Cefazolin and rifampin: A coagulopathy-inducing combination

PURPOSE

To identify risk factors that may predispose patients to rifampin- and cefazolin-induced coagulopathy.

SUMMARY

An 86-year-old man with a history of rheumatoid arthritis on chronic prednisone and stage 3 chronic kidney disease, notably not on warfarin, presented to the hospital with a 10-day history of right hip pain, swelling, and drainage after a recent right total-hip arthroplasty. The patient underwent a combination of surgical intervention and medication therapy with rifampin and ceftriaxone. After discharge and at postoperative day 9, ceftriaxone was changed to cefazolin due to increasing alkaline phosphatase levels. Four weeks after the initial debridement, antibiotics, and implant retention, the patient underwent a second irrigation and debridement due to persistent infection. Cefazolin and rifampin therapy was extended. Three days later, the patient presented to the emergency room with significant bleeding at the surgical site and a profoundly elevated prothrombin time and international normalized ratio (INR). No potential contributors were identified. The Naranjo adverse drug reaction probability scale identified cefazolin and rifampin as the probable cause of elevated INR. The Liverpool adverse drug reaction avoidability assessment tool classified this adverse event as "definitely avoidable."

CONCLUSION

Rifampin-containing regimens are often recommended to treat staphylococcal prosthetic joint infections when the implant is retained. In methicillin-susceptible staphylococcal infections, cefazolin is routinely employed as the β-lactam backbone of definitive antimicrobial regimens. Although rifampin- and cefazolin-induced hypoprothrombinemia seems to be rare, adverse consequences of its occurrence may be prevented with appropriate monitoring.

Prosthetic Joint Infections Due to Histoplasma capsulatum: A Report of 3 Cases

Histoplasma capsulatum causes pneumonia and multisystemic disease in humans. Musculoskeletal involvement in histoplasmosis is most often tenosynovitis and rarely septic arthritis. Even more uncommon is the involvement of prosthetic joints. Here, we report a series of 3 cases of prosthetic joint failures caused by infection due to H capsulatum. Together with a review of 4 previously reported cases, we summarize host characteristics, clinical presentation, surgical approaches, antifungal management, and outcomes of this rare orthopedic joint infection.

681. Induction Immunosuppression Selection in People Living with HIV Undergoing Deceased Donor Kidney Transplantation: U.S. National Trends from 2000 to 2018

Background

Human Immunodeficiency Virus (HIV) outcomes have significantly improved at the expense of other age-related diseases including chronic kidney disease. Early reports of people living with HIV (PLWH) undergoing deceased-donor kidney transplantation (DDKT) showed poor outcomes, but these have notably improved after introduction of antiretrovirals. Despite years of experience, the optimal induction immunosuppression (IIS) in PLWH remains subject of debate. Large-scale studies describing the current ISS practices in PLWH undergoing DDKT are lacking. Here, we describe the U.S. national trends of IIS used in PLWH undergoing DDKT from 2000 to 2018 using the United Network of Organ Sharing (UNOS) database.

Methods

We analyzed the UNOS database to determine the selection of IIS in PLWH undergoing first-time DDKT between 1/1/2000 and 12/31/2018. Cases with unknown HIV status at the time of transplant were excluded. Age, sex and demographics were analyzed. The regimen used for IIS was compared based on HIV serostatus and the change in induction regimen was trended over time.

Results

A total of 139,650 cases underwent DDKT during the study period. Among these, 1,384 were identified as HIV-positive. PLWH were significantly younger than HIV-negative (49±10 years vs. 51.6 ± 15.3 years; p< 0.001) (Table 1). A greater proportion of men was seen in the PLWH group compared to HIV-negative persons (76.2% vs. 60.4%; p< 0.0001). In the HIV-negative group, 12.1% undergoing DDKT did not receive IIS compared to 16.4% in PLWH (p< 0.0001). Medications that have significantly increased in use with years in PLWH included rabbit anti-thymocyte globulin (rATG), steroids, and basiliximab (3.54, 3.25, 2.28, respectively; p< 0.001). On our trend analysis (Figure 1), the percentage of PLWH receiving any IIS is increasing by 4.04% each year (p< 0.001).

Table 1

Figure 1

Conclusion

Our study suggests that IIS is an increasing practice in PLWH undergoing DDKT, predominantly using rATG, steroids, and basiliximab. Understanding the current practices might lead to further studies to determine the long-term outcomes after different induction regimens in PLWH.

Disclosures

All Authors: No reported disclosures

92. Utility of Sinus CT in the Evaluation of Patients with Febrile Neutropenia

Background

The etiology of febrile neutropenia in patients with hematological malignancy is identified in only 20–30% of cases. Sinus computed tomography (CT) is often used, regardless of symptoms, to rule out rhinocerebral source of infection. There are no clear guidelines on when to perform sinus CT in this population. In this study, we evaluated the role of sinus CT in febrile neutropenic patients.

Methods

We retrospectively reviewed medical records of all adults (age ≥18 years) with febrile neutropenia (T≥ 38.3ºC, ANC &lt; 0.5 x 109/L) and hematological malignancies who underwent sinus CT from January 2014 to May 2020. We present the preliminary analysis of the impact of sinus CT findings on the management of febrile neutropenia.

Results

47 patients with a total of 56 episodes of febrile neutropenia met the inclusion criteria. The median age at presentation was 57 years (IQR: 42 - 68 years). The most common underlying malignancy was acute myeloid leukemia (51%), followed by myelodysplastic syndrome (19%). At presentation, 47% had refractory disease, 21% were newly diagnosed, 15% had relapsed, 15% were in complete remission, and 2% were in partial remission. Of the total 56 episodes, 29 (52%) had symptoms of rhinorrhea (20%), facial pain (14%), and sinus congestion (14%). The remaining 27 of 56 episodes (48%) had no sinus symptoms. Sinus CT was abnormal in 48 of 56 episodes (86%); the most common finding was mucosal thickening (47/48; 98%), followed by air-fluid levels (7/48; 14.5%), partial opacification (6/48; 12.5%), complete opacification (2/48; 4%), and bony invasion (2/48; 4%). The source of febrile neutropenia was attributed to the CT sinus findings in 9 cases (9/48; 29%), leading to a change in therapeutic management. All 9 patients were symptomatic, with evidence of necrosis in 22% (2/9) and purulence in 22% (2/9) on nasal endoscopy.

Table 1

Conclusion

Mucosal thickening is a frequent and non-specific imaging finding, particularly in patients without sinus symptoms. Sinus CT findings in patients with febrile neutropenia without sinus symptoms had no impact on clinical management. Consequently, sinus CT may be reserved for patients presenting with sinus symptoms.

Disclosures

M. Rizwan Sohail, MD, Aziyo Biologics (Consultant)Medtronic Inc (Consultant, Research Grant or Support)

153. Development of a Pathway for Removal of Inappropriate Penicillin Allergy Labels in Hospitalized Patients

Background

More than 90% of reported penicillin allergies are found inaccurate when formally assessed. These allergy labels lead to decreased utilization of first-line beta-lactam antibiotics, and adverse clinical outcomes. The objective of this study was to develop a multi-disciplinary approach to decrease inaccurate labeling among hospitalized patients with documented penicillin allergy.

Methods

A team of clinicians, pharmacists, and nurses utilized the DMAIC quality strategy to improve accuracy of penicillin allergy labeling. Allergic reactions were stratified to develop a penicillin allergy de-labeling algorithm (Figure 1). Admission to the intensive care unit (ICU) for anaphylaxis was defined as a balancing measure. We reviewed baseline data from patients with a documented penicillin allergy admitted to a single inpatient floor at Mayo Clinic, Rochester between June and October 2019. A cause and effect diagram was used to conduct a root cause analysis. The intervention was then applied to patients who reported penicillin allergy admitted to the same floor from November 2019 to January 2020. Study data were collected and basic descriptive statistics generated.

Figure 1: Penicillin allergy delabeling algorithm

Results

96 patients were included in the control group with mean age of 71 years (range 65–84 years) and 55% females. Breakdown of documented allergic reactions are represented in Figure 2. 58 (60%) received an antibiotic for a median duration of 1.5 days (IQR: 0 – 6). Of these, 7(12%) received penicillin-class antibiotics, and 41 (70.6%) received non-beta-lactam antibiotics. 2 (2%) of these patients were de-labeled without any penicillin skin tests. Detailed metrics of each PDSA cycle are shown in Table 1. During PDSA cycle 2, inaccurate penicillin documentation was removed in 9/19 (47.4%) of hospitalized patients. There were no ICU admissions for anaphylaxis.

Figure 2: Graphic representation of proportion of type of documented allergic reactions to penicillin

Table 1: Metrics and outcomes at baseline and during successive PDSA cycles

Conclusion

Various factors contribute to penicillin allergy mislabeling. Our comprehensive algorithm addresses nuances of penicillin allergic reactions and increased accurate penicillin allergy labeling in 47.4% of the cases. Beta-lactam use also increased to 37% through our pilot project while maintaining patient safety. A multi-disciplinary and patient-centered approach aligned with institutional workflows is necessary to improve patient outcomes.

Disclosures

All Authors: No reported disclosures

Management of Bloodstream Infections in Left Ventricular Assist Device Recipients: To Suppress, or Not to Suppress?

Background

Ascertaining involvement of left ventricular assist device (LVAD) in a patient presenting with bloodstream infection (BSI) can be challenging, frequently leading to use of chronic antimicrobial suppressive (CAS) therapy. We aimed to assess the efficacy of CAS therapy to prevent relapse of BSI from LVAD and non-LVAD sources.

Methods

We retrospectively screened adults receiving LVAD support from 2010 through 2018, to identify cases of BSI. Bloodstream infection events were classified into LVAD-related, LVAD-associated, and non-LVAD BSIs.

Results

A total of 121 episodes of BSI were identified in 80 patients. Of these, 35 cases in the LVAD-related, 14 in the LVAD-associated, and 46 in the non-LVAD BSI groups completed the recommended initial course of therapy and were evaluated for CAS therapy. Chronic antimicrobial suppressive therapy was prescribed in most of the LVAD-related BSI cases (32 of 35, 91.4%) and 12 (37.5%) experienced relapse. Chronic antimicrobial suppressive therapy was not prescribed in a majority of non-LVAD BSI cases (33, 58.9%), and most (31, 93.9%) did not experience relapse. Chronic antimicrobial suppressive therapy was prescribed in 9 of 14 (64.2%) cases of LVAD-associated BSI and none experienced relapse. Of the 5 cases in this group that were managed without CAS, 2 had relapse.

Conclusions

Patients presenting with LVAD-related BSI are at high risk of relapse. Consequently, CAS therapy may be a reasonable approach in the management of these cases. In contrast, routine use of CAS therapy may be unnecessary for non-LVAD BSIs.

Management and Outcome of Left Ventricular Assist Device Infections in Patients Undergoing Cardiac Transplantation

Background

Postoperative management of patients undergoing cardiac transplantation with an infected left ventricular assist device (LVAD) is unclear.

Methods

We retrospectively screened all adults with an LVAD who underwent cardiac transplantation at our institution from 2010 through 2018. We selected all cases of LVAD-specific and LVAD-related infections who were receiving antimicrobial therapy as initial treatment course or chronic suppression at the time of cardiac transplantation. Non-LVAD infections, superficial driveline-infection, or concurrent use of right ventricular assist device or extracorporeal membrane oxygenation device were excluded.

Results

A total of 54 cases met study criteria with 18 of 54 (33.6%) classified as LVAD- specific or related infections and 36 of 54 (66.6%) as noninfected. cases of lvad infection had a higher median charlson comorbidity Index score at the time of transplantation compared with noninfected cases (P = .005). Of the 18 cases of infection, 13 of 18 (72.2%) were classified as LVAD-specific and 5 of 18 (27.8%) were classified as LVAD-related. Nine of 13 (69.2%) cases had proven LVAD-specific infections. Antimicrobial therapy was extended posttransplant to treat preceding LVAD-specific infection in all 9 cases (9 of 13, 69.2%) with a median duration of 14 days (interquartile range, 14–28). After LVAD removal, antimicrobial treatment was not continued for preceding LVAD-related infections.

Conclusions

Patients with an LVAD-specific infection were treated with 2 weeks of pathogen-directed therapy postheart transplant without any relapses. For those without LVAD-specific infection or uncomplicated LVAD-related bacteremia who had completed antimicrobial therapy pretransplant, antibiotics were discontinued after standard perioperative prophylaxis and no relapses were observed.

Diagnostic imaging in infective endocarditis: a contemporary perspective

INTRODUCTION

Infective endocarditis (IE) remains a diagnostic challenge. Prompt diagnosis is essential for accurate risk stratification and appropriate therapeutic decisions and surgical management. In recent years, the use of multimodal imaging has had a transformative effect on the diagnostic approach of IE in selected patients.

AREAS COVERED

This review assesses published literature on different imaging modalities for the diagnosis of IE published between 1 January 2009 and 1 February 2020. We illustrate the diagnostic approach to IE with three clinical cases.

EXPERT OPINION

Novel approaches to imaging for cardiac and extracardiac complications improve and individualize diagnosis, management, and prognosis in patients with suspected IE. The use of multimodal imaging should be guided by a multidisciplinary group of medical providers that includes infectious disease specialists, radiologists, cardiologists, and cardiothoracic surgeons.

Prevalence and outcomes of pneumocystis pneumonia in patients with T-cell lymphoma

e20057

Background: T-cell lymphomas (TCL) are a heterogeneous group of rare, but aggressive non-Hodgkin lymphomas. CD4+ and CD8+ T-cell function plays a vital role in the immunologic response to P.jirovecii infection. Our study aims to define the prevalence of Pneumocystis jirovecii pneumonia (PJP) in HIV-uninfected TCL patients. Methods: All patients at Mayo Clinic, Rochester MN diagnosed with TCL and a positive Pneumocystis PCR assay from either bronchoalveolar lavage (BAL) fluid or other respiratory specimens were identified from March 2005 until November 2019. Patients with TCL and a diagnosis of PJP made outside of our medical center were identified through Advanced Cohort Explorer, a query building tool. Results: A total of 922 patients with TCL were identified, and only 14 cases (1.5%) had confirmed PJP. In confirmed PJP cases, the median age of TCL diagnosis was 62 years (IQR 51-70 years), 79% were male, and the median number of chemotherapy lines was 1.5 (IQR of 1-3). Half of the cases (6/12) received CHOP as first-line of therapy, followed by CHOEP (25%, 3/12). The median time to PJP diagnosis relative to chemotherapy was 18 days (IQR 14-27 days). Peripheral TCL, not otherwise specified was the most common TCL, followed by angioimmunoblastic TCL, and CD30+ T-cell lymphoproliferative disorders (64%, 29% and 7%, respectively). The primary specimen type sampled for PJP diagnosis was BAL fluid (n = 9, 64%), followed by sputum (n = 3, 22%), induced sputum (n = 1, 7%), and transbronchial lung biopsy (n = 1, 7%). Three patients had a prior autologous stem cell transplant (ASCT), and all three cases had relapsed TCL one year after ASCT. 77% of cases received oral prednisone equivalents (median dose of 25 mg, IQR 20-40 mg) 30 days prior to PJP diagnosis. Two patients developed PJP despite anti- Pneumocystis prophylaxis with aerosolized pentamidine. At the time of PJP diagnosis, most patients had lymphopenia (88%, 8/9), and CD4+ T-cells measurement was obtained only in one patient (CD4+ of 100 cells/mL). 71% of the cases were treated with trimethoprim/sulfamethoxazole (TMP/SMX). After the initial PJP episode, 36% of the cases were transitioned to TMP/SMX for secondary prophylaxis. All cause 30-day and 90-day mortality was 7% and 29%, respectively. Mortality attributed to PJP was 7% (n = 1). Conclusions: In our TCL cohort, the occurrence of PJP was low. Primary prophylaxis should be individualized in this population.

Fishing for a Diagnosis, the Impact of Delayed Diagnosis on the Course of Mycobacterium marinum Infection: 21 Years of Experience at a Tertiary Care Hospital

Background

Mycobacterium marinum is a common but underreported mycobacterial infection. We conducted a large retrospective study to determine risk factors and describe the therapeutic interventions and outcomes in patients with uncomplicated and complicated M. marinum infection.

Methods

Culture-confirmed M. marinum infection cases were identified from the Mayo Clinic Clinical Mycology Laboratory from January 1998 to December 2018. Complicated M. marinum infection was defined as the presence of tenosynovitis, septic arthritis, or osteomyelitis. Differences in complicated vs uncomplicated M. marinum infections were analyzed using statistical comparisons.

Results

Twelve cases had a complicated M. marinum infection. Patients with a complicated infection were older (64.3 ± 11.1 vs 55.8 ± 14.5; P = .03), had longer duration of symptoms (5 vs 3 months; P = .011), and had more surgical debridements (1 vs 0; P < .001). Length of treatment and number of drugs used were not statistically significant. Complicated M. marinum cases received more medications (2 vs 1; P = .263) and were treated longer (5.7 vs 3.5 months; P = .067). Antibiotic susceptibilities were performed in 59% of the patients. All isolates were susceptible to clarithromycin. From the tetracyclines, doxycycline had a better susceptibility pattern.

Conclusions

M. marinum infection is an important cause of skin and soft tissue infection. Poor water exposure documentation, unusual clinical presentation, and empiric antibiotic treatment before definitive M. marinum diagnosis often contribute to a delayed diagnosis. Complicated M. marinum cases had longer duration of symptoms and more surgical debridements. No difference in the number of drugs used or clinical outcome was observed.

267. Fungal Culture Diagnostic Stewardship: An Avenue for Antimicrobial Stewardship in the Immunocompromised Host

Background

Bronchoalveolar lavage (BAL) is a widely used procedure in the diagnosis of pneumonia in critically ill and immunocompromised hosts. Fungal smears and cultures are commonly performed on these samples. We evaluated the yield of various fungi, including but not limited to Candida species, Aspergillus species, Penicillium species, isolated from BAL specimens at our institution to determine the yield of this test and its impact on decision making.

Methods

We identified adult immunocompromised patients who underwent “Bronchoscopy with Immunocompromised Host Protocol (ICH),” which consists of an exhaustive list of diagnostic tests for various pathogenic organisms, over a one year period from January 1, 2017 to December 31, 2017. We reviewed if positive fungal cultures led to a change in management and if this was appropriate.

Results

582 patients underwent bronchoscopy with ICH protocol. There were 285/582 (48.9%) positive fungal cultures of which 177 (62%) grew Candida species. The most common species was Candida albicans (142/177, 80%). 53(18%) were Aspergillus species of which Aspergillus fumigatus was the most common (26/53). 16/285 (5.6%) patients underwent intervention based on the results, 14(87.5%) of which were appropriate. 176/177 (99.4%) patients with Candida species in BAL cultures were not treated.10/53 (18. 8%) patients with Aspergillus species in BAL cultures were treated of which 80% were appropriate interventions based on proven/probable invasive fungal infections criteria as were rest of the 6/16 patients with other fungal organisms (Table 4). Patients with Aspergillus species in BAL cultures are 8 times more likely to have an intervention (OR: 8. 7, P = < 0. 0001) while patients with Candida species in BAL cultures are not likely to be intervened upon (OR: 0. 26, P = 0. 0098) (Table 3).

Conclusion

Although Candida species is commonly isolated in BAL cultures its clinical significance is minimal in the absence of disseminated disease even in immunosuppressed hosts. Evaluating the way that Candida cultures are communicated for respiratory specimens, along with diagnostic stewardship may be a route for antimicrobial stewardship. Consulting ID service early on is essential in assessing the significance of fungal culture data thereby resulting in appropriate changes in management.

Disclosures

All authors: No reported disclosures.

1384. Mycobacterium marinum Infection: 21 Years of Experience at a Tertiary-Care Hospital

Background

Mycobacterium marinum is a slow-growing, non-tuberculous mycobacterium responsible for skin and soft-tissue infections (SSTIs), tenosynovitis, and osteomyelitis (OM). We conducted a retrospective study describing the risk, clinical course, and outcome of M. marinum infection.

Methods

Adult patients with culture-confirmed M. marinum infections were identified from the mycology laboratory at Mayo Clinic, Rochester from January 1998 to December 2018. M. marinum infection was defined as uncomplicated (limited to SST) and complicated (tenosynovitis, OM, or disseminated).

Results

Forty-six cases of culture-confirmed infection with M. marinum were included (Table 1). Only 16 cases (35%) reported a water exposure and 22 (48%) involved finger and/or hand trauma. The median time to diagnosis was 3.6 months. Most patients (76%) presented with uncomplicated M. marinum infection with skin lesions mainly localized in the upper limb (Table 2). QuantiFERON and PPD were positive in 4 (8%) and 2 (4%) cases, respectively. Granulomatous inflammation and positive special stains were noted in 34 (74%) and 11 (24%) cases, respectively. Cases with complicated M. marinum infection had a longer duration of symptoms and length of treatment (P < 0.05) (Table 3). Prior to diagnosis, 63% of patients received at least one antibiotic for bacterial SSTIs. More than 50% of the patients diagnosed with M. marinum received a one drug regimen and 8% did not initiate therapy. Median treatment duration was 4.4 months. Twenty-six cases (56%) had susceptibilities performed and treatment modifications were made in 10 cases (38%). From the patients that started therapy, 73% completed therapy and 33% were lost to follow up. Cured was achieved in 87% of cases that completed therapy, 2 cases (6%) had a recurrence, and only one patient with active malignancy had a positive blood culture and died. Twelve (44%) and 10 cases (37%) were cured with one and two-drug regimens, respectively.

Conclusion

Most patients with M. marinum infection present as an uncomplicated infection in the upper limb. Classical exposure was only suspected in a third of the cases. Patients with complicated M. marinum infection had a prolonged duration of symptoms and lengthy treatment. Most patients were successfully treated with a one and two-drug regimen.

Disclosures

All authors: No reported disclosures.

211. Coxiella burnetii: 7 Years of Experience at a Tertiary-Care Center

Background

Q fever is a zoonotic disease caused by Coxiella burnetii. Primary infection can progress to persistent infection irrespective of initial symptomatology. Our aim is to describe the clinical features, treatment, risk of progression, use of prophylaxis, and outcomes of Coxiella burnetii infection at our institution.

Methods

We did a retrospective review of all adult patients with positive Coxiella burnetii serology at Mayo Clinic, Rochester from 1st January 2012 to 31st December 2018. Centers for Disease Control and Prevention (CDC) case definition and classification were used to group the patients into confirmed and probable acute Q fever, and confirmed and probable chronic/persistent Q fever. Data on demographics, clinical presentation, comorbid conditions, exposure history, risk factors associated with progression, serology, treatment and outcomes were collected.

Results

We found 266 patients with positive titres of Coxiella IgG or IgM greater than 1:16, of which 49 patients met the CDC case definition for Q fever. Median age at presentation was 62 years. 45/49 (91. 8%) were men, while 4/49 (8%) were women. 20/49 (40. 8%) patients presented with acute Q fever of which 5 (25%) patients progressed to persistent infection. 29/49 (59%) patients presented with persistent Q fever of which 4 patients could recall symptoms suggestive of acute Q fever. The most common presentation of acute Q fever was acute febrile illness (65%). Endocarditis (11/29) was the most common presentation of chronic/persistent Q fever. Of the 5 patients with acute Q fever that progressed to persistent infection, 3/5(60%) progressed despite being on doxycycline and hydroxychloroquine. 8/29 patients with persistent Q fever had serological resolution at last follow-up. 2/4(50%) deaths were attributable to Q fever.

Conclusion

Minority of the patients tested met the case definition. 25% of patients with acute disease progressed to chronic Q fever out of which 60%(3/5) progressed despite prophylaxis. Endocarditis and vascular infections were the most common chronic cases. Interestingly we found 4 cases of MPGN in association with Q fever. Prosthetic valves are the most important risk factors for progression (P = 0.02). Serological cure often lags behind clinical cure (27% vs. 68% in persistent infection)(Table 4).

Disclosures

All authors: No reported disclosures.

152. Brevibacterium species: Case Series and Literature Review of an Emerging Opportunistic Cause of Bloodstream Infections

Background

Brevibacterium species are non-motile, catalase-positive, obligate aerobic gram-positive bacilli. Colonies are yellow to gray-white, non-hemolytic, smooth, 6.5% sodium chloride tolerant. B. fermentans post neurosurgical meningitis was first described in 1969 in an infant. B. casei remains the most commonly isolated species (Table 4). The most commonly reported syndromes are bloodstream infections (BSIs) and endocarditis. Despite these reports, this organism continues to be listed on CDC’s NHSN commensal database.

Methods

Isolates of Brevibacterium from clinical samples at Mayo Clinic, Rochester from January 1, 2014 to December 31, 2018 were identified. Charts were reviewed to determine patient demographics, immune status, source of culture, comorbidities, antibiotic susceptibility test (AST), length of stay (LOS) in hospital and intensive care unit (ICU), and mortality. Likelihood ratio (L-R) and Pearson correlation coefficient (PCC) of nominal data were calculated using the Chi-square test and Fischer exact test (FET). We defined statistical significance as P ≤ 0.05.

Results

We identified 48 isolates from 45 unique patients, 46% were females. Distribution of age, hospital and ICU LOS, and time to culture growth, and AST data are shown in Table 1. 15.5% patients received allogeneic or autologous stem cell (SCT), or solid-organ transplant (SOT) recipients. 89% cultures were from sterile sources and 68.75% were blood cultures. Of these, 63.64% were monomicrobial. 62% of isolates identified to species level were B. casei. 5 patients were treated; an additional 10 received active antibiotics for other indications. Statistically significant variables are reported in Tables 2 and 3. Thirty-day mortality was 13%. This was higher in patients with bacteremia (L-R: 5.3 [P = 0.02]) but FET was not statistically significance (P = 0.15).

Conclusion

Accurate diagnosis of Brevibacterium may require molecular techniques. At our center, SCT or SOT recipient status and recent chemotherapy were associated with bacteremia. In these patients, this organism could represent an opportunistic cause of BSI. AST data suggest that Vancomycin offers a reasonable empiric treatment option. Additional data are needed to further define host populations in whom this organism presents pathogenicity.

Disclosures

All authors: No reported disclosures.

Correlation between Echocardiographic Pulmonary Artery Pressure Estimates and Right Heart Catheterization Measurement in Liver Transplant Candidates

BACKGROUND

Patients undergoing liver transplant have worse outcomes in the presence of pulmonary hypertension. Correlation between echocardiography and catheterization derived pressures in this population is not well studied. Our study's aim is to show the relationship between pulmonary artery systolic pressure derived from transthoracic echo (ePASP) with pulmonary artery systolic pressure measured during right heart catheterization (cPASP).

METHODS

Single center retrospective study, patients being evaluated for liver transplant (n = 31) who had an interpretable Doppler signal for ePASP and had right heart catheterization (RHC) measurements within 3 months constituted the study group. Control group (n = 49) consisted of patients who did not have liver disease.

RESULTS

There was modest correlation between ePASP and cPASP (R = 0.58, p < 0.001) in LT candidates (n = 31) compared with the control group (R = 0.74, p < 0.001, n = 49). The 95% limits of agreement by Bland-Altman analysis ranged from +33.6 mmHg to -21.7 mmHg. Using receiver operating characteristic analysis, ePASP cut-off > 47 mmHg was 59% sensitive and 78% specific to diagnose pulmonary artery (PA) hypertension (mean PA pressure > 25 mmHg) in the LT candidates, while a similar cutoff performed well in the control group (cutoff > 43 mmHg, n = 47, 91% sensitive, 100% specific).

CONCLUSIONS

Compared with other disease states, ePASP correlates modestly with cPASP in patients with advanced liver disease. A higher ePASP cutoff should be used to screen for pulmonary hypertension. A multi-center prospective study with simultaneous transthoracic echocardiography and RHC measurements is required to determine the best cut-off in this population.

Evaluation of Myocardial Strain in Patients With Amyloidosis Using Cardiac Magnetic Resonance Feature Tracking

PURPOSE

To study the use of cardiac magnetic resonance (CMR) feature tracking technique in evaluation of myocardial amyloidosis.

MATERIALS AND METHODS

CMR scans of 28 patients with biopsy proven myocardial amyloidosis and 35 controls were reviewed. Conventional short axis, vertical long axis, and 4-chamber cine steady-state free precession images from CMR scans were used to generate radial, circumferential, and longitudinal myocardial strain maps using feature tracking software. Global and regional peak radial, circumferential, and longitudinal strain values were computed.

RESULTS

There were significant decreases in radial, circumferential, and longitudinal strains in patients with myocardial amyloidosis globally and across layers (all P < 0.001). Strain was relatively preserved for the apex and most affected for the basal level. The area under the receiver operating characteristic curve for base peak radial, circumferential, and longitudinal strain 0.899, 0.884, and 0.866 and cut offs of 22.9, -13.3, and -10.9, respectively, were determined by receiver operating characteristic analysis. CMR feature tracking strain analysis of base-level strain parameters was able to differentiate patients with myocardial amyloidosis from those without myocardial amyloid with high sensitivity (82.5%) and specificity (82.9%) particularly for radial strain. The maximum sensitivity (89.3%) was achieved if any of the 3 parameters were abnormal, and the maximum specificity (88.6%) when all 3 parameters were abnormal.

CONCLUSION

Myocardial amyloidosis produces significant changes in regional and global strain parameters, and the peak radial and circumferential strain are the most affected at the basal layer.