scholarly journals 21. Current and Nadir CD4+ Counts Are Associated with Heplisav-B Seroprotection Rates in People with HIV

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S33-S35
Author(s):  
Samuel Schnittman ◽  
Roland Zepf ◽  
Jennifer Cocohoba ◽  
David Sears
Keyword(s):  
Care Center ◽  
Tertiary Care ◽  
Solid Organ Transplantation ◽  
Decompensated Cirrhosis ◽  
Solid Organ ◽  
Seroprotection Rate ◽  
Hbv Vaccine ◽  
Cd4 Counts ◽  
Hbv Vaccination ◽  
Immunocompetent Patients

Abstract Background A two-dose hepatitis B (HBV) vaccine with an immunostimulatory adjuvant (HBV-ISS, Heplisav-B), was FDA approved in 2017 for adults 18 years and older. In randomized controlled trials (RCTs), HBV-ISS demonstrated a seroprotection rate (SPR) of 90–95% versus 65–80% for Engerix-B (HBV-Eng). No RCTs, however, included people with HIV (PWH), and the SPR and its predictors in this population are unknown. Methods This retrospective cohort study enrolled PWH ages 18 years and older without current HBV seroprotection at an HIV clinic at a tertiary care center. HBV seroprotection was defined as an anti-HBV surface antibody level >= 10 mIU/mL. Patients without follow-up titers after immunization were excluded. The primary outcome was the SPR, the proportion of patients with HBV seroprotection at any point following the first HBV-ISS vaccination. Results Among the 51 PWH included, 50 received 2 doses of HBV-ISS (1 patient who received 1 dose developed seroprotection) (Table 1). Median time to antibody titer measurement was 11 weeks (IQR 7–19 weeks). Median age was 59 years, 90% were men, and 96% had VL < 200. There were no pregnant or breastfeeding patients. The SPR was 82% (42/51) in the cohort, and 86% (38/44) when patients with significant non-HIV immunosuppression (decompensated cirrhosis, solid organ transplantation, active chemotherapy) were excluded. There were no significant differences in SPR based on age, sex, BMI, diabetes mellitus, chronic kidney disease, history of remote anti-HBV surface or core antibody positivity, or prior HBV vaccination (Table 2). Lower current and nadir CD4+ counts were associated with progressively lower SPRs (P for trend < 0.0001 for both) (Figure 1). Table 1. Baseline Demographics and Characteristics Table 2. Seroprotection Rate (SPR) by Variables of Interest Figure 1. Seroprotection Rate (SPR) by Current and Nadir CD4+ Count Conclusion The SPR from HBV-ISS in PWH appears comparable to the immunocompetent patients included in RCTs, especially when patients with significant non-HIV immunosuppression are excluded. The SPR demonstrated in this single-arm, retrospective study was higher than that of HBV-Eng in immunocompetent patients, and consideration should be given to establishing HBV-ISS as first-line HBV vaccination in PWH. Finally, SPR is significantly reduced in those with lower current and nadir CD4+ counts. Further research on the effectiveness of a repeat vaccination series or higher dosing in these subgroups is needed. Disclosures Jennifer Cocohoba, PharmD, AAHIVP, BCPS, Viiv (Grant/Research Support)

scholarly journals LO66: Solid organ donation from the emergency department: A death review

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S31-S32
Author(s):  
J. McCallum ◽  
R. Yip ◽  
S. Dhanani ◽  
I. Stiell
Keyword(s):  
Emergency Department ◽  
Organ Donation ◽  
Primary Outcome ◽  
Organ Procurement ◽  
Care Center ◽  
Demographic Data ◽  
Tertiary Care ◽  
Solid Organ ◽  
Organ Donors ◽  
Organ Procurement Organization

Introduction: A significant gap exists between the number of people waiting for an organ and donors. There are currently 1,628 people awaiting organ donation in Ontario alone. In 2018 to date, 310 donors have donated 858 organs. The purpose of this study was to determine whether there were missed donors in the Emergency Department (ED) and by what percent those missed donors would increase organ donation overall. Methods: This was a health records and organ donation database review of all patients who died in the ED at a large academic tertiary care center with 2 campuses and 160,000 visits per year. Patients were included from November 1, 2014 – October 31, 2017. We collected data on demographics, cause of death, and suitability for organ donation. Data was cross-referenced between hospital records and the provincial organ procurement organization called Trillium Gift of Life Network (TGLN) to determine whether patients were appropriately referred for consideration of donation in a timely manner. Potential missed donors were manually screened for suitability according to TGLN criteria. We calculated simple descriptive statistics for demographic data and the primary outcome. The primary outcome was percentage of potential organ donors missed in the Emergency Department (ED). Results: There were 606 deaths in the ED from November 1, 2014 – October 31, 2017. Patients were an average of 71 years old, 353 (58%) were male, and 75 (12%) died of a traumatic cause. TGLN was not contacted in 12 (2%) of cases. During this period there were two donors from the ED and 92 from the ICU. There were ten missed potential donors. They were an average of 67 years, 7 (70%) were male, and 2 (20%) died of a traumatic cause. In all ten cases, patients had withdrawal of life sustaining measures for medical futility prior to TGLN being contacted for consideration of donation. There could have been an addition seven liver, six pancreatic islet, four small bowel, and seven kidney donors. The ten missed ED donors could have increased total donors by 11%. Conclusion: The ED is a significant source of missed organ donors. In all cases of missed organ donation, patients had withdrawal of life sustaining measures prior to TGLN being called. In the future, it is essential that all patients have an organ procurement organization such as TGLN called prior to withdrawal of life sustaining measures to ensure that no opportunity for consideration of organ donation is missed.

Profile of Acute Kidney Injury in Patients with Decompensated Cirrhosis at a Tertiary-Care Center in Uttarakhand, India

2019 ◽  
Vol 38 (4) ◽  
pp. 335-343
Author(s):  
Manjot S. Arora ◽  
Reshma Kaushik ◽  
Shahbaj Ahmad ◽  
Rajeev Mohan Kaushik
Keyword(s):  
Acute Kidney Injury ◽  
Care Center ◽  
Tertiary Care ◽  
Kidney Injury ◽  
International Normalized Ratio ◽  
Meld Score ◽  
Decompensated Cirrhosis ◽  
Total Leucocyte Count ◽  
Bacterial Peritonitis ◽  
Ctp Score

Objectives: To study the clinical profile and predictors of acute kidney injury (AKI) in patients with decompensated cirrhosis. Materials and Methods: This observational study was conducted at Himalayan Institute of Medical Sciences, Dehradun, India, on 175 consecutive patients with decompensated cirrhosis. Patients were studied for AKI as per International Club of Ascites-AKI criteria. Results: The prevalence of AKI was 40.6%, with prerenal AKI 67.6%, hepatorenal syndrome (HRS) 23.8%, intrinsic renal AKI 7%, and postrenal AKI 1.4%. Mean arterial pressure (MAP), platelet count, and serum albumin were significantly lower and total leucocyte count (TLC), blood urea nitrogen, serum creatinine (SCr), total bilirubin, aspartate aminotransferase, international normalized ratio, Child-Turcotte-Pugh (CTP) score, and model for end-stage liver disease (MELD) score higher in cirrhosis patients with AKI than without AKI (p < 0.05 each). MAP, hemoglobin, TLC, and SCr were significantly different in various types of AKI (p < 0.05 each). AKI had a significant association with CTP score, alcohol, spontaneous bacterial peritonitis (SBP), sepsis, and shock (p < 0.05 each). Type of AKI had significant association with SBP, sepsis, and shock (p < 0.05 each). Mortality occurred in 33.8% patients with AKI with 64.7% mortality in patients with HRS. Outcome had significant association with AKI, stage and type of AKI (p < 0.05 each). Multivariate analysis showed SBP, sepsis, and shock as independent predictors of AKI (p < 0.05 each). Conclusions: AKI occurred commonly in patients with decompensated cirrhosis. Prerenal AKI and HRS were the most common types of AKI. SBP, sepsis, and shock were important predictors of AKI.

scholarly journals 1696. Epidemiology, Clinical Characteristics and Outcomes of Invasive Aspergillosis in a Tertiary Care Hospital in Mexico

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S621-S621
Author(s):  
Carla Marina Román-Montes ◽  
María F Gonzalez-Lara ◽  
Alfredo Ponce de Leon ◽  
Maria O Valenzuela-Almada ◽  
Andrea Rangel-Cordero
Keyword(s):  
Liver Failure ◽  
Invasive Aspergillosis ◽  
Clinical Characteristics ◽  
Care Center ◽  
Tertiary Care ◽  
Solid Organ ◽  
Cell Transplant ◽  
Care Hospital ◽  
Tertiary Care Center ◽  
Eortc Criteria

Abstract Background Invasive aspergillosis is an important cause of life-threatening infection in immunocompromised patients. The objective was to describe the epidemiology, clinical characteristics, and outcome of patients with invasive aspergillosis (IA) in a tertiary care center in Mexico. Methods A laboratory-based survey was done to identify patients with positive Aspergillus culture or galactomannan from 2014 to 2018. The medical records were reviewed to include patients with proven and probable IA, according to the EORTC criteria. Descriptive analysis of clinical characteristics and risk factors for 6-week mortality was made through X2, T-test or Mann–Whitney test. A multivariate logistic regression model including variables with a P-value of <0.2 in univariate analysis was made. Results 240 cases of IA were identified: 193 (80%) probable, 27 (11%) proven, and 20 (8.3%) not meeting the EORTC criteria but considered infection. 53% were male, median age was 44 years (IQR 28–58), 78 (32.5%) had acute leukemia (AL), 42 (17.5%) hematological neoplasia, 29 (12%) hematopoietic stem-cell transplant (HSCT), 25 (10.4%) solid-organ transplant and 44 (18.3%) autoimmune diseases, 17.5% patients with AL underwent induction remission chemotherapy of which 31% received antifungal prophylaxis. Among patients with IA, 183 (82%) had a positive galactomannan and 109 (45%) had a culture with Aspergillus. Eleven had > 1 species: 55/120 (46%) were A. fumigatus, 18 (15%) A. niger and 18 (15%) A. flavus. Pulmonary disease occurred in 214 (89%). 212 patients (88%) received antifungal treatment with a median duration of 42 days (IQR 20–42). 129 (61%) received voriconazole (VRC), 20 (8.3%) Amphotericin B and 20(8.3%) were randomized to a posaconazole vs. VRC trial. Six-week mortality was 35% (n = 85). Lymphopenia (OR 3.6; 95% CI 1.4–9.0), liver failure (OR 3.3; 95% CI 1.7–6.5) and older age (OR 1.03; 95% CI 1.01–1.05) (marginally) were independently associated with increased 6-week mortality. Conclusion 240 patients with IA were identified in a 5-year period in a tertiary care center. Most had hematological neoplasias and low prevalence of antimold prophylaxis due to economical reasons. Six-week mortality was 35%, nonsurvivors had liver failure and lymphopenia more often. Increased awareness to prevent IA is needed. Disclosures All authors: No reported disclosures.

Filamentous Fungi in a Tertiary Care Hospital Environmental Surveillance and Susceptibility to Antifungal Drugs

2007 ◽  
Vol 28 (1) ◽  
pp. 60-67 ◽  
Author(s):  
Paraskevi Panagopoulou ◽  
Joanna Filioti ◽  
Evangelia Farmaki ◽  
Avgi Maloukou ◽  
Emmanuel Roilides
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Organ Transplantation ◽  
Filamentous Fungi ◽  
Tap Water ◽  
Tertiary Care ◽  
Solid Organ Transplantation ◽  
Pediatric Intensive Care ◽  
Solid Organ ◽  
Colony Forming Units

Objective.To evaluate filamentous fungi with respect to environmental load and potential drug resistance in a tertiary care teaching hospital.Design.Monthly survey in 2 buildings of the hospital during a 12-month period.Setting.Hippokration Hospital in Thessaloniki, Greece.Methods.Air, surface, and tap water sampling was performed in 4 departments with high-risk patients. As sampling sites, the solid-organ transplantation department and the hematology department (in the older building) and the pediatric oncology department and the pediatric intensive care unit (in the newer building) were selected.Results.From January to May of 2000, the fungal load in air (FLA) was low, ranging from 0 to 12 colony-forming units (cfu) per m3 in both buildings. During the summer months, when high temperature and humidity predominate, the FLA increased to 4-56 cfu/m3. The fungi commonly recovered from culture of air specimens wereAspergillus niger(25.9%),Aspergillus flavus(17.7%), andAspergillus fumigatus(12.4%). Non-Aspergillusfilamentous fungi, such asZygomycetesandDematiaceousspecies, were also recovered. The pediatric intensive care unit had the lowest mean FLA (7.7 cfu/m3), compared with the pediatric oncology department (8.7 cfu/m3), the solid-organ transplantation department (16.1 cfu/m3), and the hematology department (22.6 cfu/m3). Environmental surfaces were swabbed, and 62.7% of the swab samples cultured yielded filamentous fungi similar to the fungi recovered from air but with low numbers of colony-forming units. Despite vigorous sampling, culture of tap water yielded no fungi. The increase in FLA observed during the summer coincided with renovation in the building that housed the solid-organ transplantation and hematology departments. All 54Aspergillusair isolates randomly selected exhibited relatively low minimum inhibitory or effective concentrations for amphotericin B, itraconazole, voriconazole, posaconazole, micafungin, and anidulafungin.Conclusion.Air and surface fungal loads may vary in different departments of the same hospital, especially during months when the temperature and humidity are high. EnvironmentalAspergillusisolates are characterized by lack of resistance to clinically important antifungal agents.

scholarly journals Impact of Bacterial Translocation on Sarcopenia in Patients with Decompensated Cirrhosis

Nutrients ◽  
2019 ◽  
Vol 11 (10) ◽  
pp. 2379 ◽  
Author(s):  
Tsien ◽  
Antonova ◽  
Such ◽  
Garcia-Martinez ◽  
Wong
Keyword(s):  
Chronic Inflammation ◽  
Bacterial Translocation ◽  
Hospital Admissions ◽  
Nutritional Assessment ◽  
Care Center ◽  
Tertiary Care ◽  
Caloric Intake ◽  
Refractory Ascites ◽  
Decompensated Cirrhosis ◽  
Bacterial Dna

Advanced liver disease is associated with a persistent inflammatory state, derived from abnormal bacterial translocation from the gut, which may contribute to the development of sarcopenia in cirrhosis. We aim to document the association of chronic inflammation and bacterial translocation with the presence of sarcopenia in cirrhosis. We prospectively followed cirrhotic patients aged 18–70 years with medically refractory ascites at a single tertiary care center in Toronto, Canada. The baseline data included patient demographic variables, the presence of bacterial DNA in serum/ascitic fluid, systemic inflammatory response syndrome (SIRS) status, and nutritional assessment. Thirty-one patients were enrolled, 18 (58.1%) were sarcopenic, 9 (29%) had bacterial DNA in serum and ascites fluid. The mean MELD score was 11.5 ± 4.0 (6–23). Sarcopenic and non-sarcopenic patients did not differ significantly in their baseline MELD scores, caloric intake, resting energy expenditure, the incidence of bacterial translocation, or SIRS. While sarcopenia was not linked to increased hospital admissions or death, it was strongly associated with increased episodes of acute kidney injury (3 vs. 0, p = 0.05). This pilot study did not demonstrate an association between sarcopenia and SIRS or bacterial translocation. These results should be confirmed in future larger studies, encompassing a greater number of chronic inflammation events and quantifying levels of bacterial DNA.

Positive Cultures of Organ Preservation Fluid Predict Postoperative Infections in Solid Organ Transplantation Recipients

2012 ◽  
Vol 33 (7) ◽  
pp. 672-680 ◽  
Author(s):  
Cedric P. Yansouni ◽  
Nandini Dendukuri ◽  
Guoyuan Liu ◽  
Myriam Fernandez ◽  
Charles Frenette ◽  
...  
Keyword(s):  
High Risk ◽  
Organ Transplantation ◽  
Organ Preservation ◽  
Bacterial Infections ◽  
Normal Skin ◽  
Tertiary Care ◽  
Solid Organ Transplantation ◽  
Solid Organ ◽  
Care Hospital ◽  
Skin Flora

Objective.The significance of positive cultures of organ preservation fluid (OPF) in solid organ transplantation is not known. We sought to describe the microbiology and define the clinical impact of positive OPF cultures.Design.Retrospective cohort study.Setting.Tertiary care hospital.Patients.A consecutive sample of all solid organ transplantations at our center between July 2006 and January 2009 was reviewed. A total of 331 allografts (185 kidneys, 104 livers, 31 pancreases, and 11 hearts) met the inclusion criterion of having OPF cultures taken from the transplanted allograft.Methods.Organisms recovered from OPF were classified as high or low risk according to their virulence. Clinical outcomes were compared between recipients of organs with positive OPF cultures and recipients of organs with negative OPF cultures.Results.OPF cultures were positive in 62.2% of allografts and yielded high-risk organisms in 17.8%. Normal skin flora constituted the majority of positive OPF cultures, while Enterobacteriaceae spp. andStaphylococcus aureusmade up the majority of high-risk organisms. Recipients of allografts with positive OPF cultures developed more frequent bacterial infections, regardless of allograft type (relative risk, 2.39; 95% confidence interval [CI], 1.61–3.54). Moreover, isolation of a given organism in OPF samples was associated with the development of a clinical infection with the same organism, regardless of allograft type.Conclusions.Positive cultures of OPF are common events in solid organ transplantation, frequently involve high-risk organisms, and are associated with the development of postoperative clinical bacterial infections. Further study is required to determine the optimal strategies for their prevention and management.

scholarly journals 1705. Clinical Characteristics and Outcomes of Cryptococcosis in a Tertiary Care Center in Kentucky, 2005 to 2017

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S624-S625
Author(s):  
Mahesh Bhatt ◽  
Julie A Ribes ◽  
Vaneet Arora ◽  
Thein Myint
Keyword(s):  
Liver Disease ◽  
Cryptococcal Meningitis ◽  
Medical Center ◽  
Care Center ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
Organ Transplant ◽  
Positive Culture ◽  
Solid Organ ◽  
India Ink

Abstract Background Cryptococcosis is an invasive fungal infection that causes pneumonia and extrapulmonary infection. This study explores its presentations, diagnostic tests, and outcome in different groups over a 12-year period at an academic medical center. Methods This was a retrospective study of the patients treated at University of Kentucky HealthCare from October 16, 2005 to October 15, 2017. Inclusion criteria were positive cryptococcal antigen (Ag), positive culture, or presence of yeast morphologically consistent with Cryptococcus on cyto- or histopathology. Patients were divided into HIV-infected, solid-organ transplant (SOT) recipients, and non-HIV/non-transplant groups. Cryptococcal meningitis comprised of either positive CSF Ag, culture, cytology or histopathology. Results A total of 114 patients were identified; 23 HIV-infected, 11 SOT recipients and 80 non-HIV/non-transplant patients (Table 1). Cryptococcus neoformans was the most common yeast isolated (91.8%). Cryptococcal meningitis was seen in 56% of total patients whereas 27% had isolated cryptococcal pneumonia (P < 0.01). Blood cultures and serum Ag were positive in 34% and 70%, respectively. Only 8.7% of HIV-infected patients had isolated pulmonary cryptococcosis compared with 36.4% in SOT recipients (P < 0.01). In patients with cryptococcal meningitis, abnormal CSF cell count, protein, or glucose was noted in 85.3%; India ink was positive in 61.3% and CSF culture was positive in 73.4% (Table 2, Figure 1). CSF cryptococcal Ag was detected in 95.6% cases if CSF cultures were positive, whereas serum Ag was positive in only 85.1% of meningitis cases. Mortality was seen in 48.6% (17/35) of patients with cirrhosis/liver disease, compared with 21.5% (17/79) of non-cirrhosis/liver disease (P = 0.003). Transplant group had 54.5% mortality compared with 26.1% in HIV group (P = 0.016). Conclusion Cryptococcal meningitis was the most common presentation for cryptococcal disease in all three groups. Isolated pulmonary disease was least common in the HIV-infected group. Inpatient mortality rate was higher in patients with cirrhosis/liver disease and transplant group compared with those without cirrhosis/liver disease and HIV group, respectively. It is imperative to rule out meningitis in immunosuppressed patients with cryptococcal pneumonia. Disclosures All authors: No reported disclosures.

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