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Background Guidelines recommend multidisciplinary models for the management of infective endocarditis but have failed to incorporate the unique challenges of treating drug-use associated infective endocarditis (DUA-IE). Given the drug use and overdose epidemic with rising cases of DUA-IE, we created a multidisciplinary Drug Use Endocarditis Team (DUET), which convened monthly case conferences among the specialties involved, including Infectious Diseases, Cardiothoracic Surgery, Cardiology and Addiction Medicine. Objective: To conduct a retrospective cohort study of the patients presented at the DUET conferences from August 2018 to February 2020 to (1) assess clinical and demographic characteristics and (2) describe clinical outcomes. Methods A retrospective chart review was conducted to analyze 57 patient cases, including descriptive statistical analyses of demographics, clinical characteristics, and outcomes. Results Among our DUET cohort, 43.8% represented isolated right-sided endocarditis, and 84% involved native valve. Methicillin-susceptible Staphylococcus aureus was the most common microorganism isolated. ID was consulted in 94.7% of cases and overall 43.9% completed the planned antimicrobial course. The 7 patients who developed relapse/recurrent IE were initially managed medically, and 5 did not complete the initial antimicrobial course. Formal cardiothoracic surgery consultation was obtained in 57.9% and 24.6% were managed operatively. Of the patients managed operatively, 64.3% completed the antimicrobial course. The rate of antibiotic completion was higher among patients managed operatively but did not reach statistical significance (p=0.08). Formal addiction medicine consultation was obtained in 85.9% of cases, with 63.1% discharged on medications for opioid use disorder (MOUD). The rate of MOUD on discharge was not significantly different between patients managed operatively and non-operatively. Figure 1: Patient Characteristics Figure 2: Infection Characteristics Figure 3: Outcome Analyses Conclusion ID is nearly universally involved in the care of patients with DUA-IE, but this patient population requires input from numerous sub-specialties. Multidisciplinary care teams provide a promising framework for DUA-IE to enhance and integrate nuanced decision-making. Disclosures Sarah E. Wakeman, MD, Celero Systems (Advisor or Review Panel member)Optum Labs (Grant/Research Support)UpToDate (Other Financial or Material Support, Author)

OBJECTIVES: Imprinted genes are epigenetically regulated and play critical roles in placental development and fetal growth. We aimed to examine (1) the impact of maternal one-carbon (methyl donor) nutrition on placental imprinted gene expression, placental development, and fetal growth; (2) whether imprinted gene expression alterations mediate effects of one-carbon nutrition on placental development and fetal growth; (3) interaction effects between one-carbon nutrients and imprinted genes in placental development and fetal growth. METHODS: Histopathology and expression of 109 imprinted genes (Nanostring) were assessed in placentas from 101 women recruited at initiation of antenatal care in a prospective cohort study examining developmental effects of prenatal alcohol exposure in South Africa. Women were interviewed prenatally about demographics, alcohol, smoking, and drug use, and erythrocyte folate, serum vitamin B12, and plasma choline concentrations were assayed at recruitment. Infant weight and height were assessed at age 2 wk. RESULTS: In limma tests, women with plasma choline concentrations below the median had lower placental expression of EPS15, IGF2R, LINC00657, SGCE, ZC3H12C, and ZNF264 than women above the median (p

OBJECTIVES: The aim of this study was to examine the prospective association between the consumption of total, unprocessed, and processed red meat and the risk of frailty in older adults. METHODS: We analyzed data from 85,870 women aged ≥60 participating in the Nurses’ Health Study. Consumption of red meat was obtained from repeated food frequency questionnaires administered between 1980 and 2010. Frailty was defined as having at least three of the following five criteria from the FRAIL scale: fatigue, low strength, reduced aerobic capacity, having ≥5 chronic illnesses, and weight loss ≥5%. The occurrence of frailty was assessed every four years from 1992 to 2014. RESULTS: During follow-up we identified 13,279 incident cases of frailty. Women with a higher intake of red meat showed an increased risk of frailty after adjustment for lifestyle factors, medication use, and dietary factors. The relative risk (95% confidence interval) for one serving/day increment in consumption was 1.13 (1.08, 1.18) for total red meat, 1.08 (1.02, 1.15) for unprocessed red meat, and 1.26 (1.15, 1.39) for processed red meat. Replacing one serving/day of unprocessed red meat with other protein sources was associated with significantly lower risk of frailty; the risk reduction estimates were 21% for fish and 14% for nuts, while for replacement of processed red meat the percentages were 32% for fish, 26% for nuts, 13% for legumes, and 16% for dairy. CONCLUSIONS: Habitual consumption of red meat was associated with a higher risk of frailty. Replacement of red meat by other protein sources might reduce the risk of frailty. FUNDING SOURCES: This work was supported by grants from the Instituto de Salud Carlos III, State Secretary of R+D+I of Spain and FEDER/FSE (FIS 16/609, 16/1512, 19/319); the European Union (JPI A Healthy Diet for a Healthy Life, SALAMANDER project); and the Nurses´ health study is supported by grant UM1 CA186107 from National Institutes of Health.

OBJECTIVES: We aimed to assess the polypharmacy effect on appetite and malnutrition risk among Lebanese nursing home residents. We hypothesized that polypharmacy will be associated to lower appetite and increased of malnutrition. METHODS: A cross-sectional pilot study was carried out in two nursing homes in the North-Lebanon region. Fifty-three older adults (OA) aged 60 and above were recruited and were interviewed face-to-face. A general questionnaire was administered to gather information about their socio-demographics, dietary habits and physical activity routine. Appetite was evaluated by the Simplified Nutritional Appetite Questionnaire (SNAQ) validated for use with nursing homes residents. The participants' nutritional status was assessed using the Short Form of the Mini-Nutritional Assessment (MNA-SF). Polypharmacy was determined if OA were taking 5 or more medications. Information about attitudes towards the use, the number and the cost of medications was also collected. Differences in SNAQ and MNA scores based on polypharmacy were tested using Independent t-tests. Logistic regression was performed to assess the association between polypharmacy and nutritional status after adjusting for several factors. RESULTS: Our sample constituted of 49.1% females with an average age of 67.6 ± 3.8 and BMI of 22.3 ± 1.7 kg/m2. The majority were widowed (79.2%) and had a low level of education (85% elementary education). Regarding the MNA scores, 33% had a normal nutritional status while 59% were at risk of malnutrition and 8% were malnourished, with an average MNA score of 10.1 ± 2.2. The average SNAQ score was 11.0 ± 3.3, with 85% scoring ≤14, indicating an significant risk of at least 5% weight loss withing 6 months. Regarding medication use, 50.9% of OA take at least 5 drugs/d with an average of 4.3 ± 2 drugs. Independent t-tests showed that MNA scores were significantly lower in those taking 5 drugs/d vs those taking less (9.4 ± 2.5 vs 10.8 ± 1.6, P = .024) while no significant difference was observed for SNAQ scores (10.3 ± 2.9 vs 11.6 ± 3.6, P = .13). Logistic regressions did not show any significant association between polypharmacy and MNA or SNAQ categories. CONCLUSIONS: Lower MNA scores were observed in OA taking ≥5 drugs/d indicating a higher risk of malnutrition with polypharmacy. This is significant since malnutrition can further worsen the aging process. FUNDING SOURCES: N/A.

OBJECTIVES: In humans, perception for each taste (sweet, salt, sour, bitter and umami) has been independently related to food preferences and intake. Yet, the collective influence of perception of all 5 tastes on diet and cardiometabolic health remains unexplored. Therefore, our objective was to investigate the relations between a collective measure of taste perception – “taste perception profiles” – and adiposity. METHODS: We analyzed baseline data of 367 older adults (55–75 years; 55% female) with metabolic syndrome (MetS) participating in the PREDIMED-Plus Valencia trial. Taste perception was assessed for sweet, salt, sour, bitter and umami using sucrose, NaCl, citric acid, phenylthiocarbamide and monopotassium L-glutamate, respectively, and evaluated on a 0–5 scale. Taste perception profiles were derived from perception scores using predictive modeling and k-means clustering (KCA). Multivariable linear regression was used to evaluate the relations between taste perception profiles and BMI, body weight (BW) and waist circumference (WC), after adjustment for confounders. RESULTS: KCA identified 7 taste perception profiles: Low All (n = 79), High Umami (n = 61), High Bitter (n = 49), High Bitter & Umami (n = 44), High Sweet, Salt & Sour (n = 51), High All But Bitter (n = 49) and High All But Umami (n = 34). After adjusting for age, sex, physical activity, smoking, diabetes, medication use and energy intake, BMI, BW and WC were highest for the Low All profile (adjusted means: 33.4 kg/m(2), 87.5 kg and 108.4 cm; reference). Comparatively, mean BMI and BW were lower for High Bitter (–1.9 kg/m(2); –5.4 kg), High Bitter & Umami (–1.7; –4.7), High Sweet, Salt & Sour (–1.3; –4.6) and High All But Bitter (–1.7; –5.0) profiles; and WC was lower for High Bitter & Umami (–3.4 cm) and High All But Bitter (–4.9) profiles (all P

OBJECTIVES: Adherence to healthy lifestyle and pharmacological therapies represent two major approaches to chronic disease prevention. It remains unknown whether individuals who regularly use preventive medications still benefit from adherence to healthy lifestyle as those not using the medications. We aimed to examine the associations of healthy lifestyle with all-cause and cause-specific mortality among regular users and nonusers of major preventive medications. METHODS: We prospectively assessed lifestyles and regular use of aspirin, antihypertensives, and lipid-lowering medications through biennial questionnaires among 79,043 women in the Nurses’ Health Study (1988–2014) and 39,544 men in the Health Professionals Follow-up Study (1986–2014). A healthy lifestyle score (ranging 0–5) was defined based on body mass index of ≥18.5 and

As stimulant use and infections among persons using drugs rise nationally, evidence remains limited on how best to deliver outpatient parenteral antimicrobial therapy (OPAT) to persons using noninjection drugs. In an urban safety net population including persons using noninjection drugs, home-based OPAT completion rates were similarly high as those of non-drug-using individuals.

Background Serratia is an opportunistic pathogen known to cause an array of infectious presentations including UTIs, pneumonia, wound infections, skin and soft tissue infections, surgical site infections and although rare, endocarditis and bacteremia. The aim of the proposed study is to identify the characteristics of patients with community-acquired Serratia blood stream infection over a five-year period within the TriHealth inpatient population within the Cincinnati, Ohio Region. The study will also examine antibiotic resistance patterns among patients with Serratia bloodstream infections. Methods This is a retrospective cohort study of 107 adult patients admitted to two community hospitals from January 2014 to December 2018 with a positive blood culture for Serratia species. A complete data set of 100 patients was analyzed for complications, antibiotic resistance, in-hospital mortality, 90-day mortality, readmission within 90 days and length of Hospital Stay (LOS). Descriptive statistics was performed using frequencies for discrete variables and median (IQR) for continuous variables. Results Patients admitted with a positive Serratia blood culture were 38% female with a median (IQR) age of 54.5 years (40.25–71.75) and predominantly white (85%). Forty percent had hepatitis C (HCV) infection and 42% had a history of IV drug use. Most patients were living at home (77%), 18% in long term care and 91% were infected with Serratia marcescens. The most common complications were endocarditis (12%) and osteomyelitis (10%). Extended spectrum beta-lactamase (ESBL) production was confirmed in 13%. In-hospital mortality was 2%, 90-day mortality 2%, readmission 23% and median (IQR) LOS 7(3.25–14.75). PATIENT CHARACTERISTICS AND OUTCOMES (part 1) PATIENT CHARACTERISTICS AND OUTCOMES (part 2) PATIENT CHARACTERISTICS AND OUTCOMES (part 3) Conclusion This study demonstrates that a high proportion of patients admitted with Serratia bacteremia are IV drugs users and that they have a high prevalence of coexistent HCV infection. Endocarditis and metastatic foci of infection are relatively common. Appropriate empiric antibiotic management should take into account the significant incidence of ESBL production resulting in a prolonged LOS and a high readmission rate. Disclosures All Authors: No reported disclosures

Background Given a significant proportion of women with inflammatory bowel disease (IBD) are of child-bearing age, the development of a pregnancy IBD decision aid would benefit patients and clinicians. Lack of IBD-specific reproductive knowledge has been associated with increased “voluntary childlessness” and may contribute to inappropriate medication changes during or after pregnancy. Decision aids support decision making in pregnancy in general, as well as in multiple other chronic diseases. However existing literature has not identified such a resource for women with IBD. Aims To develop a decision aid to improve decision making regarding preconception and pregnancy in IBD among women with IBD. Methods We followed the International Patient Decision Aids Standards (IPDAS). A steering committee of Canadian and Australian health care professionals with an interest in IBD management in pregnancy, in addition to patient representatives, was established. Themes chosen for discussion included inheritance, fertility, nutrition, medications, mode of delivery, breastfeeding, infant health. Initial patient and clinician focus groups were conducted and responses recorded with written/audio mediums. We developed an electronic PIDA draft that incorporates individualised information (type of IBD, pre-conception or pregnant, surgical history, medications) in personalized decision making. Further patient focus groups and interviews were conducted to obtain user opinion of the PIDA draft. Results In July 2017, patient and clinician focus groups were conducted at a Canadian site. Three patients (pre-conception) attended the focus group. Patient concerns - impact of disease and surgery on fertility and preterm delivery; impact of drug therapies on the fetus/ infant; impact of active disease on maternal and fetal/infant health. The clinician focus group included 3 IBD specialists, 2 IBD fellows, 2 IBD nurses, an obstetrician and a neonatal intensivist. Clinician concerns - absence of pre-conception counselling and lack of patient understanding about the impact of disease activity and IBD medication use in pregnancy. Additional patient feedback obtained through interviews (n=15) at two Canadian sites since March 2019 regarding the current electronic PIDA was positive, with comments about content, personalization, readability and unbiased presentation. Suggestions were made for inclusion of additional content such as impact of IBD on sexual function, laboratory changes during pregnancy, and timing of medications post-partum. Conclusions The pre and post PIDA design patient and clinician focus groups and interviews affirmed the role for PIDA. Main decisions considered necessary to address included ideal timing of conception pending disease activity, management of medications, and delivery methods. Ongoing user feedback will be obtained at Australian and Canadian sites during planned alpha testing. Funding Agencies WCHRI, Sinai Health System, UBC

OBJECTIVES: To examine risk factors for bone mineral density (BMD) and osteoporosis at the femoral neck (FN) and lumbar spine (LS) in a cross-sectional study among Puerto Rican adults, 47- 77 y. METHODS: The Boston Puerto Rican Osteoporosis Study (BPROS) is an ancillary study to the Boston Puerto Rican Health Study, a cohort of 1504 Puerto Rican adults from the Greater Boston area. A total of 973 participants participated in the BPROS, where data on sociodemographics, health and health behaviors, and medication use were collected through questionnaire, and anthropometrics measured. Dietary intake and supplement use were assessed using a food frequency questionnaire. Fasting blood samples were collected for biochemical analysis. BMD (g/cm(2)) at the FN and LS (L2-L4) was measured using dual-energy X-ray absorptiometry. Linear regression models estimated associations between risk factors and FN and LS BMD and logistic regression for osteoporosis (T-score ≤ −2.5 g/cm(2)) at the FN and/or LS. A total of 680 participants had complete data on risk factors and bone measures. RESULTS: Average age of participants was 59.9 y ± 7.6 y and 71.3% were women. The prevalence of osteoporosis was 10.6%. Age was inversely associated with FN BMD (Table 1). BMI and height were positively associated with BMD. Neither calcium intake from food sources nor plasma 25-OH vitamin D were associated with BMD (P > 0.36). Bone medication and calcium supplement use were inversely associated with BMD, likely due to reverse causation. Magnesium intake from supplements was positively associated with LS and FN BMD (β = 0.07, P = 0.006 and β = 0.05, P = 0.008). Moderate alcohol consumption was associated with lower odds of osteoporosis, compared to no intake (OR: 0.40, P = 0.02; Table 2). Current smoking (vs. never smokers) was associated with increased odds of osteoporosis (OR: 2.5, P = 0.02). Magnesium from supplements was associated with lower odds of osteoporosis (OR: 0.41, P = 0.04). CONCLUSIONS: In contrast to expectation, dietary calcium and plasma 25-OH vitamin D were not associated with bone. Interestingly, magnesium intake from supplements was associated with higher BMD and lower odds of osteoporosis. This requires further investigation, as this may serve as a feasible intervention to improve BMD and decrease risk of osteoporosis in this high-risk population. FUNDING SOURCES: NIH/NIAMS K01 AR067894, NIH P50 HL105185, P01 AG023394, and R01 AG027087. SUPPORTING TABLES, IMAGES AND/OR GRAPHS

OBJECTIVES: High blood pressure (BP) is a common health condition, especially among the aging population. Studies suggest that diet influences blood pressure. In this cross-sectional study, we investigated the association between dietary factors and BP in older adults. METHODS: One hundred twenty-eight participants (n = 57 males and n = 71 females) aged 65–80 were included in this study. Dietary data was collected through a validated food frequency questionnaire. Demographics, anthropometric measurements, socioeconomic factors, medication information, and physical activity levels were also collected. Multiple linear regressions were conducted to examine the associations between dietary factors including meats, vegetables, grains, fruits, dairy, fats, and added sugar and changes in blood pressure. RESULTS: There were no associations between dietary factors and systolic BP when both men and women were included in the model. However, solid fruit was associated with diastolic blood pressure (beta = −0.22, P = 0.039; 95% CI −7.9, −0.2) in both males and females, and every 0.71 cup increase in solid fruit consumption was predicted to decrease diastolic BP by 2.9 mmHg. When the model was split by sex, there was a significant association between intake of added sugar and systolic (β = 0.731, P

OBJECTIVES: The purpose of this study was to assess the feasibility of using the Miami Adult Studies on HIV (MASH) cohort to conduct research on markers of gut integrity, MT, immune-activation and inflammation and their relationship to Vitamin D status in this cohort. We hypothesize that drug users infected with HIV, who have vitamin D deficiency or insufficiency, will have higher levels of MT, immune-activation, inflammation and deterioration of the gut integrity than drug users infected with HIV with sufficient Vitamin D levels. METHODS: Ninety HIV-infected drug users and HIV-infected drug non-users were identified from the MASH cohort with IRB approval. Data for this study will be collected at baseline, 6-months and 12-months. Laboratory analyses will include: determination of Lipopolysaccharide for MT, Soluble CD14, Interleukin 6, and Tumor Necrosis Factor alpha to assess immune-activation and inflammation; 25(OH)D levels for Vitamin D status, and Intestinal Fatty Acid Binding Protein as a gut integrity marker. All laboratory analyses will be completed using plasma samples and determined by enzyme-linked immunosorbent assays in the laboratories of the MASH cohort. Dietary and anthropometric data, disease progression and medical history will be collected. The MASH cohort assesses drug use with questionnaires, urine toxicology, and cocaine metabolites. RESULTS: We hypothesize that drug users infected with HIV, who have vitamin D deficiency or insufficiency, will have higher levels of MT, immune-activation, inflammation and deterioration of the gut integrity than drug users infected with HIV with sufficient Vitamin D levels. CONCLUSIONS: The MASH cohort participants are well-characterized and followed longitudinally enabling access to the participants and their information. This study will provide information to develop adjunct therapies for the management of HIV, gut health and nutrition. FUNDING SOURCES: The National Institute of Drug Abuse provides funding for the MASH cohort.

This chapter provides an overview of drug use in prison. It is centered on illicit drug use in Europe, where the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) has been collecting aggregated data from various sources for 15 years. It also reviews, based on published literature, data from the four other global regions. A total of 59 studies from 31 countries in the five world regions were included for analysis. Results show that the prevalence of drug use varies greatly between studies. Lifetime prevalence of any illicit drug use in prison ranges between 2% to 76% worldwide with, in most cases, cannabis being the most frequently reported substance. More recent (past-month) illicit drug use is reported by in prison is reported in a few studies only, varying between 2% to 77% while the prevalence of current tobacco smoking ranges between 4% to 90%. In general, available data are scarce and patchy, especially outside Europe, with large variations in methodology relating to sampling strategy and measurement. This heterogeneity hampers comparison and may, in part, account for the wide range of prevalence estimates. Comparable methods and measures of drug use and its consequences in prison populations are needed to facilitate international comparisons and provide the sound information needed for development and implementation of drug interventions in various prison settings across the globe.

Background Opioid misuse is epidemic in the United States (US), and persons who inject drugs are at increased risk for serious bacterial and fungal infections, including Candida bloodstream infections. Historically, candidemia has occurred almost exclusively among patients with severe underlying illness and extensive healthcare exposure. We examined whether the opioid crisis may be having an impact on the epidemiology of candidemia in the United States. Methods Using data from 200 US hospitals reporting to the Premier Healthcare Database (PHD) between 2012–2017, we conducted a retrospective study among hospitalized persons ≥ 18 years. Candidemia was defined by any blood culture yielding Candida species. Drug use-associated (DUA)-candidemia hospitalizations were defined as hospitalizations having both candidemia and at least one ICD-9-CM or ICD-10-CM diagnostic code for recreational drug use; drugs were classified as opioids, cocaine, amphetamines, or other drugs (excluding cannabis, alcohol, and nicotine). We described the characteristics and annual trends of candidemia hospitalizations, stratified by drug use. Results Of 7,590 candidemia hospitalizations during 2012–2017, 679 (9%) were DUA-candidemia. During this time, the rate of DUA-candidemia increased from 3.6 to 9.1 per 100,000 hospitalizations, while the rate of non-DUA-candidemia decreased from 64.7 to 55.6 per 100,000 hospitalizations. Patients with DUA-candidemia were younger (median 40 vs. 64 years), had a longer lengths of stay (median 14 vs. 13 days), and had lower in-hospital mortality (12% vs. 26%). Among DUA-candidemia hospitalizations, opioids accounted for 78% of substances identified. Among patients aged 18–44 years, the proportion of candidemia hospitalizations associated with drug use more than tripled from 13% in 2012 to 44% in 2017 (Figure 1). Conclusion DUA-candidemia hospitalizations increased almost 3-fold during 2012–2017, with drug use identified in nearly half of candidemia patients ages 18–44 years in 2017. These data suggest that the opioid crisis is having an impact on the epidemiology of candidemia in the United States, especially among young adults, underscoring an additional negative consequence of the ongoing crisis. Disclosures All authors: No reported disclosures.

Background The main driver of the Hepatitis C virus (HCV) epidemic in most western countries is injection drug use (IDU) among people who inject drugs (PWID). Iceland has provided unrestricted access to direct-acting antiviral agents (DAA) to all HCV-infected patients in the country covered by national health insurance, by a program entitled Treatment as Prevention for Hepatitis C (TraP HepC) from 2016 and is on track to become among the first to achieve the WHO goals of eliminating HCV as a public health threat. Methods We analyzed data regarding testing for HCV, incidence of IDU, prevalence of HCV viremia among PWID, drug use in the community and trends in homelessness prior to and during the first 24 months of TraP HepC to monitor outcomes and identify new or persistent challenges. Results Intensity of nationwide testing for HCV increased by 22% in 2016, 60% in 2017, and 81% in 2018 compared with previous years (P < 0.001). During 2016–2018 the incidence of new injection drug use, as surveyed among those admitted for addiction treatment increased by 48%. The total number of PWID admitted annually with HCV viremia however remained relatively stable during the entire period (2010–2018). The prevalence of HCV viremia among people recently injecting drugs admitted for addiction treatment however dropped from 48.7% to 16.2% in 2017, and to 10.2% in 2018 (P < 0.001). Analysis of data regarding stimulant use, as measured by drug levels in wastewater shows an almost threefold increase of amphetamine and an eightfold increase in cocaine levels during 2016–2018 compared with 2015. Concurrently, the number of homeless has doubled. Two years into TraP HepC > 80% of the estimated total HCV-infected population were started on their first course of DAAs. By intention to treat analysis, the cure rate was 92.4% among patients without history of IDU in the past 6 months, compared with 82.9% among active IDU (P = 0.0006); those with history of recent IDU were more likely to discontinue (P < 0.0001). Homelessness carried the highest relative risk (RR) of treatment failure (RR = 2.4, P = 0.008), mostly due to discontinuation. Conclusion Iceland is on track to eliminate HCV, but challenges such as increasing drug use in the community and homelessness need to continuously monitored and addressed; they may jeopardize the success of elimination efforts. Disclosures All Authors: No reported Disclosures.

Background Infectious sequelae of injection drug use (ISIDU) and overdose are frequent but preventable among people who inject drugs (PWID). Syringe service programs (SSP) are an evidence-based harm reduction strategy to reduce incidence of ISIDU among PWID. Additionally, SSPs are noted to produce significant cost-savings for healthcare systems. Under current state legislation, Miami houses the only SSP in Florida, the IDEA SSP. This study builds on previous work characterizing morbidity and cost of ISIDU. This study sought to evaluate differences in admission rates and associated ISIDU costs at Jackson Memorial Hospital (JMH) in Miami before and after implementation of the IDEA SSP. Methods Retrospective data collected from a chart review of patients hospitalized for ISIDU and overdose was used to evaluate morbidity and cost of ISIDU at JMH from December 1, 2015 to December 1, 2017, stratified by December 1, 2016—the opening of the IDEA SSP—as an index date. An algorithm utilizing ICD-10 codes for drug use and sequelae was used to identify PWID population. Specific infections investigated were: endocarditis, osteomyelitis, bacteremia- and/or -sepsis (BOS), and skin-and-soft-tissue-infections (SSTIs). Pearson’s chi-square test for independence used to report P-values for associations between infections and total charges using a 2-tailed t-test. Results 726 admissions were identified during the study period, 328 PWID in the pre-index cohort vs. 398 in the post-index cohort. The median age of total sample was 45.24. 95.12% of the pre-index cohort were uninsured or had publicly-funded insurance vs. 96.48% post-index. Most ISIDU did not change significantly between pre-post cohorts, although bacteremia and sepsis declined significantly among opioid injectors (P = 0.026). Overdoses decreased significantly among PWID generally (57% decline pre-post; P = 0.0006), as well as for patients who inject opioids specifically (70% decline pre-post; P = 0.0034). Median cost declined by 20.5% among PWID, and 29.1% among opioid injectors in particular. Conclusion ISIDU continues to represent significant morbidity for PWID in Miami-Dade County and substantial cost to the health system. Severe infections, including bacteremia and sepsis, declined significantly among opioid injectors, the PWID subset most strongly associated with local SSP services. This change following the establishment of a local SSP suggests direct effects on the frequency of hospital admissions for ISIDU. Despite local increases in drug use, overall PWID frequency and ISIDU charges did not change significantly. OD and admission frequency amongst opioid users and cost-per-patient declined between groups, suggesting a potential decrease in ISIDU and attendant costs. While median charges per admission declined, they were statistically insignificant and may represent stagnation in ISIDU-associated costs following SSP establishment. Diminishment in opioid user admissions and OD suggest additional possible positive epidemiological effects of the SSP. Weaknesses included difficulty of associating outcomes, limited post-index time period, and potential misclassification when establishing a standardized algorithm for PWID identification. Disclosures All authors: No reported disclosures.

BACKGROUND: In Canada, the majority of new and existing cases of hepatitis C virus (HCV) infection occur among people who inject drugs (PWID), mostly through receptive sharing of injection material. Injecting drug use has been shown to be a dynamic process characterized by transitions in and out of injection. We have previously shown that short injection cessations are associated with a reduced risk of receptive sharing of injection material when resuming injection. AIMS: This investigation aimed to assess the association between HCV infection and intermittent injecting drug use, when considering one-month injection cessation episodes. METHODS: The HEPCO study is an observational cohort of PWID recruited and followed longitudinally in Montréal (QC). At 3-month intervals, uninfected participants (HCV RNA-negative) enrolled between March 2011 and December 2014 were tested for HCV, and completed an interviewer-administered questionnaire eliciting information on sociodemographics, drug use, and related behaviors and treatments. Participants were at-risk of either primary HCV infection (anti-HCV-negative participants), or reinfection/recurrence (anti-HCV-positive participants). Injecting drug use in the past 3 months was categorized as follows: injecting within 0 (no use), 1 or 2 (intermittent use), or 3 months (continuous use). HCV infection was estimated to occur at the midpoint between two visits. Cox regression analyses with time-dependent covariates were performed, and Kaplan–Meier failure curves for multiple-record-per-subject data were estimated. RESULTS: 311 participants with ≥1 follow-up visit (mean age 40 years, 82% male, 47% anti-HCV positive) contributed 1,689 visits. HCV incidence was 11.3 per 100 person-years [95% confidence interval (CI), 8.8–14.4]. At baseline, 188 (60%), 79 (25%) and 44 (14%) participants reported continuous, intermittent and no injecting drug use in the past 3 months, respectively. In univariate Cox models, intermittent and no injecting drug use were significantly associated with a reduced risk of HCV infection [intermittent use: hazard ratio (HR) 0.36, 95%CI 0.17–0.77; no use: HR 0.23, 95%CI 0.09–0.58] compared to continuous use. In models adjusted for age, gender and opioid substitution treatment, associations remained statistically significant for both intermittent (HR 0.40, 95%CI 0.19–0.86) and no injecting drug use (HR 0.30, 95%CI 0.12–0.77). There was no evidence of effect modification by anti-HCV status at baseline. CONCLUSIONS: Intermittent injecting drug use was associated with a reduced risk of HCV infection. Findings bring new perspectives regarding injecting profiles and their relation to HCV risk, and for improving PWID’s access to clinical care and harm reduction interventions. Further work is needed to contextualize intermittent injecting drug use in the injecting drug use trajectory. FUNDING AGENCIES: CIHRFRQS

Background With 337 heroin-related deaths between 2009 and 2013, Suffolk County reported more such deaths than any other county in New York State. Suffolk County’s population of 1.5 million is larger than that of some states. Compared with the rest of New York State, median annual household income is the third highest of New York’s 62 counties and the income gap between socioeconomic classes is smaller. Methods Detailed retrospective chart review was performed on admitted patients to Stony Brook University Hospital (SBUH) from November 2015 to October 2018 with active IV drug abuse and infection. Demographics, drug use characteristics, microbiology, co-morbidities, and outcome were assessed. Results 198 active IV heroin users were admitted with a complicated infection during this time frame. Most patients were Caucasian (94%) and more were male (64%). The median age was 33 (range 17 to 58). Most patients (90%) had health insurance, many lived with others at home and were unemployed. Thirty-three were on methadone and 28 on suboxone. The median length of stay was 4.7 days (ranging from 1 to 140 days) and 29% of admitted patients left against medical advice. 60% of the patients had been admitted to a hospital in the prior 12 months. The majority (58%) presented with cellulitis, 12% were diagnosed with endocarditis, 10% with osteomyelitis, 6.5% with bacteremia/sepsis. Ten were also pregnant. Infectious disease was consulted in 55%, and Psychiatry and social worker in 46% of cases. HIV, HepC and HBV testing were not performed in less than 50% of patients. There was a total of 5 deaths during the hospitalization, 2 patients with endocarditis, 2 with sepsis and one overdose. 45% of patients with endocarditis and 43% of patients with osteomyelitis required surgical intervention. S. aureus was a common pathogen and identified in 61% of the cases, where a pathogen was isolated. Conclusion Our data show that even in an affluent community opioid addiction is not properly addressed during hospital admissions. As a consequence, users sign out against medical advice, have frequent hospital admissions, remain out of addiction treatment, and outcome is poor. A systematic multidisciplinary approach will be required to improve the care for this vulnerable patient population Disclosures All authors: No reported disclosures.

Background Caring for hospitalized patients with infective endocarditis (IE) can be challenging due to the nature of the disease and its complications, underlying medical and psychiatric problems, socioeconomic status and environmental factors.Some of these patients develop recurrent IE after the first episode treated. On-going intravenous (IV) drug use after hospital discharge is the highest predictive factor for recurrent IE. Besides IV drug use, there are limited data of other contributing factors to recurrent IE. Those factors may be modifiable during the first hospitalization to reduce the incidence of recurrent IE. Methods A retrospective cohort study was conducted at a large tertiary acute care medical center in Tampa, Florida. All consecutive patients with IE with history of IV drug use from January, 2011 to December, 2017 were included. Basic demographic information, co-morbidities (diabetes, hypertension, chronic lung and kidney diseases, HIV, Hepatitis B and C status, coronary artery diseases), valves involved, length of stay, complications at their first IE episode such as septic shock and stroke were included. Groups were identified based on the first episode, first recurrence and second or more recurrences of IE. Results A total of 106 patients were identified based on the inclusion criteria. The association between the type of valve infection (right side and left side) and IE recurrence was found to be statistically significant. (P = 0.003). Right side valves are prone to have recurrent IE episodes. People with recurrent IE were more likely to have septic shock (P = 0.02) and requiring intensive care unit (ICU) admissions (P < 0.001) during their first episode There was no statistically significant difference between other demographic information and recurrent endocarditis as well as other parameters such as organisms or type of substance used. (Table 1) Conclusion Right-sided IE and presence of septic shock during their first episode of IE may be the predictors for recurrent IE. Interventions including closer follow-up, more aggressive septic shock recognition and management, socioeconomic assessment in addition to substance abuse treatments after discharge should be considered to prevent recurrent IE. Disclosures All authors: No reported disclosures.

Background The University of Illinois Hospital Emergency Department (ED) implemented routine, electronic medical record (EMR)-driven opt-out HIV screening in November 2014. Programmatic data indicated an average consent rate of 79%, similar to other ED HIV screening programs in the country. However, there is limited evidence on the role risk factors play on consent rate. The objective of this study was to explore the relationship between patients’ risk factors for HIV and the likelihood of declining screening. Methods The ED screening algorithm has a nontargeted and targeted component qualifying individuals based on age and presence of risk factors, respectively. We retrospectively evaluated risk factors and consent responses of high-risk individuals identified by the targeted component of the EMR algorithm between January 2017 and March 2019. We performed a multivariate logistic regression analysis in R to explore the association between risk factors and the likelihood of declining screening. Results Of 47,197 screening eligible individuals, 27,044 were high-risk among whom 12% never consented. The majority of those who never consented had no history of intravenous (IV) drug use, homelessness, unsafe sexual practices, recent sexually transmitted infection (STI) and did not identify as homosexual, bisexual or transgender. Individuals who identified as homosexual, bisexual, or transgender (OR = 0.53), from high-risk zip code (OR = 0.77), with history of IV drug use (OR = 0.43), and with recent STI (OR = 0.60) were found to be significantly less likely to never consent compared with their counterparts. Also, patients who were male (OR = 1.14), White (OR = 1.38), Asian (OR = 1.57), Native Hawaiian or Pacific Islander, American Indian or Alaska Native (OR = 1.44) were significantly more likely to never consent compared with their counterparts. Conclusion Our results show that patients at high risk for HIV consent at higher rates for HIV screening in an opt-out setting. These findings suggest that while educational efforts on the importance of testing may have been successful in patients at the highest risk, additional efforts are needed to improve awareness among those who may not self-identify or be identified by medical providers as being at risk for HIV and reinforce the importance of universal screening. Disclosures All authors: No reported disclosures.

Background Research suggests nonoccupational Post Exposure Prophylaxis (nPEP) is underprescribed when indicated in the Emergency Department (ED). This study is an assessment of ED providers’ attitudes and practices regarding administration of HIV nPEP. Methods This was an anonymous survey based on literature review and modified Delphi technique. We approached 153 ED providers at work over a 4-month period from 5 hospital-based and 2 freestanding EDs with an annual census between 35,000 and 75,000 patients. The EDs are a combination of urban, suburban, and rural EDs. There were 152 completed surveys: 80 attendings, 27 residents, and 44 physician assistants. Results The majority of surveyed providers (133/149, 89.3%) believe it is their responsibility as an emergency provider to provide HIV nPEP in the emergency department (Figure 1). Although 91% (138/151) and 87% (132/151) of respondents are willing to prescribe nPEP to a patient in the ED for IV drug use and unprotected sex, respectively, only 40% (61/152) of participants felt they could confidently prescribe the appropriate regimen. Ultimately, only 25% (37/151) of participants prescribed nPEP in the last year. Number of years in practice, age, and gender did not result in a significant difference in nPEP administration. Respondents noted time (27%), access to follow-up care (26%), cost to patients (23%), patients’ perceived interest in HIV counseling (15%), and concern for ongoing risky behaviors (9%) as barriers to prescribing nPEP (Figure 2). 64% (95/149) of respondents feel that it is their responsibility as an ED provider to refer patients at risk of nonoccupational exposures for risk-reduction counseling. Conclusion This study identified an opportunity for HIV prevention in the emergency department. The majority of participants had not prescribed nPEP in the past 12 months. Although most were willing to prescribe nPEP and felt it was their responsibility, the majority of participants were not confident in prescribing it. Future interventions to increase the use of nPEP in the ED should target provider education, cost, access to follow-up care and counseling. Disclosures All authors: No reported disclosures.

Background Studies using administrative data have described increasing rates of intravenous drug use (IVDU)-associated infective endocarditis (IE) in the United States. These studies used International Classification of Disease (ICD) diagnosis codes to identify hospitalized patients with IE and any illicit drug use (i.e., opioid, amphetamine, cocaine or sedative), but were hindered by absence of specific ICD codes for IVDU. We reviewed charts to determine the positive predictive value (PPV) of ICD codes for identifying patients with IE and IVDU. Methods We examined national Veterans Affairs (VA) administrative data from January 2010 to December 2017 to identify patients hospitalized for a first episode of potential IVDU-associated IE based on inpatient ICD 9 and 10 codes for both IE and any illicit drug use, the algorithm used to identify IVDU-IE in most prior studies. We randomly selected 100 of these patients nationally and reviewed hospital charts to confirm clinical documentation of: (1) IE, (2) any illicit drug use, and (3) current or past IVDU. Results We identified 340 patients with concurrent ICD codes for IE and drug use, increasing from 28 in 2010 to 51 in 2017 (82% increase). In chart review of 100 randomly selected patients, the PPV of ICD codes was 93% (95% CI 88–98%) for a documented clinical diagnosis of IE; 96% (95% CI 92–100%) for documented drug use by any route; and 63% (95% CI 53–73%) for documented IVDU. Among the 37% of patients without clinically documented IVDU, 30% (i.e.,11% of total patients) had clinical documentation stating that drug use was only by non-IV routes, 59% (22% of total) had documented drug use without mention of route of use, and 11% (4% of total) had clinical documentation that patients denied any drug use. Conclusion The incidence of first hospitalization for IE among patients with ICD codes for drug use increased by 82% from 2010 to 2017 in VA care. Concurrent ICD codes for illicit drug use had moderate PPV for identifying IVDU in setting of IE, largely due to identification of patients using drugs without documented intravenous use. There is a need to develop more accurate case-finding algorithms for identifying patients with IVDU-associated endocarditis, for both epidemiologic surveillance and quality improvement applications. Disclosures All authors: No reported disclosures.

Background The newly introduced direct-acting antivirals (DAAs) for chronic hepatitis C virus (HCV) infection have substantially higher cure rates and less side effects compared with previous regimens. However, in order to achieve optimal patient engagement in HCV treatment, it’s highly imperative to develop comprehensive HCV treatment programs which provide optimal services that help navigate patients through a challenging healthcare system. Methods In 2014, a comprehensive HCV treatment program employing a multidisciplinary team service was created at our Ryan White sponsored clinic in Metro-Detroit. The team which included infectious disease physicians, nurse practitioners and social workers aimed at identifying and addressing the socioeconomic barriers among our underserved HCV-infected population. We present the characteristics of HCV patients enrolled in the program as well as assess the sustained viral response rates (SVR) among patients treated for HCV infection between October 2014 and January 2017. May 10, 2017 was the date of last recorded SVR for patients who completed their DAA treatment. Results Up to May 10, 2017, the program included 317 patients with HCV infection. The mean age of patients was 59 years (SD = 8). Around 68% of the cohort were males and 89% were African Americans. Of 317 patients, 61 % had Medicaid only, 14% had Medicare only and 18% had Medicare and Medicaid. The 2 most common modes of HCV transmission among our cohort was IV drug use (60%) and male to male sex (11%). Most of the patients had genotype 1a (62%) and approximately 37% of them were co-infected with HIV. One-hundred and sixty patients (51%) received or started treatment with DAA; ledipasvir/sofosbuvir being the most commonly prescribed regimen (126/160; 79%). Among 109 HCV infected patients who were expected to finish their DAA treatment 12 weeks before the date of last recorded SVR, 107 (98%) completed treatment. SVR was achieved in 100 % of patients who completed their treatment. Conclusion Despite the state Medicaid restrictions, the high DAA costs, and the challenging socioeconomic status of our population, our program was able to achieve impressive SVR rates comparable to other HCV management programs in the US. Disclosures All authors: No reported disclosures.

Background While the efficacy of Pre-Exposure Prophylaxis (PrEP) in the prevention of HIV is well established in clinical trials, its utility in clinical practice needs to be defined. In contrast to lifelong HIV treatment, the use of PrEP should be only for those who remain at continued risk of HIV infection. Using sexual transmitted infection (STI) diagnosis as an indicator of continued high-risk sexual behavior, this study aimed to evaluate risk factors associated with STIs in PrEP users in New York City. Methods This retrospective cohort study included electronic health records of patients who initiated PrEP at Mount Sinai Health System from 2013 to 2016. Patients were screened for syphilis and urethral, rectal and pharyngeal gonorrhea and chlamydia every 6 months with additional testing at providers’ discretion. Results During the study period, 599 patients (95% male) initiated PrEP at 34.3 years of age on average (SD=9.8; range=17–75). Of the 516 with information on sexual orientation, 91% was MSM; 38% was White, 17 % Hispanic, and 12 % Black. Nearly 35% of the 450 tested for STIs had at least one STI with 9% receiving 3 or more positive results. A total of 278 STIs were detected over 460 person-years of follow-up among 328 patients with a known PrEP initiation date; STI incidence was 59.7/100 person-years (95% CI: 48.68–70.63). There were no significant differences by race or ethnicity. Rectal STIs were significantly higher among those aged 25–30 (P < .01) than the other age groups and among those with PrEP-AP or Medicaid insurance coverage (P < .05) compared with private insurance. A greater number of men who reported alcohol or drug use tested positive for STIs than men who did not report substance use (P < .05). Adjusted logistic regression analysis showed the odds of being diagnosed with any STI or a rectal STI were 1.78 (95% CI: 1.14–2.77) and 2.56 (95% CI: 1.30–5.05) times among those reporting substance use. Conclusion STI incidence, including rectal STIs, was significantly higher among men who reported alcohol or drug use. This study highlights a group within this cohort of PrEP users that remain at high risk for HIV and would benefit from continued adherence to PrEP as well as enhanced counseling on substance use and reducing high-risk sexual behaviors. Disclosures All authors: No reported disclosures.

Background Despite expansion of antiretroviral therapy in recent years and growing evidence for PrEP (pre exposure prophylaxis) efficacy, HIV incidence has continued to rise while PrEP uptake has remained low, particularly in populations at risk. Our goal is to compare these populations and further identify discrepancies in populations at risk in Southern Arizona. Methods We retroactively reviewed health records for patients evaluated at Banner University Medical Center Tucson outpatient clinics between January 2014 and September 2016, either with a new HIV diagnosis or prescribed tenofovir/emtricitabine for PrEP. Results We identified 147 patients with new HIV diagnoses and 65 patients evaluated for PrEp. 63% of the newly diagnosed HIV were of Hispanic, African American or American Indian descend (46%, 14% and 3% respectively) while the majority of PrEP patients were White (58%) with a statistically significant difference between the groups (P = 0.006). There was no significant difference between the age groups [28 (19%) of the HIV and 13 (20%) of the PrEP were 18–24] or gender (88% of people accessing HIV care were men, vs. 91% men seen for PrEP). Insurance information at the time of presentation was available for 145 HIV and 64 PrEP patients with statistically significant differences between the groups. 31(21%) newly diagnosed HIV had no insurance and 71 (49%) had a Medicaid plan while 45 (70%) of PrEP patients has a private insurance plan (P < 0.001). None of the people accessing PrEP reported iv drug use as a risk factor compared with 16 (11%) of the newly diagnosed (P = 0.003). Retention in care at 3 months was similar (76% of HIV and 75% of PrEP). The predominant risk categories were MSM with multiple partners and/or condomless anal sex for both groups. Conclusion To our knowledge this is the first study evaluating HIV and PrEP health care disparities in a border region of the Southwestern US, which is home to a large Hispanic minority population. Our findings suggest that low income minority populations, such as Hispanic, African American and American Indian in this region continue to have a higher risk for HIV acquisition and highlights the ongoing need to expand research on how these populations perceive their risk for HIV and navigate complex systems, such as health insurance, when seeking clinical services for PreP. Disclosures All authors: No reported disclosures.

Background Effective January 1, 2017, Standard MM.09.01.01 addressing antimicrobial stewardship is enforceable by The Joint Commission (TJC). In order to ensure TJC survey success, we implemented a systematic approach to address each associated Element of Performance. Methods Upon notification of TJC Pre-Publication Standard MM.09.01.01 in 2016, we held an Antimicrobial Stewardship Program (ASP) team Transformational Summit, at which time we developed a strategic plan including goals and programs aimed at optimizing our existing program and satisfying TJC ASP Standard. Members of our ASP include Infectious Diseases pharmacists and physicians, pharmacy administration, the microbiology laboratory directors, infection preventionists, and a data manager. Results Specific programs developed to meet each Element of Performance included: (EP1) composing a strategic plan based on TJC ASP standard and an ASP letter of support for senior leadership to endorse; (EP2) developing an educational program for providers including a required eLearning module and work station screensavers regarding antimicrobial resistance and stewardship principles; (EP3) creating educational materials for patients to view during their inpatient stay via our online portal and creating patient-directed screensavers for the in- and outpatient settings; (EP4) expanding our ASP team to include additional members; (EP5) implementing a hospital-wide antibiotic time-out program and a plan for providing drug use feedback to front-line providers; (EP6) updating guidelines for the management of pneumonia and MRSA bacteremia and developing a systematic approach for prospective audit and feedback of restricted antimicrobials; (EP7) constructing a dashboard for tracking antimicrobial use and cost trends; (EP8) creating an ASP intervention worklist in our electronic health record identifying patients with positive blood cultures and those on high-risk antimicrobials. Conclusion As a result of TJC Standard MM.09.01.01 regarding antimicrobial stewardship, a systematic approach to addressing each Element of Performance was developed. Sharing the details of our approach may benefit other institutions as they prepare the TJC survey. Disclosures All authors: No reported disclosures.

This chapter discusses the current understanding of relations between attention deficit hyperactivity disorder (ADHD) and substance use. Children with ADHD are at risk for problems in substance use; evidence suggests that the relations between ADHD and substance use may differ across age groups, gender, and comorbid conditions. Important issues regarding appropriate assessment and developmental trajectories may play a role in how these differences are understood. In comorbid substance use and ADHD, significant overlap in genetic, neurobiological, and trait factors suggests that ADHD and substance use share a common etiology, although factors influencing the phenotypic expression of these factors continue to play an important role in how comorbidity is expressed. Finally, treatment of these comorbid conditions is discussed, both in terms of the issues surrounding medication for ADHD in the context of substance abuse and potential nonmedication treatments that address both substance use and ADHD symptoms through cognitive behavioral strategies.

Aims: The aim of the study was to analyze independent and potential interactive effects of age at drinking onset and family history of alcohol abuse on subsequent patterns of alcohol drinking, alcohol-related problems and substance use. Methods: Participants were college students (60.3% females, mean age = 20.27 ± 2.54 years) from the city of Córdoba, Argentina. Several measures were used to assess alcohol, tobacco and drug use. The Spanish version of the Brief Young Adult Alcohol Consequences Questionnaire was used to assess alcohol-related problems. Factorial analyses of variance, or its non-parametric equivalent, were performed to explore differences in substance use behaviors and alcohol-related problems in subjects with early or late drinking onset and with or without family history of alcohol abuse. Chi-square tests were conducted to analyze the association between these two risk factors and categorical measures of alcohol, tobacco and drug use. Results: Early onset of drinking was associated with amount of consumption of alcohol including up to hazardous levels, as well as tobacco and drug use. However, the frequency of alcohol problems and frequency of episodes of alcohol intoxication were only related to age of onset in those with a positive family history of alcohol problems. Conclusion: Delaying drinking debut is particularly important in the prevention of future alcohol problems in those adolescents who have a family history of such problems. Fil: Pilatti, Angelina. Universidad Nacional de Córdoba. Facultad de Psicología; Argentina Fil: Caneto, Florencia. Universidad Nacional de Córdoba. Facultad de Psicología; Argentina Fil: Garimaldi, Javier Alejandro. Universidad Nacional de Córdoba. Facultad de Psicología; Argentina Fil: Vera, Belén del Valle. Universidad Nacional de Córdoba. Facultad de Psicología; Argentina Fil: Pautassi, Ricardo Marcos. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Córdoba. Instituto de Investigación Médica Mercedes y Martín Ferreyra. Universidad Nacional de Córdoba. Instituto de Investigación Médica Mercedes y Martín Ferreyra; Argentina