bluuebunny/crossref_metadata_2025_split huggingface dataset:
1530. A Cluster of Disseminated Gonococcal Infections in a Non-Immunocompromised Veteran Population
Authors: Vissichelli Nicole C , Hill Emily , Anderson Linda E , Eckert Angela , Fagan Cynthia M , Tassone Daniel , Vaughan Leroy , Cecil Jane A , Markley John D , Hitchcock Matthew M 
Published: January 2021

Abstract

Background
Disseminated gonococcal infection (DGI) is an uncommon manifestation of N. gonorrhoeae that is estimated to occur in 0.5-3% of cases, with a decreasing incidence that has been attributed to changes in circulating serotypes. At a Veterans Affairs Medical Center (VAMC), 3 cases were identified within 4 months in 2019.

Methods
A case series of patients with DGI between March and July 2019 was conducted at a 399-bed tertiary care VAMC that serves central Virginia. Clinical case data was abstracted from the medical record, and data regarding prior gonorrhea cases at the facility was obtained from the laboratory information system.

Results
In 2019, the rate of DGI was 4.9%, with 3 cases out of 61 reported. All occurred in immunocompetent, African-American males with a mean age of 59 years, and all had female sexual partners (Table 1). All presented with joint symptoms, 2 had skin manifestations, and none had genital symptoms. Two patients had positive synovial fluid cultures and the third had a positive blood culture. All isolates were beta-lactamase negative. Orogenital testing by nucleic acid amplification was only positive in 1 patient. No other sexually transmitted infections were identified. One patient underwent surgical washout of the involved shoulder joint, but the others were managed non-operatively. All received a single dose of azithromycin and a 14-day course of ceftriaxone with full symptom resolution. These were the first positive N. gonorrhoeae isolates from invasive specimens at this VAMC since at least 2016.
Table 1. Clinical History and Laboratory Results at Presentation for Patients with Disseminated Gonococcal Infection

Conclusion
This cluster of DGI cases was unusual given the recent rarity at this VAMC, the age of the patients, and lack of overt risk factors. In Virginia, DGI is reported to the health department no differently than uncomplicated infections, so the actual rate of DGI regionally is unknown. One isolate was preserved and sent to the Centers for Disease Control and Prevention for deidentified whole genome sequencing. More refined reporting is necessary to improve understanding of local gonorrhea epidemiology, as well as coupling with additional methodologies such as serotyping or whole genome sequencing. Clinicians should be aware of the possibility of DGI, even in older patients without classic risk factors.

Disclosures
All Authors: No reported disclosures
1531. Antibiotic Selection for Neisseria gonorrhoeae among Penicillin Allergic Patients in the Emergency Department
Authors: McGuinness Matthew J , Mccoy Jonathan , Bhowmick Tanaya 
Published: January 2021

Abstract

Background
While penicillin (PCN) allergies are commonly reported, their cross-reactivity with beta-lactam antibiotics is minimal. First line treatment of gonorrheal infections includes a cephalosporin (CPH). In an emergency department (ED) environment, physicians must consider potential allergies when selecting antibiotics for a patient with symptoms concerning for sexually transmitted infection (STI).

Methods
A retrospective chart review on adult patients with symptoms concerning for STI presenting to an urban ED from January 2014 through June 2019 was performed. Chart discovery was performed using search terms of “STI”, “STD”, “urethritis”, “vaginitis”, and “gonorrhea”. Information abstracted included patient symptoms, type of care provider, and antibiotics prescribed or administered in the ED. The primary outcome was prevalence of allergy to PCN and CPH in patients evaluated for STI symptoms and secondary outcomes included prescribed antibiotic treatments. Chi-square and Fischer-exact tests were utilized to examine for statistical significance, with p values &lt; 0.05 as statistically significant.

Results
A total of 603 patients met the inclusion criteria, of which 31 reported allergies to PCN, and another 3 reported allergies to CPH. Patients reporting PCN allergy were found to be less likely to receive a CPH antibiotic (p=0.0035). Patients reporting a non-anaphylactic allergy to PCN received a CPH at a rate of 92.3%. Attending physicians in particular were less likely to prescribe a CPH antibiotic to a patient reporting allergy compared with both resident physicians and PAs (p=0.00019). Patients reporting a PCN allergy were more likely to receive alternative antibiotics beyond CPH or azithromycin (p=0.046); the most frequently given antibiotics were metronidazole, doxycycline, and levofloxacin.
Demographic Data

Antibiotic Prescriptions by Type of Penicillin Allergy

Antibiotic Prescriptions for Penicillin Allergy vs. No Allergy

Conclusion
Patients with PCN allergies represent a recurring challenge for ED physicians when faced with antibiotic selection for STI symptoms concerning for gonorrheal infection. Those with PCN allergies are significantly less likely to receive a CPH antibiotic, though these remain the only universal treatment for gonorrheal infections. These findings highlight the significant need for further physician education on allergies and antibiotic selection.

Disclosures
All Authors: No reported disclosures
1536. Impact of Type of Provider on Appropriateness of Treatment for Gonorrhea and Chlamydia in Outpatient Clinics
Authors: Sittig Katherine , Espinoza Rossana Rosa 
Published: January 2021

Abstract

Background
Patients with sexually transmitted infections (STIs) receive care in a variety of outpatient settings with medical providers of different levels of training and expertise, especially regarding STIs. We aimed to determine the impact of type of provider on the appropriateness of treatment for chlamydia and gonorrhea in a large integrated health system.

Methods
We conducted a retrospective cohort study of adult patients diagnosed with chlamydia and/or gonorrhea at any outpatient clinic within an integrated health system in Des Moines, Iowa. Nucleic-acid amplification tests were used for diagnosis, and all samples were processed at the same laboratory. Adequate treatment was defined as prescription for appropriate antibiotic, dose and duration within 7 days of the positive test. Logistic regression models with robust standard errors and adjusting for clustering by clinic were built.

Results
We identified 481 unique patients and a total of 515 unique encounters. Considering unique patients only, the median patient age was 23 years (IQR 20-26), 466/481 (96.9%) were female (96.9%), 15/481 (3.1%) were male, and 79/481 (16.4%) were pregnant. Table 1 shows the patient demographic and provider characteristics by appropriateness of treatment for individual visits.
A total of 53 patients had inappropriate treatment, some with multiple errors which are described in Table 2.
Provider type, age, type of infection, and pregnancy status were significantly associated with appropriateness of treatment. After adjusting for type of infection, pregnancy status and clustering by clinic, compared to physicians, certified nurse midwives (CNMs) had 33% lower odds of prescribing appropriate treatment (95% CI 0.49-0.91; p-value = 0.010), with no difference in appropriateness of prescribing by mid-level providers (OR 1.61, 95% CI 0.82-3.17; p-value = 0.167). Pregnancy was independently associated with lower odds of appropriate treatment (OR 0.35, 95% CI 0.24-0.52; p-value &lt; 0.001), as was infection with gonorrhea (OR 0.29, 95% CI 0.12-0.68; p-value = 0.004).
Table 1. Demographic characteristics of adult patients diagnosed with chlamydia and/or gonorrhea in outpatient clinics by appropriateness of treatment. Des Moines, Iowa, January 1, 2019 to December 31, 2019

Table 2. Type of therapeutic errors encountered among patients diagnosed with chlamydia or gonorrhea

Conclusion
CNMs had lower odds of prescribing appropriate treatment for STIs. Efforts aimed at improving prescribing by healthcare providers should actively engage with this group.

Disclosures
All Authors: No reported disclosures
1538. Pilot Study of Self-collected Pharyngeal Testing for Chlamydia and Gonorrhea in the Setting of COVID19 Restrictions
Authors: Straub Diane M , Tetlow Angela 
Published: January 2021

Abstract

Background
Given that many youth and young adults utilize multiple orifices during sexual activity, testing for STIs from multiple anatomical sites can increase rates of diagnosis. However, during the COVID pandemic, obtaining oral swabs by clinical staff was deemed an unacceptable COVID transmission risk and was discontinued in our clinic. To circumvent this obstacle to diagnosis, clinic staff developed a workaround of obtaining patient collected pharyngeal swabs for STI testing. This abstract reviews the results of this pilot intervention.

Methods
Patients presenting to an urban youth family planning/STI clinic who desired STI testing and ever engaged in oral sex were offered pharyngeal testing for chlamydia (CT) and gonorrhea (GC). Patients were instructed on how to obtain an oral sample, and subsequently sent outside of the clinic to obtain their individual sample. Chart review was conducted by clinic staff of a two month period during which this protocol was in place, and the following variables were collected: gender, sexual orientation, race/ethnicity, and STD testing results by anatomic site. Simple descriptive statistical analysis were used.

Results
146 patients received a GC/CT test from &gt; 1 anatomical site, with 34 patients having &gt; 1 positive result. All pharyngeal samples were self-collected. Four patients were positive for GC/CT from throat samples only (12% of positive tests). All were biologically female, including one transgender FTM. Sexual orientation was split evenly between bisexual and heterosexual. Reported race/ethnicity included two African-American, one white, and one “Filipino”. For comparison, of the overall subsample of patients with positive GC/CT results, patients identified as 53% female, 44% male, and 3% FTM; 74% “straight”, 15% bisexual, 9% “gay”, and 3% did not disclose; 29% white, 50% African-American, 21% unknown as other; and 11% Hispanic. Twelve patients were positive for GC/CT from the throat and either rectum and/or urine/vagina/endocervix (35% of positive tests).

Conclusion
Our experience demonstrates that obstacles created by the COVID crisis can be circumvented with creative strategies. We were able to pick up 12% and 35% of total infections by self-collected pharyngeal swabs in throat only and throat plus other sites, respectively.

Disclosures
All Authors: No reported disclosures
127. A Retrospective Review of Antibiotic Appropriateness for Urinary Tract Infections in Ambulatory Patients
Authors: Donohoe Kendall , Boeser Kimberly D 
Published: January 2021

Abstract

Background
The Centers for Disease Control and Prevention and the Joint Commission recommend establishing antibiotic stewardship in outpatient settings. Previous studies estimate over half of all antibiotic prescriptions in the outpatient setting for any indication are inappropriate. Urinary tract infections present a key stewardship opportunity, as most fluoroquinolones prescribed for acute uncomplicated cystitis are potentially inappropriate and many safety concerns exist for this drug class. This study evaluates the outpatient antimicrobial prescribing practices for cystitis and other urinary tract infections at ambulatory clinics within a health system.

Methods
This retrospective cohort study includes adults treated for cystitis or urinary tract infection at 60 primary care and 21 specialty clinics within a large academic health system over a three-year period. Diagnosis codes and individual chart review were used to collect data. The primary outcome is the proportion of patients prescribed antibiotics for urinary tract infection who received a fluoroquinolone.

Results
Of 22,099 encounters which included one of the diagnosis codes indicative of cystitis, an antibiotic was prescribed in 19,101 (86%). Among the encounters in which an antibiotic was prescribed, 29.1% included a fluoroquinolone prescription. A subset of 100 patients from this population were reviewed and assessed for appropriateness based on symptoms, comorbidities, allergies, and previous urinary isolates. The prescribed drug class was determined appropriate in 40% of the fluoroquinolone cases and in 80% of the nitrofurantoin or sulfamethoxazole/trimethoprim cases.

Conclusion
Potential strategies that may reduce the inappropriate prescribing of fluoroquinolones in our large academic health system include an EHR alert, regular dissemination of prescriber reports, and additional provider education to facilitate shared decision-making. These results provide a baseline to inform future interventions to reduce inappropriate antibiotic prescribing and to ensure compliance with Joint Commission standards.

Disclosures
All Authors: No reported disclosures
1540. Prevalence and Risk Factors associated with HIV and Syphilis Co-infection in the African Cohort Study
Authors: Gilbert Laura , Dear Nicole , Esber Allahna L , Iroezindu Michael , Bahemana Emmanuel , Kibuuka Hannah , Owuoth John , Maswai Jonah , Crowell Trevor A , Polyak Christina , Ake Julie A 
Published: January 2021

Abstract

Background
Each year, 6 million new syphilis cases are diagnosed globally. Seroprevalence studies in low-income countries (LIC) are limited but is estimated at 3.5-4.6%. Few studies have researched prevalence of sexually transmitted infections (STIs) in people living with human immunodeficiency virus (HIV; PLWH). Current guidelines for PLWH in LIC recommend STI testing for symptomatic persons and those with a new HIV diagnosis, which may lead to high rates of undiagnosed STIs. Here we provide updated STI prevalence rates and risk factors for syphilis co-infection in PLWH in the African Cohort Study (AFRICOS).

Methods
AFRICOS is an ongoing longitudinal study enrolling PLWH in four African countries where participants undergo routine medical exams, sociobehavioral questionnaires, and laboratory extraction for study purposes every 6 months. Enrollment syphilis data was extracted to determine screen-positive and serologically-confirmed syphilis prevalence rates for this study. Bivariate and multivariate analysis were performed to determine risk factors for HIV and syphilis co-infection and reported as adjusted prevalence ratios (APR) with 95% confidence intervals (CI).

Results
Between January 2013 and March 1, 2020, 2883 PLWH enrolled. Prevalence of screen-positive and confirmed syphilis was 5.2% and 3%, respectively. Among PLWH with confirmed syphilis, 58.6% were women, mean age was 37.8 years old (IQR 31.658, 45.011, p = 0.068), and genital ulcers were documented in 1.61% participants. In the multivariate model, participants with confirmed syphilis co-infection were more likely to have none or some primary education [2.65 (1.34, 5.230)], demonstrate impaired cognition [2.1 (1.25, 3.590], and consume alcohol [1.88 (1.19, 2.970] compared to those without syphilis.

Conclusion
In conclusion, our findings suggest that syphilis rates remain elevated at endemic levels in LIC where diagnosis remains challenging. Based on our analysis, current STI guidelines for PLWH in Africa are likely leading to a large proportion of undiagnosed STIs and potentially contributing to community spread. While this study observed that lower education level, alcoholism, and impaired cognition were associated with syphilis co-infection, further studies are needed to investigate these associations.

Disclosures
All Authors: No reported disclosures
1541. Prevalence of Asymptomatic Sexually Transmitted Infections (STIs) in a Philadelphia Ryan White HIV population
Authors: Stuccio Sarah , Akram Rakhshanda , Spacek Lisa A 
Published: January 2021

Abstract

Background
In 2018, Philadelphia County ranked 7th, 8th and 16th for chlamydia (CT), gonorrhea (GC), and syphilis cases, respectively, in the Centers for Disease Control (CDC) STI Surveillance Report. Asymptomatic presentations and lack of routine screening, especially at extragenital (i.e., pharyngeal and rectal) sites, increase the challenge of timely diagnosis and treatment. We determined extent of screening, reported symptoms, and asymptomatic infections.

Methods
We analyzed records of 372 patients receiving care at an urban, university-based Ryan White HIV clinic from 2016-2018. Outcomes included: positive GC/CT nucleic acid amplification tests from genital, pharyngeal, and rectal sites as well as new diagnoses of syphilis. We collected demographic data, risk factors for HIV transmission, time from HIV diagnosis, number of clinic visits, multiple sex partners, partner with STI, and injection drug use. We used logistic regression to model factors associated with STIs and determined prevalence of asymptomatic STIs.

Results
Of 372 participants, 234 (63%) were men, 262 (70%) were Black, 245 (66%) were over 40 years old, 148 (40%) identified as MSM, 140 (38%) reported inconsistent condom use, 89 (24%) reported multiple sex partners, 35 (9%) reported injection drug use, 141 (38%) had past STI, and 26 (7%) had partner with past STI. Mean time from HIV diagnosis was 12.3 years (SD, 8.8) and mean number of clinic visits was 2/year. Testing included 720 GC/CT urine, 176 GC/CT pharyngeal, 143 GC/CT rectal swabs and 887 syphilis blood tests. Asymptomatic GC/CT infections were seen in urine 6/22 (27%), pharyngeal 12/14 (86%) and rectal 28/31 (90%) swabs. And, of 39 new diagnoses of syphilis, 23 (59%) were asymptomatic. In multivariate analysis, men (aOR, 12.2, 95%CI, 2.7-55.3), &lt; 40 years (3.2, 1.7-6.1), with clinic visit in 2018 (1.4, 1.2-1.8), and partner with STI (1.7, 0.9-2.8) were more likely to have a positive GC/CT test. Patients with positive syphilis test were more likely men (4.6, 1.1-20.2), with multiple sex partners (3.7, 1.7-8.0), and more recent HIV diagnosis (1.1, 1.0-1.1).
Prevalence of Asymptomatic STIs

Conclusion
Results indicate the importance of routine, site-specific STI screening among patients living with HIV. Our findings can inform screening strategies among urban HIV populations.

Disclosures
All Authors: No reported disclosures
1546. Update in Syphilis Proctitis: Insights from a Case Series and Literature Review
Authors: Ferzacca Elizabeth S , Dunne Dana , Barbieri Andrea , Aoun-Barakat Lydia 
Published: January 2021

Abstract

Background
In the US, syphilis infections have increased 71% since 2014. Proctitis is a rare manifestation of early syphilis transmitted through anal intercourse. We suspect that its misdiagnosis results from physician under-awareness and thus we present the largest case analysis to date of syphilis proctitis.

Methods
We searched PubMed and Scopus for articles describing cases of proctitis in which Treponema pallidum was a likely causative pathogen based on serologies, and/or organism-specific staining of anorectal biopsy specimens. Furthermore, we conducted chart review to identify cases of syphilis proctitis diagnosed within our health center from 2011-2019. Pertinent data were extracted from the articles and medical records and analyzed to provide a summative account.

Results
53 cases of syphilis proctitis were identified in 38 articles. 7 additional cases were diagnosed at our institution, totaling 60 cases. All cases of syphilis proctitis were described in individuals of male sex assignment at birth. The age at diagnosis ranged from 15 to 73 years (average 39 years). In 48 cases (92%) men endorsed sex with men. In 27 cases (56%) individuals were HIV co-infected. Syphilis proctitis presented most commonly with hematochezia (68%) and anal pain (48%). The most common physical exam findings were rectal mass (38%), lymphadenopathy (33%), and rash (31%). Non-treponemal titers averaged 1:60 (range 1:2-1:1024). Endoscopy was performed in 52 cases and most commonly showed anorectal mass (42%) and anorectal ulcer (35%). In 38 cases (68%), histopathology revealed a chronic lymphoplasmacytic inflammatory infiltrate, and in 14 of these cases (37%), prominent plasma cells were described. In 24 cases (77%), treponema immunohistochemical stain revealed spirochetes.

Conclusion
Syphilitic proctitis should be suspected in boys and men presenting with lower gastrointestinal symptoms. Histopathology, while suggestive, is not pathognomonic, and serology and specific tissue staining are required to make the diagnosis. Given overlapping symptoms and histology with inflammatory bowel disease, the diagnosis may be delayed resulting in personal and public health consequences. A sexual history should be routinely elicited and further testing for syphilis pursued if exposure is suspected.

Disclosures
All Authors: No reported disclosures
128. Antibiotic Prophylaxis Prior to Dental Visits in the Veterans Health Administration (VHA), 2015–2018
Authors: Suda Katie J , Fitzpatrick Margaret A , Poggensee Linda , Echevarria Kelly , Hubbard Colin , McGregor Jessina C , Evans Charlesnika T 
Published: January 2021

Abstract

Background
Antibiotic prophylaxis (AP) is recommended prior to invasive dental visits in patients with certain cardiac conditions but is not recommended in patients with prosthetic joints. Meta-analyses indicate benefit of AP prior to dental implants and tooth extractions. Within dentistry, it is also common to prescribe AP in patients with immunocompromising conditions. Our objective was to determine appropriateness of AP by VHA dentists.

Methods
A national cross-sectional study of dental visits was conducted in VHA, 2015–2018. Antibiotics prescribed 7 days before a visit were included. Antibiotics prescribed for an oral infection were excluded (15%). Appropriate AP was defined as visits with gingival manipulation and was further delineated into narrow and broad definitions by medical comorbidities. The narrow definition (primary analysis) only included cardiac conditions at risk of infective endocarditis. The broad definition included these cardiac conditions, tooth extractions/implants or immunocompromising conditions. The association of covariates with unnecessary AP was modeled using GEE for logistic regression.

Results
Out of 367,872 patient-visit dates associated with an antibiotic, 85% were prescribed for AP (N=313,886 prescriptions; median=7 days). AP (74% amoxicillin, 18% clindamycin) was prescribed to 198,314 patients (91% male; mean age=62 years). 87% of dental visits were categorized as gingival manipulation. With the narrow definition (cardiac only), 15% of AP were guideline concordant, increasing to 73% with the broader definition (cardiac or implant/extractions or immunocompromised). For the narrow definition, Black or other non-white race, current smoking, penicillin allergy and visits located in the West or South were associated with unnecessary AP. Protective factors were older age, prosthetic joints, immunocompromised, dental implants, extractions and visits in the Midwest. Unnecessary AP increased over time.

Conclusion
Few antibiotics prescribed before dental visits were for oral infections. Focusing on improving AP duration and appropriateness may have large implications for stewardship. Guidelines should inform if AP is indicated for extractions, implants, and immunocompromised patients.

Disclosures
All Authors: No reported disclosures