bluuebunny/crossref_metadata_2025 huggingface dataset:
54. Effectiveness of a Venous Catheter Stewardship Intervention Targeting Parenteral Antimicrobial Therapy at Hospital Discharge
Authors: Athans Vasilios , Hamilton Keith W , Norris Anne , Dutcher Lauren , Degnan Kathleen , Gitelman Yevgeniy , Serpa Michael , Cimino Christo , Lee Tiffany , Binkley Shawn , Saw Stephen
Published: January 2021

Background

Peripherally inserted central catheters (PICCs) and midlines are often used in hospitalized patients who require outpatient parenteral antimicrobial therapy (OPAT) upon discharge. PICCs/midlines offer ease of insertion but still carry the risks of venous thrombosis, phlebitis, and catheter-associated infection. We report the results of a prospective audit and feedback (PAF) intervention targeting the placement of PICCs/midlines for OPAT at our institution.

Methods

We prospectively identified a cohort of patients identified by a real-time PICC/midline alert from 5/20/2019 through 5/29/2020 at two large academic medical centers. Alerts were generated by a third-party interface with the electronic health record and identified new line orders with an antimicrobial indication selected. Patients without infectious diseases (ID) consult underwent PAF by the antimicrobial stewardship team. Descriptive statistics were used to characterize patients, interventions, and outcomes.

Results

During the study period, 1267 PICC/midline alerts were identified. Most were excluded due to ID consult (85.4%). After exclusions, 113 alerts underwent full review. Median patient age was 64 years with female predominance (54.2%). Reviewable alerts most commonly originated from Pulmonary (36.5%) and Hospitalist (26.0%) services. The most frequent antimicrobial indications were pneumonia (37.5%) and bloodstream infection (28.1%), and the most frequently ordered antimicrobials were cefepime (27.1%) and piperacillin-tazobactam (17.7%). Median time from line order to insertion was 22 hours and from line insertion to discharge was 48 hours. Of 113 alerts reviewed by the stewardship team, 26 (23.0%) resulted in a recommendation to avoid line placement and 45 (39.8%) resulted in at least one specific stewardship recommendation (Table 1). Recommendations were fully or partially accepted in 58.3% of instances.

TABLE 1. Interventions Resulting from Prospective Venous Catheter Stewardship

Conclusion

Prospective audit of PICC/midline orders for OPAT identified a line-sparing opportunity in nearly 1 in 4 cases. Where line avoidance was not possible, other opportunities for antimicrobial optimization were common. This high-yield intervention should be considered for institutions that do not mandate infectious diseases consult for all OPAT discharges.

Disclosures

All Authors: No reported disclosures
55. Ertapenem for surgical prophylaxis: the impact of antimicrobial stewardship interventions on inappropriate carbapenem utilization at a community teaching hospital
Authors: Downham Gemma , Reilly Joseph , Trivedi Manish , Baptist Justin , Delfino Susan , Szymborski Shana
Published: January 2021

Background

Internal analysis of ertapenem utilization revealed overuse for surgical prophylaxis in intra-abdominal (IA) procedures. Our Antimicrobial Management Team (AMT) initiated a multimodal intervention to promote the appropriate use of ertapenem. The primary objective of this study is to describe and evaluate the impact of our interventions targeting ertapenem utilization for IA surgical prophylaxis.

Methods

From March to October 2019, a pre-post study was performed to evaluate ertapenem utilization for surgical prophylaxis. Our AMT interventions which were formally implemented in June 2019 included the following: targeted provider feedback, review and update of our surgical prophylactic antibiotic protocol (SPAP), policy, and order set addition of Cefoxitin to formulary, extensive provider education, and monitoring of SPAP compliance. Data was abstracted from the electronic medical record for IA cases and included antibiotics prescribed, procedure type, and prescriber information. In addition, surgical site infection (SSI) rates and Clostridium difficile infection rates were monitored throughout the study period.

Results

In total, 1,080 IA surgical cases were reviewed. The set quality measure of less than 5 percent ertapenem utilization was achieved each month after AMT interventions in June 2019, as demonstrated by monthly ertapenem use for surgical prophylaxis: 13.7 percent in March, 13.4 percent in April, 4.9 percent in May, 8.9 percent in June, 3.1 percent in July, 2.2 percent in August, 4.5 percent in September, and 3.4 percent in October. Overall, the number of ertapenem cases was 58 pre-study (March to June) versus 16 post-study (July to October), accounting for a 72.4 percent reduction in ertapenem utilization for IA surgical prophylaxis. The rate of SSI among IA surgeries and Clostridium difficile infection did not increase as a consequence of our interventions

Conclusion

Carbapenem use for surgical prophylaxis was consistently within threshold limits following the stewardship interventions. Incidence of surgical site infections and Clostridium difficile infection did not increase during the interventions suggesting that alternate antimicrobial agents in the SPAP are safe and effective for IA surgeries in our patient population.

Disclosures

All Authors: No reported disclosures
811. Utilizing IV team in Reducing the Central Line Associated Infections
Authors: Srialluri Swetha , Hassoun Ali
Published: January 2021

Background

Central Line-Associated Blood Stream Infections (CLABSI) are defined as the laboratory confirmed blood stream infections after 48 hours of the line placement and excluding other sources of infection. CLABSI can lead to prolonged hospital stay, increased risk of mortality and financial burden on the health care system. In our study, we aimed at evaluating the incidence of CLABSI after involving the IV team in both critically ill and non-critically ill patients.

Methods

A retrospective chart review was performed from July 2011 to August 2019 at a 971 bedded community hospital. IV team has been involved in the central line care since 2013 and started changing the scheduled central line dressings. The interventions that were introduced since then include usage of Curos, wearing masks and gloves for any contact with central lines, flushing the central lines using pulsatile method, and not drawing the routine labs. Allpoints program was introduced in July 2018 which is a retraining program to the nurses emphasizing on central line dressing changes using a sterile technique, pulsatile flushing method and medication administration. CLABSI rate was calculated per 1,000 central line days yearly and quarterly and was compared before and after the involvement of IV team.

Results

Total number of events from July 2011 to August 2019 were 275. Average central line days were 22,350. Most common organisms that were isolated are Staphylococcus aureus (13.45%) followed by Staphylococcus Epidermidis (9.8%), Candida Albicans (8.7%), E. Coli (8.72%) and Klebsiella Pneumonia (6.9%). The average CLABSI rates quarterly and yearly were 1.00 and 1.32 respectively, per 1000 central line days. Average CLABSI rates before and after the involvement of IV team were 1.32 and 1.18 respectively. CLABSI rate has decreased significantly after the involvement of the IV team in 2013. The largest impact on the CLABSI infection rate was between July 2018 to August 2019 which can be attributed to the Allpoints program. CLABSI rate in 2018 and 2019 were 0.86 and 0.6 respectively.

Conclusion

Our analysis showed that involving the IV team in the central line care and implementing the preventive strategies like usage of curos, pulsatile flush technique, wearing mask and gloves for any contact with central line helped in reducing CLABSI.

Disclosures

All Authors: No reported disclosures
819. How effective is alcohol flush and drying cycle of automatic endoscope reprocessor (AER): Stripped Endoscope (SE) model
Authors: Yassin Mohamed , Dixon Heather , Nerandzic Michelle , Donskey Curtis
Published: January 2021

Background

Endoscopic designs are more ergonomic and technically sophisticated than ever. Endoscope transmitted infections continues despite scrutiny and optimization of disinfection processes. Effective endoscopic dryness has been largely overlooked, even though it is paramount for prevention of water-borne pathogens accumulating after high level disinfection (HDL). Additionally, complete dryness is required to achieve sterilization. The aim of this study is to evaluate the dryness of the endoscopes after routine a routine disinfection process.

Methods

Three endoscopes were stripped from their outer sheaths to allow for visual inspection of the inside channels. SE were processed as per usual practice. After HLD in an automatic endoscope reprocessor (AER) that included an alcohol flush and drying cycle, SE were hung and observed for any water within the channels. SE were flushed with filtered compressed air. Dryness was monitored visually and by feeling for the impact of water spray at the distal tip of SE. Dryness of the channels before and after air flush was observed for the three SE for three trials each.

Results

All the SE were grossly wet after HLD despite the AER’s alcohol flush and drying cycle. Hanging vertically had no effect on the narrow diameter channels. Applying compressed air to each channel was effective for drying the channels based on visual inspection and water emission from the distal tip of the SE. The filtered compressed air had a flow rate of 20 L/minute for an average of 2 minutes to assure complete dryness. The nozzle for applying the filtered compressed air was ill-fitting to the openings of the cylinders and ports on the control handle, making it difficult to get a good seal for applying the filtered compressed air.

Conclusion

The AER’s drying cycle was not effective for drying endoscope channels. Vertical hanging had limited efficacy on endoscopic dryness. The application of filtered compressed air to individual channels was effective for drying the channels. This SE model was useful and direct for assessing the degree of moisture inside the channels. The application of filtered compressed air should be an essential step in endoscopic reprocessing regardless of the need for sterilization.

Disclosures

All Authors: No reported disclosures
824. Isolation Rounding - Enforcing Existing Isolation Policies to Conserve Personal Protective Equipment
Authors: Schaffzin Joshua K , Herber Stephanie , Kneflin Nicole , Frazier Matthew , Paolella Alyssa , Ewers Christine , Short Matthew , Huang Felicia Scaggs
Published: January 2021

Background

During the COVID-19 pandemic, supplies of personal protective equipment (PPE) have been limited and sold at increased cost. Prior to the pandemic, we had initiated a project to improve PPE adherence and decrease cost by removing eligible patients from transmission based precautions (TBPs). At baseline, ordering providers are responsible for TBP utilization with orders through the electronic medical record. We observed that patients were in TBP when not indicated; remained in TBP beyond the appropriate time; and a reluctance on the part of providers to discontinue the orders. We tested the effect on TBP duration and PPE utilization house-wide through frequent review of TBP by a nurse educator with communication to providers of discontinuation opportunities.

Methods

From November 2019 to February 2020, all TBP orders in the pediatric intensive care unit (PICU) were reviewed intermittently. In March 2020, review was expanded to all inpatients with daily reviews in all units. Changes recommended and completed were tracked for all reviewed patients. We estimated cost of PPE in the PICU over time based on the number of patients in isolation and type of TBP utilized to determine whether our intervention resulted in reduced PPE use.

Results

Regular rounding in the PICU increased the proportion of patients in appropriate TBP and reduced the need to communicate with providers directly (33% vs 3% requiring intervention, Figure 1). Over the same time period, less PPE was used and PPE-related costs lowered (average total PPE cost $306.18 vs $95.15 per day, Figure 2). Less of an effect was seen when analyzing house-wide data.

Figure 1 - P-chart of Percent Interventions Among Patients in TBP

Figure 2 - X-chart of Total PPE Cost in the ICU

Conclusion

Isolation rounds is an effective means to ensure proper TBP adherence and manage PPE use appropriately. Additional study is needed to confirm a return on investment, to account for variation among units, and to sustain COVID-19-influenced gains beyond the pandemic.

Disclosures

All Authors: No reported disclosures
825. An Academic-Information Technology Partnership to Create an Infectious Diseases Translational Science Database
Authors: Lancaster Christopher K , Gonzales-Luna Anne J , Beairsto Jeffrey , Neptune Randal , Killen Joanna , Dugas Corey , Webster Beth , Rutter John N , Rutter Tristan , Garey Kevin W
Published: January 2021

Background

Translational science is the process of turning observations in the laboratory, clinic, and community into interventions that improve human health. The coordinated effort to maintain integrated, validated laboratory and clinical data is often a rate-limiting step for research laboratories, especially for multi-site studies. Previous research shows a rate of error between 2.3 and 5.2% for basic data collection in clinical databases, up to 26.9% for more complex data points. The purpose of this project was to create a translational science database prototype that would be responsive to the unmet needs of the translational research community.

Methods

Translational scientists, IT experts, and lab technicians mapped the workflow of a high-throughput research laboratory including clinical and laboratory data. Database goals were to develop processes that would minimize data entry time, avoid redundancies, and validate data in a secure environment (HIPAA-compliant). Unique to this platform was the ability to map creation of new samples (for example, PCR products) from parent samples (biologic samples). The platform was developed in an iterative process utilizing interviews, workflow study, analysis of supporting artifacts, and mock-ups.

Results

The current prototype allows for electronic upload or manual data entry of clinical data. In a small controlled study we found the rate of error for basic data entry to be below 1% within it. Pre-populated data entry screens map laboratory work-flow with custom data entry fields produced based on laboratory results earlier in the work flow. Work-flow mapping includes microbiology, phenotypic descriptions (MIC), molecular biology (PCR), and customized experiments. Sequence data, housed separately, has data linkers stored in the database. The launch screen and data entry forms are populated based on specific criteria entered for each user.

Conclusion

The Translational Science Database allows for efficient capture of high-quality data with baseline validation enabling seamless linking of translational data for single or multi-site laboratories. Future development work will expand the number of experiments and also incorporate stored biobank information into the database.

Disclosures

Jeffrey Beairsto, BSc Eng (ME), Populus (Employee, Shareholder) Randal Neptune, BSc., MSc., Populus Global Solutions (Employee) Beth Webster, BSc, MBA, Populus Global Solutions Inc (Employee, Shareholder) John N. Rutter, BscEng, Populus Global Solutions (Board Member, Employee, Shareholder) Tristan Rutter, BA, Populus (Employee) Kevin W. Garey, PharMD, MS, FASHP, Merck & Co. (Grant/Research Support, Scientific Research Study Investigator)
828. Evaluation of Home Time as a Patient-Centered Metric for Pneumonia Hospitalizations: A Retrospective Cohort Study of Medicare Fee-For-Service Beneficiaries
Authors: Nair Rajeshwari , Gao Yubo , Vaughan-Sarrazin Mary , Perencevich Eli N , Girotra Saket , Pandey Ambarish
Published: January 2021

Background

The Centers for Medicare & Medicaid Services (CMS) uses hospital readmission to incentivize hospital care delivery for acute conditions including pneumonia. However, current CMS performance metrics do not account for the competing risk of mortality in the post-discharge period or during the hospital stay. Our objective was to assess home time within 30 days after discharge among pneumonia hospitalizations, as a patient-centered metric.

Methods

A retrospective observational study was conducted in a cohort of Medicare fee-for-service beneficiaries admitted between 01/01/2015 and 11/30/2017. Home time was the number of days spent alive, out of an acute care setting, skilled nursing facility, or a rehabilitation facility within 30 days of discharge. If a patient spends any part of a day in a care facility or died after discharge, then that day was not included in the calculation for home time. Hospital-level rates of risk-adjusted home time were calculated using multilevel regression models. We compared hospital performance on 30-day risk-standardized home time with its performance on 30-day risk standardized readmission rate (RSRR) and mortality rate (RSMR). Characteristics of hospitals with high and low risk-adjusted home-time were compared.

Results

Among 1.7 million pneumonia admissions admitted to 3,116 hospitals, the median 30-day risk-standardized home time was 20.5 days (interquartile range: 18.9-21.9 days). Hospital-level characteristics such as case volume, bed size, for-profit ownership, rural location of hospital, teaching status, and participation in the bundle payment program were significantly associated with home-time. RSRR (rho: -0.233, p< 0.0001) and RSMR (rho: -0.223, p< 0.0001) had weak, inverse correlations with home time. Using the home time metric, 35.5% of hospitals were reclassified as high performers compared with their average or poor performance on the RSRR or RSMR metric.

Conclusion

Home time is a novel, patient-centered, hospital-level metric that can be easily calculated using claims data, accounts for differences in post-discharge mortality and can be intuitively interpreted. Utilization of this metric could potentially have policy implications in assessing hospital performance on delivery of healthcare to pneumonia patients.

Disclosures

Rajeshwari Nair, PhD, Merck and Company, Inc. (Research Grant or Support)
830. The effect of a long-stay patient on transmission of a pathogen to shorter-stay patients in a small multi-bed hospital unit: Implications for infection control
Authors: Ong Karen , Peskin Charles , Phillips Michael
Published: January 2021

Background

Objective: To quantify the effect of a long-stay patient in a hospital unit on the likelihood of colonization of that patient and other patients in the unit.

Prolonged hospital and intensive care unit (ICU) stays have been found to be risk factors for colonization and infection with bacteria such as carbapenem-resistant Enterobacteriaceae (CRE) for which there are limited treatment options and high mortality rates, making prevention of transmission and infection important public health objectives. Many studies have shown that long-stay patients (such as inpatient rehabilitation or skilled nursing facility patients) are at higher risk for hospital-acquired infections than short-stay patients, but the impact of long-stay patients on other patients in the same hospital unit has not received as much attention. Here, we consider a mathematical model of pathogen transmission within a hospital unit and assess the impact at different patient-patient transmission rates of a single long-stay patient on the probability that any other patient leaves the unit colonized with a pathogen.

Methods

We estimated the increased risk caused by a colonized long-stay patient on colonization of other patients using an ordinary differential equation Markov model with three mechanisms of colonization (pre-existing colonization, environmental transmission, and patient-patient transmission) with parameters previously estimated from a 13-bed hospital rehabilitation unit to evaluate the probability of exiting colonized.

Results

A single colonized long-stay patient increases the probability of each other patient exiting the unit colonized from 10.4% to 17.3%, a relative increase in risk of 1.4, and increases the expected number of colonized patients within the unit from 1.37 to 2.07 (not including the long-stay colonized patient).

Probability of exiting colonized from a unit with a long-stay, initially colonized patient versus the probability of exiting colonized from a unit with no long-stay patient. The solid black line indicates a unit with regular turnover, whereas the dashed black line indicates a unit with a single long-stay, initially colonized patient. The vertical line shows the value of γ = 0.002 inferred from data from a 13-bed rehabilitation unit, and the shaded regime indicates the uncertainty in this estimate (0.000329, 0.003729).

Conclusion

Colonized long-stay patients pose a risk to other uncolonized patients in the unit, especially at higher patient-patient transmission rates. Potential long-stay patients should be screened for CRE at entry and periodically during their stay because they are both at higher risk of colonization and also of transmitting bacteria to other patients. Consider increased surveillance, isolation, and/or decolonization of long-stay patients.

Disclosures

All Authors: No reported disclosures
57. Evaluating the Utility of a Penicillin Allergy Reconciliation Program within an Infectious Diseases Consult Population in a Community Health System
Authors: Jones Bruce M , Plauche Emily , Smith Susan E , Bland Christopher M
Published: January 2021

Background

Penicillin allergy reconciliation is an important aspect of antimicrobial stewardship with ~10% of the population reporting a penicillin allergy. Our facility utilizes a Penicillin Allergy Reconciliation Program (PARP) led by an Infectious Diseases (ID) Pharmacist and pharmacy students to identify patients with penicillin allergies to reconcile and intervene when necessary. Information is collected by interview, electronic medical record (EMR) review, prescription outpatient fill history. This study evaluated reconciliations with and without a PARP in patients in a community health system.

Methods

This was a retrospective study that compared reconciliations performed on adult patients admitted at least once in 2019 with a self-reported penicillin allergy and ID physician consult at a hospital with a PARP (Institution 1) and one without a formal evaluation and intervention program (Institution 2) within the same community health system with same ID physicians. The primary outcome was documented reconciliation of a patient’s penicillin allergy during an inpatient visit in 2019. Reconciliation was defined as an edit or clarification (updating the severity, reaction, or comments section, as well as deleting) to a patient’s penicillin allergy in the EMR. The secondary outcome evaluated the percentage of total and ID consult patients with a penicillin allergy.

Results

There were 245 patients who met criteria and were included in the study, 113 from Institution 1 and 132 from Institution 2. For the primary outcome, there were 82 (72.6%) reconciliations at Institution 1 and 15 (11.4%) reconciliations at Institution 2 (p < 0.001). Interventions at Institution 1 and 2 resulted in 74 EMR updates and 8 removals and 14 EMR updates and 1 removal, respectively. Reconciliation was performed on the same visit as the ID consult in 59/82 patients (72%) at Institution 1 and 11/15 patients (73.3%) at Institution 2. All reconciliations at Institution 2 were made by pharmacist (10) or nurses (5). For the secondary outcome, 10.9% of patients with an ID consult and 12.6% of all patients admitted in 2019 had a penicillin allergy (p=0.027).

Conclusion

A PARP led by an ID pharmacist and students was an effective method to perform penicillin allergy reconciliations, even in the presence of active ID consultation.

Disclosures

Bruce M. Jones, PharmD, BCPS, ALK-Abello (Research Grant or Support)Allergan/Abbvie (Speaker’s Bureau) Christopher M. Bland, PharMD, FCCP, FIDSA, BCPS, ALK Abello, Inc. (Grant/Research Support)Biomerieux (Consultant)Merck (Consultant, Grant/Research Support, Advisor or Review Panel member, Speaker’s Bureau)Tetraphase (Speaker’s Bureau)
833. Characteristics and Utilization Patterns of Colistin Compared with Newer Agents in Gram-Negative Infections
Authors: Marcella Stephen , Doremus Casey , Echols Roger
Published: January 2021

Background

Colistin has resurfaced in light of Gram-negative (GN) resistance. New antibiotics to treat antibiotic resistant GN infections (eg, ceftazidime-avibactam, ceftolozane-tazobactam, meropenem-vaborbactam [new agents]), have recently been approved but their use vs colistin is unclear. We compared the overall use of colistin and new agents from 2014 to 2018 in patient days on therapy (PDOT).

Methods

Data on non-cystic fibrosis patients from the Premier Healthcare Database was used. PDOT was tabulated quarterly for Premier hospitals and projected to the US population. A subset of data from 2016 to 2018 with microbiologically confirmed GN (MCGN) infections was selected for adult inpatients receiving ≥3 days of therapy with colistin, new agents, carbapenems, or extended-spectrum cephalosporins. The index infection was defined either as the first carbapenem-resistant (CR) or -sensitive infection if no CR infection occurred. Patients could be treated with ≥1 antibiotic per infection. Utilization was examined by pathogen and patient characteristics.

Results

PDOT with colistin decreased from 2015 to 2018, while new agents have increased (Figure). During 2015–2018, colistin and any of 3 new agents were used by 3,320 and 5,781 inpatients, respectively, of whom, 649 (20%) and 1,284 (22%) had MCGN pathogens. Colistin-treated patients were sicker than patients treated with new agents (Table), underlying renal disease was present in 34.5% vs 36.3 %, and median length of stay of 17 vs 15 days, respectively. Mean total hospital cost was $93,815 vs $84,013 for colistin and new agents, respectively. Mortality was greater in colistin patients (18% vs 12%; p< 0.0001). CR infections constituted similar proportions of colistin and new agent use (79% vs 75%). Colistin accounted for 15.2% of CR Acinetobacter treatments and 9.7% of CR Enterobacterales (CRE) treatments compared with 4.5% and 12.8%, respectively, for new agents.

Figure. Projected Inpatient PDOT

Table.

Conclusion

Colistin use has decreased simultaneously with the introduction and increased use of new agents in the USA. Colistin was used more frequently in sicker patients and for Acinetobacter spp. infections than for CRE infections. Patients on colistin have worse outcomes, probably due to baseline differences in their health status.

Disclosures

Stephen Marcella, MD, Shionogi Inc. (Employee) Casey Doremus, MS, Shionogi Inc. (Employee) Roger Echols, MD, Shionogi Inc. (Consultant)
839. Epidemiology of Extended-Spectrum Beta-lactamase (ESBL) Producing Enterobacteriaceae in the South East Tennessee, October-December 2017
Authors: Muleta Daniel , Adre Cullen , Warner Benji-Byrd
Published: January 2021

Background

The increasing spread of drug resistant gram-negative organisms is one of the major public health challenges. ESBL-producing Enterobacteriaceae has become the most common multi drug resistant pathogen in the last three decades. These organisms confer resistance to most beta-lactam antibiotics, including penicillins, third generation cephalosporins, monobactams and tazobactam.

Methods

The Tennessee Health Department (TDH) collaborated with CDC to pilot population based surveillance of ESBL producing organisms in Maury, Wayne, Lewis and Marshall Counties during October to December 2017. A case was defined as isolation of Escherichia coli, Klebsiella pneumoniae, or Klebsiella oxytoca resistant to at least one extended-spectrum cephalosporin (ceftazidime, cefotaxime or ceftriaxone) and non-resistant to all carbapenem antibiotics from urine or normally sterile body sites from a resident of the surveillance catchment area. A line list of ESBL-producing organisms was received from the labs that serve the catchment population. Case report forms were completed for the first ESBL culture collected from a single patient in a 30 day-period.

Results

A total of 154 cases were identified during the study period. E.coli constitutes 92.2% of the ESBL producing organisms followed by Klebsiella pneumonia (5.2%) and K. oxytoca (2.6%). The estimated annual incidence rate was 400.7 per 100,000 population which is more than twice of the average rates of other sites that conducted similar studies. The most common isolate source was urine (97%), and 81.2% of all cases were female. Patient ages ranged from 3-99 years, with average of 67 years. Thirty-two isolates underwent additional sequence typing and 76.7% (23) of the isolates were ST 131. 21 (91.3%) of ST-131 isolates were resistant to ciprofloxacin.

Conclusion

The study revealed that the incidence of ESBL producing organisms is very high in the Tennessee study area compared to other sites. The most common ESBL-producing pathogen was found to be ST 131 and most of these were resistant to ciprofloxacin suggesting that resistance to fluoroquinolone may be co-transmitted in ESBL producing pathogens through plasmids. Continued surveillance of molecular epidemiology is important to guide the prevention of the spread of drug resistant pathogens.

Disclosures

All Authors: No reported disclosures
840. First Report of Pseudomonas aeruginosa Isolates Harboring the CTX-M2 and PER genes in Algeria
Authors: Almpani Marianna , Tchakal-Mesbahi Asma , Metref Merzak , Singh Vijay K , Rahme Laurence G
Published: January 2021

Background

Despite significant improvements in burn care, multidrug-resistant (MDR) Pseudomonas aeruginosa (PA) remains one of the most common causes of life-threatening infections in patients suffering from thermal injuries. The objective of this study is to investigate the prevalence of MDR PA producing Extended-Spectrum Beta-lactamases (ESBLs) and metallo-beta-lactamases (MBLs) in burn patients in Algeria.

Methods

Between April 2016 and October 2019, 47 non-redundant isolates of PA were collected from 47 burn patients admitted to the Department of Burns at the Military Hospital of Algiers in Algeria. Antibiotic susceptibility testing was performed by agar diffusion and the Phoenix automated method. Resistance genes were identified by PCR, and molecular typing of isolates was carried out by enterobacterial repetitive intergenic consensus (ERIC) sequences-polymerase chain reaction (PCR).

Results

Among the 47 non-redundant MDR PA strains isolated, 59.57% were phenotypically ESBLs-positive, and 100% were phenotypically MBL-positive. The ESBL-positive isolates were subsequently screened for five groups of bla genes encoding ESBL-type enzymes, namely CTX-M2, PER, TEM, SHV, VEB, and GES. Out of the 28 ESBL-producing strains, 23 (82.14%) were CTX-M2 positive; 18 (38.29%) were PER positive, and 16 (34.04%) were TEM positive, while 5 (17.9%) were co-harboring CTX-M2, TEM, and PER genes. The SHV, VEB, and GES genes were not detected in any of the ESBL positive isolates. Since all isolates were MBL-positive, all 47 strains were screened for the NDM-1, IMP, VIM genes that produce MBLs; however, none of these genes were detected. Additional screening for the OprD gene demonstrated that 45 (95.74%) of the isolates were positive for this gene. Finally, ERIC PCR revealed 6 distinct PA clones among the CTX-M2 positive strains.

Table 1: Occurrence of beta-lactamase genes in relation to the antimicrobial susceptibility profiles of the PA isolates.

Conclusion

This is the first report of CTX-M2-producing PA in the North Africa region and the first to detect CTX-M2-positive and PER-positive PA clinical isolates in Algeria, therefore demonstrating the spread of such MDR strains in this part of the world. Identification of genotypic alterations that confer antibiotic resistance is critical in determining effective antimicrobial strategies. Hence, these findings could potentially guide antibiotic choice decisions.

World map with countries where PER- and CTX-M2-postive Pseudomonas aeruginosa isolates have been reported.

Disclosures

All Authors: No reported disclosures
844. Nosocomial Pseudomonas aeruginosa Blood-Stream Infections; Susceptibility Pattern and Mortality at a Tertiary Care Centre in Edmonton, Alberta, Canada
Authors: Savaryn Bohdan , Van Der Walt Peet , Smith Stephanie
Published: January 2021

Background

Pseudomonas aeruginosa is one of the leading gram negative nosocomial pathogens, causing severe infections including blood-stream infections (BSI) with high mortality rates. (1). Multi-drug resistant P. aeruginosa (MDRPA) infection rates are reported to be increasing (2) and have been associated with increased mortality (3). This study aims to review the susceptibility pattern and trend of P. aeruginosa BSIs and mortality and identify patients at increased risk of BSI with a resistant P. aeruginosa isolate. This data has important treatment implications.

Methods

Cases of nosocomial P. aeruginosa bacteremia were prospectively identified at the University of Alberta, Edmonton, Alberta, Canada by the infection prevention and control surveillance program between January 1, 2007 and December 31, 2018. Patient charts were retrospectively reviewed to collect microbiological, clinical, and epidemiological information.

Results

148 cases of P. aeruginosa BSI were identified over a 12-year period between January 2007 and December 2018. There were 19 cases of MDRPA BSI and 9 cases of XDRPA BSI. The incidence of P. aeruginosa BSI was 0.47 per 10,000 patient days and remained relatively stable over the study period. 66.9% of cases occurred in men. The mean age was 60 years. The average length of stay prior to bacteremia was 42 days. The overall 30-day mortality following P. aeruginosa BSI was 36.4%. Risk factors for increased 30-day mortality included: pulmonary source of infection (OR 4.26, p < 0.001), bacteremia with extremely drug resistant Pseudomonas aeruginosa (XDRPA) (p < 0.0001), and diabetes (OR 2.24, p < 0.05). BSI with MDRPA was not an independent risk factor for increased mortality. Significant risk factors for bacteremia with an MDRPA or XDRPA were length of stay > 28 days (OR 4.22, p < 0.001) and hemodialysis (OR 8.92, p < 0.000001).

Annual hospital acquired P. aeruginosa blood-stream infections from 2007-2018

Antibiogram of P. aeruginosa blood-stream isolates from 2007-2018

Conclusion

The incidence of P. aeruginosa BSI as well as the rate of MDRPA and XDRPA BSI have remained stable at our centre between 2007 and 2018. We found that BSI with XDRPA but not MDRPA alone was a significant risk factor for mortality. Risk factors for BSI with a resistant P. aeruginosa strain may be considered to guide empiric therapy.

Disclosures

All Authors: No reported disclosures
845. Trends and Regional Differences in Community-Onset Fluoroquinolone-Resistant E. coli in Hospitalized Adults in the United States
Authors: Wolford Hannah , Baggs James , Hatfield Kelly M , Olubajo Babatunde , Preston Leigh Ellyn , Kourtis Athena P , McDonald Clifford , Jernigan John A , Reddy Sujan
Published: January 2021

Background

Escherichia coli is a common cause of community-onset (CO) infections, including urinary tract and abdominal infections, and CO sepsis. Fluoroquinolones (FQ) are used in the empiric treatment of E. coli infections, but FQ-resistance may limit their effectiveness. We examined trends and regional differences in FQ-resistant E. coli clinical cultures among hospitalized adult patients in the U.S.

Methods

We measured the incidence of E. coli clinical cultures among hospitalized adults in a cohort of hospitals in the Premier Healthcare Database and Cerner Health Facts from 2012 through 2017. FQ resistance was defined as resistance to ciprofloxacin, levofloxacin, or moxifloxacin. Only cultures collected prior to day 4 of hospitalization, defined as CO, were considered. We extrapolated national estimates using a raking procedure to generate weighted adjustments matching the American Hospital Association distribution for U.S. acute care hospitals. Weights were based on U.S. census division, bed size category, teaching status, and urban/rural designation. We used a weighted means survey procedure to calculate national estimates and weighted multivariable logistic regression to examine trends and regional differences.

Results

In 2017, we estimated 949,393 CO E. coli infections with FQ susceptibility testing; 312,304 (33%) were due to E. coli resistant to FQ. Of FQ-resistant E. coli isolates, 76% were isolated from urine. We did not observe a significant trend in FQ-resistant E. coli from 2012 to 2017 (p = 0.85). Percent FQ-resistant varied significantly by region (p < 0.0001) with an estimated range of 19% (Mountain) to 42% (Southeast Central) in 2017. We also found variability by hospital (2017 Q1: 26% and Q3: 39%). FQ-resistance rates were higher in urine (36%: 95% CI 34-38%) than blood isolates (27%: 95% CI 26-29%) and higher for males (40%: 95% CI 38-42%) than females (33%: 95% CI 31-35%).

Conclusion

FQ-resistance is common in CO E. coli infections with significant variability by region and hospital. Empiric FQ treatment for infectious syndromes commonly caused by E. coli may need to be reconsidered. Clinicians should consult with local antibiograms and antibiotic stewardship programs to determine the most appropriate empiric treatment of E. coli infections in hospitalized adults.

Disclosures

All Authors: No reported disclosures
848. Trends of Carbapenem Resistance in Enterobacterales in the US Between 2015 and 2019
Authors: Marcella Stephen , Kanakamedala Hemanth , Zhou Yun , Cai Bin , Pogue Jason M
Published: January 2021

Background

Carbapenem-resistant Enterobacterales (CRE) are considered an urgent threat to human health by the CDC. Tracking resistance over time is of importance to understand trends and patterns. Tracking carbapenem resistance is complicated by definitions which include resistance to ertapenem only which can differ in epidemiology, mechanism, and treatment options. This study examines trends of CRE from 2015 to 2019 and the impact of carbapenem resistance on outcomes.

Methods

Enterobacterales infections identified in the Premiere HealthCare database from 2015 to 2019 were categorized into 3 groups: ertapenem only resistant (Erta-R); isolates resistant to ertapenem and class 2 carbapenems (CR-1/2); and carbapenem susceptible (CS). Trends in resistance over the study period were assessed. Furthermore, patient characteristics and outcomes were compared between groups.

Results

Among 225,457 unique cultures 692 were Erta-R, 2,397 were CRE-1/2, and 222,368 were CS. Overall rates of CRE-1/2 slightly increased from 0.9% to 1.2% over the study period (P for trend of < 0.0001) while there was a slight negative trend for Erta-R rates (P for trend =0.006). Rates of CR by pathogen (Figures 1 and 2) were relatively stable over the study period. Enterobacter cloacae was the most common organism in the Erta-R group and K. pneumoniae was the most common CRE-1/2 pathogen. Differences in patient characteristics were seen between the three groups for race, gender, and comorbidities (Table). Both mortality (Erta-R: 10%, CRE-1/2: 9% vs CS: 4%, respectively) and infection-associated length of stay (Erta-R: 8 days; CRE-1/2: 8 days vs CS: 6 days, respectively) were higher in both Erta-R and CRE 1/2 when compared to CS (P< 0.001). There were no differences in outcomes between patients with Erta-R and CRE 1/2.

Figure 1. Annual rates of CRE (resistance to both classes) by pathogen over the study period

Figure 2. Annual rates of CRE (ertapenem R only) by pathogen over the study period

Table. Patient demographics and outcomes

Conclusion

CRE rates were relatively stable over the study period. Despite low incidence, CRE continue to have significant associations with morbidity and mortality. Interestingly, outcomes were similar in patients with isolates resistant to ertapenem only when compared to isolates resistant to both classes of carbapenems. This might be reflective of novel treatment options available over the study period.

Disclosures

Stephen Marcella, MD, Shionogi Inc. (Employee) Hemanth Kanakamedala, BS, Shionogi Inc. (Independent Contractor) Yun Zhou, MS, Shionogi Inc. (Independent Contractor) Bin Cai, MD, PhD, Shionogi Inc. (Employee) Jason M Pogue, PharmD, BCPS, BCIDP, Shionogi Inc. (Advisor or Review Panel member)
850. External Validation of the Methicillin-Resistant Staphylococcus aureus Bacteremia Score
Authors: Boyle Ellen , Dorgan Emily , Lunowa Cali , Molina Kyle C , Johnson Tanner M , miller matthew , Huang Misha , Fish Douglas
Published: January 2021

Background

Predictive scoring systems, such as the Pitt Bacteremia Score (PBS) and Acute Physiology and Chronic Health Evaluation II (APACHE-II), can optimize clinical decisions and provide adjustment for confounding among patients with Methicillin-Resistant Staphylococcus aureus bacteremia (MRSAB). The recently introduced MRSAB score demonstrated superior discriminatory ability in mortality prediction compared to APACHE-II and PBS, however external validation is lacking.

Methods

Single center, retrospective cohort study of adult patients admitted to University of Colorado Hospital from 2013–2020 with initial episode of MRSAB were included. Patients transferred from an outside hospital, left against medical advice, or died/pursued comfort care within 24 hours of index culture were excluded. The primary outcome was discrimination of 30-day all-cause mortality. The discriminatory abilities of APACHE-II, PBS and MRSAB were compared using receiver operating characteristic (ROC) analysis. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were analyzed, and optimal MRSAB score was identified by Youden Index.

Results

Overall, 170 patients met study inclusion. The median (IQR) age was 57 (47-66) years, 69% were male, and 19% were in an ICU during blood culture collection. The most common infection sites were skin and soft tissue (41%), musculoskeletal (23%), and line-related (19%), whereas endovascular (14%) infections were less common. The median (IQR) PBS, APACHE-II and MRSAB scores were 2 (0-4),17 (12-23), and 6.5 (3-11), respectively. Thirty-day all-cause mortality was 12.9%. ROC curve analysis revealed an area (95% CI) for the APACHE-II, PBS, and MRSAB scores of 0.84 (0.77-0.92), 0.71 (0.57-0.85), 0.79 (0.68-0.90), respectively. A threshold MRSAB score of ≥10 was identified, whereby mortality was 3.6% with MRSAB < 10, and 30% with MRSAB ≥10. A MRSAB ≥10 had a sensitivity, specificity, PPV and NPV with corresponding 95% CIs of 0.82 (0.63-0.94), 0.72 (0.68-0.79), 0.30(0.19-0.42) and 0.96(0.92-0.99), respectively.

Receiver operator characteristic (ROC) curves for the prediction of 30-day mortality

Conclusion

The MRSAB score is a useful predictive scoring model, with discriminatory ability comparable to APACHE-II, and excellent NPV at ≥10. Our findings support routine clinical and research application.

Disclosures

matthew miller, PharmD, Allergan (Speaker’s Bureau)Tetraphase (Speaker’s Bureau)
59. Evaluation of Drug-Bug Mismatch Alerts and Their Value in an Antimicrobial Stewardship Program
Authors: Whittaker Cristen A , Nhan Ethan , Storb Marc , Szymborski Shana , Trivedi Manish , Reilly Joseph
Published: January 2021

Background

Antimicrobial stewardship is a priority for hospitals and utilizing generated reports can enhance stewardship activities. At our institution, a software program was used to help optimize antimicrobial therapy by providing a drug-bug mismatch (DBM) alert which identifies patients with culture susceptibilities not covered by their current antimicrobial therapy. The purpose of this study was to evaluate the utility of this alert feature and determine whether or not an intervention was needed for patients identified.

Methods

From August 2019 to March 2020 the DBM alerts were reviewed by a pharmacist and interventions pursued when appropriate. Data collection included the patient’s culture results and source, indication for current antibiotics, and potential for intervention. Alerts were stratified into different groups based on the type of culture, including urine, blood, sputum, bone or bodily fluid, wound or tissues, and stool. Those mismatches not resulting in an intervention were categorized as a contamination, colonization, or inappropriate. This study was approved by the institutional review board.

Results

A total of 105 DBM alerts were analyzed from various sources, including 51 (47.6%) urine, 17 (16.2%) sputum, 16 (15.2%) wound or tissue, 14 (13.3%) blood, 6 (5.7%) bone or bodily fluid, and 1 stool culture. Overall, 48 of 105 (45.7%) of alerts resulted in an intervention. Urine and sputum culture alerts required interventions at the lowest rate with treatment interventions in 12 of 51 (23.5%) and 5 of 17 (29.4%) of those cases respectively. Blood culture alerts were the most successful as 9 of 14 (64.3%) alerts required an intervention. Alerts with wound or tissue cultures identified gaps in therapy as 9 of 16 (56.3%) cases required intervention. Colonization or contamination appeared to be the major cause of alerts that did not result in intervention.

Conclusion

The DBM alert can be a beneficial tool for pharmacists participating in antimicrobial stewardship activities. However, the alerts had varying value depending on the culture source. The DBM alert can identify real-time patient issues regarding appropriate antimicrobial therapy. Further modifications to our process in utilizing this DBM report are warranted to enhance value and allocate time accordingly.

Disclosures

All Authors: No reported disclosures