Guidelines for COVID-19 Management in Hematopoietic Cell Transplantation and Cellular Therapy Recipients

There are currently limited data on the epidemiology, clinical manifestations, and optimal management of Coronavirus Disease 2019 (COVID-19) in hematopoietic cell transplantation and cellular therapy recipients. Given the experience with other respiratory viruses, we anticipate that patients may develop severe clinical disease and thus provide the following general principles for cancer centers across the nation. These guidelines were developed by members of the American Society for Transplantation and Cellular Therapy Infectious Diseases Special Interest Group. Specific practices may vary depending on local epidemiology and testing capacity, and the guidance provided in this document may change as new information becomes available.

SARS CoV-2 Surveillance and Exposure in the Perioperative Setting with Universal testing and Personal Protective Equipment (PPE) Policies

Background

New York City (NYC) experienced a surge of COVID-19 cases in March and April 2020. Since then, universal PCR based surveillance testing and PPE measures are in wide use in procedural settings. There is limited published experience on the utility and sustainability of PCR based surveillance testing in areas with receding and consistently low community COVID-19 rates.

Methods

The study was conducted at a tertiary care cancer center in NYC from March 22, 2020, until August 22, 2020. Asymptomatic patients underwent SARS CoV-2 testing before surgeries, interventional radiology procedures, and endoscopy. Contact tracing in procedural areas was done if a patient with an initial negative screen re-tested positive within 48 hours of the procedure.

Results

From March 22 until August 22, 2020, 11,540 unique patients underwent 14,233 tests before surgeries or procedures at MSKCC. Overall, 65 patients were positive, with a peak rate of 4.3% that fell below 0.3 % after April 2020. For the 65 positive cases, three were pre-symptomatic, and 38 were asymptomatic. Among asymptomatic test-positive patients, 76 % had PCR cycle threshold (Ct) > 30 at first detection. Five patients tested newly positive in the immediate post-operative period, exposing 82 employees with one case of probable transmission (1.2%).

Conclusion

The prevalence of SARS-CoV-2 infection identified on pre-procedural surveillance was low in our study, which was conducted in an area with limited community spread at the later stage of the study Universal PPE is protective in procedural settings. Optimal and flexible diagnostic strategies are needed to accomplish and sustain the goals of comprehensive pre-procedure surveillance testing.

Clinical Performance of (1,3) Beta-D Glucan for the Diagnosis of Pneumocystis Pneumonia (PCP) in Cancer Patients Tested With PCP Polymerase Chain Reaction

BACKGROUND

Serum (1,3)-beta-D glucan (BDG) is increasingly used to guide the management of suspected Pneumocystis pneumonia (PCP). BDG lacks specificity for PCP, and its clinical performance in high-risk cancer patients has not been fully assessed. Polymerase chain reaction (PCR) for PCP detection is highly sensitive, but cannot differentiate between colonization and infection. We evaluated the diagnostic performance of serum BDG in conjunction with PCP PCR on respiratory samples in patients with cancer and unexplained lung infiltrates.

METHODS

We performed a retrospective analysis of adult patients evaluated for PCP at our institution from 2012 to 2015, using serum BDG and PCP PCR. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the serum BDG at different thresholds were evaluated using PCP PCR alone or in conjunction with clinical presentation in PCP PCR-positive patients.

RESULTS

With PCP PCR alone as the reference method, BDG (≥80 pg/mL) had a sensitivity of 69.8%, specificity of 81.2%, PPV of 34.6%, and NPV of 95.2% for PCP. At ≥200 pg/mL in patients with a positive PCR and a compatible PCP clinical syndrome, BDG had a sensitivity of 70%, specificity of 100%, PPV of 100%, and NPV of 52.0% for PCP.

CONCLUSIONS

Patients negative by both BDG and PCR were unlikely to have PCP. In patients with a compatible clinical syndrome for PCP, higher BDG values (>200 pg/mL) were consistently associated with clinically-significant PCP infections among PCP PCR-positive oncology patients.

Determinants of COVID-19 disease severity in patients with cancer

As of 10 April 2020, New York State had 180,458 cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and 9,385 reported deaths. Patients with cancer comprised 8.4% of deceased individuals¹. Population-based studies from China and Italy suggested a higher coronavirus disease 2019 (COVID-19) death rate in patients with cancer^2,3, although there is a knowledge gap as to which aspects of cancer and its treatment confer risk of severe COVID-19⁴. This information is critical to balance the competing safety considerations of reducing SARS-CoV-2 exposure and cancer treatment continuation. From 10 March to 7 April 2020, 423 cases of symptomatic COVID-19 were diagnosed at Memorial Sloan Kettering Cancer Center (from a total of 2,035 patients with cancer tested). Of these, 40% were hospitalized for COVID-19, 20% developed severe respiratory illness (including 9% who required mechanical ventilation) and 12% died within 30 d. Age older than 65 years and treatment with immune checkpoint inhibitors (ICIs) were predictors for hospitalization and severe disease, whereas receipt of chemotherapy and major surgery were not. Overall, COVID-19 in patients with cancer is marked by substantial rates of hospitalization and severe outcomes. The association observed between ICI and COVID-19 outcomes in our study will need further interrogation in tumor-specific cohorts.

Risk for Clostridiodes difficile Infection among Older Adults with Cancer

To assess whether risk for Clostridiodes difficile infection (CDI) is higher among older adults with cancer, we conducted a retrospective cohort study with a nested case-control analysis using population-based Surveillance, Epidemiology, and End Results-Medicare linked data for 2011. Among 93,566 Medicare beneficiaries, incident CDI and odds for acquiring CDI were higher among patients with than without cancer. Specifically, risk was significantly higher for those who had liquid tumors and higher for those who had recently diagnosed solid tumors and distant metastasis. These findings were independent of prior healthcare-associated exposure. This population-based assessment can be used to identify targets for prevention of CDI.

Different molecular characteristics and antimicrobial resistance profiles of Clostridium difficile in the Asia-Pacific region

Molecular epidemiology of Clostridium difficile infection (CDI) has been extensively studied in North America and Europe; however, limited data on CDI are available in the Asia-Pacific region. A multicentre retrospective study was conducted in this region. C. difficile isolates were subjected to multilocus sequence typing (ST) and antimicrobial susceptibility testing. Totally, 394 isolates were collected from Hangzhou, Hong Kong, China; Busan, South Korea; Fukuoka, Japan; Singapore; Perth, Sydney, Australia; New York, the United States. C. difficile isolates included 337 toxin A-positive/B-positive/binary toxin-negative (A⁺B⁺CDT^-), 48 A^-B⁺CDT^-, and nine A⁺B⁺CDT⁺. Distribution of dominant STs varied geographically with ST17 in Fukuoka (18.6%), Busan (56.0%), ST2 in Sydney (20.4%), Perth (25.8%). The antimicrobial resistance patterns were significantly different among the eight sites (χ² = 325.64, p < 0.001). Five major clonal complexes correlated with unique antimicrobial resistances. Healthcare-associated (HA) CDI was mainly from older patients with more frequent antimicrobial use and higher A^-B⁺ positive rates. Higher resistance to gatifloxacin, tetracycline, and erythromycin were observed in HA-CDI patients (χ² = 4.76-7.89, p = 0.005-0.029). In conclusion, multiple C. difficile genotypes with varied antimicrobial resistance patterns have been circulating in the Asia-Pacific region. A^-B⁺ isolates from older patients with prior antimicrobial use were correlated with HA-CDI.

Systems-level analysis of NalD mutation, a recurrent driver of rapid drug resistance in acute Pseudomonas aeruginosa infection

Pseudomonas aeruginosa, a main cause of human infection, can gain resistance to the antibiotic aztreonam through a mutation in NalD, a transcriptional repressor of cellular efflux. Here we combine computational analysis of clinical isolates, transcriptomics, metabolic modeling and experimental validation to find a strong association between NalD mutations and resistance to aztreonam-as well as resistance to other antibiotics-across P. aeruginosa isolated from different patients. A detailed analysis of one patient's timeline shows how this mutation can emerge in vivo and drive rapid evolution of resistance while the patient received cancer treatment, a bone marrow transplantation, and antibiotics up to the point of causing the patient's death. Transcriptomics analysis confirmed the primary mechanism of NalD action-a loss-of-function mutation that caused constitutive overexpression of the MexAB-OprM efflux system-which lead to aztreonam resistance but, surprisingly, had no fitness cost in the absence of the antibiotic. We constrained a genome-scale metabolic model using the transcriptomics data to investigate changes beyond the primary mechanism of resistance, including adaptations in major metabolic pathways and membrane transport concurrent with aztreonam resistance, which may explain the lack of a fitness cost. We propose that metabolic adaptations may allow resistance mutations to endure in the absence of antibiotics and could be targeted by future therapies against antibiotic resistant pathogens.

2298. Infections in Patients Receiving TVEC Therapy

Background

Oncolytic viral immunotherapy is an emerging cancer treatment, but the infectious complications are not well described outside of clinical trials. Genetically engineered replication competent herpes simplex virus (HSV-1), commercially known as IMLGYIC® (AmGen) or talimogene laherparepvec (TVEC) was the first FDA approved agent in this class and is used for the local intralesional treatment (of unresectable melanoma. TVEC is derived from a wild-type(WT) strain of HSV-1 (JS—1), which is modified to attenuate off-target effects and promote selective proliferation within cancer cells. Despite these changes local and systemic infection with HSV have been reported from trials and is the subject of an FDA mandated post-marketing review. Here we review the infectious complications of the first cohort of patients treated at our institution post-FDA approval.

Methods

Demographic and clinical information for 52 adult patients treated for unresectable melanoma with TVEC following FDA approval in 2015 was extracted from the EMR for the period October 1, 2015–June 30, 2018. EMR and microbiologic data were reviewed for evidence of local site reaction and disseminated infection.

Results

No cases of disseminated HSV infection were identified during the study period. Of cutaneous reactions, none were documented as greater than severity grade 2, based on standard adverse event reporting criteria. 3 (50%) grade 1–2 cutaneous reactions were deemed probable or definitely related to TVEC and described as pruritis or rash. 12 (23%) patients had any microbiologically confirmed infection identified following TVEC therapy; 6 were bacterial (3 UTI, 1BSI, 2 wound). 8 episodes of viral infections occurred (5 respiratory and 3 GI). A single patient was noted to have localized HSV dermal lesions more than one year after the final TVEC.

Conclusion

No local or disseminated HSV infections were encountered in the study cohort. Bacterial skin and soft-tissue infection were uncommon. Most other infections were unrelated to TVEC therapy. Real-world review of the use of an HSV-derived oncolytic viral vector therapy mimics reported infectious complications from clinical trials.

Disclosures

All authors: No reported disclosures.

2408. Genotypic Corroboration of Epidemiologically Linked Clusters to Detect Outbreaks of C. difficile at a Tertiary Care Hospital

Background

Methods

Results

Conclusion

Disclosures

553. Outbreak of Methicillin-Resistant Staphylococcus aureus Associated with Hepatic Artery Infusion Pumps

Background

Device-related infections account for a fourth of all HAIs. Hepatic artery infusion pump (HAIP) devices are used to deliver chemotherapy directly into the hepatic artery. This device is used primarily in patients with colorectal cancer for the management of unresectable hepatic metastases. We describe the infection rates and outbreak management of MRSA-related infections in newly placed HAIPs.

Methods

In December 2018, a cluster of 3 MRSA cases was identified within 15–26 days of HAIP insertion. From January 1, 2017 to December 31, 2018, patients with culture proven SSIs within 30 days of HAIP placement were identified through the infection control database to establish baseline rates. Procedural denominator data were found by querying CPT procedure codes. EMR was reviewed to extract clinical characteristics. In response to the cluster, healthcare personnel (HCP) were screened for MRSA by PCR and environmental cultures performed. PFGE and whole-genome sequencing (WGS) was performed to compare isolates recovered in culture and SNP analysis performed using the BioNumerics software v7.6.

Results

IIn December 2018, 3/15 patients with HAIP procedures developed MRSA infections within 30 days of the procedures (post-op days: 15,16,26). The baseline 30 day SSI rate for HAIP in 2017 was 1.3% (2/160). No infections, prior to the cluster, in 2017–18 were MRSA related. All patients were male, with a median age of 49 years (range: 45–54). Sixty HCP who provided direct care during the peri and early post-operative period for the 3 cases were screened for MRSA carriage; 2/60 (3.3%) were positive. All 56 environmental cultures were negative for MRSA. WGS of the 3 patient samples showed 2/3 samples were identical (1 SNP difference); confirming common source transmission. Only one HCP isolate was available for WGS and shown to be unrelated to the two patient isolates. Both employees underwent decolonization. Review of HAIP handling did not reveal obvious lapses, but mask use and strict hand hygiene were enforced with HCPs. No further infections have been identified in the 76 procedures since the cluster.

Conclusion

WGS confirmed common source transmission between two newly placed HAIP although the definitive source could not be identified. Surveillance and prevention efforts should extend to all types of vascular access devices.

Disclosures

All authors: No reported disclosures.

2390. Acquisition of Clostridium difficile Infection Following Exposure from Roommate Defined by Concordance on Genotyping

Background

Observational studies have identified same room occupancy with a hospital-onset Clostridium difficile infection (HO-CDI) case as a risk factor for subsequent CDI diagnosis. Despite this, the risk remains poorly characterized in endemic settings. Furthermore, genotyping techniques have not been applied to examine concordance between infecting strains in index patients and exposed roommates who eventually develop CDI. The study seeks to quantify transmission of C. difficile from an index case to their roommates and identify if concordance was present among strain types by the application of multi-locus sequence typing (MLST).

Methods

Laboratory-identified cases of hospital onset C. difficile infection (CDI) from October 1, 2017 through March 31, 2018, were included in the study. Patients with HO-CDI are placed in private room once diagnosis is established. Roommates who were in the same room as cases for at least 24 hours prior to diagnosis, regardless of duration of overlap, were identified through of the hospital patient tracking database to establish spatial link. Next, all exposed roommates who developed CDI within 3 months after exposure (defined as date of CDI diagnosis of index case) were identified. Strain types of linked cases was examined by MLST.

Results

During the 6-month period, 279 cases of CDI were diagnosed. Of these cases, 156 were hospitalized at the time of diagnosis including 83 (53%) in a room with shared occupancy. These 83 patients had 109 roommates that met exposure criteria. Four (3.7%) roommates developed CDI over a 90-day follow-up period. None of the examined pairs were genetically concordant.

Conclusion

Indirect patient to patient transmission of C. difficile from newly diagnosed CDI cases to roommates is not common despite the spatial proximity with shared occupancy.

Disclosures

All authors: No reported disclosures.

Preventing Measles in Immunosuppressed Cancer and Hematopoietic Cell Transplantation Patients: A Position Statement by the American Society for Transplantation and Cellular Therapy

Until recently, measles exposures were relatively rare and so, consequently, were an afterthought for cancer patients and/or blood and marrow transplant recipients and their providers. Declines in measles herd immunity have reached critical levels in many communities throughout the United States due to increasing vaccine hesitancy, so that community-based outbreaks have occurred. The reemergence of measles as a clinical disease has raised serious concerns among immunocompromised patients and those who work within the cancer and hematopoietic cell transplantation (HCT) community. Since live attenuated vaccines, such as measles, mumps, and rubella (MMR), are contraindicated in immunocompromised patients, and with no approved antiviral therapies for measles, community exposures in these patients can lead to life-threatening infection. The lack of data regarding measles prevention in this population poses a number of clinical dilemmas. Herein specialists in Infectious Diseases and HCT/cellular therapy endorsed by the American Society of Transplant and Cellular Therapy address frequently asked questions about measles in these high-risk cancer patients and HCT recipients and provide expert opinions based on the limited available data.

Artificial Differences in Clostridium difficile Infection Rates Associated with Disparity in Testing

In 2015, Clostridium difficile testing rates among 30 US community, multispecialty, and cancer hospitals were 14.0, 16.3, and 33.9/1,000 patient-days, respectively. Pooled hospital onset rates were 0.56, 0.84, and 1.57/1,000 patient-days, respectively. Higher testing rates may artificially inflate reported rates of C. difficile infection. C. difficile surveillance should consider testing frequency.

Fecal calprotectin concentrations in cancer patients with Clostridium difficile infection

Fecal calprotectin (fCPT) has been used as a surrogate marker for assessment of intestinal inflammation. We explore the utility of fCPT values as a diagnostic aid in cancer patients with suspected Clostridium difficile infection (CDI). A total of 232 stool specimens submitted for GeneXpert C. difficile PCR testing were included in the study. All specimens were tested for fCPT and toxin/GDH antigens. Clinical severity of CDI cases was determined by the IDSA/SHEA criteria. Significant differences of median fCPT values between CDI (n = 117, Median 183.6 μg/g) and non-CDI (n = 115, 145.6 μg/g, p = 0.006) patients were seen. In CDI patents, significantly lower fCPT values were found in patients with mild to moderate (n = 95, 182.1 μg/g) than those with severe and severe to complicated (n = 22, 218.5 μg/g, p = 0.014) scores, and among those that were toxin positive (n = 24, 200.2 μg/g) vs. toxin negative (n = 86, 182.8 μg/g, p = 0.044). Despite this overall trend, wide variations in fCPT values were found in all categories examined. A logistic regression analysis revealed that the fCPT values correlated independently with the severity of clinical manifestations (OR = 2.021, 95%CI = 1.132-3.608); however, it did not correlate with other clinical outcomes. Our study findings show that high fecal calprotectin levels correlate with toxin-positive and clinically severe CDI; however, wide variations in individual measurements preclude establishment of reliable cut-offs for routine diagnostic use in cancer patients.

2150. Discontinuation of Vancomycin-Resistant Enterococci (VRE) Surveillance and Contact Isolation in ICU and Transplant Units

Background

The utility of active surveillance and contact isolation of VRE colonized individuals has not been established in non-outbreak and hyperendemic settings. The practice is onerous and resource intensive, with a hospital wide impact on patient flow. There is growing body of evidence suggesting that routine isolation of VRE colonized patients may not be beneficial. At MSKCC, VRE colonization rates in BMT and ICU units are ~ 33%, individuals with colonization only account for 80 % of all new VRE cases. Active surveillance had not shown any significant reduction in incident VRE. The objective of this study was to analyze the first year after discontinuation of active surveillance and routine contact precautions for VRE in the ICU. Outcomes assessed were house wide VRE BSI rate, unit specific BSI rates, and VRE-related nosocomial outbreaks. VRE-specific isolation days were simultaneously monitored.

Methods

Beginning in September 2015, we discontinued active VRE surveillance and isolation of colonized individuals in our 20 bed ICU, followed a year later by our 25-bed transplant unit. VRE BSI rates were observed for a 12-month period following these changes.

Results

The baseline house wide VRE BSI rate was 0.31/1,000 patient days. After discontinuation of practice in ICU, the ICU rate remained unchanged over the following 12 months (pre: 0.88/1,000 patient days vs. post: 0.77/1,000 patient days; P value = 0.83). No significant difference was seen in house wide or unit specific rates after the policy was subsequently implemented in the BMT unit (Figure 1). No VRE-related outbreaks were detected. There was a 50% absolute reduction in isolation days for VRE between the pre- and post-intervention periods.

Conclusion

Discontinuation of active surveillance and contact isolation of colonized individuals did not result in an increase in incidence of VRE BSI rates in a hyperendemic setting. A reduction in isolation beds facilitated patient flow, especially access to critical care services.

Disclosures

All authors: No reported disclosures.

504. Change in Clostridium difficile Strain-Type Distribution After Implementation of Diagnostic Stewardship

Background

The aim of this study was to evaluate the change in strain-type distribution after eliminating testing of formed and laxative induced diarrheal stool.

Methods

Beginning in July 2013, all Clostridium difficile-positive stool samples by Cepheid’s GeneXpert were routinely typed using Multi-Locus Sequence Typing (MLST). MLST was performed as previously described (1). After implementation of rejection policy and re-education of staff, strain type (ST) distribution among tested samples were analyzed and compared with historic data.

Results

After evaluation of our historical typing data the 10 most frequent ST were identified. Diagnostic stewardship led to 40.0% reduction in testing volume, the positivity rate increased from 12.0% to 12.6%. The frequency distribution of threemost prevalent strain types (MLST-2, 8, and 42) declined by 38%, 60%, and 42%, respectively. The absolute number of epidemic strains, ST-1 and ST-11, remained unchanged and the frequency distribution increased from 9.6% to 14.0%. No clonal outbreaks were detected during this time.

Conclusion

Implementation of diagnostic stewardship led to a reduction in recovery of endemic strains without substantial impact on detection of hypervirulent or epidemic strains.

Disclosures

All authors: No reported disclosures.

535. Transmission of Clostridium difficile (CD) From Patients ≤2 Years of Age in a Pediatric Oncology Setting

Background

Testing for Clostridium difficile (CD) is not recommended in patients under 2 years old because of CD endemicity in young children and absence of associated disease. These patients may, however, represent a reservoir for CD transmission to other high-risk pediatric patients. We describe the strain relatedness of CD isolates among a cohort of pediatric oncology patients by multilocus sequence type (MLST) and interrogate putative transmission events originating from donors ≤2 years of age with whole-genome sequencing (WGS).

Methods

Demographic and epidemiologic information was extracted from our infection control database for all laboratory identified CD cases in pediatric patients from October 2014 to December 2017. Patients ≤2 year old were identified as potential CD donors in a temporal–spatial model of transmission based on initial MLST analysis. CD recipients were identified as any patient with overlapping hospitalization within 12 weeks of the donor, regardless of recipient’s age. Donor–recipient pairs were further characterized with WGS to investigate the validity of presumed transmission events by epidemiologic links and MLST.

Results

During the study period CD infection (CDI) was diagnosed in 179 unique pediatric patients. Thirty-nine were ≤2 years. Overall MLST distribution of strains and frequency among patients ≤2 years is shown in Figure 1. ST-2 and 42 were the dominant strains (32% total). ST-11 was not isolated among ≤2 years group and only two ST-1 were isolated without identification of any related recipient cases. Based on concordant strain type on initial MLST, 27 (69%) patients ≤2 years of age were identified as potential donors to 48 pediatric patients; 40 samples were recoverable for WGS representing seven donors and 33 recipients. Despite the high concordance on MLST, WGS revealed only one pair of related CD isolates among these based on a single nucleotide polymorphism (SNP) difference of 1. Retrospective review revealed that these patients were in adjoining rooms during an overlapping admission but were diagnosed with CDI 7 days apart.

Conclusion

In a pediatric oncology unit, hospitalized children ≤2 years of age are not a substantial reservoir for hypervirulent or epidemic strains and an infrequent source of transmission to others with spatial proximity.

Disclosures

All authors: No reported disclosures.

734. Post-exposure Management of Influenza in Roommates at a Tertiary Care Cancer Center

Background

Post-exposure antiviral chemoprophylaxis with neuraminidase inhibitors (NI) is 80% effective in preventing influenza in household members. In hospital settings, management of exposed roommates has not been specifically addressed in clinical studies. Some experts recommend immunocompromised individuals exposed to influenza to receive therapeutic doses of NI as a preventive measure regardless of duration of exposure. The objective of this study was to determine optimal intervention in high-risk patients exposed to influenza based on duration of spatial overlap and viral testing at the time exposure is recognized.

Methods

MSK is a 473-bed tertiary care cancer center. Infection Control performs contact investigation for cases diagnosed with influenza including baseline testing of exposed roommates using a multiplex PCR test. The primary team is notified of exposures and makes recommendations regarding prophylaxis. Retrospective review of patients considered exposed to influenza during three seasons was performed. Information on spatial overlap, prophylaxis, and viral testing was extracted.

Results

Out of 64 patients exposed, five (8%) developed influenza (table). Baseline testing was done in 51 (80%): none with overlap of <4 days were symptomatic or tested positive; 2/12 with overlap >4 days tested positive. Attack rate for those with exposure time <4 days who did not receive prophylaxis was 2.6%. No breakthrough infection occurred in the prophylaxis group. Post exposure follow-up revealed two more cases for those overlapping >4 days; a single case of breakthrough infection developed at 7 days, resistance testing was not performed, and patient responded to therapeutic doses of NI without persistent shedding.

Conclusion

Duration of overlap in semi-private rooms correlates with secondary cases of influenza. Prophylactic doses of NI are safe and effective for asymptomatic individuals with exposure <4 days to index case. For patients with spatial overlap >4 days, baseline testing is recommended to recognize cases early and interrupt nosocomial transmission.

Disclosures

All authors: No reported disclosures.

Impact of Empiric Treatment for Vancomycin-Resistant Enterococcus in Colonized Patients Early after Allogeneic Hematopoietic Stem Cell Transplantation

In recent years, vancomycin-resistant Enterococcus (VRE) colonization is being increasingly encountered in transplant recipients, and VRE has become one of the leading causes of bacteremia early after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Data are sparse on the effect of empiric VRE therapy for febrile, neutropenic allo-HSCT recipients colonized with VRE. All allo-HSCT recipients aged ≥18years who developed VRE bacteremia (VREB) between 2005 and 2014 were identified and categorized as to whether they received empiric or directed VRE therapy. There were 434 (33%) VRE-colonized and 872 (67%) non-VRE-colonized patients during the study period, and 172 of the 434 (40%) VRE-colonized patients received empiric therapy. There was no significant difference in incidence of VREB among colonized patients who did or did not receive empiric therapy (28 of 172 [16%] vs 55 of 262 [21%]; P = .22). There were 95 patients with VREB, of which the majority (83 of 95; 87%) was known to be VRE-colonized. Of the 95 VREB episodes, 29 (31%) were treated with empiric VRE therapy, whereas 66 (69%) were treated with directed therapy. No significant differences in clinical outcomes, including median duration of bacteremia (2 days vs 2 days; P = .39), recurrent VREB (3 of 29 [10%] vs 5 of 66 [8%]; P = .65), 30-day all-cause mortality (1 of 29 [3%] vs 4 of 66 [6%]; P = .62), or VRE-attributable mortality (1 of 29 [3%] vs 1 of 66 [2%]; P = .55), were observed between the empiric therapy and directed therapy groups. Kaplan-Meier curve analysis showed no significant difference in survival at 30days in allo-HSCT recipients with VREB who received empiric therapy and those who received directed therapy (97% vs 94%; P = .62). Based on our data, we recommend against empiric use of VRE-active agents for fever and neutropenia in VRE-colonized patients undergoing allo-HSCT.

Effectiveness of ultraviolet disinfection in reducing hospital-acquired Clostridium difficile and vancomycin-resistant Enterococcus on a bone marrow transplant unit

OBJECTIVE

To determine the effectiveness of ultraviolet (UV) environmental disinfection system on rates of hospital-acquired vancomycin-resistant enterococcus (VRE) and Clostridium difficile.

DESIGN

Using active surveillance and an interrupted time-series design, hospital-acquired acquisition of VRE and C. difficile on a bone marrow transplant (BMT) unit were examined before and after implementation of terminal disinfection with UV on all rooms regardless of isolation status of patients. The main outcomes were hospital-based acquisition measured through (1) active surveillance: admission, weekly, and discharge screening for VRE and toxigenic C. difficile (TCD) and (2) clinical surveillance: incidence of VRE and CDI on the unit.

SETTING

Bone marrow transplant unit at a tertiary-care cancer center.ParticipantsStem cell transplant (SCT) recipients.InterventionTerminal disinfection of all rooms with UV regardless of isolation status of patients.

RESULTS

During the 20-month study period, 579 patients had 704 admissions to the BMT unit, and 2,160 surveillance tests were performed. No change in level or trend in the incidence of VRE (trend incidence rate ratio [IRR], 0.96; 95% confidence interval [CI], 0.81-1.14; level IRR, 1.34; 95% CI, 0.37-1.18) or C. difficile (trend IRR, 1.08; 95% CI, 0.89-1.31; level IRR, 0.51; 95% CI, 0.13-2.11) was observed after the intervention.

CONCLUSIONS

Utilization of UV disinfection to supplement routine terminal cleaning of rooms was not effective in reducing hospital-acquired VRE and C. difficile among SCT recipients.

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Manley L, Nemery R, Charlton W, Smith P, Kerr L, Steindel-Kopp B, Alamaguer M, Tabisola-Nuesca E, Pendersen A, Larson N, Cooper-Olviver H, Chan D, Fitz-Patrick D, Carreira T, Park Y, Ruhaak R, Liljenquist D. A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.