Comparing practices to prevent infectious diseases transmission among Veterans Affairs and Nonveterans Affairs hospitals: Results from a national survey in the United States

Our national cross-sectional survey of United States hospitals found greater implementation of contact precautions for multidrug-resistant organisms and a higher percentage reporting the use of supplemental no-touch disinfection devices among Veterans Affairs (VA) versus non-VA hospitals. Nationally coordinated infection prevention initiatives within the VA could account for these practice differences.

What US hospitals are doing to prevent common device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: Results from a national survey in the United States

OBJECTIVE

The ways that device-associated infection prevention practices changed during the coronavirus disease 2019 (COVID-19) pandemic remain unknown. We collected data mid-pandemic to assess the use of several infection prevention practices and for comparison with historical data.

DESIGN

Repeated cross-sectional survey.

SETTING

US acute-care hospitals.

PARTICIPANTS

Infection preventionists.

METHODS

We surveyed infection preventionists from a national random sample of 881 US acute-care hospitals in 2021 to estimate the current use of practices to prevent catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated events (VAE). We compared the 2021 results with those from surveys occurring every 4 years since 2005.

RESULTS

The 2021 survey response rate was 47%; previous survey response rates ranged from 59% to 72%. Regular use of most practices to prevent CLABSI (chlorhexidine gluconate for site antisepsis, 99.0%, and maximum sterile barrier precautions, 98.7%) and VAE (semirecumbent positioning, 93.4%, and sedation vacation, 85.8%) continued to increase or plateaued in 2021. Conversely, use of several CAUTI prevention practices (portable bladder ultrasound scanner, 65.6%; catheter reminders or nurse-initiated discontinuation, 66.3%; and intermittent catheterization, 37.3%) was lower in 2021, with a significant decrease for some practices compared to 2017 (P ≤ .02 for all comparisons). In 2021, 42.1% of hospitals reported regular use of the newer external urinary collection devices for women.

CONCLUSIONS

Although regular use of CLABSI and VAE preventive practices continued to increase (or plateaued), use of several CAUTI preventive practices decreased during the COVID-19 pandemic. Structural issues relating to care during the pandemic may have contributed to a decrease in device-associated infection prevention practices.

RSV Infection in Older Adults

This JAMA Patient Page describes respiratory syncytial virus (RSV) and its symptoms, risk factors, and preventive measures.

Impact of Metagenomic Next-Generation Sequencing of Plasma Cell-free DNA Testing in the Management of Patients With Suspected Infectious Diseases

Metagenomic next-generation sequencing (mNGS) of cell-free DNA is an emerging modality for the diagnosis of infectious diseases, but studies on its clinical utility are limited. We conducted a retrospective single-center study including all patients who had plasma mNGS sent at the University of Michigan between 1 January 2021 and 25 July 2022. Test results were assessed for clinical impact. A total of 71 tests were sent on 69 patients; the mean ± SD age was 52 ± 19 years; and 35% of patients were immunocompromised. Forty-five (63%) mNGS test results were positive and 14 (31%) had clinical impact-from starting new antimicrobials (n = 7), discontinuing antimicrobials (n = 4), or changing antimicrobial duration (n = 2) or by affecting surgical decision making (n = 1). Twenty-six (37%) mNGS test results were negative and only 4 (15%) were impactful, leading to discontinuation of antimicrobials. Overall, just 25% of mNGS tests were clinically relevant. There was no significant difference in the proportion of tests that were clinically relevant between negative and positive results (P = .16) or if patients were immunocompromised (P = .57). Plasma mNGS was most frequently impactful (in 50% of patients) when included in the diagnostic workup of cardiovascular infection but less impactful in other clinical syndromes, including fever of unknown origin and pulmonary infection. Our findings underscore the need to further study this testing modality, particularly with prospective research including negative controls, before it is considered for widespread use.

SARS-CoV-2 Anti-Spike IgG Antibody and ACE2 Receptor Binding Inhibition Levels among Breakthrough Stage Veteran Patients

SARS-CoV-2 mRNA vaccines have been critical to curbing pandemic COVID-19; however, a major shortcoming has been the inability to assess levels of protection after vaccination. This study assessed serologic status of breakthrough infections in vaccinated patients at a Veterans Administration medical center from June through December 2021 during a SARS-CoV-2 delta variant wave. Breakthrough occurred mostly beyond 150 days after two-dose vaccination with a mean of 239 days. Anti-SARS-CoV-2 spike (S) IgG levels were low at 0 to 2 days postsymptoms but increased in subjects presenting thereafter. Population measurements of anti-S IgG and angiotensin converting enzyme-2 receptor (ACE2-R) binding inhibition among uninfected, vaccinated patients suggested immune decay occurred after 150 days with 62% having anti-S IgG levels at or below 1,000 AU comparable with breakthrough patients at 0 to 2 days postsymptom onset. In contrast, vaccination after resolved infection conferred robust enduring anti-S IgG levels (5,000 to >50,000 AU) with >90% ACE2-R binding inhibition. However, monoclonal antibody (MAb)-treated patients did not benefit from their prior infection suggesting impaired establishment of B cell memory. Analysis of boosted patients confirmed the benefit of a third vaccine dose with most having anti-S IgG levels above 5,000 AU with >90% ACE2-R binding inhibition, but a subset had levels <5,000 AU. Anti-S IgG levels >5,000 AU were associated with >90% ACE2-R binding inhibition and no documented breakthrough infections, whereas levels falling below 5,000 AU and approaching 1,000 AU were associated with breakthrough infections. Thus, quantitative antibody measurements may provide a means to guide vaccination intervals for the individual. IMPORTANCE Currently, clinicians have no guidance for the serologic assessment of SARS-Cov-2 postvaccination status regarding protection and risk of infection. Vaccination and boosters are administered blindly without evaluation of need or outcome at the individual level. The recent development of automated quantitative assays for anti-SARS-CoV-2 spike protein IgG antibodies permits accurate measurement of humoral immunity in standardized units. Clinical studies, such as reported here, will help establish protective antibody levels allowing identification and targeted management of poor vaccine responders and vaccinated subjects undergoing immune decay.

354. Invasive fungal disease in patients with severe COVID-19 infection at a midwestern academic medical center

Background

Invasive fungal diseases (IFD) have been described in patients (pts) with severe coronavirus disease 2019 (COVID), albeit with geographic variability in rates.

Methods

We performed a retrospective study to determine rates of & risk factors for IFD occurring within 30 days (d) of COVID diagnosis (dx) in adults requiring critical care for severe COVID between 5/11/20 & 2/7/21. Mortality was assessed at 90 d following COVID dx and at 84 d after IFD dx, if applicable. ECMM/ISHAM criteria were used for COVID-associated pulmonary aspergillosis (CAPA) and EORTC/MSGERC criteria were used for other IFD and treatment response.

Results

218 pts were included; median age was 62 (19 – 91) & 63% were men. Underlying conditions included solid organ transplant (Tx) (16; 7%), allogenic stem cell Tx (3; 1%), malignancy (21; 10%), & exposure to either high-dose steroids (HDS) (11; 5%) or T- or B-cell suppressants (29; 13%) within 90 d prior to COVID dx. 209 (96%) pts had respiratory failure & 127 (58%) required mechanical ventilation. 15 (7%) required extracorporeal membrane oxygenation. COVID treatment consisted of corticosteroids in 205 (96%) & tocilizumab in 10 (5%).

12 (6%) pts developed IFD. 6 pts had CAPA (2 probable, 4 possible); 50% were men, median age 64.5 (48 – 83). Mean time to CAPA dx from COVID dx was 17 d (± 14d). All pts had received corticosteroids for COVID but only 1 pt received &gt; 30d of HDS by the time of IFD dx. Mortality at 84 d from CAPA dx was 67%. 5 (2%) pts had central venous catheter associated candidemia; 80% were men & median age 61 (55 – 77). Mean time from COVID to candidemia dx was 29 d (±12 d). All pts with Candida infection had received steroids for COVID. Mortality at 84 d from candidemia dx was 60%.

A 35-year-old man with prolonged exposure to HDS had Paecilomyces pneumonia; he was alive at 84 d after IFD dx. No cases of mucormycosis were identified.

All-cause mortality in the entire cohort was 38% at 90 d after COVID dx. Mortality among pts who developed IFD was 58% at the same time point.

Conclusion

Rates of IFD in pts with severe COVID were low and most pts with IFD after COVID had CAPA or catheter-associated candidemia. All but one pt with CAPA had no risk factors for IFD. In pts with severe COVID, mortality was higher among pts who developed IFD than those who did not.

Disclosures

Marisa H. Miceli, MD, Astellas: Advisor/Consultant|F2G: Grant/Research Support|Miravista: Advisor/Consultant|PSI: Advisor/Consultant|Scynaxis: Advisor/Consultant|Scynaxis: Grant/Research Support.

Letermovir treatment of cytomegalovirus infection or disease in solid organ and hematopoietic cell transplant recipients

BACKGROUND

Few options are available for cytomegalovirus (CMV) treatment in transplant recipients resistant, refractory, or intolerant to approved agents. Letermovir (LET) is approved for prophylaxis in hematopoietic cell transplant (HCT) recipients, but little is known about efficacy in CMV infection. We conducted an observational study to determine the patterns of use and outcome of LET treatment of CMV infection in transplant recipients.

METHODS

Patients who received LET for treatment of CMV infection were identified at 13 transplant centers. Demographic and outcome data were collected.

RESULTS

Twenty-seven solid organ and 21 HCT recipients (one dual) from 13 medical centers were included. Forty-five of 47 (94%) were treated with other agents prior to LET, and 57% had a history of prior CMV disease. Seventy-seven percent were intolerant to other antivirals; 32% were started on LET because of resistance concerns. Among 37 patients with viral load < 1000 international units (IU)/ml at LET initiation, two experienced >1 log rise in viral load by week 12, and no deaths were attributed to CMV. Ten patients had viral load > 1000 IU/ml at LET initiation, and six of 10 (60%) had a CMV viral load < 1000 IU/ml at completion of therapy or last known value. LET was discontinued in two patients for an adverse event.

CONCLUSIONS

Patients treated with LET with viral load < 1000 IU/ml had good virologic outcomes. Outcomes were mixed when LET was initiated at higher viral loads. Further studies on combination therapy or alternative LET dosing are needed.

COVID-19-Associated Pulmonary Aspergillosis at an Academic Medical Center in the Midwestern United States

Pulmonary aspergillosis has been reported at high rates in patients with coronavirus disease 2019 (COVID-19) and is associated with high morbidity and mortality. We retrospectively assessed all patients admitted to an intensive care unit during the early COVID-19 surge (3/17/20–5/10/20) at our medical center in the midwestern USA for the presence of COVID-19-associated pulmonary aspergillosis (CAPA). Patients were not routinely screened for CAPA; diagnostic work-up for fungal infections was pursued when clinically indicated. Among 256 patients admitted to the ICU with severe COVID-19, 188 (73%) were intubated and 62 (24%) ultimately expired within 30 days of admission to the ICU. Only three patients (1%) were found to have CAPA; diagnosis was made by tracheal aspirate cultures in two cases and by bronchoalveolar lavage fluid Aspergillus galactomannan in one case. None of the patients who developed CAPA had classic risk factors for invasive fungal infection. The occurrence of CAPA was much lower than that reported at other centers, likely reflecting the local epidemiology.

1077. Infectious complications after second allogeneic hematopoietic cell transplant (allo-HCT) in adult patients with hematological malignancies

Background

A 2nd allo-HCT is received by some adults after relapse of their underlying malignancy, development of a second malignancy, or graft failure. Few studies have reported on infectious complications in adults given a 2nd HCT

Methods

This is a retrospective review of infectious complications and overall mortality of 60 adult patients who received a 2nd HCT from Jan. 2010 - Dec. 2015. Data were collected for 2 years post-HCT for each patient. Infections were separated into &lt; 30 days (d) post-HCT, 30-100d post-HCT, and &gt;100d post-HCT.

Results

Mean age at 2nd HCT was 49+13; 60% were men. The most common reason for the 1st HCT was acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) (73%,n= 44) The 2nd HCT was for relapse of original malignancy (62%,n=37), graft failure (27%,n=16), and new malignancy (10%,n=6). The 2nd HCT was received a median of 344d (range 29-8248) after 1st HCT. Neutrophil engraftment occurred by 13+4d in 50/60 patients.

Fifty-eight patients (97%) had at least one infection during the study period. A total of 183 infections were reported: 75 (41%) were &lt; 30d, 56 (31%) 30-100d, and 52 (28%) &gt;100d post-HCT. Bacterial infections, primarily C. difficile, vancomycin-resistant Enterococcus, and coagulase (-) Staphylococcus caused 90 (49%) infections and were seen throughout the post-HCT period. Viral infections, predominantly CMV and BK virus, caused 60 (33%) of infections, peaking at 30-100d post-HCT. Only 19 (10%) infections were fungal, most of which were mold infections and occurred &gt;30d post-HCT.

Thirty-nine (65%) patients died by 2 years post-HCT, 27 within the first year. Cause of death was infection in 16 (41%), graft failure, relapse, or GVHD in 16 (41%), other in 7 (18%). At &lt; 30d post-HCT, 5 deaths (71%) were from infection 4 of which were bacterial. At 30-100d post-HCT, 6/9 (69%) deaths were from relapse/graft failure/GVHD. All 6 deaths from fungal infections were &gt;100d post-HCT. Bacterial Infections and engraftment failure within 100d post-HCT were associated with increased mortality (p .05 and &lt; .001, respectively).

Conclusion

All but 2 patients receiving a 2nd allo-HCT developed an infection. Most deaths at &lt; 30d post-HCT were from infection. Overall 2-year mortality was 65% and 41% of deaths were related to infection.

Disclosures

Marisa H. Miceli, MD, FIDSA, SCYNEXIS, Inc. (Advisor or Review Panel member)

Evaluation of targeted versus universal prophylaxis for the prevention of invasive fungal infections following lung transplantation

BACKGROUND

Antifungal prophylaxis to prevent invasive fungal infections (IFI) is widely used following lung transplantation, but the optimal strategy remains unclear. We compared universal with targeted antifungal prophylaxis for effectiveness in preventing IFI.

METHODS

Adult patients who underwent lung transplantation at the University of Michigan from /1 July 2014-31 December 2017 were studied for 18 months post-transplant. Universal prophylaxis consisted of itraconazole with or without inhaled liposomal amphotericin B. Using specific criteria, targeted prophylaxis was given with voriconazole for patients at risk for invasive pulmonary aspergillosis (IPA) and with fluconazole or micafungin for patients at risk for invasive candidiasis. Risk factors, occurrence of proven/probable IFI, and mortality were analyzed for the two prophylaxis cohorts.

RESULTS

Of 105 lung transplant recipients, 84 (80%) received a double lung transplant, and 38 (36%) of patients underwent transplant for pulmonary fibrosis. Fifty-nine (56%) patients received universal antifungal prophylaxis, and 46 (44%), targeted antifungal prophylaxis. Among 20 proven/probable IFI, there were 14 IPA, 4 invasive candidiasis, 1 cryptococcosis, and 1 deep sternal mold infection. Six (10%) IFI occurred in the universal prophylaxis cohort and 14 (30%) in the targeted prophylaxis cohort. Five of 6 (83%) IFI in the universal prophylaxis cohort, compared with 9/14 (64%) in the targeted prophylaxis cohort, were IPA Candida infections occurred only in the targeted prophylaxis cohort. The development of IFI was more likely in the targeted prophylaxis cohort than the universal prophylaxis cohort, HR = 4.32 (1.51-12.38), P = .0064.

CONCLUSIONS

Universal antifungal prophylaxis appears to be more effective than targeted antifungal prophylaxis for prevention of IFI after lung transplant.

Performance of the (1,3)-Beta-D-Glucan Assay on Bronchoalveolar Lavage Fluid for the Diagnosis of Invasive Pulmonary Aspergillosis

Detection of (1,3)-beta-D-glucan (BDG), a component of the cell wall of many fungi, was studied in bronchoalveolar lavage fluid (BALF) as a possible aid for the diagnosis of proven/probable invasive pulmonary aspergillosis (IPA). BDG was measured on stored BALF from 13 patients with EORTC/MSGERC defined proven/probable IPA and 26 matched control patients without IPA. The median BALF BDG was 80 pg/mL (range < 45-8240 pg/mL) in the IPA cohort and 148 pg/mL (range < 45-5460 pg/mL) in the non-IPA cohort. Using a positive cutoff of ≥ 80 pg/mL, sensitivity was 54% and specificity was 38%. Higher cutoff values led to improvement in specificity but a dramatic decrease in sensitivity. ROC/AUC analysis was unable to identify an optimal cutoff value at which test performance was enhanced: AUC 0.43, 95% CI 0.24-0.63. When the BDG assay was performed on BALF, neither sensitivity nor specificity was sufficient for use in the diagnosis of IPA.

1736. Evaluation of Targeted vs. Universal Antifungal Prophylaxis (AP) for Invasive Fungal Infections (IFI) After Lung Transplant (LTx)

Background

LTx patients (pt) are at increased risk for IFI. Systemic AP is widely used, but the optimal strategy remains unclear. Our LTx program changed from universal to targeted AP in July 2016; we compared outcomes between the 2 strategies.

Methods

All adult pt who underwent LTx at U. Michigan from July 1, 2014 to December 31, 2017 were studied for 18 mo post-LTx. Universal AP consisted of itraconazole (itra) ± inhaled liposomal amphotericin-B (iAmB) for 6 months. Pt received targeted AP with voriconazole for 3 months if they had a history of pre-LTx Aspergillus colonization or invasive pulmonary aspergillosis (IPA); 14 days of a yeast-active azole was given if donor or recipient had Candida colonization at the time of LTx. All other pt received no AP. Demographics, LTx characteristics, occurrence of proven/probable IFI defined by EORTC/MSG criteria, and mortality data were recorded.

Results

Of 105 LTx patients, 73 (70%) were men and 84 (80%) received a double LTx. The most common indication for LTx was idiopathic pulmonary fibrosis (38, 36%). Of 59 pt receiving universal AP, 36 (61%) received itra, and 23 (39%) received itra+iAmB; outcomes did not differ between these 2 regimens. Of 46 patients in the targeted AP cohort, 10 (22%) received antifungals based on predefined criteria. Overall, 19 proven/probable IFI occurred: 14 IPA, 3 invasive Candida infections, 1 Cryptococcus pneumonia, and 1 mold wound infection. IFI occurred in 5 patients (8%) in universal AP group vs. 13 patients (28%) in targeted AP group, P = .008. All but 1 IFI in the targeted AP group occurred among pt for whom antifungals were not recommended or given. IPA occurred in 4 patients (7%) in universal AP group and 9 patients (20%) in targeted AP group, P = 0.05; Candida infections occurred only among patients in the targeted AP cohort. Time to IFI was similar between the 2 AP strategies with the majority occurring <180 days post-LTx (median 109 days). Death occurred in 11 patients (8 in the universal AP cohort and 3 in the targeted AP cohort, P = .34); no deaths were related to IFI.

Conclusion

When compared with universal AP, targeted AP strategy was associated with a significant increase in IFI post-LTx. Universal AP for 6 months appears to be more effective than our targeted AP strategy for prevention of IFI post-LTx.

Disclosures

Marisa H. Miceli, MD, FIDSA, Astellas: Advisory Board, Research Grant; Scynexis: Research Grant.

Clinical application of Aspergillus lateral flow device in bronchoalveolar lavage fluid of patients with classic risk factors for invasive pulmonary aspergillosis

BACKGROUND

The diagnosis of invasive pulmonary aspergillosis (IPA) remains challenging. We evaluated the performance characteristics of a newly formatted Aspergillus lateral flow test, AspLFD, in bronchoalveolar lavage (BAL) fluid from patients with classic risk factors for IPA.

METHODS

Prospectively banked BAL samples from 14 patients with proven or probable IPA defined by EORTC/MSG criteria and 28 BAL samples from age-matched high-risk patients without IPA were tested with AspLFD according to manufacturer's directions. Results were read by two independent observers, and test performance was calculated.

RESULTS

Age, gender and underlying risk factors, except for neutropenia and haematological malignancy, were similar between IPA cases and controls. Seven patients (50%) in the IPA group received a mould-active agent within 5 days prior to bronchoscopy compared with only three patients (11%) in the control group, P = .004. Of 14 patients with proven/probable IPA, AspLFD was positive in 3 and negative in 9; two tests yielded invalid results. All 28 control patients had a negative AspLFD test. AspLFD showed low sensitivity (25%, 95% CI: 5.5% to 57.2%), but high specificity (100%. (95% CI: 87.7% to 100%).

CONCLUSIONS

A positive AspLFD test in BAL fluid of patients with classic risk factors for IPA could be useful to support the diagnosis of proven/probable IPA because of its high specificity. However, as a stand-alone test for IPA, the use of AspLFD is limited by low sensitivity.

Treatment Failure of Isavuconazole in a Patient with Cryptococcosis

Isavuconazole is a broad-spectrum azole that is FDA-approved for the treatment of aspergillosis and mucormycosis; data on the use of isavuconazole for the treatment and prevention of other invasive fungal infections are limited. Here, we report a patient with pulmonary cryptococcosis treated with isavuconazole who experienced progression to disseminated infection with Cryptococcus while on isavuconazole. Caution is advised when using isavuconazole in situations where there is a paucity of data to recommend its use.

Infectious Complications After Umbilical Cord Blood Transplantation for Hematological Malignancy

Background

Umbilical cord blood transplant (UCBT) is used for patients who do not have a matched donor, but engraftment often takes longer than with a standard allogeneic transplant, likely increasing the risk for infection. We characterized specific infections and outcomes in adults undergoing UCBT at our 2 centers.

Methods

All adults who underwent UCBT between January 1, 2006 and December 31, 2015 were included. Infectious episodes from 6 months before to 2 years after UCBT were reviewed.

Results

Fifty-seven patients underwent UCBT; 47 had neutrophil engraftment. A total of 179 infectious episodes occurred in 55 patients, 73 (41%) within 30 days post-UCBT. Viruses caused 85 (47%) infections. Cytomegalovirus caused 32 infectious episodes and was most common from day 30 to 100. Human herpesvirus 6 occurred in 28 episodes, was most common within 30 days, and caused 1 death. Bacteria were responsible for 82 (46%) infections, most commonly bacteremias due to Staphylococcus spp, Enterococcus spp, and Enterobacteriaceae. Of 11 invasive fungal infections, 9 were aspergillosis, 4 of which were fatal. Overall mortality was 56% in the first year. Thirteen deaths were from infection; 11 occurred in the first 100 days and 7 in the first 30 days post-UCBT. Of 10 patients who never engrafted, 9 died, 6 from infection, within 100 days post-UCBT.

Conclusions

Infectious complications were common after UCBT, especially in the first 30 days. Deaths from viral infections were fewer than expected. Delayed engraftment and nonengraftment continue to convey increased risk for fatal bacterial and fungal infections post-UCBT.

2040. Clinical Application of Aspergillus Lateral Flow Device (AspLFD) in Bronchoalveolar Lavage (BAL) Fluid of Patients with Classic Risk Factors for Invasive Pulmonary Aspergillosis (IPA)

Background

IPA causes high morbidity and mortality in immunocompromised patients, but diagnosis remains challenging. A newly formatted AspLFD targets specific Aspergillus antigen JF5, but reported results for this test are variable. We evaluated the performance characteristics of this new AspLFD in BAL fluid of patients with IPA.

Methods

Samples tested were from patients with classic risk factors for IPA defined by EORTC/MSG criteria and that had been prospectively banked in our BAL repository. Each case of IPA identified was matched to two high-risk control patientst without IPA or other invasive fungal infection. Samples were thawed, vortexed, centrifuged, and 100 μL of supernatant was applied to the AspLFD. Results were interpreted at 15 minutes as +, ++, +++, or negative by three independent, blinded observers. Test characteristics, including sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated.

Results

Samples from 14 patients with proven/probable IPA by EORTC/MSG criteria and 28 control patients without IPA were tested. Median age was 58 (range 22–87); 28 were men. Age and gender distribution were similar between cases and controls. Among IPA cases, 9 were on T cell depleting agents, 4 on high-dose steroids, and 3 had prolonged neutropenia. Among non-IPA controls, risk factors were T-cell depleting agents (17), high-dose steroids (11), and stem cell transplant (2). Of the 14 patients with IPA, AspLFD was positive in 3, negative in 9; in 2, the internal control line did not display and these were considered invalid. Of 6 patients receiving an azole, three had a positive AspLFD test. AspLFD was negative for all 28 BAL in the non-IPA group. AspLFD showed low sensitivity (25%) and high specificity (100%); PPV was 100% and NPV was 75%. Accuracy of the test was 77.5%.

Conclusion

A positive AspLFD test in BAL of patients with classic risk factors for IPA could be useful for ruling in proven/probable IPA because of its high specificity. However, the use of AspLFD as a screening test for IPA is limited by its poor sensitivity.

Disclosures

All authors: No reported disclosures.

2042. Clinical Application of AspID PCR Alone and in Combination with Aspergillus Lateral Flow Device (AspLFD) in Bronchoalveolar Lavage (BAL) Fluid of Patients with Classic Risk Factors for Invasive Pulmonary Aspergillosis (IPA)

Background

Methods

Results

Conclusion

Disclosures

1542. Infectious Complications in Patients Following Umbilical Cord Blood Transplant (UCBT) for Hematologic Malignancy

Background

UCBT can be performed in pt with hematologic malignancies who do not have a matched donor, but engraftment often takes longer than with a standard allogeneic stem cell transplant. Delayed engraftment can increase the risk for infections, but characteristics of specific infections & outcomes have not been well characterized in adults undergoing UCBT.

Methods

All adults who underwent UCBT between January 1, 2006 and January 1, 2016 at our two centers were included. Infectious episodes within 6 months before and up to 2 years after UCBT were reviewed.

Results

Fifty-seven patients underwent UCBT. Mean age was 43 ± 14 years, and 34 patients were women. Thrity-nine (60%) had acute leukemia. Only 47 patients had neutrophil engraftment. One hundred and seventy-nine infectious episodes occurred in 55 patients, 73 (41%) within 30 days post-UCBT. Viruses caused 85 (47%) infections. HHV-6 occurred in 28 episodes, 24 of which were viremia alone, and was most common within 30 days of UCBT. One patient died of HHV-6 encephalitis. CMV caused 32 infectious episodes, 24 of which were viremia only, was most common from Days 30–100, and caused no deaths. BK viruria occurred in 18 episodes. Bacteria were responsible for 82 (46%) infections; most common were bacteremias due to Staphylococcus, van-R Enterococcus and Enterobacteriaceae. Three patients had mycobacterial infections, two of which were fatal. Of 11 invasive fungal infections (IFI), nine were invasive aspergillosis, of which four were fatal. Overall mortality was 56% in the first year, including 13 deaths from infection. Eleven of these 13 infections occurred in the first 100 days post-UCBT and seven of them in the first 30 days. Patients who died within 100 days were significantly more likely to have had IFI (P = 0.04) or infection with VRE (P = 0.03) or Enterobacteriaceae (P = 0.03) within 30 days after UCBT. Among the 10 patients who never had neutrophil engraftment, nine died within 100 days post-UCBT, six from infection.

Conclusion

Infectious complications were common after UCBT, especially in the first 30 days. Deaths from viral infections were fewer than expected, most likely because of increased screening and prophylaxis for CMV infections. Delayed engraftment and nonengraftment continue to convey increased risk for fatal bacterial and fungal infections post-UCBT.

Disclosures

All authors: No reported disclosures.

971. Breakthrough Invasive Fungal Infections (IFI) in Acute Leukemia (AL) Patients Receiving Antifungal Prophylaxis

Background

A major challenge in patients with AL receiving chemotherapy is to decrease the risk of IFI during the prolonged neutropenic period. Even with antifungal prophylaxis, the incidence of breakthrough IFI can be as high as 14%. Our objectives were to determine the incidence of all IFI and breakthrough IFI, to define risk factors associated with IFI, and to assess outcomes.

Methods

Single-center retrospective cohort analysis of all adult patients admitted to the University of Michigan for AL from January 1, 2010 to December 31, 2013. Chart review determined co-morbidities, chemotherapy regimens, antifungal prophylaxis, occurrence of IFI as determined by EORTC/MSG criteria, and outcomes. Chi-square, Fischer’s, ANOVA, and binary logistic regression tests were performed when appropriate.

Results

Of 363 patients, all but 4 had acute myeloid leukemia (AML); 124 had a stem cell transplant (SCT). A total of 103 (28%) had proven (n = 13), probable (n = 22), or possible (n = 68) IFI. Considering only those 35 patients who had proven or probable IFI, the only risk factor for development of IFI by logistic regression analysis was IFLAG chemotherapy (P = .006). Mold infections occurred in 27 patients: Aspergillus (19), Mucorales (5), both Aspergillus and Mucorales (1), Alternaria (1), and Scedosporium (1). Additionally, 5 patients had invasive candidiasis and 3 had Pneumocystis. Eighteen of 35 patients (51%) had breakthrough IFI while on posaconazole suspension (6), fluconazole (5), micafungin (5) or voriconazole (2). Factors significantly associated with breakthrough IFI were SCT (P = .04), neutrophils <500, ≥10 days at diagnosis (P = .002) and prophylaxis with posaconazole suspension (P = .003). Twelve-week mortality in proven and probable IFI was 31% (11/35). Nine of 11 deceased patients had breakthrough IFI; 8 of whom (5 with mold IFI and 3 with invasive candidiasis) died of the fungal infection.

Conclusion

Patients receiving chemotherapy for AL remain at risk for IFI despite the the use of antifungal prophylaxis. In our study, prophylaxis with posaconazole suspension was found to be an independent risk factor for breakthrough IFI. Mortality was high among patients with breakthrough IFI.

Disclosures

All authors: No reported disclosures.

Effect of underlying immune compromise on the manifestations and outcomes of group A streptococcal bacteremia

BACKGROUND

Group A streptococcal bloodstream infection is the most common presentation of invasive group A streptococcal disease. We sought to determine the impact of immunosuppression on severity of disease and clinical outcomes.

METHODS

This retrospective review of 148 patients with at least one positive blood culture for Streptococcus pyogenes from 1/2003 to 3/2013 compared immunocompromised patients with those with no immunocompromise in regards to development of severe complications and mortality.

RESULTS

Twenty-five patients (17%) were immunocompromised; 123 were not. Skin and soft tissue infection occurred in 60% of immunocompromised vs. 38% of non-immunocompromised patients, p = .04. Necrotizing fasciitis and septic shock were significantly more common in immunocompromised patients, p < .0001 and .028, respectively. Mortality at 30 days was 32% in immunocompromised patients vs. 16% in non-immunocompromised patients, p = .05.

CONCLUSION

Patients who are immunocompromised are more likely to develop necrotizing fasciitis and septic shock as complications of group A streptococcal bacteremia and have a higher mortality rate than patients who are not immunocompromised.

Evaluation of patients' skin, environmental surfaces, and urinary catheters as sources for transmission of urinary pathogens

In hospitalized patients with urinary tract infection or asymptomatic bacteriuria, urinary pathogens frequently contaminate skin, high-touch environmental surfaces, and urinary catheters. Contamination is more common in patients with a urinary catheter in place and with gram-positive pathogens. Patients' skin and environmental surfaces may provide an important source for transmission of urinary pathogens.

Morphometric analysis of intact sperm heads and of sperm nuclei in the mouse

A morphometric analysis of mouse sperm and of their nuclei was undertaken to investigate their respective post-testicular maturation. Sperm were collected from the testis, caput and cauda epididymidis, and their corresponding nuclei were isolated. Results indicate that the post-testicular maturation of sperm is distinct from that of nuclei. The size of intact sperm heads increases in the caput followed by a subsequent decrease in the cauda. In contrast, sperm nuclei decrease progressively in size. In general, a greater magnitude and number of alterations in intact heads and nuclei occur while in transit from the testis to the caput than during passage to the cauda epididymis. These results suggest that the period immediately following their release from the testis is crucial to the complete morphological maturation of sperm heads and nuclei.