Rapid response infrastructure for pandemic preparedness in a tertiary care hospital: lessons learned from the COVID-19 outbreak in Cologne, Germany, February to March 2020

The coronavirus disease (COVID-19) pandemic has caused tremendous pressure on hospital infrastructures such as emergency rooms (ER) and outpatient departments. To avoid malfunctioning of critical services because of large numbers of potentially infected patients seeking consultation, we established a COVID-19 rapid response infrastructure (CRRI), which instantly restored ER functionality. The CRRI was also used for testing of hospital personnel, provided epidemiological data and was a highly effective response to increasing numbers of suspected COVID-19 cases.

Pretreatment resistance mutations and treatment outcomes in adults living with HIV-1: a cohort study in urban Malawi

Background

Pre-treatment drug resistance (PDR) among antiretroviral drug-naïve people living with HIV (PLHIV) represents an important indicator for the risk of treatment failure and the spread of drug resistant HIV variants. We assessed the prevalence of PDR and treatment outcomes among adults living with HIV-1 in Lilongwe, Malawi.

Methods

We selected 200 participants at random from the Lighthouse Tenofovir Cohort Study (LighTen). Serum samples were drawn prior to treatment initiation in 2014 and 2015, frozen, and later analyzed for the presence of HIV-1 drug resistance mutations. Amplicons were sequenced and interpreted by Stanford HIVdb interpretation algorithm 8.4. We assessed treatment outcomes by evaluating clinical outcome and viral suppression at the end of the follow-up period in October 2019.

Results

PDR testing was successful in 197 of 200 samples. The overall NNRTI- PDR prevalence was 13.7% (27/197). The prevalence of intermediate or high level NNRTI- PDR was 11.2% (22/197). The most common mutation was K103N (5.6%, 11/197), followed by Y181C (3.6%, 7/197). In one case, we detected an NRTI resistance mutation (M184V), in combination with multiple NNRTI resistance mutations. All HIV-1 isolates analyzed were of subtype C. Of the 27 patients with NNRTI- PDR, 9 were still alive, on ART, and virally suppressed at the end of follow-up.

Conclusion

The prevalence of NNRTI- PDR was above the critical level of 10% suggested by the Global Action Plan on HIV Drug Resistance. The distribution of drug resistance mutations was similar to that seen in previous studies from the region, and further supports the introduction of integrase inhibitors in first-line treatment in Malawi. Furthermore, our findings underline the need for continued PDR surveillance and pharmacovigilance in Sub-Saharan Africa.

Protocol update for the SABATO trial: a randomized controlled trial to assess early oral switch therapy in low-risk Staphylococcus aureus bloodstream infection

BACKGROUND

SABATO (Staphylococcus aureus bacteremia antibiotic treatment options) is a randomized, parallel-group, clinical non-inferiority trial designed to examine the efficacy and safety of early oral switch therapy in low-risk Staphylococcus aureus infection. The original trial protocol was published in Trials (accessible at https://doi.org/10.1186/s13063-015-0973-x ). Here we describe final amendments to the study protocol and discuss the underlying rationale.

METHODS/DESIGN

Three major changes were introduced into the study protocol: (1) the inclusion and exclusion criteria were refined so that patients with certain comorbidities (end-stage renal disease, severe liver disease) and uninfected foreign bodies (orthopedic prosthesis, pacemaker, implanted cardiac cardioverter-defibrillator) became eligible for enrollment under certain conditions; (2) the target sample size was decreased by choosing a conventional non-inferiority margin of 10% and converting the interim analysis (215 patients) into the final analysis; and (3) an additional follow-up visit after 30 days was introduced to allow for a closer follow-up of patients.

CONCLUSION

Changes to the study protocol were introduced to improve the enrollment and follow-up of patients. Furthermore, the decrease of the sample size will facilitate completion of the trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01792804. Registered on 13 February 2013. German Clinical trials register, DRKS00004741. Registered on 4 October 2013, EudraCT 2013-000577-77.

Restriction of HIV-1 Escape by a Highly Broad and Potent Neutralizing Antibody

Broadly neutralizing antibodies (bNAbs) represent a promising approach to prevent and treat HIV-1 infection. However, viral escape through mutation of the HIV-1 envelope glycoprotein (Env) limits clinical applications. Here we describe 1-18, a new V_H1-46-encoded CD4 binding site (CD4bs) bNAb with outstanding breadth (97%) and potency (GeoMean IC₅₀ = 0.048 μg/mL). Notably, 1-18 is not susceptible to typical CD4bs escape mutations and effectively overcomes HIV-1 resistance to other CD4bs bNAbs. Moreover, mutational antigenic profiling uncovered restricted pathways of HIV-1 escape. Of most promise for therapeutic use, even 1-18 alone fully suppressed viremia in HIV-1-infected humanized mice without selecting for resistant viral variants. A 2.5-Å cryo-EM structure of a 1-18-BG505_SOSIP.664 Env complex revealed that these characteristics are likely facilitated by a heavy-chain insertion and increased inter-protomer contacts. The ability of 1-18 to effectively restrict HIV-1 escape pathways provides a new option to successfully prevent and treat HIV-1 infection.

Intensified adjunctive corticosteroid therapy for CNS tuberculomas

INTRODUCTION

Central nervous system (CNS) tuberculomas are a challenging manifestation of extrapulmonary tuberculosis often leading to neurological complications and post-treatment sequelae. The role of adjunctive corticosteroid treatment is not fully understood. Most guidelines on management of tuberculosis do not distinguish between tuberculous meningitis and CNS tuberculomas in terms of corticosteroid therapy.

METHODS

We describe five patients with CNS tuberculomas who required intensified dexamethasone treatment for several months, in two cases up to 18 months.

RESULTS

These patients were initially treated with the standard four-drug tuberculosis regimen and adjuvant dexamethasone. Neurological symptoms improved rapidly. However, multiple attempts to reduce or discontinue corticosteroids according to guideline recommendations led to clinical deterioration with generalized seizures or new CNS lesions. Thus, duration of adjunctive corticosteroid therapy was extended eventually leading to clinical cure and resolution of lesions.

CONCLUSION

In contrast to tuberculous meningitis, the treatment for CNS tuberculomas appears to require a prolonged administration of corticosteroids. These findings need to be verified in controlled clinical studies.

1269. Cohort Profile: The Translational Platform HIV (TP-HIV), a Multicenter Cohort Project in Germany

Background

While Germany has a long tradition in HIV research with many well-established regional cohorts, there was a lack of collaborative efforts toward harmonized data collection and biobanking, both key strategies for efficient translational research projects. Key challenges are heterogeneity of data systems and privacy concepts, of existing study and data collection protocols, and sample collection, storage, and sharing.

Methods

In 2013, we established the Translational Platform HIV (TP-HIV) with support of the German Centre for Infection Research (DZIF) as a collaboration between university hospitals and specialized HIV care centers throughout Germany. After assessing the individual needs of all partner sites, we have taken comprehensive action to create a common platform for collaboration in all research stages. We developed protocols, rules of operation, biobanking strategies, and privacy concepts for all collaborating partner sites. Patients infected with HIV (PLWH) who sign the informed consent for the TP-HIV are pro- and retrospectively included in the cohort.

Results

To date, the TP-HIV infrastructure is implemented at 27 member sites from 11 cities, potentially extending to more than 20,000 patients currently treated for HIV across Germany. Facing the special needs in the German research environment, the TP-HIV established a unique data- and biomaterial collection allowing expedited translational research and reduce project overheads, regulatory burden, and data security regulations for investigators. By active surveillance, rapid access to individual patient groups such as patients with acute HIV infection, TP-HIV is an ideal platform for early phase clinical trials with new drug candidates. Researchers with clinical, biological, epidemiological, and statistical expertise have been brought together within the TP-HIV, which enables an effective translational chain from bench to bedside and back. New collaborations have been established with currently 23 active study protocols.

Conclusion

The TP-HIV has demonstrated to be a powerful tool for generating and testing research hypotheses in PLWH. In the future, we will work to further expand our network and address the pressing needs in the German research environment.

Disclosures

All authors: No reported disclosures.

[Modern HIV treatment]

Human immunodeficiency virus (HIV) infection has become a chronic disease with a favourable prognosis if adequate antiretroviral therapy (ART) is applied. Therefore, each patient with HIV infection should be treated irrespectively of clinical symptoms or of immunological status. A combination of three active drugs that have to be taken life-long has been standard for many years. The regimen contains two nucleoside reverse transcriptase inhibitors plus either an integrase inhibitor, a boosted protease inhibitor, or a non-nucleoside reverse transcriptase inhibitor. Integrase inhibitors are recommended as the third partner of choice by recent guidelines due to their high efficacy and their favourable safety profile. Many combination drugs are now available which allow a simple treatment with few tablets and in many instances a one-pill combination per day is an option. Potential interactions with drugs given for other diseases have to be taken into account, especially if a pharmacological booster is part of the regimen. Combination therapy should be changed if either virological failure (HIV RNA >200 copies/ml) or drug-related adverse events occur. In special situations (e. g. pregnancy) highly experienced experts in the field should be consulted. Novel approaches for HIV therapy include dual therapy as well as treatment with long-acting substances. Beside therapy, antiretroviral drugs are used for prevention either as post-exposure prophylaxis or as pre-exposure prophylaxis.

Severe disseminated tuberculosis in HIV-negative refugees

In high-income countries, the presentation of tuberculosis is changing, primarily because of migration, and understanding the specific health needs of susceptible populations is becoming increasingly important. Although disseminated tuberculosis is well documented in HIV-positive patients, the disease is poorly described and less expected in HIV-negative individuals. In this Grand Round, we report eight HIV-negative refugees, who presented with extensively disseminated tuberculosis. We discuss the multifactorial causes, such as deprivations during long journeys, precarious living conditions, and the experience of violence, which might add to nutritional factors and chronic disorders, eventually resulting in a state of predisposition to immune deficiency. We also show that disseminated tuberculosis is often difficult to diagnose when pulmonary symptoms are absent. Communication difficulties between refugees and health-care workers are another major hurdle, and every effort should be made to get a valid patient history. This medical history is crucial to guide imaging and other diagnostic procedures to establish a definite diagnosis, which should be confirmed by a positive tuberculosis culture. Because many of these patients are at risk for multidrug-resistant tuberculosis, drug susceptibility testing is imperative to guide therapy. In the absence of treatment guidelines for this entity, clinicians can determine treatment duration according to recommendations provided for extrapulmonary tuberculosis and affected organs. Paradoxical expansion of tuberculous lesions during therapy should be treated with corticosteroids. In many cases, treatment duration must be individualised and might even exceed 12 months.

HIV therapeutic vaccine enhances non-exhausted CD4+ T cells in a randomised phase 2 trial

VAC-3S is a therapeutic vaccine comprising a highly conserved HIV-gp41 motif coupled with the CRM197 carrier protein. High levels of anti-3S antibodies (Abs) have been associated with improved protection of CD4⁺ T-cell survival. A previous phase 1 study demonstrated the safety of VAC-3S. This multicentre, randomised, double-blind, placebo-controlled phase 2 clinical trial enroled between January 2014 and March 2015 HIV-1-infected patients under ART with plasma HIV RNA levels below 50 copies/mL and CD4 counts between 200 and 500 cells/μL. Participants were immunised with 16, 32, or 64 μg of VAC-3S, and compared to placebo. The primary outcome was immunogenicity assessed by changes from baseline of anti-3S Abs levels at week 12. Secondary outcomes included adverse events and the course of plasma HIV RNA level, CD4 count, CD4/CD8 ratio, inflammation and immune checkpoints from week 0 to week 48. Vaccination was well tolerated with no serious adverse events and induced a significant increase in anti-3S Ab response in vaccinated patients (p < 0.0001), compared to placebo. In high responders, the robust increased of CD4 count was associated with a significant and sustained reduction of PD-1 expression on CD4⁺ T cells through week 48 (variance p = 0.0017). PD-1 expression was correlated with level of anti-3S Abs (p = 0.0092, r = −0.68) and expression of NKp44L (p < 0.0001; r = 0.54) in CD4⁺ T cells. Our findings regarding the increase of non-exhausted CD4⁺ T cells have potentially important application in personalised HIV vaccination for HIV-infected patients with high level of PD-1 to improve their T-cell immune function.

Increased non-AIDS mortality among persons with AIDS-defining events after antiretroviral therapy initiation

INTRODUCTION

HIV-1 infection leads to chronic inflammation and to an increased risk of non-AIDS mortality. Our objective was to determine whether AIDS-defining events (ADEs) were associated with increased overall and cause-specific non-AIDS related mortality after antiretroviral therapy (ART) initiation.

METHODS

We included HIV treatment-naïve adults from the Antiretroviral Therapy Cohort Collaboration (ART-CC) who initiated ART from 1996 to 2014. Causes of death were assigned using the Coding Causes of Death in HIV (CoDe) protocol. The adjusted hazard ratio (aHR) for overall and cause-specific non-AIDS mortality among those with an ADE (all ADEs, tuberculosis (TB), Pneumocystis jiroveci pneumonia (PJP), and non-Hodgkin's lymphoma (NHL)) compared to those without an ADE was estimated using a marginal structural model.

RESULTS

The adjusted hazard of overall non-AIDS mortality was higher among those with any ADE compared to those without any ADE (aHR 2.21, 95% confidence interval (CI) 2.00 to 2.43). The adjusted hazard of each of the cause-specific non-AIDS related deaths were higher among those with any ADE compared to those without, except metabolic deaths (malignancy aHR 2.59 (95% CI 2.13 to 3.14), accident/suicide/overdose aHR 1.37 (95% CI 1.05 to 1.79), cardiovascular aHR 1.95 (95% CI 1.54 to 2.48), infection aHR (95% CI 1.68 to 2.81), hepatic aHR 2.09 (95% CI 1.61 to 2.72), respiratory aHR 4.28 (95% CI 2.67 to 6.88), renal aHR 5.81 (95% CI 2.69 to 12.56) and central nervous aHR 1.53 (95% CI 1.18 to 5.44)). The risk of overall and cause-specific non-AIDS mortality differed depending on the specific ADE of interest (TB, PJP, NHL).

CONCLUSIONS

In this large multi-centre cohort collaboration with standardized assignment of causes of death, non-AIDS mortality was twice as high among patients with an ADE compared to without an ADE. However, non-AIDS related mortality after an ADE depended on the ADE of interest. Although there may be unmeasured confounders, these findings suggest that a common pathway may be independently driving both ADEs and NADE mortality. While prevention of ADEs may reduce subsequent death due to NADEs following ART initiation, modification of risk factors for NADE mortality remains important after ADE survival.

Hotspots of Transmission Driving the Local Human Immunodeficiency Virus Epidemic in the Cologne-Bonn Region, Germany

BACKGROUND

Geographical allocation of interventions focusing on hotspots of human immunodeficiency virus (HIV) transmission has the potential to improve efficiency. We used phylogeographic analyses to identify hotspots of the HIV transmission in Cologne-Bonn, Germany.

METHODS

We included 714 HIV-1 infected individuals, followed up at the University Hospitals Cologne and Bonn. Distance-based molecular network analyses were performed to infer putative relationships. Characteristics of genetically linked individuals and assortativity (shared characteristics) were analyzed. Geospatial diffusion (ie, viral gene flow) was evaluated using a Slatkin-Maddison approach. Geospatial dispersal was determined by calculating the average distance between the residences of linked individuals (centroids of 3-digit zip code).

RESULTS

In sum, 217/714 (30.4%) sequences had a putative genetic linkage, forming 77 clusters (size range: 2-8). Linked individuals were more likely to live in areas surrounding the city center (P = .043), <30 years of age (P = .009). and infected with HIV-1 subtype B (P = .002). Clustering individuals were nonassortative by area of residency (-.0026, P = .046). Geospatial analyses revealed a median distance between genetically linked individuals of 23.4 kilometers (km), lower than expected (P < .001). Slatkin-Maddison analyses revealed increased gene flow from central Cologne toward the surrounding areas (P < .001).

CONCLUSION

Phylogeographic analysis suggests that central Cologne may be a significant driver of the regional epidemic. Although clustering individuals lived closer than unlinked individuals, they were less likely to be linked to others from their same zip code. These results could help public health entities better understand transmission dynamics, facilitating allocation of resources to areas of greatest need.

Diagnostic challenges in infective endocarditis: is PET/CT the solution?

PURPOSE

Despite developments in both imaging and microbiological techniques, the final diagnosis of IE often remains challenging. In this single-center cohort study, we aimed to identify the specific indications for request of ¹⁸F-FDG-PET/CT in clinical practice and to evaluate the diagnostic benefit of this nuclear imaging technique.

METHODS

A total of 235 patients with possible (n = 43) or definite (n = 192) IE according to the revised Duke criteria were prospectively studied from July 2013 until December 2016. Echocardiography was generally used as the primary cardiac imaging technique. All patients were treated by a multidisciplinary Endocarditis Team. Diagnostics with ¹⁸F-FDG-PET/CT were undertaken on request by at least one member of the multidisciplinary team when overall diagnostics were inconclusive.

RESULTS

In 20 patients, ¹⁸F-FDG-PET/CT scan was performed for additional diagnostic evaluation. Hereof, 15 patients had a history of implanted cardiac prosthetic material. In six patients with definite IE, the use of ¹⁸F-FDG-PET/CT was helpful for further clarification of the diagnosis. In one patient with possible IE, the diagnosis could be reclassified to definite IE. In addition, one case of vertebral osteomyelitis as well as upper and lower leg abscesses and knee empyema were detectable as extracardiac foci. Furthermore, ¹⁸F-FDG-PET/CT leads to a modification of the management in five patients.

CONCLUSION

Our findings support the utility of ¹⁸F-FDG-PET/CT as an adjunctive diagnostic tool especially in the evaluation of prosthetic valve-/cardiac device-related IE and for the detection of extracardiac foci in some cases. However, due to remaining limitations also of this imaging technique, a multidisciplinary clinical evaluation still remains the essential basis for the diagnostic assessment.

Pretreatment human immunodeficiency virus type 1 (HIV-1) drug resistance in transmission clusters of the Cologne-Bonn region, Germany

OBJECTIVES

In Germany, previous reports have demonstrated transmitted human immunodeficiency virus type 1 (HIV-1) drug-resistance mutations (DRM) in 11% of newly diagnosed individuals, highlighting the importance of drug-resistance screening before the initiation of antiretroviral therapy (ART). Here, we sought to understand the molecular epidemiology of HIV DRM transmission in the Cologne-Bonn region of Germany, given one of the highest rates of new HIV diagnoses in western Europe (13.7 per 100 000 habitants).

METHODS

We analysed 714 HIV-1 ART-naive infected individuals diagnosed at the University Hospitals Cologne and Bonn between 2001 and 2016. Screening for DRM was performed according to the Stanford University Genotypic Resistance Interpretation. Shared DRM were defined as any DRM present in genetically linked individuals (<1.5% genetic distance). Phylogenetic and network analyses were performed to infer putative relationships and shared DRM.

RESULTS

The prevalence of any DRM at time of diagnosis was 17.2% (123/714 participants). Genetic transmission network analyses showed comparable frequencies of DRM in clustering versus non-clustering individuals (17.1% (85/497) versus 17.5% (38/217)). The observed rate of DRM in the region was higher than previous reports 10.8% (87/809) (p < 0.001), revealing the need to reduce onward transmission in this area. Genetically linked individuals harbouring shared DRM were more likely to live in suburban areas (24/38) than in central Cologne (1/38) (p < 0.001).

CONCLUSION

The rate of DRM was exceptionally high. Network analysis elucidated frequent cases of shared DRM among genetically linked individuals, revealing the potential spread of DRM and the need to prevent onward transmission of DRM in the Cologne-Bonn area.

2365. Post-operative Vertebral Osteomyelitis—A Disease With Distinct Clinical and Microbiological Characteristics

Background

A relevant subgroup (10–14%) of patients with vertebral osteomyelitis (VO) has a history of spine surgery. Infection in these patients is often caused by coagulase-negative staphylococci (CoNS) might be clinically different from native VO. However, clinical, microbiological and outcome characteristics of this disease entity have not been well studied as most trials either excluded these patients or are limited by a small cohort and short observation period.

Methods

Between January 2008 and June 2013 patients who presented to the Department of Orthopaedics at the University Hospital of Cologne with suspected VO were prospectively enrolled into the international registry Spine Tango and observed for a period of 2 years. Survival was estimated by the Kaplan–Meier method. In addition, univariable and multivariable Cox regression models were fitted to estimate unadjusted and adjusted effect of surgery. Group comparisons between patients with or without prior surgery were performed using Fisher’s exact test or Mann–Whitney U test.

Results

56 of 189 patients with confirmed diagnosis of VO reported a history of spine surgery in the same segment. Patients with native vertebral osteomyelitis (NVO) had a higher ASA score (P = 0.01), were more likely to suffer from comorbidities (P = 0.003) and had Staphylococcus aureus identified as causative infectious agent in the majority of cases (34 vs. 18%, P = 0.024). Infections caused by CoNS (20 vs. 4%, P < 0.001) and other bacteria of the skin flora were more prevalent in patients with post-operative VO (9 vs. 0%, P = 0.002). After a median follow-up of two years, univariable Cox regression revealed that patients with NVO had a 3-fold increased mortality risk compared with patients with prior surgery (HR, 3.3, 95% CI, 1.4–7.9, P = 0.006). The magnitude of the effect size remained stable in the multivariable model (HR 3.023, 95% CI 1.259–7.257, P = 0.013), adjusted for ASA score and number of comorbidities.

Conclusion

NVO and post-operative VO show distinct disease characteristics. Patients with NVO more often have comorbidities, have mainly S. aureus as causative pathogen and a 3-fold increased 2-year mortality risk compared with patients with post-operative VO.

Disclosures

H. Seifert, Accelerate Diagnostics Inc.: Research Contractor, Research grant.

1283. Pretreatment HIV-1 Drug Resistance in Transmission Clusters of the Cologne-Bonn Region, Germany

Background

In Germany, previous reports have demonstrated transmitted HIV-1 drug resistance mutations (DRM) in 10% of newly diagnosed individuals, affecting treatment failure and the choice of antiretroviral therapy (ART). Here, we sought to understand the molecular epidemiology of HIV DRM transmission throughout the Cologne-Bonn region, an area with one of the highest rate of new HIV infections in Europe (13.7 per 100,000 habitants).

Methods

We analyzed 714 HIV-1 ART naïve infected individuals diagnosed at the University Hospitals Cologne and Bonn between 2001 and 2016. Screening for DRM was performed according to the Stanford University Genotypic Resistance Interpretation. Shared DRM were defined as any DRM present in genetically linked individuals (&lt;1.5% genetic distance). Phylogenetic and network analyses were performed to infer putative relationships and shared DRMs.

Results

We detected 123 DRMs in our study population (17.2% of all sequences). Prevalence of any DRM was comparable among risk groups and was highest among people from an endemic area (i.e., country with HIV prevalence &gt;1%) (11/51, 21.6%). Nucleoside-and non-nucleoside reverse transcriptase inhibitor (NRTI/NNNRTI) resistance mutations were detected in 49 (7%) and 97 (13.6%) individuals, with the E138A in 29 (4.1%) and K103N in 11 (1.5%) being the most frequent. Frequency of DRM was comparable in clustering and not clustering individuals (17.1% vs. 17.5%). Transmission network analysis indicated that the frequency of DRM in clustering individuals was the highest in PWID (3/7, 42.9%) (Figure 1A). Genetically linked individuals harboring shared DRMs were more likely to live in suburban areas than in Central Cologne (18.8% vs. 8% of clustering sequences with DRM; Figure 1B).

Conclusion

The rate of DRMs was exceptionally high in the Cologne/Bonn area. Network analysis elucidated frequent cases of shared DRMs among genetically linked individuals, revealing the potential spread of DRMs and the need to prevent onward transmission of DRM in the Cologne-Bonn area.

Disclosures

M. Hoenigl, Gilead, Basilea, Merck: Speaker’s Bureau, Research grant and Speaker honorarium.

1767. Structured Treatment Interruptions in HIV-Infected Patients Receiving Antiretroviral Therapy—Implications for Future HIV Cure Trials: A Systematic Review and Meta-analysis

Background

Safety and tolerability of analytical treatment interruption (TI) as part of HIV cure studies has been discussed controversially. In this systematic review and meta-analysis, we report current evidence for the occurrence of adverse effects during different types of TI.

Methods

A systematic literature search on studies reporting on TIs was conducted using a defined search term, covering the period from January 1988 to May 2017. All interventional and observational studies were reviewed, and results were extracted based on predefined criteria. We evaluated the proportion of adverse effects during TI by using a random effect meta-analysis model. A meta-regression model was calculated to explore the variation across studies and the influence of key factors.

Results

We identified 1,048 studies, of which we obtained data from 24 studies investigating TI including 7,961 individuals. Sample sizes varied from 6 to 5,472 subjects. The number of reported events during TI ranged from 0 to 241. Follow-up intervals during TI varied from 2 days up to 3 months. We compared reported adverse effects in studies with long TI (&gt;4 weeks) by the lengths of follow-up intervals, comparing narrow (≤4 weeks) and wide (&gt;4 weeks) follow-up during TI. The proportion of patients exhibiting adverse events during long TI was 1% (95% CI 0–4, I2 = 24.9%) in studies with narrow and 10% (95% CI 5–117, I2 = 95.1%) in studies with wide follow-up intervals, with an overall reported rate of 5% (95% CI: 3–15, z = 3.93, P ≤ 0.00) (Figure 1). The number of reported deaths was relatively low, but higher in studies with wide follow-up compared with studies with narrow follow-up (Figure 2). Meta regression analysis indicated that adverse events were increasing with the length of the monitoring interval (β = 0.75, 95% CI 0.24–1.27, P = 0.007) (Figure 3).

Conclusion

Current evidence indicates that studies with narrow follow-up intervals did not show a substantial increase of adverse effects other than viral rebound during TI. Analytical treatment interruption may be a safe strategy as part of HIV cure trials if patients undergo intense follow-up routines.

Disclosures

All authors: No reported disclosures.

1280. Geospatial Spread of HIV in the Cologne-Bonn Region, Germany: From 2001 to 2016

Background

Geographical targeting of interventions of hotspots of HIV transmission increases the impact of HIV intervention. We combined molecular epidemiology and geospatial analyses to provide insights into the drivers of HIV transmission and the contribution of geographical hot spots to the rapidly evolving local HIV epidemic of Cologne-Bonn.

Methods

We included 714 HIV-1-infected ART naïve individuals, followed at the University Hospitals Cologne and Bonn between 2001 and 2016. Phylogenetic and network analyses were performed to infer putative relationships. Assortativity index (AI, i.e., shared attributes) and characteristics of genetically linked individuals were analyzed. The geospatial diffusion of the local epidemic (i.e., viral gene flow) was evaluated using a Slatkin-Maddison approach. Geospatial dispersal of local HIV transmission was determined by calculating the average distance between genetically linked individuals (centroids of 3-digit zip code of residency, ArcGIS®).

Results

Of 714 sequences, 217 (30.4%) had a putative linkage with at least one other sequence, forming 77 clusters (size range: 2–8). Genetically linked individuals were significantly more likely to live in suburban areas (P = 0.035), <30 years of age (P = 0.013), infected with HIV-1 subtype B (P = 0.002). AI for concurrent area of residency showed that individuals were nonassortative in the network (−0.0026, P = 0.046), indicating that clustering individuals tended to cluster with individuals living in a different zip code. Geospatial analyses revealed that the median distance between genetically linked individuals was 23.4 km, significantly lower than expected (median 39.68 km; P < 0.001) (Figure 1A). Slatkin Maddison analyses revealed increased gene flow originating from Central Cologne toward the surrounding areas (P < 0.001, Figure 1B).

Conclusion

Phylogeographic analysis suggests that central Cologne may be a significant driver of the regional epidemic. While clustering individuals lived closer than unlinked individuals, they were less likely to be linked to others from their same zip code. This may reflect individuals reaching out of their neighborhoods and social circles to meet new partners.

Disclosures

All authors: No reported disclosures.

Antiretroviral treatment indications and adherence to the German-Austrian treatment initiation guidelines in the German ClinSurv HIV Cohort between 1999 and 2016

PURPOSE

The aim of the study was to assess guideline adherence to combined antiretroviral therapy (ART) in the German ClinSurv HIV Cohort and the real-life impact of the Strategic Timing of Antiretroviral Therapy (START) study, to identify patients not treated as recommended by new guidelines.

METHODS

We used data from the multicenter ClinSurv cohort of the Robert-Koch-Institute (RKI) between 1999 and 2016. Inclusion criteria were people living with HIV/AIDS, ≥ 18 years of age and cART naïve at the first visit (FV). Adherence was defined as starting cART within 6 months of crossing the CD4⁺ T cell threshold as suggested by the German-Austrian treatment guidelines. Logistic regression was used to identify factors associated with non-adherence.

RESULTS

11,817 patients met the inclusion criteria. We observed an overall adherence rate of 60%, in patients with treatment indication who started cART timely between 2002 and 2015. Adherence rate increased constantly, demonstrating a potential increase in patients, with treatment indication, starting cART within 6 months of presentation from 55% in 2008 to 94% in 2015. Patients reporting injection drug use (OR 2.18, 95% CI 1.70-2.95) and patients between 18 years and 39 years of age at the time of their first visit (OR 2.89, 95% CI 1.35-6.18) were identified as risk groups associated with non-adherence.

CONCLUSION

The majority of patients below the CD4⁺ T cell count threshold of applicable guidelines initiated treatment within 6 months. We observed a slowly diminishing proportion of patients not starting cART timely. Delayed treatment was more frequent in patients reporting injection drug use.

Pelvic cellulitis caused by Raoultella planticola in a neutropenic patient

Raoultella planticola is a gram-negative, encapsulated, aerobic bacterium within the Enterobacteriaceae family. It has been primarily described as pathogen in cases with pneumonia and gastrointestinal infections. Here we describe a case of severe pelvic cellulitis in a patient with neutropenia following induction therapy for myeloid sarcoma. The patient experienced a septic shock and was treated successfully with antibiotic therapy. A literature review is provided to put this case in context with previous reports on R. planticola. This report highlights that awareness for uncommon pathogens is crucial in the clinical management of infections in neutropenic patients.

Combination therapy with anti-HIV-1 antibodies maintains viral suppression

HIV-1-infected individuals require lifelong antiretroviral therapy (ART) because treatment interruption leads to rapid rebound viremia. Here we report on a phase 1b clinical trial in which a combination of 3BNC117 and 10-1074, two potent monoclonal anti-HIV-1 broadly neutralizing antibodies that target independent sites on the HIV-1 envelope spike, was administered during analytical treatment interruption. Participants received three infusions of 30 mg/kg of each antibody at 0, 3 and 6 weeks. Infusions of the two antibodies were generally well tolerated. The nine enrolled individuals with antibody-sensitive latent viral reservoirs maintained suppression for 15 to > 30 weeks (median = 21 weeks), and none developed viruses resistant to both antibodies. We conclude that the combination of anti-HIV-1 monoclonal antibodies 3BNC117 and 10-1074 can maintain long-term suppression in the absence of ART in individuals with antibody-sensitive viral reservoirs.

Vancomycin-resistant enterococci (VRE): a reason to isolate?

In recent years, an increase in invasive VRE infections has been reported worldwide, including Germany. The most common gene encoding resistance to glycopeptides is VanA, but predominant VanB clones are emerging. Although neither the incidence rates nor the exact routes of nosocomial transmission of VRE are well established, screening and strict infection control measures, e.g. single room contact isolation, use of personal protective clothing by hospital staff and intensified surface disinfection for colonized individuals, are implemented in many hospitals. At the same time, the impact of VRE infection on mortality remains unclear, with current evidence being weak and contradictory. In this short review, we aim to give an overview on the current basis of evidence on the clinical effectiveness of infection control measures intended to prevent transmission of VRE and to put these findings into a larger perspective that takes further factors, e.g. VRE-associated mortality and impact on patient care, into account.

Infectious disease services: a survey from four university hospitals in Germany

PURPOSE

Involvement of infectious disease (ID) specialists in the care of hospitalized patients with infections through consultation services improves the quality of care and the outcome of patients. This survey aimed to describe activities and utilization of ID consultations at four German tertiary care hospitals.

METHODS

A 1-month (March 2016) retrospective cross-sectional study at four university hospitals (Freiburg, Jena, Cologne and Regensburg) was performed. Only ID consultations with written documentation and bedside patient evaluation were included. Consultations were analyzed with regard to requesting departments, infections, case severity, and diagnostic and therapeutic recommendations.

RESULTS

In the study period, 638 ID consultations were performed in 479 patients-corresponding to 3-4 consultations per 100 inpatient cases. Patients were characterized by a high disease complexity-the mean case mix index in patients with consultation was 10.1 compared to 1.6 for all patients. ID consultations were requested by many different specialties, with approximately half of the requests coming from surgical disciplines. ID consultations resulted in revised diagnoses in 34% of the cases, provided recommendations for additional diagnostic procedures in 66%, and for modifications of antimicrobial regimens in 70% of the cases.

CONCLUSIONS

Infectious disease consultations were requested for patients with severe and complicated diseases and resulted in recommendations that highly impacted the diagnostic work-up and therapeutic management of patients. The results of this survey may help to estimate requirements for establishment of such services in Germany.

Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2018 Recommendations of the International Antiviral Society-USA Panel

IMPORTANCE

Antiretroviral therapy (ART) is the cornerstone of prevention and management of HIV infection.

OBJECTIVE

To evaluate new data and treatments and incorporate this information into updated recommendations for initiating therapy, monitoring individuals starting therapy, changing regimens, and preventing HIV infection for individuals at risk.

EVIDENCE REVIEW

New evidence collected since the International Antiviral Society-USA 2016 recommendations via monthly PubMed and EMBASE literature searches up to April 2018; data presented at peer-reviewed scientific conferences. A volunteer panel of experts in HIV research and patient care considered these data and updated previous recommendations.

FINDINGS

ART is recommended for virtually all HIV-infected individuals, as soon as possible after HIV diagnosis. Immediate initiation (eg, rapid start), if clinically appropriate, requires adequate staffing, specialized services, and careful selection of medical therapy. An integrase strand transfer inhibitor (InSTI) plus 2 nucleoside reverse transcriptase inhibitors (NRTIs) is generally recommended for initial therapy, with unique patient circumstances (eg, concomitant diseases and conditions, potential for pregnancy, cost) guiding the treatment choice. CD4 cell count, HIV RNA level, genotype, and other laboratory tests for general health and co-infections are recommended at specified points before and during ART. If a regimen switch is indicated, treatment history, tolerability, adherence, and drug resistance history should first be assessed; 2 or 3 active drugs are recommended for a new regimen. HIV testing is recommended at least once for anyone who has ever been sexually active and more often for individuals at ongoing risk for infection. Preexposure prophylaxis with tenofovir disoproxil fumarate/emtricitabine and appropriate monitoring is recommended for individuals at risk for HIV.

CONCLUSIONS AND RELEVANCE

Advances in HIV prevention and treatment with antiretroviral drugs continue to improve clinical management and outcomes for individuals at risk for and living with HIV.

To prescribe, or not to prescribe: decision making in HIV-1 post-exposure prophylaxis

OBJECTIVES

We investigated the trend in usage of post-exposure prophylaxis (PEP) after HIV-1 risk exposure and evaluated PEP prescription decision making of physicians according to guidelines.

METHODS

All PEP consultations from January 2014 to December 2016 in patients presenting at the University Hospital of Cologne (Germany) were retrospectively analysed. HIV risk contacts included sexual and occupational exposure. The European AIDS Clinical Society (EACS) Guidelines for HIV PEP (version 9.0, 2017) were used for assessment.

RESULTS

A total of 649 patients presented at the emergency department (ED) or the clinic for infectious diseases (IDC) for PEP consultations. A continuous increase in the number of PEP requests was recorded: 189 in 2014, 208 in 2015 and 252 in 2016. PEP consultations in men who have sex with men (MSM) showed a remarkable increase in 2016 (2014, n = 96; 2015, n = 101; 2016, n = 152). Decisions taken by physicians with a specialization in infectious diseases (n = 547) included 61 (11%) guideline-discordant prescriptions [2014: 14% (n = 22); 2015: 9% (n = 16); 2016: 11% (n = 23)]. Among these, sexual exposure accounted for 45 (74%) cases, including 15 cases of nonconsensual sex, while occupational exposure accounted for 14 (23%) cases and other exposure two cases (3%). The main reason for guideline-discordant PEP prescriptions was emotional stress of the patient (n = 37/61).

CONCLUSIONS

PEP prescriptions are increasing and decision making is influenced by patients' emotional stress, but PEP prescriptions should be strictly administered according to risk assessment.