bluuebunny/crossref_metadata_2025_split huggingface dataset:
1280. A Pharmacist-led PrEP Program at the Epicenter of the HIV Epidemic in Atlanta; Our Experience
Authors: Smith Bradley L , Hester Allison M , Cantos Valeria D , James Tiffany R , Lora Meredith H 
Published: October 2019

Abstract

Background
Atlanta, GA ranks third in the nation for highest rates of new HIV diagnoses, disproportionally affecting Black men and women. Pre-exposure prophylaxis (PrEP) is underutilized in this population due to multiple barriers to uptake, including limited access to PrEP delivery programs. The advantages of a primary pharmacy-led PrEP program include: relatively low service fees, perform and assess point-of-care testing, and provide adherence counseling. Similar programs across the United States have been shown to effectively increase PrEP uptake and optimize retention in care. Grady Health System (GHS), the fifth largest public hospital system in the United States, is located at the epicenter of the HIV epidemic: downtown Atlanta. It encompasses 11 different primary care clinics, accounting for 850,000 outpatient visits per year. In August 2018, we launched a developmental pilot of a GHS pharmacy-based tele-PrEP program, aiming to optimize PrEP access for vulnerable populations who would otherwise not be able to obtain it. PrEP services are provided directly to the community and through a consultative support program for all clinical sites within the GHS system. The key pilot interventions included developing a user-friendly electronic medical record (EMR)-based PrEP order sets and brief provider education interventions in 6 GHS primary care clinics, to increase PrEP awareness among non-HIV clinicians.

Methods
We conducted a retrospective process evaluation of the pilot PrEP program based on the PrEP continuum of care.

Results
Over 9 months, 95 referrals were received from providers within the GHS clinics. Of the 95 patients referred, 56 (59%) started PrEP. Two patients were started on post-exposure prophylaxis prior to initiation of PrEP. Forty-five patients (81%) remain on PrEP as of April 2019. Six clients were diagnosed with 9 STIs on screening (4 syphilis, 2 gonorrhea, 2 chlamydia, 1 lymphogranuloma venereum). There have been no HIV seroconversions in patients on PrEP.

Conclusion
Utilizing a pharmacy-based PrEP program to train and support clinical providers in a large, hospital system can facilitate PrEP uptake and retention for patients in primary care.

Disclosures
All authors: No reported disclosures.
1325. Inpatient Initiation of ART Improves Short-Term Mortality in People Living with HIV
Authors: Campbell Jamie , Polk Christopher , Roshdy Danya , Leonard Michael 
Published: October 2019

Abstract

Background
Treatment of HIV is recommended as soon as possible and early initiation of combined antiretroviral therapy (cART) is associated with improved engagement in care; however, treatment with cART is often deferred in hospitalized patients despite being correlated with improved outcomes. We implemented an institutional intervention to ensure all people living with HIV (PLwH) were on cART during hospitalization to improve patient outcomes.

Methods
We prospectively identified all PLwH hospitalized at our institution and had ID physicians and pharmacists ensure they were on appropriate cART and linked to outpatient care. We retrospectively collected clinical and lab data to assess the impact of our intervention on inpatient mortality, 30-day mortality, 30-day readmission rate, and frequency of outpatient follow-up. Patients were excluded from analysis if they were admitted for hospice care.

Results
We identified 389 patient admissions in 275 unique patients, of which 304 admissions were already on cART at admission. After ID physician assessment, 37 of the 85 not on cART at admission were initiated on therapy. We assessed the impact of this intervention on short-term outcomes as listed in Table 1.
Despite the intervention group having similar immunologic and virologic baseline characteristics to those not initiated on cART, their inpatient and 30-day mortality was similar to those already on cART. Readmission rates also decreased in the intervention group. Thirteen of 24 patients in the intervention group who could be tracked for long-term follow-up within our system achieved virologic suppression by 90 days after hospital discharge.

Conclusion
Inpatient treatment with cART during hospitalization improves short-term mortality outcomes. This study also demonstrates the value of inpatient cART treatment as most patients achieved virologic suppression at subsequent outpatient follow-up.

Disclosures
All authors: No reported disclosures.
1328. Post-War and Post-Ebola HIV Care Continuum in a Liberian Academic Center: Fresh Insights and Trends Over 5-Year Period
Authors: Watchekwa Ian , Ogbuagu Onyema , Donato Sean , Nuta Cecilia , Barakat Lydia A 
Published: October 2019

Abstract

Background
Two-thirds of people living with HIV (PLWH) reside in sub-Saharan Africa. The UNAIDS 90-90-90 target to end the HIV epidemic is an aspirational but achievable goal. The Continuum of Care model allows evaluating the progress toward this goal as well as identifying gaps in diagnosis, linkage to care, HIV treatment. In Liberia, the estimated number of PLWH is 40,000 with only 26,000 (65%) diagnosed, 14,000 (53%) on combination ART (cART), and of those, 53% virally suppressed. After a devastating war and Ebola epidemic, the country has only one academic medical center, John F. Kennedy (JFK) Hospital in Monrovia, with the largest HIV clinic caring for a cohort of 3,000 PLWH. This study was designed to evaluate the HIV care continuum at this center over a 5-year period.

Methods
Data from 2014 to 2018 were collected from a database at JFK hospital HIV clinic. Data were extracted for all patients tested for HIV. The proportion of those tested positive, who were linked to care, retained in care, and subsequently initiated on cART was analyzed. Only a sample of PLWH received HIV viral load monitoring test. Utilizing the HIV care continuum model, data on each step of the care cascade were reported as simple percentages or proportions.

Results
Over the 5-year study period, a total of 41,343 individuals were screened for HIV and 4,066 tested positive (10%), much higher than the national rate of 3–5%. Linkage to care was inconsistent; 87% (592/678) in 2014, 98% (622/636) in 2015, 61% (644/1057) in 2016, 73% (570/786) in 2017, and 64% (584/909) in 2018 were enrolled in the clinic. ART initiation improved over time; of the PLWH enrolled in the clinic, 75%, 64%, 76%, 86%, and 84% for the years 2014, 2015, 2016, 2017, and 2018, respectively, were initiated on cART, also higher than the national rate estimated at 53%. Only a sample of 100 patients had HIV VL performed and of those 53% had viral suppression. From the total clinic cohort of 5,280 PLWH, 19–28% of HIV patients were lost to care with a 2–4% death rate annually.

Conclusion
Although the HIV Care Continuum rates at the largest academic center in Monrovia, Liberia were above national rates, they were suboptimal and fell below the 90-90-90 UNAIDS target. Current efforts are focused on understanding gaps in care and investigating opportunities to improve linkage to, and retention in care.

Disclosures
All authors: No reported disclosures.
1331. Interpretation and Application of Rapid Diagnostic Methodologies: The Positive Impact of Online, Curriculum-Based Learning
Authors: Thomas. Hurst Simi , Martorano James , Capparelli Catherine 
Published: October 2019

Abstract

Background
Antibiotic resistance has become one of the most serious public health threats today. Used appropriately, newer rapid diagnostic methodologies have the potential to positively impact care by informing a more targeted treatment approach that can reduce inappropriate antibiotic use, support antimicrobial stewardship, shorten hospital stays, and improve clinical outcomes.

Methods
To improve ID specialists’ knowledge and application of rapid diagnostic tests, a CME/ABIM MOC/ACCENT certified curriculum was developed. The curriculum comprised a series of 4 educational episodes, each with a video commentary from a clinical expert and each focused on a different site of infection: (a) Episode 1: CNS; (b) Episode 2: Gastrointestinal tract; (c) Episode 3: Respiratory tract; and (d) Episode 4: Bloodstream. The episodes in the curriculum were launched in serial fashion between October 30, 2018 and February 11, 2019, on a website dedicated to continuous professional development. Educational effectiveness was assessed with a repeated-pairs pre-/post-assessment study design; each individual served as his/her own control. A chi-square test assessed changes pre- to post-assessment. P values of < 0.05 are statistically significant. Effect sizes were evaluated using Cramer’s V (<0.05 modest; 0.06–0.15 noticeable effect; 0.16–0.26 considerable effect; >0.26 extensive effect).

Results
15,092 HCPs, including 10,894 physicians have participated in the curriculum. This initial analysis comprises data from the subset of ID specialists from each episode who answered all pre-/post-assessment questions through March 18, 2019; data collection is ongoing. Following participation, significant improvements were observed overall (P ≤ 0.002 for each episode) and on the specific topics assessed in each episode (Graph). Additionally, 51%–55% of ID specialists indicated an intent to modify their diagnostic approach and 15%–29% had increased confidence in applying the rapid diagnostic results into patient care.

Conclusion
This educational curriculum significantly improved ID specialists’ knowledge of the strengths and limitations of different rapid diagnostic methodologies and improved the applications of test findings into clinical decision-making. These findings highlight the positive impact of well-designed online education.

Disclosures
All authors: No reported disclosures.
1342. Impact of HIV Infection on Treatment Outcome of New Tuberculosis Patients Attending Tuberculosis and Antiretroviral Treatment Services in the Community-Based Hospital, Thailand: A Retrospective Cohort Study
Authors: Pinsai Subencha 
Published: October 2019

Abstract

Background
Tuberculosis (TB) and HIV are one of the significant public health problems in Thailand, and an estimated 15,000 individuals have a dual infection. Both HIV and TB each disease speeds up the progression of each other. TB is the leading cause of death in HIV-infected individuals, and HIV coinfected TB patients have disease-specific, and treatment affected their treatment outcomes. There is insufficient evidence on issues of TB and HIV co-infection patients received treatment. This study aimed to assess the impact of HIV status on treatment outcome of TB patients.

Methods
We conducted a retrospective cohort study among TB patients who registered to service at Chaophraya Abhaibhubejhr Hospital, Prachin Buri, Thailand from October 1, 2017 to October 31, 2018. All patients’ demographic data, diagnosis, and treatment were retrieved. Clinical characteristics, treatment outcome, and factors associated with treatment outcome were analyzed.

Results
There were 49 (10.65%) HIV among 460 TB patients with a median (IQR) age of 44 (32–61) years old and 65.2% were males. Disseminated TB and extrapulmonary TB were higher in HIV coinfected group (P < 0.001). All pulmonary TB patients’ lower lobe involvement was higher in HIV coinfected group (62.50 vs. 36.00, P = 0.001). In HIV coinfected group median CD4 was 134 cell/mm3 (IQR 19–294), 66.67% were diagnosed HIV infection after TB diagnosis, the median time from TB diagnosed to antiretroviral was 29 days (IQR 21–48). The overall treatment success rate was 93.04%; the treatment success rate was similar in HIV coinfected TB patients (89.80%) and non- HIV-infected patients (93.43%) (P = 0.66).Adverse drug reactions were higher in HIV coinfected group (44.89% vs 12.41%) (P < 0.001). By multiple stepwise logistic regression, factors associated with anti-TB drug adverse reactions were having HIV infection (OR 7.99; 95% CI 3.73–17.10, P < 0.001), Age >60 years (OR 2.64; 95% CI 1.43–4.87, P = 0.002) and female sex (OR 1.97; 95% CI 1.11–3.52, P = 0.02).

Conclusion
There is a high TB treatment success rate among patients who have treated for TB, but adverse drug events in HIV co-infected TB patients is higher than that observed in non-HIV-infected patients.

Disclosures
All authors: No reported disclosures.
1355. Efficacy and Tolerability of Linezolid Adjunctive Treatment for Nontuberculous Mycobacterial Infection in Patients with Acquired Anti-Interferon-Gamma Autoantibody
Authors: Chavapradit Natthakit , Suputtamongkol Yupin , Angkasekwinai Nasikarn , Phoompoung Pakpoom , Chirapapisan Niphon , Foongladda Suporn 
Published: October 2019

Abstract

Background
Despite a long duration of combined oral antimycobacterial drugs, relapse/ reinfection of nontuberculous mycobacteria (NTM) is common among patients with anti-interferon gamma autoantibodies (anti-IFN-γ auto-Abs).

Methods
We reported here, an interim analysis of the prospective study of 25 patients with anti-IFN-γ auto-Abs, who received oral linezolid (LZD) adjunctive treatment for their NTM infections, at Siriraj Hospital, Bangkok, Thailand, between December 2017 and April 2019.

Results
8 patients (32%) were male, with a median age of 52.5 years. NTM identified among them included Mycobacterium abscessus (n = 19), M. avium complex (MAC) (n = 2), M. fortuitum (n = 2), M. kansasii (n = 1), and both M. abscessus and MAC (n = 1). The median duration of follow-up was 11 months (range 1.6–15 months). LZD 600 mg/day was given until clinical remission, then reduced to 300 mg/day for a total duration of at least 9 months. Other patient’s managements, including choice and duration of other antimycobacterial therapy were determined by the attending physician. Clinical remission was achieved, and LZD was discontinued at 9 months in 10 patients. NTM infection remained active and LZD was continued to 12 months in 4 patients. Two patients only completed 6 months of LZD. Culture proven relapse of M. abscessus occurred in 3 patients during LZD treatment, and 1 patient developed M. haemophilum infection after discontinuation of all drugs for 3 months. One patient was retreated with intravenous antimycobacterial drugs based on clinical suspicious of relapse NTM infection. LZD-related serious adverse events leading to discontinue of LZD occurred in 5 patients; severe myelosuppression (n = 1), peripheral neuropathy (n = 2), exfoliative dermatitis (n = 1), and idiopathic increased intracranial pressure (n = 1). Anemia occurred in 3 patients during the 600 mg LZD once-daily treatment period. No patient developed anemia after LZD was adjusted to 300 mg twice daily. The rate of peripheral neuropathy was similar throughout the study period.

Conclusion
LZD might reduce the rate of relapsed/ reinfection of NTM infection in these patients. LZD 300 mg twice daily was less toxicity and more tolerable than 600 mg once daily. Long-term study with this modified regimen is now on-going.

Disclosures
All authors: No reported disclosures.
1358. A Novel Rapidly Growing Mycobacteria (RGM) Species Causing Soft Tissue and Orthopedic Hardware Infection After Trauma
Authors: Nguyen David C , Lisgaris Michelle , Vasireddy Sruthi , Wallace Richard J , Perez Federico , Rhoads Daniel D 
Published: October 2019

Abstract

Background
The widespread use of molecular techniques has resulted in increasing numbers of newly characterized rapidly growing mycobacteria (RGM). Many RGM cause soft tissue and orthopedic hardware infection, particularly after trauma. RGM species identification remains challenging with few genetic differences between species.

Methods
We describe a case involving RGM. We report results of matrix-assisted laser desorption/ionization time of flight (MALDI-TOF) mass spectrometry (Bruker Biotyper), sequencing of rpoB, erm(39), and 16S rRNA genes, and antibiotic susceptibility testing (AST). We review previous reports describing similar RGM infections.

Results
A 58-year-old male sustained multiple fractures and right thigh compartment syndrome after a motorcycle accident. He underwent fasciotomy and multi-stage surgical fixations. 3 months later, he had wound dehiscence, purulence and multiple fluid collections of his right leg and knee requiring surgical drainage and removal of orthopedic hardware. After 4 days, acid-fast bacilli grew on routine bacterial culture media. MALDI-TOF identified the isolate as Mycobacterium mageritense. In contrast, sequencing of 16S rRNA (100% identity) and erm(39) (> 99% identity) identified the isolate as Mycobacterium houstonense; erm(39) only had 80% similarity with Mycobacterium fortuitum. Sequencing of rpoB showed a 19 bp difference with the M. houstonense type strain, and showed similarity to M. fortuitum (97.64%) than M. houstonense (97.45%). AST demonstrated resistance to clarithromycin only. After initial treatment with imipenem, ciprofloxacin, and doxycycline, definite therapy with ciprofloxacin and doxycycline was successful. In the literature, we found one case each of M. mageritense and M. houstonense infection after trauma.

Conclusion
This case highlights the importance of RGM other than M. fortuitum as a cause of soft tissue and orthopedic hardware infections, and illustrates the difficulty of identifying them to the species level. Sequencing of erm(39) and 16S rRNA gene identified the isolate as M. houstonense, but the larger difference (>2.5%) in rpoB sequence suggests a novel species. Further characterization is underway. Efforts to determine RGM species and antibiotic susceptibility give important insight into diagnosis and management.

Disclosures
All authors: No reported disclosures.
1383. Everolimus is Associated with an Increased Risk of Tuberculosis in Solid-Organ Transplant Recipients
Authors: Sun Hsin-Yun , Cheng Aristine , Wang So-Meng , Tsai Meng-Kun , Chen Yih-Sharng , Wang Sheoi-Shen , Ho Cheng-Maw , Hu Rey-Heng , Hsu Hsao-Hsun , Fang Chi-Tai , Chen Yee-Chun , Chang Shan-Chwen 
Published: October 2019

Abstract

Background
Tuberculosis (TB) is an important post-transplant infection. Everolimus has been documented to reduce the risk of cytomegalovirus infection in transplant recipients, but its impact on other infections is less known. The present study aimed to assess immunosuppressive regimens on TB risk in solid-organ transplant (SOT) recipients via a matched case–control study.

Methods
From May 2005 to December 2018, SOT recipients with TB were retrospectively identified, and those without TB undergoing transplantation at the same university hospital were selected as controls. Controls and cases were matched by age (±5 years), transplant type and year (±5 years) at a ratio of 4:1. Conditional logistic regression was used to analyze the risk factors of TB.

Results
TB developed in 30 SOT recipients (13 kidney, 7 heart, 6 liver, and 4 lung) after a mean duration of 1,601 days after transplantation, with predominant lung involvement (87%). The diagnosis was made by culture in 70% and pathology in 17%. Rifamycins-based regimens were used in 27 cases, and 4 developed rejection without graft failure. A total of 106 controls were selected. At the time of TB diagnosis, cases were more likely to use everolimus than controls (27% vs. 11%, P < 0.05), but no significant differences were observed in the use of tacrolimus, cyclosporin, sirolimus, prednisolone, or mycophenolate mofetil. The median duration of everolimus use was 585 and 698 days in 8 cases and 12 controls, respectively. Multivariable analysis showed that everolimus use (adjust odds ratio [aOR] 22.3, 95% conference interval [CI] 2.5–203.0) and hemodialysis (aOR 19.6, 95% CI 1.3–287.1) were independently associated with TB.

Conclusion
TB is more likely to develop in SOT recipients on everolimus and hemodialysis. Further studies to confirm our findings are warranted, and TB risk assessment should be performed for those receiving everolimus and hemodialysis.

Disclosures
All authors: No reported disclosures.
1389. Risk Factors and Clinical Outcomes of Tuberculosis Among Kidney Transplant Recipients in High Endemic Country: A Case–Control Study
Authors: Thitisuriyarax Saranya , Jutivorakool Kamonwan , Udomkarnjananun Suwasin , Townamchai Natavudh , Suwanpimolkul Gompol , Vanichanan Jakapat 
Published: October 2019

Abstract

Background
Tuberculosis (TB) is considered as a challenging issue in solid-organ transplant recipients because of high morbidity and mortality. Active TB after transplant can occur from reactivation of latent infection or newly acquired from community. Understanding risk factors and clinical information of TB may provide an appropriate prevention and treatment strategies in this specific patient population; however, most of data were from non-endemic countries.

Methods
A single-center, matched case–control study was conducted in our institute. Cases were defined as newly diagnosed proven or probable active TB in patients who underwent kidney transplant between April 1992 and October 2018. For each case, 5 controls were matched by age and sex. Risk factor associated with TB was determined using univariate and multivariate conditional logistic regression.

Results
Between study period, kidney transplant was performed in 787 patients. None of the recipients was screened or treated for latent tuberculosis. Twenty-seven patients (3.43%) were diagnosed with active TB including 20 proven and 7 probable cases. The overall incidence of TB in our population was 315 cases per 100,000 patients per year. Allograft rejection was significantly associated with active TB (P < 0.001). The median onset of infection was 17 months (IQR, 4–59 months) after transplantation and 3.4 months (IQR, 2.7–16.3 months) after episode of allograft rejection. Majority of patients (96.3%) were cured after complete treatment; however, those with TB remained having significant unfavorable outcomes including higher all-cause mortality and graft loss.

Conclusion
Incidence of TB in kidney transplant recipients is higher than normal population. Increasing risk of active TB after allograft rejection is probably due to mycobacterial reactivation following high-dose immunosuppression. Since TB is associated with poor post-transplant outcomes, screening, and treatment of latent infection may be beneficial even in endemic country.

Disclosures
All authors: No reported disclosures.