Presence of Borrelia miyamotoi infection in a highly endemic area of Lyme disease

A series of cases in the Northeast of the US during 2013–2015 described a new Borrelia species, Borrelia miyamotoi, which is transmitted by the same tick species that transmits Lyme disease and causes a relapsing fever-like illness. The geographic expansion of B. miyamotoi in the US also extends to other Lyme endemic areas such as the Midwestern US. Co-infections with other tick borne diseases (TBD) may contribute to the severity of the disease. On Long Island, NY, 3–5% of ticks are infected by B. miyamotoi, but little is known about the frequency of B. miyamotoi infections in humans in this particular region. The aim of this study was to perform a chart review in all patients diagnosed with B. miyamotoi infection in Stony Brook Medicine (SBM) system to describe the clinical and epidemiological features of B. miyamotoi infection in Suffolk County, NY. In a 5 year time period (2013–2017), a total of 28 cases were positive for either IgG EIA (n = 19) or PCR (n = 9). All 9 PCR-positive cases (median age: 67; range: 22–90 years) had clinical findings suggestive of acute or relapsing infection. All these patients were thought to have a TBD, prompting the healthcare provider to order the TBD panel which includes a B. miyamotoi PCR test. In conclusion, B. miyamotoi infection should be considered in the differential diagnosis for flu-like syndromes during the summer after a deer tick bite and to prevent labeling a case with Lyme disease.

667. An Emerging Tick-Borne Disease in Long Island, New York: Relapsing Fever Caused by Borrelia miyamotoi

Background

Suffolk County (Long Island, New York) reports annually the highest absolute number of tick-borne diseases in New York. A new Borrelia species, Borrelia miyamotoi which causes a relapsing fever, has been reported in New York recently. The aim of this study was to identify the number of cases of B. miyamotoi diagnosed in Suffolk county.

Methods

A retrospective chart review was performed in Stony Brook (SB) Medicine hospitals, SB University Hospital (the only tertiary medical center in Suffolk County) and Southampton Hospital (a major hospital in the east end of Suffolk County). Laboratory records were queried for a positive B. miyamotoi PCR test from blood or a positive IgG antibody with a B. miyamotoi-specific EIA that utilizes a recombinant GlpQ antigen (both tests performed in a commercial laboratory).

Results

Twenty-eight cases were positive for serology (IgG EIA; n = 19) or PCR (n = 9). None of the IgG-positive cases had a positive PCR result indicating that individuals were likely exposed to B. miyamotoi in the past. Of the nine PCR-positive cases (median age:67 years), eight were men, three were diagnosed in the outpatient clinic (33.3%) and six were diagnosed through the emergency department and required hospitalization (66.6%). Thrombocytopenia and transaminitis were common findings. Two-thirds of these nine cases were diagnosed in the period of 2016–2017 and one-third in the period, 2013–2015 (P = 0.17).

Conclusion

An increasing number of cases of B. miyamotoi were observed in Suffolk County during 2013–2017 and two-thirds required hospitalization. The real burden of this tick borne disease in Suffolk County and the rest of the state is unknown.

Disclosures

All authors: No reported disclosures.

665. Key Clinical and Laboratory Features in Early Diagnosis of Ehrlichiosis in an Endemic Area of Long Island, New York

Background

Human monocytic ehrlichiosis (HME) is a tick-borne disease caused by Ehrlichia chafeensis in the northeast United States. Suffolk County, New York has the highest amount of HME cases in NY (176 from 2010 to 2014). Our aim is to identify risk factors for HME and compare clinical presentation and laboratory findings of young vs. older adults.

Methods

A retrospective chart review from January 1, 2014 to December 31, 2017 was performed on all patients ≥18 years who presented to the ER at Stony Brook University Hospital (SBUH) or Stony Brook Southampton Hospital (SBSH) with (i) ICD-9 code 082.4 or ICD-10 code A77.40 and (ii) a positive E. Chafeensis PCR. Data were collected on demographics, clinical presentation, and laboratory results.

Results

Twenty-seven cases of HME were found and separated into Group 1 (G1, n = 10) or Group 2 (G2, n = 17) based on age (Table 1). G1 had a significantly higher chance of being Hispanic than G2. Twenty-four of the 27 patients (89%) were hospitalized with an average length of stay of 3.4 days (range 1–14 days).The only significant difference in clinical presentation was that G1 was more likely to have myalgia (P = 0.02). 40% or more of patients in both groups presented with an acute kidney injury and the average length of hospital stay in days was 4.0 ± 2.9 and 3.2 ± 3.1 for G1 and G2, respectively. The number of cases overall have increased 6.0% per year between 2014 and 2017. Thrombocytopenia presented in all cases.

Conclusion. HME is prevalent in Suffolk County. Clinical presentation and laboratory findings were largely similar between the two groups, except the younger population more often presented with myalgia. A risk factor in this study was to be young and Hispanic, likely due to occupational exposure.

Disclosures

All authors: No reported disclosures.

Lyme Disease in Hispanics in Long Island, New York: A New Health Disparity in the U.S

Background

Lyme disease (LD) is the most commonly reported vector-borne illness in the U.S. A risk factor for acquiring LD is the exposure to outdoors. In Long Island, Hispanics compromise a large share of the outdoor occupational workforce.

Methods

A retrospective chart review was performed in all patients with ICD-9 or ICD-10 diagnostic codes for LD between 2011–2016 in SHH and 2010–2015 in SBUH. Inclusion criteria was defined as a clinical scenario compatible with LD (erythema migrans -EM, arthritis, central nervous system (CNS) involvement, carditis, meningitis) and serological confirmation by western blot according to CDC (SBUH) or Imugen® (SHH) criteria.

Results

Out of 1,026 cases (766 SBUH;260 SHH) that carried a diagnosis of LD, 284 cases (22% Hispanics) met inclusion criteria and were added to final analysis (241 SBUH: 43 SHH). The mean age was 48.8 (SD:17.8) and 48.3 (SD:17.5) years-old in H and NH, respectively (p > 0.05). Most were male (H:62.2%; NH: 54.3%; P = 0.2). In the univariate analysis, headaches were more frequently present in H (42.6%) than in NH (26.6%) (P = 0.015). In the logistic regression analysis, the following symptoms were significantly different between H and NH: headaches (OR 1.17, 96% CI 1.60–6.59, 
P = 0.001) and peripheral neuropathy (OR 0.38, 95% CI: 0.15-0.96, P = 0.04). Among seasons, H were more frequently diagnosed with Lyme during spring months than NH (H: 26.3% vs. NH: 12.6%, P = 0.03)

Conclusion

Hispanics have a greater risk for presenting with headaches and less peripheral neuropathy than NH. Initiation of outdoor work among H may be the reason of this disproportionate presentation of LD symptoms during spring months. These findings may suggest the propensity for Hispanics to go underdiagnosed with LD, despite their high likelihood of exposure through their occupations in this region.

Disclosures

All authors: No reported disclosures.

Perioperative use of beta-blocker in noncardiac surgery: a multicenter educational intervention to achieve best practice guidelines

Perioperative cardiac ischemia and infarction are important causes of morbidity and mortality in patients undergoing noncardiac surgery. There is now significant evidence that the use of prophylactic beta-adrenergic antagonists among selected patients at risk for perioperative cardiovascular complications is associated with a reduction in myocardial ischemia and cardiac events. Furthermore, consensus guidelines have incorporated the findings of recent studies and provide recommendations for the appropriate utilization of beta-adrenergic antagonists among selected patients. Despite these guidelines, it is unknown to what extent these recommendations have become translated into clinical practice. After measuring perioperative beta-blocker use among participating hospitals within the New York Presbyterian Health Network, we developed a multicenter educational intervention to improve the overall utilization of beta-adrenergic prophylactic therapy in accordance with best practice guidelines. The literature supporting the development of this intervention is presented in this paper, along with the tools that are currently being used for decision support across an academic healthcare network.

Quinupristin/dalfopristin (RP 59500) therapy for vancomycin-resistant Enterococcus faecium aortic graft infection: case report

A 46-year-old woman was admitted to the hospital with severe peripheral vascular disease, requiring multiple vascular surgical procedures. During the sixth hospital week, after prior therapy with multiple antibiotics, Enterococcus faecium was isolated as the only organism from an operating room culture of an infected aortic graft. Histological examination of the graft showed infiltration with polymorphonuclear leukocytes. Subsequently, cultures of an infected inguinal wound yielded Enterococcus faecium with mixed bacterial growth. Both isolates of Enterococcus faecium were resistant to all available antimicrobials, including ampicillin, vancomycin, tetracycline, chloramphenicol, and ciprofloxacin. Compassionate use therapy with quinupristin/dalfopristin (RP59500) was administered for 25 days, the patient's clinical condition improved, and wound healing occurred. Transient elevation of serum alkaline phosphatase was noted. This case demonstrates successful eradication of deep VREF infection by quinupristin/dalfopristin with good tolerance of prolonged therapy.

Hernioscopic retrieval of bowel for evaluation of viability during repair of a Richter's-type incarcerated femoral hernia

During the repair of a Richter's type incarcerated right femoral hernia via an infrainguinal approach, the incarcerated loop of bowel retracted back into the abdominal cavity before the bowel could be adequately examined for viability. To avoid a laparotomy to identify and possibly resect the involved loop of bowel, a laparoscope was introduced into the open femoral sac. Pneumoperitoneum was obtained, and the involved loop of small bowel was identified via the laparoscope, grasped with a grasping forceps from a second trocar port, and brought out through the hernia sac. The bowel was directly visualized and assessed for viability. This procedure required only a 5-mm trocar incision rather than an infraumbilical laparotomy incision, thus potentially minimizing postoperative morbidity, decreasing the length of hospital stay, and reducing postoperative pain. We propose this technique as a potentially useful alternative to a laparotomy in this situation on selected patients.

Reducing the inappropriate use of parenteral nutrition in an acute care teaching hospital

BACKGROUND

Parenteral nutrition (PN) is a form of nutrition that can be life-saving, but its use has inherent risks and it is expensive. Nutrition support teams have been shown to reduce both the rate of complications and excessive use of PN.

METHODS

Criteria were established to evaluate the appropriateness of PN use in a 487-bed community teaching hospital. A prospective study of 50 consecutive patients, who received either central or peripheral PN, was conducted.

RESULTS

The 50 patients received 469 days of PN. We found that 233 (49.7%) of the 469 days of PN were avoidable. This resulted in the creation of a formal approval process that required prior approval by a physician-directed multidisciplinary advisory committee before PN could be instituted. The amount of PN subsequently decreased from 500 patient days of PN per month to less than 100.

CONCLUSIONS

This study supports the idea that inappropriate use of PN can be reduced by physician education plus the continuing oversight of a physician-directed multidisciplinary advisory group.

Credentialing physicians for new technology: the physician's learning curve must not harm the patient

Laparoscopic Cholecystectomy (L.C.) offers advantages that are realized only when patient safety is assured. In November 1990, The Department of Surgery at The New York Hospital Medical Center of Queens initiated a program to introduce this new technology to surgeons who had not performed the operation previously. A preceptorship program was initiated, accompanied by contemporaneous quality assurance review. This is the experience of 15 general surgeons who performed their first 400 L.C.s from November 1990 through March 1993. There were no deaths and only one common bile duct injury (0.25%).