Fatal Primary Amebic Meningoencephalitis in Nebraska: Case Report and Environmental Investigation, August 2022

Primary amebic meningoencephalitis (PAM) is a rare and lethal infection caused by Naegleria fowleri. We report an epidemiological and environmental investigation relating to a case of PAM in a previously healthy boy age 8 years. An interview of the patient's family was conducted to determine the likely exposure site and to assess risk factors. Data from the United States Geological Survey site at Waterloo, NE, on the Elkhorn River were used to estimate water temperature and streamflow at the time and site of exposure. Data from the National Weather Service were used to estimate precipitation and ambient air temperature at the time and site of exposure. Despite conventional treatment, the patient died 2 days after hospital admission. The patient participated in recreational water activities in the Elkhorn River in northeastern Nebraska 5 days before symptom onset. In the week before exposure, water and ambient air high temperatures reached annual highs, averaging 32.4°C and 35.8°C, respectively. The day before infection, 2.2 cm of precipitation was reported. Streamflow was low (407 ft3/s). Infections in several northern states, including Nebraska, suggest an expanding geographic range of N. fowleri transmission, which may lead to increased incidence of PAM in the United States. Similar environmental investigations at suspected exposure sites of future cases will allow data aggregation, enabling investigators to correlate environmental factors with infection risk accurately.

Guidelines for Diagnosis and Management of Infective Endocarditis in Adults: A WikiGuidelines Group Consensus Statement

Importance

Practice guidelines often provide recommendations in which the strength of the recommendation is dissociated from the quality of the evidence.

Objective

To create a clinical guideline for the diagnosis and management of adult bacterial infective endocarditis (IE) that addresses the gap between the evidence and recommendation strength.

Evidence Review

This consensus statement and systematic review applied an approach previously established by the WikiGuidelines Group to construct collaborative clinical guidelines. In April 2022 a call to new and existing members was released electronically (social media and email) for the next WikiGuidelines topic, and subsequently, topics and questions related to the diagnosis and management of adult bacterial IE were crowdsourced and prioritized by vote. For each topic, PubMed literature searches were conducted including all years and languages. Evidence was reported according to the WikiGuidelines charter: clear recommendations were established only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were crafted discussing the risks and benefits of different approaches.

Findings

A total of 51 members from 10 countries reviewed 587 articles and submitted information relevant to 4 sections: establishing the diagnosis of IE (9 questions); multidisciplinary IE teams (1 question); prophylaxis (2 questions); and treatment (5 questions). Of 17 unique questions, a clear recommendation could only be provided for 1 question: 3 randomized clinical trials have established that oral transitional therapy is at least as effective as intravenous (IV)-only therapy for the treatment of IE. Clinical reviews were generated for the remaining questions.

Conclusions and Relevance

In this consensus statement that applied the WikiGuideline method for clinical guideline development, oral transitional therapy was at least as effective as IV-only therapy for the treatment of IE. Several randomized clinical trials are underway to inform other areas of practice, and further research is needed.

Adoption and Utilization of Social Media Among Adult and Pediatric Infectious Diseases Divisions and Fellowship Programs in the United States

Background

Social media (SoMe) is ubiquitous, but its adoption and utilization by infectious diseases (ID) divisions are poorly characterized in the United States.

Methods

A systematic search of US ID fellowship/division Twitter, Facebook, and Instagram accounts occurred in November-December 2021. Social media account and program characteristics, post frequency and content, and other measures of SoMe adoption and utilization were recorded and compared between adult and pediatric programs. Posts were thematically categorized as social, promotional, educational, recruitment, or other.

Results

Of 222 ID programs identified, 158 (71.2%) were adult and 64 (28.8%) pediatric. Seventy (31.5%) Twitter, 14 (6.3%) Facebook, and 14 (6.3%) Instagram accounts were identified from US programs. Twitter accounts were associated with larger programs and higher match rates. More adult than pediatric programs had Twitter accounts (37.3% vs 17.2%, P = .004); utilization was similar between adult and pediatric programs. Most Twitter posts were educational (1653 of 2859, 57.8%); most Facebook posts were promotional (68 of 128, 53.1%); and most Instagram posts were social (34 of 79, 43%). Facebook was the earliest adopted SoMe platform, but Twitter and Instagram have more recent growth. Rate of Twitter account creation increased from 1.33 accounts/month in the year before March 2020 (coronavirus disease [COVID] pandemic declaration) to 2.58 accounts/month in the year after March 2020 (P = .18).

Conclusions

Social media remains underutilized across ID divisions, but COVID-19 and virtual recruiting may have influenced recent account creation. Twitter was the most frequently used ID program SoMe platform. Social media may benefit ID programs in recruitment and amplification of their trainees, faculty, and specialty.

2362. Adoption and Utilization of Social Media among Adult and Pediatric Infectious Diseases Divisions and Fellowship Programs in the United States and Canada

Background

Social media (SoMe) is used by 72% of US adults. The utility of SoMe for infectious diseases (ID) has been highlighted by the COVID-19 pandemic. Adoption and utilization of SoMe by ID divisions is not well characterized.

Methods

We conducted a systematic search strategy for US and Canadian ID fellowship/division SoMe accounts – specifically Twitter, Facebook (FB), and Instagram (IG) – in November-December 2021. We collected data from program websites, SoMe accounts, and NRMP and FREIDA databases. Primary outcome was ID SoMe account prevalence. Secondary outcomes included measures of SoMe characteristics, adoption, and activity comparing adult and pediatric programs. We reported descriptive statistics.

Results

Of 243 ID programs in the US and Canada, 170 (70%) are adult and 73 (30%) are pediatric with 222 (91.4%) programs in the US. Twitter, FB, and IG accounts were found for 70 (31.5%), 14 (6.3%) and 14 (6.3%) US programs, respectively (Table 1); 2/21 (9.5%) Canadian programs had a SoMe account (Twitter). Twitter accounts were associated with larger programs and higher match rates (Table 2). SoMe activity and engagement before and during IDWeek 2021 is in Table 3. More adult programs had Twitter accounts (37.3% vs 17.2%, p=0.004), but utilization was similar between adult and pediatric programs. Most Twitter posts were educational (1653/2859, 57.8%); FB primarily promotional (68/128, 53.1%); IG mostly social (34/79, 43%). COVID-19 related posts were found in 821/2859 (28.7%) Twitter posts, 33/128 (25.8%) FB posts, and 5/79 (6.3%) Instagram posts. FB was the earliest adopted SoMe platform for ID, but Twitter and IG have more recent growth. The rate of Twitter account creation increased from 0.35 accounts/month prior to March 2020 (COVID pandemic declaration) to 1.95 accounts/month after March 2020. 71.4% (10/14) of IG accounts were created after March 2020.

Conclusion

SoMe remains underutilized across all ID divisions, but COVID-19 and virtual recruiting may have influenced recent account creation (Figure 1). Twitter is the most frequently used ID program SoMe platform in comparison to FB and IG, and use increased during IDWeek. ID divisions should embrace the digital and SoMe space with benefits for recruitment and amplification of their trainees, faculty, and specialty.

Disclosures

Jasmine R. Marcelin, MD, Pfizer/Mayo Clinic Global Bridges: Honoraria.

Beta-lactam allergies, surgical site infections, and prophylaxis in solid organ transplant recipients at a single center: A retrospective cohort study

BACKGROUND

Beta-lactam allergies (BLAs) are common in hospitalized patients, including transplant recipients. BLA is associated with decreased use of preferred surgical site infection (SSI) prophylaxis and increased SSIs, but this has not been studied in the transplant population.

METHODS

We reviewed adult heart, kidney, and liver transplant recipients between January 1, 2016 and December 31, 2019 to characterize reported BLA and collect SSI prophylaxis regimens at time of transplant. We compared the use of preferred SSI prophylaxis and SSI incidence based on reported BLA status. Post hoc we collected antibiotic days of therapy (DOT) (excluding pneumocystis prophylaxis) in the 30-day period posttransplant for patients without SSI. We utilized descriptive statistics for comparisons.

RESULTS

Of 691 patients included (116 heart, 400 kidney, and 175 liver transplant recipients), 118 (17%) reported BLA. Rash and hives were the two most reported BLA reactions (36% and 24%), categorized as potential T-cell mediated and IgE mediated, respectively. Preferred SSI prophylaxis was prescribed in 13 (11%) patients with BLA and 573 (92%) without BLA (p < .001). No difference could be detected in SSI incidence between BLA and non-BLA patients (4.2 vs. 4.3%, p = 1.0). Of 659 without SSI, 169 (25.6%) received antibiotics within 30 days of transplant; mean antibiotic DOT for BLA and non-BLA patients were 3.5 ± 8.0 versus 2.3 ± 5.8, p = .12.

CONCLUSION

BLA transplant recipients received nonpreferred SSI prophylaxis more frequently than non-BLA recipients, but there was no difference in 30-day SSIs between the groups. One-fourth of solid organ transplant recipients received systemic antibiotics within 30 days of transplant.

884. Evaluation of Surgical Site Infections in Solid Organ Transplant Recipients with Beta-Lactam Allergies

Background

Beta-lactam allergies (BLA) are common, but the prevalence and impact on solid organ transplant (SOT) recipients is largely unknown. We assessed the prevalence of BLA labels in SOT recipients at the time of transplant and evaluated their influence on surgical site infection (SSI) prophylaxis and SSI incidence.

Methods

All patients undergoing first heart, kidney, liver SOT at our institution were retrospectively reviewed (1/1/2015-12/31/2019). Antibiotic allergies, surgical antibiotic prophylaxis, and SSIs were abstracted from the electronic medical record. Reported BLA reactions were classified as potentially IgE-mediated, delayed, or non-allergic based on documentation. SSIs were reported according to NHSN definitions, and the incidence of SSI was compared between patients with and without reported BLA. SSI prophylaxis regimens were compared to institutional guidelines. Basic descriptive statistics were performed.

Results

Out of a total cohort of 751 patients (122 heart, 435 kidney, 209 liver, 4 multi-organ), 129 (17%) reported at least one BLA, with 104 (15%) with reactions to penicillins, 26 (3%) to cephalosporins, and 1 (0.1%) to carbapenems. Commonly reported reactions were rash (38%), hives (25%), and “other” (21%); 28% of documented reactions were not documented or classified as non-allergic. SSI developed in 7 (6.1%) of heart, 10 (2.5%) of kidney, and 16 (9.4%) of liver transplant recipients. Excluding 44 patients already on antibiotics for treatment of systemic infection, guideline concordant beta-lactam antibiotic surgical prophylaxis was administered to 6 (5.2%) of BLA group vs 490 (85.8%) in the non-BLA group (p< 0.01); among the BLA group who did not receive a beta-lactam, 96 (83%) received a regimen concordant with institutional guidelines for penicillin allergy and 14 (12%) received guideline non-adherent regimens. Patients reporting BLA did not have a higher incidence of SSIs compared to those without BLA: 6 (4.8%) vs 27 (4.5%) respectively, p=0.86.

Conclusion

BLA prevalence in our SOT population was similar to previously reported rates, but many reported reactions were not allergic in nature. Pre-transplant allergy evaluation for patients with reported BLA may improve SSI antibiotic prophylaxis compliance.

Disclosures

All Authors: No reported disclosures

Outcome of children with rhinovirus detection prior to allogeneic hematopoietic cell transplant

Rhinoviruses are commonly detected in symptomatic and asymptomatic children prior to HCT. Unlike pre-HCT detection of other respiratory viruses, it is not known whether RV detection, with or without clinical symptoms, is associated with worse outcomes in children post-HCT. In a retrospective study of children undergoing allogeneic HCT from January 2009 to February 2015, 91 children underwent allogeneic HCT, and 62 children had RPP testing within 30 days pre-HCT. Fifty-six (90%) children had either no pathogen (n = 34, 55%) or single RV detection (n = 22, 35%), which was the most common pathogen identified. Compared with virus negative children, children with pre-HCT RV detection were not more likely to require ventilated support and did not have longer length of stay, higher mortality, or less days alive and out of the hospital within the first 100 days post-HCT. In a secondary analysis of all 56 patients with RPP testing and no pathogen or RV alone detected, the seven children with LRTI had less days alive and out of the hospital within the first 100 days post-HCT compared with the 49 children who were either asymptomatic or had URTI (10 vs 60 days, P = 0.002). In a bootstrapped regression model, presence of LRTI, not RV detection, was significantly associated with decreased days alive and out of the hospital within the first 100 days post-HCT. Thus, pre-HCT detection of RV, without associated LRTI, does not always warrant HCT delay.

Systematic Epidemiological Investigations of Cases of Senecavirus A in US Swine Breeding Herds

Epidemiological investigations were conducted on a case series of six Senecavirus A (SVA)-affected breeding herds in the United States to determine potential routes of introduction and enhance the swine industry's knowledge of SVA's clinical presentation and spread. Each SVA-affected herd was evaluated using a standard form to ensure that all relevant data were collected. The form was used to guide a detailed discussion about the clinical presentation of SVA and risk events that occurred in the 4 weeks prior to the first observation of clinical signs with the herd veterinarian and farm personnel. Each event was then subjectively assigned a risk level of low, medium or high likelihood for SVA introduction by the investigation team. The clinical presentation of SVA varied by case. All SVA-affected herds (six of six) reported increases in pre-weaning mortality and sow anorexia. Vesicular lesions were observed in four of six herds, and mild-to-moderate neonatal diarrhoea was observed in three of six herds. No gross anatomic or histologic lesions were observed in neonatal pigs that tested positive for SVA via PCR. Multiple potential routes of introduction were identified. Events subjectively rated as high risk for SVA introduction were on-farm employee entry (six of six), carcass disposal (four of six), cull sow removal (three of six) and breeding replacement entry (two of six). Non-swine domestic animals, rodents, other visitors, repairs outside swine barns, feed delivery, weaned pig removal and semen entry were assigned a high risk level in one of six herds. Cases occurred in breeding herds of all sizes with variable biosecurity in both swine dense and swine sparse areas.