bluuebunny/crossref_metadata_2025_split huggingface dataset:
1357. Mycobacterium abscessus Native Tricuspid Valve Endocarditis. Is a 6-Week Course of Combination Antibiotic Therapy Enough?
Authors: Matthew. Wooten William , Lebron Dora , Winters Niki , Lagasca Alicia , Cook Paul P , Ghimire Rabindra 
Published: October 2019

Abstract

Background
Infective endocarditis of the native heart valves due to M. abscessus has been reported in individuals who inject drugs. Only one case thus far has been reported with survival beyond 4 months after completion of antibiotic therapy. 24-year-old Caucasian woman with a history of intravenous drug use presented with intermittent fevers for 3–4 months. She was having chills, night sweats, and productive cough. She acknowledged using intravenous cocaine and heroin every few days after being discharged from our hospital 6 months previously when she was treated for tricuspid valve endocarditis. Chest radiograph demonstrated right lower lobe airspace disease suggestive of pneumonia. Three days later her blood cultures grew acid-fast bacilli, later identified as M. abscessus.

Methods
She was empirically treated with azithromycin, amikacin, and imipenem. Transthoracic and transesophageal echocardiograms were suggestive of tricuspid valve endocarditis. CT angiogram of the chest showed filling defects within several large right lower lobe pulmonary arteries and dense right lower lobe consolidation with pleural effusion. The patient underwent bronchoscopy with bronchoalveolar lavage (BAL) and therapeutic thoracoscopy with drainage and thoracostomy tube placement. BAL cultures also grew AFB. Multiple sets of blood cultures drawn after commencement of antibiotic therapy during the hospital course were negative. Drug susceptibilities were available 3 weeks later. The isolate was susceptible to amikacin. Linezolid, imipenem, and cefoxitin exhibited intermediate activity, and TMP/SMX, ciprofloxacin, moxifloxacin, doxycycline, minocycline, and clarithromycin were reported resistant. Inducible erm gene was present. Azithromycin and linezolid were discontinued and tigecycline was added.

Results
Patient completed 6 weeks of antibiotics from the day of the first negative blood culture. Repeat TTE 1 month after completion of therapy revealed a decrease in tricuspid valve vegetation. Blood culture done 3 months later was sterile. AFB blood cultures done a year later did not report any growth.

Conclusion
This case opens a debate, if in a selected group of patients, a short course of combination antibiotic therapy is enough to obtain cure. This will require further analysis.

Disclosures
All authors: No reported disclosures.
1359. Clinical Experience and Challenges Utilizing Clofazimine in the Treatment of Nontuberculous Mycobacterial Pulmonary Infections
Authors: Mercurio Amanda , Fredenrich Jaela , Gompf Sandra 
Published: October 2019

Abstract

Background
Nontuberculous mycobacterial (NTM) pulmonary infections are increasingly common and associated with significant morbidity and mortality. Treatment is challenging given high rates of antimicrobial resistance, the need for prolonged therapy with multiple agents, and poor medication tolerability. Clofazimine (CFZ), an antimicrobial available under an investigational new drug (IND) program, has excellent in vitro activity but limited clinical data. We present an 18-month experience of clofazimine as part of a multidrug regimen as salvage therapy for NTM pulmonary infections at the James A. Haley Veterans’ Affairs Hospital in Tampa, FL.

Methods
We conducted a single-center, retrospective review of the medical records of 11 patients with NTM pulmonary infections who were approved for treatment with CFZ-containing regimens between September 2017 and February 2019. Basic demographics, clinical characteristics, as well as symptomatic, radiologic, and microbiologic responses to therapy were evaluated.

Results
Approval for the IND program took approximately 15 months. We then treated 8 patients with pulmonary NTM infection with CFZ-containing regimens. Of these, 88% had cavitary disease, 63% were active smokers, and all had underlying pulmonary disease. The most common etiologic organisms were Mycobacterium avium complex and Mycobacterium abscessus. All patients were required to follow up every 3 months while on therapy. For patients who had at least 3 months of follow up, 100% reported symptomatic improvement. 50% achieved negative cultures with an average time to clearance of 25 weeks. All had stable or improved imaging. CFZ was well tolerated with no significant adverse effects.

Conclusion
Once available, CFZ-containing regimens were moderately effective in treating NTM pulmonary infections with minimal adverse effects. Close patient follow up was necessary to assess response to treatment.

Disclosures
All authors: No reported disclosures.
1364. Pretreatment Chest X-ray Stability Duration and Tuberculosis Disease in San Diego County, 2012–2017
Authors: Barber Casey , Oren Eyal , Cheng Yi-Ning , Slater Madeline , Graves Susannah 
Published: October 2019

Abstract

Background
Repeated chest X-rays serve as an essential screening tool to identify and describe new or stable (i.e., unchanged) lung abnormalities suggestive of pulmonary tuberculosis (TB) disease. The time for which a patient’s chest X-ray has not demonstrated appreciable change prior to treatment, or pretreatment chest X-ray stability duration, has been considered clinically useful in distinguishing inactive from active disease at four or 6 months. This relationship, however, has not been previously quantified.

Methods
This study relied on retrospective medical record review to assess the relationship of documented pretreatment chest X-ray stability duration thresholds relative to four and 6 months with a future clinical or culture-confirmed (Class 3) diagnosis of pulmonary TB disease. Multivariable logistic regression quantified this association among 146 patients who were evaluated and started on treatment for pulmonary TB disease in the San Diego County tuberculosis clinic between May 2012 and March 2017.

Results
After adjusting for age and Class B1 TB, Pulmonary status, a CXR stability duration of 4 months or more was not significantly associated with a Class 3 pulmonary TB diagnosis (adjusted odds ratio [AOR], 0.830; 95% confidence interval [CI], 0.198–3.48). Results were similar for the 6-month cut-point after adjusting for age and Class B1 Pulmonary status (AOR, 0.970; 95% CI, 0.304–3.10). Compared with less than 4 months, CXR stability durations of four to 6 months (AOR, 0.778; 95% CI, 0.156–3.89) and greater than 6 months (AOR, 0.875; 95% CI, 0.187–4.10) were also not significantly associated with a Class 3 TB diagnosis after adjusting for covariates.

Conclusion
Repeated chest X-rays remain a valuable tool for clinicians identifying and describing new or unchanged lung abnormalities suggestive of pulmonary TB disease. This study found no statistically significant association between pretreatment chest X-ray stability duration and subsequent TB disease diagnosis, with a wide range of estimates compatible with the data, suggesting the stability duration cut points relative to four and 6 months may not be as informative as previously understood.

Disclosures
All authors: No reported disclosures.
1375. Laboratory Abnormalities Among Patients with Pulmonary Mycobacterium avium Complex Infections
Authors: Varley Cara D , Henkle Emily , Strnad Luke , Ku Jennifer , Brunton Amanda , Winthrop Kevin L 
Published: October 2019

Abstract

Background
Limited data are available regarding laboratory abnormalities in patients with pulmonary Mycobacterium avium complex (MAC) disease.

Methods
We included patients without cystic fibrosis who had pulmonary MAC and met ATS/IDSA disease criteria from the Northwest NTM Biobank with a complete blood count (CBC) 6 months prior and up to 30 days after study enrollment. The biobank is a cohort of patients with Nontuberculous mycobacterium (NTM) infections identified through statewide laboratory surveillance and OHSU regional referral NTM clinic; a complete clinical history is collected by chart review at enrollment. We evaluated the proportion of pulmonary MAC patients with abnormal laboratory tests. We examined differences using a chi-square test between patients who were antimycobacterial treatment naïve, on therapy at enrollment or previously treated, in addition to cavitary and non-cavitary disease and those who also had previous sputum isolation of additional organisms (co-isolation).

Results
147 patients had CBCs available; 112 (76.2%) were female with a median age of 69 years (22–88 years). 64 (43.5%) were antimycobacterial treatment naïve, 65 (44.2%) were on therapy at enrollment and 18 (12.2%) were previously treated. Lymphocyte count was below normal in 105 (73.4%) patients; 70 (49.3%) had lymphocyte counts below 1500 cells/mL and 27 (18.9%) were lymphopenic. Elevated monocyte percent was seen in 54 (37.2%) patients. Lymphopenia was more common in those on therapy, P = 0.01. There were no predominant laboratory abnormalities in 108 patients with metabolic panels. 34 patients had a c-reactive protein (CRP) collected, which was elevated, after age and gender correction, in 31 patients (91.2%). There was no significant difference between treatment groups. Eleven patients had cavitary disease with no differences in laboratory values compared with those with non-cavitary disease. Patients with co-isolation were more likely to be anemic (P = 0.03), have thrombocytosis (P = 0.04) and were less likely to have a monocytosis (P = 0.03).

Conclusion
A large proportion of patients with pulmonary MAC disease have low lymphocyte counts, elevated monocyte percent and CRP. Further evaluation of the meaning of these abnormalities as well as changes during therapy is needed.

Disclosures
All authors: No reported disclosures.
1376. Physician Practice Patterns for Screening and Treatment of Latent Tuberculosis Infection in the South Asian Population in Central New Jersey
Authors: Gulati Nupur , Ram Pentakota Sri , Feja Kristina N , Ghoshal Bishakha , Bhavaraju Rajita , Jindani Arpita , Sunanda Gaur , Kalyoussef Sabah 
Published: October 2019

Abstract

Background
New Jersey (NJ) has a significant burden of tuberculosis (TB) cases (ranked 8th in the United States) and 22% of the cases are among foreign-born (FB) individuals. We have approximately 33% FB residents in our targeted counties in Central NJ of whom 43% are originally from high TB burden areas of South Asia. Central NJ is home to the county with the second highest TB case rate in NJ. Latent tuberculosis infection (LTBI) treatment remains a key component of the World Health Organization TB elimination strategy. We sought to survey community physicians about their LTBI screening and treatment practices in South Asian (SA) patients.

Methods
An IRB-approved anonymous survey was distributed online to practicing staff physicians at local hospitals over a 2-month period. The primary outcome measure was whether physicians appropriately screen for LTBI. A secondary outcome measure was whether follow-up after medication initiation was provided. Predictors measured included: age, gender, self -identification of physician as SA, years in practice, and if they were a foreign medical graduate (FMG). Descriptive statistics were provided using counts and proportions. Chi-square tests were used for bivariate analyses to look for factors associated with LTBI screening and treatment.

Results
A total of 218 physicians responded to the survey; of whom, 137 identified themselves as primary care physicians (i.e., pediatrics (62%), internal medicine (30%), or family medicine (8%)). About half of them were FMG and 40% identify themselves as SA. Three out of four of these physicians (n = 101) indicated they routinely screen their patients for LTBI. Bivariate analyses using chi-square did not find any statistically significant associations with LTBI screening. A quarter of the physicians screened with an IGRA and 60% reported always offering treatment for LTBI. Isoniazid was the most common medication prescribed. A majority of respondents did not report prescribing Rifampin or Rifapentine. Follow-up after initiation of treatment was provided at least every other month by 52.7% of physicians.

Conclusion
There is wide variability in LTBI screening, treatment, and follow-up among our physician sample. Physicians have not yet adopted newer treatment regimens suggesting the need for an educational intervention.

Disclosures
All authors: No reported disclosures.
1377. Use of Interferon-Gamma Release Assays (IGRAs) Reduced Latent Tuberculosis Infection (LTBI) Diagnosis in Refugee and Immigrant Children
Authors: Kushner Lauren E , Mony Vidya , Vu David M 
Published: October 2019

Abstract

Background
For foreign-born children from countries with high tuberculosis (TB) burden, positive tuberculin skin test (TST) results, associated with Bacillus Calmette Guerin (BCG) vaccination, paradoxically increase the risk for overdiagnosis and overtreatment of latent TB infection (LTBI) during immigration. The higher specificity of interferon-gamma release assays, such as QuantiFERON-TB (QFT), may help distinguish LTBI from positive TSTs due to BCG or non-TB Mycobacteria. However, data on QFT usage in pediatric populations, particularly refugee and immigrant children, are sparse. Our objective was to assess the impact of QFT on LTBI diagnosis and treatment in the vulnerable child refugee and immigrant population.

Methods
We initiated a retrospective study of children (≤15 years) seen in Santa Clara County Refugee/Immigrant Clinic for post-immigration TB re-evaluation in 2017. We collected information from the Electronic Disease Notification system and post-immigration clinic records, including laboratory studies, imaging, and clinical impression. The primary outcome was post-immigration LTBI diagnosis in patients with positive pre-immigration TB screening. Patients with prior active TB or LTBI treatment were excluded.

Results
102/135 clinic encounters examined to date were post-immigration encounters. Median age was 9 years (range 14mo to 15y). Most (82.5%) were from Asia, primarily the Philippines (n = 48), Afghanistan (n = 10), Iran (n = 9), and Vietnam (n = 8). Sixty-six (64.7%) had documented BCG vaccination. Among 102 encounters, 71 (69.6%) were of children diagnosed pre-immigration with LTBI based on positive TST and normal chest radiograph. After post-immigration evaluation with retesting by QFT, 13/71 (18%) were diagnosed with LTBI (Table 1). There were no active TB cases among 102 patients, though long-term follow-up varied (mean 5.5 ± 6.5 months).

Conclusion
QFT use for post-immigration LTBI re-evaluation reduced LTBI diagnosis by 82% in children as young as 2 years old. Preliminary data suggest the preferential use of QFT over TST in non-United States-born children, in accordance with new California Department of Public Health TB screening recommendations for children ≥2 years, could reduce unnecessary diagnosis and treatment of LTBI in refugee and immigrant children.

Disclosures
All authors: No reported disclosures.
1382. Acid-Fast Bacilli Testing Trends at 43 In- and Outpatient Facilities and Nontuberculous Mycobacterial Pulmonary Isolation Rate, United States, 2009–2015
Authors: Ling Lai Yi , Ricotta Emily , Olivier Kenneth , Kadri Sameer S , Prevots D Rebecca 
Published: October 2019

Abstract

Background
The prevalence of nontuberculous mycobacterial pulmonary disease (NTM PD) is increasing in the United States and globally. The reasons for this increase are not clear but could be related to both gained awareness leading to increased mycobacterial testing, or to a true NTM PD increase. To further examine the role of testing rates in the observed increase, we studied trends in Acid-Fast Bacteria (AFB) testing and NTM isolation positivity using a large Electronic Health Record (EHR) dataset in the United States.

Methods
Using the Cerner Health Facts EHR dataset, we extracted microbiologic, demographic, and clinical data for patient encounters (inpatient or outpatient), with ≥1 orders for AFB respiratory cultures. The analysis was limited to the 43 facilities reporting continuously for the period 2009–2015. A patient with at least one AFB test was considered tested (AFB) and a patient with at least one pathogenic NTM respiratory isolate was considered positive. Trends in AFB testing and NTM positivity were estimated using log-linked Poisson regression (P < 0.05).

Results
From 2009 through 2015, of 14.8 million patients, 65,010 had 142,315 AFB tests, averaging 2.2 AFB tests/patient, for an overall testing prevalence of 0.43%; the annual testing prevalence remained unchanged during the study period (P = 0.44) (Figure 1). Of the 65,010 patients with AFB tests, 3,942 (6.1%) had ≥1 pathogenic NTM species, for an overall pulmonary NTM isolation prevalence of 2.7/10,000 patients represented in Cerner Health Facts dataset. Of the patients that had at least one pathogenic NTM, 3,094 (78%) had M. avium complex, and 265 (7%) had M. abscessus/chelonae, (Figure 2). Among patients with at least 1 NTM-positive culture, 138 patients had concomitant growth of M. tuberculosis.

Conclusion
Increases in NTM PD are not explained by increases in AFB testing, which remained constant in the population represented here.
This study was funded in part by the Division of Intramural Research, NIAID, NIH.

Disclosures
All authors: No reported disclosures.
1388. Characteristics of Non-Tuberculous Mycobacterial Infections in Hematopoietic Stem-Cell Transplant Patients
Authors: Gleeson Shana E , Azar Marwan M , Malinis Maricar 
Published: October 2019

Abstract

Background
Hematopoietic stem cell transplantation (HSCT) recipients are at increased risk for non-tuberculous mycobacterial infections (NTMI), but little data exists regarding NTMI in this population. This study aimed to better define the clinical and epidemiological characteristics of NTMI in HSCT patients.

Methods
We performed a retrospective review of patients age ≥ 18 who underwent HSCT between 2000 and 2017 at Yale-New Haven Hospital, and who subsequently had an NTMI based on ATS/IDSA criteria or a culture that grew NTM. We reported patient demographics, illness severity, treatment, and outcomes.

Results
Of 1371 HSCT recipients between 2000 and 2017, 17 (1.2%) had an NTMI or were culture positive. Most patients were male (76.5%), received allogeneic HSCT (70.6%), had graft vs. host disease (GVHD) (70.6%), and received immunosuppression (64.7%). Mycobacterium avium complex (MAC) was isolated in 16 (94.1%). Cultures were mainly positive in respiratory specimens (8 bronchoalveolar lavage, 2 sputum, and 1 lung tissue). Nine of 17 patients (52.9%) were deemed colonized whereas 8 (47.1%) were considered infected. In the infected group, isolated pulmonary infection was the most common presentation (n = 5, 62.5%). Two of the 8 infected patients (25%) had MAC bacteremia. Of those with NTMI, MAC was isolated in 6 (75%), MAC and M. abscessus/chelonae in 1 (12.5%), and M. kansasii in 1 (12.5%). Among those with NTMI, 3 were hypoxic (37.5%) and 4 (50%) had sepsis, though only 1 case of sepsis was directly attributable to NTM. Seven infected patients received antimycobacterial therapy. Four patients (50%) died but none were directly attributed to NTM. Diagnosis was often delayed in these patients, with a median of 44 days (range 14–155 days) from time of initial presentation to diagnosis of NTMI. Median time to death from time of NTMI diagnosis was 75 days (range 16–1825 days).

Conclusion
NTMI, including disseminated infection, was uncommon in a large cohort of HSCT patients. Careful evaluation of positive cultures in these patients is needed to distinguish infection from colonization. High mortality in HSCT patients may not be directly attributable to NTMI, but the presence of NTM may be a predictor of poor outcomes.

Disclosures
All authors: No reported disclosures.
1396. Risk Factors for Brain Abscess: A Nationwide Population-based Nested Case–Control Study
Authors: Bodilsen Jacob , Dalager-Pedersen Michael , van de Beek Diederik , Brouwer Matthijs C , Nielsen Henrik 
Published: October 2019

Abstract

Background
Knowledge of risk factors for brain abscess is limited and relies on single-center cohorts without control groups.

Methods
We accessed nationwide medical registries to conduct a population-based nested case–control study of risk factors for brain abscess. We applied risk set sampling for selection of population controls (1:10) individually matched by age, sex, and area of residence. Conditional logistic regression was used to compute adjusted odds ratios (aOR) with 95% confidence intervals (CIs). Next, population attributable fractions were calculated.

Results
We identified 1,384 brain abscess patients in Denmark from 1982 through 2016 and 13,839 matched population controls. The median age was 50 years (interquartile range 33–63) and 37% were female. Cases often had a Charlson comorbidity score>2 (16%) compared with controls (3%). Adjusted ORs were: head trauma 2.15 (1.72–2.70), neurosurgery 19.3 (14.3–26.0), dental infection 4.61 (3.39–6.26) or surgery 2.57 (1.71–3.84), ear-nose-throat infection 3.81 (3.11–4.67) or surgery 2.85 (2.21–3.70), congenital heart disease 15.6 (9.57–25.4), diabetes mellitus 1.74 (1.33–2.29), alcohol abuse 2.22 (1.58–3.11), liver disease 2.37 (1.53–3.68), kidney disease 2.04 (1.30–3.20), and lung abscess or bronchiectasis 8.15 (3.59–18.5). The aORs were 4.12 (3.37–5.04) and 8.77 (5.66–13.6) for solid and hematological cancer, 12.0 (6.13–23.7) for HIV, and 5.71 (4.22–7.75) for immuno-modulating treatments. Risks were twice as high when risk factors were observed within 5 years before brain abscess. Population attributable fractions showed that neurosurgery (12%), solid cancer (11%), ear-nose-throat infections (7%) and immuno-modulating treatments (5%) were substantial contributors to occurrence of brain abscess.

Conclusion
Important risk factors included neurosurgery, cancer, ear-nose-throat infections and immuno-modulating treatments

Disclosures
All authors: No reported disclosures.