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A young Indian man presented elsewhere with a short history of haematuria and cough. Investigations revealed renal and pulmonary lesions. Histopathology of these lesions was reported as mucormycosis. He consulted us two months after onset of symptoms, asymptomatic and clinically well, having received no treatment. In view of clinico-histopathological discordance, a review of the biopsy slides was advised but the patient refused further work-up at that time. One week later, however, he was admitted with left hemiparesis. Brain imaging showed an abscess. He underwent surgical excision of the brain abscess and nephrectomy. Review of previous slides showed septate fungal filaments with granulomatous inflammation. Intraoperative cultures grew Aspergillus flavus. He received voriconazole for one year and is well at his two-year follow-up. His immunological work-up was negative for immunodeficiency. This case illustrates that granulomatous aspergillosis may be an indolent infection in apparently normal individuals and reiterates the importance of interpreting diagnostic reports in conjunction with clinical features.

Background This study was done to investigate the utility of specific fluoroquinolone mutations in LPA in predicting the susceptibility in DST at WHO recommended Critical Concentrations of 0.5 and 2 µg/dL of moxifloxacin within a short time frame as provided by LPA. Methods In a retrospective study performed at a tertiary care hospital of Mumbai, India from October 2015 to February 2017, consecutive samples demonstrating fluoroquinolone resistance by LPA were selected. The LPA kit used was Hain Lifescience Genotype MTBDRsl (Version 1). It detects the following mutations in gyrA gene: MUT1: Ala90Val, MUT2: Ser91Pro, MUT3A: Asp94Ala, MUT3B: Asp94Asn/Tyr, MUT3C: Asp94Gly, MUT3D: Asp94His. The causal mutation was noted. For 89 of these samples, DST had been requested and results with Critical Concentration of 0.5µg/dL and 2µg/dL for moxifloxacin were available Results The 89 samples studied were as follows: Sputum (n = 60), paravertebral soft tissue (n = 2), bronchoalveolar fluid (n = 2), cerebrospinal fluid (n = 1), endotracheal tube secretion (n = 1), pleural fluid (n = 1) and site not recorded (22). 3 of these samples had double mutations. Results are as follows. Mutation in gyrA gene Number of samples (n) Susceptible at 0.5 µg/dL [n (%)] Susceptible at 2 µg/dL [n (%)] MUT1 (Ala90Val) 18 6(33.33) 16(88.89) MUT2 (Ser91Pro) 2 0(0) 1(50) MUT3A (Asp94Asn) 13 3(23.07) 11(84.61) MUT3B (Asp94Asn/Tyr) 6 1(16.67) 4(66.67) MUT3C (Asp94Gly) 51 4(8) 43(84.31) MUT3D (Asp94His) 2 0(0) 2(100) Conclusion This study showed a higher proportion of M. tuberculosis susceptibility at 2 µg/dL rather than at 0.5 µg/dL, to moxifloxacin for gyrA mutations Ala90Val (MUT1), Asp94Ala (MUT3A), Asp94Gly (MUT3C), Asp94His (MUT3D) but not for Ser91Pro (MUT2) and Asp94Asn/Tyr (MUT3B). However, the number of samples with Ser91Pro (MUT2) and Asp94Asn/Tyr (MUT3B) mutations was too small for meaningful conclusion. This susceptibility at a higher critical concentration of moxifloxacin may have clinical implications for use of high dose moxifloxacin. Since this information is available within a short time frame as provided by LPA, a more effective regimen could be devised 4 to 8 weeks earlier than after results of DST. This may result in faster sputum conversion and prevent amplification of resistance. Disclosures All authors: No reported disclosures.

Background Antimicrobial resistance in Gram-negative organism is a global problem. There is an increased interest in Fosfomycin due to its attractive PK/PD properties. The present study aimed to examine the effectiveness and safety of IV Fosfomycin which has been recently licensed in India. Methods We retrospectively studied patients who received IV Fosfomycin from January 2017 to February 2018. Patients with proven or suspected sepsis given IV Fosfomycin were included in the study. Clinical, microbiological outcome, and adverse reactions were noted. Results 27 patients received IV fosfomycin. Of these 6 were excluded from the study because 2 had SIRS due to non-infective etiology, 1 had an organism with Fosfomycin resistance and 3 had incomplete clinical records. 7 patients received empirical and 14 received directed treatment. The most frequent isolate was carbapenem-resistant Klebsiella pneumoniae found in 8 patients. 1 patient received monotherapy while 20 received combination therapy. 9 patients were clinically cured. 1 showed clinical improvement, 8 worsened on treatment due to adverse drug reactions and 3 patients died while on treatment. Microbiological cure was seen in 6 patients. 3 had persistently positive cultures. 1 patient with bacteremic UTI due to Klebsiella pneumoniae received IV fosfomycin for 14 days and relapsed after 1 week of stopping treatment with the same organism showing fosfomycin resistance. 16 patients developed adverse drug reactions. The most common adverse drug reaction was diarrhea in 13, among them 1 had C. difficile colitis. Other adverse reactions like hypernatremia and hypokalemia were observed in 7 and 10 patients, respectively. Electrolyte imbalance were seen in patients aged >50 and those who received a higher dose than was appropriate for the creatinine clearance. 2 patients developed noncardiogenic pulmonary edema within 72 hours of starting fosfomycin and 1 developed torsades de pointes with QT prolongation due to hypokalemia Conclusion Fosfomycin appears to be a useful addition to the treatment armamentarium. Although adverse events have not been considered significant in most reviews, they are highly significant in our experience. We recommend careful monitoring of fluid and electrolyte balance in patients receiving IV fosfomycin Disclosures All authors: No reported disclosures.