Epidemiology and treatment of invasive Bartonella spp. infections in the United States

OBJECTIVES

Bartonella spp., renowned for cat-scratch disease, has limited reports of dissemination. Tissue and blood cultures have limitations in detecting this fastidious pathogen. Molecular testing (polymerase chain reaction, PCR) and cell-free DNA have provided an avenue for diagnoses. This retrospective observational multicenter study describes the incidence of disseminated Bartonella spp. and treatment-related outcomes.

METHODS

Inclusion criteria were diagnosis of bartonellosis via diagnosis code, serology testing of blood, polymerase chain reaction (PCR) of blood, 16/18S tests of blood or tissue, cultures of blood or tissue, or cell-free DNA of blood or tissue from January 1, 2014, through September 1, 2021. Exclusions were patients who did not receive treatment, insufficient data on treatment course, absence of dissemination, or retinitis as dissemination.

RESULTS

Patients were primarily male (n = 25, 61.0%), white (n = 28, 68.3%), with mean age of 50 years (SD 14.4), and mean Charlson comorbidity index of 3.5 (SD 2.1). Diagnosis was primarily by serology (n = 34, 82.9%), with Bartonella henselae (n = 40, 97.6%) as the causative pathogen. Treatment was principally doxycycline with rifampin (n = 17, 41.5%). Treatment failure occurred in 16 (39.0%) patients, due to escalation of therapy during treatment (n = 5, 31.3%) or discontinuation of therapy due to an adverse event or tolerability (n = 5, 31.3%).

CONCLUSIONS

In conclusion, this is the largest United States-based cohort of disseminated Bartonella spp. infections to date with a reported 39% treatment failure. This adds to literature supporting obtaining multiple diagnostic tests when Bartonella is suspected and describes treatment options.

The Future of Telehealth in Human Immunodeficiency Virus Care: A Qualitative Study of Patient and Provider Perspectives in South Carolina

To ensure care continuity during the COVID-19 pandemic, telehealth has been widely implemented in human immunodeficiency virus (HIV) care. However, participation in and benefits from telehealth were unequal. This study aims to assess the willingness of people living with HIV (PWH) and HIV care providers to use telehealth and perceptions of the future role of telehealth. In-depth interviews with 18 PWH and 10 HIV care providers from South Carolina assessed their willingness to use telehealth, their perspectives on the future of telehealth in HIV care, and recommendations to improve telehealth. Interviews were analyzed using thematic analysis. Most PWH were female (61%), Black/African American (67%), and non-Hispanic (78%). Most PWH (61%) and all providers had used telehealth for HIV care. Most PWH and all providers reported being willing to use or (re-)consider telehealth HIV care services in the future. Providers suggested that telehealth is most suitable for routine HIV care encounters and for established, clinically stable, generally healthy PWH. Attitudes toward telehealth were heterogeneous, with most interviewees valuing telehealth similarly or superior to in-person care, yet >20% perceiving it less valuable. Recommendations to improve telehealth included multilevel strategies to address challenges across four domains: technology, the virtual nature of telehealth, administrative processes, and the sociodemographic profile of PWH. Telehealth in HIV care is here to stay; however, it may not yet be suitable for all PWH and all care encounters. Decision processes related to telehealth versus in-person care need to involve providers and PWH. Existing telehealth options require multilevel adjustments addressing persistent challenges.

A survey of South Carolina pharmacists' readiness to prescribe human immunodeficiency virus pre-exposure prophylaxis

Introduction

HIV pre-exposure prophylaxis (PrEP) is largely underutilized in the Southern United States. Given their community presence, pharmacists are well positioned to provide PrEP within rural, Southern regions. However, pharmacists' readiness to prescribe PrEP in these communities remains unknown.

Objective

To determine the perceived feasibility and acceptability of prescribing PrEP by pharmacists in South Carolina (SC).

Methods

We distributed a 43-question online descriptive survey through the University of SC Kennedy Pharmacy Innovation Center's listerv of licensed SC pharmacists. We assessed pharmacists' comfort, knowledge, and readiness to provide PrEP.

Results

A total of 150 pharmacists responded to the survey. The majority were White (73%, n=110), female (62%, n=93), and non-Hispanic (83%, n=125). Pharmacists practiced in retail (25%, n=37), hospital (22%, n=33), independent (17%, n=25), community (13%, n=19), specialty (6%, n=9), and academic settings (3%, n=4); 11% (n=17) practiced in rural locales. Pharmacists viewed PrEP as both effective (97%, n=122/125) and beneficial (74% n=97/131) for their clients. Many pharmacists reported being ready (60% n=79/130) and willing (86% n=111/129) to prescribe PrEP, although over half (62% n=73/118) cited lack of PrEP knowledge as a barrier. Pharmacists described pharmacies as an appropriate location to prescribe PrEP (72% n=97/134).

Conclusions

Most SC pharmacists surveyed considered PrEP to be effective and beneficial for individuals who frequent their pharmacy and are willing to prescribe this therapy if statewide statutes allow. Many felt that pharmacies are an appropriate location to prescribe PrEP but lack a complete understanding of required protocols to manage these patients. Further investigation into facilitators and barriers of pharmacy-driven PrEP are needed to enhance utilization within communities.

338. Epidemiology and Treatment of Invasive Bartonella spp. Infections

Background

Serology and PCR testing methods have increased ability to diagnose Bartonella spp. invasive infections. Current treatment recommendations are based primarily on case series and aging data published before newly available diagnostic techniques. These recommendations are limited in safety and effectiveness outcomes. This multicenter, retrospective cohort study describes the epidemiology and treatment outcomes of invasive bartonellosis among patients in the U.S.

Methods

Collaborating sites were selected from SERGE-45 (Southeastern Research Group Endeavor) research network. Data were collected through REDCap. Subjects were screened from adult patients with invasive bartonellosis diagnosis codes, positive Bartonella spp. serologies, PCR, 16/18S tests, cultures, and Karius® tests from blood or tissue between January 1, 2014, and September 1, 2021. Eligible patients had at least one positive test result, evidence of invasive bartonellosis, and received treatment for bartonellosis. Treatment failure was defined as admission or readmission while on treatment, mortality during treatment or within 30 days after end of treatment, required escalation or extended duration of therapy, premature discontinuation of therapy, or necessitated change in regimen. Those not meeting treatment failure criteria were considered treatment success.

Results

Of the 169 patients screened, 32 were included, with 19 having treatment success. Bartonella henselae was the most common causative pathogen (n = 31, 97%). Endocarditis was the most common invasive manifestation (n = 18, 56%). Treatment regimens are displayed in Table 1. Primary reasons for treatment failure included necessitated escalation of therapy during treatment course (n = 4, 30.8%) and discontinuation of therapy due to adverse effect (n = 4, 30.8%).

Conclusion

Doxycycline with rifampin was the most common treatment regimen for invasive bartonellosis, with extended durations used compared to often referenced 6-week courses for invasive infections. It is important to consider adverse drug effects, toxicities, and tolerability in patients being treated for invasive bartonellosis.

Disclosures

P. Brandon Bookstaver, PharmD, Spero Therapeutics: Advisor/Consultant.

2069. Prevalence of Cabotegravir and Rilpivirine Resistance Associated Mutations Among Treatment Experienced Patients in a South Carolina Outpatient Clinic

Background

Cabotegravir/rilpivirine (CAB/RPV) long-acting (LA) injectable was recently approved as a switch therapy for people living with HIV (PLWHIV) who are virologically suppressed on oral combination antiretroviral therapy (cART). Data demonstrates RPV resistance associated mutations (RAMs) correlated with CAB/RPV treatment failure. This is the first real-world retrospective, observational study evaluating epidemiology of RPV and CAB RAMs in a heavily treatment experienced population of PLWHIV.

Methods

A cohort of PLWHIV were screened for transition eligibility to CAB/RPV therapy in a large clinic in the Southeastern U.S. between April 1, 2021 and January 31, 2022. The following baseline characteristics were collected: gender, age, race, Charlson Comorbidity Index, current cART, and prior cART exposure. The Stanford University HIV Drug Resistance Database was utilized to evaluate the inferred resistance level for reverse transcriptase (RT), integrase strand transfer inhibitor (INSTI), and protease inhibitor (PI) sequences.

Results

Among 115 patients included, 64.3% were males who were predominately African American (83.4%), with a median age of 37 years old and Charlson Comorbidity Index of 1.65. Ten (8.69%) individuals had at least one RPV or CAB RAM. Among these, 7 (6%) and 3 (2.6%) displayed RPV and CAB resistance, respectively. The most prevalent types of RAMs for RPV specifically were Y181I/C (n = 4) and E138A (n = 2). Five of 7 individuals with RPV RAMs had history of cART use without documented exposure to RPV-containing regimens. Moreover, 2 of 3 individuals with CAB RAMs had history of cART with exposure to an integrase-containing regimen.

Conclusion

This is the first study that characterizes susceptibility patterns that may affect CAB/RPV in clinical practice. Within this rural Southeastern population, prevalence of RPV RAMs is higher than CAB RAMs, and RPV RAMs were commonly observed as transmitted resistance whereas CAB RAMs were typically associated with prior history of exposure to INSTI-containing regimen. It is pertinent to assess the genotypic resistance profile of RTs and history of cART exposure prior to transitioning to CAB/RPV to decrease the risk of virologic failure due to RAMs.

Disclosures

P. Brandon Bookstaver, PharmD, Spero Therapeutics: Advisor/Consultant.

Increased viral load in a hospitalized patient on treatment with crushed bictegravir/emtricitabine/tenofovir alafenamide: A case report and review of the literature

DISCLAIMER

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

To describe a case of increased viral load in a patient with HIV-1 infection receiving treatment with crushed bictegravir/emtricitabine/tenofovir alafenamide (B/FTC/TAF).

SUMMARY

A 43-year-old man, newly diagnosed with HIV, was hospitalized due to failure to thrive, neurological changes, and hypotension. Before treatment, the viral load of HIV RNA (VL) was 769,704 copies/mL and the CD4 + T-cell count was 36 cells/μL. On hospital day (HD) 8, B/FTC/TAF by mouth daily was initiated. During the hospitalization, the patient's course was complicated by opportunistic infections, bilateral pneumothorax, seizure activity, and acute respiratory distress, requiring multiple intubations and extended time in the intensive care unit. A repeat VL measurement on HD 28 was 5,887 copies/mL after the patient had received 14 of 20 scheduled B/FTC/TAF doses. Because of a failed swallow study and continued nutritional deficits, a percutaneous endoscopic gastrostomy (PEG) tube was placed on HD 38 and continuous tube feeds via the PEG tube were initiated. Subsequently, the B/FTC/TAF order was modified to be crushed, mixed in 30 mL water, and administered daily via the PEG tube. A repeat VL measurement on HD 65 showed an increase to 8,047 copies/mL, despite receipt of 37 consecutive doses of B/FTC/TAF. B/FTC/TAF was discontinued and dolutegravir 50 mg twice daily, darunavir 800 mg plus ritonavir 100 mg (DRV/r), and tenofovir disoproxil fumarate/FTC 200 mg/300 mg were started owing to virological increase, need for a viable option compatible with PEG tube delivery, and potential for integrase inhibitor resistance. At the time of regimen change (HD 67), a resistance panel showed minor mutations, E157Q and V118I. The regimen was streamlined with discontinuation of DRV/r on HD 92. The patient was discharged on HD 161. The PEG tube was removed 2 months after discharge, oral B/FTC/TAF was reinitiated, and the patient was virologically suppressed at 1 year after discharge.

CONCLUSION

Controlled studies are needed to verify acceptable pharmacokinetic and pharmacodynamic metrics for crushed B/FTC/TAF given via tube, with and without tube feeds, before use in this manner.

1388. Epidemiology and Treatment Outcomes of Nontuberculous Mycobacterial Infections at a Community Teaching Hospital in the Southeastern United States

Background

Gaps in evidence concerning the epidemiology of nontuberculous mycobacterial (NTM) organisms and their associated treatment outcomes are evident in the literature. The aim of this study was to describe NTM species distribution and susceptibility profile and associated treatment outcomes among adult patients at a tertiary referral hospital in the Southeastern United States.

Methods

A retrospective cohort study of adult patients with NTM infections from January 1, 2010 to June 30, 2020 was performed. Included patients had a positive culture for NTM species and clinical suspicion of infection. Patients were excluded if they had concurrent positive culture for M. tuberculosis (MTB) or monomicrobial culture for M. gordonae. Study endpoints included predictors for favorable treatment outcome, species distribution, and susceptibility at baseline. Favorable treatment outcome was defined as physician-guided cessation of therapy due to clinical improvement. Univariate followed by multivariate regression analysis was used to analyze favorable predictors.

Results

A total of 250 and 78 patients were included in microbiologic and outcomes cohorts, respectively. Among treated patients, 47 (60%) had a favorable treatment outcome. The outcomes cohort consisted primarily of non-Hispanic Caucasians (71%) with pulmonary infection (67%). The most common isolates observed were Mycobacterium avium complex (MAC) (67%) and M. abscessus (18%). Being self-pay, underweight, history of MTB treatment, and concurrent asthma were more common in those with unfavorable treatment outcomes. The significant favorable predictors included antibiotic change not due to escalation or de-escalation of therapy and private insurance. Among MAC isolates, clarithromycin and amikacin were highly susceptible; however, M. abscessus has reduced susceptibility to first-line agents such as amikacin, clarithromycin, and cefoxitin (Table 1).

Table 1. Baseline Susceptibility

Conclusion

Considering the long incubation time, knowledge of prevalence, antimicrobial susceptibility patterns, and outcomes could guide empirical antimicrobial selection for NTM infections. This is particularly useful for M. abscessus infections where most isolates carry significant resistance to one or more first-line agents.

Disclosures

Julie Ann Justo, PharmD, MS, BCPS-AQ ID, bioMerieux (Speaker’s Bureau)Merck & Co. (Advisor or Review Panel member)Therapeutic Research Center (Speaker’s Bureau)Vaxart (Shareholder) P. Brandon Bookstaver, Pharm D, ALK Abello, Inc. (Grant/Research Support, Advisor or Review Panel member)Biomerieux (Speaker’s Bureau)Kedrion Biopharma (Grant/Research Support, Advisor or Review Panel member)

Crushing and Splitting Direct-Acting Antivirals for Hepatitis C Virus Treatment: A Case Series and Literature Review

Limited data exist regarding the use of direct-acting antivirals (DAAs) for hepatitis C virus (HCV) in patients who are unable to swallow tablets. This case series describes HCV treatment in patients requiring tablet manipulation, providing evidence for safety and effectiveness of HCV DAA tablet manipulation.

704. Evaluation of Risk Factors and Outcomes of Early Left Ventricular Assist Device Infections

Background

Infection is a major complication of placement of left ventricular assist devices (LVADs) for patients with end stage heart failure. This study aimed to identify risk factors and evaluate outcomes of early LVAD specific and related infections in a community teaching hospital.

Methods

This was a single-center, retrospective cohort study that included adult patients with placement of LVAD from October 2012 – December 2019. LVAD specific infection was defined as a pump, cannula, pocket, or percutaneous driveline infection and LVAD related infection was defined as infective endocarditis, mediastinitis, or bloodstream infection. The primary outcome was early LVAD specific or related infection within 90 days of implantation. Secondary outcomes included time to infection, risk factors of and time to recurrent infection, and time to death. Multivariate logistic regression was used to ascertain risk factors for early infection. Cox regression was used to ascertain association with time to outcome variables.

Results

Of 160 patients who had LVADs placed during the study period, 26 experienced early LVAD infection. The majority of infections were caused by Staphylococcus spp. (32.1%). Risk factors for early infection are summarized in Table 1. Risk factors identified included placement of HeartMate III device when compared to HeartMate II and BMI > 40kg/m2. Increased hazard rate of infection was demonstrated for patients with HeartWare and HeartMate III devices compared to HeartMate II (HR 2.344; 95% CI 1.22,4.496; p-value 0.01; and HR 2.858; 95% CI 1.231, 6.635; p-value 0.015, respectively), those with BMI >40 (HR 2.437; 95% CI 1.131, 5.252; p-value 0.023), and those with history of diabetes (HR 1.736; 95% CI 1.012, 2.987; p-value 0.045). No risk factors were identified in the multivariate regression model for recurrent infection. Time to death was increased among patients with A1C > 6.4 at baseline (HR 1.028; 95% CI 1.002, 1.054; p-value: 0.032) and among patients who experienced early LVAD infection (HR 3.824; 95% CI 1.928, 7.584; p-value < 0.001).

Conclusion

HeartMate III device and BMI > 40kg/m2 were identified as risk factors for early LVAD infection. Time to mortality was decreased among patients that experienced an early LVAD infection.

Disclosures

Julie Ann Justo, PharmD, MS, BCPS-AQ ID, bioMerieux (Speaker’s Bureau)TRC Healthcare (Speaker’s Bureau)

955. Addressing Gaps and Disparities in HIV testing in the Emergency Department

Background

Early diagnosis of HIV is key to improving outcomes for persons living with HIV (PWH). The Emergency Department (ED) is a critical site for PWH to access care. Previous studies in South Carolina (SC) have shown that two-thirds of individuals newly diagnosed with HIV have visited a health care facility a mean 7 times prior to their HIV diagnosis. Over 80% of these visits were to the ED, thus representing missed opportunities. Failure to test results from a multitude of barriers, including avoidance of testing due to a perceived lack of follow up. To address this gap in care we established a rapid HIV engagement team (RHET) that assumes responsibility for post-HIV testing linkage and reporting. The goal of this study is to evaluate the effectiveness of this intervention.

Methods

This retrospective cohort study compared HIV testing rates and patterns in Prisma Health EDs from May 2018 through October 2018 (pre-RHET) to 5/2019 through 10/2019 (post-RHET). Included persons were ≥18 years of age and had ICD-10 codes for a sexually transmitted infection (STI), trichomonas, herpes simplex, and gonorrhea (GC) or Chlamydia (CT) NAAT, and/or presented with an initial complaint of a STI. Multivariable logistic regression analysis was utilized to examine impact of RHET implementation on HIV testing in ED.

Results

A total of 4104 individuals were identified, 2154 pre-RHET and 1950 post-RHET. Table 1 displays baseline characteristics for the two groups. Overall, 87% had GC testing; 9% had positive results; 95% had CT testing, 12.6% had positive results. Only 6% were tested for HIV pre-RHET implementation. HIV testing improved to 12% post-PHET implementation (p< 0.001). In the multivariate regression analysis predictors for HIV testing were presenting post-RHET (OR 2.27; 95% CI 1.81 to 2.85), male gender (OR 2.98; 95% CI 2.39 to 3.73), white race (OR 2.27; 95% CI 1.81 to 2.85), and presenting to ED for STI (OR 3.58; 95% CI 2.03 6.33).

Conclusion

HIV testing rates increased post-RHET yet, despite indications for HIV testing, only a small proportion received HIV testing. Further interventions are needed to improve HIV testing in EDs, particularly in women and blacks. The overall HIV testing rate remained low, representing ongoing missed opportunities for early HIV diagnosis.

Disclosures

All Authors: No reported disclosures

964. Opt-Out HIV- Hepatitis C (HCV) Testing at a Primary Care Resident Clinic in Columbia, SC: Who Gets Tested and Who Opts Out of Testing?

Background

South Carolina (SC) remains one of the most heavily affected states for both HIV and HCV infections. Males account for the majority of cases. Implementation of universal opt-out testing has improved screening rates but not much has been published describing the characteristics of those who opt out of testing. This becomes important as 10-50% of patients have opted out in previous studies.

Methods

Between February and August 2019, we conducted a quality improvement (QI) project which implemented opt- out HIV-HCV testing at a single primary care resident clinic in SC with the primary aim of increasing screening rates for HIV-HCV by 50%. Secondary aims included describing the demographic characteristics of the opt-out population. Persons were considered eligible for testing if they were between the ages of 18-65 years for HIV and 18-74 years for HCV. This was prior to the USPSTF 2020 guidelines which recommend HCV screening for adults aged 18-79 years. A retrospective chart review was used to obtain screening rates, opt status and demographic data. Logistic regression and the firth model were used to determine linkages between categorical variables. We present 3-month data.

Results

1253 patients were seen between May 1, 2019- July 31, 2019 (See Table 1). 985 (78%) were eligible for HIV testing. 482 (49%) were tested for HIV as a result of our QI project and all tests were negative. 212 (22%) of eligible patients opted out of HIV testing. Males were 1.59 times more likely to opt out (p=0.008). (see Table 2,3)

Regarding HCV, 1136 (90.7%) were deemed eligible for testing. 503 (44%) were tested for HCV as a result of our QI project. 12 (2.4%) were HCV antibody positive with viremia. 11 (90%) of antibody positive with viremia cases were in the 1945-1965 birth cohort (see Table 4). 244 (21%) opted out of HCV testing. Males and persons without a genitourinary chief complaint were more likely to opt out (p=0.02).

Table 1: Demographic characteristics of the population seen at the internal medicine resident clinic between May- July 2019

Table 2: Relationship between demographic variables and the odds of being tested for HIV or HCV within the last 12 months. Logistic Model.

Table 3: Relationship between demographic variables and the odds of opting out of testing for HIV or HCV. Firth Model.

Conclusion

Although implementation of routine HIV-HCV opt-out testing led to increased screening rates for both HIV and HCV, roughly 1 in 5 eligible patients chose to opt out of testing. Males were more likely to opt out despite accounting for the majority of newly diagnosed HCV cases. Future studies investigating drivers for opting-out in the male population could improve testing and assist with early diagnosis.

Table 4: Characteristics of patients newly diagnosed with HCV positive with viremia.

Disclosures

All Authors: No reported disclosures

1041. Tenofovir alafenamide associated weight change in persons living with HIV

Background

Persons living with human immunodeficiency virus (PLWH) have a higher incidence of developing obesity, diabetes, and cardiovascular disease. TAF, a newer formulation of tenofovir, has favorable effects on renal function and bone mineral density compared to TDF. However, recent evidence suggests TAF may have a higher propensity for weight gain over TDF. The purpose of this study is to evaluate weight change in patient switched from TDF to TAF, keeping constant the other components of their antiretroviral therapy.

Methods

This retrospective observational cohort study evaluated adult PLWH who were followed for 12 months pre and post TDF to TAF therapy switch holding all other ART constant. Patients were excluded if not on TDF or TAF therapy for a minimum of 12 months, if there were additional changes to their ART, or if there was inadequate documentation of weight defined as less than 2 weight records pre and post TAF switch. Data collected included height, weight, HIV RNA, CD4 count, and presence of any current opportunistic infections or chronic comorbid conditions. The primary endpoint was change in weight after TAF switch. All variables were evaluated using linear mixed effect models over time.

Results

466 patient charts were reviewed and 55 patients met study criteria and were included in the analysis. The median age (SD) of patients included was 45.9 (12.6) years with most patients being male (67%) and black (73%). Patients had an HIV diagnoses for a mean (SD) of 10 (6.6) years with a mean (SD) CD4 count of 544 (246.8). Full baseline characteristics are recorded in Table 1. Notably, most patients had either an INSTI or PI in their baseline ART regimen (Table 1). The estimated overall marginal mean weight gain was 1.91 kg (95% CI 0.25-3.57, p=0.024). The estimated overall gain in BMI was 0.63 kg/m2 (95% CI 0.08-1.18). Significant predictors of weight gain included female gender (3.09, 95% CI 0.54 – 5.65) and use of both integrase and protease inhibitors at baseline (6.97 kg, 95% CI 3.02 – 10.92).

Conclusion

In a predominantly black, male population, there was a statistically significant change in weight after a TAF switch.

As this is the only data highlighting weight changes following tenofovir formulation change, more data is needed to elucidate the extent of weight-gain in patients on TAF-based regimens.

Disclosures

All Authors: No reported disclosures

1126. Learner Driven Call Center to increase Convalescent Plasma Donation in COVID-19

Background

Convalescent plasma (CP) may be obtained from patients who have recovered from the novel coronavirus disease, COVID-19, caused by the virus SARS-CoV-2. Although not FDA approved, preliminary data suggests patients who receive convalescent plasma from recovered donors may have shortened recovery time and symptom reduction. The purpose of the study is to detail learner recruitment of convalescent plasma donation (CPD) for treating hospitalized COVID-19 patients.

Methods

Prisma Health Midlands formed a multidisciplinary CP donation team, consisting of seven COVID-19-certified pharmacy learner volunteers, two pharmacists, and two providers. Primary eligibility criteria were SARS-CoV-2 polymerase chain reaction (PCR) positivity at least 28 days prior to donation and asymptomatic for a minimum of 14 days. Donors were excluded based on FDA guidelines for CPD, limiting ineligible contact. Team learners were trained on call techniques and subsequently contacted, educated, and requested candidates donate through this program. Willing donors were then linked to The Blood Connection to circulate CP back into the Prisma Health System, creating a self-sustaining and closed-loop donation cycle.

Results

In total, 253 recovered adult patients with positive SARS-CoV-2 PCR test results were evaluated. 195 patients met baseline inclusion criteria for contact. This pre-screen reduced call and travel time for ineligible candidates. 108 patients were successfully reached. Of the 108, n=79 (73.14%) accepted referral to The Blood Connection, and n=29 (26.85%) were no longer candidates primarily due to patient communicated new exclusionary factors, such as active COVID-19 symptoms. The program allowed for rapid, internal access to CP for patients hospitalized with COVID-19 at Prisma Health Midlands.

Conclusion

Interest and awareness in COVID-19 CPD was successfully increased upon direct communication from the team and was felt to represent a personnel intense but successful model for recruiting potential CP donors. This program educated and utilized learners during this pandemic to enhance Prisma Health’s ability to obtain CP for hospitalized patients using a closed system.

Disclosures

All Authors: No reported disclosures

Short-term Adverse Events With BIC/FTC/TAF: Postmarketing Study

Bictegravir (BIC)/emtricitabine (FTC)/tenofovir alafenamide (TAF) was Food and Drug Administration approved in February 2018. The paucity of real-world data prompted this retrospective, observational evaluation of discontinuation rates, adverse effects, and virologic control. In a Southern US, predominantly African American overweight population, we found optimal virologic control and low discontinuation rates, with 4% discontinuing BIC/FTC/TAF due to rash, low platelets, loss of appetite, and insomnia.

Heterogeneous Patient Preferences for Modern Antiretroviral Therapy: Results of a Discrete Choice Experiment

OBJECTIVE

Limited data describe patient preferences for the growing number of antiretroviral therapies (ARTs). We quantified preferences for key characteristics of modern ART deemed relevant to shared decision making.

METHODS

A discrete choice experiment survey elicited preferences for ART characteristics, including dosing (frequency and number of pills), administration characteristics (pill size and meal requirement), most bothersome side effect (from diarrhea, sleep disturbance, headaches, dizziness/difficulty thinking, depression, or jaundice), and most bothersome long-term effect (from increased risk of heart attacks, bone fractures, renal dysfunction, hypercholesterolemia, or hyperglycemia). Between March and August 2017, the discrete choice experiment was fielded to 403 treatment-experienced persons living with human immunodeficiency virus (HIV), enrolled from 2 infectious diseases clinics in the southern United States and a national online panel. Participants completed 16 choice tasks, each comparing 3 treatment options. Preferences were analyzed using mixed and latent class logit models.

RESULTS

Most participants were male (68%) and older (interquartile range: 42-58 years), and had substantial treatment experience (interquartile range: 7-21 years). In mixed logit analyses, all attributes were associated with preferences. Side and long-term effects were most important, with evidence of substantial preference heterogeneity. Latent class analysis identified 5 preference classes. For classes 1 (40%), 2 (24%), and 3 (21%), side effects were most important, followed by long-term effects. For class 4 (10%), dosing was most important. Class 5 (4%) was largely indifferent to ART characteristics.

CONCLUSION

Overall, treatment-experienced persons living with HIV valued minimizing side effects and long-term toxicities over dosing and administration characteristics. Preferences varied widely, highlighting the need to elicit individual patient preferences in models of shared antiretroviral decision making.

Multicenter, Observational Cohort Study Evaluating Third-Generation Cephalosporin Therapy for Bloodstream Infections Secondary to Enterobacter, Serratia, and Citrobacter Species

OBJECTIVES

There is debate on whether the use of third-generation cephalosporins (3GC) increases the risk of clinical failure in bloodstream infections (BSIs) caused by chromosomally-mediated AmpC-producing Enterobacterales (CAE). This study evaluates the impact of definitive 3GC therapy versus other antibiotics on clinical outcomes in BSIs due to Enterobacter, Serratia, or Citrobacter species.

METHODS

This multicenter, retrospective cohort study evaluated adult hospitalized patients with BSIs secondary to Enterobacter, Serratia, or Citrobacter species from 1 January 2006 to 1 September 2014. Definitive 3GC therapy was compared to definitive therapy with other non-3GC antibiotics. Multivariable Cox proportional hazards regression evaluated the impact of definitive 3GC on overall treatment failure (OTF) as a composite of in-hospital mortality, 30-day hospital readmission, or 90-day reinfection.

RESULTS

A total of 381 patients from 18 institutions in the southeastern United States were enrolled. Common sources of BSIs were the urinary tract and central venous catheters (78 (20.5%) patients each). Definitive 3GC therapy was utilized in 65 (17.1%) patients. OTF occurred in 22/65 patients (33.9%) in the definitive 3GC group vs. 94/316 (29.8%) in the non-3GC group (p = 0.51). Individual components of OTF were comparable between groups. Risk of OTF was comparable with definitive 3GC therapy vs. definitive non-3GC therapy (aHR 0.93, 95% CI 0.51-1.72) in multivariable Cox proportional hazards regression analysis.

CONCLUSIONS

These outcomes suggest definitive 3GC therapy does not significantly alter the risk of poor clinical outcomes in the treatment of BSIs secondary to Enterobacter, Serratia, or Citrobacter species compared to other antimicrobial agents.

295. South Carolina Hepatitis C Telehealth Initiative (SCHTI): Increasing Access to HCV Care

Background

Lack of access to specialists is often a deterrent to comprehensive health care, especially in rural areas. Chronic Hepatitis C (CHC) affects 1% of the US population, and with the availability of highly efficacious treatment, it is imperative innovative steps are taken to screen and treat these patients. The South Carolina Hepatitis C Telehealth Initiative (SCHTI) is designed to provide Infectious Diseases (ID) consultation to rural providers caring for HCV-infected individuals across the Southeast. SCHTI is an interdisciplinary collaboration incorporating physicians, pharmacists, nurses and case managers from USC, MUSC, and Vanderbilt University.

Methods

SCHTI tele-consultation sessions were initiated in 2016, are held weekly, and provide a short didactic followed by discussion of patient cases with real-time feedback to the presenting providers. In addition, the program provides 1-hour continuing education certification for physicians, pharmacists and nurses. The South Carolina Department of Health and Human Services has approved SCHTI as an alternative to in-office expert consultation.

Results

From July 2016 through December 2018, 63 sessions were conducted, with 43 unique providers presenting cases and over 160 clinical attendees. Participating providers include Infectious Diseases, Family Medicine and Internal Medicine, amongst others. 259 cases have been reviewed, with a mean of 4.11 cases/session. Genotype 1a predominated and 44% of cases had advanced liver fibrosis. An increasing number of cases are young patients outside the high-prevalence birth cohort, and these individuals have a history of intravenous drug use. Overall, 13% of HCV cases were co-infected with HIV.

Conclusion

SCHTI provides multidisciplinary HCV teleconsultation to providers across the Southeast and is improving access to specialists and high-quality health care for patients across rural areas within the Southeast. Future outcomes to be assessed include sustained virologic response rates, relapse rates and impact on hepatic and extra hepatic morbidity and mortality from CHC.

Disclosures

All authors: No reported disclosures.

2489. Adverse Events with Biktarvy: Post-Marketing Study

Background

Bictegravir (BIC)/emtricitabine (FTC)/tenofovir alafenamide (TAF) was FDA approved in February 2018. There are no published post-marketing data evaluating safety and efficacy. After large uptake of BIC/FTC/TAF at our institution, reports of rash prompted a real-world review. The purpose of this study was to assess one year post-marketing safety and tolerability of BIC/FTC/TAF.

Methods

This retrospective, observational, pharmacoepidemiologic study was conducted one year post-approval of BIC/FTC/TAF, between February 2018 and March 2019 at the University of South Carolina Immunology Center. Adults receiving BIC/FTC/TAF were included. Drug discontinuation and treatment-related adverse effects were evaluated. Baseline demographics and serial laboratory data were collected.

Results

A total of 201 patients were assessed. Of those, the majority were treatment experienced (181, 90%), African American (137, 68%) males (132, 65%) with a mean age of 46 years (range 20–76 years). Four patients were transgender. 135 (67%) had a BMI of ≥ 25 kg/m2 and 77 (38%) had a BMI of ≥ 30 kg/m2. At baseline, 146 (72.6%) had virologic suppression (VS) (< 200 copies/mL) with a mean CD4 count of 529 cells/mm3 (range < 35–1573 cells/mm3). VS was maintained in 145/146 and subsequently reached in 47/55 (85.5%) at first follow-up. Of the 201, 18 (8.9%) patients reported adverse drug events (ADEs) for a total of 19 events (10 rash, 2 dizziness, 1 nausea/vomiting, 1 headache, 1 diarrhea, 1 loss of appetite, 1 weight gain, 1 fatigue, 1 insomnia). Eleven (5%) patients discontinued therapy; nine (4%) due to ADEs (7 rash, 1 insomnia and loss of appetite, and 1 feeling unwell). One patient with high AST/ALT at baseline increased from 129/243 U/L to 234/394 U/L, respectively. No other laboratory abnormalities were reported.

Conclusion

In a southern, predominantly African American overweight population, our results demonstrate low discontinuation rates associated with BIC/FTC/TAF, with rash being the predominate cause. Overall, 4% discontinued BIC/FTC/TAF due to ADEs compared with 1% as reported in the package insert. VS rates were high throughout the evaluation period. Ongoing post-marketing evaluation is important for early recognition of unexpected adverse outcomes.

Disclosures

All authors: No reported disclosures.

1251. Determinants of Infection at a Nontransplanting Cardiothoracic LVAD Program

Background

Left ventricular assist devices (LVADs) are a treatment option for end-stage heart failure, traditionally used as a bridge to a transplant. However, LVADs as a destination therapy is an option for individuals with contraindications for transplant. Infections are a common and devastating complication with significant morbidity and mortality. The purpose of this study was to assess the impact of risk factors for LVAD-associated infections in a nontransplant LVAD center.

Methods

All patients with implanted LVADs from 2013–2018 at Prisma Health were screened for inclusion. LVAD-associated infection was defined using INTERMACS criteria. Patient characteristics and device characteristics were evaluated for infection risk. Time to infection and associated mortality were also analyzed.

Results

Fifty-four of 138 (39.1%) patients developed an LVAD infection (driveline infection, or bacteremia). Mean time to infection among those who experienced infections was 7.78 months, with a standard deviation of 9.58 months. Table 1 summarizes baseline patient characteristics. HeartWare devices, compared with HeartMate II, were at an increased risk of infections and had a shorter time to infection (Figure 1) (HeartWare vs. HeartMate II, HR 2.12, P = 0.01). Those with a BMI of ≥35 kg/m² were found on average to have a number of infections 0.729 greater than those with a BMI < 35 kg/m² (P = 0.01). Prealbumin, A1C, and chronic kidney disease (any stage) were not found to be associated with infection. Staphylococcus aureus (21, 18.26%), Pseudomonas aeruginosa (24, 20.87%), and Staphylococcus epidermidis (22, 19.13%) were the most common organisms identified.

Conclusion

In an LVAD center where the majority of patients received LVAD as destination therapy, infection rates were similar as those receiving LVAD as a bridge to transplant. Modifiable risk factors for infection are areas for future interventions and prevention efforts.

Disclosures

All authors: No reported disclosures.

1950. Intentional Interprofessional Experiential Education in an HIV/Infectious Diseases Clinic

Background

Experiential education opportunities, such as interprofessional practice, are currently limited in HIV care. This intentional interprofessional experiential education (IPEE) offering aimed to improve healthcare student attitudes, perceptions, and skills regarding interprofessional practice and HIV care.

Methods

An interprofessional team of faculty and clinicians designed a 2-week rotation, with each offering consisting of 6–9 students from 4 professions (medicine, nursing, pharmacy, social work). This intentional IPEE was delivered at a single ambulatory care infectious diseases clinic in Columbia, SC. It included time in clinic with providers from varying professions, didactic lectures, a peer health advocate session, and a team capstone project (i.e., simulated, then actual student team visit with an HIV-infected patient, plus note documentation/team presentation). Twelve offerings occurred from October 2016 to February 2019. Anonymous pre- and post-IPEE surveys were provided to each student at baseline and directly after to assess attitudes, perceptions, and skills regarding interprofessional practice and HIV care. Wilcoxon signed-rank tests were used to compare pre- vs. post-survey items. Multivariable logistic regression was used to evaluate predictors for interest in HIV as a specialty.

Results

Of 87 students, 84 (97%) completed both surveys (21 medicine, 25 nursing, 19 pharmacy, 19 social work). Attitudes toward healthcare teams significantly improved in 7/11 items (all P-values ≤ 0.019), teamwork perceptions improved in 5/8 items (P ≤ 0.017), and self-perceived team skills improved in all 6 items (P < 0.001). Students rated provider time in clinic as most valuable (mean 4.6, median 5 on 5-point Likert scale). Following the IPEE, the proportion of students interested in HIV care increased from 53% to 67% (P = 0.07). After adjusting for program year and profession, interest in HIV at baseline was a significant predictor of interest in HIV post-IPEE (aOR 8.2, 95% CI 2.6–25.5).

Conclusion

Short-term, intentional IPEE can positively impact student attitudes, perceptions, and skills regarding interprofessional practice and HIV care. Clinical educators should incorporate intentional HIV IPEE in healthcare curricula.

Disclosures

All Authors: No reported Disclosures.

2493. Real-World Utilization of Ibalizumab (IBA) Without an Optimized Background Regimen (OBT)

Background

It is difficult to treat multidrug-resistant (MDR) human immunodeficiency virus (HIV). Trogarzo® (ibalizumab) a novel monoclonal antibody was approved in 2018 for heavily treatment-experienced HIV patients. Data support IBA use with at least one fully active agent, an OBR. Real-world IBA data are lacking. We report a successful case of reaching and maintaining suppression with IBA in a patient without an OBR.

Methods

Mutations were reviewed for the patient, Table 1, and evaluated for treatment. The patient is a 52- year old male, diagnosed in 1994, with MDR HIV secondary to non-adherence. Upon re-presenting to care, the patient was non-compliant with ART. Genotypic interpretation via the Stanford/ANRS algorithm was performed and interpreted, resulting in the addition of IBA intravenous administration every other week. IBA was obtained through patient assistance and costs were covered by the institution for infusion.

Results

Evaluation of the resistance profile indicated varying resistance to all available ART. More specifically, high-level resistance to all FDA-approved INSTIs, PIs, and low to high-level resistance to all NNRTIs and NRTIs. Table 2 outlines the ART history and viral load (VL) trends. The patient was initiated on daruanvir/ritonavir twice daily, etravirine twice daily, emtricitabine/tenofovir alafenamide and did not reach suppression. IBA was added off-label to a failing regimen. The patient reached VS (VL < 200 copies/mL) at Week 4 and has had an undetectable VL for 8 weeks. Notably his CD4 count has risen to 46, first detectable number since re-presenting to care.

Conclusion

We describe a heavily treatment experienced patient with an MDR HIV virus who achieved an undetectable VL without an OBT and the addition of intravenous IBA. Fostemsavir, was utilized in IBA’s phase III trial for similar patients, however, it is not currently FDA-approved nor available. Further data are needed to ensure continued susceptibility to IBA without an OBT. This patient required high-level coordination to reach each visit and receive this therapy alongside his oral agents. We conclude, IBA has allowed this patient to reach and maintain VS.

Disclosures

All authors: No reported disclosures.

Microbiologic Predictors of Pelvic Osteomyelitis Related to Decubitus Ulcers

Background

Management of pelvic osteomyelitis related to decubitus ulcers (PODU) remains challenging, whereas definitive therapy is based on blood, bone, or deep tissue cultures, empirical therapy prior to culture results may be indicated in patients with sepsis or cellulitis surrounding PODU. The objective of this retrospective case series is to develop an institutional protocol for empirical therapy of PODU when indicated based on local microbiology results.

Methods

Hospitalized adults with PODU from 1 August 2005 to 1 August 2015 at Palmetto Health hospitals in Columbia, SC were identified. PODU was defined based on clinical, radiographic, and microbiology criteria. Descriptive statistical methods (Fisher’s exact) were used for preliminary analysis.

Results

Seventy-five cases with PODU were included with a mean age of 53 years and male predominance (48; 64%). The most common comorbidities were paraplegia (45, 60%), diabetes (23, 31%) and previous strokes (17, 23%). Forty-nine cases (65%) received antibiotics within a year of PODU. Prior infections or colonization with P. aeruginosa within the past year was present in 24/75 (32%) cases. Most cases had multiple sources of cultures: blood (61; 81%), bone/deep tissue (37; 49%), and/or superficial (73; 97%). Among a total of 99 clinical isolates, 56 (57%) were Gram-positive cocci (GPC) and 43 (43%) were Gram-negative bacilli (GNB). The most common organisms were Enterobacteriaceae (26; 26%), coagulase negative staphylococci (CONS) (20, 20%), Stapylococcus aureus (19, 19%), [12 (12%) methicillin-resistant S. aureus], and P. aeruginosa (9, 9%). Of the Enterobacteriaceae, 69% (18/26) were susceptible to ciprofloxacin and 88% (23/26) to ceftriaxone. All cases (9/9) of PODU due to P. aeruginosa had a prior infection/colonization with P. aeruginosa within 1 year as compared with 15/66 (23%) in those with PODU due to other organisms (P = 0.001).

Conclusion

The microbiology of PODU is diverse (including GPC and GNB). Prior positive P. aeruginosa culture was a predictor of P. aeruginosa PODU. When empirical antimicrobial therapy is indicated, data support the use of intravenous vancomycin plus ceftriaxone in the absence of prior infection/colonization with P. aeruginosa, or intravenous vancomycin plus an anti-pseudomonal agent in the presence of prior P. aeruginosa within the past year.

Disclosures

All authors: No reported disclosures.

Help-seeking for intimate partner violence and forced sex in South Carolina

PURPOSE

In this population-based, random-digit-dial, cross-sectional survey, we assessed the lifetime victimization of intimate partner violence (IPV) and forced or coerced sex among 556 women and men in South Carolina, and the help-seeking behaviors of victims.

RESULTS

Among women, 25.3% experienced IPV (sexual, physical, or emotional violence) compared with 13.2% of men. Although women were significantly more likely to report physical or sexual IPV (17.8%) than were men (4.9%), men (8.3%) were as likely as women (7.4%) to report perceived emotional abuse without physical or sexual IPV. One half of men and women with annual incomes <$15, 000 reported IPV. Among women experiencing physical or sexual IPV, 53% sought community-based or professional services for IPV; women with higher education levels and those experiencing more severe violence were most likely to seek services.

CONCLUSIONS

These data show that IPV is common and that most victims do not receive services to address this violence.

Heat shock protein synthesis and thermotolerance in Salmonella typhimurium

The resistance of stationary phase Salmonella typhimurium to heating at 55 degrees C was greater in cells grown in nutritionally rich than in minimal media, but in all media tested resistance was enhanced by exposing cells to a primary heat shock at 48 degrees C. Chloramphenicol reduced the acquisition of thermotolerance in all media but did not completely prevent it in any. The onset of thermotolerance was accompanied by increased synthesis of major heat shock proteins of molecular weight about 83, 72, 64 and 25 kDa. When cells were shifted from 48 degrees C to 37 degrees C, however, thermotolerance was rapidly lost with no corresponding decrease in the levels of these proteins. There is thus no direct relationship between thermotolerance and the cellular content of the major heat shock proteins. One minor protein of molecular weight about 34 kDa disappeared rapidly following a temperature down-shift. Its presence in the cell was thus correlated with the thermotolerant state.