bacteremia duration >4 days or 30-day mortality) in Australian patients treated with FLU or VAN.

Methods
Sera from 86 patients with SAB (24.4% MRSA) were obtained from a clinical study of patients treated with FLU or VAN. All of the patient samples were collected at clinical presentation (day 0 or day 1 of infection) and were treated with FLU or VAN throughout. Patients were classified into either clinical success (CS = 68) or clinical failure (CF = 18), defined as death or prolonged bacteremia >4 days. Patient demographic and infection characteristics were collected. A 10-multiplex TH1/TH2 cytokine analysis was performed using electrochemoluminescence with the Meso-Scale Discovery platform analyzed by Mann–Whitney U.

Results
Patients’ median values were significantly elevated and above the normal range in CF for IL-1β (P = 0.029), IL-10 (P = 0.018), TNF-α (P = 0.042), and IL-6 (P = 0.006) (figure). Epidural abscess source was associated with CF, but no other host or pathogen characteristics correlated to outcome. Patients infected with isolates with VAN MIC = 2 mg/L (by Etest and broth dilution) had lower concentrations of IL-1β and IL-10 (P = 1.5 mg/L. In ROC analysis, IL-1β, IL-10, TNF, and IL-6 were higher sensitivity and specificity predictors of CF (AUC 0.65–0.71; P = 0.05).

Conclusion
A suboptimal host immune response to SAB at presentation predicts adverse clinical outcomes. IL-10, TNF-α, and IL-6 serum concentrations appear to reflect immunopathology in patients with SAB. These predictive markers may be considered in therapeutic clinical decision-making, such as escalation of alternative therapies in high-risk patients and/or de-escalation treatment in low-risk patients. These data offer steps toward further refining therapeutic precision for patients with SAB beyond the standard clinical or microbiological metrics that are employed in current practice.

Disclosures
All authors: No reported disclosures.
414. Developing Digital Phenotypes of Primary Immune Deficiencies Using Machine Learning on a Large Electronic Health Record Database
Authors: Meister Leo , Zerbe Christa , Notarangelo Luigi D , Kadri Sameer S , Rebecca Prevots D , Ricotta Emily 
Published: October 2019

Abstract

Background
More than 350 genetic disorders cause immune deficiencies; given the rarity of these conditions, in-depth study of infections associated with primary immune deficiencies (PID) requires extremely large sample sizes from broad populations. Using a large electronic health record (EHR) dataset, we linked clinical and microbiologic data to develop digital phenotypes for PID.

Methods
Using the Cerner HealthFacts EHR dataset from 2009 to 2017 we extracted clinical and microbiologic data for hospitalizations from patients <18 years old with ICD9/10 PID diagnoses and ≥1 positive culture for infection. Machine learning models were used to identify key features to predict PID diagnosis. Features included patient and hospitalization characteristics; infectious agent and infection site; and selected comorbidities. Model validation was done using the area under the receiver operating characteristic (AUC) curve.

Results
Overall 1316 patients with a PID were identified (Table 1). The 10 most common pathogens identified by PID are listed in Table 2. The models classified DiGeorge syndrome (positive predictive value 49%), functional disorders of polymorphonuclear neutrophils (PMN) (PPV 43%), and common variable immunodeficiency (CVID) (PPV 47%) better than combined immunodeficiency (CID) (PPV 20%); the overall true positive rate was 47% with an AUC of 0.73. Predictive features for each PID were as follows: CVID—having enteritis, hypertension, and pneumonia (Figure 1a); PMN—having hypoxia and hypertension (Figure 1b); DiGeorge syndrome—having congenital deformities and not having hypertension (Figure 1c); CID—finding Staphylococcus aureus in a wound or Escherichia coli in the blood were predictive of CID (Figure 1d).

Conclusion
Early models demonstrate some discrimination, specifically for more common PIDs (CVID) and those with highly identifying factors (DiGeorge syndrome). These models can be improved by including a wider array of clinical data, and they provide a first look at a new methodology to digitally phenotype PIDs for future diagnostic use.

Disclosures
All authors: No reported disclosures.
420. Prevalence of Oropharyngeal Meningococcal Carriage in an Urban STD Clinic
Authors: Turner Abigail N , Carter Alexandria , Tzeng Yih-Ling , Brown Morgan , Stephens David , Snyder Brandon , Prince Devlin , Bazan Jose A 
Published: October 2019

Abstract

Background
Neisseria meningitidis (Nm) can cause invasive disease, but it also asymptomatically colonizes the pharynx in approximately 10% of the general population. Older studies have reported higher carriage rates (>30%) among individuals attending sexually transmitted disease (STD) clinics. This study examined the prevalence of oropharyngeal Nm carriage in STD clinic attendees in Columbus, Ohio.

Methods
Per normal procedures, all patients presenting for care in the STD clinic who report oral sex in the last year are screened for oropharyngeal Neisseria gonorrhoeae (Ng) using nucleic acid amplification testing (NAAT). For the same patients, we also initiate cultures using media selective for Neisseria spp. Analytical Profile Index Neisseria-Haemophilus (API NH) and Nm-specific PCR screening is performed on colonies with oxidase-positive Gram-negative diplococci to distinguish between Ng and Nm. For this study, we then performed PCR-based genogrouping on confirmed Nm isolates.

Results
Between July 2018 and March 2019, oropharyngeal screening occurred at 5,015 patient visits and oropharyngeal Nm was detected at 163 visits (3.3%). Nm-positive individuals were primarily male (69.9%), Caucasian (62.6%), with non-Hispanic ethnicity (98.8%). The median age was 27 years and 5.5% were HIV-positive. Among male cases, 49.1% reported sex with men; among women, 98.0% reported sex with men. Meningococcal vaccination status was unknown for 71.2%, but 26.4% had documentation of prior MenACWY vaccination and 2.3% had prior MenB vaccination. Among the 163 cases, genogroup distribution was 23.9% B, 10.4% E, 9.8% Z, 3.1% C, 0.0% W, 0.0% Y, and 39.3% capsule null locus. For 13.5%, the selected screening approach could not determine genogroup.

Conclusion
In STD clinic patients reporting recent oral sex, we found a much lower prevalence of oropharyngeal Nm carriage compared with what has been reported historically for similar populations. While NmB was the most common capsular type identified by genogrouping, almost 40% of Nm isolates contained the capsule null locus, making them unable to express capsule. Additional studies should evaluate the effect of Nm vaccination programs on carriage among STD-clinic attendees.

Disclosures
All authors: No reported disclosures.