bluuebunny/crossref_metadata_2025 huggingface dataset:
91. Development of an Electronic Algorithm to Identify Inappropriate Antibiotic Prescribing for Pediatric Otitis Media
Authors: Lautenbach Ebbing , Gerber Jeffrey , Grundmeier Robert , Hamilton Keith W , Hicks Lauri , Neuhauser Melinda M , Frager Nicole , Menon Muida , Kratz Ellen , Jaskowiak Anne , Cressman Leigh , James Tony , Omorogbe Jacqueline
Published: January 2021

Background

Antibiotic stewardship (AS) interventions have primarily focused on acute care settings. The majority of antibiotic use, however, occurs in outpatients. The electronic health record (EHR) might provide an effective and efficient tool for outpatient AS. We aimed to develop and validate an electronic algorithm to identify inappropriate antibiotic use for pediatric outpatients with acute otitis media (AOM).

Methods

Within the Children’s Hospital of Philadelphia (CHOP) Care Network, we used ICD-10 diagnostic codes to identify patient encounters for AOM at any CHOP practice between 3/15/17 – 3/14/18. Exclusion criteria included underlying immunocompromising condition, comorbidities, and concurrent infections that might influence antibiotic use. We randomly selected 450 eligible subjects (150 each from academic practices, non-academic practices, and urgent care). Inappropriate antibiotic use based on CHOP and professional society guidelines were assessed via chart review and served as the basis for assessment of the electronic algorithm which was constructed using only data in the electronic health record (EHR). Criteria for appropriateness focused on the decision to prescribe, the choice of antibiotic, and duration of therapy.

Results

Of 450 subjects, median age was 2, 46% were female, and 88% were evaluated by a physician (vs. advanced practice provider). On chart review, the prescribing decision was correct in 438 (97%), of which 25 appropriately received no antibiotics. Of the 413 subjects who were appropriately prescribed an antibiotic, the choice of antibiotic was appropriate in 37 (9%). Finally, of the 413 patients who were appropriately treated, 412 (99.7%) received the correct duration. Test characteristics of the EHR algorithm (compared to chart review) are noted in the Table.

Conclusion

For children with AOM, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. This algorithm can also highlight for which elements of prescribing the impact of an intervention might be greatest (i.e., choice of agent). Future work should validate this approach in other health systems and geographic regions and evaluate the impact of an audit and feedback intervention based on this tool.

Table. Test Characteristics of Electronic Algorithm for Inappropriate Prescribing, Agent, and Duration

Disclosures

All Authors: No reported disclosures
92. Successful Scale-up of an Intervention to Decrease Unnecessary Urine Cultures Led to Improvements in Antibiotic Use
Authors: Grigoryan Larissa , Van John , Ramsey David J , Goebel Melanie , Walder Annette , Kramer Jennifer , Chou Andrew , Patel Payal K , Graber Christopher J , Lichtenberger Paola , Wiseman Steven , Shukla Bhavarth , Drekonja Dimitri , Calub Feliza , Naik Aanand , Trautner Barbara
Published: January 2021

Background

We previously conducted a successful single-site intervention to improve compliance with antibiotic stewardship guidelines for asymptomatic bacteriuria (ASB). In this dissemination project we explored whether we could facilitate antibiotic stewardship for ASB at a distance, in four distant VA medical centers.

Methods

Each site champion received a decision-aid algorithm, interactive teaching based on actual cases, and support with data collection. The focus of the intervention was on teaching providers in acute and long-term care to avoid ordering unnecessary urine cultures. We measured DOT (days of antibiotic therapy), LOT (length of antibiotic therapy) and urine cultures ordered per 1,000 bed-days monthly in the intervention sites and four matched control sites. Both DOT and LOT captured all systemic antibiotics initiated on day -1 to +2 of a urine culture order. We conducted segmented regression analyses for the three outcomes for the intervention and control sites separately, and difference in differences analysis for urine cultures.

Results

Over the baseline and intervention years, 12,260 urine cultures were ordered in 6823 unique patients in the acute and long-term care wards at the 8 sites. During the baseline year, the average urine-culture related DOT was 45.1 and LOT was 34.7, per 1000 bed-days. Both DOT and LOT decreased significantly over the intervention period in the intervention sites (p < 0.05 for both); a significant decrease was not seen in the control sites (Figures 1 and 2). For urine cultures, at baseline the average number of cultures ordered per month per 1000 bed-days was 13.6. Both intervention and control sites saw a significant decrease in urine cultures over the baseline year. In the intervention year, urine cultures continued to decrease in the intervention sites (p=0.001) but increased in the control sites (Figure 3).

Figure 1. Days of Therapy (DOT) per 1,000 bed-days, for antibiotics started within -1 to +2 days of a urine culture

Figure 2. Length of Therapy (LOT) per 1,000 bed-days, for antibiotics started within -1 to +2 days of a urine culture

Figure 3. Urine Cultures per 1,000 bed-days

Conclusion

Our externally-facilitated intervention significantly decreased local antibiotic use (both DOT and LOT) and urine cultures. Unnecessary urine cultures are a major driver of unnecessary antibiotic use for ASB, and our focus on diagnostic stewardship for urine cultures led to antibiotic stewardship. Our next step will be to further disseminate our intervention to other VA facilities.

Disclosures

All Authors: No reported disclosures
93. Enhanced Oral Care as Prevention for Non-ventilator Hospital Acquired Pneumonia
Authors: Giuliano Karen K , Penoyer Daleen , Middleton Aurea , Baker Dian
Published: January 2021

Background

Non ventilator hospital-acquired pneumonia (NVHAP) is now the most common HAI. The purpose was to test primary source control through reduction of germs in the mouth as a modifiable risk factor for in NVHAP prevention.

Methods

The 12-month study (10/1/18–9/31/19) was conducted at an 800-bed tertiary medical center. 1 medical and 1 surgical unit were randomized to enhanced oral care (intervention) and matched with 1 medical and 1 surgical unit providing usual oral care (control). An American Dental Association oral care protocol was delivered by nurses/nursing assistants (Intervention) vs. usual care. Frequency of oral care was tracked. Pneumonia cases were identified using ICD-10 codes and confirmed using CDC criteria.

Results

For medical control (n=2059) v. intervention (n=2706), oral care/day increased from .96 to 2.2; there was an 85% reduction in NVHAP (1.41 to 0.21)/1000 patient days which was significant by Chi-square (p< 0.001), and Cramer’s V effect size of 0.52. Using logistic regression, the odds of NVHAP were 7.1 times higher on the on the control unit v. intervention (OR:7.1 [CI 2.01:24.1] p=.002). For surgical control (n=2075) v. intervention (n=1830), oral care frequency/day increased from 1.2 to 2.1. There was a 56% reduction in NVHAP which was NS by Chi-square (p=.289), Cramer’s V effect size of 0.02, and this group was underpowered to detect a difference (post hoc actual power=.61).

NVHAP demographics

NVHAP incidence

NVHAP secondary outcomes

Conclusion

These findings add to the growing body of evidence that oral care as primary source control is likely to have a role in NVHAP prevention.

Disclosures

Karen K. Giuliano, PhD, Medline (Grant/Research Support) Daleen Penoyer, PhD, RN, Medline (Grant/Research Support) Aurea Middleton, MS, RN, Medline (Grant/Research Support) Dian Baker, PhD, RN, Medline (Grant/Research Support)
94. Clinical Correlates of Cdc’s Hospital-onset Adult Sepsis Event Surveillance Definition and Association with Reportable Healthcare-associated Infections
Authors: Page Brady , Klompas Michael , Chan Christina , Filbin Michael , Dutta Sayon , McEvoy Dustin , Rhee Chanu
Published: January 2021

Background

Hospital-onset (HO) sepsis is associated with substantial mortality but is not tracked or reported by most hospitals. CDC’s Adult Sepsis Event (ASE) definition may facilitate standardized surveillance but little is known about the clinical correlates of HO-ASEs and their association with currently reportable healthcare-associated infections (HAIs).

Methods

In this retrospective study of all adult patients admitted to an academic medical center between June 2015–2018, we assessed the overlap between HO-ASEs and HAIs reported to the National Healthcare Safety Network (NHSN) and reviewed a random subset of 110 HO-ASE cases to determine their clinical correlates.

Results

The cohort included 168,249 hospitalized patients, including 2,139 (1.3%) with HO-ASE and 2,133 (1.3%) with NHSN HAIs. Amongst the 2,139 HO-ASE patients, 480 (22.4%) had ≥1 HAI: 8.1% VAE, 6.2% CLABSI, 6.1% C.difficile, 3.1% CAUTI, 1.3% MRSA bacteremia, and 0.8% SSI. HO-ASE was associated with higher in-hospital mortality rates than HAIs (28.6% vs 14.6%, p< 0.001). HO-ASE associated mortality was high even when NHSN-reportable HAIs were absent (26.5%) whereas NHSN-reportable HAI mortality was relatively low when HO-ASE was absent (8.4%). Amongst the 110 reviewed HO-ASE cases, 102 (93%) were possible or confirmed infections, most commonly pneumonia (39%, of which 35% were ventilator-associated), non-C.difficile intra-abdominal infections (15%), febrile neutropenia (14%), urinary tract infection (7%, of which 88% were catheter-associated), and skin/soft tissue infection (7%). Most (86%) infections flagged by HO-ASEs were acquired in the hospital rather than the community. The most common non-infectious events flagged by HO-ASE were pulmonary edema and periprocedural blood loss associated with blood cultures and empiric antibiotics.

Conclusion

CDC’s hospital-onset ASE definition accurately identifies patients with nosocomial sepsis who have very high mortality rates and are generally not captured by currently reportable HAI metrics. Routine hospital-onset ASE surveillance could provide a broader window into serious nosocomial infections, identify new targets for prevention, and further improve outcomes for hospitalized patients.

Disclosures

All Authors: No reported disclosures
95. CAUTI and CLABSI in Hospitalized COVID-19 Patients
Authors: Knepper Bryan C , Wallace Kristin , Young Heather
Published: January 2021

Background

Patients hospitalized for suspected or confirmed COVID-19 often require high levels of support, including supplemental oxygen or ventilation, intravenous fluids and pressors, prone positioning, and strict input/output monitoring. Increased utilization of invasive devices such as indwelling urinary catheters and central venous catheters may be needed in this population. Staff minimize contact time with COVID-19 patients. We hypothesized higher rates of device infection in patients with COVID-19.

Table 1

Methods

This is a retrospective cohort study at a 555-bed safety net hospital. 4 units (125 beds) primarily cared for patients with confirmed infection. Other units did not accept patients until COVID status was deemed negative, except Labor & Delivery and a designated mixed unit. Indwelling urinary catheter and central venous catheter (CVC) device days are tracked in all inpatient areas. CLABSI and CAUTI surveillance is performed using NHSN definitions. The first hospitalized COVID-19 case at our hospital occurred late March 2020. April - May 2020 was considered the initial pandemic phase for our institution. Device utilization for the 6 months prior (October 2019 – March 2020) was compared to initial pandemic phase. Device infection rates were also compared. Within the initial pandemic phase, utilization and infection rates were stratified by COVID-19 vs non-COVID-19 areas.

Results

Median indwelling urinary catheter usage increased during the initial pandemic period by 36% (998 to 1355 catheter days, p=0.13); CVC usage increased 25% (997 to 1246 CVC days, p=0.13). Hospital-wide, median CAUTI rates remained constant (2.9 and 2.7 infections/1000 catheter days, p=1.00). CLABSI rates increased significantly (0.0 and 1.6 infections/1000 CVC days, p=0.008). CAUTI rates were 83% higher, and CLABSI rates were 65% higher in COVID-19 areas compared to non-COVID-19 areas (Table 1). Urine culture and blood culture ordering were 69% higher and 73% higher in COVID-19 areas, respectively.

Conclusion

Utilization of both indwelling urinary catheters and CVC increased during the initial phase of the pandemic. Hospitalized COVID-19 patients appear to be at higher risk of both CAUTI and CLABSI. Patient care protocols, device utilization and culture ordering all require further investigation.

Disclosures

All Authors: No reported disclosures
96. Surgical Site Infection Prophylaxis Selection and Postoperative Clinical Outcomes in Patients with Reported Penicillin Allergy
Authors: Dare Ryan K
Published: January 2021

Background

Administration of preoperative antibiotics are known decrease risk of postoperative surgical site infections (SSI) and deviation from first line prophylaxis increases this risk. Patients who report penicillin (PCN) allergy are less likely to receive cefazolin preoperatively despite being the preferred antibiotic for SSI prevention in the majority of surgical procedures.

Methods

A single center retrospective descriptive study was performed during the 2018–2019 academic year. Perioperative antimicrobial administration practice was evaluated for all types of surgical procedures. Patient demographics, PCN allergy history, development of Clostridioides difficile infection (CDI) within 90 days of procedure, and total hip and knee arthroplasty SSIs were assessed.

Results

During the study period, 16,376 procedures were performed with perioperative antibiotic administration. Cefazolin (12,756; 77.9%) was most frequently administered followed by clindamycin (1,396; 8.5%), and vancomycin (735, 4.5%). PCN allergy was reported in 2,051 (12.5%) patients, of which 1,180 (57.5%) had record of previously receiving a cephalosporin. Interestingly, 694 (33.8%) and 11,799 (82%) patients with and without a reported PCN allergy respectively received cefazolin perioperatively (P< 0.001). The incidence of joint replacement SSI was higher in patients with a reported PCN allergy (6 of 97; 6.2%) compared to those without (12 of 671; 1.8%) (P=0.018). CDI occurred in 44 (1.1%) of 3,883 and 70 (0.5%) of 12,493 patients who received a non-cefazolin or cefazolin respectively for prophylaxis (OR 2.1; 95% CI 1.5–2.9). In multivariate analysis controlling for surgery type, age, weight, and renal function, receipt of a non-cefazolin antibiotic was independently associated with developing CDI (OR 1.6; 95% CI 1.1–2.4).

Conclusion

Patients with a reported PCN allergy were more likely to receive a non-cefazolin antibiotic perioperatively and were more likely to develop a SSI following hip or knee replacement. Administration of a non-cefazolin antibiotic was independently associated with increased risk of CDI. Efforts should be made to minimize inappropriate avoidance of first line perioperative prophylaxis due to reported PCN allergies.

Disclosures

Ryan K. Dare, MD, MS, Accelerate Diagnostics, Inc (Research Grant or Support)
98. Antibiotic Stewardship Interventions Significantly Improve Preferred Antibiotic Prophylaxis in Total Joint Arthroplasty
Authors: Quartuccio Katelyn , Roberts Raquel , Pillinger Kelly E , Heintz Eric , Stern Jessica , Myers Thomas
Published: January 2021

Background

Most patients reporting a penicillin (PCN) allergy can tolerate cefazolin, the preferred prophylaxis in a total joint arthroplasty (TJA). The purpose of this study was to evaluate surgical prophylaxis in patients with a reported PCN allergy undergoing a TJA following a stewardship intervention that included updates to institutional guidelines, reclassification of severe PCN allergy, standardization of ordering processes, and participation of a physician champion.

Methods

This was a single center, retrospective study of adult orthopedic patients greater than 18 years old who underwent a primary elective TJA at a 261-bed community hospital from March 1, 2017 to August 30, 2017 (pre-intervention) and from March 1, 2019 to August 30, 2019 (post-intervention). The primary outcome was the difference in the composite rate of the following: 1) Patients with a reported non-severe PCN allergy without MRSA risk factors who received cefazolin; 2) Patients with a non-severe PCN allergy with MRSA risks factors who received cefazolin plus vancomycin; and 3) Patients with a severe PCN allergy who received vancomycin prior to a primary elective TJA.

Results

A total of 180 patients with a documented PCN allergy were evaluated (90 patients in the pre-intervention group and 90 patients in the post-intervention group). Rash and hives were the most commonly reported allergies in both groups (71% vs 61%, P=0.2076). Post-intervention revealed a significant increase in the primary outcome of appropriate perioperative antibiotic (55% vs 91%, P< 0.001), largely driven by patients with non-severe allergy [47% (36/76) vs 96% (73/76), P< 0.001]. No patients had signs of an allergic reaction thought to be due to cefazolin, including 8 patients with severe PCN allergy. No patients in either group developed a surgical site infection or C. difficile infection within 90 days post-procedure.

Conclusion

A multifaceted antibiotic stewardship intervention increased preferred prophylaxis in elective primary TJA. Patients with non-severe PCN allergies, even those reporting hives or local swelling, can tolerate cefazolin without issue. Patients with severe PCN allergy should undergo further evaluation as cefazolin may be a safe option.

Disclosures

Katelyn Quartuccio, PharmD, BCPS, AstraZeneca (Consultant) Kelly E. Pillinger, PharmD, BCIDP, Pharmacy Times (Other Financial or Material Support, Speaker)
99. Effectiveness of Antibiotic Prophylaxis Among Patients Undergoing Elective Transurethral Resection of the Prostate in the Era of Antibiotic Resistance
Authors: Khawcharoenporn Thana , Kanoktipakorn Pimjira
Published: January 2021

Background

Data existing on effectiveness of antibiotic prophylaxis (AP) for transurethral resection of the prostate (TURP) are limited in the era of antibiotic resistance.

Methods

A 4-year prospective observational cohort study was conducted among patients undergoing TURP in an academic tertiary-care hospital during 2016–2019. Patients were excluded if pre-operative (pre-op) urine cultures were not sent or grew mixed (>2) organisms, or they had pre-op urinary tract infection (UTI) or lost follow-up after TURP. Appropriateness of AP was defined as 1) correct dosing and duration and narrowest spectrum according to the hospital AP guidelines and local epidemiology and 2) being active against uropathogens isolated from the pre-op culture. Primary outcome was the rate of UTI within 30 days post TURP compared between appropriate antibiotic prophylaxis (AAP) and inappropriate antibiotic prophylaxis (IAP) groups.

Results

342 patients were screened and 61 were excluded. Of the 281 patients included, 139 (49%) received AAP and 142 (51%) received IAP. The reasons for IAP were prescribing too broad-spectrum antibiotics (57%), inactive antibiotics (41%) and incorrect dosing (2%). Pre-op urine cultures were no growth in 148 patients (53%). Among the 133 positive urine cultures with 144 isolates, Escherichia coli (52%) was the most commonly isolated. Thirty-one percent of these 144 isolates produced extended-spectrum beta-lactamase (ESBL) and 23 (16%) isolates were multidrug-resistant. The resistant rates of Enterobacteriaceae were 73% for ciprofloxacin, 65% for TMP-SMX and 46% for ceftriaxone. The two most commonly prescribed prophylactic antibiotics were ceftriaxone (51%) and ciprofloxacin (34%). The rate of UTI within 30 days post-TURP was significantly higher in IAP group compared to AAP group (47% vs 27%; P< 0.001). Prescribing inactive prophylactic antibiotics was the independent factor associated with 30-day post-TURP UTI (adjusted odds ratio 2.88; P=0.001).

Conclusion

Appropriate antibiotic prophylaxis significantly reduced UTI within 30 days of elective TURP. Obtaining pre-op urine culture and prescribing an active prophylactic agent are critical for preventing post-TURP UTI in the era of antibiotic resistance.

Disclosures

All Authors: No reported disclosures
104. Evaluation of a Prep Referral System: From Sexual Health Center to Federally Qualified Health Center Prep Clinic
Authors: Lillis Rebecca A , Beckford Jeremy , Fegley Joshua , Siren Julia , Hinton Bruce , Gomez Samuel J , Taylor Stephanie N , Butler Isolde , Halperin Jason , Clement Meredith E
Published: January 2021

Background

In the United States, less than one-quarter of those who are eligible for pre-exposure prophylaxis (PrEP) have been prescribed the medication. Innovative strategies of PrEP delivery are needed to facilitate access and overcome barriers to care. The objective of this study was to evaluate the referral process from a sexual health center (SHC) to a co-located PrEP clinic as an alternative model of PrEP care.

Methods

An initial report was generated from the electronic health record (EHR) to determine the number of patients seen at the SHC in 2019. Charts were then manually reviewed to determine whether a PrEP clinic referral was made. For those referred, we determined the method of the referral: PrEP clinic navigator met the patient at the SHC (handoff), the navigator was messaged in the EHR to then schedule the appointment (EHR message), or the patient was provided a card with the navigator’s contact information (card). We also determined whether patients had subsequent visits at the PrEP clinic or SHC.

Results

From January to December 2019, there were 3570 unique patients seen at the SHC, and 240 (6.7%) were referred to the PrEP clinic. Of 240 referred patients, median age was 29 years; 95 (40%) were non-Hispanic Black and 25 (11%) were Latinx. The majority (n=198, 83%) were male, 32 (13%) were cisfemale, and 9 (4%) were transfemale. An STI was diagnosed on the day of the clinic visit for 116 (49%) patients. Of those who were MSM, 75 (51%) had been diagnosed with an STI in the previous 6 months. In total, 106 referred patients attended an initial PrEP visit and the proportion attending the visit by method of referral was 81%, 38%, and 22% for handoff, EHR message, and card, respectively (p< .0001). Of the 108 patients who attended an initial PrEP visit, 66 (61%) had a subsequent PrEP visit. Of those who did not attend a PrEP visit, 36 (27%) had a subsequent visit at the SHC.

Figure 1. Method of Referral from SHC to PrEP Clinic

Conclusion

Despite co-location of these two clinics, there are significant drop-offs along the PrEP care continuum for this referral system. Navigator-facilitated handoff was the most effective method of referral from SHC to PrEP Clinic, but further efforts are needed to understand barriers to referral. Implementation of rapid PrEP provided at the SHC may be one possible solution to engaging additional patients in PrEP services.

Disclosures

Meredith E. Clement, MD, FHI360 (Consultant)Gilead (Research Grant or Support)Janssen (Scientific Research Study Investigator)
111. Outcomes Related to COVID-19 Among People Living with HIV: Cohort from a Large Academic Center
Authors: Virata Michael D , Shenoi Sheela , Ladines-Lim Joseph B , Villanueva Merceditas , Aoun-Barakat Lydia
Published: January 2021

Background

The COVID-19 pandemic has resulted in nearly 8 million cases and close to 500,000 deaths globally. Little is known about risk factors for favorable or adverse outcomes from COVID-19 among people living with HIV (PWH). Small case series have described outcomes for hospitalized PWH with COVID19.

Methods

This is a retrospective chart review of PWH with confirmed diagnosis of COVID-19 from 2 HIV ambulatory clinics from March 1 to May 31, 2020 in a large urban academic center that serves a substantial proportion of underserved minorities. Data on demographics, clinical characteristics, and outcomes were abstracted using a standardized data collection tool. Bivariate analysis was performed to identify correlates of hospitalization.

Results

Among the clinic cohort of 1469 PWH, 94 (6.4%) were tested for SARS-CoV-2 and 40 (42.5%) were positive. Fifty-percent were women, 65% were 50 years and older, 65% were black, 65% were former or active smokers, and 40% were active alcohol or substance users. The majority (90%) were on ART and 87.5% had HIV viral suppression (< 50 copies/ml). Among comorbidities, 50% had hypertension, 42.5% chronic lung disease, 42.5% cardiovascular disease (CVD), 40% obesity, 27.5% diabetes (DM), and 20% chronic kidney disease (CKD). Hospitalization occurred in 19 patients (47.5%) and of those, 4 (21%) required escalation of care. The median length of stay was 12 days (IQR5.5–15.5) and there was no inpatient mortality. Among the 12 PWH who had HIV viral load test during hospitalization, 11 (91.7%) maintained viral suppression and none of the 19 patients had ART interruption. Those who were hospitalized were more likely to be >50 years old (p=0.02); have CVD (p=0.003), DM (p=0.01), and CKD (p=0.02); or have multiple comorbidities (p=0.007) compared to those managed as outpatients. Furthermore, incremental numbers of comorbidities were associated with hospitalization (p=0.009). A history of AIDS, black race, obesity, smoking, and substance use disorders were not associated with hospitalization or adverse outcome.

Conclusion

In this initial and to our knowledge largest cohort in an urban academic center, PWH with COVID-19 had favorable short-term outcomes. The risk factors associated with hospitalization were older age and multiple non-HIV related comorbidities.

Disclosures

All Authors: No reported disclosures
117. Adjunctive Daptomycin in the Treatment of staphylococcus Aureus Bacteremia
Authors: Cheng Matthew P , Lawandi Alexander , Butler-Laporte Guillaume , De L’Etoile-Morel Samuel , Paquette Katryn , Lee Todd C
Published: January 2021

Background

Bloodstream infections (BSI) caused by methicillin-susceptible Staphylococcus aureus (MSSA) are associated with significant morbidity and mortality. The objective of our study was to determine whether daptomycin given in combination with an anti-staphylococcal beta-lactam improved outcomes in MSSA BSI.

Methods

A randomized, double blind, placebo-controlled trial was performed at two academic hospitals in Montreal, Canada. Patients ≥ 18 years of age with MSSA BSI receiving either cefazolin or cloxacillin monotherapy were considered for inclusion. In addition to the standard of care treatment, participants received a 5-day course of adjunctive daptomycin or placebo. The primary outcome was the duration of MSSA BSI in days.

Results

Of 318 participants screened, 115 were enrolled and 104 were included in the intention to treat analysis (median age 67 years; 34.5% female). The median duration of bacteremia was 2.04 days among patients who received daptomycin versus 1.65 days in those who received placebo (absolute difference 0.39 days, p=0.40). A modified intention to treat analysis involving participants who remained bacteremic at the time of enrollment found a median duration of bacteremia of 3.06 days among patients who received daptomycin versus 3.0 days in those who received placebo (absolute difference 0.06 days, p=0.77). Ninety-day mortality in the daptomycin arm was 18.9% vs. 17.7% in the placebo arm (p=1.0). There were no significant differences in the proportion of patients who developed renal failure, hepatotoxicity, or rhabdomyolysis between groups.

Conclusion

Among patients with MSSA BSI, the administration of adjunctive daptomycin therapy to standard of care treatment did not shorten the duration of bacteremia.

Disclosures

All Authors: No reported disclosures
122. Dalbavancin Use in Patients with Substance Use Disorders
Authors: Streifel Amber C , Makadia Jina , Luke Strnad , Douglass Alyse , Mayer Heather , Young Kathleen , Lewis James , Sukerman Ellie , Sikka Monica
Published: January 2021

Background

Dalbavancin, a lipoglycopeptide antibiotic, has an extended half-life that allows for weekly dosing and is an alternative to daily intravenous (IV) antibiotics. The dosing interval has the potential to expand treatment options for more severe infections in patients with substance use disorder (SUD), houselessness, and other complex social determinants of health where treatment of severe infections with long courses of IV antibiotics can have a high risk of failure. Questions remain regarding clinical outcomes for this indication and patient population.

Methods

We conducted a retrospective review of dalbavancin use for any patient with documented SUD either by ICD-10 or in chart notes. We identified all patients > 18 years who received > 1 dose of dalbavancin via medication records.

Results

53 patients with documented SUD received dalbavancin as part of their treatment regimen (Table 1). The most common indication was osteomyelitis, including 14 cases of vertebral osteomyelitis (Table 2). The most common causative organism was Staphylococcus aureus, 23 (43%) cases due to MRSA and 10 (18%) due to MSSA.

The majority of patients (41,77%) had a documented history of IV drug use (IDU) and 19% had alcohol use disorder. A structured, RN-lead multi-disciplinary discharge planning conference to discuss antibiotic options, risk factors for outpatient parenteral antibiotic therapy, and PICC safety in the community was held for 17 (32%).

Concern about outpatient PICC safety in patients with history of IDU, unsafe home environment, and prior non-adherence to outpatient antibiotics were common reasons for choosing dalbavancin. Ten (19%) patients were lost to follow-up. The 30 and 90-day readmission rates were 13% and 19% respectively but were due to relapse or recurrence of infection in only 3 (6%) at 30 days and 2 (4%) additional at 90 days. There was only one death at 90 days ant it was unrelated to infection. (Table 3)

Table 2. Dalbavancin Use

Conclusion

Dalbavancin was well tolerated and = a viable alternative for patients with SUD who often have social factors and preferences that make continuation of outpatient IV therapy high risk or impractical. Further data on clinical outcomes in complex infections is needed.

Disclosures

All Authors: No reported disclosures
126. evaluation of Addition of Outpatient Parenteral Antimicrobial Therapy and Orthopedic ID Resources to Transitions-of-care Outcomes
Authors: Young Brett , Bergman Scott , Van Schooneveld Trevor C , Cortes-Penfield Nicolas W , Alexander Bryan
Published: January 2021

Background

Our large academic medical center initiated both an Outpatient Parenteral Antimicrobial Therapy (OPAT) program supported by an infectious disease trained pharmacist, along with an Orthopedic Infectious Disease (OID) consult service to assist in caring for these specialized populations. We measured the impact of these services.

Methods

Patients discharged on parenteral antimicrobial therapy were divided into two groups. The pre-OPAT cohort included all patient receiving OPAT from 4/1/18 - 10/31/18; the post-OPAT cohort included all patients who received OPAT from 4/1/19 - 10/31/19 with OPAT consult (Fig 1). The OID consult service began in September 2018 prior to initiation of the OPAT program. The primary outcome was 30-day hospital readmission. Secondary outcomes included: length of stay (LOS), 90-day readmission, clinical outcomes, and identification of predictors of hospital readmission. Clinical outcomes included: time from final OR visit to discharge for OID patients and optimal treatment (cefazolin, oxacillin, or nafcillin) for MSSA.

Results

Introduction of these programs was associated with a reduction in all-cause 30-day readmission from 39.3% to 22.9%, and a reduction in 30-day readmission for patients on-treatment from 24.6% to 15.6% (p< 0.01 for both). No difference was seen in hospital LOS (8 days in each cohort). In a subgroup analysis (Fig 2), OID patients in the post-OPAT cohort saw a median reduction of 2 days (7 days to 5 days, p=0.002) in time from final OR visit to discharge. Use of optimal treatments for MSSA increased in the post-OPAT cohort compared to pre-OPAT (65.2% to 80.9%; p=0.06). The 90-day hospital readmission rate were higher in the post-OPAT cohort among patients who lived in metro-area zip codes (p=0.03). Having an established primary care physician was associated with lower 90-day hospital readmission in both the pre-and post-OPAT cohorts (p=0.05 and 0.01, respectively).

Conclusion

Thirty-day readmission rates among patients discharged on OPAT significantly lowered following initiation of a combination of both a pharmacist-led OPAT program and OID consult service. OPAT and OID programs accrue additional efficiencies and clinical benefits to both patients and hospitals, which can be further evaluated and used to justify such service additions.

Disclosures

All Authors: No reported disclosures
127. walking to the Virtual Era. Analysis of the Telehealth Experience in the Infectious Diseases Clinic During the COVID Pandemic
Authors: Carvajal Karen L , Pillai Prishanya , Winbush Angelina , mangat Rupinder , Louie Ted
Published: January 2021

Background

The COVID pandemic has changed and will continue changing the way we practice medicine. We sought to investigate the impact of telehealth (TH) in the delivery of healthcare in the general infectious diseases (GID), and HIV clinic during the COVID pandemic.

The University of Rochester Medical Center is a major tertiary care and referral center for ID in upstate New York. From March through May of 2020, the clinics were closed, and nearly all visits were conducted by TH.

Methods

We surveyed (either by telephone or online) a total of 260 patients who participated in TH visits, with a mean age of 56 years in the HIV group and 59 years in the GID group. With a predominance of 62.8 of males v/s 37.2 of females.

We collected information regarding the reason for the TH visits, access to technology, patient satisfaction, and preferences over in-person visits. We obtained the volume and no-show rate from prior years through EPIC. We evaluated compliance between in-person and TH visits using statistical analysis.

Results

We found 93.4% of GID and 84.3% of HIV patients surveyed, either strongly agreed or somewhat agreed that their TH visit was as satisfactory as a clinic visit. 67.5% of GID and 63% of HIV patients agreed that the option of TH would increase their compliance rate in the future. The no-show rate during the TH period in the HIV group decreased from 23% to 5% compared to the previous year, while the no-show rate in GID decreased from 9% to 4%. These results were statistically significant with a P-value < 0.005 in both groups.

Conclusion

GID patients were more likely to have TH for hospital follow-up, follow-up of acute problems, and outpatient antibiotic therapy, compared to HIV patients, who more often had TH for chronic problems. GID patients were more likely to have the capability for televideo visits when compared to the HIV group, although this was not statistically significant. TH was statistically significant in improving patient compliance with appointments in both the HIV and ID clinics. Patients were overall highly satisfied with their TH experience and many patients also reported that continued availability of telemedicine would improve their compliance with appointments.

Disclosures

All Authors: No reported disclosures
129. Beta-lactam vs Fluoroquinolone Monotherapy for pseudomonas Aeruginosa infection: A Systematic Review and Meta-analysis
Authors: Reid Eric C , Walters Ryan , Destache Christopher
Published: January 2021

Background

Pseudomonas aeruginosa (PA) is a leading cause of healthcare-associated infections, including pneumonia, bloodstream infections, and surgical site infections around the world. A variety of antibiotic classes are used in the treatment of PA infections, including beta-lactams (BLs) and fluoroquinolones (FQs), given either together in combination therapy or alone in monotherapy. Here, we report a systematic review and meta-analysis to evaluate the therapeutic efficacy of BL agents versus FQ agents as active, definitive monotherapy in PA infections in adults.

Methods

Comprehensive literature searches of Medline and Scopus electronic databases, alongside hand searches of the Cochrane Database of Systematic Reviews, PubMed, and Google Scholar, were performed in April 2019 without time restriction to identify studies published in English comparing BL and FQ agents given as monotherapy for PA infection in hospitalized adults for which mortality, bacteriological eradication, or clinical response was evaluated. One reviewer screened search results based on pre-defined selection criteria. Two reviewers independently assessed included studies for methodological quality using NIH assessment tools. Two fixed-effects meta-analyses were performed (Figure 1).

Results

A total of 368 articles were screened, and 6 studies were included in the meta-analysis. Upon evaluation of methodological quality, 2 studies were rated good, 3 fair, and 1 poor (Table 1). A meta-analysis of 3 cohort studies demonstrates FQ monotherapy for PA bacteremia is associated with increased survival compared to BL monotherapy (OR, 3.65; 95% CI, 1.27–10.44; p=.02; Figure 2). A meta-analysis of 3 randomized control studies demonstrates FQ monotherapy for PA pneumonia and skin and soft tissue infection is not significantly associated with increased bacteriological eradication compared to BL monotherapy (RD, 0.07; 95% CI, -0.09 to 0.24; p=.39; Figure 3).

Conclusion

The data appear to suggest FQ monotherapy is significantly associated with increased survival in PA bacteremia and associated with similar rates of bacteriological eradication in pneumonia and skin and soft tissue infection caused by PA compared to BL monotherapy. However, more research is needed to make meaningful clinical recommendations.

Disclosures

All Authors: No reported disclosures
137. Applying Gamification to Microbiology Core Curriculum in Undergraduate Medical Education
Authors: Walker Jeremey , Patel Mukesh , Cleveland John D , Heudebert Jose Pablo , Westfall Andrew O , Dempsey Donald , Guzman Alfredo , Long Dustin , Willig James , Lee Rachael A
Published: January 2021

Background

Gamification uses elements of game design to enhance learner engagement. We introduced a microbiology “trivia game” for first year medical students (MS1), leveraging principles of gamification (self-efficacy, points, leaderboards, etc.) to enhance participation. We hypothesized this would engage learners and improve course performance.

Methods

We created a “microbiology trivia game” using Kaizen-Education, a software platform (Kaizen) developed by our Center for Clinical and Translational Science. All MS1 in the Microbiology course at the University of Alabama at Birmingham (Fall 2019) were invited to participate by downloading the smartphone app. We created 56 questions emphasizing high yield concepts and their clinical application. Participation was voluntary during the Microbiology course (3 weeks). We collected app utilization and test performance data in this IRB approved investigation. We completed descriptive analyses of student engagement including a Player Efficiency Rating (PER). The PER is a student-level composite measure of student accuracy, play frequency and question completion. We calculated Spearman rank correlation of mean exam scores and PER. At course completion students received a survey about their experience.

Results

181 (96%) of 189 Microbiology students answered ≥ 1 question. Across those 181 students, 161 (89%) completed all questions (table 1). An average of 67 students answered questions each day. Collectively, students answered 96% of all published questions (n=10,136; 56 questions x 181 students). A total of 49% of questions were answered < 24H from publication. Survey response rate was 34% (n=61), and our teaching innovation was positively received (table 2).

Final exam performance increased from 80% (2018) to 87% (2019) among students in the gamification enhanced Microbiology course. A correlation between higher PER and better exam scores was found (0.34; p≤0.0001).

Conclusion

Our gamification infused Microbiology course was well received. Students appreciated the opportunity to apply core foundational microbiology concepts to clinical medicine scenarios early in training. Novel teaching methods may increase student engagement in Medical Microbiology courses, for many the birthplace of their passion for Infectious Diseases.

Disclosures

All Authors: No reported disclosures
138. Creation of a Clinical Educator Elective for ID Fellows
Authors: Blyth Dana M , Markelz Ana E , surry Luke , Lindholm David , Yun Heather , Barsoumian Alice
Published: January 2021

Background

While fellows are expected to educate residents and students, they often receive limited formal instruction on how to teach. To address this, we developed a 2–4 week Clinical Educator Elective (CEE) for senior ID fellows. Goals were to increase fellow teaching engagement and promote excellence in medical education by improving understanding of adult learning theory and application to medical education.

Methods

Curriculum development: Methodology used Kern’s 6 step approach. A targeted needs assessment was obtained from CEE fellows at the start of the block. A reading list was created from key areas (table). Instructional methods included flipped classroom, learner-led discussions, and exercises in evaluation and feedback of peer and faculty teaching. Fellows completed a required capstone educational project.

Learner Assessment: Standardized peer and faculty feedback surveys of fellow teaching were used.

Program Assessment: CEE narrative assessments were evaluated. Anonymous pre- and post-CEE self-assessment fellow surveys rating their confidence in knowledge and skills in clinical education on a 1–10 scale (1 lowest, 10 highest) were compared. Post-CEE fellows’ medical student (MS3) teaching was compared to a 4-year pre-CEE historical cohort (PCHC).

Results

From 2017–9, 7 of 11 (64%) senior ID fellows completed the CEE. 5 (71%) were male, 3 started fellowship post-residency, 3 were chief residents, and 1 was an internist for 2 years. They had a median of 10 hours of prior faculty development (IQR 1–26). Career goals included GME in 6 of 7 pre-CEE. Narrative assessments revealed fellows highly valued the CEE. 6 available post-rotation surveys showed increased confidence in knowledge of adult learning theory, characteristics of effective educators, and fellows’ ability to teach across a range of settings (table). 5 of 7 CEE fellows precepted MS3s compared to 1 of 8 fellows in the PCHC (p=.04). CEE and PCHC fellows won 7 and 2 teaching awards, respectively.

Fellows’ confidence in knowledge and skills of various aspects of medical education before and after the clinical educator elective

Conclusion

A CEE was highly valued and improved fellow self-assessed knowledge and skills in clinical teaching, even in those with prior teaching experience. It was also associated with more MS3 teaching. Future evaluations of long-term retention in academic medicine and teaching performance can further examine this approach.

Disclosures

All Authors: No reported disclosures
140. Symptoms and Situations Predispose Patients to Use Antibiotics Without Medical Advice
Authors: Hansen Michael , Trautner Barbara , Zoorob Roger , Germanos George , Alquicira Osvaldo , Salinas juanita , Barning Kenneth , Mahmood Hammad , Gonzalez Malissa A , Fowler Michele , Grigoryan Larissa
Published: January 2021

Background

Use of antibiotics without a prescription (non-prescription use) contributes to antimicrobial resistance. Non-prescription use includes obtaining and taking antibiotics without a prescription, taking another person’s antibiotics, or taking one’s own stored antibiotics. We conducted a quantitative survey focusing on the factors that impact patients’ decisions to use non-prescription antibiotics.

Methods

We surveyed patients visiting public safety net primary care clinics and private emergency departments in a racially/ethnically diverse urban area. Surveys were read aloud to patients in Spanish and English. Survey domains included patients’ perspectives on which syndromes require antibiotic treatment, their perceptions of health care, and their access to antibiotics without a prescription.

Results

We interviewed 190 patients, 122 from emergency departments (64%), and 68 from primary care clinics (36%). Overall, 44% reported non-prescription antibiotic use within the past 12 months. Non-prescription use was higher among primary care clinic patients (63%) than the emergency department patients (39%, p = 0.002). The majority felt that antibiotics would be needed for bronchitis (78%) while few felt antibiotics would be needed for diarrhea (30%) (Figure 1).

The most common situation identified “in which respondents would consider taking antibiotics without contacting a healthcare provider was “got better by taking this antibiotic before” (Figure 2). Primary care patients were more likely to obtain antibiotics without prescription from another country than emergency department patients (27% vs. 13%, P=0.03). Also, primary care patients were more likely to report obstacles to seeking a doctor’s care, such as the inability to take time off from work or transportation difficulties, but these comparisons were not statistically significant.

Figure 1. Patients’ agreement that antibiotics would be needed varied by symptom/syndrome.

Figure 2. Situations that lead to non-prescription antibiotic use impacted the two clinical populations differently

Conclusion

Non-prescription antibiotic use is a widespread problem in the two very different healthcare systems we included in this study, although factors underlying this practice differ by patient population. Better understanding of the factors driving non-prescription antibiotic use is essential to designing patient-focused interventions to decrease this unsafe practice.

Disclosures

All Authors: No reported disclosures