bluuebunny/crossref_metadata_2025 huggingface dataset:
99. Presence of Chronic Diseases and Compliance with Québec Provincial Guidelines for Outpatient Antibiotic Prescription, Québec, Canada, 2010-2017
Authors: Fortin Elise , Deceuninck Geneviève , Sirois Caroline , Quach Caroline , Simard Marc , Jean Sonia , Irace-Cima Alejandra , Magali-Ufitinema Nadine
Published: December 2021

Background

In Québec primary care, antimicrobial use is higher in patients with chronic diseases, but it is unclear whether this utilization may be reduced. We aimed to measure the proportion of compliant antimicrobial prescriptions according to the provincial guidelines for the treatment of common respiratory and urinary infections and measure variations in this proportion with certain chronic diseases.

Methods

Antimicrobial dispensing covered by the public drug insurance plan between April 2010 and March 2017, delivered within 2 days of an outpatient consultation for an infection was included. Infections targeted by provincial guidelines were studied: otitis media, pharyngitis, pneumonia, sinusitis, bronchitis and chronic obstructive pulmonary disease exacerbations, cystitis, and acute pyelonephritis. The proportion of prescriptions compliant with guidelines (right antimicrobial for children, and right antimicrobial and dosage for adults) was computed by age group (children or adults) and per category of chronic disease (respiratory, cardiovascular, diabetes, mental disorder, none of previous). For each infection and age group, multivariate robust Poisson regression was used to measure the impact of categories of chronic diseases on proportions of prescriptions compliant with guidelines.

Results

Between 14 677 and 312 786 prescriptions were included, for each infection. Compliance to guidelines was above 87% in children and was significantly lower (≤ 3% bellow) in children with asthma. In adults, the choice of agent was compliant for at least 73% of prescriptions, except for cases of pharyngitis (between 53% and 61%). Accounting for dosage led to lower proportions of compliance, which varied between 19% (cystitis with diabetes) and 77% (pyelonephritis with none of the studied chronic disease categories). Compliant prescriptions were 2,4% to 20,4% less frequent in the presence of chronic diseases (statistically significant).

Conclusion

Non-compliant prescriptions could still be appropriate, but their high frequency suggests there is room for improvement. Dosage seems particularly problematic. Additional support could be offered to clinicians for the prescription of antimicrobials to patients with chronic diseases.

Disclosures

All Authors: No reported disclosures
114. Optimization of Inpatient Antibiotic Use via an Electronic Antimicrobial Stewardship Module and an Infectious Diseases Pharmacy Resident
Authors: Chen Victor , Allen Lauren , Bao Hongkai , Cowman Kelsie , Nori Priya , Nori Priya , Guo Yi
Published: December 2021

Background

Antibiotic resistance is a public health crisis and antimicrobial stewardship (AMS) pharmacists serve a crucial role in preventing inappropriate use. At Montefiore Medical Center (1,500-bed hospital), a new electronic medical record AMS module was implemented with assistance from an infectious diseases (ID) pharmacy resident in October 2020. The module utilizes a dynamic scoring system to assist in prioritizing interventions, including bug-drug mismatches, insufficient coverage, or de-escalation. The AMS module is operationalized by ID pharmacists during the week and an ID pharmacy resident every other weekend. The objective of this study was to assess the impact of an ID pharmacy resident performing AMS module interventions on broad spectrum antibiotic use.

Methods

An observational study of AMS module interventions on antibiotic use (AU) in days of therapy per 1,000 days present and standardized antimicrobial administration ratio (SAAR) was performed. AU data for piperacillin-tazobactam (P/T) and SAAR prior to (October 2019– December 2019) and after (October 2020 – December 2020) the integration of an ID pharmacy resident and the AMS module was compared. Additional data collected included total number and type of interventions.

Results

A total of 539 interventions were made by AMS pharmacists and 36.5% of these were completed by the ID pharmacy resident. Across 6 different units, there was a statistically significant decrease in the SAAR for broad spectrum antibacterial agents (Figure 1), and a decrease of at least 10% in P/T use during the two different time periods (Table 1). An estimated P/T cost reduction of 26% of (&48,708 to &36,235.80) was observed. AMS pharmacists made 63 interventions in respective units. The top three intervention types were dose/frequency/duration recommendations, pharmacokinetic vancomycin dosing/monitoring, and de-escalation. The acceptance rate of interventions was 99% (534 accepted interventions/539 total interventions).

Figure 1. SAAR Comparison of Broad-Spectrum Agents

Table 1. AU Rate of Piperacillin-tazobactam

Conclusion

Overall, there was a statistically significant impact on SAARs and a >10% change in P/T AU rate with an estimated cost reduction >25% on select units after implementation of the AMS module with an ID pharmacy resident.

Disclosures

Kelsie Cowman, MPH, Merck (Research Grant or Support) Priya Nori, MD, Merck (Grant/Research Support) Priya Nori, MD, Nothing to disclose Yi Guo, PharmD, BCIDP, Merck (Research Grant or Support)
117. How Does Antimicrobial Stewardship Provider Role Affect Prospective Audit and Feedback Acceptance by the Attending Physician?
Authors: Hammond Keely , Chen Justin , Doucette Karen , Smith Stephanie , Kabbani Dima , Lau Cecilia , Bains Serena , Stewart Jackson J , Fong Karen G
Published: December 2021

Background

Antimicrobial stewardship (AMS) teams are commonly multidisciplinary. The effect of AMS provider role on prospective audit and feedback (PAF) acceptance has previously been investigated with mixed results. PAF of restricted antimicrobials (carbapenems, linezolid, daptomycin, and tigecycline) in adult inpatients at our large Canadian academic centre has been performed since 2018. Actionable feedback is communicated via chart note plus one of a phone call, direct message, or in-person discussion with the most responsible physician of the attending team in order to optimize the prescription if deemed necessary. The objective of this study was to assess the effect of AMS provider role on PAF acceptance.

Methods

A 3 year retrospective review of all PAF events was undertaken. All audited prescriptions were included. Logistic regression was used to determine odds ratios for acceptance for individual AMS provider roles of pharmacist, physician, and supervised post-graduate physician trainee.

Results

Out of 1896 prescriptions audited, actionable feedback was provided to the most responsible physician in 731 (39%) cases. 677/731 (93%) of audited antibiotics were carbapenems. The overall acceptance rate was 82% (598/731). Acceptance rate and odds of acceptance based on AMS provider role were as follows: pharmacist alone 171/208 (82%), OR 1.04, 95% CI 0.70-1.59, physician alone 141/160 (88%), OR 1.85, 95% CI 1.12-3.20, pharmacist-physician duo 211/268 (79%), OR 0.73, 95% CI 0.50-1.07, and supervised post-graduate physician trainee 75/95 (79%), OR 0.81, 95% CI 0.48-1.41.

Conclusion

The overall acceptance rate was high. There was a higher odds of acceptance if an AMS physician was providing PAF alone, highlighting the importance of physician involvement.

Disclosures

Dima Kabbani, MD, AVIR Pharma (Grant/Research Support, Other Financial or Material Support, Speaker)Edesa Biotech (Scientific Research Study Investigator)Merck (Scientific Research Study Investigator)
118. Feasibility of a Proactive Amoxicillin Oral Challenge Program for Inpatients with Penicillin Allergy at the Miami VAMC
Authors: Piazza Michael J , Lichtenberger Paola , Bjork Lauren , Lazo-Vasquez Alex , Hoang Minh , Temino Viviana
Published: December 2021

Background

Ninety percent of patients who report penicillin (PCN) allergy are not truly allergic. Penicillin skin testing (PST) followed by oral challenge (OC) with amoxicillin (AMX) can evaluate unconfirmed PCN allergy. PST is taxing and requires trained staff, while OC is an acceptable alternative in patients with low-risk histories, who can safely undergo OC without PST. OC is performed in the outpatient Miami Veterans Affairs Medical Center (MVAMC) setting. Collaboration between Allergy, Antimicrobial Stewardship Program (ASP), and Hospital Medicine identified patients with low-risk histories and offered OC to inpatients.

Methods

A daily report of MVAMC inpatients with PCN allergy was reviewed for appropriateness of OC (Fig 1). Hospice patients and those medically unstable or unable to consent were excluded. Appropriate consenting patients were challenged with AMX 500mg PO and observed for 60 minutes. If no reaction resulted, the PCN allergy label was removed. Epinephrine and diphenhydramine were available in case of adverse reaction. Those who were not OC candidates were offered outpatient PST (Fig 1).

Figure 1. Penicillin allergy history evaluation algorithm

Results

We evaluated 39 inpatients with PCN allergy from 3/10 - 5/27/21. Median age was 68 years; 94.9% were male (Table 1). The most common recorded reaction was unknown (Table 2). Thirteen (33.3%) did not qualify for OC, 7 (17.9%) refused, 2 (5.1%) were receiving a penicillin-derivative, 1 (2.6%) patient’s primary team refused consult, 2 (5.1%) patients were discharged prior to OC. Fourteen (38%) patients underwent OC with 0 adverse reactions; 0 patients required epinephrine or diphenhydramine. After OC, 5 patients had changes to their antibiotic regimen as a result of a negative OC. Limitations included 5 patients on beta-blockers, and 5 patients unable to consent.

Table 1. Demographics of Evaluated Inpatients, N = 39 (%)

Note that 1 patient out of the 39, underwent DPC with cefpodoxime 200mg PO instead of amoxicillin for a reported allergy to ceftriaxone.

Table 2. Reported Reactions, N = 41 (%)

Total N exceeds evaluated patient number as one patient reported multiple reactions to receiving penicillin.

Conclusion

Removing unnecessary PCN allergy labels using inpatient OC with AMX is safe and effective for those with low-risk allergy histories. Zero patients undergoing OC developed a reaction, suggesting that OC may be safely performed per our algorithm. Our protocol does not require specialized training and is reproducible in settings without an Allergy specialist. In the 3 months prior to this program there were 0 inpatient consults to evaluate PCN. Future plans include forming a multidisciplinary consult service.

Disclosures

All Authors: No reported disclosures
125. Antimicrobial Stewardship Hospital Activities to Promote Antibiotic Awareness Week 2019, Chicago, IL
Authors: Hanson Amy P , Walblay Kelly , Shane Elizabeth , Xydis Shannon N , Pacilli Massimo , Kim Do Young , Black Stephanie R
Published: December 2021

Background

U.S. Antibiotic Awareness Week (USAAW) is an annual campaign to increase knowledge of antimicrobial resistance (AMR) threats and the importance of appropriate antibiotic use. USAAW will be observed November 18-24, 2021 in cadence with World Antimicrobial Awareness Week.

Methods

In October 2019, the Chicago Department of Public Health (CDPH) surveyed 25 Chicago acute care hospital (ACH) antimicrobial stewardship programs (ASPs) via REDCap, an electronic data capture system, to assess their planned activities for USAAW in November 2019. Survey results from 14 (56%) respondent ACHs were collated and disseminated to all 25 ACHs prior to USAAW.

Results

ACH ASP survey responses were categorized by ACH size: smaller hospitals (SH) < 350 beds (n=7) and larger hospitals (LH) > 350 beds (n=7) and displayed in the Table. Nine respondents were Infectious Disease (ID) Pharmacists, 3 were ID Physicians, 1 was an Administrator and 1 was an Infection Prevention Nurse. Among SHs, the ASP was funded for an ID Pharmacist salaried position (FTE) < 0.5 at 4 ACHs, 0.5 in 2, and 1 FTE at 1 ACH. LHs reported ID Pharmacist funding ranging from < 0.5 – 2.5 FTE, with the majority with 1 FTE at 3 LHs. All ACHs reported 0.5 FTE or less ID Physician support for their ASPs. Eleven (79%) of respondent ACHs did not report an annual budget for ASP activities. Ten (71%) ACHs disagreed or strongly disagreed that funding was adequate in the outpatient setting compared to inpatient both for adult and pediatric ASP services. Types of planned activities for USAAW included social media posts, provider education, digital displays, and/or go-live with a new antimicrobial policy. Top three barriers to ASP advancements were financial considerations (n=9), competing responsibilities for ASP leads (n=7), and tied for third was personnel shortages (n=6) and other clinical initiatives with higher priority (n=6).

Conclusion

Public Health Departments can facilitate assessment of ACH ASPs within their jurisdiction to identify ways to advance the ASP agenda and combat AMR. A variety of strategies were used by Chicago ACHs to promote ASP initiatives during USAAW. Challenges continue with inadequate funding, especially in outpatient settings.

Disclosures

All Authors: No reported disclosures
141. A Blind Spot for Antibiotic Stewardship Programs: Misadministration of Perioperative Antibiotics
Authors: Boton Noah , Patel Payal K , Kendall Ronald E , Hershey Cheryl , Jarzebowski Mary
Published: December 2021

Background

Hospitalized patients requiring intravenous antibiotics frequently undergo surgical intervention. These surgeries involve multiple transitions of care that may lead to antibiotic delay, additional unnecessary doses, omission, or substitution. While many studies examine the use of antibiotics for surgical site infection prophylaxis, there are no studies investigating antibiotic use in the perioperative period for inpatients already on an IV antibiotic regimen. This study examined the incidence and nature of antibiotic misadministration in the perioperative period among inpatients.

Methods

We conducted a retrospective cross-sectional study at a Veterans Affairs Medical Center involving all inpatients who underwent surgery in 2019. Patients 18 years or older who were on an IV antibacterial regimen prior to surgery were included. Patients undergoing cardiac surgery and patients only receiving surgical infection prophylaxis were excluded. Through manual chart review, we collected information on the prescribed IV antibiotic regimen and timing of antibiotic doses in the perioperative period. Errors were classified as administration of additional unnecessary IV antibiotics and missed, delayed, and additional doses of prescribed IV antibiotics.

Results

There were 168 inpatients on an IV antibiotic regimen who underwent surgery in 2019. Complete data was available for 158 patients. Errors in antibiotic administration in the perioperative period were identified in 64 (41%) patients. Missed, delayed, additional unnecessary antibiotics, and additional doses of prescribed IV antibiotics were identified in 21 patients (13%), 14 patients (9%), 13 patients (8%), and 7 patients (4%), respectively (Figure 1).

Conclusion

We found errors in antibiotic administration for inpatients undergoing surgery to be common, with the most frequent error being a missed dose of a prescribed IV antibiotic. This illustrates an area for quality improvement in inpatient antibiotic stewardship in our hospital and we suspect in other hospitals as well. Future work will incorporate more centers and examine how these errors affect outcomes for inpatients undergoing surgery, particularly in patients with sepsis or those requiring surgery for infection source control.

Disclosures

All Authors: No reported disclosures
148. Implementation of Restriction Criteria within an Electronic Medical Record and Its Impact on Carbapenem Prescribing
Authors: Naderi Mandana , Welker Kimberly , Chan Gary , Nix David
Published: December 2021

Background

Carbapenem restriction criteria (CRC) were developed by our health system to conserve the prescribing of these broad-spectrum agents. The purpose of this study was to compare pre and post EMR implementation of adherence to the system-approved CRC and if there was an association with decreased utilization of carbapenems.

Methods

A retrospective cohort review from January 2018 to June 2020 was performed via the Cerner EMR at 3 community hospitals in Arizona (AZ) and California (CA) to determine if CRC was appropriate at time of carbapenem initiation. Admitted patients > 18 years prescribed meropenem or ertapenem and received at least one dose were included. Health System approved CRC are shown in Table 2.

Results

A total of 160 patients were analyzed, including 60 pre-EMR CRC intervention and 100 post intervention. Forty-five patients (28%) had a documented history of ESBL infection as shown in Table 1. Figure 1 shows carbapenem utilization over the study period. An interrupted time series analysis was performed for both AZ and CA. After correcting for pre-intervention trends, AZ days of therapy (DOT) decreased by 6.2 DOT per 1000 patient days within 1 month post intervention (23%, p< 0.0001); the model predicted a further drop of 0.6 DOT per 1000 patient days per month over the 6 months post intervention. The CA DOT decreased by 1.2 DOT per 1000 patient days 1 month post intervention (17%, p= 0.28), with a predicted further drop of 0.28 DOT per 1000 patient days per month over the 6-month period post intervention. Post implementation retrospective review as described in Table 2 aligned with EMR restriction criteria selection for 68% of patients; interfacility differences occurred with 96% of CA reviews supported by criteria and 59% of AZ reviews supported by criteria (p= 0.0025).

Conclusion

This analysis supports that implementation of an EMR tool is an effective intervention to decrease unnecessary carbapenem use at the time of prescribing. The ESBL rate was similar pre and post intervention which may indicate that decreases in DOT were not due to a difference in MDRO rate. This study also highlights the different baseline antibiotic prescribing practices that may exist between facilities.

Disclosures

All Authors: No reported disclosures
153. Utilization of Post-Exposure Prophylaxis to Prevent Lyme Disease in a Large US Healthcare Database
Authors: Marx Grace E , Fuller Candace C , Haug Nicole , Martin Dave , Corey Catherine , Beck Alyssa , Schwartz Amy M , Hinckley Alison F
Published: December 2021

Background

In the United States, at least 50,000 emergency department visits for tick bite and an estimated 476,000 Lyme disease diagnoses occur annually, with incidence of both high among children. The majority of these healthcare visits occur in the northeastern and midwestern states having high Lyme disease incidence and during the summer and fall months, corresponding to peak opportunities for exposure to blacklegged ticks. Post-exposure prophylaxis (PEP) with a single dose of doxycycline can effectively prevent Lyme disease after a tick bite that is high risk for transmission of Lyme disease. We describe characteristics of patients with dispensings of single-dose doxycycline in a large US-based system that includes patients enrolled in private and public health insurance plans.

Methods

Single-dose doxycycline (≤200 mg) dispensings during January 2009 – February 2020 were identified for patients enrolled in seven Data Partners that contributed electronic healthcare data to the Food and Drug Administration Sentinel Distributed Database, including large national insurers, an integrated delivery care network, a state Medicaid, and the 100% Medicare fee-for-service plan. We examined patient and PEP dispensing characteristics by patient age, state of residence, and month of dispensing.

Results

We identified 408,897 patients with PEP (n=474,414 total dispensings) with a mean age of 60 years at first dispensing. Overall, there were 21 patients per 10,000 eligible members with PEP dispensings. Dispensings were less common in children (< 1 and 4 patients per 10,000 eligible members aged < 8 and 8-18 years, respectively). Most dispensings (72%) occurred in states with high incidence of Lyme disease. Seasonality of dispensings was bimodal, with most occurring during April – July and October – November (71 – 83%, by year).

Conclusion

Lyme disease PEP was relatively common and mirrored geographic and seasonal trends observed for ED visits for tick bites and Lyme disease diagnoses. However, we observed more PEP among older adults, and few dispensings among children. Despite healthcare visits for tick bites and Lyme disease occurring disproportionately among pediatric age groups, PEP appears to be underutilized in children.

Disclosures

All Authors: No reported disclosures
162. Duration of Antibiotics Through Care Transitions: A Quality Improvement Initiative
Authors: Soto Caitlin , Dzintars Kate , Dzintars Kate , Keller Sara C
Published: December 2021

Background

Antibiotic resistance is increasing worldwide, largely driven by excessive antibiotic use. Antibiotic stewardship (AS) interventions have traditionally focused on acute care, long-term care, and ambulatory settings. However, as patients transition from one care setting to another, AS interventions should address antibiotic orders (agent, dose, duration) between the hospital and the home. The purpose of this study is to determine the appropriateness of a total course of antibiotics, including inpatient and outpatient prescriptions, to aid in prioritizing AS interventions.

Methods

A single-center, retrospective study was performed to evaluate antibiotic duration for adult patients discharged from a large quaternary-care academic hospital. All antibiotic prescribing data, including pre-admission, during admission, and after hospital discharge, as well as information on indication, was collected from the electronic medical record. Descriptive statistics were used to summarize the data collected.

Results

196 patients were included in the study. There were 100 instances of disagreement on antibiotic indication between the discharge summary and reviewer. However, 70% of patients were discharged on an appropriate antibiotic. The majority of patients (75%) were prescribed excess antibiotic days beyond guideline recommended total duration, and 68% of patients did not have appropriate duration of antibiotics post-discharge. Of those with excess duration, 31% were prescribed penicillins, 23% were prescribed cephalosporins, and 20% were prescribed trimethoprim/sulfamethoxazole. Excess antibiotic duration was associated most commonly with an unknown diagnosis (23%), a skin and soft tissue infection diagnosis (16%), and antibiotic prophylaxis (12%).

Conclusion

The results of this study showed that patients were often prescribed excess antibiotics at discharge, and the total duration of antibiotics from pre-admission to post-discharge were prolonged beyond guideline-recommended duration. Understanding the total duration of antibiotic prescription, including post-discharge and pre-admission durations, is key in assessing risk from antibiotics and targeting AS interventions.

Disclosures

Kate Dzintars, PharmD, Nothing to disclose
174. Development of a Machine Learning Prediction Model to Select Empirical Antibiotics in Patients with Clinically Suspected Urinary Tract Infection using Urine Culture Data
Authors: Kim Chungsoo , Park Rae Woong , Rhie Sandy J
Published: December 2021

Background

Increasing antimicrobial resistance and the emergence of superbugs are problems globally. Inappropriate empiric antibiotic use would be a reason to cause antibiotic resistance. However, it has been a challenge to prescribe empiric antibiotics as it is difficult to identify the causative organism beforehand. In this study, we aimed to develop a prediction model to estimate the risk of antibiotics resistance using urine culture tests.

Methods

The study population included adult patients who had at least one of the results from a urine culture test and antibiotic susceptibility tests (from ampicillin, ceftriaxone, ciprofloxacin, gentamicin, levofloxacin, nitrofurantoin, tetracycline, trimethoprim/sulfamethoxazole) on admission to Ajou University Medical Center. Outcomes were defined as a resistant or intermediate susceptibility. Candidate predictors were diagnosis, prescription, visit, laboratory, procedures of the study population. We split data to 75:25 for training and test. Lasso logistic regression (LLR), extreme gradient boosting machine (XGB), Random Forest (RF) were used as model algorithms. The models were evaluated by an area under the curve of receiver operator characteristics curve (AUROC), precision-recall curve (AUPRC), and its calibration. All codes are available in https://github.com/ABMI/AbxBetterChoice

Results

Total 33 covariates were selected for final prediction models. The RF showed the highest AUROC in the ceftriaxone and tetracycline models (0.823, 0.626, respectively). The XGB presented the highest AUROC for ciprofloxacin and nitrofurantoin (0.731, 0.706, respectively). The AUROC of RF and the XGB were the same in an ampicillin model (0.633). For gentamicin, levofloxacin, and trimethoprim/sulfamethoxazole, the AUROC of LLR was the highest (0.838, 0.831, 0.615, respectively). Among the models, the AUROC was the highest in the gentamicin model regardless of algorithms. All calibrations of the models were acceptable.

Conclusion

We developed prediction models with competing performances of discrimination and calibration. It would contribute to the proper selection of empiric antibiotics susceptible to those causative pathogens in hospitalized patients with a clinically suspected urinary tract infection.

Disclosures

All Authors: No reported disclosures
196. Increasing Bacteremia and Endovascular Infections due to Serratia marcescens: Implications for Evaluation and Treatment
Authors: Madeline McCrary L , Marx Ashley H , Schranz Asher J
Published: December 2021

Background

While Serratia marcescens can cause bloodstream infections (BSI), endocarditis or other endovascular infections are historically rare and typically due to injection drug use (IDU). Given the rise in IDU nationwide, and limited evidence for managing non-HACEK gram-negative endocarditis, we examined trends in the epidemiology of Serratia BSI and characterized management strategies.

Methods

Our study was a retrospective analysis of adults admitted to UNC Health, a hospital network in North Carolina, from Apr 2014 to Mar 2021 with Serratia bacteremia. We used EMERSE, a program that searches free text in clinical notes, to identify those with ‘Serratia’ and either ‘bacteremia’ or ‘endocarditis’. This helped identify patients with microbiology obtained at outside hospitals. We performed chart review to confirm the Serratia BSI and collect demographic and clinical data. We tabulated yearly hospitalizations (Apr 1 to Mar 31), proportions of endovascular infections (endocarditis, cardiac device, vascular grafts), and described demographics and treatment approaches.

Results

We identified 97 patients by EMERSE and included 66 in analysis (Fig 1). 21 (32%) had endovascular infections and 21 (32%) overall were due to IDU (Table). Endovascular infections and BSIs increased over the period (Fig 2). Until 2018-2019, there were 0-10 Serratia BSIs yearly. In the final year, there were 37, 13 (37%) of which were endovascular infections. While we did not limit to S. marcescens, no other species were seen. 59/61 (97%) isolates with 3rd generation cephalosporin susceptibility reported were sensitive. 17/21 endovascular infections were endocarditis. 10/17 (59%) patients underwent valve replacement and 8/21 (38%) received dual antibiotic therapy for ≥ 6 weeks. Of the 10 attending infectious diseases follow-up visit, 6 were prescribed oral suppressive antibiotics after parenteral therapy.

Figure 2. Serratia bloodstream infections (2014-2021)

Table 1. Characteristics of Serratia bloodstream infections

Conclusion

Serratia BSI and endovascular infections are markedly increasing, with a large component due to IDU. Given the high proportion of endocarditis, echocardiography may be considered for patients with Serratia BSI, particularly those with IDU or prosthetic material. Further studies are needed to confirm this phenomenon and to establish evidence for optimal management of Serratia endocarditis.

Disclosures

Asher J. Schranz, MD, United HealthCare (Other Financial or Material Support, Spouse provides scientific review)
201. Comparison of Bloodstream Infections Between Hospitalized Patients with and without COVID-19 Infection During the First Wave of the COVID-19 Pandemic in a Community Hospital in South Bronx: An Observational Study
Authors: Afzal Afsheen , Gomez Edgar , Guttierrez Victor Perez , Mon Aye Myat , Sarmiento Carolina Moreira , Khalid Amna , Polishchuk svetlana , Al-Khateeb Mohannad Al-Khateeb , Yusuf Mubarak , Yankulova Boyana , De Castro Yinelka Silverio , Pillai Anjana , Venugopal Usha , Feinstein Addi , LaFortune Alexander , Sittler Daniel , Hennessey Karen , Menon Vidya
Published: December 2021

Background

Comparative data on bloodstream infections (BSI) in hospitalized patients with and without SARS-CoV2 positive test is lacking.

Methods

A retrospective observational study comparing (BSI) with and without COVID-19 infection was performed was performed from Jan1- May 1, 2020. Patient demographics, clinical microbiological characteristics of infections, therapeutic interventions and outcomes was compared between the two groups.

Results

Of 155 patients with BSI, 104 were SARS-CoV2 PCR negative (N) while 51 were positive (Table 1). Majority of SARS-CoV2 positives (P) had ARDS (58.8%), required mechanical ventilation (73%), inotropic support (55%), therapeutic anticoagulation (28%), proning (35%), Rectal tube (43%), Tocilizumab (18%), and steroids (43%) (Table 2). BSI was higher in N with HIV (16.3% vs 3.9% p=0.027). Duration of antibiotic therapy (DOT) prior to BSI was significantly longer in P (15 days vs. 5 days, p < 0.0001) (table 2). In-hospital mortality was significantly higher among P with BSI (49% vs. 21% p < 0.0001). 185 BSI events were observed during the study period with 117 in N patients and 68 in P. Primary BSI was predominant (76%) in N while secondary BSI (65%) was common in P of which 50% were CLABSI. Median time from admission to positive culture was 0.86 days in N compared to 12.4 in P (p = 0.001). Majority of BSI in P were monomicrobial (88%) and hospital acquired (71%) when compared to N (p< 0.001). Enterococcus spp (28%), Candida spp(12%), MRSA (10%) and E.coli (10%) were predominant microbes in P compared to Streptococcus grp (16%), MSSA (14%), MRSA (13%) and E.coli (12%) in N (figure 1). Mortality from BSI was associated with COVID-19 infection (OR 2.403, p = 0.038), DM (OR 2.335, p = 0.032), Charlson comorbidity index >3 (OR 1.236, p = 0.004), and mechanical ventilation (OR 11.398, p < 0.001) on multivariate analysis.

Comparison of Microorganisms isolated in the BSI

X-axis represents the number of BSI events whereas the number at the end of each bar represents the percentage

Conclusion

Increased events of hospital acquired, secondary BSI (CLABSI) due to Enterococcus was observed in adult P compared to N. These patients were critically ill, developed BSI in the second week of hospitalization, had longer DOT prior to positive cultures and worse outcomes. Breakdown of infection control measures and inappropriate antimicrobial use during the surge could be contributory.

Disclosures

All Authors: No reported disclosures
205. Evaluating the Time to Oral Step-Down Therapy for Gram-Negative Bloodstream Infections Associated with a Genitourinary Source
Authors: Mulvey Nicole , Doan Thien-Ly , Nadi Lemar
Published: December 2021

Background

The transition to oral antibiotics in gram-negative bloodstream infections (BSI) can decrease length of stay, avoid central line access, and improve patient convenience. Some studies suggest that the bioavailability of the oral agent selected can impact outcomes. The purpose of this study was to determine when the most appropriate time to oral step-down is, and assess if the bioavailability of the agent selected impacts outcomes.

Methods

This retrospective observational chart review evaluated adult patients admitted to Long Island Jewish Medical Center during the study period of January 2019 – December 2019 with a gram-negative BSI from a genitourinary source. The primary objective was to assess if the time to oral step-down therapy impacts clinical success. Secondary objectives included assessment of if continued IV therapy or oral step-down impacts outcome measures including clinical failure, length of stay, and duration of therapy, and to compare high versus low bioavailability agents on treatment outcomes.

Results

A total of 130 patients were included, with 88 patients in the oral step-down group and 42 patients in the IV therapy only group. Clinical failure occurred in 10 patients in the oral step-down group, with 2 de-escalated in the 1-3 day range and 8 de-escalated in the 4-6 day range (p=0.29). There was no difference in clinical failure when the oral step-down group was compared to the IV therapy group (11 vs. 17%; p=0.41). The length of stay was significantly shorter in the oral step-down group (p< 0.0001), while the duration of therapy was shorter in the IV therapy group (p=0.0015). When comparing high and low bioavailability agents, there was no difference in the rate of treatment failure (p=0.74), length of stay (p=0.08), or duration of therapy (p=0.02).

Conclusion

There was no significant difference in outcomes if patients were de-escalated to oral therapy early versus late in their treatment course. Step-down to oral antibiotics led to decreased length of stay, and the bioavailability of the oral agent selected did not impact outcomes. This study demonstrates the safety and efficacy of prompt oral step-down for gram-negative bacteremia secondary to a genitourinary source which can have positive impacts on patient care.

Disclosures

All Authors: No reported disclosures
212. Measuring the Morbidity of Infectious Complications of the Opiate Epidemic: A Retrospective Cohort Study
Authors: Harvey Leah , Abdulkerim Hassen , Boudreau Jacqueline , Strymish Judith , Hyde Justeen , Gifford Allen , Branch-Elliman Westyn
Published: December 2021

Background

Many states have reported that the incidence of invasive bacterial and viral infections has risen alongside rates of opiate use and injection drug use. The aim of this exploratory project is to characterize the incidence of invasive bacterial infections (IBI) over time in a national Veteran population, describe screening for substance use among Veterans with IBI, and assess engagement in harm reduction services.

Methods

A national, multicenter, retrospective cohort of Veterans admitted to the Veterans Health Administration (VA) between 10/1/2008 – 9/30/2018 with a positive blood culture was created using electronic health record (EHR) data. Patients’ demographics, clinical characteristics, microbiologic cultures, prescription history, laboratory values, and administrative coding data were extracted from the EHR. All analyses were performed in Microsoft Excel.

Results

Among 5,158,137 inpatient admissions during the study period, we identified 257,926 unique patients with bacteremia (5.0%). The incidence of bacteremia/sepsis increased consistently during the study period, rising from 2.29 per 10,000 patient-days to 5.97 per 10,000 patient-days across the national VA healthcare system (Figure 1). Among Veterans with bacteremia, 17,436 (6.8%) had prior history of substance use and 24,927 (9.7%) had a history of hepatitis C virus infection. In 196,295 cases (76.1%), no urine toxicology screening was completed or the result was negative. 34,005 (13.2%) of patients with bacteremia had at least one urinary toxicology positive for opiates and of these, 6,173 (18.1%) had documentation of a prescription for either naltrexone or buprenorphine/naloxone prior to admission or on hospital discharge.

Conclusion

Similar to findings in other populations, the incidence of IBI has steadily increased within the national VA. Despite limited screening, a high proportion of patients admitted to the VA with IBI were found to have underlying substance use. Additional work, including increased screening, is needed to assess the uptake of evidence-based interventions, such as naloxone, and to identify optimal strategies for improving adoption of other harm reduction services in this population.

Disclosures

All Authors: No reported disclosures
249. Evaluation of 99 Radiologically-proven Osteomyelitis Cases
Authors: Kenanoğlu Olcay Buse , Quliyeva Gunel , Yamazhan Tansu , Arda Bilgin , Taşbakan Meltem , Pullukçu Hüsnü , Sipahi Hilal , Aydemir Şöhret , Ulusoy Sercan , Sipahi Oğuz Reşat
Published: December 2021

Background

Herein we aimed to evaluate osteomyelitis cases in our setting.

Methods

We evaluated the hospital records of patients with osteomyelitis between January 2013 and December 2020 retrospectively. Osteomyelitis was confirmed by direct radiography or magnetic resonance imaging or pathology. Demographic features, risk factors, clinical/laboratory findings, treatment response and mortality rates were evaluated. Clinical response was defined as (resolution of clinical signs including fever and purulent discharge and other symptoms) and/or negative culture at the end of antimicrobial therapy.

Results

Patients were 33 female, aged 29–85 years (mean 59±12.6). Fourty nine of the patients were diabetic foot infection, 30 were spondylodiscitis, eight were primary, seven were post-traumatic, and five were post-surgical osteomyelitis. Overall 62 patients had diabetes mellitus and 16 patients had chronic renal failure. Peripheral arterial disease, neuropathy, diabetic retinopathy and venous insufficiency rate in the DM subgroup is shown in table. Fever was present in 24.2% of the cohort. İncreasing of CRP was in 95,9%, erythrocyte sedimentation rate in 83,9%, and leukocytosis in 37.3%. The radiological findings of osteomyelitis were detected via magnetic resonance imaging in 73 patients. Etiology in biopsy cultures were elucidated in 59.5% and the most common pathogen was S. aureus (30%) Table1. The most common empirical treatment regimens were tigecycline in 27 patients, ampicillin/sulbactam in 19 patients and ceftriaxone+teicoplanin in 12 cases. Duration of treatment was 36,2±17.3 days (range 6-104 days). Overall, clinical response was obtained in 91.9%. Fifty patients were performed surgical procedure + antibacterial treatment, clinical response was 96% (p:0.091). Surgical debridement could be performed in 22 patients, clinical response was obtained in all (p:0.193). Thirteen patients developed recurrence within one year. Sixty-seven patients received oral consecutive treatment after discharge. In hospital mortality rate was 2/99 (2,02%).

Conclusion

Despite surgical debridement and/or developed antimicrobial treatment, approximately 1/5 of osteomyelitis cases required further treatment Further interventions seem to be needed to reach better outcomes.

Disclosures

All Authors: No reported disclosures
259. Impact of a Multiplex Meningitis and Encephalitis PCR on the Management of CNS Infections in Adults and Children, Houston, Texas
Authors: Aguilera Elizabeth A , Simar Shelby , Wootton Susan H , Hasbun Rodrigo , Hasbun Rodrigo
Published: December 2021

Background

The majority of adults and children with meningitis and encephalitis have unknown etiologies fostering universal admission, prolonged length of stay, empirical antibiotic and antiviral therapies. A qualitative multiplexed nucleic acid-based in vitro diagnostic test (FilmArray) is helping clinicians identify organisms and improve clinical outcomes.

Methods

Patients presenting between July 5, 2018, to April 26, 2021, with meningitis or encephalitis, cerebrospinal fluid (CSF) with WBC >5 cells/mm3, and leftover CSF were available for testing. All CSF specimens underwent testing with the Biofire® Film Array Meningitis Encephalitis (FAME) panel. This multiplex PCR tool utilizes 0.2 ml CSF sample to identify the presence of 14 viral, bacterial and fungal pathogens in 1 hour.

Results

Of 5291 CSF specimens screened, 285 (5.3%) met the criteria for meningitis or encephalitis and underwent FAME testing. The majority were adults (240, 84.2%), male (147, 51.5%), White (111, 38.9%), immunocompetent (213, 74.3%) and (212, 74.3%) had meningitis presentation. Median age was 41 years (0 mo-100 yrs) and (283, 99.2%) were admitted to the hospital. Median duration between CSF collection and viral PCR result as 13 hrs for Enterovirus, 31 hrs for HSV, and 57 hrs for VZV. The FAME panel detected a pathogen in 103 patients (36.1%) of whom 76 (73.7%) had a viral etiology. 166 (58.2%) patients were discharged with unknown etiology of whom FAME was positive in 24 (14.4%) [VZV (37.5%), HSV2 (16.6%), Enterovirus (16.6%), Haemophilus influenzae (8.3%), HHV6 (8.3%), Streptococcus pneumoniae (8.3%) and HSV1 (4.1%)]. The addition of the FAME panel to the standard of care evaluation increased the known etiologies from 119 (41.7%) to 197 pathogens (69.1%), (p< 0.05). 52 patients (18.2%) underwent a repeat LP (30, 57.6% done for additional testing). Empirical antibiotic and antiviral therapy were given to 89% and 63% of patients, respectively.

Conclusion

A rapid multiplex PCR decreases the proportion of unknown etiologies and has the potential to decrease length of stay and the use of empirical antibiotic and antiviral therapies. Testing with the FA ME panel resulted in pathogen detections not previously recognized and for which treatment is recommended.

Disclosures

Rodrigo Hasbun, MD, MPH, Biofire (Speaker’s Bureau) Rodrigo Hasbun, MD, MPH, Biofire (Individual(s) Involved: Self): Consultant, Research Grant or Support
269. A Review of Gram Negative Endogenous Endophthalmitis at University Hospital in Newark
Authors: Salazar Hernando , Ye Catherine , Schott Brian , Riddle Kristin R , Finkel Diana
Published: December 2021

Background

Endophthalmitis (EO) is an ocular emergency characterized by intraocular inflammation, usually in response to infection. While most cases are exogenous, gram negative (GN) EO account for 10-24% of all cases, and endogenous EO (EEO) account for 2-8% of all cases. Risk factors for EEO include diabetes mellitus (DM), IV drug use, and indwelling catheters. Major sources of infection are urinary tract infections (UTI), liver abscesses, pneumonia, and bacteremia. Common pathogens include K. pneumoniae, P. aeruginosa, and H. influenzae. Outcomes are poor, with only 20% of patients achieving improved visual acuity, and 30-40% requiring enucleation.

Methods

Retrospective analysis was performed on patients diagnosed with EO (n=89) at University Hospital in Newark from January 2016 to December 2020 using ICD-10 codes H44.0-H44.009, H44.1, and H44.19. Patients included were 18 years of age or older with culture proven GN endogenous EO (GNEEO) (n=7). Outcomes included anatomical success, functional success, and mortality at 28 days and 3 months.

Results

7 of 89 patients met criteria for GNEEO (median age 67, 4 males, 71.4% Hispanic/Latino). Comorbidities included hepatobiliary disease (57.1%) and DM (42.9%). All 7 patients presented with ocular symptoms and 3 had non-ocular symptoms. Primary sources of infection included UTI, prostate abscess, and pneumonia/empyema. Eye cultures identified Pseudomonas in 4 patients and Klebsiella in 3 patients. Mean antibiotic length was 17.7 days with 6 patients receiving intravitreal antibiotics. Enucleation was performed in 3 patients. 2 patients had functional success and 4 had anatomical success, with 0 mortality at 28 days and 3 months.

Table 1. Ocular symptoms on presentation of cases of gram negative endogenous endophthalmitis

Table 2. Positives cultures obtained from cases of gram negative endogenous endophthalmitis

Conclusion

Although rare, GNEEO causes significant morbidity, with only 2 recovering visual acuity and 3 requiring enucleation. Risk factors, sources of infection, and microbes were all consistent with those in previous reports. Hepatobiliary disease and DM were the most prominent risk factors while sources of infection included UTI and empyema. Eye cultures were positive for K. pneumoniae and P. aeruginosa, two common pathogens previously identified. This case series highlights the importance of prompt recognition and initial treatment of GNEEO with empiric coverage that includes vancomycin and ceftazidime.

Disclosures

All Authors: No reported disclosures
276. SARS-CoV-2 Infection in Solid Organ Transplant Candidates and Recipients at Texas Children’s Hospital: A Retrospective Review
Authors: Petters Leanne , Munoz Flor M , Bocchini Claire , Moulton Elizabeth A , Ruderfer Daniel
Published: December 2021

Background

Texas Children’s Hospital (TCH) is the largest pediatric solid organ transplant (SOT) program in the US, performing heart, kidney, liver, and lung transplants. Limited data exists about SARS-CoV-2 infection (COVID-19) in the pediatric SOT populations. We evaluated the impact of COVID-19 in a cohort of PCR positive SOT candidates and recipients. We hypothesized that COVID-19 would more severely impact SOT recipients compared to transplant candidates.

Methods

Patients with SOT or transplant candidates at TCH with a positive SARS-CoV-2 RT-PCR test since March 1, 2020 to April 12, 2021 were included in the cohort. Retrospective medical record review was performed, and descriptive statistics were used.

Results

A total of 103 SOT patients were identified, 13 candidates and 90 recipients. Of the SOT candidates, there were 1 heart, 3 kidney, and 9 liver transplant candidates. The SOT recipient cohort included 33 heart, 6 lung, 20 kidney, 33 liver and 2 multi-visceral recipients. A significant difference in age was observed between candidates and recipients with candidates being younger with median age of 4.5 years as opposed to recipient’s median age of 12.8 years (p=0.0003). The majority of patients, 70 of 101 (69%), were symptomatic. Most common symptoms reported were fever in 34/70 (49%), cough in 31/70 (44%), and headache in 19/70 (27%). A higher percentage of candidates (31%, 4 of 13) were hospitalized for acute COVID-19 infection compared to (17%, 15 of 90) of recipients. A transplant candidate who ultimately died from underlying illness and COVID-19 was the only patient in the cohort who required mechanical ventilation. More deaths (2/13, 15%) occurred in transplant candidates with COVID-19 compared to transplant recipients with COVID-19 (1/90, 1%, p=0.04); however, 2 of the deaths occurred after recovery from acute COVID-19 illness.

Conclusion

Our study suggests that pediatric candidates who are actively listed for transplant with underlying conditions have more severe acute COVID-19 illness than pediatric SOT recipients despite their immunosuppression based on the higher mortality observed in the transplant candidates. Prospective studies are needed to better understand which specific patients are at increased risk for mortality from COVID-19.

Disclosures

Leanne Petters, MSN, APRN, CPNP-AC, Pfizer (Scientific Research Study Investigator) Flor M. Munoz, MD, Biocryst (Scientific Research Study Investigator)Gilead (Scientific Research Study Investigator)Meissa (Other Financial or Material Support, DSMB)Moderna (Scientific Research Study Investigator, Other Financial or Material Support, DSMB)Pfizer (Scientific Research Study Investigator, Other Financial or Material Support, DSMB)Virometix (Other Financial or Material Support, DSMB) Elizabeth A. Moulton, MD, PhD, Pfizer (Scientific Research Study Investigator)