bluuebunny/crossref_metadata_2025 huggingface dataset:
935. Antibiotic Use (AU) Adjustment by Infection-Related Patient Volume Across a Health System
Authors: Spires Steven Shaefer , Dodds Ashley Elizabeth , Jones Travis M , Dyer April , Nelson Alicia , Anderson Deverick J , Johnson Melissa D , Zurawski Christine , Parker Todd , Moehring Rebekah W , Master Moiz , Diaz Melina , Corry-Wiggins Oida , Davis Angelina
Published: December 2022

Background

Benchmarking AU is important to identify opportunities and allocate resources within a health system. Patient level factors such as infection diagnosis codes further refine risk adjustments but have not been more widely adopted because of the burden of accurately collecting and submitting granular data. The goal of this study was to evaluate a novel metric to estimate facility-level infection burden as a potential factor to use in adjustment of AU.

Methods

We conducted a retrospective analysis of hospital administrative data (for calendar year 2020) from 8 hospitals in a single health system using a common electronic health record and coding department. We identified inpatient encounters with an infection-related primary ICD-10 code (I-PDX), based on the health system’s coding department determination and extracted the length of stay (LOS) for each encounter. For any encounter with an I-PDX, the entire LOS was classified as infection-related patient days (IPD). Overall AU in days of therapy (DOT) was adjusted using two novel infection diagnoses denominators. The first was based on proportion of total patient days (PD) attributable to I-PDX encounters (% I-PDX x PD). Since LOS tends to be longer in I-PDX, we also calculated DOT with adjustment for actual extracted IPDs. We then rank ordered study hospitals based on standard DOT / 1,000 PD, NHSN SAAR metrics, and our novel DOT / (% I-PDX x PD) and DOT / 1,000 IPD metrics.

Results

The proportion of I-PDX was highly variable among hospitals, with a system-wide median of 37.27% (range 23.48 - 43.32) (Figure 1). Using DOT / 1,000 patient days for 1 year, Hospital A was the lowest in the system and hospital H was the highest (Figure 2). However, after adjusting for the proportion of patients with I-PDX encounters and IPDs, hospital rank changed considerably, i.e. Hospital H and C respectively ranked lowest and Hospital A was highest.

Conclusion

These novel infection diagnoses PD denominators more closely associated facility level infection burden with AU, for a more refined rank order within the health system. These metrics provide an example of a parsimonious adjustment using patient level data that is already collected at any facility. Next steps might include indirect standardization using PDX categories and other patient level factors readily collected.

Disclosures

Melissa D. Johnson, PharmD, Charles River Laboratories: Grant/Research Support|Entasis: Honoraria|Merck: Grant/Research Support|Pfizer: Grant/Research Support|Scynexis: Grant/Research Support|Theratechnologies: Grant/Research Support|UpToDate: Honoraria Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties Angelina Davis, PharmD, M.S., Merck & Co.: Honoraria.
973. Clinical Outcomes and Resource Utilization in Children Who Develop Acute Kidney Injury Following Vancomycin Use for Treatment of MRSA Bacteremia and Acute Hematogenous Osteomyelitis
Authors: Challa Lasya , Challa Lasya , Ma Yuhan , Jo Chan-Hee , Copley Lawson Ashley
Published: December 2022

Background

Children with acute hematogenous osteomyelitis (AHO) and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia are often treated with vancomycin (vanc) with risk of nephrotoxicity. This study evaluates resources used, and outcomes, of children with or without acute kidney injury (AKI) when vanc is used in this setting.

Methods

Children with AHO and MRSA bacteremia treated with vanc from 2009 to 2019 were retrospectively studied. AKI was assessed by chart review, for clinical diagnosis and by Kidney Disease Improving Global Outcomes (KDIGO) criteria. Cohorts of children with or without KDIGO AKI were compared for differences of illness severity, treatment, resource utilization, and outcomes. Multivariate logistic regression analysis was accomplished to identify factors associated with risk for AKI. Cost analysis was performed using Pediatric Health Information System (PHIS) and Healthcare Cost and Utilization Project (HCUP) databases.

Results

Among 631 children with AHO, 85 children with MRSA bacteremia were treated with vanc for a sufficient duration to allow trough measurements. Of these, 14 (16.5%) had chart-diagnosed AKI, whereas 24 (28.2%) children met KDIGO criteria. Children with AKI had more febrile days and higher rates of thrombosis. They had longer duration of vanc treatment (8 vs 5 d) and higher troughs (27.8 vs 17.5 mg/L). The AKI group had more blood cultures, vanc troughs, creatinine levels, and longer length of stay (LOS; 19.9 vs 11.1 days). Multivariate analysis revealed that maximum vanc trough level (odds ratio 1.05) with a cutoff of 21.7 mg/L was a significant predictor of AKI.

PHIS data of 3,133 children with AHO treated with vanc identified 75 (2.4%) with AKI who had significantly longer LOS (13 vs 7 d) and higher billed charges ($117K vs $51K) than children without AKI. HCUP data of 13,223 children with AHO identified 384 (2.9%) with AKI who had longer LOS (27 vs 6 d) and higher billed charges ($317K vs $37K) than those without.

Conclusion

Clinical diagnosis of AKI (16.5%) grossly underestimated the KDIGO occurrence (28.2%) in our population. This study showed vanc associated AKI results in significant increases in resource utilization and healthcare costs. A high vanc trough >21.7 mg/dL is a significant contributing factor to AKI.

Disclosures

All Authors: No reported disclosures.
974. Correlation of Magnetic Resonance Imaging (MRI) and Bone Histopathology in the Diagnosis of Foot Osteomyelitis in Diabetic Patients.
Authors: Mishra Abhay , Bamberger David , Cheng An-Lin , Steigerwalt Kristy
Published: December 2022

Background

Inaccurate diagnosis of osteomyelitis (OM) in the setting of foot infection may lead to inappropriate therapy. Recommended imaging to discern OM is magnetic resonance imaging (MRI), but studies have shown varied sensitivity and specificity. The goal of our study is to determine the accuracy of MRI by comparing with bone biopsy histopathology.

Methods

Retrospective chart review of adult patients with diabetes mellitus and foot infection with concern for OM. They had MRI with contrast and subsequent bone biopsy, resection or amputation with histologic examination. A second, blinded musculoskeletal radiologist reviewed all reports in which there was diagnostic uncertainty.

Exclusion criteria: foot tumor or recent foot surgery or injury.

Results

63 eligible patients with 87 episodes of foot infection (50 males, 13 females, mean age 55 years) met study criteria. Time gap between biopsy and MRI was mean 6 days (range 0 to 23 days). 72 MRIs were positive (including 7 highly suspicious MRI reads), 11 negative and 4 indeterminate. 53 of the histologic results were positive for OM and 34 were negative. Two scenarios were created by placing 4 indeterminate MRI reads as positive in scenario 1 and negative in scenario 2.

In scenario 1, there was only 1 false negative MRI but 24 false positives. In scenario 2, there were 2 false negative MRI and 21 false positives.

Out of 74 bone specimens of those not on recent antimicrobial therapy, bone cultures were positive for pathogenic organisms on 22 specimens without histologic evidence of OM.

Conclusion

In both the above scenarios, sensitivity was high. Specificity was found to be lower than the reported specificity of MRI in the diagnosis of diabetic foot OM, which has been reported as 40% to 100%. Our data demonstrate that MRI is useful to rule out OM if negative but performs poorly in ruling in OM. Bone specimen for histopathology is essential to confirm the diagnosis. Bone culture is helpful to guide antimicrobial therapy rather than diagnosing OM. Prospective studies are warranted.

Disclosures

All Authors: No reported disclosures.
977. Effect of Antibiotic Administration Prior to Bone Sample Obtainment on Bone Culture Yields in Diabetic Foot Osteomyelitis
Authors: Zmarlicka Monika , Bangart Ryan , Roth Bryan J , Quan Asia N , Bhattarai Bikash , Hartmann Carlos , Kassis Christelle
Published: December 2022

Background

Optimal timing of bone culture obtainment relative to antibiotic initiation in diabetic foot osteomyelitis is unknown. This study aims to determine whether antibiotic administration prior to bone sample collection affects microbiological yield.

Methods

This was a single-center retrospective study. Patients at least 18 years old admitted for diabetic foot osteomyelitis management were included. Patients included in the study had an evaluable bone sample and met the following criteria: presence of imaging demonstrating osteomyelitis, documentation of wound probing to bone, or visible bone in wound; plus an elevated erythrocyte sedimentation rate or elevated C-reactive protein. Patients included also received at least one dose of antibiotics during the hospitalization. Patients with necrotizing fasciitis and those who left against medical advice were excluded.

Results

One hundred and fifteen patients were included; 78 received antibiotics prior to bone sample obtainment (prior group), and 37 received antibiotics post sample obtainment (post group). Average time from admission to bone sample obtainment in the prior group was 1.8 ± 2.1 days and 1.1 ± 1.0 days in the post group. There was a non-significant difference in microbiological yields between the two groups (78.2% vs 75.7%, p = 0.762). Further examining the prior group, the average time between the antibiotic initiation and bone sample obtainment was not significantly different between those who had microbiological growth versus those who did not (2 ± 1.4 versus 1.6 ± 2.3 days [p = 0.0942]). Logistic regression analysis did not show association of microbiological yield with any of the following variables: peripheral vascular disease, end-stage renal disease, biopsy type (bedside vs open), type of osteomyelitis (acute vs chronic vs acute-on-chronic), antibiotic use prior to admission, or types of antibiotics administered.

Conclusion

Our data suggests that approximately two days of antibiotics prior to bone biopsy does not affect microbiological yield on cultures. Bone samples were obtained expeditiously within our cohort, which may account for the lack of difference seen. Further studies are needed to better define the duration of antibiotic therapy at which a difference in bone culture yields will be expected.

Disclosures

Asia N. Quan, PharmD, BCPS, BCCCP, Shionogi: Honoraria|Trevena: Honoraria Carlos Hartmann, MD, Viiv Pharmaceuticals: Speaker.
978. Effectiveness of oral cephalexin as completing treatment for bacteremic vertebral osteomyelitis caused by Methicillin-susceptible Staphylococcus aureus
Authors: Okumura Nobumasa , Hayakawa Kayoko , Yamamoto Kei , Yamada Gen , Mezaki Kazuhisa , Ohmagari Norio
Published: December 2022

Background

Methicillin-susceptible Staphylococcus aureus (MSSA) is the most common causative microorganism of pyogenic vertebral osteomyelitis (VO). Oral antimicrobial therapy with first-generation cephalosporins can treat MSSA infection, but data on pyogenic VO are scarce.

Methods

This retrospective study included adult patients treated with oral cephalexin as the completing treatment for pyogenic VO with bacteremia due to MSSA at the National Center for Global Health and Medicine Hospital, Japan from 2012 to 2020. Treatment effectiveness of cephalexin was evaluated by comparing the improvement in symptoms and laboratory and imaging results after intravenous (IV) administration of antimicrobial agents and after oral cephalexin treatment, using a 5-point scale (Table). A score of 4 or 5 indicated treatment success.

Results

This study included 15 patients (8 [53%] females), with median age 75 years (interquartile range [IQR], 67.5–80.5), median body weight 57.0 kg (IQR, 45.5–62.5), and median Charlson comorbidity index score 2 (IQR, 0–4). Ten patients (67%) had lesions in the lumbar spine. Six patients had lesions at multiple sites (cervical and thoracic, n=1; cervical and lumbar, n=2; thoracic and lumbar, n=1; and lumbar and sacral, n=2). Twelve patients (80%) had spinal abscesses and four (27%) had remote abscesses, but none had concomitant endocarditis. In 11 patients with normal renal function, 1,500–2,000 mg/day of cephalexin was administered. Surgical intervention was performed in five cases (33%). The median duration of IV antibiotics, cephalexin, and total treatment was 36 (IQR, 32–61; range, 21–86), 29 (IQR, 19–82; range, 8–251), and 86 (IQR, 59–125; range, 37–337) days, respectively. Majority patients (≥80%) received either cefazolin or ceftriaxone as IV therapy. Two patients used oral antimicrobials other than cephalexin outside of the cephalexin treatment period. Treatment success rate after cephalexin therapy was 87%. None of the patients had recurrence during a median follow-up of 119 days (IQR, 48.5-350).

Conclusion

In patients with bacteremic VO due to MSSA, completing treatment with cephalexin is a reasonable option, even in cases with spinal abscess, if at least 3 weeks of effective IV antimicrobial therapy is provided.

Disclosures

All Authors: No reported disclosures.
982. Microbiologic Composition and Failure Rates of Prosthetic Hip and Knee Infections Managed with Debridement, Antibiotics and Implant Retention.
Authors: DeBiase Joseph M , Day Shandra R , Smith Jessica M , Agnello Sydney
Published: December 2022

Background

Success rates of prosthetic joint infections (PJI) managed by debridement, antibiotics, and implant retention (DAIR) vary according to recent literature. Our aim is to evaluate the success/failure rate of PJI managed by DAIR with respect to the microbiologic composition, antimicrobial selection, and treatment duration.

Methods

A single-center retrospective cross-sectional study was conducted from January 2017 to December 2021. All patients ≥ 18 years of age who underwent DAIR were identified from an existing internal database. Patients were included if they received at least 3 weeks but no more than 8 weeks of parenteral therapy with or without consolidative or chronic therapy. Data collection was completed via chart review including demographics, microbiologic data, antimicrobial therapy and outcomes. Failure was defined as any subsequent need for surgical intervention, infection related mortality, persistent infection, new infection, or probable treatment failure measured at a minimum of two year follow up from index DAIR.

Results

A total of 49 patients were included (15 hip, 34 knee) with 21 failures (43%) and 28 in remission (57%). Table 1 shows the breakdown of cases including time to PJI from index procedure, duration of symptoms prior to DAIR procedure, chronic antibiotics, and microbiologic composition. DAIR procedure occurred < 3 weeks from onset of symptoms in 43 patients (88%) but no observed difference in outcomes was seen based on patient’s time to PJI or symptoms duration. Staphylococcus aureus was the most common pathogen identified, n=14 (29%) and encompassed 43% of the total failures. Mean antimicrobial therapy was 42 and 180 days for parenteral and oral respectively with 17 (35%) patients on chronic/indefinite therapy. Of the failures, 48% occurred while on parenteral therapy. Need for further surgical intervention was the leading cause of failure at 37%.

Conclusion

Despite early intervention, our study found a failure rate of 43% in patients with knee and hip PJI managed with DAIR. We observed similar success rates across multiple organisms and antimicrobial treatments. Further evaluation of failure cases would help to inform which patients are the best candidates for DAIR procedures.

Disclosures

All Authors: No reported disclosures.
986. Pseudomonas Prosthetic Joint Infections: Is there a role for monotherapy?
Authors: Kim Billy I , Schwartz Andrew , Wixted Colleen M , Prado Isabel P , Polascik Breanna , Hendershot Edward F , Jiranek William A , Seidelman Jessica , Seyler Thorsten M
Published: December 2022

Background

Pseudomonas species are a less common but devastating pathogen family in prosthetic joint infections (PJI). Despite advancements in management, Pseudomonas PJI remains particularly difficult to treat due to fewer antibiotic options and robust biofilm formation. The purpose of this study was to better evaluate outcomes after Pseudomonas PJI treatment.

Methods

All hip or knee PJIs, at a single institution, with positive Pseudomonas culture were analyzed. 51 patients (29 hips and 22 knees) meeting inclusion criteria were identified. The primary outcome of interest was infection clearance at 1-year after surgical treatment, defined as reassuring aspirate without ongoing antibiotic treatment or death within one year post-operatively. Monomicrobial and polymicrobial infections were evaluated separately.

Results

Among monomicrobial PJIs, ten (50.0%) patients were clear of infection at one year post-operatively. Patients treated with 2-stage exchange (n=11) had a 1-year clearance rate of 54.5% compared to 60.0% with DAIR (n=5) and 25.0% with resection or amputation (n=4). Two of six patients treated with fluoroquinolone monotherapy met 1-year infection clearance, despite fluoroquinolone sensitivity, compared to four of five patients meeting 1-year clearance when treated with combined intravenous and oral therapy for at least 6 weeks. Resistance to anti-pseudomonal agents was infrequent (20%, n=4/20), and three of ten mono- and polymicrobial PJI patients with recurrent Pseudomonas PJI developed resistance to anti-pseudomonal therapy. Polymicrobial infections were the most common presentation (54.9%) of Pseudomonas positive PJI with a mortality rate of 46.4% (n=13/28) at a median follow-up of 4.2 years [IQR: 3.4-5.7].

Conclusion

Despite surgical and antibiotic treatment regimens consistent with traditional treatment algorithms, our data portrays poor clearance rate of Pseudomonas PJI with relatively poor outcomes in patients treated with oral or intravenous monotherapy. Pseudomonas infections are difficult to eradicate and likely require deviations from classical therapeutic protocols to improve treatment success.

Disclosures

William A. Jiranek, MD, Biomech Holdings LLC: Stocks/Bonds|DePuy, A Johnson & Johnson Company: IP royalties Thorsten M. Seyler, MD, PhD, Heraeus: Paid consultant|Pattern Health: IP royalties|Restor3d: IP royalties|Smith & Nephew: Paid consultant|Total Joint Orthopedics: Paid consultant|Zimmer: research.
989. Role of Bone Biopsy and Deep Tissue Culture for Antibiotic Stewardship in Diabetic Foot Infections
Authors: Hockney Sara M , Steker Danielle , Krueger Karen M , Bhasin Ajay , Williams Janna L , Galvin Shannon
Published: December 2022

Background

Bone biopsy is the gold standard for identifying the etiology of infectious osteomyelitis (OM) but is not always done in the setting of diabetic foot infections (DFIs), even in settings where resistant organisms are common. This study aimed to describe organisms most frequently identified on bone biopsy or deep tissue culture and determine how culture data impacted antibiotic management in patients with DFIs.

Methods

We retrospectively reviewed all patients admitted with a DFI between 2018 and 2020 and selected for patients diagnosed with infectious OM of the lower extremity for whom bone biopsy or deep tissue culture was obtained. Statistics were performed in R version 4.2.0.

Results

Of 305 patients with DFI, 47 patients received 41 deep tissue cultures and 29 bone biopsies for a total of 70 cultures. Of 45 (64%) positive cultures, 36 (80%) had gram positive organisms and 24 (34%) had gram negative organisms. Multidrug resistant organisms were isolated in 7 (14.9%) patients, including 5 cases of MRSA (10.2%) and 2 cases of ESBL-producing organisms (4.3%). Pseudomonas aeruginosa was isolated in 3 (6.4%) patients. Culture data resulted in antibiotic changes in 41 (87.2%) patients. Therapy was narrowed in 29 (61.7%) patients and broadened due to inadequate empiric coverage in 4 patients (8.5%). Culture-directed therapy was started in 4 (8.5%) patients in which it had initially been withheld. Culture data from 18 (40%) patients showed sensitivity to an oral treatment regimen with high bioavailability. There was no significant difference in rates of antibiotic utilization at discharge between patients who underwent bone biopsy or deep tissue culture relative to those who did not (80% vs 75%, p=0.857). There was a trend towards utilization of less MRSA coverage (38.2% vs 50.5%, p=0.16) and Pseudomonas coverage (34.0% vs 41.9%, p=0.36) in patients undergoing bone biopsy or deep tissue culture, but this did not reach statistical significance. Table 1:Bacteria isolated from deep tissue culture or bone biopsy and effect on antibiotic therapyFigure 1:Empiric antibiotics in hospital vs culture directed antibiotics on discharge

Conclusion

In patients with DFIs, deep tissue and bone biopsy cultures were infrequently obtained but resulted in targeted therapy changes in most patients. While culture data usually allowed for narrowing of antibiotics, it revealed inadequate empiric coverage in a subset of patients.

Disclosures

Janna L. Williams, MD, Abbvie: COVID19 Infection Prevention Consultant Shannon Galvin, MD, Gilead: Grant/Research Support.
993. “I feel like they’re actually listening to me”: A Pilot Study of Hospital Discharge-Decision Making for Patients with Injection Drug Use-Associated Infections
Authors: Thakarar Kinna , Kohut Michael R , Stoddard Henry , Burris Debra , Sikka Monica K , Solomon Daniel A , Kershaw Colleen , Eaton Ellen , Chessa Frank , Hutchinson Rebecca , Fairfield Kathleen , Friedmann Peter , Thomas J
Published: December 2022

Background

Conversation guides have the potential to transform care for patients hospitalized with injection drug use (IDU)-associated infections. This study’s objectives were to 1) pilot a structured conversation guide for hospital discharge decision making in patients with IDU-associated infections 2) investigate the guide’s feasibility and acceptability and 3) examine patient and provider experiences, patient outcomes, and lessons learned.

Methods

We developed a conversation guide and conducted semi-structured interviews with physicians and patients at a tertiary care center in Maine. We interviewed physicians after each piloted the guide with two patients. We interviewed patients less than one week after the conversation and again after 4-6 weeks. Two analysts indexed transcriptions and used the framework method to identify and organize relevant information. We conducted retrospective chart review to corroborate and contextualize qualitative data.

Results

Eight patients and four infectious disease physicians piloted the conversation guide. All patients (N=8) completed antimicrobial treatment and 88% were discharged on medication for opioid use disorder (Table 1). All providers and most patients stated that the conversation guide was important for incorporating patient preferences and antimicrobial treatment options. Patients appreciated more autonomy and their voices being included in their care. Providers felt the guide facilitated their understanding of patient values. Values and preferences between patients and providers were aligned. Participants identified the length of the guide, discussion of pain management, and addressing post-discharge needs such as housing as areas for improvement (Table 2).

Conclusion

The use of a conversation guide to inform hospital discharge decision making for patients with IDU-associated infections incorporates patient preferences and values into treatment decisions. While we identified areas for improvement, overall patients and providers believed that this novel conversation guide helped to improve patient care and autonomy.

Disclosures

Kinna Thakarar, DO, MPH, Maine Medical Center: Board Member|NIH: Grant/Research Support|University of New England: Board Member Monica K. Sikka, MD, F2G: Site research investigator Ellen Eaton, MD, MSPH, Gilead: Grant/Research Support.
1008. Implementation of Clinical Pathway for Management of Fever in Nursing Home Residents in Singapore
Authors: Smitasin Nares , Jagdishchandra Garvi , Salada Brenda Mae , Karunakaran Bindu , Fisher Dale
Published: December 2022

Background

Ageing population is a major health care problem all over the world. In Singapore, as of 2020, senior citizen (65 years and above) consists of 15.2 % of total population. By 2030, one in five Singaporeans will be more than 65 years old. Thus, nursing home (NH) is an important pillar of a health care system.

Nursing home staff are in the front line to manage common infections. However, the inexperience and the lack of guidance have led to inappropriate transfer to acute hospitals.

Infectious Diseases Community Program (IDCP) is the project to enhance partnerships with NHs. We work with NHs to develop, adapt, and implement appropriate processes related to infection control, prevention, and management. One of our objectives is the enhancement of assessment and appropriate evaluation of fever. The aim is to reduce the inappropriate admissions to acute hospitals.

Methods

Fever and desaturation pathway (figure 1) was developed by IDCP team. Six participating NHs adopted the pathway and trained their staff. The study was approved by NHG domain specific review board (DSRB). Hospital records were reviewed. We compared the rate of inappropriate admission from 2015-2017 which serve as a baseline and 2019-2020. The wash-out period was 2018 when NHs were implementing the pathway.

Inappropriate admission is defined as

< ! 1. Admission is against advanced care planning / preferred plan of care

or

2. Criteria in the pathway are not met on admission, 48 hours later and no other medical reason for admission. Figure 1

Results

Total number of fever transfers was 950 in 2015-2017 and 688 in 2019-2020. Number of inappropriate admissions was 115 in 2015-2017 and 50 in 2019-2020. Inappropriate admission was 12.11% in 2015-2017 and 7.27 % in 2019-2020 (table 1). Figure 2 shows the rate of inappropriate admissions of six participating NHs from 2015-2020. There is a decreasing trend after the pathway has been implemented in 2018. Table 1

Figure 2

Conclusion

Adopting fever and desaturation pathway has reduced the rate of inappropriate admission in six participating NHs in Singapore. However, there is an increasing trend in inappropriate admission in 2020. This could be due to the lack of isolation facility in the NHs during the COVID-19 pandemic. We are continuing the implementation of the pathway to the rest of the NHs in the western region of Singapore.

Disclosures

All Authors: No reported disclosures.
1009. Integrating a Lean Six Sigma DMAIC approach to improve transitions of care in patients discharged on outpatient parenteral antimicrobial therapy
Authors: Monday Lea M , Joshi Seema , Goteti Ravitej , Saba Janan , Weinmann Allison J
Published: December 2022

Background

Outpatient Parenteral Antimicrobial Therapy (OPAT) programs aim to facilitate early discharge and improve patient care; however, rates of readmission remain high. After discharge, safe monitoring and follow-up is logistically heterogenous and prone to error. We aimed to utilize a Six Sigma framework to evaluate our OPAT process and define opportunities for improvement in patient care.

Methods

A define, measure, analyze, improve, control (DMAIC) approach was used by a multidisciplinary group to evaluate errors and opportunities in the OPAT discharge process (Fig 1). Baseline analysis of 6-months of OPAT discharges revealed an all cause 30-day readmission rate of 19.7%, and less than half of all patients (45%) were seen in the infectious diseases (ID) clinic within 28-days. The group created a process map and identified potential opportunities for error and heterogeneity in the process.

A define, measure, analyze, improve, control (DMAIC) approach was used by a multidisciplinary group to evaluate errors and opportunities in the OPAT discharge process

Results

Process mapping revealed process heterogeneity depending on patient discharge location (Fig 2). Reliability of ordering labs and transporting patients to appointments varied by location (Skilled nursing facility (SNF) versus home infusion, etc.). Furthermore, the OPAT note was not included in the discharge summary and the process was reliant on an ID team member emailing the clinic to request follow-up. An Ishikawa diagram identified numerous factors contributing to OPAT related adverse events (Fig 3). Main opportunities for improvement included (1) the OPAT note, (2) delegation of laboratory ordering for monitoring patient after discharge, (3) patient follow-up scheduling and monitoring, and (4) skilled nursing facility (SNF) communication and expectations. Interventions resulting included working with information technology to update the OPAT note to include appointment dates, attaching OPAT note to discharge summary, and bridging communication and ensuring task completion by delegating certain reliable SNFs as centers of excellence.

Process mapping revealed significant process heterogeneity depending on patient discharge location, that the OPAT note was not included in the discharge summary, and the process was heavily reliant on an ID team member emailing the clinic to request follow-up and ensure future laboratory tracking.

An Ishikawa diagram identified numerous factors contributing to OPAT related adverse events including numerous system and individual factors

Conclusion

The DMAIC approach was useful in identifying opportunities to improve transitions of care in patients discharged on OPAT and developing interventions for targeted process improvement. Other centers may use a similar strategy to analyze and improve the care of OPAT patients.

Disclosures

All Authors: No reported disclosures.
1013. Outpatient parenteral antimicrobial therapy (OPAT)-related peripheral eosinophilia as a predictor of hypersensitivity reactions.
Authors: Khalaf Suha Abu , Jubair Fahed , Nolan Nathanial S , Jegede Olujimi
Published: December 2022

Background

The administration of outpatient parenteral antimicrobial therapy (OPAT) has significantly increased in recent decades. OPAT offers many benefits to patients and the health care system. Best practices suggest patients on OPAT require active monitoring for adverse effects of therapy. Asymptomatic eosinophilia is common finding in patients receiving OPAT and could be benign or herald allergic drug reactions. Little is known about the practice patterns of OPAT providers in their management of asymptomatic eosinophilia. This study aimed to assess the opinions and practice patterns regarding asymptomatic eosinophilia among providers managing patients on OPAT in the United States.

Methods

This is a cross-sectional study of data collected from a one-time, anonymous, self-administered survey to providers who care for patients receiving OPAT. The survey was posted in the discussion forums of the Infectious Diseases Society of America (IDSA) and shared via emails to twenty ID departments in the US. Data was collected from June to July 2021. Survey responses were analyzed using Python for statistical analysis.

Results

Sixty-five respondents completed the survey. Thirty-six percent of respondents reported that eosinophilia occurs in up to five percent of their patients, with an average time of 1-2 weeks between antibiotic exposure and the development of eosinophilia Fig (1). Sixty-nine percent of respondents reported that they do not change their laboratory monitoring frequency in patients with asymptomatic eosinophilia. Fifty-two percent of respondents would discontinue/switch antibiotics only if the patient developed complications Fig (2). The risk of subsequent hypersensitivity reaction/end-organ damage was less frequently noted, as seventy-five percent encountered it in < 10% of eosinophilia cases Fig (1). Fig. 1Reported OPAT associated eosinophilia and subsequent hypersensitivity reaction per respondents

Fig. 2 Practice patterns among survey respondents to eosinophilia

Conclusion

Per our survey results, OPAT-related eosinophilia is common though subsequent hypersensitivity/life-threatening reactions are not. Most surveyed ID providers monitor asymptomatic eosinophilia without changing antibiotics. Further prospective studies are needed to understand the course and best practice for asymptomatic eosinophilia among patients on OPAT.

Disclosures

All Authors: No reported disclosures.
1014. Patient perspectives on pharmacy experiences for antiretroviral refills
Authors: Havens Josh , Liu Yadi , Furl Renae
Published: December 2022

Background

Control and prevention of HIV infection require sustained adherence to antiretroviral therapy (ART) for patients with HIV (PWH) or those on pre-exposure prophylaxis (PrEP). ART is increasingly designated by payers as a specialty medication and often mandates specialty mail-order pharmacy for refills. Little is known about patient perspectives of pharmacy choice preferences for ART.

Methods

A 20-question survey was distributed to patients (PWH and PrEP) of the Specialty Care Center in Omaha, NE. Participants >19 years, retained in care for >6 months, and experience with ART/PrEP refills at both local and mail-order pharmacies were considered for study participation. The survey was designed in 3 parts: perspectives on both pharmacy settings, ranking of pharmacy attributes, and pharmacy preference. Descriptive analyses were performed for all survey questions.

Results

Surveys were completed by 61 participants (N=156; 39.1%). Median age was 52 years, 85% White, 13% Black, 5% Latinx, and 80% commercially insured. Forty-eight participants (79%) reported insurance mandates to use a specialty mail-order pharmacy with 28 (58%) believing the mandate impacted their medical care. Forty-one participants (67%) preferred refilling prescriptions through a local pharmacy. Participants ranked “ease of refilling” as the most important attribute (Figure 1) and favored local pharmacies vs mail-order pharmacies for all pharmacy attributes (Figure 2).

Scoring scale, 1=strongly disagree to 5=strongly agree.

Conclusion

Midwest PWH and PrEP patients generally preferred local pharmacies to refill their antiretroviral therapies versus mail-order pharmacies for nearly all pharmacy attributes. Further, many participants felt specialty pharmacy mandates negatively impacted their medical care. Insurance payers should consider removing restrictive specialty pharmacy mandates for ART/PrEP prescriptions.

Disclosures

All Authors: No reported disclosures.
1017. Residual Infusion Performance Evaluation (RIPE): A Single-Center Evaluation of Residual Volume Post-Intravenous Eravacycline Infusion
Authors: Baumann Alysa J , Cleveland Kerry O , Gelfand Michael S , Perkins Nicholson B , Covington Angela D , Hobbs Athena L V
Published: December 2022

Background

Intravenous (IV) fluid manufacturers report an acceptable volume of overfill range for a 250 mL bag of normal saline from 265-285 mL. This overfill can contribute to residual drug that is not administered to patients. Frequent instances of incomplete eravacycline infusions were noticed by infectious disease providers.

Residual Eravacycline Volume Following IV Infusion

Methods

This single-center, retrospective, quasi-experimental study evaluated residual volume after the completion of IV eravacycline infusion in patients admitted during the pre-intervention period (July 1 – 30, 2021) vs. post-intervention period (November 1 – 30, 2021). The intervention (August 1 – October 31, 2021), consisted of updating drug labels to add the drug diluent to total volume and a comment in the administration section to “infuse at current rate until bag is empty.” Nursing education was provided to encourage administration of the entire drug volume. The primary outcome compared residual antibiotic volume before and after implementation of the intervention. The secondary outcomes evaluated amount of drug lost (total mg and percent of total dose) in the pre- and post-intervention periods and cost of facility drug waste.

Nursing Education Distributed During Intervention Period

Results

There was an average residual volume of 38.0 mL (range 6 – 85 mL) for pre-intervention (n=9, total of 46 doses) vs. 12.2 mL (range 0 – 37 mL) for the post-intervention (n=7, total of 21 doses) population (p< 0.0001). Residual volume accounted for an average of 15.2% of the total bag volume compared to 4.7% for the pre- and post-intervention groups, respectively (p< 0.0001). The pre-intervention residual volume contained an average of 13.5 mg (15.3% of total dose) of eravacycline, versus 4.7 mg (4.7% of total dose) in the post-intervention (p< 0.0001). Cost analysis used average wholesale price for 50 mg vials. Residual volume in the pre-intervention period estimated $893.45 ($10,721.40 annualized) vs. $161.04 ($1,932.48 annualized) in the post-intervention period.

Pre- and Post-Intervention Comparison

Clinical Analysis of Residual Antibiotic Volume

Facility Waste

Conclusion

Average residual volume and amount of discarded drug was significantly reduced after the interventions. Following the results of this study, interventions were expanded to all admixed antimicrobials. Further studies are needed to determine the potential clinical impact when patients do not receive the complete antibiotic infusion due to residual volume.

Disclosures

Kerry O. Cleveland, MD, AbbVie: Honoraria|Cumberland: Honoraria|Merck: Honoraria|Pfizer: Honoraria Michael S. Gelfand, MD, AbbVie: Expert Testimony|La Jolla: Expert Testimony.
1018. Shifting Antimicrobial Practice to Minimize Length of Stay in Orthopedic Infections: Analysis from an Academic Tertiary Care Center
Authors: Stern Rebecca A , Wada Paul Y , Freiberg Jeffrey , Gibas Kevin , Cihlar Jennifer , Fiske Christina T , Wright Patty W , Staub Milner B
Published: December 2022

Background

Increased hospital length of stay (LOS) has been associated with increased rates of readmission, nosocomial infections, and cost during hospitalizations for orthopedic-related infections (HOIs). We hypothesized that Infectious Diseases (ID) consultation is associated with increased LOS for HOIs due to pending culture results delaying final recommendations. We assessed patient and care factors affecting LOS, including duration and timing of ID consultation, and identified process improvements to expedite discharge for HOIs.

Methods

We performed retrospective chart review of HOI admissions with ID consultation at Vanderbilt University Medical Center from May-August 2021. Differences in HOIs discharged <1 vs. >1 day after ID final recommendations were examined using Fisher’s exact, Chi-squared, and Wilcoxon rank sum testing. Clustering by patient for those with >1 admission was performed. We used multivariable and propensity score weighted negative binomial regression models to estimate adjusted rate ratios (aRR) and 95% confidence intervals (CI) for number of days followed by an ID consultant and LOS.

Results

HOIs discharged <1 day after ID final recommendations (69/105) had shorter median LOS (3 vs. 8 days, p< 0.001) (Figure 1), more oral-only antibiotic regimens (41% vs. 17%, p=0.003), and more frequent discharge to home (91% vs. 53%, p< 0.001). HOIs discharged >1 day after ID final recommendations were more likely to undergo multiple surgeries (28% vs. 12%, p=0.019) and peripherally inserted central catheter (PICC) placement (69% vs. 43%, p=0.013). For each additional day of ID consultation, there was associated increase in LOS (multivariable aRR 1.12, 95% CI 1.02-1.23; weighted aRR 1.12, 95% CI 0.99-1.26). Figure 1.Length of Stay after ID Final Recommendations

Conclusion

ID consultation is unlikely to be the primary barrier to hospital discharge but may be a marker for more complicated HOIs and increased LOS. Most patients with prolonged stays were discharged >1 day after ID final recommendations. Implementation of protocols to promote prompt ID consultation, streamline PICC placement, and coordinate outpatient intravenous antibiotics may accelerate transitions of care and discharges.

Disclosures

Milner B. Staub, MD, MPH, Gilead: Stocks/Bonds|Johnson & Johnson: Stocks/Bonds.
1024. Transitions of Care Quality Metrics in Patients Discharged on Parenteral Antimicrobial Therapy in a Large Urban Hospital that Lacks a Formal Outpatient Parenteral Antimicrobial Therapy Program
Authors: Schultz Sara K , Minuk Jeffrey , Rodriguez Leah
Published: December 2022

Background

With the evidence demonstrating the need for antimicrobial stewardship in the transition from inpatient to outpatient intravenous (IV) antibiotic therapy, it is imperative to have effective communication and coordination in a multidisciplinary team. Studies have demonstrated the utility of initiating a formal Outpatient Parenteral Antimicrobial Therapy (OPAT) program. The goal of this study is to assess quality metrics in a sample of patients discharged on IV antibiotics prior to initiation of a pilot OPAT program.

Methods

This is a retrospective, multicenter chart review of patients admitted to Temple University Health System from 10/1/2020 - 10/31/2021 who were discharged on IV antibiotics. There were no exclusion criteria. Patients with multiple admissions were documented as separate occurrences. Qualitative data were collected on the appropriateness of OPAT indication, pathogens targeted, antibiotics used, performance of infectious diseases (ID) consult, line selected, outcomes, and demographics. The primary endpoint is the percentage of global IV antibiotic prescribing errors (antibiotic, dose, route, frequency, duration, parenteral access device).

Results

There were 748 total discharges on IV antimicrobials in 705 unique patients. We chose a random sample of 109 discharges. Twenty (18%) had an oral antimicrobial available as an option. Antibiotic selection, dosing, duration, and access were correct 92%, 82%, 64% and 65% respectively (Table 2). ID recommended laboratory monitoring for 44 (40%) patients, of which 8 (18%) were sent to ID clinic; all had abnormal findings. Of the 25 patients who required ID follow-up, 11 had a scheduled ID appointment of which 8 attended. There was no mortality within 30 days from the 8 patients, but 2 were readmitted within 30 days. Overall, 39% patients readmitted within 30 days, 6% had mortality within 30 days and 50% were known to have completed therapy.

Conclusion

Our study captured a 65% rate of prescribing errors in a sample of 109 patients receiving IV antibiotics at discharge. The findings demonstrate an urgent need for an OPAT program to help with antimicrobial, parenteral access selection, monitoring, and follow-up with ID. By implementing this program, we hope to improve our ID follow-up, lab monitoring, and readmission metrics.

Disclosures

All Authors: No reported disclosures.
1046. Assessing School-Based COVID-19 Transmission in Middle and High Schools in an Underserved Population through Qualitative Interviews
Authors: Yuan Grace , Hayes Samantha , Malone Sara , Akuse Sewuese , Watterson Tremayne , Reyes Summer M , Reyes Sydney A , Evans Christina , Bonty Brittany , Prater Jasmine , Shelley Jamee T , Liu Jingxia , Fritz Stephanie A , Newland Jason
Published: December 2022

Background

Case and contact investigation is a mitigation strategy to understand transmission of diseases. The goal of this study is to assess COVID-19 transmission in schools that employ contact tracing.

Methods

Five middle and high schools provided a list of ongoing student and staff cases and their school contacts for the 2021-22 school year. Cases were eligible for interview if they had a known positive test or were a “presumed positive” by a practitioner. Contacts were eligible if they were identified as a close contact to a case within their school. Contacts who later became a case were eligible for a separate case interview. Trained interviewers contacted eligible individuals to offer COVID-19 resources and determine interests in participating in the study. Interested cases and contacts underwent a semi-structured interview with standardized questions.

Results

From 5/2021-4/2022, 360 cases (45% during Omicron surge) and their 412 contacts were identified (Fig 1). Among the 111 cases interviewed, 75% were students, half were in grades 6-8 (Fig 2). 61% of the cases were vaccinated with their primary series. 92% were symptomatic and fatigue, cough, and headaches were the most common symptoms. Transmission from school occurred in 29% (Fig 3) and most commonly occurred in the classroom. Among the 68 contacts interviewed, 96% were students. The two most reported activities contacts participated in were band (n=9) and sports (n=22), 10 from playing basketball. Three contacts reported exposure to COVID-19 within the household and five contacts reported exposure outside the home or school.

Conclusion

Case and contact investigation can be a valuable tool to assess COVID-19 transmission in schools. Almost one-third of cases reported school exposures, a greater school transmission rate than previous reported likely do to the increased transmissibility of Omicron. Assessing transmission events with this strategy alone may be limited by its reliance on self-reports. Case investigations can help schools identify potential areas to improve in limiting school-based COVID-19 transmission.

Disclosures

Sara Malone, PhD, LCSW, AHRQ: Grant/Research Support|NIH: Grant/Research Support Jason Newland, MD, AHRQ: Grant/Research Support|Merck: Grant/Research Support|NIH: Grant/Research Support|PEW Charitable Trust: Grant/Research Support|Pfizer: Grant/Research Support.
1053. Comorbidities Associated with All-Cause Readmission to the Same Hospital after Index COVID-19 Hospitalization: A Retrospective Cohort Study of 232155 Patients in the United States
Authors: Nadimpalli Gita , O’Hara Lyndsay M , Magder Lawrence , Kristie Johnson J , Haririan Abdolreza , Pineles Lisa , Goodman Katherine E , Baghdadi Jonathan , Pineles Beth , Harris Anthony
Published: December 2022

Background

Understanding comorbidities that drive all-cause readmission in patients hospitalized with Coronavirus disease 2019 (COVID-19) can inform healthcare system capacity planning and improve post-discharge care.

Methods

This was a retrospective cohort study of patients hospitalized for COVID-19 between April 2020-December 2020 (index cohort) across 760 hospitals in the Premier Healthcare Database. Patients who died or left against medical advice were excluded from the index cohort. Surviving patients in the index cohort were followed until May 2021. First readmission to the same hospital as the COVID-19 index admission was considered all-cause readmission. The all-cause 14-month risk (95% confidence interval) of readmission was calculated using the Kaplan-Meier approach. A multivariable Cox proportional hazards model adjusted for demographic variables, hospital characteristics, co-existing comorbidities, and COVID-19 severity was built to study the association between Elixhauser comorbidities and readmission.

Results

Among 232155 unique patients in the index cohort, 36680 were readmitted to the same hospital at least once, followed through May 2021. The 14-month risk of readmission was 16.2% (95% CI:16.1% - 16.4%). The most frequent primary diagnosis on readmission was infectious disease (14240, 38.8%), of which 8754 (24%) were for COVID-19. With each additional comorbidity, the readmission hazard increased by 19% (HR, 1.19; 95% CI:1.18 - 1.19). In the multivariable Cox proportional hazards model, many comorbidity categories were associated with an increased risk of readmission. Metastatic cancer (HR, 1.74; 95% CI:1.60 –1.89), lymphoma (HR, 1.61; 95% CI:1.47 – 1.77), drug abuse (HR, 1.51; 95% CI:1.41 – 1.62), congestive heart failure (HR, 1.47; 95% CI:1.44– 1.51), and alcohol abuse (HR, 1.46; 95% CI:1.36– 1.56) were associated with the highest hazard for readmission.

Conclusion

COVID-19 patients have a high risk of all-cause readmission and are frequently readmitted for COVID-19. With the continued emergence of COVID-19 variants, this study provides valuable insights into developing more informed discharge plans and improving post-discharge care for COVID-19 patients with existing comorbidities to prevent readmission.

Disclosures

Lyndsay M. O'Hara, PhD, MPH, PDI: Grant/Research Support.