Drug Use Research Articles

P-1410. Oral Antimicrobial Therapy Offers in Hospitalized Persons Who Inject Drugs who Elect for Self-directed Discharge

Abstract Background Hospitalized Persons Who Inject Drugs (PWID) who elect for self-directed discharge (SDD) are at an increased risk for poor infection outcomes, but there is limited guidance for infection management in this population. National PWID management guidelines suggest considering oral antimicrobial therapy offers (OATO) as soon as patients are clinically stable to avoid lack of antibiotic therapy at discharge. The study purpose is to evaluate infection management in PWID who elect for SDD and to identify characteristics associated with OATO. Variables Associated with Oral Antimicrobial Offers at Self-directed Discharge Methods Retrospective cohort of hospitalized adult PWID with an injection drug use (IDU)-related infection who elected for SDD between 1/1/14-1/31/24 at Henry Ford Health in Michigan. Patients were excluded if they were hospitalized for < 24-hours or if antimicrobial treatment was completed prior to SDD. The primary outcome was the proportion of patients with OATO at or prior to SDD. Secondary outcomes at 30-days included retreatment, infection-related readmission, and all-cause mortality. Results 150 patients were included; 55 (37%) were OATO patients, 95 (63%) did not receive an offer. Most patients were white (118, 79%), had prior SDD (90, 60%), and were a median (IQR) age of 34 (30-44) years. Skin infections were most common (81, 54%). Patients that received a source control procedure (27 (49%) vs. 31 (33%), P=0.05) or care from a provider ≤10 years from terminal training (49 [89%] vs. 70 [74%], P=0.04) were more likely to receive an OATO. Patient outcomes were not different between the OATO and no offer groups: infection retreatment 19 (34%) vs. 32 (34%); infection-related readmission 14 (25%) vs. 31 (33%); and all-cause mortality 1 (2%) vs. 3 (3%). Characteristics associated with OATO were prescribing or continuing medications for opioid use disorder during hospitalization, infection source control, and care from providers ≤10 years post-terminal training; infectious diseases consultation had an opposite association (Table 1). Conclusion Most hospitalized PWID with IDU-related infections with SDD did not receive an OATO. Early career providers more commonly offered oral antimicrobials in PWID with less complicated infection types. Standardizing OATO in PWID at risk for SDD should be considered as a future direction to improve health outcomes. Disclosures Rachel M. Kenney, PharmD, BCIDP, Medtronic Inc: Spouse is an employee, stockholder Dana M. Parke, MA, Pfizer Global Medical Grants & Global Bridges at Mayo Clinic (grant # 70973735): Grant/Research Support|The Kresge Foundation: Grant/Research Support

P-929. Identification and Treatment Outcomes of Patients with Infective Endocarditis Coinfected with Hepatitis C Virus

Abstract Background Patients with infective endocarditis (IE) often have co-morbid injection substance use and are at risk for infection with hepatitis C virus (HCV). As of 2023, only 10% of patients who inject drugs have been treated for HCV in the United States. Low rates of treatment may reflect the logistical challenges associated with HCV therapy. To improve access to treatment for patients with IE and HCV, we developed an interdisciplinary collaboration between pharmacy and clinical infectious diseases (ID) providers. Methods The University of Kentucky (UK) implemented a cardiovascular ID consult service in September 2021. The service including physicians, advanced practice providers, a pharmacist and nurse. The consult team worked with UK Healthcare specialty pharmacy to create a pathway connecting patients with IE and HCV to treatment and outpatient follow-up. Regimens included either glecaprevir/pibrentasvir for 8 weeks or sofosbuvir/velpatasvir for 12 weeks. IRB approval was obtained from UK. Study investigators then retrospectively reviewed the endocarditis team registry to identify patients referred for HCV treatment and collect demographic and outcomes related data. Results Between September 2021 and April 2024, 64 patients with IE and HCV who were referred for expedited treatment were identified. The mean age was 37.9 years and 40.6% were female. Sixty-two patients had recent injection drug use. Only 1 was treatment experienced and 51.6% had HCV genotype 1A. Seventy-five percent (48) started treatment and 57.8% were prescribed sofosbuvir/velpatasvir. Thirty-three of 48 (68.8%) patients who started treatment completed therapy. Of the 15 patients who did not complete treatment,10 were lost to follow-up and 3 had adverse drug reactions. Twenty-two of 48 had viral loads collected for SVR12 and 20 were negative. Conclusion Using a standardized, interdisciplinary approach, 31.3% of patients with IE and HCV completed treatment with documented evidence of SVR12. An additional 17% of patients completed therapy but were unable to complete testing for SVR12. Loss to follow-up remains the primary barrier to starting therapy and accurately recording treatment outcomes. Future efforts should focus on ease of access to treatment and follow-up. Disclosures All Authors: No reported disclosures

P-1102. Real-World Effectiveness of Dalbavancin for Invasive Gram-Positive Bacterial Infections

Abstract Background Emerging data suggest dalbavancin (DAL) may be used in complicated infections including bacteremia, prosthetic joints, osteomyelitis, and endovascular infections. The purpose of this study was to evaluate the real-world effectiveness of DAL for the treatment of invasive gram-positive infections (GPIs). Methods This multicenter, retrospective cohort study included adult patients receiving DAL for treatment of confirmed/presumed invasive GPI between February 2021 and December 2023. Invasive infections included those requiring ≥ 4 weeks of therapy. Patients were excluded if they received DAL for chronic suppression. The intention to treat (ITT) population included patients who received ≥ 1 DAL dose; the per protocol (PP) population received ≥ 2 doses within 7 days of expected administration dates. The primary outcome was clinical failure in the PP group at 90 days post-treatment. Secondary outcomes were logistical failures, clinical failures, and treatment-emergent adverse events in the ITT group at 90 days post-treatment. Results The ITT population included 150 patients (mean age 50.2 years, 65% male, 35% obese, 41% illicit drug use); the PP population included 107 patients. The most common infectious syndrome was osteomyelitis (63.3%, 95/150); the most common pathogens were MRSA (38%, 57/150) and MSSA (37%, 44/150). The most common dosing regimen was 1500 mg on day 1, followed by 1500 mg on day 8 (90%, 96/150). Among the PP population with follow-up, 22% (19/87) experienced clinical failure at 90 days post-treatment. No factors were significantly associated with clinical failure. Logistical failure occurred in 17% (26/150). Results of univariate regression analyses showed receipt of first dose at an infusion center vs. inpatient setting significantly increased logistical failure (OR 4.53, 95% CI 1.62 – 16.17; P = 0.008) while blood-based infectious syndromes significantly decreased logistical failure (OR 0.26, 95% CI 0.06 – 0.82; P = 0.038). Receipt of vancomycin within 6 weeks of DAL significantly increased risk of acute kidney injury (OR 4.12, 95% CI 1.20 – 14.68; P = 0.024). Conclusion Dalbavancin is a safe and effective treatment option for invasive GPIs; however there are modifiable risk factors associated with secondary outcomes of logistical failure and toxicity. Disclosures Julie Ann Justo, PharmD, MS, FIDSA, BCPS, Shionogi: Advisor/Consultant Bruce M. Jones, Pharm.D., FIDSA, BCPS, AbbVie: Advisor/Consultant|AbbVie: Honoraria|Ferring: Honoraria|Innoviva: Honoraria|Paratek: Honoraria Bryan White, PharmD, BCPS, BCIDP, Melinta: Advisor/Consultant|Shionogi: Grant/Research Support Joseph Sassine, MD, Ansun BioPharma: Grant/Research Support|Cidara Therapeutics: Grant/Research Support|Community Infusion Solutions: Grant/Research Support|F2G: Grant/Research Support|Shionogi: Grant/Research Support

P-2205. The impact of pharmacist-driven transitions of care protocol in the treatment of hepatitis C infection

Abstract Background Treatment for hepatitis C virus (HCV) can be delayed due to extensive documentation needed for insurance approval. Pharmacists can play critical roles in facilitating treatment approval, but the evidence regarding pharmacist-driven transitions of care protocols to facilitate HCV treatment approval and therapy initiation is limited. Therefore, we evaluated the feasibility and effectiveness of a pharmacist-driven transitions of care protocol for HCV treatment. Methods This was a non-randomized, prospective, single-center study at a large academic medical center. Adult patients admitted to the Infectious Diseases (ID) primary team were screened for HCV between 09/01/23 and 02/29/24. Exclusion criteria included decompensated cirrhosis, hepatocellular carcinoma, pregnancy/breastfeeding, current/prior HCV treatment, and transplant evaluation/receipt. Patients with HCV infection were offered treatment upon discharge at the outpatient ID clinic. Inpatient ID pharmacists performed pre-treatment workup and coordinated handoff to outpatient ID specialty pharmacists. Endpoints included treatment initiation and completion rates, time from screening to treatment initiation, and time from discharge to treatment initiation. Results Of 180 patients screened during the study, 13 (7%) were eligible for HCV treatment. The median age was 43 years, and 69% were male. More than 90% of patients were Caucasian and had a history of substance use disorder/injection drug use. Five patients (38%) were uninsured. Of the 13 patients, two had treatment approved, and one completed therapy. The remaining patients were lost to follow-up. The median times from screening to treatment initiation and from discharge to treatment initiation were 64 and 62 days, respectively. Conclusion This pharmacist-driven protocol resulted in inpatient screening of a large number of patients over six months and successfully identified 13 patients eligible to begin hepatitis C treatment after discharge. This is a novel approach to engaging patients in hepatitis C care. Despite facilitating transitions of care for these patients, the clinic no-show rate was unexpectedly high. Additional measures may be required to optimize treatment outcomes for this patient population. Disclosures All Authors: No reported disclosures

P-928. The Second Heart Program: A Peer-focused, Multidisciplinary Harm Reduction Intervention to Improve Outcomes for People Who Inject Drugs After Admission for Infective Endocarditis

Abstract Background Infective endocarditis (IE) is a severe and highly prevalent injection-related infection among people who inject drugs (PWID). IE is estimated to account for 5-10% of deaths among PWID. The long-term outcomes among PWID with infective endocarditis are poor, with 5-year mortality rates over 50%. Most long-term complications are related to ongoing drug use (re-infection). However, most PWID with IE are not offered treatment for their underlying substance use disorder while in hospital. The Second Heart (SH) program is the first interdisciplinary team in Canada designed specifically to meet the unique needs of PWID with IE and which transitions with patients from the hospital into the community. The six components of the SH team are: peer support worker, systems navigator, addiction medicine physician, infectious disease physician, cardiologist/cardiac surgeon, and family physician. Methods The Second Heart Program was a non-randomized clinical trial enrolling PWID with infective endocarditis at three tertiary care hospitals in Hamilton. It was a mixed methods study utilizing both qualitative and quantitative methods. Five quantitative surveys, two qualitative interviews, and chart review were completed over the 12-month study period. Results Participants felt that their involvement with SH supported their physical, mental, and social recovery from IE, improved their trust in the healthcare system, and increased their engagement with their care. Out of 20 enrolled participants, all were consulted with an addictions medicine provider during initial hospitalization, 16/20 were set up with a family doctor post-discharge, 9/20 completed their 1-month follow-up survey, one participant died within 12 months of enrolment, and 12/19 completed their 12-month follow-up survey. Conclusion The early success in this pilot project has led to the successful application of funding for an expanded version of the multidisciplinary intervention for people who have any injection-related infection, including Hepatitis and HIV. Disclosures All Authors: No reported disclosures

P-437. Prevalence of Hepatitis B Co-infection in People with HIV by Birth Cohort– Potential Impact of HBV Vaccination Availability

Abstract Background Due to shared modes of transmission, people with HIV (PWH) have disproportionately high rates of hepatitis B virus (HBV) infection. Availability of the HBV vaccine in the US since 1982 and recommendations for universal and catch-up vaccination of infants and children since the 1990s may be associated with lower HBV prevalence among PWH born after 1980. To study how HBV vaccination availability impacted co-infection rates in PWH, we compared the prevalence of active HBV infection at entry into an HIV cohort by birth year groups.Table 1.Baseline characteristics of patients by birth cohort Methods We included PWH from the Johns Hopkins HIV Clinical Cohort who had HBsAg testing within one year of cohort entry. HBV infection was defined as a positive HBsAg test. Patients were categorized into birth cohorts of 1940-1959, 1960-1979 and 1980-1999 and then further dichotomized to pre- and post-1980 cohorts. Descriptive statistics were used to assess HBsAg prevalence by birth cohort and HIV infection risk factors [men who have sex with men (MSM) and injection drug use (IDU)]. Log binomial regression was used to assess the association of birth cohort (pre-1980 vs post-1980) with HBsAg positivity adjusting for race/ethnicity, HIV infection risk factors (MSM, IDU), baseline viral load, and year of and age at cohort entry.Figure 1.Timeline of HBV vaccination recommendations by the Advisory Committee of Immunization Practices and the corresponding age of patients in pre- and post-1980 birth cohort Results Of the 5608 PWH enrolled in the cohort between 1993 and 2023, 77% were Black, 30% were MSM, and 39% had a history of IDU. Mean age at cohort entry was 39.6 (9.6). Overall HBV prevalence was 6.7% and prevalence by birth cohort was 6.2% (1940-1959), 7.8% (1960-1979) and 2.5% (1980-1999). Among MSM, HBV prevalence was higher at 10.6% (1940-1959), 11.4% (1960-1979) and 2.9% (1980-1999) compared to non-MSM at 5.0% (1940-1959), 6.3% (1960-1979) and 1.8% (1980-1999). HBV prevalence was similar in IDU and non-IDU groups. The risk of HBV infection was significantly lower in the post-1980 birth cohort vs the pre-1980 birth cohort (adjusted RR= 0.17; 95% CI 0.08, 0.34; adjusted RD= -0.06; 95% CI -0.07, -0.04). Conclusion PWH born after 1980 had a lower risk of HBV co-infection than PWH born before 1980, highlighting the potential impact of HBV vaccination on HBV prevalence in PWH. PWH identifying as MSM continue to have disproportionately high HBV prevalence. Additional efforts are needed to implement universal HBV vaccination of adults as recommended in 2021. Disclosures Mark S. Sulkowski, MD, AbbVie: Advisor/Consultant|Aligos Therapeutics: Advisor/Consultant|Gilead: Advisor/Consultant|GSK: Advisor/Consultant|GSK: Grant/Research Support|Janssen: Grant/Research Support|Precision Biosciences: Advisor/Consultant|Vir: Grant/Research Support|Virion: Advisor/Consultant Oluwaseun Falade-Nwulia, MBBS ,MPH, Abbvie Inc: Grant/Research Support|Gilead Sciences: Advisor/Consultant

P-526. A Low Cost, Low Technology Intervention for Hospitalized Patients Who Inject Drugs is Feasible for Increasing Evidence-Based Addiction Care but HIV PrEP Uptake Remains Limited

Abstract Background Approximately 14% of new HIV cases in Alabama are from injection drug use, and this does not include HIV transmission from substance use related behaviors such as transactional sex. Hospitalized patients who inject drugs (PWID) present an opportunity to provide addiction treatment and HIV pre-exposure prophylaxis (PrEP). The objective of this study is to assess the feasibility and acceptability of novel, low barrier interventions aimed at increasing uptake of medications for opioid use disorders (MOUD) and PrEP in PWID. Methods In this prospective study, 60 hospitalized PWID who were HIV negative and receiving care at UAB Hospital (from October 2022 to February 2024) were randomized in a two-by-two factorial design to 4 arms: a smartphrase summary of evidence-based care added in the medical record (n=15), an outpatient peer recovery coach intervention (n=15), both (n=15), or standard of care (n=15). Patients completed standardized surveys on substance use, HIV risk behaviors, and their preferences for MOUD and PrEP at baseline. Exit surveys were conducted by phone to assess utilization of addiction treatment, PrEP services, and peer coaching. Feasibility was primarily defined by the ability to recruit hospitalized PWID and retain them in the study to determine post-discharge clinical outcomes, but feasibility was also defined by appropriate use of smartphrase and access and engagement with the peer. We assessed preliminary effectiveness by including utilization of MOUD, PrEP, and the peer coach. Results In the groups who received the smartphrase with or without the peer (n=30), 70% had documentation of the smartphrase in their provider’s consult note, and 90% had a MOUD referenced in their treatment plan. In the groups who received a peer with or without the smartphrase (n=30), 100% were contacted, and 90% had MOUD referenced in treatment plan. However, PrEP was not provided on discharge for any patients in the study. Conclusion In this pilot study of two low barrier interventions for PWID, we found that both interventions are feasible and acceptable, but HIV prevention with PrEP is still lacking. Future directions are to expand the sample size to test if these interventions will increase MOUD and PrEP uptake in a Southern cohort of PWID. Disclosures All Authors: No reported disclosures

P-1027. Socioeconomic Factors Associated with Adverse Outcomes in Patients with Candidemia

Abstract Background Candidemia can be a life-threatening disease associated with multiple infectious complications, such as endocarditis and endophthalmitis. With the rise of the opioid epidemic and intravenous drug use, candidemia incidence has increased, particularly among young adult patients. While treatment standards are well-established, data on the impact of socioeconomic factors on patient outcomes is lacking. Here, we aimed to evaluate if candidemia outcomes were associated with various socioeconomic factors. Methods A single-center, retrospective chart review was conducted including all patients with candidemia from 2017 to 2022 at an academic medical center. We collected demographic data, culture results, treatment measures, discharge outcomes, and outcomes at 30 and 90 days. Patient census tract codes were used to evaluate socioeconomic markers from the American Community Survey (2020). Descriptive statistics, Chi-square, and Kruskal-Wallis tests were performed. Results 237 candidemia episodes among 199 patients were included. The mean age was 54 years, 55% were male, 58% were White, and 15% were Latino. Most cases were due to C. albicans (37%), and most patients were treated with micafungin (51%). Patients who did not speak English had a higher hospital mortality (P=0.003), 30-day mortality (P=0.01), and 90-day mortality (P=0.03). Interestingly, patients with a history of substance use disorder (P=0.006) and housing insecurity (P=0.006) were less likely to die inpatient; similar trends were found for 30 and 90-day mortality. Census tract data demonstrated that patients living in areas with more people who do not speak English well were more likely to be readmitted to the hospital within 30 (P=0.02) and 90 (P=0.001) days from discharge Conclusion Non-English-speaking patients and those residing in census tracts with higher unemployment had higher mortality. These findings underscore the importance of considering socioeconomic and demographic factors in clinical management and public health strategies aimed at improving outcomes in Candidemia patients. Further research should explore underlying mechanisms driving such disparities. Disclosures All Authors: No reported disclosures

Caregivers’ self-medication practices for perceived febrile illnesses among under-five children in central river region, the Gambia

Background Drug use for under-five children by their caregivers without professional advice constitutes a public health challenge due to its potential for drug-drug interactions, overdose, and antimicrobial resistance. In the Gambia, there are only a handful of programs that control self-medication despite its harmful effects on children. Self-medication of under-five children has been rarely reported in rural areas of the Gambia. Therefore, we assessed the knowledge, practices, and reasons for the self-medication of under-five children for perceived febrile illnesses by their caregivers in the Central River Region, the Gambia. Methods This cross-sectional study was conducted between September and October 2023 among caregivers (n=406) of under-five children from the Central River Region, The Gambia. A mixed-method approach was used to collect data. Knowledge of childhood febrile illnesses was assessed using 9-item questions. Focus group discussions and In-depth interviews were conducted using question guides. Data were analyzed using descriptive statistics, Chi-square test, and binary logistic regression (α=5%). Qualitative data were analyzed using Atlas Ti. Results The caregivers' mean age (SD) was 31.1±9.6 years and most 330(81.3%) were females. The prevalence of self-medication was 21.43% and 165(40.6%) of the caregivers had good knowledge of childhood febrile illnesses. Respondents who received information from friends (aOR=2.564; p=0.002) and those who got advice from neighbours (aOR=7.008; p=0.011) on childhood febrile illnesses were likelier to self-medicate than those who did not. Long waiting hours, lack of drugs at health facilities, and experience in self-medication were the reasons promoting self-medication in under-five children. Conclusions The prevalence of self-medication among caregivers of under-five children is low, and more than half of them had poor knowledge of childhood febrile illnesses. The practice of self-medication for under-five children was more common among younger caregivers. Caregivers of under-five children should be sensitized on the health implications of self-medication in The Gambia.

P-942. Infective Endocarditis in Pregnancy: a Retrospective Review of Maternal and Neonatal Outcomes

Abstract Background Infective endocarditis (IE) in pregnancy has an annual incidence of 0.006%. As rates of injection drug use increase across the US, there is the likelihood that the rates of pregnant people with IE increases. There is a paucity of data of IE in pregnancy and implications on maternal and neonatal outcomes. The purpose of this retrospective chart review was to describe the maternal outcomes of patients who are pregnant with IE and neonatal outcomes from a tertiary care center with a level 3 neonatal intensive care unit (NICU). Methods 33 patients were identified as having both IE and pregnancy from January 1, 2017, through January 31, 2022; 16 met inclusion criteria. Data was matched to birth records and 10 neonates were included. Maternal outcomes included survival, clinical cure, complications in pregnancy, type of birth and term of childbirth. Neonatal outcomes included survival, need for NICU admission, treatment for neonatal abstinence syndrome (NAS), and complications at birth including social issues. All maternal and neonatal results are reported in figures 1-3. Results All patients had IE of their tricuspid valve, and 1 had concomitant aortic valve infection. None had valvular surgery during pregnancy, and one had valvular surgery after pregnancy. Preeclampsia occurred in 1 patient. 40% of births were preterm, which is higher than the national average of 10.4%; 10% were cesarean births, 90% were vaginal. 70% of neonates required NICU admission and treatment for NAS, and 40% required respiratory support. The average neonatal length of stay was 39.9 days. 6 babies had delayed discharge due to social issues. Conclusion The study demonstrates 100% maternal and neonatal survival, however, conveys significant neonatal morbidity, including need for NICU level of care, increased rates of preterm births, need for treatment for NAS and prolonged hospitalization due to social issues. There are potential health consequences for the neonate, as treatment for NAS has been shown to increase risk for substance use disorder later in life. This study is limited by its small sample size; however, this cohort is one of the larger cohorts to represent this population. Disclosures Madeline King, PharmD, Innoviva: Advisor/Consultant Alexandra Hanretty, PharmD, Abbvie: Advisor/Consultant

P-480. Improving HIV Screening Rates among US Veterans: A Quality Improvement Project

Abstract Background Fifteen percent of the 1.2 million people living with human immunodeficiency virus (HIV) in the United States are unaware of their infection, which increases risk of onward transmission and negative sequalae from untreated HIV. To improve early detection of HIV infection, the US Preventive Services Task Force recommends one-time HIV testing for all adults aged 15 to 65. The goal of this quality improvement project is to understand the rate of HIV testing in US Veterans (USV) who seek care at the Northport Veterans Affairs Medical Center (NVAMC) primary care setting and assess the efficacy of a quality improvement strategy to improve HIV screening rates.Table 1:HIV, HCV, and STI screening rates, and demographic variables identified in Veterans at NVAMC primary care setting.NVAMC, Northport Veterans Affairs Medical Center; HIV, Human Immunodeficiency Virus; HCV, Hepatitis C Virus; STI, Sexually Transmitted Infections; USV, United States Veterans Methods We conducted a prospective study of USV aged 15 to 65 from three Primary Care provider panels at NVAMC. Demographics, sexual history, injection drug use (IDU), prior hepatitis C virus (HCV), and sexually transmitted infection (STI) testing rates were obtained from chart review. USV without prior HIV screening were telephoned to obtain informed HIV testing consent and testing was ordered for USV who agreed. Results We identified 368 USV, with mean age of 60 years. The majority of this cohort were male (n=366, 99.4%) and White (n=262, 72.3%). Seventy-five (20.4%) USV did not have sexual orientation screening charted, no USV were identified as men who have sex with men (MSM), and 4 (1.1%) USV were identified with IDU history. Two hundred twenty (59.8%) USV had received prior HIV testing. Sixty-eight (18.5%) USV with no prior testing gave consent to obtain an HIV test, 29 (42.6%) USV underwent testing and 29 (100%) tested negative for HIV. Prior HCV testing was common (n=262, 71.2%); 2 (0.8%) USV had prior HCV infection and were treated. Sixty-two (16.8%) USV received testing for gonorrhea, 63 (17.1%) for chlamydia, and 138 (37.5%) for syphilis; one USV was identified with chlamydia infection history. We identified patient barriers to HIV testing (refusal, provider outside VA system) and provider factors (testing not offered). Conclusion Implementation of a telephone strategy improved HIV testing rates at NVAMC. HIV screening is cost effective as early identification improves survival due to linkage to care and access to treatment. Consequently, this may prevent forward transmission of HIV. Disclosures All Authors: No reported disclosures

P-862. Hospital administered MOUD is associated with decreased one-year mortality among PWUD admitted with bloodstream infections

Abstract Background Bloodstream infections (BSI) including infective endocarditis (IE) are highly morbid complications of substance use that contribute to the syndemic of invasive bacterial infections in persons who use drugs (PWUD). In this retrospective analysis we evaluated whether inpatient administration of medication for opioid use disorder (MOUD) impacted one-year all-cause mortality and antibiotic adherence in PWUD hospitalized with BSI. Methods We conducted a retrospective cohort study of index admissions for PWUD admitted with IE cases from 2/2020 through 7/2023 and/or BSI from 7/2022 through 7/2023 at Columbia University Irving Medical Center. Patients were included if they 1) Were aged 18-65 years old 2) Had a positive blood culture with an organism known to cause invasive disease and 3) Had documented substance use (opioid and/or stimulant) within the previous 12 months. One-year all-cause mortality was the primary outcome of interest. Administration of MOUD was counted as a treatment exposure only if received for the majority (≥ 50%) of hospitalized days. We defined the primary antibiotic outcome as a percentage of days a patient received standard of care (SOC) treatment compared to the recommended duration in days for their infection. Results Of the 99 patients who met study criteria, the majority were male (69%) with a history of injection drug use (77%). Opioids (79%), cocaine (68%) and methamphetamines (19%) were the most commonly used substances (Table 1). In multivariate logistic regression, hospital administration of MOUD was associated with reduced mortality (aOR 0.14, 0.021 – 0.60, P = 0.017) after adjusting for prosthetic valve endocarditis (Table 2). In sub-analysis of the MOUD group, PWUD who received buprenorphine achieved a higher percentage of SOC antibiotic days (93%, p = 0.011) than either the methadone (61.4%) or no-MOUD (72.9%) groups (Table 3). Conclusion Hospital administration of MOUD was associated with improved survival in PWUD admitted with serious bloodstream infections. Buprenorphine receipt was associated with a greater likelihood of completing SOC antibiotic course than methadone or no MOUD. To our knowledge, this is the first study to demonstrate a survival benefit to hospital administration of MOUD in PWUD during infection-related admission. Disclosures All Authors: No reported disclosures

642. The Role of Electronic Medical Record Automation in Latent Tuberculosis Screening and Treatment in a Large Health System

Abstract Background Valley Medical Center is a tertiary county hospital in San Jose, California that also staffs 12 clinics. Our institution’s Mycobacterial and Refugee Health Clinic is the main referral center for latent tuberculosis (LTBI) and active TB cases in the county. The USPFTF recommends screening for LTBI in asymptomatic adults who are at higher risk. This is challenging in primary care settings where physicians often see a high number of patients within limited time frames. There are many points on the LTBI care cascade (Figure 1) where patients can fall off. In the age of automation, technological tools can be designed to help reduce clinician burden.Figure 1:Latent Tuberculosis Care CascadeSource: California Department of Public Health Tuberculosis Control Branch Methods An EMR tool was engineered to prompt physicians to order a QuantiFERON (QFN) if a patient meets certain criteria: 18 years or older, no prior QFN or TB skin test, and any of the following risk factors: HIV positive, in custody, drug use, homelessness, or non-English primary language (proxy for foreign birth). This EMR tool went live on 8/9/22. Using EMR data-collection tools, a retrospective analysis was done among patients who had a clinical encounter (office visit or telemedicine) between 8/9/21-8/9/22 and 8/9/22-8/9/23 (one year before and after implementation of the tool). We determined the number of patients who were eligible for screening, obtained a QFN, had a positive QFN, initiated, and completed treatment. A 2-sample Z-test was used to assess temporal trends.Table 1:LTBI Care Cascade for Patients Seen by a Primary Care Physician in 8/9/21-8/9/22 and 8/9/22-8/9/23 Results From 8/9/22-8/9/23, 34251 patients were marked eligible for LTBI screening based on the EMR tool (Table 1, Figure 2). The proportion of patients tested for LTBI increased from 45.3% to 81.2% (p-value < 2.2e-16). The proportion of positive LTBI results increased from 8.6% to 12.4% (p-value < 2.2e-16). The number of patients who initiated treatment increased from 545 (40.8%) to 1038 (30%). The number of patients who completed treatment increased from 417 (76.5%) to 770 (74.2%).Figure 2:LTBI Care Cascade for Patients Seen by a Primary Care Physician in 8/9/21-8/9/22 and 8/9/22-8/9/23 Conclusion This study highlights that a low-cost EMR intervention can lead to substantial increases in LTBI screening, and as a result higher treatment completion. EMR automation can also improve accuracy in screening, reflected by the increased proportion of positive QFN results. Future tools involving digital technology can be designed to reduce drop-offs at other points along the LTBI cascade as well. Disclosures All Authors: No reported disclosures

P-819. Epidemiology of Serratia marcescens Bloodstream Infections in a Hospital System in the Southeast U.S

Abstract Background Serratia marcescens (Sm) is an environmental gram-negative bacilli that can cause a variety of serious human infections. Sm is frequently attributed as a hospital acquired infection. However, there is not extensive documentation as to the common etiologies of Serratia bloodstream infections (BSI), frequency of antibiotic resistance, and risk factors for recurrent infection or mortality. Methods We conducted a retrospective chart review of a cohort of patients (pts) ≥ 18 years old with Serratia marcescens BSI from 5/2016 to 10/2022 at our hospital system. Sm BSI was defined as ≥ 1 blood culture positive for Sm. Multidrug resistance was defined according to Centers for Disease Control (CDC) criteria. Patients were assessed for outcomes of recurrence of bacteremia (positive blood culture with same isolate within 3 months of clearance) and 30-day mortality. Results A total of 243 patients had Sm BSI during the study period. The most frequent etiology was central line-associated BSI (38%) followed by skin and soft tissue infection (12%). The majority (96%) of isolates were not multidrug resistant. Most patients had a repeat blood culture (67%), and of these patients, 15% had recurrence of bacteremia. A total of 44 patients (18%) died within 30 days. Echocardiogram was performed in 60% of our patients, with 7 patients diagnosed as having endocarditis or device endocarditis. Current active or history of injection drug use occurred in 7.5% of patients. Conclusion Our retrospective study demonstrates a low burden of antibiotic resistance in Sm at our hospital system. Similar to prior studies, CLABSI is a frequent cause of Sm BSI, and foreign materials/devices are common in patients with Sm BSI. Our patient population has a lower rate of IVDU compared to other studies of Sm BSI, and endocarditis is not common. Further analysis is needed to evaluate treatment regimens and other risk factors for recurrent BSI and mortality. Disclosures All Authors: No reported disclosures

P-2074. Evaluation of Adherence and Access to Booster COVID-19 Vaccination in Persons with HIV

Abstract Background COVID-19 disproportionately effects minority communities. Completion of the primary COVID-19 vaccination series (≥ 2 doses) is recommended for all American adults by the Centers for Disease Control and Prevention. A population with high mortality and morbidity related to COVID-19 is persons with HIV (PWH). The Infectious Diseases Practice (IDP) at University Hospital (UH) has been providing care to PWH for over 30 years, and it was one of the designated COVID-19 vaccination centers early in the pandemic. We compared rates of PWH who receive COVID-19 vaccine (incomplete: < 2, complete: ≥ 2) amongst different demographic factors to better understand subgroups that can benefit from additional messaging to promote vaccine uptake. Methods A retrospective chart review study was conducted at the IDP at UH, Newark. Adult PWH (18-88 years old) who had an office visit to the clinic between January 2021-December 2022 were included. Demographic variables and COVID vaccine count were collected. Results The IDP identified PWH (mean age 52, 75.4% Black, 20.4% Hispanic, 39.5% women) who had either complete (n=1085) or incomplete (n=815) primary vaccine schedules for COVID-19. The most common HIV risk factors were heterosexual contact (52.8%), homosexual contact (28.16%), and injection drug use (8.58%). 54% of patients had a CD4+ count > 499, 87.08% of patients had an HbA1c < 6.4, and 72.68% of patients had an HIV viral load that was undetectable. Notably, PWH who completed the primary vaccination series were more likely to be undetectable (80.6%) years compared to PWH who did not complete their vaccination series (62.1%). Furthermore, PWH who completed the primary vaccination series were more likely to have an HbA1c< 6.4 (83.1%) compared to PWH who did not complete their vaccination series (77.9%). PWH who completed the primary vaccination series were more likely to have a CD4 count > 499 (54.4%) compared to PWH who did not complete their vaccination series (44.4%). Conclusion Patients most at risk of not completing the primary COVID-19 vaccine schedule include PWH who are virally uncontrolled, persons with diabetes, or have a low CD4+ count. This indicates medical adherence should be targeted in such populations to improve their healthcare outcomes. Disclosures Shobha Swaminathan, MD, Viiv Healthcare: Advisor/Consultant

P-948. Three Drugs, Two Pills, One Algorithm: HIV PrEP, PEP, and Treatment Initiation Consolidated Guidelines for Resource Limited and Non-Specialty Settings

Abstract Background Accessing HIV prevention and treatment remains difficult throughout the United States (US). With the shortage of infectious disease physicians and other providers offering HIV prevention and treatment services, increasing the number of clinicians offering HIV Pre-Exposure Prophylaxis (PrEP), HIV Post-Exposure Prophylaxis (PEP), and Test & Treat (T&T) (where individuals testing positive for HIV are rapidly engaged in HIV treatment) is imperative. This project’s goal is to create a consolidated algorithm for HIV treatment and prevention that simplifies care for providers with few resources or limited experience. The 3-2-1 Algorithm The algorithm includes the necessary steps, testing, and result interpretation to provide PrEP, PEP, and T&T services. Guidelines referenced in the making of this algorithm include those published the International Antiviral Society (IAS), the National Institutes of Health (NIH), and The New York State Department of Health AIDS Institute (NYSDOH AI). Methods The algorithm was designed using published HIV care guidelines from multiple clinical bodies and includes PrEP, PEP, and T&T. Only three medications are offered in the algorithm to reduce cost of implementation. The combination of tenofovir disoproxil fumarate with emtricitabine provides low-cost, generic PrEP regardless of gender, pregnancy, or intravenous drug use while also providing the backbone needed for PEP and T&T. Dolutegravir, the third medicine, was chosen for PEP and T&T because of its once daily dosing and approval in pregnancy. The algorithm was tested with US medical students. Students completed an eight-question test unassisted then immediately repeated those questions with the algorithm. Questions included clinical scenarios related to HIV testing, PrEP, PEP, and T&T. Students were recruited by email for the online test. Pearson’s chi-squared compared pre vs post test scores; total score (number of items correct) used Paired Wilcoxon signed rank test. Results 76 students from 13 medical schools completed pre and posttest questions. Correctness increased from 3 of 8 (pretest) to 6 of 8 (posttest) (p=< 0.001). All questions increased in percentage correct with the algorithm. Change in correct responses on PEP, PrEP lab work, need for quantitative RNA with prior injectable PrEP use, and selecting a T&T regimen were all statistically significant. (p=< 0.001) Conclusion This algorithm significantly improved medical students’ ability to accurately answer HIV clinical care questions and has the potential to expand access to HIV prevention and treatment. Further studies are needed to understand the algorithms’ effect in a clinical setting. Disclosures All Authors: No reported disclosures

P-1427. Continuation of HIV and hepatitis C care among refugees migrating from Ukraine - Five Times Ninety project

Abstract Background Five Times Ninety project investigates linkage to care among war refugees living with HIV displaced from Ukraine to Poland.Figure 1.Gender and mode of HIV infection of Ukrainian refugees stratified by time of registering to care in Warsaw Methods Refugees who registered to HIV care in Warsaw were followed according to “Standardized protocol for clinical management and medical data sharing for PLHIV among refugees from Ukraine” developed by WHO/CHIP,EACS, ECEE and ECDC (https://iris.who.int/handle/10665/353083). For each patient who signed informed request data were linked to database at the Public Health Center (PHC) Ministry of Health Ukraine, and sent back on standardized form.Figure 2.Cascade of HIV care of Ukrainian refugees registered to care in Warsaw Results Among 205 refugees who registered to HIV care in Warsaw (5 Mar2022 - 31Aug2023) 202 (98.7%) were linked with PHC database, 121 (59.9%) were female, median age 40.0 (range 18-69, IQR 36.0-46.0), migrating from Central (67; 33.2%), South (65; 32.2%), East (39; 19.3%), West (27; 13.4%) and North (4; 2.0%) Ukraine. Mode of HIV infection was heterosexual in 113 (55.9%), other/unknown in 51 (25.2%), injecting drug use in 28 (13.9%) and MSM in 10 (4.9%) persons. Women and persons who acquired HIV through heterosexual contacts were more likely to migrate earlier, but age structure did not significantly change over time (Figure 1). On 31Dec2023 in total 128 (63.4%) patients remained in care in Warsaw. 189 patients (93.1%) had HIV viral load measured both in Ukraine and Poland, 173 (91.5%) and 155 (82.0%) were undetectable, respectively. This translates into 9.5% loss of ART efficacy during a transition period. These improved over time (Figure 1). Switching of antiretroviral therapy occurred often, yet majority remained on integrase inhibitor (194; 98.0%) and tenofovir (176; 88.9%), Figure 4. 148 persons (73.6%) were tested with HCV serology in Ukraine and 187 (93.0%) in Poland. Of 59 (31.5%) tested positive in Poland, 24 were post-DAA therapy in Ukraine. Of 35 who were tested with PCR in Poland, 10 had undetectable HCV RNA, 25 had detectable HCV RNA of whom 10 already went through DAA therapy, Figure 3.Figure 3.HCV testing and treatment for Ukrainian refugees registered to care in Warsaw Conclusion Standardized protocol proved to be an efficient for medical data exchange. Viral suppression among Ukrainian refugees on ART decreased slightly, but in general remained high and improved with time. Routine HCV screening is a necessity, especially because there are no restrains to DAA treatment access in Poland.Figure 4.Antiretroviral therapy switches among refugees registered to care in Warsaw Disclosures All Authors: No reported disclosures

P-932. Re-classification of Endocarditis Diagnoses in Patients who Inject Drugs using the 2023 Duke-ISCVD Microbiologic Criteria

Abstract Background In 2023, the Duke Criteria for infectious endocarditis (IE) were modified for a second time. Many criteria were adjusted with significant changes to the microbiologic criteria, introduction of new imaging criteria, and greater clarity of predisposing conditions contributing to the IE diagnosis. The changes to the microbiological criteria included expanding the list of typical organisms and adding cultures from a sterile site as a possible minor criterion. Other studies have assessed the impact of the updated criteria on the diagnosis of IE in large patient subsets. However, none have evaluated the effect of the criteria on diagnosis specifically in patients who inject drugs. Methods Patients were identified through pre-existing data from a previous study and from the records of the institutional multidisciplinary endocarditis team. Charts of 237 patients with a preliminary classification as possible or rejected IE were reviewed by study investigators in the electronic medical record based on the 2000 modified Duke Criteria, the 2023 Duke-ISCVD Criteria, and for a history of intravenous drug use (IVDU). Results Between January 1st, 2017 and November 1st, 2023, 51 patients with possible or rejected IE by the modified Duke Criteria and a history of IVDU were identified. Seven (13.7%) were re-classified from possible IE to definite IE based on the 2023 Duke-ISCVD criteria. All upgraded diagnoses were secondary to the new microbiologic criteria. Three patients were re-classified due to Streptococcus agalactiae bacteremia. An additional patient was re-classified due to Staphylococcus epidermidis bacteremia in the context of intra-cardiac material. The remaining three patients were re-classified due to positive cultures from sterile sites other than blood. All three patients received antibiotics prior to blood culture collection. Conclusion Compared to the modified Duke Criteria, applying the 2023 Duke-ISCVD criteria for IE resulted in the re-classification in 13.7% of patients with a history of IVDU from possible or rejected IE to definite IE. All upgraded diagnoses were secondary to changes in the microbiologic criteria. The 2023 Duke-ISCVD criteria may lead to increased diagnosis of definite IE in patients who inject drugs. Disclosures All Authors: No reported disclosures

P-1020. Randomized control trial to study the effectiveness of tablet Fluconazole, capsule Itraconazole and tablet Terbinafine in superficial dermatophytosis

Abstract Background According to the World Health Organization, dermatophytosis is a relatively frequent superficial fungal infection of the keratinizing structures of the body with a prevalence of 20% - 25% worldwide. The organism is more widespread in tropical areas, with India acting as the main infection hub, because it prefers a hot and humid climate. Tinea corporis is the most common kind of superficial dermatophytic infection, second most common is tinea cruris followed by tinea capitis, tinea unguium, tinea faciei, tinea manuum and tinea pedis. Hot, humid weather, overcrowding, poverty, poor cleanliness, lack of health-care facilities, immunosuppression, and irrational drug use are all risk factors for dermatophytosis. Fungal skin infection responding to Oral Itraconazole Clinical response of Dermatophyte infection to Oral Itraconazole at 4 and 8 weeks as compared to baseline Methods Total of 180 patients were included in the study and divided into 3 groups based on the day of visit to the hospital and antifungals Fluconazolee, itraconazole or Terbinafine were randomly prescribed to them (60 patients in each group). Patients were followed up at 4th and 8th week for therapy response. Results At the end of 8th week KOH (Potassium hydroxide) mount was found to be negative in 86.67%, 73.33% and 63.33% among Itraconazole Fluconazole and Terbinafine groups respectively which was highly significant. Conclusion Dermatophytosis is comparatively more commonly seen in physically active age group. Clinical features waned off quicker and better with Itraconazole in comparison to Fluconazole and Terbinafine. Again fluconazole was found to be yielding better clinical outcome than Terbinafine. Overall outcome of patients with dermatophytosis was found to be more satisfactory with a 4 week oral dose of itraconazole. So from this study we conclude that Itraconazole is a better choice of drug for Dermatophytosis compared to Fluconazole and Terbinafine. Also fluconazole is comparatively a better choice than Terbinafine for the same. Disclosures All Authors: No reported disclosures

P-735. Acute Bacterial Skin and Skin Structure Infections: A Comparison of Outpatient One-Hour Infusion Oritavancin and Inpatient Vancomycin Use

Abstract Background Patients with acute bacterial skin and skin structure infections (ABSSSI) who present to the emergency department (ED) are commonly admitted for intravenous (IV) antibiotic treatment. At AtlantiCare Regional Medical Center (ARMC), oritavancin is utilized in the ED as a single 1200 mg dose to prevent ABSSSI admissions. The purpose of this study is to compare 30-day ABSSSI readmission rates between one-hour ED oritavancin infusion and inpatient vancomycin therapy transitioned to oral antibiotics. A financial assessment of both groups will also be presented.Table 1.Patient characteristics and outcomes analyzed via Student’s t-test or χ2 test. Methods Subjects with ABSSSI were included in this retrospective study if they were administered oritavancin in the ARMC ED between November 2022 and August 2023, or given IV vancomycin as an inpatient between January and August 2023. Data collection included patient demographics, history of ABSSSI, injection drug use, and length of stay (LOS). A financial analysis was performed based on diagnosis-related group (DRG) reimbursement and hospital-specific expenditures. Collected data were analyzed using a Student’s t-test or χ2 test as appropriate. Results A total of 191 patients were included in this study with 140 and 51 in the oritavancin and vancomycin arms, respectively (Table 1). The 30-day ABSSSI readmission rates were significantly lower in the oritavancin arm (n=8, 5.7%) compared to the vancomycin arm (n=10, 19.6%), p=.004. Amongst the 8 oritavancin readmissions, only 4 (2.9%) were considered oritavancin candidates based on our hospital protocol criteria which defines appropriate patients. The estimated cost after DRG-based reimbursement for a single patient in the vancomycin arm was approximately $10,300. The estimated cost avoidance for each oritavancin patient, not accounting for drug reimbursement or the subsequent decrease in readmissions, was approximately $7,240. Conclusion Oritavancin as a one-hour infusion in our ED appears to be an effective treatment option in preventing admissions and significantly decreasing 30-day ABSSSI readmissions. The financial benefits of preventing hospital admissions with single-dose oritavancin should be considered when treating ABSSSI patients in the ED setting. Disclosures Joseph Reilly, B.S., Pharm.D., Melinta Therapeutics: Advisor/Consultant