bluuebunny/crossref_metadata_2025 huggingface dataset:
1997. Real-World Impact of Accelerate Pheno Implementation with Antimicrobial Stewardship Intervention
Authors: Kinn Patrick M , Percival Kelly M , Ford Bradley A , Ince Dilek
Published: October 2019

Background

Accelerate Pheno® (AP) is a novel diagnostic system that provides rapid identification and antibiotic susceptibility results for most commonly isolated organisms within hours of blood culture (BC) positivity. There are little data on this technology’s real-world implementation with antimicrobial stewardship intervention and effect on optimal targeted therapy.

Methods

AP was implemented at UIHC in September 2018 and paired with antimicrobial stewardship team (AST) review. AST recommendations were provided in real time during weekday hours and through a retrospective review process for off-hours results. Microbiologic and clinical data were collected prospectively. Due to inconsistencies in instrument performance identified after the first month, two post-implementation periods (Group A = October 2018–January 2019; Group B = February 2019–mid-April 2019) were analyzed to assess quality improvement efforts during clinical roll-out.

Results

In the 6.5-month combined period, 690 unique BC samples were run on AP and reviewed by AST (417 in A; 273 in B). Performance of the technology improved, with 78.9% (329/417) of isolates in Grp A identified vs. 85.3% in Grp B (233/273). Percentage of runs with progression to antibiotic susceptibility improved from 76.1% to 92.3%. Over both time periods, AST intervened on 277 samples (Figure 1). Recommendations (bug-drug mismatch, de-escalation, dose optimization, and infectious disease consult) were accepted at a rate of 97.4%. Time from BC positivity to optimal therapy was 15.3 hours (Figure 2).

Conclusion

Implementation of AP with AST review resulted in rapid identification and antibiotic susceptibility results with early optimization of antimicrobial therapy. Highest impact was seen in the management of patients with resistant Gram-negative infections. Oversight of the implementation by a partnership of clinical microbiology and the antimicrobial stewardship team was critical in identifying real-time implementation issues and opportunities for quality improvement. Though real-world performance was slightly inferior to published trial data, the instrument’s exceedingly fast time to AS represents a significant advantage over other systems and enhances clinical care and patient safety particularly when paired with AST intervention.

Disclosures

All authors: No reported disclosures.
2002. BioFire® Filmarray® Pneumonia Panel: A Powerful Rapid Diagnostic Test for Antimicrobial Stewardship
Authors: Furukawa Daisuke , Kim Brian , Jeng Arthur
Published: October 2019

Background

BioFire® Filmarray® Pneumonia Panel (BFPP) is a multiplex PCR panel that identifies 33 common bacterial and viral pathogens seen in community- and hospital-acquired pneumonias. It rapidly identifies these pathogens in addition to 7 antibiotic resistance genes on sputum and bronchioalveolar lavage samples in 1 hour. As one of the test centers for this panel, our institution utilized this panel for clinical and laboratory use. We reviewed the impact of BFPP on antimicrobial stewardship, particularly its role in early discontinuation of empiric antibiotics and prompt initiation of optimized targeted therapy.

Methods

We retrospectively reviewed all cases by which BFPP was ordered. We reviewed medical records of each case to identify the results of the panel, culture data, antibiotics used, and subsequent clinical intervention.

Results

43 tests were ordered in total. 17 were for clinical use by an infectious disease specialist and 26 were randomly obtained by the microbiology lab. All 17 clinical cases were intervened upon with the following interventions: discontinuation of anti-pseudomonal antibiotics (8 cases), discontinuation of anti-MRSA antibiotics (5 cases), discontinuation of azithromycin (4 cases), discontinuation of carbapenem (1 case), prevention of inappropriate antibiotic escalation or initiation of inappropriate antibiotics (2 cases), and early IV to PO transition (3 cases). Of the random 26 samples ordered by lab, 13 had opportunities for antibiotic de-escalation if a physician were notified of the results. Viruses were identified in 15 samples with coronavirus being the most common. Virus was the sole pathogen in 9 of the 15 samples. Bacterial pathogens were identified in 20 samples that were reported as normal flora by conventional culture; none of these cases led to or potentially could have led to antibiotic escalation as the sole intervention.

Conclusion

Clinical use of BFPP had 100% intervention rate with all interventions leading to de-escalation of antibiotics or prevention of inappropriate antibiotics use. Though over-identification of colonizers is a potential limitation, BFPP is a powerful tool for antibiotic stewardship that results in rapid interventions to achieve optimal targeted therapy.

Disclosures

All authors: No reported disclosures.
2005. Successful Implementation of a Procalcitonin Algorithm Associated with Reduction in Antibiotic Days
Authors: McCoury John B , Fugit Randolph V , Bessesen Mary T
Published: October 2019

Background

Randomized controlled trials of procalcitonin (PCT)-based algorithms for antibacterial therapy have been shown to reduce antimicrobial use and improve survival. Translation of PCT algorithms to clinical settings has often been unsuccessful.

Methods

We implemented a PCT algorithm, supported by focus groups prior to introduction of the PCT test in April 2016 and clinician training on the PCT algorithm for testing and antimicrobial management after test roll-out. The standard PCT algorithm period (SPAP) was defined as October 1, 2017 to March 31, 2018. The antimicrobial stewardship team (AST) initiated an AST-supported PCT algorithm (ASPA) in August 2018. The AST prospectively evaluated patients admitted to ICU for sepsis and ordered PCT per algorithm if the primary medical team had not ordered them. The ASPA period was defined as October 1, 2018–March 31, 2019. The AST conducted concurrent review and feedback for all antibiotic orders during both periods, using PCT result when available. We compared patient characteristics and outcomes between the two periods. The primary outcome was adherence to the PCT algorithm, with subcomponents of appropriate PCT orders and antimicrobial discontinuation. Secondary outcomes were total antibiotic days, excess antibiotic days avoided, ICU and hospital length of stay (LOS), 30-day readmission and mortality. Continuous variables were analyzed with Student t-test. Categorical variables were analyzed with chi-square or Mann–Whitney test, as appropriate.

Results

There were 35 cases in the SPAP cohort and 57 cases in the ASPA cohort. There were no differences in demographics or infection site (Table 1). Baseline PCT was ordered in 57% of the SPAP cohort and 90% of the ASPA cohort (P = 0.0006) (Table 2). Follow-up PCT was performed in 23% of SPAP and 76% of ASPA (P < 0.0001). Antibiotics were discontinued per algorithm in 2/35 (7%) in the SPAP cohort and 25/57 (44%) in the ASPA cohort (P < 0.0001). Total antibiotic days was 7 (IQR 4–10) in the SPAP cohort and 5 (IQR 2–7) in the ASPA cohort (P = 0.02). There was no significant difference in LOS, ICU LOS, 30-day readmission, or mortality (Table 4).

Conclusion

A PCT algorithm successfully implemented by an AST was associated with a significant decrease in total antibiotic days. There were no differences in mortality or LOS.

Disclosures

All authors: No reported disclosures.
2009. Evaluation of Time to Organism Identification and Pharmacist Impact on Antibiotic Prescribing through Utilization of MALDI-TOF at Two Community, Teaching Hospitals
Authors: Walji Samana , Thai Xia , Ann Bruno-Murtha Lou , Osgood Rebecca , Atwell Kenneth , Barner Amanda
Published: October 2019

Background

In patients with bacteremia, delay in appropriate therapy is associated with higher morbidity and mortality. Matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) reduces the time to identification (ID) to approximately 30 minutes. Previously published studies show rapid diagnostics need to be coupled with antibiotic stewardship intervention for maximal benefit.

Methods

Retrospective, observational review at Cambridge and Everett Hospitals, two inpatient community, teaching hospitals that are part of Cambridge Health Alliance. The purpose is to evaluate the impact of MALDI-TOF by reviewing data in three phases: Microscan ID (January 1 to November 30, 2017), MALDI-TOF alone (December 1, 2017 to December 9, 2018), and MALDI-TOF coupled antimicrobial stewardship (December 10, 2018 to April 30, 2019). The laboratory batches all positive blood cultures to be run via MALDI-TOF mid-morning. In phase 3, a pharmacy resident is notified of the result via an automatic page. The resident determines appropriate empiric therapy using an algorithm developed by the Antimicrobial Stewardship Team and contacts the primary team. Data were collected via a laboratory report and chart review. The primary outcome is time to targeted antimicrobial therapy after ID. Secondary outcomes include time to ID, time to susceptibilities, duration of therapy for blood culture contaminants, and number of pharmacy interventions in phase 3.

Results

Preliminary data indicate mean time targeted antibiotic therapy was 41:45, 35:58, and 27:39 hours:minutes in phases 1, 2, and 3, respectively. Mean time to ID and final susceptibilities was also reduced in phases 2 and 3. The duration of therapy for blood culture contaminants decreased from 53:50 in phase 1 to 32:48 hours:minutes in phase 2. Pharmacy residents in phase 3 successfully implemented 47 total interventions, 24 (51%) after identification.

Conclusion

Implementation of MALDI-TOF with and without stewardship intervention successfully decreased time to targeted antibiotic therapy in two community hospitals. Future directions include adding an evening MALDI-TOF run and simplifying pharmacy resident standard operating procedure.

Disclosures

All authors: No reported disclosures.
2011. Reaction of Clinicians to Positive Respiratory Viral Panels in Non-critically Ill Patients Without Bacterial Infection
Authors: Gallagher Jason C , Lee Sara , Rodriguez Leah , Emily Von Bulow Jacqueline , Ota Sullivan Kaede
Published: October 2019

Background

Respiratory viral panels (RVPs) can detect multiple viral pathogens and give clinicians diagnostic confidence to discontinue antibiotics. However, relatively little is known about how these tests influence antibiotic prescribing in hospital settings.

Methods

This was a 26-month retrospective chart review of patients with positive RVPs. Hospitalized adults receiving antibiotics at the time of the RVP were included. Exclusion criteria were: ICU care, solid-organ transplantation (SOT), positive RVP for influenza, positive bacterial cultures, and antibiotic administration for bacterial infection (e.g., cellulitis). A multivariate linear regression model was created to investigate associations with longer antibiotic use after a positive RVP.

Results

1,346 patients were screened and 242 met inclusion criteria. Primary reasons for exclusion were SOT, ICU, and influenza diagnosis. Patients were a median age of 60.5 years [IQR 51,70] and 35.5% were men. The median length of stay (LOS) was 4 days [IQR 3.6]. 233 patients (6.3%) had chest radiology performed, of which 71 (30.4%) had possible pneumonia noted. 50 (20.7%) were immunocompromised (IC). 199 (82.2%) had a history of pulmonary disease, most commonly COPD. Rhinovirus was isolated in 156 patients (64.5%), followed by metapneumovirus (35, 14.9%) and RSV (32, 13.3%). Antibiotics were given for a median total of 3 days [IQR 3.6]; they were discontinued within 24 hours of the RVP result in 107 patients (44.2%).

Conclusion

In this population of patients with viral infection and no discernable bacterial infection, 44.2% of patients had antibiotics discontinued within 24 hours of RVP results. On multivariate linear regression analysis, younger age, longer LOS, and IC status were associated with longer antibiotic duration after a positive RVP. A comparison with patients with negative RVP results could reveal if the test prompted discontinuation.

Disclosures

All authors: No reported disclosures.
2023. Antimicrobial Resistance and Stewardship Knowledge and Perception among Medical and Pharmacy Students in Nigeria
Authors: Michael Ubaka Chukwuemeka , Schellack Natalie , Nwomeh Benedict , Goff Debra A
Published: October 2019

Background

Nigeria is the most populous country in Africa and has high rates of antimicrobial resistance (AMR). The practice of antimicrobial stewardship in Nigerian hospitals is very limited and the subject is rarely included in undergraduate medical and pharmacy curriculums. To further acceptance and implementation of antimicrobial stewardship programs (ASP) in Nigeria health system, baseline measurements of the knowledge and perceptions held by graduating medical and pharmacy students was deemed essential. This study evaluated the knowledge and perceptions of a cohort of Nigerian medical and pharmacy students in concepts of AMR and ASP.

Methods

This was a cross-sectional questionnaire-based study of final year medical and pharmacy students from the two largest schools in the southeastern region of Nigeria. A previously published 20-items questionnaire measuring knowledge and perceptions toward AMR and ASP was adopted for the study. Results were expressed as frequencies and percentages.

Results

Completed questionnaires were received from 79.3% (361 of 455 students), over half (60%) were male, and mostly between 22 and 25 years old (68.7%). More pharmacy students had formal training on ASP compared with medical students (41.3% vs. 27.5%, P < 0.05). Pharmacy students (n = 84.3% and 90.5%) were significantly more knowledgeable of factors that promote the spread of AMR and interventions to combat resistance than medical students (n = 73.9% and 82.3%), P < 0.05, respectively. Interestingly, 23.3% of medical students thought pharmacists should lead ASP teams, while 5.8% of pharmacy students thought doctors should lead ASP. However, both held poor perceptions of each other’s roles in the ASP team.

Conclusion

Knowledge of AMR and ASP among medical and pharmacy students in Nigeria is lacking. Inter-professional collaboration to change perceptions and drive ASP in urgently needed.

Disclosures

All authors: No reported disclosures.
2033. A Systematic Review of Systematic Reviews: Procalcitonin in the ICU to Guide Antibiotic Therapy
Authors: York Joshua , Varadarajan Maithili , Wilson James , Barlow Gavin
Published: October 2019

Background

Antimicrobial resistance is an emerging global health crisis with overall antimicrobial use a key contributor. Strategies to safely reduce antibiotic course length are important. Procalcitonin (PCT) is a serum biomarker produced in the presence of bacterial infection. There have been many systematic reviews (SRs) evaluating PCT in various populations but its use remains controversial. The aim of this SR of SRs was to evaluate the extent to which PCT in critical care (ICU) impacts antibiotic duration and other reported outcomes.

Methods

A systematic search of major databases using an “a priori” strategy and protocol was performed. SRs were included if one of the reported outcomes related to antibiotic duration or initiation in the ICU. Data were extracted by an author, checked and corrected independently by another author. The quality of SRs was assessed by 2 authors independently using AMSTAR II. Disagreements were resolved by consensus with a third author. Results are presented narratively and in tabular format (Table 1).

Results

Figure 1 shows the PRISMA diagram. 19 SRs were included. The number of patients included ranged from 308 to 6,037 (median = 1,316) across SRs. Overall, there was a consistent finding of a statistically significant (sf) reduction in antibiotic duration in study groups using PCT cessation protocols (all studies in Table 1). 3 SRs did not contain suitable statistics for inclusion in Table 1. SRs that presented the antibiotic duration outcome as a mean or median difference in exposure days (N = 16) showed a median reduction of 2.10 days (range −1.19 to -5) with PCT use. 1 SR found an sf decrease in mortality with PCT use. 4 SRs included antibiotic initiation as an outcome: 2 found an sf decrease in antibiotic prescription rate with PCT; 2 found no difference.

Conclusion

SRs have found that PCT use in ICU leads to an sf reduction in antibiotic duration without impacting mortality. There are no data presented in the SRs about the impact of this on antimicrobial resistance. Few SRs detail the infections included; thus the applicability of these findings to a single ICU remains challenging. Other outcomes, such as length of stay, are not affected by PCT use in ICU.

Disclosures

All authors: No reported disclosures.
2041. Impact of an Infectious Disease Specialist-led Post-Prescription Carbapenem Intervention in a Large Japanese Tertiary Hospital: A Before–After Cohort Study
Authors: Matono Takashi , Uchida Moritsugu , Koga Hidenobu , Kanatani Naoya , Furuno Yoshimi , Yamashita Tomonori , PharmD Yuichi Umeda,
Published: October 2019

Background

There are fewer board-certified infectious disease (ID) specialists in Japan (n = 1494) than in the United States (n = 8535); therefore, we have insufficient protected time for antimicrobial stewardship activities, and thus, there is a need for an innovative solution.

Methods

This study compared carbapenem consumption between a 24-month baseline period and a 12-month intervention period at the Iizuka Hospital with 1048 inpatient beds in Japan. During the intervention period, a board-certified ID specialist provided daily feedback to prescribers against prolonged carbapenem use (≥14 days) through conversations and medical records. Additionally, we reported through e-mail the weekly point prevalence surveillance data of the long-term carbapenem users for 7–13 and ≥14 days, which were aggregated by each department.

Results

We provided a total of 106 feedbacks regarding carbapenem use for ≥14 days during the intervention period. After the initiation of intervention, the trend of monthly carbapenem consumption changed (coefficient: −0.62; 95% CI: −1.15 to −0.087, P = 0.024), and its overall consumption has decreased (coefficient: −0.098; 95% CI: −0.16 to −0.039, P = 0.002, Figure 1) without a change in the in-hospital mortality (P = 0.53) as revealed by segmented regression analysis. Interestingly, the number of monthly carbapenem users, but not the duration of carbapenem use, significantly decreased (coefficient: −3.02; 95% CI: −4.63 to −1.42, P = 0.001, Figure 2). An annual estimated saving after the intervention was $82,266 with a cost reduction of 22%.

Conclusion

Our ID specialist-led daily intervention in carbapenem prescription and weekly feedback for long-term carbapenem use were effective in reducing this antibiotic’s consumption and consequently the number of carbapenem users. These feedbacks may be useful in changing the behavior of prescribers and promoting appropriate antimicrobial use even in resource-poor settings.

Disclosures

All authors: No reported disclosures.
2048. Antibiogram Use in Wisconsin Nursing Homes
Authors: Taylor Lindsay N , Vranas Lillian , Boero Joseph , Dohm Diane , Dowdell Ashlie , Ebert Steven C , Fehrenbacher Lynne , Hardgrove Paula , Podzorski Raymond , Pulia Michael , Ryther Brenda , Crnich Christopher
Published: October 2019

Background

A 2014 survey demonstrated that fewer than 10% of Wisconsin (WI) Nursing Homes (NHs) used an antibiogram. In 2016, the Centers for Medicare & Medicaid Services released regulations requiring NHs to track and report their antibiotic-related outcomes. The impact these regulations will have on the development and use of antibiograms in NHs is unknown.

Methods

To characterize antibiogram use in WI NHs, a mixed-methods approach was used consisting of two statewide surveys, a combination of semi-structured interviews with key NH personnel, and a structured survey administered to providers in a sample of facilities using an antibiogram. Answers to questions included on statewide surveys administered in 2014 and 2018 were used to assess change in antibiogram use over time. Semi-structured interviews with key NH personnel focused on antibiogram development and dissemination. Structured surveys of providers focused on their awareness of antibiogram existence and the extent to which it influenced their prescribing behavior. A copy of the antibiogram was obtained from some facilities to assess consistency with Clinical and Laboratory Standards Institute (CLSI) recommendations.

Results

Antibiogram use in WI NHs increased from 9.3% in 2014 to 32.5% in 2018. The majority of antibiograms were not facility-specific, primarily due to inadequate numbers of isolates at individual facilities. Most facilities reported that antibiogram tools were updated annually, and most made an effort to disseminate them to prescribers. However, 30% of surveyed prescribers reported being unaware of the existence of an antibiogram and only 40% reported it influenced their prescribing decisions. Review of antibiograms provided by NHs revealed that all were created using the traditional “drug-bug” format; however, none were fully compliant with CLSI recommendations.

Conclusion

Antibiogram use in WI NHs increased significantly between 2014 and 2018. The majority of antibiograms used in WI NHs are not based on facility-specific data. A substantial number of providers are unaware of the existence of an antibiogram in their facility and only a minority felt that it impacted their prescribing decisions. More research is needed on how to increase antibiogram utility in NHs.

Disclosures

All authors: No reported disclosures.
2054. Hospital-initiated Antibiotics in Nursing Homes
Authors: Furuno Jon P , Noble Brie N , Nordby Vicki , Weber Bo , McGregor Jessina C , Bearden David T , Chan Dominic , Tjia Jennifer , Crnich Christopher
Published: October 2019

Background

Nursing homes (NHs) are required by the Centers for Medicare and Medicaid Services to maintain antimicrobial stewardship programs. Hospital-initiated antibiotics may pose a barrier to optimizing antibiotic prescribing in this setting. Our objective was to characterize hospital-initiated antibiotic prescriptions among NH residents.

Methods

We collected electronic health record data on antibiotic prescribing events within 60 days of residents’ admission to 17 for-profit NHs in Oregon, California, and Nevada between January 1, and December 31, 2017. We characterized antibiotics prescribed, administration route, and proportion initiated in a hospital setting.

Results

Over the one-year study period, there were 4350 antibiotic prescribing events among 1633 NH residents. Mean (standard deviation) age was 77 (12) years and 58% were female. Approximately 45% (1,973/4,350) of antibiotics prescribed within 60 days of NH admission were hospital-initiated. The most frequently prescribed hospital-initiated antibiotics were cephalosporins (27%; 1st gen: 54%, 2nd gen: 6%, 3rd gen: 34%, 4th gen: 5%, 5th gen: 1%), fluoroquinolones (20%), and penicillins (14%; natural penicilins: 4%, semisynthetic penicillins: 3%, aminopenicillans: 57%, β-lactam/β-lactamase inhibitors: 21%, and antipseudomonal penicillins: 15%). Additionally, 24% of antibiotics were parenteral and the median (interquartile range) duration of therapy was 6 (3–10) days. Over 15% of residents with hospital-initiated antibiotics were readmitted to the hospital within 30 days.

Conclusion

Approximately 45% of antibiotic prescribing in a multistate sample of NHs were hospital-initiated, of which roughly 40% was broad-spectrum. Interventions specifically targeting antibiotic prescribing during and following the transition from hospitals to NHs are needed.

Disclosures

All authors: No reported disclosures.
2062. Improving Antibiotic Prescribing in the Ambulatory Care Setting—Stewardship through Influenza Vaccination, US Flu VE Network 2013–2014 Through 2017–2018
Authors: Smith Emily , M. Fry Alicia , Hicks Lauri , Fleming-Dutra Katherine E , Martin Emily T , Zimmerman Richard , Jackson Michael L , McLean Huong , Olson Scott C , Gaglani Manjusha , Flannery Brendan , Ferdinands Jill , Patel Manish , Patricia Nowalk Mary
Published: October 2019

Background

Improving antibiotic use is a key strategy to combat antibiotic resistance and improve patient safety. Acute respiratory illness (ARI) is a common cause of outpatient visits and accounts for ~41% of antibiotics used in the United States. We sought to determine the proportion of antibiotic prescriptions (Rx) prescribed among outpatients with ARI that can be potentially averted through influenza vaccination.

Methods

From 2013–2014 through 2017–2018 influenza seasons, we enrolled patients aged ≥6 months with ARI in the US Influenza Vaccine Effectiveness (VE) Network of >50 outpatient clinics. Antibiotic Rx and diagnosis codes were collected from medical records. Study influenza test results were not available to treating clinicians at most sites, and clinical influenza testing was infrequently performed (a), prevalence of influenza among unvaccinated ARI patients (b), prevalence of antibiotic Rx among unvaccinated influenza-positive ARI patients (c) and prevalence of antibiotic Rx among ARI patients overall (d), we derived estimates of the proportion of ARI antibiotic Rx that can be averted by influenza vaccination [(a × b × c)/d].

Results

Among 37487 outpatients with ARI, 13,316 (36%) were prescribed an antibiotic and 9,689 (26%) tested positive for influenza. Of those positive, 2,496 (26%) were prescribed an antibiotic. Adjusted VE against influenza-associated ARI was 35% (95% confidence interval (CI), 32 to 39). Among unvaccinated patients with ARI, 30% were influenza-positive and 24% received antibiotics. Based on these estimates, we determined that influenza vaccination may prevent 10.6% of all ARI syndromes and may avert 1 in 14 or 7.3% of antibiotic Rx among ARI patients.

Conclusion

By preventing influenza-associated ARI syndromes, influenza vaccination may substantially reduce antibiotic prescribing. Increasing influenza vaccine coverage and improving protection may facilitate national goals to improve antibiotic use and reduce the global threat of antibiotic resistance.

Disclosures

All authors: No reported disclosures.
2067. Improving Outpatient Antimicrobial Prescribing for Respiratory Tract Infections
Authors: Dutcher Lauren S , Degnan Kathleen , Lautenbach Ebbing , Pegues David A , David Michael Z , Cluzet Valerie , Cressman Leigh , Bilker Warren , Tolomeo Pam C , Adu-Gyamfi Afia B , Hamilton Keith W
Published: October 2019

Background

Antimicrobial stewardship often focuses on inpatients, yet inappropriate antimicrobial use is common in the outpatient setting. We performed a prospective, stepped wedge interventional study to assess the impact of an educational and feedback-based intervention on prescribing practices for respiratory tract infections (RTIs) in the adult primary care ambulatory setting.

Methods

Family and internal medicine practices were randomly placed into 6 cohorts, which received the intervention in a stepped wedge fashion at monthly intervals. The study period was July 1, 2016 to October 31, 2018, with the intervention occurring from October 1, 2017 to October 31, 2018. The intervention consisted of a 20-minute in-person educational session on appropriate antimicrobial prescribing for RTIs followed by monthly feedback to individual providers on their proportion of antibiotic prescriptions in comparison to their peers for (1) visits with a primary diagnosis of any RTI and (2) visits with a primary diagnosis of an RTI for which an antibiotic should rarely be prescribed (tier 3 diagnoses). The outcome of interest was whether an antibiotic was prescribed in RTI visits. Chi squared testing and logistic regression were used for analysis.

Results

Thirty-two practices participated, with 197,814 unique visits with a primary RTI diagnosis. Of these, 141,888 (71.7%) were physician visits and 55,926 (28.3%) were advanced practitioner visits (Figure 1). The proportion of visits with antibiotic prescriptions dropped from 37.2% to 24.0% following the intervention (P < 0.0001). Antibiotic prescriptions were significantly reduced for all primary RTI visits, OR 0.53 (95% CI 0.52 to 0.54), as well as for visits with tier 3 RTI diagnoses, OR 0.64 (95% CI 0.60 to 0.68). The proportion of visits with antibiotic prescriptions also exhibited a marked seasonal variation, another finding of the study (Figure 2).

Conclusion

An educational intervention with provider feedback successfully reduced antibiotic prescribing for RTIs in the ambulatory setting. Additional study is necessary to assess the sustainability of response over time after discontinuation of the monthly feedback.

Disclosures

All authors: No reported disclosures.
2076. Comparison of Diagnosis and Prescribing Practices between Virtual Visits and Office Visits for Sinusitis within a Primary Care Network
Authors: Johnson Kristen , Burns Kayla , Dumkow Lisa , Yee Megan , Egwuatu Nnaemeka
Published: October 2019

Background

The majority of antibiotics prescribed in the outpatient setting result from upper respiratory tract infections; however, these infections are often viral. Virtual visits (VV) have emerged as a popular alternative to office visits (OV) for sinusitis complaints and are an important area for stewardship programs to target for intervention.

Methods

A retrospective cohort study was conducted utilizing the outpatient electronic medical record for Mercy Health Physician Partners (MHPP) and Zipnosis database for VV to compare diagnosis and prescribing between OV and VV for sinusitis. VV consisted of an online questionnaire for patients to complete, which was then sent to a provider to evaluate electronically without face-to-face interaction. Adult patients were included with a diagnosis code for sinusitis during the 6-month study period from January to June 2018. The primary objective was to compare rates of appropriate diagnosis of viral vs. bacterial sinusitis between OV and VV, based on national guideline recommendations. Secondary objectives were to compare the appropriateness of antibiotic prescribing and supportive therapy prescribing between OV and VV, as well as 24-hour, 7-day and 30-day re-visits.

Results

A total of 350 patients were included in the study (OV n = 175, VV n = 175). Appropriate diagnosis per national guidelines was 45.7% in OV compared with 69.1% in the VV group (P < 0.001). Additionally, patients that completed VV were less likely to receive antibiotic prescriptions (OV 94.3%, VV 68.6%, P < 0.001). Guideline-concordant antibiotic prescribing was similar between groups (OV 60.6%, VV 58.3%, P = 0.70) and both visit types had a median duration of treatment of 10 days (P = 0.88). Patients that completed VV were more likely to re-visit for sinusitis within 24 hours (OV 1.7%, VV 8%, P = 0.006) and within 30-days (OV 7.4%, VV 14.9%, P = 0.027). In multivariate logistic regression the only factor independently associated with 24-hour re-visit was patient self-request for antibiotics (OR 0.20, 95% CI 0.06–0.68).

Conclusion

Appropriate diagnosis of sinusitis was more likely in the VV group, which shows that VV provides a good platform to target outpatient antimicrobial prescribing. These findings support opportunities for antimicrobial stewardship intervention in both OV and VV.

Disclosures

All authors: No reported disclosures.
2088. Cross-sectional Analysis of Administrative Structure and Practices for Hospital Antimicrobial Stewardship Programs (ASPs) in a Large Metropolitan City
Authors: Ha David , Lee Thomas , Gauthier Timothy , OYong Kelsey , McKinnell James
Published: October 2019

Background

Los Angeles (LA) County is large and diverse urban southern California county with a population of over 10 million and a multitude of hospitals. The state of California required hospitals to implement ASPs in July 2015. This collaborative with the LA County Department of Public Health sought to characterize administrative structure and practices of hospital ASPs in the county.

Methods

A survey of LA County hospital ASPs was conducted from November 2018 to April 2019. Initial telephone and email screenings were performed to confirm individuals’ involvement in hospital ASPs prior to survey participation.

Results

Overall, 40 of 87 (46%) hospitals responded. Of these, 90% (36/40) were private hospitals and 68% (27/40) were part of a multi-hospital network. All hospitals (40/40) reported an active ASP with 53% (21/40) established for 5 years or longer. Only 65% (26/40) reported meeting all seven CDC core elements of hospital ASPs and 85% (34/40) reported having an ASP committee. Of those with ASP committees, individuals who chaired or co-chaired the committee were predominantly ID physicians (33/34, 97%). Most held meetings quarterly (18/34, 53%). Committee member meeting attendance “all or most of the time” was highest for pharmacists (34/34, 100%) and ID physicians (33/34, 97%) and lowest for information technology (IT) personnel (9/34, 27%) and non-ID physicians (12/34, 35%). ASP committees reported to a mean of 2.4 other committees, most frequently to pharmacy and therapeutics (P&T) (32/34, 94%) and infection control (IC) (24/34, 71%). ASP committees received reports from a mean of 2.3 committees, most frequently from IC (22/34, 65%). Few ASP committees (<20%) reported to any of patient/medication safety, quality, sepsis, laboratory, risk management or nursing committees. Risk assessments and strategic planning were performed by only 35% (12/34) and 56% (19/34), respectively.

Conclusion

Our study demonstrates additional need in LA County hospital ASPs to meet CDC core measures as well as enhance ASP administrative structure. Notably, ASP committees appear to be siloed with P&T and IC with minimal reporting to other committees, do not frequently perform risk assessments or strategic planning, and have low meeting attendance by IT personnel and non-ID physicians.

Disclosures

All authors: No reported disclosures.
2090. Are Changes in Antimicrobial Use Associated with a Decline in Hospital Pathogen Rates in Veterans Affairs Medical Centers?
Authors: Jones Makoto M , Madaras-Kelly Karl , Stevens Vanessa W , Bostwick Doran , Lewis Julia , Roselle Gary , Glassman Peter A , Goetz Matthew B , Samore Matthew H , Rubin Michael , Kralovic Stephen
Published: October 2019

Background

The relationship between antimicrobial use and resistance is complex, making it difficult to understand and predict the impact of antimicrobial policies. Here, we examine trends of antimicrobial pressure and pathogen rates using novel metrics.

Methods

Data were extracted from 2007 through 2016. GEE-negative binomial regression modeled incident (within a year) hospital-onset (HO) pathogen rates, defined as the number of unique positive isolates between hospital day 3 and discharge, offset by patient-days at risk (eliminating the first 2 hospital days from the denominator, etc.). As predictors, we used pathogen-specific AM pressure metrics, summing the selection pressure of each AM regimen, given to a patient in a day, for and against the pathogen by each facility and year (e.g., if a regimen was 70% active by antibiogram then 0.7 was counted as selection against and 0.3 for the pathogen; different regimens would contribute differentially). We also adjusted by facility complexity index and pathogen admission prevalence.

Results

All HO-pathogen rates declined significantly after adjustment (raw rates in Figure 1), except Bacteroides. Admission prevalence trends were variable (Table 1 and Figure 2). Figure 3 demonstrates the trend of the log ratio of AM pressure for and against pathogens. Significant negative associations with AM pressure against 5 pathogens and for 1 were observed (Table 1).

Conclusion

There was a broad decrease in adjusted hospital pathogen rates. The negative association with selection pressure against pathogens suggests that (a) AM resistance among pathogens is decreasing, (b) it causes a decrease in infection rates, or (c) both. While residual confounding and endogeneity still exist, our findings highlight the possibility that new metrics might better predict AM effects, including potential protective effects of some patterns of AM use. It is also notable that the measured associations were not large enough nor AM pressure trends consistent enough to explain the decreases in HO-pathogen rates. This suggests that other factors not measured in this analysis, including infection prevention, likely played a large role in observed trends. Interpretation of these results should be nuanced; we are not advocating broad-spectrum AM use.

Disclosures

All authors: No reported disclosures.
2102. Does Monitoring Procalcitonin Levels in Septic and Septic Shock Patients Decrease the Use of Antibiotics and Predict Length of Hospital Stay?
Authors: Bilbe Sarah E , Azhar Ashaur , Brakta Fatima Z , Aymond Katherine N , Nsuami M Jacques , Figueroa Julio E
Published: October 2019

Background

Elevated levels of procalcitonin (PCT) reflect systemic inflammation associated with bacterial infection (BI). Compared with other acute-phase reactants, PCT levels more rapidly rise with BI and decline quickly as BI improves. A PCT protocol was implemented at University Medical Center New Orleans (UMCNO) in November 2017 that guided discontinuation of antimicrobial therapy in septic and septic shock patients if clinically improving with declining levels of PCT.

Methods

We performed a retrospective chart review of UMCNO patients 18+ years with a diagnosis of sepsis and a PCT level between January 1st, 2018 to July 31st, 2018 compared with those with sepsis and no PCT level. ICD-9/10 codes were used for diagnoses of sepsis and septic shock. The baseline characteristics including age, gender, body mass index, race and Charlston Comorbidity Index (CCI) data were collected. The primary objective was to compare the total days of antibiotic therapy (DOT) between the two groups. Secondary outcomes were broad-spectrum antibiotic DOT, patient length of stay (LOS), and all-cause 28-day mortality. SPSS was used for data analysis. P < 0.05 indicated statistical significance.

Results

There were 44 patients in the PCT group (PCTg) and 35 in the non-PCT group (nPCTg). The demographics are outlined in Table. The mean DOT was 6.25 days in PCTg and 10.74 days in nPCTg (P = 0.006). LOS was 7.5 days in PCTg and 14 in nPCTg (P = 0.006). The mean CCI was 2.4 in PCTg and 4 in nPCTg (P = 0.007). The all-cause 28-day mortality was 11% in PCTg and 23% in nPCTg (OR 0.4; 95% CI 0.128–1.466). On bivariate analysis, LOS was significantly associated with CCI (P < 0.05) and total DOT (P = 0.000). On multivariate analysis, LOS was only significantly associated with age (P = 0.015) and total DOT (P = 0.000) but not CCI (P = 0.811) nor PCTg (P = 0.250).

Conclusion

DOT was significantly shorter in the PCTg than in nPCTg. The LOS was 50% less in PCTg than in nPCTg; however, PCT monitoring did not contribute to LOS in multivariate analysis. Although the nPCTg were sicker, CCI did not correlate with LOS either. However, age and total DOT therapy remained positive predictors of LOS. Monitoring PCT levels decreased antibiotic use in septic patients. LOS, however, was not significantly affected by PCT monitoring.

Disclosures

All authors: No reported disclosures.
2115. Activity of a Long-Acting Echinocandin Rezafungin and Comparator Antifungal Agents Tested against Contemporary Invasive Fungal Isolates: SENTRY 2018
Authors: Pfaller Michael A , Carvalhaes Cecilia G , Messer Shawn A , Rhomberg Paul R , Castanheira Mariana
Published: October 2019

Background

Echinocandins are the first-line treatment of candidemia. We evaluated the activity of rezafungin (RZF), a novel long-acting echinocandin with front-loaded drug exposure and extensive distribution to sites of infection, and comparators using CLSI broth microdilution methods against 709 invasive fungal isolates collected worldwide during 2018.

Methods

Susceptibility (S) tests on 663 Candida spp. (6 species), 21 C. neoformans (CNEO), and 25 A. fumigatus (ASF) were conducted for RZF, anidulafungin (ANF), caspofungin (CSF), micafungin (MCF), and azoles. CLSI clinical breakpoint (CBP) and epidemiological cutoff value (ECV) interpretive criteria were applied. Isolates displaying echinocandin MIC>ECV were sequenced for fks hot spot (HS) mutations.

Results

RZF inhibited 99.7% of C. albicans (CA) isolates (MIC50/90, 0.015/0.06 mg/L), 100.0% of C. tropicalis (CT) (MIC50/90, 0.03/0.06 mg/L), 98.9% of C. glabrata (CG) (MIC50/90, 0.03/0.06 mg/L), 100.0% of C. krusei (CK) (MIC50/90, 0.015/0.12 mg/L), and 100.0% of C. dubliniensis (CD) (MIC50/90, 0.03/0.06 mg/L) at ≤0.12 mg/L. All (104/104 [100.0%]) C. parapsilosis (CP) isolates (MIC50/90,1/2 mg/L) were inhibited by RZF at ≤2 mg/L. Fluconazole resistance was detected among 9.0% of CG, 17.3% of CP, and 1.6% of CT. The activity of RZF against these 6 Candida spp. was similar to that of the other echinocandins, the vast majority of which were susceptible/wild type (WT) using CBP/ECV. A total of 5 isolates (3 CG, 1 CA, and 1 CT) displayed 1 or more non-WT or-resistant MIC values and were sequenced for fks HS mutations. Fluconazole and other azoles displayed good activity against CNEO whereas echinocandins including RZF displayed limited activity against CNEO isolates. Echinocandins displayed good activity against ASF, and RZF activity was similar to that of anidulafungin, caspofungin, and micafungin. All but 1 isolate (non-WT MIC for itraconazole, 2 mg/L) displayed WT MIC values for the mould-active azoles.

Conclusion

Rezafungin was as active as other echinocandins against common organisms recovered from invasive fungal infections. These in vitro data contribute to accumulating research demonstrating rezafungin potential for prevention and treatment of invasive fungal infection.

Disclosures

All authors: No reported disclosures.
2129. When Is Methicillin-resistant Staphylococcus aureus not Methicillin-resistant Staphylococcus aureus?
Authors: Gitman Melissa R , Obla Ajay , Van de Guchte Adriana , Sordillo Emilia Mia , Polanco Jose , Chung Marilyn , Oussenko Irina , Smith Melissa L , Altman Deena R , Van Bakel Harm
Published: October 2019

Background

As part of active surveillance in our NICU for methicillin-resistant Staphylococcus aureus (MRSA), two isolates representing modified S. aureus (MODSA), which are Methicillin resistant but lacking mecA or C were identified. Our current microbiology laboratory workflow for screening for MRSA involves plating isolates on chromoID agar (bioMérieux, Marcy-l’Etoile, France) as well as on sheep blood agar (SBA). Β hemolytic colonies on SBA that are catalase and coagulase positive are set up for confirmation and antimicrobial susceptibility testing on the Vitek 2 (bioMérieux, Marcy-l’Etoile, France).

Methods

These 2 isolates (from Baby 1 and Baby 2) tested positive for green colonies on the chromoagar plates. The Vitek 2 subsequently identified both these isolates as MRSA. However, for research purposes, all positive NICU MRSA isolates are tested via whole-genome sequencing (WGS). Both isolates were identified by WGS as methicillin-susceptible Staphylococcus aureus (MSSA). We subsequently went back and performed additional workup on these isolates. Isolates were plated on SBA and chromagar again and incubated for 24 hours. 2 colonies of different morphologies from the chromagar plates and 3 from the SBA were randomly selected and subcultured to chromagar and SBA for a total of 5 subcultures. Each of the subcultures was tested using staphaurex, mannitol salt agar and the Cepheid Xpert MRSA assay and all were confirmed to be Staphylococcus aureus.

Results

All 10 isolates tested negative by the Cepheid Xpert MRSA assay for MRSA. Phenotypic testing was set up again for all ten isolates using the vitek GP panel, as well as cefoxitin disk, and oxacillin E test using Mueller–Hinton agar supplemented with 2% NaCl as per CLSI methods. See table attached for results.

Conclusion

In conclusion, these two cases highlight the difficulty in identifying non-MecA, non-MecC-mediated MRSA isolates in the clinical microbiology laboratory. This is particularly important as more laboratories rely on testing for MecA by PCR for surveillance testing. These 2 cases were further complicated by heterogeneous sub-populations of Staphylococcus aureus. Failure to recognize these variant forms of MRSA can lead to difficulties in implementing appropriate therapy and infection control measures. Improved methodologies are needed.

Disclosures

All authors: No reported disclosures.
2135. Streptococcus pneumoniae DNA (lytA) Detection in Clinical Samples Sent for a Respiratory Viral Polymerase Chain Reaction: Is There Bacterial-Viral Association?
Authors: Roberts Matthew , Sadlon Tania , Higgins Geoff D
Published: October 2019

Background

Streptococcus pneumoniae (SPNEU) is a major cause of community-acquired pneumonia and frequently complicates respiratory viral infections. Clinical differentiation of viral and bacterial respiratory tract infection can be difficult, as can predicting which patients with respiratory viral infection will develop bacterial infection. A SPNEU polymerase chain reaction (PCR) to specific DNA region lytA may be able to determine which patients with viral infections may develop bacterial infection.

Methods

Stored nucleic acid extracts from clinical samples collected and tested for respiratory viral PCR (RVP) in 2015 and 2016 were tested for SPNEU lytA DNA using standard laboratory procedure. Analyses of demographic data, RVP and SPNEU PCR result were performed to determine relevant associations.

Results

1581 stored clinical RVP samples were tested for SPNEU DNA with PCR to lytA, 1550 of these had complete RVP panel results available for analysis. RVP samples from patients 0–5 years old were more likely to have a viral or bacterial pathogen detected than > 5 years old (78% vs. 45%, P < 0.001). Of 1,550 samples analyzed with SPNEU PCR, 19% were positive for SPNEU, this was more likely in those 0–5 years old than > 5 years old (50% vs. 10%, P < 0.0001). In 0–5 years old, SPNEU was more frequently detected when multiple pathogens were detected on RVP vs. those with no pathogen (63% vs. 43%, P = 0.031). In > 5 years old, compared with no pathogen samples, the presence of multiple pathogens, any single pathogen, influenza, rhinovirus and Bordetella pertussis were significantly associated with higher SPNEU positivity rates. Median SPNEU PCR DNA load was higher in multiple pathogen and single pathogen samples than in no pathogen RVP samples.

Conclusion

We have demonstrated an association between common respiratory pathogens and detection of SPNEU DNA via PCR. This association is strongest in samples with multiple RVP pathogens, suggesting additional nasopharyngeal inflammation may contribute to SPNEU presence in the nasopharynx. Previous data have focused on those 0–5 years old, we have demonstrated an SPNEU-viral association in those > 5 years old. This tool may be clinically useful to determine which individuals with viral respiratory tract infection will progress to bacterial pneumonia and warrants further investigation.

Disclosures

All authors: No reported disclosures.