Clinical Characteristics and Outcomes of Patients With Mpox Who Received Tecovirimat in a New York City Health System

Background

The 2022 global mpox outbreak was notable for transmission between persons outside of travel and zoonotic exposures and primarily through intimate contact. An understanding of the presentation of mpox in people with human immunodeficiency virus (HIV) and other immunocompromising conditions and knowledge of the efficacy of tecovirimat continue to evolve.

Methods

This retrospective study describes clinical features and outcomes of persons with mpox who received tecovirimat. Data were obtained via medical record review of patients prescribed tecovirimat in a health system in New York City during the height of the outbreak in 2022.

Results

One hundred thirty people received tecovirimat between 1 July and 1 October 2022. People with HIV (n = 80) experienced similar rates of recovery, bacterial superinfections, and hospitalization compared to patients without immunocompromising conditions. Individuals determined to be severely immunocompromised (n = 14) had a higher risk of hospitalization than those without severe immunocompromise (cohort inclusive of those with well-controlled HIV, excluding those without virologic suppression, n = 101): 50% versus 9% (P < .001). Hospitalized patients (n = 18 [13% of total]) were primarily admitted for bacterial superinfections (44.4%), with a median hospital stay of 4 days. Of those who completed follow-up (n = 85 [66%]), 97% had recovery of lesions at time of posttreatment assessment. Tecovirimat was well tolerated; there were no reported severe adverse events attributed to therapy.

Conclusions

There were no significant differences in outcomes between people with HIV when evaluated as a whole and patients without immunocompromising conditions. However, mpox infection was associated with higher rates of hospitalization in those with severe immunocompromise, including patients with HIV/AIDS. Treatment with tecovirimat was well tolerated.Key Points: In our mpox cohort, people with HIV had similar rates of recovery and complications as those without HIV or other immunocompromising conditions. Severe immunocompromise was associated with a higher hospitalization rate. Tecovirimat was well tolerated, with minimal side effects.

Correlation between Identification of β-Lactamase Resistance Genes and Antimicrobial Susceptibility Profiles in Gram-Negative Bacteria: a Laboratory Data Analysis

We reported the frequency of resistance gene detection in Gram-negative blood culture isolates and correlated these findings with corresponding antibiograms. Data were obtained from 1045 isolates tested on the GenMark Dx ePlex Blood Culture Identification Gram-Negative Panels at the Mount Sinai Hospital Clinical Microbiology Laboratory in New York from March 2019 to February 2021. Susceptibilities were performed using Vitek 2 (bioMérieux Clinical Diagnostics) or Microscan (Beckman Coulter Inc.). blaCTX-M was detected in 26.4% Klebsiella pneumoniae, 23.5% Escherichia coli, and 16.4% Proteus mirabilis isolates. As would be expected, both blaCTX-M and blaCTX-M negative isolates were likely to be susceptible to newer agents while blaCTX-M positive isolates were more likely to be resistant to earlier generations of beta-lactam antibiotics. 3/204 blaCTX-M-positive isolates were found to be ceftriaxone-susceptible. Conversely, 2.8% ceftriaxone nonsusceptible strains were negative for all β-lactamase genes on the ePlex BCID-GN panel, including blaCTX-M. The prevalence of CTX-M-producing Enterobacterales remains high in the United States. A small number of blaCTX-M-positive isolates were susceptible to ceftriaxone, and a small number of ceftriaxone nonsusceptible isolates were negative for blaCTX-M. Further studies are needed to determine the optimal management when an isolate is phenotypically susceptible to ceftriaxone, but blaCTX-M is detected. IMPORTANCE There is limited literature on corresponding results obtained from rapid molecular diagnostics with the antibiotic susceptibility profile. We reported a correlation between the results obtained from ePlex and the antibiograms against a large collection of Gram-negative bacteria. We reported that there can be a discrepancy in a small number of cases, but the clinical significance of that is unknown.

316. Use of (1-3)-β-D-Glucan Assay for Diagnosis of Candidemia in Patients Hospitalized with SARS-CoV-2 Infection

Background

Candidemia is a rare but serious complication of SARS-CoV-2 hospitalization. Combining non-culture and culture-based diagnostics allows earlier identification of candidemia. Given higher reported incidence during COVID-19 surges, we investigated the use of (1-3)-β-D-glucan (BDG) assay at our institution in those who did and did not develop candidemia.

Methods

Retrospective study of adults admitted to The Mount Sinai Hospital between March 15-June 30 2020 for SARS-CoV-2 infection, with either ≥1 BDG assay or positive fungal blood culture. Data was collected with the electronic medical record and Vigilanz. A BDG value ≥ 80 was used as a positivity cutoff. Differences in mortality were assessed by univariate logistic regression using R (version 4.0.0). Statistical significance was measured by P value < .05.

Results

There were 75 patients with ≥1 BDG assay resulted and 28 patients with candidemia, with an overlap of 9 between the cohorts. Among the 75 who had BDG assay, 23 resulted positive and 52 negative. Nine of 75 patients developed candidemia. Of the 23 with a positive assay, 5 developed candidemia and 18 did not. Seventeen of the 18 had blood cultures drawn within 7 days +/- of BDG assay. Four patients with candidemia had persistently negative BDG; 2 had cultures collected within 7 days +/- of BDG assay. With a cut-off of >80, the negative predictive value (NPV) was 0.92. When the cut-off increased to >200, NPV was 0.97 and positive predictive value (PPV) was 0.42. Average antifungal days in patients with negative BDG was 2.6 vs. 4.2 in those with a positive. Mortality was 74% in those with ≥1 positive BDG vs. 50% in those with persistently negative BDGs. There was a trend towards higher odds of death in those with positive BDG (OR = 2.83, 95% CI: 1.00-8.90, p < 0.06).

Conclusion

There was substantial use of BDG to diagnose candidemia at the peak of the COVID-19 pandemic. Blood cultures were often drawn at time of suspected candidemia but not routinely. When cultures and BDG were drawn together, BDG had a high NPV but low PPV. High NPV of BDG likely contributed to discontinuation of empiric antifungals. The candidemic COVID-19 patients had high mortality, so further investigation of algorithms for the timely diagnosis of candidemia are needed to optimize use of antifungals while improving mortality rates.

Disclosures

All Authors: No reported disclosures

84. T2Candida Panel Use Evaluation: a Quality Improvement Project

Background

Invasive candidiasis is a life-threatening infection with 40% mortality despite antifungal therapy[1] A retrospective chart review of results from our T2Candida Panels from March 2019 to March 2020 was conducted. We compared demographics, co-morbidities, days of antifungal use, length of stay (LOS) and mortality in patients with positive and negative assays.

Results

271 assays were performed, 27 were positive and were compared to 81 negatives. Baseline demographics and co-morbidities were similar in both groups. All patients tested had &gt;1 risk factor for candidemia.

78% were positive for C. albicans/C. tropicalis and 11% positive for C. glabrata/C. krusei and C. parapsilosis respectively. Blood cultures were positive in 8 individuals, of which 5 had a positive assay; among the other 3, one grew C. auris. All species in the T2Candida matched the blood cultures when available.

β-D-glucan was positive in 82% of patients with positive T2 results vs 46% in the T2 negative group (p = 0.016).

Antifungal administration within the time of assay collection was 54% in the negative group vs 74% in the positive group (p = 0.030). Mean duration of antifungal use were significantly lower in the negative group than the positive group (5.98 vs 17.55 days, p = 0.04).

Demographics and Comorbidities

Conclusion

T2Candida was an effective diagnostic and antimicrobial stewardship tool, leading to testing in high risk patients and reducing unnecessary antifungal use. Additional education is required for improved ordering of concurrent blood cultures. Negative results should be interpreted with caution in suspected invasive candidiasis with consideration for species not included in the panel.

Disclosures

All Authors: No reported disclosures

569. Pre-retained: Early Intervention for HIV Patients at High Risk of Becoming Un-retained

Background

Poor engagement in HIV care is an established barrier to achieving optimal treatment. Improved engagement is a cornerstone of the national HIV/AIDS strategy and a marker of quality care. However, there is no consensus on strategies for proactive engagement. The objective of this prospective quality improvement pilot project is to demonstrate the effectiveness of early intervention for patients at high risk of becoming un-retained to increase clinic re-engagement and decrease time to re-engagement.

Methods

The Jack Martin Fund Clinic (JMFC) is a New York State Designated AIDS Center within the Institute for Advance Medicine at Mount Sinai in Manhattan. Patients at high risk of becoming un-retained were defined as no PCP follow-up in six months. The investigator arranged an appointment and notified patients to confirm. Re-engagement was defined as PCP follow-up within 90 days of intervention. A chart review was completed to collect demographics, co-morbidities and HIV data for the intervention group (n = 84) and a retrospectively identified control group (n = 126).

Results

The intervention group achieved a statistically significant outcome of increased re-engagement in care and decreased time to re-engagement. Within the intervention group, 67 of 84 patients (80%) followed-up within 90 days compared with only 65 of 126 patients (52%) in the control (P < 0.01). The time to re-engagement after last PCP visit was also significantly decreased in the intervention group. There were no statistically significant differences between the control and intervention groups regarding race/ethnicity, case management involvement, viral load or co-morbidities.

Conclusion

This study demonstrates a low-intensity, high-yield, sustainable intervention that significantly increased re-engagement for HIV patients that are at high risk of becoming un-retained. A unique aspect of this project is the focus on patients who are currently retained, but at risk of falling out of care, as opposed to patients already un-retained. Patients that did not re-engage despite intervention may be at risk for poor retention and earlier care coordination involvement may be considered. Future directions include continuing to follow patients to demonstrate long-term effects of early intervention and re-engagement on rates of retention.

Disclosures

All authors: No reported disclosures.

Increasing Access to Hepatitis C Virus Medications: A Program Model Using Patient Navigators and Specialty Pharmacy to Obtain Prior Authorization Approval

BACKGROUND

Obtaining prior authorization (PA) approval for the new direct-acting antiviral (DAA) hepatitis C medications is time consuming and requires specific expertise. Our primary care-based program treats hepatitis C virus (HCV)-infected patients at an urban academic medical center and employs patient navigators trained in the PA process who collaborate with a nurse and specialty pharmacy to manage the PA process.

OBJECTIVE

To demonstrate the rate of PA approvals for our programmatic model and determine potential predictors of PA approval.

METHODS

We conducted a review of program databases and medical records of patients for whom DAA hepatitis C medications were ordered between November 1, 2014, and October 31, 2015 (n = 197). We first evaluated patient characteristics associated with the number of steps to approval. Then we used a multivariable ordinal regression to determine independent predictors of fewer steps to approval. Using Kaplan-Meier methods, we assessed patient characteristics associated with approval time and then fit a multivariable Cox regression model to determine independent predictors of time to approval.

RESULTS

Of the 197 patients, 69% (n = 136) had Medicaid; 12% (n = 24) had Medicare; 10% (n = 19) had both Medicaid and Medicare; 5% (n = 10) had private insurance; and 4% (n = 8) were uninsured. Ninety-three percent of the patients were eventually approved for HCV treatment. The steps in the PA cascade were approval on first submission (37%; mean days = 30.7; SD = 29.9); approval after internal appeal (45%; mean days = 66.8; SD = 70.5); approval after external appeal (11%; mean days = 124.7; SD = 60.2); and no approval obtained (7%). Unadjusted factors found to have a P value < 0.200 in relation to fewer steps in the PA cascade were older age, female gender, non-Medicaid insurance, comorbid hypertension, comorbid diabetes, being domiciled, and being nongenotype 2. After adjustment, non-Medicaid insurance and nongenotype 2 remained significant. In survival analysis, non-Medicaid insurance and mid-range fibrosis were associated with fewer days to PA approval.

CONCLUSIONS

Our program obtained 93% of PA approvals for hepatitis C medications. Patient navigators collaborating with a nurse and specialty pharmacy as a program may improve the PA approval process, although further research with a control group is necessary.

DISCLOSURES

The Respectful & Equitable Access to Comprehensive Healthcare (REACH) program receives funding from the Robin Hood Foundation and the New York State Department of Health AIDS Institute. Weiss receives grant support from Gilead Sciences and has served as a consultant for AbbVie and Gilead Sciences. Vu reports speaker fees from Peer View Institute. All other authors report no conflict of interest. Study design and concept were contributed by Chasan, Sigel, Vu, and Weiss. Riazi, Ciprian, Giardina, and Gibbs collected the data, which were interpreted by Toribio, Amory, Chasan, and Sigel. The manuscript was written by Vu and Weiss and revised by Parrella, Cambe, Camacho, and Vu. Research from this study was presented as an abstract poster on November 14, 2016, at the AASLD Liver Meeting in Boston, Massachusetts.

Low adherence of HIV providers to practice guidelines for hepatocellular carcinoma screening in HIV/hepatitis B coinfection

BACKGROUND

In the era of combination therapy for human immunodeficiency virus (HIV), liver disease, and hepatocellular carcinoma (HCC) are major causes of death for patients coinfected with HIV and hepatitis B virus (HBV). This study compared HIV provider and hepatologist awareness of and adherence to the American Association for the Study of Liver Diseases (AASLD) practice guidelines for chronic HBV management. The primary endpoint of HIV provider adherence to HCC screening recommendations was compared to that of hepatologists at a large metropolitan academic medical center.

METHODS

Medical record database searches by ICD-9 codes were used to identify HIV/HBV coinfected (n = 144) and HBV monoinfected (n = 225) patients who were seen at least twice over a 2-year period in outpatient clinics. Adherence to AASLD guidelines was assessed by chart review. Provider awareness was evaluated through a voluntary anonymous survey with knowledge-based questions.

RESULTS

Over a 2-year period, only 36.0% of HIV/HBV coinfected patients seen in HIV practices completed HCC screening compared to 81.8% of HBV monoinfected patients in hepatology practices (P < .00001). Similarly, HIV providers less frequently monitored HBV viral load (P < .0001), HBeAg/anti-HBe (P < .00001), HBsAg/anti-HBs (P < .00001) than hepatologists but screened more often for hepatitis A immunity (P = .028). Self-reported adherence and knowledge scores were similar among 19 HIV providers and 16 hepatologists.

CONCLUSIONS

HIV providers ordered significantly fewer HCC screening and HBV monitoring tests than hepatologists within a single academic medical center. In the setting of increased reliance on quality indicators for care, both patients and providers will benefit from greater adherence to established guidelines.

Ventricular tachycardias in patients with pulmonary hypertension: an underestimated prevalence? A prospective clinical study

BACKGROUND

Sudden cardiac death (SCD) accounts for approximately 30 % in patients with pulmonary arterial hypertension (PAH). The exact circumference for SCD in this patient population is still unclear. Malignant cardiac arrhythmias are reported to be rarely present. There are no systematic data concerning long-term electrocardiographic (ECG) recording in patients with PAH.

OBJECTIVES

We sought to investigate the rate of potentially relevant arrhythmias in patients with pulmonary hypertension (PH).

METHODS

Consecutive patients without diagnosis of known cardiac arrhythmias followed in our outpatient clinic for PH were enrolled in the study. All patients underwent a 72-h Holter ECG. Clinical data, 6-min walk distance, laboratory values, and echocardiography were collected/performed.

RESULTS

Ninety-two consecutive patients (New York Heart Association class (NYHA) III/IV: 65.2 %/5.4 %, PH Group 1: 35.9 %, Group 3: 10.9 %, Group 4: 28.3 %, Group 5: 2.2 %) were investigated. Relevant arrhythmias were newly detected in 17 patients: non-sustained ventricular tachycardia (n = 12), intermittent second-degree heart block (n = 1), intermittent third-degree heart block (n= 3), and atrial flutter (n = 1). Echocardiographic systolic pulmonary pressure and diameter of the right heart were elevated in patients with relevant arrhythmias. Right heart catheterization revealed higher pulmonary vascular resistance (672 vs. 542 dyn · s · cm(-5), p = 0.247) and lower cardiac index (2.46 vs. 2.82 l/min/m(2), p = 0.184).

CONCLUSIONS

Ventricular tachycardias occur more often in PH patients than previously reported. However, the prognostic relevance of non-sustained ventricular tachycardias in this cohort remains unclear. As a large number of PH patients die from SCD, closer monitoring, e.g., using implantable event recorders, might be useful to identify patients at high risk.

Primary hepatic aspergillosis following induction chemotherapy for acute leukemia

Invasive aspergillosis (IA) contributes significantly to the burden of infectious complications in heavily immunosuppressed patients with acute leukemia. The infection is typically acquired via inhalation into the respiratory tract, and the lungs are most commonly involved. However, disseminated disease may occur and reports of isolated extrapulmonary infection suggest the gastrointestinal tract is likely an additional portal of entry for this organism. We describe a case of primary hepatic aspergillosis in a patient with acute myelogenous leukemia. The patient did not respond to medical therapy with antifungals and ultimately required surgical exploration and drainage. IA should be considered in an immunosuppressed patient with hepatic abscesses and may require a combined surgical and medical approach to therapy.

Effects of caffeic acid phenethyl ester (CAPE) on membrane potential and intracellular calcium in human endothelial cells

BACKGROUNG AND OBJECTIVES: Caffeic acid phenethyl ester (CAPE) is an active component of the resin propolis obtained from beehives. Propolis has a long history of medicinal use and a number of studies have already reported on some of its pharmaceutical properties. This study aimed to explore the effects of CAPE on the cytosolic Ca2+ concentration, cell proliferation, membrane potential and NO levels in human endothelial cells.

MATERIALS AND METHODS

Isolated human umbilical vein endothelial cells (HUVEC) were incubated with CAPE (1-100 µM) at 37°C for 48 hours. Cell proliferation was estimated by counting cell numbers with use of a Neubauer chamber. The effect of CAPE (1-100 µM) on the membrane potential was measured with the fluorescence dye DIBAC4(3) whereas its effect on the cytosolic Ca2+ concentration was measured by use of the fluorescence probe Fluo-3 AM (Invitrogen, Leiden, Netherlands). NO production was assayed using the flourophore DAF~AM (Invitrogen, Leiden, Netherlands). Changes in fluorescence intensity was determined with the GENios plate reader (Genios, Tecan, Austria).

RESULTS

A dose-dependent hyperpolarization of the endothelial cell membrane was observed with CAPE stimulation. The initial increase in the intracellular Ca2+ concentration showed a subsequent decrease over time. CAPE stimulation also resulted in an increase in NO production; however, at higher doses a decrease in NO levels was observed. HUVEC proliferation was inhibited by CAPE.

CONCLUSIONS

Here we report on the effect of CAPE stimulation on the cytosolic Ca2+ concentration, cell proliferation, membrane potential and NO production in HUVEC in a dose-dependent manner. These findings provide important insights into some potential key roles that both calcium and the membrane potential play in the CAPE activation of endothelial cells in a concentration-dependent manner.

HIV and Hepatitis B Virus Coinfection: Approach to Management: Case Study and Commentary

OBJECTIVE

To review diagnosis and treatment in patients with HIV and hepatitis B virus (HBV) coinfection.

METHODS

Review of the literature in the context of a clinical case.

RESULTS

All patients with HIV should be screened for the presence of coinfection with HBV. Following diagnosis with HBV infection, the level of HBV activity should be assessed with testing for HBeAg, HBV DNA, and potentially a biopsy for staging the degree of fibrosis present. Based on the results of this workup, a decision regarding the role of anti-hepatitis treatment should be made. According to the latest chronic hepatitis B and HIV treatment guidelines, coinfected patients who require treatment for chronic hepatitis B should be started on a regimen that is fully active against both HIV and HBV. A first-line regimen for coinfected patients is generally composed of tenofovir and emtricitabine, plus one other agent active against HIV. In coinfected patients, durable responses are rare, and therefore patients are usually required to remain on therapy indefinitely.

CONCLUSION

Intensification of surveillance techniques and education programs should be developed to help prevent transmission of infection and integrate coinfected patients into the health care system. Once engaged in care, coinfected patients should receive treatment for both HIV and chronic hepatitis B with the goal of a decrease in liver failure, cirrhosis, hepatocellular carcinoma, and chronic hepatitis B-related mortality.

Occupational toxicant inhalation injury: the World Trade Center (WTC) experience

OBJECTIVE AND METHODS

Clinical descriptive data is presented on a group of 554 former workers and volunteers (with more than 90 different occupations) at the World Trade Center (WTC) disaster site. A subsample of 168 workers (30% of the group) was selected to examine lower airway disease risk in relation to smoking and WTC exposure variables.

RESULTS

Five diagnostic categories clearly predominate: upper airway disease (78.5%), gastroesophageal reflux disease (57.6%), lower airway disease (48.9%), psychological (41.9%) and chronic musculoskeletal illnesses (17.8%). The most frequent pattern of presentation was a combination of the first three of those categories (29.8%). Associations were found between arrival at the WTC site within the first 48 h of the terrorist attack and lower airway and gastroesophageal reflux disease, and between past or present cigarette smoking and lower airway disease.

CONCLUSION

Occupational exposures at the WTC remain consistently associated with a disease profile, which includes five major diagnostic categories. These conditions often coexist in different combinations, which (as expected) mutually enhances their clinical expression, complicates medical management, and slows recovery. Cigarette smoking and early arrival at the WTC site appear to be risk factors for lower airway disease diagnosis.

Activation of the easter zymogen is regulated by five other genes to define dorsal-ventral polarity in the Drosophila embryo

The product of the Drosophila easter gene, a member of the trypsin family of serine proteases, must be more active ventrally than dorsally to promote normal embryonic polarity. The majority of the easter protein in the embryo is present in the unprocessed zymogen form and appears to be evenly distributed in the extracellular space, indicating that the asymmetric activity of wild-type easter must arise post-translationally. A dominant mutant form of easter that does not require cleavage of the zymogen for activity (ea delta N) is active both dorsally and ventrally. The ea delta N mutant bypasses the requirement for five other maternal effect genes, indicating that these five genes exert their effects on dorsal-ventral patterning solely by controlling the activation of the easter zymogen. We propose that dorsal-ventral asymmetry is initiated by a ventrally-localized molecule in the vitelline membrane that nucleates an easter zymogen activation complex, leading to the production of ventrally active easter enzyme.