bluuebunny/crossref_metadata_2025 huggingface dataset:
597. Comparison of Vancomycin and Daptomycin Complications and Interventions in Outpatient Parenteral Antimicrobial Therapy
Authors: Nakrani Monark , Yu Diana , Sikka Monica , Lewis James , Douglass Alyse , Mayer Heather , Young Kathleen , Streifel Amber C
Published: January 2021

Background

Vancomycin and daptomycin are commonly used in outpatient parenteral antimicrobial therapy (OPAT) for patients requiring lengthy courses of intravenous antimicrobials who are otherwise stable for discharge. Balancing the convenience and cost-savings of OPAT with the potential for adverse effects is challenging, this study compared the rates of complications and antimicrobial interventions for patients receiving vancomycin versus daptomycin across multiple OPAT settings.

Methods

We performed a retrospective chart review of adult OPAT patients who received >72 hours of vancomycin or daptomycin via home infusion, infusion center, or skilled nursing facility between January 2017 and August 2019. The outcomes evaluated included the rates of adverse drug reactions (ADRs), laboratory results above a defined threshold (vancomycin levels >20 mg/mL in the vancomycin arm and creatinine phosphokinase (CPK) levels >500 units/L in the daptomycin group), line complications, emergency department (ED) visits, and hospital readmissions. Other outcomes included additional phone calls and interventions required to coordinate care (additional labs, assessment of symptoms, additional test or antimicrobial-related dose changes) by the OPAT team.

Results

180 patients were included; 130 received vancomycin and 50 received daptomycin. (Table 1) Patients in the vancomycin group had more supratherapeutic vancomycin troughs than elevated CPK for patients in the daptomycin group (rate ratio [RR] 0.16, 95% CI 0.05-0.50, p=0.0018). Rates of interventions (RR 0.37, 95% CI 0.26-0.52, p< 0.0001) and additional phone calls (RR 0.56, 95% CI 0.43-0.72, p< 0.0001) were also higher for patients in the vancomycin group. There were no statistically significant differences between groups in the rates of ADRs, line complications, ED visits, or hospital readmissions. (Table 2)

Table 1. Baseline Characteristics

Table 2. Outcomes

Conclusion

Vancomycin-treated patients had significantly more laboratory abnormalities and required significantly more time in patient care coordination by the OPAT team. The difference in healthcare utilization between these groups suggests a potential for significant cost-savings for OPAT patients and the healthcare system.

Disclosures

All Authors: No reported disclosures
598. Correlation of International Classification of Diseases (ICD) codes to initial provider-selected antibiotic indications in hospitalized adult patients within the Duke Antimicrobial Stewardship Outreach Network (DASON)
Authors: Livengood Spencer J , Jones Travis M , Moehring Rebekah W , Spires Steven S , Johnson Melissa D , Dyer April , Davis Angelina , Ashley Elizabeth Dodds
Published: January 2021

Background

Provider-selected antibiotic indications are a measure to help track antibiotic use, and facilitate stewardship activities. International Classification of Diseases 10th version (ICD-10) codes have been widely used in the medical field for a variety of purposes, including billing for reimbursement, disease epidemiology, administration, and research. The ability of these codes to accurately describe the true disease diagnosis has been questioned. The purpose of this study is to provide insight into correlation between ICD-10 codes and provider-selected antibiotic indications recorded upon antibiotic order entry.

Methods

This multicenter, retrospective cohort study was performed using data from 17 hospitals in the DASON network. Antibiotic orders during calendar year 2019 for inpatients ≥ 18 years of age that included an indication for use were extracted from the DASON antimicrobial stewardship assessment portal. Orders with the antibiotic indication category of prophylaxis (medical or surgical) and other were excluded. The primary outcome was agreement between antibiotic indication and any discharge ICD-10 code from the same hospital admission. Secondary analyses stratified results by antibiotic and indication. Descriptive statistics were used to describe outcomes.

Results

A total of 246,999 unique antibiotic orders were identified in 180,109 admissions. After removing prophylaxis (n=75,124) and other (n=36,359), 135,516 orders were included. Most orders did not have an ICD-10 code matching the prescriber indication (92,237 [68%]). All indications except HEENT (18% mismatch) and genitourinary infections (46% mismatch) lacked a corresponding diagnosis code in more than 50% of cases (Table 1). Urinary tract infections (93%), bloodstream infections (90%), and central nervous system infections (80%) showed the highest rates of mismatch among indications (Table 1).

Table 1: Correlation of ICD-10 Codes to Provider Selected Indications

Conclusion

We observed a high rate of mismatch between antibiotic indications and ICD-10 codes. Provider-selected antibiotic indications at the time of empiric treatment may be more reflective of diagnostic differential but is a poor indicator of ultimate patient diagnosis.

Disclosures

Rebekah W. Moehring, MD, MPH, Agency for Healthcare Quality and Research (Grant/Research Support)Centers for Disease Control and Prevention (Grant/Research Support) Melissa D. Johnson, PharmD, MHS, Charles River Laboratories (Grant/Research Support)Cidara (Consultant)Merck & Co (Scientific Research Study Investigator)Paratek (Consultant)Scynexis (Scientific Research Study Investigator)Shionogi (Consultant)UpToDate (Other Financial or Material Support, Royalties)
599. Dalbavancin Utilization in Rural Healthcare Setting: A Single Center Three Years’ Experience
Authors: AlSalman Ahmad , Worby Craig P , Considine emma , Zijoo Ritika , Kershaw Colleen
Published: January 2021

Background

Dalbavancin is a second generation lipoglycopeptide, approved by the Food and Drug Administration (FDA) for treatment of acute bacterial skin and skin structure infections (ABSSSI). The weekly dosing of Dalbavancin has encouraged its off-label use to treat other severe infections, especially in patients deemed to be poor candidates for intravenous antimicrobial therapy through a long-term intravenous catheter.

Methods

Single center retrospective chart review of 33 patients who were planned to receive Dalbavancin between March 2015 and March 2019 at a rural medical center in New Hampshire.

We reviewed demographics, indications, microbiological, intravenous drug use status and compliance data.

Results

Dalbavancin therapy was planned for 25/33 patients (75.75%) specifically due to safety concerns around use of a peripherally inserted central catheter (PICC) in Persons Who Inject Drugs (PWID). All 25 patients (75.75%) were actively injecting at the time of the infection with 16/33 patients (48.48%) receiving or newly enrolled in medication assisted treatment. The planned duration of therapy was not completed in 15/33 patients (45.45%) and all were PWID. 11/33 patients (33.3%) were lost to follow up. Additionally, 6 patients experienced insurance coverage issues or difficulty having peripheral access placed. The average driving distance between home and infusion suite was 47 miles.

Methicillin Resistant Staphylococcus aureus (19/33) and Methicillin Susceptible Staphylococcus aureus (8/33) were the most commonly treated organisms and the average pathogen-directed therapy duration prior to starting Dalbavancin was 15 days.

Conclusion

Despite recent data suggesting that Dalbavancin therapy for PWID has good compliance rates in urban settings, our experience suggests that the same principle might not be true in rural settings as the non-compliance and loss to follow up rates were very high.

Disclosures

All Authors: No reported disclosures
600. Decreased Hospital Readmission After Programmatic Strengthening of an Outpatient Parenteral Antimicrobial Therapy (OPAT) Program
Authors: Agnihotri Gaurav , Gross Alan E , Seok Minji , Yen Cheng Yu , Khan Farah , Ebbitt Laura M , Bleasdale Susan C , Sikka Monica K , Trotter Andrew B
Published: January 2021

Background

Although it is recommended that an OPAT program should be managed by a formal OPAT team that supports the treating physician, many OPAT programs face challenges in obtaining necessary program staff (i.e nurses or pharmacists) due to limited data examining the impact of a dedicated OPAT team on patient outcomes. Our objective was to compare OPAT-related readmission rates among patients receiving OPAT before and after the implementation of a strengthened OPAT program.

Methods

This retrospective quasi-experiment compared adult patients discharged on intravenous (IV) antibiotics from the University of Illinois Hospital before and after implementation of programmatic changes to strengthen the OPAT program. Data from our previous study were used as the pre-intervention group (1/1/2012 to 8/1/2013), where only individual infectious disease (ID) physicians coordinated OPAT. Post-intervention (10/1/2017 to 1/1/2019), a dedicated OPAT nurse provided full time support to the treating ID physicians through care coordination, utilization of protocols for lab monitoring and management, and enhanced documentation. Factors associated with readmission for OPAT-related problems at a significance level of p< 0.1 in univariate analysis were eligible for testing in a forward stepwise multinomial logistic regression to identify independent predictors of readmission.

Results

Demographics, antimicrobial indications, and OPAT administration location of the 428 patients pre- and post-intervention are listed in Table 1. After implementation of the strengthened OPAT program, the readmission rate due to OPAT-related complications decreased from 17.8% (13/73) to 6.5% (23/355) (p=0.001). OPAT-related readmission reasons included: infection recurrence/progression (56%), adverse drug reaction (28%), or line-associated issues (17%). Independent predictors of hospital readmission due to OPAT-related problems are listed in Table 2.

Table 1. OPAT Patient Demographics and Factors Pre- and Post-intervention

Table 2. Factors independently associated with hospital readmission in OPAT patients

Conclusion

An OPAT program with dedicated staff at a large academic tertiary care hospital was independently associated with decreased risk for readmission, which provides critical evidence to substantiate additional resources being dedicated to OPAT by health systems in the future.

Disclosures

All Authors: No reported disclosures
601. Disparities in Diabetes Care: Smoking Cessation among Women and Minorities Living with HIV at an Urban Academic Medical Center
Authors: Cangialosi Peter , Liotta Mark , Finkel Diana , Swaminathan Shobha , Keller Steven
Published: January 2021

Background

People living with HIV (PLWH) and diabetes mellitus are at increased risk of developing significant medical complications such as atherosclerotic cardiovascular disease. Disproportionate rates of diabetes and HIV among minority groups raise the issue of how demographic disparities may impact care. The American Diabetes Association (ADA) 2020 guidelines for diabetes care recommend optimal glycemic levels (A), blood pressure control (B), lipid reduction (C), and smoking cessation (N), commonly referred to as ABC or ABCN criteria. This quality assessment project examines diabetes management in PLWH by gender, race/ethnicity, and BMI, in a predominantly minority-serving clinic, as assessed by rates of guideline adherence to the above metrics.

Methods

This project was reviewed and approved by the Rutgers IRB. Patients from an HIV registry of University Hospital Infectious Disease Outpatient clinic in Newark, NJ were reviewed for a diagnosis of diabetes and both a clinic visit and an A1c score recorded between 2/1/2019 and 1/31/2020. Achieving glycemic target was defined as HbA1c < 7.5 for patients < 65 and HbA1c < 8 for patients > 65. Target adherence criteria also included a blood pressure average of < 140/90 over this period and an LDL-c of < 100 mg/dL. Non-smoking status includes both former and never smokers.

Results

Of 1035 patients reviewed, a total of 172 met criteria. Adherence rate for achieving goal HbA1c was 61.6% (95% CI 54.2-68.6, n=172). Blood pressure and LDL-c adherence rates were 65.1% (95% CI 57.7-71.8, n=172) and 67.4% (95% CI 60.1-74.0, n=172), respectively. ABC and ABCN rates were 24.4% (95% CI 18.6-31.4, n=172) and 18.6% (95% CI 13.5-25.1, n=172). The overall smoking rate, as well as the rates in the female subgroup, those with BMI 18.5-24.9, and the non-Hispanic black subgroup were significantly higher than the national average (P< 0.05).

Table 1: Demographic Data of PLWH and Diabetes

Table 2: Adherence to ABCN Criteria in Diabetes Care by Demographics for PLWH from 2/1/2019 – 1/31/2020

Conclusion

For diabetic PLWH, smoking cessation requires improvement, particularly in female, normal BMI, and non-Hispanic black subgroups. These findings, in addition to a majority overweight patient population, highlight the need for increased education and interventions aimed at nutritional counseling and risk factor mitigation among all patient subgroups.

Disclosures

All Authors: No reported disclosures
602. Do These Labs Really Matter? Searching for the Benefit of Laboratory Monitoring in Outpatient Parenteral Antimicrobial Therapy (OPAT)
Authors: Zukauckas Kelsea N , Benefield Russell J , Certain Laura
Published: January 2021

Background

Weekly laboratory monitoring is routinely performed for patients treated with Outpatient Parenteral Antimicrobial Therapy (OPAT). However, minimal evidence exists to guide this practice.

Methods

This was a single-center, retrospective cohort study to assess the value of laboratory monitoring in patients being treated with beta-lactam OPAT. This study included adult patients discharged from University of Utah Health (UUH) between January 1, 2018, and July 31, 2019, on beta-lactam OPAT with follow-up care with a UUH Infectious Diseases (ID) Provider. Patients discharged to a skilled nursing facility or long-term acute care hospital, or who received OPAT for a duration less than 7 days, were excluded. The primary aim was to describe how often abnormal laboratory values led to a therapy modification or documented adverse drug reaction (ADR) for patients receiving beta-lactam OPAT. Abnormal laboratory values were defined by consensus criteria for clinical significance (e.g., RIFLE criteria for kidney injury). Therapy modification and ADR occurrence was determined by chart review for UUH ID Provider documentation.

Results

A total of 346 patients were included; two hundred seventy-four (79%) had abnormal laboratory values during OPAT. Of these, 12 patients had a modification to their OPAT due to abnormal laboratory values. The most common therapy modification due to abnormal laboratory values was a change of antibiotic (9/12). Two hundred thirteen of 274 patients (78%) with abnormal laboratory values were maintained on their OPAT regimen without a modification. Of the 67 therapy modifications observed, 55 (82%) were due to reasons other than abnormal laboratory results (Table 1).

Abnormal laboratory values meeting criteria for clinical significance and possible ADR were observed in 469 instances. Of these, 43 (9%) were considered ADRs by the ID provider (Table 2).

Table 1 describes therapy modifications for patients on beta-lactam OPAT

Table 2 describes documented ADRs in the presence of abnormal labs for patients on beta-lactam OPAT

Conclusion

Weekly laboratory monitoring was associated with therapy modifications and documented ADRs in a small number of patients receiving beta-lactam agents as OPAT. This supports current guideline recommendations for laboratory monitoring, even for beta-lactam agents, which are considered relatively safe. Further investigation into the cost-effectiveness of this approach is warranted.

Disclosures

Russell J. Benefield, PharmD, Merck and Co (Grant/Research Support)Paratek Pharmaceuticals (Grant/Research Support)Rempex Pharmaceuticals (Grant/Research Support)
603. Evaluating the Effects of Centers for Medicare & Medicaid Services Sepsis Core Measure in a Community Hospital
Authors: Kim So , Ty Peter
Published: January 2021

Background

Sepsis is the leading cause of morbidity and mortality in hospitals, accounting for 30% of deaths in the emergency department. In 2001, Rivers et al. found that early goal-directed therapy (EGDT) led to significant mortality benefits, which ultimately prompted United States Centers for Medicare and Medicaid Services (CMS) to mandate EGDT in hospitals through its implementation of sepsis core measures. CMS core measures are intended to facilitate the broad implementation of evidence-based treatment standards, and while voluntary, non-compliance is associated with negative consequences to both quality and financial metrics for participating hospitals. However, while quality measures are implemented to ultimately improve patient care, its effects on the healthcare system can also include negative unanticipated consequences. This study seeks to characterize the effect of the CMS sepsis core measure on sepsis identification, antimicrobial utilization, and nd specific prescribing patterns.

Methods

This is a retrospective cohort review of 175 randomly selected patients greater than and equal to 18 years of age with admitting diagnosis of sepsis, severe sepsis, and septic shock from January 2013 to December 2018. Medical charts were reviewed for relevant data.

Results

Comparing ED antibiotic prescribing patterns between pre-and post-Sepsis CMS Core Measures, there was no statistical difference in total antibiotics usage and the initiation of broad antibiotics. There was a decreased time to the first antibiotic, an increase in receiving Normal Saline boluses post-Sepsis CMS Core Measures.

Conclusion

1. No significant changes were seen in ED antibiotic prescribing behaviors with regard to volume and spectrum

2. ED time to antibiotic administration was significantly faster after the implementation of CMS Core Measures. Also, there was a significant positive shift in time to fluid bolus, fluid selection, and fluid volume

3. Significantly decreased ICU length of stay after implementation of CMS Core Measures possibly associated with above behavior changes

4. No outcomes benefits (mortality, hospital length of stay) realized after implementation of CMS Core Measures

Disclosures

All Authors: No reported disclosures
604. Factors Associated with Adverse Drug Reactions Leading to Discontinuation of Vancomycin in Outpatient Parenteral Antimicrobial Therapy
Authors: McDonald Josh , Benefield Russell J , Certain Laura
Published: January 2021

Background

Over 250,000 patients receive outpatient parenteral antimicrobial therapy (OPAT) in the United States each year. Vancomycin is commonly used in OPAT but has a high rate of discontinuations due to adverse drug reactions (ADRs). Being able to predict the occurrence of these ADRs and assess their impact could improve the overall quality of OPAT services when utilizing vancomycin.

Methods

This was a retrospective chart review of all adult University of Utah Health (UUH) patients who received vancomycin OPAT and had planned follow-up with UUH infectious disease (ID) providers between October 25, 2018 and July 31, 2019. Patients were excluded if they were less than 18 years of age, pregnant, did not have planned follow up with UUH ID physicians, or were on any form of renal replacement therapy. The primary outcome assessed was discontinuation of vancomycin due to ADR, as documented by the ID provider. Type of ADR leading to discontinuation and 30-day unplanned readmission were also assessed.

Results

One hundred fifty-eight patients met inclusion criteria (n=158). The mean age of patients was 55 years with a median Charlson comorbidity score of 3. Most patients utilized a non-UUH infusion service (116, 73% vs 42, 27%) and utilized vancomycin as their sole antibiotic (83, 53%). The majority of patients were being treated for orthopedic infections (78, 49%). Twenty-eight patients discontinued vancomycin OPAT due to an ADR (18%). The most common ADR leading to discontinuation was acute kidney injury (10, 36%). Variables associated with ADRs leading to discontinuation included utilization of UUH home infusion services (54% vs 21%, P < 0.001) and initial vancomycin plasma concentrations obtained less than 7 days after discharge (92% vs 71%, P < 0.001). The overall 30 day readmission rate was 10% and the rate among patients who experienced an ADR leading to discontinuation was higher than those who did not (25% vs 8%, P < 0.001).

Conclusion

The overall rate of discontinuation of vancomycin OPAT due to ADR in the UUH population is similar to what has been described in previous literature. The higher rate of unplanned readmission in the population of patients who experienced ADRs warrants further study. The results of this study will be utilized for future quality improvement interventions at our institution.

Disclosures

Russell J. Benefield, PharmD, Merck and Co (Grant/Research Support)Paratek Pharmaceuticals (Grant/Research Support)Rempex Pharmaceuticals (Grant/Research Support)
606. HIV Homecare: Understanding its Impact for Lost-to-Follow-Up Populations
Authors: Bonadonna Lily , Guerrero Esther , McClendon Tammie , Union Sheronda , Kabbani Dana , Veltman Jennifer
Published: January 2021

Background

Maintaining people living with HIV (PLWH) in clinical care is a global priority. In the metro-Detroit area of Michigan, approximately 30% of PLWH are out of care. To re-engage lost-to-follow-up patients, the Wayne State University Physician Group – Infectious Disease clinic launched an innovative Homecare program in 2017. In addition to home healthcare delivery, the program included links to community resources and quarterly community meetings. In the first year of Homecare, 28 of 34 participants became virally suppressed at least once. We aimed to understand reasons why people who left clinic-based treatment were able to become virally suppressed in this program. We included data from PLWH and their healthcare workers.

Methods

We used a mixed-methods design, including (1) semi-structured interviews with PLWH and healthcare workers, and (2) a validated Likert scale questionnaire rating illness perception before and after Homecare. Data were collected from 15 PLWH in metro-Detroit and two healthcare workers responsible for program delivery. Semi-structured interviews focused on obstacles to clinic-based care, support networks, and illness perceptions. Interview data were transcribed and analyzed using a grounded theory approach. A fully coded analysis was used to create a conceptual framework of factors contributing to Homecare’s success. Means in eight categories of the brief illness perception questionnaire (BIPQ) were compared using paired T-tests.

Results

The Homecare program offered (1) social support and stigma reduction through strong relationships with healthcare workers; (2) removal of physical and resource barriers such as transportation; and (3) positive changes in illness perceptions. PLWH worked towards functional coping strategies, including improvements in emotional regulation, acceptance of their diagnosis, and more positive perspectives of control. BIPQ showed significant changes in six domains before and after Homecare.

Homecare Conceptual Framework

General

Joint Display: Brief Illness Perception Questionnaire

Conclusion

Homecare offers an innovative system for successfully re-engaging and maintaining lost-to-follow-up PLWH in care. These findings have implications for HIV control efforts and could inform the development of future programs for difficult to reach populations.

Disclosures

All Authors: No reported disclosures
607. Identifying Intervention Opportunities to Prevent Readmissions during OPAT
Authors: Swartwood Michael J , Farel Claire E , Mavrogiorgos Nikolaos , Boerneke Renae A , Marx Ashley , Ciccone Emily J , Schranz Asher J , Kinlaw Alan C
Published: January 2021

Background

Patients receiving outpatient parenteral antimicrobial therapy (OPAT) experience high rates of unplanned readmissions. To inform interventions that may reduce risk of unplanned readmissions during OPAT, we examined the frequency and reasons for readmission in a large cohort of OPAT patients.

Methods

We analyzed data on all patients enrolled in UNC’s OPAT program from February 2015-February 2020. Patients were evaluated by an infectious diseases (ID) physician prior to OPAT enrollment, discharged with >14 remaining days of prescribed therapy, and received care coordination and systematic monitoring by an ID pharmacist. We abstracted EHR data into a REDCap database to ascertain information on each patient’s OPAT course and readmission details: length of stay, primary ICD-9-CM/ICD-10-CM diagnosis code associated with readmission, and reason for readmission from clinical notes. Diagnosis codes and notes were adjudicated and summarized by a multidisciplinary team.

Results

Among 1,165 OPAT courses, 19% resulted in at least one readmission during therapy, lasting for a median length of stay of 5 days. Among those patients who were readmitted during OPAT, the median time from OPAT start to readmission was 17 days (interquartile range, IQR: 8-29 days). 66% of readmissions preceded the scheduled follow-up appointment during OPAT (median time to scheduled follow-up was 27 days, IQR: 15-35 days). 55% of readmissions were unrelated to OPAT diagnosis. Based on ICD-9-CM/ICD-10-CM code classifications, the most common infectious diseases-related reasons for readmission were worsening OPAT infection (18%), OPAT-related adverse drug reaction (12%), and new infection (11%).

Conclusion

One-fifth of OPAT courses resulted in readmission during therapy. Half of readmissions were associated with OPAT or other infection, and half were for other reasons. Earlier post-discharge follow-up by a multidisciplinary team (including primary care providers, case management, and OPAT) might prevent infection-related readmissions for OPAT patients. Future work should also address the need for enhanced care coordination with non-infectious disease providers to manage OPAT patients.

Disclosures

All Authors: No reported disclosures
609. Implementation and Post-implementation Analysis of a Pilot Program for Inpatient Review of Outpatient Parenteral Antimicrobial Therapy Prior to Discharge
Authors: Hart Delaney , McCoy Hailey , Gens Krista , Wankum Michael , Tarleton Andrew
Published: January 2021

Background

The Infectious Diseases Society of America OPAT (outpatient parenteral antimicrobial therapy) guidelines state that effective OPAT programs require a multidisciplinary team1. Currently within the health system, there is no formal OPAT program in place, and OPAT prescribing is not limited to any specialty. This project aimed to pilot a pharmacist-driven program across five hospitals.

Methods

Adult patients with OPAT ordered between February 1 and May 1, 2020 were included. Patients were excluded if the OPAT was prescribed by infectious diseases (ID) providers or if patients were on OPAT prior to hospital admission. An alert was generated in the electronic health record (EHR) when an order for an intravenous catheter was placed for patients with concomitant antimicrobials. Follow up was performed and documented via a progress note in the EHR as appropriate. Data was collected via retrospective chart review and statistical analysis was performed using Chi-squared test with Yates’ correction.

Results

101 pre- and 7 patients post-implementation were included in this study. There were a total of 51 patients pre-implementation that received inappropriate OPAT care per the IDSA OPAT guidelines, and post-implementation 2 patients (50.5% vs 28.6%, p=0.47). The secondary outcomes of 30-day readmission rates were 17% and 0% (p=0.52); and complications related to OPAT (e.g. central-line associated blood stream infections) were 12% and 0% (p=0.73), respectively. 2 midline catheters were recommended by the OPAT team, and a cost savings of up to $6,796 was calculated.

Conclusion

This pilot showed a trend towards decreased inappropriate OPAT prescribing and cost avoidance of an ID pharmacist-driven review of OPAT prior to patient hospital discharge. Limitations to this pilot included being underpowered due to the limited time-frame of the post-implementation period, and an inability for follow up with patients discharged utilizing an alternative home infusion service.

Disclosures

All Authors: No reported disclosures
614. Long-Acting Lipoglycopeptides for the Treatment of Bone and Joint Infections and Bacteremia in Infectious Disease Outpatient Infusion Clinics
Authors: Metzger Brian S , Prokesch Richard C , Bernett Jorge R , Mandel Richard M , Nathan Ramesh V , Nathan Ramesh V , Stock Kent , Hardin Thomas C , Schroeder Claudia P , Van Anglen Lucinda J
Published: January 2021

Background

Long-acting lipoglycopeptides (LGPs) are approved for the treatment of acute bacterial skin and skin-structure infections. Broad Gram-positive coverage and weekly dosing regimens are useful for other diagnoses, but real-world data supporting such use are sparse. We review our experience of dalbavancin and oritavancin for the treatment of bone and joint infection (BJI) and bacteremia (BAC) in outpatient infusion clinics (OICs).

Methods

We conducted a multicenter, retrospective, observational cohort study of patients (pts) receiving long-acting LGPs in OICs over 2 yrs from 2018-2019 for BJI and BAC. Data collected included demographics, diagnosis, dosing regimen, microbiology, clinical outcomes, and adverse events (AEs). Clinical success, defined as resolution of infection with continued oral antibiotics allowed, was assessed at the next follow-up visit. Worsening infection, the need for additional intravenous therapy, and discontinuations during therapy were deemed non-successful.

Results

We identified 70 pts (mean age: 64±16 years, 53% male) from 25 OICs, who received dalbavancin (n=50), oritavancin (n=19) and both (n=1). BJI accounted for 55 (79%) with 31 osteomyelitis, 9 bursitis, 7 prosthetic joint, 7 septic arthritis and 1 tenosynovitis. BAC was the primary diagnosis in 15 (21%) and sources were 6 device, 2 lower respiratory tract, 2 urinary tract and 5 unknown. 46% of pts were treated in the OIC without prior hospitalization. 72 Gram-positive isolates were obtained from 67 pts, with Staphylococcus aureus predominant (42/72, 58%), including methicillin-resistant (26/72, 36%) and methicillin-susceptible isolates (16/72, 22%). Median number of doses administered were 2 [IQR 1-2] in BJI and 1 in BAC [IQR 1-2]. Overall clinical success was 86% (57/66), with 4 non-evaluable. BJI had 85% success (44/52), with 90% in osteomyelitis (28/31), 50% in prosthetic joint (3/6) and 87% (13/15) in the others. Clinical success was 93% (13/14) in BAC. Three pts (4%) on dalbavancin experienced mild AEs, none resulting in discontinuation of therapy.

Conclusion

This multicenter real-world study of long-acting LGPs demonstrates safety and high clinical success rates in BJI and BAC. Our experience suggests a role for use of these agents in treatment of BJI and BAC in the outpatient setting.

Disclosures

Brian S. Metzger, MD, MPH, Allergan (Speaker’s Bureau)Cumberland (Speaker’s Bureau)Melinta (Speaker’s Bureau) Ramesh V. Nathan, MD, FIDSA, Merck & Co. (Other Financial or Material Support, Grant Steering Committee Member) Lucinda J. Van Anglen, PharmD, Merck & Co. (Grant/Research Support)
617. Physician Perspective: Utilization of Advanced Practice Providers (APPs) in the ID Workforce
Authors: Beieler Alison M , Beieler Alison M , Yoke Leah H , Yoke Leah H , Liu Catherine , Pergam Steven A , Wald Anna , Wald Anna , Dhanireddy Shireesha , Dhanireddy Shireesha
Published: January 2021

Background

Applicants entering Infectious Disease (ID) fellowships are declining and shortages of ID physicians is a challenge recognized by the clinical workforce and Infectious Diseases Society of America (IDSA). There is increased awareness of more Advanced Practice Providers (APPs) being used within ID to expand and extend existing practices. However, little is known about APP utilization, APP clinical scope of practice, specific roles, and opportunities for education.

Methods

To evaluate physician perspectives on APP utilization in ID, we created an anonymous and voluntary survey using the REDCap data tool that was distributed by social media, key stakeholder emails, and IDSA online community forum between 12/1/2019-1/31/2020. In addition to collecting geographic information and the type of ID practice, participants were also surveyed about the use of APPs and any perceived barriers that may limit their use.

Results

218 practicing ID physicians responded to the survey (Figure 1). 155 (71%) physicians work with APPs in their current practice (Figure 2); specifically, 56 (27%) with 1 APP, 62 (30%) with 2-4 APPs, 28 (13%) with 5-9 APPs, and 11 (5%) with > 10 APPs. Of respondents, 104 (48%) practiced at University/Medical schools, 80 (37%) in hospitals/clinics, and 28 (13%) in private practice (Table 1); most work in adult inpatient/outpatient ID. The main reasons selected by respondents for not using APPs in their practice included concerns around a lack of formal ID training 22 (15%), lack of time/lack of ability to assist with APP training 29 (20%), practice is already sufficiently staffed 19 (13%), and concern for physician revenue loss 16 (11%) (Table 1).

Figure 1. Physician Responses by Region, n = 218

Figure 2. Physicians Utilizing APPs in Practice, n = 210 (*no response, 8)

Table 1. Physician ID Practice Type, Setting, and Concerns

Conclusion

Results suggest that while collaboration between ID physicians and APPs exists to meet current needs, a lack of ID training is a limiting factor. Our findings demonstrate there is an opportunity for formal ID education and resource development both to enhance APPs clinical skills and address perceived knowledge gaps. Inclusion of APPs in the ID workforce may allow physicians to expand ID care into more resource limited areas to continue to provide high quality patient care.

Disclosures

Steven A. Pergam, MD, MPH, Chimerix, Inc (Scientific Research Study Investigator)Global Life Technologies, Inc. (Research Grant or Support)Merck & Co. (Scientific Research Study Investigator)Sanofi-Aventis (Other Financial or Material Support, Participate in clinical trial sponsored by NIAID (U01-AI132004); vaccines for this trial are provided by Sanofi-Aventis)
619. Quantifying the non-billable workload of Outpatient Parenteral Antibiotic Therapy (OPAT) services in a University Infectious Diseases (ID) Clinic
Authors: Burgoyne Colleen , Calisir Nurhan , Munsiff Sonal
Published: January 2021

Background

OPAT service has health and economic benefits for the patient, health care facility and the general community. Management of patients receiving OPAT requires an interdisciplinary team approach and complex care coordination and has been shown to decrease adverse reaction, and rehospitalizations. Much of the work involved in caring for patients on OPAT occurs outside of a billable office visit. Describing and quantifying this workload is important to justify staffing and to advocate for change in reimbursement structure.

Methods

Patients enrolled in OPAT program at our clinic in 2019 were identified from the electronic medical record (EMR) and information was extracted on all EMR encounters by ID faculty and staff occurring from the start of OPAT monitoring until 14 days after OPAT ended, or until March 31, 2020 for patients still on OPAT on that date.

Results

During 2019, 835 unique OPAT courses were monitored for 767 patients. Activities include a sign-on process, monitoring labs, drug levels, coordinating care, weekly review by OPAT team (Medical Director or an ID attending, nurse practitioner (NP), nurse (RN) and ID pharmacist). We identified 7,640 encounters; 1,072 were office visits. Thus, 86% (N=6569) of encounters were for managing and coordinating care. The OPAT RN created 3435 of 6568 (52%) encounters, 2034 (31%) were by physicians and nurse practitioners, 500 by other clinic RNs and 599 were by administrative staff

Conclusion

Our results quantify the immense care for OPAT patients that is not compensated by insurance. However, this work contributes to patient safety and satisfaction. Our data does not account for time spent by the multidisciplinary team on weekly review of all active OPAT patients which lasts about 3 hours and is essential to ensuring patient safety. This data also does not quantify the contribution of the ID pharmacist who is consulted by OPAT team for multiple issues but whose recommendations are documented by the providers. The total time involved in all this work could not be determined. The quantification of the uncompensated workload of such monitoring is important as it can be justification for modernization of reimbursement for OPAT patient care, making the establishment and maintenance of such programs more financially solvent for health care organizations.

Disclosures

All Authors: No reported disclosures
620. Real-World Insights on HIV Treatment Decision-Making in Federal and Public Healthcare Settings
Authors: Okulicz Jason F , Zawitz Chad J , Blaylock Jason M , Taneva Ekaterina S , Simone Laura , Carter Jeffrey , Sapir Tamar
Published: January 2021

Background

Evidence-based guidelines and novel antiretroviral therapies (ART) for people living with HIV (PLHIV) are quickly evolving. Understanding the practice patterns, gaps, and needs of healthcare professionals (HCPs) who care for PLHIV in specific settings, such as those in the federal and public healthcare sector, can inform education and improvement strategies.

Methods

Surveys were administered before and after a series of 1.5 hour continuing education programs (n=20) on HIV treatment conducted live in various US cities between April 2019 and March 2020. These programs were designed for HCPs in federal and public healthcare systems, such as the Veterans Affairs Medical Centers, Military Medical Treatment Facilities, and Federally Qualified Health Centers.

Results

Survey respondents (n=655) were mostly physicians (35%) or nurse practitioners/physician assistants (25%) practicing in federal healthcare settings (Table 1). Respondents reported a mean patient volume of 1,893 (±240) PLHIV monthly.

Before and after the education, only 34% and 61% of HCPs, respectively, correctly identified recommended first-line ART for most PLHIV. Only 19% and 38% of HCPs reported high levels of confidence in selecting ART for rapid ART initiation before and after the education.

A case-based survey item showed that 35% (pre-education) and 45% (post-education) of HCPs would recommend switching a virologically suppressed patient over age 50 with comorbidities from a boosted protease inhibitor-based regimen to an integrase inhibitor-based regimen. Only 13% and 33% of HCPs reported high confidence in switching ART for older patients with comorbidities before and after the education, respectively.

The biggest challenges identified by HCPs were related to ART selection and patient management (Table 1). After the education, HCPs reported needs and intention to improve their team-based processes to: 1) facilitate rapid ART initiation; 2) optimize ART for patients with comorbidities; 3) optimize treatment for patients with virologic failure.

Conclusion

This educational program improved knowledge and competency in evidence-based HIV treatment and supported team-based action planning. The findings also inform persistent challenges and needs among HCPs in federal settings.

Disclosures

Chad J. Zawitz, MD, Gilead Sciences (Speaker’s Bureau)ViiV (Advisor or Review Panel member) Tamar Sapir, PhD, Gilead Sciences, Inc. (Other Financial or Material Support, Independent medical education grant)ViiV Healthcare (Other Financial or Material Support, Independent medical education grant)
622. Risk Factors for 30-Day Unplanned Readmissions in Patients Discharged with Outpatient Parenteral Antimicrobial Therapy
Authors: Shah Megan , Kidd Catherine , Thomas Tania A , Eby Joshua
Published: January 2021

Background

Outpatient parenteral antimicrobial therapy (OPAT) programs have shown to reduce hospital readmissions; however, 20-25% of OPAT patients are readmitted. As 30-day readmissions is a healthcare quality measure, it is important to recognize predictors for readmissions in OPAT patients in an effort to minimize risk factors and optimize patient outcomes. The aim of this study was to identify modifiable and non-modifiable risk factors for 30-day unplanned readmission in patients discharged with OPAT.

Methods

This was a retrospective cohort study of patients admitted to University of Virginia (UVA) Health System between March 2019 and December 2019 who were discharged home with intravenous antimicrobials followed by the UVA OPAT program. Data collected included patient demographics, comorbidities, infection diagnosis, source control, and antimicrobial class. Variables were compared between patients with a 30-day unplanned readmission and those without a readmission. Mann-Whitney U, Pearson chi-squared, and Fisher’s exact tests were utilized, as appropriate. A multiple logistic regression analysis was performed to determine predictors of 30-day unplanned readmission.

Results

There were 334 OPAT patients who met inclusion criteria. Median age was 58 years, 58% were male, and the most common infection diagnoses were bone/joint (49%), bloodstream (22%), and endovascular (13%). There were 64 (19%) patients who had an unplanned 30-day readmission. The most common reasons for readmission included non-infection related (45%), worsening infection (28%), and antimicrobial-related complication (17%). Readmitted patients were more likely to have a higher Charlson Comorbidity Index (CCI); prior admissions; bloodstream, endovascular, or pulmonary infection; no source control; and an infection caused by a multi-drug resistant organism. CCI was found to be an independent predictor of readmission (OR 1.096, 95% CI 1.001-1.200).

Conclusion

Unplanned readmissions were common in patients discharged with OPAT. There should be an emphasis on interventions to prevent readmissions in OPAT patients, particularly those with high-risk clinical characteristics.

Disclosures

All Authors: No reported disclosures
623. Self-Administered Outpatient Parenteral Antimicrobial Therapy (S-OPAT) in Uninsured Patients
Authors: Hamad Yasir , Min Jaspur , Burnett Yvonne
Published: January 2021

Background

Uninsured patients requiring long-term intravenous (IV) antimicrobials do not have access to outpatient parenteral antimicrobial therapy (OPAT) and often remain hospitalized for the duration of their treatment, transition to inferior oral antimicrobials, or leave against medical advice. A hospital-supported self-administered OPAT (S-OPAT) program was piloted in uninsured patients to decrease hospital length of stay and improve access to care.

Methods

Uninsured adult patients requiring IV antimicrobials were enrolled in an S-OPAT pilot study from July 2019 to April 2020. Patients with drug use history or documented non-adherence were excluded. S-OPAT patients attended weekly clinic visits for blood draws, dressing changes, and medication supply. The measured outcomes were hospital days saved, and potential income generated by earlier discharges. The latter was calculated by multiplying the number of hospital days saved by the daily charge for a hospital bed to insured patients.

Results

Seventeen patients were enrolled in S-OPAT, 14 (82%) were males, 8 (47%) were black, and the mean age was 39 years. The most common indication for OPAT was bone and joint infections in 12 (71%), and most commonly used antibiotic was ceftriaxone in 12 (71%) patients (Table). Early discontinuation occurred in 3 (17%) patients due to clinic visit non-adherence resulted in 2 (12%) and adverse drug events in 1 (6%). Only one (6%) patient had unplanned hospital readmission during OPAT. Transition to S-OPAT resulted in 533 hospital days avoided, and a net saving of approximately $900,000.

Conclusion

S-OPAT model is safe and can enhance care for uninsured patients while optimizing health-system resources.

Table

Disclosures

All Authors: No reported disclosures
624. Significant Institutional Cost Savings from OPAT-Facilitated Discharge for Patients with Challenging Situations
Authors: Alexander Bryan , Bergman Scott , Van Schooneveld Trevor C , Cortes-Penfield Nicolas W
Published: January 2021

Background

Outpatient parenteral antimicrobial therapy (OPAT) programs are becoming a standard of care, however, program cost justification remains a challenge. One area of focus for institutions is facilitating timely discharge from the inpatient setting, and difficult to discharge patients are a group with which OPAT teams can be particularly impactful.

Methods

This retrospective review identified patients intervened upon by the Nebraska Medicine OPAT team during the initial nine months after program implementation (4/1/19 - 12/31/19) for which routine efforts at discharge by primary teams had failed. Patients were planned for extended inpatient stays to complete the full duration of parenteral antibiotic therapy due to discharge issues given the therapy plan initially recommended by infectious disease consult teams. Outcomes evaluated included inpatient days of therapy avoided, associated financial metrics, and 30-day readmission rates. A matched cohort of patients with similar lengths-of-stay, infectious disease indications, medication use, and lack of major complications was identified to calculate a cost per inpatient day avoided.

Results

A total of 17 difficult to discharge patients were intervened on by the OPAT team, leading to avoidance of 429 planned inpatient days. Based on calculation from internal matched cohort data, these OPAT interventions avoided an estimated $943,000 in total inpatient costs. All-cause 30-day readmission was 24% (4 of 17 patients). Additionally, 15 of these therapy courses were shifted to hospital-associated outpatient infusion centers. Facilitation of enrollment for 11 of these patients in pharmaceutical manufacturer patient assistance programs resulted in replacement of outpatient medication totaling over $28,000 in value. Reimbursements for two additional patients through either governmental or private insurance generated over $11,000 in margin for the health system.

Conclusion

Attention to complex discharge facilitation by OPAT programs can be a significant contribution to program cost justification, while also transitioning patients to therapy plans that lead to similar clinical outcomes when compared to the overall OPAT population.

Disclosures

All Authors: No reported disclosures