Autoimmunity increases susceptibility to and mortality from sepsis

Our prior publication detailing how sepsis influences subsequent development of EAE presented a conceptual advance in understanding the post-sepsis chronic immunoparalysis state (Jensen et al., 2020). However, the reverse scenario (autoimmunity prior to sepsis) defines a high-risk patient population whose susceptibility to sepsis remains poorly defined. Herein, we present a retrospective analysis of University of Iowa Hospital and Clinics patients demonstrating increased sepsis incidence among MS, relative to non-MS, patients. To interrogate how autoimmune disease influences host susceptibility to sepsis well-established murine models of MS and sepsis, EAE and CLP, respectively, were utilized. EAE, relative to non-EAE, mice were highly susceptible to sepsis-induced mortality with elevated cytokine storms. These results were further recapitulated in LPS and S. pneumoniae sepsis models. This work highlights both the relevance of identifying highly susceptible patient populations and expands the growing body of literature that host immune status at the time of septic insult is a potent mortality determinant.

753. Screening for Latent Mycobacterium tuberculosis Infection (LTBI): A Clinical Conundrum of Public Health Concern

Background Tumor necrosis factor (TNF)-α inhibitors increase the risk of reactivating LTBI, hence screening is crucial prior to starting therapy. There is a lack of evidence to support a preferred screening regimen in this population, and either tuberculin skin tests (TST) or interferon-γ release assays (IGRAs) are acceptable. Although difficult to assess, the sensitivity of IGRAs and TST are similar (80–95%), while IGRAs are considered to be more specific. Methods A 48-year-old White female in rural Iowa with a 30-year history of Crohn’s disease was evaluated for TNF inhibitor therapy. She had no known risk factors for LTBI and was screened using an IGRA which yielded an indeterminate result. A repeat IGRA and a two-step TST were both negative. Subsequently, adalimumab was initiated. Adalimumab was discontinued after 9 months due to progression of Crohn’s, and the patient underwent bowel surgery at a California hospital. Her course was complicated by bilateral pleural effusions requiring thoracentesis twice. Results The patient presented 1 month later with upper lobe infiltrative changes and mediastinal adenopathy. A third IGRA was performed and was non-reactive. A bronchoscopy with biopsy was then performed. The next day her dyspnea, cough and fevers worsened. She was admitted to an Iowa hospital where she was immediately put in airborne precautions. Her bronchoalveolar lavage acid-fast bacilli (AFB) smear was 4+, and an induced sputum showed 3+ AFB. Standard TB treatment was initiated. At least 59 patients (17 immunocompromised) and five employees in a private office and 13 employees at the Iowa hospital were exposed, in addition to an unknown number in California. Conclusion Although rare, there appears to be a risk for patients on TNF inhibitors who have multiple negative screening tests to become infected with TB. It is unclear whether this represents reactivation of undetected LTBI or new infection, although new TB cases are less likely in rural Iowa where the incidence is 1.53 per 100,000. Patients should be counseled to report any pulmonary symptoms to providers. As demonstrated by this case, airborne precautions should be implemented as soon as possible if clinical suspicion of TB is high despite negative screening tests to reduce exposure to others. Disclosures All authors: No reported disclosures.

What factors do critical access hospital trustee/board members believe are important to recruitment of physicians and do they differ from hospital administrators and physicians

Background: Rural hospitals continue to struggle to recruit physicians. Examining trustee/board member perceptions of their community’s strengths and challenges related to physician recruitment may provide insight on how to sustain an effective workforce in these facilities.Objective: The purpose of this study is to identify similarities and differences between critical access hospital (CAH) trustee/board members’ perspectives on factors important to physician recruitment compared to their hospital administrators and physicians practicing in their facilities.Methods: The CAH Community Apgar Questionnaire (CAH CAQ) was expanded to include trustee/board member participation in Iowa. Online survey methods were used to compile information from trustees/board members, hospital administrators and physician from participating CAHs recruited by the Iowa Hospital Association.Results: A total of 16 Iowa CAH communities participated in the project in 2015. There were 17 administrators, 39 physicians and 23 board members respondents for a total of 79 respondents. Significant differences were found between trustee/board members and hospital administrators ratings on CAH CAQ factors loan repayment and transfer arrangements. Trustee/board members and physicians showed significant differences on scores for the CAH CAQ class factor hospital/community support and on factor ratings for teaching, administration, hospital sponsored continuing medical education and welcome and recruitment programs.Discussion: This study has identified commonalities and differences in how rural hospital trustee/board members and the administrators and physicians who work at their facilities view community strengths related to physician recruitment. Analyzing and discussing the areas of consensus and differences of opinion could help develop more effective physician recruitment strategies for these communities.

Persistence ofLegionella Pneumophilain a Hospital's Water System: A 13-Year Survey

Objective:To describe the molecular epidemiology ofLegionella pneumophilainfections in the University of Iowa Hospitals and Clinics (UIHC).Design:Molecular epidemiological study using pulsed-field gel electrophoresis (PFGE).Setting:A large university teaching hospital.Isolates:All surviving isolates obtained from culture-proven nosocomialL pneumophilainfections and all surviving isolates obtained from the University of Iowa Hospital and Clinics' water supply between 1981 and 1993.Results:Thirty-three isolates from culture-proven nosocomial cases ofL pneumophilapneumonia were available for typing. PFGE of genomic DNA from the clinical isolates identified six different strains. However, only strain C (16 cases) and strain D (13 cases) caused more than 1 case. Strain C caused clusters of nosocomial infection in 1981, 1986, and 1993 and also caused 4 sporadic cases. Strain D caused a cluster in 1987 and 1988 plus 4 sporadic cases. Of the six strains causing clinical infections, only strains C and D were identified in water samples. PFGE identified three strains in the water supply, of which strains C and D caused clinical disease and also persisted in the water supply during most of the study period.Conclusion:Specific strains ofL pneumophilacan colonize hospital water supplies and cause nosocomial infections over long periods of time.