bluuebunny/crossref_metadata_2025 huggingface dataset:
953. Implementation Outcomes in an Antibiotic Stewardship Program (Kicking CAUTI) in Four Veterans Hospitals Correlated with Clinical Outcomes
Authors: Amenta Eva , Grigoryan Larissa , Ramsey David J , Kramer Jennifer , Walder Annette , Chou Andrew , Van John , Sales Anne , Naik Aanand , Trautner Barbara
Published: December 2022

Background

One of the major barriers to scale up of antibiotic stewardship interventions is the difficulty of engaging already overtaxed personnel. As part of a multisite antibiotic stewardship project to decrease antibiotics treatment of asymptomatic bacteriuria, we explored how to measure local implementation efforts, and what dose of the intervention was necessary to improve clinical outcomes.

Methods

The intervention was implemented in 4 different sites from February 2019 through May 2020. We chose 3 measures of implementation: the number of intervention delivery sessions (adoption), total number of health care professionals reached (penetration), and minutes spent in delivery of the intervention (adoption). Local site champions kept activity logs. Antibiotic prescriptions were included if ordered within one calendar day prior or two days after a urine culture was ordered on the same patient. Correlation between implementation measures and clinical outcomes (number of urine cultures ordered, days of antibiotic treatment (DOT), and length of antibiotic treatment (LOT)) was calculated using the mixed linear models method.

Results

Overall, the minutes spent in delivery ranged from 2567 minutes at the most engaged site to 679 in the least engaged site (Figure 1). The number of healthcare professionals reached ranged from 798 to 433, and the number of sessions delivered ranged from 240 to 45. Minutes spent in delivery was inversely correlated with two of our three clinical metrics, DOT (R -0.3, P=0.04) and LOT (R -0.3, P=0.02); minutes spent and urine cultures were not significantly correlated (Table 1). We did not find a significant relationship between the number of intervention delivery sessions or total number of health care professionals reached and any of the clinical outcomes. Figure 1Total Minutes Spent in Delivery of the Intervention Across Four Intervention Sites

Table 1 Correlation Coefficients (with p-values) Comparing Implementation Outcomes with Clinical Outcomes (bolded results are statistically significant)

Conclusion

We found a significant inverse correlation between the number of minutes a local site champion spent delivering the antibiotic stewardship intervention and antibiotic use, both DOT and LOT. In other words, more time spent delivering the intervention locally was associated with a decrease in antibiotics ordered. Our implementation metric (adoption) is scalable and readily adaptable to large antibiotic stewardship dissemination projects.

Disclosures

Larissa Grigoryan, MD, PhD, Rebiotix Inc: Grant/Research Support Barbara Trautner, MD, PhD, Genetech: Advisor/Consultant.
954. Implementing UTI Stewardship in Critical Access Hospitals Through A Collaborative Tele-Antimicrobial Stewardship Program: One Size Fits One
Authors: Kassamali-Escobar Zahra , Hartlage Whitney , Martinez-Paz Natalia , Lynch John B , Chan Jeannie D , Jain Rupali , Pottinger Paul , Castillo Alyssa Y , Castillo Alyssa Y , Bryson-Cahn Chloe
Published: December 2022

Background

Critical access hospitals (CAHs) in the United States service nearly one fifth of the US population, predominantly in rural areas. CAHs are required to provide antimicrobial stewardship (AMS) services, however, access to infectious diseases and antimicrobial stewardship expertise is limited. We assessed the feasibility of implementing a tele-AMS intervention in CAHs.

Methods

We piloted a one-year, biphasic, intensive quality improvement collaborative of self-selected CAHs to address asymptomatic bacteriuria (ASB). In phase 1, we engaged multidisciplinary teams from participating hospitals, facilitated goal-setting, and implemented a monthly curriculum to train local stewards regarding appropriate diagnosis and management of urinary tract infections (UTIs). In phase 2, we focused on quality improvement education and data collection. We discussed stewardship strategies and addressed barriers identified on a one-on-one basis.

Results

Nineteen CAHs in five states across the Western region participated in this pilot. Nine of 19 attended all 8 monthly didactic sessions. The median number of one-on-one sessions attended per site was 3 (range, 1-4). Eighteen of 19 hospitals set a goal and documented it in a Plan-Do-Study-Act framework. Six CAHs set a goal related to staff and/or patient education, 10 CAHs focused on workflow and processes surrounding identification of UTI including reflex of urine analyses to urine culture, and 2 CAHs set goals to prospectively review cases of ASB treated with antibiotics and provide feedback to prescribers. Commonly encountered barriers included turnaround time for urine culture data, difficulty obtaining data from the electronic medical record, resistance to change among personnel, high staff turnover, limited time and availability to perform stewardship, and short duration of the collaborative.

Conclusion

We successfully launched a tele-stewardship training program to mentor CAH antimicrobial stewards to identify and manage ASB and use quality improvement tools. A standardized approach to address asymptomatic bacteriuria or other AMS goals are unlikely to be successful in CAHs without significant tailoring to fit specific site and process needs.

Disclosures

Chloe Bryson-Cahn, MD, Alaska Airlines: Advisor/Consultant.
959. It Takes a Village: Reducing Empiric Vancomycin Use by Leveraging Primary Team Pharmacist Oversight of a 72-hour Approval Process
Authors: Pettit Natasha N , Nguyen Cynthia T , Lew Alison K , Pisano Jennifer
Published: December 2022

Background

Vancomycin is often initiated empirically in hospitalized patients for broad spectrum gram-positive coverage, however in many cases it is initiated unnecessarily and/or continued empirically for longer durations than necessary. Strategies to facilitate timely discontinuation of vancomycin when unnecessary may reduce antibiotic toxicity (e.g. nephrotoxicity) and the development of bacterial resistance. In large hospital systems, it may not be feasible for stewardship programs to implement prior authorization requirements or prospective audit/feedback for all vancomycin orders. Novel strategies to enlist other clinicians to serve as stewards of antibiotic use are needed.

Methods

On February 1, 2020, we implemented a protocol requiring providers to obtain approval from the primary team pharmacist to continue empiric vancomycin regimens >72 hours. Primary team pharmacists were provided a list of appropriate indications for vancomycin continuation. After 72 hours, the pharmacist placed a note describing the approved indication or if ASP or ID consult was obtained. We evaluated the standardized antibiotic administration ratio (SAAR) for antibacterial agents for resistant gram-positive infections for FY2019 (pre-protocol) and FY2020 (post-protocol) to assess the impact of this intervention. Vancomycin utilization was also evaluated in days of therapy (DOT)/1000 patient days during both time periods.

Results

The SAAR for antibacterial agents for resistant gram-positive infections for FY2019 was 1.17 and FY2020 was 1.04 (95% CI (0.87, 0.91), p-value < 0.001). A significant reduction in SAAR was observed in patients admitted to the ICU and floor (Figure 1). Overall vancomycin utilization according to days of therapy/1000 patient days was reduced from 111.13 (FY2019) to 104.08 (FY2020).

Conclusion

Leveraging the oversight of primary team pharmacists proved to be an effective strategy to reduce empiric vancomycin durations of therapy. Following the implementation of a 72-hour approval protocol with primary team pharmacist oversight, we observed a significant reduction in the SAAR for antibacterials for resistant gram-positive infections with a corresponding reduction in vancomycin utilization.

Disclosures

All Authors: No reported disclosures.
968. The Impact of Film Array Detection of High-risk and Resistant Pathogens on the Time to Optimal Antibiotic Therapy at a Community Health System
Authors: Baumeister Tyler W , Sinclair Emily , Zeigler Dustin , Frens Jeremy J
Published: December 2022

Background

The importance of effective antibiotic therapy for the treatment of bloodstream infections has been well described. Rapid diagnostic testing platforms like the BioFire® FilmArray® blood culture identification (BCID) have the potential to decrease time to effective antibiotics when acted on appropriately. The Cone Health stewardship team has collaborated with clinical pharmacists and infectious diseases physicians to define a process to optimize antibiotic therapy. This process involves microbiology calling a pharmacist with newly positive blood cultures, and the pharmacist notifies the attending physician with the results and evidence-based treatment recommendations. We transitioned from BCID to BCID2 in August, 2021. As CTX-M (marker for extended spectrum beta-lactamase production) was not a target on BCID, we were interested in how the addition of this marker could improve care in this subset of patients.

Procedure for Positive Blood Culture Workup and Notification

Treatment Recommendations for Selected Organisms

Methods

From August 2021 - March 2022, the times to administration of effective and optimal antibiotics were evaluated in patients with the following BCID2 organism and resistance gene targets identified: S. aureus, P. aeruginosa, CTX-M, KPC, OXA-48 like, IMP, VIM, NDM, and vancomycin resistant enterococci. An effective antibiotic was defined as an antibiotic with in vitro activity to the organism, and an optimal antibiotic was defined as the preferred agent based on institutional guidelines. For CTX-M isolates, we compared effective and optimal times to a historical control of ceftriaxone resistant enterobacterales and analyzed by student’s t-test.

Results

The combined mean time from BCID2 to administration of effective antibiotics = 1.2 hours (range 0-7.9 hours) and to optimal therapy =7.6 hours (range 0 – 113.8 hours). Prior to the BCID2 transition, patients found to be growing ceftriaxone resistant enterobacterales had an average time to optimal antibiotic administration of 17.7 hours, which improved to 2.8 hours after BCID2 implementation (p=0.0041).

Time to Effective and Optimal Antibiotics after implementation of BCID2 (August 2021 – March 2022)

Time to Effective and Optimal Antibiotics for Ceftriaxone Resistant Enterobacterales Prior to BCID2 Implementation (January 2021 - July 2021)

Conclusion

BioFire® FilmArray® coupled with antibiotic stewardship team support can help optimize time to effective and optimal antibiotic therapy in bloodstream infection. The addition of the CTX-M target to BCID2 was a helpful addition to the panel which allowed for decreased time to optimal antibiotic therapy.

Disclosures

All Authors: No reported disclosures.
969. The Importance of a Strong Handshake: Expanding Antimicrobial Stewardship to Engage Frontline Providers in Adult Medicine
Authors: Sapozhnikov Julia , Hoff Brian M , Adams Jenna , Santarossa Maressa , Kalathiya Sonali , Albarillo Fritzie S
Published: December 2022

Background

The Joint Commission highlighted handshake stewardship (HS) as a leading practice in antimicrobial stewardship (AMS). However, intervention and outcomes data in adult populations are lacking. Additionally, limited human resources remain a barrier to widespread implementation of HS services. In February 2022, our antimicrobial stewardship program (ASP) expanded to include a HS service supporting adult internal medicine patients managed by hospitalist staff at an academic medical center. Here we aim to describe the interventions made to support and improve care in this population.

Methods

This was a single-center, retrospective quality improvement initiative at a 547-bed academic medical center. Beginning in February 2022, the ASP structure expanded to include 2-week rotations between HS, general infectious diseases (ID) consult rounds, and whole house AMS (a combination of prospective audit and feedback and pre-authorization). During the HS rotation, all prescribed antimicrobials were prospectively reviewed Monday-Friday by the ID pharmacist and recommendations to improve quality, safety, and transitions of care were discussed in-person during daily rounds with hospitalists. Interventions were documented daily and data generated between February 1, 2022 and April 30, 2022 were reviewed to categorize the impact of the expanded service.

Results

A total of 316 interventions were made for 101 unique patients over a 3-month period. We observed 286 accepted interventions (90.5%) during the intervention period. On average, the HS pharmacist reviewed 24 charts per day and spent 68 minutes in chart review, 16 minutes in rounds, and 23 minutes in other direct communication with providers per day. Table 1 and Figure 1 describe the distribution of interventions by type and indication. Table 2 quantifies the number of days broad spectrum antibiotics were avoided directly attributable to interventions. Since implementation, the HS service has contributed to an estimated cost savings of $73,470.19 for our hospital. Table 1.Intervention by TypeFigure 1.Antibiotic Indication for Cases with Interventions

Conclusion

Implementation of HS in two adult internal medicine teams was associated with many interventions with high acceptance by hospitalist staff. Interventions led to tangible reductions in broad spectrum antibiotic days of therapy and cost.

Disclosures

Sonali Kalathiya, PharmD, MPH, BCIDP, Blueprint Medicines: Spouse is employed by Blueprint Medicines|Blueprint Medicines: Stocks/Bonds.
988. Risk of surgical site infection and Clostridioides difficile infection after perioperative clindamycin in patients labeled penicillin and/or cephalosporin allergic
Authors: Jeffres Meghan N , Porter Melissa , Ricco Madison , Norvell Miranda , Koonce Ryan , Bassler Eric , Hogan Craig
Published: December 2022

Background

Perioperative antibiotics reduce surgical site infections after hip and knee arthroplasty. Clindamycin is routinely used as a perioperative antibiotic in patients with beta-lactam allergy labels instead of first-line antibiotics like cefazolin. The purpose of this study is to assess the risk of adverse outcomes associated with the use of clindamycin to prevent surgical site infections (SSI) after total joint arthroplasty.

Methods

This retrospective review included adult patients labeled as allergic to penicillin or cephalosporin antibiotics, who underwent a primary total hip and/or knee arthroplasty between January 2020 through July 2021, and received perioperative antibiotics. The outcomes of SSI and Clostridioides difficile infection (CDI) within 90 days was compared between patients receiving perioperative clindamycin vs. non-clindamycin antibiotics.

Results

A total of 1,121 surgical procedures in 1,047 patients were included. The frequency of SSI for the cohort was 1.6% and CDI was 0.4%. SSI occurred more frequently in the clindamycin group than in the non-clindamycin group (4.3% vs 0.7%, p< .01). The average duration from surgery to SSI was 22.7 ± 11.6 days in the clindamycin group and 24.8 ± 11.1 days in the non-clindamycin group. The frequency of CDI occurrence was greater in the clindamycin group than the non-clindamycin group (1.1% vs. 0.1%, p=.05). The average duration from surgery to CDI was 32.6 + 26.6 days in the clindamycin group and 4.6 days in the non-clindamycin group. Multivariable logistic regression identified clindamycin-containing perioperative antibiotic regimens (odds ratio (OR) 5.5) and opioid use prior to surgery (OR 8.7) as risk factors for 90-day surgical site infection. Staphylococcus aureus was the cultured pathogen in 9 of the 17 SSIs.

Conclusion

This study found a significantly higher frequency of SSI and CDI when clindamycin-based regimens are used perioperatively for primary hip and knee arthroplasty. These results are likely related to decreased activity of clindamycin against Staphylococcus aureus and greater alterations of the microbiome in comparison to beta-lactams.

Disclosures

All Authors: No reported disclosures.
990. Sex-Specific Analysis of Clinical Features and Outcomes in Staphylococcal Periprosthetic Joint Infections Managed with Two-Stage Exchange Arthroplasty
Authors: Higgins Eibhlin , Tai Don Bambino Geno , Lahr Brian D , Suh Gina A , Tande Aaron J
Published: December 2022

Background

There are anatomical, pharmacokinetic, and joint biomechanical differences between males and females. Whether these differences result in differing presentation, treatment tolerability and outcomes in periprosthetic joint infection (PJI) has not been widely evaluated.

Methods

We undertook a retrospective case matched study of patients with staphylococcal PJI managed with two-stage exchange arthroplasty. In order to control for differences other than sex which may influence outcome or presentation, males and females were case-matched for age, causative organism (Coagulase-negative staphylococci vs Staphylococcus aureus) and joint involved. The two matched groups were analyzed for differences in duration of symptoms, inflammatory markers, duration of hospital stay, antimicrobial side effects, post-operative complications and recurrence rate. Recurrence of infection was defined as per Musculoskeletal Infection Society criteria for PJI and included both relapse with original microorganism or with an additional organism.

Results

78 pairs of males and females with staphylococcal PJI were successfully matched. There were no significant baseline differences by sex, except for greater use of chronic immunosuppression among females (16.7% vs. 4.1%; p=0.012). Clinical characteristics and outcomes of the patients are summarized in table 1. We did not detect a statistically significant between the outcomes of the two groups. Overall, 16 recurrent infections occurred during a median follow-up time of 2.9 (IQR: 1.5 - 5.3) years. The 3-year cumulative incidence of treatment failure depicted in figure 1 was 16.1% for females, compared with 8.8% for males (p=0.434).

Conclusion

Success rates for PJI treated with two-stage exchange arthroplasty are high consistent with previously reported literature. A larger cohort of patients may be required to detect differences in relapse rates. This study included only staphylococcal PJI and was thus unable to evaluate the differences in microbiology of PJI between males and females, which could also impact outcomes. This retrospective case-matched study did not detect any significant differences in outcomes between males and females with staphylococcal PJI who underwent two stage exchange arthroplasty.

Disclosures

Gina A. Suh, M.D., Adaptive Phage Therapeutics (APT): Grant/Research Support|Adaptive Phage Therapeutics (APT): Dr. Suh received grants and has an equity and royalty-bearing know-how agreement with Adaptive Phage Therapeutics but is unrelated to project Aaron J. Tande, M.D., Uptodate: Dr Tande has received an honorarium from Uptodate for medical writing unrelated to this project.
991. Single Center, Exploratory, Open-label Prospective Study Using the Minimally Invasive LysinDAIR Procedure (Lysin Administration During an Arthroscopic DAIR Procedure) in Patients with Suspected Relapsing Chronic Coagulase-Negative Staphylococci (CNS) Prosthetic Hip Infection (PHI)
Authors: Ferry Tristan , Conrad Anne , Kolenda Camille , Laurent Frederic , Schmidt Axel , Cassino Cara , Lustig Sebastien , Batailler Cécile
Published: December 2022

Background

Exebacase, a recombinant staphylococcal lysin, has: (i) reported proof-of-concept data in Phase II in S. aureus bacteremia; (ii) demonstrated antibiofilm activity in vitro against S. epidermidis; and (iii) been used as salvage therapy in 4 patients with relapsing multidrug-resistant (MDR) S. epidermidis knee prosthetic joint infection (PJI) using the LysinDAIR (arthroscopic administration of exebacase [Lysin] with Debridement and Antibiotics Implant Retention) procedure. Surgical treatment of recurrent PHIs has high risk of morbidity and loss of function. We now report our experience with the LysinDAIR procedure for PHIs.

Methods

We performed a single center, exploratory, open-label prospective study using LysinDAIR and suppressive antimicrobial therapy (SAT) in patients with recurrent, chronic (inoculation >3 months prior to treatment) CNS PHI. In agreement with the French Health authority, exebacase (2 to 3.5 total mg in 30-50 ml [∼0.067 – 0.075 mg/ml]) was arthroscopically administered directly into the joint.

Results

Three consecutive patients were included (55 to 75 years). All had previous iterative hip prosthesis exchange with a high total number of surgeries (from 6 to 10) and recent persistent or intermittent fistula (Figure). All refused hip prosthesis explantation or surgeon considered explantation too high risk for loss of function and severe post-operative complications. Patients A and B had MDR S. epidermidis; Patient B had P. aeruginosa co-infection at the time of LysinDAIR. Patient C had a prior persistent S. lugdunensis PHI and relapse on arthrocentesis; K. pneumoniae was cultured at the time of LysinDAIR. No adverse events related to exebacase or the procedure were reported. At 2 years follow up, all patients had resolution of fistula and no clinical signs of infection on SAT (tedizolid (+/- ciprofloxacin [Patient B] or cotrimoxazole [Patient C]).

Description of the patients treated with the LysinDAIR procedure

Local signs of infection with discharge of the three patients (A, B and C) with complex relapsing prosthetic hip infection with X-ray before the LysinDAIR procedure and at 2 years of follow-up

Conclusion

The LysinDAIR procedure was easy-to-perform, safe and may have therapeutic potential to facilitate the success of SAT salvage therapy for chronic relapsing CNS PJIs, and potential cure of initial chronic PJI. Randomized clinical trials evaluating the LysinDAIR procedure in these clinical situations are clearly warranted.

Disclosures

Tristan Ferry, MD, PhD, Contrafect: Advisor/Consultant Camille Kolenda, n/a, Contrafect: Research grant frederic Laurent, n/a, Contrafect: Research grant cara cassino, n/a, Contrafect: Employee.
995. Acute Kidney Injury Rates Before and After Implementation of Integrated Bayesian Software for Vancomycin Dosing
Authors: Tigh Jeremy E , Jantrakul Nicholas A , Miller Molly M , Alexander Bryan T , Avedissian Sean , Van Schooneveld Trevor C , Bergman Scott J
Published: December 2022

Background

Therapeutic drug monitoring of vancomycin with Bayesian models is recommended to maximize efficacy and minimize nephrotoxicity by targeting a 24-hour area under the curve (AUC24) of 400-600mg*h/L. Minimal real-world evidence exists on the impact of this strategy. In 2020, we integrated Bayesian software from DoseMeRx into Epic OneChart and converted from trough-based vancomycin to AUC-guided dosing. We assessed the incidence of acute kidney injury (AKI) in patients receiving vancomycin before and after this change and sought to establish an efficient method of assessment.

Methods

This was a retrospective, single-center quasi-experimental study. Patients were divided into pre-Bayesian software (trough guided dosing, Jan-Jun 2018) and post- (Jan-Jun 2021). Preliminary data showed 10% & 6% AKI rates, respectively. Therefore, a sample of 1442 patients was needed to detect a difference. Adults were included with a baseline Scr ≤2 mg/L, who received ≥3 vancomycin doses and had ≥1 vancomycin level measured. The primary outcome was AKI incidence assessed using AKIN criteria. Patients were reviewed in each period until 500 met inclusion criteria. This sample was used to determine the feasibility and accuracy of using EHR-generated reports.

Results

Of the 1,000 patients reviewed, baseline characteristics were similar; however, indications varied as pneumonia was more common in the pre-group and skin and soft tissue infection was more common in the post-group (Table 1). Initial daily dose and duration of vancomycin treatment were not different between groups. Incidence of AKI was decreased in the post-integration group, although this was not significant by bivariate analysis (15.4% vs. 12.6%, p=0.20). Fewer trough concentrations were drawn in the post-group (2 vs. 1.8, p=0.005), with overall lower vancomycin levels (13.2 vs. 12.1 mg/L, p=0.04).

Conclusion

The rate of AKI was numerically lower in patients monitored and dosed with Bayesian AUC-guided dosing software for vancomycin. Trough levels were lower, and vancomycin levels were needed less often. AKI incidence was higher than in our pilot but similar to what is reported in other studies. Further investigation is required to establish statistical significance and whether the assessment process can be automated.

Disclosures

Bryan T. Alexander, PharmD, BCIDP, AAHIVP, Astellas Pharma: Advisor/Consultant Trevor C. Van Schooneveld, MD, bioMerieux: Advisor/Consultant|bioMerieux: Grant/Research Support|Insmed: Grant/Research Support|Merck: Grant/Research Support|Thermo-Fischer: Advisor/Consultant Scott J. Bergman, PharmD, BCIDP, FCCP, FIDSA, Merck & Co., Inc: Advisor/Consultant|Merck & Co., Inc: Grant/Research Support|Merck & Co., Inc: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Honoraria.
997. Burden of Inappropriate Urine Culture Collection and Processing on the Environment
Authors: Farshidpour Leyla , Wilson Tyler E , Hauser Naomi , Desai Angel
Published: December 2022

Background

Healthcare is the second-most energy-intensive commercial sector in the United States. Clinical laboratories make up a large portion of that energy use and contribute significantly to waste production (7, 8, 9, 10). We aimed to estimate the environmental impact of urine cultures and suggest inappropriate culturing as a target for diagnostic stewardship and waste mitigation.

Methods

The total number of urine cultures performed by our facility’s microbiology laboratory was gathered. The plastic components, including bacterial culture plates, urine sample collection cups, and biohazard bags, were weighed.

Results

Between 3/07-03/13/21, 533 urine cultures were processed by our facility. Since the number of bacterial culture plates varies between samples, we calculated a range from 2 cell-culture plates (clean catch sample) to 4 cell-culture plates (in-and-out catheterization sample), with an additional 1-2 plates per isolate for susceptibility testing. This yielded a range of 3-6 total plates (30g for bacterial culture plates, 120g for susceptibility plates) used per processed urine culture. Each sample also requires a collection cup (27.2g or 19.1g) and a biohazard bag (4.1g) yielding a range of 95 - 192kg of plastic waste over the study period. Assuming this week represents an average week, our projected annual waste is between 6.5 to 12 tons for urine culture collection and testing.

Conclusion

In this single-center pilot study, urine cultures produced an estimated 6.5 to 12 tons of plastic waste annually. Prior studies suggest that 58%-68% of urine cultures are not clinically indicated (2, 3). This includes up to 35% of emergency department urine cultures being done in the context of a negative urinalysis, 20% of urine cultures sent without a urinalysis, and a urine culture contamination rate of at least 5% (4). While the effects of inappropriate urine cultures on length of hospital stay, antibiotic stewardship, and healthcare costs have been investigated, the subsequent impact on the environment has not been well studied (5). Although this study was limited by its reliance on estimated numbers, the sizable impact on healthcare’s net waste production suggests that further quantifying inappropriate culturing and how to alleviate it is an important area for further investigation.

Disclosures

All Authors: No reported disclosures.
1001. Comparison of Periodic In-Person ID Care to Daily Tele-ID Care at a Community Hospital
Authors: Nanjappa Sowmya , Volpe Peter , Gupta Nupur , Li Sui Kwong , Perez Christian , Gass Kate , Oelkers Keith , Overly Shannon , Mellors John W , Abdel-Massih Rima
Published: December 2022

Background

Access to ID specialists is absent in most US counties. Remote access to ID specialists via telemedicine is a potential alternative to in-person ID care, although comparative data are lacking. We compared outcomes between periodic in-person and daily remote ID care.

Methods

Retrospective EHR analysis of 200 patients at a 164-bed community hospital, which historically had access to an in-person ID specialist every 3rd day with limited telephonic follow-up. In May of 2020, access to a team of Tele-ID specialists was provided through live audio-visual and e-consults, with telephonic consults after hours and on weekends. Outcomes for 100 consecutive patients cared for by the in-person physician from 01/2019 to 11/2019 were compared to the first 100 patients care for via Tele-ID from 05/2020 to 08/2020.

Results

Of the 100 patients seen via Tele-ID, 73 were live initial consults and 27 initial e-consults. These 100 consults occurred over 4 months compared with 11 months for the 100 in-person ID consults, revealing greater utilization. Most patients were Caucasian, male, and >60 years old (Table 1). Tele-ID patients had significantly higher Charlson Comorbidity Index (CCI) scores (5.3 vs 4.5, p=0.047), shorter LOS (7.5 vs 9.08 days, p=0.003), less frequent discharge on IV antibiotics (34% vs 51%, p=0.007), and more frequent discharge on PO antibiotics (39% vs 23%, p=0.014; Table 2). There were no significant differences in the frequency of transfer to tertiary care (13% vs 14%, p=0.84) or in-hospital mortality (2% vs 2%). The 30-day readmission rate was higher for Tele-ID (11% vs 1%, p< 0.01); however, only one readmission was ID-related (a new C.difficile). The diversity of ID diagnoses made was not different (Figure 1). Table 1.Patient DemographicsTable 2.OutcomesFigure 1.Diagnoses

Conclusion

A Tele-ID service with daily availability increased utilization of ID care at a community hospital. Despite higher CCI scores in Tele-ID patients, LOS was shorter and discharge on IV antibiotics was less frequent compared with the In-person service with no difference in ID related readmissions or in-house mortality. These findings support remote Tele-ID care as a solution where access to ID expertise is limited.

Disclosures

John W. Mellors, MD, Abound Bio: Multiple|Abound Bio: Ownership Interest|Gilead Sciences: Advisor/Consultant|Infectious Disease Connect: Advisor/Consultant|Infectious Disease Connect: Ownership Interest Rima Abdel-Massih, MD, Infectious Disease Connect: Co founder and Chief Medical Officer|Infectious Disease Connect: Ownership Interest.
1002. Complex Outpatient Antimicrobial Therapy (COpAT) Program at a Rural Academic Medical Center: Evaluation of First 100 Patients
Authors: Juskowich Joy J , Ward Andrew , Spigelmyer Amy E , Howard Catessa A , Slain Douglas , Guilfoose John A , Edmond Michael B , Sarwari Arif R
Published: December 2022

Background

Literature shows early intravenous (IV) to oral (PO) antimicrobial transition for infective endocarditis (IE) and bone and joint infection (BJI) is noninferior to prolonged IV antimicrobial therapy. COVID-19 pandemic peaks resulted in critical shortages of staffed hospital beds spurring innovation. Outpatient parenteral antimicrobial therapy (OPAT), a well-established program using prolonged IV antimicrobials, faces challenges such as infusion resource needs and social circumstance limitations. Complex outpatient antimicrobial therapy (COpAT) uses PO in place of IV antimicrobials. We hypothesized rapid adoption of COpAT would decrease hospital length of stay and open beds while retaining satisfactory clinical outcomes.

Methods

COpAT protocols (Image 1) and guidelines by infection type and isolated organism (Image 2) were created. Hospitalized patients including persons who inject drugs (PWID) were evaluated for IV to PO antimicrobial transition by an infectious diseases (ID) physician and then followed by an ID physician-pharmacist team. Demographic, ID, and clinical outcome data for the first 100 COpAT patients between December 2020 and February 2022 were obtained by retrospective chart review. Image 1.COpAT Inpatient and Outpatient Protocols

Image 2. COpAT Guidelines by Infection Type and Isolated Organism

MSSA = methicillin-susceptible Staphylococcus aureus; MRSA = methicillin-resistant Staphylococcus aureus; spp. = species; TMP/SMX = trimethoprim-sulfamethoxazole; DS = double strength; SSTI = skin and soft tissue infection; CAP = community-acquired pneumonia

Results

PWID accounted for 78% of COpAT patients. BJI followed by mixed infection (IE and BJI) was most prevalent (Image 3) with bacteremia in 53% of cases. Staphylococcus aureus was most frequently isolated (Image 4). Oral linezolid and fluoroquinolones, often in combination, were most commonly used. IV and PO antimicrobials were taken for a median 28 and 14 days, respectively. The COpAT program saved 1425 IV antimicrobial and 1363 hospital days. Assuming daily inpatient cost of $2050, cost avoided was $2,794,150. COpAT patients participated in ID follow-up and adhered to PO antimicrobials with low 30-day readmission rates (Image 5). Image 3.Infection TypeImage 4.Isolated Organism CoNS = coagulase-negative staphylococci Image 5.Clinical Outcomes

Conclusion

In a sample of 100 COpAT patients including PWID, IV to PO antimicrobial transition safely saved hospital days and mitigated critical bed shortages during pandemic peaks. A successful COpAT program requires a multidisciplinary group: close ID physician-pharmacist collaboration extending to OPAT and antimicrobial stewardship teams. With a COpAT program in place, even earlier IV to PO antimicrobial transitions should be studied.

Disclosures

All Authors: No reported disclosures.
1007. Impact of an Interdisciplinary Outpatient Parenteral Antimicrobial Therapy (OPAT) Clinic During the COVID-19 Pandemic
Authors: Zaki Amir , Xu Teena H , Khan Parisa , Ahmed Amna , Breaux Katharine
Published: December 2022

Background

At the Michael E. DeBakey Veterans Affairs Medical Center, an interdisciplinary outpatient parenteral antimicrobial therapy (OPAT) clinic was developed in August 2020 during the COVID-19 pandemic (Figure 1). Standardized weekly safety monitoring and clinical follow-up was implemented via tele-OPAT visits by an infectious diseases (ID) pharmacist or ID PA with ID physician oversight. This study aimed to describe the practices implemented through initiation of our OPAT clinic, and its impact on clinical outcomes. Figure 1:Description of intervention and clinic model

Methods

This retrospective cohort study compared clinical outcomes of veterans receiving home OPAT one year pre- and post-implementation of a dedicated OPAT clinic. OPAT episodes initiated during the intervention period, prescribed for less than 7 days, not completed at time of analysis, administered with hospice services, or at a hemodialysis center, infusion suite, skilled nursing facility or long-term care facility were excluded. The primary endpoint was treatment failure during or within 30 days of OPAT completion defined as requiring repeat OPAT course for the same infection, unplanned admission, unplanned surgical intervention or procedure for additional source control, or death from any cause.

Results

A total of 191 OPAT episodes were included in the analysis (pre-intervention group, n= 76 vs. post-intervention, n=115). The most common indications for OPAT included bone/joint infections (34%), bacteremia (24%), and endocarditis (13%). Treatment failure was lower in the post-intervention vs. pre-intervention group (29% vs 46%, p = 0.01) with a median time to treatment failure of 24 days. Treatment failures in both groups were primarily driven by unplanned hospital admissions (Table 3). The median time to ID follow-up from OPAT initiation was shorter in the post-intervention vs. pre-intervention arms (6 days vs. 9 days, p< 0.001). The adverse event rate was higher (13% vs. 4%, p= 0.06), and modifications were made more frequently in the post-intervention (49% vs. 29%, p=0.007). Table 1:Demographics and baseline characteristicsTable 2:OPAT indications, antimicrobials, and microbiologyTable 3:OPAT follow-up, complications, and treatment failure

Conclusion

Implementation of an interdisciplinary OPAT clinic led to shorter time to ID follow-up, more frequent OPAT modifications, and reduced treatment failure. The median time to treatment failure suggests the need for ongoing surveillance beyond the initial 2 weeks of OPAT.

Disclosures

All Authors: No reported disclosures.
1011. Outcomes Associated with the Creation of a Pharmacy-led Outpatient Parenteral Antimicrobial Therapy (OPAT) Service to Facilitate Transitions of Care
Authors: Manning Kyle B , Certain Laura , Tritle Brandon , Fong Karen , Newman Mike , Benefield Russell J
Published: December 2022

Background

We previously demonstrated that standardizing the documentation of the outpatient parenteral antimicrobial therapy (OPAT) plan led to improved post-discharge outcomes. This study investigated whether centralizing the OPAT documentation to an infectious diseases (ID) pharmacist would lead to improved documentation quality and further improvements in post-discharge outcomes.

Methods

We conducted a single-center, retrospective study to evaluate outcomes associated with the centralization of the OPAT plan documentation to an ID pharmacist. The study was a multiphase quality improvement study consisting of a pre-intervention period and two intervention periods on each of the General ID consult services (first on Team 1 then on Team 2). The scope of the intervention was focused on the timeliness and completeness of OPAT note documentation, while other workflow processes involving OPAT remained unchanged. The primary objective was to compare hospital length of stay (LOS) between patients with OPAT Notes documented by an ID pharmacist versus ID providers. Secondary objectives were to compare post-discharge outcomes.

Results

A total of 350 patients met inclusion criteria; baseline characteristics were similar between the pharmacist and provider groups (Table 1). OPAT note documentation quality improved during the pharmacist intervention phases for each General ID team (Figure 1). The median LOS was 7.9 days in the pharmacist documentation group compared to 6.8 days in the provider group [Median difference, 1.1; 95% Confidence Interval (CI), -0.4 - 3.7]. Laboratory monitoring within 10 days of discharge, 30- and 60-day death or readmission rates, and late ID visit cancellations between the two groups were comparable (Table 2). ID clinic no show appointments occurred less often in the pharmacist documentation patients. Table 1:Baseline DemographicsFigure 1:Control Chart Comparisons of OPAT Notes Without All “Perfect Care” ElementsTable 2:Post-discharge outcomes for pharmacist compared to provider documentation patientsa: Pharmacist note patients are the reference for all comparisonsb: Adjusted for discharge destination and primary payorc: Adjusted for Charlson comorbidity indexd: Adjusted for age and primary payor

Conclusion

Improved OPAT note documentation did not translate into shorter hospital LOS. Post-discharge outcomes were similar between pharmacist and provider patients, although no show visits occurred less often when pharmacists documented the OPAT plan.

Disclosures

Russell J. Benefield, PharmD, BCPS-AQ ID, Paratek Pharmaceuticals: Grant/Research Support.
1012. Outcomes of a Quality Improvement Initiative: Multi-Disciplinary Team for Infective Endocarditis Improves the Numbers of Patients Who Undergo Surgery
Authors: Crosby Haley W , Pierce Robert P , Regunath Hariharan
Published: December 2022

Background

In a prior study we identified leverage points for improving infective endocarditis (IE) outcomes at an academic medical center¹. We aimed to improve the rate of surgery for those with guideline-based indications for surgery by 50%.

Methods

We recorded outcomes and surgical indications for patients with IE from December 2018 to June 2020 and compared to our prior published data from January to December 2016, using similar criteria.¹ Changes implemented in the interim period included development of a multidisciplinary team (MDT) for IE that provided recurring conferences, participated in heart valve team case discussions, and promoted the use of a home-grown algorithmic clinical care pathway within the electronic health record to guide providers on the next steps in management. Primary outcomes were surgery or transfer to a higher center for surgery, and in-hospital death. Odds ratios were calculated using a multivariate logistic regression model including age and sex covariates.

Results

We identified 31 IE patients with guideline indications for surgery. Of those patients, 15(48.39%) were female, 15(48.4%) were 18 - 44 years of age, 8(25.8%) were 45 - 64 years, 8(25.8%) were >64 years, 28(90.3%) white, 2(6.4%) black, 1(3.2%) East Asian, 17(54.8%) were intravenous drug users. Prior to the intervention, 6 of 21 (28.6%) patients with indications underwent surgery or were transferred outside for surgery and 6 (28.6%) patients died. Post-intervention, 17 of 31 (54.8%) patients with indications underwent or were transferred for surgery, and 5 (16.1%) died. After adjustment for age and sex, compared to the pre-intervention period, the odds of surgery or transfer for surgery for patients in the post-intervention period was 4.88 (95% CI 1.20, 19.79, p=.027). The odds ratio for death among patients in the post-intervention period was 0.40 (95% CI 0.09, 1.69, p=0.21).

Pre- and post-intervention outcomes for infective endocarditis patients

Conclusion

MDT team with continued educational and health IT interventions improved the number of surgeries performed for IE.

1. Regunath H, Vasudevan A, Vyas K, et al. A Quality Improvement Initiative: Developing a Multi-Disciplinary Team for Infective Endocarditis. Mo Med. 2019;116(4):291-296.

Disclosures

All Authors: No reported disclosures.
1015. Real World Use of Dalbavancin and Oritavancin for Optimized Outpatient Antimicrobial Therapy in Patients Inappropriate for Standard Therapy
Authors: Weichman Brittani , Bushman Amanda , Aarhus Angela , Terrero Salcedo David A , Drake Ty C
Published: December 2022

Background

Dalbavancin and oritavancin are long acting lipoglycopeptide antibiotics (LaLGP) approved for treatment of acute bacterial skin and skin structure infections (ABSSSI) caused by susceptible gram-positive organisms. These antibiotics have shown promise in treatment of non-FDA approved gram-positive infections including bacteremia, endocarditis, pneumonia, and osteomyelitis. The aim of this review was to determine indication, length of therapy, treatment failures, and adverse drug events (ADE) in patients receiving LaLGP at our institution.

Methods

Retrospective study of adult patients that received LaLGP within an integrated health system consisting of 3 hospitals and 2 outpatient infusion centers, between July 2016 and February 2022. Data collection included dosing regimen specifics for both LaLGP and non-LaLGP, indication and justification for LaLGP use, culture results, labs, ADE, incidence of readmission and Emergency (ED)/Urgent Care presentation, and treatment failure defined as readmission or return to the ED/Urgent care within 90 days of therapy completion.

Results

36 patients received LaLGP during the study period. A majority of patients received LaLGP for an indication other than ABSSSI (64%)(Table 1). Four patients were lost to follow-up but included in analysis of indication and justification for LaLGP use. Staphylococcus aureus (30% MRSA, 26% MSSA) was the most commonly identified pathogen in patients who received LaLGP for non-ABSSSI indications.

Justification for use of LaLGP over standard therapy is shown in Table 2. The median duration of standard therapy prior to transitioning to LaLGP was 7 days.

Table 3 shows agent selection, number of doses, and outcomes for ABSSSI indications vs non-ABSSSI indications. ABSSSI patients received a maximum of 2 doses; non-ABSSSI indications received 1-8 doses. Re-admission rates were higher in the ABSSSI group compared to non-ABSSSI while ED/Urgent care presentations were higher in non-ABSSSI indications.

Conclusion

LaLGP is a viable option for therapy completion after improvement is seen while on standard therapy in patients where daily outpatient antimicrobial therapy is not feasible. While LaLGP is currently only approved for ABSSSI, they appear to be safe and effective for other indications.

Disclosures

All Authors: No reported disclosures.
1016. Real-World Use of Omadacycline in Physician Office Infusion Centers (POICs)
Authors: Van Anglen Lucinda J , Schroeder Claudia P , Couch Kimberly A
Published: December 2022

Background

Omadacycline (OMC) is approved for the treatment of community-acquired bacterial pneumonia and acute bacterial skin and skin structure infections. Real-world data on the use of OMC are limited. We present a multicenter observational review of OMC outpatient use in Infectious Disease POICs.

Methods

Medical records of patients (pts) receiving intravenous OMC from May 2019 to April 2022 from 5 POICs were included in this ongoing study. Data included demographics, diagnosis, medical history, microbiology, OMC regimen, adverse events (AEs), health care utilization and clinical outcomes. Clinical success was defined as complete or partial symptom resolution at completion of OMC with oral antibiotics as needed. Persistent or recurrent infection and premature discontinuation of OMC were deemed non-success. Indeterminate outcomes were excluded in outcome assessment. Chi Square, Fisher’s exact, and t-test were used to identify characteristics associated with clinical outcome.

Results

Overall, 37 pts (mean age: 61±13 yrs, 65% male) were identified. Infections treated were 62% bone and joint (BJI), 24% complicated skin and skin structure infections (CSSSI), 11% pulmonary nontuberculous mycobacterial (NTM) and 3% diverticulitis. A total of 61 pathogens were identified in 30 pts of which 83% had ≥1 Gram-positive isolate. Polymicrobial pathogens were reported in 13/30 pts (43%). Ten pts (27%) received concomitant IV antibiotics. Median duration of OMC therapy was 38 days (IQR, 21-47). OMC was initiated in the POIC without prior hospitalization in 62% of pts. Overall clinical success was 75% (24/31). Non-success due to persistent infection was reported in 5 pts (3 BJI, 2 CSSSI), of which 4 were hospitalized. Three additional pts were deemed non-successful due to early discontinuations (2 difficulty with administration, 1 AE) (Fig 1). Six pts were non-evaluable for outcome. Ten pts reported 14 AEs, most commonly nausea (4 pts) and elevated liver function tests (3 pts). Figure 1.Clinical outcome of omadacycline by infection type

Conclusion

These real-world results support the outpatient use of omadacycline in additional, difficult to treat, complicated infections, including bone and joint infections.

Disclosures

Lucinda J. Van Anglen, PharmD, Merck & Co.: Grant/Research Support|Paratek: Grant/Research Support.