Real-world Experience of Posaconazole Therapeutic Drug Monitoring in Oncology Patients: Clinical Implications of Hypoalbuminemia as a Predictor of Subtherapeutic Posaconazole Levels

Background

Posaconazole maintains broad antifungal activity and is employed for prevention and treatment of invasive fungal infections in oncology patients. Older formulations required therapeutic drug monitoring, and specific plasma drug levels have been recommended. This study evaluated factors associated with subtherapeutic concentrations with the newer delayed-release tablet formulation.

Methods

In this retrospective, single-center cohort study at a national comprehensive cancer center, all oncology patients receiving delayed-release posaconazole at standard dosing of 300 mg orally per day from 06/2021 to 07/2023 with plasma drug concentration evaluation were identified. Demographic, clinical, and laboratory data were evaluated to identify risk factors associated with subtherapeutic drug levels at targets of ≥1.25 µg/mL and ≥1.8 µg/mL.

Results

Of 110 patients identified, 98 met criteria for inclusion in the study. The median time from initiation of posaconazole to drug level assessment was 13 days, and the median concentration was 1.29 µg/mL. Of the 22 patients receiving posaconazole for prophylaxis, 5 (22.7%) failed to achieve concentrations ≥0.7 µg/mL, and of 76 patients receiving posaconazole for treatment, 38 (50%) failed to achieve concentrations of ≥1.25 µg/mL. In multivariable analysis, albumin of ≤3 g/dL and ideal body weight ≥60 kg were found to be associated with subtherapeutic levels. For a higher target of ≥1.8 µg/mL, only albumin ≤3 g/dL was associated with subtherapeutic levels for the variables evaluated.

Conclusions

A higher initial dosing strategy and therapeutic drug monitoring for oncology patients with albumin ≤3 g/dL receiving posaconazole, particularly for the treatment of invasive fungal infection, could be considered.

Chemotherapy Extravasation Causing Soft-Tissue Necrosis Mimicking Infection: A Longitudinal Case Study

Extravasation injuries are uncommon, underreported, and often misdiagnosed in patients. The signs and symptoms of extravasation injuries vary from simple pain and tenderness to tissue necrosis and potentially fatal secondary infections. Extravasation may progress to more severe conditions such as necrotizing fasciitis (NF) or cellulitis, so special care is needed by physicians to identify and treat these injuries correctly. Here, we explore a case study on extravasation injuries mimicking NF leading to infectious complications and discuss the proper diagnosis and treatment of extravasation injuries as well as other NF-mimicking diseases. We present a case of a 44-year-old Hispanic male with a history of B-cell acute lymphoblastic leukemia who underwent inpatient chemotherapy treatment via a chest port.

Clinical outcomes in hospitalized plasma and platelet transfusion recipients prior to and following widespread blood donor SARS-CoV-2 infection and vaccination

BACKGROUND

The safety of transfusion of SARS-CoV-2 antibodies in high plasma volume blood components to recipients without COVID-19 is not established. We assessed whether transfusion of plasma or platelet products during periods of increasing prevalence of blood donor SARS-CoV-2 infection and vaccination was associated with changes in outcomes in hospitalized patients without COVID-19.

METHODS

We conducted a retrospective cohort study of hospitalized adults who received plasma or platelet transfusions at 21 hospitals during pre-COVID-19 (3/1/2018-2/29/2020), COVID-19 pre-vaccine (3/1/2020-2/28/2021), and COVID-19 post-vaccine (3/1/2021-8/31/2022) study periods. We used multivariable logistic regression with generalized estimating equations to adjust for demographics and comorbidities to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Among 21,750 hospitalizations of 18,584 transfusion recipients without COVID-19, there were 697 post-transfusion thrombotic events, and oxygen requirements were increased in 1751 hospitalizations. Intensive care unit length of stay (n = 11,683) was 3 days (interquartile range 1-5), hospital mortality occurred in 3223 (14.8%), and 30-day rehospitalization in 4144 (23.7%). Comparing the pre-COVID, pre-vaccine and post-vaccine study periods, there were no trends in thromboses (OR 0.9 [95% CI 0.8, 1.1]; p = .22) or oxygen requirements (OR 1.0 [95% CI 0.9, 1.1]; p = .41). In parallel, there were no trends across study periods for ICU length of stay (p = .83), adjusted hospital mortality (OR 1.0 [95% CI 0.9-1.0]; p = .36), or 30-day rehospitalization (p = .29).

DISCUSSION

Transfusion of plasma and platelet blood components collected during the pre-vaccine and post-vaccine periods of the COVID-19 pandemic was not associated with increased adverse outcomes in transfusion recipients without COVID-19.

Malignant pleural disease

Malignant pleural disease represents a growing healthcare burden. Malignant pleural effusion affects approximately 1 million people globally per year, causes disabling breathlessness and indicates a shortened life expectancy. Timely diagnosis is imperative to relieve symptoms and optimise quality of life, and should give consideration to individual patient factors. This review aims to provide an overview of epidemiology, pathogenesis and suggested diagnostic pathways in malignant pleural disease, to outline management options for malignant pleural effusion and malignant pleural mesothelioma, highlighting the need for a holistic approach, and to discuss potential challenges including non-expandable lung and septated effusions.

Sputter sample preparation for ion beam delivery of radium-223 at ATLAS

A radium-223 ion beam was delivered to an experiment from the electron cyclotron resonance ion source, ECR2, at the Argonne Tandem Linac Accelerator System (ATLAS). The radium-223 material was in a nitrate salt form within a vial, prior to being converted to a usable sputter sample. The sputter sample was produced using a new sample preparation method, where the radium nitrate was dissolved into a solution and pipetted onto pressed aluminum powder. This sample was then allowed to dry, distributing the radium-223 material throughout the sputter sample. Ion source operation using the radium sputter sample is described with the operating parameters listed. The intensity and energy requirements for this ion beam were 1 × 106 particles/s and 1.07 GeV, respectively. Because the intensity is relatively low compared to most experiments at ATLAS, previously developed accelerator mass spectrometry methods were used Scott et al. [Rev. Sci. Instrum. 87, 02A732 (2016)] to avoid the need for tuning of the low-intensity beam of interest. Handling of the radium material, as well as loading and unloading of the sputter sample from ECR2, required collaboration with Health Physics. Procedures were used and dry runs were carried out before, during, and after the experiment to ensure the safety of the workers. The processes used and lessons learned are described within.

Angular Correlations in the β Decay of ^{8}B: First Tensor-Current Limits from a Mirror-Nucleus Pair

We present the first measurement of the α-β-ν angular correlation in the Gamow-Teller β^{+} decay of ^{8}B. This was accomplished using the Beta-decay Paul Trap, expanding on our previous work on the β^{-} decay of ^{8}Li. The ^{8}B result is consistent with the V-A electroweak interaction of the standard model and, on its own, provides a limit on the exotic right-handed tensor current relative to the axial-vector current of |C_{T}/C_{A}|^{2}<0.013 at the 95.5% confidence level. This represents the first high-precision angular correlation measurements in mirror decays and was made possible through the use of an ion trap. By combining this ^{8}B result with our previous ^{8}Li results, we demonstrate a new pathway for increased precision in searches for exotic currents.

ExPeCT: a randomised trial examining the impact of exercise on quality of life in men with metastatic prostate cancer

PURPOSE

All patients living with cancer, including those with metastatic cancer, are encouraged to be physically active. This paper examines the secondary endpoints of an aerobic exercise intervention for men with metastatic prostate cancer.

METHODS

ExPeCT (Exercise, Prostate Cancer and Circulating Tumour Cells), was a multi-centre randomised control trial with a 6-month aerobic exercise intervention arm or a standard care control arm. Exercise adherence data was collected via heart rate monitors. Quality of life (FACT-P) and physical activity (self-administered questionnaire) assessments were completed at baseline, at 3 months and at 6 months.

RESULTS

A total of 61 patients were included (69.4 ± 7.3 yr, body mass index 29.2 ± 5.8 kg/m²). The median time since diagnosis was 34 months (IQR 7-54). A total of 35 (55%) of participants had > 1 region affected by metastatic disease. No adverse events were reported by participants. There was no effect of exercise on quality of life (Cohen's d =  - 0.082). Overall adherence to the supervised sessions was 83% (329 out of 396 possible sessions attended by participants). Overall adherence to the non-supervised home exercise sessions was 72% (months 1-3) and 67% (months 3-6). Modelling results for overall physical activity scores showed no significant main effect for the group (p-value = 0.25) or for time (p-value = 0.24).

CONCLUSION

In a group of patients with a high burden of metastatic prostate cancer, a 6-month aerobic exercise intervention did not lead to change in quality of life. Further exercise studies examining the role of exercise for people living with metastatic prostate cancer are needed.

TRIAL REGISTRATION

The trial was registered at clinicaltrials.gov (NCT02453139) on May 25th 2015.

Intestinal Coccidian Infections in Cancer Patients: A Case Series

Introduction Coccidian protozoa and microsporidian fungi are opportunistic pathogens increasingly implicated in infections in immunosuppressed individuals. These parasites typically infect the intestinal epithelium, resulting in secretory diarrhea and malabsorption. The disease burden and timeline are both greater and longer among immunosuppressed patients. Therapeutic options for immunocompromised individuals are limited. As a result, we wanted to better characterize the disease course and treatment efficacy of these parasitic gastrointestinal infections. Methods We performed a single-center, retrospective MedMined (BD Healthsight Analytics, Birmingham, AL, USA) chart review of patients between January 2012 and June 2022 diagnosed with coccidian or microsporidian infections. Relevant data were collected from Cerner's PowerChart (Oracle Cerner, Austin, TX, USA). Descriptive analysis was performed with IBM SPSS Statistics (IBM Corp., Armonk, NY, USA), and Microsoft Excel (Microsoft, Redmond, WA, USA) was used to generate graphs and tables. Results In these 10 years, there were 17 patients with Cryptosporidium infections, four with Cyclospora infections, and no positive cultures for Cystoisospora belli or microsporidian infections. In both infections, the majority of patients experienced diarrhea, fatigue, and nausea, with vomiting, abdominal pain, appetite loss, weight loss, and fever occurring to a lesser degree. Nitazoxanide was the most common treatment for Cryptosporidium, while trimethoprim-sulfamethoxazole or ciprofloxacin were the treatments of choice for Cyclospora. Of the Cryptosporidium infections, three received combination therapy with azithromycin, immunoreconstitution, or IV immunoglobulins. Among the four Cyclospora-infected patients, one received combination therapy of ciprofloxacin and trimethoprim-sulfamethoxazole. Treatment lasted around two weeks, and 88% of Cryptosporidium patients and 75% of Cyclospora patients had a resolution of symptoms. Conclusion The most detected coccidian infection was Cryptosporidium, followed by Cyclospora, with the lack of Cystoisospora or microsporidian infections likely due to diagnostic limitations and prevalence. Cryptosporidium and Cyclospora likely caused their associated symptoms in most cases, with other possible etiologies, including graft-versus-host disease, medications, and feeding tubes. The small number of patients receiving combination therapy prohibited a comparison with monotherapy. In our patient population, though, there was a clinical response to treatment despite immunosuppression. While promising, additional randomized control experiments are required to fully understand the efficacy of parasitic treatments.

Neurological update: structural and functional imaging in epilepsy surgery

Structural and functional imaging prior to surgery in drug-resistant focal epilepsy, has an important role to play alongside electroencephalography (EEG) techniques, in planning the surgical approach and predicting post-operative outcome. This paper reviews the role of structural and functional imaging of the brain, namely computed tomography (CT), magnetic resonance imaging (MRI), functional MRI (fMRI), single photon emission computed tomography (SPECT) and positron emission tomography (PET) imaging in the preoperative work-up of people with medically refractory epilepsy. In MRI-negative patients, the precise localisation of the epileptogenic zone may be established by demonstrating hypometabolism on PET imaging or hyperperfusion on SPECT imaging in the area surrounding the seizure focus. These imaging modalities are far less invasive than intracranial EEG, which is the gold standard but requires surgical placement of electrodes or recording grids. Even when intracranial EEG is needed, PET or SPECT imaging can assist in the planning of EEG electrode placement, due to its' limited spatial sampling. Multimodal imaging techniques now allow the multidisciplinary epilepsy surgery team to identify and better characterise focal pathology, determine its' relationship to eloquent areas of the brain and the degree of interconnectedness within both physiological and pathological networks, as well as improve planning and surgical outcomes for patients. This paper will update the reader on this whole field and provide them with a practical guide, to aid them in the selection of appropriate investigations, interpretation of the findings and facilitating patient discussions in individuals with drug-resistant focal epilepsy.

The prognostic value of the derived neutrophil-to-lymphocyte ratio (dNLR) in patients treated with immune checkpoint inhibitors

BACKGROUND

The (derived) neutrophil-to-lymphocyte ratio (dNLR) is a potential predictive biomarker in the era of checkpoint inhibitors (CPI). An elevated dNLR is associated with worse outcomes across several malignancies. However, there is no clearly defined cut-off in the clinical setting.

AIM

To compare outcomes in patients prescribed CPI with a baseline dNLR₀ > 3 and dNLR₀ ≤ 3. The dNLR₆ was measured 6 weeks later to determine its impact on patient overall survival (OS).

METHODS

Prospectively maintained pharmacy databases in a regional cancer centre were interrogated for patients who were prescribed CPI in the advanced setting between January 2017 and May 2020.

RESULTS

There were 121 patients with advanced cancer and a median age of 68 (range 30 to 88) years. Forty-four percent (n = 53) received prior systemic therapy. Patients with an initial dNLR₀ > 3 when compared with a dNLR₀ ≤ 3 had significantly shorter median progression-free survival (PFS), 3 vs. 14 months (p = 0.001) and median OS, 6.4 vs. 30.2 months (p = 0.001). Patients with an initial dNLR₀ > 3 and increased dNLR at 6 weeks (dNLR₆) had significantly reduced median PFS (3.5 vs. 14.7 months, p = 0.03) and OS (5.7 vs. 16.3, p = 0.03) when compared with those whose dNLR decreased. In the dNLR₀ ≤ 3 cohort, any increased dNLR when compared with decreased dNLR after 6 weeks of CPI had significantly reduced PFS (8.4 months vs. NR, p = 0.01) and OS (24.2 months vs. NR, p = 0.02).

CONCLUSIONS

Lower pre-CPI treatment dNLR is associated with improved OS. A decrease in dNLR during treatment confers improved OS.

Safety and Outcomes With Combination Therapy With Sarilumab and Baricitinib for Severe COVID-19 Respiratory Infection in Cancer Patients

OBJECTIVES

This study aims to describe the clinical outcomes of combination therapy with sarilumab and baricitinib for severe novel Coronavirus-19 (COVID-19) infection in cancer patients. With this study, we aim to evaluate the role of expanded immunotherapy for severely ill patients with COVID-19 respiratory infections with limited options. The secondary objective is to assess the safety of combination therapy with sarilumab and baricitinib for severe COVID-19 infection.

METHODS

This was a retrospective cohort study of patients admitted to Moffitt Cancer Center with COVID-19 infection between January 2020 and April 2022. Our research received a waiver to sign consent by the patients according to our institutional IRB because it was free of any risk for the patients and respected the patient's privacy. Following the Institutional IRB approval and relevant Equator guidelines, we collected information on patients with severe COVID-19 infection and received sarilumab and baricitinib. We evaluated the survival rate and safety of combination therapy. All the patient's information was de-identified to protect their information according to Health Insurance Portability and Accountability Act (HIPAA).

RESULTS

Four patients were included in the data analysis. Two survived, and two of them died (Table 1). All the patients that survived were previously vaccinated. Among the two patients who died, one was vaccinated, and the other was unvaccinated. All the patients tolerated the combination therapy well, and none of the patients who survived developed secondary infections or COVID-19-associated complications beyond 12 months of discharge.

CONCLUSION

Our study explores the potential safe combination use of different immune modulators targeting multiple pathways of the inflammatory cascade for severe and refractory COVID-19 respiratory infections in high-risk oncology patients. The small number of patients in our observational study was a limitation. A larger sample of patients will be needed to conclude more precisely the efficacy of the combination therapy of sarilumab and baricitinib for refractory cases of severe COVID-19 respiratory infection. Moreover, exploring other cytokine release signaling pathway targets may be the key to significantly reducing inflammation and further pulmonary fibrosis with chronic unbearable respiratory sequela.

Nocardia niwae Disseminated Nocardiosis: A Novel Species Presenting Concurrently With Lung Adenocarcinoma

Nocardia includes over 90 species of filamentous gram-positive bacilli that may cause disease in immunocompromised or immunocompetent hosts. Presentations may include pulmonary, 4, cutaneous, or disseminated infections. Tissue diagnosis may be required as it may mimic alternative etiologies. There is a paucity of data regarding rarer species of Nocardia. Intraspecies variability in antimicrobial susceptibility limits many treatment regimens to in-vitro activity data and treatment regimens often must be tailored to individual patients based on microbiologic cultures. We describe the case of a 63-year-old female who presented with disseminated Nocardia niwae, a species that was previously first identified in Florida for which little clinical data is known, along with concurrent lung adenocarcinoma with pulmonary and central nervous system lesions. Typical susceptibility patterns are discussed along with potential side effects of antimicrobial therapy.

Adults hospitalized with breakthrough COVID-19 have lower mortality than matched unvaccinated adults

BACKGROUND

Coronavirus disease 2019 (COVID-19) breakthrough infections are common.

OBJECTIVE

Evaluate in-hospital mortality of patients with COVID-19 by vaccination status using retrospective cohort study.

METHODS

We generated propensity scores for receipt of full vaccination in adults requiring supplemental oxygen hospitalized at Kaiser Permanente Northern California (1 April 2021 to 30 November 2021) with positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction tests. Optimal matching of fully vaccinated/unvaccinated patients was performed comparing in-hospital mortality.

RESULTS

Of 7305 patients, 1463 (20.0%) were full, 138 (1.9%) were partial, and 5704 (78.1%) were unvaccinated. Fully vaccinated were older than partial or unvaccinated (71.0, 63.0, and 54.0 years, respectively, p < 0.001) with more comorbidities (Comorbidity Point Scores 33.0, 22.0, and 10.0, p < 0.001) and immunosuppressant (11.5%, 8.7%, and 3.0%, p < 0.001) or chemotherapy exposure (2.8%, 0.7%, and 0.4%, p < 0.001). Fewer fully vaccinated patients died compared to matched unvaccinated (9.0% vs. 16.3%, p < 0.0001).

CONCLUSION

Fully vaccinated patients are less likely to die compared to matched unvaccinated patients.

Infectious Complications of DiGeorge Syndrome in the Setting of Malignancy

This report describes a case of a young man with DiGeorge Syndrome, repaired Tetralogy of Fallot, relapsed metastatic Hodgkin’s Lymphoma, immunodeficiency, and a history of recurrent and severe infections. A review of the literature indicates that patients with DiGeorge Syndrome are at greater risk for infection, malignancy, and cardiac events due to anatomic and immunologic complications resulting from a deletion in the 22q11.2 chromosome. As an increased number of patients with DiGeorge Syndrome are surviving into adulthood, it is important to understand the progression of the disease and the long-term implications associated with variable degrees of thymic hypoplasia and immune deficiency. 

Implementation of a 2-for-1 Price Incentive for Fruits and Vegetables in a Grocery Retail Setting

BACKGROUND AND PURPOSE

There is growing interest in expanding healthy eating interventions in the retail setting. The purpose of this study was to evaluate the implementation of a successful 2-for-1 price incentive for fruits and vegetables (F&V), including frozen and canned, that took place in partnership with a large chain grocery retailer in Maine. Intervention Approach. A randomized controlled trial (RCT) pilot study was conducted in 2015-2016, followed by a larger RCT in 2016-2017, to assess whether a supermarket double-dollar F&V incentive increased purchases of these items.

EVALUATION METHODS

A convergent, parallel mixed-methods design was used to examine barriers and facilitators to implementing the interventions, using six implementation outcomes: acceptability, adoption, appropriateness, feasibility, implementation fidelity, and perceived cost.

RESULTS

The intervention was deemed highly acceptable, appropriate, and feasible by shoppers, retailers, and researchers. The F&V discount had a high rate of initial adoption. There was a moderate degree of fidelity, which improved over time based on lessons learned from the pilot and applied to the subsequent RCT. Specific costs associated with implementation from the research perspective are reported. Implications for Practice, Policy, and Research. Partnerships between academic researchers and retailers can be an effective model for improving healthful purchases among shoppers. These findings are relevant for investigators, public health advocates, and retailers interested in implementing similar grocery retail-based interventions.

Rosacea Granulomatosis in a Neutropenic Leukemic Patient

Rosacea granulomatosis is a common, chronic skin disorder that primarily affects the central face, namely the cheek, nose, chin, and central forehead. Although rosacea is mainly a disorder of innate and adaptive immunity, a variety of endogenous and exogenous triggers such as Demodex may stimulate it. Often found as commensal organisms in human skin, Demodex ​​​​​​​can be parasitic if there is a change in the host’s cutaneous environment. This is especially relevant for immunosuppressed patients, who need prompt treatment to prevent further complications. We review the literature regarding rosacea granulomatosis in immunosuppression and present an acute myelogenous leukemia patient with severe neutropenia, which may have promoted the development of rosacea due to Demodex ​​​​​​​mite proliferation. This local proliferation of the ectoparasite on the face can cause an atypical skin rash that mimics severe infections in the setting of neutropenia.

Targeting OXPHOS and the electronic transport chain in cancer; molecular and therapeutic implications

Oxidative phosphorylation (OXPHOS) takes place in mitochondria and is the process whereby cells use carbon fuels and oxygen to generate ATP. Formerly OXPHOS was thought to be reduced in tumours and that glycolysis was the critical pathway for generation of ATP but it is now clear that OXPHOS, at least in many tumour types, plays a critical role in delivering the bioenergetic and macromolecular anabolic requirements of cancer cells. There is now great interest in targeting the OXPHOS and the electron transport chain for cancer therapy and in this review article we describe current therapeutic approaches and challenges.

First Case of Infective Endocarditis With Streptococcus equinus in an Immunocompetent Patient in North America: A Case Report and Review of Literature

Infective endocarditis (IE) can be caused by bacterial or fungal infections invading the endocardial surface of the heart, such as its valves and chambers. Staphylococcus and Streptococcus species are mainly responsible for IE. Streptococcus equinus (S. equinus) has been rarely noted to cause IE. We present a case of a 69-year-old white male with a past medical history of severe aortic regurgitation, who during an elective aortic heart valve replacement surgery was noted to have multiple plaque-like vegetations at the base of the mitral valve that were positive for S. equinus. To date, there are only four cases of S. equinus endocarditis reported worldwide, with a high possibility of our case being the first reported in North America.

755. Clostridioides difficile Testing and the Use of Laxatives in Immunocompromised Adults

Background

Clostridioides difficile infection (CDI) rates have plateaued at historical highs in the United States since 2010 and remains a major health problem. While optimal CDI testing remains unclear, current literature recommends testing patients whose symptoms are not clinically attributable to underlying conditions, e.g., laxatives. At Moffitt Cancer Center, a soft-stop alert was implemented to alert the provider if the patient received a laxative within the previous 48 hours of CDI testing. We aim to evaluate the incidence of CDI rates with prior laxative use in immunocompromised patients, as well as, the impact of the soft-stop alert in reducing CDI testing.

Methods

Retrospective, single-center, review of adult patients who were tested for CDI after the implementation of the soft-stop alert from October 1, 2020 to December 21, 2020. These patients were compared to a historical cohort of patients who were tested for CDI prior to the alert implementation from October 1, 2019 to December 31, 2019. The primary outcome was the percent of patients that received a laxative within 48 hours of CDI testing pre-alert compared to post-alert. Secondary outcomes included the percent of colonization versus active infection in this immunocompromised population, number and type of laxatives administered prior to testing, and the frequency of alert and reduction of CDI tests ordered. A cost-benefit analysis was also performed.

Results

In the historical cohort (n=480), 14.8% received a laxative within 48 hours of CDI testing (Figure 1). Within patients who received a laxative in this group, 4.2% had a definitive active infection. After the alert was implemented, a total of 630 CDI tests were ordered from October 1, 2020 to December 31, 2020, and the alert was fired for 123 (19.5%) tests ordered (Figure 2). Of the tests where the alert was fired, the CDI test was removed for 42.3% and continued for 57.7% of orders resulting in savings of &3,263. In this cohort, 5.6% of patients had a definitive active CDI infection who received a laxative and testing was continued (Figure 3).

Conclusion

The soft-stop alert implemented reduced CDI testing in patients who received a laxative in the last 48 hours correlating with a financial benefit, improvement in guideline adherence, and reduction in laboratory labor.

Disclosures

All Authors: No reported disclosures

1316. Uncommon Presentations of Common Variable Immunodeficiency

Background

Common Variable Immunodeficiency (CVID) is a primary immunodeficiency disorder which affects B lymphocyte function and differentiation causing decreased levels of Immunoglobulin G (IgG), Immunoglobulin A (IgA) and Immunoglobulin M (IgM).¹ The objective of this study is to highlight how hypogammaglobulinemia can lead to respiratory infections with microbes that are lesser known in the background of CVID with the help of a two-case series.

Methods

Medical records of two patients with CVID were reviewed who were found to have mycobacterium avium-complex intracellulare and streptococcus agalactiae lung infections respectively.

Results

Decreased IgG in CVID means reduced antibody production, low IgA leads to mucosal inflammation and increased susceptibility to respiratory infections² and lower IgM memory B-cells causes infections with encapsulated microorganisms.³ Table 1 highlights the various respiratory infections and their etiologies that have been reported with CVID, the most common being encapsulated organisms like Haemophilus influenza, Streptococcus pneumonia, Neisseria meningitidis along with enterovirus. Table 2 demonstrates our findings. In the first case we have reported a patient with mycobacterium avium-complex intracellulare (MAC-I). This could be because of hypogammaglobulinemia, decreased B and T-cell interaction and reduced T-cell signaling caused by CVID.⁴ Although, mycobacterium tuberculosis, simiae and hominis lung infections and mycobacterium bovis systemic infections have been reported before, MAC-I is relatively rare in CVID.⁵ In our second case, the patient developed streptococcus agalactiae or Group-B streptococcus (GBS) empyema. Most cases of GBS have been reported in pregnant women and infants. Infections with other encapsulated organisms have been reported in CVID but GBS empyema is less frequent and can happen due to decreased bacteria-specific CD4 cells, microbial translocation and hypogammaglobulinemia.^{6 .}

Table 1. Respiratory Infections reported in CVID along with their etiologies.

Figure 1. CT image of MAC-I infection.

Conclusion

We encountered two unique cases of CVID with rare infectious etiologies. The cases are intended to create an awareness and vigilance regarding CVID induced hypogammaglobulinemia which can cause respiratory infections with lesser known pathogens where antibodies may be important.

Disclosures

All Authors: No reported disclosures

A Case Series of Elizabethkingia meningosepticum Bacteremia in the Cancer Population

Elizabethkingia meningosepticum (E.meningosepticum) is a ubiquitous microorganism previously known as Chryseobacterium meningosepticum. It is emerging as a pathogen responsible for bacteremia in the immunocompromised population, particularly in cancer patients and those with a history of prolonged hospital stay and frequent instrumentations. A retrospective chart review of all cases over 10 years at the Moffitt Cancer Center showed a total of three patients with E.meningosepticum infection. The first patient (history of multiple myeloma) underwent endoscopy complicated by aspiration pneumonia and positive blood culture for E.meningosepticum infection. The second patient (current acute myelogenous leukemia) had neutropenic fever in the setting of a recent chest port infection. Blood culture from the chest port showed E. meningosepticum. The third patient (history of esophageal adenocarcinoma and acute myelogenous leukemia) had a history of recent pneumonia and cellulitis who presented with recurrent neutropenic fever. Blood culture was positive for E. meningosepticum. E.meningosepticum bacteremia has a high 28-day mortality rate (41%). As these three cases illustrate, early identification of the pathogen along with empiric treatment with a fluoroquinolone and/or minocycline is indicated to reduce morbidity and mortality.

Radium-223 in combination with enzalutamide in metastatic castration-resistant prostate cancer: a multi-centre, phase II open-label study

Background:

Radium-223 and enzalutamide are approved agents for patients with metastatic castration-resistant prostate cancer (mCRPC). Combining radium-223 and enzalutamide to improve outcomes is of clinical interest due to their differing modes of action and non-overlapping toxicity profiles.

Methods:

This phase II study enrolled patients with mCRPC and bone metastases. Patients received six cycles of radium-223 in combination with enzalutamide, followed by enzalutamide alone. The primary endpoint was safety for the combination; secondary endpoints included radiographic/clinical progression-free survival (PFS), PSA PFS, overall survival (OS), change in alkaline phosphatase, patient-reported pain outcomes and skeletal related events.

Results:

Forty-five patients received the combination treatment: 42 patients (93.3%) received all six cycles. Fourteen patients (31.1%) developed grade 3 or 4 toxicities, most commonly fatigue and neutropaenia. Fractures during the combination period occurred in four patients (8.9%). A further 13 patients (28.9%) developed fractures after completing combination treatment, giving a total of 17 patients (37.8%) who developed a fracture at any time on study. The median time to fracture was greater than 17.2 months [95% confidence interval (CI), 17.2–not estimable]. The median time to PSA progression was 18.1 months (95% CI, 12.68–22.60) and the median time to radiological/clinical progression was 28.0 months (95% CI, 22.54–not reached). At the primary analysis, 19 (42.2%) out of 45 patients had died with a median OS not reached (mean 34.8 months, standard error 1.4).

Conclusion:

In men with progressive mCRPC and bone metastases, the combination of radium-223 and enzalutamide was tolerable with the majority of patients completing the combination treatment. Bone fractures during the combination period were uncommon; however, we did identify a higher incidence of fractures occurring in patients after completing combination treatment. Bone health agents should be administered and bone health should be closely monitored following treatment with radium-223 and enzalutamide.

Moraxella Bacteremia in Cancer Patients

Moraxella is a gram-negative bacterium part of the Moraxellaceae family. It is a pathogen that is commonly found in the upper respiratory tract of humans. It is a rare cause of community-acquired pneumonia and can be found in immunocompromised individuals, especially those with impaired humoral immunity such as hypogammaglobulinemia and those with lung diseases.

We present three cases of Moraxella infections at the Moffitt Cancer Center between the years 2011 and 2017. We performed a literature review of Moraxella bacteremia in cancer patients and included three patients, two with a history of multiple myeloma and one undergoing radiation therapy for non-small cell lung carcinoma. None of the patients died as a result of the infection. Moraxella infections can result in a range of severity with increasing resistance to antibiotic therapy.

COVID-19 Virus Infection in Three Patients With Hypogammaglobulinemia

The world is experiencing the COVID-19 outbreak and there are no evidence-based treatment strategies available for immunocompromised patients. COVID-19 is a novel beta coronavirus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients with cancer are more susceptible to infection than individuals without cancer due to their impaired humoral and cellular immune function caused by the malignancy itself and chemotherapy. We present three cases of cancer patients with hypogammaglobulinemia with varying clinical outcomes associated with infection. These include one mantle cell lymphoma patient with recurrent respiratory infection requiring intravenous immunoglobulin (IVIG) support and two multiple myeloma patients with continued viral shedding.

Necrotizing Cellulitis and Myositis in a Neutropenic Leukemic Patient

In this article, we review a case of necrotizing cellulitis and myositis in a neutropenic leukemic patient. He underwent a series of investigations to reach the diagnosis of pyoderma gangrenosum (PG). The lesion improved dramatically after pertinent identification and initiation of appropriate treatment. The management of PG is exceedingly challenging due to a lack of proper clinical criteria for detection and guidelines for treatment. PG must be considered as a differential in patients with enlarging, sterile, necrotic lesions, unresponsive to prolonged broad-spectrum antibiotics. Prompt recognition can prevent deeper infections and the formation of a chronic open wound causing cosmetic disfigurement along with other catastrophic complications.

COVID-19 pandemic causing medical and public health ethical dilemmas: A case report and review of literature

The COVID-19 pandemic presented myriad of unprecedented and daunting ethical dilemmas to healthcare workers, patients, their families, and the public health. Here we present a case of a 42-years-old Hispanic female with underlying hematological malignancy that developed severe SARS-COV-2 infection amidst the pandemic. This case illustrates some remarkable ethical dilemmas during pandemic times, including the lack of advanced directive planning, the repercussions of restricting family visits, and what ethics in crisis and moral injury entails. Identifying the ethical challenges emerging from the pandemic will assist physicians and other providers in making proper decisions and maintaining the best standard of care.

Differential CircRNA Expression Signatures May Serve as Potential Novel Biomarkers in Prostate Cancer

Circular RNAs (circRNAs), a recently discovered non-coding RNA, have a number of functions including the regulation of miRNA expression. They have been detected in a number of malignancies including prostate cancer (PCa). The differential expression pattern of circRNAs associated with PCa and androgen receptor (AR) status was investigated in this study. circRNA profiling was performed using a high throughout microarray assay on a panel of prostate cell lines, which consisted of normal, benign, and malignant cells (n = 9). circRNAs were more commonly significantly up-regulated (p < 0.05) than downregulated in malignant cell lines (n = 3,409) vs. benign cell lines (n = 2,949). In a grouped analysis based on AR status, there were 2,127 down-regulated circRNAs in androgen independent cell lines compared to 2,236 in androgen dependent cell lines, thus identifying a potential circRNA signature reflective of androgen dependency. Through a bioinformatics approach, the parental genes associated with the top 10 differentially expressed circRNAs were identified such as hsa_circ_0064644, whose predicted parental gene target is RBMS3, and hsa_circ_0060539, whose predicted gene target is SDC4. Furthermore, we identified three circRNAs associated with the parental gene Caprin1 (hsa_circ_0021652, hsa_circ_0000288, and hsa_circ_0021647). Other studies have shown the importance of Caprin1 in PCa cell survival and drug resistance. Given the modified circRNA expression signatures identified here, these hypothesis generating results suggest that circRNAs may serve as potential putative diagnostic and predictive markers in PCa. However, further validation studies are required to assess the true potential of these markers in the clinical setting.

Management of Severe Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a devastating and disfiguring disease of the skin involving the terminal follicular epithelium within the apocrine-gland-bearing skin. We present an interesting case of a 58-year-old female who presented with a 10-year history of refractory HS of the gluteal, perineal, perianal, and groin region. She had been chronically treated with multiple antibiotics in the past with no improvement. The patient subsequently underwent surgical local excision with complex closure. Medical management alone may not be optimal, especially in refractory disease. Early and aggressive surgical intervention and interdisciplinary approach are needed for patients with chronic and advanced stage of HS.

Successful Treatment of Community-Acquired Methicillin-Resistant Staphylococcus Aureus Necrotizing Pneumonia in the Setting of Chronic Graft-Versus-Host Disease

Necrotizing pneumonia (NP) is a rare complication of community-acquired pneumonia that results in tissue necrosis and permanent destruction of the lung parenchyma.

This study presents a case of a 21-year old male patient with T-cell acute lymphoblastic lymphoma who was treated with chemotherapy and matched-unrelated donor stem cell transplantation. His post-transplant course included chronic graft-versus-host disease (GVHD) and subsequent community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) necrotizing pneumonia. In addition to antibiotics, steroids were used to help blunt the proinflammatory response following CA-MRSA pneumonia and this led to a rapid improvement in our patient’s clinical course.

CA-MRSA pneumonia is often treated with vancomycin. Given the nature of necrotizing pneumonia, the use of a toxin reducing agent like linezolid and adjunct therapy with corticosteroids was beneficial in the management of this disease process in our patient with chronic GVHD. Further prospective studies are needed to evaluate this regimen as a therapeutic alternative.

894. Patient and Surgery Characteristics on Wound Complication and Surgical Site Infection in Sarcoma Patients undergoing Hemipelvectomy

Background

Hemipelvectomy is associated with a significant risk of wound complications, including infections, bleeding and injuries to nearby neurovascular structures as well as the gastrointestinal and genitourinary tract. This study aimed to determine the patient characteristics and approach to treatment that could affect the occurrence of surgical site infection or wound complications in sarcoma patients undergone hemipelvectomy.

Methods

We conducted a retrospective analysis of 33 adult patients who underwent hemipelvectomy at Moffitt Cancer Center, Tampa, FL, from 2008 to 2016. We used Chi-square (Exact Fisher) test to investigate the association between wound complication and categorical variables. We used a T-test to evaluate the difference in numerical variables for outcomes.

Results

Out of 33 patients, 12 (36.4%) patients experienced wound complications after hemipelvectomy (Table 1). The average age of patients with wound complications was 63.3 3 (57.1±15.4) years old, significantly higher than that of patients without wound complications (p=0.004). Without adjustment, the use of computer navigation had a lower wound complication rate (p=0.027). Patients with wound complications had longer hospital length of stay (14.8 vs. 7.0 days, p=0.016). Among patients with surgical site infection (Table 2), there were no patients’ characteristics or surgical characteristics associated with this outcome. Five (15%) patients developed surgical site infection and they had longer hospital stay (19.4 vs. 8.1 days, p=0.001). The organisms identified from wound cultures include methicillin-resistant Staphylococcus aureus, viridans Streptococcus, Peptostreptococcus asaccharolyticus, Enterobacter cloacae, Pseudomonas aeruginosa, Candida albicans. The organisms in late infections (more than 6 months since surgery), included above organisms plus Stenotrophomonas maltophilia and Achromobacter xylosidans.

Conclusion

Older patients undergoing hemipelvectomy are at an increased risk of developing wound complications with a prolonged hospital stay. Initial antimicrobial therapy for suspected surgical site infection should include a broad-spectrum coverage to include skin and gastrointestinal flora.

Disclosures

All Authors: No reported disclosures

282. Epidemiological Evaluation of Methicillin-Resistant Staphylococcus aureus (MRSA) and Methicillin-Susceptible Staphylococcus aureus (MSSA) Bacteremia: A Comprehensive Cancer Center’s 10-Year Experience

Background

Coagulase-positive Staphylococcus aureus bacteremia among cancer patients carries significant morbidity and mortality. This study aims to compare the risk factors and clinical outcomes among cancer patients diagnosed with bloodstream infection (BSI) with methicillin-sensitive S. aureus (MSSA) or methicillin-resistant S. aureus (MRSA).

Methods

We performed a retrospective cohort study on all patients diagnosed with an active solid tumor or hematologic cancer with positive blood culture for S. aureus from January 2009 to May 2019. We collected data on demographics, comorbidities, malignancy type, venous access, neutropenia status, echocardiogram results, treatment (tx) duration, antibiotics usage pre/post culture, hospital LOS, infection severity, and 7-day and 30-day mortality. We used the Chi-square test to analyze categorical variables, t-test to analyze continuous variables, and the Kaplan-Meier survival curve and multivariate regression to analyze mortality.

Results

Two hundred eighty-three cases with malignancies and S. aureus BSIs were reviewed, and 168 were identified with BSIs for MRSA or MSSA during the ten years. The mean age for MRSA cases was 73.1 (±13.7) and 70.1 (± 14.6) for MSSA; male patients were most of the sex (P < 0.01). MRSA and MSSA bacteremia presented equally in hematologic malignancies, while MSSA was observed more in skin cancer than MRSA. Cancers that obstruct GU tracts may be associated with MRSA and MSSA from urine source as both were overrepresented in patients with bladder and rectal cancer. In most patients, the CVC was promptly removed and appropriate antibiotics were given promptly within 1 hour of the positive blood culture. For patients who underwent echocardiogram, most had a negative result in both groups. There was no significant difference for seven and 30-day mortality between the two groups. The mean hospital LOS was longer for MRSA cases (10.5 ± 13.5) versus MSSA cases (4.88 ± 9.1), (P < 0.01).

Figures 1 & 2. Kaplan-Meier Survival Curve Comparing 7 and 30-day Mortality of Cancer Patients with MRSA vs MSSA BSI

Figure 3 & 4. Distribution of Cancer Types for MRSA (n=84) and MSSA (n=84) BSI

Conclusion

Endocarditis with either MRSA or MSSA BSI is not a prominent finding among cancer patients at our institution. Given the extensive usage of CVCs and devices in patients with malignancies, prompt removal and antibiotic administration are essential to reduce morbidity; even then, the LOS for MRSA BSI remains longer than MSSA BSI.

Disclosures

All Authors: No reported disclosures

Platelet cloaking of circulating tumour cells in patients with metastatic prostate cancer: Results from ExPeCT, a randomised controlled trial

Background

Circulating tumour cells (CTCs) represent a morphologically distinct subset of cancer cells, which aid the metastatic spread. The ExPeCT trial aimed to examine the effectiveness of a structured exercise programme in modulating levels of CTCs and platelet cloaking in patients with metastatic prostate cancer.

Methods

Participants (n = 61) were randomised into either standard care (control) or exercise arms. Whole blood was collected for all participants at baseline (T0), three months (T3) and six months (T6), and analysed for the presence of CTCs, CTC clusters and platelet cloaking. CTC data was correlated with clinico-pathological information.

Results

Changes in CTC number were observed within group over time, however no significant difference in CTC number was observed between groups over time. Platelet cloaking was identified in 29.5% of participants. A positive correlation between CTC number and white cell count (WCC) was observed (p = 0.0001), in addition to a positive relationship between CTC clusters and PSA levels (p = 0.0393).

Conclusion

The presence of platelet cloaking has been observed in this patient population for the first time, in addition to a significant correlation between CTC number and WCC.

Trial registration

ClincalTrials.gov identifier NCT02453139.

A Case of Alpha-1 Antitrypsin Deficiency and Organizing Pneumonia

Alpha-1 antitrypsin deficiency (AATD) is an autosomal dominant genetic disorder that presents with pulmonary complications and is most commonly manifested by panacinar emphysema and chronic obstructive pulmonary disease. A 49-year-old Caucasian female with a history of AATD and chronic tobacco use was referred to both infectious disease and thoracic surgery clinics with worsening cough and chronic intermittent hemoptysis for the evaluation of possible superimposed infection or malignancy. She had previously been treated with multiple antibiotics and Prolastin-CÒ (alpha-1-proteinase inhibitor). Initial CT of the chest showed known chronic bronchiectasis, severe lower lung emphysema, and right-sided lower lobe pulmonary masses. CT-guided biopsy of one mass showed nonspecific inflammation, negative cultures, and negative cytology. Subsequent follow-up with chest CT scans showed a decreasing size of right-sided pulmonary masses and new left-sided nodule formation, which later stabilized in growth. Based on symptoms and radiological and pathological findings, a diagnosis of organizing pneumonia was made. We present an unusual case of bilateral pulmonary masses mimicking infection and malignancy later found to be most consistent with an organizing pneumonia in a patient with underlying AATD.

Linking Circulating Serum Proteins with Clinical Outcomes in Esophageal Adenocarcinoma-An Emerging Role for Chemokines

Simple Summary

Cancer of the esophagus (food pipe) is an aggressive type of cancer with poor prognosis and rates are increasing. Current treatments help to prolong survival but only for a minority of patients, therefore there is an urgent need to discover why some people do not respond and to develop new and improved treatments. Newer treatments targeting the immune system show promise but the anti-tumor immune response in esophageal cancer is not well understood. This study measured levels of 54 immune markers in serum of patients with esophageal cancer and evaluated a link with patient clinical outcomes, e.g., survival time, response to treatment, and adverse events. We found that certain chemokines, proteins which control immune cell trafficking, were particularly high in patients who survived longer (CCL22 and CCL26) and responded to treatment (CCL4), suggesting the importance of immune cell movement in orchestrating an effective immune response to esophageal cancer.

Abstract

Esophageal adenocarcinoma (EAC) is an aggressive cancer with poor prognosis and incidence is increasing rapidly in the Western world. Multi-modal treatment has improved survival outcomes but only for a minority of patients. Currently no markers have been identified to predict treatment response. This study investigated the association between clinical outcomes and pre-treatment levels of 54 serum proteins in n = 80 patients with EAC. Low tumor regression grade (TRG), corresponding to a favorable treatment response, was linked to prolonged overall survival (OS). CCL4 was higher in patients with a favorable treatment response, while Tie2 and CRP were higher in poor responders. Elevated CCL22 and CCL26 was associated with improved OS, while elevated IL-10 showed a negative association. CCL3, CCL4, IL-1α and IL-12/IL23p40 were highest in individuals with no adverse features of tumor biology, whereas levels of Tie2 and VEGF were lowest in this cohort. CCL4 was also elevated in patients with high tumor lymphocyte infiltration. Comparison of matched pre- and post-treatment serum (n = 28) showed a large reduction in VEGFC, and a concomitant increase in other cytokines, including CCL4. These data link several serum markers with clinical outcomes, highlighting an important role for immune cell trafficking in the EAC antitumor immune response.

Production, Collection, and Purification of 47Ca for the Generation of 47Sc through Isotope Harvesting at the National Superconducting Cyclotron Laboratory

An experiment was performed at the National Superconducting Cyclotron Laboratory using a 140 MeV/nucleon ⁴⁸Ca beam and a flowing-water target to produce ⁴⁷Ca for the first time with this production route. A production rate of 0.020 ± 0.004 ⁴⁷Ca nuclei per incoming beam particle was measured. An isotope harvesting system attached to the target was used to collect radioactive cationic products, including ⁴⁷Ca, from the water on a cation-exchange resin. The ⁴⁷Ca collected was purified using three separation methods optimized for this work: (1) DGA extraction chromatography resin with HNO₃ and HCl, (2) AG MP-50 cation-exchange resin with an increasing concentration gradient of HCl, and (3) AG MP-50 cation-exchange resin with a methanolic HCl gradient. These methods resulted in ≥99 ± 2% separation yield of ⁴⁷Ca with 100% radionuclidic purity within the limits of detection for HPGe measurements. Inductively coupled plasma-optical emission spectrometry (ICP-OES) was used to identify low levels of stable ions in the water of the isotope harvesting system during the irradiation and in the final purified solution of ⁴⁷Ca. For the first time, this experiment demonstrated the feasibility of the production, collection, and purification of ⁴⁷Ca through isotope harvesting for the generation of ⁴⁷Sc for nuclear medicine applications.

Sweet's syndrome associated with hematological malignancies

BACKGROUND

Sweet's syndrome, or acute febrile neutrophilic dermatosis, is often mistaken for a skin infection given its similar clinical presentation.

OBJECTIVE

To describe the clinical presentations and management of a rare dermatologic condition associated with hematological malignancies.

METHODS

Case series; Chart review of patients at Moffitt Cancer Center between 2017 and 2020.

RESULTS

The subjects are a 79 year-old man (Patient 1) with Myelodysplastic Syndrome (MDS), a 66 year-old woman (Patient 2) with Acute Myeloid Leukemia (AML), a 56 year-old man (Patient 3) with AML, and a 69 year-old man (Patient 4) with MDS. Patient 1 was initially misdiagnosed with neutropenic fever. Patient 2 was incidentally discovered to have erythematous skin lesions prior to initiating chemotherapy. Before starting second line chemotherapy, patient 3 developed pathergy at the site of a PICC line. Patient 4 developed erythema around a newly placed port before initiating chemotherapy. Only patients 1 and 3 received glucocorticoids. Patients 2, 3, and 4 were able to initiate chemotherapy without further complications.

LIMITATIONS

Heterogeneity of subjects in terms of prognostic factors, stage at diagnosis, and treatment strategies.

CONCLUSION

Early recognition and treatment of malignancy-associated Sweet's syndrome is imperative to limit patient morbidity and expeditiously provide anti-cancer treatments.

Disseminated Corynebacterium jeikeium Infection in Cancer Patients

Corynebacterium jeikeium is a multidrug-resistant gram-positive bacterium of the human skin flora and one of the most clinically important nondiphtherial corynebacteria in the acute care setting. C. jeikeium can cause different forms of infections, especially in immunocompromised patients with underlying risk factors and comorbidities. C. jeikeium was initially described in 1976 as a highly resistant coryneform bacteria causing severe sepsis in patients with hematologic malignancies and profound neutropenia. C. jeikeium infection has also been reported in the setting of endocarditis, septicemia, meningitis, pneumonia, and soft tissue infections. Management of disseminated C. jeikeium infection in immunocompromised cancer patients can be challenging due to its high virulence and rapid skin colonization. We present two cases of disseminated C. jeikeium infection in patients with acute myelogenous leukemia (AML) and underlying comorbidities. Both patients presented with neutropenic fever resistant to initial standard empiric antibiotic therapy.

Synthesis and crystal structure of (2S,4aR,8aR)-6-oxo-2,4a,6,8a-tetra-hydro-pyrano[3,2-b]pyran-2-carboxamide

The pyran-opyran amide (2S,4aR,8aR)-6-oxo-2,4a,6,8a-tetra-hydro-pyrano[3,2-b]pyran-2-carboxamide, C9H9NO4, 3, was prepared by a chemoselective hydration of the corresponding nitrile, 2, using a heterogeneous catalytic method based on copper(II) supported on mol-ecular sieves, in the presence of acetaldoxime. Compound 3 belongs to a new class of pyran-opyrans that possess anti-bacterial and phytotoxic activity. Crystallographic analysis of 3 shows a bent structure for the cis-fused bicyclic pyran-opyran, similar to nitrile 2. Evidence of an intra-molecular hydrogen bond involving the amide group and ring oxygen was not observed; however, two separate inter-molecular hydrogen-bonding inter-actions were observed between the amide hydrogen atoms and adjacent carbonyl oxygen atoms along the b- and a-axis directions. The latter inter-action may also be supported by an inter-molecular C-H⋯O hydrogen bond. The lattice is filled out by close-packed layers of this hydrogen-bonded network along the c-axis direction, related from one to the next by a 21 screw axis.

Meeting the challenge of the 2019 novel coronavirus disease in patients with cancer

The alarming situation of the 2019 novel coronavirus disease (COVID‐19) is contrasted by the limited efforts to curb the spread and impact of the disease among patients with cancer. This commentary proposes a simple 5‐part strategy plus rapidly expanded use of telemedicine to anticipate and deal with COVID‐19 and, by extension, future epidemics in patients with cancer.

Second generation degrader foil for the CARIBU project

The Californium Rare Ion Breeder Upgrade (CARIBU) project utilizes 252Cf to provide beams of neutron-rich nuclides with intensities not currently available at other facilities. The electroplated 252Cf source is positioned inside a large helium gas catcher, where the ejected fission fragments lose their energy and are slowed. Prior to entering this gas catcher, the ions first pass through a gold cover foil to contain self-sputtering recoil emissions and then through an aluminium degrader foil, where much of their residual energy is reduced. In the past due to production limitations, a less than ideal cylindrical shaped degrader was utilized. This resulted in non-uniform energy loss as the ions passed through the degrader. With the advent of 3D printing, a new hemispherical degrader was prepared to enable a more uniform energy loss. The design, production, and assembly will be discussed.

Method development for producing thin 14C foils

Thin, isotopic 14C foils are of great interest to the nuclear physics community as neutron-rich targets. Historically, these foils have been extremely difficult to prepare and an effort is underway to make them readily available. The stock material of 14C available at Argonne contains a number of oxide impurities (SiO2, MgO, and Al2O3), which affect the composition and stability of the fabricated foil. A simple, robust method was developed (using natC as a surrogate) to purify the 14C material while minimizing loss and potential spread of the material. Thin foils were fabricated using the purified carbon, the unpurified carbon/oxide mix, and purchased high-purity carbon powder. SEM and EDS of the resulting foils was performed and the efficacy of this purification method was demonstrated.

Anthropogenic control over wintertime oxidation of atmospheric pollutants

During winter in the mid-latitudes, photochemical oxidation is significantly slower than in summer and the main radical oxidants driving formation of secondary pollutants, such as fine particulate matter and ozone, remain uncertain, owing to a lack of observations in this season. Using airborne observations, we quantify the contribution of various oxidants on a regional basis during winter, enabling improved chemical descriptions of wintertime air pollution transformations. We show that 25-60% of NO_x is converted to N₂O₅ via multiphase reactions between gas-phase nitrogen oxide reservoirs and aerosol particles, with ~93% reacting in the marine boundary layer to form >2.5 ppbv ClNO₂. This results in >70% of the oxidizing capacity of polluted air during winter being controlled, not by typical photochemical reactions, but from these multiphase reactions and emissions of volatile organic compounds, such as HCHO, highlighting the control local anthropogenic emissions have on the oxidizing capacity of the polluted wintertime atmosphere.

478. Outcomes of Extended-Spectrum β-Lactamase-Producing Escherichia coli Bloodstream Infection in Neutropenic Patients with Hematological Malignancies

Background

Infections with extended-spectrum β-lactamase (ESBL) producing Enterobacteriaceae is an emerging problem leading to poor clinical outcomes and increased mortality. The purpose of this study was to determine the prevalence, risk factors and outcomes of ESBL-producing E. coli (EC) in bloodstream infections (BSIs) of neutropenic patients with hematological malignancies and compare the difference with Non-ESBL producing EC.

Methods

Through an IRB approved protocol, a retrospective cohort study was conducted at the H. Lee Moffitt Cancer Center from January, 2007 till October, 2017. Of the 310 records, who had +ive blood cultures for E. Coli, a total of 63 neutropenic patients with hematological malignancies were identified based on the bloodstream infections with ESBL-EC and Non ESBL EC. Data included demographics, underlying malignancy, type of bone marrow transplant, duration of neutropenia, antibiotics use pre and post culture, length of hospital stay, severity of infection, ventilator use, and mortality data.

Results

A total of 310 cases with hematological malignancy and neutropenia were reviewed, 63 were identified as +ive blood culture for E. coli. Out of the 63 cases, 17 were ESBL-EC +ive and 46 were non-ESBL-EC. The prevalence of ESBL-EC was highest in the year 2015 (29.4%) and decreased in the subsequent years (Figure 1). The mean ages of the two groups were 53.59 ±12.4 and 60.82 ± 11.1, respectively. The average length of stay for the ESBL-EC group was 26.59 ± 11.2 days, longer than the non-ESBL EC group 21.96 ± 11.2. Days of neutropenia in non-ESBL vs. ESBL EC were 9 days ± 8.3, and 19 days ± 22.0, respectively, P < 0.01). No differences were observed in the 30–60 day mortality and other outcomes listed in Table 1.

Conclusion

The prevalence of ESBL-EC was observed to be higher in patients who were neutropenic for longer duration, were older and resulted in longer hospital stay. Early identification and empirical therapy in neutropenic patients suspected to have ESBL-EC infection is crucial. Also, the infection with ESBL-EC was higher in the year 2015 and decreased in the subsequent years. After higher rates, perhaps infection control, lab reporting changes, antibiotic stewardship and transmission-based precautions might have played a role.

Disclosures

All authors: No reported disclosures.

437. Gram-Negative Rod Skin and Soft-tissue infections following Breast Tissue Expander Surgery in Breast Cancer Patients

Background

Breast cancer patients who undergo tissue expander surgery (TES) are at an increased risk of developing gram-negative rod (GNR) skin and soft-tissue infection (SSIs) and its complications including prolonged antibiotic therapy, antibiotics side effects, and implant removal. Current perioperative antimicrobials focus mostly on gram-positive organisms, but the presence of a foreign body increases the risk of GNR SSI. We describe here the most common GNR bacteria and their susceptibility patterns that cause SSI after TES among breast cancer patients.

Methods

We conducted a retrospective cohort study at Moffitt Cancer Center, Tampa, FL from January 2016, to January 2018, on all breast cancer patients who developed GNR SSIs following TES. We reviewed records after approval from the Institutional Review Board. The data collected included patient’s age, pathogens from wound culture, antibiotic susceptibilities, the perioperative and definitive antibiotics used.

Results

A total of 38 cases of GNR SSI with a mean age of 56 ± 11 years were identified. The 3 most common pathogens were Pseudomonas aeruginosa (45%), Serratia marcescens (16%), and Klebsiella pneumoniae (8%) (Figure 1). The susceptibility pattern was available for 33 cases. Pseudomonas and Klebsiella isolates were susceptible to all tested antibiotics (Table 1). The Stenotrophomonas isolates showed resistance to ceftazidime. Enterobacter cloacae, Enterobacter aerogenes, Morganella morganii, and Acinetobacter baumannii complex, showed resistance to cefazolin. Twenty-five cases (74%) received perioperative antibiotics for gram-positive organisms; mostly cefazolin, and vancomycin. The common antibiotics used for definitive treatment were ciprofloxacin, cefepime, ceftazidime, piperacillin–tazobactam, and meropenem.

Conclusion

In centers with a high percentage of GNR SSI following TES should consider using perioperative antibiotics that include coverage against Pseudomonas aeruginosa, the most common isolate (45%). The use only of cefazolin or other antibiotics against gram-positive organism may be inadequate. However, GNR infection may occur from 48 hours to 2 weeks postoperatively and may be from the acquisition of the GNR at home in which perioperative antibiotics may have minimal effect.

Disclosures

All authors: No reported disclosures.

1354. Nocardia bejingensis: A Novel Isolate Affecting Immunocompromised Patients in the United States

Background

Nocardia species can cause localized or disseminated disease in humans. Infection results from direct inoculation or inhalation. In recent years, several new species have been identified via molecular methods. Further speciation is crucial as each organism has its own spectrum of disease and unique antibiotic susceptibility patterns. Immunosuppression, alcoholism, and certain lung diseases are well-established risk factors for nocardiosis. In fact, cases have incremented in association with increasing population of immunocompromised hosts as well as improved methods for detection and identification. Thus, Nocardia species may be considered opportunistic pathogens.

Nocardia bejingensis was first isolated in 2001 by Wang et al from sewage soil in China. The first human infections were reported in Asia. Subsequently, cases were reported in Europe and a few cases have been described in the United States but it has been infrequently cited in the literature. Thus, not much is known about its spectrum of disease.

Methods

The primary objective of this study was to determine the risk factors and clinical manifestations of Nocardia bejingensis infection via retrospective chart review of 6 cases identified in Tampa General Hospital and Moffitt Cancer Center within a 5-year period. We aimed to evaluate the treatment used and the antibiotic susceptibility patterns of the isolates.

Results

All patients were immunocompromised (1/3 HIV/AIDS, 1/3 hematologic malignancy, 1/3 solid-organ transplant). Most were male (67%) and mean age of 48. The majority had lung involvement (67%). Thecal sac infection and femur osteomyelitis (OM) were atypical manifestations. Localized disease predominated. Combination therapy was preferred. Trimethoprim-sulfamethoxazole (TMP-SMX), Ceftriaxone, and carbapenems were mostly used. All isolates were susceptible to TMP-SMX. See Table 1.

Conclusion

This case series depicts clinical features, risk factors, and epidemiology of Nocardia bejingensis infections. Our observations suggest that it is a novel pathogen in the United States, affecting mainly immunocompromised hosts. Early detection, appropriate antibiotics, and surgery were keys in successful management. However, further studies are needed to further elucidate its pathogenesis.

Disclosures

All authors: No reported disclosures.