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272. Clinical Utility of Sulfamethoxazole Serum Level Monitoring in the Treatment of Brain Abscesses due to Nocardia Species

272. Clinical Utility of Sulfamethoxazole Serum Level Monitoring in the Treatment of Brain... Disclosures. All Authors: No reported disclosures 5 (45.5%) reported drug toxicity, including nausea in 3, acute kidney injury in 2, and thrombocytopenia in 2 patients. Ninety-four percent of the patients with SMX levels had surgical intervention for therapeutic purposes vs. 83% of those without it (P=.65). 271. US Hospitalizations and 60-Day Readmission Rates Associated with Herpes A total of 11 (50%) patients were cured, 3 (18.8%) relapsed, and 2 (12.5%) died.  Simplex Virus Encephalitis Conclusion. Patients with SMX serum level monitoring are more likely to be on 1 2 Michael Hansen, MD, MPH, MS ; Rodrigo Hasbun, MD, MPH ; HD, during the induction phase and among those with higher and more frequent dos- 2 1 2 Rodrigo Hasbun, MD, MPH ; Baylor College of Medicine, Houston, TX; University ing. About half of patients with SMX levels >150 mcg/mL experienced drug toxicity; of Texas Health Science Center, Bellaire, TX however, SMX levels did not impact patient outcome and length of treatment. Disclosures. All Authors: No reported disclosures Session: P-13. CNS Infection Background. Herpes Simplex encephalitis (HSE) is the most common cause of encephalitis hospitalizations with a known etiology. However, it remains a challenge to 273. Neurological Involvement Caused by Intracellular Bacteria 1 1 1 capture a comprehensive and robust understanding of the disease, particularly for long Fatma Hammami, MD ; Makram Koubaa, MD ; Amal Chakroun, MD ; 1 1 1 term outcomes aer ac ft ute diagnosis and treatment. In particular, there is a growing Khaoula Rekik, MD ; Chakib Marrakchi, MD ; Fatma Smaoui, MD ; 1 1 body of literature showing increased concern for recurrent encephalopathic disease Mounir Ben Jemaa, MD ; Infectious Diseases Department, Hedi Chaker University several weeks aer ini ft tial HSE recovery. We sought to describe and analyze features Hospital, University of Sfax, Tunisia, Sfax, Sfax, Tunisia associated with all cause readmissions and encephalopathy associated readmissions Session: P-13. CNS Infection amongst HSE cases.  Methods. HSE hospitalizations and 60-day rehospitalizations were assessed in Background. Infection of the central nervous system is a severe and fatal dis- a retrospective cohort using linked hospitalizations from the Healthcare Utilization ease. Causative agents include bacteria, viruses or fungi. Intracellular bacteria are not Project (HCUP) National Readmission Database (NRD) from 2010 through 2017. Risk only overlooked, but also underdiagnosed. We aimed to study the clinical, laboratory factors for all-cause readmissions and encephalopathy associated readmissions were and evolutionary features of neurological involvement caused by intracellular bacteria. assessed with a weighted logistic regression model. Methods. We conducted a retrospective study including all patients hospitalized Results. er Th e were 10,272 HSE cases in the United States between 2010 and in the infectious disease department for neurological involvement caused by intracel- 2017, resulting in a national rate of 4.95 per 100,000 hospitalizations. A total of 23.7% lular bacteria between 1995 and 2020. The diagnosis was confirmed by serology. were readmitted at least once within 60-days. Patients that were readmitted were older Results. We encountered 76 cases among which 43 were males (56.6%). The (mean age 62.4 vs. 57.9, p< 0.0001), had a greater number of procedures at the index mean age was 32±18  years. e Th revealing symptoms included fever (97.4%), cepha - hospitalization (aOR 1.03, p< 0.0001) and have a higher Charlson comorbidity score lalgia (73.7%), vomiting (64.5%) and arthralgia (51.3%). Lumbar puncture revealed (aOR 1.11, p< 0.0001). Amongst those readmitted, 465 (16.5%) had an encephalopathy a median white blood cell count of 120[56-340]/mm . Lymphocytic pleocytosis was related diagnosis. Over eight years, the prevalence of encephalopathy associated read- noted in 62% of the cases. Elevated cerebrospinal fluid (CSF) protein level was noted missions increased from 0.12 to 0.20 (figure 1). Encephalopathy specific readmissions in 37 cases (48.7%) with a median of 0.84[0.6-1.37] g/L. Low CSF fluid glucose level were found to be associated with greater age (mean age 6.9 vs. 61.7, p  =  0.004) and was noted in 14 cases (18.4%). There were 70 cases (92.1%) of meningitis and 6 cases findings of cerebral edema at index hospitalization (aOR 2.16, p < 0.0001). of meningoencephalitis (7.9%). The causative agent included Rickettsia species in 47 Most Common Diagnosis Groups Listed at the 60-Day Readmission cases (61.8%), Brucella species in 17 cases (22.4%) and Mycoplasma species in 12 cases (15.8%). Laboratory investigations included elevated C-reactive protein levels (40.7%), thrombocytopenia (32.8%) and increase in hepatic enzyme levels (21%). Anemia was noted in 27 cases (35.5%), leukocytosis in 24 cases (31.5%) and leucopoenia in 6 cases (7.8%). Blood and CSF cultures were positive for Brucella in 2 cases (2.6%) and 5 cases (6.5%), respectively. The mean duration of treatment was 156±94  days for brucel - losis cases, 9±4 days for rickettsiosis cases and 10±6 days for Mycoplasma cases. The disease evolution was favorable in 72 cases (94.7%). Four patients were dead (5.3%). Complications were noted in 5 cases (6.5%) and sequelae in 2 cases (2.6%). Conclusion. Intracellular bacteria including Brucella, Rickettsia and Mycoplasma species should be considered in front of neurological symptoms. Meningitis with lymphocytic pleocytosis was the most common clinical presentation. An early diag- Conclusion. HSE 60-day readmissions are relatively common, particularly nosis followed by the adequate treatment might avoid complications and death. among older and sicker individuals. Readmissions were oen a ft ssociated with new Disclosures. All Authors: No reported disclosures neurological symptoms concerning for either recurrent or new encephalopathic events. Early signs and symptoms of neurological disease at index were correlated with encephalopathic specific readmissions. 274. Legionella bozemanii (Fluoribacter bozemanae) Brain Abscess in a Renal Disclosures. Rodrigo Hasbun, MD, MPH, Biofire (Speaker’s Bureau) Rodrigo Transplant Recipient 1 2 3 Hasbun, MD, MPH, Biofire (Individual(s) Involved: Self ): Consultant, Research Grant Abrar Khan, DO ; Sreechandra L. Kruthiventi, MD ; Rahul Mahapatra, DO ; 1 4 1 or Support Soma Sanyal, MD ; Wesley Kufel, PharmD ; SUNY Upstate University, Jamesville, 2 3 New York; Upstate Medical University, Syracuse, New York; State University of New York Upstate, Syracuse, New York; Binghamton University, Binghamton, New York 272. Clinical Utility of Sulfamethoxazole Serum Level Monitoring in the Session: P-13. CNS Infection Treatment of Brain Abscesses due to Nocardia Species 1 1 Cristina G. Corsini Campioli, MD ; Christina G. Rivera, Pharm.D ; Background. Legionnaires’ disease is a potentially fatal multi-system disease 1 1 1 Kristin Mara, MS ; Omar Abu Saleh, M.B.B.S ; Mayo Clinic, Rochester, Minnesota caused by Legionella species. However, extra-pulmonary Legionella disease is rare and is typically associated with Legionella species other than L. pneumophila in immuno- Session: P-13. CNS Infection compromised patients.  Background. Although trimethoprim-sulfamethoxazole (TMP-SMX) has con- Methods. We present a 55-year-old immunocompromised male with history sistently demonstrated significant interindividual variability, therapeutic drug mon - of living-related renal transplant secondary to IgA nephropathy (day 0)  which was itoring is used to optimize dosing and avoid adverse reactions that may contribute complicated by T-cell mediated rejection requiring anti-thymocyte globulin and elo- to treatment interruption. While data exists on the use of SMX level monitoring in tuzumab (day 130).  pneumocystis, there is a lack of data in SMX serum monitoring utility for invasive Results. Patient was hospitalized on day 184 with community-acquired pneu- Nocardia infections.  monia and treated with piperacillin-tazobactam and azithromycin. Three weeks Methods. We retrospectively reviewed adults who received TMP-SMX to treat later (day 214), he presented with new-onset seizures and was found to have a nocardial brain abscess (BA) and underwent SMX testing level from January 2010 to frontal brain abscess on MRI. His clinical course and brain imaging worsened des- December 2020. pite undergoing multiple operative drainage procedures, placement of an extra Results. Overall, 24 patients had Nocardia spp. BA; Twenty-two (91.7%) were ventricular drain, and receiving broad-spectrum antimicrobials. L. bozemanii was treated with TMP-SMX, and 16/22 (72.7%) had a documented SMX serum level. The first identified from cerebrospinal fluid (CSF) on buffered charcoal yeast extract median age was 64 (IQR 58-69) years, and the majority were males (77.3%). Compared (BCYE) agar from day 240 and was also later confirmed by 16S rRNA sequencing. to those who did not have a documented SMX serum level, patients with SMX levels Susceptibilities were unavailable due to poor organism growth. Of note, his allergy had a higher prevalence of hemodialysis (HD, 42.9% vs. 33%; P=.99) and malignancy history was significant for rash with ciprofloxacin and levofloxacin. Based on the (50% vs. 33.3%; P=.65). The most common BA location was the frontal lobe (43.8% low severity of the allergic reaction and need for central nervous system penetra- vs. 33.3%; P=.99), with a single (68.8% vs. 50%; P=.62) and smaller (1.3 vs. 1.9  cm; tion, moxifloxacin 400 mg intravenously every 24 hours was initiated on day 244 P=.58) brain fluid collection, and with fewer midline shift (6.3% vs. 16.7%; P=.48), in addition to broad-spectrum antibiotics. Subsequent CSF cultures were positive respectively. The median TMP-SMX duration was 350  days (P=.31). The most com - for L. bozemanii until the CSF culture on day 250. Due to poor clinical response, mon dosing was 2-double strength, three times a day (31.8%). The SMX median level azithromycin and intrathecal polymyxin B were added for salvage therapy on day was 158.5 (IQR 120-218) mcg/mL, collected at two hours (75%) post-administration 255. His neurological status continued to worsen and he eventually succumbed to in the induction phase (81.3%). The most common recommendation was to continue his illness on day 262. therapy based on the level results. Eleven (46%) patients had a level >150 mcg/mL, and 08/31/20 MRI Brain S242 • OFID 2021:8 (Suppl 1) • Abstracts http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Open Forum Infectious Diseases Oxford University Press

272. Clinical Utility of Sulfamethoxazole Serum Level Monitoring in the Treatment of Brain Abscesses due to Nocardia Species

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Oxford University Press
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© The Author(s) 2021. Published by Oxford University Press on behalf of Infectious Diseases Society of America.
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2328-8957
DOI
10.1093/ofid/ofab466.474
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Abstract

Disclosures. All Authors: No reported disclosures 5 (45.5%) reported drug toxicity, including nausea in 3, acute kidney injury in 2, and thrombocytopenia in 2 patients. Ninety-four percent of the patients with SMX levels had surgical intervention for therapeutic purposes vs. 83% of those without it (P=.65). 271. US Hospitalizations and 60-Day Readmission Rates Associated with Herpes A total of 11 (50%) patients were cured, 3 (18.8%) relapsed, and 2 (12.5%) died.  Simplex Virus Encephalitis Conclusion. Patients with SMX serum level monitoring are more likely to be on 1 2 Michael Hansen, MD, MPH, MS ; Rodrigo Hasbun, MD, MPH ; HD, during the induction phase and among those with higher and more frequent dos- 2 1 2 Rodrigo Hasbun, MD, MPH ; Baylor College of Medicine, Houston, TX; University ing. About half of patients with SMX levels >150 mcg/mL experienced drug toxicity; of Texas Health Science Center, Bellaire, TX however, SMX levels did not impact patient outcome and length of treatment. Disclosures. All Authors: No reported disclosures Session: P-13. CNS Infection Background. Herpes Simplex encephalitis (HSE) is the most common cause of encephalitis hospitalizations with a known etiology. However, it remains a challenge to 273. Neurological Involvement Caused by Intracellular Bacteria 1 1 1 capture a comprehensive and robust understanding of the disease, particularly for long Fatma Hammami, MD ; Makram Koubaa, MD ; Amal Chakroun, MD ; 1 1 1 term outcomes aer ac ft ute diagnosis and treatment. In particular, there is a growing Khaoula Rekik, MD ; Chakib Marrakchi, MD ; Fatma Smaoui, MD ; 1 1 body of literature showing increased concern for recurrent encephalopathic disease Mounir Ben Jemaa, MD ; Infectious Diseases Department, Hedi Chaker University several weeks aer ini ft tial HSE recovery. We sought to describe and analyze features Hospital, University of Sfax, Tunisia, Sfax, Sfax, Tunisia associated with all cause readmissions and encephalopathy associated readmissions Session: P-13. CNS Infection amongst HSE cases.  Methods. HSE hospitalizations and 60-day rehospitalizations were assessed in Background. Infection of the central nervous system is a severe and fatal dis- a retrospective cohort using linked hospitalizations from the Healthcare Utilization ease. Causative agents include bacteria, viruses or fungi. Intracellular bacteria are not Project (HCUP) National Readmission Database (NRD) from 2010 through 2017. Risk only overlooked, but also underdiagnosed. We aimed to study the clinical, laboratory factors for all-cause readmissions and encephalopathy associated readmissions were and evolutionary features of neurological involvement caused by intracellular bacteria. assessed with a weighted logistic regression model. Methods. We conducted a retrospective study including all patients hospitalized Results. er Th e were 10,272 HSE cases in the United States between 2010 and in the infectious disease department for neurological involvement caused by intracel- 2017, resulting in a national rate of 4.95 per 100,000 hospitalizations. A total of 23.7% lular bacteria between 1995 and 2020. The diagnosis was confirmed by serology. were readmitted at least once within 60-days. Patients that were readmitted were older Results. We encountered 76 cases among which 43 were males (56.6%). The (mean age 62.4 vs. 57.9, p< 0.0001), had a greater number of procedures at the index mean age was 32±18  years. e Th revealing symptoms included fever (97.4%), cepha - hospitalization (aOR 1.03, p< 0.0001) and have a higher Charlson comorbidity score lalgia (73.7%), vomiting (64.5%) and arthralgia (51.3%). Lumbar puncture revealed (aOR 1.11, p< 0.0001). Amongst those readmitted, 465 (16.5%) had an encephalopathy a median white blood cell count of 120[56-340]/mm . Lymphocytic pleocytosis was related diagnosis. Over eight years, the prevalence of encephalopathy associated read- noted in 62% of the cases. Elevated cerebrospinal fluid (CSF) protein level was noted missions increased from 0.12 to 0.20 (figure 1). Encephalopathy specific readmissions in 37 cases (48.7%) with a median of 0.84[0.6-1.37] g/L. Low CSF fluid glucose level were found to be associated with greater age (mean age 6.9 vs. 61.7, p  =  0.004) and was noted in 14 cases (18.4%). There were 70 cases (92.1%) of meningitis and 6 cases findings of cerebral edema at index hospitalization (aOR 2.16, p < 0.0001). of meningoencephalitis (7.9%). The causative agent included Rickettsia species in 47 Most Common Diagnosis Groups Listed at the 60-Day Readmission cases (61.8%), Brucella species in 17 cases (22.4%) and Mycoplasma species in 12 cases (15.8%). Laboratory investigations included elevated C-reactive protein levels (40.7%), thrombocytopenia (32.8%) and increase in hepatic enzyme levels (21%). Anemia was noted in 27 cases (35.5%), leukocytosis in 24 cases (31.5%) and leucopoenia in 6 cases (7.8%). Blood and CSF cultures were positive for Brucella in 2 cases (2.6%) and 5 cases (6.5%), respectively. The mean duration of treatment was 156±94  days for brucel - losis cases, 9±4 days for rickettsiosis cases and 10±6 days for Mycoplasma cases. The disease evolution was favorable in 72 cases (94.7%). Four patients were dead (5.3%). Complications were noted in 5 cases (6.5%) and sequelae in 2 cases (2.6%). Conclusion. Intracellular bacteria including Brucella, Rickettsia and Mycoplasma species should be considered in front of neurological symptoms. Meningitis with lymphocytic pleocytosis was the most common clinical presentation. An early diag- Conclusion. HSE 60-day readmissions are relatively common, particularly nosis followed by the adequate treatment might avoid complications and death. among older and sicker individuals. Readmissions were oen a ft ssociated with new Disclosures. All Authors: No reported disclosures neurological symptoms concerning for either recurrent or new encephalopathic events. Early signs and symptoms of neurological disease at index were correlated with encephalopathic specific readmissions. 274. Legionella bozemanii (Fluoribacter bozemanae) Brain Abscess in a Renal Disclosures. Rodrigo Hasbun, MD, MPH, Biofire (Speaker’s Bureau) Rodrigo Transplant Recipient 1 2 3 Hasbun, MD, MPH, Biofire (Individual(s) Involved: Self ): Consultant, Research Grant Abrar Khan, DO ; Sreechandra L. Kruthiventi, MD ; Rahul Mahapatra, DO ; 1 4 1 or Support Soma Sanyal, MD ; Wesley Kufel, PharmD ; SUNY Upstate University, Jamesville, 2 3 New York; Upstate Medical University, Syracuse, New York; State University of New York Upstate, Syracuse, New York; Binghamton University, Binghamton, New York 272. Clinical Utility of Sulfamethoxazole Serum Level Monitoring in the Session: P-13. CNS Infection Treatment of Brain Abscesses due to Nocardia Species 1 1 Cristina G. Corsini Campioli, MD ; Christina G. Rivera, Pharm.D ; Background. Legionnaires’ disease is a potentially fatal multi-system disease 1 1 1 Kristin Mara, MS ; Omar Abu Saleh, M.B.B.S ; Mayo Clinic, Rochester, Minnesota caused by Legionella species. However, extra-pulmonary Legionella disease is rare and is typically associated with Legionella species other than L. pneumophila in immuno- Session: P-13. CNS Infection compromised patients.  Background. Although trimethoprim-sulfamethoxazole (TMP-SMX) has con- Methods. We present a 55-year-old immunocompromised male with history sistently demonstrated significant interindividual variability, therapeutic drug mon - of living-related renal transplant secondary to IgA nephropathy (day 0)  which was itoring is used to optimize dosing and avoid adverse reactions that may contribute complicated by T-cell mediated rejection requiring anti-thymocyte globulin and elo- to treatment interruption. While data exists on the use of SMX level monitoring in tuzumab (day 130).  pneumocystis, there is a lack of data in SMX serum monitoring utility for invasive Results. Patient was hospitalized on day 184 with community-acquired pneu- Nocardia infections.  monia and treated with piperacillin-tazobactam and azithromycin. Three weeks Methods. We retrospectively reviewed adults who received TMP-SMX to treat later (day 214), he presented with new-onset seizures and was found to have a nocardial brain abscess (BA) and underwent SMX testing level from January 2010 to frontal brain abscess on MRI. His clinical course and brain imaging worsened des- December 2020. pite undergoing multiple operative drainage procedures, placement of an extra Results. Overall, 24 patients had Nocardia spp. BA; Twenty-two (91.7%) were ventricular drain, and receiving broad-spectrum antimicrobials. L. bozemanii was treated with TMP-SMX, and 16/22 (72.7%) had a documented SMX serum level. The first identified from cerebrospinal fluid (CSF) on buffered charcoal yeast extract median age was 64 (IQR 58-69) years, and the majority were males (77.3%). Compared (BCYE) agar from day 240 and was also later confirmed by 16S rRNA sequencing. to those who did not have a documented SMX serum level, patients with SMX levels Susceptibilities were unavailable due to poor organism growth. Of note, his allergy had a higher prevalence of hemodialysis (HD, 42.9% vs. 33%; P=.99) and malignancy history was significant for rash with ciprofloxacin and levofloxacin. Based on the (50% vs. 33.3%; P=.65). The most common BA location was the frontal lobe (43.8% low severity of the allergic reaction and need for central nervous system penetra- vs. 33.3%; P=.99), with a single (68.8% vs. 50%; P=.62) and smaller (1.3 vs. 1.9  cm; tion, moxifloxacin 400 mg intravenously every 24 hours was initiated on day 244 P=.58) brain fluid collection, and with fewer midline shift (6.3% vs. 16.7%; P=.48), in addition to broad-spectrum antibiotics. Subsequent CSF cultures were positive respectively. The median TMP-SMX duration was 350  days (P=.31). The most com - for L. bozemanii until the CSF culture on day 250. Due to poor clinical response, mon dosing was 2-double strength, three times a day (31.8%). The SMX median level azithromycin and intrathecal polymyxin B were added for salvage therapy on day was 158.5 (IQR 120-218) mcg/mL, collected at two hours (75%) post-administration 255. His neurological status continued to worsen and he eventually succumbed to in the induction phase (81.3%). The most common recommendation was to continue his illness on day 262. therapy based on the level results. Eleven (46%) patients had a level >150 mcg/mL, and 08/31/20 MRI Brain S242 • OFID 2021:8 (Suppl 1) • Abstracts

Journal

Open Forum Infectious Diseases – Oxford University Press

Published: Dec 4, 2021

There are no references for this article.