Kasten, Mary J.

ABSTRACT Background Mycobacterium genavense is a rare opportunistic non-tuberculous mycobacterium primarily reported in advanced human immunodeficiency virus infection. Case Summary A 70-year-old woman with systemic lupus erythematosus developed progressive abdominal pain, weight loss, and mesenteric lymphadenitis repeatedly responsive to corticosteroids. Endoscopic biopsies revealed abundant acid-fast bacilli, and molecular testing confirmed the presence of M. genavense . Treatment with azithromycin, ethambutol, and rifabutin led to gradual recovery. Conclusion Steroid-responsive mesenteric inflammation in immunocompromised patients should prompt evaluation for infection, including mycobacteria and other culture-negative microorganisms using molecular diagnostics. This case report highlights the importance of plasma microbial cell-free DNA assays in the identification of fastidious organisms, like M. genavense , and, in some cases, serial testing may be useful to monitor treatment response.

Objective: Our study aimed to assess the impact of pharmacogenomic panel testing in people with HIV (PWH). Design: Prospective, observational intervention assessment Methods: One hundred PWH were provided a comprehensive pharmacogenomic panel during routine care visits within the HIV specialty clinic of a large academic medical center. The panel determined the presence of specific genetic variants that could predict response or toxicity to commonly prescribed antiretroviral therapy (ART) and non-ART medications. An HIV specialty pharmacist reviewed the results with participants and the care team. The pharmacist (1) recommended clinically actionable interventions based on the participants’ current drug therapy, (2) assessed for genetic explanations for prior medication failures, adverse effects, or intolerances, and (3) advised on potential future clinically actionable care interventions based on individual genetic phenotypes. Results: Ninety-six participants (median age 53 years, 74% white, 84% men, 89% viral load <50 copies/ml) completed panel testing, yielding 682 clinically relevant pharmacogenomic results (133 major, 549 mild–moderate). Ninety participants (89 on ART) completed follow-up visits with 65 (72%) receiving clinical recommendations based on current medication profiles. Of the 105 clinical recommendations, 70% advised additional monitoring for efficacy or toxicity, and 10% advised alteration of drug therapy. Panel results offered explanation for prior ART inefficacy in one participant and ART intolerance in 29%. Genetic explanation for non-ART toxicity was seen in 21% of participants, with genetic contributors to inefficacy of non-ART therapy identified in 39% of participants. Conclusion: Preliminary data in a small cohort of PWH demonstrates benefit of routine pharmacogenomic panel testing.

Life-changing progress has been made over the past 30 years in the treatment of HIV infection. HIV has transformed from an illness that resulted in one complication after another and nearly always resulted in death to a chronic illness that for most patients is more easily managed than diabetes or heart disease. Antiretroviral therapy (ART) is now simple and well-tolerated. The most important priority of HIV treatment is ensuring that people living with HIV stay on continuous, effective ART. ART, although not curative, suppresses the virus and allows the immune system to recover. Even when the CD4 count remains low, suppressive ART helps prevent opportunistic infections and other HIV related complications. (1) Suppressive ART is important not only to the individual living with HIV health but is an important public health goal since people living with HIV will not transmit HIV to their sexual partners if their viral load is undetectable. (2) A respectful, culturally appropriate patient–provider relationship is one of the most important factors in keeping people living with HIV engaged in care. (3) Persons living with HIV deserve both excellent HIV and primary care. Some communities have providers that are experts in both, but often people living with HIV receive the best care by collaboration between their primary care provider and an HIV expert. This article is written to help primary care givers who are not HIV experts provide appropriate primary care to their patients who are living with HIV and emphasizes issues that deserve additional attention in people living with HIV compared to the general population

Bilophila wadsworthia, a recently described anaerobic gram-negative bacillus, was isolated from blood cultures of two patients with liver abscesses. These isolates exhibited the expected phenotypic characteristics, and identification was confirmed by cell wall fatty acid analysis by gas-liquid chromatography. This is the first documentation of bacteremia due to B. wadsworthia.

Abstract Background Over 80% of patients with hematologic malignancies develop some form of infectious complication, most commonly febrile neutropenia. Patients with febrile neutropenia have 10% mortality, which increases if antibiotic administration is delayed past 30 minutes. Studies have suggested β-lactam allergy may delay administration of antibiotic while putting patients at greater risk for inappropriate antibiotic choice and adverse effects stemming from this. We sought to describe the risks associated with β-lactam allergy in the neutropenic population. Methods We conducted a retrospective, descriptive study from January 2016 to December 2017 identifying patients with febrile neutropenia and a reported history of β-lactam allergy. Baseline characteristics, allergy data, treatment data, and outcomes were collected and analyzed. Results We identified 31 patients with febrile neutropenia and β-lactam allergy during this time period. Etiologies of neutropenia were hematologic malignancy (61.2%), stem cell transplantation (12.9%), solid-organ malignancy (22.6%), and autoimmune (3.3%). Reported reactions to β-lactams were rash (41.9%), hives (9.7%), anaphylaxis (3.2%), other (9.7%), and unknown (35.5%). Average time to antibiotic administration was 142.5 minutes. Antibiotic choice was cefepime (61.3%), piperacillin–tazobactam (6.5%), carbapenem (22.6%), fluoroquinolone (6.5%), cefepime and fluoroquinolone (3.2%), and vancomycin (58.1%). 51.6% received initial antibiotics consistent with the 2010 IDSA guidelines. Six patients underwent penicillin skin testing, all negative. 1 patient developed C. difficile infection, 1 developed MRSA colonization, and 3 developed VRE colonization. Mortality was 3.2% at 30 days and 16.1% at 90 days. Conclusion Our study estimated the antibiotic usage patterns and outcomes in patients with febrile neutropenia and reported β-lactam allergy. This showed low adherence to an established guideline for antibiotic choice in these patients. With rising antimicrobial resistance, there is a need to develop strategies to reduce inappropriate antimicrobial use, especially in patients with febrile neutropenia. Preemptive β-lactam allergy evaluation warrants further evaluation in the neutropenic population. Disclosures All authors: No reported disclosures.

Abstract Background Pre-travel consultation involves an in-clinic face-to-face consult (F2F) with a Travel Medicine provider. F2F involves education/counseling which is time-consuming for both patients and providers. Although electronic consultations (synchronous and asynchronous) are well established in many subspecialties, pretravel eConsults are not well known. We compared pretravel education via F2F to an innovative hybrid electronic consultation (HeC) combined with a Video Supported PowerPoint (VSP) for selected travelers. Methods We conducted a prospective trial comparing HeC-VSP to F2F to determine the quality of pretravel education. Study was approved by the Mayo Clinic IRB. Patients were enrolled from May 2014 through May 2015. Patients in both arms were given pretravel and post-travel surveys. Exclusions included age less than 18 years, first trip to Africa, immunocompromised host, non-English-speaking traveler, or travel for longer than 4 weeks. Results 194 patients were enrolled; 100 in HeC-VSP and 94 in F2F arm completed pretravel survey. Post-travel survey was completed in 54.2% (51/94) of the F2F, 67% (67/100) in the HeC-VSP group. The groups are similar in demographics and prior travel experience (Table 1). 36.2% of the F2F group felt that the consultation could have been effectively accomplished through a video-based education, while 33% felt that a F2F was needed; in contrast a majority (63.3%) in the HeC-VSP group would not have preferred a F2F consultation. HeC-VSP-based pretravel education was similar compared with that provided via the F2F consults. There were no statistically significant differences in the responses obtained in both groups to knowledge assessment questions (Table 2) except for one question. A higher proportion (76/100; 76%) in the HeC-VSP group compared with 55.4% (51/94) chose the correct response (P = 0.0018) regarding management of bloody diarrhea with fever. Self-reported change in behaviors to prevent travel-related illnesses was reported overall in 53% of the patients with no statistically significant differences between the groups. Conclusion Nonsynchronous eConsultation combined with VSP provides a viable solution to provide pretravel education for a select travel population. Disclosures All authors: No reported disclosures.