malignancy or hematopoietic stem cell transplant (HSCT) (11 patients), use of immu- Background. Discrepancies between histomorphologic finding and indirect test nosuppressing medications (11 patients), and invasive procedures. (9 patients). At the results such as galactomannan (GM) assay make diagnosis of invasive fungal time of diagnosis, only six patients were on an antifungal with mold activity. Eight difficult. We investigated the frequency and clinical characterisitics of positive GM patients died during hospitalization. The distribution of cases over time was compared assay results in patients with mucormycosis. with weather data for Colorado. A cluster of cases occurred in 2013 (6 cases) and in Methods. Patients who met the modified criteria for proven or probable mucor- 2017 (8 cases). A majority of cases were diagnosed during the summer and fall months mycosis and had serum and/or bronchoalveolar lavage (BAL) fluid GM assay result with July being the month with the most number of cases. There were higher levels of were enrolled at a tertiary hospital from July 2009 to October 2017. Proven mucor- precipitation that occurred prior to or during the cluster of cases. mycosis was defined as histologic evidence of tissue invasion of hyphae with positive Conclusion. Cases of mucormycosis at UCH were associated with DM, hemato- mucormycosis immunohistochemistry (IHC) test result and the recovery of agents of logic malignancy/HSCT, use of immunosuppressive therapy, and invasive procedures. mucormycosis (Rhizopus spp., Cunninghamella spp., Apophysomyces spp., Saksenaea The increase of cases seen 2013 and 2017 occurred in the summer and fall months after spp., Absidia spp., Mucor spp.) by culture from sterile specimens. Probable mucor- higher levels of precipitation were observed in Colorado. Providers at UCH may con- mycosis was defined as histologic evidence of tissue invasion of hyphae with positive sider modifying antifungal prophylaxis to include mold coverage in patients with >2 mucormycosis IHC test result with or without recovery of agents of mucormycosis by risk factors for mucormycosis who are admitted during the summer and fall. culture from nonsterile specimens. Disclosures. M. Barron, Astellas Pharma: Investigator, Research support. Results. Among 50 patients of proven or probable mucormycosis, 20 (40%) patients were positive for serum and/or BAL fluid GM assay results; 13 of 20 (65.0%) were positive in serum, nine of 12 (75.0%) were positive in BAL fluid, and two of 12 399. Multi-centre Observational Study on Epidemiology, Treatment, and Outcome (16.7%) were positive in both. There were more patients with gastrointestinal infec- of Mucormycosis in India tions (4 of 20 [20%] vs. 0 of 30 [0%], P = 0.021) and diagnosed as histomorphologically 1,2 3 4 Atul Patel, MD, FIDSA ; Harsimran Kaur, MD ; Immaculata Xess, MD ; Joy aspergillosis (6 of 20 [30%] vs. 1 of 30 [3%], P = 0.012) in GM positive group than GM 5 6 S Michael, MD, FRC(Path) ; Jayanthi Savio, MD ; Shivaprakash Rudramurthy, negative group. 3 7 8 9 MD ; Rakesh Singh, MD ; Prakash Shastri, MD ; Pamidimukkala Umabala, MD ; Conclusion. These results suggest that positive GM assay results are not uncom- 10 11 12 Raman Sardana, MD ; Anupama Jyoti Kindo, MD ; Malini Capoor, MD ; mon in mucormycosis. GM assay results from the patients with mucormycosis appear 13 14 1 Sangeetha Mohan, MD and Arunaloke Chakrabarti, MD, FIDSA ; Infectious to be related with gastrointestinal and histomorphologic diagnosis of asper- 2 Diseases, Veda. Inst. of Med.Sci, Ahmedabad, India, Department of Internal gillosis. Further studies are needed on the mechanism of positive GM results in patients 3 Medicine, University of South Florida, Tampa, Florida, Department of Microbiology, with mucormycosis and possible coinfection with other fungi such as Aspergillus spe- 4 PGIMER, Chandigarh, India, Department of Microbiology, All India Institute of cies in these patients. 5 Medical Sciences, New Delhi, India, Clinical Microbiology, Professor, Vellore, India, Disclosures. S. H. Kim, the Korea Health Technology R&D Project through the 6 7 St. John’s Medical College Hospital, Banaglore, India, Department of Microbiology, Korea Health Industry Development Institute (KHIDI): Investigator, Grant recipient JIPMER, Pondicherry, India, 8Intensive Care Medicine, Sir Gangaram Hospital, New Delhi, India, 9Department of Microbiology, Nijam Institute of Medical Sciences, Hyderabad, India, 10Department of Microbiology, Indraprastha Apollo Hospital, 401. Pneumocystis jirovecii Pneumonia in Renal Transplant Recipients After a New Delhi, India, 11Department of Microbiology, Sri Ramachandra Medical College, 6-Month Trimethoprim–Sulfamethoxazole Prophylaxis: A Case–Control Study Chennai, India, 12Department of Microbiology, Safdarjung Hospital, New Delhi, Se Yoon Park, MD1; Sung Shin, MD2; Young-Hoon Kim, MD2; Joo Hee Jung, India, 13Christian Medical College, Ludhiana, India, 14Medical Microbiology, RN2; Sung-Han Kim, MD, PhD3 and Duck Jong Han, MD, PhD2; 1Department Postgraduate Institute of Medical Education and Research, Chandigarh, India of Infectious Diseases, Soonchunhyang University Seoul Hospital, Seoul, Korea, Republic of (South), 2Department of Surgery, Asan Medical Center, University Session: 56. Fungal Disease: Management and Outcomes 3 of Ulsan College of Medicine, Seoul, Korea, Republic of (South), Department of Thursday, October 4, 2018: 12:30 PM Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Background. Though the rise in number of mucormycosis cases has been Seoul, Korea, Republic of (South) reported globally, the rise in India is alarming especially in uncontrolled diabetics. Session: 56. Fungal Disease: Management and Outcomes However, multiple gaps exist in the understanding of the disease in this country. Thursday, October 4, 2018: 12:30 PM Methods. To describe the epidemiology, diagnosis, treatment practices, and outcome of mucormycosis in India. A single-arm prospective observational study Background. Pneumocystis jiroveci pneumonia (PCP) is an important cause of was conducted in the network of 17 tertiary care centres across India during April morbidity and mortality in kidney transplant recipients (KTRs). Chemoprophylaxis 2016 through September 2017. All consecutive proven mucormycosis patients were with trimethoprim-sulfamethoxazole (TMP-SMX) is recommended about enrolled in this study. Clinical data including risk factors, investigations, and treatment 6–12 months after solid-organ transplantation. However, PCP occasionally occurs were collected. All isolates and histopathological specimens were sent to Mycology after the recommended prophylaxis periods. The aim of this study was to investigate Reference Laboratory at Chandigarh for final identification (phenotypic and sequenc- the incidence and risk factors for PCP in KTRs with 6-month TMP-SMX prophylaxis. ing) and drug susceptibility testing. Methods. We performed a case–control study of adult patients diagnosed with Results. A total of 474 cases were enrolled between the study period. Rhino- PCP from 1999 to 2015 in a tertiary care hospital. All patients received 6-month PCP orbito-cerebral mucormycosis was common (42.7%) presentation with 22.8% patients prophylaxis with TMP-SMX after kidney transplantation (KT). If there were rejection had brain involvement, followed by pulmonary (14.6%), cutaneous (11.8%), isolated episodes, PCP prophylaxis was provided for additional 3 months. During the study renal (3.9%), and intra-abdominal (2.8%) mucormycosis. The underlying disease or period, CMV viremia was not indication of PCP prophylaxis because of the concern predisposing factors were noted in 79.7% cases (84.9% diabetes mellitus, 12.9% ster- of the nephrotoxicity of TMP-SMX. We defined the classification of early or late-onset oids, 10.3% trauma or history of surgery, 9.7% malignancy, and 9.2% transplant). The PCP as one year after transplantation. most common agents isolated were Rhizopus species (75.9%, R. arrhizus [74.3%] and Results. Among 3,941 kidney or pancreas-kidney transplant recipients, 67 (1.7%) R. homothallicus [6.7%]) followed by Apophysomyces variabilis (7.4%), Mucor species patients developed PCP after the discontinuation of TMP-SMX prophylaxis. Among (6%), and Lichtheimia corymbifera (4%). The patients were managed by medical ther- them, patients who was transferred from other hospitals (n = 14) and pancreas-kid- apy in 82.8%, surgery in 56.8% while 51.7% received combined medical and surgical ney transplant recipients (n = 6) were excluded. Finally, 47 of KT PCP and 94 control management. Amphotericin B (96.8%) either lipid formulations (65.7%) or conven- patients were included. Of the 47 patients with PCP, 24 (51%) revealed early PCP while tional form (39.1%) was the common antifungal used. The mortality of patients was the remaining 23 (49%) exhibited late PCP. Duration of PCP prophylaxis was similar 30.4%; of which, 80.3% patients died within 6 weeks of their diagnosis. 24.3% patients between case and control (median 6 months, respectively). In multivariate analysis, left hospital against medical advice while 50.1% survived. rejection (OR, 3.9; 95% CI, 1.4–11.1) and cytomegalovirus infection (OR, 2.4; 95% Conclusion. Rhino-orbital-cerebral mucormysosis in uncontrolled diabetics is CI, 1.0–5.8) were independently associated with the development PCP after TMP- common presentation in India. R. arrhizus followed by A. variabilis are common spe- SMX prophylaxis. Rejection or CMV viremia were observed in 70% of patients with cies isolated from those patients. Survival was noted only in half of the patients despite PCP patients. Time to development of PCP after rejection (median 6 months; IQR increased awareness and diagnosis. 5–19 months) was slightly shorter than that after CMV viremia (median 9 months; Disclosures. All authors: No reported disclosures. IQR 5–12 months), although this difference did not reach any statistical significance (P = 0.18). 400. The Frequency and Clinical Characteristics of Positive Galactomannan Assay Conclusion. Rejection and CMV viremia appear to be risk factors for the devel- Results in Patients With Mucormycosis opment of PCP after completing early transplantation period chemoprophylaxis. Our Sungim Choi, MD1; Joon Seon Song, MD2; Ji Hyun Yun, MD2; Jung Wan Park, data suggest that at least 6- to 9-month chemoprophylaxis for PCP may be needed for MD2; Kyung Hwa Jung, MD2; Kyeong Min Jo, MD1; Jiwon Jung, MD; Min KTRs with rejection or CMV viremia. Jae Kim, MD1; Yong Pil Chong, MD, PhD1; Young Soo Park, MD2; Sang-Oh Lee, Disclosures. All authors: No reported disclosures. MD, PhD1; Sang-Ho Choi, MD, PhD1; Jun Hee Woo, MD; Yang Soo Kim, MD, PhD1 and Sung-Han Kim, MD, PhD1; 1Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, Republic of 402. Breakthrough Pneumocystis jirovecii Pneumonia Among Cancer Patients: 2 Opportunity for Antimicrobial Stewardship? (South), Pathology, Asan Medical Center, University of Ulsan College of Medicine, 1 2 1,3 6 Steven Roncaioli, MPH ; Andrew Bryan, MD, PhD ; Erica Stohs, MD, MPH ; Songpa-gu, Seoul, Korea, Republic of (South), , Internal Medicine, Ulsan University 1,3,4,5 4,6 Hospital, Ulsan, Korea, Republic of (South) Catherine Liu, MD, FIDSA ; Ania Sweet, PharmD and Steven Pergam, MD, MPH, FIDSA1,3,4,5; 1Vaccine and Infectious Disease Division, Fred Hutchinson Session: 56. Fungal Disease: Management and Outcomes Cancer Research Center, Seattle, Washington, 2Department of Laboratory Medicine, Thursday, October 4, 2018: 12:30 PM University of Washington Medical Center, Seattle, Washington, 3Division of Allergy

S154 • OFID 2018:5 (Suppl 1) • Poster Abstracts and Infectious Diseases, University of Washington, Seattle, Washington, 4Seattle Activity of Olorofim againstScedosporium spp. and LoPro will be evaluated in an Cancer Care Alliance, Seattle, Washington, 5Clinical Research Division, Fred upcoming phase III trial. Hutchinson Cancer Research Center, Seattle, Washington, 6Department of Pharmacy, Disclosures. J. Vehreschild, Merck / MSD: Consultant, Research Contractor and University of Washington, Seattle, Washington Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. Gilead: Consultant, Research Contractor and Speaker’s Bureau, Consulting fee, Research grant Session: 56. Fungal Disease: Management and Outcomes and Speaker honorarium. Pfizer: Research Contractor and Speaker’s Bureau, Research Thursday, October 4, 2018: 12:30 PM grant and Speaker honorarium. Astellas Pharma: Consultant, Research Contractor and Background. Despite available prophylaxis, Pneumocystis jirovecii pneumonia Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. Basilea: (PJP) still occurs in immunocompromised hosts. We set out to determine the overall bur- Consultant, Research Contractor and Speaker’s Bureau, Consulting fee, Research den of PJP among cancer patients in the modern era at our cancer center. Furthermore, grant and Speaker honorarium. Deutsches Zentrum für Infektionsforschung: Member, we sought to describe reasons for failure to use prophylaxis among these patients. Research Contractor and Speaker’s Bureau, Research grant and Speaker honorarium Methods. In this retrospective cohort study, we identified PJP cases among Uniklinik Freiburg / Kongress und Kommunikation: Speaker’s Bureau, Speaker hon- patients admitted between January 2007 and December 2016 at our center. PJP was orarium. Akademie für Infektionsmedizin: Speaker’s Bureau, Speaker honorarium. defined as any positive test (immunofluorescence or PCR) from sputum and/or bron- Universität Manchester: Speaker’s Bureau, Speaker honorarium, Deutsche Gesellschaft choalveolar lavage. Patient demographics, underlying malignancy, anti-pneumocystis für Infektiologie: Member and Speaker’s Bureau, Speaker honorarium. Ärztekammer antibiotics and mortality were assessed through electronic medical records. Current Nordrhein: Speaker’s Bureau, Speaker honorarium. Uniklinik Aachen: Speaker’s Bureau, National Comprehensive Cancer Network (NCCN) guidelines were used to determine Speaker honorarium. Back Bay Strategies: Speaker’s Bureau, Speaker honorarium. who should have received prophylaxis. Cases not on prophylaxis at the time of diagnosis Deutsche Gesellschaft für Innere Medizin: Member and Speaker’s Bureau, Speaker hon- were reviewed to determine reasons why prophylaxis was not administered. Incidence orarium. M. J. G. T. Vehreschild, Pfizer: Speaker’s Bureau, Speaker honorarium. MSD/ of PJP for the last 5 years of the study was estimated based on a Poisson distribution. Merck: Consultant and Speaker’s Bureau, Consulting fee and Speaker honorarium. Results. A total of 37 patients had confirmed PJP over the 10-year study period. Gilead Sciences: Research Contractor and Speaker’s Bureau, Research grant and Speaker The majority were male (68%) with a median age of 60 years (IQR: 47, 67). The most honorarium. Organobalance: Speaker’s Bureau, Speaker honorarium Astellas Pharma: common underlying malignancy was acute myeloid leukemia (24%); 24/37 (65%) were Consultant, Research Contractor and Speaker’s Bureau, Consulting fee, Research bone marrow transplant recipients. The 5-year incidence between 2012 and 2016 was grant and Speaker honorarium. 3M: Research Contractor, Research grant. DaVolterra: 2.28 per 10,000 inpatient days (95% CI, 1.50–3.32). There was no evidence of cluster- Research Contractor, Research grant. Berlin Chemie: Consultant, Consulting fee ing of PJP diagnoses. Overall, 26/37 (70%) of PJP patients were not on prophylaxis O. A. Cornely, Amplyx Pharmaceuticals, Basilea Pharmaceutica, F2G, Gilead at the time of diagnosis, 12 of whom met NCCN criteria for use. Twenty-three were Sciences, MSD Sharp and Dohme, Scynexis Inc.: Consultant, Consulting fee deceased by the end of the study with 11/23 (48%) deaths occurring within 30 days of Amplyx Pharmaceuticals, Basilea Pharmaceutica, F2G, Gilead Sciences, MSD diagnosis. The main reason prophylaxis was not administered was neutropenia (19%). Sharp and Dohme, Scynexis Inc.: Grant Investigator, Research grant A documented sulfa allergy was noted in seven PJP cases (19%); 2/7 (29%) were not Basilea Pharmaceutica, Gilead Sciences, MSD Sharp and Dohme, Pfizer: administered alternate prophylaxis despite recommendations for use. Speaker’s Bureau, Speaker honorarium Conclusion. PJP incidence in this large cohort of cancer patients was low, but one-third of patients who developed PJP were not on recommended prophylaxis in accordance with NCCN guidelines. Infection Prevention and Antimicrobial 404. Tinea Capitis: Are Epidemiologic Shifts Associated With Distinct Clinical Stewardship teams should enhance efforts to address missed opportunities for PJP Presentations? Sigrid Collier, MD; Cuong Nguyen, MD; Ashley Marten, MD; Sheilagh Maguiness, prophylaxis in high-risk patients. 1 Disclosures. S. Pergam, Merck: Consultant, Consulting fee. Chimerix: MD and Kristen Hook, MD; Department of Dermatology, University of Minnesota, Consultant, Consulting fee. Minneapolis, Minnesota Session: 56. Fungal Disease: Management and Outcomes 403. Prognostic Factors in 260 Adults With Invasive Scedosporiosis From Thursday, October 4, 2018: 12:30 PM Literature and FungiScope™ 1 2 3 Background. Tinea capitis is an infection of the hair on the scalp caused by Danila Seidel, PhD ; Arne Meißner, MD ; Michaela Lackner, PhD ; dermatophytic fungi. Geographic distribution of individual organisms has changed Ellen Piepenbrock, MD4; Jon Salmanton García, MSc4; Sibylle Mellinghoff, MD1; 5 1 significantly over time. In early 20th century Europe, M. audouinii and T. schoenlein- Axel Hamprecht, MD ; Janne Vehreschild, Prof. Dr. Med. ; Maria J. G. T. Vehreschild, iipredominated, both of which are anthropophilic species, being passed from human MD6; Hilmar Wisplinghoff, MD7,8 and Oliver A. Cornely, MD9; 1University Hospital 2 to human. This was followed by a rise of zoophilic species, those passed from animals of Cologne, Cologne, Germany, Department of Hospital Hygiene and Infection to humans, such as M. canis and T. mentagrophytes. The epidemiological and biological Control, University Hospital of Cologne, Cologne, Germany, 3Innsbruck Medical 4 underpinnings of these continuous changes over time are complex and the importance University, Innsbruck, Austria, University Hospital Cologne, Cologne, Germany, of environmental factors, genetic predisposition, and movement of populations has 5Institute for Medical Microbiology, Immunology and Hygiene, University Hospital 6 been broadly debated. This study aims to characterise the organisms causing tinea capi- of Cologne, Cologne, Germany, University Hospital of Cologne and German Centre tis at a pediatric tertiary care center in Minneapolis, Minnesota. for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany, 7Laboratory 8 Methods. We retrospectively reviewed the electronic medical record from 2010– medicine cologne, Dres. Wisplinghoff and Colleagues, Cologne, Germany, Institute 2015 and identified 42 children with culture positive tinea capitis. for Medical Microbiology and Hygiene, University of Cologne, Cologne, Germany, 9 Results. In the 18 (42.9%) patients that were infected with either T. violaceum or Cecad Cluster of Excellence, University of Cologne, Germany, Cologne, Germany T. soudanese, all were of African ethnicity. In contrast, T. tonsurans, which is now the Session: 56. Fungal Disease: Management and Outcomes most common cause of tinea capitis in the United States, was identified in a minority Thursday, October 4, 2018: 12:30 PM of African patients (3.8%). These ethnic differences in infective species were statisti- cally significant (Fischer exact testP- value <0.0001). We also identified inter-species Background. Invasive scedosporiosis (iS) and lomentosporiosis (iL) are an differences in the presence of an inflammatory response as measured by bogginess, increasing concern due to intrinsic resistance of such pathogens to antifungal ther- pustulation, and lymphadenopathy (P = 0.027). Though anthropophilic species such apy. Guidelines recommend voriconazole, amphotericin B and surgery to treat as T. tonsurans and T. violaceum classically cause less , we identified dif- scedosporiosis, irrespective of the causative species. Scedosporium spp. are often ferences between these anthropophilic species. Specifically, we found that T. tonsurans resistant to amphotericin B but susceptible to posaconazole and voriconazole, whereas was more likely to cause an inflammatory response thanT. violaceum (68% vs. 22%). Lomentospora prolificans (LoPro) is usually pan-resistant. Mortality rates rise to 90%, Conclusion. Historically, T. violaceum was partially geographically limited to despite comprehensive treatment. Here, we describe the epidemiology of iS/L. Africa and Asia, while T. soudanese was seen only in Africa. Both T. violaceum and Methods. A retrospective analysis of patients with iS/iL was conducted to evaluate T. soudanese can cause tinea capitis with minimal inflammation, mimicking seborrheic clinical characteristics and outcomes. Cases diagnosed from January 2000 until August dermatitis, and leading to misdiagnosis and incorrect treatment. Studying epidemio- 2017 were selected from the literature and the FungiScope™ registry. In vitro susceptibility to logic changes in tinea capitis can help us understand shifts in the clinical presentation approved and new antifungals was determined according to EUCAST and CLSI methods. of this disease as our population make-up evolves, allowing us to provide crucial qual- Results. We identified 208 cases with infection caused byScedosporium spp. and ity health care to all. 56 by LoPro. iS was most frequently reported in patients after solid organ transplanta- Disclosures. All authors: No reported disclosures. tion (27.9%), iL in patients with underlying malignancy (51.9%). Skin, lung, CNS, and eye were most frequently involved in iS cases, whereas involvement of lung, eye, and stream infection were most common in iL cases. Posaconazole and voricona- 405. Outbreak of Prototheca Wickerhamii Algaemia in a Tertiary Care zole showed good in vitro activity against most Scedosporium spp. isolates, but not Chemoradiation Oncology Unit LoPro. The new antifungal drug Olorofim was highly active against all isolates testedin Inam Danish Khan, MBBS, MD, DNB, DHCM, MISCD, MIPHA; Clinical vitro, also LoPro. All-cause mortality in Scedosporium spp. cases ranged from 12.5% in Microbiology and Infectious Diseases, Army College of Medical Sciences and Base trauma patients to 55.2% in patients with malignancy, in the LoPro group from 28.6% Hospital, New Delhi 110010, India in surgical patients to 85.2% in patients with malignancy. In iS cases worse outcome Session: 56. Fungal Disease: Management and Outcomes was associated with disseminated disease and CNS involvement in transplant recipi- Thursday, October 4, 2018: 12:30 PM ents, and lung involvement in patients with malignancy. In iL cases, malignancy and were associated with worse outcome. Background. Prototheca is an emerging, opportunistic, pathogenic, zoonotic Conclusion. Clinical presentation and outcome vary between iS and iL cases. achlorophyllous green alga, expanding in pathogenicity and host range, causing local- Blood stream infection and CNS involvement are associated with worse outcome. ized and disseminated infections. This outbreak of Prototheca wickerhamii algaemia

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