The world has faced several high consequence infectious diseases or infections (HCI) over the past years with outbreaks traveling from country to country. Recent outbreaks such as Marburg virus in Tanzania (2023) Ebola virus in Uganda (2022), Middle East Respiratory Syndrome Coronavirus (MERS) in Saudi Arabia (2018) serve as a frightening reminder that HCI can circulate at any given time, generating considerable public health and economic consequences. Our Veterans Affairs Medical Center (VAMC) has a response HCI plan. We evaluated the knowledge of the existence of this plan and of HCI among health care employees (HCE) receiving the influenza vaccine during a drive-thru flu point of distribution (POD) driveFigure 1Questionnaire given to employees receiving the influenza vaccineFigure 2Education Pamphlet given to employees upon receipt of vaccine and completion of questionnaire HCE influenza vaccination was planned in the fall of 2024 as a drive-thru flu POD, a single day, 90 min event. The location was the main employee entrance at Northport VAMC. A questionnaire was given to each employee who received the influenza vaccine. Completion was voluntary. The questionnaire is depicted in figure 1. The participants were asked to circle which of the following are HCI: the choices were “FLU, RSV, MERS, EBOLA, CHICHEN POX.” The second question: “Does Northport VA have a HCI response plan, Yes/No/Unsure”. The 3rd question “Do you have a role in the HCI plan, Yes/No/Unsure.” An education pamphlet on MERS and EBOLA was provided at completion of the questionnaire. see figure 2Table 1Answers of the Questionnaire 311 employees received the vaccine and 262 completed the questionnaire. Table 1 shows the answers. Equal number of HCE (199) identified the seasonal influenza and Ebola (199) as HCI. 71% of nurses and 72% of physicians/physician assistants/extenders regarded influenza as HCI. While 210 responded of awareness of the facility HCI plan, only 125 were clear of their role in this plan. Fewer identified chicken pox as HCI (115) followed by RSV responses (146). MERS received less votes (180) than influenza In our project we identified that our fellow HCE exhibited significant knowledge gaps in identifying what constitutes a HCI and what should be their role in event of HCI event in our facility. This is an opportunity for enhanced training and education to be conducted by infection control and emergency management teams as a HCI event occurring in the United States soon may become unavoidable All Authors: No reported disclosures

In the US infectious gastroenteritis remains a significant cause for morbidity and a public health concern. While stool culture had been the standard tool for microbiological diagnosis, known for its time consuming and often lower yields, rapid diagnostic tests have now been developed. Multiplex gastrointestinal (GI) polymerase chain reaction (PCR) testing is commercially available as a rapid, sensitive method for detecting GI pathogens, bacteria, viruses, and parasites in a single stool sample. Nevertheless, challenges in interpreting results can appear especially in mixed infections where detections may not be clinically significant. While high sensitivity of testing is desirable, false positive results require careful interpretation. We reviewed the performance of GI PCR tests in our facilityTable 1GI PCR resultsTable 2GI PCR COINFECTIONS Retrospective chart review from 2021 to 2024 of US Veterans at Northport Veteran Affairs Medical Center who had positive results on Biofire® FilmArray GI PCR. We focused on norovirus, Campylobacter and Vibrio results. Norovirus positive specimens were sent to LabCorp reference laboratory. Campylobacter results were compared to culture from Campylobacter selective agar plate. Vibrio and Salmonella spp results were sent for confirmation to our local department of health 111 GI PCR results were reviewed. The median age of the patients was 75 years (27-96). 8 were women. 64% Caucasian, 12% Black, 12% Hispanic. Table 1 lists the PCR results, Table 2 the coinfections. Of the 15 Campylobacter positive results, culture was done in 8 and cultured in 5. All 3 Vibrio results were not confirmed by culture. The 1 Salmonella result was confirmed as non-typhi. Of the 2 Yersinia results, one was cultured and was confirmed. Of the 93 Norovirus results, 52 were tested at LabCorp, 30 (58%) were negative. Genogroup II was most common (36%) A significant percentage of our Biofire GI PCR Norovirus positive results were false positive. Also, the Vibrio results were not reliable. On the other hand, it was more sensitive for Campylobacter. While the Biofire GI PCR is a valuable tool for detecting several gastrointestinal pathogens, it is important to be aware of the potential for false positive Norovirus and Vibrio results and to use clinical judgment and confirmatory testing when appropriate All Authors: No reported disclosures

Background: Sodium-glucose cotransporter 2 inhibitors are important therapies to control blood glucose levels in patients with type 2 diabetes mellitus. The mechanism by which they achieve this is through the excretion of glucose in urine, which can promote an environment for genitourinary infections. The incidence of such infections is more common in geriatric patients, which make up most of the patients in Veteran Affairs medical centers. The aim of this study is to evaluate the incidence of cystitis, vaginitis, and balanitis in Veterans on SGLT-2 therapy.Methods: We did a retrospective chart review of Veterans who received at least 6 months of SGLT-2 empagliflozin for diabetes. Indication for heart failure only was an exclusion. The study years were 2018 to 2023. Demographic data, urine cultures, and medical charts were reviewed for documentation of cystitis and clinical diagnosis of vaginitis and balanitis.Results: A total of 400 Veterans were analyzed. The median age was 74.5 years. Most of the patients were men. There were 43 (10.75%) occasions of infectious complications: 32 cystitis, 6 balanitis, and 5 fungal vaginitis. There were no multidrug-resistant organisms isolated. There were no differences in the 2 groups (infectious complications versus noninfectious) in terms of age, hemoglobin A1C, body mass index, or duration of treatment. However, benign prostatic hyperplasia was more common in the infectious group.Conclusions: The incidence of infectious complications in our diabetic Veterans was minimal in number, with cystitis being at 8% and observed more in men with prostatomegaly. E. coli was the most frequent isolate in urine cultures. Isolation of multidrug-resistant organisms was not observed.

Kenison, David Ziya-Karal DO; Mohsin, Sabrina DO; Psevdos, George MD Author Information

Abstract Background The CDC strongly recommends nursing homes take resolute steps to improve antibiotic prescribing practices and reduce inappropriate use. This is because studies have shown that up to 70% residents of US nursing homes receive 1 or more courses of antibiotics in a year while 75% of these prescriptions may be unnecessary or inappropriate. Antibiotic stewardship programs (ASP) are committed to optimize treatment of infections and reduce adverse events by close monitoring, education, and preventing unsuitable use. We analyzed the effect of our ASP over antibiotic prescribing of four Veterans Affairs (VA) community living centers (CLC). Table 1. Methods Retrospective review of ASP notes in the year 2023- the inaugural year for ASP reviewing CLCs- addressing requests for restricted antibiotics over 4 CLCs at Northport VA campus. The 4 CLCs are structured nursing homes with a 139 total bed capacity with two long term residential care units, one mental health, and one combined subacute rehab/hospice. We compared antibiotic use as days of therapy (DOT)/1000 days, for total antibiotics use, and analyzing cephalosporins, fluoroquinolones anti-MRSA, anti-MSSA, for years of pandemic 2020-2022 vs. 2023. Figure 1a Results Comparing 2020-22 vs. 2023 there was a decrease in all antimicrobial use in the CLCs, from 142 DOT/1000 days to 88. In 2023 the ASP team reviewed 135 CLC requests for restricted antibiotics, and 56 E-advice requests for guidance. 10% of the requests were denied. See table 1. The most common request for E- advice was whether to treat asymptomatic bacteriuria with/or without presence of urinary catheter. Comparing 2020-22 vs. 2023 there was a decrease in cephalosporins use by DOT/1000 days, 29.3 vs. 10.8, P: 0.09. There was no difference in Fluoroquinolones 2.0 vs. 6.0 P: 0.953, anti-MRSA antibiotics, 7.02 vs. 4.04 P:0.348, anti MSSA 0.67 vs. 0.8 P: 0.574. See figures 1a/1b. Figure 2 shows a downward trend of C. difficile infections in our CLCs. Figure 1b Conclusion Our ASP was overall successful in decreasing antibiotic use in our CLCs, notably for cephalosporins, while keeping FQ and other antibiotics use low. We were successful in education and preventing antibiotics especially for asymptomatic bacteriuria. An equally important achievement for our program was the decreasing rate of C. difficile infections. Figure 2 Disclosures All Authors: No reported disclosures

Abstract Background Sodium glucose co-transporter 2 inhibitors (SGLT-2) are currently recommended for type 2 Diabetes, chronic kidney disease and atherosclerotic cardiovascular disease. Despite their known health benefits, a recent study within the Veterans Affairs (VA) Health care system found a relatively low rate of utilization for SGLT-2. Several studies have shown an association of SGLT-2 with increased risk for genital mycotic infections, cystitis and urosepsis. We evaluated the incidence of such infectious complications in US Veterans (VET)Table 1.Demographic Characteristics of the Cohort Methods Retrospective chart review of VET at Northport VA Medical Center who had received at least six months of SGLT-2 empagliflozin (EMP) for diabetes. VET who received EMP for heart failure only were excluded. The study years were 2018-2023. Demographic data, urinalysis, urine cultures, medical charts were reviewed for documentation of cystitis, clinical diagnosis of vaginitis/balanitis and need for hospitalization for urosepsisTable 2.Comparison of the two groups: infectious vs. no infectious complications Results 400 VET were analyzed in the study period. The median age was 74.5 years. 78% were Caucasian, 15.5% black. 93% men. Table 1 shows the demographics of the cohort. There were 43 (10.75%) occasions of infectious complications: 32 (8%) cystitis (4 in women; one recurrent), 6 Balanitis, 5 fungal vaginitis (2 recurrent) . EMP was discontinued in all cases. 7/32 cystitis were clinical diagnoses without culture data. 6 cases of cystitis had more than 1 organism isolated. 2 VET were hospitalized due to urosepsis. There were no multidrug resistant organisms isolated (2 E. coli were resistant to ciprofloxacin) 1 case of balanitis in an HIV-infected man was cultured and grew Trichoderma atroviride. No cultures were obtained in cases of vaginitis. There were no differences in the two groups (infectious complications vs. noninfectious) in terms of age, HbA1c, BMI, GFR, duration of EMP treatment, use of insulin; However BPH was more common in the infectious group. See table 2. Table 3 lists the organisms isolated in urine cultures. No patient died from infectious complicationsTable 3.Organisms isolated in clinical specimens Conclusion The incidence of infectious complications in our diabetic VET due to EMP was overall low, with cystitis being at 8%, and observed more in men with prostatomegaly. E. coli was the most frequent isolate in urine cultures but no multidrug resistant organisms seen Disclosures All Authors: No reported disclosures

Abstract Background Previous reports in patients with HIV (PWH) and infective endocarditis (IE) have reported variable mortality compared to their non-HIV counterparts. However, most studies are older, have included younger patients with high rates of IV drug use, and uncontrolled HIV status with low CD4 count. Contemporary antiretroviral therapy has stabilized HIV, but little is known about IE outcomes in the current PWH population, as underlying HIV-related inflammatory process may impact outcomes or HIV status may affect therapeutic approaches due to access issues or provider bias.Table 1.Baseline characteritics of the propensity matched cohorts. Methods We used data from the TriNetX Research Network, an electronic health records network with over 100 million patients. We identified (1) a cohort of patients age ≥65 with HIV (ICD-10-CM code B.20) and IE (code I33.X) diagnosed between 1/1/2014 and 12/31/2023, and (2) a propensity score-matched cohort of patients age ≥65 with IE without HIV, matched for demographics, social history including substance abuse, and comorbid conditions. We evaluated 1-year rates of all-cause mortality, stroke, heart failure, and cerebral infections. We also evaluated the proportions of patients who underwent cardiac surgery in both groups. We used Cox proportional hazards regression to compare 1-year outcomes and logistic regression to estimate odds ratio for surgical treatment.Figure 1.One-Year Kaplan-Meier rates of death, incident stroke, incident heart failure, and cerebral infections among patients with infective endocarditis and HIV (+) (black line) vs. HIV (-) (red line) status Results We identified 269 PWH and IE and 269 matched patients with IE without HIV. The baseline characteristics of the cohorts were well balanced, Table 1. After 1-year, 68 (28.5%) patients in the PWH group had died vs. 69 (30.4%) in the non-HIV group (HR: 0.88, 95%CI 0.63 – 1.23; P=0.46). Both patient groups experienced similar 1-year rates of stroke (7.6% vs. 4.3%; P=0.23), heart failure (14.3% vs. 16.5%; P=0.55), and cerebral infections (0.8% vs. 0.8%; P=0.99), Fig. 1. Only 10 patients in each group (3.7% for both) underwent cardiac surgery (P >0.99). Conclusion In contemporary older (age ≥65) PWH and IE, compared to matched patients without HIV and IE, no difference in 1-year mortality was observed. Other IE-associated outcomes were also similar. Interestingly, rates of cardiac surgery were similar but low in both groups. Therefore, our data suggest that possible HIV-related inflammation does not affect outcomes in IE among older patients with stable HIV status. Disclosures All Authors: No reported disclosures

From the ∗Department of Infectious Diseases, Stony Brook Medical Center, Stony Brook †Department of infectious diseases, Northport Veterans Affairs Medical Center, Northport, NY. Correspondence to: George Psevdos, MD, Chief of infectious diseases, Department of infectious diseases Northport Veterans Affairs Medical Center, 79 Middleville Rd, Northport, New York, 11678. E-mail: [email protected]. The authors have no funding or conflicts of interest to disclose.

Division of Infectious Diseases, Northport Veterans Affairs, Northport, NY [email protected] Division of Infectious Diseases, Northport Veterans Affairs, Northport, NY. The authors have no funding or conflicts of interest to disclose.

Sajib, Monirul I. MD; Ford, Florence RN, BSN, MSN; Psevdos, George MD Author Information

Abstract Background Infectious gastroenteritis remains a common cause of morbidity in the US. While stool culture had been the standard tool for microbiological diagnosis, known for its time consuming and often lower yields, rapid diagnostic tests have now been developed. Individual and multiplex gastrointestinal (GI) polymerase chain reaction (PCR) are commercially available that can provide rapid and accurate results. We reviewed the GI infections in US Veterans (VET) assessing the use of GI PCR Methods Retrospective chart review from 10/1/2021 to 3/31/2023 of US VET at Northport VAMC who had positive results on Biofire® GI PCR panel; positive ova and parasites (O+P), positive stool cultures, C-difficile GDH/toxin B assays and H.pylori stool antigens Results In the study period there were 264 GI PCR and 224 O+P tests. 86 VET had GI infections. GI PCR identified 26 viral infections with norovirus being the most common. 16 coinfections identified. The median age was 58.5 years. 77% White, 19% Black. 81 were men. 78/86 had presented with diarrhea, 31 with abdominal pain/dyspepsia. 30 VET were treated as inpatient. 18/86 had Diabetes, 32, GERD, 11 Asthma, 13 COPD, 45 HTN, 46 HLD, 3 HIV, 20 CAD, 7 with malignancies (carcinoid, MALT lymphoma, Non-Hodgins lymphoma, lung, tonsil, prostate, multiple myeloma). 25 VET had recent exposure to antibiotics. 10 had recent travel. 59 received antibiotic therapy. 25 had prior history of C. difficile infection (CDI). Of the 30 positive tests by GI PCR, 19 were clinically treated for CDI: 14 with oral vancomycin 5 with fidaxomicin. Of the 6 campylobacter infections by GI PCR, 4 were confirmed by culture. Of the 2 positive vibrio spp by GI PCR: one vibrio cholera was not confirmed by culture and toxin assay (this patient was not included in the analysis); the other vibrio spp by PCR, culture confirmed V. parahaemolyticus. 1 VET with multiple myeloma and CDI died due to multiorgan failure. One dual infection with salmonella and Yersinia by PCR: only salmonella (non typhi) was confirmed by culture GI Infections Travel History, Co-Infections Conclusion GI PCR can offer a rapid diagnosis for viral etiologies and can be more sensitive as compared to culture for campylobacteriosis. However, vibrio and Yersinia spp results would need to be confirmed by culture. Also diagnosis of CDI would need interpretation of GDH/toxin and clinical judgement Disclosures All Authors: No reported disclosures

Sir, The COVID-19 pandemic has caused a historic public health emergency, with an estimated 458 million confirmed cases and 6 million deaths.[1] The highly transmissible SARS-CoV-2 virus can cause severe pneumonia as well as extrapulmonary sequelae, making accurate diagnosis and management crucial.[2] Legionnaire's disease is a severe atypical bacterial pneumonia that can be associated with SARS-CoV-2 infection.[3] Like SARS-CoV-2 infection, legionella may be associated with extrapulmonary symptoms, including diarrhea, hyponatremia, and neurological manifestations such as encephalopathy, among others.[4] Importantly, the mortality rate of legionella infection is high, with one study reporting over 6% mortality despite appropriate antibiotic therapy with either azithromycin or a fluoroquinolone.[5] A 74-year-old male presented to our institution with dyspnea, cough, and fever, found to be hypoxic with laboratory abnormalities including hyponatremia, hypophosphatemia, transaminitis, and acute kidney injury. Infectious work up detected SARS-CoV-2 RNA and a positive legionella urinary antigen. Chest x-ray was obtained demonstrating diffuse bilateral infiltrates [Figure 1]. He was treated with a 7-day course of azithromycin and symptoms as well as laboratory abnormalities resolved.Figure 1: High resolution chest X-ray from our patient with Legionella pneumonia demonstrating diffuse bilateral infiltratesWhile the COVID-19 pandemic continues to stress health-care systems worldwide, the presence of SARS-CoV-2 infection does not preclude the presence of other pneumonias. Multiple case reports have described SARS-CoV-2 and Legionella coinfection.[3,6,7] In 2 of 3 cases, a fever was documented. In addition, hyponatremia was seen in all three cases and an elevated white blood cell count and procalcitonin in 2 of 3 cases. These reports highlight the various overlapping signs and symptoms that make diagnosis challenging. The high mortality associated with both pneumonias necessitates a differential on the part of the healthcare provider to include bacterial superinfections in patients presenting with suspected or confirmed COVID-19 infection. Further, rapid diagnosis of bacterial pneumonia may allow for avoidance of COVID-19-specific therapy, such as dexamethasone or tocilizumab, which may affect viral clearance and alter recovery from bacterial pneumonia. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

The Advisory Committee on Immunization Practices recommends all healthcare practitioners and hospital staff receive an annual influenza vaccination. Many challenges were noted in achieving this goal; especially during the last 2 influenza seasons throughout the COVID-19 pandemic. Over the past 3 years our institution has implemented a Drive-Thru fixed Point of Distribution (POD) event for this purpose. Drive-Thru PODs can be a safe and effective strategy for employee vaccination during a pandemic.

From the ∗Stony Brook University Hospital, Stony Brook †Division of Infectious Disease, Northport Veteran Affairs, Northport, NY. Correspondence to: Alexander Njoroge, MD, Stony Brook University Hospital, 100 Nicolls Rd, Stony Brook, NY 11794. E-mail: [email protected]. The authors have no funding or conflicts of interest to disclose.

Zahra, Aleena MD; Thorne, Monique EdD, MS, NPD-BC; Psevdos, George MD Author Information

Abstract Background Legionella is found in all natural water sources & has been linked to waterborne environmental outbreaks of pneumonia. Environmental surveillance in healthcare facilities is of paramount importance to prevent Legionella overgrowth and acquired infections. This can a be a challenging task for our large 268-acre Veterans Affairs campus with its own water supply wells and water distribution system, 10 buildings housing acute care, outpatient clinics, residential and nursing homes. While the COVID 19 pandemic absorbed resources & time, water testing was not neglected. We report our experience of Legionella water testing during the pandemic Methods Water Legionella sample testing is done quarterly involving 180 faucets & showers throughout the facility, ice machines and 4 cooling towers (CT). Cultures are performed in a reference laboratory. Annual cost $100,000. A positive detection is defined as 1 colony forming unit (CFU)/mL from faucets and 10 CFU/mL from CT. Every positive detection is managed as follows: remediation by hyperchlorination, resampling, disinfection of cooling towers, and removal of equipment (ice machines) Results In fiscal Years 2020-22 4853 Veterans were hospitalized and 455 were tested for Legionella via urinary antigen; 3/455 patients had legionellosis, all were community-related, & 1 had a concurrent coinfection with COVID-19. 2221 water samples were collected. Table 1 shows detections and locations. All detections were remediated by localized chlorine disinfection & then resampled. Retreatments with increased disinfectant dosage was implemented in repeat positive detections. In few instances up to 3 retreatments were required to achieve negative growth. For repeat positive detections for CTs remediation utilized addition of a 2nd biocide No employee/patient case of Legionella pneumonia has been associated with exposure to positive water testing Table 1 Positive Legionella detections Figure 1 Facility Diagram location of buildings and Cooling Towers Conclusion Preventing Legionella water overgrowth in a large Veteran Affairs campus can be a tedious and costly endeavor. L. pneumophila and non pneumophila species were detected in various locations including the CTs, nevertheless remediation protocols were immediately followed and proved successful. There were only 3 cases of Legionella pneumonia in the study period, but none were facility associated Disclosures All Authors: No reported disclosures

Abstract Background In the last 3 years the novel severe acute respiratory syndrome coronavirus 2 (SARS CoV-2), which causes coronavirus disease 2019 (COVID 19), has menaced the world causing morbidity and mortality. Infection control preventionists had stepped up and were instrumental in the prevention of hospital acquired COVID infections. Discontinuation of isolation precautions in prolonged hospitalized patients and with persistently positive reverse-transcriptase polymerase chain reaction (RT-PCR) can be quite challenging. Distinguishing prolonged viral shedding vs. detection of inactive viral remnant is not easy. Cycle threshold (Ct) values can be of help, knowing that Ct values > 35 are not related with viable virus. We reviewed our experience of using Ct for infection control decisions Methods Retrospective chart review of hospitalized Veterans (VETS) in Northport VAMC from 1/1/2021 to 3/31/23. Viral burden rebound was defined as a case of Ct showing the following trend: from low numbers to ≥35 and then decreasing to below 35. Ct values were obtained from SARS CoV-2 RT-PCR, Xpert® Xpress, Cepheid Results 2730 VETS had COVID 19 during the pandemic. Of the 235 VETS hospitalized in the study period 20 had Ct values that remains ≤ 35 for > 14 days. All were men. 80% Caucasian. The median age was 78.5. 2 were unvaccinated. 3 had COVID in the past (5, 8, 20 months prior). See Table 1. 90% had hypertension and 30% had active malignancy. The median length of stay was 23 days (16-76). The median days duration of Ct being < 35 is 20 (16-45). The lowest Ct values ranged from 16 to 29.3. In 8 patients the lowest value was on admission, in the rest it ranged from hospital day 3 to 23. 7 patients showed evidence of viral burden rebound with 1/7 having a Ct < 35 for 45 days. 2/7 had received monoclonal antibody therapies, 1 molnupiravir, and 4 remdesivir/steroids. The median duration of COVID 19 precautions was 20, range 15 to 55. 1 VET required intubation. 2 died but did not have evidence for viral burden rebound. 3 remained asymptomatic and did not need treatment Table 1 Demographics Table Conclusion Prolongation of COVID 19 precautions for more than 14 days were noted in elderly Veterans with comorbidities, with 1/3 having active malignancy. Utilization of Ct value was crucial in identifying cases of viral burden rebound and thus extending infection control measures Disclosures All Authors: No reported disclosures