Prevalence of infectious diseases, immunity to vaccine-preventable diseases and chronic medical conditions among Ukrainian refugees in Germany - A cross sectional study from the German Network University Medicine (NUM)

BACKGROUND

Vulnerability to infectious diseases in refugees is dependent on country of origin, flight routes, and conditions. Information on specific medical needs of different groups of refugees is lacking. We assessed the prevalence of infectious diseases, immunity to vaccine-preventable diseases, and chronic medical conditions in children, adolescents, and adult refugees from Ukraine who arrived in Germany in 2022.

METHODS

Using different media, we recruited Ukrainian refugees at 13 sites between 9-12/2022. An antigen test for acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection, serologies for a range of vaccine-preventable diseases, as well as interferon gamma release assays (IGRAs) for tuberculosis (TB), and SARS-CoV-2 were performed. We assessed personal and family history of chronic medical conditions, infectious diseases, vaccination status, and conditions during migration.

RESULTS

Overall, 1793 refugees (1401 adults and 392 children/adolescents) were included. Most participants were females (n = 1307; 72·3%) and from Eastern or Southern Ukraine. TB IGRA was positive in 13% (n = 184) of the adults and in 2% (n = 7) of the children. Serology-based immunological response was insufficient in approximately 21% (360/1793) of the participants for measles, 32% (572/1793) for diphtheria, and 74% (1289/1793) for hepatitis B.

CONCLUSIONS

We show evidence of low serological response to vaccine-preventable infections and increased LTBI prevalence in Ukrainian refugees. These findings should be integrated into guidelines for screening and treatment of infectious diseases in migrants and refugees in Germany and Europe. Furthermore, low immunity for vaccine-preventable diseases in Ukrainians independent of their refugee status, calls for tailor-made communication efforts.

Analysis of acute COVID-19 including chronic morbidity: protocol for the deep phenotyping National Pandemic Cohort Network in Germany (NAPKON-HAP)

BACKGROUND

The severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) pandemic causes a high burden of acute and long-term morbidity and mortality worldwide despite global efforts in containment, prophylaxis, and therapy. With unprecedented speed, the global scientific community has generated pivotal insights into the pathogen and the host response evoked by the infection. However, deeper characterization of the pathophysiology and pathology remains a high priority to reduce morbidity and mortality of coronavirus disease 2019 (COVID-19).

METHODS

NAPKON-HAP is a multi-centered prospective observational study with a long-term follow-up phase of up to 36 months post-SARS-CoV-2 infection. It constitutes a central platform for harmonized data and biospecimen for interdisciplinary characterization of acute SARS-CoV-2 infection and long-term outcomes of diverging disease severities of hospitalized patients.

RESULTS

Primary outcome measures include clinical scores and quality of life assessment captured during hospitalization and at outpatient follow-up visits to assess acute and chronic morbidity. Secondary measures include results of biomolecular and immunological investigations and assessment of organ-specific involvement during and post-COVID-19 infection. NAPKON-HAP constitutes a national platform to provide accessibility and usability of the comprehensive data and biospecimen collection to global research.

CONCLUSION

NAPKON-HAP establishes a platform with standardized high-resolution data and biospecimen collection of hospitalized COVID-19 patients of different disease severities in Germany. With this study, we will add significant scientific insights and provide high-quality data to aid researchers to investigate COVID-19 pathophysiology, pathology, and chronic morbidity.

Estimation of Improvements in Mortality in Spectrum Among Adults With HIV Receiving Antiretroviral Therapy in High-Income Countries

INTRODUCTION

Mortality rates for people living with HIV (PLHIV) on antiretroviral therapy (ART) in high-income countries continue to decline. We compared mortality rates among PLHIV on ART in Europe for 2016-2020 with Spectrum's estimates.

METHODS

The AIDS Impact Module in Spectrum is a compartmental HIV epidemic model coupled with a demographic population projection model. We used national Spectrum projections developed for the 2022 HIV estimates round to calculate mortality rates among PLHIV on ART, adjusting to the age/country distribution of PLHIV starting ART from 1996 to 2020 in the Antiretroviral Therapy Cohort Collaboration (ART-CC)'s European cohorts.

RESULTS

In the ART-CC, 11,504 of 162,835 PLHIV died. Between 1996-1999 and 2016-2020, AIDS-related mortality in the ART-CC decreased from 8.8 (95% CI: 7.6 to 10.1) to 1.0 (0.9-1.2) and from 5.9 (4.4-8.1) to 1.1 (0.9-1.4) deaths per 1000 person-years among men and women, respectively. Non-AIDS-related mortality decreased from 9.1 (7.9-10.5) to 6.1 (5.8-6.5) and from 7.0 (5.2-9.3) to 4.8 (4.3-5.2) deaths per 1000 person-years among men and women, respectively. Adjusted all-cause mortality rates in Spectrum among men were near ART-CC estimates for 2016-2020 (Spectrum: 7.02-7.47 deaths per 1000 person-years) but approximately 20% lower in women (Spectrum: 4.66-4.70). Adjusted excess mortality rates in Spectrum were 2.5-fold higher in women and 3.1-3.4-fold higher in men in comparison to the ART-CC's AIDS-specific mortality rates.

DISCUSSION

Spectrum's all-cause mortality estimates among PLHIV are consistent with age/country-controlled mortality observed in ART-CC, with some underestimation of mortality among women. Comparing results suggest that 60%-70% of excess deaths among PLHIV on ART in Spectrum are from non-AIDS causes.

Adaptability of Existing Feasibility Tools for Clinical Study Research Data Platforms

INTRODUCTION

The increasing need for secondary use of clinical study data requires FAIR infrastructures, i.e. provide findable, accessible, interoperable and reusable data. It is crucial for data scientists to assess the number and distribution of cohorts that meet complex combinations of criteria defined by the research question. This so-called feasibility test is increasingly offered as a self-service, where scientists can filter the available data according to specific parameters. Early feasibility tools have been developed for biosamples or image collections. They are of high interest for clinical study platforms that federate multiple studies and data types, but they pose specific requirements on the integration of data sources and data protection.

METHODS

Mandatory and desired requirements for such tools were acquired from two user groups - primary users and staff managing a platform's transfer office. Open Source feasibility tools were sought by different literature search strategies and evaluated on their adaptability to the requirements.

RESULTS

We identified seven feasibility tools that we evaluated based on six mandatory properties.

DISCUSSION

We determined five feasibility tools to be most promising candidates for adaption to a clinical study research data platform, the Clinical Communication Platform, the German Portal for Medical Research Data, the Feasibility Explorer, Medical Controlling, and the Sample Locator.

The Importance of Being FAIR and FAST - The Clinical Epidemiology and Study Platform of the German Network University Medicine (NUKLEUS)

The COVID-19 pandemic has urged the need to set up, conduct and analyze high-quality epidemiological studies within a very short time-scale to provide timely evidence on influential factors on the pandemic, e.g. COVID-19 severity and disease course. The comprehensive research infrastructure developed to run the German National Pandemic Cohort Network within the Network University Medicine is now maintained within a generic clinical epidemiology and study platform NUKLEUS. It is operated and subsequently extended to allow efficient joint planning, execution and evaluation of clinical and clinical-epidemiological studies. We aim to provide high-quality biomedical data and biospecimens and make its results widely available to the scientific community by implementing findability, accessibility, interoperability and reusability - i.e. following the FAIR guiding principles. Thus, NUKLEUS might serve as role model for FAIR and fast implementation of clinical epidemiological studies within the setting of University Medical Centers and beyond.

COVIDAL: A machine learning classifier for digital COVID-19 diagnosis in German hospitals

For the fight against the COVID-19 pandemic, it is particularly important to map the course of infection, in terms of patients who have currently tested SARS-CoV-2 positive, as accurately as possible. In hospitals, this is even more important because resources have become scarce. Although polymerase chain reaction (PCR) and point of care (POC) antigen testing capacities have been massively expanded, they are often very time-consuming and cost-intensive and, in some cases, lack appropriate performance. To meet these challenges, we propose the COVIDAL classifier for AI-based diagnosis of symptomatic COVID-19 subjects in hospitals based on laboratory parameters. We evaluate the algorithm's performance by unique multicenter data with approx. 4,000 patients and an extraordinary high ratio of SARS-CoV-2 positive patients. We analyze the influence of data preparation, flexibility in optimization targets as well as the selection of the test set on the COVIDAL outcome. The algorithm is compared with standard AI, PCR, POC antigen testing and manual classifications of seven physicians by a decision theoretic scoring model including performance metrics, turnaround times and cost. Thereby, we define health care settings in which a certain classifier for COVID-19 diagnosis is to be applied. We find sensitivities, specificities and accuracies of the COVIDAL algorithm of up to 90 percent. Our scoring model suggests using PCR testing for a focus on performance metrics. For turnaround times, POC antigen testing should be used. If balancing performance, turnaround times and cost is of interest, as, for example, in the emergency department, COVIDAL is superior based on the scoring model.

Harmonized procedure coding system for surgical procedures and analysis of surgical site infections (SSI) of five European countries

BACKGROUND

The use of routine data will be essential in future healthcare research. Therefore, harmonizing procedure codes is a first step to facilitate this approach as international research endeavour. An example for the use of routine data on a large scope is the investigation of surgical site infections (SSI). Ongoing surveillance programs evaluate the incidence of SSI on a national or regional basis in a limited number of procedures. For example, analyses by the European Centre for Disease Prevention (ECDC) nine procedures and provides a mapping table for two coding systems (ICD9, National Healthcare Safety Network [NHSN]). However, indicator procedures do not reliably depict overall SSI epidemiology. Thus, a broader analysis of all surgical procedures is desirable. The need for manual translation of country specific procedures codes, however, impedes the use of routine data for such an analysis on an international level. This project aimed to create an international surgical procedure coding systems allowing for automatic translation and categorization of procedures documented in country-specific codes.

METHODS

We included the existing surgical procedure coding systems of five European countries (France, Germany, Italy, Spain, and the United Kingdom [UK]). In an iterative process, country specific codes were grouped in ever more categories until each group represented a coherent unit based on method of surgery, interventions performed, extent and site of the surgical procedure. Next two ID specialist (arbitrated by a third in case of disagreement) independently assigned country-specific codes to the resulting categories. Finally, specialist from each surgical discipline reviewed these assignments for their respective field.

RESULTS

A total number of 153 SALT (Staphylococcus aureus Surgical Site Infection Multinational Epidemiology in Europe) codes from 10 specialties were assigned to 15,432 surgical procedures. Almost 4000 (26%) procedure codes from the SALT coding system were classified as orthopaedic and trauma surgeries, thus this medical field represents the most diverse group within the SALT coding system, followed by abdominal surgical procedures with 2390 (15%) procedure codes.

CONCLUSION

Mapping country-specific codes procedure codes onto to a limited number of coherent, internally and externally validated codes proofed feasible. The resultant SALT procedure code gives the opportunity to harmonize big data sets containing surgical procedures from international centres, and may simplify comparability of future international trial findings.

TRIAL REGISTRATION

The study was registered at clinicaltrials.gov under NCT03353532 on November 27^th, 2017.

Obesity and Impaired Metabolic Health Increase Risk of COVID-19-Related Mortality in Young and Middle-Aged Adults to the Level Observed in Older People: The LEOSS Registry

Advanced age, followed by male sex, by far poses the greatest risk for severe COVID-19. An unresolved question is the extent to which modifiable comorbidities increase the risk of COVID-19-related mortality among younger patients, in whom COVID-19-related hospitalization strongly increased in 2021. A total of 3,163 patients with SARS-COV-2 diagnosis in the Lean European Open Survey on SARS-CoV-2-Infected Patients (LEOSS) cohort were studied. LEOSS is a European non-interventional multi-center cohort study established in March 2020 to investigate the epidemiology and clinical course of SARS-CoV-2 infection. Data from hospitalized patients and those who received ambulatory care, with a positive SARS-CoV-2 test, were included in the study. An additive effect of obesity, diabetes and hypertension on the risk of mortality was observed, which was particularly strong in young and middle-aged patients. Compared to young and middle-aged (18-55 years) patients without obesity, diabetes and hypertension (non-obese and metabolically healthy; n = 593), young and middle-aged adult patients with all three risk parameters (obese and metabolically unhealthy; n = 31) had a similar adjusted increased risk of mortality [OR 7.42 (95% CI 1.55-27.3)] as older (56-75 years) non-obese and metabolically healthy patients [n = 339; OR 8.21 (95% CI 4.10-18.3)]. Furthermore, increased CRP levels explained part of the elevated risk of COVID-19-related mortality with age, specifically in the absence of obesity and impaired metabolic health. In conclusion, the modifiable risk factors obesity, diabetes and hypertension increase the risk of COVID-19-related mortality in young and middle-aged patients to the level of risk observed in advanced age.

All-cause mortality and disease progression in SARS-CoV-2-infected patients with or without antibiotic therapy: an analysis of the LEOSS cohort

Purpose

Reported antibiotic use in coronavirus disease 2019 (COVID-19) is far higher than the actual rate of reported bacterial co- and superinfection. A better understanding of antibiotic therapy in COVID-19 is necessary.

Methods

6457 SARS-CoV-2-infected cases, documented from March 18, 2020, until February 16, 2021, in the LEOSS cohort were analyzed. As primary endpoint, the correlation between any antibiotic treatment and all-cause mortality/progression to the next more advanced phase of disease was calculated for adult patients in the complicated phase of disease and procalcitonin (PCT) ≤ 0.5 ng/ml. The analysis took the confounders gender, age, and comorbidities into account.

Results

Three thousand, six hundred twenty-seven cases matched all inclusion criteria for analyses. For the primary endpoint, antibiotic treatment was not correlated with lower all-cause mortality or progression to the next more advanced (critical) phase (n = 996) (both p > 0.05). For the secondary endpoints, patients in the uncomplicated phase (n = 1195), regardless of PCT level, had no lower all-cause mortality and did not progress less to the next more advanced (complicated) phase when treated with antibiotics (p > 0.05). Patients in the complicated phase with PCT > 0.5 ng/ml and antibiotic treatment (n = 286) had a significantly increased all-cause mortality (p = 0.029) but no significantly different probability of progression to the critical phase (p > 0.05).

Conclusion

In this cohort, antibiotics in SARS-CoV-2-infected patients were not associated with positive effects on all-cause mortality or disease progression. Additional studies are needed. Advice of local antibiotic stewardship- (ABS-) teams and local educational campaigns should be sought to improve rational antibiotic use in COVID-19 patients.

Cause-specific mortality after diagnosis of cancer among HIV-positive patients: A collaborative analysis of cohort studies

People living with HIV (PLHIV) are more likely than the general population to develop AIDS-defining malignancies (ADMs) and several non-ADMs (NADMs). Information is lacking on survival outcomes and cause-specific mortality after cancer diagnosis among PLHIV. We investigated causes of death within 5 years of cancer diagnosis in PLHIV enrolled in European and North American HIV cohorts starting antiretroviral therapy (ART) 1996-2015, aged ≥16 years, and subsequently diagnosed with cancer. Cancers were grouped: ADMs, viral NADMs and nonviral NADMs. We calculated cause-specific mortality rates (MR) after diagnosis of specific cancers and compared 5-year survival with the UK and France general populations. Among 83,856 PLHIV there were 4,436 cancer diagnoses. Of 603 deaths after ADM diagnosis, 292 (48%) were due to an ADM. There were 467/847 (55%) and 74/189 (39%) deaths that were due to an NADM after nonviral and viral NADM diagnoses, respectively. MR were higher for diagnoses between 1996 and 2005 versus 2006-2015: ADMs 102 (95% CI 92-113) per 1,000 years versus 88 (78-100), viral NADMs 134 (106-169) versus 111 (93-133) and nonviral NADMs 264 (232-300) versus 226 (206-248). Estimated 5-year survival for PLHIV diagnosed with liver (29% [19-39%]), lung (18% [13-23%]) and cervical (75% [63-84%]) cancer was similar to general populations. Survival after Hodgkin's lymphoma diagnosis was lower in PLHIV (75% [67-81%]). Among ART-treated PLHIV diagnosed with cancer, MR and causes of death varied by cancer type, with mortality highest for liver and lung cancers. Deaths within 5 years of NADM diagnoses were more likely to be from cancer than AIDS.

580. Key Factors for Treatment Changes Within 1 Year After Starting ART in the German ClinSurv Cohort: Between 2005 and 2014

Background

Initiation of combined antiretroviral therapy (cART) has markedly increased survival and quality of life in HIV-infected patients. With the advent of new treatment options, including an increasing number of single-tablets, the durability of first-line ART regimes is developing.

Methods

We used data from the prospective multicenter German Clinical Surveillance of HIV Disease (ClinSurv) cohort of the Robert-Koch-Institute. Time to event was calculated as time between initiation of first-line cART and therapy change. We used a Cox model to assess predictors of treatment change 1 year after starting cART.

Results

We included 6,894 patients who initiated ART between 2005 and 2014. The sample population was predominantly men (79%) with German origin (69.8%), of which 49.6% were reporting sex with men (MSM) as main risk factor. Median age (IQR) was 38 (31–46) years. The most frequently treatment combinations were 2NRTI/PIr (48.1%) and 2NRTI/1NNRTI (42.2%), 2NRTI/1II (5.2%). 22.6% patients changed their first-line treatment within 1 year. Median (IQR) length between first intake and stop of the regime was 105 (35–214) days, which did not change significantly between 2005 (108; 38–217) and 2014 (128; 74–200) (P = 0.28). Most common documented causes were side effects of drugs 418 (44.0%) and non-adherence 173 (18.2%). In the Cox model (Figure 1), we identified numerous covariates associated with discontinuation of the first-line regime. A 2NRTI/1NNRTI regime was associated with higher rates (hazard ratio [HR] 1.28, 95% CI 1.06–1.55) and a 2NRTI/1II regime with lower rates (HR 0.34, 95% CI 0.23–0.51) of treatment modification (ref.: 2NRTI/1PIr). The HR increased markedly with the amount of daily-administered tablets from HR 2.15, 95% CI 1.48–3.11 (2–3 tablets) to HR 3.98, 95% CI 2.16–7.31 (10 tablets) (ref.: one tablet). We observed an association with a baseline viral load (VL) of >100 copies/mL (HR 0.65, 95% CI 0.53–0.81) and >100.000 copies/mL (HR 0.68, 95% CI 0.54–0.85) (ref.: VL > 1 Mio. copies/mL).

Conclusion

Our analysis revealed, that side effects of drugs, the number of tablets per day and the VL at baseline are significantly associated with treatment change within the first year. A first-line regime with 2NRTI/1II seems to improve the adherence to the initial regime significantly.

Disclosures

All authors: No reported disclosures.

412. Clinical and Pharmacoeconomic Evaluation of Antifungal Prophylaxis With Continuous Micafungin Compared to Posaconazole With Micafungin Bridging in Patients Undergoing Allogeneic Stem Cell Transplantation: A 6-Year Cohort Analysis

Background

Methods

Results

Conclusion

Disclosures

1568. Implementation of a Standard Diet Regimen for Neutropenic High-Risk Cancer Patients: Effects on Incidence of Infections, Foodborne Diseases, and Outcome

Background

Neutropenia is a major risk factor for infections in cancer patients. Even though evidence to support a germ-free neutropenic diet (ND) is missing, many oncology departments still maintain ND regimens. While benefits of an ND remain uncertain, restrictions of food and rigorous preparation rules impact quality of life and may further increase malnutrition rates in cancer patients.

Methods

Based on the Cologne Cohort of Neutropenic Patients database, we conducted a retrospective analysis of high-risk hematological/oncological patients with a confirmed period of neutropenia (neutrophils < 500/mm³) which lasted longer than 5 days. The interval of four years before and after replacing the ND by a standard hospital diet (SD) in January 2008 was compared. Patients undergoing allogenic stem-cell transplantation were excluded. The relative days of febrile neutropenia (relFN) before (neutropenic diet group, NDG) and after (standard diet group, SDG) the change of diet were analyzed in a propensity score-matched cohort. Secondary outcomes were the incidence of food borne disease, bloodstream infections (BSI), antibiotic treatment, diarrhea, weight change, nausea, and death.

Results

A total of 774 neutropenic episodes of each NDG and SDG were included into the analysis. The median days of neutropenia were 11 (IQR 8–16) in the NDG and 10 (IQR 8–16) in the SDG (P = 0.320). The rate of acute leukemia for NDG and SDG was 47% (P = 0.839). The mean relFN was 0.20 in the NDG and 0.22 in the SDG (P = 0.270). In our multivariate model, no association between diet and relFN was identified (OR 0.03; IQR −0.04–0.09; P = 0.410). Diarrhea occurred in 52% in the NDG and 40% in the SDG (P < 0.001), nausea in 72% and 66% (P < 0.001). No significant changes in frequency of gastrointestinal infections (NDG: 2; SDG: 1; P = 0.719) or BSI related to foodborne disease (NDG: 0; SDG: 3 P = 0.248) were detected after change of diet. The detected BSI (NDG: 29%; SDG: 30%; P = 0.867), antibiotic treatment (NDG: 78%; SDG: 77%; P = 0.760), weight gain (NDG: 11%; SDG: 14%; P = 0.121), and median 28-day mortality (NDG: 13.5 (IQR 8.8–32.5); SDG: 17 (IQR 10–29); P = 0.118) were equally distributed after change of diet (see Figure 1).

Conclusion

We did not detect a change in relFN after replacing the ND with an SD. In our population, an SD was safe for neutropenic high-risk patients.

Disclosures

All authors: No reported disclosures.

2046. FungiScope™: News on the Global Emerging Fungal Infection Registry

Background

Numbers of rare invasive fungal diseases (IFD) are rising worldwide due to increasing patient population at risk. To broaden the knowledge on epidemiology of rare IFD and eventually improving diagnosis and clinical outcome, FungiScope™, a global registry for rare IFD, has been initiated.

Methods

FungiScope™ uses web-based data capture (www.clinicalsurveys.net). Eligible are cases with proven or probable infection due to rare, non-endemic fungi. Data collected include demographics, underlying conditions, clinical presentation, diagnostics, antifungal therapy and outcome. Clinical isolates are collected for centralized identification, susceptibility testing and exchange between collaborators.

Results

To date, 728 valid cases of rare IFD from 41 countries are included in the registry: IFD due to Mucormycetes (n = 358), Fusarium spp. (n = 87), rare yeasts (n = 83), dematiaceae (n = 69), and Scedosporium spp. (n = 55) are the most frequently reported. FungiScope™ is supported by central labs in the Czech Republic, India, Russia, and Spain. Recently, FungiScope™ collaborators jointly published results on (I) invasive mucormycosis in children analyzed together with cases from the registry study Zygomyco.net, (II) disseminated fusariosis in 10 children, and (III) invasive infections due to Saprochaete and Geotrichum spp. in 23 patients.

Conclusion

The clinical relevance and by this the awareness of emerging IFD is increasing. FungiScope™ is a valuable resource used for collaborative studies on rare IFD. Operating and management of the registry requires considerable effort to ensure high data quality for comprehensive analyses, which provide insights into current clinical management of the diseases and thus, hold the potential to identify strategies for early diagnosis and effective treatment.

Disclosures

M. J. G. T. Vehreschild, Pfizer: Speaker’s Bureau, Speaker honorarium; MSD/Merck: Consultant and Speaker’s Bureau, Consulting fee and Speaker honorarium; Gilead Sciences: Research Contractor and Speaker’s Bureau, Research grant and Speaker honorarium; Organobalance: Speaker’s Bureau, Speaker honorarium; Astellas Pharma: Consultant, Research Contractor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium; 3M: Research Contractor, Research grant; DaVolterra: Research Contractor, Research grant; Berlin Chemie: Consultant, Consulting fee. J. Vehreschild, Merck / MSD: Consultant, Research Contractor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium; Gilead: Consultant, Research Contractor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium; Pfizer: Research Contractor and Speaker’s Bureau, Research grant and Speaker honorarium; Astellas Pharma: Consultant, Research Contractor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium; Basilea: Consultant, Research Contractor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium; Deutsches Zentrum für Infektionsforschung: Member, Research Contractor and Speaker’s Bureau, Research grant and Speaker honorarium; Uniklinik Freiburg/Kongress und Kommunikation: Speaker’s Bureau, Speaker honorarium; Akademie für Infektionsmedizin: Speaker’s Bureau, Speaker honorarium; Universität Manchester: Speaker’s Bureau, Speaker honorarium; Deutsche Gesellschaft für Infektiologie: Member and Speaker’s Bureau, Speaker honorarium; Ärztekammer Nordrhein: Speaker’s Bureau, Speaker honorarium; Uniklinik Aachen: Speaker’s Bureau, Speaker honorarium; Back Bay Strategies: Speaker’s Bureau, Speaker honorarium; Deutsche Gesellschaft für Innere Medizin: Member and Speaker’s Bureau, Speaker honorarium. O. A. Cornely, Amplyx Pharmaceuticals, Basilea Pharmaceutica, F2G, Gilead Sciences, MSD Sharp and Dohme, Scynexis Inc.: Consultant, Consulting fee; Amplyx Pharmaceuticals, Basilea Pharmaceutica, F2G, Gilead Sciences, MSD Sharp and Dohme, Scynexis Inc.: Grant Investigator, Research grant; Basilea Pharmaceutica, Gilead Sciences, MSD Sharp and Dohme, Pfizer: Speaker’s Bureau, Speaker honorarium.

413. Intravenous and Tablet Formulation of Posaconazole in Antifungal Therapy and Prophylaxis: A Retrospective, Non-Interventional, Multicenter Analysis of Patients Treated in German Tertiary-Care Hospitals

Background

Novel formulations (gastro-resistant tablet and intravenous solution) of posaconazole (POS) have been approved in prophylaxis and therapy of invasive fungal diseases (IFDs). The aim of this multicenter noninterventional study was to analyze treatment strategies and clinical effectiveness of these new options.

Methods

We set up a web-based registry on the science platform www.ClinicalSurveys.net and members of the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology (AGIHO) were invited to provide clinical data on patients who received novel POS formulations. Data analysis was split into two groups of patients who received novel POS formulations for antifungal prophylaxis (posaconazole prophylaxis group) and antifungal therapy (posaconazole therapy group), respectively.

Results

One hundred eighty hospitalized patients (151 in the posaconazole prophylaxis group and 29 in the posaconazole therapy group) from six German tertiary care centers treated between July 2014 and March 2016 were included into our analysis. Seventy-six patients were female (42%) and median age was 58 years (range: 19 – 77 years). Most patients (n = 111; 62%) had an acute myeloid leukemia as primary underlying disease. In the posaconazole prophylaxis group and posaconazole therapy group, mean POS serum levels at steady-state were 1,154 µg/L (n = 40; 95% CI: 911 – 1,396 µg/L) and 1,097 µg/L (n = 19; 95% CI: 817 – 1,378 µg/L), respectively (P = 0.776). In the posaconazole prophylaxis group, nine (6%) probable/proven fungal breakthroughs were reported. In the posaconazole therapy group, 17 and 12 patients received POS as first-line therapy and salvage therapy, respectively. Most frequent indications were possible (n = 9) and probable (n = 7) aspergillosis and proven (n = 7) mucormycosis. The median overall duration of POS therapy was 18 days (IQR: 7–23 days). Thirteen patients (45%) had progressive IFD under treatment with novel POS formulations.

Conclusion

Our study demonstrates clinical effectiveness of antifungal prophylaxis with novel POS formulations. In patients treated for possible/probable/proven IFD, the observed tolerability and overall mortality was comparable to previous studies with other antifungals in similar patient population.

Disclosures

S. M. Heimann, MSD: Consultant, Grant Investigator and Lecture honoraria, Research grant and Speaker honorarium. W. J. Heinz, MSD: Grant Investigator and Speaker’s Bureau, Research grant and Speaker honorarium. J. Vehreschild, MSD: Grant Investigator and Speaker’s Bureau, Research grant and Speaker honorarium.

403. Prognostic Factors in 260 Adults With Invasive Scedosporiosis From Literature and FungiScope™

Background

Invasive scedosporiosis (iS) and lomentosporiosis (iL) are an increasing concern due to intrinsic resistance of such pathogens to antifungal therapy. Guidelines recommend voriconazole, amphotericin B and surgery to treat scedosporiosis, irrespective of the causative species. Scedosporium spp. are often resistant to amphotericin B but susceptible to posaconazole and voriconazole, whereas Lomentospora prolificans (LoPro) is usually pan-resistant. Mortality rates rise to 90%, despite comprehensive treatment. Here, we describe the epidemiology of iS/L.

Methods

A retrospective analysis of patients with iS/iL was conducted to evaluate clinical characteristics and outcomes. Cases diagnosed from January 2000 until August 2017 were selected from the literature and the FungiScope™ registry. In vitro susceptibility to approved and new antifungals was determined according to EUCAST and CLSI methods.

Results

We identified 208 cases with infection caused by Scedosporium spp. and 56 by LoPro. iS was most frequently reported in patients after solid organ transplantation (27.9%), iL in patients with underlying malignancy (51.9%). Skin, lung, CNS, and eye were most frequently involved in iS cases, whereas involvement of lung, eye, and blood stream infection were most common in iL cases. Posaconazole and voriconazole showed good in vitro activity against most Scedosporium spp. isolates, but not LoPro. The new antifungal drug Olorofim was highly active against all isolates tested in vitro, also LoPro. All-cause mortality in Scedosporium spp. cases ranged from 12.5% in trauma patients to 55.2% in patients with malignancy, in the LoPro group from 28.6% in surgical patients to 85.2% in patients with malignancy. In iS cases worse outcome was associated with disseminated disease and CNS involvement in transplant recipients, and lung involvement in patients with malignancy. In iL cases, malignancy and fungemia were associated with worse outcome.

Conclusion

Clinical presentation and outcome vary between iS and iL cases. Blood stream infection and CNS involvement are associated with worse outcome. Activity of Olorofim against Scedosporium spp. and LoPro will be evaluated in an upcoming phase III trial.

Disclosures

J. Vehreschild, Merck / MSD: Consultant, Research Contractor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. Gilead: Consultant, Research Contractor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. Pfizer: Research Contractor and Speaker’s Bureau, Research grant and Speaker honorarium. Astellas Pharma: Consultant, Research Contractor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. Basilea: Consultant, Research Contractor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. Deutsches Zentrum für Infektionsforschung: Member, Research Contractor and Speaker’s Bureau, Research grant and Speaker honorarium Uniklinik Freiburg / Kongress und Kommunikation: Speaker’s Bureau, Speaker honorarium. Akademie für Infektionsmedizin: Speaker’s Bureau, Speaker honorarium. Universität Manchester: Speaker’s Bureau, Speaker honorarium, Deutsche Gesellschaft für Infektiologie: Member and Speaker’s Bureau, Speaker honorarium. Ärztekammer Nordrhein: Speaker’s Bureau, Speaker honorarium. Uniklinik Aachen: Speaker’s Bureau, Speaker honorarium. Back Bay Strategies: Speaker’s Bureau, Speaker honorarium. Deutsche Gesellschaft für Innere Medizin: Member and Speaker’s Bureau, Speaker honorarium. M. J. G. T. Vehreschild, Pfizer: Speaker’s Bureau, Speaker honorarium. MSD/Merck: Consultant and Speaker’s Bureau, Consulting fee and Speaker honorarium. Gilead Sciences: Research Contractor and Speaker’s Bureau, Research grant and Speaker honorarium. Organobalance: Speaker’s Bureau, Speaker honorarium Astellas Pharma: Consultant, Research Contractor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. 3M: Research Contractor, Research grant. DaVolterra: Research Contractor, Research grant. Berlin Chemie: Consultant, Consulting fee

O. A. Cornely, Amplyx Pharmaceuticals, Basilea Pharmaceutica, F2G, Gilead Sciences, MSD Sharp and Dohme, Scynexis Inc.: Consultant, Consulting fee

Amplyx Pharmaceuticals, Basilea Pharmaceutica, F2G, Gilead Sciences, MSD Sharp and Dohme, Scynexis Inc.: Grant Investigator, Research grant

Basilea Pharmaceutica, Gilead Sciences, MSD Sharp and Dohme, Pfizer: Speaker’s Bureau, Speaker honorarium

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.

Transplantationsmedizin in der Intensivmedizin

Die Betreuung von Patienten vor und nach einer Organtransplantation gehört zum Gebiet der „speziellen Intensivmedizin“ des jeweiligen Fachbereichs. Die transplantationsspezifische Intensivmedizin setzt daher ein interdisziplinäres Management voraus. Neben der Organprotektion bzw. dem Monitoring von speziellen transplantationsrelevanten Problemen steht die Immunsuppression. Auf das Management mit Immunsuppressiva und von transplantationsassoziierten, intensivmedizinisch relevanten Problemen wird in diesem Kapitel eingegangen. Speziell werden Herz-, Lungen-, Leber-, Nieren- und Stammzelltransplantationen dargestellt.

Cause-Specific Mortality in HIV-Positive Patients Who Survived Ten Years after Starting Antiretroviral Therapy

OBJECTIVES

To estimate mortality rates and prognostic factors in HIV-positive patients who started combination antiretroviral therapy between 1996-1999 and survived for more than ten years.

METHODS

We used data from 18 European and North American HIV cohort studies contributing to the Antiretroviral Therapy Cohort Collaboration. We followed up patients from ten years after start of combination antiretroviral therapy. We estimated overall and cause-specific mortality rate ratios for age, sex, transmission through injection drug use, AIDS, CD4 count and HIV-1 RNA.

RESULTS

During 50,593 person years 656/13,011 (5%) patients died. Older age, male sex, injecting drug use transmission, AIDS, and low CD4 count and detectable viral replication ten years after starting combination antiretroviral therapy were associated with higher subsequent mortality. CD4 count at ART start did not predict mortality in models adjusted for patient characteristics ten years after start of antiretroviral therapy. The most frequent causes of death (among 340 classified) were non-AIDS cancer, AIDS, cardiovascular, and liver-related disease. Older age was strongly associated with cardiovascular mortality, injecting drug use transmission with non-AIDS infection and liver-related mortality, and low CD4 and detectable viral replication ten years after starting antiretroviral therapy with AIDS mortality. Five-year mortality risk was <5% in 60% of all patients, and in 30% of those aged over 60 years.

CONCLUSIONS

Viral replication, lower CD4 count, prior AIDS, and transmission via injecting drug use continue to predict higher all-cause and AIDS-related mortality in patients treated with combination antiretroviral therapy for over a decade. Deaths from AIDS and non-AIDS infection are less frequent than deaths from other non-AIDS causes.

[Rotating physician in CHIR-Net. Evaluation of the curriculum]

BACKGROUND

Conduction of and participation in clinical trials is a major challenge for surgical departments especially as job performance in hospitals has increased immensely during the last few years due to economic aspects. Only 11.7 % of published clinical studies are randomized controlled trials. As more and more treatment procedures in medicine have an evidence-based design the aim must be to present randomized controlled trials with an evidence level 1 for an increasing number of surgical therapies. Since 2006 the German National Surgical Trial Network (CHIR-Net) has been established and funded by the Federal Ministry of Education and Research (BMBF) in order to promote the realization of clinical trials in surgery. Thus the basis for the execution of high quality clinical studies in surgery has been extended further. In the individual CHIR-Net centers clinical trials are planned, organized and supervised which requires extensive knowledge of prevalent international standards. Teaching them to rotating physicians is one of the tasks of CHIR-Net. Therefore, a special curriculum for physicians has been developed which is evaluated in this study.

MATERIALS AND METHODS

From December 2010 to March 2011 an online survey of physicians who had previously rotated in the CHIR-Net was conducted, starting from the Surgical Regional Center (CRZ) Witten-Herdecke/Cologne. A total of 19 partly open and partly closed questions concerning the person, training, duration of the rotation, the funding applied for and the generated scientific output were surveyed. In addition, the curriculum for physicians and rotation time was checked by means of 17 questions in an evaluation matrix.

RESULTS

In this article the results of the rotating physician evaluation are presented. The satisfaction of physicians with the training during the rotation is presented as well as an analysis of how many of the submitted publications were directly supported by CHIR-Net. It was also evaluated how many rotating physicians requested funding and what the type of funding was.

CONCLUSION

With the rotating physician model of CHIR-Net a working concept for the training of surgeons in clinical research and the realization of randomized surgical trials was established as a viable solution for the difficult situation of clinical research in the surgical disciplines with the double burden of research and clinical practice.

Fatal pneumonia associated with human metapneumovirus (HMPV) in a patient with myeloid leukemia and adenocarcinoma in the lung

We describe a clinical case of a 59 old caucasian male who was delivered to the hospital for severe pneumonia associated to human metapneumovirus. The patient suffered from a leukemia and an adenocarcinoma in the lung and died two weeks after submission due to fatal respiratory failure.