Citations

Abstract Background Intravesical Mycobacterium bovis bacillus Calmette-Guérin (BCG) is standard therapy for high-risk nonmuscle-invasive bladder cancer. However, M bovis infections can occur and are not well understood. We aimed to characterize clinical phenotypes, diagnosis, management, and outcomes of culture-confirmed M bovis BCG infections following intravesical therapy for urothelial carcinoma. Methods A retrospective single-center review of adults with culture-confirmed M bovis infection after intravesical BCG (May 2009–July 2024) was conducted, abstracting clinical, microbiologic, treatment, and outcome data. Results Twenty-two White male patients (median age, 77 years) were included; 8 (36.4%) had localized genitourinary infection, 6 (27.3%) had dissemination limited to blood, and 8 (36.4%) had dissemination to other organs. Patients with bloodstream-only infection presented acutely (median 1.5 days after last BCG), whereas those with localized or organ-disseminated disease presented months to years after BCG, with the longest diagnostic delays in organ-disseminated infection. Despite all cases had culture-proven M bovis BCG infection, acid-fast smear, Mycobacterium tuberculosis complex polymerase chain reaction, and histopathology had limited sensitivity. All isolates were susceptible to rifampin, isoniazid, and ethambutol; all were resistant to pyrazinamide. Median treatment duration exceeded 9 months, 94.7% achieved cure, and attributable mortality was 5.0% (1 vascular graft infection). Conclusions M bovis BCG infections following intravesical therapy have favorable outcomes but are often associated with diagnostic delays and prolonged treatment. Early suspicion, comprehensive diagnostic evaluation, and timely surgical source control when indicated are critical. Management strategies should be tailored based on the extent of disease dissemination and individual host factors.

Abstract Background The Grading Recommendations, Assessment, Development, and Evaluations (GRADE) framework is widely applied in clinical guidelines to facilitate transparent evidence evaluation. While developing Infectious Diseases Society of America (IDSA) guidelines on the management of patients with coronavirus disease 2019 (COVID-19), panel members suggested developing and implementing a visual aid to enable quicker identification of key information by providers at bedside seeking guidance. Methods We conducted a mixed-methods study evaluating the usability of a newly designed infographic/icon using a survey and focus groups. The survey incorporated a simulated COVID-19 IDSA guideline with and without the icon, followed by comprehension questions. Focus group discussions provided qualitative feedback on the GRADE methodology and icon usability. Results The survey was returned by 289 health care providers. There was no statistical difference in the correct response rates between icon-aided and non-icon-aided guideline questions (McNemar's chi-square test, P > .1 for both questions). Interactions with the icon notably increased the time taken and number of clicks required to respond to the first question (Wilcoxon signed-rank test, P < .01). In contrast, response time did not differ between versions for the second question (P = .38). Most subjects (85%) indicated that the icon improved the readability of the guidelines. A focus group follow-up suggested alternative designs for the icon. Conclusions This study highlights the promise of iconography in clinical guidelines, although the specific icons tested did not measurably improve usability metrics. Future research should focus on icon design and testing within a formal usability framework, considering the impact of GRADE language on user experience.

Abstract Background We aimed to determine the factors associated with sequential blood culture time to positivity (STTP) and validate the previously defined time to positivity (TTP) ratio threshold of 1.5 in predicting adverse disease outcomes and mortality of Staphylococcus aureus bacteremia (SAB). Methods We conducted an observational study of adult patients with SAB. The TTP ratio was calculated by dividing the TTP of the second blood culture by that of the first. Results Of 186 patients, 69 (37%) were female, with a mean age of 63.6 years. Median TTP was 12 hours (interquartile range [IQR], 10–15 hours) from the initial and 21 hours (17–29) from sequential blood cultures. Methicillin-resistant S aureus (MRSA)–infected patients had significantly shorter STTPs (P < .001) and lower TTP ratios (P < .001) compared to patients with methicillin-susceptible S aureus (MSSA). A significant correlation between initial and STTP was observed in patients with MRSA (r = 0.42, P = .002) but not in those with MSSA. A higher rate of native valve endocarditis (NVE) significantly correlated with a TTP ratio of ≤1.5 (odds ratio, 2.65 [95% confidence interval, 1.3–5.6]; P = .01). The subgroup having an initial TTP <12 hours combined with a TTP ratio ≤1.5 showed the highest prevalence of NVE. Conclusions The STTP varies based on methicillin susceptibility of S aureus isolate. This study suggests a potential clinical utility of the STTP to identify patients at a higher risk of NVE. However, prospective studies are required to validate these findings.

Abstract Background As the acute phase of the COVID-19 pandemic subsides, an increasing number of individuals are recognized as having long COVID, affecting over 65 million people worldwide. Recent studies have suggested a potential link between long COVID and alterations in the gut microbiome. In this study, we examined the gut microbiome of a large outpatient cohort during acute phase of infection, with the ultimate goal of determining predictors of long-term COVID-19 health outcomes. Methods We conducted a study of 394 COVID-19 patients with positive SARS-CoV-2 testing from November 2020 to September 2021 at a multi-site healthcare system. Long COVID was defined as the persistence of symptoms for four weeks or more after illness onset. DNA extraction was performed using the MoBio PowerSoil Pro DNA isolation kit. Samples were sequenced using shotgun metagenomics. Stool SARS-CoV-2 RNA was tested using qRT-PCR of the E gene, and stool ELISA was performed for calprotectin levels. Standard biostatistical tools in R (v 4.2.3) were used for statistical analysis. Results Of the 394 COVID-19 patients, 84 (21%) had long COVID, with fatigue being the most common persistent symptom (Table 1). No significant differences were seen in age, BMI, and antibiotic use. Those with long COVID were more likely to be female, had higher Charlson's comorbidity scores, more severe index illnesses. However, the two groups had no difference in SARS-CoV-2 stool PCR positivity or stool calprotectin levels (Table 2). Principal coordinate analysis of Bray Curtis dissimilarities revealed that patients with long COVID had a distinct microbial composition compared with those without long COVID during the acute phase of infection (ANOSIM R2= 0.005, P= 0.01). Categorizing patients by number of long COVID symptoms showed significant differences among groups (ANOSIM R2=0.1, P=0.007), mainly between patients with >3 symptoms and those with 0-1 symptoms (Bonferroni, P= 0.018). Alpha diversity was lower in patients with > 3 symptoms, although this was not statistically significant (Shannon diversity, two-way-ANOVA, P=0.051). Figure 1 Conclusion Long COVID patients show distinct gut microbial composition during the acute phase of infection, suggesting a potential role in predicting long-term COVID health outcomes. Disclosures John C. O'Horo, Sr., MD, MPH, Janssen Pharmaceuticals.: Grant/Research Support|nference: Grant/Research Support Purna C. Kashyap, MD, Intrinsic Medicine: Advisor/Consultant|Novome Biotechnologies: Advisor/Consultant|Pendulum Therapeutics: Advisor/Consultant

Abstract Background Staphylococcus aureus bacteriuria (SABU) represents 0.2–4% of all positive urine cultures. While asymptomatic colonization or infection of the urinary tract is possible, hematogenous seeding from S. aureus bacteremia (SAB) represents a potentially life-threatening condition. The rate of concomitant SAB is estimated to be 6.9–17.2% among those with SABU, and these patients are at higher risk of in-hospital mortality, infective endocarditis, embolic events, and vertebral osteomyelitis. Detection of SABU represents an opportunity for early detection and intervention in SAB. Methods We conducted a retrospective analysis of clinical and microbiological characteristics of adult patients with SABU as our pre-intervention baseline. We then implemented a comment with the urine culture result in the electronic medical record (EMR) advising providers about the possibility of concomitant bacteremia. We conducted an interim analysis of early post-intervention data. Figure 1: Study Workflow Figure 1: Study workflow depicting case recruitment and blood culture results. Figure 2: Intervention Flag Figure 2: Example of intervention comment displayed with the urine culture result in the EMR. Results 250 adult patients developed SABU from January 1, 2021, to January 31, 2023. Of these, 87 (34.8%) had urinary tract symptoms, and 91 (36.4%) had a chronic indwelling urinary catheter. 74 (29.6%) patients had blood cultures collected within 7 days of positive urine culture. The presence of urinary symptoms or indwelling catheter was not associated with blood culture collection. Only 22 patients (8.8%) had SAB with SABU. One patient was diagnosed with SAB 20 days after detection of SABU with infective endocarditis and disseminated infection, representing a delay in diagnosis. Following implementation of the intervention, an additional 86 patients with SABU had the result comment displayed in the EMR. Blood cultures were collected in 19 (22.1%) patients, and 2 (2.3%) were positive for S. aureus. There were no significant differences in rates of blood culture collection or SAB after implementation of the EMR result comment. Conclusion Our results show a similar rate of SABU associated SAB to that previously reported in the literature. Delayed diagnosis of SAB in SABU is uncommon but does occur rarely with significant morbidity. The addition of a result comment is a simple and cost-effective intervention; however, evaluation of its efficacy is presently limited by a short follow-up duration. Disclosures All Authors: No reported disclosures

Leptotrichia species are anaerobic, Gram-negative bacilli increasingly recognized as pathogens capable of causing invasive infections such as bloodstream infection (BSI), particularly among immunocompromised patients. However, there is a paucity of data regarding epidemiology, antimicrobial susceptibility, optimal treatment, and clinical outcomes among patients with Leptotrichia bacteremia.

Abstract Background The role of sequential blood culture time to positivity (TTP) as a surrogate marker for bacterial load and as a prognostic indicator in S. aureus bacteremia (SAB) is not well established in the literature. Methods We performed a single healthcare system, multi-site, retrospective review of adult patients with positive blood culture for S. aureus between January 2019 and December 2019. Sequential TTP was defined as the TTP of the first subsequent blood cultures obtained from patients with SAB for at least 24 hours. We adapted the previously described TTP ratio of < 1.5 as the cut-off for study groups. Infective endocarditis (IE) was defined according to modified Duke’s criteria. High-grade bacteremia was defined as the growth of the organism in two or more sets of blood cultures or growth in >50% of all bottles collected. Descriptive, comparative statistics and survival analysis were performed using Python 3 and IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp. Results A total of 602 patients with SAB were identified, and 186 patients who met the study criteria were included. Sixty-nine patients (37%) were female, and the mean age was 63.6 years. Patients with initial TTP < 12 hours had higher 30-day and 90-day mortality than those with initial TTP ≥ 12 hours. Patients with TTP ratio of > 1.5 had higher rates of cardiac prosthetic device (30 [26.1%] vs. 9 [12.7%], p = .03) and high-grade bacteremia (106 [92.2%] vs. 56 [78.9%], p = .01). In univariate analysis, history of myocardial infarction, cardiac prosthetic device, and findings of high-grade bacteremia and native valve vegetation in echocardiogram were significant predictors for a TTP ratio of < 1.5. In multivariate analysis, native valve vegetation (OR 2.4; 95% CI 1.2-4.84), and high-grade bacteremia (OR, 0.3; 95% CI, 0.13- 0.77) were independent predictors (Table 1 and 2). No differences in 30- day or 90-day survival based on the TTP ratio were seen (Figure 1). Figure 1.Kaplan-Meier (KM) curves and log rank test results based on time to positivity (TTP) of initial blood cultures and TTP ratio of sequential to initial blood culture The X-axis represents the days elapsed from the initial blood culture collection. Number of patients at risk and events are given below the x-axis for each group. 30-day and 90-day survival rates were significantly lower in patients with initial TTP of < 12 hours compared with those with ≥ 12 hours. There were no statistically significant differences in survival based on TTP ratio. Conclusion In patients with SAB, a second TTP to first TPP ratio of > 1.5 was associated with higher rates of presence of the cardiac prosthetic device and high-grade bacteremia. Initial TTP < 12 hours was associated with lower survival; however sequential TTP ratio didn’t predict mortality. Disclosures All Authors: No reported disclosures.