Background Non-attendance of 42% has been reported for outpatient colonoscopy among persons with low socioeconomic status (SES) in an open access system in the United States. Objectives To evaluate attendance to outpatient endoscopy among populations with low SES after in-person consultations with endoscopists prior to scheduling. Methods Retrospectively, we reviewed the endoscopy schedule from September 2009 to August 2010 in an inner city teaching hospital in Washington DC. We identified patients who came for their procedures. We defined non-attendance as when patients did not notify the facility up to 24 hours prior to their scheduled procedures and did not show up . Results A total of 3,304 patients were scheduled for outpatient endoscopy (mean age 55.2 years; 59.5% females). Only 36 (1.1%) patients were uninsured. 716 (21.7%) patients did not show up for their procedures. There were no differences in attendance by age, sex and race. Patients seen in a private endoscopist's office (OR=1.47; 95%CI: 1.07–2.04) were more likely to attend when compared to patients seen in trainees’ continuity clinic. Married patients (OR=1.40; 95%CI: 1.11–1.78) were also more likely to attend. Conversely, Medicaid and uninsured patients were less likely to attend. Restricting our analysis to patients scheduled for only colonoscopy yielded similar results except that patients who were 50 years and older were more likely to attend. Conclusions Our study suggests improved attendance to endoscopy when populations with lower SES undergo prior consultation with an endoscopist. There is a potential to further improve attendance to out-patient endoscopy by directly involving the social support of the patients.

Men who have sex with men and transgender women in the United States are at increased risk for HIV and may benefit from pre-exposure prophylaxis (PrEP), a once-a-day pill to prevent HIV. Due to stigma and discrimination, sexual and gender minority (SGM) populations are also at risk for depression and anxiety. This scoping review sought to identify literature addressing relationships between the PrEP care continuum, depression, and anxiety among SGM individuals and others at high risk for HIV. We conducted a systematic review of four databases (i.e., PubMed, PsycInfo, Web of Science, Google Scholar) and identified 692 unique articles that were screened for inclusion criteria, with 51 articles meeting the final inclusion criteria. Data were extracted for key study criteria (e.g., geographic location, participant demographics, study design, main findings). Results suggest that while depression and anxiety are not associated with PrEP awareness or willingness to use, they can be barriers to seeking care and to PrEP adherence. However, empirical studies show that taking PrEP is associated with reductions in anxiety. Findings suggest the need to implement mental health screenings in PrEP clinical care. In addition, addressing systemic and structural issues that contribute to mental health disorders, as well as PrEP-related barriers, is critical.

No abstract

No abstract

BackgroundHIV Pre-Exposure Prophylaxis (PrEP) has been shown to be 90–92% effective in preventing HIV, but uptake in the South is the lowest in the country. Expanded implementation into clinical practice requires systemic efforts to improve education among providers early in their careers.MethodsThe objectives were to investigate medical trainees’ perceptions, knowledge, and attitudes regarding PrEP and to improve knowledge with a brief interventional education session. Trainees were affiliated with the University Of South Carolina and received a ten-minute, 23-question survey starting June 2018. This was followed by the intervention and then a post intervention survey.Results157 trainees (31 residents, 86 medical students and 40 others) responded to survey and attended the intervention. Post intervention survey was completed by 43 trainees. Prior to intervention 83% of trainees (n = 131) had heard about PrEP and 80% (n = 125) knew of PrEP for HIV prevention. Half, mainly medical students and residents, had formal PrEP education as part of their curriculum but only 38% identified the appropriate regimen (n = 60). Trainees’ concerns included non-adherence (n = 96, 61%), side effects (n = 91, 58%), development of resistance (n = 81, 52%) and poor risk reduction practices (n = 55, 35%). 33% (n = 52) felt confident evaluating patient’s eligibility for PrEP and 47% (n = 74) felt comfortable recommending PrEP. Post intervention 91% (n = 39) of trainees who responded identified the appropriate regimen. No statistically significant changes in trainees’ perceptions regarding SE, adherence development of resistance and risk reduction practices were observed. 93% (n = 40) felt confident evaluating patient’s eligibility for PrEP and 98% (n = 42) felt comfortable recommending PrEP (P < 0.0001). 95% (n = 41) felt that the intervention was beneficial and 98% (n = 42) would recommend the education intervention to other trainees.ConclusionAfter a brief intervention medical trainees’ knowledge and comfort with prescribing PrEP improved. Modifications to the intervention are needed to improve perception regarding safety and efficacy. Improving PrEP uptake in the South will need continued formal PrEP education in the curriculum to advance perceptions and knowledge.Disclosures All authors: No reported disclosures.

Prompt treatment of candidemia, especially in immunocompromised hosts, is known to improve outcomes. We present a case of discordance among results of Gram stain, multiplex polymerase chain reaction (PCR)-based rapid diagnostic technology, and conventional cultures that subsequently resulted in delayed therapy and hospitalization. An immunocompromised patient presented to the outpatient oncology clinic with signs and symptoms of systemic infection. Blood cultures were obtained, and Gram stain showed gram-negative rods, while multiplex PCR results (BioFire® FilmArray® BCID 1) returned positive for both Enterobacter cloacae and Candida parapsilosis. Conventional cultures only grew E. cloacae. Because of the discordant results, the primary team elected to give ertapenem monotherapy and defer antifungal therapy. The patient’s symptoms progressed, and 11 days later, the patient was admitted with subsequent positive blood cultures for C. parapsilosis. The patient required a 9-day hospitalization due to complications associated with candidemia. This case highlights the value of understanding and interpretation of rapid diagnostics, shared decision-making in antimicrobial management of high-risk patients, and the important responsibility of antimicrobial stewardship teams across the continuum of care.

Background Management of pelvic osteomyelitis related to decubitus ulcers (PODU) remains challenging, whereas definitive therapy is based on blood, bone, or deep tissue cultures, empirical therapy prior to culture results may be indicated in patients with sepsis or cellulitis surrounding PODU. The objective of this retrospective case series is to develop an institutional protocol for empirical therapy of PODU when indicated based on local microbiology results.Methods Hospitalized adults with PODU from 1 August 2005 to 1 August 2015 at Palmetto Health hospitals in Columbia, SC were identified. PODU was defined based on clinical, radiographic, and microbiology criteria. Descriptive statistical methods (Fisher’s exact) were used for preliminary analysis.ResultsSeventy-five cases with PODU were included with a mean age of 53 years and male predominance (48; 64%). The most common comorbidities were paraplegia (45, 60%), diabetes (23, 31%) and previous strokes (17, 23%). Forty-nine cases (65%) received antibiotics within a year of PODU. Prior infections or colonization with P. aeruginosa within the past year was present in 24/75 (32%) cases. Most cases had multiple sources of cultures: blood (61; 81%), bone/deep tissue (37; 49%), and/or superficial (73; 97%). Among a total of 99 clinical isolates, 56 (57%) were Gram-positive cocci (GPC) and 43 (43%) were Gram-negative bacilli (GNB). The most common organisms were Enterobacteriaceae (26; 26%), coagulase negative staphylococci (CONS) (20, 20%), Stapylococcus aureus (19, 19%), [12 (12%) methicillin-resistant S. aureus], and P. aeruginosa (9, 9%). Of the Enterobacteriaceae, 69% (18/26) were susceptible to ciprofloxacin and 88% (23/26) to ceftriaxone. All cases (9/9) of PODU due to P. aeruginosa had a prior infection/colonization with P. aeruginosa within 1 year as compared with 15/66 (23%) in those with PODU due to other organisms (P = 0.001).Conclusion The microbiology of PODU is diverse (including GPC and GNB). Prior positive P. aeruginosa culture was a predictor of P. aeruginosa PODU. When empirical antimicrobial therapy is indicated, data support the use of intravenous vancomycin plus ceftriaxone in the absence of prior infection/colonization with P. aeruginosa, or intravenous vancomycin plus an anti-pseudomonal agent in the presence of prior P. aeruginosa within the past year.Disclosures All authors: No reported disclosures.

BackgroundEarly recognition of deep seated infections (osteomyelitis and abscesses) in the pediatric population may be difficult, given nonspecific symptoms and signs but remains crucial in the management. There is increasing emphasis on ionizing radiation dose reduction, making whole-body MRI (WBMRI) with short TI inversion recovery (STIR) the advanced imaging modality of choice over bone scintigraphy and CT-scans.MethodsA retrospective chart review of pediatric patients, <19 years, at Palmetto Health, Columbia, SC who had WBMRI with infectious indications during 9/2011 to 12/2013 was performed. The aims of this research were to describe complications related to sedation/contrast, to determine what portion of patients had new evidence of deep seated infections and to obtain initial evidence for effectiveness of WBMRI.Results20 patients were included with male predominance (12; 60%). 9/20 patients < 12 months old and 4 between the ages of 12–70 months. The most common comorbidity was sickle cell syndrome (n = 6) and 16/20 patients had a recent/current central venous catheter. The reasons for imaging were fever (9, 45%), pain/swelling (5, 25%), and abnormal labs/imaging (6, 30%). 19 patients had other diagnostics studies prior to WBMRI, 17 of whom had ionizing radiation using studies (X-rays / CT scans). 10/19 also had additional trips to the radiology department for focal MRIs. Duration of sedation for WBMRI averaged 88 minutes, with propofol (10/14) being the most common agent used. No complications from the sedation or the MRI contrast were recorded. WBMRI found an average of 1–4 areas of osteomyelitis in 11 patients and up to 8 other locations of deep seated infections in 15 patients. 11/20 had post WBMRI surgical intervention of debridement/drainage. Gram-positive cocci were isolated from 10/17 patients with positive blood/tissue cultures. Of those, 6 were methicillin-resistant Staphylococcus aureus.ConclusionUtilized as an early imaging modality in pediatric patients with persistent bacteremia/fevers, WBMRI commonly facilitated timely definitive interventions while sparing the patient exposure to ionizing radiation. WBMRI with STIR was safe and is likely to be cost effective.Disclosures All authors: No reported disclosures.