bluuebunny/crossref_metadata_2025 huggingface dataset:
571. Determining the Utility of Methicillin-Resistant Staphylococcus aureus Nares Screening in Antimicrobial Stewardship
Authors: Mergenhagen Kari A , Victor Kaitlyn , Sellick John , Wattengel Bethany A , Sumon Zarchi , Lesse Alan
Published: October 2019

Background

Treatment of suspected Methicillin-resistant Staphylococcus aureus (MRSA) is a cornerstone of many antibiotic regimens; however, some anti-MRSA antibiotics are associated with toxicity. The Veterans Affairs (VA) screens each patient on admission for MRSA nares colonization. The objective of this study was to determine whether MRSA nares screening can be used as a stewardship tool for de-escalation as well as avoidance of anti-MRSA therapy.

Methods

This was a retrospective cohort study across VA medical centers nationwide from January 1, 2007 to January 1, 2018. Data from patients with MRSA nares screening were obtained from the Corporate Data Warehouse. Subsequent clinical cultures within 7 days of the nares swab were evaluated for the presence of MRSA. Sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs) were calculated for the entire cohort, as well as subgroups for specific culture sites. Cultures were considered to be from a sterile site if they were from a fluid/aspirate, bone, tissue, or blood taken from the periphery. NPVs and PPVs were calculated for each of these sterile sites.

Results

A total of 447,579 clinical cultures were included in the final analysis. The NPV of MRSA nares screening for ruling out MRSA was 95.7% for all cultures submitted. The sensitivity and specificity for positive clinical cultures were 67.4% and 83%, respectively. The NPV for bloodstream infections (n = 64,128) was 96.2% for intra-abdominal cultures (n = 8,071) was 97.9%, for respiratory cultures (n = 75,242) was 95.3%, for wound cultures (n = 95,832) was 90.4%, and for renal cultures (n = 164,330) was 99.1%. NPVs for sterile sites are as follows: intra-abdominal (n = 7,426) was 98.1%, respiratory (n = 15,583) was 95.2%, wound (n = 51,793) was 91%.

Conclusion

MRSA nares screening has a high NPV and specificity for ruling out potential MRSA infections at a variety of culture sites including bloodstream, intra-abdominal, respiratory, renal, and wounds. MRSA nares screening is a powerful stewardship tool for de-escalation and avoidance of empirical anti-MRSA therapy.

Disclosures

All authors: No reported disclosures.
581. The Epidemiology of Imipenem-Resistant Acinetobacter baumannii Bacteremia in a Pediatric Intensive Care Unit and Carbapenem Use
Authors: Kim Dongsub , Lee Haejeong , Croney Christina M , Sup Park Ki , Jung Park Hyo , Cho Joongbum , Soo Ko Kwan , Kim Jinyeong , Son Sohee , Choi Joon-sik , Choi Soo-Han , Huh Heejae , Ryeon Chung Doo , Yong Lee Nam , Kim Yae-Jean
Published: October 2019

Background

Acinetobacter baumannii (AB) infections cause high mortality and morbidity in intensive care unit patients. There are limited data on the epidemiology of imipenem-resistant A. baumannii (IRAB) amongst pediatric ICU patients.

Methods

A retrospective chart review was performed in patients with AB bacteremia in a pediatric intensive care unit at a tertiary teaching hospital from January 2000 to December 2016. Antimicrobial susceptibility tests, multilocus sequence typing (MLST) and PCR for antimicrobial resistance genes were performed for stored isolates. In addition, antibiotic prescription days of therapy (DOT per 1,000 patient-days) of the pediatric department from January 2001 to December 2016 was analyzed.

Results

Bacteremia episodes occurred in 27 patients. Male patients were 11 (41%) and the median age at the onset of bacteremia was 5.2 years (range, 0–18.6 years). There was a clear shift in antibiogram of AB during the study period. From 2000 to 2003, all isolates were imipenem-sensitive (ISAB, N = 6). From 2005 to 2008, both IRAB (N = 5) and ISAB (N = 4) were isolated. However, since 2009, all the AB isolates were IRAB (N = 12). In 33% (9/27) of patients, first AB was isolated from tracheal aspirate and patients developed bacteremia later (median duration from AB positive tracheal culture to AB positive blood culture, 8 days [range 5–124]). The overall mortality of patients with AB bacteremia was 59.3% (16/27) within 28 days. There was no statistical difference in mortality between ISAB and IRAB groups (50% vs. 71%; P = 0.42). From MLST analysis of 10 available isolates, sequence type 138 was predominant (N = 7). All 10 isolates were positive for OXA-23-like and OXA-51-like carbapenemase. In 2001, carbapenem DOT per 1,000 patient-days was 15.3 and later strikingly raised to 82.5 in 2009 when all the isolates were imipenem resistant. After this IRAB outbreak in PICU, proactive infection control and antimicrobial stewardship were reinforced among multidisciplinary teams in PICU. IRAB outbreak was terminated and carbapenem DOT per 1,000 patient-days was decreased to 51.7 in 2016.

Conclusion

IRAB bacteremia causes serious threat in high-risk pediatric patients in PICU. Proactive infection control measures and antimicrobial stewardship are crucial to manage serious IRAB infection in PICU.

Disclosures

All authors: No reported disclosures.
598. In Vitro Activity of Aztreonam in Combination with Ceftazidime–Avibactam, Amoxicillin–Clavulanate, and Piperacillin–Tazobactam vs. NDM-Producing Escherichia coli and Klebsiella pneumoniae Clinical Isolates
Authors: Walkty Andrew , Karlowsky James
Published: October 2019

Background

There are limited options available for the treatment of infections caused by Enterobacteriaceae that produce an NDM metallo-β-lactamase. The purpose of this study was to compare the in vitro activity of aztreonam in combination with three different β-lactam/β-lactamase inhibitors (ceftazidime–avibactam, amoxicillin-clavulanate, piperacillin–tazobactam) vs. NDM-positive Enterobacteriaceae clinical isolates.

Methods

Seven Escherichia coli and three Klebsiella pneumoniae clinical isolates (all NDM-positive by PCR) were included in this study. The in vitro activities of ceftazidime–avibactam, amoxicillin-clavulanate, piperacillin–tazobactam, and aztreonam were determined by disk diffusion as described by CLSI. For synergy testing, disks containing a β-lactamase inhibitor (ceftazidime–avibactam, amoxicillin-clavulanate, piperacillin tazobactam) were applied to Mueller–Hinton agar plates inoculated with the test organisms, and the plates were incubated for 1 hour. The disks were then removed and aztreonam disks were dropped on the previous disk sites. The plates were then incubated as per standard CLSI recommendations for disk diffusion testing.

Results

All ten isolates demonstrated phenotypic resistance to aztreonam, amoxicillin-clavulanate, and piperacillin–tazobactam, and eight were resistant to ceftazidime–avibactam (CLSI breakpoints). The zone diameter observed for aztreonam in combination with ceftazidime–avibactam was greater than for either antimicrobial on its own for nine isolates. Seven isolates (70%) had susceptibility to aztreonam restored (zone diameter ≥21 mm) in the presence of avibactam. Aztreonam in combination with amoxicillin-clavulanate demonstrated in increase in zone diameter for all isolates relative to the zone for each antimicrobial alone, but only two (20%) had aztreonam susceptibility restored. Aztreonam susceptibility was not restored for any of the isolates in combination with piperacillin–tazobactam.

Conclusion

Of the three β-lactam/β-lactamase inhibitor-aztreonam combinations evaluated, ceftazidime–avibactam plus aztreonam demonstrated the greatest in vitro activity vs. NDM-producing Enterobacteriaceae.

Disclosures

All authors: No reported disclosures.
615. Daptomycin (DAP) Synergy with β-Lactams in DAP-Resistant (DAP-R) E. faecium (Efm) Is Dependent On PBP5 Sequence and β-Lactam-binding Affinity
Authors: Khan Ayesha , Kebriaei Razieh , Singh, Kavindra V , Murray Barbara E , Rybak Michael J , Arias Cesar A
Published: October 2019

Background

DAP in combination with β-lactams is a viable option to treat recalcitrant DAP-R/tolerant strains of Efm. Ampicillin (AMP), ceftaroline (CPT), and ertapenem (ERT) have the best synergism. Using a DAP tolerant strain (503; DAP MIC 2 µg/mL) of Efm, we previously showed that AMP, CPT, and ERT combined with DAP were effective in reducing bacterial loads and prevented emergence of resistance in a simulated endocardial vegetation model. However, against a DAP-R Efm strain (R497, DAP MIC of 16 µg/mL), CPT, ERT failed to synergize with DAP. Here, we dissect the mechanistic basis of the differing DAP plus β-lactam synergistic effect.

Methods

We performed comparative transcriptional profiling of pbp genes in Efm 503 vs. R497 using qRT–PCR. PBP5 protein levels were assessed by immunoblotting. The β-lactam-binding affinity of PBPs was quantified with bocillin-FL staining and SDS–PAGE. PBP5 sequences of Efm Com15 (AMP and DAP-susceptible strain) and clinical strains S447, 503 and R497 (all with AMP MIC > 256 µg/mL) were compared in silico to identify amino acid (AA) differences in key protein sites which were verified with sequencing

Results

Pbp gene transcripts and PBP5 amounts were similar between 503 vs. R497. Interestingly, bocillin SDS–PAGE showed increased β-lactam binding affinity in PBP5 of 503 compared with that of R497 and S447. PBP5 sequences of S447 and R497 were identical. All three clinical strains had classic mutations (M485A and 466’S) important for high-level AMP-R. However, 503 had additional substitutions in the transpeptidase domain (H408Q, A462V, T546N, T558A, S582G, V586L) and penicillin-binding domain (Q632K, L642P) compared with R497 and S447. The latter AA sequences in 503 are common to AMP-susceptible Efm strains

Conclusion

We uncovered that a “hybrid” pbp5 allele of 503 (DAP-tolerant) correlated with synergism of DAP plus AMP, CPT or ERT and was associated with increased PBP5 β-lactam binding affinity. Lack of synergism of DAP plus CPT or ERT is associated with specific PBP amino acids in the transpeptidase and penicillin-binding domains. Thus, pbp5 alleles are major determinants of the DAP plus β-lactam synergistic effect and could be used as a diagnostic tool to guide therapy in recalcitrant Efm infections

Disclosures

All authors: No reported disclosures.
633. Incidence, Microbial Etiology and Antibiotic Resistance Patterns with Special Reference to Shunt Infections in Neurosurgery at a Tertiary Center in North India
Authors: Gupta Manisha , Dhole Tapan
Published: October 2019

Background

Ventriculoperitoneal (VP) shunt is one of the commonest procedures in neurosurgical practice. A significant problem encountered in shunt procedures is infection, with infection rate ranging from 2 to 27%, often with poor outcome. The objectives of the study were to retrospectively evaluate the infection rate associated with central nervous system (CNS) shunts, assess the frequency of the pathogens as well as their antibiotic sensitivity pattern to aim at suitable prophylaxis.

Methods

Materials and Methods. Retrospective study conducted in the Microbiology Department, SGPGI, Lucknow from December 2017 to August 2018. A total of 168 CSF samples were received with a suspected shunt infection. Samples were analyzed by wet mount, India ink, gram stain and inoculated on blood agar and MacConkey agar. Identification and AST were done by MALDI- TOF system (VITEK-MS) and Vitek 2.0 automated sensitivity system.

Results

During the study period, 37/168(22.02%) CSF were positive by culture. Most frequently isolated pathogen was Acinetobacter baumannii 20/37(54.05%), followed by Staphylococcus aureus 06/37 (16.20%), Enterococcus faecalis 04/37(10.81%) coagulase negative staphylococci- CONS 04/37(10.81%), Klebsiella pneumoniae 2/37 (5.40%)and Escherichia coli 1/37(2.70%). 100% of A. baumannii and E. coli strains were found to be XDR and carbapenem-resistant showing susceptibility to minocycline and colistin only. All strains of K.pneumoniae were MDR. 66.7% S.aureus were MRSA and showed 100% resistance to fluoroquinolone. A similar pattern was seen in CONS. 25% of Enterococci were found to be vancomycin resistant.

Conclusion

Discussion and Conclusion. The antibiotic sensitivity pattern suggests aminoglycosides, colistin and vancomycin to be a better choice of antibiotics either prophylactically/therapeutically, which may result in effective sterilization of the CSF. Infections following VP shunt procedure are secondary to catheter blockage complicating the results of surgery and are associated with high morbidity and mortality rates.

Disclosures

All authors: No reported disclosures.
644. Comparative Evaluation of ETEST® ERV bioMérieux with the CLSI Broth Microdilution Method for Eravacycline MIC Determination
Authors: Sauvonnet Veronique , Fyfe Corey , Halimi Diane , Martelin Roland , Zambardi Gilles
Published: October 2019

Background

Eravacycline (XERAVA™) is a novel, FDA and EMA-approved fully-synthetic fluorocycline antibiotic developed by Tetraphase Pharmaceuticals Inc. for the treatment of complicated intra-abdominal infections (cIAI) including those caused by multidrug-resistant (MDR) pathogens that have been highlighted as urgent public health threats by the US CDC and the WHO.

The new ETEST ERV strip (MIC range 0.002 – 32 µg/mL) has been developed by bioMérieux and calibrated vs. the broth microdilution reference method (BMD) as described by the Clinical and Laboratory Standards Institute (CLSI) to determine the minimal inhibitory concentration (MIC) of eravacycline against Enterobacterales and Enterococci. The aim of the study was to compare ETEST ERV to the CLSI BMD method on a panel of 166 strains comprising 131 Enterobacterales and 35 Enterococci.

Methods

Quality control was performed with the CLSI QC strains E.coli ATCC 25922 and E.faecalis ATCC 29212. The ETEST ERV strip was applied on a Mueller–Hinton agar plate previously seeded with a 0.5 McF bacterial suspension. After incubation for 16–20H at 35°C, the reading was performed using the bacteriostatic mode i.e.,80% of growth. The FDA-approved breakpoints were applied (S≤0.5µg/mL for Enterobacterales and S ≤0.064 µg/mL for Enterococci).

Results

The MIC essential agreement was 99.4% at ±1 dilution for the whole panel and the category agreement was 96.4% with 4.8% Major Errors (1 E. coli, 2 K. pneumoniae, 1 K.aerogenes, 1 C. koseri, 1 E. faecalis), all at ±1 dilution around the single breakpoint. No Very Major Error (VME) was observed.

Conclusion

In this study, the new ETEST ERV strip has been found to be substantially equivalent to the CLI reference method. MIC end-points appear easier to read in comparison to the reference method. With a 15-dilution MIC range and simplicity of use, ETEST ERV could represent a valuable tool for MIC determination and an alternative to the BMD reference method. ETEST ERV will undergo clinical studies to seek IVD FDA clearance and CE marking. For Research Use Only. The performance characteristics of this product have not yet been established.

Disclosures

All authors: No reported disclosures.
654. Evaluation of the Febridx Host Response Point-of-Care Test to Differentiate Viral From Bacterial Etiology in Adults Hospitalized with Acute Respiratory Illness During Influenza Season
Authors: Beard Kate , Chan Cathleen , Mills Samuel , Poole Stephen , Brendish Nathan , Clark Tristan William
Published: October 2019

Background

Antibiotics are overused in patients hospitalized with acute respiratory illness (ARI). Diagnostic uncertainty regarding microbial etiology contributes to this practice and so a host response test that can distinguish between viral and bacterial infection has the potential to reduce unnecessary antibiotic use. The FebriDx is a low cost, rapid, host response POCT that uses fingerpick blood samples to distinguish between viral and bacterial infection but has not been evaluated in hospitalized adults with ARI.

Methods

We took fingerpick blood samples from adult patients with ARI, hospitalized during influenza season, and tested them on the FebriDx. Respiratory samples were tested for viruses on the FilmArray Respiratory Panel (FARP). The FebriDx was evaluated for ease of use, failure rate and accuracy of the results (Viral, Bacterial, Negative).

Results

149 patients were approached and 10 patients declined fingerpick testing. A valid result was obtained from 124/139 (89%) overall. Common user comments included test failure due to difficulty of getting blood to fill the capillary tube and difficulty in interpreting the results lines due to the variability of color change. 111/124 (89%) were tested for viruses by FARP. 69/111 (62%) had viruses detected. Of 69 patients with viruses detected, 41 (59%) had influenza, 12 (17%) rhino/enterovirus and 16 (23%) other viruses. 44/69 (64%) had a viral FebriDx result. For influenza-positive patients 34/41 (83%) had a viral FebriDx result, 1/12(8%) of rhinovirus-positive patients had a viral FebriDx result and 9/16 (56%) of patients with other viruses detected had a viral FebriDx result. These are interim results. Full results for 200 patients will be available at presentation.

Conclusion

The use of the FebriDx POC was associated with a failure rate of ~10% and problems with the interpretation of result lines. FebriDx was not sufficiently accurate in differentiating viral and bacterial infection when using detection of virus by PCR as the definition of viral infection; however, FebriDx had a high PPV for all viral detection and for influenza detection in this cohort and could have utility in hospital emergency departments.

Disclosures

All authors: No reported disclosures.
657. Evaluation of Nanopore-Based 16S Ribosomal RNA (rRNA) Gene Sequencing for the Development of a Rapid Infection Intervention Clinical Service
Authors: Batra Rahul , Baldan R , Cliff P , Patel Amita , Edgeworth Jonathan , Chand M
Published: October 2019

Background

Rapid and accurate identification of bacteria is the basis of appropriate antibiotic treatment and effective clinical decision-making. Next-generation sequencing (NGS) platforms such as Oxford Nanopore Technologies (ONT) holds the promise of a diagnostic revolution by overcoming the limitations of culture-based identification with rapid molecular detection of bacteria. We have developed a pilot to evaluate an ONT 16S rRNA gene assay with the ability to provide real-time analysis and identification of bacterial species. Our aim was to investigate whether long-read sequencing and high-speed analysis can be combined to create a clinically useful, rapid diagnostic tool.

Methods

A collection of bacterial isolates representing pathogenic species received by the clinical laboratory over 1 year was assembled. Sample preparation was as described in the ONT 16S protocol and included bead beating sample disruption, MagNA Pure automated nucleic acid extraction (Roche), and PCR amplification (Thermo). Sequencing was performed on the MinION and GridION X5 platforms. Output was analyzed with ONT’s automated EPI2ME 16S pipeline which assigns reads to taxa using BLAST results and the NCBI 16S Bacterial database.

Results

A total of 155 clinical samples with 139 species were sequenced. 119 species were identified at the species level. For 20 samples, a species in the same genus claimed the majority of reads, with the true species being matched to 3%-41% of reads. The average proportion of reads assigned to the correct species was 62.2%, specifically 67% for non-Enterobacteriaceae and 33% for Enterobacteriaceae. 4 clinical samples (3 Bronchoalveolar lavages (BALs), positive for (1) K. pneumoniae, (2) S. pneumoniae, and (3) S. pneumoniae, S. enterica, and S. typhimurium, and 1 bone positive for P. aeruginosa) were also analyzed with sequencing results matching culture.

Conclusion

Early results show that 16S rRNA sequencing coupled with real-time analysis was able to accelerate pathogen detection and was able to discriminate the majority of species from a relevant clinical collection. Pipeline refinement is required and subsequent confirmatory consensus-based identification may be a helpful adjunct. Nanopore sequencing shows promise as a rapid bacterial pathogen detection platform for clinical service.

Disclosures

All authors: No reported disclosures.
708. In Vitro Activity of Plazomicin vs. Clinical Isolates of Gram-Negative Bacilli, Including Aminoglycoside Nonsusceptible and Multidrug-Resistant Subsets, Recovered from Patients Across Canada as Part of the CANWARD study, 2011–2018
Authors: Walkty Andrew , Adam Heather , Baxter Melanie , Lagace-Wiens Philippe , Karlowsky James , Zhanel George
Published: October 2019

Background

Plazomicin (PLZ) is a next-generation aminoglycoside currently approved by the US FDA for the treatment of complicated urinary tract infections, including pyelonephritis. The purpose of this study was to evaluate the in vitro activity of PLZ against a large collection of Gram-negative bacilli obtained from patients attending Canadian hospitals.

Methods

Annually from 2011 to 2018, sentinel hospitals across Canada submitted blood, respiratory, urine, and wound isolates from patients attending ERs, medical and surgical wards, hospital clinics, and ICUs (CANWARD). Susceptibility testing was performed using broth microdilution (and breakpoints) as described by CLSI (FDA breakpoints used for PLZ).

Results

See table.

S, susceptible; NS, nonsusceptible; ESBL, extended-spectrum β-lactamase; MDR, multidrug-resistant (NS to antimicrobials from three or more classes); n.d., not defined.

Conclusion

PLZ demonstrated excellent in vitro activity vs. E. coli and K. pneumoniae clinical isolates, including aminoglycoside NS, ESBL-positive, and MDR subsets.

Disclosures

All authors: No reported disclosures.
718. Activity of Ceftolozane–Tazobactam and Ceftazidime–Avibactam Against Clinical P. aeruginosa Isolates Collected in United States and Canada—SMART 2018
Authors: Lob Sibylle , Kazmierczak Krystyna , Raddatz Janet , DePestel Daryl , Young Katherine , Motyl Mary , Sahm Daniel F
Published: October 2019

Background

Ceftolozane–tazobactam (C/T) is an antipseudomonal cephalosporin combined with a β-lactamase inhibitor. The combination was cleared by FDA and EMA and is approved in the United States and over 60 countries worldwide. Using clinical isolates collected in the United States and Canada as part of the global SMART surveillance program, we compared the activity of C/T and ceftazidime–avibactam (CAZ/AVI) against P. aeruginosa isolates and subsets nonsusceptible (NS) to selected antimicrobial agents.

Methods

In 2018, 31 clinical laboratories from United States and Canada collected up to 250 consecutive, aerobic or facultatively anaerobic, Gram-negative pathogens (GNP) from blood, intra-abdominal, urinary, and lower respiratory tract infections. A total of 6,178 GNP were collected, of which 1,138 (18.4%) were P. aeruginosa. MICs were determined using CLSI broth microdilution and interpreted with CLSI 2019 breakpoints.

Results

The MIC distributions of C/T and CAZ/AVI against 1,138 P. aeruginosa are shown below. The modal MIC value for C/T was ≥2 doubling dilutions lower than that for CAZ/AVI, and it was ≥3 dilutions lower than the C/T CLSI susceptible breakpoint, whereas the modal MIC value for CAZ/AVI was 2 dilutions lower than its susceptible breakpoint. Among all P. aeruginosa isolates, percentages of susceptibility were 96.0% (C/T), 93.8% (CAZ/AVI), 76.6% (CAZ and cefepime), 67.0% (imipenem [IMI]), 74.0% (meropenem [MEM]), 71.5% (piperacillin–tazobactam [TZP]), and 64.9% (aztreonam). Among subsets of nonsusceptible isolates, susceptibilities to C/T and CAZ/AVI were 83.5% and 74.4%, respectively (CAZ-NS subset, n = 266), 91.0% and 85.1% (IMI-NS, n = 376), 87.5% and 80.1% (MEM-NS, n = 296), 87.0% and 79.6% (TZP-NS, n = 324), and 72.4% and 57.8% among isolates nonsusceptible to all tested β-lactams (n = 116).

Conclusion

The activity of C/T exceeded that of CAZ/AVI and other tested comparators against a recent collection of clinical isolates of P. aeruginosa, including subsets of isolates nonsusceptible to other β-lactams. Susceptibilities to C/T were 6–14 percentage points higher than observed for CAZ/AVI among β-lactam-NS subsets. C/T promises to be an important treatment option for patients with antimicrobial-resistant P. aeruginosa infections.

Disclosures

All authors: No reported disclosures.
745. Operationalization of Comprehensive Sexual Wellness Clinic at a Large Urban Emergency Department
Authors: Hazra Aniruddha , Schmitt Jessica , Bender Alvie , Moore Michelle , Scott Cheryl , Garcia Damaris , Pitrak David
Published: October 2019

Background

Due to the closure of surrounding city-run sexually transmitted infection (STI) clinics, uninsured and underinsured patients living near an urban academic medical center have been relying on the Emergency Department (ED) for their sexual health needs. A novel Sexual Wellness Clinic (SWC) was created to provide comprehensive sexual healthcare and primary care linkage to patients presenting to the ED with STI complaints.

Methods

SWC-eligible patients are identified at ED intake and undergo a Medical Screening Exam (MSE) by a triage physician before transport to clinic. Notable exceptions to the SWC are patients who are pregnant, younger than 18 years of age, victims of sexual assault, or deemed to require higher acuity care. Once at the SWC, patients undergo a complete history and physical examination, comprehensive STI testing, and, if indicated, empiric treatment as well as same-day initiation of Pre-Exposure Prophylaxis (PrEP). Social services within the clinic also assist in arranging primary care follow-up either at the medical center or an affiliated Federally Qualified Health Center (FQHC).

Results

During its initial 8 weeks, 28 patients were seen in the SWC; 35.6% were cis-female and 64.2% were cis-male. All female patients identified as women who have sex with men, 89% of male patients identified as men who exclusively have sex with women. Patient ages ranged from 18 to 55 with a mean age of 25. Overall, 17.8% of patients tested positive for gonorrhea; 7.1% tested positive for chlamydia, and 0% tested positive for syphilis. One new HIV diagnosis was identified. Same-day PrEP was initiated in 28.5% of patients of which 62.5% (n = 5) were female and 37.5% (n = 3) were male. SWC linked 79% of patients to primary care.

Conclusion

We demonstrated the feasibility of this unique workflow bringing patients from the ED to a specialized sexual health clinic. The majority of patients visiting SWC identified as heterosexual men and women, which differs from other metropolitan STI clinics. Identifying these populations with untreated STIs and other HIV risk factors for targeted intervention is integral to local and national HIV elimination efforts.

Disclosures

All authors: No reported disclosures.
746. Improving Monitoring of Outpatient Parenteral Antimicrobial Therapy (OPAT) for Solid Tumor Patients at a Comprehensive Cancer Center
Authors: Dishner Emma L , McDaneld Patrick , Rowan Meagan , Robins Alison , Bartek Jalen , Dailey Garnes Natalie J
Published: October 2019

Background

Increasing rates of antimicrobial resistance require more frequent parenteral antimicrobial therapy. OPAT improves patient quality of life and is cost-effective. Although IDSA OPAT guidelines are applied to cancer patients, few studies have addressed implementation in this unique population. Through our quality improvement project, we aimed to improve monitoring of solid tumor patients recommended for OPAT by infectious diseases (ID) consultation as measured by an increased percentage of patients with physician follow-up and laboratory monitoring.

Methods

We used the plan-do-study-act methodology to guide our quality improvement project. To establish baseline frequencies, we retrospectively reviewed a subset of solid tumor patients seen for ID consultation and recommended for OPAT. We used brainstorming, fishbone analysis, and process mapping to analyze our current process. We standardized a sign-off note for inclusion with OPAT recommendations within our electronic medical record. We reminded ID providers of the new process weekly and to notify the OPAT team and outpatient clinical nursing staff of OPAT-enrolled patients.

Results

We found that clarifying recommendations addressed several identified obstacles to monitoring. After instituting our intervention, the percentage of patients who completed follow-up increased from 44% to 78% during the 6-week intervention period. Although the frequency of laboratory monitoring recommendations increased from 43% to 86%, the percentage of patients completing such monitoring did not improve. Our results were sustainable during the 3-month post-intervention observation period.

Conclusion

By standardizing ID recommendations, we increased outpatient follow-up frequency. Our inability to increase the frequency of laboratory monitoring likely reflects the increased complexity of the process, which requires action from external stakeholders. We learned that a simple intervention can have a meaningful impact and that gains can be limited without involvement of all stakeholders. We plan to expand to a comprehensive OPAT clinic for all patients at our facility and further characterize challenges and opportunities for utilizing OPAT in cancer patients.

Disclosures

All authors: No reported disclosures.
747. Implementation of a Pharmacist-led Intervention for Infectious Diseases Patients Discharged on Antimicrobials: the Infectious Diseases Discharge Outreach and Retention (ID DOOR) Program
Authors: Walston Bobbi Jo , Fletcher Lisa A , Wilson William , Boerneke Renae A , Marx Ashley H , Vargas John D , Farel Claire E
Published: October 2019

Background

Hospitalized patients who require Infectious Diseases (ID) consultative services and are discharged on antimicrobials (AM) are medically complex and at high risk of readmission. Complications related to AM toxicity, suboptimal regimen completion, or lack of AM access are prevalent. Our ID clinic pharmacist contacted patients affiliated with ID services within 72 hours of discharge to identify and intervene on needs such as AM access and management, toxicity monitoring, AM administration teaching, and to assess discharge care progression. The goal of this intervention was to leverage the subject matter expertise of an ID-trained pharmacist to create a protocolized intervention to improve the inpatient-to-outpatient transition for ID patients.

Methods

During a 12 week time period, 173 patients were identified and enrolled in the ID DOOR intervention. Patients who received consultative care by an ID physician were tracked and automatically referred to ID DOOR; those discharged on antimicrobials were included in the intervention group. Phone-based assessment of discharge AM access, education, and administration was initiated by the ID pharmacist within 72 hours of discharge (Table 1).

Results

Of the 173 patients, 155 (90%) were successfully contacted post-discharge. The majority of needs identified were AM education, access, and coordination of care (Table 2). In addition, discrepancies between discharge orders, summary content, and patient instructions were prevalent. Based on the medication-related assessment performed by the ID-trained pharmacists, they were able to resolve AM-related issues and identify, triage, and link patients to appropriate multidisciplinary providers to coordinate care plans.

Conclusion

The data highlight the prevalence of immediate post-discharge needs related to antimicrobial for patients and the critical role of ID-trained pharmacists in addressing these needs. In a large public academic medical center with uninsured and underinsured patients, additional support for AM access, education, and navigation of care plans is needed. For medically and socially complex ID patients, an ID-trained pharmacist plays a critical role in reducing risk inherent in the transition from inpatient to outpatient care.

Disclosures

All authors: No reported disclosures.
752. Timing of Antibiotics Administration in Emergency Department and Mortality in Sepsis by Sepsis-3 Definition
Authors: Seok Hyeri , Song Ju-Hyun , Hoon Jeon Ji , Kyoung Choi Hee , Suk Choi Won , Moon Sungwoo , Won Park Dae
Published: October 2019

Background

Even after the introduction of the Sepsis-3 definition, there is still debate on the ideal antibiotic administration time in patients with sepsis. This study was performed to evaluate the association between the timing of antibiotic administration and mortality in sepsis patients who visited the emergency room.

Methods

A prospective cohort study was conducted on patients who were diagnosed as sepsis with Sepsis-3 definition among patients who visited the emergency department (ED) of Korea University Ansan Hospital from September 2017 to January 2019. The timing of antibiotic administration was defined as the time in hours from ED arrival until the first antibiotic administration. Cox logistic regression analysis was used to estimate the association between time to antibiotics and 7-, 14-, and 28-day mortality.

Results

During the study period, a total of 251 patients were enrolled with a 7-, 14-, and 28-day mortality of 16.7%, 36.3%, and 57.4%, respectively. The median time to antibiotic administration was 247 minutes (interquartile range 72 – 202 minutes). The mean age was 72 ± 15 years old and 122 patients (48.6%) were female. The most common site of infection was respiratory infection. The timing of antibiotic administration were not associated with 7-, 14-, and 28-day mortality. Female (adjusted hazard ratio [HR] 2.06 [95% confidence interval (CI) 1.21 – 3.53]; P value = 0.008), SOFA score (aHR 1.17 [95% CI 1.05 - 1.31]; P = 0.005), and initial lactate level (aHR 1.13 [95% CI 1.05 - 1.22]; P = 0.001) increased the risk of 7-day mortality. Female (aHR 2.07 [95% CI 1.48 – 2.89]; P ≤ 0.001), Charlson comorbidity index (aHR 1.12 [95% CI 1.02 - 1.24]; P = 0.025), and initial lactate level (aHR 1.19 [95% CI 1.02 - 1.16]; P = 0.011) increased the risk of 14-day mortality. Female (aHR 1.95 [95% CI 1.50 – 2.54]; P = 0.001) increased the risk of 28-day mortality in patients with sepsis.

Conclusion

The timing of antibiotic administration did not increase the risk of mortality in the treatment of sepsis patients who visited ED. Rather, the SOFA score, lactate, female, and comorbidity increased the mortality associated with sepsis.

Disclosures

All authors: No reported disclosures.
768. Use of a Machine-Learning-based Prediction Model to Guide Antibiotic De-escalation in the Treatment of Urinary Tract Infections
Authors: Huggins Jonathan , Hamilton Keith W , Barnett Ian
Published: October 2019

Background

A patient-specific antibiogram (PS-ABG) issues personalized predicted antibiotic susceptibility results by incorporating patient factors into a prediction model. Predictions, reported as percent likelihood of susceptibility, are available to providers in real-time. In this study, we evaluated the performance characteristics of a PS-ABG based on a machine-learning algorithm in predicting susceptibility of Enterobacteriaceae isolated on urine cultures.

Methods

This cross-sectional study included 2,517 urine cultures with Enterobacteriaceae collected from 2,211 unique patients over a 12-week period from January 1 through April 15, 2019 in a single health system. Receiver operating curves (ROC) were generated for commonly prescribed antibiotics to assess discrimination. Threshold values to determine when an antibiotic could be used were then determined based on ROC curves. Brier scores were generated for all antibiotics collectively and for individual antibiotics to evaluate the accuracy of the predictions compared with that of the usual practice (UP) of traditional antibiograms.

Results

The ability of the PS-ABG to discriminate susceptible and nonsusceptible isolates varied by antibiotic [area under the curve (AUC) range: 0.71 - 0.95]. When all antibiotics were considered, AUC was 0.88 (95% C.I. 0.88 – 0.89). Brier score ranged from 0.0037 - 0.2087, representing between a 9 - 56% improvement compared with UP. For all antibiotics, the software had a 32% improvement over UP (median Brier score 0.0794 v. 0.1114, P < 0.0001). Overall, a susceptibility threshold of 95% was associated with a specificity of 96%. A threshold of 95% was associated with a ≥90% specificity in all agents except for cefepime (specificity 70%) and meropenem (specificity 73%). For cefepime and meropenem, specificity reached 90% at a threshold of 97%.

Conclusion

The PS-ABG demonstrated excellent discriminatory power for all antibiotics tested and was more accurate than UP. A cutoff of 95% likelihood of susceptibility affords high specificity for most agents and may be a reasonable threshold for selecting an appropriate antibiotic. A higher susceptibility threshold yields similar specificity for cefepime and meropenem, but this finding is likely a result of the low number of resistant isolates.

Disclosures

All authors: No reported disclosures.
776. Effect of the SEP-1 Sepsis Bundle on Mortality in Hospital-Onset v. Community-Onset Sepsis
Authors: Baghdadi Jonathan , Uslan Daniel , Bell Douglas , Wong Mitchell
Published: October 2019

Background

The SEP-1 sepsis bundle is a performance measure from the Centers for Medicare and Medicaid Services that requires blood cultures, serum lactate, broad-spectrum antibiotics, and IV fluids (in some cases) within 3 hours of onset of sepsis. Published evidence regarding an effect of SEP-1 on mortality is mixed and largely excludes cases of hospital-onset sepsis.

Methods

Retrospective cohort study using clinical data from 4 University of California hospitals. Sepsis-related admissions from 2014–2017 were identified by diagnosis codes. We compared the effect of the SEP-1 sepsis bundle on in-hospital mortality in cohorts with community-onset and hospital-onset sepsis. To control for selection bias, patients who did and did not receive the SEP-1 bundle from each cohort were balanced on key variables related to likelihood of treatment using Mahalanobis distance matching.

Results

5,034 out of 6,005 sepsis-related patient encounters were matched, including 1,770 (35%) patients who received the SEP-1 bundle and 3,264 (65%) who did not. The SEP-1 bundle was not associated with an effect on mortality in the unmatched (Table 2) or matched analyses (Table 3). Point estimates from the matched analysis suggested a greater potential benefit associated with SEP-1 and its components in community-onset sepsis, but differences in effect size between community-onset and hospital-onset were nonsignificant. Among bundle components, timely blood cultures, lactate, and antibiotics were not associated with an effect on mortality, while IV fluids were associated with a 3-percentage-point increase in mortality risk. In subgroup analysis, IV fluids were associated with increased mortality in patients with pneumonia and immunosuppression.

Conclusion

The use of the SEP-1 sepsis bundle was not associated with an effect on mortality. Subgroup analyses suggested situations in which IV fluids may be harmful, though prospective data are needed.

Disclosures

All authors: No reported disclosures.
777. Experience with Liposomal Amphotericin B in Outpatient Parenteral Antimicrobial Therapy (OPAT)
Authors: Burnett Yvonne , Hamad Yasir
Published: October 2019

Background

While OPAT is known to be a safe, effective, and convenient treatment strategy for patients receiving intravenous antimicrobials in the outpatient setting, the risk of adverse events (AEs) increases when high-risk medications, such as liposomal amphotericin B (L-AMB), are utilized. There is limited data available describing the use and safety of L-AMB in the OPAT setting.

Methods

Electronic medical records of patients discharged from Barnes Jewish Hospital on L-AMB between January 2015 and July 2018 were retrospectively reviewed. The primary objective of this study was to describe the population of OPAT patients discharged on L-AMB and to evaluate factors associated with readmission and AEs. Univariate analysis was performed to evaluate for predictors of worse outcomes.

Results

Forty-two patients (67% male, median age 50 years) were identified. The most common indications were histoplasmosis (n = 13, 31%) and aspergillosis (n = 7, 17%). The majority of patients were discharged to home (n = 35, 83%) on a median dose of 4 mg/kg L-AMB. More than half of the patients completed their anticipated course of L-AMB (n = 26, 62%), 17 without any interruption or change in therapy, while 16/42 patients required early discontinuation of therapy, 11 of which required a change in therapy. Twenty-one patients (50%) were readmitted during their L-AMB course with a median time to readmission of 10 days (IQR 4–18). While hypokalemia and AKI (increase in serum creatinine by 0.5 mg/dL or 50% from baseline) were common AEs, occurring in 62% (n = 26) and 49% (n = 20), only 5 (12%) were readmitted to the hospital due L-AMB-associated AE (hypokalemia (K < 3 mEq/L), n = 2; AKI, n = 3. Factors associated with all-cause readmission included malignancy (not readmitted 6/21 vs. readmitted 13/21, P = 0.02) and duration of therapy (median of 15 vs. 32 days in not readmitted vs. readmitted, P = 0.02). OPAT lab monitoring was performed at a median of 2 times per week. No patients required hemodialysis due to AKI.

Conclusion

L-AMB is associated with significant AEs; however, these results suggest treatment is feasible in the outpatient setting with close monitoring. The majority of AEs were managed effectively as an outpatient without long-term sequelae.

Disclosures

All authors: No reported disclosures.
782. Provider to Provider Electronic Consultation (E-consult): A Tool for the Pediatric Infectious Diseases Specialist to Document Encounters and Quantify Effort.
Authors: Gonzalez Blanca E , Foster Charles B , Esper Frank , Daniels Heather , Saracusa Carla , Boutros Jasmine , Isakov Daniela , Sabella Camille
Published: October 2019

Background

Curbside consultation is a ubiquitous practice within the medical field informally providing advice to community providers. The electronic consult (E-Consult) allows direct provider-to-provider communication between the primary care provider (PCP) and specialists using a secure electronic platform while documenting these interactions within the patient’s medical record (EMR). They offer PCP’s a forum for asking nonurgent questions. For the specialist, it allows review of the EMR, reduces medical liability of the curbside consult and provides a mechanism for generating RVUs. This service was implemented in our healthcare network (of over 300 pediatricians and pediatric specialists who see more than 500,000 pediatric visits each year) in April 2018. Our aim was to review and analyze the E-consults provided by the Pediatric Infectious Diseases (PID) service.

Methods

Cross-sectional study of E-consults performed by the PID from April 11 -2018-April 22 2019. Clinical queries were categorized by type and tabulated. Consult Billing was as following: Level 1=5 minutes (min); Level 2 =10min; Level 3= 15 minutes; Level 4= 25 minutes. RVU values were institutionally derived and assigned.

Results

We performed 171 E- consults with an average of 13 per month (range 3–18) generated from 59 providers (52 (88%) physicians and 7 (12%) certified nurse practitioners). Common reasons for the E-consult included: vaccine questions (25.7%), diagnosis questions (21.6%), exposure questions (20.4%) and treatment recommendations (10.5%). Of vaccine questions, 43% related to vaccine schedules /boosters, 13% vaccines for travel and 11.3% vaccines for the immunocompromised host. Consultation in the PID clinic was recommended for 25.7% patients, 9% requiring urgent evaluation. Of the 171 E-consults, 12.2% were evaluated in the PID clinic and 5% by another specialty. Billing was performed for 168 of the E consults= 9 level 1, 35 level 2, 83 level 3 and 41 level 4 generating 161 RVUs (equivalent to 53 level 4 new outpatient visits at our institution).

Conclusion

E-consults are an alternative to informal curbside consults for nonurgent clinical queries. Encounters are documented in the EMR and professional effort devoted to the task is tracked providing an additional source of RVU generation for the PID physician.

Disclosures

All authors: No reported disclosures.
784. Do Patients and Healthcare Professionals See Eye-to-Eye on the Usefulness of Strategies for Promoting HIV Care?
Authors: Felzien Gregory S , McIntosh Sean J , Taneva Ekaterina S , Simone Laura , Greene Laurence , Carter Jeffrey , Sapir Tamar
Published: October 2019

Background

Many studies have identified barriers to achieving goals for HIV care, thereby informing various intervention strategies. However, whether a given strategy can effectively overcome key barriers may depend on the extent to which patients and healthcare professionals (HCPs) agree that it is useful. To address this gap, we conducted a survey study to compare patients’ and HCPs’ perceptions of strategies for promoting HIV prevention, medication adherence, and care retention.

Methods

The survey was administered to patients and their HCPs as part of collaborative educational programs held in 12 community clinics in urban and suburban areas across 6 southeastern states. Participants included each clinic’s staff and their patients living with or at risk for HIV infection. The surveys listed 12 strategies for overcoming barriers to HIV prevention, adherence, and retention. Patients and HCPs rated the extent to which each strategy would be helpful for achieving desired goals (scale: 1 = very unhelpful to 5 = very helpful). We conducted χ 2 or Fisher’s exact tests to assess between-group differences in the frequency of pooled ratings of 4 (helpful) and 5 (very helpful).

Results

Surveys were completed by 224 patients (69% with HIV diagnosis, mean age 47 years, 42% women, 75% African American) and 39 HCPs (42% health educators/counselors, 31% nurse practitioners, 24% social workers, 3% physicians). Among other findings (Figures 1–3), similar percentages of patients and HCPs, respectively, gave ratings of 4 or 5 for taking pills (PrEP) that prevent HIV (83%, 80%); using a smartphone app with medication reminders (78%, 74%); and making it easier to get clinic appointments (90%, 85%). More discordant perceptions, all reflecting lower percentages of 4 or 5 ratings among patients than HCPs, were evident for talking with a counselor (82%, 90%); getting support from friends and family (82%, 92%); and improving relationships with clinic staff (85%, 100%).

Conclusion

These findings may inform interventions that are perceived by both patients and HCPs to be helpful for promoting HIV prevention, medication adherence, and retention. Effective interventions must address any discordance between patients and HCPs in the usefulness of selected strategies.

Disclosures

All authors: No reported disclosures.