bluuebunny/crossref_metadata_2025 huggingface dataset:
551. Convalescent plasma early in disease course improves survival in COVID-19
Authors: Nauriyal Varidhi , Shallal Anita , Vahia Amit T , Samuel Linoj , Tibbetts Robert , Lopez-Plaza Ileana , Ramesh Mayur
Published: January 2021

Background

Convalescent plasma (CP) has been described as a potential therapy for coronavirus disease 2019 (COVID-19). Given paucity of data, we sought to describe characteristics of CP recipients in survivors and non-survivors.

Methods

We conducted retrospective review of electronic medical records which included any patient with a positive SARS-CoV-2 PCR test who received CP at an 890-bed quaternary care hospital in Southeast Michigan between March-May 2020. Data collected included: demographics, co-morbidities, mSOFA score on admission, laboratory values, and treatment. Outcomes assessed included inflammatory markers and clinical status based on an 8-point ordinal scalea. These values were recorded on admission, the date of CP (day 1), day 3, 7, and day 30 post-CP. Patient outcomes were stratified by ordinal scale score and compared using Mann-Whitney U tests to examine differences in clinical characteristics: scale of 1–4 (“meaningful survivor”), 5–7 (“survivor”), and 8 (“non-survivor”).

Results

Results of our study are summarized in Table 1 and 2. Non-survivors were older than survivors (62 vs 71 years; p=0.026). There was no statistically significant difference between patient gender, race, number of days from positive PCR test to CP, treatments, and co-morbidities. There was a trend toward higher mSOFA score on admission in non-survivors (p=0.056). A lower ordinal scale score on the date of receiving CP was significantly associated with meaningful survivorship (6 vs 7, p=0.005).

Comparisons of Characteristics Based on Ordinal Scale at Day 30

Comparisons of Outcomes Based on Ordinal Scale at Day 30

Conclusion

Patients who have a lower ordinal scale score on the date of CP administration are most likely to have meaningful survivorship at day 30. Future studies should evaluate optimal timing and outcomes for CP therapy in COVID-19.

Disclosures

All Authors: No reported disclosures
555. Effectiveness of a Treatment Team on Adherence to Health System Guidelines for Hydroxychloroquine Use During Two Phases of the COVID-19 Epidemic
Authors: Viehman J Alex , Nguyen M Hong , Garner Will , Apostolopoulou Anna , Harris Gavin H , Lucas Aaron , Jagadeesan Vidya , Butler Sharlay , Rapinski Glen J , McCreary Erin K , Arbulu Ricardo , Ganchuk Steven , Yang Anne , Avasarala Amitha , Trificante Rosalie , Bollam Rahul , Zou Richard H , Moghbeli Kaveh , Darwish Malik , Hemadri Amit , Weslander Erin , Campfield Brian T , Michaels Marian G , Haidar Ghady , Daley Jesssica , Martin Elise , Bariola J Ryan
Published: January 2021

Background

Our hospital system created system guidelines to standardize care across 24 hospitals for COVID-19 treatment during the pandemic. Guidelines changed over time. Hydroxychloroquine (HCQ) was unrestricted during phase 1, then restricted by pharmacy outside of a randomized clinical trial (RCT) during phase 2 (excepting those ineligible for RCTs).

Methods

This was a prospective study to assess system-wide adherence to COVID-19 treatment guidelines, and to evaluate patient outcomes.

Results

Of 261 patients, median age was 67 years (IQR 56–76); 49% (129/261) were male, and 45% (118/261) required ICU care.

Overall, 47% (122/261) were in phase 1; HCQ was offered to 57% (69/122) during this phase. The rate of HCQ prescription in phase 2 decreased significantly to 10% (14/136), (p < 0.001). Adherence to COVID-19 treatment protocol was 97% (135/139) during phase 2. Mortality was similar in both phases (22% vs 28%, p=0.32), as was median length of stay (8 vs 7 days, p=0.3). Overall 66 patients (25%) died in the hospital; neither non-adherence (p=1) to system guidelines nor receipt of HCQ (p=0.17) were risk factors for death.

Independent predictors of mortality included: new renal replacement therapy (OR 61, 95%CI 6.7–560, p < 0.001), mechanical ventilation (OR 4.9, 95%CI 2.0–11, p < 0.001), abnormal chest X-ray (OR 4.3, 95%CI 1.4–12.6, p =0.009), history of heart failure (OR 3.9, 95%CI 1.5–11, p=0.006), lack of fever on admission (OR 3.5, 95%CI 1.7 -7.6, p =0.001), receipt of corticosteroids (OR 2.7 95%CI 1.1–6.6, p=0.026) and increased age (OR 1.07 per year, 95%CI 1.04–1.1, p < 0.001). Bacterial pneumonia occurred in 8% (21/261), more commonly in those who died (p=0.02). Black patients had a higher race-specific death rate (308 vs 197) per 1000 than white patients (p< 0.001).

Conclusion

During the COVID-19 pandemic, our health system guidelines and pharmacy restrictions were successful in delivering consistent care across hospitals. Restriction of HCQ for COVID-19 treatment to RCTs reduced its use in phase two. Non-adherence to systemic guidelines was infrequent, and not associated with adverse outcomes. A COVID-19 treatment team of physicians and pharmacists can effectively coordinate therapy across hospitals in the setting of rapidly changing guidelines.

Disclosures

J. Ryan Bariola, MD, Infectious Disease Connect (Employee)Mayne Pharma (Advisor or Review Panel member)Merck (Research Grant or Support)
558. Innovative CME Tools in the Teaching of Evolving Strategies in the Management and Prevention of COVID-19
Authors: Hanson Brianna , Welch Lauren , Frese Matthew , Gallo Christina
Published: January 2021

Background

In 2020, Med Learning Group (MLG) launched an interactive, multi-faceted educational initiative focusing on COVID-19. The innovative education & tools developed for FRONTLINE are publicly available for the entire healthcare community to use. Learners range from a variety of specialties, including infectious disease specialists, pulmonary medicine specialists, emergency room practitioners, advanced practitioners, nurses, & other healthcare professionals to help support them in their effort to optimize care of patients with COVID-19.

MLG partnered with Health Resources & Services Administration, Project ECHO, Public Health Foundation & community, VA & academic centers to create a collaborative network with shared goals for education.

Methods

This initiative seeks to reach over 25,000 learners with innovative educational programs & tools to enhance the learning experience, facilitate continuous learning & support the translation of education into practice, & encourage HCP-patient dialogue:

• COVID Community of Care Website/Application

• COVID Frontline Update Podcast Series

• Virtual/Live ECHO Series with 3D animations of pathophysiology

• Enduring ECHO Module with Case Discussions

• Quality Improvement Personalized Posters

Results

By September 2020, we will have the results from pre/posttests, intra-activity Q&A, evaluations, & 60- to 90-day follow-on assessments. We will evaluate learners’ changes in knowledge & competence, & reported practice changes. In addition, MLG will have feedback collected via surveys & interviews on the various point-of-care tools. Based off previous MLG educational initiatives, it is expected that learners will find value in the various tools available in this programming.

Conclusion

Advanced tools like virtual live learning platforms, mobile websites/apps, 3D animations & podcasts will prove to be an asset to the continuing education of HCPs treating patients with COVID-19. The outcomes are expected to demonstrate the extent to which HCPs have enhanced their ability to identify clinical predictors of disease severity of COVID-19 & apply current treatment guidelines, clinical trial data, & patient-specific factors to the management of patients with COVID-19. These results will be available in time to share via a poster at IDWeek 2020.

Disclosures

All Authors: No reported disclosures
562. Tocilizumab for the Treatment of Severe COVID-19: A Retrospective, Multi-Center, Case-Matched Series
Authors: Norman Sarah , Jones Sara , Reeves David , Cheatham Christian
Published: January 2021

Background

At the time of this writing, there is no FDA approved medication for the treatment of COVID-19. One medication currently under investigation for COVID-19 treatment is tocilizumab, an interleukin-6 (IL-6) inhibitor. It has been shown there are increased levels of cytokines including IL-6 in severe COVID-19 hospitalized patients attributed to cytokine release syndrome (CRS). Therefore, inhibition of IL-6 receptors may lead to a reduction in cytokines and prevent progression of CRS. The purpose of this retrospective study is to utilize a case-matched design to investigate clinical outcomes associated with the use of tocilizumab in severe COVID-19 hospitalized patients.

Methods

This was a retrospective, multi-center, case-matched series matched 1:1 on age, BMI, and days since symptom onset. Inclusion criteria included ≥ 18 years of age, laboratory confirmed positive SARS-CoV-2 result, admitted to a community hospital from March 1st – May 8th, 2020, and received tocilizumab while admitted. The primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay, total mechanical ventilation days, mechanical ventilation mortality, and incidence of secondary bacterial or fungal infections.

Results

The following results are presented as tocilizumab vs control respectively. The primary outcome of in-hospital mortality for tocilizumab (n=26) vs control (n=26) was 10 (38%) vs 11 (42%) patients, p=0.777. The median hospital length of stay for tocilizumab vs control was 14 vs 11 days, p=0.275. The median days of mechanical ventilation for tocilizumab (n=21) vs control (n=15) was 8 vs 7 days, p=0.139, and the mechanical ventilation mortality was 10 (48%) vs 9 (60%) patients, p=0.463. In the tocilizumab group, for those expired (n=10) vs alive (n=16), 10 (100%) vs 7 (50%) patients respectively had a peak ferritin > 600 ng/mL, and 6 (60%) vs 8 (50%) patients had a peak D-dimer > 2,000 ng/mL. The incidence of secondary bacterial or fungal infections within 7 days of tocilizumab administration occurred in 5 (19%) patients.

Conclusion

These findings suggest that tocilizumab may be a beneficial treatment modality for severe COVID-19 patients. Larger, prospective, placebo-controlled trials are needed to further validate results.

Disclosures

Christian Cheatham, PharmD, BCIDP, Antimicrobial Resistance Solutions (Shareholder)
566. Tocilizumab: A Friend or a Foe in COVID-19 Management?
Authors: Hernandez Jarelys M , Jariwala Ripal , Piccicacco Nicholas , Aslam Sadaf , Lakshmi Seetha
Published: January 2021

Background

The emergence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has led to many proposed treatments for COVID-19 induced cytokine release syndrome (CRS). We aimed to investigate the treatment response of Tocilizumab (TZB), an Interleukin-6 (IL-6) inhibitor in this single center study.

Methods

A retrospective chart review in COVID-19 patients was conducted from 03/18/20 - 05/20/20. Patients with PCR confirmed COVID-19 who received TZB were included. Variables included dose and timing of TZB, trend of acute phase reactants, time to improved oxygenation and defervescence, 30-day mortality, and hospital/intensive care unit (ICU) length of stay (LOS). Descriptive statistics were used.

Results

Twelve patients received TZB at least once during the study period. Median patient age was 51.5 years (interquartile range (IQR), 34–87), and mean body weight of 109 kg (SD = 33.8). At time of admission, mean day of illness was 6.6 days (SD = 3.3) into their illness. All patients received a standardized TZB dose of 400 mg, and 2 patients received a second dose. Nine out of 11 patients (75%) had elevated median IL-6 baseline levels of 38.3 (IQR < 5- 96.22). The average CRS score was elevated at 3.3 at the time of TZB administration.

All patients who received TZB were on supplemental oxygen, and 58% were mechanically ventilated. A decrease in oxygen requirement in 24 hours was seen in mechanically ventilated patients (71%) compared to those not on mechanical ventilation (20%). Median ICU days were 17.5 (IQR, 3–39), and median LOS days were 21.5 (IQR 8–46). All patients had sustained decreases in CRP post-TZB administration.

Almost half of patients (42%) were treated for bacterial pneumonia post TZB and 3 (25%) patients were treated for herpes simplex virus (HSV) reactivation. Majority (92%) of patients received additional COVID-19 therapies such as hydroxychloroquine, convalescent plasma, or remdesivir. During the study period only one patient expired.

Conclusion

Our findings suggest that TZB may have a role in mechanically ventilated patients in decreasing oxygen requirement. However larger randomized studies are needed to understand which patients would benefit the most. Our study also highlights secondary infections and HSV reactivation in TZB patients.

Disclosures

All Authors: No reported disclosures
569. A Multidisciplinary Approach to the Pre-evaluation Process of Pediatric Solid Organ Transplant Patients
Authors: Toia Jacquie , Le Kevin , Panek Natalia , Boese Justin , Jhaveri Ravi , Muller William J , Mithal Leena B
Published: January 2021

Background

Pediatric transplant recipients are at increased risk of infection-related morbidity and mortality, both from opportunistic infections and vaccine-preventable diseases. Since vaccine immunogenicity may wane with organ failure and immunosuppressive therapies, it is recommended that transplant candidates are immunized early in their disease course, prior to transplant. However, transplant candidates are often incompletely immunized due to factors including complexity of care and multiple providers. A multidisciplinary approach involving Infectious Diseases (ID) is crucial to ensure that vaccination status is optimized prior to transplant and to prevent and treat infectious complications.

Methods

During the solid organ transplant evaluation process, liver, intestinal, and heart transplant candidates and their families meet with Infectious Diseases, Transplant Pharmacy, and Organ Procurement clinicians. The multidisciplinary team effort ensures that transplant candidates receive appropriate vaccines prior to transplant, based on immunization history and serology results. The team helps to manage infections diagnosed during the evaluation process (active or latent), identify risk factors for infection, optimize antimicrobial dosing based on comorbid conditions and concomitant medications, and follows patients post-transplant. Transplant candidates and their families are educated on how organ donation and organ allocation function in the US.

Results

Since launch of our multidisciplinary solid organ transplant team, we have completed pre-transplant ID evaluations on 64 patients [Table 1]. Nearly all (97%) of pre-transplant evaluated patients received vaccine optimization (booster/new vaccine doses) [Table 2]. Forty-five patients (70%) underwent organ transplant. Many intestinal (67%), cardiac (46%), and liver (27%) transplant candidates with pre-transplant evaluations required subsequent ID consultation.

Table 1

Table 2

Conclusion

Multidisciplinary ID pre-transplant evaluation leads to individualized vaccine optimization and infection management. Families benefit from education and counseling as well as familiarity with the Transplant ID consult service, involved in a large percentage of these patients in their peri- and post-transplant course.

Disclosures

All Authors: No reported disclosures
570. “I don’t know”: The Typical Response When Taking Pneumococcal Immunization Histories in Kidney Transplant Candidates
Authors: Ramakrishna Jahanavi M , Jarmi Tambi , Libertin Claudia R
Published: January 2021

Background

Vaccine-preventable diseases account for significant morbidity and mortality in the kidney transplant (KT) patient population. AST Guidelines support review and documentation of pneumococcal vaccines in KT candidate infectious disease (ID) evaluations. The objective of this study is to determine the number of KT candidates screened for prior pneumococcal immunizations and the frequency of vaccines ordered by providers when indicated at Mayo Clinic Florida’s (MCF) Transplant Center.

Methods

This study was an institution-based retrospective analysis of all KT candidates evaluated at MCF from December 2, 2019 – January 14, 2020. Data collection was obtained by electronic health record review. Outcomes included known history and documentation rates of prior pneumococcal vaccinations (both Prevnar 13 and Pneumovax 23) by infectious disease (ID) providers, as well as pneumococcal vaccine order frequency during ID pre-transplant evaluation when indicated. Data analysis was done using simple descriptive statistics.

Results

Sixty-one patients underwent KT evaluation during the study period. Among the 61 patients, 20 (32.8%) and 20 (32.8%) had a known prior history of receiving Prevnar 13 and Pneumovax 23 vaccinations, respectively. Vaccine history was unknown for Prevnar 13 and Pneumovax 23 in 39 (63.9%) patients. Vaccine status was not documented by ID providers in 2 (3.3%) patients. When appropriate, ID providers ordered Prevnar 13 and Pneumovax 23 in 38 (92.7%) and 41 (100%) patients, respectively. Orders included both electronic and written documentation to account for patients planning immunization elsewhere. Of the 38 patients advised to receive the Prevnar 13 vaccine, 17 (41.5%) patients were documented completing immunization. Pneumovax 23 order completion rates were not recorded since the study period only lasted six weeks due to closure by COVID-19.

Table 1. Pneumococcal Vaccine History Documentation Rates Obtained by Patient Recall or Records

Table 2. Pneumococcal Vaccine Order Rates at Pre-Kidney Transplant Consultations

Table 3. Prevnar 13 Order Completion Rate by Documentation

Conclusion

The data reflect a high number of patients who either do not recall or have documentation of prior pneumococcal vaccination available at time of KT ID evaluation. Providers documented history of pneumococcal vaccinations extremely well, ordering immunizations when necessary. This study highlights lack of portability of immunization histories in a given patient population and opportunity for improved care.

Disclosures

Claudia R. Libertin, MD, Pfizer, Inc. (Grant/Research Support, Research Grant or Support)
572. Antiviral Toxicities Among Pediatric Solid Organ Transplant Recipients
Authors: Downes Kevin J , Sharova Anna , Mitrou Marina , Hayes Molly , Galetaki Despoina , Gianchetti Lauren , Vella Laura A , Li Yun
Published: January 2021

Background

Ganciclovir (GCV) and valganciclovir (VGCV) are used for prophylaxis (PPX) and treatment for CMV in pediatric solid organ transplant (SOT) recipients, but the frequency and impact of toxicities from these medications are not well described.

Methods

Retrospective cohort study of children undergoing SOT at Children’s Hospital of Philadelphia from Jan 2012 - Jun 2018. EMR were reviewed to identify laboratory-based toxicities between 15 days and 1 year post-transplant; medication management within 14 days of toxicity onset was recorded. Toxicities were defined as GCV or VGCV-associated if a patient was on the antiviral at toxicity onset. We defined acute kidney injury (AKI) as ≥50% change in creatinine (Cr) from 30 days prior, leukopenia as WBC < 3500/µL, neutropenia as ANC < 1000/µL, and thrombocytopenia as < 100K/µL. Incidence rates of toxicities on PPX and treatment were compared to rates during no antiviral using univariate Poisson regression.

Results

285 children received 299 SOTs: 108 liver, 91 kidney, 69 heart, 31 lung. Nearly half (46%) of toxicities during the first year after transplant occurred while on GCV or VGCV PPX or treatment, but their use accounted for only 23% of all follow-up time. Receipt of VGCV and GCV PPX and treatment were associated with significantly higher incidence rates of toxicities compared to no antiviral (Fig 1). Of 259 GCV or VGCV-associated toxicities, 44% (n=113) were leukopenia, 26% (66) neutropenia, 26% (66) AKI, and 6% (15) thrombocytopenia (Table 1). Most recipients of VGCV PPX (64%) sustained at least one toxicity while on PPX. AKI during VGCV PPX led to stopping/dose-adjusting of VGCV in 43% and of immunosuppression in 57% of cases. Neutropenia during VGCV PPX resulted in stopping/dose-adjusting of VGCV in 63%, of immunosuppression in 36%, and of TMPX/SMX PPX in 36% of cases. During VGCV PPX, 81% of AKI was stage II/III (≥100% change in Cr) and 65% of neutropenia was severe (< 500/µL); 11% of both AKI (n=6) and neutropenia (n=7) during VGCV PPX resulted in hospitalization.

Figure 1. Incidence Rates of Toxicities from Day 15 through 1 Year After Transplant

Table 1. Antiviral Use and Toxicity 2 Weeks to 1 Year After Transplant

Conclusion

GCV and VGCV use was associated with significant renal and hematological toxicities in pediatric SOT recipients. While VGCV and GCV are effective at preventing CMV disease in pediatric SOT, clinicians should consider risk of toxicity when evaluating CMV prevention strategies.

Disclosures

Kevin J. Downes, MD, Merck, Inc. (Grant/Research Support)
573. Continuing Medical Education: Leveraging a Digital Tool to Help Improve CMV Management Strategies
Authors: Hurst Simi Thomas , Martorano James
Published: January 2021

Background

Increasing the risk for complications and negatively impacting patient health outcomes, an estimated 45% - 80% of HSCT patients experience CMV infection/reactivation, with mortality rates sometimes reaching as high as 60%.

Figure. Assessment of Educational Effectiveness

Methods

This study assessed the ability of digital education to improve the ability of ID specialists to make evidence-based recommendations for CMV management in HSCT recipients. A CME/ABIM MOC educational program featuring interactive discussion between two ID faculty was developed and launched on 12/12/19, on a website dedicated to continuous professional development. Educational effectiveness was assessed with a repeated-pairs pre-/post-assessment study design; each individual served as his/her own control. A chi-square test assessed changes pre- to post-assessment. P values < 0.05 are statistically significant. Effect sizes were evaluated using Cramer’s V (< 0.05 modest; 0.06–0.15 noticeable effect; 0.16–0.26 considerable effect; > 0.26 extensive effect). Data for this matched-learner analysis were collected through 04/14/20.

Results

To date, 3315 HCPs (2891 physicians; 162 nurses/NPs) have participated in the activity. Data from the subset of ID specialists (n=190) who answered all pre-/post-assessment questions during the initial study period were analyzed. Following activity participation, significant improvements were observed in the proportion of ID specialists who answered all assessment questions correctly (8% pre vs 28% post; P < .0001; V=.217). Improvements were also observed in several specific areas of assessment (Figure). Additionally, 65% of ID specialists indicated they planned to modify their patient assessment or treatment approach because of participating in the education.

Conclusion

Participation in this digital educational program significantly improved ID specialists’ ability to differentiate among therapeutic options when developing management strategies for HSCT recipients with CMV infection/reactivation. These findings highlight the potential for well-designed online education to positively impact physicians’ competence and confidence.

Disclosures

All Authors: No reported disclosures
575. Effectiveness of Short vs Long Course Perioperative Antibiotics in Lung Transplant Recipients with Donor Positive Respiratory Cultures
Authors: Groff Lindsey T , Reed Erica E , Coe Kelci E , El Boghdadly Zeinab , Keller Brian C , Whitson Bryan A , Burcham Pamela K
Published: January 2021

Background

Lung transplant recipients are at increased risk for infection in the early post-operative phase. Perioperative antibiotic (POA) practices are variable among transplant centers with sparse data regarding optimal antibiotic prophylaxis duration. This study aimed to evaluate the efficacy of short course (SC) (≤10 days) vs long course (LC) (≥11 days) POA in lung transplant patients.

Methods

This was a single-center, retrospective study of non-cystic fibrosis first time lung transplant recipients with donor positive cultures between Aug 2013 and Sept 2019. Patients who died within 14 days of transplant were excluded. Data collected included baseline characteristics, donor and recipient cultures, POA, and hospitalization details. The primary outcome was 30-day recipient freedom from donor-derived respiratory bacterial infection. Secondary outcomes included development of Clostridioides difficile infection (CDI), cumulative time on ventilator, post-op time to extubation, in-hospital all-cause mortality, and 30-day development of POA resistance. Descriptive statistics were used for analysis. Continuous variables were compared using the Wilcoxon rank sum test while categorical variables were compared using the chi-square or Fisher’s exact test. Statistical significance was defined as p< 0.05.

Results

A total of 147 patients were included (58 SC vs 89 LC). Median POA duration in the SC group was 6.5 days vs 13 days in the LC group (p< 0.0001). The primary outcome of 30-day freedom from donor-derived respiratory infection was present in 56 (97%) patients in the SC vs. 85 (96%) patients in the LC group (p= 1). There was no difference in development of CDI (p = 0.4), mortality (p = 1), or resistant organisms (p=0.28) while cumulative ventilator time and time to post-op extubation were longer in the LC group (p = 0.002 & 0.007, respectively). Methicillin-sensitive Staphylococcus aureus was the most common organism isolated from donors in the SC (23, 40%) and LC (48, 54%) groups.

Conclusion

Among lung transplant recipients with positive donor cultures, short course POA was as effective as long course in preventing donor-derived bacterial pneumonia. Further studies are needed to assess heterogeneity in POA practices and optimal duration among transplant centers.

Disclosures

Brian C. Keller, MD, PhD, CareDx, Inc. (Grant/Research Support) Bryan A. Whitson, MD, PhD, Abbott Laboratories (Consultant)TransMedics OCS (Other Financial or Material Support, Serves on the Clinical Events Committee)
577. Incidence and Outcomes of Positive Outpatient Surveillance Blood Cultures in Hematopoietic Stem Cell Transplant (HSCT) Patients with Graft Versus Host Disease (GvHD) On High Dose ≥ 0.5 mg/kg/day (HD) and Low Dose < 0.5mg/kg/day (LD) Steroid Therapy
Authors: Perreault Sarah , Schiffer Molly , Zhao Jennifer , McManus Dayna , Foss Francine , Gowda Lohith , Isufi Iris , Seropian Stuart , Topal Jeffrey E
Published: January 2021

Background

Treatment of GvHD with steroids increases the risk of infection in HSCT patients due to additive immunosuppression and may delay the diagnosis of infection due to lack of symptoms. Outpatient surveillance blood cultures in HSCT with GvHD being treated with HD steroids has demonstrated a blood culture positivity rate of 3.5%. Currently, the utility of surveillance cultures in patients receiving LD steroid therapy is unknown. Our practice includes weekly outpatient surveillance cultures for all GvHD patients treated with steroids regardless of the dose. The primary endpoint of this study was to assess the incidence of positive surveillance blood cultures in GvHD patients receiving HD or LD steroids. Secondary endpoints included number of patients treated, hospitalization, 30 day mortality due to infection, and organisms isolated.

Methods

This was a single-center, retrospective review of GvHD patients at Yale New Haven Hospital between January 2013 and May 2019. Patients were excluded if: lack of signs or symptoms of GvHD, treatment with steroids for any indication other than GvHD, and active GvHD without central line. Cultures from patients receiving antibiotics for concurrent infection were also excluded.

Results

A total of 71 patients met criteria with 901 blood cultures. On HD, eight patients (14%) had 12 positive cultures (4%), and on LD, 16 patients (25%) had 22 positive cultures (4%) (p=0.15). Treatment occurred in six patients (75%) with four (24%) requiring hospitalization on HD, and 12 patients (75%) with 10 (83%) requiring hospitalization on LD (p=0.45). The median duration of steroid therapy was 93 and 236 days with a median dose of steroids of 1mg/kg/day and 0.15mg/kg/day, respectively. The number of positive cultures/1000 steroid days was 1.2 on HD and 0.5 on LD (RR 2.2). 30 day mortality was only noted in one patient (8%) on LD. The most common organism in both groups was Coagulase-negative staphylococci with all six cultures on HD classified as contaminants and 6/10 cultures requiring treatment on LD.

Conclusion

Although the relative risk of positive surveillance blood cultures in HD patients compared to LD was twofold higher, there were clinically significant infections identified in the LD group.

Disclosures

All Authors: No reported disclosures
581. Risks versus Benefits of Metronidazole Use for the Prevention of Acute GVHD in Allogeneic Stem Cell Transplant Recipients
Authors: Young Mary T , Monogue Marguerite , Patel Hetalkumari
Published: January 2021

Background

Currently, acute graft versus host disease (aGVHD) prophylaxis in hematopoietic stem cell transplants (HSCT) varies amongst different institutions. There is a lack of data supporting the use of metronidazole for aGVHD prophylaxis in HSCT. To further investigate if metronidazole has an effect on aGVHD, allogeneic HSCT recipients will be examined to determine if metronidazole post-transplantation decreases the incidence of aGVHD and the risks of adverse drug events (ADE) associated with this practice.

Methods

This retrospective study included 120 adult patients who received an allogeneic HSCT between January 1, 2010 to December 31, 2013. The primary endpoint is the incidence of aGVHD, defined as within 100 days post-transplant. Secondary endpoints include the rate of metronidazole discontinuation due to intolerance, frequency of metronidazole-related adverse effects, incidence of Clostridioides difficile infection, mortality, and overall survival.

Results

One hundred six patients met the inclusion criteria. The majority of patients received metronidazole (88 vs. 18). Less patients in the metronidazole arm developed aGHVD (51.1% vs 61.1%, p=0.44). In the subcategories of liver, skin, and gastrointestinal aGHVD, patients who received metronidazole developed less gastrointestinal aGVHD (26.1% vs 50.0%, p=0.045). Gastrointestinal ADEs were the most common metronidazole-related ADEs (19.3%, Table 1). There were no significant differences in the incidence of C. difficile infection, mortality, and overall survival between the two arms (Table 2).

Table 1. Adverse Drug Events and Discontinuation of Therapy

Table 2. Additional Secondary Outcomes

Conclusion

Despite a reduction in gastrointestinal aGVHD in the metronidazole arm, approximately one in four patients experienced an ADE to the medication, likely due to the prolonged use of the medication (33 days). The utilization of post-transplant cyclophosphamide for GVHD prophylaxis likely eliminates the need for metronidazole; however our findings suggest a benefit in preventing gastrointestinal aGVHD with metronidazole; albeit, caution is warranted given the high incidence of ADE associated with prolonged use.

Disclosures

All Authors: No reported disclosures
584. Ventricular assist device infections with Pseudomonas aeruginosa
Authors: Roberts Scott C , Nam Hannah H , Kumar Rebecca N , Zembower Teresa , Qi Chao , Malczynski Michael , Rich Jonathan D , Pawale Amit A , Harap Rebecca S , Stosor Valentina
Published: January 2021

Background

Infection is a leading cause of morbidity and mortality in ventricular assist device (VAD) recipients. Pseudomonas aeruginosa (PA) is the second most common organism implicated in VAD infections, occurring in 10–50% of infections. The epidemiology of VAD recipients with PA infection are poorly described.

Methods

We identified patients (pts) at Northwestern Memorial Hospital with a VAD-specific PA infection from January 1, 2012 to Dec 31, 2019. VADs included the Heartmate II, Heartmate 3, and Heartware HVAD devices. VAD-specific infections were defined according to the 2013 ISHLT Guidelines.

Results

Seventeen out of 91 (18.7%) VAD infections were due to PA. Infections of the driveline exit site (DLES) occurred most commonly (n=15, 88.2%), followed by pocket (n=2, 11.8%) and pump (n=2, 11.8%) infections. Median time to infection after VAD implantation was 295 days (IQR 154 – 440 days). Eight (47.1%) pt isolates were not fluoroquinolone (FQ) susceptible. Resistance to multiple antibiotic classes was observed in pts in whom serial cultures were obtained. Median antibiotic treatment was 107 days (IQR 55 – 183 days, maximum 775 days). Five (29.4%) pts received FQ monotherapy on initial diagnosis, 3 (60%) of whom required change to a different class for resistance. Surgical debridement and VAD exchange were performed in 5 (29.4%) and 3 (17.6%) pts respectively. Co-pathogens were identified in 9 (52.9%) pts, the most common being Staphylococcus aureus (n=2) and Enterococcus spp (n=2). A total of 5 (29.4%) pts went on to successful heart transplantation; one had recurrent PA infection at the prior DLES requiring prolonged antibiotics and removal of retained DL material. All cause 1-year mortality rate was 11.7% (n = 2), both of whom died from cerebrovascular accidents.

Conclusion

VAD-specific infections with PA occurred late after device implantation and required prolonged antibiotic courses. Antimicrobial resistance was high at diagnosis and worsened in pts on prolonged therapy. Morbidity and mortality in pts with PA VAD infections were high. The preponderance of DLES infections warrants further study and highlights the need for improvements in DLES care and infection prevention strategies.

Disclosures

All Authors: No reported disclosures
588. Implementation of a standardized OPAT SmartForm was associated with improved post-discharge outcomes
Authors: Certain Laura , Benefield Russell J , Thomas Frank O
Published: January 2021

Background

The outpatient parenteral antimicrobial therapy (OPAT) plan has frequently been omitted or incompletely communicated during transitions of care at our institution. Better communication of the OPAT plan at discharge has the potential to improve patient outcomes.

Methods

A standardized OPAT documentation tool (SmartForm) was developed in our electronic health record system for use by our inpatient Infectious Disease (ID) consult service. This intervention was part of an ongoing quality improvement project to improve communication of the OPAT plan at discharge. Outcomes were assessed prospectively during the post-intervention time period (11/18/2019 - 4/13/2020) and compared to the pre-intervention time period (10/14/2019 - 11/11/2019). Patients were included if discharged on IV antibiotics with follow up by a University of Utah Health ID provider. Patients discharged to long-term acute care facilities were excluded.

Results

Three hundred five patients were included: 231 in the post-intervention period and 74 in the pre-intervention period. Demographic characteristics were similar between time periods with the exception of older age (mean 60 vs 56 years), a greater percentage of patients receiving OPAT via an infusion center (19% vs 9%), and fewer patients receiving OPAT via home health (54% vs 64%) in the pre-intervention cohort. Documentation of an OPAT progress note occurred more frequently (94% vs 85%, p = 0.02) and patients were more likely to be enrolled in our OPAT program (77% vs 51%, p < 0.0001) after implementation of the OPAT SmartForm. Outpatient laboratory monitoring occurred with similar frequency during the pre- and post-intervention time periods (85% vs 82% of expected laboratory encounters completed, p = 0.31). Sixty-day unplanned hospital readmissions were reduced after implementation of the SmartForm (22% vs 35%, p = 0.02). Multivariable logistic regression identified Charlson comorbidity index (OR 1.10, 95% CI: 1.02–1.18) and the pre-intervention time period (OR 1.78, 95% CI: 0.99–3.18) as variables independently associated with readmission.

Conclusion

Implementation of an OPAT SmartForm was associated with improved documentation of the OPAT plan, increased enrollment in the OPAT program, and reduction in hospital readmissions.

Disclosures

Russell J. Benefield, PharmD, Merck and Co (Grant/Research Support)Paratek Pharmaceuticals (Grant/Research Support)Rempex Pharmaceuticals (Grant/Research Support)
589. Use of Dalbavancin in Facilitating Discharge of High Risk Patients in Low Resource Settings
Authors: Milgrom Alexander
Published: January 2021

Background

Patients who inject intravenous drugs (PWID) can have devastating infections with poor outcomes while being burdensome to the healthcare system, both in terms of lack of payment and length of stay. These issues are only exacerbated in settings where addiction treatment resources such as medication assisted therapy (MAT) are limited. One potential method of alleviating some of this burden is with long acting glyco-lipopeptide antibiotics, such as dalbavancin, to reduce length of stay.

Methods

A retrospective evaluation of 10 PWID patients treated with dalbavancin to facilitate early discharge was performed at Prisma Health Richland hospital in 2019. Reduction in length of stay was calculated based on estimated length of stay typical for treatment of their clinical syndrome.

Results

Average length of stay was reduced by 22.4 days. 9 of the patients were seen inpatient, and one was evaluated outpatient. 4 patients (40%) had documented mental illness in their chart diagnoses, and 7 (70%) of patients were uninsured. 4 (40%) of patients had a history of leaving AMA, 2 (20%) were rehospitalized within 30 days, Of these 10 patients, only 1 patient who already had been following as an outpatient had appropriate follow-up with an Infectious Disease specialist after treatment.

Conclusion

Discussion

Long acting glyco-lipopeptide antibiotics can facilitate discharging patients from an inpatient setting where status as PWID cannot be managed in an outpatient setting. On average, a little over 3 weeks was saved in terms of hospital days, which is a significant savings for the hospital system. However, it remains unclear how much this benefits the patient as follow-up for this treatment was abysmal and thus it is difficult to assess for the clinical response. Further evaluation is required to the utility of such treatments, as well as the implementation of MAT and more widespread assistance for this vulnerable population.

Disclosures

All Authors: No reported disclosures
590. Vancomycin Infusion: Algorithmic Analysis of Unstructured Real-World Data Captured from Automated Infusion Devices
Authors: Bostick David L , Yu Kalvin , Yamaga Cynthia , Liu-Ferrara Ann , Morel Didier , Tabak Ying P
Published: January 2021

Background

Large scale research on antimicrobial usage in real-world populations traditionally does not consist of infusion data. With automation, detailed infusion events are captured in device systems, providing opportunities to harness them for patient safety studies. However, due to the unstructured nature of infusion data, the scale-up of data ingestion, cleansing, and processing is challenging.

Figure 1. Illustration of dosing complexity

Methods

We applied algorithmic techniques to quantitate and visualize vancomycin administration data captured in real-time by automated infusion devices from 3 acute care hospitals. The device data included timestamped infusion events – infusion started, paused, restarted, alarmed, and stopped. We used time density-based segmentation algorithms to depict infusion sessions as bursts of event activity. We examined clinical interpretability of the cluster-defined sessions in defining infusion events, dosing intensity, and duration.

Results

The algorithms identified 13,339 vancomycin infusion sessions from 2,417 unique patients (mean = 5.5 sessions per patient). Clustering captured vancomycin infusion sessions consistently with correct event labels in >98% of cases. It disentangled ambiguity associated with unexpected events (e.g. multiple stopped/started events within a single infusion session). Segmentation of vancomycin infusion events on an example patient timeline is illustrated in Figure 1. The median duration of infusion sessions was 1.55 (1st, 3rd quartiles: 1.14, 2.02) hours, demonstrating clinical plausibility.

Conclusion

Passively captured vancomycin administration data from automated infusion device systems provide ramifications for real-time bed-side patient care practice. With large volume of data, temporal event segmentation can be an efficient approach to generate clinically interpretable insights. This method scales up accuracy and consistency in handling longitudinal dosing data. It can enable real-time population surveillance and patient-specific clinical decision support for large patient populations. Better understanding of infusion data may also have implications for vancomycin pharmacokinetic dosing.

Disclosures

David L. Bostick, PhD, Becton, Dickinson and Co. (Employee) Kalvin Yu, MD, Becton, Dickinson and Company (Employee)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Cynthia Yamaga, PharmD, BD (Employee) Ann Liu-Ferrara, PhD, Becton, Dickinson and Co. (Employee) Didier Morel, PhD, Becton, Dickinson and Co. (Employee) Ying P. Tabak, PhD, Becton, Dickinson and Co. (Employee)
591. A Model for assessing staffing needs for an Outpatient Parenteral Antibiotic Therapy (OPAT) program
Authors: Munsiff Sonal , Burgoyne Colleen , Goins Peter
Published: January 2021

Background

Management of patients needing OPAT is complex, and requires a multidisciplinary team for transitioning patients from inpatient to outpatient care, ongoing monitoring of labs, antibiotic levels, managing complications of the drugs and intravenous access, and communicating with patients, family, home infusion pharmacies, home care nursing agencies, and the patients’ physicians and other providers. In addition, documentation of each of these activities in the EMR is necessary. Guidance on how to determine number of staff needed for an OPAT program is lacking.

Methods

We created a detailed step by step list of the various activities done by our OPAT nurse (RN) and determined the time needed to perform each activity. We calculated how many hours of nursing time would be needed per week to perform all the activities for patient care based on our OPAT volume.

Results

In 2019 we enrolled 767 patients in 835 episodes of OPAT. Our weekly census averages about 120–135 patients. Median duration on OPAT was 30 days. We calculated that our OPAT RN workload was an average of 47.5 hours/week (range of 40–55 hours/week), with time per activity ranging from 5 minutes to 3 hours (table). As this calculated to more than one full time RN position, additional staff were requested.

Assessment of Staffing Requirements for an OPAT Program

Conclusion

We have assessed the workload for OPAT RN(s) in our program based on our 2019 patient volume. We recommend that one RN can safely manage about 500–550 patients per year. Based on this analysis we were successfully able to justify the need for a second RN for our program.

Any OPAT Program can do such analysis to determine their OPAT staffing needs, and also plan for the anticipated increases in OPAT volume because of increasing longevity of the population, increase in diabetes incidence, invasive procedures such as arthroplasties, cardiac devices, etc.

Limitations

This analysis does not include time spent by inpatient staff to arrange for home care and home infusion services. It also does not account for an ID pharmacist time, or the physicians and APP time for management of these patients outside of the billable visit.

Disclosures

All Authors: No reported disclosures
595. Characteristics of Antimicrobials Which Affect Parenteral Antibiotic Therapy Outcomes
Authors: Shah haroon M , Guenther Erin , Dysart Claire , Sherman Katherine , Gundacker Nathan
Published: January 2021

Background

Outpatient parenteral antibiotic therapy (OPAT) has reduced length of stay, decreased nosocomial infections, and improved patient satisfaction/outcomes. Factors for choosing candidates and regimens for OPAT include: type of infection, organisms, antibiotic side effects, number of antibiotics and frequency of administration. This study sought to evaluate if antibiotic type, frequency, and duration, are associated with complications, and particularly if vancomycin is associated with an increase rate of complication.

Methods

Retrospective chart review of Zablocki VA Medical Center patients, Milwaukee, WI discharged from 2013-2017 on OPAT evaluated types of infection, antimicrobial regimens, number of antibiotics, duration, frequency, adverse events and outcomes. Primary outcome analyzed was whether or not there was a complication. Complication defined as antibiotic change/dose adjustment, PICC line complication, or additional clinic/hospital visit

Results

294 cases identified during study period. 286 (95.7%) were male. Most common antibiotics were vancomycin (78; 26.53%), daptomycin (42;14.9%) ertapenem (81, 27.55%), cefazolin (24;8.16%) and ceftriaxone (50;17%). Staphylococcus and Streptococcus were the most common organisms at 42.86% and 22.79% respectively. Univariate analysis of the most common antibiotics, maximum frequency and duration are summarized in table 1. A multivariable found cephalosporins were associated with no complication (OR 2.23, CI 1.20-4.35), and Vancomycin (OR 0.20, CI 0.11-0.36) and Gentamicin (OR 0.06, CI 0.06-0.58) were significantly associated with complication. Antibiotic frequency, duration, bacterial speciation were associated with no complication when controlling for antibiotic type

Table 1

Conclusion

Antibiotics given for longer durations or require more frequent monitoring like vancomycin may have higher rates of complications. This study supports the hypothesis that vancomycin and aminoglycosides are associated with complications even when controlling for duration and frequency; cephalosporins are associated with no complication. New, safer antibiotics like long acting lipoglycopeptides may provide alternatives to Vancomycin to diminish the burden on ancillary OPAT staff who deal with OPAT complications.

Disclosures

All Authors: No reported disclosures