Inclusion, Diversity, Access, and Equity in Infectious Diseases Fellowship Training: Tools for Program Directors

The Infectious Diseases Society of America (IDSA) has set clear priorities in recent years to promote inclusion, diversity, access, and equity (IDA&E) in infectious disease (ID) clinical practice, medical education, and research. The IDSA IDA&E Task Force was launched in 2018 to ensure implementation of these principles. The IDSA Training Program Directors Committee met in 2021 and discussed IDA&E best practices as they pertain to the education of ID fellows. Committee members sought to develop specific goals and strategies related to recruitment, clinical training, didactics, and faculty development. This article represents a presentation of ideas brought forth at the meeting in those spheres and is meant to serve as a reference document for ID training program directors seeking guidance in this area.

Blastomycosis in New England: 5 Cases and a Review

The geographic range of blastomycosis is thought to include New England, but documentation is sparse. We report 5 cases of infection with Blastomyces dermatitidis that were likely acquired in New England between 2011 and 2021. Our experience suggests that chart coding for the diagnosis of blastomycosis is imprecise and that mandatory reporting might help resolve uncertainties about the prevalence and extent of blastomycosis.

1306. Early Transition to Oral Antibiotics, Including Fluoroquinolone Therapy, for Streptococcus milleri Empyema Following Video-Assisted Thoracoscopic Surgery

Background

Pleural empyema from Streptococcus milleri (SM) is often complex and requires a combination of surgery and intravenous (IV) antibiotics. There is a paucity of data on the efficacy of oral (PO) treatment due to concerns about the development of resistance, particularly to fluoroquinolones (FQ). We report outcomes of postoperative antibiotic treatment for SM empyema over 3 years, including PO therapy.

Methods

A single-center retrospective chart review was performed of 20 patients treated with video-assisted thoracoscopic surgery (VATS) from October 2015 to March 2018 and SM diagnosed by thoracentesis or operative culture. We reviewed clinical factors, route and duration of antibiotics, complications (empyema recurrence, repeat surgery, 30-day readmission due to empyema), and mortality (30-day and 1-year)

Results

Of the 20 patients, 12 (60%) received all IV and 8 (40%) transitioned to PO therapy (Table 1). Median age was 60 and 58 in the IV and PO group, respectively. IV treated patients had more comorbidities. Cultures were primarily monomicrobial. Isolates tested were susceptible (S) to penicillin (Table 1), Of 10 tested specimen, all had moxifloxacin MIC < 0.19 μg/mL

and 8/8 specimens tested were S to levofloxacin. The average duration of antibiotic therapy in the IV group was 34 days and 32 days in the PO group. There were no complications in the IV group: however, there were 2 deaths (1 patient died from comorbid complications and 1 patient was readmitted and died due to MSSA endocarditis). There were no complications or deaths in patients treated PO.

Conclusion

Our review suggests that early transition to PO antibiotics may be a viable option for operatively managed empyema caused by SM in certain patients. FQs have been generally avoided due to concerns about the rapid development of resistance that has been shown in-vitro; however, no in-vivo data have been reported regarding this concern. We show excellent outcomes with the use of PO therapy in susceptible isolates, particularly FQs, with no failure or reported resistance in patients with SM empyema treated with VATS. Further study is needed to validate these findings and determine optimal patient characteristics for transition to PO therapy.

Disclosures

All Authors: No reported disclosures

950. The Challenge of Fellowship Interviews During COVID-19: An Online Post-interview Survey

Background

COVID-19 has significantly disrupted social and personal interactions, including fellowship recruitment. In-person interviews were replaced by virtual interviews, which created uncertainties for both programs and candidates. We distributed a survey to interviewees for fellowship programs in an effort to gather data and improve the process.

Methods

An anonymous online survey on the Qualtrics® platform assessed satisfaction with the interview process, evaluated the advantages and disadvantages of virtual interviews, and requested comments to improve the process. Surveys were sent out to candidates within 7 days of interview for Infectious Disease and Palliative care fellowship programs at our institution.

Results

Surveys were sent to 51 candidates, 24 (47%) responded; 8 (33%) from Palliative care and 16 (67%) from ID. All candidates felt that they had a good sense about the programs and enough information to make a decision for ranking. Most candidates felt that they conveyed themselves well (71%) to very well (25%) during interview except one person who did not. 63% of candidates felt that the process was seamless, although 3 (12.5%) mentioned technical difficulties during the interviews. While 79% felt that the time spent on the interview was about right, 16% of candidates felt that interviews were too long and 1 person felt that it was too short. Cost-saving was the top advantage of the virtual interview with time-saving second. Interestingly, ability to interview at more programs was not ranked as highly as an advantage. Despite these advantages, 19 of 24 (79%) of candidates would have preferred an in-person interview if it was available. Lack of personal interaction and inability to see the location were equally chosen to be the greatest disadvantages of the virtual process by most of the candidates.

Conclusion

Despite the challenges of the virtual interview process, our survey showed positive feedback from candidates regarding their experiences. The lack of social interaction and inability to explore the location were important, prompting 79% of candidates to prefer an in-person interview if that was an option. Many factors should be considered to ensure an equitable and comprehensive process where candidates and programs can make decisions to optimize outcomes.

Disclosures

All Authors: No reported disclosures

184. Channeling Alexander Fleming: Efficacy of Penicillin (PCN) to Treat Staphylococcus aureus (SA) Bacteremia

Background

Up to 20% of SA isolates in the United States are penicillin-susceptible (PSSA); however, treatment with penicillin has been discouraged because of concern that routine testing may miss strains that have the capacity to produce clinically significant ß-lactamase in vivo. We performed a retrospective analysis to determine whether PCN therapy for the treatment of PSSA bacteremia was of comparable efficacy and safety to standard therapies.

Methods

We identified all episodes of SA bacteremia (March 18, 2010–July 23, 2018). SA penicillin susceptibility testing in our lab was performed by broth microdilution followed by nitrocefin ß-lactamase testing per CLSI guidelines on these isolates. A retrospective chart review was performed and our primary outcome was a composite endpoint of clinical success (no change in PSSA therapy due to persistent or worsening signs and symptoms, no PSSA bacteremia recurrence or persistence, and no infection‐related mortality). Microbiologic failure was defined as either failure to clear bacteremia/infection or recurrence after completion of therapy. Patients were followed until last contact with our medical system, the only tertiary center in the region. We compared our rates of success, mortality, and adverse drug reaction to historical SA bacteremia controls from the literature.

Results

PSSA accounted for 13% (130/971) of SA bloodstream episodes. Nineteen patients with PSSA (15%) were treated with PCN and 79% (15/19) achieved the primary endpoint of clinical success. Of the 4 patients who did not achieve the endpoint, 2 developed rash and were switched to a different antibiotic and 2 died from complications of sepsis. One of the patients died after clearing blood cultures but had DIC and a catastrophic intracranial hemorrhage, the other died of overwhelming sepsis after 4 days (2 days nafcillin, 2 days PCN) with continued bacteremia. Thus, our only microbiologic failure was due to early death from sepsis. Rates of success, mortality and drug reaction were similar to prior reports of alternative standard therapies (Table 1).

Conclusion

PCN is a viable treatment option for PSSA bacteremia as identified by routine laboratory testing. Further study will include characterizing the presence of ß-lactamase in these patient’s isolates.

Disclosures

All authors: No reported disclosures.

Herpes simplex virus infections in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of HSV in the pre- and post-transplant period. A majority of transplant recipients are seropositive for HSV-1 or 2. Compared with immunocompetent persons, SOT recipients shed HSV more frequently, have more severe clinical manifestations, and are slower to respond to therapy. Most HSV infection is diagnosed on clinical grounds, but patients may present with atypical lesions and/or other clinical manifestations. Acquisition from the donor is rare. Polymerase chain reaction is the preferred diagnostic test unless culture is needed for resistance testing. For limited mucocutaneous lesions, oral therapy can be used; however, in severe, disseminated, visceral or CNS involvement, acyclovir doses of up to 10 mg/kg every 8 hours intravenously should be initiated. Acyclovir-resistant HSV is less common in SOT patients than in HSCT and can be treated with foscarnet, though other novel therapies are currently under investigation. HSV-specific prophylaxis should be considered for all HSV-1 and HSV-2-seropositive organ recipients who are not receiving antiviral medication for CMV prevention that has activity against HSV.

Patterns of human herpesvirus-8 oral shedding among diverse cohorts of human herpesvirus-8 seropositive persons

Background

Human herpesvirus-8 (HHV-8), the etiologic agent of Kaposi sarcoma (KS), establishes lifelong latent infection with periodic lytic replication (“shedding”) at mucosal sites, especially the oropharynx. Patterns of HHV-8 shedding are not well understood, and require elucidation to better predict risk of HHV-8 related malignancies in those infected. We sought to characterize patterns of HHV-8 oropharyngeal shedding among diverse cohorts that enrolled HHV-8 seropositive persons.

Methods

We quantified HHV-8 oral shedding using PCR among HHV-8 seropositive persons who collected at least 14 days of oral swabs in 22 studies on 3 continents. We excluded persons taking antivirals during sampling or any prior use of antiretrovirals in those who were HIV-infected.

Results

248 participants were enrolled from the US, Peru, Cameroon, Uganda, and Kenya; 61 % were men, 58 % were HIV seropositive, and 16 % had KS. Overall, 3,123 of 10,557 samples (29.6 %) had HHV-8 detected. Quantity of virus shed was highly correlated with shedding rate, (ρ = 0.72, p < 0.0001). HHV-8 was detected in ≥1 sample in 55 % of participants with a median of 7 % of days in the US and Kenya, 0 % in Uganda and Peru, and 18 % in Cameroon. Median episode duration was three days, and episodes with high median quantity lasted longer (42 vs 3 days, p < 0.0001). In persons with multiple observations over time, 66 % of shedding rate variance was attributable to differences between individuals.

Conclusions

In HHV-8 infected individuals from diverse settings, oral mucosal shedding rate, quantity, and duration were correlated; individual shedding was highly variable. Studies are needed to determine factors accounting for between-person variation and the relationship of HHV-8 shedding to development of associated diseases.

Transmission of Hepatitis C Virus From Organ Donors Despite Nucleic Acid Test Screening

Nucleic acid testing (NAT) for hepatitis C virus (HCV) is recommended for screening of organ donors, yet not all donor infections may be detected. We describe three US clusters of HCV transmission from donors at increased risk for HCV infection. Donor's and recipients' medical records were reviewed. Newly infected recipients were interviewed. Donor-derived HCV infection was considered when infection was newly detected after transplantation in recipients of organs from increased risk donors. Stored donor sera and tissue samples were tested for HCV RNA with high-sensitivity quantitative PCR. Posttransplant and pretransplant recipient sera were tested for HCV RNA. Quasispecies analysis of hypervariable region-1 was used to establish genetic relatedness of recipient HCV variants. Each donor had evidence of injection drug use preceding death. Of 12 recipients, 8 were HCV-infected-6 were newly diagnosed posttransplant. HCV RNA was retrospectively detected in stored samples from donor immunologic tissue collected at organ procurement. Phylogenetic analysis showed two clusters of closely related HCV variants from recipients. These investigations identified the first known HCV transmissions from increased risk organ donors with negative NAT screening, indicating very recent donor infection. Recipient informed consent and posttransplant screening for blood-borne pathogens are essential when considering increased risk donors.

Varicella zoster virus (VZV) and herpes simplex virus (HSV) in solid organ transplant patients

Varicella zoster virus (VZV) and the two herpes simplex viruses (HSV) are human α-herpesviruses that establish life-long latency in neural ganglia after initial primary infection. In the solid organ transplant (SOT) population, manifestations of VZV or HSV may be seen in up to 70% of recipients if no prophylaxis is used, some of them life and organ threatening. While there are effective vaccines to prevent VZV primary infection and reactivation in immunocompetent adults, these vaccines are contraindicated after SOT because they are live-virus vaccines. For HSV, prevention has focused primarily on antiviral strategies because the immunologic correlates of protection and control are different from VZV, making vaccine development more challenging. Current antiviral therapy remains effective for the majority of clinical VZV and HSV infections.

Mucormycosis peritonitis: more than 2 years of disease-free follow-up after posaconazole salvage therapy after failure of liposomal amphotericin B

A 57-year-old woman with end-stage kidney disease secondary to autosomal dominant polycystic kidney disease developed peritoneal dialysis-related Mucor peritonitis after her pet cockatoo bit through her transfer set. The infection persisted despite more than 8 weeks of treatment with liposomal amphotericin B. On a compassionate basis, she then received oral posaconazole, 800 mg/d, in divided doses for 6 months. She experienced complete remission and has remained disease free since then, for more than 2 years. We review the medical literature about mucormycosis peritonitis which, albeit rare, carries very high mortality. The treatment of choice is liposomal amphotericin B, which failed in our patient. Our case report suggests that posaconazole is an attractive treatment option in patients with peritoneal dialysis-related Mucor peritonitis.

Herpes simplex virus (HSV) suppression with valacyclovir reduces rectal and blood plasma HIV-1 levels in HIV-1/HSV-2-seropositive men: a randomized, double-blind, placebo-controlled crossover trial

BACKGROUND

Herpes simplex virus type 2 (HSV-2) infection is common among human immunodeficiency virus (HIV)-infected persons, and HSV reactivation increases plasma and genital HIV-1 levels. We studied HIV-1 levels during HSV suppression in coinfected persons in a placebo-controlled crossover trial.

METHODS

Twenty antiretroviral therapy (ART)-naive HIV-1/HSV-2-seropositive men who have sex with men in Lima, Peru, with CD4 cell counts >200 cells/ microL were randomized to receive either valacyclovir at 500 mg twice daily or placebo for 8 weeks, after which they underwent a 2-week washout period and then received the alternative regimen for 8 weeks. Specimens included daily anogenital swabs (for HSV DNA polymerase chain reaction [PCR]), thrice weekly rectal mucosal secretions (for HIV-1 RNA and HSV DNA PCR) obtained by anoscopy, and weekly plasma (for HIV-1 RNA PCR). Outcomes were rectal and plasma HIV-1 RNA levels by treatment arm.

RESULTS

HIV-1 was detected in 73% of 844 rectal and 99% of 288 plasma specimens. HSV was detected in 29% and 4% of mucocutaneous specimens obtained during placebo and valacyclovir administration, respectively (P<.001). Valacyclovir resulted in a 0.16 (95% confidence interval [CI], 0.07-0.25; P=.0008; 33% decrease) log(10) copies/mL lower mean within-subject rectal HIV-1 level and a 0.33 (95% CI, 0.23-0.42; P<.0001; 53% decrease) log(10) copies/mL lower plasma HIV-1 level, compared with values for placebo.

CONCLUSIONS

Valacyclovir significantly reduces rectal and plasma HIV-1 levels in HIV-1/HSV-2-coinfected men. HSV suppression may provide clinical benefits to persons not receiving highly active ART as well as public health benefits.

Higher concentration of HIV RNA in rectal mucosa secretions than in blood and seminal plasma, among men who have sex with men, independent of antiretroviral therapy

High levels of human immunodeficiency virus (HIV) in rectal secretions and semen likely increase the risk of HIV transmission. HIV-infected men who have sex with men made 2-3 study visits, over 4 weeks, to assess rectal, seminal, and plasma levels of HIV RNA. Mixed-effects models estimated the effect of factors on HIV shedding. Twenty-seven (42%) of 64 men were receiving antiretroviral therapy (ART); regardless of ART use, median HIV RNA levels were higher in rectal secretions (4.96 log(10) copies/mL) than in blood plasma (4.24 log(10) copies/mL) or seminal plasma (3.55 log(10) copies/mL; P<.05, each comparison). ART was associated with a 1.3-log(10) reduction in rectal HIV RNA in a model without plasma HIV RNA; with and without plasma RNA in models, ART accounted for a >1-log(10) decrease in seminal HIV RNA levels. Thus, controlling for plasma HIV RNA, ART had an independent effect on seminal, but not rectal, HIV levels.

Factors associated with oropharyngeal human immunodeficiency virus shedding

Orogenital transmission of human immunodeficiency virus (HIV) is considered to be inefficient, and infectious HIV is rarely detected in saliva. To evaluate the posterior oropharynx as a source of HIV shedding, we studied 64 HIV-infected men who have sex with men in Seattle, Washington, and Lima, Peru. In multivariate analysis, receipt of antiretroviral therapy, higher CD4 cell count, and history of tonsillectomy were predictors of lower pharyngeal HIV RNA levels.

Undetected vancomycin-resistant Enterococcus in surgical intensive care unit patients

The rates of vancomycin-resistant Enterococcus (VRE) in a high-risk population were investigated prospectively using an active surveillance method. The costs of conducting active surveillance were calculated. Among the 10 patients found to have VRE, routine cultures identified 3 (30%); thus, 70% of the VRE-colonized patients would have gone undetected in the absence of active surveillance. The total cost for 5 weeks of active surveillance was $2,234. Although active surveillance identified a high rate of VRE-colonized patients who otherwise may not have been identified, it remains to be determined if the additional costs are justified and result in reduced transmission.

Tuberculosis screening in a sexually transmitted diseases clinic

BACKGROUND AND OBJECTIVES

Patients attending sexually transmitted diseases (STD) clinics may be at high risk for tuberculosis (TB) infection. The authors conducted a pilot study of TB screening in this setting to determine the prevalence of TB infection and compliance of the population with a screening program.

GOALS

To determine the prevalence of positive skin test results indicating TB among patients attending an STD clinic and to test a simple incentive designed to enhance compliance with return visits for skin test interpretation.

STUDY DESIGN

Skin tests for TB were offered to clients attending an STD clinic. Testing was accompanied by self-assessment questionnaires designed to assess risk for TB. After 2 months, a simple incentive package was initiated to enhance compliance with skin test interpretation.

RESULTS

The prevalence of positive skin test results was 34%. Compliance with return visits was doubled by use of the simple incentive package.

CONCLUSIONS

Patients attending STD clinics are at high risk for TB and can be motivated toward increased compliance by the use of simple incentives.

The anatomy and functional morphology of the large hermaphroditic duct of three species of Aplysia, with special reference to the atrial gland

The anatomy and functional morphology of the large hermaphroditic duct of three species of gastropod mollusc (Aplysia californica, A. dactylomela, and A. brasiliana) were examined. Each duct is composed of two parallel compartments, the red hemiduct (RHD) and the white hemiduct (WHD), which are distinguishable from the outside of the duct. Four secretory regions, all exocrine in morphology, are recognizable: the RHD secretory epithelium, the atrial gland (or atrial gland-like epithelium), the WHD secretory epithelium, and the accessory gland of the copulatory duct (AGCD). Of these regions, only the atrial gland (or atrial gland-like epithelium) contains egglaying activity and only the atrial gland (or atrial gland-like epithelium) is immunocytochemically labeled by serum antibodies generated against low molecular weight A. californica atrial gland peptides. The RHD is the functional oviduct: the egg cordon passes through a channel lined by the RHD secretory epithelium and bordered by the atrial gland (or atrial gland-like epithelium); the eggs are separated from both the WHD secretory epithelium and the AGCD by internal folds of the duct. The WHD is the functional copulatory duct: the penis, exogenous sperm, and endogenous sperm pass directly by the AGCD and in close proximity to the WHD secretory epithelium; they are separated from both the RHD secretory epithelium and the atrial gland (or atrial gland-like epithelium) by internal folds. The atrial gland (or atrial gland-like epithelium) is thus not likely to have a prostatic function or to be directly stimulated by the penis during copulation; it may play a role in oviductal function.