The Addition of Systemic Terbinafine to Antifungal Combination Therapy in the Treatment of Disseminated Drug-Resistant Mold Infections in a National Cancer Institute Comprehensive Cancer Center: A Six-Year Study

Introduction Combination antifungal regimens are frequently employed in the treatment of invasive fungal infections in patients who are immunocompromised, particularly for cancer and transplant patients. Terbinafine is a potential agent of interest for combination regimens. Methods We reviewed data over a six-year period examining patient outcomes in terms of both mortality and distribution of pathogens. The total number of patients in our study was 64. The use of terbinafine versus no terbinafine in combination therapy was assessed. Of the 64 patients analyzed, only 14 received terbinafine. Mortality was calculated for both groups, and demographics were analyzed by descriptive statistics. Results There was no statistical difference in mortality outcomes in either group. The addition of terbinafine was well tolerated and did not appear to result in any undue toxicity concerns. Discussion We wish to draw greater attention to this potential agent within our armamentarium for invasive fungal infections. To our knowledge, the total number of patients in our study, while small, represents the largest reported cohort in the literature to date. Sensitivities are crucial to be obtained for fungal pathogens as this likely undermined the utility of terbinafine in our study with larger than expected numbers of multidrug-resistant Fusarium. With limited patient numbers, a multicenter trial would be beneficial to further examine terbinafine in combination regimens.

483. Use of Terbinafine in Combination with Other Systemic Anti-fungal Agents As Treatment for Invasive Mold Infections. Experience from A National Cancer Institute Designated Cancer Center

Background

The severely Immunocompromised are at an increased risk of fatal infection caused by invasive molds. Amphotericin B and triazole agents with anti-mold activity are commonly used in treating invasive mold infections. There is some data from in-vitro experiments to suggest an enhanced killing of some molds when terbinafine is used in combination with certain azoles or amphotericin B. At our center, terbinafine is occasionally used in combination with other systemic anti-fungal agents in treating severely immunocompromised patients with invasive mold infections.

Methods

The study was a retrospective review of electronic medical records. Sixty-four patients treated for culture confirmed infection with mold isolates at the Moffitt Cancer Center from 1/1/2015 to 6/1/2021 were included in this study. There were 2 treatment groups: Group A comprised of those treated with a terbinafine containing regimen and Group B comprised of patients that were not treated with a terbinafine containing regimen.

Results

Treatment group A: Comprised of 14 patients. Twenty-nine percent (4/14) had skin/soft tissue infections, 21% (3/14) had rhinosinusitis, 21% (3/14) had pulmonary infections and 4 patients (29%) had disseminated infection. Thirty-six percent (5/14) were discharged with treatment response, 57% (8/14) did not respond to treatment or died due to the invasive mold infection and 7% (1/14) died as a result of malignancy.

Treatment group B: Had 50 patients. thirty-eight percent (19/50) had pulmonary infections, 28% (14/50) with skin/soft tissue infections, 16% (8/50) had rhinosinusitis, 2% (1/50) were diagnosed with central nervous system infection, 2% (1/50) had gastrointestinal infection, 14% (7/50) had an unclear source of infection. Forty-eight percent (24/50) were discharged with treatment response, 42% (21/50) had treatment failure or died due to the invasive mold infection and 10% (5/50) died as a result of malignancy. Table 1Figure 1

Conclusion

There was no statistically significant improvement in outcome observed in this study when terbinafine was used in addition to other systemic anti-fungal medications as treatment of invasive mold infections. There is a need for larger studies to determine if terbinafine has a role in the treatment of invasive mold infections.

Disclosures

All Authors: No reported disclosures.

9. Influenza Vaccine Rates Amongst Patients With Limited English Proficiency In A Primary Health Care Clinic; Our 3 Years Experience

Background

Influenza has been recognized to be a significant cause of morbidity and mortality. It was the cause of 10.1% of all deaths recorded on death certificates during the week ending January 20, 2018.In order to reduce the risk of influenza, Centers for Disease Control recommends that every person six months and older who have no contraindications be vaccinated with the influenza vaccine.

Limited English Proficiency (LEP) describes individuals who have limited ability to speak, read, write or understand English language. Sadly, there is an increasing body of data that suggest that patients with LEP are less likely to seek out medical attention in a timely manner, are less adherent to medically recommended preventive and therapeutic measures. The purpose of this study was to determine the rate of acceptance of the Influenza vaccine amongst patients with LEP in our resident ran out-patient clinic.

Methods

This study was retrospective, data was obtained through chart review of the electronical medical records (EMR). Patients had to be at least 18 years old and registered patients at our primary health care clinic to be enrolled in this study. Data was gathered for the 2015–2016, 2016–2017 and 2017–2018 influenza seasons. The months of October to May were designated as the Influenza season as these months have been identified as the time frame that the influenza virus has the most activity.

Results

109 of 499 the randomly selected participants were not included in the final analysis due to reasons like: no visit to the primary health care clinic during specified periods, ability to communicate in English, insufficient data in to the EMR. Data from 390 patients were analyzed. 43.3% spoke Spanish, 36.2% were Portuguese speaking and 20.5% spoke other languages. A large majority of patients across all language groups did not receive the influenza vaccine each season.

Table 1

Figure 1

Figure 2

Conclusion

Results from this study indicate that there was an alarmingly low rate of influenza vaccination among patients with LEP in our primary care clinic in during the 2015–2016, 2016–2017 and 2017–2018 influenza seasons. This highlights the need for implementing interventions aimed at both understanding why this vaccination gap exist and improving the vaccine acceptance rate amongst this venerable population.

Disclosures

All Authors: No reported disclosures

1195. Influence of Histoplasma capsulatum Infection on Endothelin-1 mRNA Gene Expression in Bone Marrow Derived Macrophages

Background

Endothelin-1 (ET-1) is increasingly recognized as an immune modulator; it exerts a pro-inflammatory effect by increasing the release of cytokines like interferon gamma. ET-1 is secreted by a variety of cells such as macrophages, neurons and endothelial cells. Activation of the endothelin system has been implicated in the pathogenesis of sepsis caused by bacteria, viruses and even parasites. However, there are no published studies that have explored the role of ET-1 in Histoplasma capsulatum infection. Studying the role of ET-1 in histoplasmosis is important because understanding its role in the host defense mechanism may serve as the foundation for future discovery of novel therapeutic options.

Methods

Bone marrow cells were isolated from mice and set up for tissue culture. Bone marrow derived macrophages (BMDM) were harvested after 5-7 days of incubation, and infected with varying ratios (0.5,1 and 5) of yeasts to macrophages. RNA was extracted from the BMDM after 3, 6, 24 and 48 hours of infection. For comparison, RNA was also extracted from uninfected BMDM at the same time points. Real-time PCR (polymerase chain reaction) was performed on complementary DNA. ET-1 (Edn1) messenger RNA (mRNA) gene expression was quantified relative to the expression of the house keeping /endogenous control gene that encodes for beta-2 microglobulin (B2m).

Results

In BMDM infected with H. capsulatum there was upregulation of Edn1 after 3, 6 and 24 hours of infection. During this same time points, the expression of ET-1 mRNA in the uninfected BMDM remained constant. Expression of Edn1 was highest in the BMDM infected with 5x H. capsulatum after 3 and 6 hours of infection. After 24 hours, the expression of ET-1 mRNA decreased markedly in all concentrations of H. capsulatum. At 48 hours post-infection the Edn1 was downregulated in the 0.5,1 and 5-fold quantities of H. capsulatum across all time the time intervals.

Figure 1

Conclusion

Results from this study indicate that H. capsulatum infection induced an upregulation of the Edn-1 in BMDM. This may correlate with an increase in levels of ET-1 production by the BMDM in the face of H. capsulatum infection. These results provide a platform in which to examine the influence of ET-1 on the host response to this fungus.

Disclosures

All Authors: No reported disclosures