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Background: Handshake antimicrobial stewardship (AMS), characterized by regular, face-to-face interactions with antimicrobial prescribers with broad review of all active antimicrobials, is considered an AMS best practice. This approach fosters relationship building and increases opportunities for targeted education compared to traditional AMS activities. Reports of handshake AMS within surgical services are limited. We evaluated the impact of once-weekly handshake AMS rounds among general surgery teams in a 368-bed academic medical center. Methods: An infectious diseases physician and pharmacist conducted weekly rounds in general surgery offices with surgical residents, chief residents, advanced practice providers (APPs), medical students, and occasionally attending surgeons. All patients on antimicrobials and without an active ID consult were reviewed and recommendations with targeted education were provided. The number, type, and acceptance rate of recommendations were collected prospectively. Antimicrobial utilization within general surgery was reviewed pre- (1/1/2024-12/31/2024) and post-implementation (1/1/2025-12/31/2025) of handshake AMS rounds. Antimicrobial use data are presented as days of therapy (DOT)/1000 days present (DP). Results: From January 7, 2025, through January 6, 2026, 47 handshake AMS sessions were performed. Over this period, 215 recommendations were provided, and 173 recommendations were implemented, yielding a recommendation implementation rate of 80.5% and an average of 4.6 recommendations/session. The most common accepted recommendation types were duration modification (n=42, 24.3%), antibiotic stop (n=38, 22.0%), and de-escalation (n=33, 19.1%). Average DOT/1000 DP on general surgery teams for all agents dropped from 481.3 pre- to 462.8 post-implementation (3.8% relative reduction, p=0.578). Broad-spectrum antibiotic use dropped by 17.5%, from 369.2 pre- to 304.6 post-implementation (p=0.055). Anti-MRSA agent utilization remained stably low, with an average of 45.4 pre- vs 49.0 DOT/1000 DP post-implementation. The use of enteral metronidazole increased, from 4.9% pre- to 18.2% enteral/IV DOT post-implementation. Surgical providers consistently expressed appreciation for the practice-changing education provided during handshake AMS rounds and the resulting enhancements in antimicrobial decision-making and patient care. Conclusion: Targeted, once-weekly handshake AMS rounds with general surgery resulted in high-yield interventions with a high acceptance rate. Handshake AMS rounds could be an effective stewardship intervention in surgical practices and is doable despite the challenges of unpredictable operating room/provider schedules.

ABSTRACT Background Strongyloides stercoralis is an intestinal parasitic nematode that can infect humans with a 2%–7% prevalence in the United States. Immunosuppression is a crucial risk factor for disseminated infection. Diagnosis is often delayed and targeted treatment is frequently initiated late. We therefore sought to review the prevalence of positive Strongyloides antibody results and undertook a descriptive analysis of such patients. Methods We retrospectively reviewed patients with positive Strongyloides IgG serology from August 2012 to April 2023 across geographically distinct academic medical centers. Study period pre‐dated universal donor and recipient Strongyloides screening recommendation by the Organ Procurement and transplantation network (OPTN). Clinical presentation was classified into three categories: chronic infection (positive Strongyloides IgG serology without additional clinical manifestations), hyperinfection syndrome (positive serology with involvement of the skin, gastrointestinal tract, or lungs), and disseminated infection (positive serology with involvement beyond those typically involved in hyperinfection). Results A total of 412 patients were identified; median age was 59 years and 66% (272) were male. The primary indication for testing was pretransplant evaluation in 230 (56%), eosinophilia workup in 84 (20%), suspicion of symptomatic infection in 74 (18%), testing based on travel history in 27 (7%), and pre‐immunosuppression screening in 27 (7%). Furthermore, 401 patients (97.3%) were categorized as having chronic infection, 10 patients (2.42%) had hyperinfection, and one patient (0.24%) had disseminated infection, presenting with Escherichia coli bacteremia and meningitis. Symptomatic infection was more common at the Mayo Clinic in Rochester and Mayo Clinic Health Sciences than at the Arizona and Florida Mayo Clinic sites (6% vs. 2%, p = 0.079). Treatment was administered to 366/412 (89%) patients. Conclusion Most patients with positive Strongyloides serology were asymptomatic, and treatment regimens were not uniform. Patients who tested positive should be treated prior to immunosuppression initiation, though this was not systematically assessed in this cohort. The observed variability in treatment regimens highlights the need for standardized protocols.

Peritoneal coccidioidomycosis is a rare, disseminated manifestation of Coccidioides infection with limited representation in the literature. We report 37 proven or probable cases from a single institution, including 12 patients (32%) with immunosuppression. Thirty-six patients received antifungal therapy, all of whom demonstrated clinical response. Among 11 (29.7%) patients who completed and stopped therapy after a median duration of 26 months, 2 (5%) experienced a relapse and were successfully retreated. Nine patients (24%) had no known relapse. Thirteen patients (35%) required modification of antifungal regimens, primarily due to azole adverse effects. Treatment approaches and median duration of therapy (57 months) were similar between immunosuppressed and non-immunosuppressed groups. No deaths were attributable to infection. Overall, outcomes were favorable, with strong clinical responses to azole therapy. Patients without identifiable immunologic deficits or additional sites of dissemination, when managed with antifungal therapy and close clinical, radiologic, and serologic monitoring, may achieve good prognosis, particularly when indefinite azole therapy is not feasible.

Abstract Background Metabolic dysfunction–associated steatotic liver disease (MASLD) is increasingly recognized among people with human immunodeficiency virus (PWH), which is likely related to metabolic alterations and fat redistribution. Anthropometric measures such as body mass index (BMI) and waist circumference (WC) are commonly used for assessing metabolic risk. However, their predictive accuracy for MASLD in this population remains uncertain. Method This multicenter cross-sectional study enrolled adults with HIV who underwent transient elastography with controlled attenuation parameter (CAP) measurement. Anthropometric and metabolic indices, including BMI, WC, hip circumference, waist-to-hip ratio (WHR), and visceral adiposity index (VAI), were collected from the study participants. Receiver operating characteristic (ROC) curve analyses were performed to determine the diagnostic performance of these indices for detecting hepatic steatosis, defined as CAP value of ≥248 dB/m. Analyses were stratified by sex assigned at birth. Results Altogether, 256 participants were included. WC demonstrated the numerically highest discrimination for CAP-defined steatosis (area under the ROC curve 0.769), followed by BMI and hip circumference, whereas WHR and VAI showed weaker performance. In sex-stratified analyses, WC remained the numerically highest-performing measure among males, whereas BMI, WC, hip circumference, and VAI showed similar discrimination among females. Conclusions Simple anthropometric measures, particularly WC, show fair ability to discriminate CAP-defined hepatic steatosis in PWH and may facilitate targeted fatty liver screening in routine HIV care.

Abstract Background Strongyloides stercoralis is an intestinal parasitic nematode with a 2% - 7% prevalence in the United States. Immunosuppression can predispose to disseminated infection, concurrent bacterial sepsis and significant morbidity and mortality. We sought to review positive Strongyloides serology (PSS) results across 3 academic medical centers. Methods Electronic medical records of patients with PSS were reviewed between 2012 and 2023. Extracted data included demographics, country of origin, travel history, testing indication, clinical presentation, treatment regimen and duration. Patients were classified into chronic infection (PSS without additional clinical manifestations), hyper infection syndrome (cutaneous, gastrointestinal tract, or lung involvement), and disseminated infection (evidence of involvement of distant sites beyond hyper infection such as the brain, liver, kidneys, or bloodstream). Results Overall PSS rate across the 3 sites was 5.5%. A total of 412 patients with PSS were identified with a mean age of 56.7 years (SD ±14.2); 272 (66%) were male. The primary indication for testing was transplant evaluation in 230 (56%), eosinophilia workup in 84 (20%), suspicion of active infection in 74 (18%), travel history in 27 (7%), and pre-immunosuppression screening in 27 (7%). 401 (97.3%) were categorized as chronic infection,10 (2%) as hyper infection, and one patient (0.2%) as disseminated infection. Treatment was administered to 366 (89.3%) patients: 226 (61.7%) received 2 doses of Ivermectin on consecutive days, 94 (25.7%) received a single dose, 26 (7.1%) received 2 doses repeated 2 weeks later, and 20 (5.5%) received alternative regimens. The patient with disseminated infection received 2 weeks of Ivermectin followed by monthly dosing. Conclusion Majority of the patients with PSS were asymptomatic, and treatment regimens were not uniform. Screening should be considered for patients currently receiving or initiating long-term immunosuppression that can potentiate Strongyloides dissemination. Developing a targeted testing algorithm based on epidemiologic factors, clinical suspicion, laboratory parameters and nature of immunosuppression can help identify at-risk patients who can receive pre-emptive therapy if infected. Disclosures All Authors: No reported disclosures

Abstract Background Handshake antimicrobial stewardship (HAS) is an effective stewardship approach characterized by regular, face-to-face interactions with antimicrobial prescribers and broad review of all active antimicrobials. Benefits of this approach include enhanced relationship building and opportunities for targeted education. We conducted a mixed methods study to evaluate the impact of once-weekly HAS rounds among Hospital Internal Medicine (HIM) teams in an academic medical center. Methods An infectious diseases (ID) physician and pharmacist conducted weekly table rounds with a HIM teaching team consisting of a hospitalist, advanced practice providers (APPs), APP fellow(s), and sometimes medical students. All patients on antimicrobials and without an active ID consult were reviewed and recommendations were provided. Thereafter, the stewardship team solicited ad hoc questions from other HIM teams via walking rounds in their offices. The number, type, and acceptance rate of recommendations were collected prospectively. A survey was sent to all HIM providers to obtain feedback on HAS rounds. Results HAS rounds were conducted weekly from February 7, 2024, to February 19, 2025, with a total of 52 sessions. Over the study period, 340 recommendations were provided, and 314 recommendations were implemented, yielding a recommendation implementation rate of 92.4%. The most common recommendation types were antimicrobial discontinuation (n=76, 22.4%), duration modification (n=63, 18.5%), and de-escalation (n=39, 11.5%). The survey was sent to 102 HIM providers and completed by 19 for a response rate of 18.6%. All respondents stated HAS added value or greatly added value to their practice. Antimicrobial selection (n=16, 84.2%), de-escalation (n=12, 63.2%), and pharmacy expertise (n=6, 31.6%) were areas in which providers saw the greatest benefit. Eighteen providers (94.7%) recommended expansion of HAS to non-HIM services. Conclusion Targeted, once-weekly HAS rounds resulted in high-yield interventions that were frequently accepted and perceived as highly valuable by HIM providers. Once-weekly or intermittent HAS practices might be considered in practice settings where resources or logistical constraints limit broader, hospital-wide handshake stewardship practices. Disclosures All Authors: No reported disclosures

This essay describes diagnostic criteria for and thoracic imaging appearances of acute and chronic coccidioidal pneumonia, unusual disease manifestations, and disseminated disease appearances.