Almeida, Natalia E. Castillo

Abstract Background Post-operative 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 18/54 (33.6%) classified as LVAD- specific or related infections and 36/54 (66.6%) as non-infected. Cases of LVAD-infection had a higher median Charlson Comorbidity Index score at the time of transplantation compared to non-infected cases (P=.005). Of the 18 cases of infection, 13/18 (72.2%) were classified as LVAD-specific and 5/18 (27.8%) as LVAD-related. A total of 9/13 (69.2%) cases had proven LVAD-specific infections. Antimicrobial therapy was extended post-transplant to treat preceding LVAD-specific infection in all nine cases (9/13, 69.2%) with a median duration of 14 days (IQR 14-28). Following LVAD removal, antimicrobial treatment was not continued for preceding LVAD-related infections. Conclusions Patients with an LVAD-specific infection were treated with two weeks of pathogen-directed therapy post heart transplant without any relapses. For those without LVAD-specific infection or uncomplicated LVAD-related bacteremia who had completed antimicrobial therapy pre-transplant, antibiotics were discontinued after standard peri-operative prophylaxis and no relapses were observed.

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.

AbstractBackgroundMycobacterium 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.MethodsCulture-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.ResultsTwelve 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.ConclusionsM. 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.

Abstract 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.

Abstract 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.