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Abstract Background Respiratory syncytial virus (RSV) infections in lung transplant recipients (LTRs) have been associated with bronchiolitis obliterans syndrome (BOS). However, limited data exists regarding the association of RSV with other types of rejection. Methods This retrospective study of all RSV-infected LTRs at Duke University from January 2013 to May 2017 examined acute cellular rejection (ACR), acute antibody mediated rejection (AMR), new human leukocyte antigen (HLA) detection, new donor-specific antigen (DSA) detection, new BOS development and BOS progression at 1 year after RSV infection. Early and late RSV was defined as infection occurring ≤ or >180 days post lung transplant, respectively. Logistic regression was performed to adjust risk of rejection. Results Of 114 RSV-infected LTRs, 20 and 94 had early and late infection respectively. The cohort differs regarding underlying prior BOS, site of infection and RBV treatment (see table). Overall 1-year ACR after RSV infection was 44.7% (75% vs. 38.3% in early and late groups, respectively). Patients with early RSV infection had significantly higher rate of new HLA and DSA detection (see table). After adjusting by infection site and RBV exposure, the odd ratios (OR) for new HLA detection for patients with early RSV was 5.4 [1.4, 20.7]. Both oral and inhaled RBV did not decrease the OR for ACR after adjusting for infection and timing of RSV infection after lung transplantation. Conclusion Our data showed RSV infection was associated with very high rates of ACR in both early and later RSV groups. Patients with early RSV had higher rates of new HLA and DSA detection. Early RSV N = 20 (%) Late RSV N = 94 (%) P-value Underlying BOS prior to RSV infection 0 24 (25.5) 0.01 Site of infection 0.03 Upper tract 3 (15) 41 (43.6) Lower tract 9 (45) 36 (38.3) Asymptomatic 8 (40) 17 (18.1) Treatment <0.001 Oral RBV 4 (20) 66 (70.2) Inhaled RBV 10 (50) 22 (23.4) Supportive care 6 (30) 6 (6.4) Concomitant IVIG 3 (15) 18 (19.4) 0.65 Rejections ACR 15 (75) 36 (38.3) 0.03 Median episodes of ACR within 1 year after RSV infection (range) 1 (1–5) 1 (1–3) 0.38 AMR 3 (15) 4 (4.3) 0.07 New detection of: HLA 7 (35) 10 (10.6) 0.005 DSA 6/7 (85.7) 3/10 (30) 0.03 BOS 4/20 (20) 19/70(27.1) 0.52 BOS progression (patients with prior BOS) - 9/24 (37.5) - Disclosures R. Miller, scynexis: Investigator, Research support.

1599. Rejection Outcomes in Lung Transplant Recipients Post Respiratory Syncytial Virus Infections