Throughout the coronavirus disease 2019 (COVID-19) pandemic, clinicians and researchers with appointments in separate divisions of infectious diseases (ID) and preventive medicine (PM) subspecialties collaborated on multiple projects, programmatic activities, and large-scale interventions at a tertiary academic medical center in the US Midwest. This collaboration was one of the reasons that prompted the integration of these groups into 1 unified academic division. Although this integrated structure is uncommon in the United States, the rationale, circumstances, and culture leading to this realignment may be common to other academic health systems.

Objective:Our study aimed to assess the impact of pharmacogenomic panel testing in people with HIV (PWH).Design:Prospective, observational intervention assessmentMethods:One hundred PWH were provided a comprehensive pharmacogenomic panel during routine care visits within the HIV specialty clinic of a large academic medical center. The panel determined the presence of specific genetic variants that could predict response or toxicity to commonly prescribed antiretroviral therapy (ART) and non-ART medications. An HIV specialty pharmacist reviewed the results with participants and the care team. The pharmacist (1) recommended clinically actionable interventions based on the participants' current drug therapy, (2) assessed for genetic explanations for prior medication failures, adverse effects, or intolerances, and (3) advised on potential future clinically actionable care interventions based on individual genetic phenotypes.Results:Ninety-six participants (median age 53 years, 74% white, 84% men, 89% viral load <50 copies/ml) completed panel testing, yielding 682 clinically relevant pharmacogenomic results (133 major, 549 mild-moderate). Ninety participants (89 on ART) completed follow-up visits with 65 (72%) receiving clinical recommendations based on current medication profiles. Of the 105 clinical recommendations, 70% advised additional monitoring for efficacy or toxicity, and 10% advised alteration of drug therapy. Panel results offered explanation for prior ART inefficacy in one participant and ART intolerance in 29%. Genetic explanation for non-ART toxicity was seen in 21% of participants, with genetic contributors to inefficacy of non-ART therapy identified in 39% of participants.Conclusion:Preliminary data in a small cohort of PWH demonstrates benefit of routine pharmacogenomic panel testing.

The role of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) convalescent plasma in the treatment of Coronavirus Disease 2019 (COVID-19) in immunosuppressed individuals remains controversial. We describe the course of COVID-19 in patients who had received anti-CD20 therapy within the 3 years prior to infection. We compared outcomes between those treated with and those not treated with high titer SARS-CoV2 convalescent plasma. We identified 144 adults treated at Mayo clinic sites who had received anti-CD20 therapies within a median of 5.9 months prior to the COVID-19 index date. About one-third (34.7%) were hospitalized within 14 days and nearly half (47.9%) within 90 days. COVID-19 directed therapy included anti-spike monoclonal antibodies (n = 30, 20.8%), and, among those hospitalized within 14 days (n = 50), remdesivir (n = 45, 90.0%), glucocorticoids (n = 36, 72.0%) and convalescent plasma (n = 24, 48.0%). The duration from receipt of last dose of anti-CD20 therapy did not correlate with outcomes. The overall 90-day mortality rate was 14.7%. Administration of convalescent plasma within 14 days of the COVID-19 diagnosis was not significantly associated with any study outcome. Further study of COVID-19 in CD20-depleted individuals is needed focusing on the early administration of new and potentially combination antiviral agents, associated or not with vaccine-boosted convalescent plasma.

Background: Accuracy of screening tests is vital in the diagnosis of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) infection. Objective: Our goal is to report false-positive serologic tests secondary to heterophile antibodies in a group of pork processing plant workers. Methods: We conducted a case series study of seven pork processing plant workers referred to our clinic between 2017 and 2020 for a positive fourth-generation HIV test. Results: All patients had undetectable HIV-1 and HIV-2 RNA viral load, ruling out HIV infection. Five patients had initial positive HBV serologies but were negative upon retesting with neutralizing antibodies or heterophile antibody binding reagent. Three patients presented with respiratory symptoms. After extensive workup, they were diagnosed with interstitial lung disease of unknown etiology. For patients who left the plant, their symptoms resolved, and serologic test results reverted to negative. Conclusions: : Occupational exposure to pork meat products may elicit heterophile antibody development and yield false-positive serologic results for HIV and viral hepatitis. Clinicians should interpret serologic tests carefully together with other relevant patient history and molecular tests. Further investigation is warranted to determine the etiology, pathophysiology, and occupational link of the pneumonitis syndrome.

Perioperative medical management is challenging because of the rising complexity of patients presenting for surgical procedures. A key part of preoperative optimization is appropriate management of long-term medications, yet guidelines and consensus statements for perioperative medication management are lacking. Available resources use recommendations derived from individual studies and do not include a multidisciplinary focus on formal consensus. The Society for Perioperative Assessment and Quality Improvement identified a lack of authoritative clinical guidance as an opportunity to use its multidisciplinary membership to improve evidence-based perioperative care. The Society for Perioperative Assessment and Quality Improvement seeks to provide guidance on perioperative medication management that synthesizes available literature with expert consensus. The aim of this consensus statement is to provide practical guidance on the preoperative management of immunosuppressive, biologic, antiretroviral, and anti-inflammatory medications. A panel of experts including hospitalists, anesthesiologists, internal medicine physicians, infectious disease specialists, and rheumatologists was appointed to identify the common medications in each of these categories. The authors then used a modified Delphi process to critically review the literature and to generate consensus recommendations.

Life-changing progress has been made over the past 30 years in the treatment of HIV infection. HIV has transformed from an illness that resulted in one complication after another and nearly always resulted in death to a chronic illness that for most patients is more easily managed than diabetes or heart disease. Antiretroviral therapy (ART) is now simple and well-tolerated. The most important priority of HIV treatment is ensuring that people living with HIV stay on continuous, effective ART. ART, although not curative, suppresses the virus and allows the immune system to recover. Even when the CD4 count remains low, suppressive ART helps prevent opportunistic infections and other HIV related complications. (1) Suppressive ART is important not only to the individual living with HIV health but is an important public health goal since people living with HIV will not transmit HIV to their sexual partners if their viral load is undetectable. (2) A respectful, culturally appropriate patient–provider relationship is one of the most important factors in keeping people living with HIV engaged in care. (3) Persons living with HIV deserve both excellent HIV and primary care. Some communities have providers that are experts in both, but often people living with HIV receive the best care by collaboration between their primary care provider and an HIV expert. This article is written to help primary care givers who are not HIV experts provide appropriate primary care to their patients who are living with HIV and emphasizes issues that deserve additional attention in people living with HIV compared to the general population

Purpose: To present a case of subretinal abscess associated with pneumonia and meningitis caused by Cryptococcus gattii in an immunocompetent host. Observations: A 37-year-old man presented with sub-acute painless unilateral vision loss and a white submacular elevation. Systemic evaluation revealed a lung lesion and cerebrospinal fluid evidence of Cryptococcus gattii infection. Conclusions and importance: While Crypococcus neoformans has been well described as a cause of chorioretinitis in immunocompetent and immunocompromised hosts, this report demonstrates that Cryptocuccus gattii is a related uncommon pathogen to be considered in similar presentations. Submacular surgical debridement may be challenging and OCT imaging may be helpful to detect full-thickness retinal necrosis.

Infections of the urinary system may involve the lower urinary tract (confined to the bladder) or the upper urinary tract (pyelonephritis). The spectrum of urinary conditions ranges from asymptomatic bacteriuria, symptomatic urinary tract infection (UTI), and sepsis associated with UTI that requires hospital admission. The treatment of UTIs include antibiotics that can result in long-term alteration of the normal microbiota of the gastrointestinal tract and in the development of multidrug-resistant microorganisms. For this reason, a urine sample should be cultured to identify causative organisms and their antimicrobial susceptibilities.

Tuberculosis transmission has been documented in health care settings where health care providers and patients encounter persons with unsuspected, infectious tuberculosis disease who have not been isolated in a timely manner or have not received appropriate treatment. Initial risk assessment for tuberculosis is crucial for determining administrative, environmental, and respiratory protective measures. Preventing the spread of aerosol-transmissible pathogens requires the use of airborne infection isolation rooms. In addition, respiratory protection with an N95 or higher-level respirator is recommended. Patients with suspected or confirmed respiratory tuberculosis disease should not share rooms.

A 44-year-old male presented with headaches and fever for one month. Six months prior, he had hemoptysis that resolved without treatment. Chest computed tomography revealed a necrotizing lung nodule on the right mid lobe with lymphadenopathy (Fig. 1). He was originally from Mexico, worked in landscaping, and denied exposure to tuberculosis. In the ED, he had fever and tachycardia with no meningeal signs. Magnetic resonance imaging (MRI) of the brain revealed an enhancing sellar mass (Fig. 2A). Cerebrospinal fluid (CSF) analysis showed 96 total nucleated cells/μL (TNC), 91% lymphocytes, 30 mg/dL protein, and 55 mg/dL glucose (parallel blood glucose 98 mg/dL). CSF bacterial and fungal/mycobacterial cultures on empirical antimicrobials were negative. Endoscopic transsphenoidal biopsy revealed a necrotic, purulent hypophyseal cyst, and histopathology demonstrated acute inflammation without granulomas. Bacterial, fungal/mycobacterial cultures, Histoplasma, and Blastomyces polymerase-chain-reaction (PCR) of the sampled tissue were unrevealing. The patient was discharged on empiric ertapenem and vancomycin for four weeks.

Health care providers are frequently faced with the challenge of caring for patients who have limited English proficiency. These patients experience challenges accessing health care and are at higher risk of receiving suboptimal health care than native English speakers. Health care interpreters are crucial partners to help break down communication barriers and prevent these patients from facing health care disparities. Many providers lack the skill set and knowledge that are vital to successful collaboration with an interpreter. The objective of this article is to address a number of questions surrounding the use of health care interpreters and to provide concrete suggestions that will enable providers to best serve their patients.

Background: Pretravel consultation involves a face-to-face visit with a Travel Medicine expert and includes time consuming educating/counseling. Efficacy of electronic consultations for pretravel is unknown. We compared pretravel education via face-to-face consult to an electronic consultations combined with education via Video Supported PowerPoint for select travelers. Methods: We conducted a prospective trial comparing pre-travel education via electronic consultations versus face-to-face consult. Study was conducted from May 2014 through May 2015. Results: Pretravel surveys were completed by 100 in electronic consult arm and 94 in face-to-face consult arm; 67/100 (67%) in the electronic consult and 51/94 (54.2%) in the face-to-face group completed post-travel surveys. Both groups had similar baseline demographics. 36.2% of the face-to-face group felt the trip preparation could have effectively been accomplished through electronic consult, while 33% felt that a face-to-face consult was needed; in contrast, a majority (63.3%) of electronic consult group preferred the electronic consult. Pretravel education effectiveness was similar in both groups. No statistically significant differences in responses were noted in both groups to 5 of the 6 knowledge assessment questions. A higher proportion (76/100; 76%) in the electronic consult group compared to 55.4% (51/94) (p = 0.0018) in face-to-face group chose the correct response regarding management of febrile bloody diarrhea. 53% reported behavior change to prevent travel related illnesses, with no statistically significant differences between the groups. Conclusions: electronic consultation with Video Supported PowerPoint pre-travel education is as effective as education via face-to-face consultations and provides a viable alternative to face-to-face consultations in select travelers.

The coronavirus disease 2019 (COVID-19) pandemic has disrupted the traditional medical training of residents and fellows. Suspension of large-group, face-to-face interactions is certainly needed to flatten the curve of COVID-19 transmission. Therefore, in-person conferences have been suspended to keep learners safe and clinical medicine is increasingly being practiced virtually, with the human touch to care restricted. However, these changes substantially challenged our ability, as faculty, to supervise learners and ensure that our programs delivered high-quality education during the pandemic.

Abstract This chapter describes the transmission, diagnosis, disease history, care, associated infections and conditions, possible treatments, and lifestyle adjustments for living with an HIV infection.

Abstract Background Over 80% of patients with hematologic malignancies develop some form of infectious complication, most commonly febrile neutropenia. Patients with febrile neutropenia have 10% mortality, which increases if antibiotic administration is delayed past 30 minutes. Studies have suggested β-lactam allergy may delay administration of antibiotic while putting patients at greater risk for inappropriate antibiotic choice and adverse effects stemming from this. We sought to describe the risks associated with β-lactam allergy in the neutropenic population. Methods We conducted a retrospective, descriptive study from January 2016 to December 2017 identifying patients with febrile neutropenia and a reported history of β-lactam allergy. Baseline characteristics, allergy data, treatment data, and outcomes were collected and analyzed. Results We identified 31 patients with febrile neutropenia and β-lactam allergy during this time period. Etiologies of neutropenia were hematologic malignancy (61.2%), stem cell transplantation (12.9%), solid-organ malignancy (22.6%), and autoimmune (3.3%). Reported reactions to β-lactams were rash (41.9%), hives (9.7%), anaphylaxis (3.2%), other (9.7%), and unknown (35.5%). Average time to antibiotic administration was 142.5 minutes. Antibiotic choice was cefepime (61.3%), piperacillin–tazobactam (6.5%), carbapenem (22.6%), fluoroquinolone (6.5%), cefepime and fluoroquinolone (3.2%), and vancomycin (58.1%). 51.6% received initial antibiotics consistent with the 2010 IDSA guidelines. Six patients underwent penicillin skin testing, all negative. 1 patient developed C. difficile infection, 1 developed MRSA colonization, and 3 developed VRE colonization. Mortality was 3.2% at 30 days and 16.1% at 90 days. Conclusion Our study estimated the antibiotic usage patterns and outcomes in patients with febrile neutropenia and reported β-lactam allergy. This showed low adherence to an established guideline for antibiotic choice in these patients. With rising antimicrobial resistance, there is a need to develop strategies to reduce inappropriate antimicrobial use, especially in patients with febrile neutropenia. Preemptive β-lactam allergy evaluation warrants further evaluation in the neutropenic population. Disclosures All authors: No reported disclosures.

Abstract Background Pre-travel consultation involves an in-clinic face-to-face consult (F2F) with a Travel Medicine provider. F2F involves education/counseling which is time-consuming for both patients and providers. Although electronic consultations (synchronous and asynchronous) are well established in many subspecialties, pretravel eConsults are not well known. We compared pretravel education via F2F to an innovative hybrid electronic consultation (HeC) combined with a Video Supported PowerPoint (VSP) for selected travelers. Methods We conducted a prospective trial comparing HeC-VSP to F2F to determine the quality of pretravel education. Study was approved by the Mayo Clinic IRB. Patients were enrolled from May 2014 through May 2015. Patients in both arms were given pretravel and post-travel surveys. Exclusions included age less than 18 years, first trip to Africa, immunocompromised host, non-English-speaking traveler, or travel for longer than 4 weeks. Results 194 patients were enrolled; 100 in HeC-VSP and 94 in F2F arm completed pretravel survey. Post-travel survey was completed in 54.2% (51/94) of the F2F, 67% (67/100) in the HeC-VSP group. The groups are similar in demographics and prior travel experience (Table 1). 36.2% of the F2F group felt that the consultation could have been effectively accomplished through a video-based education, while 33% felt that a F2F was needed; in contrast a majority (63.3%) in the HeC-VSP group would not have preferred a F2F consultation. HeC-VSP-based pretravel education was similar compared with that provided via the F2F consults. There were no statistically significant differences in the responses obtained in both groups to knowledge assessment questions (Table 2) except for one question. A higher proportion (76/100; 76%) in the HeC-VSP group compared with 55.4% (51/94) chose the correct response (P = 0.0018) regarding management of bloody diarrhea with fever. Self-reported change in behaviors to prevent travel-related illnesses was reported overall in 53% of the patients with no statistically significant differences between the groups. Conclusion Nonsynchronous eConsultation combined with VSP provides a viable solution to provide pretravel education for a select travel population. Disclosures All authors: No reported disclosures.

Purpose: The aims of this study are to evaluate the impact of a novel immunization curriculum based on the Preferred Cognitive Styles and Decision Making Model (PCSDM) on internal medicine (IM) resident continuity clinic patient panel immunization rates, as well as resident immunization knowledge, attitudes, and practices (KAP). Methods: A cluster-randomized controlled trial was performed among 143 IM residents at Mayo Clinic to evaluate the PCSDM curriculum plus fact-based immunization curriculum (intervention) compared to fact-based immunization curriculum alone (control) on the outcomes of resident continuity clinic patient panel immunization rates for influenza, pneumococcal, tetanus, pertussis, and zoster vaccines. Pre-study and post-study immunization KAP surveys were administered to IM residents. Results: Ninety-nine residents participated in the study. Eighty-two residents completed pre-study and post-study surveys. Influenza and pertussis immunization rates improved for both intervention and control groups. There was no significant difference in immunization rate improvement between the groups. Influenza immunization rates improved significantly by 33.4% and 32.3% in the intervention and control groups, respectively. The odds of receiving influenza immunization at the end of the study relative to pre-study for the entire study cohort was 4.6 (p < 0.0001). The odds of having received pertussis immunization at the end of the study relative to pre-study for the entire study cohort was 1.2 (p = 0.0002). Both groups had significant improvements in immunization knowledge. The intervention group had significant improvements in multiple domains that assessed confidence in counseling patients on immunizations. Conclusions: Fact-based immunization education was useful in improving IM resident immunization rates for influenza and pertussis. The PCSDM immunization curriculum did not lead to increases in immunization rates compared with the fact-based curriculum, but it did significantly increase resident confidence in communicating with patients about vaccines. (C) 2018 Elsevier Ltd. All rights reserved.

The Conference on Retroviruses and Opportunistic Infections (CROI) is a major annual scientific meeting on HIV/AIDS and associated conditions. Tuberculosis (TB) is the number one cause of death among people living with HIV in developing countries and is the subject of numerous CROI presentations. This report will focus on the presentations at CROI that the author believes are most relevant to clinicians, the public health community and investigators interested in tuberculosis.