Mucormycosis is a highly invasive and rapidly progressing form of fungal infection that can be fatal. The infection usually begins after oral or nasal inhalation of fungal spores and can enter the host through a disrupted mucosa or an extraction wound. The organism becomes pathogenic when the host is in an immunocompromised state. There are several clinical presentations of mucormycosis including rhinocerebral, pulmonary, cutaneous, gastrointestinal, disseminated, and miscellaneous forms. The most common clinical presentation of mucormycosis is the rhinocerebral form which has a high predilection for patients with diabetes and metabolic acidosis. An indolent disease course taking weeks to months of this infection is rare making it difficult to diagnose. Therefore, early detection and prompt treatment with surgical and antifungal therapy are very important in achieving good treatment outcomes.

INTRODUCTION: Accumulating evidence indicates an association between CD4 count and Ulcerative colitis (UC) flares in patients with Human Immunodeficiency Virus (HIV)[1,4], whereby patients who have low CD4 counts are less likely to experience UC flares compared to those who have normal CD4 counts. While the exact mechanism is unknown, it is hypothesized that an immunosuppressed state allows for the remission of UC; this idea has been deemed the “Remission Hypothesis” [1]. CASE DESCRIPTION/METHODS: Objective: To present a case series of 3 patients with concomitant HIV and Ulcerative Colitis (UC) and examine the association between UC flares, CD4 counts and viral load over time. METHODS: Patient records at two urban university-affiliated medical centers were queried for patients with concomitant HIV and UC. ICD 9 and ICD 10 diagnostic codes for HIV and UC were used to identify patients. Inclusion criteria were confirmed UC via endoscopy, outpatient follow up, viral load and CD4 count documentation. CD4 counts and viral loads levels were compared during hospitalizations and outpatient follow-ups. RESULTS: 7 patients with UC and HIV were identified; 3 of these 7 patients had sufficient data available for further analysis. Our three patients lived with HIV for an average of 10 years. Patient 1 experienced 4 UC flares requiring inpatient hospitalizations while maintaining CD4 counts above 250 cells/µL and undetectable viral loads (Table 1). Patient 2 had five UC flares with CD4 counts above 250 cells/µL; an undetectable viral load was noted during 4 of the UC flares (Table 2). Patient 1 had two flares with CD4 counts above 250 cells/µL; the viral load was undetectable during flares (Table 3). DISCUSSION: The remission hypothesis suggests that patients who have concomitant HIV and UC can experience remission of their inflammatory bowel disease as their CD4 count declines [1]. HIV viral load is a more accurate and more important marker of HIV disease progression, and therefore, a relationship between viral load and UC flares need to be further studied. Our patients continued to experience flares despite suppressed viral load, and CD4 counts above 250 cells/µL. This case series is the first study that considers viral load and CD4 counts when considering IBD flares and disease progression. These findings raise the question of whether IBD flares occurs as a consequence of CD4 count above 250 or low viral load. Further studies with larger populations are needed to elucidate the pathophysiology of IBD and HIV coexistence.

Background:The “Remission Hypothesis” suggests that in patients with both HIV and UC an immunosuppressed state allows for the remission of UC and decreased number of flares. While the exact mechanism is unknown, this theory considers the relationship between CD4 count and flare progression. However, currently literature does not take into account the role that viral load might play in modulating flare activity.Methods:This is a case series including three patients with concurrent HIV and IBD at two large urban academic centers. A retrospective chart review was done and clinical information such as CD4+ count, viral load and flare symptoms were collected for each patient.Results:Three patients with a total of eleven UC flares were evaluated between the years of 2007 and 2018. Of the eleven flares, nine flares occurred while the viral load was undetectable, one flare occurred while the viral load was unknown, and one flare while the viral load was detectable.Conclusions:Nine out of eleven UC flares occurred while the patients’ viral loads were undetectable, which can support a “Remission Hypothesis” which is inclusive of viral load instead of CD4+ count. However, it is important to note that the disease progression of Patient 3 does not completely support this version of the hypothesis. While we cannot comment on whether the “Remission Hypothesis” is true or not, we do believe a more inclusive theory including viral load should be considered.

BackgroundOverutilization of urine cultures may lead to inappropriate use of antibiotics. We implemented a computerized urine culture order set where urine specimens are not processed for culture unless there is evidence of pyuria (≥10 WBC per high power field) on urinalysis (UA), or if a patient is pregnant, neutropenic, neonate, renal transplant recipient, planned for or had a recent urologic procedure. Here we evaluated the impact of this order set on antibiotic utilization, urine culture volumes and rates of catheter-associated urinary tract infections (CAUTI).MethodsWe performed a retrospective chart review before and after the order set implementation (August–December 2017 and 2018, respectively). The analysis had two distinct components: first was at institution-level, where data for all adult and pediatric inpatients were compared for urine culture volumes and antibiotic use regardless of indication. The second component was done at patient-level, where we compared clinical data and days of therapy (DOT) for all adult inpatients who had urine cultures without pyuria in the specified pre-intervention period, and those with canceled urine cultures due to absence of pyuria post-intervention.ResultsAt the institution-level analysis, a statistically significant reduction was observed in rates of urine cultures performed (P = 0.02), as well as use of penicillins, carbapenems and Trimethoprim-Sulfamethoxazole (TMP-SMX) (P < 0.05). However, the use of cephalosporins has increased post-intervention (P < 0.001). No significant change was noted for aminoglycosides or fluoroquinolones.At the patient-level analysis, DOT means in patients with negative pyuria did not change significantly (5.16 pre-intervention, 6.54 post-intervention, P = 0.202). Prevalence of treatment for bacteriuria despite absence of pyuria was 5.3% (20/380) pre-intervention, vs. 1.9% (1/53) post-intervention (P = 0.494). In the pre-intervention period, three cases met the criteria for CAUTI despite negative pyuria. This misdiagnosis could have been avoided by implementation of the urine culture order set.ConclusionImplementation of a urine culture order set in our institution led to a statistically significant reduction in rates of urine cultures performed, as well as use of penicillins, carbapenems and TMP-SMX. Disclosures All authors: No reported disclosures.

BackgroundThe U.S. Department of Agriculture (USDA) defines food insecurity as a lack of consistent access to enough food for an active and healthy life. A review of the literature indicates that there are only few studies on food insecurity and people living with human immunodeficiency virus (HIV) in the United States, despite it being one of the most basic physiological need. Here, we aimed to examine the association between food insecurity and viral load suppression in people with HIV on antiretroviral therapy (ART) at an HIV primary care practice.MethodsThis was a cross-sectional study conducted at an urban university hospital HIV primary care practice in Brooklyn, New York. It included patients seen during a six month period, from July 1 until December 31, 2018, that were found to have an unsuppressed viral load while reporting being on ART. We defined unsuppressed viral load as viral load >200 copies/milliliters. Food security was measured with the Household Food Insecurity Access Scale (HFIAS), a questionnaire by USAID’s Food and Nutrition Technical Assistance Program, which has demonstrated cross-cultured validity. It categorized patients into four groups: food secure and mildly, moderately or severely food insecure. Patient were contacted in clinic during their appointment or by telephone survey.ResultsA total of 145 patients were found to have an unsuppressed viral load while on ART, with 54 patients (37%) reporting food insecurity. Based on HFIAS’s classification, 44 patients (30%) reported mild or moderate food insecurity, and 10 patients (7%) reported severe food insecurity. The study population demographics was 86% African American or blacks, 12% Hispanics and 2% of other race. Seventy-three patients (50%) also reported receiving benefits from New York’s Supplemental Nutrition Assistance Program.ConclusionFood insecurity can be associated with unsuppressed viral load and was found in over one-third of our study population, with half relying on food assistance programs. It represents a complex problem fundamentally connected to issues such as poverty and unstable housing, which can negatively impact patient engagement and retention in care. Our findings highlight the importance of integrating food and social services into HIV programs, especially in lower-income populations.Disclosures All authors: No reported disclosures.