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Objective The COVID-19 pandemic necessitated use of remote assessments by clinical neuropsychologists. Telehealth was particularly important for vulnerable groups, including persons living with HIV (PLWH); however, limited internet access can be a serious barrier to care. This study examined the preliminary validity of a telephone-based neuropsychological assessment in a clinical sample of PLWH. Method A consecutive series of 59 PLWH were assessed via telephone at an HIV clinic in the southern U.S. between April 2020 and July 2022. The battery included auditory-verbal neuropsychological tests of memory, attention, and executive functions, and questionnaires assessing self-reported mood and activities of daily living (ADL). Results Study measures demonstrated acceptable internal consistency. PLWH demonstrated worse neuropsychological performance compared with expectations derived from the normal curve and an HIV-seronegative adult sample (N  = 44). PLWH assessed via telephone demonstrated similar impairment rates to that of a consecutive series of PLWH (N  = 41) assessed in-person immediately prior to the pandemic. Higher telephone-based global neuropsychological scores were related to younger age, more education, better fund of knowledge, White race/ethnicity, fewer medical conditions, and fewer depression symptoms. Global neuropsychological impairment was strongly and independently associated with greater dependence in ADL domains, particularly for instrumental activities. Conclusions Although telephone-based approaches to neuropsychological assessment are not ideal, these data provide support for the feasibility, internal consistency, and preliminary validity of this method in a consecutive clinical series of PLWH. The direct comparability of telephone-based and in-person neuropsychological assessments remains to be determined by prospective, counterbalanced study designs examining both PLWH and seronegative individuals. [ABSTRACT FROM AUTHOR]

Background Encephalitis represents a challenging condition to diagnose and treat. To assist physicians in considering autoimmune encephalitis (AE) sooner, we developed and validated a risk score. Methods The study was conducted as a retrospective cohort of patients with a diagnosis of definite viral encephalitis (VE) and AE from​​ February 2005 to December 2019. Clinically relevant and statistically significant features between cases of AE and VE were explored in a bivariate logistic regression model and results were used to identify variables for inclusion in the risk score. A multivariable logistic model was used to generate risk score values and predict risk for AE. Results were externally validated. Results A total of 1310 patients were screened. Of the 279 enrolled, 36 patients met criteria for definite AE and 88 criteria for definite VE. Patients with AE compared with VE were more likely to have a subacute to chronic presentation (odds ratio [OR] = 22.36; 95% confidence interval [CI], 2.05–243.7), Charlson comorbidity index <2 (OR = 6.62; 95% CI, 1.05–41.4), psychiatric and/or memory complaints (OR = 203.0; 95% CI, 7.57–5445), and absence of robust inflammation in the cerebrospinal fluid defined as <50 white blood cells/µL and protein <50 mg/dL (OR = 0.06; 95% CI,.005–0.50). Using these 4 variables, patients were classified into 3 risk categories for AE: low (0–1), intermediate (2–3), and high (4). Results were externally validated and the performance of the score achieved an area under the curve of 0.918 (95% CI,.871–.966). Discussion This risk score allows clinicians to estimate the probability of AE in patients presenting with encephalitis and may assist with earlier diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Background A significant proportion of patients with severe and persistent coronavirus disease 2019 (COVID-19) require continuous ventilatory support and occasional extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS). Lung transplantation is a treatment option for patients who develop severe ARDS. Methods Our lung transplant database was retrospectively reviewed for patients who underwent lung transplantation for COVID-19 pulmonary disease at Memorial Hermann Hospital, Texas Medical Center, Houston, Texas, from January 2020 to March 2022. We evaluated outcomes of patients who were followed in our clinic at least 6 months post-transplant. Pretransplant patient characteristics, COVID-19-related treatment, histopathology results, and postdischarge course were evaluated. Results Among a total of 13 lung transplant recipients, 6 consecutive patients were identified who had a minimum of 6 months of follow-up post–lung transplantation. The average age of patients was 55 years, with a male predominance. The median time to transplantation was 111 days. All 6 patients had significant postinfectious complications due to COVID-19 before transplant. Histopathological findings from explanted lungs showed a predominance of fibrotic change. There were no reported cases of rejection or graft dysfunction. 5 patients had minimal to no post-transplant infectious complications. One patient died 218 days post-transplant from infectious complications. Conclusions Five out of six lung transplant recipients at our institution have demonstrated excellent long-term outcomes after index hospitalization, for a mean follow-up of 13 months post–lung transplantation. Lung transplantation for lung fibrosis due to COVID-19 is an acceptable salvage treatment option. Larger studies are warranted to confirm these findings. [ABSTRACT FROM AUTHOR]

Background Herpes simplex encephalitis (HSE) is the most common cause of encephalitis hospitalizations. We sought to describe and analyze features associated with all cause readmissions and encephalopathy associated readmissions amongst HSE cases. Methods HSE hospitalizations and 60-day rehospitalizations were assessed in a retrospective cohort using linked hospitalizations from the Healthcare Utilization Project (HCUP) National Readmission Database (NRD) from 2010 through 2017. Risk factors for all-cause readmissions and encephalopathy associated readmissions were assessed with a weighted logistic regression model. Results There were 10 272 HSE cases in the US between 2010 and 2017, resulting in a national rate of 4.95 per 100 000 hospitalizations. A total of 23.7% were readmitted at least once within 60-days. Patients that were readmitted were older (mean age 62.4 vs 57.9, P  < .001), had a greater number of procedures at the index hospitalization (adjusted odds ratio [aOR] 1.03, P  < .001) and have a higher Charlson comorbidity score (aOR 1.11, P  < .001). Among those readmitted, 465 (16.5%) had an encephalopathy related diagnosis. Over 8 years, the rate of encephalopathy associated readmissions increased from 0.12 to 0.20. Encephalopathy specific readmissions were found to be associated with greater age (mean age 65.9 vs 61.7, P  = .004) and findings of cerebral edema at index hospitalization (aOR 2.16, P  < .001). Conclusions HSE readmissions are relatively common, particularly among older and sicker individuals. However, early signs and symptoms of neurological disease at index were correlated with encephalopathic specific readmissions. [ABSTRACT FROM AUTHOR]

Objective Spaced retrieval practice (SRP) and self-generation are among the most replicated and effective mnemonic strategies in the cognitive psychology literature, but their benefits have not yet been realized in healthcare settings. This study used a randomized, between-subjects design to examine the hypothesis that SRP with a self-generation booster can improve memory for health-related information among clinically referred persons with HIV (PWH), who often have difficulty acquiring new health knowledge. Method A consecutive series of 41 PWH referred to a county-funded urban neuropsychology clinic were enrolled. Participants were randomly assigned to learn four statements about the treatment of a mock infectious disease in either a massed study control condition (n  = 20) or an SRP condition (n  = 21) in which they received two distributed free recall training tests supplemented with self-generation for missed items. The primary outcome was participants' free recall of the four treatment statements after a 20-minute delay filled with nonverbal tests. Results PWH participants in the SRP condition were four times more likely than controls to recall at least one treatment statement at the 20-minute delay. SRP was not related to post-test recognition or health-related decision-making performance but was associated with moderately better self-efficacy for decision-making. Conclusions Findings from this pilot study show the potential of SRP with a self-generation booster to improve learning and memory for health-related information among PWH in clinic. [ABSTRACT FROM AUTHOR]

Background Identifying underlying commonalities among all-cause encephalitis cases can be extraordinarily useful in predicting meaningful risk factors associated with inpatient mortality. Methods A retrospective cohort of patients with encephalitis was derived from a clinical chart review of adult patients (age ≥18 years) across 16 different hospitals in Houston, Texas, between January 2005 and July 2015. Clinical features at admission were assessed for their correlation with inpatient mortality and used to derive a final risk score prediction tool. Results The study included a total of 273 adult patients with all-cause encephalitis, 27 (9.9%) of whom died during hospitalization. A limited number of clinical features were substantially different between patients who survived and those who died (Charlson score, Glasgow coma scale [GCS], immunosuppression, fever on admission, multiple serologic studies, and abnormal imaging). A final multivariable logistic model was derived with the following risk factors, which were transformed into a scoring system: 1 point was assigned to the presence of a Charlson score >2, thrombocytopenia, or cerebral edema, and 2 points for a GCS value <8. Patients were then classified into different risk groups for inpatient mortality: 0 points (0%), 1 point (7%), 2 points (10.9%), 3 points (36.8%), and ≥4 points (81.8%). Conclusions The risk score developed from this study shows a high predictive value. This can be highly beneficial in alerting care providers to key clinical risk factors associated with in-hospital mortality in adults with encephalitis. [ABSTRACT FROM AUTHOR]

Background Universal HIV testing in adults presenting to a health care setting was recommended by the Centers for Disease Control and Prevention (CDC) in 2006, but compliance in central nervous system (CNS) infections is unknown. Methods A multicenter study of adults presenting with CNS infections to 18 hospitals in Houston and New Orleans between 2000 and 2015 was done to characterize HIV testing and explore factors associated with a positive HIV test. Results A total of 1478 patients with a diagnosis of meningitis or encephalitis were identified; 180 were excluded because of known HIV diagnosis (n = 100) or were <17 years old (n = 80). Out of 1292 patients, 642 (49.7%) had HIV testing, and testing did not differ significantly before or after the CDC recommendations in 2006 (53% vs 48%; P =.068). An HIV test was more commonly done in patients who were non-Caucasian, had fever >38°C, or had seizures on presentation, and of those tested, non-Caucasian patients and those with photophobia were more likely to have a positive HIV test (P <.05). HIV testing also varied by type of CNS infection: community-acquired bacterial meningitis (98/130, 75.4%), encephalitis (174/255, 68.2%), aseptic meningitis (285/619, 46.0%), and health care–associated meningitis (85/288, 29.5%; P <.001). Conclusions Even though HIV testing should be done in all adults presenting with a CNS infection, testing remains ~50% and did not improve after the recommendation for universal testing by the CDC in 2006. [ABSTRACT FROM AUTHOR]

Background Encephalitis is associated with significant morbidity and mortality, with unknown etiologies in the majority of patients. Large prognostic studies evaluating elderly patients are currently lacking. Methods We performed a retrospective cohort of encephalitis cases in 19 hospitals from New Orleans, Louisiana, and Houston, Texas, between the years 2000 and 2017. Results A total of 340 adult (aged ≥17 years) patients with confirmed encephalitis were enrolled, and 194 (57%) had unknown etiologies. A cerebrospinal fluid polymerase chain reaction (PCR) for herpes simplex virus (HSV) and varicella zoster virus was done in 237 (69%) and 82 (24%) patients, respectively. Furthermore, an arboviral serology was done in 169 (49%) patients and measurements of anti-N-methyl-D-aspartate receptor antibodies were taken in 49 (14%) patients. A total of 172 out of 323 patients (53%) had adverse clinical outcomes (ACOs) at discharge. Older individuals (>65 years of age) had a lower prevalence of human immunodeficiency virus, had a higher number of comorbidities, were less likely to receive adjuvant steroids, were more likely to have a positive arbovirus serology, were more likely to have a positive HSV PCR, were more likely to have abnormal computerized tomography findings, and were more likely to have to have an ACO (all P values <.05). Prognostic factors independently associated with an ACO were age ≥65, fever, Glasgow Coma Scale (GCS) score <13, and seizures (all P values ≤0.01). Conclusions Encephalitis in adults remain with unknown etiologies and adverse clinical outcomes in the majority of patients. Independent prognostic factors include age ≥65 years, fever, GCS score <13, and seizures. [ABSTRACT FROM AUTHOR]

Objective: HIV-associated neurocognitive disorders (HAND) have historically been characterized as a subcortical condition that does not affect semantic memory; however, recent evidence suggests that the cortical regions that support semantic memory may be affected in HIV. Method: The current study examined the effects of HAND on semantic memory in 85 HIV+ individuals with HAND, 193 HIV+ individuals without HAND, and 181 HIV- individuals who completed the Boston Naming Test (BNT) and the Famous Faces subtest of the Kauffman Adolescent and Adult Intelligence Test (KAIT-FF). Results: Linear regressions revealed a significant adverse effect of HAND on total scores on the BNT and the KAIT-FF (all ps < .01). Analyses of BNT errors showed that individuals with HAND committed more semantically related errors as compared to the other two study groups (all ps < .05). However, there were no group differences in rates of visually based errors, which are more commonly observed in traditional subcortical diseases (all ps > .10). Conclusions: Results indicate that HAND may impose adverse effects on individuals' object naming and identification abilities suggestive of mild semantic deficits that parallel traditional cortical diseases such as Alzheimer's disease. [ABSTRACT FROM AUTHOR]

Background. Large epidemiological studies evaluating the etiologies, management decisions, and outcomes of adults with meningitis or encephalitis in the United States (US) are lacking. Methods. Adult patients (≥18 years) with meningitis or encephalitis by International Classification of Diseases, Ninth Revision codes available in the Premier Healthcare Database during 2011–2014 were analyzed. Results. A total of 26 429 patients with meningitis or encephalitis were identified. The median age was 43 years; 53% were female. The most common etiology was enterovirus (13 463 [51.6%]), followed by unknown (4944 [21.4%]), bacterial meningitis (3692 [14.1%]), herpes simplex virus (2184 [8.3%]), noninfectious (921 [3.5%]), fungal (720 [2.7%]), arboviruses (291 [1.1%]), and other viruses (214 [0.8%]). Empiric antibiotics, antivirals, and antifungals were administered in 85.8%, 53.4%, and 7.8%, respectively, and varied by etiologies. Adjunctive steroids were utilized in 15.9% of all patients and in 39.3% of patients with pneumococcal meningitis, with an associated decrease in mortality (6.67% vs 12.5%, P = .0245). The median length of stay was 4 days, with the longest duration in those with fungal (13), arboviral (10), and bacterial meningitis (7). Overall inpatient mortality was 2.9% and was higher in those with bacterial (8.2%), fungal (8.2%), or arboviral (8.9%) disease. Overall readmission rate at 30 days was 3.2%; patients with arboviral (12.7%), bacterial (6.7%), and fungal (5.4%) etiologies had higher rates. Conclusions. Viruses are the most common cause of meningitis and encephalitis in the United States and are treated with antibiotic therapy in the majority of cases. Adjunctive steroid treatment is underutilized in pneumococcal meningitis, where it has shown to decrease mortality. [ABSTRACT FROM AUTHOR]

Background. The Infectious Diseases Society of America (IDSA) guidelines delineate criteria for the use of computed tomography (CT) scan of the head before lumbar puncture (LP) in adults with community-acquired meningitis (CAM). There are limited data to document adherence to these guidelines and assess the clinical utility of brain imaging. Methods. This was a retrospective analysis from January 2005 to January 2010 in Houston, Texas. Results. Among 614 adults with CAM, 407 patients (66.3%) did not have an indication for a head CT scan and 207 (33.7%) did. Patients with a CT scan indication were older, had more comorbidities, were sicker, and had more urgent treatable etiologies and adverse clinical outcomes (P < .001). A CT scan was ordered before the LP in 549 patients (89%). Overall, clinicians did not adhere to clinical guidelines in 368 of 614 (60%) subjects. A CT of the head was ordered when not indicated in 355 of 549 patients (64%), and not done when indicated in 13 of 207 patients (0.6%). CT of the head revealed intracranial abnormalities in 35 of 193 patients (18.1%) with an indication for brain imaging, compared with only 2 of 356 (0.05%) with no indication (P < .05). Major intracranial findings were seen in only 15 of 549 (2.7%) patients, all with an indication for brain imaging. Furthermore, only 8 patients had abnormalities that affected clinical management. Conclusions. Most clinicians do not adhere to IDSA guidelines, delaying diagnostic LP and increasing costs. Usefulness of head CT in patients with CAM without an indication for imaging is limited and has no impact in clinical management. [ABSTRACT FROM AUTHOR]

The Infectious Diseases Society of America (IDSA) Standards and Practice Guidelines Committee collaborated with partner organizations to convene a panel of 10 experts on healthcare-associated ventriculitis and meningitis. The panel represented pediatric and adult specialists in the field of infectious diseases and represented other organizations whose members care for patients with healthcare-associated ventriculitis and meningitis (American Academy of Neurology, American Association of Neurological Surgeons, and Neurocritical Care Society). The panel reviewed articles based on literature reviews, review articles and book chapters, evaluated the evidence and drafted recommendations. Questions were reviewed and approved by panel members. Subcategories were included for some questions based on specific populations of patients who may develop healthcare-associated ventriculitis and meningitis after the following procedures or situations: cerebrospinal fluid shunts, cerebrospinal fluid drains, implantation of intrathecal infusion pumps, implantation of deep brain stimulation hardware, and general neurosurgery and head trauma. Recommendations were followed by the strength of the recommendation and the quality of the evidence supporting the recommendation. Many recommendations, however, were based on expert opinion because rigorous clinical data are not available. These guidelines represent a practical and useful approach to assist practicing clinicians in the management of these challenging infections. [ABSTRACT FROM AUTHOR]

Background. Daptomycin has become a front-line antibiotic for multidrug-resistant Enterococcus faecium bloodstream infections (BSIs).We previously showed that E. faecium strains with daptomycin minimum inhibitory concentrations (MICs) in the higher end of susceptibility frequently harbor mutations associated with daptomycin resistance. We postulate that patients with E. faecium BSIs exhibiting daptomycin MICs of 3–4 μg/mL treated with daptomycin are more likely to have worse clinical outcomes than those exhibiting daptomycin MICs ≤2 μg/mL. Methods. We conducted a multicenter retrospective cohort study that included adult patients with E. faecium BSI for whom initial isolates, follow-up blood culture data, and daptomycin administration data were available. A central laboratory performed standardized daptomycin MIC testing for all isolates. The primary outcome was microbiologic failure, defined as clearance of bacteremia ≥4 days after the index blood culture. The secondary outcome was all-cause in-hospital mortality. Results. A total of 62 patients were included. Thirty-one patients were infected with isolates that exhibited daptomycin MICs of 3–4 μg/mL. Overall, 34 patients had microbiologic failure and 25 died during hospitalization. In a multivariate logistic regression model, daptomycin MICs of 3–4 μg/mL (odds ratio [OR], 4.7 [1.37–16.12]; P = .014) and immunosuppression (OR, 5.32 [1.20– 23.54]; P = .028) were significantly associated with microbiologic failure. Initial daptomycin dose of ≥8 mg/kg was not significantly associated with evaluated outcomes. Conclusions. Daptomycin MICs of 3–4 μg/mL in the initial E. faecium blood isolate predicted microbiological failure of daptomycin therapy, suggesting that modification in the daptomycin breakpoint for enterococci should be considered. [ABSTRACT FROM AUTHOR]

We conducted a phase 2, double-blind, placebo-controlled study to evaluate the safety and antifungal activity of adjuvant recombinant interferon (rIFN)-γ1b in patients with acquired immunodeficiency syndrome and acute cryptococcal meningitis. Patients received 100 or 200 μg of rIFN-γ1b or placebo, thrice weekly for 10 weeks, plus standard therapy with intravenous amphotericin B, with or without flucytosine, followed by therapy with fluconazole. End points included conversion of cerebrospinal fluid fungal cultures from positive to negative at 2 weeks, resolution of symptoms, and survival. Among 75 patients, 2-week culture conversion occurred in 13% of placebo recipients, 36% of rIFN-γ1b (100 μg) recipients, and 32% of rIFN-γ1b (200 μg) recipients. There was a trend toward improved combined mycologic and clinical success in rIFN-γ1b recipients (26% vs. 8%; p = .078). Therapy with rIFN--γ1b was well tolerated, and there was no apparent influence on serial CD4 cell counts and human immunodeficiency virus load measurements. Adjunctive therapy with rIFN-γ1b holds promise for patients with acute cryptococcal meningitis and warrants further study. [ABSTRACT FROM AUTHOR]

High-level penicillin resistance has been associated with treatment failure in patients with Streptococcus pneumoniae infections. To identify a subgroup of patients at low risk for high-level penicillin-nonsusceptible S. pneumoniae bacteremia, a cross-sectional study of 303 patients was performed. For the total study population, penicillin resistance was observed in 98 (32%) of 303 patients; high-level resistance was seen in 33 (11%). A predictive model was created by using 3 baseline variables that were independently associated with high-level penicillin resistance: previous beta -lactam antibiotic use, previous stay in a risk area (defined as stay in day care facilities, prisons, homeless shelters, nursing homes, or other long-term care facilities), and previous respiratory tract infection. The model was used to identify patients at low and high risk for high-level penicillin-resistant pneumococcal bacteremia. None of the isolates of patients in the low-risk subgroup had ceftriaxone resistance. Patients in the low-risk subgroup could be empirically treated with fluoroquinolone-sparing regimens. [ABSTRACT FROM AUTHOR]

Previous antibiotic exposure is one of the most important predictors for acquisition of penicillin-nonsusceptible Streptococcus pneumoniae (PNSP) infection. To determine the impact of duration of exposure to different antibiotic classes, a study of 303 patients with S. pneumoniae bacteremia was undertaken. Ninety-eight cases of bacteremia (32) were caused by a penicillin-nonsusceptible isolate. Bivariate analysis revealed that use of β-lactams, sulfonamides, and macrolides within the last 1 and 6 months before presentation was associated with PNSP bacteremia (P < .05). Fluoroquinolone consumption was not related to bacteremia due to PNSP (P > .1). Both short- and long-term β-lactam use significantly increased the risk for PNSP infection. Logistic regression analysis revealed that use of β-lactams and macrolides in the 6 months before the first positive blood culture result were independent risk factors (P < .05). Risk for acquiring PNSP infection depends on both the class of antibiotic to which the patient was exposed and the duration of therapy. [ABSTRACT FROM AUTHOR]

To determine the diagnostic accuracy of Kernig's sign, Brudzinski's sign, and nuchal rigidity for meningitis, 297 adults with suspected meningitis were prospectively evaluated for the presence of these meningeal signs before lumbar puncture was done. Kernig's sign (sensitivity, 5%; likelihood ratio for a positive test result [LR[sup -]], 0.97), Brudzinski's sign (sensitivity, 5%; LR[sup +], 0.97), and nuchal rigidity (sensitivity; 30%; LW[sup +], 0.94) did not accurately discriminate between patients with meningitis (≥6 white blood cells [WBCs]/mL of cerebrospinal fluid [CSF]) and patients without meningitis. The diagnostic accuracy of these signs was not significantly better in the subsets of patients with moderate meningeal inflammation (≥100 WBCs/mL of CSF) or microbiological evidence of CSF infection. Only for 4 patients with severe meningeal inflammation (≥ 1000 WBCs/ mL of CSF) did nuchal rigidity show diagnostic value (sensitivity, 100%; negative predictive value, 100%). In the broad spectrum of adults with suspected meningitis, 3 classic meningeal signs did not have diagnostic value; better bedside diagnostic signs are needed. [ABSTRACT FROM AUTHOR]

Background Currently multiple sets of recommendations exist to guide the use of cranial imaging before lumbar puncture in adults with suspected meningitis. We aimed to compare the utility of the four main guidelines [Infectious Diseases Society of America (IDSA), European Society for Clinical Microbiology and Infectious Diseases (ESCMID), UK, and Swedish guidelines] in detecting major head CT scan findings that eventually impacted clinical management in adults with community-acquired bacterial meningitis. Methods A retrospective observational study of 111 adults (age > 17 years) with community-acquired bacterial meningitis admitted to 10 tertiary care hospitals in Houston TX, between December 2004 and March 2016. Major and minor CT findings were stratified based on their inclusion status within the four separate guidelines. Results A total of 38 (34%) patients had minor head CT scans (small ischemic white matter changes, lacunar strokes) and 17 (15%) patients had major CT findings (hydrocephalus, subarachnoid hemorrhage or interventricular hemorrhage, cerebral edema, pneumocephalus, ventriculomegaly, septic embolus, hindbrain herniation, and temporal lobe encephalitis). Of those 17 with major CT findings, 6 patients had a change in clinical management [External Ventricular Drainage (EVD) placement] as a direct result of their CT findings. The IDSA set of guidelines was the only one that included all of the major CT scan findings and all the cases in which the findings of a brain CT resulted in a change in management (EVD placement). Conclusion The IDSA was the most inclusive guideline in regards to (1) indications for cranial imaging that would have detected all major abnormal brain CT findings and 2) including cranial imaging that resulted in significant changes in clinical management in adults with community-acquired bacterial meningitis. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background To describe the use and the impact on clinical outcomes of adjunctive steroids in adults with encephalitis. Methods We conducted a retrospective observational study of 230 adults (age >17 years) who met the international consortium definition for encephalitis. An adverse clinical outcome was defined as a Glasgow outcome score of 1–4. The study took place at three tertiary care hospitals in Houston TX, between August 2008 and September 2017. Results A total of 230 adults with encephalitis were enrolled, out of which 121 (52.6%) received steroids. Adjunctive steroids were given more frequently to those with focal neurological deficits (P = 0.013), had a positive cerebrospinal fluid (CSF) HSV PCR (P = 0.013), required mechanical ventilation (MV) (P = 0.011), required intensive care unit (ICU) admission (P < 0.001), had white matter abnormalities (P = 0.014) or had cerebral edema on the brain magnetic resonance imaging (MRI) (P = 0.003). An adverse outcome was seen in 139 (60.7%) of patients. Predictors for adverse outcomes included a Glasgow coma score (GCS) < 8, fever, seizures, ICU admission, and presence of edema on brain MRI. The use of adjunctive steroids did not impact clinical outcomes (P = 0.521). Independent prognostic factors on logistic regression analysis were edema on brain MRI (7.780 [1.717–35.263] P = 0.008), GCS < 8 (6.339 [1.992–20.168] P = 0.002), and fever (2.601 [1.342–5.038] P = 0.005). Conclusion Adults with encephalitis continues to be associated with significant adverse clinical outcomes in the majority of patients. Adjunctive steroids are used in the sicker patients and it is not associated with improved clinical outcomes. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background The Biofire® FilmArray Meningitis Encephalitis (FAME) is a multiplex polymerase chain reaction (PCR) test can rapidly detect up to 14 pathogens that cause meningitis and encephalitis. The impact on preventing repeat lumbar punctures to obtain more diagnostic studies is currently unknown. Methods Patients admitted to Memorial Hermann Hospital (MHH) between July 2018-February 2019 with community-acquired symptoms of meningitis or encephalitis, CSF with white blood cell count >5 cells/mm3, and with leftover CSF at the MHH microbiology laboratory were eligible for the study. Testing FAME was performed after discharge for specimens that had not been centrifuged, had a volume of ≥200 μL, were appropriately stored, and were collected by lumbar puncture (LP) for evaluation of suspected meningitis/encephalitis. Results Of 1,382 CSF specimens screened, 70 (5.0%) met the criteria and were tested with FAME. The majority was adults (72.8%), non-Caucasian (68.6%), male (60%), immunocompetent (75.7%) and had a meningitis presentation (75.7%). Mean age was 36.9 years (1 mo-89 years). The mean duration between CSF collection and any PCR result done in the hospital was 60 hours. Fifteen patients (21.4%) required 25 repeat LPs [13 (86.6%) for additional testing (7 (53.8%) pediatric patients) and 2 (13.3%) for cryptococcal meningitis assessment]. The FAME could have prevented repeat LPs in 86.6% of patients. Five of the 13 repeat LP (38.4%) FA ME showed a pathogen [VZV (2), HSV 1 (1), HHSV-6 (1), Neisseria meningitidis (1)]. Of 46 tests with negative FA ME, acyclovir therapy was started in 22 (47.8%) with a mean of 6 doses dispensed. 38 (26.6%) patients were discharged with an unknown etiology of whom FA ME was positive in 8 (21%) [HSV2 (37.5%), VZV (25%), Enterovirus (25%) and HSV1 (12.5%)]. PCR was ordered in the hospital for only 4 (50%) of these patients. Conclusion The FAME identified an etiology in 21% of patients with meningitis and encephalitis symptoms discharged with an unknown etiology. A total of 18.5% of patients required a repeat LP for additional testing. FAME testing offers an avenue for reducing the burden of repeat LPs and duration of unnecessary anti-infective therapy while increasing diagnostic yield. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background The Centers for Disease Control and Prevention recommends that all patients be tested for HIV while in a healthcare setting. HIV testing is especially important in patients with a central nervous system (CNS) infection because it impacts the differential diagnosis. In this study, we determined the rate of HIV testing in patients who presented with a CNS infection. Methods We performed a multicenter retrospective study of 1,312 patients over the age of 17 years with community or healthcare-acquired meningitis, aseptic meningitis or encephalitis admitted to 18 hospitals in New Orleans, LA and Houston, TX from July 1, 1998 through December 31, 2017. Prospective patients were identified using ICD 9 coding, physical examination findings, and cerebrospinal fluid analysis. The electronic medical records for these patients were reviewed for HIV testing and diagnosis. Aseptic meningitis cases were also reviewed for HIV RNA PCR testing. 100 patients with a known HIV diagnosis were excluded (2 aseptic meningitis, 82 encephalitis, and 16 community-acquired meningitis). Results Out of 1,312 patients presenting with a confirmed CNS infection, 664 (50.6%) had an HIV test done. A total of 81 patients (12.2%) were newly diagnosed with HIV during admission. Patients who underwent HIV testing were more likely to be non-caucasian, have no underlying comorbidities, lower Glasgow coma scale, and more seizures on presentation (P < 0.05). HIV testing also varied by type of CNS infection: community-acquired meningitis (98/142, 69.0%); encephalitis (180/261, 69.0%), aseptic meningitis (300/643, 46.6%), and healthcare-associated meningitis (86/289, 29.7%). In only 35 out of 547 patients (6.4%) presenting with acute aseptic meningitis was an HIV RNA PCR test ordered; 26 out of the 35 (74%) HIV RNA PCRs were positive with 9 patients being diagnosed with acute HIV seroconversion syndrome. Conclusion HIV testing is done in only one-half of patients with CNS infections with only a minority of patients presenting with acute aseptic meningitis being evaluated for acute HIV seroconversion syndrome. Clinicians should order an HIV test on all patients with CNS infections and consider testing for HIV RNA PCR in patients presenting with acute aseptic meningitis especially in those where the etiologic diagnosis remains unknown. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Cytomegalovirus (CMV) is a rare cause of meningoencephalitis (ME) with clinical data limited to case reports. Methods Retrospective observational study of all viral central nervous system (CNS) infections identified in 17 hospitals in the Greater Houston area from 2000 to 2017. CMV, herpes simplex virus (HSV), varicella zoster virus (VZV), and enterovirus were all identified by a positive cerebrospinal fluid (CSF) polymerase chain reaction (PCR) and all arboviruses were identified by serology. Results A total of 361 patients with viral CNS infections were identified: CMV (n = 33), enterovirus (n = 147), herpes simplex virus (n = 83), varicella zoster virus (n = 28), and arbovirus (n = 70). CMV ME occurred more frequently in immunosuppressed patients [e.g. Acquired Immune Deficiency Syndrome (AIDS)], had more hypoglycorrhachia (59%), and had worse clinical outcomes (61%) as compared with those with HSV, enterovirus, VZV and arboviruses. Furthermore, CMV ME had more altered mental status than enterovirus and HSV and had lower CSF pleocytosis compared with HSV. Additionally, CMV ME had higher CSF protein levels than enteroviral infections and had less CSF lymphocytosis than HSV and VZV. Conclusion CMV meningoencephalitis is seen more frequently in immunosuppressed patients (e.g. AIDS), is associated with more hypoglycorrhachia and have worse clinical outcomes compared with other viral CNS pathogens. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Disseminated strongyloidiasis in solid organ transplant recipients is a rare but devastating infection. In our center, we implemented a universal screening of all candidates for kidney transplantation. We assessed the seroprevalence and utility of universal screening for strongyloidiasis in our center. Methods Patients were identified from our transplant referral list (from July 2012 to June 2017). Demographics, pretransplant laboratory, and serological screenings were retrospectively collected. For Strongyloides- seropositive (SSp) patients, data on travel history, symptoms, treatment, and stool ova and parasite examinations were extracted. Logistic regression and multiple imputation for missing data were performed. Results A total of 1689 patients underwent serological screening, of whom 168 (9.9%) were SSp. Univariate analysis revealed that SSp patients had higher rates of eosinophilia, diabetes mellitus, latent tuberculosis and were likely to be either Hispanic or Asian (P <.05). In multivariate analysis, eosinophilia (P =.01), diabetes mellitus (P =.02), and Asian race (P =.03) were associated with being SSp, but 45 (27%) of the SSp patients did not have any of these 3 factors, and 18 SSp patients (11%) had no epidemiological risk factors. All patients received ivermectin, and none developed disseminated strongyloidiasis. Of patients who underwent serological screening on multiple occasions, 6.8% seroconverted while waiting for kidney transplantation. Conclusions We found a high rate of Strongyloides seropositivity among our kidney transplantation candidates. No epidemiological risk factors effectively predicted SSp status in our population, and universal screening identified a large number of patients without such factors. Serial screening should be considered when a long wait time is expected before transplantation. [ABSTRACT FROM AUTHOR]

The impact of antibiotic therapy on the diagnosis of healthcare–associated ventriculitis and meningitis (HCAVM) is unknown. Antibiotics were administered before obtaining cerebrospinal fluid (CSF) in 217 out of 326 (66%) patients with HCAVM, and they impacted the sensitivity of the cerebrospinal fluid Gram stain and culture (P ≤.004). [ABSTRACT FROM AUTHOR]

Background The treatment of vancomycin-resistant enterococcal (VRE) bacteraemia remains challenging. Daptomycin is a new antibiotic with bactericidal activity against VRE, but available clinical data are limited. Methods A retrospective study was performed on 98 adult patients with VRE bacteraemia admitted to two hospitals between September 2003 and December 2007 to compare the efficacy of daptomycin with that of linezolid. Multivariable analyses were performed to compare the microbiological and clinical outcomes of both groups. Results Out of 98 patients with VRE bacteraemia, 68 were treated with linezolid and 30 with daptomycin. Univariate analyses showed no significant differences between the groups regarding baseline demographic and clinical characteristics, severity of illness and co-morbidity. Daptomycin was associated with a trend towards a higher mortality rate (26.7% versus 20.6%), longer median duration of bacteraemia (3 days versus 2 days) and higher relapse rate (6.7% versus 2.9%), but these differences did not reach statistical significance (P > 0.2). Microbiological cure rates were 90% for the daptomycin group and 88.2% for the linezolid group (P = 0.92). Conclusions Despite a trend towards worse outcomes, daptomycin was as effective as linezolid in treating VRE bacteraemia. A randomized clinical trial is needed to confirm these results. [ABSTRACT FROM AUTHOR]