Impact of an Innovative Endowed Chair Program on Medical Educator Recipients

PURPOSE

Rarely do faculty members receive endowed chairs as recognition for their work as educators. In addition to the title, endowed chairholders have traditionally received discretionary income to pursue value-added work. This study assessed the impact on recipients of receiving an endowed chair for education.

METHOD

The authors conducted a qualitative thematic analysis between 2018 and 2020, interviewing University of California, San Francisco, School of Medicine chairholders who had completed at least one 5-year term. Authors double-coded all transcripts, reconciled codes, applied social cognitive career theory during analysis, and identified themes through an iterative consensus-building approach.

RESULTS

Twenty-three of 24 (96%) eligible faculty members from 16 departments participated. Themes identified were symbolism, resources, education and educator credibility, development, and impact. The chair was a symbol that brought recognition, indicated quality, and amplified visibility and status within the institution and externally. Receiving an endowed chair conferred credibility on recipients and empowered them in the educational domain. The resources allowed chairholders the flexibility to undertake activities that were of value to them, to mentees, and to the organization. Holding the chair facilitated professional development for self and others. Chair recipients reported impact that persisted long after their term(s) concluded. A model of impact emerged, suggesting that simply possessing the chair title led to visibility and gravitas, which, combined with resources, allowed the holder to leverage opportunities in education.

CONCLUSIONS

The endowed chair is an important strategy for career development in education for the chairholder and enhances the position of education institutionally. Having a plan sharpens the focus on activities, results, and impact.

HOPE in action: A prospective multicenter pilot study of liver transplantation from donors with HIV to recipients with HIV

Liver transplantation (LT) from donors-with-HIV to recipients-with-HIV (HIV D+/R+) is permitted under the HOPE Act. There are only three international single-case reports of HIV D+/R+ LT, each with limited follow-up. We performed a prospective multicenter pilot study comparing HIV D+/R+ to donors-without-HIV to recipients-with-HIV (HIV D-/R+) LT. We quantified patient survival, graft survival, rejection, serious adverse events (SAEs), human immunodeficiency virus (HIV) breakthrough, infections, and malignancies, using Cox and negative binomial regression with inverse probability of treatment weighting. Between March 2016-July 2019, there were 45 LTs (8 simultaneous liver-kidney) at 9 centers: 24 HIV D+/R+, 21 HIV D-/R+ (10 D- were false-positive). The median follow-up time was 23 months. Median recipient CD4 was 287 cells/µL with 100% on antiretroviral therapy; 56% were hepatitis C virus (HCV)-seropositive, 13% HCV-viremic. Weighted 1-year survival was 83.3% versus 100.0% in D+ versus D- groups (p = .04). There were no differences in one-year graft survival (96.0% vs. 100.0%), rejection (10.8% vs. 18.2%), HIV breakthrough (8% vs. 10%), or SAEs (all p > .05). HIV D+/R+ had more opportunistic infections, infectious hospitalizations, and cancer. In this multicenter pilot study of HIV D+/R+ LT, patient and graft survival were better than historical cohorts, however, a potential increase in infections and cancer merits further investigation.

Characteristics of High-Titer Convalescent Plasma and Antibody Dynamics After Administration in Patients With Severe Coronavirus Disease 2019

We characterized the antibody composition of coronavirus disease 2019 (COVID-19) convalescent plasma (CCP) and the immunologic responses of hospitalized COVID-19 patients after receiving CCP or nonimmune fresh frozen plasma. Despite selection of CCP with significantly higher total immunoglobulin G than recipients, neutralizing antibody levels did not differ between donor plasma and CCP recipients.

Kidney Transplantation in HIV-positive Patients: Current Practice and Management Strategies

BACKGROUND

HIV-positive patients had been successfully transplanted for the last 15 y and the donor pool had successfully been expanded to also include HIV-positive donors.

METHODS

We aimed to evaluate the effectiveness of transplantation in HIV-positive patients and highlight some of the important issues reported in the literature. We pooled clinical data from different cohorts to show some of the common issues encountered in HIV-positive transplantation. Furthermore, we searched MEDLINE via PubMed, EMBASE, Cochrane CENTRAL to create a comprehensive table for current evidence for different issues currently encountered when transplanting HIV-positive patients.

RESULTS

We included data from 19 cohort studies and reported on outcomes of the current HIV-positive transplant programs. We made recommendations based on personal experience as well as the experience reported in the literature regarding rejection, opportunistic infection, and HIV-associated nephropathy. Opportunistic infections and malignancies are not a major problem for this population group.

CONCLUSIONS

HIV-positive patients encounter very specific issues after transplantation, specifically related to drug interactions and higher rejection rates. When utilizing HIV-positive donors, the recurrence of HIV-associated nephropathy in the graft kidney is an issue which can be important. Despite some issues with high rejection rates, HIV-positive patients have similar results to HIV-negative patients posttransplantation.

Testing deceased organ donors for infections: An organ procurement organization survey

Organ procurement organizations (OPO) test potential deceased organ donors for infectious diseases required by policy, but many also perform testing for additional infections. The current state of donor testing in the United States is unknown. We sent an IRB approved survey to all 57 U.S. OPOs using REDCap. Descriptive statistics were performed. From the 57 OPOs, we received 46 (80.7%) unique responses with all 11 United Network of Organ Sharing regions represented. Forty of 46 (87%) OPO respondents consulted an Infectious Diseases physician when needed. Eighteen of 46 (39%) tested for West Nile virus (WNV) and 17 of 18 (94%) tested year-round. Eleven of 46 (23.9%) tested for Strongyloides infection while 17 of 46 (37%) tested for Chagas disease. All OPOs performed prospective nucleic acid testing (NAT) for HIV, hepatitis B and hepatitis C on all donors. OPO testing of additional infections has increased since prior surveys but remains variable. Standardization of organ donor infectious diseases evaluation should be considered.

A prospective multicenter pilot study of HIV-positive deceased donor to HIV-positive recipient kidney transplantation: HOPE in action

HIV-positive donor to HIV-positive recipient (HIV D+/R+) transplantation is permitted in the United States under the HIV Organ Policy Equity Act. To explore safety and the risk attributable to an HIV+ donor, we performed a prospective multicenter pilot study comparing HIV D+/R+ vs HIV-negative donor to HIV+ recipient (HIV D-/R+) kidney transplantation (KT). From 3/2016 to 7/2019 at 14 centers, there were 75 HIV+ KTs: 25 D+ and 50 D- (22 recipients from D- with false positive HIV tests). Median follow-up was 1.7 years. There were no deaths nor differences in 1-year graft survival (91% D+ vs 92% D-, P = .9), 1-year mean estimated glomerular filtration rate (63 mL/min D+ vs 57 mL/min D-, P = .31), HIV breakthrough (4% D+ vs 6% D-, P > .99), infectious hospitalizations (28% vs 26%, P = .85), or opportunistic infections (16% vs 12%, P = .72). One-year rejection was higher for D+ recipients (50% vs 29%, HR: 1.83, 95% CI 0.84-3.95, P = .13) but did not reach statistical significance; rejection was lower with lymphocyte-depleting induction (21% vs 44%, HR: 0.33, 95% CI 0.21-0.87, P = .03). In this multicenter pilot study directly comparing HIV D+/R+ with HIV D-/R+ KT, overall transplant and HIV outcomes were excellent; a trend toward higher rejection with D+ raises concerns that merit further investigation.

1127. Medical School in the Era of COVID-19: Innovations in Direct Near Peer Teaching of Immunology/Microbiology Content During the Pandemic

Background

Near-peer teaching (NPT) is increasingly utilized in undergraduate medical education. At our institution’s NPT program, teachers are recruited and trained in the final block of their first year, involving simultaneous learning and teaching of Immunology and Microbiology content to classmates. This year, in-person training and teaching was conducted virtually due to COVID19. This study aims to understand how NPT in a newly virtual curriculum impacted student experiences of learning infectious disease content.

Methods

We conducted one-on-one interviews with student-learners and direct-peer student-teachers at the end of their first year in June 2020. Using constructivist grounded theory, we coded, reconciled, and analyzed interview transcripts to identify themes.

Results

Qualitative analysis of interviews with students (n=5) and near-peer teachers (n=7) yielded the following themes:

1.Optimized learning environment: Direct peer teaching leads to students feeling more personally invested in their peers’ lessons and wellbeing, creating a safe community and increased engagement despite the virtual format and recordings.

2.Benefits of education technology: Teachers employed creative virtual learning modalities to promote students’ mastery of challenging memorization-based microbiology content.

3.COVID-19 relevance: Learning microbiology and immunology content synchronously with the COVID pandemic conferred more content relevance, but presented academic challenges due to social and personal stressors.

4.Educator development: Despite the difficulty of occupying a dual student-teacher role, teachers derived many benefits from teaching, including improved communication skills, which extended to the clinic, content mastery, and increased confidence.

Conclusion

The COVID-19 pandemic led to unprecedented disruptions in medical education. However, the shift to virtual direct peer teaching presented an opportunity for creative virtual teaching strategies and increased lesson accessibility via recordings. Unexpectedly, virtual lessons were perceived as non-inferior to in-person lessons. Findings from this study support the use of virtual near-peer teaching programs in infectious diseases medical education.

Disclosures

All Authors: No reported disclosures

969. TNF-alpha inhibition in the setting of undiagnosed HIV infection: a call for enhanced screening guidelines

Background

Despite the risks of immunosuppression, recommendations regarding screening for HIV infection prior to initiation of biologic therapies targeting common autoimmune disorders, including inflammatory bowel disease (IBD) and inflammatory arthritides, are limited. Few cases of patients started on biologics while living with undiagnosed HIV have been reported.

Methods

We report 3 cases of patients initiated on biologics in the absence of recent or concurrent HIV screening who developed refractory disease or unanticipated complications and were later found to have undiagnosed chronic HIV infection.

Results

In Case 1, a 53-year-old man who has sex with men (MSM) with negative HIV testing 10 years prior presented with presumed rheumatoid arthritis. He did not respond to methotrexate (MTX), so adalimumab (ADA) was started. HIV testing to evaluate persistent symptoms was positive 9 months later; CD4 was 800 cells/uL. Antiretroviral therapy (ART) resulted in resolution of symptoms, which were attributed to HIV-associated arthropathy.

In Case 2, a 55-year-old woman with injection drug use in remission and no prior HIV testing presented with Hidradenitis Suppurativa (HS). She was initiated on infliximab (IFX) and MTX with good response. After she developed weight loss and lymphopenia, an HIV test was positive; CD4 was 334 cells/uL. Biologic HS therapy was discontinued, with subsequent poor HS control.

In Case 3, a 32-year-old MSM with no prior HIV testing presented with presumed IBD; IFX and steroids were started. Symptoms progressed despite IBD-directed therapy, and he was diagnosed with extensive Kaposi Sarcoma (KS) with visceral and cutaneous involvement likely exacerbated by immunosuppression. HIV testing was positive; CD4 was 250 cells/uL. KS initially worsened due to ART-associated immune reconstitution inflammatory syndrome. He is now improving with systemic chemotherapy and ART. HIV-associated KS is presumed to be hte underlying diagnosis.

Conclusion

All 3 patients had elevated risk for HIV infection, and 2 had final diagnoses attributed to chronic HIV infection, not warranting therapeutic immunosuppression. Screening for HIV infection prior to initiation of biologic therapy should be incorporated into clinical practice guidelines.

Disclosures

All Authors: No reported disclosures

A systematic review and meta-analysis assessing the impact of droughts, flooding, and climate variability on malnutrition

BACKGROUND

Both the World Health Organization and the Intergovernmental Panel on Climate Change project that malnutrition will be the greatest contributor to climate change-associated morbidity and mortality. Although there have been several studies that have examined the potential effects of climate change on human health broadly, the effects on malnutrition are still not well understood. We conducted a systematic review investigating the role of three climate change proxies (droughts, floods, and climate variability) on malnutrition in children and adults.

METHODS AND FINDINGS

We identified 22 studies examining the effects of droughts, floods, and climate variability on at least one malnutrition metric. We found that 17 out of 22 studies reported a significant relationship between climate change proxies and at least one malnutrition metric. In meta-analysis, drought conditions were significantly associated with both wasting (Odds Ratio [OR] 1.46, 95% Confidence Interval [CI] 1.05-2.04) and underweight prevalence (OR 1.46, 95% CI 1.01-2.11).

CONCLUSIONS

Given the long-term consequences of malnutrition on individuals and society, adoption of climate change adaptation strategies such as sustainable agriculture and water irrigation practices, as well as improving nutritional interventions aimed at children aged 1-2 years and older adults, should be prioritised on global policy agendas in the coming years.

Treatment of immunocompromised COVID-19 patients with convalescent plasma

Immunosuppressed patients such as solid organ transplant and hematologic malignancy patients appear to be at increased risk for morbidity and mortality due to coronavirus disease 2019 (COVID‐19) caused by SARS coronavirus 2 (SARS‐CoV‐2). Convalescent plasma, a method of passive immunization that has been applied to prior viral pandemics, holds promise as a potential treatment for COVID‐19. Immunocompromised patients may experience more benefit from convalescent plasma given underlying deficits in B and T cell immunity as well as contraindications to antiviral and immunomodulatory therapy. We describe our institutional experience with four immunosuppressed patients (two kidney transplant recipients, one lung transplant recipient, and one chronic myelogenous leukemia patient) treated with COVID‐19 convalescent plasma through the Expanded Access Program (NCT 04338360). All patients clinically improved after administration (two fully recovered and two discharged to skilled nursing facilities) and none experienced a transfusion reaction. We also report the characteristics of convalescent plasma product from a local blood center including positive SARS‐CoV‐2 IgG and negative SARS‐CoV‐2 PCR in all samples tested. This preliminary evidence suggest that convalescent plasma may be safe among immunosuppressed patients with COVID‐19 and emphasizes the need for further data on the efficacy of convalescent plasma as either primary or adjunctive therapy for COVID‐19.

Molecular Insights in Transmission of Cancer From an Organ Donor to Four Transplant Recipients

Organ donors are systematically screened for infection, whereas screening for malignancy is less rigorous. The true incidence of donor-transmitted malignancies is unknown due to a lack of universal tumor testing in the posttransplant setting. Donor-transmitted malignancy may occur even when not suspected based on donor or recipient factors, including age and time to cancer diagnosis. We describe the detection of a gastrointestinal adenocarcinoma transmitted from a young donor to 4 transplant recipients. Multidimensional histopathologic and genomic profiling showed a CDH1 mutation and MET amplification, consistent with gastric origin. At the time of writing, one patient in this series remains alive and without evidence of cancer after prompt organ explant after cancer was reported in other recipients. Because identification of a donor-derived malignancy changes management, our recommendation is to routinely perform short tandem repeat testing (or a comparable assay) immediately upon diagnosis of cancer in any organ transplant recipient. Routine testing for a donor-origin cancer and centralized reporting of outcomes are necessary to establish a robust evidence base for the future development of clinical practice guidelines.

Clinical outcomes and serologic response in solid organ transplant recipients with COVID-19: A case series from the United States

The coronavirus disease 2019 (COVID-19) pandemic caused by SARS coronavirus 2 (SARS-CoV-2) has caused significant morbidity and mortality for patients and stressed healthcare systems worldwide. The clinical features, disease course, and serologic response of COVID-19 among immunosuppressed patients such as solid organ transplant (SOT) recipients, who are at presumed risk for more severe disease, are not well characterized. We describe our institutional experience with COVID-19 among 10 SOT patients, including the clinical presentation, treatment modalities, and outcomes of 7 renal transplant recipients, 1 liver transplant recipient, 1 heart transplant recipient, and 1 lung transplant recipient. In addition, we report the serologic response in SOT recipients, documenting a positive IgG response in all 7 hospitalized patients. We also review the existing literature on COVID-19 in SOT recipients to consolidate the current knowledge on COVID-19 in the SOT population for the transplant community.

Pulling at the heart: COVID-19, race/ethnicity and ongoing disparities

Social determinants of health in the African diaspora drive the lack of disease testing, increased prevalence of comorbid disease and reduced access to drugs, resulting in disproportionately higher COVID-19-related mortality among Black individuals than the rest of the population. We urge decisive attention to and action against ethnicity-based inequities that undermine cardiovascular health.

Molecular characterization of a gastric cancer transmitted from an organ donor to four transplant recipients

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Background: Donor-derived malignancy may occur even when not suspected based on donor or recipient factors, including age and time to cancer diagnosis. Early recognition of donor-derived malignancy has treatment implications. We describe the molecular characterization of a gastric cancer transmitted from an organ donor to heart, liver (LR), left kidney (LKR), and right kidney-pancreas (KPR) recipients. Methods: IRB approval for chart review was obtained; LR, LKR, and KPR also provided research consent for molecular profiling. Short Tandem Repeat (STR) genotyping was performed by polymerase chain reaction and gel electrophoresis. Tumor and germline DNA from patients and the organ donor were subjected to next generation sequencing (NGS) of 479 genes. Fluorescence in situ hybridization (FISH) was used to confirm MET amplification. Results: Donor origin was established by STR analysis, with the tumors showing high levels of donor alleles. Pathology revealed a poorly differentiated adenocarcinoma with signet ring features. Immunohistochemical staining and CA-19-9 elevation were most consistent with gastric or pancreas origin. Tumor sequencing was notable for somatic mutation of CDH1, MET amplification and wild-type KRAS genes. Tumors from LR and KPR were nearly identical based on pathogenic variants, allele frequency, and copy number variation. Insufficient tumor cellularity in all LKR specimens precluded NGS profiling, but clinical testing found that the cancer was mismatch repair proficient; ERBB2 equivocal; and PDL-1 positive. A circulating tumor DNA test did not uncover any genomic alterations; however, MET amplification was confirmed in this tumor using FISH probes. Conclusions: STR analysis and reporting should be standard immediately following diagnosis of cancer in an organ transplant recipient to ascertain donor derivation. Further molecular characterization, including NGS, may aid in defining primary tumor origin. Here, diagnosis with PDL1-positive gastric cancer enabled use of pembrolizumab. One patient remains alive and without evidence of cancer following prompt organ explant after cancer was reported in other recipients.

324. Outcomes of Immunomodulatory and Biologic Therapy in People Living with HIV: A Report from Two Academic Hospitals

Background

The use of immunomodulatory drugs (IMDs) is increasingly common. However, data on outcomes of IMD use in people living with HIV (PLWH) are limited and may be biased due to selective reporting of certain outcomes. Institution-level data reflecting patient-time at risk have not been described.

Methods

We systematically identified all PLWH prescribed non-steroidal IMDs from 2012 to 2019 at two centers. We defined a treatment episode (TE) as an uninterrupted period on a particular IMD regimen. Patients contributed multiple TEs if interrupting or switching therapy. We excluded those with lymphoproliferative disorders or transplants. We quantified infections and blips, defined as a detectable viral load following an undetectable result.

Results

35 patients contributed 55 TEs comprising 24,020 patient-days at risk. 29/35 (83%) were male, median age was 53 (IQR 39–59), median CD4 nadir was 197 (IQR 100–314), and 12/35 (34%) had a prior opportunistic infection. TEs utilized TNF inhibitors (19/55, 35%), PD-1 inhibitors (11/55, 20%), antimetabolites (7/55, 13%), interleukin inhibitors (7/55, 13%), and other agents (7/55, 13%). 4/55 (7%) involved in dual therapy. 32/35 (94%) patients were on antiretroviral therapy (ART) at IMD initiation; one was off therapy, one already on IMDs-acquired HIV, and one was an elite controller. Median CD4 count was 472 (IQR 337–807); CD4 was < 500 in 28/55 TEs (51%). Preceding plasma HIV RNA was undetectable in 36/55 (65%) TEs. Of these, 18 (50%) were associated with a viral blip within 1 year; one blip was >200 copies and none resulted in sustained viremia. Compared with other agents, PD-1 inhibitors were associated with a higher blip rate (incidence rate ratio 4.3, 1.3–12.3). 17/55 (32%) TEs were initiated with detectable plasma HIV RNA, which declined on ART in 13/15 (87%) TEs with follow-up testing; one patient stopped ART and one later suppressed. 9/55 (16%) TEs involved an infectious complication (7 soft-tissue infections, 2 pneumonias), although none was clearly attributed to IMDs. 36/55 (65%) TEs had good therapeutic response.

Conclusion

IMDs can be used without major complications in PLWH on ART, including those not yet suppressed or with CD4 counts < 500. PD-1 inhibitors may be associated with a higher rate of viral blips, although the clinical significance is unclear.

Disclosures

All authors: No reported disclosures.

1757. Hepatitis C-Infected Donors and Hepatitis C-Infected Recipients: Analysis of Renal Transplant Outcomes

Background

Increased utilization of hepatitis C virus (HCV)-infected organs could reduce the supply–demand mismatch in organ transplantation. It is important to determine precise outcomes of HCV-positive organs transplanted into HCV-positive recipients (HCV D+\R+) to quantify risk for patients and other stakeholders. Small studies have identified shorter wait times in HCV D+\R+ compared with HCV-negative donor and HCV-positive recipients (HCV D−\R+), but there is little information about survival and rejection in the era of effective direct-acting antivirals (DAA).

Methods

We performed a retrospective cohort study of all cases of renal transplantation involving HCV-positive recipients at an academic medical center from 2008 to 2019. We extracted data using the institutional electronic transplant database. Demographics, incidence of organ rejection, renal function and patient mortality data were compared between HCV D+\R+ and HCV D−\R+.

Results

Among 3,781 patients who received a kidney transplant between 2008–19, 139 were HCV D-\R+ and 51 were HCV D+\R+. Both groups had similar waiting list time (1,196 ± 889 days vs. 1,301 ± 1240 days, P > 0.20), donor mean age (37 ± 11 y vs. 39 ± 13 years, P > 0.20) and sex (female: 37% vs. 42%, P > 0.20). Follow-up time was similar between both groups (5.2 ± 4 years vs. 5.3 ± 3 years, P > 0.20). The incidence of mortality (16% vs. 17%, P > 0.20) [Figure 1] and rejection (18% vs. 19%, P > 0.20) [Figure 2] was similar between two groups. Using a Cox Hazards model, we found no association between HCV D+/R+ and increasing risk of rejection (HR 0.92, 95% CI 0.43–1.95, P > 0.20) or mortality (HR 0.93, 95% CI 0.42–2.1, P > 0.20). In a multivariate analysis, age was the only independent risk factor for HCV D+/R+ mortality (HR = 1.09, 95% CI 1.03–1.14, P < 0.001).

Conclusion

Patients who are HCV-positive did not have worse mortality or graft rejection if they received HCV-positive kidneys compared with HCV-negative kidneys. Providers can use these data to give specific risk information to HCV-positive patients about accepting an HCV-positive kidney for transplant, even perhaps encouraging it. Increasing the utilization of HCV-positive kidneys for transplantation in the era of effective DAA has the potential to offer life-saving treatment to substantially more patients.

Disclosures

All authors: No reported disclosures.

A prospective multicenter observational study of cell-mediated immunity as a predictor for cytomegalovirus infection in kidney transplant recipients

T cell immunity is essential for the control of cytomegalovirus (CMV) infection after transplantation. We evaluated a CMV-specific peptide-based enzyme-linked immunosorbent spot (ELISPOT) assay to determine whether assay results could predict subsequent CMV events. Adult kidney transplant recipients at 43 centers underwent ELISPOT testing to enumerate interferon gamma (IFN-γ) binding spot-forming units (sfu) after stimulation of cells with an overlapping peptide pool of CMV phosphoprotein 65 (pp65) and immediate early-1 (IE-1) protein at the end of antiviral prophylaxis (EOP) and various time points thereafter. The primary outcome was a CMV event in the first posttransplant year. In 583 kidney transplant recipients (260 seropositive donor [D+]/seronegative recipient [R-] and 277 R+), CMV events occurred in 44 of 368 eligible patients (11.8%) at a median of 227 days (range 92-360) posttransplant. A cutoff value of >40 sfu/2.5 × 10⁵  cells for either IE-1 or pp65 was derived as a threshold for positivity, with a negative predictive value of >97% for CMV events. CMV events were significantly lower in assay positive vs assay negative patients (3.0% vs 19.5%, P < .0001 for pp65). Time to CMV event post-EOP was significantly greater in those with sfu >40 at EOP (P < .0001). In this large, multicenter trial of kidney transplant recipients, we show that an assessment of CMV-specific immunity using a novel ELISPOT assay is able to predict protection from CMV infection.

A Multi-Institution Collaboration to Define Core Content and Design Flexible Curricular Components for a Foundational Medical School Course: Implications for National Curriculum Reform

Medical educators have not reached widespread agreement on core content for a U.S. medical school curriculum. As a first step toward addressing this, five U.S. medical schools formed the Robert Wood Johnson Foundation Reimagining Medical Education collaborative to define, create, implement, and freely share core content for a foundational medical school course on microbiology and immunology. This proof-of-concept project involved delivery of core content to preclinical medical students through online videos and class-time interactions between students and facilitators. A flexible, modular design allowed four of the medical schools to successfully implement the content modules in diverse curricular settings. Compared with the prior year, student satisfaction ratings after implementation were comparable or showed a statistically significant improvement. Students who took this course at a time point in their training similar to when the USMLE Step 1 reference group took Step 1 earned equivalent scores on National Board of Medical Examiners-Customized Assessment Services microbiology exam items. Exam scores for three schools ranged from 0.82 to 0.84, compared with 0.81 for the national reference group; exam scores were 0.70 at the fourth school, where students took the exam in their first quarter, two years earlier than the reference group. This project demonstrates that core content for a foundational medical school course can be defined, created, and used by multiple medical schools without compromising student satisfaction or knowledge. This project offers one approach to collaboratively defining core content and designing curricular resources for preclinical medical school education that can be shared.

Infectious and Other Complications of Immunobiologic Agents

Individuals with HIV infection are living longer, and are at risk of autoimmune disorders and cancers associated with aging. Many of these conditions are treated with immunobiologic agents that affect immune function and may increase risk of opportunistic infections (OIs) and other immune disorders in individuals with HIV infection. For example, tumor necrosis factor-alpha inhibitors, used to treat such disorders as Crohn's disease, are associated with risk of tuberculosis and histoplasmosis. Rituximab, used to treat lymphoma, has been associated with progressive multifocal leukoencephalopathy due to JC virus and reactivation of other viral infections. Idealisib, used to treat chronic lymphocytic leukemia, has been associated with Pneumocystis pneumonia, and immune checkpoint inhibitors used to treat a variety of cancers have been associated with a wide range of immune-related adverse effects. Practitioners must maintain high vigilance for OIs and other immune-related disorders in patients with HIV infection who are receiving biologic therapies. This article summarizes a presentation by Peter Chin-Hong, MD, at the IAS-USA continuing education program held in Chicago in May 2018.

977. An Innovative 3-Year Medical Student Spiral Curriculum in Antimicrobial Stewardship and Infectious Diseases

Background

By 2050, infections due antimicrobial-resistant organisms are predicted to account for 10 million deaths/year worldwide. Physician antibiotic prescribing patterns are a significant factor in the development of antibiotic resistance organisms. Early, continual, and integrated medical student education may help students develop a framework for responsible antimicrobial use as they develop prescribing patterns.

Methods

We designed a spiral antimicrobial stewardship curriculum (defined as revisiting the same concept but with increasing complexity) for medical students in years 2–4. Data provided by the Graduation Questionnaire (GQ) administered by the US Association of American Colleges were used. We compared student responses during the curriculum rollout in 2013–2015 between students at our institution and other schools. We also surveyed graduating seniors in 2015 about antimicrobial stewardship training.

Results

Using GQ data for the class of 2013 (preintervention), a similar proportion of UCSF medical students compared with other US medical students rated microbiology clinical preparation as excellent (43.6% vs. 45.1%, P > 0.20). For the 2014 class, we developed interactive case-based sessions at the beginning of years 3 and 4. After this first intervention, a higher proportion of UCSF students rated the microbiology clinical preparation as excellent (51.3%) compared with responses at all schools (39.8%, odds ratio [OR] 1.59, 95% confidence interval [CI] 1.1–2.3, P = 0.013). For the class of 2015, we added content during the medicine clerkship and 1 week before graduation. For the 2015 class, an even higher proportion of UCSF students rated microbiology preparation as excellent (57.6%), compared with all schools (41.2%, OR 2.23, 95% CI 1.54–3.22, P < 0.0001). From our survey, 88% were very or extremely satisfied with antimicrobial stewardship training.

Conclusion

A spiral curriculum focusing on antimicrobial stewardship and infectious diseases increases student perception of clinical preparation prior to graduation. As the curriculum was incrementally introduced, students’ knowledge increased indicating a dose–response pattern. Based on these positive results, we plan to introduce more content throughout UME, and link to curriculum for GME and practicing clinicians.

Disclosures

All authors: No reported disclosures.

1586. Prevalence and Significance of Pre-transplant BK Viremia and Viruria in Deceased and Living Kidney Donors and Kidney Transplant Recipients

Background

BK virus (BKV) is a major cause of nephropathy in kidney transplantation. Pre-transplant BKV shedding in the donor or recipient may increase the risk for developing BKV viremia in kidney transplant recipients.

Methods

From August 2016 to December 2017, we prospectively performed pre-transplant BKV DNA PCR testing on plasma and urine samples from deceased kidney donors procured through Donor Network West, our local organ procurement organization and third largest in the country. We also simultaneously performed pre-transplant BKV DNA PCR testing of plasma and urine from living kidney donors and adult kidney transplant recipients as well as post-transplant surveillance testing of recipients at Stanford University Medical Center.

Results

BKV DNA PCR testing of plasma and urine samples from 212 deceased kidney donors revealed 17 donors that were positive (16 in urine, 1 in plasma; 8.02% BKV DNA detection). Fifty of these specimens went to Stanford kidney transplant recipients, including four donors with BKV viruria (8.00%). During the study period, we obtained complete pre-transplant donor and recipient pairings for 47 deceased and 39 living adult kidney transplant recipients. Of these 86 kidney recipients, none had detectable BKV DNA in pre-transplant donor or recipient plasma specimens, while 10 (four deceased, six living) had BKV DNA detected in the urine. The majority (9/10) were positive in the donor urine, with one positive in the recipient and one in both the recipient and donor. After a minimum follow-up of 5 months, three (30%) had developed BKV viremia, compared with three of the 76 (3.9%, P = 0.009) with negative pre-transplant BKV DNA. The rate of BKV viruria was not significantly different between deceased and living kidney donors (4/47 (8.5%) vs. 6/39 (15.4%), P = 0.32).

Conclusion

In one of the largest cohorts in the United States that also includes deceased donor testing, we demonstrate that pre-transplant BKV viruria, particularly of the donor, is associated with development of BKV viremia in kidney transplant recipients. Pre-transplant BKV DNA screening in the urine of kidney donors (deceased and living) may be useful in predicting risk for BKV viremia.

Disclosures

All authors: No reported disclosures.

Plasma Cell-Free DNA Next-Generation Sequencing to Diagnose and Monitor Infections in Allogeneic Hematopoietic Stem Cell Transplant Patients

Allogeneic hematopoietic stem cell transplant patients are at risk for common and atypical infections. Superior diagnostics can decrease infection-related morbidity and mortality. A novel plasma cell-free DNA next-generation sequencing test detected an uncommon presentation of Chlamydia trachomatis and recurrent and metastatic complications of Staphylococcus aureus bacteremia before standard microbiology.

Adjunctive Corticosteroid Therapy in the Treatment of Coccidioidal Meningitis

Coccidioidal meningitis (CM) has high morbidity, and adjunctive measures to improve outcomes are needed. Using an established multicenter retrospective cohort study of CM (N = 221), we found that patients receiving adjunctive corticosteroids had a significant reduction in secondary cerebrovascular events (P = .0049). Those with CM-associated cerebrovascular events (8%) may benefit from short-term corticosteroids.

Three Cases of Neurologic Syndrome Caused by Donor-Derived Microsporidiosis

Encephalitozoon cuniculi was transmitted from an infected donor to 3 solid organ recipients, 1 of whom died.

In April 2014, a kidney transplant recipient in the United States experienced headache, diplopia, and confusion, followed by neurologic decline and death. An investigation to evaluate the possibility of donor-derived infection determined that 3 patients had received 4 organs (kidney, liver, heart/kidney) from the same donor. The liver recipient experienced tremor and gait instability; the heart/kidney and contralateral kidney recipients were hospitalized with encephalitis. None experienced gastrointestinal symptoms. Encephalitozoon cuniculi was detected by tissue PCR in the central nervous system of the deceased kidney recipient and in renal allograft tissue from both kidney recipients. Urine PCR was positive for E. cuniculi in the 2 surviving recipients. Donor serum was positive for E. cuniculi antibodies. E. cuniculi was transmitted to 3 recipients from 1 donor. This rare presentation of disseminated disease resulted in diagnostic delays. Clinicians should consider donor-derived microsporidial infection in organ recipients with unexplained encephalitis, even when gastrointestinal manifestations are absent.

Baylisascaris procyonis-Associated Meningoencephalitis in a Previously Healthy Adult, California, USA

After severe neurocognitive decline developed in an otherwise healthy 63-year-old man, brain magnetic resonance imaging showed eosinophilic meningoencephalitis and enhancing lesions. The patient tested positive for antibodies to Baylisascaris spp. roundworms, was treated with albendazole and dexamethasone, and showed improvement after 3 months. Baylisascariasis should be considered for all patients with eosinophilic meningitis.

Raccoon Roundworm Infection Associated with Central Nervous System Disease and Ocular Disease - Six States, 2013-2015

Baylisascaris procyonis, predominantly found in raccoons, is a ubiquitous roundworm found throughout North America. Although raccoons are typically asymptomatic when infected with the parasite, the larval form of Baylisascaris procyonis can result in fatal human disease or severe neurologic outcomes if not treated rapidly. In the United States, Baylisascaris procyonis is more commonly enzootic in raccoons in the midwestern and northeastern regions and along the West Coast (1). However, since 2002, infections have been documented in other states (Florida and Georgia) and regions (2). Baylisascariasis is not a nationally notifiable disease in the United States, and little is known about how commonly it occurs or the range of clinical disease in humans. Case reports of seven human baylisascariasis cases in the United States diagnosed by Baylisascaris procyonis immunoblot testing at CDC are described, including review of clinical history and laboratory data. Although all seven patients survived, approximately half were left with severe neurologic deficits. Prevention through close monitoring of children at play, frequent handwashing, and clearing of raccoon latrines (communal sites where raccoons defecate) are critical interventions in curbing Baylisascaris infections. Early treatment of suspected cases is critical to prevent permanent sequelae.

Steak tartare endocarditis

This report describes a case of Campylobacter fetus prosthetic valve infective endocarditis and discusses the subsequent management. Although C. fetus has a tropism for vascular endothelium, infective endocarditis has rarely been reported. In this patient, despite initial optimal antimicrobial therapy, valve replacement was ultimately required due to ongoing infectious emboli to the brain in the setting of evidence of vegetation enlargement on echocardiogram. The prosthetic valve was replaced, the patient completed a 6-week course of parenteral antibiotics after surgical intervention and he made a full recovery with no long-term neurological sequelae. This case highlights the fact that despite the relatively low prevalence of C. fetus endocarditis, it is associated with a high degree of mortality and valve replacement is often indicated.

Late aspergilloma of a renal allograft without need for operative management: a case report and review of the literature

Aspergillus infection localized to the renal allograft is a rare and potentially life-threatening infection and typically requires a combination of operative and medical management. We report the case of a renal allograft aspergilloma in a renal transplant patient presenting 2 years post transplant, successfully managed non-surgically. To our knowledge, this is the first report of a patient presenting with an allograft aspergilloma so long after transplantation and being successfully managed with antifungal therapy alone.

Voriconazole Exposure and Risk of Cutaneous Squamous Cell Carcinoma, Aspergillus Colonization, Invasive Aspergillosis and Death in Lung Transplant Recipients

Voriconazole is a triazole antifungal used to prevent and treat invasive fungal infections after lung transplantation, but it has been associated with an increased risk of developing cutaneous squamous cell carcinoma (SCC). Despite widespread use, there are no clear guidelines for optimal prophylactic regimens that balance the competing risks and benefits. We conducted a retrospective cohort study of all lung transplant recipients at the University of California, San Francisco, who were transplanted between October 1991 and December 2012 (n = 455) to investigate whether voriconazole exposure affected development of SCC, Aspergillus colonization, invasive aspergillosis and all-cause mortality. Voriconazole exposure was associated with a 73% increased risk of developing SCC (hazard ratio [HR] 1.73; 95% confidence interval [CI]: 1.04-2.88; p = 0.03), with each additional 30-day exposure at the standard dose increasing the risk by 3.0% (HR 1.03; 95% CI: 1.02-1.04; p < 0.001). Voriconazole exposure reduced risk of Aspergillus colonization by 50% (HR 0.50; 95% CI: 0.34-0.72; p < 0.001), but we were underpowered to detect risk reduction for invasive aspergillosis. Voriconazole exposure significantly reduced all-cause mortality among subjects who developed Aspergillus colonization (HR 0.34; 95% CI: 0.13-0.91; p = 0.03) but had no significant impact on those without colonization. Physicians should consider patient-specific factors that modify the potential risks and benefits of voriconazole for the care of lung transplant recipients.

Under seize: neurocysticercosis in an immigrant woman and review of a growing neglected disease

Neurocysticercosis (NCC) is a significantly neglected tropical disease and, with increasing globalisation, a notable emerging infection in the developed world. We describe a case of ventricular NCC in a 22-year-old Mexican-American woman with a history of seizures, who presented with 2 weeks of headaches and intermittent fevers progressing to altered mental status and vomiting. Initial imaging revealed a cystic mass at the posteroinferior aspect of the third ventricle superior to the aqueduct of Sylvius, calcifications scattered throughout the parenchyma, and enlargement of the lateral and third ventricles. Initial laboratories were unrevealing and serum investigations for Taenia solium antibody were negative, but T. solium antibody was subsequently returned positive from cerebrospinal fluid. This case highlights important issues regarding the clinical presentation, diagnostic evaluation and treatment of NCC relevant to providers not only in areas with endemic disease but, importantly, in locales with diverse immigrant populations.

A paradoxical decline: intracranial lesions in two HIV-positive patients recovering from cryptococcal meningitis

Cryptococcal immune reconstitution inflammatory syndrome (C-IRIS) is an increasingly important manifestation among patients with HIV/AIDS, especially as the use of antiretroviral therapy (ART) is expanding worldwide. Cryptococcus and associated C-IRIS are common causes of meningitis. While intracranial lesions are common in HIV/AIDS, they are rarely due to cryptococcosis or C-IRIS. We describe two cases of paradoxical C-IRIS associated with the development of intracranial cryptococcomas in HIV/AIDS. Both patients had an initial episode of cryptococcal meningitis treated with antifungal therapy. At the time, they had initiated or modified ART with subsequent evidence of immune reconstitution. Two months later, they developed aseptic meningitis with intracranial lesions. After exhaustive work ups, both patients were diagnosed with paradoxical C-IRIS and biopsy confirmed intracranial cryptococcomas. We review the important clinical, diagnostic and therapeutic features of cryptococcomas associated with C-IRIS in HIV/AIDS.

Epstein-Barr virus encephalitis in a renal transplant recipient manifesting as hemorrhagic, ring-enhancing mass lesions

Epstein-Barr virus (EBV) encephalitis has been infrequently described in immunocompromised patients. Here, we report a unique case of biopsy-proven EBV encephalitis in a renal transplant recipient presenting with altered mental status, prominent visual disturbances, and hemorrhagic, ring-enhancing mass lesions on magnetic resonance imaging. The patient was successfully treated with a prolonged course of antivirals. This case illustrates the difficulty in interpretation of cerebrospinal fluid EBV polymerase chain reaction assay, given the lack of specificity in immunocompromised patients.

Trichomonas vaginalis infection among homeless and unstably housed adult women living in a resource-rich urban environment

OBJECTIVE

The social context of poverty is consistently linked to Trichomonas vaginalis infection, yet few studies regarding T. vaginalis have been conducted exclusively among low-income individuals. We identified social determinants of health associated with prevalent T. vaginalis infection among homeless and unstably housed adult women.

METHODS

Between April and October of 2010, we conducted cross-sectional T. vaginalis screening and behavioural interviews in an existing cohort of San Francisco homeless and unstably housed women. Data were analysed using multivariable logistical regression.

RESULTS

Among 245 study participants, the median age was 47 years and 72% were of non-Caucasian race/ethnicity. T. vaginalis prevalence was 12%, compared to 3% in the general population, and 33% of infected individuals reported no gynaecological symptoms. In adjusted analysis, the odds of T. vaginalis infection were lower among persons older than 47 years, the population median (OR=0.14, 95% CI 0.04 to 0.38), and higher among those reporting recent short-term homeless shelter stays (OR=5.36, 95% CI 1.57 to 18.26). Race and income did not reach levels of significance. Sensitivity analyses indicated that testing all women who report recent unprotected sex would identify more infections than testing those who report gynaecological symptoms (20/30 vs 10/30; p=0.01).

CONCLUSIONS

The prevalence of T. vaginalis is high among homeless and unstably housed adult women, over one-third of infected individuals have no gynaecological symptoms, and correlates of infection differ from those reported in the general population. Targeted screening and treatment among impoverished women reporting recent unprotected sex, particularly young impoverished women and all women experiencing short-term homelessness, may reduce complications related to this treatable infection.

Transplant tourism: understanding the risks

Transplant tourism is commonly defined as travel abroad for the purpose of transplantation, but the term evokes ethical and legal concerns about commercial transplantation. Due to the mismatch in supply and demand for organs, transplant tourism has increased over the last several decades and now accounts for 10 % of transplants worldwide. Patients from the USA who pursue transplantation abroad do so most commonly for renal transplantation, and travel mostly to China, the Philippines, and India. Transplant tourism puts the organ recipient at risk for surgical complications, poor graft outcome, increased mortality, and a variety of infectious complications. Bacterial, viral, fungal, and parasitic infections have all been described, and most concerning are the high rates of blood-borne viral infections and invasive, often fatal, fungal infections. Transplant and infectious diseases physicians should have a high degree of suspicion for infectious complications in patients returning from transplantation abroad.